Multidisciplinary care team for cancer patients and its implementation in several Middle Eastern countries.

This article introduces palliative care to cancer patients in Middle Eastern countries. It considers the importance of the multidisciplinary team in providing an adequate service to the patient and his/her family. It provides views of professionals from the various countries with regard to the role of the nurse in such teams; whereby the three elements of palliative care nursing entail: 1. Working directly with patients and families; 2. Working with other health and social care professionals to network and co-ordinate services; and 3. working at an organizational level to plan, develop and manage service provision in local, regional and national settings. This article also details the challenges that nurses face in the Middle East and outlines the preferable ways to overcome such challenges. The latter include more focused educational activities at the undergraduate and graduate levels and continuous clinical training throughout their work as palliative care nurse specialists.

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018.

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider's recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Health risk associated with airborne particulate matter and its components in Jeddah, Saudi Arabia.

Samples of PM2.5 and PM10 have been collected in all of four seasons at seven sites within the city of Jeddah, Saudi Arabia. The samples have been analysed for a range of trace elements. There is a large loading of wind-blown dust and the majority of elements are predominantly associated with coarse particles. Enrichment factors, however, show that some elements are markedly enriched above crustal abundance. Using mean data for the PM2.5 and PM10 fractions from each of the seven sampling sites, health risks have been estimated for particulate matter mass, the elements Cr, Mn, Ni, Pb, As, Cd and V measured in this study, and polycyclic aromatic hydrocarbons using data from an earlier study within Jeddah. Cancer risks are calculated from mean airborne concentrations and cancer slope factors for the carcinogenic metals and PAH, but the cancer risks are relatively modest compared to the lifetime risk of mortality due to PM2.5 exposure. The risks associated with exposure to V and Mn are considered to be small, while concentrations of cadmium far exceed the European Union Limit Value and World Health Organisation guideline. Cadmium shows a very high crustal enrichment factor but is present predominantly in the coarse particle fraction suggesting that local soils and surface dusts are unusually enriched in Cd relative to the global average. Using national data for mortality rates, the excess mortality due to PM2.5 exposure has been calculated and amounts to over 1100 deaths annually for the city of Jeddah.

Maternal and perinatal outcome of pregnancies complicated by cardiac disease.

OBJECTIVE: The aim of this study was to assess the maternal and perinatal outcome of pregnancies complicated by cardiac disease in a tertiary care center in Egypt. METHODS: During a 1-year period, a total of 86 pregnant women with cardiac disease were admitted. Maternal and perinatal morbidity and mortality were calculated and compared with a control group. RESULTS: Seventy-seven (89.5%) patients were due to rheumatic affection, and 60 patients were classified as NYHA classes I-II. There was one case of maternal mortality (1.16%), and 10 other cases developed life-threatening complications. Two perinatal mortalities (2.32%) occurred in this series. Birth weight of babies born to mothers with functional classes III and IV were significantly lower than those of functional classes I-II and control group. CONCLUSION: Rheumatic heart disease with pregnancy is still predominant in Egypt. Maternal and perinatal morbidity and mortality are strongly correlated to maternal cardiac functional classification.

Neuroimmunotoxicology: humoral assessment of neurotoxicity and autoimmune mechanisms.

The interactions between the nervous and immune systems have been recognized in the development of neurodegenerative disease. This can be exploited through detection of the immune response to autoantigens in assessing the neurotoxicity of environmental chemicals. To test this hypothesis, the following questions were addressed. a) Are autoantibodies to nervous system (NS) antigens detected in populations exposed to environmental or occupational chemicals? In sera of male workers exposed to lead or mercury, autoantibodies, primarily IgG, to neuronal cytoskeletal proteins, neurofilaments (NFs), and myelin basic protein (MBP) were prevalent. These findings were confirmed in mice and rats exposed to either metal. b) Do autoantibodies to NS antigens relate to indices of exposure? In humans exposed to either metal, and similarly in exposed rats, titers of IgG against NFs and MBP significantly correlated with blood lead or urinary mercury, the typical indices of exposure. c) Do autoantibodies correlate with sensorimotor deficits? In workers exposed to lead or mercury, a significant correlation was observed between IgG titers and subclinical deficits. Doses of metals used in rat exposures were subclinical, suggesting that autoantibodies may be predictive of neurotoxicity. d) Is the detection indicative of nervous system pathology? In rats exposed to metals, histopathology indicated central nervous system (CNS) and peripheral nervous system (PNS) damage. In addition there was evidence of astrogliosis, which is indicative of neuronal damage in the CNS, and the presence of IgG concentrated along the blood-brain barrier, as indicated by immunostaining for antibodies. e) Are immune responses to NS antigens pathogenic? Immunoglobulin fractions from rat and human sera interfered with neuromuscular function. These studies suggest that the detection of autoantibodies to NS-specific antigens may be used to monitor the development of neurotoxicity to environmental chemicals and that immune mechanisms may be involved in the progression of neurodegeneration.

Chromosomal aberrations and micronuclei in reinforced plastics workers exposed to styrene.

The aim of this study was to investigate the cytogenetic changes induced in humans exposed to styrene in a reinforced plastics plant. Blood and urine samples were collected from 18 styrene exposed workers and 18 age and sex matched control subjects from the administrative department of the same factory. Chromosome aberrations (CAs) and micronuclei (MN) (cytokinesis block method) were analyzed in blood lymphocytes. All of the subjects included in the study were male non-smokers. The duration of employment ranged from 10 to 22 years (14.3 +/- 4.4). In order to monitor exposure to styrene, urinary mandelic acid (MA) levels were measured using a standard colorimetric method. The level of thioethers in the urine was also determined colorimetrically. The mean level of mandelic acid was significantly higher in the exposed workers (328.44 +/- 266.21 mg/g creatinine) compared with that of the controls (50.09 +/- 16.84 mg/g creatinine) (p < 0.05). The level of urinary thioethers was found to be higher among the exposed workers. The number of cells with chromosomal aberrations was significantly higher in the workers (6.06 +/- 4.41) compared with the controls (3.44 +/- 2.28) (p < 0.05). There was no significant increase in the frequency of micronuclei in the exposed workers compared to controls. Our results support earlier findings on increased rates of chromosomal aberrations in reinforced plastics workers.

Interaction of nickel with UV-light in the induction of cytogenetic effects in human peripheral lymphocytes.

Chemical interaction is of major concern in the assessment of risk by regulatory agencies. In the present study, treatment of human lymphocytes with NiSO4 (1-100 microM) or UV-light (200, 1000 ergs/mm2) induced micronuclei (MN) in a dose-dependent fashion. Statistical analysis of the interaction factor (IF), showed that combined treatments of Ni(II) (1-100 microM) with UV-light (200, or 1000 ergs/mm2) interacted antagonistically for the induction of MN. Recently we reported that Ni(II) (0.5-10 microM) with UV-light (200 or 1000 ergs/mm2) or Cr(VI) or X-rays interacted antagonistically for the induction of sister chromatid exchanges (SCE), in peripheral human lymphocytes. These observations suggest that nickel present in complex mixtures may reduce the response, even in the presence of strong MN or SCE inducers, and may lead, therefore, to an underestimate of chemical exposure as assessed by these assays. Furthermore, metals affecting certain microsteps in the process of DNA replication or repair (e.g., histones, polymerases, ligases) may have similar antagonistic effects. Further studies are therefore recommended.

Biological monitoring of occupational exposure to electrophilic compounds.

Electrophilic compounds are widely used in industry. Plastic and dyeing industries are foremost examples of sites where workers are exposed to electrophilic compounds. Besides their immediate effect on different body systems, electrophilic compounds include most mutagenic and carcinogenic substances. The present study was carried out to elucidate the possibility of using nonselective assays in the biological monitoring of occupational exposure to electrophilic compounds. The study included a total number of 225 workers selected from the Plastic and Battery Company where workers are exposed to styrene (n = 70), and the Kafr El Dawar chemical and Dyeing Company where workers are exposed to aniline (n = 60) and benzidine (n = 25). Workers exposed to diesel engine exhaust were selected from a bus garage in Smoha (n = 70). A comparison group consisting of 141 subjects was selected from the administrative departments of the selected factories. The biochemical tests carried out on each subject included: (1) estimation of the biological indices of exposure: urinary mandelic acid and benzidine, blood methemoglobin, and carboxyhemoglobin, (2) liver and kidney function tests; and (3) nonselective biochemical parameters of early detection of carcinogenic and mutagenic risk: urinary thioether levels, urinary RNase and alpha esterase activities. The study revealed that two out of three nonselective assays have been affected by occupational exposure to electrophilic compounds. These were the urinary thioethers and RNase levels. Their determination is recommended in the biological monitoring of workers exposed to such agents especially in developing countries.

Somatic cell mutation in workers occupationally exposed to mercury vapors.

Somatic cell mutation in human peripheral lymphocytes is one of the tools used recently in the biological monitoring of the work environment. The scope of this review was to test whether biomonitoring methods are sensitive to the presence of mercury (Hg) in the body. We used the following techniques: micronucleus frequency (MN), sister chromatid exchanges (SCE), and hypoxanthine guanine phosphoribosyl transferase (HGPRT) assay in human lymphocytes. A total number of 30 male workers exposed to Hg vapors in chloralkali industry had been selected and compared with 30 control subjects. The concentration of mercury in urine (HgU) was used as a biological index of exposure. The exposed group showed higher levels of MN (32.0 +/- 1.7), SCE (7.3 +/- 0.2),and HGPRT mutations (0.94 +/- 0.01) then the nonexposed controls. We recommend the introduction of somatic cell mutation analysis in the periodic medical examination of workers exposed to Hg vapors.

Different patterns of intestinal helminth infection among young workers in urban and rural areas of Alexandria Governorate, Egypt.

The process of urbanisation taking place in most developing countries is creating favourable conditions for an increase in prevalence of infections, especially with intestinal parasites, in the marginal areas of the towns. The present study was implemented in 1996 to assess the varying prevalence and intensity of infection among young workers in urban and rural areas of the same Governorate (Alexandria, Egypt). The sample comprised 408 male subjects, 8 to 19 years of age, in various occupations: 308 from urban areas, 67 from an industrialised village close to the desert, and 33 from a rural village. A quantitative diagnosis of intestinal helminth infections was made using the Kato-Katz technique, with a double reading of each slide. The results showed a higher prevalence (> 50%) and intensity of infection (indirectly measured as number of eggs per gram of faeces) than in previous studies. Furthermore, a higher prevalence and intensity of infection with Ascaris lumbricoides and Trichuris trichiura was detected in urban districts, as compared to rural areas. This difference was statistically significant. High crowding index, latrine shared with other families and no piped water inside the household, were more common in urban areas as compared with rural settlements and also associated with a higher intensity of infection by soil-transmitted helminths. The trend toward urbanisation seems to have caused deterioration of living conditions and sanitation standards in some areas of Alexandria city, with the most vulnerable people experiencing an increase in intestinal parasitic infections.

Study of some biochemical changes among workers occupationally exposed to phenol, alone or in combination with other organic solvents.

The present study was aimed for the effects of exposure to multiple organic solvent vapors in comparison with single exposure to phenol. It included 20 workers exposed to phenol alone and 32 workers of combined exposure to phenol, benzene, toluene and methyl ethyl ketone. A control group of 30 subjects was also included. The levels of transaminases, total proteins, prothrombin time, bleeding time, clotting time, fasting blood sugar, serum creatinine and some trace elements (copper, zinc, iron, magnesium, manganese and calcium) were determined in blood together with a complete blood picture. Urine samples were analyzed for phenol, hippuric acid and methyl ethyl ketone. The effects of combined exposure did not differ from that of exposure to phenol alone concerning the majority of the tested parameters. Only the levels of platelets count, prothrombin time, eosinophils, copper and iron have been affected by combined exposure in a probably additive manner.

Biological monitoring of occupational exposure to contraceptive drugs.

The present study was carried out for screening some biochemical changes due to occupational exposure to contraceptive drugs. It included 18 male workers and 22 female workers involved in the manufacture of contraceptive pills and 34 female workers manufacturing contraceptive ampoules. The levels of some sex hormones and gonadotropins were evaluated. Some parameters of blood picture, blood coagulation, liver and kidney functions, lipid profile and trace elements metabolism were assessed. Results were compared with those of a control group composed of 19 males and 27 females. Increased levels of estrogen among exposed workers was the main finding. It has been attributed to liver rather than pituitary dysfunction. A less atherogenic lipid profile has also been found. Referral to preventive measures has been recommended.

Anaemia among young male workers in Alexandria, Egypt.

In a cross-sectional survey, we investigated exposure to and the presence of factors associated with anaemia, such as socioeconomic conditions, dietary habits, intestinal parasitic infections and lead among 355 young male workers (7-19 years of age) employed in private workshops. Of the total study sample, 44.5% (158 participants) were found to be anaemic. The major risk factors for anaemia were multiple parasitic infection, high intensity of parasitic (Ascaris lumbricoides) infection and drinking tea soon after a meal. A significantly lower prevalence of anaemia was noted after Ramadan; it appeared to be the main factor associated with the presence or absence of anaemia and warrants further attention.

Effect of nickel sulfate alone and with ultraviolet light on micronuclei frequency in cultured human lymphocytes.

Comutagenic or cocarcinogenic activities have been reported between nickel compounds and UV light. The presence of micronuclei in a binucleated lymphocyte is regarded as an alternative to classical cytogenic methods for monitoring chromosomal damage. The present study aimed to detect this comutagenicity as regards micronuclei induction. Human peripheral lymphocytes were treated with different concentrations of nickel sulfate and/or with UV light at 200 and 1000 ergs/mm2. Cells have been cultured and 100 binucleated cells were counted and the micronuclei frequency recorded. The observed values for all concentrations of nickel sulfate combined with UV were less than expected for an additive response of two agents computed as the combined increase over the values of the control for the metal and UV alone. Caution is advised when interpreting cytogenic values in multiple exposures.

Study of the lipoprotein pattern among workers exposed to lead.

Occupational exposure to lead fumes constitutes a serious problem in Egypt, since a considerable number of workers might be involved in its deleterious effect. The present study aimed to elucidate the effect of lead exposure on the lipoprotein pattern of exposed workers. The study has been carried out in a plant manufacturing lead batteries. It consists of 89 workers exposed to lead and 25 control subjects. Fasting blood samples were collected for the determination of serum lipoprotein pattern and their cholesterol and phospholipid content. Levels of lead in blood and delta amino levulinic acid in urine have been determined as biological indices of lead exposure. Lead exposure caused mainly a cumulative effect on the cholesterol and phospholipid content of lipoproteins since only workers exposed for more than 10 years showed significant changes. These changes might be referred to the effect of lead exposure on liver and/or on trace metal metabolism.

Autoantibodies to neurofilaments (NF), glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP) in workers exposed to lead.

An expanded follow-up assessment of the autoantibody response to neuronal and astroglial autoantigens (NF68; NF160; NF200; MBP; GFAP) as early markers of neurotoxicity was performed in male workers exposed to lead (Pb) of a battery factory (n=50) and a matched reference group (R) of workers at a food packing plant (n=39). Mean age, years of exposure and blood lead (PbB ug/dl) (+/-SD) for lead and R, respectively, were: Age:39 +/- 6; 41 +/- 7; Yrs. Exposed: 14 +/- 6:0; PbB: 32 +/- 11: 16 +/- 5 percent with detectable titers to nervous system proteins in the Pb and R populations, respectively, were: Anti-NF68: 59; 17; Anti-NF160: 28; 15; Anti-NF200: 25; 0; Anti-GFAP: 90; 20; Anti-MBP: 16; 4. Autoantibodies to nervous system proteins predominated in workers occupationally exposed to Pb compared to R. Anti-NF68 and GFAP titers were the most frequently encountered. Anti-NF68 titers were significantly correlated with years of exposure (r = 0.538, p < 0.0001) and with PbB (r=0.325, p < 0.05). Furthermore, the number of detectable autoantibody types correlated with clinical scores of sensorimotor deficits (r = 0.459, p < 0.0001). This study suggests that autoantibodies provide a promising biomarker of neurotoxicity while providing information on subcellular targets. It also raises concerns of toxicant-induced autoimmune neuropathy.

Assessment of antisperm antibody in sera of mercury and lead exposed workers.

Occupational exposure to lead or mercury was found to make protein better antigens. The production of autoantibodies to nervous system protein is one example of such effect. The present study aims to detect the possibility of induction of antisperm autoantibodies due to occupational exposure to lead or mercury. Male workers exposed to lead (n = 50) or to mercury (n = 39) were selected for this purpose and compared to a matched control group (n = 39). A negative control consisting of 17 females was also included. All subjects had two or more children. Blood samples were collected and the ELISA technique was applied to detect antisperm antibodies. Also, the levels of lead in blood and mercury in urine were determined as biological indices of exposure. Antisperm antibodies were detected in 90% of workers exposed to lead with the predominance of the IgG type and 84.6% of workers exposed to mercury with the predominance of the IgM type. Although the results did not correlate with the biological indices of exposure, it seems advisable to use the detection of sperm antibodies of sera of workers exposed to metals as a biological monitoring tool.

New MRI grading system for the diagnosis and management of mycetoma.

The management of patients with mycetoma depends on accurate identification of the causative organisms and of the extent of disease involvement along the different tissue planes. Disease involvement cannot accurately be assessed with the available diagnostic tools, so in this study we set out to evaluate the effectiveness of MRI in the diagnosis and management of mycetoma. Forty-two patients with confirmed mycetoma had MRI examination of the affected parts. A grading system, The Mycetoma Skin, Muscle, Bone Grading System (MSMBS), was used to describe and grade disease severity on the basis of MRI findings. The logistic regression test was used to correlate the clinical and MRI findings. The study showed that MRI can help in the diagnosis and management of mycetoma patients. The dot-in-circle sign, conglomerated foci with low signal intensity and macro- and micro-abscesses on a background of a hypointense matrix are all diagnostic of mycetoma. In patients with mycetoma, the MSMBS can grade disease severity, compare patients and help to manage them. Further studies are needed to determine to what extent the grading system can be used to determine a patient's prognosis.

Anaemia and intestinal parasitic infections among school age children in Behera Governorate, Egypt. Behera Survey Team.

Anaemia is considered a serious public health problem in Egypt, although updated population-based data are lacking. Similarly, data on prevalence and intensity of infection with intestinal parasites, which are considered one possible cause of anaemia, are available only from small, unrepresentative sample surveys. The present research was implemented on an entire Governorate representative sample. The aim of the study was to assess the prevalence of anaemia and intestinal parasites in the area and to evaluate the role of each parasite in the epidemiology of anaemia among school age children. At the end of the survey, results of faecal analyses from direct smear and the Kato-Katz examination techniques were available from 1844 and 1783 children respectively, as well as haemoglobin levels measured by spectrophotometer from 1238 children aged 6-12 years. The prevalence of anaemia in the area was high (90 per cent), but very few serve forms were detected (< 2 per cent). Prevalence of intestinal parasites was high only for protozoa (Giardia intestinalis 24.7 per cent Entamoeba histolytica 17.5 per cent) and Schistosoma mansoni (20.7 per cent). From analysis of the results, Fasciola infection appeared to be highly endemic, even among children (3 per cent), and emerged as the factor most strongly correlated with low levels of haemoglobin (p < 0.0001). The effect of Fasciola on haemoglobin levels was related to the intensity of infection with this parasite. The role of S. mansoni as a risk factor for anaemia was supported by the present study. Among the protozoa, G. intestinalis was significantly correlated with low haemoglobin levels (p < 0.05). The present results substantiated similar findings from smaller studies. In future research, the relationship between Fasciola infection and anaemia needs to be studied with a well-controlled longitudinal design.