Physical activity and the risk of non-Hodgkin lymphoma subtypes: A pooled analysis.

Non-Hodgkin lymphoma (NHL) is composed of a heterogeneous collection of subtypes with considerable differences in genetics, biology and aetiology. Studies to date on physical activity and NHL risk have not had sufficient sample size to evaluate whether associations differ by subtype. We pooled data from nine case-control studies to examine the association between moderate-to-vigorous intensity physical activity (MVPA) and risk of NHL overall and by subtype (diffuse large B-cell lymphoma, follicular lymphoma, chronic lymphocytic leukaemia/small lymphocytic lymphoma, marginal zone lymphoma and mature T-cell lymphoma). A total of 5653 cases and 9115 controls were included in the pooled analysis. Physical activity was harmonised across nine studies and modelled as study-specific tertiles. Multinomial logistic regression was used to estimate the association between physical activity and NHL, adjusting for confounders. The overall odds of NHL was 13% lower among participants in the most active tertile of MVPA compared to the least active tertile (adjusted odds ratio = 0.87, 95% CI = 0.80, 0.95). Similar decreases were observed across NHL subtypes. In summary, in this pooled analysis of case-control studies, physical activity was associated with a modest risk reduction for each NHL subtype examined and with overall NHL.

Machine learning techniques for predicting depression and anxiety in pregnant and postpartum women during the COVID-19 pandemic: a cross-sectional regional study.

Background: Maternal depression and anxiety are significant public health concerns that play an important role in the health and well-being of mothers and children. The COVID-19 pandemic, the consequential lockdowns and related safety restrictions worldwide negatively affected the mental health of pregnant and postpartum women. Methods: This regional study aimed to develop a machine learning (ML) model for the prediction of maternal depression and anxiety. The study used a dataset collected from five Arab countries during the COVID-19 pandemic between July to December 2020. The population sample included 3569 women (1939 pregnant and 1630 postpartum) from five countries (Jordan, Palestine, Lebanon, Saudi Arabia, and Bahrain). The performance of seven machine learning algorithms was assessed for the prediction of depression and anxiety symptoms. Results: The Gradient Boosting (GB) and Random Forest (RF) models outperformed other studied ML algorithms with accuracy values of 83.3% and 83.2% for depression, respectively, and values of 82.9% and 81.3% for anxiety, respectively. The Mathew's Correlation Coefficient was evaluated for the ML models; the Naïve Bayes (NB) and GB models presented the highest performance measures (0.63 and 0.59) for depression and (0.74 and 0.73) for anxiety, respectively. The features' importance ranking was evaluated, the results showed that stress during pregnancy, family support, financial issues, income, and social support were the most significant values in predicting anxiety and depression. Conclusion: Overall, the study evidenced the power of ML models in predicting maternal depression and anxiety and proved to be an efficient tool for identifying and predicting the associated risk factors that influence maternal mental health. The deployment of machine learning models for screening and early detection of depression and anxiety among pregnant and postpartum women might facilitate the development of health prevention and intervention programs that will enhance maternal and child health in low- and middle-income countries.

Adherence to the United States Department of Agriculture Dietary Recommendations Pre- and During the Coronavirus Disease-19 Pandemic Among Pregnant Women in Arab Countries.

During pregnancy, woman's diet is one of the most preeminent factors affecting mother and child's health. Prior to the coronavirus disease-19 (COVID-19) pandemic, inadequate maternal diet and low adherence to dietary guidelines was reported among pregnant women in the Arab countries. Nowadays, COVID-19 infection during pregnancy is widely discussed among literature. However, there is limited data on the health impacts of the COVID-19 pandemic on non-infected pregnant women. This substantially larger group also suffered significant lifestyle changes during the lockdown period. The aim of the study is to characterize dietary patterns, intake and adherence to the United States Department of Agriculture (USDA) pregnancy guidelines before and during the COVID-19 pandemic in Arab pregnant women. Using a specially designed questionnaire and using the snowball sampling method, the survey was carried out among a convenient sample of 1,939 pregnant women from five Arab countries. Our study found an increment in the consumption of cereals, fruits, vegetables, dairy products, meats, and nuts that occurred during the pandemic compared to the preceding period. Despite this noticeable increase during the pandemic, the Arab pregnant women in this study had significantly lower adherence to the USDA pregnancy guidelines. The daily consumption of almost all food groups was lower than the USDA's daily recommendations, except for fruits intake, which was higher than the daily standard. Demonstrated poor adherence to prenatal USDA dietary guidelines by Arab pregnant women can lead to numerous deficiencies and health risks among their offspring. In conclusion, our study showed that before and during the COVID-19 pandemic, poor adherence to dietary recommendations occurred in a considerable number of Arab pregnant women. The findings emphasize the need for nutritional education and intervention during prenatal visits.

Dietary Diversity in the Eastern Mediterranean Region Before and During the COVID-19 Pandemic: Disparities, Challenges, and Mitigation Measures.

The COVID-19 pandemic has revealed the Eastern Mediterranean Region's food system's fragility posing severe challenges to maintaining healthy sustainable lifestyle. The aim of this cross-sectional study (N = 13,527 household's family members, mean age: 30.3 ±11.6, 80% women) is to examine the impact of the COVID-19 pandemic on food consumption patterns and household's dietary diversity in 10 Eastern Mediterranean countries. A food frequency questionnaire was used to investigate the consumption patterns along with the calculation of the Food Consumption Score (FCS), a proxy indicator of dietary diversity. Data collected on cooking attitudes, shopping and food stock explore the community mitigation measures. In the overall population, before and during the pandemic, most food groups were consumed less or equal to 4 times per week. As evident from our findings and considering that the pandemic may be better, but it's not over, small to moderate changes in food consumption patterns in relatively short time periods can become permanent and lead to substantial poor dietary diversity over time. While it is a priority to mitigate the immediate impact, one area of great concern is the long-term effects of this pandemic on dietary patterns and dietary diversity in Eastern Mediterranean households. To conclude, the COVID-19 crisis revealed the region's unpreparedness to deal with a pandemic. While the aggressive containment strategy was essential for most countries to help prevent the spread, it came at a high nutritional cost, driving poor dietary diversity.

Acute Respiratory Tract Infections among Hospitalized Palestinian Patients (2011-2016): A Retrospective Study.

Respiratory tract infections (RTIs) are a major public health concern. This study aims to investigate the profiles and epidemiological characteristics of acute RTIs and respiratory pathogens in Palestinian hospitalized patients. Clinical samples from hospitalized patients with symptoms of acute RTIs admitted between January 2011 and December 2016 were referred to the Palestinian Central Public Health Laboratory (PHCL) to identify the causative pathogen. Patients' demographic information and the results of the molecular identification were retrieved from the electronic database at the PHCL. A total of 15413 patients with acute RTIs were hospitalized during the study period. The causal agent was identified only in 28.7% of the patients. Overall, influenza viruses were the most common cause of RTIs among hospitalized Palestinian patients in the West Bank. Children and elderlies were the most affected with RTIs. The elderly population (≥60 years old) had the highest rates. After influenza A virus, respiratory syncytial virus (RSV), and Bordetella pertussis (B. pertussis) were the most common causes of acute RTIs among hospitalized Palestinian patients. Children showed the highest hospitalization rates for RSV, B. pertussis, adenovirus, enterovirus, and Streptococcus pneumoniae. On the other hand, elderlies had the highest rates of influenza. Outbreaks of RTIs occurred mainly during winter (between December and March). The resurgence of B. pertussis in spite of vaccination is alarming and requires further investigation.

Health Status of Patients With ß-Thalassemia in the West Bank: A Retrospective-Cohort Study.

Management of ß-thalassemia in developing countries is demanding in the absence of available therapies rather than recurrent transfusions. This study describes the characteristics and evaluates the hematological, biochemical, and hormonal findings of patients with ß-thalassemia in the West Bank. We conducted a retrospective cohort study between January 2017 and December 2018. Data were collected through medical files of the patients with ß-thalassemia from eight primary healthcare clinics, nine emergency departments, and 11 governmental hospitals across the West Bank. Results of the hematological, biochemical, and hormonal evaluations, in addition to demographic data and the use of iron chelation were included in the study and analyzed. A total of 309 patients with ß-thalassemia were included with a male-to-female ratio of 1:1 and an average age of 23.4 ± 10.4 years. The anemic presentation was reported in 78.6% of the patients as indicated by hemoglobin level (mean ± SD = 8.4 ± 1.4 g/dl), and 73.1% had iron overload with serum ferritin (SF) levels ≥ 1,000 µg/L (mean ± SD = 317.8 ± 3,378.8 µg/L). Evaluation of the liver function tests showed that alanine transaminase (ALT) and aspartate transaminase (AST) levels were high among 38.1 and 61.2% of the patients, respectively. ALT and AST showed significant positive correlations with SF levels, while the kidney tests did not. As for iron chelation medications, patients receiving deferoxamine (26.5%) showed significantly higher SF levels compared with patients receiving deferasirox (73.5%). This study highlights the importance of establishing patient-tailored comprehensive assessment and follow-up protocols for the management of ß-thalassemia with an emphasis on blood transfusion and iron chelation practices.

Prevalence of tobacco use among young adults in Palestine.

BACKGROUND: Smoking tobacco is a worldwide public health issue. Over the last few decades, smoking patterns have been changing, reflected by increasing rates among young people and females in particular. AIMS: This study aimed to determine the prevalence and modalities of smoking and to assess the factors, habits and beliefs that might encourage or discourage smoking among young adults in Palestine. METHODS: A cross-sectional study was conducted in the West Bank in 2014 among Palestinians aged 18-25 years old. Subjects were recruited from six Palestinian universities (n=1997). Participants were asked to complete a questionnaire focusing on sociodemographics, knowledge and beliefs towards tobacco smoking, and the reasons that motivate or hinder smokers to quit. RESULTS: The prevalence of tobacco smoking was found to be 47.7%. Males had higher smoking rates, consumption levels, and initiated smoking at younger ages (74.4% started at ≤18 years old). Smoking cigarettes and waterpipe were the most common forms among both sexes. Smokers were also found to consume higher amounts of caffeinated drinks and fast food, showed lower scores towards anti-smoking beliefs, and reported significantly higher prevalence of smoking-related symptoms and diseases, primarily shortness of breath (20.5%) and cough (16.6%). The majority of smokers reported attempting and willingness to quit smoking. Health and financial costs were the strongest factors encouraging quitting while mood changes and lack of self-control were the most reported discouraging factors. Moreover, smoking among family members and peers increased the odds of smoking. CONCLUSIONS: Increasing rates of smoking among young Palestinians and a growing popularity of waterpipe use should alert stakeholders to the necessity for the implementation of smoking prevention and awareness policies and programmes.

Study of Frequency and Characteristics of Red Blood Cell Alloimmunization in Thalassemic Patients: Multicenter Study from Palestine.

Background. ß-Thalassemia is a common inherited hemolytic disorder in Palestine. Red blood cell (RBC) transfusion is the principal treatment but it may cause RBC alloimmunization. This study was conducted to determine the prevalence and characteristics of RBC alloimmunization among thalassemic patients in northern governorates of Palestine. Methods. A prospective multicenter observational study was conducted in the thalassemia transfusion centers in the northern governorates of Palestine. The study included 215 thalassemia patients who received regular blood transfusions. Clinical and transfusion records of patients were examined. Antibody screening and identification was conducted using the microcolum gel technique. Results. Two hundred fifteen patients were included in the study. More than half (52.1%) of the patients were males. The median age of patients was 18 years (range: 12-24 years). The most frequent blood group was A (40.5%). Alloantibodies were detected in 12.6% of patients. Anti-D (33.3%), anti-K (25.9%) and anti-E (14.8%) were the most commonly isolated antibodies. There was no association between age, sex, starting age of transfusion, number of transfused units, history of splenectomy and alloimmunization. Conclusions. Anti-Rh and anti-K antibodies were common among this cohort of patients. Age, sex, starting age of transfusion, number of transfused units, and history of splenectomy could not predict the occurrence of alloimmunization.

SNP variations in IL10, TNFα and TNFAIP3 genes in patients with dry eye syndrome and Sjogren's syndrome.

BACKGROUND: Cytokines are known to be key players in dry eye syndrome (DES) and Sjogren's syndrome (SS) pathogenesis. In this study we compared single nucleotide polymorphism (SNP) variations in genes encoding cytokine levels among SS and DES patients in Israel. METHODS: We recruited 180 subjects, 82 with SS and 98 with DES. Using a candidate gene approach and allele-specific PCR technique for genotyping, proportions of risk alleles in Tumor Necrosis Factor α (TNFα) (rs1800629), IinterLeukin-10 (IL-10) (rs1800896) and TNFAIP3 (rs2230926) SNPs were compared between study groups. RESULTS: Allelic distribution was found very similar to Caucasian (CEU - Utah residents with Northern and Western European roots) population distributions in these SNPs. While none of the SNPs' variants were significantly associated with SS or DES in a recessive model, in an additive model the TNFα G risk allele was found higher among SS patients compared to DES (Homozygote-G: 84.2% vs. 70.8%; Heterozygote: 26.9% vs. 11.2%, respectively, p = 0.02). After adjustment for age, gender and ethnicity, these variants weren't associated with SS. Genetic scoring reveals that SS patients are more likely to present variants of all three SNPs than DES subjects. CONCLUSIONS: This is the first study evaluating these SNP variations among both patients with DES and patients with SS. We found the allelic distribution in each SNP to be very similar to that found in healthy Caucasian populations presented in the HapMap project. We found the TNFα allele significantly associated with DES for homozygotes, and associated with SS for heterozygotes in the additive model.

Laboratory Medicine in Palestine.

BACKGROUND: Laboratory Medicine (LM) is one of the cornerstones of healthcare. In Palestine, 3.5% of health expenditure is allocated to clinical laboratories. METHODOLOGY: The Palestinian Ministry of Health (MOH) started to invest in the development and expansion of laboratory services including the introduction of full automation in blood banks and histopathology, molecular testing in microbiology, and testing for autoimmune diseases and metabolic disorders. Improvements have not been limited to new tests but also included external quality assurance (EQA) and accreditation programs. RESULTS: Latest investments have cut the costs of purchasing tests from outside MOH by more than 3.6 million dollars during the last five years. Al-Quds University established a Center for External Quality Control in LM which was supported by the Palestinian MOH and the National Metrology Institute of Germany. This has led to a significant improvement in the performance of the affiliated laboratories. An accreditation unit was established within the MOH, yet the number of laboratories that have been accredited with ISO-15189 are still limited but significantly increasing.The academic institutions have been working in parallel to the MOH in improving LM in Palestine. A new academic curriculum for LM has been developed according to the quality standards of curricula-based competencies determined by the needs of the labor market and the emerging technologies. CONCLUSIONS: Despite the invested efforts, still, the Palestinian LM suffers from shortage of human resources which are qualified in the new emerging diagnostic approaches.

Comparison of early effects of pneumococcal conjugate vaccines: PCV7, PCV10 and PCV13 on Streptococcus pneumoniae nasopharyngeal carriage in a population based study; The Palestinian-Israeli Collaborative Research (PICR).

BACKGROUND: Pneumococcal conjugate vaccines (PCVs), PCV10 and PCV13, are currently used in different countries. We have previously reported the effectiveness of PCV7, following its introduction in Israel and before PCVs were introduced in Palestine. Here, we extended the study and compared the initial impact of PCV10 to that of PCV7/13. METHODS: Four cross-sectional surveys of S. pneumoniae carriage among children <5y through 2009-2014 were preformed among two proximate populations, living under two distinct health authorities, with different vaccination policies. In East-Jerusalem (EJ), PCV7 was implemented in 2009 and replaced by PCV13 in late 2010, while in Palestine (PA), PCV10 was implemented in 2011. RESULTS: A total of 1267 and 2414 children from EJ and PA were screened. In 2014, S. pneumoniae was detected in 30.7% and 28.6% of the children in EJ and PA respectively Implementation of both PCV7 (in EJ) and PCV10 (in PA) did not affect overall S. pneumoniae carriage, but resulted in a significant decrease in the prevalence of vaccine-type strains. In the pre-vaccine era, VT7/VT13 strains consisted 47.0%/62.0% and 41.2%/54.8% of pneumococci in EJ and PA, respectively. A 48.6% and 53.9% decrease in VT7 strains was observed within 3 years of PCV7 implementation in EJ (p = 0.001) and PCV10 in PA (p<0.0001), respectively. These vaccination policies also resulted in ~50% reduction in VT13-added serotypes especially 6A (from 11.0% to 0.0% (EJ) and 9.5% to 4.9% (PA)). Three years after PCV13 implementation in EJ, an additional 67% decrease in VT13 strains was observed, yet an increase in serotype 3 was observed (0.0% to 3.4%, p = 0.056). While the prevalence of VT13 strains decreased significantly during the study period, the overall carriage rate didn't change significantly due to replacement with non-VT13 strains which comprised 89.8% and 70.7% of all pneumococci, in EJ and in PA respectively in the last study year. CONCLUSIONS: Within the first three years following PCV implementation, we observed similar reductions in carriage of VT10 and VT13 strains with either vaccination policies, with no effect on overall carriage. Further follow-up is needed to compare the long-term effects.

Presence of autoimmune disease affects not only risk but also survival in patients with B-cell non-Hodgkin lymphoma.

Although autoimmune diseases (AIDs) are known to predispose to non-Hodgkin lymphoma (NHL), their association with NHL prognosis has rarely been investigated. We examined associations between autoimmunity and B-cell NHL onset by comparing AID history (determined by self-report and medication review and supplemented by chart review where possible) among 435 adult B-NHL patients in Hadassah-Hebrew University Medical Center, diagnosed 2009-2014, and 414 age-and-sex frequency-matched controls. We examined AIDs as a whole, B- and T-cell-mediated AIDs, and autoimmune thyroid diseases. Among cases, we used Kaplan-Meier and Cox regression models to assess the association of AID with overall survival and relapse-free survival, adjusting for prognostically important patient and disease characteristics such as Ki67% staining, International Prognostic Index, rituximab treatment, and histological subgroup. Autoimmune diseases were associated with B-NHL (odds ratio [OR] = 1.95; 95% confidence interval (CI), 1.31-2.92), especially AIDs mediated by B-cell activation (OR = 5.20; CI, 1.90-14.3), which were particularly associated with marginal zone lymphoma (OR = 19.3; CI, 4.59-80.9). We found that time to relapse for all B-NHL patients with AIDs was significantly shorter (mean of 49.21 mo [±3.22]) than among patients without AID (mean of 59.74 mo [±1.62]), adjusted hazard ratio [HRadj ] = 1.69 (CI, 1.03-2.79). Specifically, in patients with diffuse large B-cell lymphoma, of whom 91.8% had received rituximab, a history of B-cell-mediated AIDs was associated with shorter relapse-free survival and overall survival, HRadj  = 8.34 (CI, 3.01-23.1) and HRadj  = 3.83 (CI, 1.20-12.3), respectively. Beyond confirming the well-known association between AIDs and B-NHL, we found that AID is an adverse prognostic factor in B-cell lymphoma, associated with a shortened time to relapse, suggesting that there are specific therapeutic challenges in the subgroup of patients suffering from both these diseases. Further work is required to address mechanisms of resistance to standard treatment in the setting of AID-associated B-NHL. In the era of immunotherapy, these findings have particular relevance.

Ethnic variation in medical and lifestyle risk factors for B cell non-Hodgkin lymphoma: A case-control study among Israelis and Palestinians.

BACKGROUND: Risk factors for B-cell non-Hodgkin lymphoma (B-NHL) have not been assessed among Palestinian Arabs (PA) and Israeli Jews (IJ). METHODS: In a case-control study we investigated self-reported medical and lifestyle exposures, reporting odds ratios (ORs) and 95% confidence intervals [CIs], by ethnicity, for overall B-NHL and subtypes. RESULTS: We recruited 823 cases and 808 healthy controls. Among 307 PA/516 IJ B-NHL cases (mean age at diagnosis = 51 [±17] versus 60 [±15] years, respectively) subtype distributions differed, with diffuse large B-cell lymphoma (DLBCL) being prominent among PA (71%) compared to IJ (41%); follicular lymphoma (FL), was observed in 14% versus 28%, and marginal zone lymphoma, in 2% versus 14%, respectively. Overall B-NHL in both populations was associated with recreational sun exposure OR = 1.43 [CI:1.07-1.91], black hair-dye use OR = 1.70 [CI:1.00-2.87], hospitalization for infection OR = 1.68 [CI:1.34-2.11], and first-degree relative with hematopoietic cancer, OR = 1.69 [CI:1.16-2.48]. An inverse association was noted with alcohol use, OR = 0.46 [CI:0.34-0.62]. Subtype-specific exposures included smoking (FL, OR = 1.46 [CI:1.01-2.11]) and >monthly indoor pesticide use (DLBCL, OR = 2.01 [CI:1.35-3.00]). Associations observed for overall B-NHL in PA only included: gardening OR = 1.93 [CI:1.39-2.70]; history of herpes, mononucleosis, rubella, blood transfusion (OR>2.5, P<0.01 for all); while for IJ risk factors included growing fruits and vegetables, OR = 1.87 [CI:1.11-3.15]; and self-reported autoimmune diseases, OR = 1.99 [CI:1.34-2.95]. CONCLUSIONS: In these geographically proximate populations we found some unique risk factors for B-NHL. Heterogeneity in the observed associations by ethnicity could reflect differences in lifestyle, medical systems, and reporting patterns, while variations by histology infer specific etiologic factors for lymphoma subtypes.

Urinary organophosphate metabolite levels in Palestinian pregnant women: results of the Middle East Regional Cooperation Project.

The purpose of the study was to measure urinary organophosphate (OP) metabolites in Palestinian pregnant women, and to compare levels with those in pregnant women in Jerusalem and women from the general population in Israel. We measured six dialkyl phosphates in urine samples collected from 148 pregnant women from the West Bank area. Median total dimethyl phosphate (DM(total)) levels were significantly lower in Palestinian women compared to Jerusalem pregnant women and women in Israel (p = 0.041). In Palestinian women reporting that their place of residence was near an agricultural field, DM(total) levels were significantly higher (p = 0.037). Lower urinary excretion of dimethyl phosphate pesticide metabolites in Palestinian women compared to Israeli women may result from lower consumption of fruits and vegetables in the Palestinian population. Our findings highlight differences in OP pesticide exposure in populations with close geographical proximity but with differences in culture, diet, lifestyle, and regulatory oversight of pesticides.