Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1
- تاريخ المؤتمر: 22-23 Mar 2016
- الموقع: Qatar National Convention Center (QNCC), Doha, Qatar
- رقم المجلد: 2016
- المنشور: ٢١ مارس ٢٠١٦
241 - 260 of 656 نتائج
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Exploring the SIRT1/P53 Pathway in Adipocytes Hyperplasia
المؤلفون: Houari AbdesselemThe 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.
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Effectiveness of Self Myofascial Release Technique in the Management of Non-Specific Low Back Pain in Nursing Professionals
المؤلفون: Ms AjimshaNonspecific low back pain (NSLBP) is defined as low back pain not attributed to recognizable, known specific pathology (van Tulder 2006). The global prevalence of activity-limiting LBP was recently estimated to be approximately 39% for lifetime prevalence and 18% for point-prevalence (Hoy et al. 2012). In spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase. (Deyo et al. 2009) NSLBP remains a common and exorbitant problem among the nursing profession with a lifetime prevalence extending between 73% and 90% (Maul et al., 2003), a major cause of suffering, disability, and days of work lost. The frequency of reported disability from back injuries in nurses is among the highest of all worker groups (Jensen 1987). It accounts for 16·2% of all sick leave for nurses (Stubbs et al. 1983) and impairs performance. Myofascial release (MFR) is a form of manual therapy which involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function (Barnes, 1990). It has been hypothesized that fascial restrictions in one part of the body cause undue tension in other parts of the body due to fascial continuity. This may result in stress on any structures that are enveloped, divided, or supported by fascia (Schleip, 2003). Self MFR involves the application of MFR by themselves with the help of fingers, hands or hand held devices. A recent study by Ajimsha et al (2015) found that MFR was more effective than a control intervention in the back pain management of nursing professionals. The main objective of this study was to investigate whether Self Myofascial Release (SMFR) technique can reduces pain and disability in non-specific low back pain (NSLBP) in comparison with a control group receiving a sham Myofascial release (Sham-MFR) in nursing professionals.
Methods
This study was designed as a Randomized, controlled, single blinded trial and carried out in the clinical wing of Myofascial Therapy and Research Foundation, Kerala, India. Inclusion criteria for this study was nursing professionals aged 30–50 years with a diagnosis of NSLBP of 3 or more month's duration. Patients were excluded if they displayed: 1) osteoporosis of the spine; 2) primary joint disease such as active rheumatoid arthritis; 3) metabolic bone disease; 4) malignant bone disease; 5) fracture; 6) hyper mobility of the lumbar/sacral spine; 7) cardiovascular or other medical disorder preventing the person from engaging in strenuous exercise; 8) evidence of radiculopathy, or primary complaint of radiating pain; 9) pregnancy; or 10) severe psychiatric disturbance. Use of oral/systemic steroids, use of analgesics on more than 10 days a month and any other treatment for LBP during the previous 6 months were also excluded from the study. The Research Ethics Committee of the Myofascial Therapy and Research Foundation and Medical Research wing of Mahatma Gandhi University, Kerala, India, reviewed the study and raised no objections from an ethical point of view. Between May 2013 and October 2014, 73 nursing professionals were referred to the Myofascial Therapy and Research Foundation with a diagnosis of NSLBP. Of these, 57 individuals who met the inclusion criteria and provided written informed consent were randomized to the Self MFR (SMFR) or to the control arm of the study. Participants were asked to maintain a pain and medication diary in which any medication or change in pain pattern during the treatment period was to be recorded with date and time. The SMFR were administered by the nurses themselves whereas the sham-MFR was applied by physical therapists in a predetermined dosage (12 sessions in 4 weeks).
Main outcome measure
The McGill Pain Questionnaire (MPQ) for subjective pain experience and Quebec Back Pain Disability Scale (QBPDS) to assess the disability associated with NSLBP. The primary outcome measure was the difference in MPQ and QBPDS scores between week 1 (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Two evaluators blinded to the group to which the participants belonged analyzed scores from the MPQ and QBPDS. Procedure Subjects in each group received either SMFR, or a sham MFR program. The 2 interventions were provided for 3 times per week for 4 weeks (weeks 1–4), with a minimum of a 1 day gap between the 2 sessions; the duration of each treatment session was set as 45 min. A recorded audio which gives step wise instruction for the SMFR was given to the SMFR group with fixed daily timing for the release. A research assistant calls and confirms the SMFR adherence in a daily basis. MFR procedure We used the following treatment protocol for all the patients in the SMFR group derived from the protocol used by Ajimsha et al (2015) in his study. A normal tennis ball and a Rumble Roller® (RR 316, blue, original density) were the items given to the clients in the SMFR group. The clients in the SMFR group were given one hour training for the SMFR and were asked to demonstrate it on the very next day to a therapist who was not the instructor of the SMFR. Control intervention Patients in the control group received sham MFR over the same areas as the application of SMFR (in the other group) for same time and duration. Sham MFR were applied by gently placing the hand over the areas treated in the SMFR group just enough to maintain contact for the desired time. All study participants were advised to take medications only when there were any exacerbations, but were required to record them in their patient diaries, which were analyzed at weeks 4 and 12 after randomization SMFR protocol. a) MFR of the Gluteus Maximus and piriformis Client's Position: Supine with hips and knees bend Technique: By using a tennis ball at the area of release (between the posterior superior iliac spine and the greater trochanter, the client will be asked to slowly press the body against the ball in a way that it elicits an aching pain the region. The body has to be adjusted by using the weight transferred through the feet to roll the ball between the above positions. The client has to stop the rolling for 30 seconds at any point where he/she feels more pain. (Duration: 5 min × 2 sides = 10 min) b) Back work lower Client's Position: Supine with hips and knees flexed The client places themselves over a Rumble Roller so that the foam roller will be positioned at the lower back in the lumbosacral region. The client is trained in moving the lower back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release = 10 min). b) Back work upper Client's Position: Supine with hips and knees flexed. The Rumble Roller was positioned at the upper back in the thoracic region. The client is trained in moving the upper back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release = 10 min). c) The Trunk sides Client's Position: Side lying, head supported by a pillow. Hips in 450 of flexion, knees in 350 of flexion. The client places themselves over a Rumble Roller in a side line position so that the area between greater trochanter and lower ribs can be released. The client stabilizes himself over the form roller with the help of the upper and lower extremities opposite to the lying side. The feet will be used to move the lateral trunk over the roller. (Duration: 5 minutes × 2 sides = 10 minutes) d) Seated focused release Client's Position: Seated in a rolling stool with hips higher than the knees feet slightly forward of the knees and well connected to the ground. The client supports their back via their feet and legs. The client will use a tennis ball between the lower back and a wall and by moving the back against the ball by means of counter pressure, releases the deeper muscles of the back. The clients were encouraged to isolate the specific segments on which the pressure was applied. (Duration 5 minutes) Statistics Participants in both groups were comparable at baseline. The primary outcome measure was the difference in MPQ and QBPDS scores between baseline (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Statistical analysis of the data was done by using a 2 × 3 (group × time) analysis of variance (ANOVA) and 2 × 2 (group × time) and 2 × 3 (group × time) repeated-measures ANOVA. The between groups (group), within-groups (time), and mixed-groups (group × time) interactions were examined; then, in accordance with the primary objective of the study, we compared the MPQ and QBPDS scores of the SMFR and control groups at different time intervals. A P < 0.05 was accepted as statistically significant.
Results
The mean differences between groups vary by time. This indicates the possible existence of their interaction effect. The simple main effects analysis showed that the SMFR group performed better than the control group in weeks 4 and 12 (P < 0.005). The patients in the SMFR group reported a 62.6% reduction in their pain and 36.3% reduction in functional disability as shown in the MPQ and QBPDS scores in week 4, which persisted as a 43.8% reduction of pain and 29.2% reduction of functional disability in the follow-up at week 12 in the SMFR group compared to the baseline. The patients in the control group reported a 9.5% and 3.6% reduction in their MPQ and QBPDS scores in week 4. The proportion of responders, defined as participants who had at least a 50% reduction in pain between weeks 1 and 4, was 63% in the SMFR group and 0 in the control group. The test's between subject effects showed a significant interaction between the effects of group and time on value (F2,189 Z 522.418, P < 0.001). The simple main effects analysis (Table 3) showed that the SMFR group significantly performed better than the control group in weeks 4 and 12 (P < 0.001), but there were no differences between the groups at baseline (P > 0.001). We observed that the interactions between time and group were significant based on univariate and multivariate methods for all 3 repeated-measures ANOVAs. Significant pairs of SMFR and control groups vary at weeks 4 and 12 due to the interaction effect between group type and time. Study limitations One limitation of this trial was that practitioners could not be blinded. Second, long-term outcomes were not assessed, and it is not known whether the differences observed at post-treatment can be maintained over a long time. We also did not examine other important treatment outcomes such as pain beliefs, mood, and quality of life.
Conclusions
This study provides evidence that SMFR can be a useful tool in the management of NSLBP in nursing professionals than a control. A cost and time benefit analysis can be undertaken in the future studies. A major section of nursing professionals with NSLBP might benefit from the use of SMFR and can be taught as a LBP prevention strategy for nursing professionals.
Keywords
Myofascial release; Non specific low back pain, Nursing professionals
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Secondhand Smoke Emission levels in Waterpipe Cafes in Doha, Qatar
المؤلفون: Nadia FanousBackground
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.
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Improving Documentation of Cardio-Vascular Disease Risk in Medical Records of Diabetic Patients attending Non Communicable Disease Clinics at West Bay Health Center in Qatar
المؤلفون: Mohamed Salem, Amal Alali and Zelikha BashwarBackground
Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD. Multiple clinical trials have demonstrated significant effects of pharmacological (primarily statin) therapy on CVD outcomes in individual subjects with CHD and for primary CVD prevention. Our aim is to improve documentation of cardiovascular disease risk in medical records of diabetic patients attending non communicable disease clinics at west bay health center from 13% to 70% using world health organization cardiovascular disease risk Prediction Charts from September 2014 to January 2015.
Methods
Baseline audit to determine the percentage of cardiovascular disease risk documentation, Brain storming session was done to identify the causes of such problem including fish bone analysis, Survey questionnaire was designated to assess the main causes of the problem and distributed to all nurses working in non communicable disease clinics, The results demonstrated in paretto chart, We discover the main causes of the problem lies on two main causes (nurses were not oriented to new non communicable disease format and some of them were not trained to calculate risk).Intervention in form of: Education session for nurses working in these clinics were done particularly on: Orientation about new format and cardiovascular disease riskdocumentation, Orientation sessions for clinic running physicians, Putting reminder posters in clinics and staff nurse stations. Several audits done retrospectively for two weeks (3 days each week) to show average percentage of documentation in pre-intervention stage from 15th September to 13th November 2014, Several audits done for three weeks (3 days each week) and then weekly for 5 weeks to show average percentage in post-intervention stage ending at 15th January 2015, All data was demonstrated using run chart.
Results
The intervention began in November 2014 to January 2015 reveals that: Percentage of complete cardiovascular risk documentation for diabetic patients average was 7% in pre-intervention stage and increased to average of 59% after the intervention
Conclusions
Intervention in the form of nurse education and physician orientation improved Documentation of cardiovascular disease risk by 52%. Raising the average of documentation from 7% to 59%. Sustainability is very important for success in such improvement processes.
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Relationship of Violence Exposure and Mental Health of Youth in Iraq
المؤلفون: Ameel Farooq AlshawiIntroduction
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.
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Disinfection by-products of Chlorine
المؤلفون: Fatima Al-Otoum and Mohammad Al-GhoutiThe occurrence of disinfection by-products (DBPs) of chlorine dioxide (ClO2) in drinking water, namely: chlorite, chlorate, and THMs as well as the concentration of ClO2 were investigated. Two hundred ninety four drinking water samples were collected during the time period from March to August 2014. The water samples were collected from seven desalination plants (DPs), four reservoirs and eight mosques distributed in South and North Qatar. The ClO2 level was ranged from 0.38 to less than 0.02 mg/L, with mean value of 0.17, 0.12, and 0.04 mg/L in the desalination plants (DPs), the reservoirs (R), and the mosques (M), respectively. The chlorite level was varied from 12.78 – 436.36 ppb with median values varied from 12.78 to 230.76, from 77.43 to 325.25, and from 84.73 to 436.36 ppb in the DPs, the reservoirs, and the mosques, respectively. While chlorate was varied from 10.66 ppb to 282.71 ppb with mean values varied from 35.58 to 282.72 ppb, from 11.02 to 200.69, and from 10.66 to 150.38 ppb in the DPs, R, and M respectively. However, the average value of THMs was 4.90 ppb, while maximum value reached 76.97. Lower disinfectant residual was observed in few samples, however this could be attributed to the normal decomposition reaction of ClO2 with organic and inorganic compounds, including biofilms, pipe materials, corrosion products, formation of slime or may due to the fact the water in distribution system experience water aging problem. Significant differences were observed in the concentration level of chlorite, chlorate and THMs between DPs, reservoirs and the mosques. However, the concentrations of all DBPs fell within the range of the regulatory limit set by GSO 149/2009, WHO and KAHRAMAA (KM). It is recommended to slightly increase the average ClO2 dosage at the DPs. Such slight increase would provide safer margin at the customer point of use in case of any microbial activities. Consideration must be given to the overall demand and should account for seasonal variations, temperature, and application points. As well as a monitoring approach is recommended for the drinking water safety assessment. Re-conducting the study to include other DPs of ClO2 is recommended.
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“The use of Arabic version of Social Communication Questionnaires (SCQ) in School Screening for Autism Spectrum Disorder (ASD) in Qatar”
المؤلفون: Fouad Alshaban, Eric Fombonne, Mohammad Aldosari, Saba El-Haj, Hawraa Alshammari and Iman GhazalIntroduction
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).
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Design and Development of Textile Based Strain Sensor for Medical Textiles Applications
المؤلفون: Muhammet UzubIntegrating strain sensors into textiles opens new applications. For example when attaching the sensors in the knee or elbow region, the bending angle of the joints can be measured. Such a measurement can be used in sports (e.g. to measure the number of steps and the speed while jogging) or in rehabilitation to give the patient an online feedback whether he practices the injured joint in the appropriate range. Measurement of fabric strain flexion of human joints caused an elongation of the affixed skin up to 45% in the region of the knee and 30% in the region of the lower back. Consequently, strain sensitive materials that react to elongation were integrated into tight fitting garments for a reconstruction of the joint angle. One could even think of a whole body posture measurement which enables a quality and quantity measurement of exercise conduction in fitness training and rehabilitation.
Keywords
Medical textiles; Conductive yarns; Flexible strain sensors; knitted structures; Rehabilitation
Introduction
The fabrication of electronic systems onto substrates represents a breakthrough in many areas of application, such as virtual reality, tele-operation, tele-presence, ergonomics and rehabilitation engineering. The need of the hour is to develop such an integrated effective system for medical textile applications which is not only flexible but also conformable to the human body, for such type of flexible strain sensors, one should focus on some crucial parameters like development of optimized composite conductive yarns used for the substrate and flexible strain gauges based on composite conductive yarns. Measuring strain in textile is a problem addressed by different research groups. One of the first groups who mentioned this problem was Tognetti et al. They built a knitted strain sensor which was integrated into a jacket and was used to measure upper body movements [1]. Gibbs et al. designed a textile potential divider to measure joint movements. In a thin layer of poly-pyrrole (using chemical vapor deposition) was applied on the fabric substrate at low temperature. With this configuration, a measurement range of up to 50% strain and a strain sensitivity of 80 was achieved [2]. Mattmann et al. investigated ethylene-vinyl acetate (EVA) and ethylene-propylenediene rubber (EPDM) composites for sensor applications. Such carbon composite materials show high relaxation behavior and creep which means that the change in resistivity is influenced by the strain rate [3]. An elastomer/carbon black-composite (CE) was used by Tognetti et al. to measure arm and finger movements. This sensor showed high relaxation behavior too. Carbon black/elastomer- and rubber-composites need to be cured after compounding and shaping [4]. In contrast, when using thermoplastic elastomer (TPE) based composites, curing is not necessary and simple thermoplastic processing technology can be used for shaping. Therefore, such polymers are interesting when developing strain sensors with large strain. Yamada et al. presented a sensor of a thermoplastic elastomer and filled with carbon black (27.6 by %vol.). They focused on noncyclic strain sensing and looked at influences of temperature and humidity on the resistance. The sensor showed a dependence of the resistance on the humidity but not on the temperature [5]. In this paper we use a similar composition (50wt–%/32vol–% carbon black) but focus on the characterization of the sensor's dynamic behavior, as sensors integrated into textiles are exposed to repeated strain cycles. The conductive fibers can be incorporated into the yarn (Figure1) and then subsequently incorporated into fabric. Integrating strain sensors into textiles opens new applications in medical textiles, for example, when attaching the sensors in the knee or elbow region, the bending angle of the joints can be measured. Such a measurement can be used in rehabilitation to give the patients an online feedback whether they practiced the injured joint in the appropriate range or not. One could even think of a whole body posture measurement which enables a quality and quantity measurement of exercise conduction in fitness training and rehabilitation. Measuring the posture using strain sensors enables an unobtrusive integration into textile currently not possible with other sensors (e.g. accelerometer, gyroscope, and magnetometer). This calls for a combined effort on one hand from the materials side in terms of developing functionalized fabrics and tackling integration issues, and also from the computer applications side to provide user-friendly interfaces. Through characterization of their response and assess functionality for specific applications. These are not only valuable to the athlete who wish get the most from their training regime and assess their progress but also for different patient who need rehabilitation. This project will focus on the development of optimized composite conductive yarns and strain sensors which measures strain in textiles. Furthermore, these strain sensors will be integrated in to braces which could be used for many applications such as patient rehabilitation and monitoring and controlling of athlete movements. The scope of this work is to develop a device capable of measuring strain, based on conductive textile yarns and using them as strain sensors. Furthermore, these sensors can also be incorporated into intelligent braces which can be used for endless medical textile applications.
Material
The conductive yarns will be prepared by TPE (thermoplastic elastomer) based composites and for shaping simple thermoplastic processing technology will be used. The TPE material such as SEBS-Block copolymer (THERMOLAST Kr (FD-Series)), Compound No. TF7- ATL produced by KRAIBURG TPE GmbH, Germany may be used. Thermoplastic elastomers (TPE), sometimes referred to as thermoplastic rubbers, are a class of copolymers or a physical mix of polymers (usually a plastic and a rubber) which consist of materials with both thermoplastic and elastomeric properties. While most elastomers are thermosets, thermoplastics are in contrast relatively easy to use in manufacturing. The carbon black powder (ENSACO 250 produced by TIMCAL, Belgium) may be used and will be added in TPE during fiber manufacturing.
Method for producing filament
For the fibre manufacturing we will use extrusion and drawing method. The TPE pellets will be filled in an electrically heated torque rheometer with roller blade configuration. After melting the thermoplastic part of the TPE, carbon black powder will be added and subsequently homogenized and dispersed into the polymer. The rotation speed may be constant (10 rpm) during the whole procedure. After compounding, the fibre will be produced by using a capillary rheometer, and an extrusion die. The composite material will be preheated and compacted in the cylinder of the rheometer. By using the furnace (proposed) furnace we can produce activated carbon through stabilization and carbonization of different materials like polyamide and PAN (Polyacrylonitrile) in the presence of inert atmosphere. Then through ball milling machine (proposed) we can create nano particles of this activated carbon. The coating of these nano particles will give us good results regarding electrical and thermal conductivity. Strain sensor Preparation: Textile Stretch Sensor will be manufactured by Flat Hand Knitting through incorporate conductive yarns into fabric. With the help of weft knitted machine this sensor will be prepared. For the effectiveness of sensors, we may change different parameters such as Loose knitted with and without lycra yarn Tight knitted with and without lycra yarn Single Plied knitting Double plied knitting Testing: The Strain sensors will be characterized in terms of quasi-static and dynamic electromechanical transduction properties. Thermal and aging properties of the sensing fabrics will also be determined through cyclic loading on UTM machine. Conductive properties of the Textile Stretch Sensor (TSS) will be tested on ohm meter in BUITEMS Textile lab. All measurements will be performed on Electronic Extensometer (proposed). The resistance will be measured in parallel with a multi meter. These strain measurements will be done at a speed of 200 mm/min which corresponds to a strain rate of 16% = sec (sensor length 2 cm) which is achieved in typical body movements. Brace Performance Testing Following is the picture of the preliminary developed sensor. The target will be the improvement of reproducibility for the accurate results. We may also miniature the circuits involved to make it easy to wear.
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X-linked Genes with Novel Rare Variants Identified by WGS in ASD Patients are Involved in Neurodevelopment
المؤلفون: Vasiliki Chini, Karim Shalaby, Yasser Al-Sarraj, Rowaida Taha, Fouad Alshaban, Marios Kambouris and Hatem El-ShantiTwo 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.
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The Miniaturization of Reverse Addition-fragmentation atom Transfer Living Polymerizations — the Democratization of RAFT
المؤلفون: Albert Ryszard LiberskiReverse addition-fragmentation atom transfer (RAFT) living polymerization, a popular means of preparing coplymers of methacrylate and methyl methacrylate with narrowly defined size distributions and architectures, can readily be performed in sub-mililiter quantities in the absence of stirring, yielding biocompatible materials with excellent yields and low PDI values, and a linear molecular weight response curve extending to above 180,000 g·mol–1. When multiple studies were done involving the variation on the RAFT/monomer ratio under a variety of concentrations, the corresponding molecular weights of the materials exhibited a linear response. Furthermore, in comparing the resulting material to polymers prepared using more classical free-radical polymerization techniques, the miniaturized RAFT-mediated batches showed similar biocompatibility. These facile reaction conditions offer the prospect of preparing well defined polymeric systems in parallel with minimal equipment investment, without compromising the quality of the final product. The resulting polymers were then inkjet printed onto an agarose-coated glass slide, and then tested for bioactivity.
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Characterization and Antibacterial Efficacy of Mycosynthesized Silver Nanoparticles from the Desert Truffle Tirmania Nivea
المؤلفون: Tawfik Muhammed Muhsin and Ahmad K. HachimDesert 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.
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Association of Seminal Fluid -Immunologic Inflammatory Markers with Cotinine Concentration in Smoker Unexplained Infertile- Males
المؤلفون: Naael Hussein AliObjective
To determine the causing association of the cigarettes smoking (measured by cotinine level in the seminal plasma) on the immunologic inflammatory markers (PMN-elastase, pro-inflammatory cytokines, and leukocytospermia) in seminal fluid (SF) of unexplained infertile men.
Materials and Methods
Tow hundred-thirty six unexplained infertile men, one hundred fourteen smoking and ninety six non-smokers were included in the study. They were being found without evident cause for infertility after initial workups. Other ninety fertile healthy non-smokers men were enrolled in the study as a control group. Seminal immunologic inflammatory markers (PMN-elastase, pro-inflammatory cytokines IL-8 and IL-6, and leukocytospermia) were measured in seminal plasma (SP) of all participants. Cotinine level in SP was measured as well, and correlated with inflammatory markers in all three hundred- twenty six specimens.
Results
The differences of seminal plasma inflammatory markers and cotinine level were significant between the three groups of the study, and significantly correlated with inflammatory markers.
Conclusion
The resulted substantial negative impact on sperm motility and morphology, and the correlation of cotinine level with immunologic inflammatory markers in SP, strongly indicate the presence of immunologic reaction in genital tract of the smokers. That may lead to silent genital tract inflammation. Which is, may be, the main cause for their unexplained infertility, and so, it would be sensible to advise infertile men to abstain from smoking cigarettes.
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3D Printing Assisted Prototyping of Anatomically Accurate Aortic Valve Alginate Scaffolds
المؤلفون: Albert Ryszard LiberskiWithin 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.
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Physical Therapist's Perceptions of Cultural Influences on Stroke Rehabilitation in the State of Qatar: An Exploratory Analysis
Introduction
Culture has been defined as: “a tradition of knowledge and practice that is shared, albeit imperfectly, across the members of a society and across its generations” [Zou et al 2009]. It shapes people's experiences and their emotional reactions [Gard et al 2005], including their understandings of what it means to be healthy, the meanings of symptoms, attitudes towards disability and treatment, and coping strategies [Dean et al 2006; Gallaher et al 2001]. The study suggested here may offer new insights by exploring how culture shapes the experience of stroke care through the perceptions of Physical therapists working in the state of Qatar. Qatar is one of the wealthiest countries in the world. The culture reveals the modernising influences associated with oil exploration and technological advances whilst preserving collective traditions. The state provides extensive financial support for its own citizens including generous pensions and access to health care. However, in common with other Gulf states, the majority of the population are migrant or expatriate workers [Gallahar et al 2001], The Islamic faith plays a central role in government legislation and everyday life. This is a unique culture, as in Qatar, strong commitment to the Muslim religion, collective values, and generous financial support to purchase physical therapy services abroad, may result in an experience of care that is different from that reported in other areas of the world. Physiotherapists require not only cultural sensitivity but cultural competency, which is “the ability to honor, understand, and respect the beliefs, lifestyles, attitudes and behaviors demonstrated by diverse groups of people, and to diligently act on that understanding” [Omu et al 2012; Dean et al 2006]. Culturally competent care invites maximal cooperation with patients and their family members with the aim of promoting better outcomes [Niemeier et al 2007; Balcazar et al 2010].
Purpose
The aim of this study was to investigate the perceptions of Physical therapy professionals who treat stroke patients regarding cultural influences on the experience of stroke rehabilitation in the state of Qatar. Physical therapy professionals interviewed were from a variety of cultural backgrounds thus providing an opportunity to investigate how they perceived the influence of culture on stroke recovery and Physical therapy in Qatar.
Method
A descriptive qualitative exploratory research approach was used for the study. Semi-structured interviews were carried out with 23 Physical therapy professionals with current/recent stroke Physical therapy experience meeting the inclusion criteria from the department of Physical therapy, Rumailah hospital, Hamad Medical Corporation, Doha, Qatar, followed by thematic analysis of the verbatim transcripts.
Inclusion Criteria: Physical therapy professionals with current experience of working in stroke rehabilitation in the Department of Physical therapy, Hamad Medical Corporation, Doha, Qatar, those who are able and willing to participate in a 45-minute face-to-face interview which will be audio recorded, those who are having clinical experience of 5 years or more in the field of stroke rehabilitation and those who are having more than 2 year's experience working in stroke rehabilitation in the state of Qatar.
Exclusion crieteria: Other Health Care professionals and Physiotherapists poor in English language Data Collection: Primary data was collected through semi-structured face-to-face interviews. The interview consist of structured open ended questions. Trained researchers conducted all the informant interviews at the department. All interviews were conducted in English, and once the interview were completed, the researcher immediately transcribed it into an MS Word document. A second researcher who had not transcribed the interviews reviewed each of the audio recordings and subsequent transcriptions in order to ensure that the qualitative data is accurately transcribed and translated.
Procedure
The interviews were taken place in a quiet room at the Physiotherapy department, Rumailah Hospital. Interviews were conducted in English and were of 45 minutes duration which were audio recorded. The main questions/topic were as follows: In your experience, what are the Most significant challenges faced by stroke patients in the state of Qatar? How have you addressed psychological social issues during stroke rehabilitation? In your experience, does culture have any influence on the stroke experience and rehabilitation process in the state of Qatar (if so, why and how?)? What is your opinion regarding willingness of the patients for home exercise programs and their motivation level for doing so, does the culture is having any impact over this?
Data Analysis
Transcribed interview data were entered into a qualitative data analysis software package (NVivo 2.0) for systematic coding. A content analysis was performed to identify themes that emerged from the interviews. Content analysis, or qualitative description, has been reported as useful when the description of phenomena is desired (Pope et al. 2000). The identified themes were based on informants' collective perceptions and experiences relevant to the issues being explored in the study. Once transcripts were coded, reports weer generated which the research team analyzed according to the research objectives. The team met regularly to share impressions, develop main themes and discuss alternate interpretations.
Results
The Physical therapy professionals identified several features of the Qatari culture that they believed affected the experiences of stroke patients. These were religious views, family participation, lack of awareness regarding expected outcomes and use of Physical therapy, inadequate education and public information about stroke, prevailing negative attitudes toward stroke, depression and loss of hope, social stigma and the public invisibility of disabled people, difficulties in identifying meaningful goals for Physical therapy, lack of patient and family centeredness and an reception of reliance linked with the extensive help of maids or helpers in Qatari homes. Community reintegration of the stroke victims need to be addressed in a vider perspective Lack of ‘self help groups’ with expert back up is not yet established to satisfy the demand. Lack of recreational and group activity scenarios for the stroke survivors in association with community groups Perodic councelling and antidepression measues at the social level has to be addressed. The key features identified for non-Qatari populations are insecurity, financial burden, social and emotional isolation. The anxiety of the future, lack of family support, fear of unemployment and repatriation worsens the scenario for those staying in group accommodations. Majority of the non-Qatari population wants a complete recovery and participates heavily in Physical therapy practice in order to resume back to their jobs as early as possible.
Conclusion
To offer culturally delicate care, these issues should be taken into account during the provision of Physical therapy or rehabilitation for stroke survivors in a culturally compatable way. There should be more emphasis on ongoing education, community out reach programs and environmental modifications for an ulitilame rehabilitation of such patients Insinuations for Rehabilitation Physical therapy professionals need to mold therapy to the patient's and family's model of care, reflecting their cultural background. Physical therapy professional can suggest, develop and actively participate stroke awareness sessions and community out reach programs, deliverable at home and community levels addressing the nation. Physical therapy professionals may need to be attentive that the presence of house maids and privately hired nursing staff may decrease the motivation of people to engage in Physical therapy after stroke. A care giver education and training should be considered as an important adjunct to the stroke physical therapy care. Cultural variations in degree of family involvement, prevailing negative attitudes towards stroke, and acceptance of dependency should be taken into consideration by stroke Physical therapy professionals. Physical therapy professionals should participate actively in the community based rehabilitation of stroke survivors. As patients spent more time with Physical Therapy professionals than any other health care professionals, physical therapists can act as counselors and/or motivators for the survivors. Physical therapist can be deployed as captains of self help groups which can be designed in the national level. There should be community out reach programs for the stroke survivors where Physical therapy potentials can be tapped further Physical therapist can facilitate the ongoing rehabilitation process of non Qatari expatriate survivors with the help of concerned employers and embassies once they are discharged from the active care, if it is acceptable.
Limitation
The main limitation was the sample size and difference in the percentage of national and expatriate Physical therapists interviewed, which any way will have a strong influence on the result. This was a reporting own perceptions about the stroke physical therapy care and familial and cultural back ground of the patients which will be different from the patient perspectives. Conclusions Physical Therapy professionals need to deliver therapy which is culturally molded and acceptable to the patient, family and the community. Care giver training need special emphasize in Qatari culture. Qatari and non-Qatari patients are facing dissimilar psychosocial issues which needs to be analyzed and managed as different topics. Cultural sensitivity entails Physical therapy professionals to engross with the family of the stroke survivors and to escalate their confidence and hue their perception own their disability, as well as offering more education about the principles behind therapeutic strategies.
Declaration of interest
The authors report no conflicts of interest.
References
Zou X, Tam KP, Morris MW, Lee SL, Lau IY, Chiu CY. Culture as common sense: Perceived consensus versus personal beliefs as mechanisms of cultural influence. J Pers Soc Psychol 2009;97:579–597.
Gard G, Cavlak U, Sunden B, Ozdincler A. Life-views and ethical viewpoints among Physical therapy students in Sweden and Turkey: A comparative study. Advances in Physical therapy
Dean E, Mahomed S, Maulana A. Cultural considerations for Middle Eastern cultures. In: Lattanzi J, Purnell L, (eds.). Developing cultural competence in physical therapy practice. Philadelphia, PA: F.A. Davis Company; 2006. pp. 260–275.
Gallaher C, Hough S. Ethnicity and age issues: Attitudes affecting rehabilitation of individuals with spinal cord injury. Rehabilitation Psychology 2001;46:312–321.
Omu, Onutobor, and Frances Reynolds. “Health professionals' perceptions of cultural influences on stroke experiences and rehabilitation in Kuwait.”Disability and rehabilitation 34.2 (2012): 119–127
Pope, C., S. Ziebland and N. Mays. 2000. “Qualitative Research in Health Care: Analyzing Qualitative Data.” British Medical Journal 320: 114–6.
Niemeier J, Carlos Arango-Lasprilla J. Toward improved rehabilitation services for ethnically diverse survivors of traumatic brain injury. J Head Trauma Rehabil 2007;22:75–84.
Balcazar F, Suarez-Balcazar Y, Taylor-Ritzler T, Keys, C. Race, culture, and disability: Rehabilitation science and practice. Boston, MA, US: Jones and Bartlett; 2010.
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Lipidomics for the Prediction of the Unstable Coronary Plaque
المؤلفون: Shana Sunny Jacob, Nasser Rizk, Rajvir Singh, Jassim Al Suwaidi and Magdi YacoubPlaques 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.
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Altered Myofilament Structure and Function in Dogs with Duchenne Muscular Dystrophy Cardiomyopathy
Aims
Duchenne Muscular Dystrophy (DMD) is a disease that mainly affects young mans. It is characterized by striated muscle disorder. DMD is associated with depressed heart pump function resulting from a down regulation of the left ventricular (LV) contractility. However, its effects on myofilament structure and function are poorly understood. A healthy heart is characterized by gradient of contractility spanning throughout its left ventricular (LV) wall thickness. The inner layer of the wall is known as the sub-endocardium layer (ENDO) and the outer layer is known as the sub-epicardium (EPI). The gradient of contractility is established due to the significantly high contractility of the ENDO compared to EPI. During heart failure, the contractile heterogeneity between ENDO and EPI is suppressed eliminating, thus, the gradient of contractility. Interestingly, this effect of pathology is mainly due to ENDO contractile dysfunction. These observations have maid ENDO layer to be an ideal target for heart failure treatment. Golden Retriever Muscular Dystrophy (GRMD) is a dog model of DMD observed in human. In the present study, we employed this animal model to evaluate the impact of DMD on the myofilament structure-function relationship. Accordingly, we isolated cardiac multicellular and single cells samples on which we evaluated myofilament lattice spacing, myofilament calcium sensitivity and contraction kinetics. It is to note that the force developed by cardiac single cell and multicellular preparations depends on their stretch status. For instance, at long length tension developed by an isolated single cardiac cell is higher than when it is maintained at slack length. During heart failure, this stretch effect on the contractility is significantly reduced particularly in the ENDO layer. Sarcomere length (SL) is the unit commonly used by investigators to evaluate muscle length. Accordingly, in the present study, we conducted our experiment on samples isolated from EPI and ENDO layers of GRMD animals at both short and long SL.
Methods and results
To evaluate the effect of muscular dystrophy on the myofilament structure, we have employed synchrotron x-rays diffraction approach to measure myofilament lattice spacing at various sarcomere lengths (SL) on permeabilized LV myocardium. Moreover, to evaluate transmural contractile heterogeneity in normal dog heart, myocardium samples were isolated from both EPI and ENDO left ventricular layers. Here we tested whether the lattice spacing responds differently to stretch in ENDO and EPI tissues. We obtained clear X-ray patterns from our tissue sample showing sharp equatorial reflections. As expected, spacing between thin and thick filament was reduced upon stretching. We found that d1,0 decreased linearly with SL over the SL range from 2.1 to 2.5 μm in ENDO and EPI, and that the slope of the SL–d1,0 relationship was similar in both myocardial tissue layers (Fig. 1). Despite the lack of regional lattice spacing heterogeneity, we investigated sarcomere function in isolated myocytes from the same hearts to measure myofilament calcium sensitivity. Force-pCa relationship was fitted with a modified Hill equation and EC50 ([Ca2+] generating 50% of maximal active force) was estimated. Both ENDO and EPI cardiomyocytes showed a decreased EC50 at long SL indicating increased calcium sensitivity (Fig. 2, A). To estimate myofilament length dependent activation (LDA), we computed the difference between [Ca2+] generating half of the maximal force at short (1.9 mm) and long (2.3 mm) sarcomere length (DEC50). This parameter is commonly employed to evaluate LDA. We found LDA to be higher in ENDO cardiomyocytes (Fig. 2, B) as indexed by a significantly higher DEC50 in this region. These results indicate that in dog myocardium, the higher length sensitivity of activation in the inner layer of the ventricle cannot be explained by differential interfilament lattice spacing. We evaluated myofilament Ca2+ sensitivity and LDA on permeabilized cardiomyocytes isolated from both CTRL and GRMD dogs. Myofilament calcium sensitivity was higher at short SL in ENDO GRMD myocytes compared with control dogs as indexed by a significant lower EC50 (Fig. 4, A). Differences of myofilament calcium sensitivity between CTRL and GRMD ENDO myocytes disappeared following stretch. As a result, LDA indexed by the DEC50 was lower in GRMD myocytes (Fig. 4, B). We did not find any significant difference in EPI cardiomyocytes contractile parameters. To determine whether the changes in myofilament calcium sensitivity in myocytes from failing hearts were associated with myofilament structure alteration, we performed X-ray diffraction experiments on permeabilized normal and GRMD dog ENDO myocardium at short (∼1.9 mm) and long (∼2.3 mm) sarcomere length (Fig. 4). Next, we used small -angle X-ray diffraction to assess changes in myofilament lattice structure with increasing sarcomere length in GRMD and normal dog myocardium to see if structural changes correlate with LDA. Figure 4 Panel A shows a typical CCD image of X-ray diffraction pattern. Pixel intensity was plotted and the 1,0 equatorial reflection estimated (Fig. 3, B). As observed with the first experiments (Fig. 1), the lattice spacing is reduced with stretch on CTRL myocardium (Fig. 3, C). Interestingly, the interfilament spacing was significantly higher on GRMD ENDO myocardium compared with the normal myocardium. Stretch reduced the interfilament spacing of ENDO GRMD myocardium that matches the spacing obtained on CTRL dog myocardium. The myopathy induced a myofilament lattice expansion that exceeded the physiological range. In order to test that the expansion in interfilament spacing was not due to the lack of dystrophin we also analyzed the myocardium dissected from the sub-epicardium. The higher lattice spacing in ENDO GRMD myocardium may impact myofilament calcium sensitivity and/or cross-bridge cycling kinetics. At the permeabilized single cardiomyocytes level, kinetic of tension redevelopment (ktr) was measured by mechanically disrupting force-generating cross-bridges at either sub-maximal activating solution ([Ca2+] = 1.3 μM) or at maximal calcium activation ([Ca2+] = 32 μM). Cross-bridge disruption was induced by rapid release/restretch protocol. Cardiomyocytes were perfused with activating solution, when developed force reached steady state, a rapid (2 ms) release/restretch of 20% original cell length was applied. The cell was shortly kept (20 ms) at the unload shortening prior to 100% restretch. Following the release step, force dropped to zero indicating a complete cross-bridge detachment. The restretch step, in the other hand, was characterized by an apparent monoexponential raise of force up to initial maximal force with rate constant ktr. This experimental protocol has been applied on both CTRL and GRMD permeabilized ENDO cardiomyocytes (Fig. 5). Ktr is usually used to estimate the rate of transition from weakly bound (non-force-generating) to strongly bound (force-generating) cross-bridges. Therefore, an estimation of cross-bridge cycling performance can be obtained. In ENDO cardiomyocytes from healthy dogs, ktr obtained at sub-maximal calcium activation tended to increase after stretch but it did not reach significance (Fig. 5, B). Interestingly, ktr was significantly accelerated in ENDO GRMD myocytes only at short SL (Fig. 5, A and B). Collectively, our results suggest that in myocytes from GRMD dog with heart failure there are structural changes that affect the myofilament contractile properties.
Conclusions
At short SL myopathy induces an excessive expansion of the myofilament lattice spacing that may affect myosin heads orientation. This myofilament restructuration improves weak to strong cross-bridge transition as indicated by ktr acceleration. The positive cooperative activation of thin filament through strongly bound cross-bridges improves myofilament Ca2+ sensitivity and overall cardiomyocyte active tension. Additional experiment need to be conducted to better understand the interconnection between myofilament lattice spacing and performance in myopathy induced heart failure of large animal model.
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Dimensional Shapes, Similar in the Shape and Architecture to the cup-like Structure of a Normal Human Valve, Produced using PET Spatial Knitted Fabric
المؤلفون: Albert Ryszard LiberskiRecently 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.
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The Molecular Basis of Alpha-Thalassemia in the Qatari Pediatric Population
المؤلفون: Madeeha Kamal, Ramin Badii, Aliaa Amer, Shaza Abu Sirriya and Marina KleanthousBackground
Anemia is the most common hematologic abnormality that a pediatrician encounters in clinical practice. Alpha-Thalassemia (a-thal) is widely reported in the Arabian Peninsula as one of the main causes ofasymptomatic microcytic hypochromic red blood cells with or without anemia in the pediatric population. The most common cause of anemia is either iron deficiency or thalassemia trait. Majority of the carriers for beta-thalassemia and some forms of alpha-thalassemia are clinically asymptomatic and although their hematologic phenotypes (i.e. microcytic hypochromic red blood cells) with or without anemia are predictive markers, they are not specific and overlap with conditions such as iron deficiency. Precise diagnosis of alpha-thalassemia is particularly important in the Gulf region where certain forms of alpha-thalassemia (especially non-deletional) are found, resulting in more severe phenotypes. Geographical prevalence's in the region are also variable as seen in a recent large survey of cord blood from Oman at the Sultan Qaboos University Hospital revealing a minimal frequency of approximately 50% of alpha-thalassemia of which hematologically relevant form is expected to represent a significant proportion. Unlike beta-thalassemia for which differential diagnosis can be made by measuring HbA2 levels, it is difficult to distinguish between alpha-thalassemia and iron deficiency, and DNA based diagnosis is essential. Furthermore, DNA diagnostics can provide insight into the commonly observed discrepancies between phenotypes and genotypes, especially in cases of sickle cell disease and beta-thalassemia, where alphathalassemia is known to act as a genetic modifier. To date neither diagnosis of alpha-thalassemia (trait) nor its molecular spectrum had been accurately performed and described in Qatar. This is despite the fact that in Qatar, both beta and alpha-thalassemias (Hb Barts at birth) are not uncommon and nutritional anemia can rarely be expected as cause of such microcytic hypochromic red cells because of therelatively high socioeconomic status of the country. The only published work on alpha-thalassemia in Qatar is a hospital based study in which 1,702 Qatari nationals (905 females, 797 males) were investigated for hemoglobinopathies and of which 8.05% of the patients were suspected to be alpha-thalassemia trait. Preliminary hematology results from the first year of the national premarital program in Qatar further support these results (unpublished data). Our study is the first of its kind in attempting to characterize the molecular spectrum of alpha-thalassemia in Qatar. For this purpose the study population were selected from Qatari school children. According to Qatar's national preschool assessmentprogram, all students are required to undergo routine physical checkup and blood analysis for anemia, prior to the start of their school. Results are then forwarded to the school where the school nurse will review and refer students with low Hb leveland/or low normal Hb along with low MCV values, to the Consultant Pediatrician at Qatar's Pediatric Clinic at the School Objectives:
● Determine the mutation spectrum of alpha-thalassemia in Qatari school children population.
● Making a preliminary assessment of the prevalence of inherited alpha-thalassemia in Qatari school children with hypochromic microcytic red cell with or without anemia.
● Establish molecular diagnostic protocols for diagnosis of alpha-thalassemia in Qatar, more specifically in HMC.
● Improving the healthcare management (treatment options) of individuals with hypochromic microcytic red cell with or without anemia.
● Depending upon the spectrum obtained, making recommendations regarding expansion of the current premarital and genetic counseling services in Hamad Medical Corporation.
Methodology
This was a prospective study that began in May 2012 for duration of two years and extended for an extra year searching for further mutations and analysis. Random samples were selected through the pre-school health assessment program at Qatari public schools. It is mandatory for all students to submit a full blood work-up on admission, to be held on record at their respective schools. The designated health professionals at these schools evaluate the complete blood count (CBC), and identify students with hypochromic mycrocytic red cells with or without anemia. Those with definite clinical and laboratory determination of iron-deficiency anemia are treated first for nutritional anemia. For this study, children that continued to have microcytosis (low MCV) were randomly selected. Hemoglobin (Hb) electrophoresis was performed to rule out other causes of microcytic anemia, including beta-thal. The group was ultimately narrowed down to a pool of 127 individuals with findings highly suggestive of alpha-thal, although not yet molecularly diagnosed. The samples were screened for the presence of the –alpha3.7 deletion and the alpha–5 nt, alphapoly A1 (alphaT-Saudi) and alphapolyA2 nondeletional mutations. A second group of 110 children who attended the pediatric clinic for reasons other than anemia were randomly selected. and included in this study in order to determine the alleles and genotype frequencies of the –alpha3.7 deletion in the Qatari population.
Results
Among the samples of 127 individuals, a total of 50 samples exhibited the 3.7 kb deletion; 38 (30.0%) subjects were heterozygous for the mutation, while 12 (9.4%) subjects were homozygous for the mutation. Only one subject (0.8%) was found to be heterozygous for the alpha–5 nt mutation. Three samples were positive for the alphapolyA1 (alphaT-Saudi) mutation, two (1.6%) of the three were heterozygotes and one was a compound heterozygote with the –alpha3.7 deletion. None of the subjects carried the apolyA2 mutation. Fifteen (11.8%) subjectswith mild indices who tested negative for the presence of the–alpha3.7 deletion were considered normal for alpha-thal, while 58 (45.6%) subjects were negative for all four alpha-thal mutations. These subjects were characterized by severe hypochromic microcytic anemia necessitating the extension of the screening for other alpha-thal mutations by sequencing both alpha-globingenes for nondeletional mutations or by multiplex ligand dependent probe amplification (MLPA) (P140 HBA kit; MRC-Holland, Amsterdam, The Netherlands) (http://www.mlpa.com) analysis of the a locus for large deletions. The 110 individuals who constituted the random sample were subsequently screened for the presence of the –alpha3.7deletion that was the most common alpha-thal mutation in the 127 individuals with hypochromic microcytic anemia. Twenty nine (26.4%) out of 110 samples were found to be heterozygous, while five (4.5%) samples were homozygous for the–alpha3.7 deletion. The –alpha3.7 allele frequency in the Qatari population was calculated from these data as 17.7%. Using this frequency, the expected carrier frequencies in the Qatari population were calculated as 3.13% for homozygotes and 29.13% for heterozygotes.
Conclusion
were found positive for one of the three mutations, the ? α3.7 deletion, αpolyA1 and the α?5 nt mutations. In this pool of individuals, the ? α3.7 deletion was the most common with 9.4% homozygotes, 30.0% heterozygotes and an allele frequency of 19.7%. 57.2% of children failed to exhibit any mutation despite their clinical presentations highly suggest alpha-thalassemia. This suggests the possibility of other existing mutations in Qatari populations that are yet to be elicited. The mutations found in this study are ground breaking for the Qatari medical community, and have provided a solid explanation for patients with findings suggestive of alpha-thal. This study has paved the way for diagnostic testing for alpha-thal in the Qatari pediatric population. This data will be shared in order to establish an algorithm for prevention, treatment and counseling related to alpha-thal in the Qatari pediatric population. This study has provided important clinical diagnostic insight for physicians treating patients suspected of alpha-thalassemia in Qatari pediatric population and also molecular diagnostic tools for laboratories to test such patients.
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Diagnostic Delay of Tuberculosis in Qatar: Results of an Exploratory Study
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.
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Physical Therapist's Adherence to a Structured Evidence Based Practice Guideline Improves Practice Behavior and Quality of Care; Result of an Exploratory Analysis in a Tertiary Level Hospital in Qatar
Background
Development of clinical guidelines in health services is generally considered important for improving and managing the care process (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). 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, Grimshaw and Hutchinson 1995, 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. No reviews have been published which specifically review the effect of strategies to increase the implementation of Physical therapy guidelines. In a study by Rebbeck et al., (2007), the effect of implementation of spinal pain guidelines was reviewed. Although 14 trials were included in the review, only three included Physical therapy interventions 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 II of the PAAS guideline trail focuses on the adherence of Physical therapists on the implemented guideline through file monitoring to compare its effectiveness before and after the guideline. ‘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 structured clinical practice guideline in the quality of care and practice behavior of Physical therapist's practicing in stroke in the Physical therapy department of Rumailah hospital.
Alternative Hypothesis
A PAAS structured clinical practice guideline is an effective way to improve the quality of care and practice behavior of the stroke practicing Physical therapists of Rumailah hospital.
Design
The project was structured in an observational prospective cohort model implemented during the year 2015 in the Physical therapy unit, Rumailah hospital, which will include all the practicing Physical therapists of Physical therapy unit of Rumailah hospital. We have chosen Physical therapists even from other units who are seeing stroke patients at its different stages to maintain the continuum of care and coalesce the practice. We have identified the ‘Health Service Executive (HSE) model of change’ as the suitable model since it is to fit the health care organizations. HSE model of emphasizes 4 major steps: (1) Initiation of change, (2) Planning of the change, (3) implementation stage and (4) Mainstreaming comprises evaluating and learning from the change.
The change process was initiated by January 2015, around 30 Physical therapists from the concerned area were involved in the program. Staff orientation and competency to the guideline were introduced through an in-depth training programs with pre and post-tests, periodical refresher courses and information leaflets.
Method
A subspecialty stroke form was developed as an additional form to be added with the general stroke assessment form from 1 April 2015. The subspecialty stroke form exactly reflects the PAAS guideline in its evaluation and management. It was made mandatory that the sub specialty form has to be attached with the general neurology assessment form when assessing and managing a stroke case with effect from 1 April 2015. A retrospective file monitoring was initiated to understand the practice behaviour before the PAAS guideline implementation by selecting 2 closed files of stroke patients per therapist treated from 1 January to 29 March 2015. Post guideline monitoring was started between 21 June and 30 June 2015 to cover the closed files from 1 April to 29 June 2015. The same monitoring tool was used for both the phases of monitoring. Evaluations or goals where rated as met or not met. Use of at least 80% of the basic neurological and 60% of functional measurement tools were considered as ‘MET’ in the evaluation criteria. At least 5 recommended approaches per domain from any four out of five domains during the whole treatment course as per the assessment or review was decided as ‘MET’ for the Physical therapy management part. In the pre guideline phase total number of outcome measures and total number of approaches were used to reach up the conclusion.
Result
The PASS guideline adherence analysis revealed marked difference in the Physical therapy evaluation and practice of the hemiplegic patients. Since there was no organized systems before the implementation of PAAS guideline, the evaluation and treatment part was in the ‘NOT MET’ status as pre guideline implementation phase the 80 and 60% rule in evaluation phase and 4 out of 5 domain rule in the treatment part couldn't reached. The Guideline Task Force (GTF) decided to go with the direct counting of outcome measures and treatment techniques to compare between the two phases. Comparison of stroke specific outcome measures before and after the guideline implementation revealed that the use of stroke specific outcome measures became 74% post guideline compared to 36% in the pre guideline implementation phase (Fig. 1). Comparison of use of evidence based approaches for stroke care before and after the guideline implementation has shown that 73% post guideline compared to 35% pre guideline implementation (Fig. 2) with an overall 45% gain in evidence based care post guideline implementation (Fig. 3) A paired ‘t’ test was executed to analyses the pre and post file monitoring results. The ‘t’ statistics was observed as, t = 20.003, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference (table 1). The null hypothesis was rejected, since p < 0.05.
Conclusion
There is strong evidence (p = 0.001) that the structured guideline improved the practice behavior and quality of care post guideline implementation. In this data set, it improved use of outcome measures and evidence based approaches after the guideline implementation directly reflects the change in practice behavior and quality of care of stroke practicing Physical therapists of Rumailah hospital.
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.
Rebbeck, Timothy R., et al. “A retrospective case-control study of the use of hormone-related supplements and association with breast cancer.” International journal of cancer 120.7 (2007): 1523–1528.
Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.
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