Strengthening laboratories in response to outbreaks in humanitarian emergencies and conflict settings: Results, challenges and lessons from expanding PCR diagnostic capacities for COVID-19 testing in Yemen

BACKGROUND

When the COVID-19 pandemic was declared, Yemen, a country facing years of conflict had only one laboratory with PCR testing capacity. In this article, we describe the outcome of the implementation of molecular based diagnostics platform in Yemen and highlight the key milestones the country went through to increase access to testing for its populations residing in a geographically vast and politically divided country.

METHODS

A retrospective assessment of COVID-19 laboratory response activities was done detailing the needs assessment process, timelines, geographical coverage, and outcomes of the activities. Laboratory data was analyzed to construct the geographical locations of COVID-19 testing laboratories and the numbers of tests performed in each facility to highlight the demands of testing for travelers. Finally, we discuss the impact these activities had in enabling the movement of people across international borders for economic gains and in delivery of critical humanitarian aid.

OUTCOME

PCR testing capacities in Yemen significantly improved, from one laboratory in Sanaa in April 2020 to 18 facilities across the country by June 2022. In addition, the number of functional Real-Time PCR thermocyclers increased from one to 32, the PCR tests output per day improved from 192 to 6144 tests per day. Results from analysis of laboratory data showed there were four peaks of COVID-19 in Yemen as October 2022. The majority of laboratory tests were performed for travelers than for medical or public health reasons. Demand for laboratory testing in Yemen was generally low and waned over time as the perceived risk of COVID-19 declined, in parallel with rollout of the COVID-19 vaccines.

DISCUSSION/CONCLUSION

The successful expansion of laboratory testing capacity was instrumental in the control and management of COVID-19 cases and critical in the implementation of public response strategies, including restrictions on gathering. Laboratory testing also facilitated the movement of humanitarian agencies and delivery of aid and enabled hundreds of thousands of Yemeni nationals to travel internationally. By virtue of these outcomes, the impact of laboratory strengthening activities was thus felt in the health sector and beyond.

WHO's Investigations and Studies, Unity Studies: A global initiative creating equitable opportunities for enhanced surveillance, operational research, capacity building, and global knowledge sharing

The World Health Organization's Unity Studies global initiative provides a generic preparedness and readiness framework for conducting detailed investigations and epidemiological studies critical for the early and ongoing assessment of emerging respiratory pathogens of pandemic potential. During the COVID-19 pandemic, the initiative produced standardized investigation protocols and supported Member States to generate robust and comparable data to inform public health decision making. The subsequent iteration of the initiative is being implemented to develop revised and new investigation protocols, implementation toolkits and work to build a sustainable global network of sites, enabling the global community to be better prepared for the next emerging respiratory pathogen with epidemic or pandemic potential.

A phased strengthening of laboratory capacity in the Eastern Mediterranean Region during the COVID-19 pandemic

The Eastern Mediterranean Region (EMR) faces ongoing challenges in its public health system due to limited resources, logistical issues, and political disruptions. The COVID-19 pandemic accelerated the need for stronger laboratory capacities to handle the increased demand for testing. In a phased response, EMR countries utilized the National Influenza Centers to rapidly establish and scale molecular testing for SARS-CoV-2, the causative agent of COVID-19. The expansion of capacity included strong collaborations between public health bodies and private and academic sectors to decentralize and expand testing to the subnational level. To ensure that the quality of testing was not impacted by rapid expansion, national and subnational laboratories were enrolled in external quality assurance programs for the duration of the response. Implementation of genomic surveillance was prioritized for variant tracking, leading to the establishment of regional sequencing reference laboratories and the distribution of MinION sequencing platforms to complex emergency countries who previously had limited experience with pathogen sequencing. Challenges included a lack of technical expertise, including in implementing novel diagnostic assays and sequencing, a lack of bioinformatics expertise in the region, and significant logistical and procurement challenges. The collaborative approach, coordinated through the WHO Eastern Mediterranean Regional Office, enabled all 22 countries to achieve SARS-CoV-2 diagnostic capabilities, highlighting the pivotal role of laboratories in global health security.

Monitoring the quality of SARS-CoV-2 virus detection in molecular diagnostic laboratories in the Eastern Mediterranean Region during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic placed unprecedented stress on laboratories in the Eastern Mediterranean Region. Building on existing capacity for influenza diagnostics, countries introduced COVID-19 diagnostic support to ~100% regional coverage. A key challenge during the expansion was maintaining quality testing in laboratories, ensuring that correct results were shared with medical facilities.

METHODS

WHO organized two rounds of independently monitored severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) external quality assurance programs (EQAP). The Public Health Laboratory (PHL) division of WHO supplied external quality assurance (EQA) panels, from the Royal College of Pathologists of Australasia Quality Assurance Programme (RCPAQAP) Australia to laboratories not enrolled in recurring Global Influenza Surveillance and Response System (GISRS) quality assurance programs, in which national influenza centers routinely participate.

RESULTS

Fifteen and 14 countries participated in PHL/EQAP for SARS-CoV-2 between 2020 and 2022. Concordance was consistent between rounds, reaching 96.4% and 89.9%. A separate assessment of GISRS/EQAP to national-level laboratories identified high levels of response and concordance for SARS-CoV-2 (100% response, 93% concordance), which was reduced for influenza (50% response rate, 80% concordance), reflecting the challenge of prioritizing pathogens during outbreaks.

CONCLUSION

The proliferation of laboratories in response to COVID-19 was a success story from the pandemic. However, monitoring the quality of laboratories was challenging via existing EQAP. The addition of PHL/EQAP provided a mechanism to monitor performance of laboratories that were not designated as national influenza centers. While a high proportion of laboratories attained good results, continual emphasis on quality and enrollment in EQAP is key to ensuring sustainability of laboratory testing in future.

Implementation and expansion of laboratory capacity for molecular diagnostics in response to COVID-19 and preparedness for other emerging infectious diseases in the Islamic Emirate of Afghanistan

Background

Afghanistan experienced various outbreaks before and during the Covid-19 pandemic, including dengue, Crimean Congo hemorrhagic fever (CCHF), measles, and acute watery diarrhea (AWD). Diagnostic and surveillance support was limited, with only the Central Public Health Laboratory equipped to handle outbreak responses. This article highlights initiatives taken to improve diagnostic capabilities for COVID-19 and other outbreaks of public health concern encountered during the pandemic.

Background

The World Health Organization (WHO) Afghanistan Country Office collaborated with the WHO Eastern Mediterranean Regional Office (EMRO), Central Public Health Laboratory (CPHL), and National Influenza Center (NIC) to enhance COVID-19 diagnostic capacity at national and subnational facilities. To alleviate pressure on CPHL, a state-of-the-art laboratory was established at the National Infectious Disease Hospital (NIDH) in Kabul in 2021-2022, while WHO EMRO facilitated the regionalization of testing to subnational facilities for dengue, CCHF, and AWD in 2022-2023.

Results

COVID-19 testing capacity expanded nationwide to 34 Biosafety Level II labs, improving diagnosis time. Daily testing rose from 1000 in 2020 to 9200 in 2023, with 848,799 cumulative tests. NIDH identified 229 CCHF cases and 45 cases nationally. Dengue and CCHF testing, decentralized to Nangarhar and Kandahar labs, identified 338 dengue and 18 CCHF cases. AWD testing shifted to NIDH and five subnational facilities (Kandahar, Paktia, Balkh, Herat, and Nangarhar labs), while measles testing also decentralized to nine subnational facilities.

Conclusion

Afghanistan implemented a remarkable, multisectoral response to priority pathogens. The nation now possesses diagnostic expertise at national and subnational levels, supported by genomic surveillance. Future efforts should concentrate on expanding and sustaining this capacity to enhance public health responses.

RANDOMIZED COMPARATIVE STUDY OF DEFINITIVE EXTERNAL FIXATION VERSUS ORIF IN PILON FRACTURES: AN EARLY CLINICAL OUTCOME REPORT

Repairing Pilon fractures remains challenging. ORIF allows direct anatomical reduction, but at the expense of soft tissues dissection which are associated with recovery. On the other hand, External Fixation allows indirect reduction and causes less soft tissue damage. However, a few studies conclude that External Fixation is associated with high rates of malunion.The objectives were to evaluate and compare: primary outcome measure: ankle hindfoot function (AOFAS at 9 months) and secondary outcome measures: quality of reduction, bone union, arthritic changes, other potential complications and ultimately the optimum management for pilon fractures.A prospective randomized comparative clinical study. 40 Patients were included in the study with comminuted closed Pilon fracture. Patients were randomized by closed envelope technique into two groups: Group (1) Included 20 patients managed by external fixation with limited internal fixation. Group (2) Included 20 patients managed by open reduction and internal fixation. Skeletally immature, type 43A AO/OTA, Open fractures, compartment syndrome, Pathological fractures were excluded.There was no significant difference between External fixation and ORIF as methods of fixation for Pilon fracture in the functional activity of the patient after 9 months as evidenced by AOFAS score (P=0.547) and the development of complications (P=0.227). However, there was statistically significant difference (P<0.001) regarding the time to weight bearing between both groups, and statistically significant difference (P=0.042) regarding time to union.The best surgical modality to treat Pilon fractures is still debatable. While external fixation is used by many to avoid major complications, it has been associated with high rates of malunion, and osteoarthritis.

A case report of two Moroccan patients with hereditary neurological disorders and molecular modeling study on the S72L de novo PMP22 variant

Hereditary neurological disorders represent a wild group of hereditary illnesses affecting mainly the nervous system, the majority of which have a Mendelian inheritance pattern. Here we present the case of two Moroccan patients each affected by a different hereditary neurological disorder. In the first patient WES analysis revealed the presence of the p.Ser72Leu de novo mutation in the PMP22 gene reported for the first time in Africa, specifically in Morocco. This variant is predicted to be in a mutation "hot-spot" region causing Dejerine-Sottas syndrome called also Charcot-Marie-Tooth type 3. The molecular modeling study suggests an important alteration of hydrogen and hydrophobic interactions between the residue in position 72 of the PMP22 protein and its surrounding amino acids. On the other hand, the p.Ala177Thr mutation on the RNASEH2B gene, responsible of Aicardi-Goutières syndrome 2, was carried in a homozygous state by the second patient descending from a consanguineous family. This mutation is common among the Moroccan population as well as in other North African countries. The present results contributed to a better follow-up of both cases allowing better symptom management with convenient treatments.

Circulation patterns and molecular epidemiology of human respiratory syncytial virus over five consecutive seasons in Morocco

Background

Respiratory syncytial virus (HRSV) is the leading cause of respiratory tract infections in infants and young children. we investigated the prevalence and characteristics of HRSV in Morocco and explored trends in circulating genotypes through partial G gene analysis of HRSV strains prevalent from 2012 to 2017.

Methods

Respiratory samples were gathered from both outpatients and inpatients meeting ILI or SARI case definitions. The patients' ages varied from 1 month to 99 years old. Nucleic acids were extracted and HRSV type/subtype was detected by RT-qPCR. A subset of positive samples was randomly selected in each epidemic year, the complete viral genome was sequenced, phylogenetic analysis was performed using the MEGA7 program and the genotypes were confirmed.

Results

The 3679 specimens were collected from 2012 to 2017, of which 726 (19.7%) were positive for HRSV. The 35% (257/726) of HRSV-positives were of the HRSV-A subtype, while the HRSV-B subtype accounted for 61% (442/726). The co-infection rate was 3.7% (27/726). The virus circulates in a periodic pattern, where epidemics occur during the fall months through early spring. HRSV genotype was confirmed in 127 specimens (56 HRSV-A and 71 HRSV-B). Based on phylogenetic analysis, all HRSV-A were ON1 genotype, and HRSV-B were mostly BA9 genotype. HRSV-B belonging to the BA10 genotype was detected in 2012 exclusively.

Conclusions

BA9, BA10, and ON1 were the only HRSV genotypes detected between 2012 and 2017. Variations in the G gene amino acid chain were identified in local strains, which suggests an increased need for continuous genomic surveillance.

Key aspects defining the development and implementation of a regional genomic surveillance strategy for the Eastern Mediterranean Region

The COVID-19 pandemic highlighted the critical role of pathogen sequencing in making informed public health decisions. Initially, the Eastern Mediterranean Region faced limitations in sequencing capacity. However, with robust WHO and stakeholder support, the situation significantly improved. By 2022, COVID-19 sequencing was underway in 22 out of 23 regional countries, with varying throughput and capacity. Notably, three genomic hubs were established in Oman, UAE, and Morocco, playing a key role in providing expanded genomics training and support across the region. While primarily for COVID-19 surveillance, this sequencing capacity offers an opportunity to integrate genomic surveillance into existing networks. This integration can enable early detection and response to high-threat pathogens with pandemic potential. To advance this, WHO/EMRO collaborated with stakeholders to formulate the Eastern Mediterranean Regional Genomic Surveillance Strategy for Emerging Pathogens of Pandemic Concern. Consultative meetings with regional and international genomic surveillance experts identified strategy focal points, key partners, priority pathogens, and implementation steps. As the strategy awaits member states' ratification in Q4 2023, this manuscript outlines pivotal facets defined by member states and the strategic document's key deliverables and opportunities. These efforts aim to yield a substantial positive impact within the region.

Strengthening pathogen genomic surveillance for health emergencies: insights from the World Health Organization's regional initiatives

The onset of the COVID-19 pandemic triggered a rapid scale-up in the use of genomic surveillance as a pandemic preparedness and response tool. As a result, the number of countries with in-country SARS-CoV-2 genomic sequencing capability increased by 40% from February 2021 to July 2022. The Global Genomic Surveillance Strategy for Pathogens with Pandemic and Epidemic Potential 2022-2032 was launched by the World Health Organization (WHO) in March 2022 to bring greater coherence to ongoing work to strengthen genomic surveillance. This paper describes how WHO's tailored regional approaches contribute to expanding and further institutionalizing the use of genomic surveillance to guide pandemic preparedness and response measures as part of a harmonized global undertaking. Challenges to achieving this vision include difficulties obtaining sequencing equipment and supplies, shortages of skilled staff, and obstacles to maximizing the utility of genomic data to inform risk assessment and public health action. WHO is helping to overcome these challenges in collaboration with partners. Through its global headquarters, six regional offices, and 153 country offices, WHO is providing support for country-driven efforts to strengthen genomic surveillance in its 194 Member States, with activities reflecting regional specificities. WHO's regional offices serve as platforms for those countries in their respective regions to share resources and knowledge, engage stakeholders in ways that reflect national and regional priorities, and develop regionally aligned approaches to implementing and sustaining genomic surveillance within public health systems.

Current concepts in the management of radial head fractures: a national survey and review of the literature

INTRODUCTION

This study aims to report on current practice in the management of radial head fractures (RHFs) in the United Kingdom and to review the literature to identify areas for future investigation.

METHODS

A 12-question online survey was sent to 500 surgeon members of the British Elbow and Shoulder Society in 2021. Questions focused on clinical assessment, indications for surgical treatment and willingness to participate in future studies. Descriptive statistical analysis summarised the responses.

RESULTS

The response rate was 20.4% (n = 102). For minimally displaced RHFs, non-operative management with immediate mobilisation was reported by 90.2% (n = 92) as opposed to 9.8% (n = 10) for initial immobilisation in plaster or brace. The most cited indication for radial head arthroplasty as opposed to fixation was increased patient age or low functional demand in 69.9% of responses (n = 71). In total, 41.2% (n = 42) indicated the need for a future randomised controlled trial (RCT) concerning the management of RHF. Only five RCTs were returned by the literature review.

DISCUSSION

There is considerable variability in the management of RHF among an experienced cohort of surgeons. With the interest declared by the participating surgeons, there is a call for a well-designed sufficiently powered RCT.

Genomic sequencing for epidemic and pandemic preparedness and response: EMRO's vision and strategic interventions

Whole-genome sequencing (WGS) is an approach for studying and analysing the entire genomic sequence of pathogens. It provides the most comprehensive characterization of an organism's genetic make-up. In January 2020, scientists used next-generation sequencing (NGS) as one of several sequencing technologies to study severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and to reveal the first genetic makeup of this new virus only 11 days after the first cluster of cases due to the COVID-19 pandemic was reported. This crucial information was vital to the subsequent rapid development of test kits, vaccines and treatment regimens to respond to the pandemic. The sequencing information, later as the pandemic evolved, became essential for informing public health policies through monitoring and characterization of SARS-CoV-2 variants.

Use of photosensitizers activated by photodynamic therapy on the canal disinfection of radicular dentin bonded to Dimethacrylate-based glass fiber post: an assessment of pushout bond strength

OBJECTIVE

The present lab-based investigation aimed at evaluating the canal disinfectants using photodynamic therapy (PDT) using different photosensitizers, conventional NaOCl, a mixture of doxycycline, citric acid, and a detergent (MTAD) and their impact on the bond strength of glass fiber post to radicular dentin.

MATERIALS AND METHODS

Forty extracted human premolars were gathered and disinfected. The decoration was performed up to the cementoenamel junction. Using the crown down technique cleaning of the canal was done following rinse with distilled water. All canals were dried with paper points and obturated with gutta-percha. Post space was prepared using peso reamers and samples were randomly allocated into four groups following different disinfection regimes: Group 1 - Methylene blue photosensitizer (MBP) + MTAD; Group 2 - RBP (Rose Bengal photosensitizer) + MTAD; Group 3 - CP (curcumin photosensitizer) + MTAD and Group 4 - 2.25% NaOCl + MTAD (control). Following disinfection, the canals were dried and the post was placed and cemented within the canal. Samples were dissected at coronal, middle, and apical third and placed in a universal testing machine for push-out bond strength (PBS). Debonded surfaces were evaluated for failure modes. PBS was examined using a one-way analysis of variance (ANOVA). The means of PBS were compared using Tukey multiple comparison tests with a significance threshold of (p<0.05).

RESULTS

Group 3 canals disinfected with CP and MTAD had the highest PBS at two levels: cervical (9.57±1.21 MPa), middle (6.37±0.79 MPa), and group 2 canal space disinfected by RBP and MTAD had the maximum PBS in apical portion (5.35±0.42 MPa). No significant difference at all root levels between group 2 (RBP + MTAD) and group 3 (p>0.05). Canal irrigation with group 1 (MBP + MTAD) and group 4 control (2.25% NaOCl + MTAD) exhibited comparable PBS at all three levels of the root.

CONCLUSIONS

CP, MTAD, RBP and MTAD for canal disinfection and bonding of glass fiber post to radicular dentin demonstrated comparable bond values at all three root levels and can be recommended in clinical settings after further investigations.

Transmission of SARS-CoV-2 in standardised first few X cases and household transmission investigations: A systematic review and meta-analysis

We aimed to estimate the household secondary infection attack rate (hSAR) of SARS-CoV-2 in investigations aligned with the WHO Unity Studies Household Transmission Investigations (HHTI) protocol. We conducted a systematic review and meta-analysis according to PRISMA 2020 guidelines. We searched Medline, Embase, Web of Science, Scopus and medRxiv/bioRxiv for "Unity-aligned" First Few X cases (FFX) and HHTIs published 1 December 2019 to 26 July 2021. Standardised early results were shared by WHO Unity Studies collaborators (to 1 October 2021). We used a bespoke tool to assess investigation methodological quality. Values for hSAR and 95% confidence intervals (CIs) were extracted or calculated from crude data. Heterogeneity was assessed by visually inspecting overlap of CIs on forest plots and quantified in meta-analyses. Of 9988 records retrieved, 80 articles (64 from databases; 16 provided by Unity Studies collaborators) were retained in the systematic review; 62 were included in the primary meta-analysis. hSAR point estimates ranged from 2% to 90% (95% prediction interval: 3%-71%; I ² = 99.7%); I ² values remained >99% in subgroup analyses, indicating high, unexplained heterogeneity and leading to a decision not to report pooled hSAR estimates. FFX and HHTI remain critical epidemiological tools for early and ongoing characterisation of novel infectious pathogens. The large, unexplained variance in hSAR estimates emphasises the need to further support standardisation in planning, conduct and analysis, and for clear and comprehensive reporting of FFX and HHTIs in time and place, to guide evidence-based pandemic preparedness and response efforts for SARS-CoV-2, influenza and future novel respiratory viruses.

Emerging and Re-emerging Infectious Diseases in the WHO Eastern Mediterranean Region, 2001-2018

BACKGROUND

Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018.

METHODS

To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect.

RESULTS

Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia.

CONCLUSION

EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.

COVID-19 morbidity in Afghanistan: a nationwide, population-based seroepidemiological study

OBJECTIVE

The primary objectives were to determine the magnitude of COVID-19 infections in the general population and age-specific cumulative incidence, as determined by seropositivity and clinical symptoms of COVID-19, and to determine the magnitude of asymptomatic or subclinical infections.

DESIGN, SETTING AND PARTICIPANTS

We describe a population-based, cross-sectional, age-stratified seroepidemiological study conducted throughout Afghanistan during June/July 2020. Participants were interviewed to complete a questionnaire, and rapid diagnostic tests were used to test for SARS-CoV-2 antibodies. This national study was conducted in eight regions of Afghanistan plus Kabul province, considered a separate region. The total sample size was 9514, and the number of participants required in each region was estimated proportionally to the population size of each region. For each region, 31-44 enumeration areas (EAs) were randomly selected, and a total of 360 clusters and 16 households per EA were selected using random sampling. To adjust the seroprevalence for test sensitivity and specificity, and seroreversion, Bernoulli's model methodology was used to infer the population exposure in Afghanistan.

OUTCOME MEASURES

The main outcome was to determine the prevalence of current or past COVID-19 infection.

RESULTS

The survey revealed that, to July 2020, around 10 million people in Afghanistan (31.5% of the population) had either current or previous COVID-19 infection. By age group, COVID-19 seroprevalence was reported to be 35.1% and 25.3% among participants aged ≥18 and 5-17 years, respectively. This implies that most of the population remained at risk of infection. However, a large proportion of the population had been infected in some localities, for example, Kabul province, where more than half of the population had been infected with COVID-19.

CONCLUSION

As most of the population remained at risk of infection at the time of the study, any lifting of public health and social measures needed to be considered gradually.

Influenza activity in the Eastern Mediterranean Region (EMR) in 2020-2021 amidst the COVID-19 pandemic

Introduction

A global reduction in influenza virus activity during the COVID-19 pandemic has been observed, including in the Eastern Mediterranean Region (EMR). However, these changes have not been thoroughly evaluated scientifically in the EMR.

Objective

We aim to present data on seasonal influenza activity during the pre-pandemic period (2016–2019) and compare it to the pandemic period (2020–2021) in EM countries.

Methods

Epidemiological and virological influenza surveillance data were retrieved from both WHO FluNet and EMFLU networks. Four pre-pandemic analytical periods were used in the comparative analysis. We compiled and calculated weekly aggregated epidemiological data on the number of enrolled patients, number of tested specimens and number of positive influenza specimens.

Results

19 out of the 22 countries of the EMR have functioning sentinel influenza surveillance systems, and these countries report the influenza data to WHO through FluNet and EMFLU. The number of enrolled patients and tested specimens increased gradually from 51 384 and 50 672, respectively, in 2016–2017 analytical period to 194 049 enrolled patients and 124 697 tested specimens in 2019–2020. A decrease has been witnessed in both enrolled patients and tested specimens in 2020–2021 ‘pandemic period’ (166 576 and 44 764, respectively). By comparing influenza activity of analytical period 2020–2021 with that of 2016–2019 analytical periods, we found that there has been a decrease in influenza positivity rate in the EMR by 89%.

Conclusion

The implementation of non-pharmaceutical interventions to control the COVID-19 pandemic may have also impacted the spread of influenza viruses. The low circulation of influenza viruses during 2020–2021 and the associated potential immunity gap may result in increased transmission and severity of post-pandemic influenza seasons. This necessitates high vigilance to continuous data and virus sharing to monitor circulating viruses in a timely fashion to reduce the intensity and severity of future influenza epidemics.

WHO's support for COVID-19 research and knowledge management in the Eastern Mediterranean Region

Health research, innovation and knowledge management remain major priorities of the WHO’s response to the COVID-19 pandemic. WHO’s Eastern Mediterranean Regional Office (EMRO) supports priority research initiatives that address gaps in current knowledge regarding the COVID-19 pandemic. Through a specific call for proposals, 122 research proposals were received and reviewed in 2020, of which 17 were recommended for funding from eight countries. Ten countries in the region participated in the global solidarity trial to assess potential therapies for COVID-19. In addition, WHO advocated for early serological and epidemiological investigations (‘COVID-19 Unity Studies’) on the general population, healthcare workers, pregnant women and neonates, and extending technical, financial and material support for them.

Starting in early 2020, scholarly articles on COVID-19 have been published in every issue of the Eastern Mediterranean Health Journal. More than 6300 publications on COVID-19 were made available on the WHO knowledge management portal in the last year alone. WHO is also supporting countries in conducting studies to assess the field effectiveness of vaccines deployed nationally. To build and strengthen country capacities, regional webinars and intercountry meetings were conducted on research ethics, national health information systems and evidence-based health policy making. With support from WHO EMRO’s new research and knowledge management pillar, countries in the region were well equipped to contribute to a global understanding of the novel virus’s characteristics, as well as employ a national response based on informed evidence.

The correlation between coronary artery disease and left ventricular filling pressure: which correlates more LVEDP or LV pre-A wave?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and Uneversity Heart Surgery Center, Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) affects left ventricular (LV) systolic and diastolic function. This  results in high filling pressure which expressed by different waves and may be assessed by invasive and noninvasive methods. Validation and comparing the correlation between CAD and different LV filling pressure waves may add a step forward in CAD diagnosis, prognosis and treatment.

Purpose

This study invasively validates the correlation between coronary artery disease (CAD) and left ventricular end-diastolic pressure (LVEDP) as well as left ventricular pre-A wave (LV pre-A wave) and compare the results.

Methods

124 patients who accepted to participate for this study underwent left heart catheterization for medical indications. This study obtained the results of LV filling pressures (LVEDP and LV pre-A wave), as well as, coronary angiography results with assessing the severity and extents (if CAD presents) by vessels number and Gensini Score (GS). Spearman r correlation were used for continuous/continuous or continuous/ordinal variables and Chi square test for nominal/nominal variables. Then we compared the results.

Results

CAD presence with elevated LVEDP incidence (OR = 4.29, relative risk = 1.85 P = 0.0123). Vessel number, plaque number and Gensini score correlations with LVEDP were (P = 0.0038 r = 0.34, P = 0.0002 r = 0.44, p = 0.0002 r = 0.43 and p = 0.0622 r = 0.22) respectively. In the same way, CAD presence with LV pre-a wave (OR = 2.75, relative risk = 1.5, P = 0.0447). Vessels number, plaque numbers and Gensini score relations with LV pre-A wave were (P = 0.0379 r = 0.23, P = 0.0004 r = 0.39, p = 0.0002 r = 0.40 and p = 0.0568 r = 0.21) respectively. All the results are summarized in Tables (1 + 2+3).

Conclusions

LV filling pressure had a significant correlation with CAD presence, vessel number and plaque number but it did not have a correlation with Gensini score. LVEDP had a stronger correlation with CAD presence, severity, sensitivity and extent but lower specificity than LV pre-A wave. Abstract Tables of results (1 + 2)  Abstract Table of result 3

A check of the grading system among the 2009 and 2016 EACVI/ASE left ventricular diastolic function guidelines statistically and invasively

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular diastolic function assessment undergoes continuous updates. EACVI/ASE 2016 guidelines handles with this case, which is an expert consensus and simplified update of the 2009 recommendations. As stated in the latest guidelines, studies need to check that the simplicity does not affect much the accuracy.

Aim

This study compares the corresponding subgroups between the 2009 and 2016 EACVI/ASE guidelines, for the assessment of left ventricular diastolic function statistically. Furthermore, it invasively validates of the relation between the grading results of each guidelines and  the measured LV filling pressure during catheterization lab.

Methods

124 patients underwent transthoracic echocardiography just before angiography. A trained echo cardiographer obtained E/A mitral flow, Av E/e", LAVI, TR, septal and lateral e" and other supportive parameters to assess LV diastolic function and filling pressure according to 2009 and 2016 EACVI/ASE guidelines algorithms and we compared the results with LV pre-a wave during catheterization with a cut-off &gt;12mmhg considered elevated.

Results

EACVI/ASE 2016 resulted in {normal (46.77%), Grade I (29.03%), Grade II (10.48%), Grade III  (7.26%) and indeterminate (6.45%)}, while EACVI/ASE 2009 resulted in {normal (39.52%), Grade I (25%), Grade II (13.71%), Grade III  (7.26%) and indeterminate (14.52%)} with no statically significant difference between subgroups. EACVI/ASE 2016 vs. 2009 in assessment LV filling pressure (odds ratio =0.51 and p value = 0.034. EACVI/ASE 2016 sensitivity and specificity were (0.36, 0.94 ) respectively and EACVI/ASE 2009 sensitivity and specificity were (0.63, 0.80) respectively. All results are summarized in (tables: 1 + 2+3 + 4+5 + 6).

Conclusion

This study found that the updated and simplified 2016 EACVI/ASE guidelines algorithm did not affect statistically the grading results of 2009 EACVI/ASE. Even more, 2016 had a higher relation between diastolic subgroups and invasively measured LV filling pressure which reflects the higher specificity than 2009. On the other hand 2016 was less able to detect elevated LV filling pressure which reflects a lower sensitivity than 2009. 2016 was more specific but less sensitive than 2009. There were no statistically significant difference between the means of invasively measured LV filling pressures among both guidelines. Abstract Figure.  Abstract Figure.

Invasive validation of the different echo parameters and cut-offs among the trilogy of left ventricular filling pressure assessment guidelines: EACVI/ASE 2016, ESC 2016, HFA 2019

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular filling pressure assessment is a challenge. Three guidelines concerned about this are: EACVI/ASE 2016, ESC 2016 and the HFA 2019 guidelines. Echo assessment is a corner stone in their algorithms with different cutoffs and different parameters used depending on expert consensus that should be validated in an invasive manner as the authors stated.

Aims

This study validates and tests the accuracy of the different cutoffs and parameters used in echo LV filling pressure assessment in the three guidelines: EACVI/ASE 2016, ESC 2016 and HFA 2019 by direct measure in the catheterization lab.

Methods

82 patients with EF ≥ 50%, signs and symptoms of HF underwent transthoracic echocardiography immediately before catheterization. Av E/e", TR, LAVI, LVMI, RWT, LV wall thickness, Septal, lateral and mean e" were used to assess LV filling pressure with respect to EACVI/ASE 2016, ESC 2016 and HFA guidelines algorithms" different cutoffs and  parameters used. This study used LV pre-A wave with a cutoff &gt;12mmhg defined high as a reference and then we compared the results.

Results

all the results of functional and structural echo parameters" diagnostic criteria (sensitivity, specificity, NPV, PPV and accuracy) are summarized in (Table:1 + 2).

Conclusion

From an echo view, each algorithm depends on  modest to high specific but low to modest sensitive echo parameters. There is no single parameter makes a guidelines superior to others. Although that the fact of combining more echo indices make the diagnosis and eventually the algorithm more reliable as in HFA 2019, that was for the cost of simplicity and ease of application. Av E/e"&gt;13 was the best cutoff (ESC 2016). Orientation for the cause of use (sensitivity, specificity, NPV or PPV) should employ the echo indices and cutoffs in best benefit, as for mitral (e"), although that septal &lt; 7 and lateral e"&lt;10 (EACVI/ASE 2016 and HFA 2019) had an overall more accuracy than mean e"&lt;9 (ESC 2016), sub analysis showed that the first is better used for specificity and NPV but the latter better for sensitivity and PPV. Same idea for LVMI≥145/122 (m/f)+RWT &gt; 0.42 (HFA 2019 major criteria) which had more specificity than LVMI≥115/95 (m/F) cutoffs (HFA2019 minor criteria and ESC2016) but in the cost of lower sensitivity, furthermore, sub analysis showed this LVMI high cutoffs were more benefit in female than in men after taking the NPV, PPV and accuracy in consideration. Abstract Figure.  Abstract Figure.

The correlation of ESC 2016 diastolic guidelines with invasively measured left ventricular filling pressure

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

left ventricular (LV) diastolic function and filling pressure assessment is a challenge. ESC 2016 diastolic guidelines handles with this issue. Validation of and comparing the correlation between this guidelines and invasively measured different waves may add a step forward in the assessment, prognosis and treatment of LV diastolic function by echo.

Purpose

this study validates of the correlation of ESC 2016 left ventricular filling pressure echo guidelines with invasively measured left ventricular end-diastolic pressure and left ventricular pre-a.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before left heart catheterization. This study obtained echo parameters to assess LV filling pressure according to ESC 2016 algorithms. It also obtained left ventricular end-diastolic pressure (LVEDP) and LV pre-a waves during catheterization. It analyzed the data and compared the results.

Results

Correlations of grading system (normal, abnormal parameters 1,2 and 3 present) with LV pre-a and LVEDP waves were (P= &lt; 0.0001 r = 0.47, P = 0.0027 r = 0.41), respectively. After excluding group of patients with only one abnormal parameter as indeterminate group, pressure assessment guidelines correlations with the presence of LV pre-a and LVEDP waves were (P = 0.0009 OR = 31.76, p= 0.0170 OR = 36.00), respectively. Means difference of LV pre-a and LVEDP waves between pressure guidelines presence and absence two groups were (LV pre-a: 12.72, 7.52, P &lt; 0.0001and LVEDP: 21.03 10.36, P = 0.0043), respectively. All results are summarized in (Table:1 + 2+3 + 4+5).

Conclusion

ESC 2016 guidelines pressure assessment correlated strongly with both LV pre-a and LVEDP waves which means that the higher the number of abnormal echo parameters is resulted by echo guidelines, the higher the LV pre-a or LVEDP is presented invasively. Different approaches had different diagnostic accuracy, the best specific was cutoff≥ 2 abnormal echo parameters and the best sensitive and overall accuracy was still cutoff≥2 but after excluding only one abnormal echo parameter group as indeterminate group. The difference between means between echo guidelines pressure assessment was more significant statistically in LV pre-a wave than in LVEDP. Abstract Figure. Abstract Figure.

A comparison between left ventricular filling pressure two waves: end-diastolic and pre-a for the correlation with echocardiographic parameters

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center Damascus, Syrian Arab Republic.

Background

left ventricular (LV) filling pressure has an important prognostic and therapeutic role. Echocardiography plays an essential noninvasive role in its assessment and diagnosis. Checking of the correlation between echo parameters and different LV filling pressure wave invasively measure may add a step forward in its diagnosis, prognosis and treatment.

Purpose

this study invasively measures left end-diastolic pressure (LVEDP) and left ventricular pre-a wave (LV pre-a wave) and validates the correlation of each wave with echo parameters obtained immediately before angiography.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography just before catheterization. E/A, Av E/e", lateral and septal e", TR. LAVI, S/D, AR-A and other parameters were obtained to validate and compare the correlation with LVEDP and LV pre-a wave.

Results

  Correlation of different echo parameters with LVEDP and LV pre-a wave are summarized in table.

Conclusion

Among these echo parameters of this study, there was a significant correlation between LVEDP and E, E/A, TR, S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave had a significant correlation with LAVI, EF, FS, Av E/e", E velocity, A velocity, E/A, TR, S velocity, S/D, AR duration, AR-A duration, LVDd, RWT, LVDs and LVMI. LVEDP correlated more than LV pre-a wave with S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave correlated more than LVEDP with TR and E velocity. E/A was equally correlated with LVEDP and LV pre-a wave. Abstract Table of results 1  Abstract Table of results 2

An echocardiographic algorithm for predicting coronary artery disease: is it time to establish one?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) is a major clinical issue. CAD affects left ventricular systolic, diastolic function and LV filling pressure. Echocardiography has been known as the best noninvasive way for the assessment of systolic, diastolic function and LV filling pressure. Finding a correlation between CAD and echocardiographic parameters may help in the early assessment, prognosis and treatment of CAD.

Purpose

Finding a correlation between coronary artery disease and echocardiographic parameters with cutoffs to use in a diagnostic algorithm.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before their medically indicated left heart catheterization . An experienced echo cardiographer obtained mitral flow E velocity, A velocity, E/A, A duration, Av E/e", septal, lateral and mean e", pulmonary veins S velocity, D velocity, S/D, AR velocity, AR duration, AR-A duration, left atrial volume index (LAVI), tricuspid regurgitation (TR), inter ventricular septum (IVS), left inter ventricular diameter (LIVD), posterior wall diameter (PW) and some other echo parameters and assessed LV diastolic function and filling pressure according to EACVI/ASE 2016 guidelines. This study obtained angiography results and then analyzed and compared the results.

Results

Echo parameters that correlated with CAD were: EDT ≥ 160 (P = 0.0012 OR = 5.46), Av E/e" ≥ 7 (P = 0.0066 OR = 3.67), E ≥ 44 cm/s (P = 0.0026 OR = 10.00), A duration &gt; 140 (P = 0.0256 OR = 10.50), E/A ≥ 1 (P = 0.0036 OR = 4.17) and AR duration ≥ 210 (P = 0.0001 OR = 85.00). When Cutoffs ≥ 3 present, the correlation with CAD was (P= &lt; 0.0001 OR = 8.80) with diagnostic accuracy of (sensitivity = 0.76, specificity = 0.74, NPV = 0.68, PPV = 0.81). All the results are summarized in (Picture1:Tables 1 and 2).

Conclusion

Echo parameters (EDT, Av E/e", E velocity, A duration, E/A, AR duration) had strong correlations with the presence of coronary artery disease. The presence of three or more abnormal parameters had a significant diagnostic accuracy for CAD, and the more the abnormal parameters were positive, the higher the specificity and positive predictive value were for the diagnosis of CAD. The presence of only two abnormal parameters had a low specificity for CAD and the presence of 2016 EACVI/ASE diastolic dysfunction correlated with CAD with modest specificity which needs further assessment for the differential diagnosis. Furthermore, one or no abnormal parameters ruled out CAD with strong negative predictive value. Depending on the results of this study we kindly propose a resting echocardiographic algorithm for the diagnosis of CAD in (picture2: a proposed algorithm). Further studies should validate this algorithm and find other echo parameters especially strain echocardiography wether for resting or exercise algorithms. Abstract Tables of results  Abstract Figure. A proposed algorithm

SARS-CoV-2 Seroprevalence in Aden, Yemen: A population-based study

Background

In Yemen, initial surveillance of coronavirus disease 2019 (COVID-19) focused primarily on patients with symptoms or severe disease. The full spectrum of the disease remains unclear. To the best of the authors’ knowledge, this is the first seroprevalence study performed in Yemen.

Methods

This cross-sectional investigation included 2001 participants from all age groups from four districts in Aden, southern Yemen. A multi-stage sampling method was used. Data were collected using a well-structured questionnaire, and blood samples were taken. Healgen COVID-19 IgG/IgM Rapid Diagnostic Test (RDT) Cassettes were used in all participants. All positive RDTs and 14% of negative RDTs underwent enzyme-linked immunosorbent assay (ELISA) testing (WANTAI SARS-CoV-2 Ab ELISA Kit) for confirmation.

Results

In total, 549 of 2001 participants were RDT positive and confirmed by ELISA, giving a prevalence of COVID-19 of 27.4%. The prevalence of immunoglobulin G was 25%. The prevalence of asymptomatic COVID-19 in the entire study group was 7.9%. The highest prevalence was observed in Al-Mansurah district (33.4%). Regarding sociodemographic factors, the prevalence of COVID-19 was significantly higher among females, housewives and subjects with a history of contact with a COVID-19 patient: 32%, 31% and 39%, respectively.

Conclusion

This study found high prevalence of COVID-19 in the study population. Household transmission was common.

Comparison between the British and the American/European guidelines for the assessment of left ventricular diastolic function with invasive validation of left ventricular filling pressure

Background

Left ventricle diastolic function and filling pressures assessment is still a major challenge to echocardiographer. There are two echo guidelines regarding this issue: the British Society of Echocardiography (BSE 2013) and the American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI 2016). The 2016 guidelines, which is an expert consensus and simplified update of 2009 guidelines, needs an invasive validation according to its authors. Recent studies raised questions about the diagnostic accuracy as sensitivity results varied very widely (34% to 87%) and also that of 2009 (43% to 79%). This study validated the diastolic pressure invasively in the cath lab and compared the results with the echo guidline algorithms were done immediately before the catheterization. When possible, it included additional assessment of S/D and Ar-A duration.

Purpose

Validation of the diagnostic accuracy of the 2009, the updated 2016 ASE/EACVI and 2013 BSE echocardiographic LV filling pressure predicting algorithms, as well as pulmonary veins flow (S/D) and (Ar-A) durations with invasively measured LV-pre-A wave.

Methods

124 patients (58.06% males) underwent transthoracic echocardiography immediately before left heart catheterization. A trained echocardiographer obtained E/A mitral flow, E/e', left atrial volume index, TR, EDT, lateral and septal e' to estimate LV filling pressure as normal, elevated or indeterminate using the 2009, 2016

ASE/EACVI algorithms and 2013 BSE algorithm. He also obtained Secondary parameters as (S/D) and (Ar-A) duration. Invasive LV pre-A pressure was the reference of this study, with &gt;12 mm Hg defined as elevated.

Results

Invasive LV pre-A pressure was elevated in 60 (48.38%) patients. When they could determine LV filling pressure, 2016 sensitivity was 0.36 and specificity 0.94, 2009 had 0.56 sensitivity and 0.90 specificity and 2013 resulted in 0.63 sensitivity and 0.80 specificity. Results of diagnostic accuracy of each algorithm as well as (S/D) and (Ar-A) summarized in tables associated in (picture 1: Tables of results). EDT≥150 msec raised NPV in normal, grade one diastolic dysfunction and indeterminate pressure.

Conclusion

2016 was the most specific but the least sensitive with modest NPV and PPV between the 2013 and 2009. 2013 was the most sensitive with the highest indeterminate pressure rate to execlude. Adding S/D or Ar-A duration markedly improved the sensitivity and reduced class indeterminate among all algorithms with more benefit when both combined. EDT had a rule out role in normal, grade one diastolic dysfunction and indeterminate pressure patients. We kindly propose a modification of 2016 algorithm by adding S/D, Ar-A and EDT as optional parameters to increase sensitivity and reduce indeterminate class without affecting simplicity or specificity (picture 2: Proposed algorithms A+B). We recommend future studies to validate the diagnostic accuracy of the proposed algorithms.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Al mouwasat University Hospital and University Heart Surgery Center at Damascus, Syrian Arab Republic. Tables of resultsProposed Algorithms A+B

DSPECT-specific normal limits for LV measurements: a new approach to derivation

Funding Acknowledgements

Type of funding sources: None.

Background

Differences in spatial resolution and image filtering between the solid-state DSPECT and traditional Anger SPECT (A-SPECT) cameras are likely to result in differences in LV measurements. However, DSPECT- specific normal values have not been systematically derived. We used healthy organ-donor subjects from our high-volume solid organ transplant center for derivation of normal values.

Purpose

To report DSPECT-specific LV measurements normal limits derived from a unique cohort of donor subjects.

Methods

Subjects were 92 consecutive kidney or liver donors who underwent single day rest (5 mCi)- stress (15mCi) Tc-99m sestamibi gated SPECT myocardial perfusion imaging (MPI) on the DSPECT for pre-operative evaluation. Exclusion criteria included any cardiac disease or medications. LV measurements were made on the post-stress supine stress images using QGS®.

Results

Of 92 subjects (mean age 54.4 ± 15.0 and 39% men), mean EF for women and men were 77.2 ± 14.1% and 70.0 ± 14.7%, respectively. Mean end-diastolic volume for women and men were 67.0 ± 32.2 ml and 99.6 ± 51.6 ml (indexed 38.3 ± 17.2 ml/m2 and 48.1 ± 25.9 ml/m2), respectively. Mean LV wall volume for women and men were 95.9 ± 26.0 ml and 112.0 ± 48.8 ml (indexed 55.0 ± 13.8 ml/m2 and 54.1 ± 24.6 ml/m2), respectively.

Conclusion

We report DSPECT-specific LV measurements from normal subjects from which limits of normality can be derived for clinic use. Organ-donors who undergo pre-operative MPI are a suitable cohort for the derivation of normal values.

Thalamic versus midbrain tremor; two distinct types of Holmes' Tremor: a review of 17 cases

INTRODUCTION

Holmes Tremor (HT) is a unique and debilitating movement disorder. It usually results from lesions of the midbrain and its connection but can also result from posterior thalamic injury. Clinical examination can help lesion localization between these two areas. We studied the clinical features and their radiological correlations to distinguish midbrain HT (HT-m) from thalamic HT (HT-t).

METHODS

Retrospective review of 17 patients with a HT-type presentation was conducted. Tremor characteristics, associated clinical signs and radiological findings were studied.

RESULTS

Eleven patients had a myorythmic rest tremor, large amplitude proximal tremor with goal-directed worsening, with or without mild distal dystonic posturing, representing HT-m. Six patients had slow, large amplitude proximal tremors and distal choreathetoid movements, significant proximal/distal dystonic posturing, associated with proprioceptive sensory loss, representing HT-t. Haemorrhagic lesions were the predominant cause of HT-m; whereas, ischaemia was more commonly associated with HT-t.

CONCLUSION

When assessing patients with HT, attentiveness to the presence of associated signs in the affected limb, such as a proprioceptive sensory deficits and additional movement disorders, can aid lesion localisation, which can have implications for management.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background

There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.

Methods

Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.

Results

Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).

Conclusions

Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Intensive home treatment in comparison with care as usual: Cost-utility analysis from a pre-randomized controlled trial in the netherlands

Introduction

The implementation of Intensive Home Treatment (IHT) aims to decrease the pressure on acute inpatient services that could lead to prevent hospitalization and reduce the number of hospitalization days and, ultimately, reduce cost in the mental health services. Although there are studies assessing the effectiveness of IHT, there is a shortage of research studying the cost-effectiveness.

Objectives

The aim of this study is to present an cost-utility analysis of IHT compared to care as usual (CAU)

Methods

Patients between 18 and 65 years of age whose mental health professionals considered hospitalization were included. These patients were pre-randomized in either IHT or CAU and followed up for 12-months. For this study, the base case analysis was performed from the societal and healthcare perspective. For the cost-utility analyses the Euroqol 5D was used to calculate quality adjusted life years (QALYs) as a generic measure of health gains.

Results

Data of 198 patients were used. From a sociatal perspective, the cost-utility analysis resulted in an incremental cost-effectiveness ratios (ICERs) of €58 730, and a 37% likelihood that IHT leads to higher QALYs at lower costs. The probability of IHT being cost-effective was >50% if there was no willingness to pay more for extra QALY than in the current situation under CAU.

Conclusions

Professionals working in crisis care are able to offer IHT with the same effect as other crisis care interventions at lower costs. IHT seem to be cost-effective compared with CAU over 52 weeks follow-up for patients who experience psychiatric crises.

Disclosure

No significant relationships.

In vitro haemostatic efficacy of aqueous, methanol and ethanol plant extracts of three medicinal plant species in Palestine

Abstract The haemostatic efficacy of different extract types of Satureja thymbra L., Thymbra spicata L. (Lamiaceae) and Verbascum fruticulosum Post. (Scrophulariaceae) was evaluated in this study via the Prothrombin time (PT) and Activated partial thromboplastin time (aPTT) analysis. Aqueous, methanol and ethanol extracts of the examined plant species leaves were prepared to a final concentration 50 mg/mL. In vitro PT and aPTT assays were conducted on normal platelet poor plasma blood samples by a digital coagulation analyzer. The obtained results revealed anticoagulation activity of all investigated plant species with observed variations among them. The aqueous and ethanol extracts of T. spicata as well as the aqueous extract of S. thymbra prolonged PT values significantly (p < 0.05). While, all V. fruticulosum extract types have had no significant effect on the PT values. The recorded aPTT data showed that all aqueous extracts have had a significant effect on the blood haemostasis as they increased aPTT values in all plant species under study. Out of which, both the ethanol and methanol extracts of T. spicata and methanol extract of S. thymbra showed similar effect. Of great concern, it was clearly noticed that the aqueous and ethanol extract of T. spicata and the aqueous extract of S. thymbra possess the strongest anticoagulation effect as they increased both PT and aPTT values significantly relative to the control (p < 0.05). The variable anticoagulation bioactivity among the studied plant species could be referred to the various solvents degrees of solubility of different phyto-constituents. Thus, the efficacy of the plant species extracts evaluation as anticoagulants or coagulants were related to the plant species and to the solvent of extraction.

Are positive-pressure ventilation lobby rooms effective for protective and source isolation?

High-efficiency particulate air supplied to a positive-pressure ventilation lobby (PPVL) in isolation rooms offers the dual advantage of protective and source isolation. This study demonstrates the in-use validity of PPVL rooms for protective isolation of patients. Of the 48 PPVL air samples investigated, Aspergillus fumigatus was detected from only one (2%) sample. Local and remote monitoring of the PPVL rooms is essential for the safety of patients and healthcare workers. Remote and point-of-use engineering controls are essential for ongoing ventilation monitoring, but this should be complemented by visual inspection of the isolation suite. Periodic microbiological monitoring should also be considered with other control measures.

Epidemiology of severe cases of influenza and other acute respiratory infections in the Eastern Mediterranean Region, July 2016 to June 2018

BACKGROUND

Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018.

METHODS

Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons.

RESULTS

A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%).

CONCLUSION

Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic.

Hepatitis A Virus Genotype IB Outbreak among Internally Displaced Persons, Syria

In 2018, a hepatitis A virus outbreak was identified among internally displaced persons in Syria. Sequence analysis based on the viral protein 1/2A junction revealed that the causative virus belonged to genotype IB. A high displacement rate, deteriorated sanitary and health conditions, and poor water quality likely contributed to this outbreak.

The epidemiological signature of influenza B virus and its B/Victoria and B/Yamagata lineages in the 21st century

We describe the epidemiological characteristics, pattern of circulation, and geographical distribution of influenza B viruses and its lineages using data from the Global Influenza B Study. We included over 1.8 million influenza cases occurred in thirty-one countries during 2000–2018. We calculated the proportion of cases caused by influenza B and its lineages; determined the timing of influenza A and B epidemics; compared the age distribution of B/Victoria and B/Yamagata cases; and evaluated the frequency of lineage-level mismatch for the trivalent vaccine. The median proportion of influenza cases caused by influenza B virus was 23.4%, with a tendency (borderline statistical significance, p = 0.060) to be higher in tropical vs. temperate countries. Influenza B was the dominant virus type in about one every seven seasons. In temperate countries, influenza B epidemics occurred on average three weeks later than influenza A epidemics; no consistent pattern emerged in the tropics. The two B lineages caused a comparable proportion of influenza B cases globally, however the B/Yamagata was more frequent in temperate countries, and the B/Victoria in the tropics (p = 0.048). B/Yamagata patients were significantly older than B/Victoria patients in almost all countries. A lineage-level vaccine mismatch was observed in over 40% of seasons in temperate countries and in 30% of seasons in the tropics. The type B virus caused a substantial proportion of influenza infections globally in the 21^st century, and its two virus lineages differed in terms of age and geographical distribution of patients. These findings will help inform health policy decisions aiming to reduce disease burden associated with seasonal influenza.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014–2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

Computational studies of 2-(4-oxo-3-phenylthiazolidin-2-ylidene)malononitrile

The molecular structure of the 2-(4-oxo-3-phenylthiazolidin-2-ylidene) malononitrile (3) is calculated using DFT B3LYP/6-311G(d, p) method. The calculated geometric parameters are in good agreement with the experimental data. The NBO calculations were performed to predict the natural atomic charges at the different atomic sites and study the different intramolecular charge transfer (ICT) interactions occurring in the studied system. The BD(2)C17-C19 → BD*(2)C14-C15, LP(2)O2 → BD*(1)N5-C9 and LP(1)N5 → BD*(2)C10-C11 ICT interactions causing stabilization of the system by 23.30, 30.63 and 52.48 kcal/mol, respectively. The two intense electronic transition bands observed experimentally at 249 nm and 296 nm are predicted using the TD-DFT calculations at 237.9 nm (f = 0.1618) and 276.4 nm (f = 0.3408), respectively. These electronic transitions are due to H-3 → L (94%) and H → L (95%) excitations, respectively.