Medical and Health Sciences

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    PHENOTYPIC AND MOLECULAR CHARACTERIZATION OF MULTI-DRUG RESISTANT ENTEROBACTERALES ISOLATED FROM CLINICAL SAMPLES, PALESTINE.
    (An-Najah National University, 2024-11-11) Ibaideya, Mamoun
    Background: Infections resulting from multidrug-resistant Enterobacterales (MDRE) pose a growing global threat, presenting challenges in treatment and contributing significantly to morbidity and mortality rates. The main objective of this study was to characterize phenotypically and genetically MDRE isolated from clinical samples in the West Bank, Palestine. Methods: A cross-sectional study was conducted in October 2023 on clinical bacterial isolates collected from five governmental hospitals in the West Bank, Palestine. The isolates obtained from the microbiology laboratories of the participating hospitals, underwent identification and antibiotic susceptibility testing (AST) using the VITEK® 2 Compact system, and colistin tests. MDRE was determined by the Vitek2 Compact system. A modified carbapenem inactivation method (mCIM) was employed to identify carbapenemase-producing Enterobacterales (CPE). Resistance genes were detected by real-time PCR. Results: Out of the total 1380 collected isolates, we randomly selected 600 isolates for analysis. Our analysis indicated that 287 (47.83%) were extended-spectrum beta-lactamase producers (ESBLE), and 102 (17%) were carbapenem-resistant Enterobacterales (CRE) isolates. A total of 424 isolates (70.67%) were identified as multidrug-resistant Enterobacterales (MDRE). The most prevalent ESBL species were Klebsiella pneumoniae (n=124; 43.2%), Escherichia coli (n=119; 41.5%) and Enterobacter cloacae (n=31; 10.8%). Among the CRE isolates, 85 (83.33%) were CPE. The most frequent CRE species were K. pneumoniae (n=63; 61.7%), E. coli (n=25; 24.5%) and E. cloacae (n=13; 12.8%). Additionally, 47out of 600 (7.83%) isolates exhibited resistance to colistin, with 38 out of 101 (37.62%) being colistin-resistant CRE, and 9 out of 274 (3.3%) being colistin-resistant ESBLE. MDRE exhibited varied resistance patterns across different none ꞵ-lactam antibiotic classes. We noticed that 11 isolates (6 K. pneumoniae and 5 E. cloacae) demonstrated sensitivity to carbapenems by phenotype but carried silent CPE genes (1 blaOXA48, and 6 blaNDM, 4 blaOXA48, blaNDM). Conclusion: This study showed the high burden of the ESBLE and CRE among the samples collected from the participating hospitals. The most common species were K. pneumoniae and E. coli. There was a high prevalence of blaCTXm. Adopting both conventional and molecular techniques is essential for better surveillance of the emergence and spread of MDRE infections in Palestine.
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    THE IMPACT OF ABCDE BUNDLE IMPLEMENTATION ON MECHANICALLY VENTILATED PATIENTS OUTCOMES AT ICU IN HEBRON GOVERNMENTAL HOSPITAL
    (An-Najah National University, 2024-10-15) Sawsan, Al-Sarahinah
    Background: ABCDE bundle implementation is an evidence based and recommended practice to adequately manage mechanically ventilated patients, but application of this bundle in environment with shortage of resources and has no specific protocol to deal with mechanically ventilated patients is unknown Objective: to measure the impact of ABCDE bundle implementation on mechanically ventilated patients' outcomes: ICU length of stay, ventilator free days, delirium occurrence and duration, and early mobility at ICU in Hebron Governmental Hospital. Methods: a prospective-quasi experimental study was conducted between December-2022 to March-2024, in which 76 patients on mechanical ventilation were divided into two groups. In the pre ABCDE bundle (n=36), traditional approach to deal with mechanically ventilated patients was used. In the post ABCDE bundle group (n=40), ABCDE bundle was used. Those outcomes were compared between both groups: ICU LOS, VFDs, delirium occurrence and duration, and early mobility. Results: the results showed no statistically significant differences between two groups regarding ICU LOS, VFDs (P=0.88, P=0.9) respectively. The median duration of MV was less in the intervention group 3 days in comparison to 3.5 days in control group (P=0.378). The percentage of early mobility was higher in ABCDE group (P=0.242). ABCDE group was more lightly sedated than non-ABCDE group who was more deeply sedated. Delirium occurrence and duration were less in ABCDE group (P= 0.362, P=0.22) respectively. Restraints use was significantly decreased in group who adapted bundle (20.5% in intervention group versus 44.4% in control group) with P value=0.008. Conclusion: ABCDE bundle helped in making mechanically ventilated patients more awake and oriented to environment and decreased using of restrains among them. It also minimized the use of benzodiazepines to half. Other outcomes like ICU LOS, VFDs, delirium occurrence and duration, and early mobility needs more research with larger sample size and more effective adherence to bundle. This study gave background for the future research to implement this bundle in environment with shortage of resources. Keywords: ABCDE bundle, ICU LOS, mechanical ventilation, delirium, early mobility.
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    CONTINUOUS TRAUMATIC STRESS RESPONSE AND COPING STRATEGIES AMONG ADULTS EXPOSED TO POLITICAL VIOLENCE IN THE NORTH OF THE PALESTINIAN TERRITORIES: A MIXED METHOD STUDY
    (An-Najah National University, 2024-10-02) Ghannam, Maram
    Background: Prolonged exposure to political violence, such that which occurred during the Israeli-Palestinian occupation, has caused serious physical and mental distress for Palestinian civilians. It is crucial to examine that people experience anxiety, dread, and sense of perceived threat during continuous traumatic stress are directly affect coping strategies.  The aim of the study :  To assess the level of Continuous Traumatic Stress Response and coping strategies among Palestinian adults exposed to political violence. Method: A mixed method of quantitative and qualitative research study design was adopted in this study. A purposive sampling method of adults who are from Jenin and Nablus camps and Nablus Old City. Out of 407 participants were included in this study. The Politically Violent Events Scale, continues traumatic stress response scale and the Jalowiec Coping Scale were used.Ten participants were included in this study in qualitative study for in depth interviews. Results: The findings indicated that the participants' greatest exposure (76.7%) was to their home being searched by the military. In terms of the event's severe impact, curfews or being prohibited from leaving one's home or city was ranked as the most severe influences. Participants feels fear and helplessness (63.6%), followed by feeling of exhausted and detachment (62.61%), and finally feeling of rage and betrayed(59.35%). the focus on concentrating their efforts on doing something about the situation  was the highest among the approach coping method and their ‏trying to find comfort in religion was the highest among the avoidant coping method among the study participants. In the qualitative findings, Six themes were emerged: Military occupation as a source of danger,  terror, sabotage, deprivation of freedom and rights. a source of psychological and physical diseases, loss of loved ones. And the “Challenging the occupation as a source of hope” theme . Conclusion: Enhanced comprehension of the psychological ramifications of possibly traumatic incidents can eventually result in better CTSR prevention and treatment strategies. The promotion of mental health and well-being among people impacted by stress and trauma connected to conflict requires standardized instruments, family support, and cultural sensitivity.
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    QUINOLONE RESISTANCE AMONG ESCHERICHIA COLI AND KLEBSIELLA PNEUMONIAE BACTERIA ISOLATED AT RAFIDIA AND AN-NAJAH NATIONAL UNIVERSITY HOSPITALS IN NABLUS DISTRICT: PROSPECTIVE CROSS-SECTIONAL STUDY
    (An-Najah National University, 2024-10-24) Khatatbeh, Marah
    Background: Among several bacterial genera, quinolone resistance has become more prevalent in recent years. This was clear among common nosocomial pathogens such as Escherichia coli and Klebsiella pneumoniae. While quinolones are a valuable part of the current antimicrobial treatment options, growing quinolone resistance poses a threat to their continued efficacy. Objectives: First, this study aimed to determine the prevalence of resistance of E. coli and K. pneumoniae to quinolone antibiotics (ciprofloxacin and levofloxacin) at two major hospitals in Nablus District, Rafidia and An-Najah National University Hospital. Second, the association of resistance to these antibiotics with various demographic and clinical findings was examined. Third, mechanisms of quinolone resistance among E. coli and K. pneumoniae were determined through resistance gene detection by PCR. Methodology: A cross-sectional study design was selected. A total of 219 bacterial isolates (169 isolates of E. coli and 50 isolates of K. pneumoniae) were collected from the first of June 2023 to the last day of September 2023, from all patients infected with those bacterial species. The included bacteria in this study were isolated from patients admitted to the two mentioned Hospitals during the study period. Types of bacteria were already identified by the VITEK 2 system (BioMérieux) in the two mentioned hospitals. Resistance of the included bacteria to ciprofloxacin and levofloxacin was determined by the disk diffusion method. In addition, multiplex PCR was used for detection of resistant genes in order to determine quinolone resistance mechanisms among 118 resistant strains. The detected mechanisms and genes were target modification (qnrA, qnrB, and qnrS genes), enzymatic modification (aac(6’)-Ib-cr gene), and efflux pump mechanism (QepA, OqxA, and OqxB genes). Association of quinolone resistance with clinical symptoms, demographic information, and other risk factors were evaluated. Results: Relatively high frequencies of ciprofloxacin resistance (46.1%) and levofloxacin resistance (47.9%) were found among E. coli isolates. Higher resistance frequency of ciprofloxacin (70%) and levofloxacin (68%) among K. pneumoniae isolates were detected. Escherichia coli and K. pneumoniae ciprofloxacin resistant bacteria isolated at An-Najah National University Hospital (60% and 92.9%, respectively) were significantly higher (P= 0.000 and P= 0.001, respectively) than that of the isolates obtained from Rafidia Hospital (37.3% and 40.9%, respectively). Ciprofloxacin resistance among E. coli isolated from the general surgery unit was significantly higher than that of the emergency ward (54.5%; P=0.002) and the outpatients (36.9%; P= 0.016). However, E. coli levofloxacin resistance frequency in the intensive care unit was significantly higher than that of the outpatients (49.2%; P=0.018), emergency (45.5%; P=0.022), and general surgery (42.9%; P=0.037). Escherichia coli isolation rate from urine (80%) was significantly higher than that of wound swabs (76.3%; P=0.013). Furthermore, K. pneumoniae isolation rate from urine (20%) was significantly higher than that of wound swabs (23.7%; P=0.036). Escherichia coli ciprofloxacin resistance was significantly higher (P=0.008) in male isolates (53.6%) than in female isolates (36.3%). Escherichia coli isolated from patients over 65 years of age had the highest levofloxacin resistance frequency (62.5%), which was also significantly (P= 0.007) higher than that of the 40–65-year age group. Escherichia coli ciprofloxacin resistant bacterium isolated from patients with urinary catheters (91.7%) had a significantly higher frequency than that of hypertension patients (85.5%; P=0.013), diabetes mellitus patients (84.8%; P=0.017), cancer patients (81.9%; P=0.022), and hepatic cirrhosis patients (64.1%; P=0.028). However, K. pneumoniae ciprofloxacin resistant bacterium isolated from hepatic cirrhosis patients (77.8%) had a significantly higher frequency than that of hypertension patients (65.2%; P=0.003), cancer patients (61.9%; P=0.019), and diabetes mellitus patients (58.9%; P=0.032). Frequency of levofloxacin resistant E. coli isolated from diabetes mellitus patients (89.1%) was significantly higher than that of hypertension patients (76.3%; P=0.013), cancer patients (73.6%; P=0.016), patient with the urinary catheter (77.8%; P=0.021), and hepatic cirrhosis patients (51.3%; P=0.028). On the other hand, levofloxacin resistant K. pneumoniae isolated from diabetes mellitus patients (71.8%) had a significantly higher frequency than that of hypertension patients (56.5%; P=0.009), cancer patients (52.4%; P=0.016), hepatic cirrhosis patients (59.3%; P=0.023), and patient with the urinary catheter (48%; P=0.031). With respect to the quinolone resistance mechanisms, the efflux pump among E. coli isolates was the most predominant (43.3%) with OqxA (23.5%) being the most common gene, followed by enzymatic modification by Aac(6’)-Ib-cr enzyme (29.6%) and target modification mechanism (26%) in which the QnrS gene was the most common (13.6%). Similarly, the efflux pump mechanism of quinolones resistance among K. pneumoniae isolates was also the most common (37.8%) with the OqxA gene exhibiting the highest frequency (27%), followed by enzymatic modification by Aac(6’)-Ib-cr enzyme (32.4%) and target modification mechanism (29.7%) with QnrS and QnrB being the most commonly detected genes (10.8%). Conclusion: Our findings showed high rates of ciprofloxacin and levofloxacin resistance among E. coli and K. pneumoniae isolates, also a high percentage of the efflux pump mechanism with OqxA being the most common gene, followed by enzymatic modification by Aac(6’)-Ib-cr enzyme and target modification mechanism in which the QnrS gene was the most common. We emphasize that it is necessary to perform an antibiotic susceptibility test before choosing a prescription. Monitoring the rates of resistance in the nations clinical facilities should be a greater priority for the relevant government health departments.
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    THE EFFECTIVENESS OF A COGNITIVE BEHAVIORAL THERAPY PROGRAM IN REDUCING SYMPTOMS AND IMPROVING SOCIAL SKILLS IN PATIENTS WITH SCHIZOPHRENIA
    (An-Najah National University, 2024-09-02) Abu Snineh, Suhiab
    Background: According to the DSM-5, schizophrenia is a severe mental disorder marked by a disconnect between reality and mind, jumbled thoughts, perceptions, emotions, and behavior. It is a grave psychiatric ailment that hampers normal thinking and behavior, significantly affecting both the individual and those around them. Previous research has demonstrated that cognitive-behavioral treatment improves social skills and reduces both positive and negative symptoms in patients with schizophrenia. Therefore, this study attempted to explore the role of cognitive behavioral therapy in strengthening social skills and reducing symptoms in people with schizophrenia. Method: The study follows a quasi-experimental research approach. The study involved 16 individuals diagnosed with schizophrenia, all of whom are Palestinian Arabs residing in occupied Jerusalem and receiving care at the Nathan Center for Mental Health. The researcher utilized the Schizophrenia Social Skills Scale and the Positive and Negative Symptoms Scale to evaluate the enhancement of social skills and reduction of symptoms in these patients. Results: Among Palestinian patients in Jerusalem diagnosed with schizophrenia, at the Nathan Center for Mental Health, the study revealed a moderate level of schizophrenia symptoms alongside a moderate level of social skills. Despite undergoing Cognitive-Behavioral Therapy Program (CBTP) treatments, the experimental group did not experience significant improvements in social skills or reduction of schizophrenia symptoms. Notably, the CBTP did lead to improved emotional control among schizophrenic patients in the experimental group compared to the control group. Conclusion: The study investigates whether there is an effectiveness of cognitive behavioral treatment in reducing symptoms and enhancing social skills in patients with schizophrenia. Before starting its implementation, the study emphasizes the importance of educating therapists about treatment techniques and raising general awareness among patients targeted in the treatment program on the importance of psychotherapy in preventing and treating mental health issues.