The Symptom Burden and Quality of Life in Cancer Patients in the Gaza Strip, Palestine: A Cross-Sectional Study.

OBJECTIVES: Cancer is the second leading cause of death in the Gaza Strip, Palestine, but there is an absence of evidence systematically assessing symptom burden and quality of life (QoL) using validated tools. Our objective was to assess associations between socio-demographic and disease-related characteristics, symptom burden and QoL in a sample of cancer patients accessing outpatient services in the Gaza Strip. DESIGN: A cross-sectional, descriptive survey using interviews and medical record review involving patients with cancer accessing oncology outpatient services at Al Rantisi Hospital and European Gaza Hospital (EGH) in the Gaza Strip was employed. Socio-demographic and disease-related data, the Lebanese version of the Memorial Symptom Assessment Scale (MSAS-Leb), and the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) were collected. Multiple linear regression was used to judge the relative influence of determinants of QoL. RESULTS: Of 414 cancer patients approached, 385 patients consented to participation. The majority were women (64.7%) with a mean age of 52 years (SD = 16.7). Common cancer diagnoses were breast (32.2%), haematological (17.9%) and colorectal (9.1%). The median number of symptoms was 10 (IQR 1.5-18.5). Mean overall QoL was 70.5 (SD 19.9) with common physical and psychological symptoms identified. A higher burden of symptoms was associated with marital status, education and income. Limited access to both opioids and psychological support were reported. CONCLUSIONS: A high symptom burden was identified in outpatients with cancer. Increasing provision and access to supportive care for physical and psychological symptoms should be prioritised alongside exploring routine assessment of symptom burden and QoL.

Medical Students Can be Trained to be Life-Saving First Aid Instructors for Laypeople: A Feasibility Study from Gaza, Occupied Palestinian Territory.

INTRODUCTION: Bystanders can improve the outcome in emergencies by activating the "chain of survival." Gaza's (Palestine) population has little, if any, access to training in Basic Life Support (BLS) and cardiopulmonary resuscitation (CPR). The goal was to recruit local medical students to be life-saving first aid instructors, and have them train 3,000 laypeople in BLS and CPR. METHODS: One hundred and seventeen medical students from Al Azhar University-Gaza (Gaza City, Palestine) were trained as BLS and CPR instructors. Twelve training hours were delivered in practical BLS and CPR skills, plus four in communication and didactical skills, to enable training of laypeople. Students answered a questionnaire exploring demographics, prior training experience, expectations, and motivation to join the training. Teaching material were developed after the European Resuscitation Council (ERC; Niel, Belgium) guidelines and similar training at The Arctic University of Norway (Tromsø, Norway). RESULTS: A total of 117 medical students (52.1% female; 47.9% male), from third through sixth year, completed training, and all were in their early twenties. Ninety-five (81.2%) agreed to answer the questionnaire. Of those, five students lost family members during Israeli military operations. Eighty-two (70.1%) never had hands-on first aid training. Seventy-six (80.0%) hoped the training would improve their community's response to emergencies. With 58 training sessions completed, 1,312 laypeople (596 males; 716 females) were trained: 5.52 lay trainees per student instructor. The majority (n = 1,012; 77.1%) were school students aged 13-20 years. CONCLUSION: It is feasible to recruit local medical students for practical BLS and CPR trainings targeting laypeople in communities under stress. The training impact on local resilience and patients' outcomes need further studies.

The role of EEG recordings in children undergoing cardiac surgery for congenital heart disease.

BACKGROUND: Neurological dysfunction may occur after corrective cardiac surgery using cardio-pulmonary bypass (CPB) with or without circulatory arrest. Different neurophysiological monitoring systems have been employed to detect neurological complications and possible brain injury in infants and children during and after cardiac surgery. The value of Elecetroencephalogram (EEG) in infants and children at risk for neurological sequelae has not been systematically studied. METHODS: Sequential performance of two EEGs before and after cardiac surgery at a tertiary University Hospital to screen for possible brain injury after cardiac surgery in neonates and children undergoing CPB surgery. In addition, a complete neurological examination and assessment by a physiotherapist was performed. RESULTS: Over a 4-year period, in 313 patients (age: 54.2 ± 55.7 months; normal initial EEG) after cardiac surgery CPB (duration of surgery: 146.0 ± 58.9 min; aortic cross clamp time: 34.1 ± 19.1 min), a 19-channel EEG recording was performed 2.4 ± 1.8 days prior to and 11.6 ± 5.3 days after cardiac surgery. An abnormal EEG was detected in only 8 of 313 patients (2.5%; focal slowing: 1, generalised slowing: 5, epiletiform discharges: 2) after cardiac surgery, while the EEG was normal in the remaining 305 patients (97.5%). In 1 patient, an intra-cerebral pathology was seen on MRI (ischemic); in 5 patients, follow-up EEGs were performed, which revealed normalized findings. None of the 8 patients demonstrated new focal neurological deficits on physical examination, but 33 (9.7%) children demonstrated minor abnormalities (e.g., subtle motor asymmetry, increase in muscle tone, etc.), which were unrelated to abnormal EEG findings. CONCLUSIONS: According to the used protocol, pathological EEG findings were very infrequent in our study cohort. The routine and indiscriminative recording of EEGs in children before and after corrective or palliative cardiac surgery for congenital heart disease using CPB is not recommended. Further intra-operative neuromonitoring methods with immediate intervention should be evaluated.

Predicting portal hypertension and variceal bleeding using non-invasive measurements of metabolic variables.

BACKGROUND & AIM: This study assessed the involvement of metabolic factors (anthropometric indices, insulin resistance (IR) and adipocytokines) in the prediction of portal hypertension, esophageal varices and risk of variceal bleeding in cirrhotic patients. MATERIAL AND METHODS: Two prospective and retrospective cohorts of cirrhotic patients were selected (n = 357). The first prospective cohort (n = 280) enrolled consecutively in three centers, underwent upper gastrointestinal endoscopy, seeking evidence of esophageal varices. Clinical, anthropometric, liver function tests, ultrasonographic, and metabolic features were recorded at the time of endoscopy, patients were followed-up every 6 months until death, liver transplantation or variceal bleeding. The second retrospective cohort (n = 48 patients) had measurements of the hepatic venous pressure gradient (HVPG). Statistical analyses of the data were with the SPSS package. RESULTS: The presence of esophageal varices was independently associated with lower platelet count, raised HOMA index and adiponectin levels. This relationship extended to subset analysis in patients with Child A cirrhosis. HOMA index and adiponectin levels significantly correlated with HVPG. Beside Child-Pugh class, variceal size and glucagonemia, HOMA index but not adiponectin and leptin plasma levels were associated with higher risk of variceal bleeding. CONCLUSION: In patients with cirrhosis, HOMA score correlates with HVPG and independently predict clinical outcomes. Three simple markers i.e. platelet count, IR assessed by HOMA-IR and adiponectin significantly predict the presence of esophageal varices in cirrhotic patients.

Association of serum adipocytokines with insulin resistance and liver injury in patients with chronic hepatitis C genotype 4.

BACKGROUND: Hepatitis C virus (HCV) infection, especially genotypes 1 and 4, is associated with metabolic dysfunction. We investigated the potential role of adipocytokines in HCV-induced insulin resistance (IR) and modulating the progression of liver disease in patients with HCV-4. METHODS: Serum adiponectin, high molecular weight adiponectin, leptin, tumor necrosis factor-α, interluekin-6, homeostasis model for the assessment of insulin resistance, and M30 protein were measured in 147 HCV patients and 89 controls. Liver biopsies were evaluated for steatosis/inflammation/fibrosis, adiponectin mRNA/protein, AdipoR1/-R2 mRNA, and phosphoenolpyruvate carboxykinase gene expression, and adiponectin and CD95 immunoreactivity. RESULTS: CD95 immunoreactivity and adiponectin immunoreactivity were detected in all biopsies examined. Hepatic adiponectin immunostaining correlated positively with the intensity of hepatic CD95/Fas immunostaining (r=0.424; P=0.001). Hepatocyte CD95/Fas upregulation correlated with fibrosis, inflammation, and steatosis (r=0.52, P=0.0001; r=0.16, P=0.04; r=0.24, P=0.0001; respectively). Significant correlations of serum adiponectin, its receptors mRNA expression, hepatic adiponectin immunostaining, and mRNA transcription for phosphoenolpyruvate carboxykinase were identified with steatosis. A positive association between adiponectin and hepatic inflammation and fibrosis was identified. This correlation remained significant even after adjusting for age, sex, and body mass index. Among body mass index, age, and sex-matched HCV-negative controls, patients with HCV-4 have higher serum leptin, adiponectin, and high molecular weight adiponectin, and these changes are independently correlated with IR. CONCLUSIONS: Our findings in patients with HCV-4 show that adiponectin correlates with IR and with the different stages of liver injury. Steatosis upregulates hepatocyte CD95/Fas and thus increases apoptosis, which facilitates inflammation and fibrosis. These findings may provide potential clues for novel therapeutic intervention.

Prevalence of occult hepatitis B virus infection in hemodialysis patients from egypt with or without hepatitis C virus infection.

BACKGROUND: While prevalence of Hepatitis B virus (HBV) in patients with end-stage renal failure (ESRF) who are undergoing dialysis has decreased significantly during the past few decades, it still remains a distinct clinical problem. The immunosuppressive nature of renal disease often leads to chronicity of the HBV infection and an opportunity for nosocomial spread of the infection among dialysis patients. Egypt is among the countries with intermediate endemicity of HBsAg (range, 2%-7%). Large-scale geographic heterogeneity in HBV prevalence has been reported worldwide and HBV prevalence is especially heterogeneous in Egypt. OBJECTIVES: To assess the prevalence of occult HBV infection (OBI) in hemodialysis patients with or without chronic hepatitis C (HCV) from Minia and Assuit, Upper Egypt, using HBV DNA assays. PATIENT AND METHODS: Sera from 145 hemodialysis patients with negative HbsAg were investigated for HBV DNA using real-time polymerase chain reaction (RT-PCR). Only serum samples with repeatedly detectable HBV DNA were considered positive. Patients were divided into 2 groups: HCV RNA positive and HCV RNA negative, based on the results of a third generation enzyme linked immunosorbent assay (ELISA) anti-HCV test and HCV RNA PCR. RESULTS: HBV DNA was detected in 6 of the 145 patients (4.1%) and HBcAb was detected in 29/145 patients (20%). There were no statistically significant differences in the age, duration of hemodialysis, biochemical parameters, serological markers of HBV, or HBV DNA between patients with and without HCV infection. CONCLUSIONS: Four percent of the hemodialysis patients had OBI. There was no significant difference in the prevalence of OBI between hemodialysis patients with or without HCV co-infection.

Association between metabolic abnormalities and hepatitis C-related hepatocellular carcinoma.

BACKGROUND AND AIM: Metabolic syndrome is recognised as a potential risk factor for the development of hepatocellular carcinoma (HCC). The association between metabolic factors and hepatitis C (HCV)-related HCC has not yet been well clarified. This study was conducted to elucidate the role of metabolic factors in HCV-related HCC. MATERIAL AND METHODS: We recruited 147 HCC patients and compared them with 147 matched CHC patients and 320 controls. The plasma levels of homeostasis model assessment-IR (HOMA-IR), adiponectin and lipids for all participants were assessed. RESULTS: The HCC group showed significantly higher levels of insulin, glucose, HOMA-IR and adiponectin as well as lower levels of total cholesterol, HDL-C, LDL-C, and triglycerides compared with the matched CHC patients and controls. HOMA-IR did not correlate with pathologic features of HCC, whereas serum adiponectin levels correlated positively with the size of tumour nodules (P = 0.009). Based on stepwise logistic regression analysis, age (OR: 1.456, 95% CI: 1.072-1.979, P < 0.01), HOMA-IR (OR: 2.50, 95% CI: 1.70-3.69, P = 0.001), and adiponectin (OR: 1.585, 95% CI: 1.269-1.980, P = 0.001) were independently associated with HCC. CONCLUSIONS: Metabolic abnormalities are closely associated with the occurrence and development of HCV-related HCC. Patients with CHC and high serum adiponectin levels face a higher risk of developing liver cancer. Insulin resistance, as measured by HOMA-IR, is significantly associated with HCV-related HCC.

Changes in adipocytokines and insulin sensitivity during and after antiviral therapy for hepatitis C genotype 4.

BACKGROUND: Hepatitis C virus (HCV) infection, especially genotypes 1 and 4, is associated with wide metabolic disarrangements. AIM: To assess whether host metabolic factors influence sustained virological response (SVR) in patients with chronic hepatitis C genotype 4 (HCV-4) treated with peginterferon / ribavirin and to evaluate the impact of antiviral therapy on insulin resistance (IR) and serum levels of adipocytokines. METHODS: Changes in levels of adiponectin, leptin, TNF-α and the homeostasis model assessment for insulin resistance (HOMA-IR) on antiviral combination in patients with HCV-4 were analyzed and effect on response was studied. RESULTS: 107 patients were included (M/F 86/21; mean age 41.4±5.6 years). Neither serum adipocytokines nor HOMA-IR was correlated with viral load. SVR was achieved by 57% of patients and was associated with fibrosis score (odds ratio: 6.5; P = 0.001) and adiponectin level (odds ratio: 1.3; P = 0.01). At the end of follow-up, HOMA-IR, adiponectin, leptin and TNF-α were reduced, all these changes unrelated to predicting the outcome of treatment. At follow-up, HOMA-IR and adiponectin continued to decrease in patients with SVR, but remained unchanged significantly in patients who did not response or relapse. CONCLUSIONS: Serum adiponectin at baseline appears to be an independent predictor for the achievement of SVR and can be utilized as an additional predictive marker. Changes of IR and adipocytokines occur under treatment which is more evident with the resolution of HCV infection, suggesting that HCV could have a direct role in these metabolic changes.

The role of EEG recordings in children undergoing cardiac surgery for congenital heart disease.

Neurological dysfunction may occur after corrective cardiac surgery using cardio-pulmonary bypass (CPB) with or without circulatory arrest. Different neurophysiological monitoring systems have been employed to detect neurological complications and possible brain injury in infants and children during and after cardiac surgery. The value of EEG in infants and children at risk for neurological sequelae has not been systematically studied. Sequential performance of 2 EEGs before and after cardiac surgery at a tertiary University Hospital to screen for possible brain injury after cardiac surgery. In addition, a complete neurological examination was performed. In 313 patients (age: 54.2±55.7 months; normal initial EEG) after cardiac surgery CPB (duration of surgery: 146.0±58.9 minutes; aortic cross clamp time: 34.1±19.1 minutes) a 19-channel EEG recording was performed 2.4±1.8 days prior and 11.6±5.3 days after cardiac surgery. An abnormal EEG was detected in only 8 of 313 patients (2.5%; focal slowing(1), generalised slowing (5), epiletiform discharges(2)) after cardiac surgery, while the EEG was normal in the remaining 305 patients (97.5%). In one patient, an intra-cerebral pathology was seen on MRI (ischemic); in 5 patients follow-up EEGs were performed, which revealed normalised findings. None of the 8 patients demonstrated new focal neurological deficits on physical examination, but 33 (9.7%) children demonstrated minor abnormalities (eg, subtle motor asymmetry, increase in muscle tone, etc.), which were unrelated to abnormal EEG findings. According to the used protocol pathological EEG findings were very infrequent in our study cohort. The routine and indiscriminative recording of EEGs in children before and after corrective or palliative cardiac surgery for congenital heart disease using CPB is not recommended. Further intra-operative neuromonitoring methods with immediate intervention should be evaluated.

Serum lipids and chronic hepatitis C genotype 4: interaction and significance.

BACKGROUND & AIM: Metabolic abnormalities are common in chronic hepatitis C infection (CHC). However, the genotypic differences of these disarrangements in patients infected with CHC genotype 4 (HCV-4) and its association with liver histology and viral loads remain unknown. MATERIAL AND METHODS: We consecutively enrolled 183 HCV-4 patients and 106 healthy matched controls; to compare metabolic profiles and assess pattern of association of HCV RNA levels as well as histological factors with the serum lipid profile. RESULTS: HCV-4 infection is associated with higher homeostasis model assessment of insulin resistance (HOMA-IR) index, despite that, a favourable lipid pattern, consisting of an elevation in HDL- C and a reduction in serum cholesterol (TC), LDL-C and triglyceride (TG) levels, in comparison with normal matched adults. Significant fibrosis was independently associated with HOMA-IR, portal/periportal inflammation grade, serum cholesterol and age. Univariate association was elucidated between lower LDL-C and TC and Metavir activity score and between higher TG and TC and steatosis. In multivariate analysis, severe hepatitis activity, milder hepatic fibrosis, and triglyceride levels are associated with higher HCV RNA levels. CONCLUSION: HCV-4 is associated with wide metabolic changes. A proportional relationship is found between serum lipid profiles and hepatitis C viral load and liver histology in patients with HCV-4.

Diagnostic significance of plasma osteopontin in hepatitis C virus-related hepatocellular carcinoma.

BACKGROUND AND AIM: Outcome of hepatocellular carcinoma (HCC) depends mainly on its early diagnosis. The performance of traditional biomarkers is not satisfactory. Osteopontin (OPN) is of potential importance. This study aim to assess the diagnostic value of plasma OPN compared with alpha-fetoprotein (AFP) for the diagnosis of HCV- related HCC. METHODS: We recruited 113 HCC patients compared with 120 matched cirrhotic patients and 120 Controls. The plasma level of OPN and serum AFP for all participants were assessed. RESULTS: The median plasma OPN level was significantly higher in the HCC group than in the cirrhotic patient group or in the normal control group (p-value < 0.001), while OPN levels were not differed significantly in correlation with the degree of liver function deterioration in terms of advanced Child-Pugh class (p-value < 0.9). The diagnostic efficacy of OPN were superior to AFP in terms of AUC, sensitivity, specificity, PPV and NPV either in diagnosis of early or late stages of HCC (0.88 vs. 0.56; P = 0.0001, 0.991vs. 0.899; p = 0.01; respectively). CONCLUSION: Plasma OPN level is a potential diagnostic marker for HCC, especially among high-risk group of patients. These values extend beyond the traditional tumor biomarkers as AFP, as it possesses good prognostic value.

Insulin resistance predicts rapid virologic response to peginterferon/ribavirin combination therapy in hepatitis C genotype 4 patients.

OBJECTIVES: In patients with chronic hepatitis C (CHC) of genotype 4, the predictors of rapid virologic response (RVR) have not been determined adequately. We aimed to assess which pretreatment variables might predict an RVR and a sustained virologic response (SVR). METHODS: A total of 131 non-diabetic, genotype 4 CHC patients were enrolled for analysis and treated with peginterferon-alpha-2b/ribavirin. Insulin resistance (IR) was evaluated by homeostasis model assessment-IR (HOMA-IR). Hepatitis C virus (HCV)-RNA levels were measured at baseline, during therapy and at follow-up. RESULTS: The overall SVR rate was 60.3%. The SVR rate in patients with an RVR was 100%. Age, HOMA-IR, fibrosis, severity of the steatosis, and HCV viral load were all significantly associated with RVR in the univariate analysis. After logistic regression, both HOMA-IR (odds ratio: 0.12, P=0.002) and HCV viral load (odds ratio: 1.43, P=0.02) remained independent variables associated with RVR. Age, HOMA-IR, viral load, fibrosis, RVR, and "complete" early virological response were all significantly associated with SVR in the univariate analysis. After logistic regression, fibrosis (odds ratio: 5.23, P=0.007), HOMA-IR (odds ratio: 14.29, P=0.004), and viral load (odds ratio: 0.16, P=0.005) were independent factors associated with SVR. By linear regression, body mass index (P=0.001) and waist circumference (P=0.0003) were independently associated with HOMA-IR. CONCLUSIONS: IR is a major determinant of both RVR and SVR in genotype 4 CHC patients. HOMA-IR would seem to be a useful tool for predicting the response to therapy.

Hepatic steatosis in genotype 4 chronic hepatitis C patients: implication for therapy.

BACKGROUND AND AIM: The association of hepatitis C virus genotype 4 (HCV-4) with hepatic steatosis has not been clarified. We aimed to determine the parameters associated with steatosis among HCV-4 patients and to assess the effect of steatosis on treatment with peginterferon and ribavirin. METHODS: In a prospective study; 131 nondiabetic genotype 4 CHC patients were enrolled for analysis, treated with peginterferon-α-2b/ribavirin. Histopathologic, anthropometric, clinical, biochemical features, and insulin resistance (IR) estimated by the homeostasis model assessment index (HOMA-IR). RESULTS: Hepatic steatosis was present in 58 patients (44.2%); 62% of them experienced mild steatosis. In univariable analysis, steatosis was associated with HOMA-IR, body mass index, waist circumference, serum triglycerides, cholesterol level, systolic hypertension, and histologic scores for inflammation and fibrosis. Multivariate analysis revealed that body mass index, waist circumference, and HOMA-IR were found to be significantly associated with steatosis. IR but not steatosis was associated with a lower rate of sustained virologic response when adjusted for known factors that predict response (odds ratio: 0.16, 95% CI 0.046-0.59, P=0.005). CONCLUSIONS: In HCV-4 patients, the prevalence of steatosis was 44.2%; the majority (62%) has mild steatosis. Steatosis was significantly associated with metabolic factors. IR but not steatosis was independently associated with lower sustained virologic response.