Middle East and North Africa consensus on osteoporosis

With the increasing life expectancy, osteoporosis is becoming a major worldwide health problem. The magnitude of the disease may become larger in developing countries, more particularly in the Middle East region where the prevalence of low bone mass is higher than in western countries. Although several local organizations and countries have developed guidelines for osteoporosis, no previous regional guidelines have been developed encompassing all Middle-Eastern and North African countries. The present document reviews all the regional published data on bone mineral density, risk factors, fracture prevalence and vitamin D status. It also gives simple recommendations applicable to all these countries. This document was endorsed by leading members of all the different regional countries including, Iran, Egypt, Tunisia, Jordan, Palestine, Syria, Iraq, Libya, Oman, Kuwait, Saudi Arabia and Bahrain.     

Minority politics in the Middle East and North Africa: the prospects for transformative change

This special issue explores the prospects for what Jacob Mundy calls ‘transformative minority politics’ in the Middle East and North Africa (MENA) region – that is, a form of minority politics that strengthens democratic reform in the region, and that helps deepen a culture of human rights and democratic citizenship. The cases examined in the special issue include the Amazigh in North Africa, the Copts in Egypt, the Kurds in Iraq, the Palestinians in Israel, the ‘minoritarian’ regimes in Syria and Bahrain, and the various ethnic minorities in Iran. In this introduction, we try to situate this debate in a larger historical and international context, identifying some of the factors that might help support a new transformative minority politics in the region, while also emphasizing the factors that have inhibited it in the past, and why they remain powerful.     

Founder mutations in Tunisia: implications for diagnosis in North Africa and Middle East

ABSTRACT: Background Tunisia is a North African country of 10 million inhabitants. The native background population is Berber. However, throughout its history, Tunisia has been the site of invasions and migratory waves of allogenic populations and ethnic groups such as Phoenicians, Romans, Vandals, Arabs, Ottomans and French. Like neighbouring and Middle Eastern countries, the Tunisian population shows a relatively high rate of consanguinity and endogamy that favor expression of recessive genetic disorders at relatively high rates. Many factors could contribute to the recurrence of monogenic morbid trait expression. Among them, founder mutations that arise in one ancestral individual and diffuse through generations in isolated communities. Method We report here on founder mutations in the Tunisian population by a systematic review of all available data from PubMed, other sources of the scientific literature as well as unpublished data from our research laboratory. Results We identified two different classes of founder mutations. The first includes founder mutations so far reported only among Tunisians that are responsible for 30 genetic diseases. The second group represents founder haplotypes described in 51 inherited conditions that occur among Tunisians and are also shared with other North African and Middle Eastern countries. Several heavily disabilitating diseases are caused by recessive founder mutations. They include, among others, neuromuscular diseases such as congenital muscular dystrophy and spastic paraglegia and also severe genodermatoses such as dystrophic epidermolysis bullosa and xeroderma pigmentosa. Conclusion This report provides informations on founder mutations for 73 genetic diseases either specific to Tunisians or shared by other populations. Taking into account the relatively high number and frequency of genetic diseases in the region and the limited resources, screening for these founder mutations should provide a rapid and cost effective tool for molecular diagnosis. Indeed, our report should help designing appropriate measures for carrier screening, better evaluation of diseases burden and setting up of preventive measures at the regional level.     

Founder mutations in Tunisia: implications for diagnosis in North Africa and Middle East

Cystinuria (OMIM 220100) is an inborn congenital disorder characterised by a defective cystine metabolism resulting in the formation of cystine stones. Among the heterogeneous group of kidney stone diseases, cystinuria is the only disorder which is exclusively caused by gene mutations. So far, two genes responsible for cystinuria have been identified: SLC3A1 (chromosome 2p21) encodes the heavy subunit rBAT of a renal b^0,+ transporter while SLC7A9 (chromosome 19q12) encodes its interacting light subunit b^0,+AT. Mutations in SLC3A1 are generally associated with an autosomal-recessive mode of inheritance whereas SLC7A9 variants result in a broad clinical variability even within the same family. The detection rate for mutations in these genes is larger than 85%, but it is influenced by the ethnic origin of a patient and the pathophysiological significance of the mutations. In addition to isolated cystinuria, patients suffering from the hypotonia-cystinuria syndrome have been reported carrying deletions including at least the SLC3A1 and the PREPL genes in 2p21. By extensive molecular screening studies in large cohort of patients a broad spectrum of mutations could be identified, several of these variants were functionally analysed and thereby allowed insights in the pathology of the disease as well as in the renal trafficking of cystine and the dibasic amino acids. In our review we will summarize the current knowledge on the physiological and the genetic basis of cystinuria as an inborn cause of kidney stones, and the application of this knowledge in genetic testing strategies.     

Cardiovascular Risk Factor Burden in Africa and the Middle East: The Africa Middle East Cardiovascular Epidemiological (ACE) Study

Background

Increased urbanization in the developing world parallels a rising burden of chronic diseases. Developing countries account for ∼80% of global cardiovascular (CV) deaths, but contribute a paucity of systematic epidemiological data on CV risk factors.

Objective

To estimate the prevalence of CV risk factors in rural and urban cohorts attending general practice clinics in the Africa and Middle East (AfME) region.

Methods

In a cross-sectional epidemiological study, the presence of CV risk factors (hypertension, diabetes mellitus (diabetes), dyslipidemia, obesity, smoking and abdominal obesity) were evaluated in stable adult outpatients attending general practice primary care clinics. A rural population was defined as isolated (>50 km or lack of easy access to commuter transportation) from urban centers.

Results

4,378 outpatients were systematically recruited from 94 clinics across 14 AfME countries. Mean age was 46±14 years and 52% of outpatients were female. A high prevalence of dyslipidemia (70%) and abdominal obesity (68%) were observed, followed by hypertension (43%) and diabetes (25%). The vast majority of outpatients (92%) had at least one modifiable CV risk factor, many (74%) had more than one, and half (53%) had 3 or more. These findings were observed in both genders and across urban and rural centers. Among outpatients with pre-existing hypertension or dyslipidemia, many were not at their target blood pressure or LDL-cholesterol goals.

Conclusion

Cardiovascular risk factors are highly prevalent among relatively young, stable outpatients attending general practice clinics across AfME. The findings support opportunistic screening for CV risk factors whenever outpatients visit a general practitioner and provide an opportunity for early identification and management of CV risk factors, including lifestyle interventions.     

Terrestrial venomous animals,the envenomings they cause,and treatment perspectives in the Middle East and North Africa

The Middle East and Northern Africa, collectively known as the MENA region, are inhabited by a plethora of venomous animals that cause up to 420,000 bites and stings each year. To understand the resultant health burden and the key variables affecting it, this review describes the epidemiology of snake, scorpion, and spider envenomings primarily based on heterogenous hospital data in the MENA region and the pathologies associated with their venoms. In addition, we discuss the venom composition and the key medically relevant toxins of these venomous animals, and, finally, the antivenoms that are currently in use to counteract them. Unlike Asia and sub-Saharan Africa, scorpion stings are significantly more common (approximately 350,000 cases/year) than snakebites (approximately 70,000 cases/year) and present the most significant contributor to the overall health burden of envenomings, with spider bites being negligible. However, this review also indicates that there is a substantial lack of high-quality envenoming data available for the MENA region, rendering many of these estimates speculative. Our understanding of the venoms and the toxins they contain is also incomplete, but already presents clear trends. For instance, the majority of snake venoms contain snake venom metalloproteinases, while sodium channel–binding toxins and potassium channel–binding toxins are the scorpion toxins that cause most health-related challenges. There also currently exist a plethora of antivenoms, yet only few are clinically validated, and their high cost and limited availability present a substantial health challenge. Yet, some of the insights presented in this review might help direct future research and policy efforts toward the appropriate prioritization of efforts and aid the development of future therapeutic solutions, such as next-generation antivenoms.     

HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis

Background

It is perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA.

Methods and Findings

This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting (1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or (2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or (3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases.We estimated that there are 626,000 PWID in MENA (range: 335,000–1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%–15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%–28% in the last injection), the low levels of condom use (20%–54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%–30% and 2%–10% in the last year, respectively), and of selling sex (5%–29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%–64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics.

Conclusions

Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems. Please see later in the article for the Editors'' Summary     

Distribution and variability of deformed wing virus of honeybees (Apis mellifera) in the Middle East and North Africa

Three hundred and eleven honeybee samples from 12 countries in the Middle East and North Africa (MENA) (Jordan, Lebanon, Syria, Iraq, Egypt, Libya, Tunisia, Algeria, Morocco, Yemen, Palestine, and Sudan) were analyzed for the presence of deformed wing virus (DWV). The prevalence of DWV throughout the MENA region was pervasive, but variable. The highest prevalence was found in Lebanon and Syria, with prevalence dropping in Palestine, Jordan, and Egypt before increasing slightly moving westwards to Algeria and Morocco Phylogenetic analysis of a 194 nucleotide section of the DWV Lp gene did not identify any significant phylogenetic resolution among the samples, although the sequences did show consistent regional clustering, including an interesting geographic gradient from Morocco through North Africa to Jordan and Syria. The sequences revealed several clear variability hotspots in the deduced amino acid sequence, which furthermore showed some patterns of regional identity. Furthermore, the sequence variants from the Middle East and North Africa appear more numerous and diverse than those from Europe.     

Memory and Violence

Perilous Memories: The Asia-Pacific War(s). T. Fujitani. Geoffrey M. White. and Lisa Yoneyama. eds. Durham, NC: Duke University Press, 2002. 472 pp.
Disturbing Remains: Memory, History and Crisis in the Twentieth Century. Michael S. Roth and Charles G. Salas. eds. Los Angeles: Getty Trust Publications, 2001. 300 pp.     

Impact of twenty-first century climate change on diadromous fish spread over Europe, North Africa and the Middle East

Climate change is expected to drive species ranges towards the poles and to have a strong influence on species distributions. In this study, we focused on diadromous species that are of economical and ecological importance in the whole of Europe. We investigated the potential distribution of all diadromous fish regularly encountered in Europe, North Africa and the Middle East (28 species) under conditions predicted for twenty‐first century climate change. To do so, we investigated the 1900 distribution of each species in 196 basins spread across all of Europe, North Africa and the Middle East. Four levels were used to semiquantitatively describe the abundance of species, that is missing, rare, common and abundant. We then selected five variables describing the prevailing climate in the basins, the physical nature of the basins and reflecting historical events known to have affected freshwater fish distribution. Logistic regressions with a four‐level ordinal response variable were used to develop species‐specific models. These predictive models related the observed distribution of these species in 1900 to the most explanatory combination of variables. Finally, we selected the A2 SRES scenario and the HadCM3 (Hadley Centre Coupled Model version 3) global climate model (GCM) to obtain climate variables (temperature and precipitation) at the end of this century. We used these 2100 variables in our models and obtained maps of climatically suitable and unsuitable basins, percentages of contraction or expansion for each species. Twenty‐two models were successfully built, that is there were five species for which no model could be established because their distribution range was too narrow and the Acipenser sturio model failed during calibration. All the models selected temperature or/and precipitation as explanatory variables. Responses to climate change were species‐specific but could be classified into three categories: little or no change in the distribution (five species), expansion of the distribution range (three species gaining suitable basins mainly northward) and contraction of the distribution (14 species losing suitable basins). Shifting ranges were in accordance with those found in other studies and underlined the high sensitivity of diadromous fish to modifications in their environment.     

Neglected tropical diseases of the Middle East and North Africa: review of their prevalence, distribution, and opportunities for control

The neglected tropical diseases (NTDs) are highly endemic but patchily distributed among the 20 countries and almost 400 million people of the Middle East and North Africa (MENA) region, and disproportionately affect an estimated 65 million people living on less than US$2 per day. Egypt has the largest number of people living in poverty of any MENA nation, while Yemen has the highest prevalence of people living in poverty. These two nations stand out for having suffered the highest rates of many NTDs, including the soil-transmitted nematode infections, filarial infections, schistosomiasis, fascioliasis, leprosy, and trachoma, although they should be recognized for recent measures aimed at NTD control. Leishmaniasis, especially cutaneous leishmaniasis, is endemic in Syria, Iran, Iraq, Libya, Morocco, and elsewhere in the region. Both zoonotic (Leishmania major) and anthroponotic (Leishmania tropica) forms are endemic in MENA in rural arid regions and urban regions, respectively. Other endemic zoonotic NTDs include cystic echinococcosis, fascioliasis, and brucellosis. Dengue is endemic in Saudi Arabia, where Rift Valley fever and Alkhurma hemorrhagic fever have also emerged. Great strides have been made towards elimination of several endemic NTDs, including lymphatic filariasis in Egypt and Yemen; schistosomiasis in Iran, Morocco, and Oman; and trachoma in Morocco, Algeria, Iran, Libya, Oman, Saudi Arabia, Tunisia, and the United Arab Emirates. A particularly noteworthy achievement is the long battle waged against schistosomiasis in Egypt, where prevalence has been brought down by regular praziquantel treatment. Conflict and human and animal migrations are key social determinants in preventing the control or elimination of NTDs in the MENA, while local political will, strengthened international and intersectoral cooperative efforts for surveillance, mass drug administration, and vaccination are essential for elimination.     

Satellite tracking a wide-ranging endangered vulture species to target conservation actions in the Middle East and East Africa

Vultures comprise the most endangered avian foraging guild (obligate scavengers) and their loss from ecosystems can trigger trophic cascades, mesopredator release, and human rabies epidemics, indicating their keystone species status. Vultures’ extremely large home ranges, which often cross international borders of countries that have differing laws and capacity for wildlife conservation, makes conserving them challenging. However, satellite-tracking data can be used to identify habitat preferences and critical sites to target conservation actions. We tracked 16 Egyptian Vultures, Neophron percnopterus, in the Middle East and East Africa. We used dynamic Brownian bridge movement models to calculate home ranges and core-use areas, and we analyzed habitat use in a resource selection framework. Combined summer and winter ranges (99% utilization distributions) of all birds covered 209,800 and 274,300 km², respectively. However, the core-use areas (50% utilization distributions) in the summer and winter ranges, accounted for only 0.4–1.1% of this area (900 and 3100 km², respectively). These core-use areas are where the home ranges of multiple individuals overlapped and/or where individuals spent a lot of time, such as feeding and roosting sites, and are places where conservation actions could focus. Resource selection models predicted Egyptian Vulture occurrence throughout little-studied parts of the species’ range in the Middle East and East Africa, and revealed strong selection for proximity to highways, power distribution lines, and towns. While providing roosts (e.g. power pylons) and food (e.g. garbage dumps), anthropogenic features may also function as ecological traps by increasing exposure to electrocution and dietary toxins.     

A review of medicinal plant of Middle East and North Africa (MENA) region as source in tuberculosis drug discovery

Tuberculosis (TB) is a disease that affects one-third of the world’s population. Although currently available TB drugs have many side effects, such as nausea, headache and gastrointestinal discomfort, no new anti-TB drugs have been produced in the past 30 years. Therefore, the discovery of a new anti-TB agent with minimal or no side effects is urgently needed. Many previous works have reported the effects of medicinal plants against Mycobacterium tuberculosis (MTB). However, none have focused on medicinal plants from the Middle Eastern and North African (MENA) region. This review highlights the effects of medicinal plants from the MENA region on TB. Medicinal plants from the MENA region have been successfully used as traditional medicine and first aid against TB related problems. A total of 184 plants species representing 73 families were studied. Amongst these species, 93 species contained more active compounds with strong anti-MTB activity (crude extracts and/or bioactive compounds with activities of 0–100 µg/ml). The extract of Inula helenium, Khaya senegalensis, Premna odorata and Rosmarinus officinalis presented the strongest anti-MTB activity. In addition, Boswellia papyrifera (Del) Hochst olibanum, Eucalyptus camaldulensis Dehnh leaves (river red gum), Nigella sativa (black cumin) seeds and genus Cymbopogon exhibited anti-TB activity. The most potent bioactive compounds included alantolactone, octyl acetate, 1,8-cineole, thymoquinone, piperitone, α- verbenol, citral b and α-pinene. These compounds affect the permeability of microbial plasma membranes, thus kill the mycobacterium spp. As a conclusion, plant species collected from the MENA region are potential sources of novel drugs against TB.     

Genie differentiation in M. m. domesticus populations from Europe, the Middle East and North Africa: geographic patterns and colonization events

Geographic patterns of genie differentiation were investigated in the commensal house mouse subspecies, M. m. domesticus . The analysis by protein electrophoresis of 40 populations throughout Europe, the Middle East and North Africa indicated that genie differentiation was not highly structured on a macrogeographic scale. Mean genie distances between regions showed, however, that populations fell into three levels of differentiation: a low level in southern Europe within which interregional distances were no larger than intraregional ones, an intermediate level between southern European populations and North European and African ones, and finally, a higher level between all the latter and the Middle Eastern populations.
Gene flow estimates indicated that the homogeneity of southern European populations does not result from present high levels of gene flow, but more likely from a very recent ancestry. These data when argumented with the fossil records of mice from the Mediterranean Basin suggest a two-step colonization process, the most recent of which occurred very rapidly and resulted in the multiple founding of populations in southern Europe. The relationship of M. m. domesticus to other subspecies of mice is discussed in relation to introgression and taxonomy.
Microdifferentiation patterns with low levels of within population substructuring and of gene flow suggest that genie differentiation in the western European house mouse is largely determined by genetic drift and/or founder effects. Although historical factors are determinant in the large scale patterns of genie variation in commensal house mice, dispersal by man no longer seems to be a prominent feature moulding the genetic structure of M. m. domesticus .