Implementation of Palliative Care in Palestine: Cultural and Religious Perspectives

The care of terminally ill cancer patients poses a significant global public health problem.1 Populations are growing older as healthcare interventions become increasingly more effective in the management of chronic diseases.2 Care of the terminally ill patients has evolved significantly over the centuries in the developed countries from Hospice services to highly specialized palliative care programs and facilities. In the Middle East, the progress in this area has been very slow over the last two decades which could be attributed to several reasons including the lack of education, training, budgets and several other barriers.3 Although age projection for Palestinians does not indicate generational transition toward an older population,4 yet the increasing incidence of cancer cases and other chronic diseases that need palliation, alerts the policy makers to the crucial need of introducing and developing palliative care services. Thus, the aim of this paper is to: 1) Reflect on the need and access of the Palestinians living in the West Bank and Gaza Strip to palliative care; 2) Define the factors that might interfere with the proper introduction of palliative care; and 3) Focus on the positive compensatory effect of religion and culture on palliative care. The Palestinian population in the West Bank and Gaza Strip at the end of 2016 was 4.88 million (61% and 39%, respectively.4 Palestinians live in refugee camps were about 41.9% distributed between the West Bank and Gaza strip, and 16.7% live in rural areas (2.7% in Gaza Strip compared to 25.6% in the West Bank.4 The Palestinian population is a young generation, though it has been gradually aging; birth, fertility, and death rates have been dropping. In fact, the median age of the Palestinians was 16.4 years in 2000 and increased to 20 years in 2016, with 39.1% of the population under 15 years old compared to 2.9% over 65 years of age. The life expectancy of the population was 73.7 years in 2016 compared to 72.4 years in 2011.4,5 The Palestinian population has low income, and the majority do not have health insurance and cannot afford to seek medical care

Diabetes mellitus: The epidemic of the century

The epidemic nature of diabetes mellitus in different regions is reviewed. The Middle East and North Africa region has the highest prevalence of diabetes in adults (10.9%) whereas, the Western Pacific region has the highest number of adults diagnosed with diabetes and has countries with the highest prevalence of diabetes (37.5%). Different classes of diabetes mellitus, type 1, type 2, gestational diabetes and other types of diabetes mellitus are compared in terms of diagnostic criteria, etiology and genetics. The molecular genetics of diabetes received extensive attention in recent years by many prominent investigators and research groups in the biomedical field. A large array of mutations and single nucleotide polymorphisms in genes that play a role in the various steps and pathways involved in glucose metabolism and the development, control and function of pancreatic cells at various levels are reviewed. The major advances in the molecular understanding of diabetes in relation to the different types of diabetes in comparison to the previous understanding in this field are briefly reviewed here. Despite the accumulation of extensive data at the molecular and cellular levels, the mechanism of diabetes development and complications are still not fully understood. Definitely, more extensive research is needed in this field that will eventually reflect on the ultimate objective to improve diagnoses, therapy and minimize the chance of chronic complications development

Diabetes mellitus: The epidemic of the century

The epidemic nature of diabetes mellitus in different regions is reviewed. The Middle East and North Africa region has the highest prevalence of diabetes in adults (10.9%) whereas, the Western Pacific region has the highest number of adults diagnosed with diabetes and has countries with the highest prevalence of diabetes (37.5%). Different classes of diabetes mellitus, type 1, type 2, gestational diabetes and other types of diabetes mellitus are compared in terms of diagnostic criteria, etiology and genetics. The molecular genetics of diabetes received extensive attention in recent years by many prominent investigators and research groups in the biomedical field. A large array of mutations and single nucleotide polymorphisms in genes that play a role in the various steps and pathways involved in glucose metabolism and the development, control and function of pancreatic cells at various levels are reviewed. The major advances in the molecular understanding of diabetes in relation to the different types of diabetes in comparison to the previous understanding in this field are briefly reviewed here. Despite the accumulation of extensive data at the molecular and cellular levels, the mechanism of diabetes development and complications are still not fully understood. Definitely, more extensive research is needed in this field that will eventually reflect on the ultimate objective to improve diagnoses, therapy and minimize the chance of chronic complications development

Prevalence of tobacco use among young adults in Palestine

Background: Smoking tobacco is a worldwide public health issue. Over the last few decades, smoking patterns have been changing, reflected by increasing rates among young people and females in particular. Aims: This study aimed to determine the prevalence and modalities of smoking and to assess the factors, habits and beliefs that might encourage or discourage smoking among young adults in Palestine. Methods: A cross-sectional study was conducted in the West Bank in 2014 among Palestinians aged 18–25 years old. Subjects were recruited from six Palestinian universities (n=1997). Participants were asked to complete a questionnaire focusing on sociodemographics, knowledge and beliefs towards tobacco smoking, and the reasons that motivate or hinder smokers to quit. Results: The prevalence of tobacco smoking was found to be 47.7%. Males had higher smoking rates, consumption levels, and initiated smoking at younger ages (74.4% started at ≤18 years old). Smoking cigarettes and waterpipe were the most common forms among both sexes. Smokers were also found to consume higher amounts of caffeinated drinks and fast food, showed lower scores towards anti-smoking beliefs, and reported significantly higher prevalence of smoking-related symptoms and diseases, primarily shortness of breath (20.5%) and cough (16.6%). The majority of smokers reported attempting and willingness to quit smoking. Health and financial costs were the strongest factors encouraging quitting while mood changes and lack of self-control were the most reported discouraging factors. Moreover, smoking among family members and peers increased the odds of smoking. Conclusions: Increasing rates of smoking among young Palestinians and a growing popularity of waterpipe use should alert stakeholders to the necessity for the implementation of smoking prevention and awareness policies and programmes.Acknowledgements The authors thank the 1st year medical students at Al-Quds University, Palestine. Funding: None

Evaluation of the validity of osteoporosis and fracture risk assessment tools (IOF One Minute Test, SCORE, and FRAX) in postmenopausal Palestinian women

The need for simple self-assessment tools is necessary to predict women at high risk for developing osteoporosis. In this study, tools like the IOF One Minute Test, Fracture Risk Assessment Tool (FRAX), and Simple Calculated Osteoporosis Risk Estimation (SCORE) were found to be valid for Palestinian women. The threshold for predicting women at risk for each tool was estimated. Purpose The purpose of this study is to evaluate the validity of the updated IOF (International Osteoporosis Foundation) One Minute Osteoporosis Risk Assessment Test, FRAX, SCORE as well as age alone to detect the risk of developing osteoporosis in postmenopausal Palestinian women. Methods Three hundred eighty-two women 45 years and older were recruited including 131 women with osteoporosis and 251 controls following bone mineral density (BMD) measurement, 287 completed questionnaires of the different risk assessment tools. Receiver operating characteristic (ROC) curves were evaluated for each tool using bone BMD as the gold standard for osteoporosis. Results The area under the ROC curve (AUC) was the highest for FRAX calculated with BMD for predicting hip fractures (0.897) followed by FRAX for major fractures (0.826) with cut-off values ˃1.5 and ˃7.8%, respectively. The IOF One Minute Test AUC (0.629) was the lowest compared to other tested tools but with sufficient accuracy for predicting the risk of developing osteoporosis with a cut-off value ˃4 total yes questions out of 18. SCORE test and age alone were also as good predictors of risk for developing osteoporosis. According to the ROC curve for age, women ≥64 years had a higher risk of developing osteoporosis. Higher percentage of women with low BMD (T-score ≤−1.5) or osteoporosis (Tscore ≤−2.5) was found among women who were not exposed to the sun, who had menopause before the age of 45 years, or had lower body mass index (BMI) compared to controls. Women who often fall had lower BMI and approximately 27% of the recruited postmenopausal Palestinian women had accidents that caused fractures. Conclusions Simple self-assessment tools like FRAX without BMD, SCORE, and the IOF One Minute Tests were valid for predicting Palestinian postmenopausal women at high risk of developing osteoporosis

Serum 25-hydroxyvitamin D and bone turnover markers in Palestinian postmenopausal osteoporosis and normal women

Summary This study evaluated the association of vitaminD and bone markers with the development osteoporosis in Palestinian postmenopausal women. Even though vitamin D deficiency was very high for the recruited subjects, it was not associated with osteoporosis except for bones of the hip. Age and obesity were the strongest determining factors of the disease. Purpose The purpose of this study was to investigate the association of bone mineral density (BMD) with serum vitamin D levels, parathyroid hormone (PTH), calcium, obesity, and bone turnover markers in Palestinian postmenopausal women. Methods Three hundred eighty-two postmenopausal women (≥45 years) were recruited from various women clinics for BMD assessment (131 women had osteoporosis and 251 were normal and served as controls). Blood samples were obtained for serum calcium, PTH, 25(OH)D, bone formation (N-terminal propeptide (PINP)), and bone resorption (serum Cterminal telopeptide of type I collagen (CTX1)) markers. Results Women with osteoporosis had statistically significant lower mean weight, height, body mass index (BMI), and serum calcium (p < 0.05) compared to controls. No significant differences were detected between the mean values of bone turnover markers (CTX and PINP), 25(OH)D, and PTH of the two groups. Women with vitamin D deficiency (severe and insufficiency) represented 85.9% of the study subjects. Multiple and logistic regression showed that age and BMI significantly affected BMD and vitamin D had a significant association with BMD only at the lumbar spine. BMI was positively correlated with BMD and PTH but negatively correlated with vitamin D. Logistic regression showed that the odds ratio (OR) for having osteoporosis decreased with increasing BMI (overweight OR = 0.11, p = 0.053; obese OR = 0.05, p = 0.007). Conclusions There was no direct correlation between BMD and PTH, bone turnover markers, and vitamin D except at the lumbar spine. A negative correlation between BMD and age and a positive correlation with BMI were observed. The protective effect of obesity on osteoporosis was complicated by the effect of obesity on vitamin D and PTH.This work was supported in part by a special grant from the Palestinianministry of education and higher education (MEHE)

Evaluation of Glycated Hemoglobin (HbA1c) for Diagnosing Type 2 Diabetes and Prediabetes among Palestinian Arab Population

The purpose of the study is to compare the potential of HbA1c to diagnose diabetes among Palestinian Arabs compared to fasting plasma glucose (FPG). A cross-sectional sample of 1370 Palestinian men (468) and women (902) without known diabetes and above the age of 30 years were recruited. Whole blood was used to estimate HbA1c and plasma for FPG and total lipid profile. Fasting plasma glucose was used as a reference to diagnose diabetes ($126 mg/dL) and prediabetes (100–125 mg/dL). The area under the receiver operating characteristic curve (AUC) for HbA1c was 81.9diabetes and 63.90.498) and low with prediabetes (K = 0.142). The optimal cut-off value for HbA1c to diagnose diabetes was$ 6.3% (45 mmol/mol). The sensitivity, specificity and the discriminant ability were 65.6% (53.1–76.3%), 94.5% (93.1–95.6%), 80.0% (72.8–87.3%), respectively. However, using cut-off value of $6.5the sensitivity, specificity and the discriminant ability were 57.4For diagnosing prediabetes with HbA1c between 5.7–6.4discriminant ability were 62.7value of$ 6.5% (48 mmol/mol) by itself diagnosed 5.3% and 48.3% as having diabetes and prediabetes compared to 4.5% and 24.2% using FPG, respectively. Mean HbA1c and FPG increase significantly with increasing body mass index. In conclusion, the ROC curves showed HbA1c could be used for diagnosing diabetes when compared to FPG but not for prediabetes in Palestinians Arabs even though only about 50% of the diabetic subjects were identified by the both HbA1c and FPG.This project was partially supported by United Nation Relief and Working Agency (UNRWA. No additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Evaluation of Glycated Hemoglobin (HbA1c) for Diagnosing Type 2 Diabetes and Prediabetes among Palestinian Arab Population

The purpose of the study is to compare the potential of HbA1c to diagnose diabetes among Palestinian Arabs compared to fasting plasma glucose (FPG). A cross-sectional sample of 1370 Palestinian men (468) and women (902) without known diabetes and above the age of 30 years were recruited. Whole blood was used to estimate HbA1c and plasma for FPG and total lipid profile. Fasting plasma glucose was used as a reference to diagnose diabetes ($126 mg/dL) and prediabetes (100–125 mg/dL). The area under the receiver operating characteristic curve (AUC) for HbA1c was 81.9diabetes and 63.90.498) and low with prediabetes (K = 0.142). The optimal cut-off value for HbA1c to diagnose diabetes was$ 6.3% (45 mmol/mol). The sensitivity, specificity and the discriminant ability were 65.6% (53.1–76.3%), 94.5% (93.1–95.6%), 80.0% (72.8–87.3%), respectively. However, using cut-off value of $6.5the sensitivity, specificity and the discriminant ability were 57.4For diagnosing prediabetes with HbA1c between 5.7–6.4discriminant ability were 62.7value of$ 6.5% (48 mmol/mol) by itself diagnosed 5.3% and 48.3% as having diabetes and prediabetes compared to 4.5% and 24.2% using FPG, respectively. Mean HbA1c and FPG increase significantly with increasing body mass index. In conclusion, the ROC curves showed HbA1c could be used for diagnosing diabetes when compared to FPG but not for prediabetes in Palestinians Arabs even though only about 50% of the diabetic subjects were identified by the both HbA1c and FPG.This project was partially supported by United Nation Relief and Working Agency (UNRWA. No additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors thank Fida Zeidan from UNRWA for organizing the teams at different UNRWA clinics. Also, the authors thank the staff of UNRWA clinics for their cooperation in the study. Thanks to Dr. Khaldoun Bader from Al-Quds University for his assistance in statistical analysis.Guarantor: Akram T. Kharroubi

Holistic Assessment of Community Palliative Care Needs Among Palestinian Cancer Patients

Background: Palliative care focuses on improving the quality of life of terminally ill patients and their families. Objectives: This cross-sectional study aims to assess the level of community palliative care among terminally ill Palestinian cancer patients and the needs of their families in the West-Bank and Gaza strip. Methodology: A cross-sectional survey was conducted among cancer patients. Patients were recruited through five hospitals that provide cancer care in the West Bank and Gaza Strip (Al-Hussein Hospital, Beit Jala; Augusta Victoria Hospital, Jerusalem; Istishari Arab Hospital, Ramallah; European Hospital and Abd Al-Aziz Al-Rantisi Hospital; Gaza). Data were collected using an interview-based questionnaire. The questionnaire focused on assessment of physical, psychosocial, emotional, and spiritual components of palliative care. In addition, the questionnaire assessed caregiver’s needs. Results: A total of 238 patients were interviewed. The mean age of the participants was 53.8±15 years. The most common types of cancer among patients were breast cancer (51 [21.4%]) and colorectal cancer (33 [13.9%]). Fifty percent of the patients had their children as their primary caregivers. Overall, the majority of the patients had good psychosocial, spiritual, and emotional scores. On the other hand, >80% had moderate to poor physical functioning scores. Psychosocial and emotional scores decreased significantly as the disease progressed. More than 33% of the patients reported that their caregivers were in need of financial, legal, and work-related support. In addition, other commonly reported unmet needs included support in understanding what to expect in the future and dealing with the feelings and worries of the patient. Conclusions: Cancer patients suffer mostly from their physical symptoms in addition to financial problems. On the other hand, assessment of the emotional, spiritual and psychological functioning of Palestinian patients indicates that the strength of religious beliefs and the support of the family and the friends in the Palestinian community had a great impact on the patients and help reduced the gap in palliative care services

Venn Diagrams for Diabetes, ADA standards.

<p>Diabetes diagnosed by HbA_1c ≥ 6.5% (48 mmol/mol, n = 73) or FPG ≥ 126 mg/dL (n = 61). Prediabetes diagnosed by HbA_1c 5.7–6.4% (39–46 mmol/mol, n = 628) or FPG 100–125 mg/dL (n = 337). Normal diagnosed by HbA_1c < 5.7% (39 mmol/mol, n = 669) or FPG <100 mg/dL (n = 972).</p