Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1

The continuing enhancement of energy recovery cycles that exploit low grade energy resources requires an efficient heat absorption and rejection system. Implementation of a conventional surface type heat exchanger, evaporator or condenser has many disadvantages. The low efficiency, fouling, corrosion problems, high cost and high heat transfer resistance are the most important shortcomings that emerge as a result of the metallic barriers involved. On the other hand, a direct contact heat transfer device offers a high heat transfer area and reduces or eliminates fouling and corrosion problems. They can also work with very low temperature differences and subsequently can enhance the cycle efficiency. Direct contact heat exchangers clearly have many advantages over surface type heat exchangers and can also be efficiently used in places where the surface heat exchanger cannot be.

Accordingly, direct contact heat exchanger can be found in different applications, such as water desalination and power generation from geothermal brine. Water desalination utilising direct contact heat exchangers can be achieved by two general methods: direct contact freezing-melting and direct contact evaporation- condensation. The former is based on the ability to remove water from a solution by freezing it out as crystalline ice. The ice or crystal should contain only pure water; therefore the partial freezing separates the fresh water from brine. The ice melts at another stage to produce distilled water. Direct contact freezing exploits the concept of direct contact evaporation of a low boiling point working fluid by absorbing heat from surrounding continuous fluid (water). The heat absorbed by the working fluid; which causes the water to freeze, is equivalent to the energy required to melt the ice. The working fluid used must have a low boiling point and a high freezing point along with other properties mentioned above. Refrigerants such as carbon dioxide and butane are widely used as a working fluid. For second application, the most common application of direct contact heat exchangers is in the generation of electricity from hot geothermal brine, utilising low boiling point fluids and the conventional Rankine cycle. The first plant utilising a spray column, which produces 500 k. We was designed by Barber-Nichols Engineering and installed at the East Mesa Geothermal Field in the U.S. in 1980. The spray column was 12 m in length and 1 m diameter. Hot brine is flashed to remove the non-condensable gases before entering the spray column from the top, while the isopentane liquid is injected in to the bottom of the column through a suitable distributer. Direct contact counter-current heat transfer between the two fluids takes place throughout the column height. According to the density difference, isopentane drops/bubbles rise upward with brine falling down and exiting the column at the bottom after being cooled down. On the other hand, isopentane heats up as a result of absorbing heat from the brine, and leaves the column as a superheated vapour from the top of the column. Isopentane vapour expands through a turbine to produce electricity, is liquefied in a condenser, and sent back to the direct contact heat exchanger again.

For a bubble type three-phase direct contact condenser, it is widely reported that its performance is characterised by a volumetric heat transfer coefficient, which is directly proportional to the holdup ratio in the column. It is both economical and practical for the bubble type direct contact condenser to operate at the maximum possible holdup ratio. This, of course, increases the possibility of flooding, which considerably impairs the performance of the column. Flooding can be either defined as the case when the continuous phase is completely held up by the dispersed phase or the dispersed phase is swept backward by the continuous phase.

Two mechanisms could lead to the inception of flooding in the three direct contact columns, depending on the critical velocity of each individual phase. The critical velocity can be defined as a maximum velocity that can be achieved by a given direct contact system and it is a function of the bubble size, the flow rate and the physical properties of the phases. The first mechanism depends on the reduction in the dispersed phase (bubbles) upward velocity due to the interactions within a swarm of two-phase bubbles. The two-phase bubbles move closer together when the dispersed phase flow rate increases, which results in a further dispersed phase slowing. Bubbles are swept down and drain out with the continuous phase from the bottom of the column. Therefore, the danger from this form of flooding form is the increased loss of the working fluid. The second scenario assumes that the continuous phase is swept upwards because of a high dispersed phase flow rate. This occurs when the dispersed phase velocity passes the critical velocity. The result of this flooding type lies in a change of geometry and makes the heat transfer relationships available invalid. Accordingly, flooding can be defined as the case when the continuous phase is completely held up by the dispersed phase or the dispersed phase is swept backward by the continuous phase.

As the first time, experiments to study the limitation of flooding inception of three-phase direct contact condenser have been carried out in a counter-current small diameter vertical condenser. The total column height was 70 cm and 4 cm diameter. Only 48 cm has been used as an active three-phase direct contact condenser height. Vapour pentane with three different initial temperatures (40°, 43.5° and 47.5°) and water with a constant temperature (19°) have been used as a dispersed phase and a continuous phase respectively. Five different continuous phase mass flow rate and four different dispersed phase mass flow rate have been tested throughout the experiments.

The experimental results showed that the effect of dispersed phase initial temperature on flooding inception to be insignificant at low continuous phase velocity (v_L^(*1/2).

Green House Gases (GHG) that are currently being emitted from conventional energy production methods are of global concern; especially with the climate change that is occurring. The United Nations has taken the initiative by holding a global conference that aims combating climate change “United Nations Framework Convention on Climate Change (UNFCCC)”, which sets a common ground of regulations and agreements that aim at reducing polluting production methods. Qatar, as part of the UNFCCC, has signed and agreed to the Kyoto protocol. The first component of the protocol determines that countries should enhance energy efficiency in different sectors of their national economy.

In addition, “Qatar National Vision 2030”, states: “The rights of future generations would be threatened if the depletion of non-renewable resources were not compensated by the creation of new sources of renewable wealth”. With the increase in numbers of large-scale educational, industrial, commercial and residential buildings, Qatar needs to look into means of making them more energy efficient. Adopting solar energy is a priority for Qatar because of high abundance.

Photovoltaic (PV) systems transform sunlight into useful electricity with efficiencies that range from 12 to 20% without concentrators. PVs are designed with two layers, the n-layer (negative) and the p-layer (positive), which get charged when exposed to sunlight causing potential difference across the cell. PVs are static devices, eco-friendly, noise-less and require minimal maintenance. According to a study that compares unit generation costs of gas turbines and PVs, PVs are becoming a more viable alternative despite of the fact that they are still more expensive due to their initial installation costs. Another major disadvantage is the lower conversion efficiency. Power conditioning is also required in a solar PV system to convert DC power to AC power, regulate the load flow, offer different types of protection and keep the total harmonic distortion (THD) within the specified limit. Different types of inverters (DC to AC converter) have been employed for solar PV systems.

Dynamic behavior of solar energy resource entails the need of robust controllers that can converge to the maximum power point (MPP) to maximize energy harvest. The low conversion efficiency of PV systems is a significant hindrance to their growth, therefore Maximum Power Point Tracking (MPPT) is required to ensure the maximum available solar energy is harnessed from the solar panel. It is common in the industry that power conditioning is done at the array level. Less common but proven more efficient is to do conditioning at the module level. This guarantees maximum power is harnessed from one module regardless of the irradiance condition of the other neighboring modules. It would even be more efficient to do power conditioning at the cell level. In which case, each array of cells within a single module, has its own MPPT controller.

This project explores an improved Perturb and Observe (P&O) technique that combines a fixed step model predictive controller (MPC), to speed up the control loop, applied to a boost converter. The proposed MPC Maximum Power Point Tracking (MPPT) technique had proven higher efficacy and robustness over conventional MPPT. The main characteristic of MPC is predicting the future behavior of the desired control variables until a predefined step ahead in horizon of time. The predicted variables will be used to obtain the optimal switching state by minimizing a cost function.

A boost converter is used as a DC/DC converter prior to the sub multi-level inverter. P&O determines the reference current for the MPC, which determines the next switching state. This technique predicts the error of the next sampling time and based on optimization of the cost function g, the switching state will be determined. The inputs to the predictive controller are the PV system current and voltage, and the reference current. By deriving the discrete time set of equations, the behavior of control variables can be predicted at next sampling time k+1. The proposed methodology is based on the fact that the slope of the PV array power curve is zero at the predicted MPP, positive on the left and negative on the right of the predicted MPP.

The improved MPC-MPPT is tested for the first time on an MPC strategy of 33-level SubMultilevel Inverter (SMI) using 16 power arms cascaded with the H-bridge inverter. SMIs use less switches than conventional MIs and this is noticeable at larger number of levels. Such topology uses a switching frequency for the H-bridge that is equal to the grid frequency, which allows for lower switching losses when compared to conventional MIs. Such topology brings about many sizable benefits such as reduced number of power switches and their grate drivers when compared to the traditional multilevel inverter. MPC is also used as the control strategy for the SMI to eliminate complexities in the space vector pulse width modulation (SVPWM) and overcome the weaknesses of the inner control loop performance. This topology allows for each module to be divided into 16 parts each comprised of an array of cells. Each array of cells is connected to the MPC-MPPT boost converter. Then the 16 levels are fed to the input stage of the SMI. Finally, each module will have its own H-Bridge inverter that directly feeds the grid. Such topology provides the advantage of localized MPPT tracking, increased reliability of the whole power system as the failure of one cell won't fail the whole system, and lower components withstand ratings.

To verify the dynamic and steady-state performances of the proposed MPC scheme under various load and reference currents, simulation studies are performed with Matlab & Simulink software.

Broadly speaking, one of the most important aspects of Sustainable Development Goals (SDGs) of United Nations is to increase awareness of people for sustainability related issues namely economic, environmental and social problems. In this direction, it can be concluded that there is a lack of awareness for individuals regarding their habits and their related impacts on sustainability. Especially in developed countries, it is well-known that people are linked to over consumption, overweight, over waste, over pollution and so on. However, most of them are not aware of the results which are caused from their daily activities in terms of pollution, waste, energy footprints and their related effects on global sustainability. Mobility is one such area resulting in that kind of problems especially in urban areas. Our current road-based transportation system which is mainly dependent on automobile use causes a wide range of formidable problems. These include traffic congestion, air pollution, noise, accidents and related fatalities, depletion of non-renewable resources and inaccessibility of amenities and services. To illustrate this, more than one-quarter of total U.S. greenhouse gas emissions come from the transportation sector and light vehicles are responsible for 59% of transportation energy use (see Fig. 1). Due to the accidents on roads, approximately one million people dies except the millions of injuries (WHO, 2010). In addition to that, there are many cities suffering from traffic congestion which slows down daily businesses, causes unreliability in terms of time, results in unpleasant life in urban life and costs billions of dollars to the economies (Everyday Money, 2014; TomTom, 2013). These are just few figures to illustrate detrimental effects of transportation especially due to automobile use in urban areas. Transport demand, however, increases as economic growth increases (EU Energy, 2012) which will make the situation even worse in the upcoming years. Therefore, there are various dimensions of transport system which can be group into three categories: economic, environmental, and social (see Table 1). Given these problems, and their associated economic, environmental, and social impacts, the current transportation system especially in urban areas may be considered as unsustainable from various respects. To counter this challenge of moving towards sustainable transportation, much more effort is needed.

According to World Business Council on Sustainable Development (2004), sustainable mobility is defined as ‘the ability to meet the needs of society to move freely, gain access, communicate, trade, and establish relationships without sacrificing other essential human or ecological values today or in the future’. To this end, there are certain areas to focus on to mitigate transport related problems and make a transition towards sustainable transport (C2ES, 2012). Firstly, on the fuels side, transitioning to low-carbon energy sources such as biofuels or electricity from renewable resources to directly reduce emissions from fuel consumption is required. Secondly, more efficient transportation equipment is needed to run on these low-carbon fuel sources. Thirdly, increasing the efficiency of existing transportation system is needed such as applying advanced traffic monitoring and signaling. Lastly, switching from unsustainable modes (mostly personal car usage) to alternative (or sustainable) travel modes such as public transportation, walking and cycling is needed to reduce the demand for the use of more energy intensive by changing land use patterns, increasing and promoting sustainable travel options while dis-incentivizing the use of unsustainable modes. After all, it can be said that a “new mobility” is needed which is a vision of the cities in which resident no longer excessively rely on their cars but on public transportation, shared cars, bikes or walking. Therefore, there will be less pollution, less noise, less stress at the end; cities will be more livable environments.

In this direction, we are working on a mobile application project which will be capable of tracking individuals’ daily mobility activities; walking, bicycling, and driving. According to these mobility activities, the application will present the sustainability level of each individual in a sustainability scale and its related impacts on his\her health and the environment. By doing that, we aim to increase awareness of individuals for their current actions and encourage them to change their related behaviors into more sustainable ways by using different incentive and awareness tools. The application will prepare individualized packages to show people their mobility footprint with its effects on their life and on the environment and suggest other sustainable mobility ways.

Our main target group will be mostly educated people from younger and middle age groups, rich-enough to having a smart-phone, and most importantly having unsustainable mobility activities. After successfully completion of the application, as a pilot area, Education City would be a perfect place to conduct pilot experiments where members of the community are suitable to our potential customer portfolio then it can spread all over the world through Qatar and Gulf Cooperation Council (GCC) countries. By doing that, we need to tailor incentive and awareness tools towards culture and expectations of the community. In this sense, we are going to present our findings from initial phases we have conducted so far in this developing process which includes; (1) literature review, (2) market assessments via various interviews with different stakeholders and survey questionnaire with people from potential target groups to figure out their perceptions and needs regarding this behavioral change for mobility, (3) analysis of requirements based on the results from previous phase and (4) concept design which includes flow diagrams, database schema and sketching user interfaces etc. In addition to these, we will utilize Quality Function Deployment (QFD) in our concept design to transform business requirements and specs of GMAP into it. Comparison of the competitive mobile applications will be able to seen in QFD as well. GMAP intends to raise public awareness on the impacts of their behaviors, to make them healthier, to reduce carbon emissions a little by walking much more and to build a green social network who shares the same thoughts on sustainability. In short, we believe our application (when being turned into reality) will contribute orienting people into the new sustainable lifestyles or it will pave the way at least.

References

C2ES. (2012). Transportation Overview | Center for Climate and Energy Solutions. Retrieved November 9, 2015, from http://www.c2es.org/energy/use/transportation

EU Energy. (2012). Transport in Figures, Statistical Pocketbook 2012, European Commission.

Everyday Money. (2014). No Title. Retrieved November 10, 2015, from http://time.com/money/3511481/traffic-jams-cost-americans-124-billion-time-money/

Rahman, A., & Grol, R. van. (2005). SUMMA final publishable report v. 2.0; July 2005. Available Online on Http://www. Summa-Eu.Org/control/

TomTom. (2013). TomTom Congestion Index -. Retrieved from http://www.tomtom.com/en_gb/congestionindex/

WHO. (2010). Number of road traffic deaths. Retrieved November 9, 2015, from http://www.who.int/gho/road_safety/mortality/traffic_deaths_number/en/

World Business Council on Sustainable Development. (2004). Mobility 2030: Meeting the Challenges to Sustainability.

Selenium (Se) is an essential trace element for animals and humans because it functions as an antioxidant and catalyst for the production of active thyroid hormone. However, higher intake of Se can cause disease and death to humans. This study investigates the removal of inorganic Se (selenite, Se (IV)) from contaminated water which is known as less bioavailable and more toxic than organic forms. Several technologies exist for Se removal such as lime neutralization, bacterial reduction, ion exchange membranes, electrocoagulation, sorption, and hybrid processes such as coagulation/filtration. However, these techniques were demonstrated to be effective only at low Se concentrations levels (below 5 mg/L). This study employs an advanced reduction process (ARP) that combines a reducing agent and an activation method and investigates its applicability for Se removal at high concentrations (∼10 mg/L).

The goal of this research is to investigate the effectiveness of ARP for reducing Se (IV) to elemental Se or stable solids composing of Se and S (e.g. SeS or SeS2) in water using a combination of dithionite or sulfide as reducing agents and UV light as an activating method. Three different UV light sources including monochromatic 254 nm UV-L, UV-M with primary energy peak at 365 nm, and 312 nm UV-B were evaluated. This work studied the effects of operating conditions such as concentrations of reducing agents, solution pH, and initial selenium concentration for the optimum combination that achieves the efficient reduction of Se (IV).

In industrial applications, sulfur dioxide has been used as the reactant to reduce Se (IV) to elemental Se, but it was reported that SO2 was ineffective for Se (IV) reduction for waters with low Se concentration at room temperature. In this study, sodium dithionite and sodium sulfide were used as a strong reducing agent of interest. Sodium dithionite was proven to be an effective reductant and produce active reducing radicals when activated by UV light. It has been shown to be very effective in reducing chlorate, trichloroethylene or 1,2-dichloroethane in our earlier studies. It is known that dithionite undergoes decomposition reactions which is strongly dependent on the pH and is rapid in the acidic environment and its major decomposition products are thiosulfate (S2O3 ^2–) and bisulfite (HSO^3–). Decomposition reaction is very complicated because its reaction products can decompose and interact with each other and can be activated by UV irradiation at various rates, which will result in the production of elemental sulfur or selenium, or precipitates of Se-S at different stages. In Se-S solution, the compounds having a general formula, SeSn (n:1–7) can be produced and it can form crystalline or amorphous composition. Therefore, we investigated the chemistry of dithionite and sulfide in Se-S water system and the behavior Se removal under UV irradiation.

Screening tests of various combinations of reducing agents and UV light types showed that the greatest Se removal (86.4%) was found with dithionite irradiated by UV-L lamp (254 nm) at around pH 5. Sulfide as a reducing reagent at neutral pH resulted in selenium removal percentages of 83.5% and 92.5% without and with UV-L irradiation, respectively. Maximum removal efficiency of Se was observed when sulfide or dithionite molar concentration was 40 times the initial Se molar concentration under UV light at given conditions. A typical color of the Se-dithionite mixture solution was milky yellow during UV-L irradiation.

Yellow-colored solids were precipitated. The combination of dithionite and UV-B (major peak at 312 nm) showed orange-colored solid in 3 hours of irradiation. It is expected that dithionite or dithionite decomposition products will produce active radicals dependent on UV light types, which may change Se-S solid chemistry. To investigate surface chemistry of solids and sulfur-containing species, X-ray powder diffraction (XRD), X-ray photoelectron spectroscopy (XPS), and scanning electron microscopy/energy dispersive spectrometry (SEM/EDS) were utilized. Also, incremental reducing agent solution injection or electrocoagulation method was utilized to reduce final Se concentration to below the maximum contaminant level.

Bulk heterojuntion organic solar cells (BHJ OSCs) have gained much attraction in recent years. These solar cells have layered geometric structure and optimization of each layer is essential to achieve the overall performance of the device. Active layer consisting of donor and acceptor material is sandwiched between two electrodes. In order to improve the device stability and efficiency, often interfacial layers, namely electron and hole transport layers, between the active layer and electrodes are introduced. Poly (3.4-ethylenedioxythiophene): Poly (styrenesulfonate) (PEDOT:PSS) is most commonly applied hole transport layer (HTL) in OSCs. However, it limits the device performance due to its highly hygroscopic and acidic nature which arise reliability issues while reducing the cell life drastically. Metal oxides have been proved to be a good alternative to it. These metal oxides improve the device efficiency comparable with standard HTL and at the same time they substantially enhance cell stability. The aim of this work is to optimize the hole transport layer by using different metal oxides such as vanadium pentaoxide (V2O5) by improving its structural, optical, and electrical properties. V2O5 has been extensively studied as a promising candidate for charge extraction and transportation because of its exceptional electronic properties. It proved to be more stable due to its good transparency, low resistance and better adhesions to the active layer. The novelty of our study is to develop a highly controllable, reproducible and cost effective fabrication technique to build our device with poly [N-9’-heptadecanyl-2,7-carbazole-alt-5,5-(4’,7’-di-2-thienyl-2’,1’,3’-benzothiadiazole)] (PCDTBT), and (6,6)-Phenyl C71 butyric acid methyl ester (PC71BM) based active layer yielding high stability and efficiency. This work is focused on improving the device stability along with the efficiency which has not been explored much to date.

In this work, we demonstrate the fabrication of PCDTBT:PC71BM based bulk heterojunction solar cells with two variants of hole transport layer (HTL) in different fabrication atmospheres. Device with standard PEDOT:PSS hole transport layer has been compared with its organic-inorganic (V2O5 in PEDOT:PSS) hybrid variant in terms of efficiency and life time stability when they are fabricated in controlled mode in the nitrogen filled atmosphere and an ambient mode in the presence of oxygen and 65% relative humidity (RH). Vanadium pentaoxide (V2O5) nanoparticles, synthesized by co precipitation method, are mixed in PEDOT:PSS layer to form an organic-inorganic hybrid HTL. Both variant of hole transport layer are further characterised for their structural and optical properties to optimise these fundamental properties to ensure highly stable and efficient solar cell. Normalized efficiencies are calculated as a function of time for life time stability tests of both types of devices fabricated in both atmospheric modes. The best performance is achieved for a device with hybrid HTL fabricated in controlled mode where the life time stability has improved from 70% to 94% over one week period and from 65% to 90% over four week time when they are compared with their standard PEDOT:PSS HTL counterpart. Our results confirm that fabrication environment play a key role in device performance in terms of stability and efficiency along with the improvement brought by addition of V2O5 nanoparticles in the pristine PEDOT:PSS hole transport layer.

Keywords: Hole transport layer; Organic solar cells; PEDOT:PSS; Stability; V2O5

Introduction: The de novo synthesis and “intracrine” production of androgens by prostate tumors provides a significant survival advantage leading to the outgrowth of castration resistant tumors. Currently, targeting residual androgens in metastatic prostate cancer (PC) microenvironment is the toughest challenge in the clinical management of advanced PC patients treated with androgen ablation therapy (AAT), as they are implicated for development of castration-resistant PC (CRPC). Our previous studies (Stem Cells, 2014) demonstrate that PC-derived adipose derived stem cells (pASCs) promote tumor growth and undergo PC mimicry through neoplastic reprogramming. The present study examines the role of pASCs in synthesizing and producing and rogens and its potential in supporting growth of hormone-dependent PC cells under castrate conditions in vitro and in vivo. Further more, the study attempts to identify key players among the and rogen-metabolizing enzymes (AMEs) in the backdoor pathway for targeting and degradation of androgen synthesis in the prostate tumor microenvironment, by both in vitro and in vivo assays. Methods: Based on an IRB approved protocol, the pASCs were isolated from fatt issues procured from PC patients undergoing radical prostatectomies. The purity of the pASC isolates was validated by FACS analysis and differentiation assays. The ability of pASCs exposed to PC-derived conditioned media (CM) to produce androgens was monitored by expression of AMEs (PCR) and androgen release (EIAkit). The ability of pASC CM to support growth of androgen-dependent LNCaP cells was assessed by MTT assay and growth of LNCaP tumors co-transplanted with pASCs in castrated mice in vivo. Normal donor-derived adipose derived stem cells (nASCs) were enriched for tumor tropicity by a transwell system. Next, we subcloned in a GFP bicistronic IRES lentivirus construct (pLVX-IRES-ZsGreen1) the rat androgen hydrolyzing enzyme 3α-hydroxysteroid dehydrogenase (Type I, 3α-HSD), as known as AKRIC14, in-frame with IL-2SS sequence at the N-terminus. R1C14. The ILL2SS sequencec enables the AKR1C14 by the transduced cells. Upon transduction, the enriched nASC population was monitored for the transgene expression and release by qRT-PCR, immunoblotting and EIA kit. The efficacy and functional activity of the recombinant enzyme and the nASC-released ANR1C14 enzyme were monitored by MTT, LDH and luciferase reporterassays in the androgen-dependent LNCaP cells in vitro. The tumor-homing potential of the GFP-AKRC14 expressing nASCs infused by IV route was validated by their engraftment in LNCaP tumor-bearing mice. To examine the efficacy of secreted enzyme to hydrolyze androgens andinduce tumor regression in vivo, the GFP-AKR1C14 transduced nASCs were injected in mice bearing LNCaP tumors and tumor volumes were measured weekly. Results: We demonstrate here in that unlike normal adipose-tissue derived stem cells (nASCs), the PC cell microenvironment subverts tumor-tropic PC patients' derived ASCs (pASCs) to synthesize and produce androgens in the tumor microenvironment. The pASC-mediated hormone production was sufficient to support the growth of androgen-dependent LNCaP PC cells in vitro under hormone-deprivation conditions as well as in castrated nude mice. Comparative analysis of gene expression of AMEs in microdissected cells versus the adjacent normal tissue revealed AKR1C4, an alpha keto reductase, to be the most promising candidate for targeting the backdoor pathway in dihydrotestesterone (DHT) synthesis. Type 1 3α-HSD enzyme has been shown to readily oxidize testosterone to Δ4-androstene-3, 17-dione in a substrate dependent reaction. The recombinant AKR1C4 induced cytotoxicity and apoptosis in androgen-dependent PC cells in vitro. Next, using a GFP bicistronic IRES lentivirus construct, we demonstrate that the genetically engineered tumor-tropic nASCs enable expression and secretion of AKR1C14. The results showed that the engineered nASCs are capable of expressing the enzyme, which in turn catabolizes androgens in vitro and induce apoptosis in androgen-dependent LNCaP cells. The AKR1C14 transduced nASCs successfully engrafted in and reduced growth of LNCaP tumors in nude mice. Conclusions: Together, our data demonstrates that selective delivery of alpha keto reductases by nASCs could eliminate residual androgens and further paves the way for their potential use in combination with AAT for treatment of CRPC.

Accumulation of lipid peroxidation products in response to oxidative stress can cause dysfunction and pathology in a variety of tissues. In this study, we investigated the presence of 4-hydroxynonenal (4-HNE), the most abundant lipid peroxidation end product, in paired subcutaneous (SC) and omental (OM) tissues obtained from morbidly obese individuals undergoing weight reduction surgery. We further assessed 4-HNE effect on proliferation and differentiation of preadipocytes derived from these tissues in two metabolically distinct groups. Levels of 4-HNE accumulation were positively correlated between the paired SC and OM tissues (R² = 0.9, p = 0.01) and exhibited a higher accumulation in OM-adipocytes and connective tissues compared to SC-derived counterparts. Exposure of tissues-derived preadipocytes to physiological levels of 4-HNE caused inhibition of proliferation and differentiation of SC, but not OM-derived preadipocytes. When samples were dichotomized into insulin sensitive (IS) and insulin resistant (IR) groups based on their HOMA-IR index, 4-HNE treatment caused a greater reduction of both proliferation by 76% with a mean difference of 11.4% (3–45.3) and differentiation capacity by 56% with a mean difference of 25.9% (3.9–55.7) in IS compared to IR. This data suggest that 4-HNE induced oxidative stress plays a role in the regulation of adipocyte proliferation and differentiation in a depot and insulin sensitivity-specific manners and may therefore contribute to metabolic dysfunction associated with insulin resistance. This research was sponsored by Qatar National Research Fund (QNRF), Grant number NPRP6-235-1-048.

Introduction

Cardiovascular diseases are the leading cause of death. Studies show that depression is associated with an increased morbidity and mortality among cardiovascular (CV) patients. Depression contributed to patients’ unfavorable prognosis after a cardiac event, hamper cardiac rehabilitation, and increase hospital re-admission rate among CV patients. Studies show that 15 – 30% of CV patients experience depression. Early detection and intervention for depression among cardiovascular patients can reduce morbidity and mortality rates. Understanding factors contribute to the risk of depression and its management among cardiovascular patients is necessary to adequately address the complex nature of depression as co-morbidity among Arab CV patients in the Middle East region. Objectives: (1) To evaluate the prevalence and severity of depression among patients who have confirmed diagnosis of cardiovascular diseases; and (2) To find ways to manage depression among male and female Arab CV patients. Methods: Using non-probability, convenient sampling method, a cross-sectional survey was conducted with 1000 Arab CV patients of which 688 (69%) male and 312 (31%) females between January, 2013 and September, 2014 at the Heart Hospital in Qatar. Inclusion criteria were ≥ 20 years of age, agreeing to participate in the study (98% response rate), and having final confirmation of acute cardiac conditions. Face-to-face interviews were conducted using structured survey questionnaires which included an Arabic demographic questionnaire and the Arabic version of the Beck Depression Inventory 2nd Edition (BDI-II) - a self-report instrument, which had been translated into Arabic and validated for its validity and reliability. Descriptive and inferential statistics were performed using SPSS version 20. Results: Almost half of the male and female participants were Qatari nationals (46%). Citizens of the Levant countries (Syria, Lebanon, Palestine, Jordan) constituted 20% and North African countries (Egypt, Libya, Tunisia, Algeria, Morocco) constituted 17% of the participants. 80% of the patients had no depressive symptoms, 15% of the patients had Mild Mood Disturbance and 5% had symptoms of clinical depression. Almost twice as many females (29%) than males (16%) were found to suffer from Mild Mood Disturbance and Clinical Depression. Approximately half of both male and female patients who scored ≥ 17 on the BDI-II (suggesting symptoms of clinical depression) refused psychiatric assistance. Chi Square tests indicated that age and socioeconomic factors, nationality, marital status, monthly income, employment, occupation, financial stress and support were significantly related to gender and depression (all p <  0.001).

Conclusion: (1) In-depth systematic assessment of mental health status and screening for depression should be performed routinely for all patients who had diagnosed with cardiovascular diseases, particularly females.

(2) Public awareness and education about mental health are critical in order to reduce the stigma associated with accessing treatment for it.

(3) Practices, treatments and diagnostic tools for depression should be thoroughly investigated and adapted to the Arab Middle Eastern context in order to facilitate the development of culturally appropriate mental health care and uptake of cardiac interventions and rehabilitation.

(4) Health policy makers should encourage and support psychiatric training and primary health care providers should be trained to provide psychiatric assistance to CV patients.

(5) Socioeconomic related factors influence the mental health of male and female CV patients differently and accordingly their CV conditions and outcomes.

(6) To effectively manage and treat depression among Arab CV patients, health care providers should be encourage to integrate gender differences approach into clinical practice.

Background: Workplace stress can lead to poor health and work-related injuries. Health care professionals comprise an important group of individuals who are affected by emotional states and stress because of their unique work environment. The employee's stress level and satisfaction with his/her job are primary factors that influence the quality of work and individual productivity. In health care, employee job stress can have a negative impact on the quality of patient care. Among this group, studies have found various causes of stress, including varied working hours, heavy work load, night shifts resulting in sleep deprivation, imbalance between work and life, isolated feelings, and minimal control over the workplace accompanied by minimal autonomy. Results of various researchers show that stress, fatigue, burnout, depression, and general psychological distress negatively affect health care systems and patient care. While there are a few published studies examining the prevalence of stress and job satisfaction among health care professionals in the Middle East, no such studies are available from Kingdom of Saudi Arabia (KSA). Objective: To measure the prevalence of job stress and job satisfaction among healthcare professionals and to identify potential factors that could affect job stress or satisfaction among health care workers were also explored. Research Design: The design of this study was a quantitative, multi-center, cross-sectional, correlational study where job stress and job satisfaction validated questionnaires were administered to randomly selected health care professionals working at National Guard Health Affairs, Eastern Region, Kingdom of Saudi Arabia. A total sample size of 620 subjects was needed to produce a two-sided 99% confidence interval (44.8%–55.2%), with an effect size of 5.2%. Subjects: Physicians, residents, nurses, and radiologists working at National Guard Health Affairs, Eastern Region, Kingdom of Saudi Arabia. Measures: Job stress and satisfaction were measured using 25 specific questions about sources of work-related stress and 17 questions about sources of work related satisfaction. Demographic and job characteristics variable data were also collected.

Statistical Methods Descriptive results for all demographic variables, job characteristics, and socioeconomic factors were reported using mean ±  standard deviation (SD) and number (percentage) as appropriate. Logistic regression analysis was performed to identify predictors among the demographic variables, job characteristics, and socioeconomic factors between those who were stressed and not stressed using Wald test-statistics. Results were expressed as odds ratios using a 95% confidence interval. Multiple logistic regression models were used to identify significant independent predictors of job stress after adjusting for potentially confounding factors. Results were expressed as adjusted odds ratios with 95% confidence intervals. The final model was assessed using the Pearson chi-square goodness-of-fit test to see how well the model fit the data. Statistical significance was established when p <  .05 (two-tailed). All statistical analyses were performed using SPSS (Statistical Package for Social Sciences version 20.0). Results: A total of 626 of the 1168 health care professionals completed the job stress and job satisfaction surveys, resulting in a response rate of 54%. Twenty-nine percent of the respondents were male, and 71.0% were female. The mean age among all participants was 39.3 years. Job Stress Results indicated that the majority of the health care professionals who participated reported moderate to high stress levels, and the overall prevalence of job stress was 66.2%. Results indicated that, on average, younger staff had higher stress levels than older staff (OR =  0.968; 95% CI: 0.95–0.987; p =  .001). Residents reported a higher level of stress (p =  .003). Being of Saudi nationality resulted in 4.4 times more stress than being non-Saudi (OR: 4.36; 95% CI: 2.46–7.73; p <  .001) while education level did not result in a statistically significant relationship. Those who work more than 50 hours per week were more stressed (79.4%; p =  .001). Of those who always worked night shifts, 84.0% were more stressed (p <  .001), and of those who always worked weekends were also more stressed (81.8%’ p =  .001) compared to those who never or sometimes worked weekends or nights shifts. Those who received free time compensation all the time were less stressed (56.8%) than those who received it sometimes (62.2%) or not at all (70.9%; p =  .044).

Additionally, 93.9% of those who felt under pressure all the time, 95.2% of those who had conflicts of demand all the time, and 73.1% of those who believed there was inadequate staff to do the job were more stressed (p <  .001 for all three groups). Health care professionals who don't know whom to approach if they have stress affecting their work and life were more stressed (76.3%; p <  .001), and those who were exposed to a stressful event outside of work within a year were more stressed (73.8% p <  .001). Those variables that were significantly associated with job stress using univariate analysis were considered for step-by step multiple logistic regression models to identify the statistically significant independent factors associated with job stress. These factors were: working on weekends, not getting free time compensation, feeling under pressure to meet deadlines, conflicts in the demand on time, being Saudi, believing there is inadequate staff to do the job, not knowing whom to approach if they are under stress, and being exposed to a stressful event outside of work within a year. Conclusion: This study shows that the current workplace environment could increase the risk of stress among health care professionals. However, the satisfaction rate was high and not negatively associated with low stress levels. The high satisfaction rate among the highly stressed could be a result of the benefits and incentive system applied in this organization. Our study identifies some potential factors, which if eliminated or changed, could lead to a decrease the stress level among health care workers. Future research is recommended to assess the impact of high stress on medical errors. This should be accompanied by studying the introduction of new policies and programs that could reduce the stress level among our health care staff.

Background: During the past decade, the IT industry has introduced several new concepts within the health domain including e-health, electronic health record, digital hospital, and many more. Although each of these terms has brought its own unique definition and perspectives, they were all based on the foundation that healthcare and wellness management are dependent on effectively using technology to access accurate data in a timely fashion; ensuring enhanced patient care and medical error reduction. The Electronic Health Record (EHR) is an integrated system that collects data from different healthcare providers to create a unified electronic record for each patient among the population. Today, the patient's health information is scattered across different healthcare facilities causing significant inefficiencies within the healthcare system. A national EHR system will tackle these challenges by producing a personal health record for each patient, integrating information from all healthcare providers, and additionally giving access to patients themselves allowing their contribution. Motivation: There are many health IT implementations for EHR programs around the world that serve as great learning experiences for Qatar, offering it a great opportunity to leverage the best national EHR implementation strategies and practices. National EHR initiatives in Qatar emphasize the need to have secure electronic management of health data in structured and standardized formats, which can be communicated across its hospitals, primary healthcare centres, and other healthcare facilities. Personalized medicine initiatives share and extend these goals, with additional precision provided by genetic/genomic-based improved diagnostic, prognostic, and preventive information; thereby demanding a coordinated extension for the adoption and implementation requirements of an integrated national EHR system. It is for this purpose and understanding that the State of Qatar has taken the first concrete steps towards a promising EHR journey that will promote significant changes on how healthcare services are delivered, and more importantly, how each individual in Qatar can be empowered to become an active contributor to the management of their own health. In moving towards the widespread adoption and implementation of a national EHR system in Qatar, it is important to study the different challenges and trends used for the adoption of EHR systems, under national strategies, in other countries. This is essential for health informatics researchers, clinicians, and policy makers, to gain greater insight into the issues concerning the transformation of healthcare using a national EHR system. The results of this review study shall complement, explain, and extend the conclusions of earlier studies commissioned to explore the health information technology ecosystem in the State of Qatar. Objectives: The purpose of this study is to review EHR programs from various countries with regard to the issues documented in the studies commissioned in these countries. Our analysis will derive the most common critical aspects and lessons learned from international experiences during the implementation of national EHR programs. Additionally, it will explore opportunities, constraints, and characteristics present in Qatar, necessary for tailoring the strategies and approaches to fully realize a national EHR system in the country. This review study presents two important contributions: 1) it will significantly support promoting health IT solutions that are right for Qatar's need, recognizing the size and capabilities of the country, leveraging existing healthcare organizations and solutions, and respecting the unique cultural characteristics of its population. 2) it will serve as a baseline from which comparisons, performance against target measures, and forward thinking can be scoped; allowing significant contribution towards productive future development of health information technology and personalized medicine initiatives in Qatar. Methods: The data collection techniques included: (a) literature review for articles about EHR adoption under national strategies in several countries, (b) review of reports regarding national e-health strategy and government policies in Qatar, and (c) interviews of people participating in the policy making for national EHR system in Qatar (health and academic professionals involved in health IT research in Qatar). The reviewed EHR programs were selected according to the following criteria: (a) program for the implementation of national EHR system has been initiated since at least 5 years, (b) pilot projects have already been conducted, and (c) the planned EHR systems encompass various approaches of implementation. In line with these criteria, the EHR programs that have been studied were those of the following five countries: United States, England, Estonia, Japan, and Australia. Results: The analysis performed on the selected international EHR programs revealed many lessons learned, including: 1) To achieve a successful EHR implementation, it is critical to increase the awareness of the Qatari population about the upcoming changes in their healthcare experiences, paving the way to a smoother transition while having people's trust and confidence in the new system. 2) It is essential to legally define the legislation of privacy protection of personal medical data to support new e-health concepts and eliminate the risk of violating the privacy of patient data. 3) It is important to allow appropriate time for procurement, utilization, benefit realization and the complete project, otherwise you may risk having stakeholders and the public lose confidence in the EHR project. 4) Financial incentives for healthcare providers proved to be an effective method towards raising the EHR adoption rate. 5) To expedite EHR program acceptance, it is imperative to recruit knowledgeable and experienced technical staff and healthcare leaders, who encourage others to play a critical role during the transition process, and view this change as a dominantly positive one. 6) In order to make EHR an everyday tool for doctors, nurses, patients and public authorities, it is necessary to implement services based on the interests of the healthcare providers and society. 7) Continuous adjustment and enhancement is needed in order to sustain a successful and efficient system. Conclusion: Experiences from other countries suggest that a clear focus needs to be carefully placed on technical, clinical, organizational, financial, social, and patient perspectives to ensure that the full benefits of a national EHR system in Qatar can be realized. In addition, it demonstrates that strategic and human challenges are more difficult to master than technical aspects. The results of this review study can be used as a baseline to provide recommendations on how to tackle potential barriers towards successful adoption of a national EHR system in Qatar.

Summary

Insulin resistance manifest in skeletal muscle, liver and adipocytes. Insulin stimulates muscle glucose uptake, suppresses the rate of hepatic glucose production (HGP) and restrains lipolysis. In insulin resistant individuals, insulin-stimulated glucose uptake is markedly reduced in skeletal muscle, impaired insulin-mediated suppression of hepatic glucose production (HGP) and inhibition of lipolysis. It is evident from human and animal studies that diabetes alters miRNAs expression in metabolically important organs (adipose, liver and skeletal muscle).micRNA are small non coding RNA molecules. However, they play critical role in the regulation of gene expression via post-transcriptional mechanisms. They are small in size (21?23 nucleotides) and recent studies have demonstrated that they play important role in many human complex diseases including diabetes. The ability of miRNA that simultaneously regulate many target genes makes them attractive candidates for regulating insulin production/secretion and action. mRNA are secreted to the circulation and are taken up from the circulation by several tissues, making them an attractive mechanism for inter-tissue signaling molecules. Thus, if micro RNA play role in the pathogenesis of insulin resistance or in communicating between insulin resistant tissues and the beta cell to regulate the level of beta cell function in concert with the prevailing level of insulin resistance, we anticipate a change in the circulatory profile of micro RNA in insulin resistant individuals compared to insulin sensitive individuals. Such a distinct circulatory profile of micro RNA in insulin sensitive versus insulin resistant individuals could provide a signature for the identification of insulin resistant individuals. Moreover, differentially expressed micro RNA molecules in insulin resistant individuals could serve signaling molecules which convey messages between insulin resistant tissues, i.e. liver, skeletal muscle and adipocytes and the beta cell. Insulin sensitivity is commonly assessed to predict the risk and evaluate the management of type 2 diabetes in clinical and research settings. Insulin sensitivity can be measured using a variety of techniques that are commonly employed in diabetes research and care. Among them, euglycemic hyperinsulemic clamp is the gold-standard method to quantify the sensitivity to insulin.

The aim of the present study is to determine the profile of miRNA in the plasma in insulin sensitive Arab individuals and compare the result to that in insulin resistant Arab individuals.

specific aims are;

1. To discover the circulatory profile of microRNA in insulin sensitive and insulin resistant Arab individuals by using next generation sequencing technology.

2. To identify novel microRNA/targets which are differentially expressed in insulin resistant individuals by real time Taq-Man PCR.

3. To explore the effects changes of these miRNAs in insulin resistance diabetes β-Cell Biology. The experiments range from relevant tissue and cell cultures systems to human physiology. Design and methods: The circulating miRNA profile was assessed in a pilot study of 20 healthy volunteers whom glucose tolerance status was determined by the OGTT, and their insulin sensitivity was quantitated by the gold standard method the euglycemic hyperinsulemic clamp. Based on Glucose Infusion rate (GIR: mg/kg/min), before and after a 6-h hyperinsulinemeic euglycemic clamp, we selected two groups: 10 with high levels of GIR (insulin-sensitive group) and 10 with Very low levels of GIR (insulin resistant group).The serum samples was collected from the two groups for miRNA extraction and subsequent sequencing using the True-seq Illumina protocol. A small RNA library was generated from samples using the Illumina Truseq™ Small. The purified cDNA library was used for cluster generation on Illumina's Cluster Station and then sequenced on Illumina GAIIx following vendor's instruction for running the instrument. Raw sequencing reads (40 nts) were obtained using Illumina's Sequencing Control Studio software version 2.8 (SCS v2.8) following real-time sequencing image analysis and base-calling by Illumina's Real-Time Analysis version 1.8.70 (RTA v1.8.70). Result: Sequencing of the small circulating RNA isolated from insulin-resistant and insulin-sensitive healthy samples produced 69,559,764 raw reads. A total of 41,697,300 mappable reads was obtained after sequence filtering. Using a 2-fold expression difference as a cutoff, 33 miRNAs showed significally differential expression between insulin sensitive and insulin-resistant group. Among which, 10 were up-regulated and 22 were down-regulated. This RNA-seq discovery study shows that the most changes in miRNAs expression is in accordance with previous studies performed to explore circulating miRNAs in human insulin resistance or T2DM. Indeed, among the 54 selected miRNAs, we have identified the same changes in mir-126 expression that has described by Zampetaki and colleagues. This group reported that mir-126 is a unique plasma miRNA signature in 800 patients with T2D and observed that the reduced levels of mir-126 showed the strongest association with T2D. From the 33 miRNAs, a relative number of them are much documented to be associated with insulin resistance and type 2 diabetes. Nevertheless, some identified miRNAs are potential novel candidates and need to be deeply exploring during the event of the pathogenesis of T2D. Conclusion: This study provides a comparative profiling of circulating miRNAs in insulin-resistant versus insulin–sensitive subjects and the identification of specific miRNAs in circulation that changes are associated with insulin action. To our knowledge, this is the first study to investigate insulin resistance in Arab population using euglycemic hyperinsulemic clamp the gold-standard method to assess insulin sensitivity and aim to identify changes in circulating miRNAs expression associated to insulin action and signaling. The study also provides evidence that Insulin Resistance in human is related to changes in multiples microRNAs. Functional Validation studies of the differentially expressed miRNAs and relevant target and signaling pathways are ongoing.

Neural stem cells (NSC) have self-renewal and multipotent properties and may serve as an ideal cell source for transplantation to treat neurodegenerative insults such as Parkinson's, Alzheimer's, and spinal cord injury (SCI). Obtaining NSCs from adult human olfactory bulb (OB) would avoid ethical issues associated with the use of embryonic tissue, and provide an easily accessible cell source that would preclude the need for invasive brain surgery.

We used Agilent and Illumina Whole Human Genome Oligonucleotide Microarray to compare the genomic profiles of human embryonic NSC at a single time point in culture; and a multicellular tissue from postmortem adult substantia nigra (SN), an area rich in dopaminergic (DA) neurons. We identified 13525 up-regulated genes in both cell types of which 3737 (27.6%) genes were up-regulated in the hENSC, 4116 (30.4%) genes were up-regulated in the human substantia nigra dopaminergic cells, and 5672 (41.93%) were significantly up-regulated in both cell populations. Careful analysis of the data using DAVID has permitted us to distinguish several genes and pathways involved in dopaminergic (DA) differentiation, and to identify the crucial signaling pathways that direct this process. The set of genes expressed more highly at hENSC is enriched in molecules known or predicted to be involved in the M phase of the mitotic cell cycle. On the other hand, the genes expressed in SN cells include a different set of functional categories, namely synaptic transmission, central nervous system development, structural constituents of the myelin sheath, the internode region of axons, myelination, cell projection, cell somata, ion transport, and the voltage-gated ion channel complex. These data were compared with data from various databases, and between different types of arrays, Agilent versus Illumina. This approach has allowed us to confirm the consistency of our results for a large number of genes that delineate the phenotypical differences of embryonic NSCs, and SN cells.

Next we studied global gene expression profiling using RNA from human embryonic neural stem cells (hENSC), and adult human olfactory bulb-derived neural stem cells (OBNSCs), to define the gene expression pattern and signaling pathways specific for each cell lineage. We demonstrated large differences in the gene expression profile of human embryonic NSC, and adult human OBNSCs, but less variability between parallel cultures. Transcripts of genes involved in neural tube development and patterning (ALDH1A2, FOXA2), progenitor marker genes (LMX1a, ALDH1A1, SOX10), proliferation of neural progenitors (WNT1 and WNT3a), neuroplastin (NPTN), POU3F1 (OCT6), neuroligin (NLGN4X), MEIS2, and NPAS1 were up-regulated in both cell populations. Using Gene Ontology, 325 out of 3875 investigated gene sets were different. 41 out of the 307 investigated Cellular Component (CC) categories, 45 out of the 620 investigated Molecular Function (MF) categories, and 239 out of the 2948 investigated Biological Process (BP) categories were significant. KEGG Pathway Class Comparison revealed that 75 out of 171 investigated gene sets passed the 0.005 significance threshold. Levels of gene expression were explored in three signaling pathways, Notch, Wnt, and mTOR, all known to be involved in NS cell fate determination. The transcriptional signature also clarifies the role of genes involved in epigenetic modifications. The SWI/SNF DNA chromatin remodeling complex family, including SMARCC1 and SMARCE1, was specifically up-regulated in OBNSC but not in hENSC. Differences in the gene expression profile of transcripts controlling epigenetic modifications and signaling pathways might indicate differences in the therapeutic potential of the two cell populations with respect to potential cell survival, proliferation, migration, and differentiation following engraftments in different CNS insults.

Next, the transcriptional factors (TF) and genomic markers associated with neurogenesis, proliferation, differentiation, and epigenetic control in human embryonic neural stem cells (hENSC), and adult human olfactory bulb neural stem cells (OBNSC) were studied using immunohistochemistry (IHC) and DNA microarrays. The biological impact of TF gene changes in the examined cell types was estimated using DAVID to specify a different GO class and signaling pathway based on KEGG database. Eleven, and twenty eight TF genes were up-regulated (fold change ≤ 2–39) in OBNSC, and hENSC respectively. KEGG pathway analysis for the up-regulated TF genes revealed significant enrichments for the basal transcription factor pathway, and Notch signaling pathway in OBNSCs, and hENSCs, respectively. Immunofluorescence analysis revealed a significantly greater expression of β-tubulin III (TUBB3),MAP, glial fibrillary acidic protein (GFAP), and O4 in hENSC compared to OBNSC. Furthermore, the expression of epigenetic-related TF-genes SMARCC1, TAF12, and UHRF1 increased significantly in OBNSC when compared with hENSC.

This suggests that exogenous application of NGF may be a promising therapeutic strategy for traumatic and neurodegenerative diseases. However, effective delivery of NGF into the CNS parenchyma is still challenging due to its limited ability to cross the blood–brain barrier, and the intolerable side effects if administered into the brain ventricular system. An effective method to ensure delivery of NGF into the parenchyma of CNS might be genetic modification of NSC to overexpress the NGF gene. Overexpression of NGF in adult human OBNSC is expected to alter their proliferation and differentiation, possibly enhancing their therapeutic potential. We genetically modified adult human OBNS/PC to overexpress human NGF (hNGF) and green fluorescent protein (GFP) genes, hoping to provide insight about the effects of hNGF and GFP gene overexpression in adult human OBNS/PC and on their in vitro multipotentiality using DNA microarray, immunophenotyping, and Western blot (WB) protocols. Our analysis revealed that OBNS/PC-GFP and OBNS/PCGFP- hNGF differentiation is a multifaceted process involving changes in major biological processes as reflected in alteration of the gene expression levels of crucial markers such as cell cycle and survival markers, stemness markers, and differentiation markers. The differentiation of both cell classes was also associated with modulations of key signaling pathways such MAPK signaling pathway, ErbB signaling pathway, and neuroactive ligand-receptor interaction pathway for OBNS/PC-GFP, and axon guidance, calcium channel, voltage-dependent, gamma subunit 7 for OBNS/PC-GFP-hNGF, as revealed by GO and KEGG. Differentiated OBNS/PC-GFP-hNGF displayed extensively branched cytoplasmic processes, a significantly faster growth rate and up modulated the expression of oligodendroglia precursor cells markers (PDGFRα, NG2 and CNPase) respect to OBNS/PC-GFP counterparts. These findings suggest an enhanced proliferation and oligodendrocytic differentiation potential for OBNS/PC-GFP-hNGF as compared to OBNS/PC-GFP.

To assess the therapeutic potential of OBNSCs, we studied the fate of allogenic adult human olfactory bulb neural stem/progenitor cells (OBNSC/NPCs) transplanted into the rat hippocampus treated with ibotenic acid (IBO), a neurotoxicant specific to hippocampal cholinergic neurons that are lost in Alzheimer's disease. We assessed their possible ability to survive, integrate, proliferate, and differentiate into different neuronal and glial elements: we also evaluated their possible therapeutic potential, and the mechanism(s) relevant to neuroprotection following their engraftment into the CNS milieu. The isolated OBNSC/NPCs-hNGF were stereotaxically transplanted into the hippocampus of IBO-treated animals and controls. Stereological analysis of engrafted OBNSCs eight weeks post transplantation revealed a 1.89 fold increase with respect to the initial cell population, indicating a marked ability for survival and proliferation. In addition, 54.71_11.38%, 30.18_6.00%, and 15.09_5.38% of engrafted OBNSCs were identified by morphological criteria suggestive of mature neurons, oligodendrocytes and astrocytes respectively. Taken together, this work demonstrated that human OBNSCs expressing NGF ameliorate the cognitive deficiencies associated with IBO-induced lesions in AD model rats, and the improvement can probably be attributed primarily to neuronal and glial cell replacement as well as the trophic influence exerted by the secreted NGF.

Next, the hNFG-GFP-OBNSCs were transplanted into the striatum of 6-OHDA Parkinsonian rats. The grafted cells survived in the lesion environment for more than eight weeks after implantation with no tumor formation. The grafted cells differentiated in vivo into oligodendrocyte-like (25 ± 2.88%), neuron-like (52.63 ± 4.16%), and astrocytic-like (22.36 ± 1.56%) lineages based on morphological criteria. Transplanted rats exhibited a significant partial correction in stepping and placing non-pharmacological behavioral tests, using a pole and rotarod. Taken together, our data encourage further investigations for the possible use of OBNSCs as a promising cell-based therapeutic strategy for Parkinson's disease.

Finally, hNGF-GFP-OBNSCs were engrafted in a rat model of SCI at day 7 post injury. All transplanted animals exhibited successful engraftment. The survival rate was about 30% relevant to initially transplanted cells. 27% of the engrafted cells differentiated along the oligodendrocyte, nearly as many (16%) differentiated into neurons, and about 56% of the cells displayed astrocyte morphology. The study revealed that hNGF-GFP-OBNSCs were able to survive in the lesion environment for more than eight weeks after implantation; this was supported by transgenic overexpression of hNGF on engrafted cells. We didn't observe locomotor recovery by BBB test, footprint analysis and grid walk tests three months post-treatment. No sign of immunorejections were recorded during the 8 week time window of the study. Engrafted cells were distributed throughout gray and white matter of the cord with no evidence of abnormal morphology or any mass formation indicative of tumorigenesis.

In Algeria, there is about seventy percent of the population that lives in remote areas and the desert. These areas are cut from health services, and the people do not have access to modern health services existing in Northern Algeria. The limited health care budget-delivered to these desert areas, and the shortage of doctors (health care specialists) jeopardize the improvement of health care system in the desert areas in Southern Algeria. Recently, although the Centre du Development des Technologies Avancées (CDTA) was granted the right to develop the feasibility of telemedicine in the country, the project centered in the city of Ouarlga, 600 km South of Algiers, giving only medical consultation and diagnostic to pediatrics. However, this initial project does not cover all the Southern remote and desert areas in the country. Also, it does not provide universal health care coverage to all the people living there. The paper discusses the challenges faced by the local authorities to develop health care system coverage in the South of Algeria. Also, it introduces how ICTs and internet-based technologies can integrated into health care system to help people with delivering most of the modern health services while living the desert areas. It proposes a telemedicine project which is based on WINDOWS NET, Adruino, and other ICT applications to develop an eHealth strategy in the country.

Keywords

ICT applications, internet-based technologies, Health care system, Arduino, desert areas.

Background

Acute myeloid leukemia (AML) is a heterogeneous disease with respect to clinical picture and therapeutic outcome, partly reflected by differences in molecular and cyto-genetics. Clonal cytogenetic abnormalities are one of the most important factors predicting clinical outcome in acute myeloid leukemia and are used to guide risk-adapted treatment strategies.

Deregulated expression of genes coding transcription factors involved in cell proliferation, survival or differentiation is known to be implicated in the process of leukomogenesis. Brain and acute leukemia, cytoplasmic gene (BAALC) and ETS-related gene (ERG) are examples of these transcription factors BAALC gene, located on chromosome band 8q22.3, is considered as a marker of early hematopoietic progenitor cells. High levels of BAALC expression were found in AML patients with trisomy 8, as well as in a subset of cytogenetically normal–AML(CN-AML) patients in which it was considered as poor prognostic factor The role of BAALC in leukemogenesis is not fully understood, but it was proposed that BAALC blocks myeloid differentiation ERG gene, located on chromosome band 21q22, belongs to the ETS family of transcription factors required for normal hematopoiesis. It is a transforming proto-oncogene that is expressed in stem cells and endothelial cells. It is frequently overexpressed in AML patients with complex karyotypes and amplification of chromosome 21. The ERG gene has been found to be involved in atypical chromosomal rearrangements with alterations of the transcription factor in several cancers. Aberrant expression of full-length ERG protein has been found in acute myeloid leukemia and acute T-lymphoblastic Leukemia. Chromosomal rearrangements driving the formation of EWS/ERG and FUS/ERG fusion proteins have been described in a subset of Ewing sarcoma and in acute myeloid leukemia.

Most of the previous researches were concerned about levels and prognostic effect of BAALC and ERG in CN-AML patients, while data about their incidence in AML and relation to cases with abnormal karyotype were lacking. The objective of this study was to detect the incidence of BAALC and ERG in a group of AML patients with abnormal karyotype in comparison to normal individuals, their levels and distribution among AML FAB subtypes as well as to study their impact on the disease outcome and reliability in detection of minimal residual disease in relation to the cytogenetic markers.

Methods

The current study was carried out on 44 patients with acute myeloid leukemia (AML), in the period between, July 2011 and July 2012 among cases referred to nuclear medicine and oncology unit of Kasr Alainy School of medicine, Cairo University with follow up period of 18 months, as well as 44 age and sex matched controls. They were patients suspected to have hyperspleenism or idiopathic thrombocytopenia coming for BM aspirate. Cases were diagnosed according to WHO criteria. The diagnosis of AML was based on morphological and phenotypic data. Subtypes according to the French–American–British classification were available for all the patients. Patients were 21 males and 23 females. Age ranged from 21 to 65 years. The control group included 17 male and 27 females with no medical history of any type of cancer. Their ages ranged between 22 and 50 years. All patients and controls were analyzed for clinical and laboratory findings, including full history taking, clinical examination, routine laboratory investigations, LDH, abdominal ultrasound for detection of organomegaly and lymphadenopathy. The patients were subjected as well to cytochemical, immunophenotypic and cytogenetic analysis to confirm diagnosis and to divide the patients into their subtypes. Local institutional research board approval as well as written informed consent was obtained from all the participants before including them in the study. All patients included in the study were treated according to the protocol of the nuclear medicine and oncology department, Cairo University, using ongoing induction and consolidation regimens for treatment of adult AML cases.

Induction of remission

Patients were subjected to 7–3 protocol for induction of remission: Novantrone: 12 mg/m², IV on day 1 and 3. ARA – C: 100 mg/m², continuous IV infusion, from day l–7. If remission is not achieved, this protocol was repeated again. If no or minimal response, patients were shifted to high dose chemotherapy. Induction therapy for acute promyelocytic leukemia (PML) included oral administration of all-trans-retinoic acid (ATRA) 45 mg/m²/day until induces remission.

Consolidation

High dose ARA-C for 4 cycles. ARA-C: 2 g/m², over 2 hours infusions, every 12 hours on days 1–4. Significant association to relapse free survival and overall survival were estimated for studied genes at a median follow-up of 18 months. Complete remission (CR) was defined as recovery of morphologically normal BM and peripheral blood cells with white cell counts ≥ 1,500/L, and platelets ≥ 100,000/L, less than 5% BM blasts and no evidence of extramedullary leukemia. Relapse was defined by ≥ 5% BM or peripheral blood blasts, or development of extramedullary leukemia in patients with previously documented CR. Relapse free survival (RFS) was measured from the date of CR until date of relapse or death. Quantitative real-time reverse transcription polymerase chain reaction (RT-PCR) assay was performed for estimation of BAALC and ERG expression.

Results

BAALC was expressed in 36(81.82%) of AML cases versus 10(22.72%) of the control group which was highly statistically significant (P <  0.001). While ERG was positive in 39(88.64%) of cases and 8(18.18 %) of controls and that was also highly statistically significant (P <  0.001). The distribution of the positive cases among FAB subtypes did not show any significant differences. The lower values of BAALC and ERG in the cases compared to controls means higher levels in the cases as the numerical value of the CT is inversely related to the amount of amplicon in the reaction. Follow up of the patients revealed 12 cases of CR and 32 with unfavorable outcome; 17 showed partial recovery (PR), 8 cases relapsed and 7 patients died. Highly significant correlation was detected between positive genes expression and presence of bulky tumor and organomegaly. The levels of each gene were expressed as 2-ΔΔ CT i.e. number of fold increased above the mean level of the control group. Patients were divided into two groups according to these levels (high and low) as described previously in statistic paragraph. BAALC levels median and range were 1479.8(220.8–7550.2) for high levels group and 10.1(0.13–54.9) for low levels group. While levels of ERG were 425.5(27–1985) and 2.44(0.021–8.17) for high and low levels groups respectively. There were statistically no significant differences between the 2 studied groups regarding the BAALC gene expression before and after treatment (P value = 0.86) or the ERG gene expression before and after treatment (P value = 0.75). Multivariate regression test had revealed that BAALC and ERG are independent risk factors of acute leukemia, because (table7). Although we abolished the effect of bad prognostic factors (age>60 years, high serum LDH and WBC levels, high bone marrow blast percentage, presence of bulky tumor), still high levels of these genes are associated with lower CR, RFS, and shorter OS.

Conclusion

As regard ERG, the levels in AML cases did not differ significantly from theirs in normal BM. So determination of cut off value to detect MRD will not be applicable. Further researches still needed to clarify the role of BAALC and ERG in the pathogenesis of leukemia and their importance as targets for treatment of AML that could be promising due to their high incidence of expression in AML.

Keywords

BAALC, ERG, gene expression, Quantitative real-time RT-PCR, AML.

Background

Pesticide poisoning is a global public health problem. Annually, 3 million people are hospitalized due to pesticide poisoning with over 250,000 deaths all over the world 1. With the growing population and rapid industrialization in Qatar, there has been a natural increase in pesticide usage and hence, exposure amongst the workers handling them. It is therefore vital to not only understand the existing knowledge, attitudes and practices about handling pesticides, but also to explore the effectiveness of measures like education and personal protective equipment on the general well being of the workers. We hypothesize that training the workers to handle pesticides is vital in maintaining high safety standards, thereby preventing associated toxicity while handling them that the use of personal protective equipment (PPE) improves the general health of pesticide handlers in the long run.

Methods

100 municipality employees in Qatar who work with pesticides, were interviewed in person by trained bilingual staff using a structured questionnaire model (Table 4). The questionnaire included basic demographic data, questions related to methods of pesticide storage, retrieval, application and disposition, usage of PPEs, adherence to safety practices and views of the worker on the company safety protocols and their implementation. The data was then entered into excel format and analyzed using descriptive statistics and associations inferred by odds ratios.

Results

The mean age of the workers was 37.4(SD-9.9)(Table1). Amongst workers nearly 2.9 % of them who did not use personal protective equipment visited hospital annually when compared to 1.4% of workers who used personal protective equipment (Table 2). Of the interviewed workers 81.1% did not know the contents or the name of the pesticides they were handling at work (Table 3). Unsafe behaviors such as preparation of pesticides at the site of its usage rather than in a specified preparation room (29.6%), noncompliance with wearing protective clothing (38.8%), handling of drinking water (22%) and food (10%) on site where pesticides are used and not washing clothes every day after work (45.9%) were observed. Around a quarter of the interviewees did not receive any training on preparation and handling of pesticides (Table 3). Workers who received training in pesticides usage were more likely to be aware of its effects on the environment (61.6%)(OR–3.9), less likely to eat or drink while handling pesticides(83.6%) (OR–4.3) and more likely to give household members appropriate instructions prior to application of pesticides (90.4%)(OR–5.0)(Table3).Workers who did not wear special protective clothes at work were found to be, more than twice as likely to visit hospitals per year, than those who wore(RR-2.2)(Table3). A third of the workers were not aware if their company had safety protocols in place, whereas a similar proportion felt no such protocols exist.

Conclusion

Unsafe practices were found to be significantly common amongst the personnel using pesticides in Qatar. Workers who received prior training, handled pesticides with better safety standards, highlighting the importance of training in pesticide handling. Wearing protective clothing most likely has a positive impact on the general well being of the workers.

Keywords

Improved safety standards, municipality workers, pesticide exposure, protective clothing.

Resources 1-World Health Organization

The Impacts of Pesticides on Health: Preventing Intentional and Unintentional Deaths from Pesticide Poisoning (fact sheet) 2- Gunnell, David and Eddleston, Michael. “Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries.” International Journal of Epidemiology 32 (2003): 902–909.

Table 1 (DEMOGRAPHIC DATA) Demographic variables (n = 100) Percentage* Age Less than 20 1 21 to 35 48.9 36 to 50 36.7 More than 50 13.3 Mean 37.4 years Education Primary 33.7 Secondary 44.9 Not educated 11.2 Other 8.2 Number of years working with pesticides < 1 11.2 1 to 5 30.6 6 to 10 24.5 >10 32.7 Living with Family 14.3 Friends 30.6 Colleagues 54.1 Children 0.00 Other 2.0 *Total may not be 100% if there were missing values

Table 2 (Comparison of variables for those wore special protective clothes to those who didn't) Variable Wore Special protective clothes (n,%) Did not wear(n,%) Number 59(59) 38(38) Age(mean) 37.4 37.5 Education Primary 27(45.8) 5(13.2) Secondary 20(33.9) 24(63.2) Not educated 8(13.6) 3(7.9) Years Working with pesticides < 1 5(8.5) 6(15.8) 1–5 20(33.9) 10(26.3) 6–10 14(23.7) 10(26.3) >10 20(33.9) 11(28.9) Co morbid conditions 16(27.1) 9(23.7) Knowledge on content of pesticides Yes 7(11.9) 11(28.9) No 52(88.1) 27(71.1) Any training received? Yes 46(77.9) 27(71.1) No 13(22.0) 11(28.9) Average hospital visit/year 1.4(0.8–1.9) 2.9(1.9–4.1)

Table 3 (ODDS RATIO) Variable Trained in pesticides (n = 73) Not trained in pesticides (n = 24) Odds Ratio with 95%CI Workers view on effect on environment YES 45 7 3.9(1.4 to 10.6) NO 28 17 Do not handle food/water at site 61 13 4.3(1.6–11.9) Wear special clothes 46 13 1.4(0.6–3.7) Knowledge of contents in pesticides present 16 2 3.1(0.7 – 14.5) Instruction to Household members 66 15 5.7(1.8–17.6) Washing clothes after work 40 13 1.02(0.41–2.59) Average visits to hospital/year 2.05(1.35–2.77) 2.04(0.68–3.41)

Table 4 (RESPONSE TO QUESTIONNAIRE IN PERCENTAGE) Affirmative response Do you know the contents of the pesticide you are using? 18.4 When spraying inside do you give any instructions to the household members? 82.7 If yes what are they? Stay away from home 56.3 Don't prepare food at home 7.5 Don't get into the room for a specified period of time 35 Pesticides are poisonous 1.3 Where do you prepare the pesticides? On site 29.6 Comes prepared 3.1 Preparation room 58.2 Other 0.00 Did you receive any education on how to prepare/apply the pesticides? 74.5 If yes, who educated you? Foreman 19.7 Supervisor 40.9 Senior co worker 27.3 Other staff 12.1 When were you educated? At the start of job 55.3 Periodically 28.7 Where do you store the pesticides? Home 0.00 At the site 15.3 Buy and use immediately 1.0 Specific store 83.7 How do you dispose the containers? Yourself 15.3 By the company 73.5 Other 6.1 Do you wear special protective clothes, while using the pesticides? 60.2 Do you wash your clothes daily after work? 64 Do you wash them separately? 59 Powder 75.5 Solid tablets 41.8 Spray 74.5 Liquid 26.5 Smoke 33.7 Other 3.1 Which form of pesticide do you use out door? Powder 52.6 Solid tablets 38.1 Spray 82.5 Liquid 32.9 Smoke 60.8 Other 1.0 What personal protective equipment are you using? Masks 95.9 Gloves 93.9 Clothes 67.4 Shoes 83.7 Goggles 51.0 Other 2.0 Do you know the effects of pesticides? On Humans 81 On the environment 53 Pesticides can be absorbed through? Skin 46.3 Mouth 75.8 Inhalation 93.7 Other 6.3 Pesticides have? Only acute effects 42.3 Only chronic effects 14.4 Both 29.9 Neither 13.4 In case of accident exposure, what do you do? Wash with water and soap 78.5 Drink milk 13.3 Call ambulance 8.1 Go to hospital 11.2 Inform supervisor 7.1 How do you dispose this equipment? General waste 28.9 Specific site for disposal 25.3 Company does it 30.1 Plastic bags 6 Reuse/keep it to oneself 3.6 During application, do you? Eat 10.3 Drink 22.7 Both 1.0 None 76.3 After application, do you wash hands? 98.9 Do you have any co morbid conditions? 25.5 Are you taking any medications? 20.4 How many visits to the Health care/E.D/Admissions per year? 1.9(1.4–2.5) Are there any safety protocols at your company/work place? Yes 29.6 No 39.8 Don't know 30.6 Is your Company/Employer strict about compliance of safety protocols? Yes 48.5 No 23.7 Don't Know 27.8 If any untoward incident occurs, are they documented/informed to respective officials? Yes 43.9 No 43.9 Don't Know 13.3 Did you ever witness any case of sever morbidity or death in your company workers due to pesticide poisoning? Yes 17.4 No 82.7 Does your company provide compensation for pesticide poisoned workers? Yes 1.0 No 40.8 Don't Know 58.2.

A variety of climatic factors are known to influence respiratory health, usually through their impact on air quality. High temperatures, for example, are often associated with an increase in ground levels of ozone, which in turn negatively impact respiratory function (Thurston and Ito 1999; WHO 2000). In New York City, high temperatures were correlated with increased hospital admissions for both chronic airway obstruction and asthma (as well as some cardiovascular problems) (Lin et al. 2009). Humidity levels are often positively correlated with allergenic spores (e.g., Hasnain et al. 2012) and other particulates (e.g., Kulshrestha et al. 2012) and thus can trigger asthmatic attacks or other forms of respiratory distress. More recently, investigators have begun to examine the relationship between dust-sand storms and respiratory health. For example, Waness et al. (2011) cited evidence suggesting that exposure to dust-sand storms in the Middle East may contribute to pulmonary alveolar proteinosis and silicosis. In this study, we conducted a detailed correlational analysis between various climatic variables, the density of airborne particulate matter, and the incidence of hospital admissions related to respiratory problems.Inhalation of air particulates may result in serious health problems, most notably with the respiratory system. Due to a variety of factors (traffic, construction, weather patterns), the air in Doha is of poor quality and is significantly over targets for PM2.5 and PM10 (WHO, 2014 rankings). We examined the levels of particulate matter to determine if there was a daily or weekly pattern. We then compared the number of air particulates in the summer and winter and attempted to determine if small (0.5–2.5 mg/l) or large (>2.5 mg) particulate matter was related to weather patterns and resulted in increased use of the nebulizer at a local clinic. We found that particle number (both small and large) was highest around 6 am and lowest around 12 pm, a pattern that didn't change between months. The number of large and small particles was generally lower on Friday when human activity was lowest. The temperature decreased in winter while humidity increased; wind speed remained relatively constant. Data suggest that nebulizer use was higher in the winter and lower in the summer although the reasons for this are speculative. There was no relationship found between the number of people using the nebulizer and the number of air particles.

Obesity and type 2 diabetes is characterized by insulin resistance which has been reported as the major risk factors associated with the development of the endothelial dysfunction and vascular complications such as atherosclerosis. Induction of the vascular dysfunction is obviously a proved metabolic consequence of insulin resistance. Diabetes leads to altered retinal microvascular function and ultimately diabetic retinopathy. Insulin signaling may play a role in this process, and animal studies indicated a role of the insulin in the pathogenesis of retinal neovascularization through its effect on endothelial cells. Endothelial dysfunction impairs ocular hemodynamics by reducing the bioavailability of NO and increasing the production of reactive oxygen species (ROS) and may be responsible for the pathogenesis of vascular dysfunction in retinopathy. Diabetic retinopathy (DR) a major consequence of diabetes is considered the leading cause of vision loss and blindness worldwide among working adults. Endothelial dysfunction expediting imbalance in vascular homeostasis, is one of the primary manifestation leading to the pathogenesis of DR. NO a major vasodilator involved in the regulation of vascular homeostasis is reported to be released by insulin dependent PI3K/Akt signaling pathway. Endothelial dysfunction impairs ocular hemodynamics by reducing the bioavailability of NO and increasing the production of reactive oxygen species (ROS) and may be responsible for the pathogenesis of vascular dysfunction in retinopathy. Insulin stimulated NO productions are reported to be well established in cardiovascular and macrovascular endothelium and its association with PI3K/Akt pathway. Contrary to this insulin signaling in retinal endothelium have minimal reports with some studies suggesting it to be an important physiology player in hyperglycemia or insulin resistance induced DR. This prompted us to investigate the association between hyperglycemia and insulin mediated PI3K/Akt pathway eNOS directed NO production and associated multivariate effect on HRMECs survival, proliferation, angiogenesis, adhesion, apoptotic and inflammatory markers. The aim of this study is to examine the examine the effect of insulin on NO production in human retinal microvascular endothelial cells cultured in hyperglcemic conditions. In the current study in order to examine the effect of insulin on NO production, HRECs cells were cultured and grown in high glucose (30 mM) and normal (5 mM) glucose for 24 hours. Subsequently, the cells were treated with 100 nM insulin for 10 minutes, 1, 2, and 4 hours. The various parameters of PI3K/Akt signaling pathway were analyzed. IRS-1, IRS-2, PI3K, Akt, eNOS, VEFGA, NFkB were analyzed for gene expression. Adhesion molecules such as P-selectin and ICAM-1 were assessed by flow cytometry. ROS and NO production were measured by immunofluorescence and fluorometry respectively. The cell viability, cell cycle, apoptosis and total oxidative stress were evaluated by imaging flowcytometery. This study demonstrated that hyperglycemia causes an increase in ROS/oxidative stress and apoptosis, while insulin promotes a significant decrease in ROS and apoptosis. eNOS mediated NO production increases with hyperglycemia but remarkably decreases with insulin treatment after 1 hour, 2 hours and 4 hours. This dissimilarity of the results to previously reported studies could be due to different endothelial cell types used or varied duration of experimental hyperglycemia. The most significant reason for the variation may be due to different method of NO measurement where, most previous studies measured NO production by isolated NO meters. However, in the current study fluorometry a more sensititve method to measure oxidized product of NO, nitrite an indicator direct NO production was utilized and confirmed by the immunoflouresence technique using the dye DAF-FM Diacetate. The assessment of PI3K/Akt pathway gene expression revealed that this study demonstrates a slight increase but insignificant elevation of IRS-1 and IRS-2 genes expression in hyperglycemic condition compared to the basal control condition, while gene expression of PI3K, Akt and eNOS were significantly upregulated in the presence of high glucose. Insulin treatment caused an up regulation of IRS-1 and IRS-2 genes after 1 hour however, PI3K, Akt and eNOS were significantly reduced. The analysis of angiogenic and proapoptotic markers VEGFA and NFkB by RT-PCR showed no significant change in the expression of NFkB in hyperglycemic alone, hyperglycemic and normoglycemic cells with insulin treatment at all-time points. However, hyperglycemia significantly increased the expression of VEGF. Though compared to basal control group insulin treatment significantly increased the expression of VEGFA in both hyperglycemic and normoglycemic cells yet the expression was low compared to HG state. Consistent with the VEGFA gene expression HG significantly increased the increase the cell migration and angiogenesis while insulin treatment significantly improves barrier function. Hyperglycemia significantly increased adhesion protein P-selectin with significant reduction at 4hrs insulin treatment in the current study. This study demonstrated a significant reduction in P-selectin after insulin suggesting that insulin could participate in preventing leukocyte adhesion thereby attenuating the progression of DR. This study could not demonstrate significance change in the ICAM-1 protein. This could be due to difference in the endothelial cells used, the duration and the type of insulin treatment used. This study reported that short acting insulin commonly used in the treatment of DR could control the metabolic fluxes thereby leading to improvement in oxidative stress and apoptosis. This could prevent early changes in vasodilator, adhesion and angiogenic markers such as NO, VEGFA, P-selectin involved in the angiogenesis, inflammation and neovascularization involved in retinal vascular functioning. The study shows the potent effect of short-acting insulin treatment to counteract these biomarkers and factors involved in the pathogenesis of DR and conserving microvascular function in HRMECs exposed to hyperglycemia (30 mM) and were reported to be improved. Thus, the diabetic interventions using insulin as a key therapy with others may have the potential to be utilized as a readily available, safe and inexpensive medicine to protect against microvascular complications of DR and delay its onset. In conclusion, this study demonstrated that Hyperglycemia causes an increase in ROS/oxidative stress and apoptosis, while insulin promotes a significant decrease in ROS and apoptosis, eNOS mediated NO production increases with hyperglycemia but remarkably decreases with insulin treatment after 1 hour, 2 hours and 4 hours, insulin could counteract the hyperglycemic effect on AKT/pI3 kinase which mediates NO production and VEGF-A, decreased adhesion molecules p-selectin involved in barrier disorder of retinal endothelial cells. Thus it could be proposed that insulin could be considered as regulators of angiogenesis.

People in developing countries of the world are facing a changing environment due to urbanization – changes that include lifestyle changes as well as changes in the dietary habits (and content). These lifestyle changes are now known to contribute to an epidemic of metabolic disease. The underlying mechanisms are unclear. The burden of type 2 diabetes mellitus (T2D) is increasing worldwide, particularly in developing countries, where it is predicted that over 70% of the global burden of T2D will exist by 2030 (Echouffo-Tcheugui and Dagogo-Jack, 2012). Although reasons for the increasing rates of T2D in developing countries are not fully elucidated, important factors include lifestyle changes involving rural-to-urban migration (“urbanization”), intra-uterine undernutrition and foetal programming (epigenetic changes progressively introduced over multiple generations and associated with maternal undernutrition). During the past two decades, increasing evidence arising from multiple clinical studies conducted by the research teams of Yajnik and Barker support an important role of early life undernutrition, and specifically disturbances of one-carbon metabolism, in the heightened susceptibility of Indians to diabetes at a younger age, and in the absence of generalized obesity (Kulkarni et al., 2007; Yajnik et al., 2014; Yajnik and Deshmukh, 2012; Yajnik et al., 2003; Yajnik et al., 1995). The Pune Maternal Nutrition Studies have highlighted the body composition and nutritional-metabolic peculiarities of multigenerationally undernourished Indians: a thin-fat (low lean mass, high fat mass) phenotype compared to Europeans, with predominant visceral deposition of fat. This body composition is strongly associated with insulin resistance and related metabolic-endocrine abnormalities. Importantly, this ‘thin-fat’ phenotype was present at birth and therefore, programmed during intrauterine life, possibly through epigenetic mechanisms over multiple generations. Maternal intergenerational undernutrition, evident in stunting, low BMI, and a disturbance of dietary methyl donors (low protein and vitamin B12 and high folate status related to vegetarian food habits) appear contributory to the increased risk of diabetes and CVD in Indians (Yajnik, 2004; Yajnik and Deshmukh, 2012; Yajnik et al., 2008; Yajnik et al., 2003). It is now well-appreciated that the intra-uterine environment can induce heritable alterations that may be retained over generations (Aiken and Ozanne, 2014; Good speed et al., 2014; Ng et al., 2010). A primate maternal high-fat diet supplemented with calorically dense treats leading to obesity has been shown to epigenetically alter chromatin structure in their progeny via SIRT1 mediated covalent modifications of histones (Aagaard-Tillery et al., 2008; Cox et al., 2009; Suter et al., 2012). Increased adiposity and insulin resistance have also been reported in high fat diet fed rodent models. Intra-uterine programming may involve epigenetic changes, which are passed over generations, and may promote the development of adiposity and T2D. Recently, we demonstrated (cover story; August 2015 issue of Cell Metabolism) that the metabolic effects introduced over multiple (50) generations of undernutrition cannot be reversed after two generations of unrestricted access to nutrients. Undernourished rats demonstrated low birth-weight, high visceral adiposity (DXA/MRI), and insulin resistance (hyperinsulinemic-euglycemic clamps), compared to age/gender-matched Control rats. Relative to Controls, Undernourished rats had higher circulating insulin, homocysteine, endotoxin and leptin levels, lower adiponectin, vitamin B12 and folate levels, and an eight-fold increased susceptibility to diabetes, after Streptozotocin (STZ) exposure. These metabolic abnormalities were not reversed after two generations of recuperation. Adverse epigenetic (histone modification) profiles in insulin gene promoter region of Undernourished rats are not reversed following two generations of macro-nutrient availability and might explain the persistent detrimental metabolic profiles in similar multigenerational undernourished human populations. One of the major strengths of this study is that the current animal model of diabetes was not generated by genetic manipulations but rather by feeding Control rats with an undernourished died for 50 generations (over 12 years) and then a normal diet for two generations. The Undernourished rats showed visceral adiposity and were less sensitivity to insulin. They also demonstrated several markers of metabolic disease. In order to correct this state, we allowed Undernourished rats to have unrestricted access to Control chow and water (now called as “Recuperation” rats). Recuperation rats, surprisingly, show increased visceral adiposity, continue to be less sensitive to insulin, and have the same level of diabetes susceptibility as Undernourished rats. Analysis of epigenetic signatures at insulin gene promoter region in the pancreatic islet cells confirms that although a slight improvement is seen in histone modifications as well as the recruitment of histone methyl transferases at the insulin gene promoter region, two generations of normal nutrient availability is in itself not sufficient to reverse the epigenetic changes to Control levels. These studies underscore the importance of epigenetic regulation of gene expression and indicate that micronutrient or other appropriate supplementation should be considered in dietary intervention studies on populations that have faced undernutrition over multiple generations. I will present our recent data from animal models as well as our data from two independent clinical cohorts; first, the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial of around 10,000 Type 2 diabetic individuals followed over 12 years and secondly, the Pune Maternal Nutrition Study comprising of around 700 women and their babies over a period of 18 years of follow-up. Our studies (Discovery Analysis of MicroRNAs in Gene-Environment Interactions: DAMAGE-I study) involve analysis of DNA methylation changes (using the Illumina 450 K methylation arrays), GWAS analysis (using the Affymetrix platform), Telomere length assay (using quantitative real-time PCR) and microRNA analysis (using high throughput high sensitivity real-time TaqMan-PCR panels/chips, in addition to several (over 100) clinical biomarkers. Studies are also in progress to understand the role of gut microbiota – our inner environment that significantly influences human physiology. These studies demonstrate that the change in diet and lifestyle (urbanization) leads to significant changes in the short-chain fatty acid-producing gut bacteria and influence our lifestyle through epigenetic programming of gut cells. Overall, the studies discussed above, demonstrate the potential for integrative research technologies that we have used in understanding newer molecular biomarkers of diabetes and cardiovascular health and will allow future application of these molecular biomarkers to understanding the progression of diabetes and its complications in other (non-Australian) cohorts of at-risk of diabetes individuals worldwide. Hopefully, these technologies will help in better understanding the progression of Diabetes in individuals at risk of diabetes, provide newer tools to clinicians for predicting treatment efficacies and patient stratification and enable the development of newer and effective strategies to manage and cure diabetes.

Declarations

The current research discussed here is funded via three different grants to Professor Hardikar from the Australian Research Council (ARC), the National Health and Medical Research Council (NHMRC) and the Juvenile Diabetes Research Foundation (JDRF). Professor Hardikar is also on the advisory committee for Abbott Pharmaceuticals in relation to a probiotic formulation that has the potential for improving metabolic health in diabetes.

Chicken meat from the shelves of supermarkets in Qatar was tested for the presence of Camplobacter spp., and the presence of five virulence genes (htrB, cdtB, clpB, cadF and ciaB) was assessed in isolates. Forty eight percent of the chickens provided for supermarkets by Saudi (53%) and Qatari (45.9%) producers were found to be contaminated and the most important factor affecting the overall prevalence of contaminated chickens was the store from which chicken samples originated. Variation in prevalence of Camplylobacter in chicken meat from different stores was evident even when the same producer supplied the three stores in our survey. Differences in the prevalence and in the combinations of virulence genes in isolates that can and cannot grow in a classic maintenance medium (karmali) were identified, providing a starting point for linking presence/absence of particular virulence genes with actual in vivo virulence and pathogenicity. Because of the relatively low infective doses of Canpylobacter that are required to initiate infection in humans, it will be important to explore further the relationships we identified between certain Campylobacter virulence genes and their capacity for survival in poultry meat, and hence their contribution to the incidence of campylobacteriosis.

The expansion of fat mass in the obese state is due to increased adipocyte hypertrophy and hyperplasia. Knowledge on what drives adipocyte hyperplasia in obesity remains limited. SIRT1, a key regulator of mammalian metabolism, maintains proper metabolic functions in many tissues counteracting obesity. By stably knocking down SIRT1 in mouse 3T3-L1 preadipocytes, we demonstrate that SIRT1 is a key regulator of proliferation in preadipocytes and mitotic clonal expansion (MCE) in differentiating adipocytes. Quantitative proteomics reveals that the p53 pathways is altered to drive enhanced proliferation in SIRT1 knockdown preadipocytes. Moreover, p53 is hyperacetylated, p27 is reduced and CDK2 is activated in SIRT1-silenced preadipocytes. Remarkably, differentiating SIRT1-silenced preadipocytes exhibit enhanced MCE accompanied with reduced p27, increased C/EBPβ, and also have hyperacetylated p53, leading to hyperplastic and dysfunctional adipocytes. Better understanding of the molecular mechanisms of adipocyte hyperplasia will open new venues towards understanding obesity.

Background

Morbidity and premature mortality associated with exposure to secondhand tobacco smoke (SHS) represent a major global public health burden, and SHS exposure arising from all sources is responsible for an estimated 600 000 premature deaths. 1 The adverse health effects associated with waterpipe (WP) SHS exposure have been less well investigated compared with cigarette SHS. 2 Nonetheless, evidence shows that WP SHS contains similar tobacco-related toxicants as cigarette SHS, including more than 60 carcinogens, and fine respirable suspended particles, which can be deposited deep into the lung. Article 8 of the WHO's Framework Convention on Tobacco Control (FCTC) requires party nations, in part, to adopt, implement and actively promote effective legislative or other measures to protect the public from exposure to secondhand smoke in indoor workplaces and public places. In 2002, Qatar adopted smoke-free legislation that prohibits cigarette smoking inside public venues. 12 Although fines ranging between QAR200 and QAR500 (approximately US$55–US$137) may be imposed, the clean indoor air law is seldom enforced in Qatar. Tobacco WP use has recently experienced a marked increase in popularity in Middle Eastern and South Asian countries, where it has been a traditional form of tobacco use since at least the mid-17th century. 15 The tobacco WP, also often referred to as ‘shisha’ in Qatar and many Middle Eastern countries and ‘hookah’ in western countries, heats highly flavoured, moist mo'assel tobacco. One factor that may contribute to the popularity of WP use is the perception of lowered risk of WP smoking, compared with cigarette smoking. Objective data on indoor air quality in public venues in Qatar have not previously been reported. Air quality measurements in public venues have now been conducted among a substantial number of jurisdictions internationally to help promote smoke-free policy development and assess legislative compliance. 28 The purpose of this investigation was to measure respirable suspended particulate matter of 2.5 μ or less (PM2.5), a marker for SHS, in WP cafes in Qatar's largest city, Doha. The small size of PM2.5 emissions, which arise from combusted tobacco, allow them to be easily inhaled and deposited deep within the lungs, contributing to serious respiratory and cardiovascular diseases. Methods Particulate matter (PM2.5) levels were measured inside and outside of a sample of 40 waterpipe cafes and 16 smoke-free venues in Doha, Qatar between July and October 2012. In addition, the number of waterpipes being smoked and the number of cigarette smokers were counted within each venue. Non-paired and paired sample t tests were used to assess differences in mean PM2.5 measurements between venue type (waterpipe vs smoke-free) and environment (indoor vs outdoor).

Results

The air quality in 40 WP cafes (smoking venues) was measured for a mean duration of 35.6 min (SD = 3.7). The mean internal volume of smoking venues (365.8 m³, range = 85–1449) tended to be smaller than that of non-smoking venues (682.1 m³, range = 34–3120), although the difference was not statistically significant (t(52) ≤ 1.0, p = 0.90). The smoke-free venues were monitored for a mean duration of 35.4 min (SD = 8.5). Active smoking of WPs and cigarettes was observed in all 40 smoking venues with more WP smoking being observed. The mean number of WPs observed in active use was 9.4 (range = 0.7–27.3), while the mean number of cigarette smokers observed was 1.5 (range = 0.3–4.6). The mean WP ASD (mean = 0.035 smokers/m³; SD = 0.027) was significantly greater than the cigarette ASD (mean = 0.006 smokers/m³; D = 0.005: t(39) = 16.0, p < 0.001). No active smoking (WP or cigarette) was observed inside the smoke-free venues. The mean PM2.5 level inside the 40 WP cafes (mean = 476.1 μg/m³; SD = 309.6) was significantly higher than the mean PM2.5 level found immediately outside these venues (mean = 34.5 μg/m³, SD = 11.6; t(39) = 25.7, p < 0.001). PM2.5 levels inside the smoking venues also were significantly higher than inside the smoke-free venues (mean = 16.8 μg/m³, SD = 12.1; t(54) = 16.9, p < 0.001). Mean PM2.5 levels outside the smoke-free venues (mean = 30.3 μg/m³, SD = 33.4) were significantly higher than the levels observed inside those venues (t(15) = 3.4, p = 0.003). The proportion of active WP smokers, as a per cent of total smokers WP + cigarette), ranged from 58? to 97?. There was a significant positive correlation between PM2.5 levels and WP ASD (r = 0.38, p = 0.015), but not with cigarette ASD (r = 0.20, p = 0.223). ASD for the non-smoking venues was 0.

Conclusions

The mean levels of fine particulate pollution observed among a sample of WP cafes in Doha, Qatar were found to be significantly higher compared with smoke-free venues. Particulate levels were also more than 13-fold greater inside WP cafes, compared with outside these venues. To contextualise the observed PM2.5 levels, the WHO has set an air quality guideline for 24 h exposure of 25 μg/m³. 32 While patrons and staff are not likely to experience 24 h exposure, exposure to the levels observed here for just a few hours a day is likely to comprise a serious health risk in the longer term. These data reveal that the exemption for WP cafes in Qatar's smoke-free legislation has resulted in environments that are unsafe for workers and the public. As such, further actions and amendments for the law are needed. In 2013, after the completion of data collection for the present study, the Qatari Supreme Council of Health started working on introducing amendments to the smoke-free law of 2002. The amended smoke-free law is intended to provide more comprehensive protections and will prohibit all types of indoor smoking in public places, including WPs, and increase fines for non-compliance. Further, Qatar has succeeded in banning tobacco advertisements and promotions. These actions provide an excellent opportunity to ensure that implementation and enforcement of the new law is performed optimally. Future research should investigate the short-term impact of banning WP smoking on air quality and SHS exposure, and, in the longer term, the potential for changes in social norms and the relationship to the prevalence of use and health outcomes. The current investigation adds to the growing literature on the contributions of WP SHS on indoor air quality. Qatar has demonstrated its intent to protect the public from the dangers of SHS by enacting its smoke-free legislation, and by ratifying the FCTC. However, SHS remains a major contributor to elevated levels of PM2.5 in WP cafes. Comprehensive smoke-free legislation, which applies to all venues and for all combusted tobacco products, is a welcome development in the tobacco control policy of Qatar. If implemented and enforced appropriately, the experience of Qatar may serve as an example to the wider EMR. These data provide further evidence for policymakers that indoor WP use threatens to undermine the potential benefits of tobacco control policies in the Middle Eastern region and other countries in which WP use is a popular practice. Comprehensive indoor smoking bans, which do not exclude WP use, are needed to address a significant flaw in the smoke-free laws of some jurisdictions.

Introduction

Violence is an important public health problem that may be seen in every part of the life and has been increasing in the world. World Health Organization (WHO) defines violence as: “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation”. Violence exposure can lead to: Mental disorders such as anxiety, depression and posttraumatic stress disorder (PTSD).Behavior, Cognitive and social problems such as social withdrawal, alienation, poor academic functioning. ∅ Physical effects such as cardiovascular strain, fatigue, reduced immune response. Age limit of Youth “Time in a person's life between childhood and adulthood. The term “youth” in general refers to those who are between the ages of 15 to 25.” - World Bank Youth… those persons between the ages of 15 and 24 years.” - United Nations General Assembly. Objective of the research paper: ∅ To estimate the prevalence of symptoms of psycho-social disorders and problems among youths due to exposure to violence in Iraq. Iraqi youth and violence For more than three decades, the Iraqi nation as a whole has been suffering from wars, sanctions and violence. The Iraqi children and youth have been so greatly affected by these dire conditions especially after 2003 and mostly deteriorated since 2006. Research documented that the violence is the main cause of death in men between the age of 15 and 59 years during three years after 2003 invasion. Pre-invasion mortality rates were 5.5 per 1000 people per year compared with 13.3 per 1000 people in the 40 months post-invasion (after 2003 war). A household survey of Iraq that conducted in 2006 has found that approximately 600,000 people have been killed in the violence of the war that began with the U.S. invasion in March 2003 and gunfire remains the most common reason for death, though deaths from car bombing. The 2006 bombing of the Askirya shrine in Samarra, and the widespread sectarian violence that followed, displaced 1.6 million persons within Iraq. In a survey which was conducted by the International Organization for Migration and the Iraqi Ministry of Displacement and Migration (2008) found that there are more than 177000 internally displaced families and the reasons most commonly given by internally displaced persons (IDPs) for displacement were direct threats to life (61%), presence of generalized violence (47%), and fear (40%). An estimated 1 million of Iraq's displaced persons were without adequate access to shelter and food, and an estimated 300000 are without access to clean water. The UNHCR estimated that Iraq has 1.13 million internally displaced persons in 2013, and a total population of concern of 2.2 million. Refugees International put the number at 2.8 million. The condition is much deteriorated after 10 June 2014, Mental disorders among Iraqi youth - Posttraumatic stress disorder (PTSD): Posttraumatic stress disorder (PTSD) is a syndrome that develops after a person sees, involved in, or hears of an extreme traumatic stressor. The person acts to this experience with fear and helplessness, persistently relives the event, and tries to avoid being reminded of it. To make diagnosis, the symptoms must last for more than a month after the event and must significantly affect important areas of life such as family and work. The life time prevalence of PTSD is estimated to be about 8 percent of the general population. The more vulnerable categories for post-traumatic stress disorder (PTSD) attacks are children and young people, females (widows and divorcees). Prevalence of PTSD among Iraqi youth: According to certain academic studies which were conducted in different regions of Iraq (that have experienced high levels of violence and military operations), about 25% of youth have symptoms of PTSD. The table (1) shows prevalence of PTSD among Iraqi youth Region PTSD % Year of study Baghdad 26.43% (males: 17–19 years) 2012 Baghdad 22.9% (18–24 years) 2010 Erbil* 26.5% *(Among youth of displaced families) 2008 Mosul 22.13% 2007 Diyala 27.4% (12–18 years) 2006 - Depression which is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration. The percentage of depressive symptoms among university student in Baghdad (2010) was more than 35%; the violence was the leading cause for symptoms of depression. A recent study which was conducted during 2013–2014, showing that percentage of youth (18–25 years) in Baghdad with depression feeling was 41%, among of them 16% had thoughts that would be better off dead, or of hurting in some way. Social problems: Exposure of violence and academic performance. Through a study which was conducted in 2010 on a sample of students from the University of Baghdad (for ages between 18–24 years) found that 30% of them had history of academic failure during their studies earlier, and there was a strong association between violence exposure and history of academic failure – among of these trauma exposure: threat of assault, kidnapping and displacement. Substance abuse Research documented that alcohol and drug abuse may have increased in Iraq since 2006–2007. This apparent increase may be due to increased availability of substances and more traumas experienced by the population. A study was conducted in 2009, showing that the prevalence of alcohol and drug abuse among youth (18–23 years) in Baghdad was 10.7% and 4.9 % respectively.

Conclusion

Iraqi youth are facing very real dangers of diseases, starvation, psychosocial - physical disorders and death due to military operations and terrorism. The real problem What has been mentioned of the figures is an alarm (snapshot) attempting to shed light on the current psychological and social problems which faced by the people especially the youth in Iraq. The important fact is the psychological effects may continue to next generations. The real problem is lack of wide national studies and statistics to document the effects of direct and indirect exposure to wars, military operations and violence against civilians, and thus lack of scientific programs for community development and therapeutic strategies at the official, local or international organizations levels. With ongoing violence, the health system is heavily focused on curative and trauma care, leaving public health programs less supported. Iraqis have witnessed a depletion of social capital, which led to social deprivation in most sectors of the society. Recommendation Urgent need for further wide scale national researches to explore the long term effect of violence exposure on Iraqi population. Establish programs for building resilience among most vulnerable groups (children, youth, and women) via cooperation of national and international organizations that concerned with such subject…Establish mental and social health support centers, especially in the governorates that exposed to high level of violence and military operations…Need the efforts of activists in the field of human rights -individuals and organizations - to claim for compensation about physical and psychological disorders that resulting from the US occupation of Iraq.

Introduction

The prevalence rate of Autism Spectrum Disorder (ASD) in Qatar is uncertain, obtaining a reliable estimate is important in shedding the light on the magnitude of the problem, and help in better planning for providing the health care facilities needed for early detection and management of this disorder, since early intensive rehabilitation can improve the outcome of those affected tremendously.

Aims of the study

To estimate the prevalence rate of ASD among children age 5–12 years residing in Qatar.

Methodology

The research plan is to identify children with possible ASD among children attending ordinary primary schools as a “Low Probability Group”, through using the Social Communication Questionnaires (SCQ), and those who score above the cut-off point will be further diagnosed using the Autism Diagnostic Interview-Revised (ADI-R) and/or the Autism Diagnostic Observation Schedule-2 (ADOS–2).

Results

We worked on translating the English version of SCQ to Arabic, and we worked to validate this version through a pilot screening study that involved 35 cases of ASD and 778 controls from the schools. The pilot sample includes 813 (35 cases of ASD and 778 control children). The control children were selected in 8 schools, 3 for girls, 3 for boys and 2 mixed, between 14/6/2015 and 28/6/2015. The ASD children surveyed with the SCQ were selected from the Shafalla Center (N = 35). The boy: girl ratio was 4.0:1 (61/41; 80% male) in the ASD group. In the control group, the corresponding values were 0.59:1 (287/488; 35.9% male). The mean SCQ total score was significantly higher in cases as compared to controls (18.06 (SD = 7.2) vs 7.31 (SD = 5.2); p < .0001); as expected, the variability was larger in cases than in controls as illustrated by the standard deviations. Figure 1 shows the distribution of the SCQ scores in the total sample, and the distribution separately for cases and controls. A total of 93 children (22 cases, 71 controls) had scores equal or above the cut-off of 15; the remaining 13 cases (37.1% of the cases) had scores below the cut-off.

Conclusions

The analysis to examine the overall performance of the SCQ showed excellent discrimination between cases and controls. An examination of the performance for each possible cut point on the SCQ showed that the sensitivity and specificity were optimal for the cut-offs of 10, compared to the published cut-off of the SCQ (15).

Two boys with Autism Spectrum Disorder (ASD) from two unrelated consanguineous families of Arabic origin were studied by Whole Genome Sequencing (WGS) together with their parents. Thugs data of the X chromosome were analyzed to identify possible predisposing, recessive and/or de novo, X-linked variants. Comparative analysis of the WGS data for X-linked de novo inheritance identified no variants, while the recessive inheritance analysis identified the following three strong candidate gene variations, in order of priority; Family 1: IL1RAPL2c.206G>C/p.S69T; Family 2: SHROOM4 c.3370C>G/p.Q1124E, and SYTL5c.1370G>A/p.R457Q. All variations found to be damaging and conserved, validated by Sanger Sequencing, co-segregate with the disease phenotype within each family and are absent in known polymorphism databases, as well as in 1800 ethnically matched control chromosomes, genotyped by TaqMan assays and Real-Time PCR. For the Comparative Analysis, the CLC Genomic Workbench Software package was used, as well as the in-house pipeline, setting the MAF cutoff at 1% and including data for pathogen city, conservation, protein effect, variants databases and so on. In Family 1: IL1RAPL2 is associated with non-syndromic X-linked ID and/or ASD and the proteinis detected at low levels in fetal and adult brain (particularly in the frontal lobe, temporal lobe and cerebellum). In Family 2: SHROOM4 plays a role in cytoskeletal architecture and it is considered an XLMR gene, as mutations have been linked to Stocco dos Santos Syndrome. Deleterious mutations might affect the morphology of the neural cells and eventually the neural development. The SYTL5 encoded protein belongs to the synaptogamin-like protein family and seems to play a role in protein transportation in specific tissues, as it is expression is restricted to placenta and liver. Maybe during embryonic development its expression is required for downstream gene control that plays a role in neural development. Genes function and suggested mechanisms, as well as the absence of the mutations from the ethnically matched control population and publically available databases, indicate that these novel rare variants identified are strong candidates for predisposition to the development of ASD. Future studies on transcriptome analysis and gene expression will enable to confirm the indications and the mechanisms might justify their involvement to ASD.

Desert truffles are an obligate hypogenous ectomycorrhizal fungi in association with host plant roots Helianthemum sp. and are of socioeconomically important and naturally grown in the Middle East, North Africa, Southern Europe, Mediterranean countries including Arab Gulf countries. Truffles are edible and a rich source of protein and various chemical compounds and traditionally have been used as folk medicine in the Arabian countries. The last decade has witnessed an increase research interest focused on the biosynthesis of metal nanoparticles using fungi as natural sources and as a good tool in nanobiotechnology. Nevertheless, recently metal nanoparticles have been widely applied in multidisciplinary fields including medical and pharmaceutical applications. Among nanometals, silver nanoparticles are of great significance to be used in pharmaceutical aspect as antimicrobial agent. According to our knowledge little information so far is available regarding biosynthesis of silver nanoparticles by the truffles and to search for new antimicrobial alternatives, therefore, the objective of this study was to explore the desert truffle (Tirmania nivea) for its potentiality to biosynthesize silver nanoparticles (AgNPs) and to examine their efficacy against five strains of human pathogenic bacteria namely; Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Salmonella typhi and Staphylococcus aureus. Fruiting bodies (Ascocarps) of the truffle T. nivea were collected from the sandy desert of Iraq and brought to the laboratory, washed thoroughly with distilled water and dried at room temperature. Twenty gram of dried fruit bodies of truffle were grounded and dissolved in boiled water and filtered using Whatman filter paper No 1. For synthesis process of silver nanoparticles, 100 mL of truffle extract filtrate was treated with 1 mM of AgNO3 solution and kept for 24 hr at dark condition and synthesis of silver nanoparticles (AgNPs) was checked by visual observation of color changes from pale yellow to dark brown and was further confirmed by UV – Vis spectrum. Fungal filtrate without AgNO3 was maintained as control. The potentiality of silver nanoparticles was examined for their antibacterial efficiency using agar well diffusion method against the selected strains of pathogenic bacteria. Wells (5 mm diam) were made in Muller-Hinton agar (MHA) plates streaked with swabs of each bacterial strain. The wells were loaded with two concentrations (50 and 100 μl) of synthesized silver nanoparticles solutions, incubated at 37 °C for 24 hr and examined for the appearance of inhibition zones around the wells and their diameters were measured. Minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) assay was carried out using the micro dilution method with serial dilutions (100, 50, 25, 12, 6.5, 3.13, 1.56, 0.78, 0.39, 0.2, 0.1, 0.05, 0.025 μg/L) of the truffle extract filtrate against two strains of bacteria E. coli (ATCC 25922) and S. aureus (NCTC 6571). Disc diffusion method was used to assay the synergistic effect of synthesized AgNPs with commonly used antibiotic Gentamycin. Cytotoxicity of the truffle extract was examined against human blood. Characterization of the biosynthesized silver nanoparticles from truffle extract was carried out by using UV-Vis spectrophotometer analysis, Fourier transform infrared spectroscopy (FTIR) and scanning electron microscope (SEM). The results showed that the biosynthesized silver nanoparticles exhibited a high growth inhibition activity at 50 μl/ml concentration (12–25.5 mm inhibition zones dim) and at 100 μl/ml (14.5–28 mm inhibition zones diam) against the tested pathogenic bacterial strains. Among the tested bacteria, highest growth inhibition was noticed against P. aeruginosa (25.5 and 228 mm diam) at the two concentrations of AgNPs, respectively. However, a remarkable increase of bacterial growth inhibition zones (23–37 mm diam) was observed for a combination of silver nanoparticles and Gentamycin compared with Gentamycin alone (20–30 mm diam). MIC values were very low (0.312 and 0.0097 μg/ml) against the two tested bacterial strains E. coli and S. aureus, respectively. The truffle extract did not show any toxicity against human blood. UV-Vis spectrophotometer analysis revealed a peak at 420 nm indicating the biosynthesis of silver nanoparticles, FTIR analysis verified the detection of protein capping of biosynthesized AgNPs while SEM images showed that the synthesized silver nanoparticles are dispersed or aggregated and mostly spherical shape and their size ranging between 3–41 nm. It can be concluded that the biosynthesized silver nanoparticles by the desert truffle T. nivea are a promising for future medical and pharmaceutical applications as antibacterial agent and a further investigation to examine their efficacy in vivo is recommended.

Within the field of biomedicine, the scope of alginate application is broad and includes: wound healing, cell transplantation, delivery of bioactive agents such as chemical drugs and proteins, heat burns, acid reflux, and weight control applications. Recently the alginate based biomaterials for the treatment of myocardial infarction are entering into the advanced clinical trials stage. The non-thrombogenic nature of this polymer has made it an attractive candidate for cardiac applications, including scaffold fabrication for heart valve tissue engineering. The next pivotal property of alginates is their ability to form films, fibers, beads and virtually any shape in a variety of sizes. Moreover, alginates could form the gels in mild conditions, for example by adding calcium salt to an aqueous solution of alginate. The calcium ions displace the sodium from the alginate, and grasp the long alginate molecules together, resulting in a gel. This property is a base for obtaining the alginate scaffold with complex geometry of the aortic heart valve, in a few easy steps. These steps could be freely adjusted to yield the structure consenting precisely allocated viable cells. Alginate scaffold preparation was carried out by immersing the agarose mold saturated in CaCl2 solution (2% w/w). The calcium ions diffused form the mold and cross-linked alginate, subsequently the mold was removed. Obtained structure closely matched the mold geometry. The mold was made by casting the agarose into the 3d printed form. Moreover by extending the time of mold immersion into the sodium alginate solution, the thickness of scaffold and its composition can be controlled. The details of the process are discussed in this report. The drawback of alginate is that it yields relatively soft mechanically unstable structures. As reported elsewhere, that could improve if the scaffold will be saturated with viable proliferating cells. Alternatively the hydrogel can be reinforced by polymeric yarns.

Plaques that build up in the lining of the coronary arteries are made up of lipids, inflammatory cells, smooth muscle cells and connective tissue. Thormbosis of a not necessarily occlusive but unstable plaque most often causes episodes of unstable angina and myocardial infarction (MI). Preventing this sudden and adverse event seems to be the only effective startegy to reduce mortality and morbidity of coronary artery disease (CAD). Countries in the Middle East bear a heavy burden from cardiovascular disease. The population of Qatar is particularly prone to CAD with patients presenting with MI at a young age. The prevalence of CAD is in turn promoted by risk factors such as smoking, hypertension, dyslipidemia, diabetes and sedentary lifestyles. Metabolomics approaches to the identification of disease biomarkers rely principally on the comparitive analysis of metabolite expression in normal and disease patients, animal models or cell cultures to identify aberrantly expressed proteins or concentration changes in metabolites that may represent new biomarkers or elucidate a disease mechanism. Lipidomics is the global identification and quantification of a diverse range of lipids in biological systems and is a subset field in metabolomics. The eukaryotic lipidome might compise of 10,000 to 100,000 individual species of lipids originating from a few hundred lipid classes. These lipids are distributed as part of biological membranes, energy storage substances and sometimes function as signal transducers. Altered lipid metabolism and dyslipidemia in the context of inflammation and oxidative stress are driving forces in the transition from stable to unstable plaques. Therefore, a characteristic lipid signature within unstable human plaques and also in the circulating blood plasma could be a predictor of an oncoming cardiac event. This ongoing study was conducted on samples volunteered by acute coronary syndrome (ACS) patients at the Heart Hospital, Doha, Qatar. ACS is a term that describes any condition brought on by the sudden reduced blood flow to the heart due to thrombosis in the coronary arteries and encompasses unstable angina (UA) and both ST-segment elevation (STEMI) and non ST-segment elevation myocardial infarction (NSTEMI). A complete occlusive thrombi leads to extensive myocardial cell death and typically produces an elevated ST-segment in the electrocardiogram. In UA, ischemia occurs unpredictably and suddenly and is caused by the temporary formation of blood clots within the coronary arteries. Unstable angina often occurs before a MI. Distinguished from ACS are patients with stable angina (SA) who develop symptoms due to exertional ischemia. The aim of this study was to profile the global individual lipid levels of subjects in Qatar with unstable CAD, comparing global lipid levels between patients with unstable angina and ST-elevated myocardial infarction. We chose to discover the lipid biomarkers using a workflow utilizing tandem mass spectrometry with on-line ultra-high pressure liquid chromatography (UPLC-MS/MS). Mass spectrometry is a powerful technique that can be used to identify unknown compounds, to quantify known materials and to elucidate the structure and chemical properties of molecules. Recent advances in the accuracy and speed to the technology allow data acquisition for the global analysis of proteins, lipids and metabolites from complex samples such as blood plasma or serum. As we were trying to discover a new lipid biomarker, a technique that would maximise the number of compounds detected, identified and quantified them was favourable. Once the samples were analysed by tandem mass spectrometry, the ion intensity data from each sample was aligned with each other by retention time and lipid mass, normalised and deconvoluted. The signals were then attributed to a particular lipid species by utilising a lipid database and comparing the mass of the detected lipid and piecing together information gained from the fragment data of that lipid from the orbitrap. Statistical analyses of the signals for each individual lipid were then conducted by comparing within group percent coefficient of variation (?CV), fold change and analysis of variance (ANOVA) tests between sample groups and q-value and power calculations. Principal component analysis (PCA) was conducted in order to differentiate the samples under supervised conditions into STEMI and UA groups. A total of 1,663 and 874 lipid compounds were identified in positive and negative modes of mass spectrometry respectively. Of these, 7 compounds showed a significant change (ANOVA p-value <  or equal to 0.001) between the STEMI and UA groups. The identities of these compounds are yet to be elucidated. Of the compounds with a significant change between sample groups of ANOVA p-value <  or equal to 0.005, five compounds were able to be identified by mass and spectral matching with a lipid database. The PCA scores plot, which distributes samples in multi-dimensional space according to the variance seen in each principal component, showed very low evidence of discrimination between the sample groups with sample scores clustered in a single mixed pattern. This analysis suggests that the lipid abundance changes between the sample groups were difficult to find. This was most likely due to a combination of two reasons: (1) large within-group biological variance that needs to be overcome to detect the between-group variances and (2) the low differences in lipid concentrations between the sample groups. With a greater number of samples, this results is expected to change as the power of the study would increase. Successful results obtained from this study will aid healthcare professional in intervening with appropriate treatment in persons showing no symptoms but are under threat of developing angina or acute MI. The discovery of a lipid biomarker could assist healthcare professionals in prevention of an acute cardiac event thereby saving lives.

Recently multiple examples of applications of knitted fabrics in HVTE were reported. One of the most frequently citrated strategy was developed in Mela's group. In that case, the fibrin constituting the leaflets of valves is enforced using a warp-knitted tubular mesh, made out of polyethylene terephthalate (PET). In all reports, the authors evaluated biocompatibility of the construct by encapsulating the cells in the fibrin gel constituting the leaflets and quantifying the secreted ECM proteins. Other authors reported that in vivo implantation with fibrin-based tissue-engineered heart valves revealed an absence of calcification, thrombus formation, aneurysm development or stenosis. After 90 days of implantation, it was also observed that a monolayer of endothelial cells was formed, which exhibits the promise of fibrin scaffolds for HVTE. This approach is potentially adaptable for the intelligent scaffold development, which will require replacing non-degradable yarns with bioresorbable yarns. This would be necessary since in the smart solutions; the synthetic yarns need to be finally absorbed and replaced by extra cellular matrix proteins, deposited by in situ recruited cells. PET is not a bioresorbable material, thus alternative strategies need to be proposed to enable growth of valve tissue within the patient. The solutions proposed by Mela and colleagues are promising and encourageable. Inspired by these reports, we fabricated valve leaflets using spatial PET knitted fabric. The construct obtained very closely matched the histological structure of leaflets with 3 layer architecture. This is already important accomplishment towards scaffold closely matching architecture of native valves. The future steps will involve replacing PET with polycaprolactone yarns to enhance construct biocompatibility.

Background

According to the World Health Organization Report on Tuberculosis in 2013, it is estimated that 9 million people developed tuberculosis and 1.5 died of the disease. In Qatar, the incidence of tuberculosis is the highest in the Gulf countries but this mainly depends on migrant laborers from countries with high incidence, especially Nepal, India, and the Philippines. It is important to consider that only India contributes with the 25% of the global burden of tuberculosis. Among the strategies for the prevention and control of tuberculosis are included measures to promote the early diagnosis and the compliance with treatment. The delay in the diagnosis has a critical role in the control of tuberculosis and it constitutes a threat for the community and it worsens the prognosis for the patient's improvement in the clinical status. In a literature review of 52 studies, Sreeramareddy CT et al reported that (median or mean) total delay, patient delay, healthcare system delay for diagnosis of tuberculosis were ranging from 25 to 185 days, 4.9 to 16.2 days and 2 to 8.9 days respectively. The overall average patient delay was similar to health system delay (31.03 versus 27.2 days). According to a multinational study about diagnostic delay carried out in the Eastern Mediterranean Region (EMR) in 2003–2004 the mean duration of delay between the onsets of symptoms until treatment with anti-tuberculosis drugs ranged from one month and a half to 4 months in the different countries. The mean delay was 46 days in Iraq, 57 in Egypt, 59.2 in Yemen, 79.5 in Somalia, 80.4 in the Syrian Arab Republic, 100 in Pakistan, and 127 in the Islamic Republic of Iran. This report comments that the infection control programs are able to detect an average of one third of smear-positive tuberculosis cases, while the rest continue to transmit infection in the community until treated, whether adequate or inadequate by other health sectors. Recently published papers report total diagnosis delay of 60 days (Porto Alegre and Yemen, 2013), and 36 days (Guimaraes, 2015), patient delay of 15 days (Brazil, 2013 - Porto Alegre, 2013) and system delay of 15 days (Croatia, 2013) and 18 days (Porto Alegre, 2013). No previous reports have been published about the topic in Qatar. Based on the previous information and on the national goal for prevention and control of communicable diseases we considered necessary to conduct an epidemiological research to describe the diagnostic delay in tuberculosis, as an initial step for a population-based study.

Objective

– To identify the diagnostic delay in patients with tuberculosis and to describe the patient and healthcare system components.

– To test the method of collection of information for the design of a population-based study.

Methods

An exploratory study was carried out in 49 newly diagnosed tuberculosis patients admitted to a hospital facility during the period of May-October, 2015 Criteria for inclusion:

– Patient who accepts to answer the questions during a regular clinical interview.

– Patient with a clinical status who allows the interview, regardless of the type of tuberculosis (pulmonary or extra pulmonary) Criteria for exclusion

– Unstable clinical status that interferes with a proper communication

– Language barrier that could not be overcome due to unavailability of interpreter for any specific language.

Procedure During the admission period, and during the regular clinical evaluation, the patients answered the study questions. The interview was conducted by a nurse, using an interpreter if considered necessary. It was collected information about the first time the patient arrived in Qatar and the date of onset of symptoms related with tuberculosis. If the patient visited an outpatient or emergency department of another healthcare facility during the symptomatic period and before the admission, it was defined the date and the type of facility (primary level facility, hospital facility) and if the treatment recommended included antibiotics. The date of diagnosis was considered to be the date of the collection of the confirmatory laboratory test (acid fast bacilli or GeneXpert PCR positive for mycobacterium tuberculosis complex in clinical samples).

Definitions

– Patient delay was considered as the time between symptoms onset and first contact with the healthcare system, regardless the category or level of care provided by the facility (primary healthcare facility, hospital).

– System delay was considered as the time between the first contact with the healthcare system and the diagnosis.

Analysis

Data were entered in JMP 10.0 (SAS Institute, http://www.jmp.com). Descriptive statistical methods were used. Median and percentile distribution was calculated for patient and healthcare system delay, and boxplot graph was obtained. The interquartile range [IQR] was calculated (Q3 – Q1).

Results

The patients have lived in Qatar a mean time of 5.5 years, with a maximum of 32 years. All patients were confirmed with pulmonary or pleural tuberculosis by means of a smear positive for acid fast bacilli, PCR positive for mycobacterium tuberculosis complex in clinical samples (sputum, pleural fluid, biopsy samples). The median total delay was 30 days (IQR 23.5 days, maximum 365 days), the patient delay was 21 days (IQR 22 days, maximum 362 days), and the system delay was 3 days (IQR 8 days, maximum 60 days). 26 patients out of 42 who visited another facility before admission (61.9%) were attended in a primary healthcare facility and 16 patients (38.1%) in a hospital facility. The 92% of these patients received antibiotic treatment for the management of the respiratory symptoms and were discharged from these ambulatory contacts. After that, due to no improvement of their clinical status they were admitted to hospital and the diagnosis of tuberculosis was confirmed. The above-mentioned results highlight the contribution of the patient component in the diagnosis delay in tuberculosis, which constitutes a significant risk for community transmission. Consequently, this finding should guide the actions for the prevention and control of tuberculosis. It is important to stand out the strengths of the tuberculosis program in Qatar, including the availability of the latest technology for its diagnosis (Gene Xpert PCR, Quantiferon TB Gold, PCR for rifampicin resistance), which is performed in a central laboratory at a national level, and a devoted Tuberculosis clinic for diagnosis and follow up with devoted staff with expertise on this field. In addition, the national law supports the free of charge healthcare services for tuberculosis patients, including the admission in hospital, anti tuberculosis treatment and follow-up.

Conclusion

Our findings provide insights about the delay of tuberculosis diagnosis and the need to identify strategies for its reduction, especially the patient component.

Recommendations

To conduct a population-based or cohort study to identify the risk factors and determinants for delay in the diagnosis of tuberculosis, including detailed information about the health-seeking behavior of patients with suspected tuberculosis.

Background

Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care (Field and Lohr 1992). Higher quality of care and improved cost effectiveness are important goals in guideline development, optimally resulting in improved health (Woolf et al., 1999). Moreover, the process of guideline development addresses the need to decrease variability in professional practice, and practitioners' desire to legitimize their profession in the eyes of external stakeholders (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). The concept of evidence-based practice, supported by clinical guidelines, is a common aspect of health care today. Currently there is no formal training or education sessions to unify the Physical therapy practice in the department, which in turn resulting in greater practice variations and results. Grater variability in professional practice directly influences the outcome of patient care. To counteract this, Physical therapy unit, Rumailah hospital, Qatar has developed Physical therapy specific clinical practice guideline called ‘PAAS Guideline’ (Physical Therapy After Acute Stroke) to enhance the effectiveness and efficiency of post acute stroke Physical therapy care. Evidence argues that guideline-adherent care results in better health outcomes, quality of care, shorter treatment period and reduced cost of care. The phase I of the PAAS G adherence trail focuses on the knowledge dissemination phase of the clinical practice guideline through a structured competency workshop and its effectiveness. ‘Physical Therapy After Acute Stroke’ (PAAS) guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care ‘exclusively’ developed by the Physical therapists of Rumailah hospital. The goal of the PAAS guideline is to improve the quality, transparency, and uniformity of the physical therapy provided to patients whose main diagnosis is a stroke (cerebrovascular accident), throughout the chain of integrated care, by explicitly describing the Physical therapist's management of these patients on the basis of scientific research, adjusted where necessary on the basis of consensus among Physical therapy experts in primary, secondary and tertiary care, as well as associated professions in the field.

Objective

To find out the effectiveness of a cost effective competency workshop in disseminating knowledge of ‘Physical Therapy After Acute Stroke (PAAS) guideline’ among physical therapist of Rumailah Hospital, Qatar Method Participants and procedure: Through the intranet system of the Hamad Medical Corporation the competency workshop was announced well in advance of the date. The workshop and the competency training were made mandatory for all the Physical therapists practicing the neurological Physical therapy of Rumailah hospital. The supervisors of other Physical therapy department were informed to select physical therapists practicing stroke physical therapy in their unit in order to coalesce the practice across the corporation.

Workshop Structure

The program offered Physical therapists free one day eight hour PAAS guideline training. Upon successful completion of the workshop (60% marks in the post competency examination), participants will receive a ‘PAAS guideline competency certificate’ of one year validity. One full day was prepared as a competency training day by cancelling all the clinical related works of that day. The essential clinical duties of the day were rescheduled to one public holiday with 2 physical therapists on overtime coverage. The cost of the program was strictly controlled with an intention to create a cost effective workshop model which can be employed even in other units. We used our gym hall as the lecture room with all the furniture and audio-visual medias of the department. A two time simple snack was provided by using unit and hospital petty cash facility. All the printing and the publication works were done using the unit internal resources. Medical corporation media was informed to cover the event. The pre and post workshop competency exam were conducted at the beginning and very end of the program with 30 minutes given to answer 20 guideline related questions. A feedback recording was taken concerning the workshop and the arrangement in a structured course feedback form.

The training

Program agenda of the workshop was announced well in advance of the date (Table 1). All the topics were the direct reflections of the PAAS guideline converted to power point presentations. The 1-day, 8 hour training was organized in a ‘constructivist didactics’ way followed by clinically relevant examples as a way to maximize active participation by the attendees. A course and session objectives and lesson plan were given before every presentation. For every five slides of the powerpoint presentation, one review question was given inorder to refresh and refocus the attendees back to the session. The conclusion was made interactive by highlighting all the key points discussed on the session and by randomly asking the attendees to expand the key words into ideas that has learned. A five minute break was given for every presentation which was used as a question and answer session. The specialists of the department of the physical therapy, conducted the training. All the training presentations were unified in there structure and content and verified for errors well in advance of the course. The PAAS guideline was made available to all the participants before the workshop. Participating Physical therapists received author-developed handouts adapted from the workshop. The guideline was presented as seven sessions covering the seven topics of the PAAS guideline. The trainers did not target training with special conclusion nor were attendees told what would be learned and evaluated at the end of the training. However, participants were encouraged to increase the number and diversity of reflections used, diminish the frequency of questions and increase the use of open questions. PAAS guideline knowledge building was the clear goal of the training, but the emphasis was on the participants understanding and amalgamation of the given evidences with the current practices and experiences they have.

Competency examination

The participants of the PAAS guideline training were required to complete a guideline competency exam at the beginning and at the end of the training. The objectives of the competency exam was to evaluate and document the percentage of knowledge acquisition by the attendees. We believed that a respectable launch of the PASS guideline implementation should begin from an effective and equally distributed knowledge dissemination process. Twenty questions were created from the eight sessions of the guideline based on the Bloom's taxonomy. PAAS competency examination was designed with 10% questions to test the knowledge domain, 20% with comprehension, 25% with application, 20% analysis, 15% with synthesis and 10% to test the evaluation skills (Fig. 1). A total 30 minutes were provided to complete the examination. Test validation As a part of test validation 3 Physical therapy specialists with stroke rehabilitation experience from different hospital background were given the designed questionnaire and were asked to mark any questions that were unclear to them when they were taking the test. After the test, a discussion session was organized to ensure their understanding of the test questions was the same as what was intended. Two questions were adjusted based on this ‘internal pre-testing’ measure.

Results

The candidates were given the pre and post examination with the same question set. No information or clues were given to the participants regarding the posttest examination during the pretest or workshop. The same question set was used inorder to quantify the transfer of knowledge from the workshop. The maximum possible mark in the question set was 20. The average mark scored by the candidates in the pretest was six (6) out of 20 with standard deviation of (SD) 1.9. The average mark scored by the candidates in the post test was 14.5 out of 20 with standard deviation of (SD) 3.0 indicating difference of 8.5 marks with standard deviation of (SD) 1.6 between the two examinations. This has proven that the cost effective competency workshop succeeded in improving PAAS guideline knowledge to 141.7% compared to the pre workshop. Figure 2 represents the PAAS G examination mark analysis. A paired t test was executed to analyze the pre and post workshop test results. The t statistics was observed as, t = 21.496, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference. The null hypothesis was rejected, since p <  0.05 (Table 2).

Conclusion

There is strong evidence (p <  0.05) that the cost effective competency workshop improved PAAS G knowledge. In this data set, it improved marks, on average, by approximately 8.5 points or 141.7% with a 95% Confidence Interval (7.7–9.3). The feedback evaluation revealed an overall very good to excellent rating for the competency workshop (Fig. 3).

Implication

PAAS guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care, developed by the guideline task force of Physical therapy unit, Rumailah Hospital. PAAS Guideline offers recommendations for appropriate care. An evaluation of the guideline adherence and practice variations helps to fine tune the Physical therapy care to a highest possible standard of practice. A proper assessment of the relationship between the process of Physical therapy care and outcomes with a comprehensive set of process indicators will be implemented during the year 2016. We strongly believe that by means of systematic approach and implementation we can change the culture of practice so that it can suit and align with the international quality care in evidence based manner there by uplifting the corporation and its vision of becoming an internationally recognized center of excellence in health care. We believe that this ‘small changes will make a big difference in our health care system in the coming years’.

Physical Therapy, Practice behavior, Clinical practice guideline, Adherence

References

Field, Marilyn J., and Kathleen N. Lohr. “A provisional instrument for assessing clinical practice guidelines.” (1992). Grimshaw, Jeremy, et al. “Developing and implementing clinical practice guidelines.” Quality in Health care 4.1 (1995): 55.

Grimshaw, Jeremy, Martin Eccles, and Ian Russell. “Developing clinically valid practice guidelines.” Journal of evaluation in clinical practice 1.1 (1995): 37–48.

Grol, Richard. “Successes and failures in the implementation of evidence-based guidelines for clinical practice.” Medical care 39.8 (2001): II–46.

Grol, Richard, and Jeremy Grimshaw. “From best evidence to best practice: effective implementation of change in patients' care.” The lancet 362.9391 (2003): 1225–1230.

Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.

Introduction

Most of neurological disorders are network-based diseases. The networks associated with these diseases usually involve spatially disturbed brain regions. Thus efforts were recently evolving from identifying pathological “zones” toward identifying “networks”. In a very recent review, Fornito and colleagues revealed that the identification of alterations in brain networks is one of the most promising paradigms in brain disorders research (Fornito and Bullmore, 2014; Fornito et al., 2015). So far, approaches based on graph theory have characterized the brain networks as sets of nodes connected by edges (Bullmore and Sporns, 2009). Once the nodes (brain regions) and edges (functional/structural connections between regions) are defined from neuroimaging technique, methods based on graph theory may be used to describe the topological properties of the identified networks. This network-based analysis has been largely used to investigate normal (Bressler and Menon, 2010) and pathological (Fornito et al., 2015) brain activities from numerous modalities. It has been used in many clinical applications such as Alzheimer's disease (He et al., 2008; Lo et al., 2010; Mallio et al., 2015; Stam et al., 2007), schizophrenia (Fornito et al., 2011; Liu et al., 2008; van den Heuvel et al., 2013) and autism (Guye et al., 2010; Li et al., 2014). However, a precise tracking of the spatiotemporal dynamics of large-scale pathological networks is still an unsolved issue (Hutchison et al., 2013). The only noninvasive technique that provides the sufficient temporal resolution to track dynamics of brain activity at millisecond scale is the Electro/Magneto encephalogram (EEG/MEG).

Methods

Therefore, the focus of our work is to develop advanced methods to, noninvasively, identify dynamics of functional brain networks using dense EEG signals (256 electrodes). The key advantage of our method, called ‘EEG source connectivity’ (Fig. 1), is the possibility of identifying functional brain networks with excellent temporal (∼ 1 ms) and spatial resolutions (Hassan et al., 2015a; Hassan et al., 2014; Hassan et al., 2015b). The EEG source connectivity involves two main steps: i) the reconstruction of regional time series by solving the EEG inverse problem and ii) the estimation of the functional connectivity using phase synchronization among oscillations present in the time-courses of reconstructed regional time series. The method was originally developed to track dynamics of functional brain networks during short time cognitive activity such as picture naming task ( < 1 second) (Hassan et al., 2015a). In this abstract, we show the first results of applying EEG source connectivity method to two neurological disorders: Epilepsy and Parkinson's disease. Figure 1: Illustrative structure of the proposed method. Dense EEG were used to record data from patients (and healthy control). Structural MRI images will be also recorded, segmented and then anatomically parcellated into a desired number of brain regions (regions of interest). The functional connectivity was then computed giving rise to high-resolution functional brain networks. These networks (graphs) will be finally characterized (quantified) using approach from graph theory to characterize the brain networks (regions and sub regions) involved in the analyzed pathology.

Results

First, in the context of epilepsy, data were recorded from epileptic patients who underwent a full pre-surgical evaluation for drug-resistant partial epilepsy. The patients had a comprehensive evaluation including detailed history and neurological examination, neuropsychological testing, structural MRI, standard 32-channels (Micromed) as well as High-Resolution 256-channels (EGI, Electrical Geodesic Inc.) scalp EEG with video recordings and intracerebral EEG recordings (SEEG). We applied our method to identify epileptogenic networks from the scalp dense-EEG. We also estimated the functional network from depth-EEG. The results revealed a very good matching between networks identified from noninvasive EEG and those obtained using the intra-cerebral electrodes (ground truth). We were able, for the first time from scalp recordings, to identify the network of brain regions (nodes) involved in the generation of the seizure as selected by the epileptologist. Second, we recently applied the EEG source connectivity method to detect alterations in functional networks involved in cognitive impairments. Dense-EEG (128 electrodes) were recorded during task-free paradigm (resting state, eye closed) to produce whole-brain functional connectivity networks in patients with different cognitive phenotypes (Dujardin et al., 2013): 1) cognitively intact patients, 2) patients with mild cognitive impairment and 3) patients with very severe cognitive impairment. Functional connectivity was assessed between each pair of 68 brain regions in 124 patients at different EEG frequency bands. Network measures were realized at global level topology, region-wise connectivity and edge-wise connectivity. Using Network Based Statistics (NBS) (Zalesky et al., 2010), results showed significant differences at alpha band (7–13 Hz) between all groups. The quantification of the networks showed that most of significant alterations (decreased connections) were frontotemporal (functional connections between frontal and temporal lobes) which perfectly match with previous findings of cognitive impairments in patient with neurodegenerative disorders (Pievani et al., 2011).

Discussion

We consider that the identification of pathological brain networks from noninvasive EEG recordings is a topic of great interest. The results of the EEG source connectivity methods on cognitive task (Hassan et al., 2015a) as well on neurological disorders such as epilepsy and Parkinson's disease as presented here, may open new perspectives in the clinical use of such approach. These network dysfunctions may be specific to the clinical syndromes and, in Parkinson's disease and frontotemporal dementia for instance, network disruption may track the pattern of pathological alterations. We speculate that our findings might have practical repercussions for diagnostic purpose, allowing earlier detection of neurodegenerative diseases and tracking of disease development.

Acknowledgment

This work has received a French government support granted to the CominLabs excellence laboratory and managed by the National Research Agency in the “Investing for the Future” program under reference ANR-10-LABX-07-01.

References

Bressler, S.L., Menon, V., 2010. Large-scale brain networks in cognition: emerging methods and principles. Trends in cognitive sciences 14, 277–290.

Bullmore, E., Sporns, O., 2009. Complex brain networks: graph theoretical analysis of structural and functional systems. Nature Reviews Neuroscience 10, 186–198.

Dujardin, K., Leentjens, A.F., Langlois, C., Moonen, A.J., Duits, A.A., Carette, A.S., Duhamel, A., 2013. The spectrum of cognitive disorders in Parkinson's disease: A data-driven approach. Movement Disorders 28, 183–189.

Fornito, A., Bullmore, E.T., 2014. Connectomics: a new paradigm for understanding brain disease. European Neuropsychopharmacology.

Fornito, A., Yoon, J., Zalesky, A., Bullmore, E.T., Carter, C.S., 2011. General and specific functional connectivity disturbances in first-episode schizophrenia during cognitive control performance. Biological psychiatry 70, 64–72.

Fornito, A., Zalesky, A., Breakspear, M., 2015. The connectomics of brain disorders. Nature Reviews Neuroscience 16, 159–172.

Guye, M., Bettus, G., Bartolomei, F., Cozzone, P.J., 2010. Graph theoretical analysis of structural and functional connectivity MRI in normal and pathological brain networks. Magnetic Resonance Materials in Physics, Biology and Medicine 23, 409–421.

Hassan, M., Benquet, P., Biraben, A., Berrou, C., Dufor, O., Wendling, F., 2015a. Dynamic reorganization of functional brain networks during picture naming. Cortex 73, 276–288.

Hassan, M., Dufor, O., Merlet, I., Berrou, C., Wendling, F., 2014. EEG Source Connectivity Analysis: From Dense Array Recordings to Brain Networks. PloS one 9, e105041.

Hassan, M., Shamas, M., Khalil, M., El Falou, W., Wendling, F., 2015b. EEGNET: An Open Source Tool for Analyzing and Visualizing M/EEG Connectome. PloS one 10, e0138297.

He, Y., Chen, Z., Evans, A., 2008. Structural insights into aberrant topological patterns of large-scale cortical networks in Alzheimer's disease. The Journal of neuroscience 28, 4756–4766.

Hutchison, R.M., Womelsdorf, T., Allen, E.A., Bandettini, P.A., Calhoun, V.D., Corbetta, M., Della Penna, S., Duyn, J.H., Glover, G.H., Gonzalez-Castillo, J., 2013. Dynamic functional connectivity: promise, issues, and interpretations. NeuroImage 80, 360–378.

Li, H., Xue, Z., Ellmore, T.M., Frye, R.E., Wong, S.T., 2014. Network-based analysis reveals stronger local diffusion-based connectivity and different correlations with oral language skills in brains of children with high functioning autism spectrum disorders. Human brain mapping 35, 396–413.

Liu, Y., Liang, M., Zhou, Y., He, Y., Hao, Y., Song, M., Yu, C., Liu, H., Liu, Z., Jiang, T., 2008. Disrupted small-world networks in schizophrenia. Brain 131, 945–961.

Lo, C.-Y., Wang, P.-N., Chou, K.-H., Wang, J., He, Y., Lin, C.-P., 2010. Diffusion tensor tractography reveals abnormal topological organization in structural cortical networks in Alzheimer's disease. The Journal of neuroscience 30, 16876–16885.

Mallio, C.A., Schmidt, R., Reus, M.A., Vernieri, F., Quintiliani, L., Curcio, G., Beomonte Zobel, B., Quattrocchi, C.C., den Heuvel, M.P., 2015. Epicentral Disruption of Structural Connectivity in Alzheimer's Disease. CNS Neuroscience & Therapeutics.

Pievani, M., de Haan, W., Wu, T., Seeley, W.W., Frisoni, G.B., 2011. Functional network disruption in the degenerative dementias. The Lancet Neurology 10, 829–843.

Stam, C., Jones, B., Nolte, G., Breakspear, M., Scheltens, P., 2007. Small-world networks and functional connectivity in Alzheimer's disease. Cerebral Cortex 17, 92–99.

van den Heuvel, M.P., Sporns, O., Collin, G., Scheewe, T., Mandl, R.C., Cahn, W., Goñi, J., Pol, H.E.H., Kahn, R.S., 2013. Abnormal rich club organization and functional brain dynamics in schizophrenia. JAMA psychiatry 70, 783–792.

Zalesky, A., Fornito, A., Bullmore, E.T., 2010. Network-based statistic: identifying differences in brain networks. NeuroImage 53, 1197–1207.

Background

There has been some anecdotal evidence linking certain infectious pathogens (such as Chlamydia pneumoniae) with stroke. C. pneumoniae infection may be one of several contributing factors for the development of inflammation of blood vessels and atherosclerosis. Furthermore, a number of inflammatory markers (such as plasma CRP, fibrinogen, IL-6, IL-1ra, ESR, WCC) have recently been linked with acute ischemic stroke. However, their value in predicting short and long-term prognosis has been questioned and deemed to be not useful in defining outcomes due to the lack of evidence and cost implications.

Aims

The aims of this study are to (i) investigate the presence of C. pneumoniae in both echogenic and echolucent carotid plaques; and (ii) explore their role in the destabilization of the plaque, leading to embolization and cerebrovascular events.

Methods

(i) Study design: A prospective study involving carotid plaque specimens collected from routine endarterectomy surgical operations. Carotid plaques were removed en bloc during surgery to preserve the entire plaque structure. (ii) Carotid plaque samples: Twenty specimens of carotid atherosclerotic plaques (ten predominantly echolucent, Types I & II and ten predominantly echogenic Types III & IV) were used. The non-invasive ultrasonic appearance (i.e. echogenicity or echolucency) and the quantitative grading of these plaques were determined pre-operatively using duplex scanning aided by computerized measurements according to the criteria adopted by Gray-Weale et al. (1988). (iii) Immunohistochemistry: Levels of C. pneumoniae, Matrix Metalloproteinase-3 (MMP3), Nitric Oxide Synthase (NOS), Superoxide Dismutase (SOD) enzymes in echogenic (fibrous) and echolucent (lipid-laden) atherosclerotic carotid plaques were determined using immuno-histochemical and Western blotting techniques. (iv) Histological methods: Haematoxylin-Eosin stain was performed to stain the slides that will be used for morphological studies by light microscopy. For Laser Scanning Confocal Microscopy (LSCM), slides were stained with saturated aqueous fluorescein for a few minutes and then dehydrated, cleared and mounted in DPX. Carotid plaque specimens were first examined by light microscopy (at magnification 10, 40 times) to characterize the following histological features: necrosis, calcification, fibrous cap, erosion or ulceration, hemorrhage, fibrous tissue and lipid content. Sections from the same specimens were then analyzed using LSCM; slides were viewed with 488 excitation and 515 LP emission. The presence or absence as well as the pattern of distribution of these markers (proteins) were correlated with the histological and preoperative ultrasonic appearances of the plaques.

Results

Ultrasound imaging of carotid plaques revealed 10 with echolucent (lipid-laden/unstable) properties and 10 with echogenic (fibrous/stable) features. Intense immune-reactivity for C pneumoniae was observed in two thirds of echolucent plaques, clustering near endothelial cells of the intimal region, and in the neo-endothelial regions of the specimens. By contrast, low level and scattered C pneumoniae immune-reactivity was observed in echogenic plaques. MMP-3 (stromelysin) level was higher in echolucent than in echogenic plaques. High levels of this enzyme were observed near regions of ulceration, necrosis and in areas where the fibrous cap was thin or torn. Isoforms of NOS enzymes were seen in all carotid plaques irrespective of intra-plaque features however, levels of inducible NOS (NOS-II) were higher in echolucent than in echogenic plaques. Higher levels of immune-reactive SOD were also observed in plaques with higher degree of stenosis (more than 75%–80% measured by ultrasound scan). No direct relationship was evident between the neurological features experienced by the study group and the immuno-histochemical findings. There was however a relationship between the morphology of the plaque and the immuno-histochemical results. Both bright-field microscopy and Laser Scanning Confocal Microscopy (LSCM) were used to generate 3D images of surgically removed carotid plaques. 3D imaging of carotid plaques, using LSCM showed that most specimens were predominately composed of lipid material, comprising necrotic core of amorphous debris and cholesterol clefts, with varying degrees of fibrous tissue present in all plaques. Regions of actual fibrous cap disruption and some ulceration were also seen. Fraying of the fibrous cap was notable with fibrous cap erosion and exposure of underlying necrotic core to lumen. The extent of breaks in the fibrous cap varied with each plaque. Evidence of carotid plaque vulnerability (to rupture) was demonstrated by reduced fibrous cap thickness, a large lipid-necrotic core, and increased inflammatory cells infiltrate with evidence of cracking.

Discussion

Although the findings of this study are suggestive that C. pneumoniae may be involved in the worsening and destabilization of the carotid atherosclerotic plaque, more evidence is needed to ascertain whether C. pneumoniae infection may be an independent, modifiable risk factor for ischemic stroke. Results of this study also showed that MMP3 or its pro-enzyme may play an important role in digesting fibrous tissue of the plaque, leading to thinning or tearing of the fibrous cap. This might result in subsequent destabilization of the plaque, leading to embolization and cerebrovascular events. Furthermore, increased level of SOD expression in carotid plaques might be linked to the degree of stenosis of the affected carotid artery. Enzymes identified in this study may have been influenced by (i) inflammatory conditions prevailing in these plaques (e.g., C. pneumoniae might be responsible for triggering cascades of inflammatory events leading to activation of these enzymes), or (ii) shear stress which might be responsible for stimulation of these enzymes. The 3D geometry of carotid plaque also showed evidence of shearing stresses, resulting from fluid flow which might contribute to the degree of instability of the plaque. This is a complex process which might also include the mechanical activation of enzymes such as matrix metalloproteinases, nitric oxide synthases and Superoxide Dismutase. The behavior of these enzymes in response to fluctuations in the velocity field in both echogenic and echolucent plaques is yet to be investigated. Possible activation of these enzymes by fluid dynamical instabilities and the implications of such activation on the destabilization and progression of atherosclerotic plaques require further investigation. Once the role of 3D geometry and microrheology on plaque stability has been investigated and quantified, more opportunities will be available for translating the results into clinical applications.

Conclusion

There is a need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable. It has been suggested that mechanically induced or flow-sensitive enzymes contain positive and negative shear stress response elements in their encoding genes and can be stimulated or suppressed according to the nature of blood flow. However, it is still not possible to show any definite link between specific enzyme(s) and cerebrovascular events. Such an association is probably multifactorial and mediated by a combination of the degree of stenosis, plaque morphology, dynamic and biological factors. We are currently investigating the link between certain inflammatory markers and cerebral blood flow and cerebral auto-regulation in patients presenting with Transient Ischemic Attack (TIA or mini stroke) for the first time to explore further the role of inflammation in stroke. This study has just started; it involves 200 patients recruited from Qatar and UK. One of its outcomes will be to correlate impaired cerebral auto-regulation with a range of pro-inflammatory and anti-inflammatory markers in first time TIA patients. In doing so, we will study the profile, rather than just the level, of these inflammatory markers in each patient, taking into account the time lapse between onset of symptoms and the collection of blood specimen (for cytokines analysis) from each patient. “Part of this study was made possible by grant NPRP 6 – 565 – 3 – 141 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the author[s].”

Background

Worldwide, cerebrovascular disease (CVD) is the leading disease-related cause of chronic disability; the second most common cause of death and dementia; and a significant burden to patients, caregivers, and healthcare systems. Major risk factors for stroke include diabetes, hypertension, smoking and dyslipidemia which are highly prevalent in the gulf region. Indeed in Qatar, the incidence of cerebrovascular disease is increasing and most patients have major vascular risk factors. In data from the HMC Stroke Registry ∼71% of patients presenting with stroke had diabetes and indeed diabetes was undiagnosed at the time of presentation in 35% of patients. Current imaging techniques to detect early sub-clinical cerebral damage and hence those at risk of stroke includes computerized tomography (CT) and magnetic resonance imaging (MRI). MRI in particular can detect features of small vessel disease such as accumulating silent infarcts, cerebral microbleeds [CMB], periventricular white matter hyperintensity and perivascular spaces which all predict a higher risk of stroke. However, these abnormalities provide a measure of vascular and not neuronal integrity and it is not feasible or practical to undertake MRI simply to identify those at risk of stroke. There is therefore an unmet need for a rapid, non-invasive, sensitive, cost-effective, reproducible and easily imaging biomarker for neuronal damage in subjects at risk of stroke. We have pioneered the technique of corneal confocal microscopy (CCM). Our studies (NIH (5RO1-NS46259-03, R01DK077903-01A1 NINDS), JDRF (17-2008-1031, 8-2008-362)) have shown that corneal confocal microscopy (CCM) can quantify early axonal damage in diabetic neuropathy (1), reliably (2), with high sensitivity and specificity (3). Furthermore, we have shown that subjects with impaired glucose tolerance (IGT) and other vascular risk factors also show corneal nerve loss using CCM (4). Furthermore, these abnormalities improve with an improvement in blood pressure, lipids and HbA1c, all risk factors for stroke (5) and with change in glucose tolerance (6). We have recently published a large normative reference database (7) and developed an automated image analysis algorithm to enable rapid and objective quantification of corneal nerve morphology (8). We therefore hypothesized that CCM may identify corneal nerve loss driven by the common vascular risk factors which may lead to stroke and thereby provide a surrogate for cerebral neuronal loss. Hence, CCM may allow us to identify subjects who may be at high risk of developing stroke and enable risk stratification and targeted risk factor intervention in these individuals.

Aim

We undertook CCM in a cohort of patients admitted to HMC with a clinical and radiological diagnosis of stroke.

Methods

17 stroke patients (age: 53.13 ± 9.09, years) and 15 age-matched healthy control participants (age: 55.30 ± 8.98, years) underwent corneal nerve assessment using CCM (Heidelberg HRT III) to quantify corneal nerve fiber density (CNFD)(no./mm²), corneal nerve fiber branch density (CNFBD)(no./mm²), corneal nerve fiber nerve length (CNFL)(mm/mm²) and corneal nerve fiber tortuosity (TC) and metabolic testing. Stroke patients underwent detailed neurological assessment to define the severity of the stroke using a National Institute of Health Stroke Scale (NIHSS), 3D Carotid Doppler and 3 Tesla MRI. Stroke patients were stratified into different groups for analysis: Normoglycemia (HbA1c <  5.7) (age: 57 ± 8.12, years, n = 5) v dysglycemia (HbA1c ≥  5.7), n = 12); neurological disability: NIHSS <  4 (n = 9) v NIHSS ≥  4 (n = 8), Pathology on MRI: <  10 silent infarcts n = 5 v > 10 silent infarcts (n = 4), patients with periventricular white matter hyperintensity (n = 11) v no periventricular white matter hyperintensity (n = 4).

Results

There was significant difference in HbA1c (8.51 ± 2.35; 5.72 ± 0.36, %, p <  0.001) between stroke patients with dysglycemia and healthy control participants and patients with dysglycemia compared to normoglycemia (8.51 ± 2.35; 5.18 ± 0.35, %, p <  0.009). There was no difference in the total cholesterol (4.96 ± 1.62, 5.34 ± 0.80, mmol/L, p <  0.457), triglycerides (1.32 ± 0.35, 1.64 ± 0.48, mmol/L, p <  0.118), HDL (1.73 ± 1.57, 1.44 ± 0.47, mmol/L, p <  0.527), LDL (2.92 ± 1.42, 3.16 ± 0.69, mmol/L, p <  0.593), hypertension (hypertensive/normal tension, 1/11, 0/15, p <  0.255), height (172.00 ± 4.24, 169.24 ± 9.85, cm, p <  0.708) weight (88.50 ± 13.44, 81.51 ± 13.37, kg, p <  0.500) or BMI (30.00 ± 2.83, 28.47 ± 4.44, Kg/m2, p <  0.649) between stroke patients and control subjects. There was a significant reduction in CNFD (30.47 ± 5.76; 39.50 ± 8.49; p <  0.043) but no change in CNBD (117.50 ± 25.99; 100.54 ± 37.30; p <  0.365), CNFL (29.49 ± 2.65; 27.45 ± 5.56; p <  0.447) or CNFT (19.27 ± 5.07; 15.32 ± 3.94; p <  0.091) in the stroke patients with NGT as compared to the healthy control participants. There was a significant reduction in CNFD (30.17 ± 5.68; 39.06 ± 8.36; p <  0.004) and increase in CNBD (127.71 ± 34.09; 97.80 ± 37.49; p <  0.042) and CNFT (18.57 ± 4.36; 14.93 ± 4.08; p <  0.035) but no change in CNFL (27.06 ± 4.76; 26.97 ± 5.67; p <  0.965) in stroke patients with dysglycemia as compared to the healthy control participants. There was no difference in CNFD (30.17 ± 5.68; 30.47 ± 5.76; p <  0.921), CNBD (127.71 ± 34.09; 117.50 ± 25.99; p <  0.559), CNFT (18.57 ± 4.36; 19.27 ± 5.07; p <  0.777) or CNFL (27.06 ± 4.76; 29.49 ± 2.65; p <  0.306) between stroke patients with and without dysglycemia. There was no significant difference in CNFD (30.36 ± 5.26; 30.14 ± 6.17; p <  0.941), CNBD (123.46 ± 32.58; 126.12 ± 32.37; p <  0.869), CNFT (19.26 ± 5.30; 18.22 ± 3.48; p <  0.645) or CNFL (27.05 ± 4.38; 28.60 ± 4.38; p <  0.479) in stroke patients with NIHSS <  4 compared to NIHSS ≥  4. There was no significant difference in CNFD (30.52 ± 5.27; 32.16 ± 7.73; p <  0.715), CNBD (120.00 ± 39.76; 134.96 ± 43.98; p <  0.609), CNFT (15.71 ± 2.55; 17.61 ± 4.59; p <  0.453) or CNFL (26.54 ± 5.43; 28.43 ± 4.90; p <  0.606) in stroke patients with silent infarcts <  10 vs ≥  10. There was no significant difference in CNFD (30.18 ± 5.15; 30.08 ± 6.00; p <  0.973), CNBD (127.20 ± 28.08; 121.35 ± 45.78; p <  0.766), CNFT (20.36 ± 4.53; 15.15 ± 2.56; p <  0.051) or CNFL (28.91 ± 2.95; 25.50 ± 5.67; p <  0.144) in stroke patients with white matter ischemia compared to stroke patients without white matter ischemia.

Conclusion

Corneal confocal microscopy identifies greater corneal nerve fibre abnormalities in patients admitted with stroke, which is present in patients with and without dysglycemia. It may therefore reflect the consequence of vascular risk factors independent of glycemic status. However, the extent of corneal nerve fibre pathology does not differ in relation to the severity of neurological disability or extent of pathology on MRI. Larger, longitudinal follow up studies are required to determine the prognostic ability and utility of CCM as a surrogate imaging biomarker for stratifying patients at risk of stroke.

References

1. Petropoulos IN, Alam U, Fadavi H, Asghar O, Green P, Ponirakis G, et al. Corneal nerve loss detected with corneal confocal microscopy is symmetrical and related to the severity of diabetic polyneuropathy. Diabetes care. 2013;36(11):3646–51.

2. Petropoulos IN, Manzoor T, Morgan P, Fadavi H, Asghar O, Alam U, et al. Repeatability of in vivo corneal confocal microscopy to quantify corneal nerve morphology. Cornea. 2013;32(5):e83–e9.

3. Petropoulos IN, Alam U, Fadavi H, Marshall A, Asghar O, Dabbah MA, et al. Rapid automated diagnosis of diabetic peripheral neuropathy with in vivo corneal confocal microscopy. Investigative ophthalmology & visual science. 2014;55(4):2071–8.

4. Asghar O, Petropoulos IN, Alam U, Jones W, Jeziorska M, Marshall A, et al. Corneal confocal microscopy detects neuropathy in subjects with impaired glucose tolerance. Diabetes care. 2014;37(9):2643–6.

5. Tavakoli M, Kallinikos P, Iqbal A, Herbert A, Fadavi H, Efron N, et al. Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. Diabetic medicine: a journal of the British Diabetic Association. 2011;28(10):1261–7.

6. Azmi S, Ferdousi M, Petropoulos IN, Ponirakis G, Alam U, Fadavi H, et al. Corneal Confocal Microscopy Identifies Small-Fiber Neuropathy in Subjects With Impaired Glucose Tolerance Who Develop Type 2 Diabetes. Diabetes care. 2015;38(8):1502–8.

7. Tavakoli M, Ferdousi M, Petropoulos IN, Morris J, Pritchard N, Zhivov A, et al. Normative values for corneal nerve morphology assessed using corneal confocal microscopy: A multinational normative data set. Diabetes care. 2015;38(5):838–43.

8. Dabbah M, Graham J, Petropoulos I, Tavakoli M, Malik R. Automatic analysis of diabetic peripheral neuropathy using multi-scale quantitative morphology of nerve fibres in corneal confocal microscopy imaging. Medical image analysis. 2011;15(5):738–47.

Background

Road Traffic Injuries (RTIs) are the leading cause of death in Qatar1, but the epidemiology of these injuries in the infant (0–1 years) and toddler (2–4 years) [IAT] population has not been reported. This study aimed to document and analyze the epidemiology of RTIs in IATs of Qatar and make recommendations for targeted and age-specific recommendations to improve road safety for this population.

Methods

A retrospective analysis of data on child RTIs and RTI deaths admitted to the Hamad Medical Corporation [HMC] Trauma Center or Mortuary in Doha, Qatar, from 2008–2014, was conducted. Temporal trends in the nature of RTI's and RTI deaths, road user types and mortality rates were calculated and analyzed for the years that age-group population size was available.

Results

There were 189 severe RTIs and 15 RTI deaths during the study period. Males made up 80% of the injured and 60% of fatalities. The average age of the injured was 3 years and for fatalities was 2.8 years. Pedestrians [53%] and unrestrained passengers [43%] made up the majority of the injured. There have been steady declines in severe RTI and RTI death rates from 2008 to 2012 [25.9 to 22.2 RTIs per 100,000 and 0.9 to 4.0 RTI deaths per 100,000], but these rates are still two times higher than those for IAT in other high-income countries [HICs] like the United States and Germany2.

Conclusions

RTIs and RTI death rates in IAT in Qatar have been declining but proven programs for improved safety of child pedestrians and passengers must be implemented if it is to approximate those in other HICs. This includes programs around child restraint use and improving pedestrian environments and practices/supervision for IAT.

Background

Patient counseling is a term used in the field of pharmacy to describe the communication that takes place between a pharmacist and a patient in regards to his or her medication therapy. Patient counseling is deemed to be the professional responsibility of pharmacists. Patients require education on the proper use of medications to improve therapeutic outcomes and avoid treatment failure. 1 Pharmacists are in an excellent position to provide this type of education and counseling to patients, and are readily accessible to the public as a first point of contact for patients with medical inquiries. 2 Several studies have shown that counseling provided by pharmacists can prevent medication related problems, improve patient compliance with medications, and contribute to positive therapeutic outcomes. 3, 4 Patient counseling practices among Arab countries are not clearly identified in literature or mandated by governing authorities or agencies. The reason may be the low expectation by the public of the pharmacist who for so long had confined their role to filling and selling medications. Many studies have identified various aspects such as the busyness of the pharmacies and the education, age, and attitude of the pharmacists as barriers for the provision of counseling. 4 The assessment of these barriers in addition to patient characteristics will assist in further evaluating and understanding pharmacist's counseling practices in community pharmacies. Since patient counseling is an essential element of patient care, investigating the current state of patient counseling practices in Qatar is necessary. One of the methods that help to gain an accurate assessment of pharmacist's counseling practices is to observe pharmacists in their natural environment without prior knowledge to the minimize the Hawthorne effect. 5 Therefore, to lessen the potential Hawthorne effect (change in someone's behavior due to the knowledge that s/he is being observed), this research project will utilize simulated patients (also known as mystery shopper) to examine the counseling practices of community pharmacists in Qatar. The objectives of this research project are to evaluate the quality of patient counseling practices by community pharmacists in Qatar and to determine if an association exists between the content of patient counseling and the characteristics of community pharmacists, patients, and community pharmacies.

Methods

This is an observational cross sectional study to evaluate the community pharmacist's counseling practices in Qatar using simulated patients. Two patient scenarios were created to assess the counseling provided by the pharmacist to the patients with diabetes and asthma. Two simulated patients of Arab decent fluent in Arabic and two simulated patients of non-Arab decent fluent in English were recruited for this study. Each simulated patient was randomly assigned to either the diabetes or asthma scenario. Each simulated patient entered the community pharmacy and observed the number of customers to assess for busyness of the pharmacy. The simulated patient then asked to speak to the pharmacist and requested their assigned medication. Prompting questions were initiated by the patient after each pharmacist was provided with the opportunity to counseling the patient. The simulated patient then purchased the medication to authenticate the interaction and left the pharmacy. Immediately following the interaction, the simulated patient completed a form that assessed the pharmacist's counseling ability. Once completed, the simulated patient returned to the same the pharmacist to explain the purpose of the study. Consent was obtained from the pharmacist and a survey written in English or Arabic was administered only to those who provided consent. The written survey included questions related to pharmacist demographics (gender, age, native language, pharmacy degree received, country of pharmacy education, graduation year, and practice experience), pharmacist's perception on patient counseling (barriers and importance), and pharmacy characteristics (number of staff, availability of a counseling area, and busyness of the pharmacy).

Results

One hundred and twenty-nine pharmacists consented to participate in this study. The majority of pharmacists were young male pharmacists with at least 2 years of practice experience in Qatar. Most pharmacists have received their pharmacy degree from India and Egypt. Most of the community pharmacies had one pharmacist per shift and no private patient counseling area. In the diabetes scenario (n = 64), the male simulated patient received significantly better counseling from the pharmacist when compared to the female simulated patient. The pharmacist's knowledge regarding diabetes was considered poor with over 60% of pharmacists referring the patient to the physician. For the asthma scenario (n = 65), the male simulated patient received significantly better counseling from the pharmacist compared to the female simulated patients. Only 6% of the pharmacists were able to properly demonstrate the correct inhaler technique to patients. However, more than 50% of the pharmacists were are able educate the simulated patient on the role of the asthma medications. Overall, the pharmacist's gender, age, native language, pharmacy degree, country of pharmacy education, and years of practice experience did not seem to have an effect on the quality of counseling provided to patients. Better counseling was provided by the community pharmacists to the simulated patients when the pharmacy was not busy. Not having a private counseling area in the pharmacy was a significant barrier leading to lower counseling practices among community pharmacists. Some other barriers related to patient counseling identified by pharmacist include time, no access to patient medication records, and patients not interested in the counseling provided by the pharmacist.

Conclusion

The findings from this study suggest the current counseling practices among community pharmacists in Qatar is substandard. Development of continuing education programs for practicing pharmacists to enhance their communication skills and knowledge to improve counseling practices is strongly advocated. These educational programs will need to be tailored to meet the needs of the pharmacists to address the fundamental communication skills that each pharmacist should possess for practice. In addition, pharmacy laws and regulations need to be updated to meet the changes in the pharmacy profession from dispensing to a patient centered care focus. Community pharmacies need to be equipped with a counseling area, mandatory drug information resources, and the ability to maintain medication profiles for each patient. Pharmacy regulations should also consider mandating all pharmacists to provide counseling for each patient.

References

Resnik DB et al. The conflict between ethics and business in community pharmacy: what about patient counseling? Journal of Business Ethics 2000;28:179–186.

Taylor J. OTC counseling: review of pharmacist performance. Medscape Pharmacists [serial online] 2001 Aug [cited 2009 Dec 21]; 2(2). Available from URL: http://www.medscape.com.

American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Hosp Phar 1997;54:431–4.

Svarstad BL, Bultman DC, Mount JK. Patient counseling provided in community pharmacies: Effects of state regulation, pharmacist age, and busyness. J Am Pharm Assoc 2004;44:22–29.

Puspitasari HP, et al. A review of counseling practices on prescription medicines in community pharmacies. Res Soc Admin Pharm 2009;5:197–210.

Background

Peripheral intravenous catheters (PIVs) are invasive catheters that may endure risks of clinical complications affecting health care outcomes and patient satisfaction. Patients requiring frequent PIV insertions due to an extended length of stay of one week or more would undergo multiple PIV pricks during their course of hospitalization. The combined factors of multiple PIV insertions and extended hospital stay make chronic patients especially at a higher risk for phlebitis and subsequently infection No studies in the literature review discussed the phlebitis rates and risks when toxic medications were infused using a peripheral catheter. The aim of this study was to determine the pattern and incidence of PIV complications among patients admitted to a tertiary care military health care facility in central region of Kingdom of Saudi Arabia. This was achieved through the following objectives: (1) Estimation of the cumulative incidence and incidence density for major PIV complications (catheter occlusion, dislodgment, infiltration, and phlebitis) during a period of 1 month, (2) Identification of significant risk factors for PIV complications such as patient related characteristics (gender, age, co-morbidities) or catheter related characteristics (catheter size, dressing, site of insertion, type of infusion, dwell times), and (3) Determination of the time line for the occurrence of various PIV complications.

Methods

An observational prospective cohort study investigated PIV pattern and complications among 359 adults with 842 PIV catheters, admitted to various wards at KAMC with a total of 2505 catheter days. Data on patient characteristics (age, gender, and health complaints) and PIV characteristics (Catheter size, duration, insertion site, nature of PIV infusate, and type of dressing) was collected. PIV catheters-related clinical outcomes (Pain, Phlebitis, leaking and others) were recorded on 12–hour intervals, using the Visual Inspection Phlebitis (VIP) scale. Phlebitis was defined as the presence of two or more signs of pain, tenderness, warmth, erythema, swelling, or a palpable cord, with or without purulent drainage from the catheter insertion site. Infusion Phlebitis scale can range from (0), indicating no symptoms of phlebitis, to (5), with signs of purulent drainage, redness, and a palpable cord greater than 3 inches. Infiltration was defined as permeation of intravenous fluid into the interstitial compartment, causing swelling of the tissue around the site of the catheter. All PIV catheters were changed for a score of 2 or more, determined by the presence of a cold/warmth skin region around the insertion site, pain, redness, and/or edema extending from 1 to 2 inches above the PIV site. Incidence density (DI) and cumulative incidence (CI) of complications were calculated. Regression analyses were applied to determine the significant predictors of complications. Significance limits were set at P < 0.05.

Results

One half of all patients were 65 years and above, with no significant sex difference. The majority of patients (76.88%) had medical chief admission complaints, whereas (51.53%) were admitted in cardiac wards. Complicated catheters were found in 141(39.3%) patients, with 273 complications (32.4/100 catheters), 190 complicated catheters (CI =  22.56/100 catheters & DI =  75.84/1000 catheter days). Phlebitis ranked first among complications, with a CI of (17.58%), followed by pain (7.60%), leaking (3.92%) and dislodgement (2.38%), and extravasations and occlusion (0.48% each). When the analysis was based on failure per 1000 device days, and after adjusting for all possible confounders, female gender remained as a significant predictor of higher incidence of overall complications (p = 0.00001), phlebitis (p = 0.000003) as well as other complications (p = 0.0.0003). Insertion in fore/upper arm was a significant predictor of both phlebitis (0.024) and other complications (0.049), while medical infusion was a significant predictor of phlebitis (0.02) and overall complications (0.006).

Conclusion

Incidence of complications in this study is comparable with figures in previous studies, however, better insertion techniques may be sought to lower the incidences of PIV complications, thus extending their onset beyond day 3. Changing catheters is recommended when clinically indicated rather than routinely post 72 hours of insertion which in return minimizes the frequency of insertions per patient and subsequently complications.

Network querying algorithms provide computational means to identify conserved network modules in large-scale biological networks that are similar to known functional modules, such as pathways or molecular complexes. Two main challenges for network querying algorithms are the high computational complexity of detecting potential isomorphisms between graphs and ensuring the biological significance of the query results. In this work, we propose a novel network querying algorithm that can enhance the biological significance of the query results through the use of a context-sensitive random walk (CSRW) model. In order to identify conserved subnetwork regions in the target network that are similar to a given query network, the algorithm estimates the node correspondence between the query and the target networks based on the CSRW model. Inspired by the pair hidden Markov model (pair-HMM) that has been widely used in comparative sequence analysis, the CSRW model can effectively capture the similarities between graphs by explicitly accounting for potentially inserted and deleted network nodes. Based on the estimated CSRW node correspondence scores, our algorithm first identifies high-scoring regions (referred to as the seed networks) in the target network that bear considerable similarity with (part of) the query. The seed networks are further extended by maximally minimizing the network conductance, which can effectively identify nearby nodes (e.g., proteins) that may share similar functions with other nodes in the current seed. Finally, the query result is pruned by removing irrelevant nodes based on an extension reward score, thereby improving the consistency of the final query result. Through extensive numerical simulations based on 938 real biological complexes, we show that our proposed algorithm yields accurate query results with enhanced biological significance.

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Introduction

The frequent outbreaks of novel or emerging infectious diseases are alarming. There is a need for urgent and appropriate intervention that can be adapted quickly for such diseases. Middle East respiratory syndrome coronavirus (MERS-CoV) previously known as novel CoV is a viral infection that causes severe acute respiratory illness. MERS-CoV is a respiratory pathogen and contagious that is contracted via close contact with infected subject. It appears to have been transmitted from camels to humans, recent studies have revealed an association among the virus found in humans and that found in camels (Drosten, et al., 2014). The epidemic that started in 2012 in the Kingdom of Saudi Arabia has spread to many countries, mostly in the Middle East and North Africa, and more recently South Korea. The new epidemic started when the virus crossed from an infected individual who had recently traveled to the Middle East and subsequently began spreading between people via direct contact while in some cases the infection crossed from animal to human. This has exposed the general populace and especially the healthcare workers to greater risk. Similar to the reaction during other infection outbreaks, such as SARS and Ebola virus, many countries have issued travel restrictions and advisories to the affected countries because of fear of international spread of the disease. The rate at which the outbreak is evolving cannot be overemphasized and the geographical extension of its spread is widening. Neighborhoods constitute a key determinant of socioeconomic disparities and health habits, and therefore there is a high risk that people at geographical proximity to the infection are particularly vulnerable. Additionally, people with preexisting chronic medical conditions are more prone to being infected by the illness or developing a severe case resulting in fatality (Assiri, et al., 2013). Strong links between healthcare facilities and the outbreak of the disease has been found in Jeddah, where the majority of patients were in contact with other patients or health care facilities (Oboho, et al., 2015). Elsewhere, the transmission of MERS-CoV in household contacts revealed that an outcome of approximately 5% as the rate of secondary transmission occurred at home (Assiri, et al., 2013). In spite of the many research conducted on MERS-CoV, very few have investigated the effect of ecological factors on the transmission of the disease. Moreover, very little is known on the possibility of airborne transmission of the virus and discussion is still on going on this issue. Airborne transmission of the pathogen may also occur through dust and movement of people, equipment and animals within infected countries which may contribute to the spread of the virus. Additionally, the effect of alternating temperature highs and lows may imply seasonality that could alter the transmission and survivability of the virus. Objectives During infectious disease outbreaks, transmission of disease may form networks of infected individuals because of the way virus crossed from infected individual to susceptible individual. See figure 1a for a subset of the infection network for MERS disease used in this study. The infected individuals may form network of individuals connected by source of infection (contact) as direct or indirection connection. The study intends to (1) explore and investigate the relationship between the intensity of the disease in a given region and environmental variables, (2) We sought to evaluate the risk factors of and trends in mortality as a result of MERS-CoV infection in a large cohort of patients between June 6, 2012 and May 19, 2015. Use covariate adjustment to correctly assess the disease-risk factor associated with the survival outcome, (3) It also aims to understand the dynamic pattern of the disease over different temporal and spatial scales. A functional spatial time series method of estimating the death rate in the outbreaks will be formulated. Spatial time series analysis of disease outbreaks are versatile tools for studying and understanding transmission and spread of a disease and may be useful in the different frontiers of its upsurge and in the possibility of its containment or eradication. And lastly, (3) a flexible dependence model that reflect the relationship among infected individuals in the same network.

Figure 1: (Top) Network for subset of the MERS data. The numbers represent the identification number of the patient while the arrow represents the infection direction. (Bottom) Showing the patients that were infected by patient 27.

Figure 2: Number of patients infected by each main contact (patient ID). Preliminary Exploratory Analysis This study is based on a retrospective analysis of the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in the Arabian Peninsula between June 6, 2012 and May 19, 2015.

Table 1 presents the summary of data used in this study. Of the 958 cases recorded during the study period more than 90% (866) of the disease incidence occurred in the Kingdom of Saudi Arabia while Kuwait has the least incidence of 3. Seventeen percent of those infected with MERS disease were heath care worker. The fatality for the disease is about 0.35 among the total population. The mean age of the infected persons was 50.22 ± 18.37 years, with large percentage (55%) reported that they had some kind of comorbidity. Spatial analyses of disease outbreaks are versatile tools for studying and understanding transmission and spread of a disease.

Figure 3 shows the spread of MERS disease across the Arabian Peninsula within the study period. Majority of the disease incidence occurred in KSA and closed countries.

Table 1. Summary of the MERS data Country No. of Patients No. of Male/female No. with comorbidity Age at incidence % of HCW % fatal Mean/median mean SD KSA 866 565/284 469 49.66/50 49.66 ± 18.54 153 302 UAE 70 50/18 49 54/56 54 ± 15.33 9 30 Qatar 12 9/3 5 59.1/58 59.1 ± 15.99 1 3 Kuwait 3 1/2 3 54/43 54 ± 27.22 0 1 Oman 7 7/0 2 56.28/60 56.28 ± 17.54 1 3 Total 958 632/307 528 50.22/50.5 50.22 ± 18.37 164 339

Hearing loss is a common sensory deficit that can affect all levels of society. The two age groups where hearing loss is most likely to be identified is in newborns and in the elderly. Newborn screens have been very effective in finding individuals affected by hearing loss. The general hearing loss incidence in newborns is 0.2%, with roughly 50% of all cases being hereditary. A recent study in Qatar found that the incidence of hearing loss in newborns was as high as 5.2% 1, 25 times higher than the general global incidence. Much of this increase can be attributed to hereditary forms of hearing loss, as the rate of consanguinity in Qatar is high 1,2. The elderly are the other population group where hearing loss is often identified. Globally, the hearing loss incidence for people over 50 is around 40%, with men showing a higher incidence than women 3,4. In Qatar, 66% of the Qatari population over the age of 50 suffers hearing loss, compared to ∼35% for the non-Qatari populations 5. The gender distribution of hearing loss within the Qatari population is also different from the global trend, with the incidence being 75% for women and 59% percent for men5. Therefore, the incidence of hearing loss is dramatically higher in the Qatari population than it is globally, and presents an important health issue that should be addressed. We have previously shown that the outer nuclear membrane protein Nesprin 4 is essential for hearing in humans and in mice. Nesprin 4 is expressed in the sensory outer hair cells (OHCs) of the cochlea and is important for the proper nuclear positioning and survival of these cells. In the absence of functional Nesprin 4, the nuclei are apically mispositioned and the OHCs die. OHCs act as cochlear amplifiers, augmenting sound signals by up to 100-fold6. This amplification is achieved, at least in part, through electromotility, a somatic cell motility that causes cell length changes in response to depolarization or hyperpolarization of the cell. Electromotility is mediated by SLC26A5/prestin, a membrane protein enriched in the lateral membranes of OHCs7. Prestin-mediated electromotility develops postnatally in mice, with full activity occurring at 12–14 days after birth. We observed that the majority of OHCs in mice lacking Nesprin 4 die around this time and predicted that the mislocalized nucleus was incompatible with electromotility. To test this hypothesis we generated double-null mice for Nesprin 4 and prestin and examined the fate of OHCs in these animals. We found that loss of prestin rescues the loss of OHCs in Nesprin 4-null animals, indicating that while a mispositioned nucleus is incompatible with electromotility, it does not affect cell viability independent of mechanical stress. Others have previously shown that animals heterozygous for the prestin allele exhibit a reduced electromotility. We predicted that a reduction in electromotility should yield a partial rescue of OHCs in Nesprin 4-null animals. When we examine the Nesprin 4-null/prestin heterozygous animals, we did indeed observe a partial rescue of OHCs. Together, these results indicate that proper nuclear positioning mediated by Nesprin 4 in OHCs is essential for these cells to survive the mechanical stress of electromotility.

References

1. Bener, A., EIHakeem, A. A. M. & Abdulhadi, K. Is there any association between consanguinity and hearing loss. Int J Pediatr Otorhinolaryngol 69, 327–333 (2005).

2. Girotto, G. et al. Consanguinity and Hereditary Hearing Loss in Qatar. Hum Hered 77, 175–182 (2014).

3. Roberts, A. Sensorineural Hearing Loss. Synopsis of Causation, Ministry of Defence 1–30 (2008).

4. Action on Hearing Loss. at < http://www.actiononhearingloss.org.uk/your-hearing/about-deafness-and-hearing-loss/statistics.aspx>

5. Bener, A., Salahaldin, A. H., Darwish, S. M., Al-Hamaq, A. & Gansan, L. Association between hearing loss and type 2 diabetes mellitus in elderly people in a newly developed society. Biomed Res 19, 187–195 (2008).

6. Liberman, M. C. et al. Prestin is required for electromotility of the outer hair cell and for the cochlear amplifier. Nature 419, 300–304 (2002).

7. Dallos, P. & Fakler, B. PRESTIN, A NEW TYPE OF MOTOR PROTEIN. Nat Rev Mol Cell Biol 3, 104–111 (2002).

The aortic arch and its branches form during the third week of embryogenesis, which involves a complex process. Abnormalities of the arch branching pattern arise by persistence of segments of arches that normally disappear or the disappearance of segments of arches that normally remain, or both [1]. The most common human aortic arch branching pattern has the innominate artery, the left common carotid artery and the left subclavian artery all as separate branches (Fig. 1). The most common variant branching pattern involves the left common carotid artery arising in a common origin with the innominate artery (Fig. 2), and the next most common the similar left common carotid artery originating from the innominate artery itself (Fig. 3). A true bovine arch involves a single common brachiocephalic trunk arising from the arch which then splits into the right subclavian artery, a bicarotid trunk and a left subclavian artery (Fig. 4), and is actually extremely uncommon in humans [2]. Originally the variations of the arch branching patterns were made by post-mortem studies [3], but, more recently large imaging studies have been performed [4,5] confirming that approximately 70% of people have a normal branching pattern with 20% having a common origin of the innominate artery and left common carotid artery (as in Fig. 2) [4,5], but these studies were performed without reference to the anatomy of the aortic valve (bicuspid versus tricuspid). Bicuspid aortic valve (BAV) is the commonest congenital cardiac malformation with 1–2% of the population being affected [6], and is associated with other cardiac anomalies, especially coarctation [6]. BAV is also associated with dilatation of the ascending aorta which is thought to be related to intrinsic pathological properties of the aortic wall and altered flow dynamics through the abnormal valve [7,8], with increased risk of aortic dissection compared to tricuspid aortic valve (TAV) patients [9,10]. As BAV is a common congenital anomaly and the variants of the aortic branching pattern are developmental in origin we decided to see if the frequency of arch variants in BAV and TAV patients differed, as this has not previously been looked at. We examined Computerised Tomographic aortograms (CT) and echocardiograms of BAV and TAV patients to assess the aortic arch branching pattern and any possible association with the valve morphology.

Materials and Methods

An established BAV patient database at the Heart Hospital, Doha, Qatar was used to retrieve patients. All BAV patients with CT scans of the aorta were examined. During the same period (September 2011–2014) 200 CT aortograms were performed in the Radiology department of the Heart Hospital and from these TAV patients were selected for comparison. Basic demographic data were collected for all the patients. This study was approved by the Institutional Review Board with waiver of consent as all tests had been preformed previously. Aortic images, obtained with Multidetector CT aortic angiography (MDCT) using dual source 128 multi slice CT, were further processed by the reporting consultant radiologist for three-dimensional reconstructions to obtain volume rendered images and maximum intensity projections for assessment of the aortic arch branching variation. Echocardiograms of both the BAV and TAV patients were examined to confirm valve anatomy, (images assessed by an echocardiography trained cardiologist, not just reading reports).

Results

Results of the 129 BAV patients in the BAV database 28 had ‘readable’ (branch pattern could be clearly discerned) CT scans. Fifty-seven (double the number of BAV patients) CT aortograms were selected from the radiology archive (first 57 that were ‘readable’ from September 2011 that had also undergone echocardiography). The sex and ethnic distributions are shown in Tables 1 and 2. Eighty-five patients’ images were assessed with 28 BAV and 57 TAV. All 85 patients had their echocardiographic images re-examined to verify BAV or TAV morphology. For BAV the aortic branching patterns were: 86% normal (24/28) and 14% abnormal branching patterns (4/28), and for TAV: 70% normal (40/57) and 30% abnormal branching patterns (17/57). The BAV patients abnormal patterns were all the left common carotid artery common origin with innominate artery (as in Fig. 2), whereas the TAV patients had 16 of the type left common carotid artery common origin with innominate artery (as in Fig. 2) and one left common carotid arising from the innominate artery (as in Fig. 3). There were no true bovine variants in our group. Other anomalies found in our group include 1 coarctation (BAV patient) and 1 dissection (BAV patient). The valve morphology was discernable in 42 (49%) of the 85 CT scans.

Discussion/Conclusions

Bicuspid aortic valve has previously been quoted as having a related aortopathy, but is this embryological or functional (related to intrinsic wall properties) in origin? [7,8]. If in fact BAV patients have fewer arch variations it may support the idea that the aortopathy is related to functional changes in the wall rather than embryological origins (excluding coarctation). In our group it does not appear to affect the embryological development of the branches of the aortic arch and we actually appear to have fewer arch variants in the BAV group. Although this is a small study our TAV group had similar percentages of normal (70%) and abnormal (30%) arch variants as the reported literature [1,2,4,5]. Our BAV group is small and we will expand it further in the future but the results at this stage suggest no increase, in fact a possible decrease in arch variants compared to the TAV patients. Despite this it would not be possible to exclude an embryologically based pathological change to the aorta in BAV patients. Some racial variations have been reported but these studies were done many years ago and involved post-mortem analysis [3], and suggested that arch branching variants were more common in African Americans (about 50%) [3], but these studies would be difficult to repeat due to widespread racial mixing nowadays and could only be looked at in isolated communities with a single racial group. In Qatar 60% of the population is originally from the Asian Indian Subcontinent so there may in fact be a greater prevalence of Bicuspid valves in the MENA region patients and also Arch Variants appear to be more common in the MENA region patients. The two large radiological studies that have looked at the aortic arch anatomy showed that approximately 70% of patients had normal configuration of the arch vessels and 20% had a common origin of the innominate artery and left common carotid artery [7,8], but these studies were performed without reference to the anatomy of the aortic valve. This is the first study in the literature to look at the arch branching variants when consideration of the aortic valve morphology (BAV versus TAV) is taken into account. Although there is little physiological significance in the majority of patients, these variations may have an impact if endovascular or surgical procedures are planned in the region of the arch. BAV patients have been shown to have ascending and arch dilatation [7–11] and are more likely to require intervention than TAV patients (due to concomitant valve dysfunction), so knowing the arch anatomy will become more important. We will continue to expand our numbers as this is a relatively small study.

Acknowledgement

Mr Mohammed Abdulsamad for diagrams. Conflicts of interest, disclosures: none declared by any author.

Table 1: Sex and Ethnicity for tricuspid valves. Tricuspid Male Female Ethnicity Numbers Normal (n = 40) 36 4 Africa 0 Asian Indian Subcontinent 15 Asian Oriental 3 Caucasian 3 MENA Region 19 Arch Variant (n = 17) 15 2 Africa 1 Asian Indian Subcontinent 5 Asian Oriental 2 Caucasian 0 MENA Region 9

Table 2: Sex and Ethnicity for bicuspid valves. Bicuspid Male Female Ethnicity Numbers Normal (n = 24) 24 0 Africa 1 Asian Indian Subcontinent 7 Asian Oriental 3 MENA Region 13 Arch Variant (n = 4) 4 0 Africa Asian Indian Subcontinent 2 Asian Oriental MENA Region 2

References

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[2] Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS. Bovine aortic arch variant in humans: clarification of a common misnomer. American Journal of Neuroradiol 2006;27:1541–42.

[3] De Garis CF, Black IH, Riemenschneider EA. Patterns of the aortic arch in American white and negro stocks, with comparative notes on certain other mammals. J Anat 1933;67:599–618.

[4] Jakanani GC, Adair W. Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clinical Radiology 2010;65:481–487.

[5] Shakeri A, Pourisa M, Deldar A, Goldust M. Anatomic variations of aortic arch branches and relationship with diameter of aortic arch by 64-row CT angiography. Pak J Biol Sci 2013;16(10):496–500.

[6] Nistri S, Basso C, Marzari C, Mormino P, Thiene G. Frequency of bicuspid aortic valve in young male conscripts by echocardiogram. Am J Cardiology. 2005;96(5):718–721.

[7] Mahadevia R, Barker AJ, Schnell S, Entezari P, Kansal P, Fedak PW, Malaisrie SC, McCarthy P, Collins J, Carr J, Markl M. Bicuspid aortic cusp fusion morphology alters aortic three-dimensional outflow patterns, wall shear stress, and expression or aortopathy. Circ 2014;129(6):673–82.

[8] Phillippi JA, Green BR, Eskay MA, Kotlarczyk MP, Hill MR, Robertson AM, Watkins SC, Vorp DA, Gleason TG. Mechanism of aortic medial matrix remodeling is distinct in patients with bicuspid aortic valveJ Thorac Cardiovasc Surg 2014;147(3):1056–64.

[9] Michelena HI, Khanna AD, Mahoney D, Margaryan E, Topilsky Y, Suri RM, Eidem B, Edwards WD, Sundt TM 3rd, Enriquez-Sarano M. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA 2011;306(10):1104–12.

[10] Eleid MF, Forde I, Edwards WD, Maleszewski JJ, Suri RM, Schaff HV, Enriquez-Sarano M, Michelena HI. Type A aortic dissection in patients with bicuspid aortic valves: clinical and pathological comparison with tricuspid aortic valves. Heart 2013;99(22):1668–74.

[11] Fazel SS, Mallidi HR, Lee RS, Sheehan MP, Laing D, Fleischman D, Herfkens R, Mitchell RS, Miller DC. The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. The Journal of Thoracic and Cardiovascular Surgery 2008;135:901–7.

Figure Legends

Figure 1: the most common human aortic arch branching pattern with the innominate artery (IA), the left common carotid artery (LCA) and the left subclavian artery (LSA) arising as separate branches from the arch. Other branches shown are right subclavian artery (RSA), right common carotid artery (RCA), right vertebral artery (RVA) and left vertebral artery (LVA).

Figure 2: the left common carotid artery arising from a common origin with the innominate artery. Incidental finding on the central image - left vertebral artery arising from the arch, directly after the common origin vessel.

Figure 3: the left common carotid artery originating from the innominate artery itself.

Figure 4: the true bovine arch involving a single common brachiocephalic trunk arising from the arch which then splits into the right subclavian, a bicarotid trunk and a left subclavian artery.

Table 1: Sex and Ethnicity for tricuspid valves.

Table 2: Sex and Ethnicity for bicuspid valves.

Background & Objectives

Epilepsy is a neurological disorder that is associated with repeated episodes of seizures. In epilepsy, the normal pattern of neural activity is disturbed, causing the patient to experience various symptoms ranging from staring blanking for a few seconds to long periods of vigorous convulsions and unconsciousness. In many patients, the injuries they endure are a direct result of the confusion, loss of muscle control, and unconsciousness caused by the seizure. These injuries include fractures, head injuries, and burns. In an attempt to mitigate such risks, extensive research has been dedicated to developing a device that can detect or predict the onset of seizure episodes. The clinical behavior of an epileptic seizure is preceded and then accompanied by electroencephalographic alterations. As a result, electroencephalography (EEG) is the most common tool to measure these alterations. EEG measures the voltage fluctuations resulting from ionic current flows within the neurons of the brain. Research has demonstrated that epileptic seizures are caused by disturbances in the electrical activity between neurons in the brain. In the healthy brain, neurons fire in an asynchronous manner, relaying messages from one neural network to the other. However, in the epileptic brain, the complex interactions between neuronal networks are characterized by the evolution of synchronization between them. Excessive neuronal synchronization leads to a hyper-synchronous state that triggers the onset of a seizure. Extensive research has been dedicated to the detection of the earliest signs of electrographic changes associated with a seizure using either scalp or inter-cranial EEG. A device that has the ability to detect the electrographic onset of a seizure (seizure onset detector) will enable epileptic patients to lead a more normal and secure life, and will help them to avoid injuries due to the sudden nature of the seizure. At its most basic form, a seizure onset detector (SOD) is comprised of two major components, the feature extraction unit and the classification unit. In the feature extraction unit, relevant features are extracted from the multi-channel EEG and are fed into a classification unit where the features are classified as seizure or non-seizure in nature.

Methods

In this research, we present a novel patient-specific epileptic seizure onset detector using scalp EEG where we aim to exploit the benefits of integrating EEG channel selection and feature enhancement to improve the SOD's performance. Hence, we propose a detector architecture that is composed of five stages, namely, EEG channel selection, feature enhancement, spatial averaging, feature extraction, and classification. Assuming the collected scalp-EEG data contains M-channels, the channel selection stage chooses the N EEG channels that contain the most relevant electrographic seizure information. This stage is important because it reduces the detector's computational burden and omits the need to evaluate channels that have invaluable information, which may deterioted the detector's performance. The main goal of the feature enhancement stage is to emphasize the seizure EEG relative to the non-seizure EEG (background EEG). For this, a differentiation and exponentiation approach is adopted. Following the feature enhancement stage, the next stage is spatial averaging. In this stage, the N selected channels with enhanced features are averaged so that a single EEG vector is obtained. The main idea of this stage is to reduce the number of features extracted from the EEG channels to further decrease the computational complexity. The onset of a seizure is usually associated with rhythmic activity composed of multiple frequency components. Therefore, to utilize the information contained in the EEG, features are extracted from each frequency sub-band separately. A multi-resolution wavelet decomposition is used to extract relevant frequency components from the EEG. From this point, the energy from each frequency EEG sub-component is calculated as the EEG feature. The last stage of our detection is the classification and detection stage. A support vector machine (SVM) is used to classify EEG epochs as seizure or non-seizure.

Results

The data used to evaluate the proposed detector is from a publicly available database consisting of EEG recordings from pediatric subjects with intractable seizures, collected at the Children's Hospital Boston. The subjects have been monitored for up to several days following withdrawal of anti-seizure medication in order to characterize their seizures and assess their candidacy for surgical intervention. The proposed detector was tested on six of these patients, where a leave-one-out cross-validation testing scheme is adopted for each patient. In the leave-one-out cross-validation testing scheme, the SVM is given a training set that includes the seizure and non-seizure epochs from all but one of the subject's recordings. The detector then attempts to detect the seizure from the excluded recording using the learned knowledge from the training set. This process is repeated until all recordings have been tested. To test the effectiveness of our proposed detector, the energy difference between pre-seizure and seizure states are calculated for a detector that only implements spatial averaging, a detector that implements a feature enhancement stage with no channel selection, and our proposed detector. It is found that the energy difference when feature enhancement is used is higher than when no feature enhancement is implemented in the detector. The energy difference is further enhanced for the case when the detector implements both feature enhancement and channel selection. The performance of the detector is compared to a benchmark detector that uses only feature enhancement. Our proposed detector achieves a detection latency of 4 seconds, which is closely aligned with the electrographic seizure onset time that an expert has visually determined. Furthermore, the proposed detector achieves a sensitivity of 87.5% whereas the benchmark detector achieves a sensitivity level of 80.6%.

Conclusion

Our research proposes a novel architecture for an epileptic seizure onset detector. The combination of the channel selection and feature enhancement stages has led to an improved detection performance. An increase in the energy difference between seizure and pre-seizure states is observed when the proposed detection is implemented, versus implementing the detection system without any form of channel selection. The proposed system also performed better in terms of false alarm rate and sensitivity.

Background

Maternal health refers to the health of women pre-pregnancy, during pregnancy, childbirth and postpartum. Pregnancy is a state of altered physiology and medication use during this period is remarkably challenging. For various reasons medication use during pregnancy cannot be completely avoided however, due to altered drug pharmacokinetics and crossing of placenta many of these drugs could significantly still harm the growing fetus. Pharmacists are medication experts with great knowledge of pharmacology, pharmacokinetics and are trained to apply evidence based clinical knowledge. Although pharmacists are having great potential to modify and optimize drug therapy in pregnancy, current evidence demonstrates they do not actively provide this care and are least interested in doing so.

Objective

The primary objective of the study was to determine the knowledge, perception, attitude and experience of pharmacist in Qatar regarding risk benefits ratio, concerns, advice, and source of information about drug use in pregnancy and secondary objective aimed to correlate knowledge with different variables.

Methods

A prospective cross sectional questionnaire based study was conducted by Women's Hospital pharmacy department for 3 months in 2010 (June – August). A 23-item self-completed anonymous questionnaire was distributed to 400 licensed pharmacists in Qatar including community pharmacists, hospital pharmacists, Primary Health Centers (PHC) and pharmacists working in polyclinics. Five pharmacists from women's hospital were selected to distribute and collect the questionnaire. A convenient sampling technique was used. All licensed pharmacist were included while pharmacy technicians were excluded. Pilot study was conducted on 30 pharmacists (16 community and 14 hospital pharmacists), were almost consistent in terms of answering, except for two questions (concerning knowledge and pharmacists confidence levels while dealing with physicians) which were modified accordingly. The questionnaire was classified into 4 sections: 1) Section 1, about their practice 2) Section 2, about knowledge and perception of medication use in pregnancy 3) Section 3, about pharmacist's level of confidence while dealing with patient and physician 4) Section 4, about source of drug information and certain general statements regarding their beliefs Data was analyzed by SPSS version 17. Descriptive statistics was applied for all the collected variables. Knowledge level of each respondent is determined by ranking their answers based on a scale developed with maximum 28 scores. To see association between Knowledge levels and variables, χ² test was used. P value 0.05 was considered as statistical significant. The study conformed to the ethical principles of Hamad Medical Corporation Research center. Descriptive statistics was applied for all the collected variables.

Results

An overall response rate of 51.75% (207/400) was obtained, and majority (54.1%) of whom were males. The highest percentages of respondents were practicing hospital pharmacists (46.8%), followed by community pharmacist (35.3%) whereas only 13% responded from primary healthcare centers. Most of them had a bachelors' degree (95.7%) in pharmacy. More than 50% of pharmacists responded to have no continuous education or received any CE points in last 12 months. 66% of these respondents reasoned work related issues (time, workload) for not attending these educational activities. 86% of the respondents were aware of the risk and benefits associated with the medication use in pregnancy. Majority (64.7%) of pharmacist possessed ‘average knowledge levels’, 34.3% with ‘good knowledge’ very few (1%) had ‘very good knowledge’. Only 33.3% were comfortable giving advices/counselling to pregnant women. Approximately 89% (strongly agree 39.6% and agree 49.8%) respondents believed they were competent enough to inform pregnant population about their medication where as 1.5% disagreed (strongly disagree 0.5% plus 1% disagree) and around 9% being unsure. Respondents with experience of 5 years and above had better knowledge levels than others. There was a significant positive association between respondents having Continuous Educational activities and their knowledge levels. Respondents who were very comfortable and somewhat comfortable (69.4%) were more knowledgeable than those uncomfortable and somewhat uncomfortable (10.6%). Knowledge of respondents who contacted prescribers with an alternative medication was 79.6% compared to ones who contacted prescribers without an alternative 8.3%. Respondents who agreed and strongly agreed that they were confident enough to advice both physicians (87%) and pregnant patients (91.3%) were more knowledgeable than others.

Conclusion

Our study provided a baseline data regarding knowledge, perception and experience of pharmacist in Qatar regarding drug use in pregnancy. With majority of respondents lacking educational activities, there is an urgent need to stress on the importance of continuous pharmacy education tailored to meet the requirements of specialized areas. Pharmacist should be aware of medications used during pregnancy and should be familiar regarding risks and benefits of the medication used and to provide appropriate drug related information to pregnant women and healthcare professionals taking care of pregnant women.

Calreticulin is a molecular chaperone responsible for proper protein folding in the endoplasmic reticulum (ER), and supports assembly of protein oligomers. Calreticulin also plays a role in quality control of protein expression in the ER. Calreticulin is a ubiquitous protein that shows high levels of expression in fetal cardiomyocytes. Both knockout and over-expression of Calreticulin in the mouse embryos is lethal arguing for an important role for this protein in survival and importantly for tight regulation of its expression in that regard to support physiological functions. Interestingly, over-expression of constitutively active Calreticulin only in the hearts of Calreticulin-null mice, rescues the lethal phenotype. Collectively these results argue for an important role for Calreticulin in the development and differentiation of cardiac myocytes. The exact mechanism by which Calreticulin affects cardiac development remains unclear. Previous studies on Calreticulin knockout cells showed inhibition of IP3– dependent Ca2+ release, suggesting a role for Calreticulin in Ca2+ homeostasis. Ca2+ is a ubiquitous second messenger that can be either release from intracellular Ca2+ stores or flows into the cell from the extracellular space through multiple Ca2+ influx pathways at the cell membrane. Ca2+ release occurs through either the IP3-receptor (IP3R) or the ryanodine receptor depending on the cell type. An important Ca2+ influx pathway at the cell membrane is the store-operated Ca2+ entry pathway (SOCE). SOCE is activated in response to the depletion of intracellular Ca2+ store following Ca2+ release. SOCE is mediated by two primary molecules, stim1 and Orai1. stim1 is an ER resident membrane protein with lumenal EF-hands that allows it to sense ER Ca2+ levels. Upon store depletion stim1 clusters and moves close to the cell membrane where it binds to and activates Orai1. Orai1 is a four trans-membrane pass Ca2+ channel that is gated by direct coupling to stim1. Both Orai1 and Stim1 were shown to be expressed in cardiomyocytes and required for cardiomyocyte SOCE. SOCE is important in cardiomyocyte biology and was shown to regulate normal and hypertrophic postnatal cardiac growth. Moreover, studies in zebra fish suggest an important role of Orai1 in regulating cardiac function, linking Orai1-mediated calcium signaling to cardiomyocyte function. Ca2+ influx through SOCE has been shown to activate the transcription factor, nuclear factor of activated T-cells (NFAT), by enhancing its translocation from the cytoplasm to the nucleus, leading to specific induction of gene expression. NFAT activation occurs downstream of the activation of the Ca2+-dependent phosphatase calcineurin. This nuclear import of NFAT was shown to be impaired in Calreticulin knockout cells. This supports a role for Calreticulin in the Ca2+/calcineurin/NF-AT transcription pathway. Here we use Calreticulin knockout MEF cells to study the effect of the absence of Calreticulin on SOCE. We specifically focus on Orai1, and study its subcellular localization and function in Calreticulin knockout MEFs as compared to wild type MEFs. We used specific Ca2+ imaging assays to asses SOCE function. Our Calcium imaging data show no difference in SOCE between wild-type and Calreticulin knockout MEF cells. We further studied the membrane trafficking and plasma membrane localization of YFP-tagged Orai1 in knockout MEF cells. Calreticulin knockout cells show higher proliferation rate than wildtype cells in culture, which will be further investigated by MTT and CFSE labeling. Our results suggest that the lethal phenotype in Calreticulin-null mice is not due to improper folding of Orai1, but can be related to the change of calcium homeostasis in the absence of Calreticulin.

The study includes the isolation and extraction of some active molecules like (flavonoid and total poly phenolic) and plant insulin (Glucokinin) from leaves and flowers of B. variegate L. belonging to the family Leguminosae which cultivated in Iraq. Also the study employed an in vivo evaluation of Bauhinia leaves (petroleum ether and methanol extract) and methanol extract and flowers extraction in mice at concentrations (200 and 400 mg/kg) for (LM1 and LM2) and (200 mg/kg) for F given intra peritoneal for 10 days after inducing diabetes mellitus type 2 by alloxan (200 mg/1 kg body weight). The serum was isolated from blood by cardiac puncture for the biochemical tests, including glucose, cholesterol (ch), Triglyceride (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and very low density lipoprotein (VLDL). At day 10 the animal was killed and the liver and pancreas were kept in 10% formalin for preparation of histopathological sections. We concluded that the Plant insulin (Glucokinin) may be responsible for some of the actions at plant extracts for their antidiabetic properties. From the observations, it was concluded that the reduction of blood glucose levels in diabetic rats were found to be dose dependent and also dependent on duration of action. So it might be useful in the treatment of diabetes without toxicity.

Keywords

Bauhinia variegata, Antidiabetic activity, Hyperglycemia, Hypolipidemic

Introduction

Blood cultures are commonly performed in hospitals daily as it is employed to detect infections that are spreading through the bloodstream (eg; bacteremia, septicemia). This is possible because the bloodstream is usually a sterile environment. Positive blood cultures indicate either bacteremia, or false positive blood cultures from contamination with bacterial skin flora through improper technique. False positive blood cultures are associated with unnecessary hospitalization and/or extended length of stay with consequent financial burden. False positive blood culture rates in Emergency Departments (ED) are often twice as high as on the medical wards. We present the results of an intervention – ANTT (Aseptic Non-touch technique) to decrease false Positive blood culture rates at Hamad General Hospital during the period from Nov 2014 through Nov 2015.

Aim

The HGH Microbiology lab indicator showed that our blood culture contamination rate has been consistently higher than the international benchmark, thereby we aim to reduce it in the critical area of ED BY 50% by the end of July 2015 and at least 90% by end of February 2016.

Methods

A pilot area was chosen in the Emergency Dept. to do a study for 44 weeks after which blood culture kits (previously trolleys & trays were used) containing sterile gloves, masks, and blood culture supplies were introduced into the Critical area of ED-HGH in August 2015. Training included- new instructions to have two staff members present when drawing blood cultures (Preceptor-preceptee methodology) there by prohibiting drawing blood cultures from pre-existing lines and proper follow-up of every step. False positive blood culture rates were measured in the weeks preceding and the weeks following, this intervention.

Results

In the 8 weeks following the intervention, the average false positive blood culture contamination rate in HGH ED reached 1.9%–(which was the benchmark) out of 318 blood culture samples. In the 6 months preceding, the blood culture contamination rates ranged from 4% to 1.5% each month.Conclusion:Blood culture kits and educational training on proper technique resulted in significant reduction (> 60%) in the false positive blood culture rate in the Critical areas of ED-HGH. Studies at other institutions have suggested that reducing the false positive blood culture rate could decrease costs by preventing unnecessary hospitalizations and administration of unnecessary antibiotics, as well as helping to prevent the development of multi-drug resistant organisms.

Background

Chronic myeloid leukemia is characterized by the reciprocal chromosomal translocation t(9;22)(q34;q11), leading to the formation of the Philadelphia chromosome. This encodes the constitutively active Bcr-Abl tyrosine kinase, which profoundly affects proliferation, apoptosis, and cell adhesion signaling pathways. Despite remarkable success in controlling CML at chronic phase by Bcr-Abl tyrosine kinase inhibitors (TKIs), a significant proportion of CML patients treated with TKIs develop drug resistance. Therefore, there is an urgent need for more potent and safer therapies against CML cells for the efficient management of CML.Proteasome inhibitors are attractive cancer therapeutic agents because they can regulate apoptosis-related proteins. Bortezomib also known as bortezomib, a proteasome inhibitor that has been approved by the food and Drug Administration for treatment of patients with multiple myeloma, and many clinical trials are ongoing to examine to the efficacy of bortezomib for the treatment of other malignancies. Bortezomib has been shown to induce apoptosis and inhibit cell growth of many cancer cells. In current study, we determine whether bortezomib induces cell death/apoptosis in CML.

Material and Methods

Reagents

Bortezomib and antibodies against caspase-3, caspase-9, PARP, p27, GAPDH were obtained from Santa Cruz Biotechnology Inc (USA). Antibodies against SKP2 and caspase-8 were obtained from Cell Signaling Technology, Inc USA) Arsenic trioxide (As2O3) and cyclohexamide were purchased from Sigma. Chronic myelogenous leukemia cells (CML) cell lines: K562, LAMA and AR230 cell lines were cultured in RPMI 1640 medium supplemented with 10? (v/v) fetal bovine serum (FBS), 100 U/ml penicillin, 100 U/ml streptomycin at 37°C in an humidified atmosphere containing 5? CO2. Proliferation assays: 104 cells were incubated in triplicate in a 96-well plate in the presence or absence of indicated test doses of Bortezomib in a final volume of 0.20 ml for 24 hour. The ability of Bortezomib to suppress cell growth was determined by MTT cell proliferation assays.

Apoptosis

CML cell lines were treated with bortezomib in different conditions as indicated in each experiment for 24 hours. Apoptosis was determined by flow cytometry using Annexin V (Molecular probes, Eugene, OR), PI staining for cell cycle analysis and DNA laddering using an apoptotic kit (Roche, Indianapolis, IN).

JC1 staining

1 × 106 cells were treated with different doses of bortezomib for 24 hours and stained with 10 mMol JC1 (Alexis corp., San Diego, CA) and measured by flow cytometry.

Western blot

Equal amounts of protein were separated by SDS-PAGE, transferred to PVDF membranes and probed with specific antibodies. Cytochrome c release from mitochondria: 20 μg of proteins from the cytosolic fraction were analyzed by immunoblotting with a specific antibody.

Results

Our data showed that proteasome inhibitor bortezomib decreased cell viability as well as induced apoptosis in a dose-dependent manner in a panel of CML cell lines. S-phase kinase-associated protein 2 (SKP2) is an F-box protein that targets cell cycle regulators including cyclin-dependent kinase inhibitor p27Kip1 via ubiquitin-mediated degradation. SKP2 is overexpressed in CML cells, and Bortezomib treatment of these cells resulted in down-regulation of SKP2 and stabilization of p27Kip1. Furthermore, bortezomib-treatment of CML cells led to the loss of mitochondrial membrane potential with the subsequent release of cytochrome c from mitochondria into the cytosol. Cytochrome c release caused activation of caspase-3 followed by polyadenosin-5-diphosphate-ribose polymerase (PARP) cleavage. Finally, we assessed effects on leukemic progenitors (CFU-L) using clonogenic assays in methylcellulose. The treatment of CML cells with bortezomib resulted in inhibition of CFU-L colony growth of leukemic precursors in the CML cell lines. We also provide evidence that co-treatment of chronic CML cells with bortezomib and arsenic trioxide (As2O3) potentiated the inhibition of cell viability. In addition clonogenic assays in methylcellulose demonstrate potent suppressive effects of the combination of these agents on primitive leukemic progenitors derived from CML cells.

Conclusion

Altogether, our results suggest that bortezomib-mediated downregulation SKP2-induced efficient apoptosis in CML cells and exhibited antileukemic effects. Furthermore, co-treatment of CML cells with bortezomib and As2O3 potentiated anti-cancer effects. These data suggests that proteasome-ubiquitin pathway may be a potential target for therapeutic intervention for treatment of CML.

Keywords

Proteasome Pathway, CML, Apoptosis

Introduction

Accumulating evidence suggests that adipose tissue is a dynamic organ that undergoes expansion and contraction in response to energy demands and obesity-associated tissue injury. The dynamic nature of the adipose tissue is achieved via changes in both size and number of mature adipocytes through adipocyte hypertrophy and preadipocytes proliferation and differentiation respectively. These changes are mediated through various growth factors and cytokines secreted by cells within the adipose tissues (Spalding et al. 2008). Hypertrophied adipocytes secrete cytokines such as IL-6 that can trigger macrophage infiltration and secretion of IL-1β, TNFα and IL-8 (Bjorntorp 1974; Kobashi et al. 2009), causing impairment of preadipocytes differentiation and induction of insulin resistance (Gustafson et al. 2007; Veilleux et al. 2009). TNFα-stimulates HGF release from fibroblasts and monocytes within the adipose tissue serving as a potent mitogenic factor (Bell et al. 2008). Mature adipocytes secrete IGF-I that plays a major role in preadipocyte differentiation (Bluher et al. 2005). Other growth factors such as VEGF were suggested to regulate the balance between osteoblast and adipocyte differentiation from pre-preadipocytes (mesenchymal stem cells) (Liu et al. 2012). Preadipocytes exhibit unique depot-specific characteristics that persist in expanded in vitro such as different size, lipoprotein binding, fatty acid transfer, protein secretion and response to insulin and lipolytic agents (Tchkonia et al. 2013). Cultured human abdominal subcutaneous preadipocytes (SC) accumulate more fat and exhibit a greater expression of adipogenic transcription factor than omental preadipocytes (OM) (Tchkonia et al. 2005). SC adipocytes serve as the first optimal fat storage choice (Tchkonia et al. 2013). Obesity causes impairment in SC fat storing capacity as a result of reduction in the number of differentiating preadipocytes and hypertrophy of mature adipocytes (Isakson et al. 2009; Spalding et al. 2008). This leads to expansion of visceral fat, including OM depot, with ectopic fat accumulation in the liver, skeletal muscle and heart (Okuno et al. 1998; Tchkonia et al. 2010). Visceral and ectopic fat accumulation results in further augmentation of insulin resistance in these tissues (Petersen and Shulman 2006), which is associated with a depot-dependent (OM > SC) IL-6 release in vivo and ex vivo (Fried et al. 1998; Mohamed-Ali et al. 1997).

Methods

In this study we compared the secretion of IL-6, IL-1β, TNFα and IL-8 in 15 paired subcutaneous (SC) and omental (OM) preadipocytes cultures expanded from stromal-vascular fraction (SVF), isolated from morbidly obese patients (8 males and 7 females) undergoing weight reduction surgery at Hamad Medical Corporation (HMC). We further evaluated the effect of IGF-1, HGF and VEGF on preadipocytes proliferation and differentiation in paired SC and OM preadipocytes cultures isolated from 3 randomly selected female subjects matched for age and BMI. For this purpose, SVF-derived cells (passage 1–2) were grown in stromal medium overnight then incubated in differentiation medium for 7 days, followed by 12 days in maintenance medium as previously described (Lee et al. 2012). Accumulated levels of secreted IL-6, IL-1β, TNFα and IL-8 in the last four days of differentiation were measured in media supernatants using Inflammatory Cytokine Human Magnetic 5-Plex (Life Technologies) according to manufacturer's instructions and assessed by Luminex Flexmap 3D using xPONENT® software. For experiments investigating the effect of growth factors on preadipocytes proliferation and differentiation, cells were grown as above in the absence or presence of 200 ng/ml IGF-1, 100 ng/ml HGF or 50 ng/ml VEGF for the entire differentiation and maintenance periods (once every 3–4 days). To assess proliferation and differentiation capacity, cells were fixed with 4% formalin for 10 min, stained with DAPI and subsequently with Lipidtox (Life Technologies) for 20 min. Total number of nuclei (DAPI, indicator of proliferation) and differentiated adipocytes (Lipidtox positive cells) were scored in 20 fields per well by ArrayScan XTI (Thermo Scientific) using automated spot detection module. Differentiation capacity was assessed by calculating the ratio of Lipidtox positive cells/total number of stained nuclei and presented as a percentage (adipogenic capacity). All protocols were approved by Institutional Research Boards of ADLQ and HMC (SCH-ADL-070, SCH-JOINT-111).

Results

Levels of secreted IL-6, IL-1β and IL-8 were significantly higher in OM preadipocytes compared to their SC-derived counterparts (Fig. 1), whereas secreted TNFα levels were below the level of detection. Compared to their age and BMI matched males counterpart, SC preadipocytes from females exhibited significantly higher levels of secreted IL-6 by 49.2% (p = 0.05) (Table 1) with no significant differences in other measured cytokines in either tissue. Treatment of SC and OM preadipocytes with IGF1, HGF and VEGF increased subcutaneous preadipocytes proliferation by 20% (n = 3, p ≤ 0.01) but had no significant effect on omental preadipocytes (Fig. 2). In contrast, IGF1 increased omental preadipocyte differentiation by 50% (p = 0.02), whereas neither HGF nor VEGF exhibited significant effect on subcutaneous or omental preadipocytes differentiation (Fig. 3).

Discussion and Conclusion

Our data suggest that elevated levels of secreted IL-6, IL-1β and IL-8 in OM compared to SC expanded cultures confirm the greater inflammatory nature of OM-expanded in vitro cultures shown previously in vivo and ex vivo (Fain 2006; Fried et al. 1998; Maury et al. 2007). The greater IL-6 secretion in female SC preadipocytes may suggest a role of sex steroid hormones (estrogen and androgen), but mechanisms for depot-specific differences remain poorly understood (Lee et al. 2013). Previous data has shown that preadipocytes are potent sources of growth factors such as VEGF, HGF, and IGF-1 in response to inflammatory mediators via a p38 MAPK-dependent mechanism (Wang et al. 2006). Investigation of the function of these growth factors on proliferation and differentiation of SC and OM expanded cultures confirmed the mitogenic nature of all these growth factors in SC but not in OM preadipocytes, while only IGF-1 enhanced differentiation of OM preadipocytes. These depot-specific differences in preadipocyte proliferation and differentiation in response to various mitogenic and adipogenic factors may be explained by their different cellular composition and physiological role (Lee et al. 2013). The molecular mechanisms underlying these differences and their impact on metabolic syndrome remain elusive. The contribution of secreted cytokines and growth factors on depot-specific differences and metabolic complications associated with central obesity may shed some light on these mechanisms.

Acknowledgment

This research was sponsored by Qatar National Research Fund (QNRF), Grant number NPRP6-235-1-048.

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Objective

To evaluate the concordance of Pap smear, Colposcopy and histopathology in patients with cervical intraepithelial neoplasia (CIN) in a local tertiary care hospital.

Design

Retrospective descriptive study.

Materials and methods

All patient with CIN undergoing LLETZ during the period from January 2007 to July 2013 were included in the study. Case records were reviewed regarding demographics and clinical data, Pap smear reports, colposcopy findings and histopathology (HPR) reports following colposcopically directed cervical biopsy (CDB) and that following Large Loop excision of Transformation zone (LLETZ).

Results

patients with CIN undergoing LLETZ were included. Agreement between Pap smear and HPR was 96.2% with sensitivity of 80.6% and specificity of 60%. Agreement between CDB and HPR was 86.4% for high grade and only 33.3% for low grade lesions. Level of concordance of Pap smear with CDB was 96.2% for high grade and only 50% for low grade lesions.

Main Outcome Measures

Agreement between Pap smear, colposcopy, CBD and HPR.

Conclusion

Pap smear and CDB are complimentary to each other, and each cannot be used independently. LLETZ improves the yield of high grade lesions and detecs minimally invasive cancer which could be missed by CDB.