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The role of the hospital in the changing landscape of UAE health care: a focus on Dubai
(2011) Sharif, Amer
Abstract: In the UAE, health services have developed greatly in the past 40 years and there have been enormous improvements in population health. The hospital sector is growing strongly with private sector investment. However the current and future health needs of the population are complex and may not be properly served by the continued expansion of hospital capacity. In this paper, using the Emirate of Dubai as a case study, we examine the changes that have taken place in health services and attempt to predict their optimum configuration and capacity in the future taking into account population structure and growth and levels of morbidity and service use.
The legal framework and initiatives for promoting safety in the United Arab Emirates
(2012) Sharif, Amer
Introduction: Injury is a leading cause of morbidity and mortality in the United Arab Emirates (UAE). The UAE is a rapidly developing country with fast economic growth, demographical and environmental changes that are associated with new hazards emerging at a similar pace. The UAE as a federal entity has federal and local systems responsible for safety policy, regulations and enforcement. To set priorities for safety promotion and injury prevention, it is necessary to have data on the most frequent external causes of injury and the main individual, equipment and environmental risk factors that contribute to injury. However good quality data for injury prevention are scarce. The aim of this paper is to describe the scale of injury as a public health problem in the UAE, and the development of safety policies, regulations and promotion efforts with special emphasis on traffic, occupational and child safety.
Population structure and the burden of disease in the United Arab Emirates
(2012) Amer, Sharif
Abstract: To carry out their duties more effectively, health care professionals in the UAE often ask about the population structure and the main causes of mortality and morbidity in the country. This paper summarizes what is known about these topics drawing on secondary data sources that are available in the public domain, including census data, population estimates, births and deaths, proportionate mortality, age-standardized mortality rates and disability adjusted life-years. There are inconsistencies and flaws in some of this data which this paper will highlight and attempt to explain. Since 2005, the UAE population has grown substantially owing to high natural growth and high net inward migration and is currently estimated to be about 8.2 million. In 2008, injuries, heart disease, neoplasms and cerebrovascular disease accounted for 57% of deaths, and this is well known. Less is reported about the risk of death, disease, injury and disability. The population of the UAE is diverse, and there are variations in mortality and morbidity risk by age-group, sex and nationality. The authors recommend improvements in the timeliness, completeness and consistency of data. They conclude that better data will encourage more analysis which will generate health intelligence leading to health improvement for the UAE population.
Teaching about health systems in the UAE
(2012) Sharif, Amer
Introduction: In many countries, health systems face challenges as they adapt to demographic change, new disease patterns and rising costs. The United Arab Emirates (UAE) is no exception. Its health system is facing the twin challenges of maintaining quality while avoiding escalating costs. As the future leaders of the health system in which they work, medical students will be in a strong position to bring about change and improvement. However their effectiveness will be restricted by gaps in their knowledge of what health systems are and how they function, topics that are rarely dealt with in medical school curricula (Patel et al. 2009). The undergraduate medical curriculum should prepare students not only for clinical excellence but also to take their place as leaders of complex health systems (Berwick & Finkelstein 2010).
Health and health systems performance in the United Arab Emirates
(2013) Sharif, Amer
Abstract: In the early 2000s, the United Arab Emirates (UAE) had good levels of health and its health system was ranked twenty-seventh in the world by the World Health Organization. Since that time, to further improve the situation and to address cost and quality challenges, the UAE has embarked on an ambitious programme of health system reform. These reforms have focused on the introduction of private health insurance and encouraging the growth of private health provision. In these areas there have been impressive achievements but while it is too early to say whether these reforms are succeeding some anxieties are emerging. These include the rising cost of services with no obvious improvement in outcomes, a growth in hospital provision that may not best meet the needs of the population, rising levels of chronic disease risk factors and an insufficient focus on public health services, public health leadership, health work-force planning and research.
An analysis of the health status of the United Arab Emirates: the ‘Big 4’ public health issues
(2013) Sharif, Amer
Background: The United Arab Emirates (UAE) is a rapidly developing country composed of a multinational population with varying educational backgrounds, religious beliefs, and cultural practices, which pose a challenge for population-based public health strategies. A number of public health issues significantly contribute to morbidity and mortality in the UAE. This article summarises the findings of a panel of medical and public health specialists from UAE University and various government health agencies commissioned to report on the health status of the UAE population. Methods: A systematic literature search was conducted to retrieve peer-reviewed articles on health in the UAE, and unpublished data were provided by government health authorities and local hospitals. Results: The panel reviewed and evaluated all available evidence to list and rank (1highest priority) the top four main public health issues: 1) Cardiovascular disease accounted for more than 25% of deaths in 2010; 2) Injury caused 17% of mortality for all age groups in 2010; 3) Cancer accounted for 10% of all deaths in 2010, and the incidence of all cancers is projected to double by 2020; and 4) Respiratory disorders were the second most common non-fatal condition in 2010. Conclusion: The major public health challenges posed by certain personal (e.g. ethnicity, family history), lifestyle, occupational, and environmental factors associated with the development of chronic disease are not isolated to the UAE; rather, they form part of a global health problem, which requires international collaboration and action. Future research should focus on population-based public health interventions that target the factors associated with the development of various chronic diseases.
The “Arab World” is not a useful concept when addressing challenges to public health, public health education, and research in the Middle East
(2014) Sharif, Amer
Introduction: Interest in public health in the “Arab World” has intensified following the political and social changes that have affected the Middle East since 2010. A new textbook has been published (1), an international meeting has been held (2), a network of experts has been formed, and a special edition of major medical journal has been published (3). But how useful is the “Arab World” as a way of defining a geographical region in order to focus attention on the health challenges that it faces and in particular the challenges relating to public health research and education. In this brief essay, the authors argue that its usefulness is limited because the countries of the Arab World, however defined, are too heterogeneous to allow meaningful communal debate of their problems and solutions. As an alternative it is recommended that countries in the region form smaller more homogenous issue-specific groupings to discuss common challenges and action.
Cross-Nation Comparison of Oral Cancer in the Eastern Mediterranean Region: an Ecological Overview
(2015) Chattopadhyay, Amit
Abstract: Eastern Mediterranean (EM) region countries include countries from the Mediterranean region and North Africa representing regions with wide variations in their politics, economy, peaceful status, and healthcare infrastructure. Commonly known lip and oral cancer risk factors such as consumption of tobacco and alcohol are widely prevalent in the region. Globocan data suggests that age-standardized incidence rates and age-adjusted mortality rates are higher in the region compared to world averages whereas 1-, 2-, and 3-year prevalence proportions are lower. These statistical profiles are generally similar for men and women. Within the region, in general, incidence, mortality, and prevalence is greater in men than women. However, there are important differences in overall incidence, prevalence, and mortality; differences between genders in these statistics which vary between countries. This manuscript describes and compares oral cancer statistics of the countries in the EM region.
Oral cavity and oropharyngeal cancer incidence trends and disparities in the United States: 2000–2010
(2015-05-11) Chattopadhyay, Amit
Background: Changes in the incidence of oral cancer based on anatomic location and demographic factors over time have been reported in the United States. The purpose of this study was to use recent data to examine oral cancer incidence trends and disparities by demographic factors and anatomic location. Methods: Surveillance, Epidemiology, and End Results (SEER) incidence data from 2000 to 2010 were used to characterize and analyze oral cancer incidence trends by anatomic region and subsite, age at diagnosis, gender, race/ethnicity, and stage at diagnosis. Poisson regression was used to compare incidence risk by select demographic factors. Results: About 75,468 incident oral cancer cases were diagnosed from 2000 to 2010. The tonsil was the most frequently diagnosed anatomic subsite (23.1%) and the subsite with the greatest contribution to the overall, age-standardized cumulative incidence rate of 8.4 cases per 100,000 (95% confidence interval (CI): 8.3, 8.4). An increasing incidence trend was observed for cancers in the oropharyngeal region, in contrast to a decreasing trend seen in the oral cavity region. In the Poisson regression model, all race/ ethnicity groups showed a lower incidence risk relative to whites for oral cavity and oropharyngeal cancer, and white males displayed the highest incidence rate of all race/ethnicity-gender groups during the study period (14.1 per 100,000; 95% CI: 14.0, 14.2). Conclusions: This study’s epidemiological findings are especially important for oral health care providers, patient education, and the identification of risk profiles associated with oral cancer. The distinct epidemiological trends of oral cavity and oropharyngeal cancers dictate that oral cancer can no longer be viewed as a discrete entity. Oral health providers should have a strong understanding of the different risk factors associated with oral cavity and oropharyngeal cancers and educate their patients accordingly.
Validation of the Canada Acute Coronary Syndrome Risk Score for Hospital Mortality in the Gulf Registry of Acute Coronary Events-2
(2015-07-24) Alsheikh-Ali, Alawi
Background: Several risk scores have been developed for acute coronary syndrome (ACS) patients, but their use is limited by their complexity. The new Canada Acute Coronary Syndrome (C-ACS) risk score is a simple risk-assessment tool for ACS patients. This study assessed the performance of the C-ACS risk score in predicting hospital mortality in a contemporary Middle Eastern ACS cohort. Hypothesis: The C-ACS score accurately predicts hospital mortality in ACS patients. Methods: The baseline risk of 7929 patients from 6 Arab countries who were enrolled in the Gulf RACE-2 registry was assessed using the C-ACS risk score. The score ranged from 0 to 4, with 1 point assigned for the presence of each of the following variables: age ≥75 years, Killip class >1, systolic blood pressure <100mm Hg, and heart rate >100 bpm. The discriminative ability and calibration of the score were assessed using C statistics and goodness-of-fit tests, respectively. Results: The C-ACS score demonstrated good predictive values for hospital mortality in all ACS patients with a C statistic of 0.77 (95% confidence interval [CI]: 0.74-0.80) and in ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome patients (C statistic: 0.76, 95% CI: 0.73-0.79; and C statistic: 0.80, 95%CI: 0.75-0.84, respectively). The discriminative ability of the score was moderate regardless of age category, nationality, and diabetic status. Overall, calibration was optimal in all subgroups. Conclusions: The new C-ACS score performed well in predicting hospital mortality in a contemporary ACS population outside North America.
Between-ward disparities in colorectal cancer incidence and screening in Washington DC
(2015-09-04) Chattopadhyay, Amit
Abstract This study aims to investigate the incidence and determinants of colorectal cancer (CRC) and its screening in District of Columbia (DC), and identify modifiable risk factors. Data (2000–2009) from the DC Cancer Registry, Behavioral Risk Factor Surveillance System (BRFSS-DC) and Surveillance Epidemiology and End Results (SEER) were used to estimate CRC incidence in eight DC Wards. Risk factors and CRC screening were analyzed using uni-, bi-, and multivariable statistical methods with survey procedures in SAS (version 9.2) including binary, unconditional multivariable logistic regression analysis. Factors measured included stage of diagnosis, age, gender, race/ethnicity, smoking, alcohol, exercise, body weight, health insurance, education, employment, and income. Over the study time, CRC screening increased from 48.4% to 68.6%. Mean age at diagnosis was 67 years. CRC incidence is high in DC. Furthermore, CRC incidence rates in DC below 50 years age were higher than the SEER18 average. Disparities exist between CRC incidence and screening among DC Wards. Identified risk factors for CRC are smoking, obesity, and low physical activity; screening was less prevalent among the uninsured and low socio-economic group. Local variations in CRC occurrence exist and may vary from average national experiences. Identification of local regions which vary from national trends in disease occurrence is important for comprehensive understanding of the disease in the community.
The Gulf Implantable Cardioverter-defibrillator Registry: Rationale, Methodology, and Implementation
(2015-12) Alsheikh-Ali, Alawi
Background: The implantable cardioverter-defibrillator (ICD) is effective in the prevention of sudden cardiac death in high-risk patients. Little is known about ICD use in the Arabian Gulf. We designed a study to describe the characteristics and outcomes of patients receiving ICDs in the Arab Gulf region. Methods: Gulf ICD is a prospective, multi-center, multinational, and observational study. All adult patients 18 years or older, receiving a de novo ICD implant and willing to sign a consent form will be eligible. Data on baseline characteristics, ICD indication, procedure and programing, in-hospital, and 1-year outcomes will be collected. Target enrollment is 1500 patients, which will provide adequate precision across a wide range of expected event rates. Results: Fifteen centers in six countries are enrolling patients (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Bahrain, and Qatar). Two-thirds of the centers have dedicated electrophysiology laboratories, and in almost all centers ICDs are implanted exclusively by electrophysiologists. Nearly three-quarters of the centers reported annual ICD implant volumes of ≤150 devices, and pulse generator replacements constitute <30% of implants in the majority of centers. Enrollment started in December 2013, and accrual rate increased as more centers entered the study reaching an average of 98 patients per month. Conclusions: Gulf ICD is the first prospective, observational, multi-center, and multinational study of the characteristics and, the outcomes of patients receiving ICDs in the Arab Gulf region. The study will provide valuable insights into the utilization of and outcomes related to ICD therapy in the Gulf region.
Rapid detection of European orthobunyaviruses by reverse transcription loop-mediated isothermal amplification assays
(2016) Nowotny, Nobert
Abstract: The development of reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assays are described herein for the detection of two orthobunyaviruses (Bunyaviridae), which represent the two main serogroups found in mosquitoes in Central Europe. The RT-LAMP assays were optimized for the detection ofˇTahyˇna virus (a California encephalitis group virus found in Aedes sp or Ochlerotatus spmosquitoes) and Batai virus (also called ˇCalovo virus, a Bunyamwera group virus found in Anopheles maculipennis s.l. mosquitoes) nucleic acid using endemic European virus isolates. The sensitivity of the RT-LAMP assays was determined to be comparable to that of conventional tests, with a limit of detection < 0.1pfu per reaction. The assays can be performed in 60 min under isothermal conditions using very simple equipment. Furthermore, it was possible to proceed with the assays without nucleic acid extraction, albeit at a 100-fold loss of sensitivity. The RT-LAMP assays are a sensitive, cost-efficient method for both arbovirus surveillance as well as diagnostic laboratories to detect the presence of these endemic orthobunyaviruses.
What Do We Need to Protect, at All Costs, During the 21st Century? Reflections From a Curated, Interactive Co-Created Intellectual Jazz Performance
(2016) Davis, David A
Abstract: The question that forms the title of this article, “What do we need to protect, at all costs, during the 21st century?,” speaks to the sizable changes in health care systems and settings that surround the continuing professional development (CPD) provider, and the need to establish a core set of principles and practices as the field moves forward from both theoretical and practical aspects. It also provided the focus for one of the five keynote lectures presented during the 2016 World Congress on Continuing Professional Development. As the planners of this keynote session, we sought to evoke answers to the question, not from the speaker, but from the audience itself, a process enabled by a highly engaging presentation style and powered by interactive digital technologies. Further, we believed that the session would not directly lead to suggestions to improve the theory and practice of CPD, but rather to create the biopsychosocial context—a sort of platform—on which such discussions can occur.
Impact of Digoxin on Mortality in Patients With Atrial Fibrillation Stratified by Heart Failure: Findings From Gulf Survey of Atrial Fibrillation Events in the Middle East
(2016) Alsheikh-Ali, Alawi
Objective: The use of digoxin in patients having atrial fibrillation (AF) with or without heart failure (HF) is not without controversy. The aim of this study was to examine the impact of digoxin therapy on mortality stratified by HF. Methods: Gulf Survey of Atrial Fibrillation Events was a prospective, multinational, observational registry of consecutive patients with AF recruited from the emergency department of 23 hospitals in 6 countries in the Middle East. Patients were recruited between October 2009 and June 2010 and followed up for 1 year after enrollment. Analyses were performed using univariate and multivariate statistical techniques. Results: The study included a total of 1962 patients with AF, with an overall mean age of 56+16 years, and 52% (n ¼ 1026) were males. At hospital discharge, digoxin was prescribed in 36% (n ¼ 709) of the patients, whereas HF was present in 27% (n ¼ 528) of the cohort. A total of 225 (12.1%) patients died during the 12-month follow-up period after discharge (5.3% [n ¼ 104] were lost to follow-up). Patients with HF were consistently associated with higher mortality at 1 month (5.1% vs 2.1%; P < .001), 6 months (17.2% vs 5.0%; P < 0.001), and 12 months (24.3% vs 7.6%; P < .001) when compared to those without HF. When stratified by HF, digoxin therapy was associated with significantly higher mortality in those without HF at 6 months (8.7% vs 3.7%; adjusted odds ratio (aOR), 5.07; P < .001) and 12 months (12.3% vs 6.0%; aOR, 4.22; P < .001) but not in those with HF (6 months: 18.6% vs 14.7%; aOR, 1.62; P ¼ .177 and 12 months: 25.4% vs 22.4%; aOR, 1.37; P ¼ .317). Conclusions: In patients with AF and HF, digoxin did not offer any survival advantages. However, in those without HF, digoxin therapy was, in fact, associated with significantly higher long-term mortality.
Coronary artery disease prevalence and outcome in patients hospitalized with acute heart failure: an observational report from seven Middle Eastern countries
(2016) Alsheikh-Ali, Alawi
Objectives: The purpose of this study was to report prevalence, clinical characteristics, precipitating factors, management and outcome of patients with coronary artery disease (CAD) among patients hospitalized with heart failure (HF) in seven Middle Eastern countries and compare them to non-CAD patients. Methods: Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute HF during February-November 2012 in 7 Middle Eastern countries. Results: The prevalence of CAD among Acute Heart Failure (AHF) patients was 60.2% and varied significantly among the 7 countries (Qatar 65.7%, UAE 66.6%, Kuwait 68.0%, Oman 65.9%, Saudi Arabia 62.5%, Bahrain 52.7% and Yemen 49.1%) with lower values in the lower income countries. CAD patients were older and more likely to have diabetes, hypertension, dyslipidemia and chronic kidney disease. Moreover, CAD patients were more likely to have history of cerebrovascular and peripheral vascular disease when compared to non-CAD patients. In-hospital mortality rates were comparable although CAD patients had more frequent rehospitalization and worse long-term outcome. However, CAD was not an independent predictor of poor outcome. Conclusion: The prevalence of CAD amongst patients with HF in the Middle East is variable and may be related to healthcare sources. Regional and national studies are needed for assessing further the impact of various etiologies of HF and for developing appropriate strategies to combat this global concern.
Specialty Preferences and Motivating Factors: A National Survey on Medical Students from Five UAE Medical Schools
(2016) AlShaer, Laila
Background: Workforce planning is critical for being able to deliver appropriate health service and thus is relevant to medical education. It is, therefore, important to understand medical students’ future specialty choices and the factors that influence them. This study was conducted to identify, explore, and analyze the factors influencing specialty preferences among medical students of the United Arab Emirates (UAE). Methods: A multiyear, multicenter survey of medical student career choice was conducted with all five UAE medical schools. The questionnaire consisted of five sections. Chi‑squared tests, regression analysis, and stepwise logistic regression were performed. Results: The overall response rate was 46% (956/2079). Factors that students reported to be extremely important when considering their future career preferences were intellectual satisfaction (87%), work–life balance (71%), having the required talent (70%), and having a stable and secure future (69%). The majority of students (60%) preferred internal medicine, surgery, emergency medicine, or family Medicine. The most common reason given for choosing a particular specialty was personal interest (21%), followed by flexibility of working hours (17%). Discussion: The data show that a variety of factors inspires medical students in the UAE in their choice of a future medical specialty. These factors can be used by health policymakers, university mentors, and directors of residency training programs to motivate students to choose specialties that are scarce in the UAE and therefore better serve the health‑care system and the national community.
Patient and System-Related Delays of Emergency Medical Services Use in Acute STElevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps)
(2016-01-25) Alsheikh-Ali, Alawi
Background Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries. Methods Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015. Results We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter- Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-toballoon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes. Conclusion Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.
Serogenotyping and emergence of extended-spectrum blactamase genes in non-typhoidal Salmonella: first report from Saudi Arabia
(2016-04-12) Senok, Abiola
Salmonella are Gram-negative bacteria with >50 serogroups and >2500 serotypes. Ubiquitous non-typhoidal Salmonella (NTS) serotypes are associated with high morbidity and mortality. The classical approach for Salmonella classification into O-groups based on the O-antigen has been replaced by the Kauffmann–White–Le Minor scheme in which antigenic formulae of the serovars based on the Oantigen, H1-antigen and H2-antigen are denoted (Grimont & Weill, 2007; Guibourdenche et al., 2010). The Kauffmann–White–Le Minor scheme is now the internationally accepted gold standard for Salmonella nomenclature to facilitate international comparability of Salmonella surveillance data and for outbreak investigations (Tindall et al., 2005; Guibourdenche et al., 2010). Available data on the distribution of Salmonella serotypes in Saudi Arabia have been based on classical O-antigen detection method (Kambal, 1996; Somily et al., 2012; Elhadi et al., 2013). In recent years, resistant NTS including those harbouring extended-spectrum blactamase (ESBL) and carbapenemase genes have emerged (S aanchez-Vargas et al., 2011; Somily et al., 2012; Huang et al., 2013). This study was carried out to characterize NTS isolates from Saudi Arabia using serogenotyping and to determine carriage of ESBL and carbapenemase genes.
First record of the Asian bush mosquito, Aedes japonicus japonicus, in Italy: invasion from an established Austrian population
(2016-05-16) Nowotny, Norbert
Background: In 2011 we identified the Asian bush mosquito, Aedes japonicus japonicus (Theobald, 1901) (Diptera: Culicidae) for the first time in northern Slovenia and in the bordering Austrian federal state of Styria. Between May and July 2012 the distribution area of Ae. j. japonicus was already found to be extended westwards into Carinthia and eastwards towards Burgenland and bordering Hungary. In August 2012 the species was first detected in a western province of Hungary. In subsequent years, follow-up field studies demonstrated an active spread westwards throughout Carinthia, reaching the border to northern Italy. Findings: In July 2015 several aquatic-stage specimens of the species were discovered at three different sites in the Friuli Venezia Giulia region, north-eastern Italy. In September 2015, co-occurrence of Ae. j. japonicus and Aedes albopictus (Skuse, 1895) was observed in the same sample in that region. Conclusions: Ae. j. japonicus actively extended its geographic range from an established population in Carinthia (Austria) southwards to northern Italy by crossing Alpine ranges. Since Ae. albopictus and Aedes koreicus (Edwards, 1917) are already well established in northern Italy, it will be pivotal to monitor the consequences of a third invasive mosquito species trying to populate the same geographic region.

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