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Abstract Book of Accepted Abstracts LPHA 2017 Conference, Birzeit University, oPt

Abstracts ordered by Appearance on Agenda

1. Adherence to medication treatment among Palestine refugees with diabetes mellitus in Jordan: a cross-sectional study Giulia Canali (UNRWA research intern, Amman), Victoria Tittle (UNRWA research intern, Amman); Akihiro Seita (Director of UNRWA Health Department, Amman) Abstract submitted on November 20, 2016 by Giulia Canali ([email protected]) Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) estimated that today 10.8% of Palestine refugees (PRs) above 40 years of age in Jordan are diagnosed with diabetes mellitus (DM) and that only 44.8% of the PRs diabetic cohort can be classified as ‘controlled’. Being medication adherence one of the most significant modifiable self-care behaviour to achieve adequate metabolic control, the objectives of this study were to measure the rate of medication adherence and to review the factors associated with different levels of adherence to diabetes drug therapy among PRs accessing UNRWA primary healthcare delivered in Jordan. Findings from this study would help guide UNRWA care programs for diabetes patients. Methods This is a cross-sectional survey of type 1 and type 2 diabetic patients attending medical care at Amman New Camp health centre in Jordan. The rate of medication adherence was measured using the Morisky Medication Adherence Scale (MMAS-8). Results from the MMAS8 were coded as binary and used as outcome variable (non-adherent: MMAS-8 < 8, adherent: MMAS-8=8). Data on factors associated with adherence were collected using a pre-tested patient questionnaire and used as explanatory variables. These included sociodemographic, health status, patient-related and health system-related variables. Clinical data were extracted from patients’ electronic records. Logistic regression univariable analysis of each explanatory variable against the outcome variable was performed to provide crude odds ratios (ORs). Findings A total of 763 patients were included in the study: 73% of these were found nonadherent to their diabetes drug therapy. Forgetfulness was reported by 49.6% of the non-adherent population as a factor affecting their medication-taking behaviours. Univariate analysis showed that 5 factors are significantly associated with non-adherence at 95% confidence interval: the use of multiple providers for diabetes care (cOR = 0.51, CI = 0.28-0.91), the use of multiple providers of diabetes medications (cOR = 0.22, CI=0.09-0.56), satisfaction with the quality of UNRWA’s diabetes care (cOR = 4.51, CI = 1.05-19.45), satisfaction with the explanation of the condition and treatment presented by UNRWA’s health professionals (cOR = 2.72, CI = 1.245.29) and trust in UNRWA’s health staff (cOR = 3.61, CI = 1.4-9.32). More specifically, decreased odds of adherence were associated with the use of multiple providers of care and DM medication while odds of adherence were significantly increased by full satisfaction with the quality of care, explanation of the condition and treatment and trust in UNRWA healthcare staff.

Interpretation These findings demonstrated the significance of health system-related factors in affecting adherence to drug therapy among a population of Palestine Refugees with diabetes, accessing UNRWA healthcare in Jordan. Increasing medication adherence with targeted pharmacy-driven interventions and the application of a patient-centered approach aimed at increasing trust and satisfaction with the quality of diabetes care should be given high policy priority in order to improve metabolic control and health resources utilization. Word count: 473 2. “The overestimation and the inappropriate promotion of the benefits of mammographic screening in the research into breast cancer in Gaza” – A Literature Review a

Professor Klim McPherson, University of Oxford, [email protected] Shaymaa AlWaheidi, International Medical Corps, Gaza Abstract submitted on November 20, 2016 by Shaymaa AlWaheidi ([email protected]) b

Background The aim of screening is to reduce mortality from breast cancer by detecting the disease at an early stage. Evidence from recent US Cancer Registry reviews found that women who undergo mammography are more likely to have breast cancer that was an over-diagnosis, and therefore would not cause them problems, than to have earlier detection of real tumours that destined to become large. The observed reduction in breast cancer mortality worldwide is mostly due to significant improvements in chemotherapy, radiotherapy and surgery. In Gaza, policy appears to have exaggerated the benefits to be gained from mammography screening. A review was conducted to identify how research in Gaza has approached breast cancer screening. Methods Primary and secondary research papers that have focused on breast screening in Gaza (or elsewhere in Palestine) were identified from medical databases, journals, and by contacting the authors of relevant articles. A thematic analysis was carried out to document the opinions and citations of authors on the effect of mammography. The purpose of each paper and the methods used to collect, analyse, and report results were documented. Findings Eleven studies were identified, 6 in Gaza and 5 elsewhere in Palestine. Six crosssectional studies found that 60%-80% of Palestinian women had never had a mammogram and less than 30% of them were willing to undergo mammography, while one cross-sectional study found that more than 60% of women had positive beliefs about mammography. Some of these studies argued that the implementation of mammographic screening programs would improve survival rates by more than 20% in Gaza. These studies did not take into account recent evidence that mammography is cost-ineffective, when properly costed. Two retrospective cohort studies concluded that Palestinian women have low survival rates due to the poor availability of mammography, and another could not measure the association between mammography and women’s morbidity due to the lack of complete data at the cancer registry. Out of the 11 studies,

3 mentioned the harmful effects of mammography, one mentioned its marginal benefits on mortality rates, and another one referred to the lack of access of treatments in Gaza. No studies have documented the treatments for breast cancer received or denied for women in Gaza, or after referral, or explored the reasons for any deficiencies. Interpretation Research in Gaza has overestimated the reduction in breast cancer deaths that can be attributable to mammographic screening, and this would encourage women to undergo screening without knowing that it could harm them. Since the benefit gained is marginal and the harm caused is considerable, research and funding for breast cancer mammography are unjustifiable. Reasons behind efforts made to increase mammography in Gaza remain obscure and more effort should ensure appropriate surgery, radiotherapy and chemotherapy for women with breast cancer symptoms. Word count: 456 3. The effectiveness of different proposed counseling intervention scenarios in reducing HbA1c levels among Type 2 Diabetes Mellitus patients. *Mohammed B. Sarhan (BDS, MPH)1, Rula Ghandour (MPH)1, Niveen Abu Rmeileh (PhD)1 1 Institute of Community and Public Health, Birzeit University Abstract submitted on November 20, 2016 by Mohammad Sarhan ([email protected]) Background: In Palestine, the burden of Type 2 Diabetes Mellitus (T2DM) is rapidly increasing, which calls for an immediate application of interventions to control the disease. Globally, different forms of counseling and educational interventions have been suggested due to their ability to reduce HbA1C levels among T2DM patients. The current study aims to assess the effectiveness of different proposed counseling interventions aimed at improving glycemic control among T2DM patients. Methods: A thorough literature review was conducted to identify various counseling interventions at the primary healthcare (PHC) level, aimed at T2DM patients. The interventions assessed were directly related to the World Health Organization’s (WHO) recommended “Best Buys.” An in-depth analysis of the review was conducted to identify the most effective intervention, taking into consideration its feasibility, acceptability and potential effectiveness. Effectiveness of these interventions on HbA1c was extracted from the published literature. Data were entered in predefined tables using Microsoft excel Software. A regression line was plotted and the unstandardized β-coefficient was identified for each intervention to predict its effectiveness on reducing HbA1c levels. Findings: Three different counseling interventions s were identified through the literature review as they were the most effective interventions among those proposed by the WHO’s best buys. These interventions were: (1) individual counseling intervention at the PHC level, which includes creating multidisciplinary healthcare professional (HCP) teams and providing capacity

building for these teams, and providing a number of annual individual counselling sessions depending on patients’ glycemic control. Each team will consist of a general practitioner, nurse, dietitian and pharmacist. (2) Community Health Workers (CHWs) intervention, which will provide four annual home counseling visits for uncontrolled T2DM patients. (3) Telehealth intervention in which educational SMS will be sent to patients five times per week. All proposed interventions were found to have an effect on HbA1C reduction in T2DM patients. Telehealth using SMS was the most effective intervention (β=0.65, R²=0.10), followed by CHWs intervention (β=0.27, R² = 0.28) and individual counseling intervention (β=0.14, R²=0.01). Individual counseling intervention was divided into two parts. The first part was HCP capacity building, and it showed no effectiveness (β=-0.45, R²=0.18). The second part was the individual counseling session, which was found to be effective (β=0.44, R²=0.06). Interpretation: It is recommended to integrate at least one intervention, CHWs, telehealth or individual counseling, within the Palestinian healthcare system. Implementing one or more of the identified interventions could help in the fight against the increasing burden of T2DM and its complications in the Palestinian community. Word count: 409 4.Anemia among Children 5-12 Years Old in the Gaza Strip in the aftermath of the 2014 Israeli attack Jehad Elhissi, Ph.D.1, Sr. Bridget Tighe, FMDM,1 Maysa Kassabry, MPH2 1 Caritas Jerusalem, Gaza Health Center, 2Caritas Jerusalem, East Jerusalem, SOP Abstract submitted on November 19, 2016 by Maysa ([email protected]) Background Iron deficiency anemia (IDA), remains one of the most severe and important nutritional deficiencies in the world today. Iron deficiency impairs the children’s cognitive development, damages their immune mechanisms and delayed their physical growth. It is associated with increased morbidity rates. In the Gaza Strip, the importance of iron deficiency anemia as a public health problem has been increasingly recognized by health authorities and policy makers. Trends of anemia in the Gaza Strip is increasing despite the widespread interventions to combat it. Methods The analyzed data was extracted from the Phase 2 Emergency Appeal for Gaza Strip Project that was conducted to rehabilitate the Palestinian people after the 2014 war on Gaza. One of the project aims was to assess the state of nutrition of children aged 5-12 years by identifying their hemoglobin level and the root causes of their anemia. The study depends on WHO cut off point for diagnosis of anemia and the z-score of 0.001). Most of them, 185 (90.2%), encouraged the availability of such facility 24 hour a day. Physicians were more keener to access the center compared to other practitioners (P > 0.05). Interpretations: Acute poisoning has been increased in Gaza strip. At the same time, most of health care professionals especially doctors highlighted the need for poison control and drug information center in Gaza to provide immediate poisoning consultation and treatment. Word count: 285 29. Herbal Remedies Use by Breast Cancer Patients in the West Bank of Palestine Nidal Amin Jaradat1, Abdel Naser Zaid1, Ahmad Eid1 1 Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, P.O. Box 7, Nablus, Palestine. Abstract submitted on November 2, 2016 by Nidal Jaradat ([email protected]) Background: Recent ethnopharmacological surveys showed that herbal remedies are the most preferred modality of complementary and alternative medicine (CAM). In Palestine as in many other countries, herbal remedies are widely used in the treatment of many diseases. Cancer is a deadly disease affecting millions of people around the globe. In the United States, one in every

four deaths is attributed to cancer. According to the statistics of the Palestinian Ministry of Health, the incidence of cancer in the West Bank in 2010 was about 53.7 per 100,000 of the Palestinian population. Of these cases, 18.8% were breast cancer. To meet their healthcare needs, patients with cancer often seek therapies within as well as outside the allopathic therapy paradigm. The term complementary and alternative medicine (CAM) has evolved to include a variety of behavioral techniques and clinical approaches including the use of herbal remedies. In Palestine as in many other countries, herbal remedies are widely used as CAM in cancer therapy. Recent surveys showed that about two-thirds of cancer survivors used CAM. Prior studies reported even a higher CAM use rates among breast cancer patients, ranging from 67% to 83%. Patients might use CAM in addition to (complementary) or instead of (alternative) allopathic medications. Aim of the study: The aim of this study was to investigate the use of herbal remedies by women living with breast cancer in the West Bank of Palestine. Methods: This study was a questionnaire based cross-sectional descriptive study on the use of herbal remedies by breast cancer patients in the West Bank. A questionnaire was distributed to 115 patients at outpatient cancer clinics in face to face interviews. Results: The study had a response rate of 89.6%. Of all respondents, 68% were herbal remedies users. Women with breast cancer used 46 plant species belonging to 32 families. Of these, Brassicaceae and Lamiaceae were the most prevalent. Ephedra alata was the most commonly used plant species in the treatment of breast cancer. Leaves and seeds were the most commonly used parts and decoction was the most commonly used method of preparation. Herbal remedies users were more likely to use herbal remedies instead of chemotherapy. The most commonly stated reason for using herbal remedies was the belief in boosting the patient’s immune system to fight cancer. Conclusion: The use of herbal remedies is prevalent in breast cancer patients in Palestine. The use of herbal remedies was associated with educational level, time since diagnosis, type of surgery use, and use of endocrine therapy. It was apparent that the majority of users were satisfied with herbal remedies use. Clinical trials and pharmacological tests are required to be established for the presence of side effects, toxicity and efficacy for these herbal remedies. Word count: 451

30. Main Factors Affecting Adherence to Appointment System in the NCD Clinic in UNRWA’s Khan Younis Health Centre and the Role of Text Messaging Reminders to Improving Adherence, 2016 Sanaa Al Najjar; UNRWA Health Department, Gaza Field; Tamer Al Shaer, UNRWA Health Department, Gaza Field Abstract submitted on November 12, 2016 by Mahmoud Shaker ([email protected] Correspondence to Sanaa Jamil Al Najjar ([email protected]) Background: In order to meet the emergent needs of the growing numbers of NCD patients, the text messaging reminders system aims to i) support the improvement of the quality of care provided to clients who are considered highly vulnerable, and ii)regulating the work load in the NCD clinics at UNRWA centres, in order to provide optimum care with optimum contact time and minimum waiting time as stated in UNRWA guidelines. Methods: This is a simple cross sectional descriptive analytic study, conducted in the UNRWA KYHC, to study causes of lack of adherence to the NCD appointment system. And to provide timely intervention for improving the adherence by applying text messaging reminders for a period of 1 month as a primary experimental study. The study targeted KYHC as it reflects the same situation as in other UNRWA health centres serving the same refugee population and following the same guidelines with minimal variation. Data is collected through interviewer administered questionnaires with all 10 medical staff members involved in the appointment process in the NCD clinic and 50 NCD clients who came for their assessment to KYHC. Findings: The main barriers to adherence to appointments in the NCD clinic according to this study were: Lack of NCD awareness, forgetting their appointments, clinic overcrowding, appointments do not match their preference, availability of other service providers, financial issues and others. The intervention, March 2016: An electronic message technique is developed to remind NCD clients about their appointments by day and time in a previous day. The reminder consisted of 1000 electronic messages sent to a random sample of 1000 NCD clients, clearly reminding them of their appointment date and time. The messages were sent by the quality improvement team from their own laptops during post duty time. NCD clients contact information, file numbers and their registered appointments by date and time were easily searched and printed out through the e-health system after management approval. Post intervention process regarding the sample of 1000 NCD clients who were sent phone text message reminders, the following findings were noted: the percentage of NCD patients who were adherent to their appointment by date and time was 76% in March 2016 which is considered a recognized achievement regarding the general monthly result when compared to about 45% in January and February 2016.

Recommendations: The intervention should be continued and integrated in daily tasks as a way of sustaining the gain, and more financial resources are needed and to support text messaging reminder system. Improving communication skills among staff members and their counselling abilities is very important in improving adherence to appointment system, and NCD clients should always be consulted about their preferred appointment date and time as this will lead to higher client commitment rate. Word count: 385 31. The impact of smoking on expected lifetime without chronic disease among Palestinian men in the West Bank Henrik Bronnum-Hansen, Department of Public Health, University of Copenhagen, Copenhagen, Denmark Marie Jonassen, Department of Public Health, University of Copenhagen, Copenhagen, Denmark. Amira Shaheen, Public Health Division, An Najah National University, Palestine Mohammed Duraidi, Palestinian Central Bureau of Statistics, Ramallah, Palestine Khaled Qalalwa, Palestinian Central Bureau of Statistics, Ramallah, Palestine Bernard Jeune, Institute of Public Health, University of Southern Denmark, Odense, Denmark Abstract submitted on November 16, 2016 by Henrik Bronnum-Hansen ([email protected]) Background: Smoking is a serious preventable killer and in spite of smokers’ shorter life expectancy, they live on average fewer years in good health than non-smokers do. More than 40 per cent of the West Bank male population are smokers. The purpose of the study was to estimate life expectancy and the average lifetime without and with chronic disease among West Bank male never smokers, ex-smokers, and smokers. Methods: The study was based on an abridged life table for the West Bank male population. This life table and Danish relative risk estimates for death for moderate smokers (20 or less cigarettes per day), heavy smokers (more than 20 cigarettes per day), and ex-smokers versus never smokers were used to construct life tables for smokers and ex-smokers. Furthermore, the study utilized data on smoking habits and self-reported chronic disease from the Palestinian Family Survey 2010 collected by the Palestinian Central Bureau of Statistics. Life tables and prevalence of chronic disease by age and smoking category for men aged 15 years and older were combined and expected lifetime without and with chronic disease was calculated by Sullivan's method. Finally, the contributions from the mortality effect and the morbidity effect to smoking related difference in average lifetime without and with chronic disease were assessed by decomposition. Findings Life expectancy of a 15-year-old Palestinian man in the West Bank who will never start smoking was 59.5 years, 41.1 (95% CI: 40.3-41.9) of which were expected to be without

chronic disease. The corresponding figures for a moderate smoking man were 55.6 years, 41.2 (CI: 40.1-42.3) of which were without chronic disease. For lifelong heavy smokers, the expected lifetime was reduced to 52.6 years, of which 38.5 years (CI: 37.3-39.7) were without chronic disease. The estimated average lifetime with chronic disease was 18.4 years (CI: 17.6-19.2) for never smokers, 14.4 years (CI: 13.3-15.4) for moderate smokers, and 14.1 years (CI: 12.9-15.2) for heavy smokers. Ex-smokers could expect 57.9 years of remaining lifetime, 37.7 years (CI: 35.9-39.4) to be spend without disease and 20.2 years (CI: 18.4-22.0) with disease. The mortality effect from the decomposition contributed by 2.5 years of expected lifetime without chronic disease and by 4.4 years with disease to the total loss of 6.9 years of life expectancy of heavy smokers compared to never smokers. The contribution from the morbidity component is negligible (0.06 years without disease). For moderate smokers the mortality effect contributed by 1.6 years without and 2.3 years with chronic disease, whereas the morbidity effect accounted for 1.7 years with chronic disease reflecting that the mortality effect of abstaining from smoking exceeds the gain in expected lifetime without disease by 1.7 years. Comparing ex-smokers with never smokers showed that the mortality effect contributes by 0.5 years without and 1.1 years with chronic disease and the morbidity effect contributed by 2.9 years without disease. Interpretation Smoking reduces life expectancy and expected lifetime without chronic disease. The health gain from successful interventions against smoking is substantial. Word count: 493 32. Describing cardiovascular health in Palestine- Results from PURE Rasha Khatib, Loyola University Chicago Stritch School of Medicine Maywood, IL Abstract submitted on September 19, 2016 by Rasha Khatib Email: [email protected] Background: Life's Simple 7 is a new metric developed by the American Heart Association based on modifiable health behaviors and factors to promote improvements to cardiovascular health at the population level. In this study we use Life’s Simple 7 to describe cardiovascular health in a representative sample from the West Bank in Palestine. Methods: Data were taken from the Palestinian Prospective Urban Rural Epidemiology (PURE) study cohort. Baseline data were available for 1,384 participants ages 35-70 years, representing urban (34%), refugee camp (20%), rural (23%), and seam zone (23%) communities. Information was collected using structured questionnaires, physical examinations, and fasting blood samples. Poor cardiovascular health was defined as not smoking, body mass index ≥30 kg/m2, not being physically active, eating an unhealthy diet, blood pressure ≥140 /≥90 mm Hg, blood cholesterol ≥240 mg/dL, and blood glucose ≥ 126 mg/dL. Findings: Among the 1,286 (93%) participants free from cardiovascular disease,

29% (n=371) are current smokers, 47% (n=604) have a body mass index of 30 kg/m2 or higher, 20% (n=252) reported low levels of physical activity, 33% reported eating an unhealthy diet, 16% (207) have elevated blood pressure levels, 3% have high blood cholesterol levels, and 19% have high blood glucose levels. These metrics were used to create a score for overall cardiovascular health. Three and half percent (n=45) have inadequate cardiovascular health, 63% (n=815) have average cardiovascular health, and 33% (n=426) have optimal cardiovascular health. Optimal health was higher among females (41%) compared to males (24%) and among participants with trade school or higher (38%) compared to secondary school (35%) or primary or no schooling (27%). Interpretation: Life's Simple 7 provides an easy way for people to understand and track their risk of having a stroke or heart disease. Our analyses suggest that very few Palestinians are following life’s simple 7 and therefore cardiovascular health in Palestine is poor, and is worse among males and those with low levels of education. Our findings can help identify cardiovascular health behaviors and health factors that require population wide interventions in order to improve overall cardiovascular health. Findings from this study can be used to identify targets that are specific to the Palestinian context. Once defined, these targets should be monitored over time and interventions should be aimed at reaching these targets with the aim of improving overall cardiovascular health. Word Count: 385 33. PATTERNS OF TRAUMATIC OCULAR INJURIES AMONGST PRESENTED PATIENTS IN GAZA EYE HOSPITAL DURING WAR 2014 Dr. Abdallah Mohamed Alkashef, Ophthalmologist, Gaza Eye Hospital, MOH, Palestine Abstract submitted on October 18, 2016 by Abdallah Mohamed Alkashef ([email protected]) Background: Despite the fact that eyeballs are relatively small organ, their direct Explosive injuries are usually extensive and severe. It is due to the short distance and proximity of the explosives. Very often civilians are more frequently victims of such a trauma than military personnel on the modern battlefield. Ocular trauma is the most common cause of blindness especially among children. Methods: A retrospective study of all patients who reported in the Ophthalmic Emergency Department and admitted to the Gaza Eye hospital in 51 days of Gaza War in 2014. Results & Finding: The total number of patients presented to the Emergency Room with ocular injuries due to military operation during War 2014 is 184, (82%) 152 patients are managed in the ER and not hospitalized , 33 patient (18%) hospitalized. Fifty percent of the patients were in the age group of 11-30 years and 79% were Male patients. 33.7% (62 cases) of the presented patients to ER are children and 15 cases (45.5%) are hospitalized with poor visual outcome. the patients

distributed to the four major areas in Gaza Strip, The most presented patients to the hospital ER were from Gaza city (51%) , (36%) of patients from North area. (12%) from Middle area and (1%) from south area. Among the 33 patients hospitalized in Gaza Eye Hospital the ocular injuries 61% have penetrating ocular injuries The other 39% have Non penetrating ocular injuries distributed between the following diagnosis: Deep Conjunctival and corneal FBs, Thermal Burn, Traumatic Hyphema, Retrobulbar Hemorrhage, Vitreous Hemorrhage and Retinal Detachment. Intra Ocular Foreign bodies (IOFB) were found in 7 patients (21.2%) and Traumatic cataract in 3 cases (10%). Six patients had Retinal Detachment. Most of the Admitted patient Managed Surgically (85%), the range of hospital stays duration from 1 to 6 days. It is estimated that ocular injuries are Bilateral in 15.2%. Conclusion: Ocular trauma is the most common reason for hospitalization of ophthalmic patients and the commonest cause of uniocular blindness. The extent of trauma may range from simple superficial injuries to devastating penetrating injuries of the eyelids, lacrimal system, and globe The surgical management of such injuries is directed primarily at the restoration of normal ocular anatomy, the ultimate goal is to prevent secondary complications and maximize the patient’s visual prognosis. Word count: 379 34. “No place to hide ”: Exposure to military attacks of pregnant women in 2014 war on Gaza and load of toxic and teratogen metal contaminants in mother and child at delivery. Paola Manduca, Prof. Genetics, University of Genoa and NWRG, Italy* Safwat Y. Diab, Ph.D., Al Quds Open University , Gaza Palestine, Samir R. Qouta, PhD, Prof. Psychology, Islamic University Gaza, Gaza, Palestine, Nabil M.A.Albarqouni Consultant Pediatrician and Neonatologist, A.Professor in IUG. Raija-Leena Punamäki, Prof. Psychology, University of Tampere, School of Social Sciences, Finland Abstract submitted on November 7, 2016 by Paola Manduca ([email protected]) Background. Prenatal exposure to weapon-derived toxicants and teratogen metals can have long term damaging consequences on infants due to their environmental stability and progressive accumulation in-body. We examined the levels of 23 metals in delivering mothers and their newborns after mothers' being exposed to the 2014 war on Gaza during early pregnancy, and tested the associations between personal exposure and toxicant and teratogen load. Methods. Observational population based cohort study. Participants were 502 Palestinian mothers and their newborns delivered in four maternities in the Gaza Strip. All mothers delivering in the day’s first shift in the hospitals were included. At delivery, mothers consented for their and their babies' hair samples be taken, and reported genetic background, reproductive history, exposures to military attacks, and civilian use of chemicals, type of drinking water, fish eating, smoking and use of drugs. Mother and newborn hair samples were analyzed by ICP/MS.

Included metals were weapon components and war remnants, such as lead, barium, mercury, arsenic, zinc, cadmium, tin, uranium, tungsten and aluminum. Statistic was by multiple quantile regression models, least-absolute-value models (LAV or MAD) and minimum L1-norm models for women grouped according to recalled and objectively documented exposure subgroups. Findings. The whole cohort had significantly higher median load for most tested toxic and teratogen metals compared to standards from non-war area. To understand the impact of the last attacks on the contamination by metal war-remnants we compared metal loads between subgroups formed on the basis of reported and documented exposures to military attacks or for use reported of other chemicals or other environmental exposures. 68% of the women reported to have been under or immediately next to military attacks and these had significantly higher load of toxicants/teratogens than the 32% reporting non-exposure; no significant difference were found according to use of household or agricultural chemicals and no other confounders were identified. The metals load in newborn correlated positively with mothers’ load. Interpretations. Direct exposure to military attacks during 2014 attacks was very frequent in the random cohort examined. We documented and confirmed in 78% of the cases the women recall of exposure to attacks on their home while inside. Exposure correlated with high toxic and teratogen metals load among delivering mothers and their newborn. Surveillance and further research are necessary to follow up metal accumulation, as this is a long term continuing process, for reproductive damage, metals passage to infant in utero, and the impact on child development. Criteria for counselling, prevention and remediation need to be identified. Word count: 414 35. The Relationship between War Trauma, and Maternal Communication and infant development among 6-7 months old infants Samir R. Qouta, PhD, Prof. Psychology, Islamic University Gaza, Gaza, Palestine, S Safwat Y. Diab, Ph.D., Al Quds Open University , Gaza Palestine, Paola Manduca, Prof. Genetics, University of Genoa and NWRG, Italy* Nabil M.A.Albarqouni Consultant Pediatrician and Neonatologist, A.Professor in IUG. Raija-Leena Punamäki, Prof. Psychology, University of Tampere, School of Social Sciences, Finland Abstract submitted by Samir Quota ([email protected]) Background Little is known about the infant development in the atmosphere of political violence, The aims of this study were : a_ to understand how war and trauma effect on the maternal communication b_ How Maternal communication affect aspects of development of the infant in the early months of his birth, C- And how the trauma and PTSD correlate the child Maternal communication, motor, sensomotor and language development .

Method: The sample consists of 392 Palestinian mothers and their 6-7 month-old infants living in in Gaza strip. Mother s age ranged between 16- 46 (m = 24.77+ 5.55 ) Mothers reported PTSD,motor development, sensomotor ,language development, emotional communication ,and Psychometric co-efficients were good. Results: Revealed ,first it was found that there is relationship between the emotional communication and motor,sensemotor,language and cognitive development of the children, Second it was found that the more trauma the more PTSD,. Third PTSD of the mothers Stimulates the emotional communication and increased the language of the children Interpretation: The findings of the study contributes valuable and detailed insights into how the emotional communication correlates with the child development, and how the trauma and PTSD interact with the process of communication and development. Word count: 134 36. Current practices of contraceptive use among Palestine Refugee mothers of young children attending UNRWA clinics, a follow up study 2015 HABABEH Majed MD1 , ZEIDAN WAFAA BSc2 , ABDEL EL-KADER Mariam MD3 , Al THAHER Anwar MD4 , KASSIM Nimer MD5, HABASH Elias MD6, ARAB Hasan MD 7 , KAHDER Ali MD8 , SEITA Akihiro MD9 1. Dr. Majed Hababeh – Chief Health Protection and Promotion, MD, UNRWA Health Department Headquarters 2. Wafa’a Zeidan – Health Information Officer, BSc, UNRWA Health Department Headquarters 3. Dr. Mariam Abdel-Kader – Field family health officer, MD, UNRWA Gaza Field Office 4. Dr. Anwar Al Thaher – Field family health officer, MD, UNRWA Jordan Field Office 5. Dr. Nimer Kassim – Field family health officer, MD, UNRWA Lebanon Field Office 6. Dr. Elias Habash – Field family health officer, MD, UNRWA West Bank Field Office 7. Dr. Hasan Arab – Field family health officer, MD, UNRWA Syria Field Office 8. Dr. Ali Khader – Health policy and planning officer, MD, UNRWA Health Department Headquarters 9. Dr. Akihiro Seita – Director of Health, MD, UNRWA Health Department Headquarters Abstract submitted on November 19, 2016 by Yousif Shaheen ([email protected]) Correspondence to Majed Hababeh ([email protected]) Background UNRWA introduced family planning services in 1994 as an integral part of its expanded maternal and child health care program. The main objective of UNRWA’s family planning program is to promote the health of mothers, children and subsequently their families The ultimate objective of this follow-up study was to assess the current situation regarding contraceptive practices among the target population after five years from the 2010 follow-up

study and to identify future program needs leading to the development of action-oriented activities Methods A cross-sectional survey was conducted by trained nurses from June - December 2015. Participants were Palestine refugee mothers who attended well-baby clinics with their youngest child (aged 2 months through 5 years) at all UNRWA health centers. A sample size of 10478 participants was calculated based on contraceptive use prevalence in 2010, using Epi Info sample size calculation. Mothers were interviewed and retrospective data from health records was used as supplement. All participants provided verbal informed consent. The study protocol approved and cleared by UNRWA health department ethical committee. A multiple logistic regression was performed to test if maternal age and parity predicted contraceptive use. Chi- square was used to analyze the relationship between previous contraceptive use and birth interval, birth weight, and gestational age. Findings Data was obtained from 9860 mothers, with a mean age of 29.8 years. Of them, 59.3% were using modern contraceptives at the time of the survey, 17.7% were using traditional methods, and 23.0% were not using any contraceptive method. The most common modern contraceptive was intrauterine device (37.4%), and UNRWA was the main provider for 82.6% of women currently using modern contraceptives. The most common reasons for not using contraceptives were child wish (21.7%), pregnancy (18.6%) and husband opposition (19.7%). Using women with 40mg Prednisolone daily. 21.8% received Prednisolone for 5 days, as recommended. While the majority received a shorter course. On discharge, patients received no corticosteroids or mainly 10mg. Other treatments included 92.7% had oxygen, 100% antibiotics, 5.5% antiviral medication and 3.6% theophylline. NO patient received SABA-SC or chest physiotherapy. Interpretation: Overall adherence to guidelines was moderately good. All patients received antibiotics and 94.7% oxygen, which are both recommended for all patients. Chest physiotherapy was not advocated, which is known to be ineffective for this indication. Less useful therapies were also rarely prescribed. However, some areas showed poor adherence and this might be due to a lack of awareness of recent evidence. Firstly, more patients received SAMA than SABA, although SABA are more effective and therefore the first line treatment for COPD exacerbation. 96.4% of patients received systemic corticosteroids. However, the mostly prescribed dose (75mg Prednisolone) exceeds the recommendation, which is 40mg for 5 days. Generally, awareness and adherence to clinical guidelines has to be improved. This goes hand in hand with fostering evidence based medicine across the Gaza-Strip. As other audit projects, this one also found documentation to be of a very poor standard. This is in urgent need of improvement across Gaza, in order to foster a meaningful audit culture. Word count: 443 83. Providing mental health services for Palestinians in Gaza: Integrating a public health and human rights approach Marwan Diab1,2, Yasser Abu Jamei1,2, Ashraf Kagee2, and Guido Veronese3 1. Gaza Community Mental Health Programme 2. Stellenbosch University 3. University of Milano-Bicocca Abstract submitted on November 18, 2016 by Marwan Diab ([email protected])

Background: The ten years long siege on Gaza creates severe restrictions on travel and on economic development for Gaza’s residents. Three recent assaults and the continuous threat of military strikes have created an atmosphere of prevailing trauma and associated mental health problems. The Gaza Community Mental Health Programme provides mental health services and psychosocial interventions that fit the cultural and social norms of this Palestinian society. The presentation will discuss how, in the context of severe violations of basic human rights and ongoing insecurity, community-oriented mental health programs can respond to the population needs. A community mental health approach, aimed at protecting the psychological well-being of the people of Gaza and advocating on mental health issues, is more context-appropriate than interventions that are exclusively symptom-focused or biologically informed. Method: GCMHP services are provided at primary, secondary and tertiary levels of preventative public health. Primary prevention: The GCMHP conducts advocacy, public awareness and media campaigns aimed at promoting culture and discussion on common mental disorders such as trauma related syndromes, anxiety and depression disorders, and behavioural difficulties among children. It is estimated that 19,135 people benefited from these services from January, 2014 – June, 2016. Psychoeducation of this nature provides information on how to access support and resources from family members and the broader community. In addition, GCMHP facilitates the integration of mental health services in schools and kindergartens (9408 beneficiaries in the last 30 months). A key goal is to mitigating mistrust about mental health services in Gaza. Secondary prevention: GCMHP provides interventions such as psychological first aid and crisis intervention to vulnerable groups. These include persons living in border areas and those experienced loss. There have been approximately 12,943 direct and 8,526 indirect beneficiaries between June 2014 and June 2016. Free telephone counselling is provided to citizens as a way to circumvent the stigma associated with seeking mental health services and to reach individuals for whom transportation to a treatment center is prohibitive. A total of 2590 individuals received telephone counselling in the same reporting period. The purpose of these secondary prevention efforts is to alleviate the likelihood of psychological symptoms progressing to fully developed disorders. Tertiary prevention: GCMHP provides individual and group counselling, psychotherapy and routine home visits with diagnosed and mentally disordered patients such as, torture survivors, individuals and families exposed to cumulative trauma. There were 20,269 beneficiaries of these services from January 2014 to June, 2016. Interpretation: A public health oriented approach to the provision of mental health services fits the social/ecological model that locates individuals and families within the context of their community, society, religio-cultural context, and social, economic and political systems. In a fragile political environment, with a multitude of psychosocial needs, the GCMHP uses a

flexible approach in its interventions. With social responsibility embedded as a core value, the work of GCMHP aims to restore and guarantee the right for mental health and psychological well-being in Gaza. Word count: 483 84. Management of acute Palestine: a clinical audit








Mohammed Alkhatib(1), Tamer Abd-Alghafoor(2), AlaaEldeen Elmassry(3), Loai Albarqouni(4) , Bettina Böttcher(5) 1, 2. Intern doctors, Nasser hospital, Ministry of Health, Palestine. 3. Consultant internist, Nasser hospital, Ministry of Health, Palestine 4.Research Assistant, Faculty of Health Sciences and Medicine, Bond University, Australia. 5. Research & clinical audit director, Islamic University of Gaza Medical School. Abstract submitted on November 19, 2016 by Mohammad Alkhatib Introduction Stroke is a leading cause of morbidity and mortality worldwide. Strokes are classified into ischemic and hemorrhagic strokes. Ischemic stroke is defined as “an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction”. Our aim is to assess the quality of the current practice and standard of care for stroke patients at the internal medicine department, Nasser hospital, Gaza Strip. Methods We conducted a retrospective case note clinical audit. We selected a random sample of 100 patients records out of the 200 stroke patients who were admitted to the internal medicine department between January and August 2016.We compared our clinical practice with the recommendations of the AHA/ASA guidelines 2013. Data were collected from the medical records using a data collection sheet including data about investigations and received treatment. Data were analyzed using SPSS. Findings Of the 100 sampled records, the International Classification of Diseases (ICD10) code was not reported in 5 records, therefore, were excluded. Of the 95 patients, 51(54%)patients were male and aged 6714. More than half of the cases (n=53) presented with dysarthria. The duration of stroke symptoms was not reported in 86(91%) records.49(52%) patients had no previous events, 31(33%) had previous strokes, 64(67%)were hypertensive, and 46(48%) have diabetes mellitus. Most of the initial diagnostic tests were performed at the time of admission. Complete blood count and renal function tests were performed for all patients, lipid profile for 87(92%) patients, ECG for 85(89%) patients, carotid duplex ultrasound for 32(34%) patients and CT scan in all patients. However, none of the patients had continuous cardiac monitoring or swallowing function assessment. Regarding the stroke management, immediate antiplatelet therapy of 325mg aspirin was given to 70(73.7%)patients as recommended per guideline, but 17(17.9%) received 100mg aspirin,and

5(5.3%) patients received dual antiplatelet therapy (aspirin 100mg and clopidogrel 75mg), whereas 3(3.2%)patients did not receive any antiplatelet therapy. Most patients (80; 85%) received prophylactic dose of anticoagulation for DVT, but 10(10.5%) patients received therapeutic dose of anticoagulation with no obvious indication. About half of the patients (50; 52.6%) received neuroprotective agents (Vitamin B Complex), 41(43%) patients received prophylactic antibiotics with no clear indication. None of our patients received thrombolytic therapy.Regarding hypertension management, 41(43.2%) patients did not receive any antihypertensive agents in the first day of hospitalization as recommended per guideline. However, 54 (56.8%) patients received one or two antihypertensive agents within the first day with no justifiable indications .Regarding the glycemic control, 20(43.5%) of the 46 diabetic patients achieved the target blood glucose level(140-180)in the first day of admission, 24(52.1%) patients in the second day and 26(56.5%) patients in the third day. Interpretation: There is no local evidence-based guideline regarding the management of ischemic stroke patients and management derived by personal experience rather than evidence. So, we recommend to develop evidence-based guideline to improve ischemic stroke management and to establish a specialized stroke care unit with thrombolytic service and a multidisciplinary team care approach. Word count: 483 85. The clinical effectiveness of the Bispectral Index (BIS) to reduce the risk of awareness for elective surgical patients undergoing general anesthesia: A prospective, randomized, double-blind, controlled trial Tasneem Tarayrah RN, MSN, Faculty of Graduate Studies, An-Najah National University; A. Nazzal MD, Faculty of Graduate Studies, An-Najah National University Hospital, A. Alkaissi RN, PhD, An-Najah National University, Faculty of Medicine and Health Sciences- Nursing & Midwifery Department, Nablus- Palestine Abstract submitted on October 4, 2016 by Aidah Alkaissi ([email protected]) Background: Awareness is postoperative recall of events experienced under general anesthesia. Awareness can be experienced by patients as horrific events that leave lasting mental trauma behind. Patients may have both auditory and tactile perception, accompanied by feelings of helplessness, inability to move, pain, and panic ranging to an acute fear of death. BIS is used as a monitor to measure the depth of anesthesia and to help guide the titration of medications. BIS monitoring has shown to reduce awareness and improve recovery times from general anesthesia. Aims: to evaluate the clinical effectiveness of BIS monitoring and its relevance to hemodynamic parameters, drug consumption, incidence of awareness, recovery times and end-tidal volatile concentration in adult patients undergoing different types of surgery under general anesthesia.

Method: A prospective, randomized, double-blind, single-center study. Fifty nine adult patients (ASA) physical status I-III, aged 18 to 72 years scheduled for different types of surgery under general anesthesia, were randomly assigned to BIS-guided anesthesia (n=30) and BIS recommended to maintain between (40–60) or routine care group (RC) (n=29). A BIS sensor was applied to the forehead of patients. BIS values and hemodynamic parameters, SPO2 were marked before induction, also during the operation every 5 minutes until extubation. Patients were assessed by a blinded observer at 24-36 hr. after surgery. An independent committee, blinded to group identity, assessed every report of awareness. Results: There is statistically significant difference in awareness between the routine care group 8/29 (27.6%) and BIS group 2/30 (6.7%) (P = 0.032), BIS-guided anesthesia reduced the risk of awareness with 20.9% (95% CI (1.4% -40%). There is statistically significant difference in the inspired concentration of the anesthetic between RC group mean SD 0.028 ±0.007 which was reduced for BIS group to 0.024 ±0.013 (P= 0.043). There is significant difference in the mean dose of inhaled anesthetic agents between RC group mean SD 0.029 ±0.008 which was reduced to 0.025 ±0.009 for the BIS group, P=- 0.023. There is significant difference in the Fentanyl between the two groups: for the BIS group mean SD 115.56 ug±94.18 which was reduced to 77.76 ±40.523 for RC group P= 0.035. The percentage of Jerking intra-operative was reduced from (27.6%) in the RC group to (6.9%) in the BIS group P= 0.037. The time to phonation for the RC group 12.82±6.11 min and it was reduced to 10.21 ±5.127 for the BIS group, P=0.026. The mild level of pain 25% for RC group which is higher than that for the BIS group (0%) P=0.011. There is significant difference in the time to discharge from PACU , the mean SD 12.38 ±4.989 minutes for the RC group which was reduced to 9.23 ±3.819 for the BIS group, the P= 0.007. There are statistically significant differences, between the two groups during operation for SBP, DBP and MAP at different points of operation. Conclusions: BIS-guided management may be superior to routine care to reduce awareness, volatile anesthetic consumption, anesthetic recovery times and hemodynamic changes. Word count: 493 86. An Age Old Problem: Pain management in labour(PML): A Clinical Audit at ElEmarati Hospital-Gaza(EEH) Reem Yahia Dabbour1, Tayseer Hasan Awad 1, Maha Sadat Al-Faqawi1, Bettina Boucher2 1. Institution: students at the Islamic University of Gaza-School of medicine 2. Institution: Assistant Professor at the Islamic University of Gaza-School of medicine Abstract submitted on October 8, 2016 by Reem Dabbour ([email protected]) Background: Pain is the oldest medical problem and the universal physical affliction of mankind. It has been a part of childbirth for this time. Over the last 100 years and especially recent decades, a multitude of different methods for management of pain in labour have become

available to women. However, no guideline exits in the Emirati Hospital to help staff and patients benefit from these recent developments. Aim: The aim of this audit is to assess the practice of pain management in labour at El-emarati Hospital in Rafah in the Gaza-Strip and compare this to the NICE guidelines. Objectives: In particular the following points are to be looked at: 1.What are the available strategies used in PML in EEH? 2.Are the patients informed about those strategies? 3. Are the patients informed about the side effects of the strategies used? 4.Do patients ask for specific strategies? Methods: A data collection sheet was prepared and filled in for each patient admitted to the delivery room. All patients were included consecutively by the time we started the work of data collection starting from the day of 1st February 2016 to the 1st April 2016, this is the period which during it, we choose the patients of our sample who were admitted to get into delivery. Data collection sheets were completed by the audit team or, if not available, by the medical staff on labour ward. Altogether, 50 patients were included in the audit. The NICE guidelines were used as the standards and the data collection sheet had been prepared according to them. Results: From the total of 50 patients, 22 were primigarvidae and 28 multigravidae. All patients had received at least one or more of non-pharmacological management methods. 100% (50px) of them were managed by breathing and relaxing techniques, 70%(35px) received abdominal massage, but no patient received Enotox. 40% (20px) of patients were managed pharmacologically. about the availability or the side effects of the drugs used.

But no patient was informed before

Finally, none of the patients was offered or received regional anaethesia for pain management during labour Discussion: There is a significant shortfall in the management of pain during labour, especially as many options and techniques are not used or offered to the patients. Another weakness found was the limited discussion and lack of choice available to patients with regard to the use of pain relief. As pain is a highly subjective experience and varies greatly between patients, so does the preference for use of pain relief. This should be reflected in practice. Recommendations: 1. Inform all patients about the methods available.

2. Explain any expected side effects of the drugs used. 3. Provision of an approved reliable protocol in order to make the management easier and more accessible to different practitioners on labour ward. 4. Consider the use of regional anesthesia during labour. Word count: 472 87. General versus spinal anaesthesia for caesarean section: a quasi-randomised controlled trial Raed M Tafish1; Khaled I Abu El Aish2; Haly S Zourob3 1 Anaesthesia and Intensive Care specialist, Anaesthesia department, Al Helal Al Emirati Hospital 2 Master of Pharmacy, Pharmacy department, Al Helal Al Emirati Hospital 3 Obstetrics and Gynecology specialist, Obstetrics and Gynecology department, Al Helal Al Emirati Hospital Abstract submitted on November 12, 2016 by Raed M Tafish ([email protected]) Correspondence to Khaled I Abu El Aish. Pharmacy Department, Al Helal Al Emirati Hospital Rafah, Gaza strip, Palestine ([email protected]) Background:- General (GA) and spinal anaesthesia (SA) are commonly used for caesarean section (CS). So, this study was carried out to compare effects of GA with those of SA on the outcomes of CS to find the most efficient and safe anesthesia for CS. Methods:- Hundred eighty one patients (aged 19-46.5 years) undergoing either elective or emergency lower-segment cesarean section were enrolled in quasi-randomised controlled trial, at Al Helal Al Emirati Hospital, Rafah, Gaza Strip, occupied Palestinian territory. Women were randomly assigned into two groups either, GA group (n=79) received 20% intravenous propofol for induction of anaesthesia then atracurium besylate for muscle relaxation, nitrous oxide and oxygen were given for anaesthesia maintenance, or SA Group (n=102) received intrathecally hyperbaric solution of 0.5% bupivacaine combined with 20μg fentanyl. Primary outcomes measures were: hospital length of stay, operation length, postoperative pain assessment by visual analogue scales (VAS; range 0–10, 0=no pain and 10=pain as bad as it could be) 1 hour after the end of surgical procedure, time from induction of anesthesia to the first demand of analgesia, and the total amounts of analgesics used in 24 hours. Secondary outcomes were headache after CS. Data were analysed with SPSS (version 22.0). Groups were compared by using the Mann-Whitney U test, student’s t test, OR, or χ2. A P-value of < 0.05 was considered statistically significant at the level of confidence interval of 95%. The study was approved by the Ministry of Health and Helsinki Committee, Gaza Strip. Women provided informed consent before their participation in the trial and consent to undergo a cesarean.

Findings:- There were no statistically significant differences in age (mean 30.6±6.5 vs. 28.5±5.4 years p=0.077), weight (82.2±14.2 vs. 28.5±5.4 kg p=0.263), duration of CS (39.9±10.1vs 41.6±9.1 minutes p=0.077), stay period after CS (38.7±14.5 vs. 40.1±12.5 hours p=0.541), hospital readmission (OR=0.770 [0.106-5.590] CI=95%) or emergency vs. elective CS (36.7% vs. 45.1% and 63.3% vs. 59.1% respectively p=0.256) between GA and SA group.VAS one hour after the end of surgical procedure was seen to be greater in GA group in comparison with SA group (5.43±2.9 vs. 2.38±2.32 p=0.00) but no difference in time to the first demand of analgesia was seen in the two groups (2.4±2.0 vs. 2.5±1.1 p=0.634). In GA group less patients needed second and third analgesics in comparison with SA group (22.7% vs. 47.0% needed two analgesics, 4.0% vs. 26.5% needed three or more analgesics respectively p=0.000).Two patients only from SA group experienced headache after CS (OR=0.559 [0.490-0.636] CI=95%). Conclusions:- GA and SA appeared to be equally in safety and can be applied according to patients needs and medical situation in the hospital. Word count: 436 88. Prescribing practices for hypertension management and control among Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Amman, Jordan: a chart review Jenny Guadamuz1,2*, Rawan Saadeh1, Ali Khader1, Yousef Shahin1, Akihiro Seita1, and Dima M Qato3 1. United Nations Relief and Works Agency for Palestine Refugees in the Near East, Amman, Jordan 2. Department Health Policy and Administration, University of Illinois at Chicago, Chicago, Illinois, USA 3. Department Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, Chicago, Illinois, USA Abstract submitted on November 19, 2016 by Jenny Guadamuz ([email protected]) Background Management and control of hypertension can be achieved with appropriate prescribing of antihypertensive medications. Previous studies have examined use of hypertensives in the United Nations Relief and Works Agency (UNRWA) primary care patient population using procurement data, however, information on prescribing practices for the treatment of hypertension is limited. The objective of this study is to examine prescribing of antihypertensive medications in UNRWA patient population with hypertension. Methods Chart reviews were completed for two primary health care centers using medical charts in Amman, Jordan. Systemic sampling (nth selection technique) was used to select patients with hypertension in each clinic. A power analysis using EpiInfo was completed to determine the appropriate sample size. Patients younger than 40 years of age and patients that had not visited their health center in the past 12 months (as of July 2016) were excluded from the study. Non-

identifiable demographic and health information from the 2015 calendar year was recorded manually using a data collection instrument. Clinical appropriateness of prescribing was determined using the Eighth Joint National Committee (JNC 8) guideline. Findings Among the patient population with hypertension using primary health care centers sampled (N=73 patients) in Amman, the vast majority were prescribed (97%) antihypertensive medications; 75% were prescribed two or more antihypertensives. Ninety-two percent of patients were prescribed first-line agents, including: thiazide-type diuretics (23%), angiotensinconverting-enzyme inhibitors (63%), calcium channel blockers (52%), and angiotensin receptor blockers (11%). Sixty-four percent of patients were prescribed other agents, including β-blockers (60%) and loop diuretics (11%). Fifty-nine percent of patients were prescribed first-line agents concurrently with β-blockers or loop diuretics. Our sample also experienced high rates of cardiovascular risk factors: 82% of patients are overweight or obese, 60% have diabetes, and 27% have elevated total cholesterol levels (>200 mg/dL). Forty-four percent of patients had uncontrolled hypertension (blood pressure >140/90mmHg in the last recorded measurement or in one of two measurements taken in preceding visits). The most prevalent complications of hypertension and/or diabetes were: cardiovascular disease (15%; 11% myocardial infraction or cardiac failure), renal damage (8%; 1% end-stage), ophthalmological damage (7%; 3% blindness), neuropathy (7%), and stroke (4%). Thirty percent of patients experienced at least one early or late complication. Interpretation Nearly all patients with hypertension served by UNRWA primary care clinics are prescribed antihypertensive medicines. A majority of these patients are prescribed agents which that are not first-line agents according to the most recent treatment guidelines. Efforts to reduce the high rates of uncontrolled hypertension in this population should target improvements in prescribing practices for patients most at-risk. Word count: 419 89. Adenovirus respiratory tract infections in infants a cause of major panic Shaden Mohammad Jobran, Senior Pediatric Resident Doctor, Caritas baby hospital; Randa Said Kattan, Medical Technologist, Caritas baby hospital; Jamal Jeries Shamaa, Pediatrician, Caritas baby hospital; Hiyam Marzouq Marzouqa, Medical Director at Caritas baby hospital; Musa Yehya Hindiyeh, Director: Clinical Laboratory and Infection Control, Caritas baby hospital. Abstract submitted on September 30, 2016 by Shaden Jobran [email protected] Background: Human adenoviruses (HAdV) are nonenveloped double stranded DNA viruses with icosahedral protein capsid. Antigenic variability in surface proteins of the virion defines more than 50 serotypes grouped into 8 species. Virus spread is usually through respiratory and fecal oral routes. HAdV plays a significant role in pediatric respiratory tract infections. It is estimated that HAdV is the causative agent of 2-5% of the overall respiratory tract infections and 4-10% of all pneumonias.

Objectives: To evaluate the clinical presentation and the impact of HAdV infection on the management of infected infants. Materials and Methods: Medical records of 491 patients admitted to Caritas baby Hospital between January 2006 and June 2016 and infected with adenovirus were included in the study. Adenovirus respiratory tract infection was diagnosed from nasopharyngeal aspirates collected from all patients using direct fluorescent antibody staining. The data collected from the medical records included, patient clinical presentation, medical workup, laboratory workup and antibiotic administration. Results: HAdV activity was noted throughout the months of the study period with major activity during the late winter, spring and early summer with peak patient presentation in April (14.3%). Males appear to be the most affected (M : F = 2:1). Upon admission, 37.8% patients were afebrile while 62.2% were febrile. With regards to the clinical presentations, 66.6% presented with upper respiratory tract infection symptoms, 33.6% presented with gastrointestinal tract symptoms, 12% presented with difficulty of breathing while 9.4% had conjunctivitis. Leukocytosis was found in 56.8% of the patients while the C-reactive protein (CRP) titer was between 5 and 50μg/mL in 46.4% of the patients, and CRP titer was above 50μg/mL in 46% of the patients. Lumbar puncture was performed on 18.7% of the patients and viral meningitis was found in 2.4%. Co-infections with respiratory syncytial virus (RSV) and human metapneumovirus (hMPV) was noted in 0.41% and 0.81% of the patients, respectively. Overall, 71.8% of the patients received antibiotic treatment. Chest X-Ray results showing infiltrations were noted in 27% of the patients while, mechanical ventilation was needed in 1.2% of the patients. Patient’s hospital length of stay ranged between 1-10 days with the majority of the patients being discharged on day 3. Thus, leading to an average hospitalization cost of 1180.5$. Conclusions: Our study showed that HAdV infections in infants can present with sepsis like picture mandating unnecessary interventions. Thus, hospitals clinical laboratories must have rapid and sensitive HAdV detection techniques in order to assist the physicians in making appropriate decisions of treatment. Word count: 409 90. Studying the effect of oral zinc supplementation for the treatment of acute diarrhea in children: a quasi-experimental research Rola S Abu Dalfa1, Khaled I Abu El Aish2, Mohamed B El Raai3, Nermeen K El Gazaly1, Ahmed I Shatat4 1 Bachlour of Pharmacy, Pharmacy department, El-Dorra Pediatric Hospital 2 Master of Pharmacy, Pharmacy department, Al Helal Al Emirati Hospital 3 Master of Clinical Nutrition, General Practitioner, El-Dorra Pediatric Hospital 4 Pediatric specialist, Medical Director of El-Dorra Pediatric Hospital Abstract submitted on October 8, 2016 by Rola Abu Dalfa ([email protected])

Corresponding author: Khaled I Abu El Aish. Pharmacy Department, Al Helal Al Emirati Hospital Rafah, Gaza strip, Palestine. [email protected] Background: Diarrhea causes 15% of all deaths in children under five years and accounts for nearly 1.4 million child deaths in developing countries. Zinc stores in the body are known to be depleted during acute diarrhea. So, this trial was carried out evaluate the efficacy of zinc supplementation when given with standard treatment to children with acute diarrhea. Methods: One hundred forty children aged 1-120 months with more than three unformed stools in the prior 24 hours; duration of diarrhea up to 72 hours; and ability to accept oral fluids or feeds were enrolled in this quasi-experimental study, at El-Dorra Pediatric Hospital in Gaza strip, Palestine. Children were assigned equally into standard treatment (St) group (received standard treatment only as ORS) and zinc (Zn) group (received additionally to standard treatment oral zinc supplement (10 mg zinc for less than 6 months old children and 20 mg for more than or equal to 6 months old children) as zinc sulfate) for a total of 14 days. Primary outcomes measures were: duration of diarrhea (in days) from start of treatment until cessation of diarrhea (passage of soft/formed or no stools for two consecutive 8-hour periods), severity and amount of diarrhea during the illness. Secondary outcomes included changes in child weight the rate of complications and drugs side effects, and episodes of any or severe dehydration. Data were analyzed with SPSS (version 22.0). Groups were compared by using the Mann-Whitney U test, student’s t test, OR, or χ2. A P-value of < 0.05 was considered statistically significant at the level of confidence interval of 95%.The study was approved by the Ministry of Health and Helsinki Committee, Gaza Strip. Parents of the enrolled children were provided verbal informed consent before their participation in the trial. Findings: Mean duration of diarrhea among Zn group was shorter in comparison with St group (2.34days vs. 7.20 p=0.00). Frequency of diarrhea in Zn group was clearly less in comparison with St group in the observed period as it reduced from 6.38 and 6.99 to 2.38 and 4.68times daily respectively. Also, severity of diarrhea was seen to be markedly less in Zn group in comparison with St group overall the study period. We noticed, 71.4% increase in weight among Zn group while 71.4% decreased weight among St group in the same period (p=0.00). 2.9%, 17.6%, 14.7% of Zn group developed constipation after the 5th ,6th and 7th day (p=1.51, 0.000 and 0.001 respectively). Conclusions: Zinc supplementation added to standard treatment as ORS was effective and resulted reductions in the duration and severity of diarrhea. Word count: 425