A vision to strengthen resources and capacity of the Palestinian health research system: a qualitative assessment.

BACKGROUND: The World Health Organization has proposed a global strategy to build a robust Health Research System Resources and Infrastructural Capacity (HRSRIC). Despite the growing research productivity, HRSRIC in Palestine has rarely been investigated. AIMS: To analyse perceptions of health research system performers to understand the status of HRSRIC, identify its gaps, and propose policy solutions to strengthen HRSRIC. METHODS: This qualitative study targeted 3 health sectors: government, academia, and local and international organizations. Fifty-two in-depth interviews and 6 focus group discussions were conducted with key informants who were selected purposively. Data were analysed using MAXQDA 12. RESULTS: Despite the availability of competent personnel, the overall HRSRIC, such as human and financial resources, and facilities, forms a central challenge. HR financing is limited, unsustainable, and flows from external and individual sources. The public and private funds are largely in shortage with resources misallocation and donors' conditionality. HR quality is moderate while knowledge transfer and translation are not well conceptualized and inappropriately performed. Lack of governance, coordination, HRSRIC strategy, resource allocation, systematic and reliable data, evidence-informed culture, and environmental impacts are the main common gaps. CONCLUSIONS: The overall status of HRSRIC in Palestine is still lacking and major challenges persist where the pace of strengthening efforts is steady. There is an emphasis that strengthening HRSRIC is an imperative step and real investment opportunity for building a successful health research system. Political commitment, consolidated leadership structure, operational capacity building strengthening strategy, resources mobilization, and sovereignty are key requirements.

Mapping stakeholders of the Palestinian Health Research System: a qualitative study.

BACKGROUND: There is a growing international and regional interest in Health Research Systems (HRSs) in light of a global strategy for HRS stakeholders' (HRSSHs) active involvement. HRSSHs in Palestine have rarely been investigated with regard to uncertainties. AIMS: This study aimed to analyse perceptions of HRSSHs in order to understand their roles and involvement, identify gaps, and offer policy solutions for stakeholders' engagement in the Palestinian HRS. METHODS: This qualitative study targeted three local Palestinian health sectors, government, academia, and local and international agencies. Data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) and then analysed using MAXQDA 12 software. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: The overall HRS stakeholders' roles were unsatisfactory, with low involvement from society, the private sector, local and international sectors. The role of academia and the Ministry of Health is vital but observed moderate in health research while that of international agencies is weak due to conflicting agendas and lack of a guiding body. Most universities have poor representation in public decision-making and scarcity in health research potential and capacity. Interest-power imbalance among stakeholders is reported where political, organizational, and technical shortfalls were indicative of weak roles and low involvement, along with a lack of health research culture, structure, resources, defined roles, and network. CONCLUSIONS: Tackling the inadequate roles, interests' disparity, and poor involvement of HRSSHs is imperative for HRS strengthening. Redefining HRSSHs' roles and involving all stakeholders is key through strategic dialogue, consolidated leadership, and resource mobilization.

Rare case of diaphragmatic rupture following resuscitation in a pregnant woman first in literature.

INTRODUCTION: Complications following Cardiopulmonary resuscitation (CPR) are rare and usually follows a vigorous CPR or in special cases like pregnancy are due to lack of knowledge and clinical practice of how to preform CPR in pregnancy. One of this complication is diaphragmatic rupture with herniation of abdominal organs. Surgical intervention needs to be planned carefully in multidisciplinary team approach and requires fine surgical techniques for better outcome. There are few reported cases of diaphragmatic rupture after Cardiopulmonary resuscitation but none in pregnant woman. CASE PRESENTATION: We report a rare case of diaphragmatic rupture in a 29-year-old pregnant patient who experienced a full-blown diaphragmatic defect and herniation of the abdominal organs into the thoracic cavity, as a complication of CPR. Following careful assessment and diagnosis, the patient underwent urgent laparotomy with reduction of the contents and primary closure of the defect. One year follow up was satisfactory. To the best of our knowledge, this is the first reported case of diaphragmatic rupture with herniation of the abdominal organs following CPR in a pregnant woman in the literature. CONCLUSION: The application of external cardiac massage through CPR is a life-saving procedure for the management of cardiac arrest. Common complications related to CPR include rib fractures, sternal fractures and haemothorax. Diaphragmatic rupture with herniation of the abdominal organs is a rare complication, having been reported only once in the literature (Sabzi F, Faraji R, Tanaffos 16:170-172, 2017); however, it represents a serious and life-threating event. Thus, careful evaluation of the patient by a multidisciplinary team and prompt intervention is recommended in order to improve outcomes.

Mediators of gender effects on depression among cardiovascular disease patients in Palestine.

BACKGROUND: Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD). METHODS: Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM). RESULTS: Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression. CONCLUSION: This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.

Correction to: Case report and management approach in idiopathic pulmonary arteries aneurysm.

The original article [1] contained an error whereby the author, Ahmad Darwazah's name was spelt incorrectly.

Case report and management approach in idiopathic pulmonary arteries aneurysm.

BACKGROUND: Idiopathic pulmonary artery aneurysm is a rare anomaly with only a handful reports in the literature. It is often asymptomatic, while the first presentation could be severe hemoptysis or death. Surgical intervention needs to be planned carefully with a multidisciplinary team approach to secure optimal outcome. We hope to spread our experience with such cases and to encourage other surgeons worldwide to deal surgically with these cases when its indicated. CASE PRESENTATION: A 47 years old man presented to our institution after three episodes of hemoptysis, echo demonstrated good left ventricle (LV) systolic function, normal right ventricle (RV) size and function, Chest computed tomography (CT) revealed aneurysmal dilatation with pending rupture of the pulmonary artery trunk (4.5 cm), the left pulmonary artery (6 cm) and the right pulmonary artery (2.3 cm). The patient successfully underwent replacement of Pulmonary artery trunk, left pulmonary artery and right pulmonary artery by Wovex Prosthetic graft (28 mm). The patient discharged home on the eight postoperative day in good clinical condition . CONCLUSION: With this case report we wish to emphasize the need for a careful multidisciplinary approach given the complex and rare nature of the reported pathology.

The Palestinian health research system: who orchestrates the system, how and based on what? A qualitative assessment.

BACKGROUND: In 2011, the WHO Eastern Mediterranean Region committee launched a strategy for scaling up research in the region to address the countries' health needs through formulating and analysing the National Health Research System (HRS). Stewardship comprises three functions, namely governance, policy and priorities, and is a central pillar of this system to ensure a well-organised and functioning HRS. This study aims to examine the perceptions of the HRS performers to understand these functions and to generate insights for system strengthening. METHODS: The study was carried out in Palestine, targetting three sectors in the health field, including relevant governmental health institutions, schools of public health, and major local and international health agencies. The data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) with policy-makers, academics, directors, and experts. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: A total of 104 experts participated in the IDIs (52 participants) and FGDs (52 participants in 6 FGDs), highlighting that stewardship functions remain problematic and insufficiently performed, mainly due to a missing health research structural and regulatory framework and dispersed health research work. Despite the limited good practices, the majority of the participants described the Ethical Review and Clearance as weak due to the lack of an agreed-upon national committee and procedural quality and ethics guidelines for non-compliance. A policy or strategy dedicated to health research is lacking. The exercises of research priority-setting appear to be evolving despite the lack of consensus and the low levels of knowledge and experience in research prioritisation. Common gaps, such as weak political will and capacity support, the absence of a national unified regulating body, and the indirect effects of political conditions on strengthening the HRS as well as other sectors, also emerged. CONCLUSIONS: The stewardship functions of the Palestinian HRS remain weak along with substantial political, structural, and resources and capacity gaps. The study emphasises the imperative need to initiate strategic efforts led by the MOH and the Palestinian National Institute of Public Health alongside with other players to strengthen a national HRS through improving the stewardship functions. To achieve this, attention and support of decision-makers, involvement, mobilisation and strategic dialogue are indispensable, in order to embark on building a well-regulated and coordinated structure, operational research policy, and prioritisation of essential research.

Assessing policy-makers', academics' and experts' satisfaction with the performance of the Palestinian health research system: a qualitative study.

BACKGROUND: There is a growing demand within international health agencies to ensure health research systems (HRSs) are strengthened and well-functioning to support healthcare systems (HCSs). Understanding HRS performance through system actors is an indispensable move in analysing this system. This study aims to examine policy-makers', academics' and experts' satisfaction with overall HRS performance, while also investigating their perceptions about political will and attention towards health research. Ultimately, we want to identify gaps related to performance and generate insights on how to move forward for HRS performance strengthening. METHODS: This study was carried out in Palestine, targeting three sectors, namely government institutions, public health universities, and major local and international health non-governmental organisations (NGOs). Semi-structured, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with participants. The institutions from the three sectors were selected based on stated criteria and peer reviews. Data were translated from Arabic into English, transcribed, content checked by the principal investigator, imported to a software programme (MAXQDA 12), and then coded. Thematic content analysis was used. RESULTS: A total of 104 experts participated in 52 IDIs and 52 experts participated in 6 FGDs. Findings revealed three principal domains. First, the HRS in Palestine is remarkably underperforming, and the majority of experts were unsatisfied. Participants perceived the system as ineffective and inefficient, poorly managed and lacking systematic assessment. Second, the factors behind system underperformance were (1) an unstructured system and the lack of a research culture as well as of a governing body or policies; (2) health research was seen as individualistic, non-development driven and unutilised in policy decisions; and (3) considerably deficient coordination and essential resources. The third finding showed inadequate political support and engagement, which then also related to system underperformance. CONCLUSIONS: The Palestinian HRS is perceived as underperforming by health experts at different levels, where research is not on the leadership agendas. Potential actions should be taken to actively engage the state health decision-makers and inform them of the importance, uses and impacts of performance assessment. Findings urge policy-makers and legislators to build an inclusive and national body of governance with agreed strategies including fundamentally hybrid and aligned performance assessment mechanisms, such as a research observatory platform. In addition, it is recommended to establish a strategic plan to expand professionals' research awareness and abilities, as well as empower the institution's research monitoring and evaluation capacities.

Outcomes of ICDs and CRTs in patients with chronic kidney disease: a meta-analysis of 21,000 patients.

PURPOSE: The efficacy of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in patients with chronic kidney disease (CKD) remains unclear. The aim of this meta-analysis is to explore the association between ICD/CRT and mortality in CKD patients. METHODS: An electronic search was conducted using MEDLINE. We included studies that reported outcomes of interest in CKD patients stratified by the presence of ICD, CRT, or none. The primary outcome was all-cause mortality. Outcomes were pooled using random effects model. Odds ratios (OR) were reported for dichotomous variables. RESULTS: The literature search resulted in 11 studies (observational studies) including 21,136 adult patients: seven studies compared ICD vs. no ICD and four studies compared CRT vs. ICD. All-cause mortality was significantly lower in the ICD group in comparison to that in the no ICD group (OR 0.66 (95% confidence interval [CI] 0.45; 0.98), P = 0.04). Among dialysis-only patients, all-cause mortality was significantly lower in the ICD group (OR 0.49 (95% CI 0.38; 0.64), P < 0.001). All-cause mortality was significantly lower in the CRT group in comparison to that in the ICD group (OR 0.73 (95% CI 0.57; 0.92), P = 0.01). CONCLUSIONS: The use of ICDs is associated with lower all-cause mortality in observational studies of CKD patients. CRT use was also associated with lower all-cause mortality in CKD patients in comparison to ICDs. A randomized controlled trial is required to definitively define the role of ICDs/CRTs in CKD patients.

Understanding the concept and importance of the health research system in Palestine: a qualitative study.

BACKGROUND: The importance of a health research system (HRS), namely an instrument for developing and enabling health systems, is increasing, particularly in developing countries. Assessing the perceptions of system performers is a necessary part of system analysis, which seeks to recognize a system's strengths and limitations aiming towards improvement. This study assesses the perceptions of policy-makers, academicians and experts regarding the HRS concept and its importance to generate insights for system strengthening. In Palestine, HRS is just emerging, helping to address the many public health-related challenges faced by the country. METHODS: The study was implemented from January until July 2016, targeting three sectors, namely relevant government institutions, schools of public health, and major local and international health agencies. Data was collected through 52 in-depth interviews and six focus group discussions (FGDs) with policy-makers, academics, directors and experts. Participants and institutions were selected based on stated criteria and peer review. Data were translated, transcribed, checked and then imported to a software program (MAXQDA 12) for thematic and content analysis. RESULTS: A total of 104 experts participated, wherein 52 were interviewed and 52 participated in the six FGDs. The HRS concept, as defined by WHO, was conceptualized differently among participants with unclear delineations between various components. Inconsistencies appeared when participants attempted to conceptualize HRS in broader contexts, though HRS goals and functions were sufficiently delineated. The majority of participants agreed that HRS correlates with notions of 'improvement' and recognized HRS 'as a significant gain'. Neglect of HRS was perceived as a big loss. CONCLUSIONS: The study revealed that the level of understanding of HRS among health experts in Palestine is inadequate and not sufficiently conceptualized for its application. Findings also underlined the need to establish a central governance coordination body that promotes HRS understanding, awareness and culture as an enabler for HRS strengthening.

Reduction in unnecessary ventricular pacing fails to affect hard clinical outcomes in patients with preserved left ventricular function: a meta-analysis.

Aims: Several pacing modalities across multiple manufacturers have been introduced to minimize unnecessary right ventricular pacing. We conducted a meta-analysis to assess whether ventricular pacing reduction modalities (VPRM) influence hard clinical outcomes in comparison to standard dual-chamber pacing (DDD). Methods and Results: An electronic search was performed using Cochrane Central Register, PubMed, Embase, and Scopus. Only randomized controlled trials (RCT) were included in this analysis. Outcomes of interest included: frequency of ventricular pacing (VP), incident persistent/permanent atrial fibrillation (PerAF), all-cause hospitalization and all-cause mortality. Odds ratios (OR) were reported for dichotomous variables. Seven RCTs involving 4119 adult patients were identified. Ventricular pacing reduction modalities were employed in 2069 patients: (MVP, Medtronic Inc.) in 1423 and (SafeR, Sorin CRM, Clamart) in 646 patients. Baseline demographics and clinical characteristics were similar between VPRM and DDD groups. The mean follow-up period was 2.5 ± 0.9 years. Ventricular pacing reduction modalities showed uniform reduction in VP in comparison to DDD groups among all individual studies. The incidence of PerAF was similar between both groups {8 vs. 10%, OR 0.84 [95% confidence interval (CI) 0.57; 1.24], P = 0.38}. Ventricular pacing reduction modalities showed no significant differences in comparison to DDD for all-cause hospitalization or all-cause mortality [9 vs. 11%, OR 0.82 (95% CI 0.65; 1.03), P= 0.09; 6 vs. 6%, OR 0.97 (95% CI 0.74; 1.28), P = 0.84, respectively]. Conclusion: Novel VPRM measures effectively reduce VP in comparison to standard DDD. When actively programmed, VPRM did not improve clinical outcomes and were not superior to standard DDD programming in reducing incidence of PerAF, all-cause hospitalization, or all-cause mortality.

Hemorrhoids screening and treatment prior to LVAD: is it a necessity?

Continuous-flow left ventricle assist devices (CF-LVADs) has become an essential modality in the management of stage D heart failure (HF) with significant improvement in survival and quality of life. Due to the durability of such devices and long term support complications such as bleeding and aortic insufficiency has emerged. Bleeding accounts for more than 20 % with the majority being from the gastrointestinal tract. The increase of bleeding tendency are mainly attributed to the loss of large von Willebrand's Factor (vWF) multimers due to shear stress with the chronic intake of anticoagulants. We are reporting two cases of patients with Stage D HF and history of hemorrhoids presenting for LVAD implantation. Many efforts that decrease bleeding related to CF-LVADs will be discussed with focus on hemorrhoids.

Saved Lives at Risk in the Middle East.

In the Middle East, heart failure prevalence seems to be high as the rest of the world. Few countries in the region recently have started implanting left ventricular assist devices (LVADs), basically as destination therapy. Terrorism and terrorist activities have been expanded worldwide especially in this part of the world. We present a case that highlights the relation between suicide bombers and LVAD patients.

Is lower base rate detrimental to transcatheter aortic valve implantation patients requiring pacemakers?

Sudden cardiac death related to polymorphic ventricular tachycardia/ventricular fibrillation has been well reported post atrioventricular junction ablation. The practice of faster pacing rate immediately after atrioventricular junction ablation is well recognized to decrease the risk of sudden cardiac death. We propose that this practice (faster pacing rate) be implemented in patients who need permanent pacemakers secondary to transcatheter aortic valve implantation (or even surgical aortic valve interventions).

Impact of Contact Force Technology on Atrial Fibrillation Ablation: A Meta-Analysis.

BACKGROUND: Catheter-tissue contact is essential for effective lesion formation, thus there is growing usage of contact force (CF) technology in atrial fibrillation ablation. We conducted a meta-analysis to assess the impact of CF on clinical outcomes and procedural parameters in comparison to conventional catheter for atrial fibrillation ablation. METHODS AND RESULTS: An electronic search was performed using major databases. Outcomes of interest were recurrence rate, major complications, total procedure, and fluoroscopic times. Continuous variables were reported as standardized mean difference; odds ratios were reported for dichotomous variables. Eleven studies (2 randomized controlled studies and 9 cohorts) involving 1428 adult patients were identified. CF was deployed in 552 patients. The range of CF used was between 2 to 60 gram-force. The follow-up period ranged between 10 and 53 weeks. In comparing CF and conventional catheter groups, the recurrence rate was lower with CF (35.1% versus 45.5%, odds ratio 0.62 [95% CI 0.45-0.86], P=0.004). Shorter procedure and fluoroscopic times were achieved with CF (procedure time: 156 versus 173 minutes, standardized mean difference -0.85 [95% CI -1.48 to -0.21], P=0.009; fluoroscopic time: 28 versus 36 minutes, standardized mean difference -0.94 [95% CI -1.66; -0.21], P=0.01). Major complication rate was lower numerically in the CF group but not statistically significant (1.3% versus 1.9%, odds ratio 0.71 [95% CI 0.29-1.73], P=0.45). CONCLUSIONS: The use of CF technology results in significant reduction of the atrial fibrillation recurrence rate after atrial fibrillation ablation in comparison to the conventional catheter group. CF technology is able to significantly reduce procedure and fluoroscopic times without compromising complication rate.

Ventricular assist devices as rescue therapy in cardiogenic shock after subarachnoid hemorrhage.

We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.

How small is too small? A systematic review of center volume and outcome after cardiac transplantation.

BACKGROUND: The aim of this study was to assess the relationship between the volume of cardiac transplantation procedures performed in a center and the outcome after cardiac transplantation. METHODS AND RESULTS: PubMed, Embase, and the Cochrane library were searched for articles on the volume-outcome relationship in cardiac transplantation. Ten studies were identified, and all adopted a different approach to data analysis and varied in adjustment for baseline characteristics. The number of patients in each study ranged from 798 to 14401, and observed 1-year mortality ranged from 12.6% to 34%. There was no association between the continuous variables of center volume and observed mortality. There was a weak association between the continuous variables of center volume and adjusted mortality up to 1 year and a stronger association at 5 years. When centers were grouped in volume categories, low-volume centers had the highest adjusted mortality, intermediate-volume centers had lower adjusted mortality, and high-volume centers had the lowest adjusted mortality but were not significantly better than intermediate-volume centers. Category limits were arbitrary and varied between studies. CONCLUSIONS: There is a relationship between center volume and mortality in heart transplantation. The existence of a minimum acceptable center volume or threshold is unproven. However, a level of 10 to 12 heart transplants per year corresponds to the upper limit of low-volume categories that may have relatively higher mortality. It is not known whether outcomes for patients treated in low-volume transplant centers would be improved by reorganizing centers to ensure volumes in excess of 10 to 12 heart transplants per year.

Use of implantable cardioverter defibrillators in patients with left ventricular assist devices.

Patients with left ventricular assist devices (LVADs) are at high risk of sustained ventricular arrhythmias, but these may be remarkably well tolerated and the association with sudden death is unclear. Many patients who receive an LVAD already have an implantable cardioverter defibrillator (ICD). While it is standard practice to reactivate a previously implanted ICD in an LVAD recipient, this should include discussion of the revised risks and benefits of ICD therapy following LVAD implantation. In particular, patients should be warned that they might receive a significant number of ICD shocks that may not be life saving. When ICDs are reactivated, device programming should minimize the risk of repeated shocks for non-sustained or well-tolerated ventricular arrhythmias. Implantation of a primary prevention ICD after implantation of an LVAD is not supported by current evidence, poses potential risks, and should be the subject of a clinical trial before it becomes standard practice.

Local iodine pleurodesis versus thoracoscopic talc insufflation in recurrent malignant pleural effusion: a prospective randomized control trial.

OBJECTIVE: To compare the efficacy, safety, and outcome of thoracoscopic talc poudrage (TTP) versus povidone-iodine pleurodesis (PIP) through a thoracostomy tube as a palliative treatment of pleural effusion due to metastatic breast carcinoma (MBC). METHODS: A total of 42 MBC patients were prospectively enrolled in a randomized controlled trial. Twenty-two patients received TTP (group A), whereas 20 patients (group B) underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure. RESULTS: The mean age was 48.2 ± 9.9 (range: 29-64) years and 50.2 ± 7 (range: 32-62) years for groups A and B, respectively (p=ns). At presentation, all patients had moderate to severe dyspnea, New York Heart Association (NYHA)>II and Medical Research Council (MRC) dyspnea scale 3-5. Morbidity in both groups was low. Post-procedure analgesic requirements due to severe pleuritic chest pain were higher in group A (18% vs 0%, p=0.2). Four patients in group A (18%) and one in group B (5%) were febrile (>38°C) within 48 h of the procedure. Both groups achieved good symptom control, with improvement in MRC dyspnea scale (1-3). There were no in-hospital deaths. Post-procedure hospital stay was lower in group B (p=0.009). The mean progression-free interval was 6.6 (range 3-15) months. At follow-up (mean: 22.6 (range: 8-48) months), recurrence of significant pleural effusion requiring intervention was noted in two and three patients in group A and group B, respectively (p=ns). CONCLUSION: Povidone-iodine can be considered as a good alternative to TTP to ensure effective pleurodesis for patients with malignant pleural effusion due to MBC. The drug is available, cost effective and safe, can be given through a thoracostomy tube and can be repeated if necessary.