Effects of diabetes definition on global surveillance of diabetes prevalence and diagnosis: a pooled analysis of 96 population-based studies with 331 288 participants.

Background Diabetes has been defi ned on the basis of diff erent biomarkers, including fasting plasma glucose (FPG), 2-h plasma glucose in an oral glucose tolerance test (2hOGTT), and HbA1c. We assessed the eff ect of diff erent diagnostic defi nitions on both the population prevalence of diabetes and the classifi cation of previously undiagnosed individuals as having diabetes versus not having diabetes in a pooled analysis of data from population-based health examination surveys in diff erent regions. Methods We used data from 96 population-based health examination surveys that had measured at least two of the biomarkers used for defi ning diabetes. Diabetes was defi ned using HbA1c (HbA1c ≥6·5% or history of diabetes diagnosis or using insulin or oral hypoglycaemic drugs) compared with either FPG only or FPG-or-2hOGTT defi nitions (FPG ≥7·0 mmol/L or 2hOGTT ≥11·1 mmol/L or history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated diabetes prevalence, taking into account complex survey design and survey sample weights. We compared the prevalences of diabetes using diff erent defi nitions graphically and by regression analyses. We calculated sensitivity and specifi city of diabetes diagnosis based on HbA1c compared with diagnosis based on glucose among previously undiagnosed individuals (ie, excluding those with history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated sensitivity and specifi city in each survey, and then pooled results using a random-eff ects model. We assessed the sources of heterogeneity of sensitivity by meta-regressions for study characteristics selected a priori. Findings Population prevalence of diabetes based on FPG-or-2hOGTT was correlated with prevalence based on FPG alone (r=0·98), but was higher by 2–6 percentage points at diff erent prevalence levels. Prevalence based on HbA1c was lower than prevalence based on FPG in 42·8% of age–sex–survey groups and higher in another 41·6%; in the other 15·6%, the two defi nitions provided similar prevalence estimates. The variation across studies in the relation between glucose-based and HbA1c-based prevalences was partly related to participants’ age, followed by natural logarithm of per person gross domestic product, the year of survey, mean BMI, and whether the survey population was national, subnational, or from specifi c communities. Diabetes defi ned as HbA1c 6·5% or more had a pooled sensitivity of 52·8% (95% CI 51·3–54·3%) and a pooled specifi city of 99·74% (99·71–99·78%) compared with FPG 7·0 mmol/L or more for diagnosing previously undiagnosed participants; sensitivity compared with diabetes defi ned based on FPGor- 2hOGTT was 30·5% (28·7–32·3%). None of the preselected study-level characteristics explained the heterogeneity in the sensitivity of HbA1c versus FPG.Wellcome Trust, US National Institutes of Health

Molecular Detection and Identification of Spotted Fever Group Rickettsiae in Ticks Collected from the West Bank, Palestinian Territories

Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group (SFG) rickettsiae. Although Spotted Fever is prevalent in the Middle East, no reports for the presence of tick-borne pathogens are available or any studies on the epidemiology of this disease in the West Bank. We aimed to identify the circulating hard tick vectors and genetically characterize SFG Rickettsia species in ixodid ticks from the West Bank-Palestinian territories.This study was funded by the Netherlands Ministry of Foreign Affairs, The Hague, The Netherlands and NVHU under grant reference number 2014.52146 and USAID grant MERC TAMOU- 12-M32-038. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript

Molecular Detection of Theileria ovis and Theleiria equi in Livestock from Palestine

Theileria and Babesia are intracellular protozoan parasites infecting a wide range of animals. In Palestine, there is limited information on the prevalence of Theileria and Babesia spp. in livestock. We used PCR of the 18S ribosomal RNA gene followed by DNA sequencing to detect and identify parasite DNA in blood samples from sheep (n = 49), goats (n = 48), horses (n = 40), camels (n = 34), donkeys (n = 28) and mules (n = 2) from four districts of Palestine. DNA of T. ovis and T. equi was detected in 19 and 2 ovine blood samples, respectively. None of the camels, donkeys, and goats were positive for T. ovis. Sheep had a significantly higher rate of infection than other animals (P < 0.05). Theileria ovis is highly prevalent in sheep, while T. equi DNA was detected in a small proportion of the equids in Palestine.We would like to thank all the people who helped in blood collection from the studied animals. This study was supported financially by grant 2014·52146 funded by the Netherlands Ministry of Foreign Affairs, The Hague, Netherlands and USAID grant MERC TAMOU-12-M32-038

Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem

Aim:&nbsp;This study aims to assess the Palestinian girls’ dietary habits and physical activity patterns as a baseline for intervention. Methods:&nbsp;A cross-sectional study of grade 4 and 5 pupils (mean age: 11 years) in 14 all-girl schools in East Jerusalem, of four different types of school ownership (overall N=897), was conducted, using self-administered questionnaires and&nbsp; height and weight measurements. Logistic regressions were conducted to determine predictors of healthy behaviours. Results:&nbsp;Only 36.6% of the pupils reported eating breakfast daily, with UNRWA schools having the highest rate of daily breakfast consumption (42.6%). About 28% reported eating the recommended daily quantity of five portions of fruits and vegetables. Only 15% of the pupils reported being active at least five days a week and more than one third of the schoolchildren viewed TV for ≥4 hours a day. The&nbsp; prevalence of overweight and obesity was 22.2% and 7.6%, respectively, with private schools having the highest rates, 29.6% and 12.8% respectively (P=0.001). Additional predictors of overweight and obesity were: being the first child in the family, watching TV for more than four hours a day, always eating while watching TV and being physically active less than five days a week.&nbsp; Conclusions:&nbsp;Most Palestinian pupils miss breakfast, eat less fruits and vegetables than recommended and have sedentary behaviours. These findings raise serious concerns and point to the urgent need for tailored interventions. Source of funding:&nbsp;This study is a part of Ph.D. degree. Maha Nubani-Husseini received a scholarship from Joint Distribution Committee (JDC). She thanks Nutrition and Health Research Institute Al-Quds University for funding part of the research. The Linda Joy Pollin Cardiovascular Wellness Center for Women at the Division of Cardiology of Hadassah University Medical Center, directed by Dr. Donna Zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the programme at the control schools one year after the study ended, as they were promised when they got selected. Acknowledgments:&nbsp;The authors thank the participating schools, the Palestinian Ministry of Education, the UNRWA Office of Education and Jerusalem Municipality for facilitating fieldwork. Their gratitude also goes to Mr. Radwan Qasrawi (Al-Quds University), Dr. Marrio Baras and Dr. Deena Jaffeh (Hebrew University) for statistical support, and&nbsp; to Mrs. Suzy Daher for editing

Molecular Characterization of Methicillin Resistant Staphylococcus aureus in West Bank-Palestine

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a public health threat and a major cause of hospital-acquired and community-acquired infections. This study aimed to investigate the genetic diversity of MRSA isolates from 2015 to 2017 and to characterize the major MRSA clones and anti-biogram trends in Palestine. Methodology: Isolates were obtained from 112 patients admitted to different hospitals of West Bank and East Jerusalem, originating from different clinical sources. Antibiotic susceptibility patterns, staphylococcal chromosomal cassette mec (SCCmec) typing, and Staphylococcus aureus protein A (spa) typing were determined. Also, a panel of toxin genes and virulence factors was studied, including: Panton-Valentine Leukocidin (PVL), ACME-arcA, Toxic Shock Syndrome Toxin-1 (TSST-1), and Exfoliative Toxin A (ETA). Results: Of the 112 confirmed MRSA isolates, 100% were resistant to all β-lactam antibiotics. Resistance rates to other non- β-lactam classes were as the following: 18.8% were resistant to trimethoprim-sulfamethoxazole, 23.2% were resistant to gentamicin, 34.8% to clindamycin, 39.3% to ciprofloxacin, and 63.4% to erythromycin. All MRSA isolates were susceptible to vancomycin (100%). Of all isolates, 32 isolates (28.6%) were multidrug- resistant (MDR). The majority of the isolates were identified as SCCmec type IV (86.6%). The molecular typing identified 29 spa types representing 12 MLST-clonal complexes (CC). The most prevalent spa types were: spa type t386 (CC1)/(12.5%), spa type t044 (CC80)/(10.7%), spa type t008 (CC8)/(10.7%), and spa type t223 (CC22)/(9.8%). PVL toxin gene was detected in (29.5%) of all isolates, while ACME-arcA gene was present in 18.8% of all isolates and 23.2% had the TSST-1 gene. The two most common spa types among the TSST-1positive isolates were the spa type t223 (CC22)/(Gaza clone) and the spa type t021 (CC30)/(South West Pacific clone). All isolates with the spa type t991 were ETA positive (5.4%). USA-300 clone (spa type t008, positive for PVL toxin gene and ACME-arcA genes) was found in nine isolates (8.0%). Conclusions: Our results provide insights into the epidemiology of MRSA strains in Palestine. We report a high diversity of MRSA strains among hospitals in Palestine, with frequent SCCmec type IV carriage. The four prominent clones detected were: t386-IV/ CC1, the European clone (t044/CC80), Gaza clone (t223/CC22), and the USA-300 clone (t008/CC8).We greatly acknowledge all hospitals that provided us with the isolates and responded to our contact. Special thanks to Al- Makassed Islamic Charitable Hospital/microbiology laboratory in East Jerusalem; including; Mr. Sabri Baragthithi and Mrs. Suzan Idkaidek. Also, many thanks to Mr. Mamoun Obeideia from the Palestine Medical complex and Mrs. Namir Sabri from the Red Crescent Society in Jerusalem. Many special thanks to Dr. G. Regev-Yochay and Asaf Biber from Sheba Medical Center, assistance. This data were presented as partial requirements for a master degree of Microbiology and Immunology/Al-Quds University under supervision of KA

MDR tuberculosis and non-compliance with therapy

The emergence of multidrug-resistant (MDR) tuberculosis is a worldwide public health problem. We reported a case of pulmonary MDR tuberculosis in a 41-year-old man with diabetes from the West Bank, Palestine. 1 The bacteria belonged to the Beijing family, which is highly virulent and easily disseminated. 2 The patient withdrew from treatment after 2 years while still sputum-positive. Despite persistent efforts of the tuberculosis directly observed treatment programme, he disappeared and cannot be located. The patient might have fled to a neighbouring country, and there is a risk that he will pass on MDR tuberculosis to people with whom he has contact

The teratogenicity and behavioral teratogenicity of di(2-ethylhexyl) phthalate (DEHP) and di-butyl Phthalate (DBP) in a chick model

Phthalates are industrial chemicals widely used in consumer products, plastics and children toys, and the risk of exposure to phthalates, especially prenatal exposure, is a growing concern justifying the development of an animal model to better understand their effect. The present study was designed to evaluate the suitability of a chick model for phthalate DEHP teratogenicity and neurobehavioral teratogenicity, a model which is simple and devoid of potential confounding factors such as maternal toxicity, maternal-fetal unit and maternalneonatal interactions; major findings were confirmed in the DBP study. Prehatch exposure to DEHP in doses ranging from 20 to 100 mg/kg, reduced the percent hatching from 80% in control eggs to 65%, and increased late hatchings from 12.5% in control eggs to 29.4%. In addition it induced developmental defects characterized by an opening or weakening of abdominal muscles allowing internal organs to protrude externally with or without a sac, omphalocele or gastroschisis, respectively. The effect was dose dependent ranging from 8% with DEHP (20 mg/kg) to 22% (100 mg/kg). Similar treatment with DBP 100 mg/kg has reduced percentage hatching to 57% and increased late hatching to 37.5%, with a 14% increase in gastroschisis. Biochemical evaluation revealed elevated levels of alkaline phosphatase, which reflects non-specific toxicity of DEHP at such a high dose. Behavioral evaluation using an imprinting test and locomotor activity on chicks pretreated with DEHP (100 mg/kg) has shown an abolishment of imprinting performance from the control (0.65) preference ratio. DNA damage measurements of the metabolite 8-hydroxydeoxyguanosine (8-OH-dG) in blood samples showed an increase of 39.7% after prehatch exposure to phthalates. This was statistically significant for DEHP and indicates genetic toxicity, since part of the teratogenic activity is associated with oxidative stress and DNA damage.This study was supported by a grant from the Al-Quds Nutrition & Health Research Institute. The authors would like to thank Mr. Rateb Hussein and Mr. Munther Metani for their technical assistance, and Dr. Tamer Essawi and Mr. Firas Hassan for their help in performing the biochemical measurements

Molecular Characterization of Methicillin Resistant Staphylococcus aureus in West Bank-Palestine

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a public health threat and a major cause of hospital-acquired and community-acquired infections. This study aimed to investigate the genetic diversity of MRSA isolates from 2015 to 2017 and to characterize the major MRSA clones and anti-biogram trends in Palestine.Methodology: Isolates were obtained from 112 patients admitted to different hospitals of West Bank and East Jerusalem, originating from different clinical sources. Antibiotic susceptibility patterns, staphylococcal chromosomal cassette mec (SCCmec) typing, and Staphylococcus aureus protein A (spa) typing were determined. Also, a panel of toxin genes and virulence factors was studied, including: Panton-Valentine Leukocidin (PVL), ACME-arcA, Toxic Shock Syndrome Toxin-1 (TSST-1), and Exfoliative Toxin A (ETA).Results: Of the 112 confirmed MRSA isolates, 100% were resistant to all β-lactam antibiotics. Resistance rates to other non- β-lactam classes were as the following: 18.8% were resistant to trimethoprim-sulfamethoxazole, 23.2% were resistant to gentamicin, 34.8% to clindamycin, 39.3% to ciprofloxacin, and 63.4% to erythromycin. All MRSA isolates were susceptible to vancomycin (100%). Of all isolates, 32 isolates (28.6%) were multidrug- resistant (MDR). The majority of the isolates were identified as SCCmec type IV (86.6%). The molecular typing identified 29 spa types representing 12 MLST-clonal complexes (CC). The most prevalent spa types were: spa type t386 (CC1)/(12.5%), spa type t044 (CC80)/(10.7%), spa type t008 (CC8)/(10.7%), and spa type t223 (CC22)/(9.8%). PVL toxin gene was detected in (29.5%) of all isolates, while ACME-arcA gene was present in 18.8% of all isolates and 23.2% had the TSST-1 gene. The two most common spa types among the TSST-1positive isolates were the spa type t223 (CC22)/(Gaza clone) and the spa type t021 (CC30)/(South West Pacific clone). All isolates with the spa type t991 were ETA positive (5.4%). USA-300 clone (spa type t008, positive for PVL toxin gene and ACME-arcA genes) was found in nine isolates (8.0%).Conclusions: Our results provide insights into the epidemiology of MRSA strains in Palestine. We report a high diversity of MRSA strains among hospitals in Palestine, with frequent SCCmec type IV carriage. The four prominent clones detected were: t386-IV/ CC1, the European clone (t044/CC80), Gaza clone (t223/CC22), and the USA-300 clone (t008/CC8)

Overweight and Obesity among Palestinian Adults: Analyses of the Anthropometric Data from the First National Health and Nutrition Survey (1999-2000)

Background. A cross-sectional survey was designed to provide a baseline data on the prevalence and distribution of overweight and obesity and their associations among adults in Palestine. Methods. A random representative sample of 3617 adults aged 18–64 years was collected between October 1999 and October 2000. Results. The prevalence of overweight was 35.5% in women and 40.3% in men, obesity was 31.5% in women and 17.5% in men. Adults aged 45–54 years old were significantly more likely to be obese (29.2% in men and 50.2% in women) or overweight (48.1% in men and 37.2% in women). When compared with women, men showed significantly more normal BMI level (40.5% versus 31.6%; P < 0.05). Cut-off points for a high waist circumference and high waist-to-hip ratio identified 57.8% and 47.2% of the population, respectively, to be at an increased and high risk for cardiovascular disease. Sociodemographic factors (age, sex, educational level, and marital status) were also found to be significantly related to BMI. Conclusion. Obesity and overweight are enormous public health problems in Palestine. Population-based research at the national level to investigate the social and cultural factors associated with high prevalence of overweight and obesity among Palestinian adults should be implemented

Molecular Detection of Theileria, Babesia, and Hepatozoon spp. in ixodid ticks from Palestine

Ixodid ticks transmit various infectious agents that cause disease in humans and livestock worldwide. A cross-sectional survey on the presence of protozoan pathogens in ticks was carried out to assess the impact of tick-borne protozoa on domestic animals in Palestine. Ticks were collected from herds with sheep, goats and dogs in different geographic districts and their species were determined using morphological keys. The presence of piroplasms and Hepatozoon spp. was determined by PCR amplification of a 460–540 bp fragment of the 18S rRNA gene followed by RFLP or DNA sequencing. A PCR-RFLP method based on the 18S rRNA was used in order to detect and to identify Hepatozoon, Babesia and Theileria spp. A total of 516 ticks were collected from animals in six Palestinian localities. Five tick species were found: Rhipicephalus sanguineus sensu lato, Rhipicephalus turanicus, Rhipicephalus bursa, Haemaphysalis parva and Haemaphysalis adleri. PCR-based analyses of the ticks revealed Theileria ovis (5.4%), Hepatozoon canis (4.3%), Babesia ovis (0.6%), and Babesia vogeli (0.4%). Theileria ovis was significantly associated with ticks from sheep and with R. turanicus ticks (p < 0.01). H. canis was detected only in R. sanguineus s.l. and was significantly associated with ticks from dogs (p < 0.01). To our knowledge, this is the first report describing the presence of these pathogens in ticks collected from Palestine. Communicating these findings with health and veterinary professionals will increase their awareness, and contribute to improved diagnosis and treatment of tick-borne diseases.This study was supported financially by grant 2014.52146 funded by the Netherlands Ministry of Foreign Affairs, The Hague, Netherlands and USAID grant MERC TA-MOU-12-M32-038. We thank Mr. Samir Sawalha, Taher Zaid and Ahmad Abdelkader for their kind help during sample collection