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Background: The use of simulated patient (SP) methodology in pharmacy practice settings has increased recently. However, its applications can vary significantly within a region, hence affecting the quality of the SP methodology. Objective: The purpose of this systematic review is to critically assess the use of the SP methodology for assessing the practice of community pharmacists (CP) in the Middle East and North Africa (MENA) region. Methods: A comprehensive literature search was conducted using EMBASE, MEDLINE, ProQuest, and SCOPUS to identify articles published from 2011 to 2022. The selection of relevant studies for inclusion in the systematic review was based on the pre-determined inclusion criteria. The Mixed Method Appraisal Tool (MMAT) was used to assess the methodological quality of the included studies. Results: Electronic search yielded 478 publications. A total of 45 studies were reviewed. The studies were conducted in 12 countries of the MENA region. The sample size between the reviewed articles ranged from 20 to 1000 (median= 129). A greater number of the included studies measured the adequacy of skill (pre-dispensing and/or post-dispensing) 38 (84.4%). The vast majority of the studies reported unsatisfactory results regarding the competencies of CP. The number of the SP ranged from 1 to 37 (median= 2). Most of the studies recruited only one SP per pharmacy 35 (77.8%). The most common data collection method was written data collection form 42 (93.3%). Few studies only had a detection system for SP visits 11 (24.4%), and only six studies incorporated performance feedback (13.3%). More than two-thirds of the studies provided a training session for SP 37 (82.2%). There was variation in the symptoms and drugs used in the SP scenarios in the studies. Conclusion: Although the results demonstrate the growth in the use of the SP method in MENA region countries, studies showed high variability in the level of reporting the study methodology. Consequently, we argue the need for standardized reporting of these studies. [ABSTRACT FROM AUTHOR]

Background: Although several studies assessing the needs of advanced cancer patients have been conducted globally, most have focused on a specific type of cancer such as lung or breast cancer. The variation across studies has also created difficulties in generalizing the results and applying the findings in other countries. The aim of this study was to provide comprehensive information on the needs of Palestinian advanced cancer patients. The quality of life (QOL), distress levels, depression, anxiety, and spiritual well-being of the patients were also assessed. Methods: A hospital-based study with a cross-sectional design was conducted on a convenience sample of patients aged 18 or above who had been diagnosed with advanced-stage cancer. The unmet needs of the patients were assessed using the Short form of the Supportive Care Needs Survey (SCNS-SF34). Four instruments were utilized to examine their distress, anxiety, depression, QOL, and spirituality. A modified Supportive Care Framework was adopted to guide the design of this study. Descriptive statistics and hierarchical linear regression were utilized to analyse the data. Results: Of the 404 cancer patients invited to the study, 379 patients consented to participate and complete the questionnaire. Of them 96.8% stated that they had at least one 'moderate to high' level unmet need. The most frequent unmet needs were those in the physical aspects of daily living (Mean 58.94; SD ± 20.93) and psychological (Mean 58.84; SD ± 19.49) domains. Most of the patients (91%) were physically ill and reported experiencing physical symptoms. About 78.1% had a high level of distress. Almost 90% reported signs of depression and anxiety. Although they felt that their spiritual well-being was good, their QOL was poor. Hierarchical linear regression analyses confirmed that educational level, age, gender, marital status, cancer stage, cancer type, physical symptoms, depression, anxiety, distress, QOL, and spirituality were independently associated with unmet supportive care needs. Conclusion: Palestinian advanced cancer patients exhibit a significantly higher prevalence of unmet needs than those in other countries, indicating a need to develop a palliative care programme within the healthcare system. They have a great need for physical, emotional/psychosocial, self-management and other services, which should be made available to them, particularly in the routine delivery of cancer care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Irritable bowel syndrome (IBS) is the most frequent functional gastrointestinal (GI) disorder. In this study, we aimed to evaluate the different aspects of IBS among Middle Eastern residents. METHODS: During the study period, patients attending gastroenterology clinics of nine tertiary referral centers in four Middle Eastern couturiers (Iran, Egypt, Kuwait, and Turkey) were evaluated by Rome IV diagnostic criteria, and those who fulfilled the diagnostic criteria of IBS were asked to fill in a questionnaire covering different demographics and clinical aspects. RESULTS: Overall, during a 6-month period, 509 patients with IBS were included. 41.3% of the participants were male (210 patients), and 37.4% of them had academic education. 50% of the participants were Caucasian, and 34% were Arab, and originally, they were citizens of 18 countries. 77.4% of the participants were residents of subtropical areas, while 22.2% were living in temperate regions. The average age of the participants during the first presentation in subtropical and temperate areas were 38.4 ± 12.19 and 38.06 ± 12.18 years, respectively (P = 0.726). The most common subtypes of IBS in subtropical areas were unclassified (IBS-U, 44.4%), constipation dominant (IBS-C, 27.6%), mixed pattern (IBS-M, 21%), and diarrhea dominant (IBS-D, 6.8%) in descending order while in temperate areas the most common subtypes were IBS-U (43.3%), and IBS-D (22.1%), respectively (P < 0.001). Besides abdominal pain, the most common symptom of patients in each region was bloating (62.2% and 68.1%, respectively, P = 0.246). The rate of depression and anxiety were significantly higher among the residents of temperate areas in comparison with subtropical regions (41.6% vs. 16.5% and 80.5% vs. 58.4%, respectively, P < 0.001). CONCLUSION: Although the average age of IBS presentation is the same in subtropical and temperate areas, it seems that in temperate areas, the rate of IBS-D is more prevalent than in subtropical regions. The rate of anxiety and depression are significantly higher among those who searched social media and the internet to get information about their problems. [ABSTRACT FROM AUTHOR]

Background. Life expectancy is an important health status indicator based on average number of years a person at a given age may be expected to live given current mortality rates. Given this significance, it would be necessary to probe into the factors affecting the life expectancy. Ensuring that information and communication technology (ICT) services are properly used could contribute to development and achievement, as it represents an important issue for the countries moving toward knowledge-based and information-based societies. Therefore, this study explored the impact of the information and communication technology on life expectancy. Methods. This study covers annual data from 2008 to 2018 for a group of countries in the Middle East. Data were retrieved from the Annual Reports such as World Bank and International Telecommunication Union (ITU) data sets. The effects of ICT on life expectancy are estimated with the Panel model. We also used the Hausman test to investigate fixed versus random effects. The data were analyzed by Stata 14 software. Results. The core findings of this study confirm the significant impact of ICT on life expectancy in the Middle East. The calculated Coefficient of the regression was 0.551 indicating how much life expectancy changes when ICT variable increases by one unit. Moreover, the rho (intraclass correlation) was found to be 0.975 showing that 97.5% of the variance is due to differences across panels. Conclusion. Considering the effect of ICT on life expectancy, policymakers of the Middle Eastern countries should integrate the use of ICT with the existing programs and systems. Technology is not an end in itself but merely the means to reinforce the existing system and to meet the locally determined goals. It can be used as a tool to attain broader health and development goals. [ABSTRACT FROM AUTHOR]

Much of the existing literature on vaccine hesitancy and resistance focuses on the explicit reasons individuals justify their opposition to a particular vaccine or vaccination programs in general. We were therefore interested to assess vaccine hesitancy among university students in Palestine. A valid and reliable multi-item questionnaire was made available through social media to recruit Palestinian students. The survey was conducted between February and June 2021, and included socio-demographic information, knowledge and source of information about the disease, and attitudes towards COVID-19 conspiracy theories. The total number of respondents in this study was 840 students. Approximately 80% of the respondents were females, 5.8% of the respondents suffered from chronic diseases, and 38.9% of the respondents either suffered from COVID-19 or had a family member who did. The respondents' intention to receive the COVID-19 vaccine was as follows: 65% of males, 45% of females, 53% with chronic diseases, 48% without chronic diseases, and 51% of patients previously suffered from COVID-19. General intention to get the influenza vaccine was 315 (37.5%) of those surveyed. The general assumption that COVID-19 is a man-made disease was agreed by 390 (46%), with 66% of these respondents intending to be vaccinated. The overall intent to receive the COVID-19 vaccine was highest among students who were relying on scientific sources for their information about the vaccine (63%). Misinformation triggered by unregulated social media can have potentially serious repercussions on individuals and the community if it takes precedence over evidencebased guidelines. [ABSTRACT FROM AUTHOR]

Background. Obesity has become a significant public health issue worldwide, and it is a major risk factor for many noncommunicable diseases. This systematic review aimed to identify the prevalence of obesity and overweight in the Middle East region and different countries in this region. Materials and Methods. PubMed, Google Scholar, and MEDLINE databases were searched from 2000–2020 to identify relevant studies in the Middle East area. The survey was carried out using combinations of Medical Subject Headings (Mesh) keywords like "body mass index", "obesity", "overweight", "prevalence", "Middle-East", and "Countries in the Middle East area". Analysis of the data was done using STATA-14, and a random-effects model was used to estimate the pooled prevalence. Results. A total of 101 studies with 698905 participants have been identified that met inclusion criteria for this meta-analysis. The pooled estimates of the prevalence of obesity and overweight in the Middle East area were 21.17 (95% CI: 17.05–26.29) and 33.14 (95% CI: 26.87–40.87), respectively. The findings showed that obesity prevalence increased with age so that the highest prevalence of obesity and overweight was observed in people >40 years old. Obesity prevalence in the Middle East area remained steady between 2000–2006 and 2014–2020 (23%). During these time intervals, the prevalence of overweight decreased from 34.83 (95% CI: 32.40–37.45) to 32.85 (95% CI: 31.39–34.38). Conclusions. Despite the relative stabilization of the overweight and obesity trend in the Middle East, current interventions to combat the overweight epidemic need to be maintained and strengthened because the prevalence of overweight and obesity in this region is still very high. The prevalence of obesity increases with age so that people over 40 have the highest percentage of obesity and overweight. Therefore, implementing intervention programs to prevent and control obesity and overweight in the Middle East is essential. [ABSTRACT FROM AUTHOR]

Background : Optimum glycemic control is necessary to reduce and even prevent the risk of micro- and macrovascular complications of type 1 diabetes mellitus (T1DM). The main aim of this study was to assess the prevalence of T1DM patients with adequate glycemic control in 4 Arabian Gulf countries. Methods: This study was a multicenter, observational, cross-sectional disease registry. Data were collected from adult T1DM patients who were treated with insulin within 6 months prior to the study visit. Results: Out of 241 patients whose data were eligible for primary endpoint analysis, 27.4% had adequate glycemic control (HbA1c < 7%). The patients' age ranged from 18 to 64 years, and 53% were males. The mean (SD) duration of diabetes was 14.6 (9) years and the mean HbA1c was 8.11 (1.8) %. At the time of T1DM diagnosis, mean HbA1c was 10.7 (2.17) %. About 98% of the patients were normotensive and the lipid profile of patients was found to be optimal. The main variables associated with adequate glycemic control were low HbA1c at diagnosis (P < 0.001) and absence of a family history of diabetes (P = 0.002). Conclusions: We found that the glycemic control of T1DM adult patients in Kuwait, UAE, Oman and Bahrain is suboptimal. More efforts are necessary to pinpoint the causes of inadequate control in this population. [ABSTRACT FROM AUTHOR]

Introduction. Acute kidney injury (AKI) remains a critical issue for cancer patients despite recent treatment improvements. This study aimed to assess the incidence of AKI in cancer patients and its related risk factors. Methods. A Retrospective cohort study was conducted at tertiary hospitals in the period 2016–2018. A data abstraction sheet was used to collect related variables from patients' records. During admission, the incidence of AKI was assessed using creatinine measurements. RIFLE criteria were used to classify it into five categories of severity: risk, injury, failure, loss, and end-stage renal disease. Results. Using RIFLE (Risk, Injury, Failure, Loss, and End-stage renal disease) criteria, 6.9% of admissions were complicated with AKI. The severity of these fell into the categories of risk, injury, and failure, 3.3%, 1.7%, and 1.9%, respectively. In the multivariate model, the odds for developing AKI was significantly higher for patients with congestive heart failure (AOR = 17.1, 95% CI 1.7–80.1), chronic kidney disease (adjusted OR = 6.8, 95% CI 1.4–32.2 (P value 0.017)), sepsis (AOR = 4.4, 95% CI 1.9–10.1), hypercalcemia (AOR = 8.4, 95% CI 1.3–46.1), and admission to the ICU (AOR = 5.8, 95% CI 2.1–16.2). In addition, the mortality rate was nearly seven times higher for patients complicated by AKI (relative risk = 7.6, 95% CI 3.2–18.2). Conclusion. AKI was significantly associated with congestive heart failure, chronic kidney disease, sepsis, ICU admission, and hypercalcemia in cancer patients, resulting in poorer outcomes and higher mortality rates. AKI assessment for hospitalized cancer patients should be performed regularly, especially for patients at increased risk. [ABSTRACT FROM AUTHOR]

Background: Chronic inflammation has been associated with insulin resistance and related metabolic dysregulation, including type 2 diabetes mellitus (T2DM). Several non modifiable (i.e. genetic predisposition) and modifiable (i.e. sedentary lifestyle, energy-dense food) risk factors were suggested to explain the mechanisms involved in the development of inflammation, but are difficult to assess in clinical routine. The present study aimed to identify easy to asses clinical and biological risk factors associated with inflammation in patients with T2DM. Methods: One hundred nine patients (51 men, 58 women), 28–60 years old, from seven primary healthcare centers in Gaza City, Palestine, took part to the cross-sectional study (November 2013–May 2014). Study participants had T2DM with no history of inflammatory diseases, cardiovascular diseases, medication and/or any health condition that might affect the inflammatory markers, interleukin 6 (IL-6) and C-reactive protein (CRP). Inflammation was defined for IL-6 ≥ 2 pg/mL and CRP ≥ 6 mg/L. Multivariable logistic regressions were used to identify the relationship between inflammation and clinical and biological risk factors. Results: After adjustment for age and gender, inflammation seems to increase with increased body mass index (BMI) (OR: 1.427 [1.055–1.931]), increased fasting blood glucose (OR: 1.029 [1.007–1.052]) and decreased adiponectin values (OR: 0.571 [0.361–0.903]). There were also significant relationships between inflammation and BMI (OR: 1.432 [1.042–1.968]), fasting blood glucose (OR: 1.029 [1.006–1.052]) and adiponectin (OR: 0.569 [0.359–0.902]), after adjustment for smoking habits and physical activity. Conclusion: Managing obesity and associated complications (i.e. hyperglycemia, high adiponectin levels) might help decreasing inflammation in individuals with T2DM. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) was proposed in 2010 as a minimally invasive procedure for the treatment of achalasia. In this article, we describe the Middle Eastern experience with the procedure in terms of efficacy, length of admission, and short- and long-term complications. Methods: A retrospective analysis of our prospectively collected data on patients who underwent a POEM procedure was conducted between March 2019 and May 2020. The primary outcome was clinical success rate, defined as a postprocedure Eckardt score ≤3 at ≥3 months. Secondary outcomes included the length of hospital stay, presence of reflux symptoms or need for proton pump inhibitors (PPIs) ≥3 months, and adverse events. Results: During the study period, 67 patients (35 females) underwent the procedure for achalasia. The participants' ages ranged from 11 to 80 years (mean 41 ± 18 years). Eckardt scores before the treatment ranged between 4 and 12 (mean 8.85 ± 1.75). Sixty-four patients (95.5%) achieved Eckardt scores of ≤3 at ≥3 months after the procedure (95% confidence interval [CI]: 91%–100%). The difference between pre- and post-procedural Eckardt scores averaged around -8 points (95% CI: −7.5 to -8.5 P < 0.0001). Adverse events were reported in 24 patients (35.8%) and included pneumoperitoneum (32.8%), reflux symptoms at 3 months (29.9%), and surgical emphysema (3%). Six patients had adverse events that led to prolongation of admission; 3% of whom had aspiration pneumonia, 3% had pneumoperitoneum, 1.5% had both, and 1.5% had an esophageal tear. Conclusions: POEM is a promising procedure for the treatment of achalasia with a high clinical success rate, short hospital admission, and a reassuring safety profile. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric nursing students are expected to work hard to help children realize their full potential by giving care, knowing their growth process, and being responsive to their needs. Students should be able to communicate effectively and solve problems. Nurses who care for pediatric patients experience compassion fatigue as well as moderate to severe levels of work-related stress. The purpose of this study was to investigate the effect of progressive muscle relaxation exercise on anxiety among nursing students during pediatric nursing clinical training. Methods: A quasi-experimental, pre-post study was conducted in the faculty of nursing at the Arab American University/ Palestine. The sample of the study consists of 60 nursing students enrolled in the pediatric nursing course were selected through convenience sampling. This study was conducted on one group of nursing students that received Jacobson's progressive muscle relaxation exercise for five consecutive days per week for two weeks before entering the clinical environment. The S-anxiety scale (STAI Form Y-1) was applied to collect data before and after the intervention. Results: The magnitude of anxiety after the progressive muscle relaxation exercise was greater reduced than before (t (59) =21.1, P < 0.05). There was less anxiety post the program (M=1.34 ±0.36) than pre-program (M =2.83±0.35). Conclusion: The study findings indicated the positive influence of progressive muscle relaxation exercise on nursing students' anxiety levels in pediatric clinical settings. As a result, it is recommended that teaching programs on this approach be conducted for nursing students at nursing schools prior to the commencement of pediatric clinical practice in order to lessen anxiety. [ABSTRACT FROM AUTHOR]

Purpose: To provide the first scrutiny of adult height prediction protocols based on automated Greulich-Pyle and Tanner-Whitehouse (TW) skeletal ages applied to elite youth soccer players from the Middle East. Methods : We examined the application of modified Bayley-Pinneau (BoneXpert(R)), TW-II, and TW-III protocols using mixed-longitudinal data available for 103 subjects (chronological age range, 19.4 to 27.9 yr) previously enrolled as academy student-athletes (annual screening range, one to six visits). Random-effects generalized additive models quantified the presence of systematic mean differences between actual versus predicted adult height. Effects were deemed practically equivalent based on the location of the confidence interval (95% CI) against a realistic difference value of [DELTA] = +/- 1 cm. Each model pooled residual standard deviation described the actual precision of height predictions and was used to calculate a 95% prediction interval. Results : The BoneXpert(R) method overpredicted adult height systematically at chronological ages in the range of approximately 13.5 to 14.5 yr (95% CI range, -1.9 to -1 cm) and Greulich-Pyle skeletal ages between 13.5 and 15 yr (95% CI range, -3.1 to -1 cm). Effects based on TW-II were practically equivalent across the chronological and skeletal age measurement ranges, with this protocol yielding adult height predictions with a precision (standard deviation) of approximately +/-2.6 cm. The mean TW-III effects indicated systematic adult height overpredictions until the attainment of 14.5 and 15 yr of chronological age (95% CI range, -3.8 to -1.1 cm) and TW-III skeletal age (95% CI range: -5.2 to -2.3 cm), respectively. Conclusions : Tanner-Whitehouse-II adult height prediction method provided more consistent estimates and can be considered the method of choice for talent development purposes in youth soccer players from the Middle East. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Hypertension is among the most commonly managed diseases in general practice. Therapeutic inertia could be responsible for the vast majority of cardiovascular events in patients with hypertension. The present study was conducted to explore views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine and achieve formal consensus on promoters of the phenomenon of therapeutic inertia from their point of view. STUDY DESIGN: In this exploratory study, a mixed-methods approach combining literature search, qualitative interviews, and 2 Delphi technique rounds was used. METHODS: Interviews with key contact clinicians (n = 18) were conducted. To achieve formal consensus on promoters of therapeutic inertia in hypertension, 2 Delphi rounds were conducted using a panel of general practitioners, family medicine specialists, and internal medicine specialists (n = 50). RESULTS: The majority of the panel members (90%) agreed that therapeutic inertia was prevalent in treating patients with hypertension in Palestine. Of the 41 potential promoters, consensus was achieved on 37 (90.2%). Of these 37 promoters, 21 (56.8%) were clinician-related, 10 (27.0%) were patient-related, and 6 (16.2%) were health care system--related factors. The study explored views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine relevant to therapeutic inertia in hypertension. CONCLUSIONS: Findings of this study could inform policy and decision makers to devise strategies to eliminate or reduce therapeutic inertia in managing hypertension in Palestinian clinical practice. Future studies are needed to determine whether such strategies can improve outcomes of patients with hypertension. [ABSTRACT FROM AUTHOR]

Background: The role of somatic mutations in breast cancer prognosis and management continues to be recognized. However, data on the molecular profiles of Arab women are limited. Materials and Methods: This was a cross‐sectional study based on medical chart review of all Arab women diagnosed with breast cancer at a single institution between 2010 and 2018 who underwent next‐generation sequencing with Ampliseq 46‐Gene or 50‐Gene. Results: A total of 78 Arab women were identified, with a median age at diagnosis of 52.3 years (range: 37–82 years; 38.5% ≤50 years). The majority of patients had stage III or IV disease (74.4%). Next‐generation sequencing revealed the following somatic mutation rates: TP53, 23.1%; ATM, 2.6%; IDH1, 2.6%; IDH2, 3.8%; PTEN, 7.7%; PIK3CA, 15.4%; APC, 7.7%; NPM1, 2.5%; MPL, 1.3%; JAK2, 2.5%; KIT, 7.7%; KRAS, 3.8%; and NRAS, 3.8%. Conclusion: Our study illustrates frequencies of somatic mutations in Arab women with breast cancer and suggests potential variations from estimates reported in the Western population. These data calls for larger epidemiologic studies considering the evolving role of such mutations in prognostication and personalized management. Breast cancer in the Arab population has different clinicopathological and immunohistochemical features compared with the Western population. This article evaluates the frequency of somatic mutations identified using next‐generation sequencing in a sample of Arab women with breast cancer. [ABSTRACT FROM AUTHOR]

The impact of dust storms on human health has been well described in Asian and European countries. Several research studies have examined adverse health outcomes attributable to dust and dust storm events, including respiratory and cardiovascular diseases, across these and other developed countries. Despite an increasing number of dust storm events plaguing the Middle East attributable to climate change, little is presently understood about the effects of dust storms on the health of human populations residing in this region. This review sought to identify and assess what is currently understood about the health impacts of dust storms in the Middle East. A systematic review was designed and conducted using MEDLINE/PubMed and Google Scholar. Out of 534 articles identified, 16 met predetermined eligibility criteria and were included in our analysis. Our review identified a number of health consequences associated with dust events in the region of interest, existing gaps in available literature, vulnerable populations, and directions for future research. [ABSTRACT FROM AUTHOR]

Ensuring diets of children aged 6–23 months meet recommended guidance is crucial for growth and development and for the prevention of malnutrition including stunting, wasting and micronutrient deficiencies. Despite some improvement, indicators related to undernutrition and overnutrition fall short of global targets in the Middle East and North Africa (MENA) region that consist of low‐ and middle‐income countries witnessing political and social changes and a nutrition transition. This research aims at reviewing the situation related to the diets of children aged 6–23 months in five selected countries in the MENA region, examining factors affecting complementary feeding and providing recommendations for guiding effective strategies to improve it. The study triangulated data on complementary feeding status and predictors from semistructured interviews with 30 key informants, and multivariable analysis of household surveys in Egypt, Jordan, Lebanon, State of Palestine and Sudan including data on refugees in Lebanon and Jordan. There remain considerable gaps in complementary feeding differing noticeably among geographic areas. Findings from qualitative and quantitative analyses showed that maternal factors, including maternal education and age, household level factors such as paternal education and wealth, community‐level factors (culture and geographic location), and utilization of health services, were associated with minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) at varied levels in the five countries. Interventions to improve complementary feeding practices should include actions tailored to the needs of the population at multiple levels including at the caregiver's level, household, service use, community and policy level. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) has rapidly spread globally, forcing countries to apply lockdowns and strict social distancing measures. The aim of this study was to assess eating habits and lifestyle behaviours among residents of the Middle East and North Africa (MENA) region during the lockdown. A cross-sectional study among adult residents of the MENA region was conducted using an online questionnaire designed on Google Forms during April 2020. A total of 2970 participants from eighteen countries participated in the present study. During the pandemic, over 30 % reported weight gain, 6·2 % consumed five or more meals per d compared with 2·2 % before the pandemic (P < 0·001) and 48·8 % did not consume fruits on a daily basis. Moreover, 39·1 % did not engage in physical activity, and over 35 % spent more than 5 h/d on screens. A significant association between the frequency of training during the pandemic and the reported change in weight was found (P < 0·001). A significantly higher percentage of participants reported physical and emotional exhaustion, irritability and tension either all the time or a large part of the time during the pandemic (P < 0·001). Although a high percentage of participants reported sleeping more hours per night during the pandemic, 63 % had sleep disturbances. The study highlights that the lockdown due to the COVID-19 pandemic caused a variety of lifestyle changes, physical inactivity and psychological problems among adults in the MENA region. [ABSTRACT FROM AUTHOR]

Background: During this pandemic, nurses have always been on the frontline and are probably the first healthcare providers to interact with patients presenting with symptoms of COVID-19. The main aim of this multicenter study was to assess knowledge, attitude, and use of protective measures against COVID-19 among nurses across the Occupied Palestinian Territory (oPt) during the ongoing pandemic. Methods: This was a questionnaire-based multicenter cross-sectional study that was conducted in the period between October 2020 to December 2020. The study tool tested knowledge (8-item), attitude (2-item), and use of protective measures against COVID-19 (3-item) among nurses. Associations between nurses' characteristics and their knowledge, attitude, and use of protective measures were investigated using Student's t-test, Analysis of Variance, and Pearson's correlations. To control potentially confounding variables, predictors of higher knowledge, attitude, and use of protective measures were identified using multiple regression analyses. Results: The study tool was complete by 455 nurses. The mean of knowledge, attitude, and use of protective measures scores were 75.7% (SD:12.4%), 75.1% (SD: 17.7%), and 91.6% (SD: 18.2%), respectively. Multiple linear regression models showed that high knowledge was predicted by being female (p-value = 0.004) and self-rating social status as high (p-value = 0.005). Higher attitude was predicted by being female (p-value = 0.005), self-rating academic achievements as high (p-value = 0.007), and having contracted COVID-19 (p-value = 0.001). Higher use of protective measures was predicted by self-rating academic achievements as high (p-value = 0.010). Conclusion: Findings of this study suggested that nurses in the oPt had high knowledge, relatively optimistic attitude, and appropriately used protective measures against COVID-19 during the ongoing pandemic. Knowledge, attitude, and use of protective measures among nurses should continuously be updated as information unfold during the ongoing pandemic. More efforts are still needed to ensure protection of healthcare providers including nurses from contracting COVID-19. [ABSTRACT FROM AUTHOR]

Objectives: The World Health Organization (WHO) published a global strategic response plan in February 2020 aiming to mitigate the impact of the novel coronavirus disease 2019 (COVID-19) outbreak. It identified immediate activities required for global preparedness and response to the outbreak and set eight priority areas (pillars) essential for scaling up countries' operational readiness and response. Despite a semiannual progress report on implementing the Global Strategic Plan in June 2020, there is limited granular information available on the extent of the national plan's content and implementation, particularly in the Member States of the Gulf Cooperation Council (GCC). Therefore, we sought to review the preparedness and responsiveness towards the COVID-19 outbreak in the GCC in the first phase of the pandemic and to document lessons learned for improving the ongoing response efforts and preparedness for future pandemics. Methods: A rapid appraisal was conducted in June 2020 according to the WHO Strategic Preparedness and Response Plan and the accompanying Operational Planning Guidelines. The survey was administered to public health professionals or/and infectious disease experts in the states. The findings were cross-triangulated with secondary data that was publicly available for each country. Results: The preparedness and response efforts of Bahrain, Saudi Arabia, and the UAE were fully compliant with all 11 (100%) pillars of the modified strategic response measures. Kuwait, Oman, and Qatar complied with eight of the pillars. The component on conducting COVID-19 related research was the lowest-performing across all the six states. Conclusions: All GCC states demonstrated an effective response to the pandemic, enhanced existing infrastructures, and accelerated reforms that would have otherwise taken longer. The lessons learned through the early phase of the pandemic continue to steer the states in realigning their strategies and resetting their goals of controlling the outbreak, particularly in the current context of vaccine introduction and increasing preparedness capacities for future pandemics. [ABSTRACT FROM AUTHOR]

Background: Infants fed contaminated breast milk are at an increased risk of exposure to lead. Breast milk to blood (M/B) ratios have not been investigated among women in Palestine. The aim of this study was to assess blood, breast milk, and M/B lead ratios in samples collected from Palestinian breastfeeding women. Associations between sociodemographic characteristics with breast milk lead levels and M/B lead ratios were also investigated. Methods: This study was conducted in a cross-sectional design in the period between October 2017 and April 2018. Breastfeeding women visiting maternity care centers in different regions of the West Bank of Palestine were recruited to the study by the nurses in the maternity care centers. Sociodemographic characteristics, venous blood, and breast milk samples were collected from each participant. Lead concentrations were analyzed using a validated inductively coupled plasma-mass spectrometric method. Mann–Whitney U test, Pearson's Chi-square, Fisher's exact, and Spearman's correlations were used to analyze the data. Odds ratios (OR) were computed using a multivariate logistic regression model. Results: Matching blood and milk samples were collected from 80 women. Lead concentrations in 11 (13.8%) of the breast milk samples were above the World Health Organization's recommended levels. Breast milk lead levels were more likely to be ≥5 μg/L in breastfeeding women who lived in urban areas (aOR 4.96; 95% CI 1.10, 22.38) compared to those who lived in rural areas. Breast milk to blood lead ratios were more likely to be ≥25% in breastfeeding women who lived in urban areas (aOR 7.06; 95% CI 1.68, 29.77), used eye kohl (aOR 14.29; 95% CI 1.32, 155.06), and used hair dye (aOR 5.33; 95% CI 1.58, 18.00) compared to those who lived in rural areas, did not use eye kohl, and did not use hair dye, respectively. Conclusions: Higher M/B lead ratios were predicted by living in urban areas, using eye kohl, and using hair dye. Decision makers in health authorities should address sources of exposure to lead in urban areas. Cosmetics containing lead should be assessed and regulated for lead content. [ABSTRACT FROM AUTHOR]

Preliminary evidence points to higher morbidity and mortality from coronavirus disease 2019 (COVID-19) in certain racial and ethnic groups, but population-based studies using microlevel data are lacking so far. We used register-based cohort data including all adults living in Stockholm, Sweden, between January 31, 2020 (the date of the first confirmed case of COVID-19) and May 4, 2020 (n  = 1,778,670) to conduct Poisson regression analyses with region/country of birth as the exposure and underlying cause of COVID-19 death as the outcome, estimating relative risks and 95% confidence intervals. Migrants from Middle Eastern countries (relative risk (RR) = 3.2, 95% confidence interval (CI): 2.6, 3.8), Africa (RR = 3.0, 95% CI: 2.2, 4.3), and non-Sweden Nordic countries (RR = 1.5, 95% CI: 1.2, 1.8) had higher mortality from COVID-19 than persons born in Sweden. Especially high mortality risks from COVID-19 were found among persons born in Somalia, Lebanon, Syria, Turkey, Iran, and Iraq. Socioeconomic status, number of working-age household members, and neighborhood population density attenuated up to half of the increased COVID-19 mortality risks among the foreign-born. Disadvantaged socioeconomic and living conditions may increase infection rates in migrants and contribute to their higher risk of COVID-19 mortality. [ABSTRACT FROM AUTHOR]

Background: The current study assessed different dietary habits, energy drinks intake, body mass index (BMI) and physical activity and associated factors among Palestinian adolescents attending marginalized schools. Methods: A cross-sectional study targeted a random sample of 1480 students in the sixth and ninth grades attending 20 marginalized public schools in the West Bank area of the Occupied Palestinian Territories (oPt). Students were interviewed in-person by trained senior dental students about their dietary habits, physical activity, fathers' employment and mothers' level of education. Weight and height were measured, and BMI percentile was calculated. Descriptive statistics were generated for the study's main variables and the dependent variables were compared by grade, gender, mothers' level of education and father's employment. Results: A total of 1282 students (98% response) completed the questionnaire. Of them, 6% were 'underweight' (fifth percentile or under) and 34% were 'overweight' or 'obese' (85th percentile or over). Ninth graders had more added sugar than 6th graders (P = 0.002), less frequent milk consumption (P < 0.001), more frequent energy drink consumption (P = 0.001), and less physical activity (P < 0.0001). Frequency of carbonated and sweetened drink consumption was associated with being overweight or obese (P = 0.016, P = 0.001). Frequency of carbonated drinks consumption was higher among children of mothers with a high school level of education or less (P < 0.001). In addition, children of mothers educated to high school level or below were associated with being underweight (P = 0.05) Conclusion: Dietary habits and physical activity get worse between the ages of 12 and 15. Mothers' level of education is an important factor in being overweight or underweight. Energy drink consumption among boys and milk consumption among girls are two challenges that need to be addressed urgently and adequately. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Cystic fibrosis (CF) is the commonest life-limiting inherited illness in the Caucasian population but is uncommon in the Middle East, and so the genotypes and clinical course of disease in this population is not well known. MATERIAL AND METHODS: In this retrospective observational study, we collected and reviewed the data on CF mutations, body mass index (BMI), lung function, microbiology, and the demographics in adult CF patients in the United Arab Emirates (UAE). RESULTS: Data was reviewed for 39 adult CF patients. The median age of adult CF patients presenting to our clinic was 25 years (interquartile range (IQR) 22-31), the median BMI was 19 (IQR 17-22), and the median percentage predicted forced expiratory volume at 1 second (FEV1) was 49.5% (IQR 38.5-62.5). S549R was the commonest mutation (n = 11, 28%) followed by AF508 (n = 9, 23%). Only 5 (13%) out of 39 patients were heterozygote for CF mutations which reflects the high level of consanguinity in the region. Twelve (30%) patients were diagnosed after the age of 16, and in total, 19 (48%) were diagnosed after the age of 10. Thirty-two (82%) of patients are pseudomonas colonized, and 31% had 3 or more exacerbations in the last 12 months. CONCLUSION: The CF mutation patterns in the UAE are different from western populations with low AF508 prevalence, with the presence of rare mutations more specific to this region and a high rate of homozygosity. Late diagnosis, high pseudomonas colonization rate, and exacerbation frequency remain a problem in this region and lead to poor long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: Transport-related injuries (TIs) are a substantial public health concern for all regions of the world. The present study quantified the burden of TIs and deaths in the Eastern Mediterranean region (EMR) in 2017 by sex and age. Methods: TIs and deaths were estimated by age, sex, country, and year using Cause of Death Ensemble modelling (CODEm) and DisMod-MR 2.1. Disability-adjusted life years (DALYs), which quantify the total burden of years lost due to premature death or disability, were also estimated per 100 000 population. All estimates were reported along with their corresponding 95% uncertainty intervals (UIs). Results: In 2017, there were 5.5 million (UI 4.9-6.2) transport-related incident cases in the EMR -- a substantial increase from 1990 (2.8 million; UI 2.5-3.1). The age-standardized incidence rate for the EMR in 2017 was 787 (UI 705.5-876.2) per 100 000, which has not changed significantly since 1990 (-0.9%; UI -4.7 to 3). These rates differed remarkably between countries, such that Oman (1303.9; UI 1167.3-1441.5) and Palestine (486.5; UI 434.5-545.9) had the highest and lowest age-standardized incidence rates per 100 000, respectively. In 2017, there were 185.3 thousand (UI 170.8-200.6) transport-related fatalities in the EMR -- a substantial increase since 1990 (140.4 thousand; UI 118.7-156.9). The age-standardized death rate for the EMR in 2017 was 29.5 (UI 27.1-31.9) per 100 000, which was 30.5% lower than that found in 1990 (42.5; UI 36.8-47.3). In 2017, Somalia (54; UI 30-77.4) and Lebanon (7.1; UI 4.8-8.6) had the highest and lowest age-standardized death rates per 100,000, respectively. The age-standardised DALY rate for the EMR in 2017 was 1,528.8 (UI 1412.5-1651.3) per 100 000, which was 34.4% lower than that found in 1990 (2,331.3; UI 1,993.1-2,589.9). In 2017, the highest DALY rate was found in Pakistan (3 454 121; UI 2 297 890-4 342 908) and the lowest was found in Bahrain (8616; UI 7670-9751). Conclusion: The present study shows that while road traffic has become relatively safer (measured by deaths and DALYs per 100 000 population), the number of transport-related fatalities in the EMR is growing and needs to be addressed urgently. [ABSTRACT FROM AUTHOR]

Background: To end the COVID-19 pandemic, a large part of the world must be immune to the virus by vaccination. Therefore, this study aimed to gauge intent to be vaccinated against COVID-19 among ordinary people and to identify attitudes towards vaccines and barriers for vaccine acceptance. Methods: The study population comprises 1880 people residing in different countries that answer a prepared questionnaire. The questionnaire topics are demographics, historical issues, participants' attitudes and beliefs regarding vaccines, concerns, and vaccine hesitancy. Results: Attitudes and beliefs relating to vaccines in general, and the COVID-19 vaccine, were ascertained. Overall, 66.81% of the contributors would like to be vaccinated against COVID-19, while %33.19 did not intend to be vaccinated. Reasons for COVID-19 vaccine hesitancy included concern regarding vaccine side effects, fear of getting sick from the uptake of the vaccine, and the absence of accurate vaccine promotion news. Individuals with higher education believe that India (68.6%) produces the best vaccine (P <0.001), while healthcare workers think the Chinese vaccine (44.2%) is the best (P =0.020). Individuals with higher education have not been vaccinated, not be healthcare workers, and females were the most contributors to effective of the vaccine in reducing mortality from COVID-19 disease. Conclusion: Given the degree of hesitancy against COVID-19 vaccination, a multifaceted approach to facilitate vaccine uptake that includes vaccine education, behavioral change strategies, and health promotion, is paramount. [ABSTRACT FROM AUTHOR]

BACKGROUND: Severe asthma is a major burden on health-economic resources; hence, knoing the epidemiology of these patients is important in planning and provision of asthma care. In addition, identifying and managing the comorbidities helps improve symptoms and reduce associated morbidity and mortality. OBJECTIVES: Epidemiology of difficult asthma has not been ell studied in the Middle East, so in this study, e present the demographic and clinical characteristics of severe asthma in the United Arab Emirates (UAE). METHODS: We retrospectively revieed the notes of severe asthma patients attending three tertiary care hospitals beteen May 2015 and December 2019. Data on baseline demographics, asthma characteristics, treatment, and comorbidities ere collected. RESULTS: We revieed the notes of 458 patients (271 females and 187 males) that fulfilled the 2019 Global Initiative for Asthma guidelines for the diagnosis of severe asthma. The mean age as 47.7 (standard deviation 17.2) years. Males had significantly higher asthma control test scores (17.9 vs. 16, P = 0.01) and mean blood eosinophils (0.401 vs. 0.294, P <0.01) than females. The most common comorbidity observed as allergic rhinitis (52.2%) folloed by gastroesophageal reflux disease (27.1%). In total, 109 (23.8%) patients ere on biological therapies ith most patients being on omalizumab and dupilumab (29 and 18 patients, respectively). Most patients ere nonsmokers (97.2%), and majority ere of TH2-high phenotype (75.7%). CONCLUSIONS: In this first report of severe asthma characteristics in the UAE, e found a pattern of female preponderance and most patients having a Th2-high phenotype. The findings are likely to help optimize asthma care in the region in the era of biologic therapies. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the knowledge, believes, psychological and behavioural impact of COVID-19 on the general population in the Middle East, exploring how it impacted public lives. Methods: A descriptive cross-sectional online survey was sent to a convenience sample in the Middle East through social media (Facebook and WhatsApp) between 16th of June and 30th of June 2020. The questionnaire was designed to collect the demographic, participant's source of information regarding COVID-19, knowledge and believes about COVID-19, the psychological consequences of COVID-19, impact of COVID-19 on participant's behaviour. The final version of the questionnaire was further tested for content validity by experts in the field. Results: A total of 2,061 participants completed the survey, with the majority being females (n=1394, 67.6%), from urban areas (n=1896, 92%) and the majority were from countries of The Levant (n=1199, 58.1%), followed by the Arabian Peninsula (n=392, 19.1%), Iraq (n=300, 14.6%) and Egypt (n=138, 6.7%). Few participants (3.0%) reported to have been infected and many (n=1847, 89.6%) were committed to quarantine at home. Social media platforms were the most common sources of information (41.2%). Many (63%) believed that COVID-19 is a biological weapon and were afraid of visiting crowded places (85%). The majority avoided public facilities (86.9%) such as prayer places and believed that the news about COVID-19 made them anxious (49.5%). [ABSTRACT FROM AUTHOR]

Background: The use of complementary and alternative medicine (CAM) is increasing worldwide. To the best of knowledge, there is a lack of studies that assess CAM use by Palestinian women during pregnancy. This research aims to determine the prevalence of Palestinian women's use of CAM during pregnancy, the most frequently used CAM products during the pregnancy period, the main sources that encourage the use of CAM among pregnant women, and the causes of CAM use. Methods: A descriptive, cross-sectional study was conducted in Palestine using a questionnaire from April 2018 to March 2019. The samples were selected by convenience sampling, including currently pregnant or previously pregnant women in the Obstetrics and Gynecology (OBGYN) clinic at Rafedia Hospital and in primary health care clinics in Nablus city-Palestine. The questionnaire covered socio-demographic variables, health status, types and frequency of CAM used, patients' sources of information, causes of their usage, attitudes, and beliefs. Results: Four hundred currently or previously pregnant women participated. Three hundred fifty-five (91.5%) used at least one method of CAM during pregnancy. Most women used at least one method of biologically-based therapies during pregnancy (87.7%). One hundred and one pregnant women (26.7%) utilised at least one type of herb during pregnancy. The most-reported herb used by 12.3% of participants was anise. Of the mind-body therapies, prayer was the most commonly used method during pregnancy (8.3%). Two hundred and sixty-one (65.3%) participants used CAM because they believed CAM was not harmful to them or their babies during pregnancy. Participants gained most of their information about CAM from their families (43.8%) and friends (24.3%). Approximately two-thirds of participants (64.0%) thought that obstetricians should be able to advise on commonly used CAM. Conclusions: During pregnancy, CAM products are commonly used, and it is important to determine what types are being used by women in Palestine. These findings supplement the body of knowledge on the use of CAM by pregnant women. Pregnancy care providers need to be aware to the familiar types of CAM that women use. [ABSTRACT FROM AUTHOR]

The emergence of the coronavirus pandemic led to the implementation of several precautionary measures across the globe. For densely populated regions in the world, this may have been challenging given the proximity of people to one other. Thus, this brief report sought to compare the measures across 2 densely populated locations, Hong Kong and Gaza. Epidemiological data was obtained from governmental online repositories and was compared with the data presented by the Johns Hopkins coronavirus map to ensure consistency. Descriptive statistics were used to interpret the data obtained over the period of the study. The data suggested that although Hong Kong and Gaza implemented similar strategies, Gaza recorded marginally higher cases compared with Hong Kong in the same timeframe. The strategies implemented in both settings included border closures, social distancing, proper hand hygiene, and mask usage. Cultural and socio-demographic differences may have played a part in this variation in case numbers, in addition to lessons Hong Kong had previously learned from a similar outbreak. As the pandemic is ongoing it is essential that public sensitization to adherence to precautionary measures at the personal/family level does not occur. [ABSTRACT FROM AUTHOR]

Background: Generally, complementary and alternative therapies (CAT) are accepted methods of treatment by patients with various types of conditions. Their use is becoming especially prevalent among patients with eye problems even in developed countries. Thus, we aimed to determine the pattern of use of CAT in this patient population, to identify the patient characteristics associated with the use of CAT, and to assess the types of CAT used. Methods: A descriptive, cross-sectional study was conducted in Palestine at An-Najah National University Hospital between the time periods of October 2019 to May 2020, using questionnaire-based face to face interviews. Data were collected through convenience sampling. Patients responded to the questionnaire, which was focused on information adapted from previous research in this area, covering socio-demographic and clinical characteristics, types of CAT, source of information, and side effects on CAT use. Results: A total of 86 patients were interviewed for our study. Over two thirds, 67% reported using CAT for the specific purpose of improving their eye condition, and about one third (29.1%) received more than one therapy. The most common therapies reported were duea' (i.e. supplication) (47.1%) and herbal therapies (24.1%). It was shown that patients with bilateral involvement of their eyes were almost twice more likely to describe using CAT than patients with unilateral eye pathology (p = 0.006). Also, patients who underwent surgery as their route of treatment were significantly less likely to use CAT (p = 0.043). Most of our study participants mentioned a non-physician source as their source of information regarding CAT with family members being the most frequently mentioned (30.2%) followed by the internet (25.6%) and friends (19.8%). Conclusions: The prevalence of CAT use among patients with eye disease is somewhat high in our study population. Because CAT may trigger adverse reactions, influence the progression of the disease, and interfere with conventional treatment, the ophthalmologist should frequently be asked patients with such diagnostics regarding the use of these therapies. Further work is required to analyze the mechanisms of action and to establish realistic guidelines for the use of these modalities. [ABSTRACT FROM AUTHOR]

Background. Thalassemia has a burden on the healthcare systems of many countries. About 56000 conceptions result in thalassemia, globally. Objective. To assess the epidemiological profile of thalassemia in the Gulf Cooperation Council (GCC) countries. Methods. A systematic search was conducted in MEDLINE/PubMed (National Library of Medicine), CINAHL, and Embase. Relevant observational studies reporting the epidemiology of thalassemia among the GCC population were selected. Data on the prevalence, frequency, and complications of thalassemia were extracted. The quality of the retrieved studies was assessed according to the Newcastle–Ottawa Quality Assessment Scale. Results. Eighteen studies (14 cross-sectional studies, two retrospective observational studies, and two retrospective analysis) with a total of 3343042 participants were included in this systematic review. Of the 18 studies, 11 studies were conducted in Saudi Arabia, two in the Kingdom of Bahrain, one in Kuwait, three in the United Arab Emirates (UAE), and one in Qatar. The prevalence of thalassemia among children below five years of age ranged from 0.25% to 33%, while it was 0.9% in children above five years and from 0.035% to 43.3% among adult thalassemia patients. The most-reported risk factors were consanguineous marriage and high-risk marriage. There was a lack of data regarding mortality rates in thalassemia. Conclusions. Despite the premarital screening and genetic counseling (PMSGC) program for thalassemia, the incidence of high-risk couple marriages in GCC countries cannot be effectively diminished. This study suggested that the PMSGC program should adopt more attention for the high-risk areas, to enhance the level of consciousness about the hemoglobinopathy diseases and the consequences of consanguinity among the at-risk couple. [ABSTRACT FROM AUTHOR]

Background. Drug-drug interactions (DDIs) are a common issue that leads to adverse drug reactions in hospitals. Patients in the surgical department are expected to have potential DDIs that may lead to morbidity and mortality. Objectives. To study potential DDI prevalence in the surgery departments in 3 hospitals in Palestine. Moreover, to identify pertinent factors that are associated with drug-drug interactions. Method. A cross-sectional study in 3 governmental Palestinian hospitals: Palestine Medical Complex, Rafidia Hospital, and Beit Jala Hospital. Patients who are 20 years old or above and admitted to the surgical wards between September 2017 and February 2018 were included in the study. Patient demographics, all medications given in the hospital, and hospitalization period were obtained from medical files. The digital clinical decision support system Micromedex® was used for analysis and classification of possible drug interactions. Bivariate analysis and logistic regression were used to study the risk factors for developing DDIs. Results. 502 patients were included in this report. The prevalence of potential DDIs among patients admitted to surgery wards in three Palestinian hospitals was 56%. The number of detected potential DDIs per patient was 2.22 ± 3.76. The number of prescribed medications (P < 0.001) was found to increase the possibility of having drug interactions. Conclusions. DDIs in Palestinian hospitals are a prevalent problem, and caution should be taken when ordering medications to hospitalized patients in surgery departments. [ABSTRACT FROM AUTHOR]

Background: There is a lack of data on the use of complementary and alternative medicine (CAM) in patients with coronary heart disease (CHD). This study examined the use of CAM among patients with CHD, the reasons and factors influencing their use, the types of CAM used, and the relationship between patient's demographics and the use of CAM. Methods: In order to determine the prevalence and usage of CAM among Palestinian patients with CHD, a cross-sectional descriptive study was performed from three different hospitals. Using a convenient sampling method, a questionnaire was completed in a face-to-face interview with the patients. Descriptive statistics were used for socio-demographic, and clinical variables. Siahpush scale was used to examine the attitude of CHD patients toward CAM use. Results: Of the 150 patients that were interviewed, 128 (85.3%) of the patients completed the questionnaire. The majority of CAM users reported CAM use for health problems other than CHD, while a total of 59 (45.9%) patients have used CAM for their heart problems. On the other hand, it was found that the place of residency and pattern of CHD were significantly associated with CAM use (p = 0.039 and 0.044, respectively). In addition, religious practices were found to be the most common form of CAM used by patients, while body and traditional alternative methods were the least being used. A significant association between the attitudes of patients with CHD and their use of CAM was found (patients' attitudes towards alternative medicine and natural remedies were p = 0.011 and 0.044, respectively). Conclusions: CAM use among our respondents is common. Despite a lack of evidence-based research supporting its potential benefits and side effects. Understanding the factors that affect CAM use by CHD patients offers healthcare workers and policymakers an opportunity to better understand CAM use and ultimately improve patient-physician interactions. [ABSTRACT FROM AUTHOR]

Aims: Vitamin D measurement is a composite of vitamin D2 (25(OH)D2) and D3 (25(OH)D3) levels, and its deficiency is associated with the development of type 2 diabetes (T2DM) and diabetic complications; vitamin D deficiency may be treated with vitamin D2 supplements. This study was undertaken to determine if vitamin D2 and D3 levels differed between those with and without T2DM in this Middle Eastern population, and the relationship between diabetic microvascular complications and vitamin D2 and vitamin D3 levels in subjects with T2DM. Methods: Four hundred ninety-six Qatari subjects, 274 with and 222 without T2DM participated in the study. Plasma levels of total vitamin D2 and D3 were measured by LC-MS/MS analysis. Results: All subjects were taking vitamin D2 and none were taking D3 supplements. Vitamin D2 levels were higher in diabetics, particularly in females, and higher levels were associated with hypertension and dyslipidemia in the diabetic subjects (p < 0.001), but were not related to diabetic retinopathy or nephropathy. Vitamin D3 levels measured in the same subjects were lower in diabetics, particularly in females (p < 0.001), were unrelated to dyslipidemia or hypertension, but were associated with retinopathy (p < 0.014). Neither vitamin D2 nor vitamin D3 were associated with neuropathy. For those subjects with hypertension, dyslipidemia, retinopathy or neuropathy, comparison of highest with lowest tertiles for vitamin D2 and vitamin D3 showed no difference. Conclusions: In this Qatari cohort, vitamin D2 was associated with hypertension and dyslipidemia, whilst vitamin D3 levels were associated with diabetic retinopathy. Vitamin D2 levels were higher, whilst vitamin D3 were lower in diabetics and females, likely due to ingestion of vitamin D2 supplements. [ABSTRACT FROM AUTHOR]

Introduction. The kidney affects the thyroid gland causing various derangements in its function whenever the kidney is impaired, even with a minor imperfection in its job, and this makes dialysis patients more prone to thyroid disorders with subsequent increase in mortality and morbidity. This study aims to assess the prevalence of thyroid disease (hypo- and hyperthyroidism) among dialysis patients and their associated factors. Methods. This cross-sectional study was conducted in the dialysis unit of An-Najah National University Hospital. 209 dialysis patients (60% were male, 57.6 ± 14.5 years, mean age) meeting our inclusion criteria were tested for thyrotropin (TSH) and free thyroxine (FT4) in addition to routine laboratory tests. Findings. The prevalence of hypothyroidism was assessed as 16.3% (95% CI = 11.29% to 21.3%), overt hypothyroidism was 9.1%, and subclinical hypothyroidism was 7.2%. Subclinical hyperthyroidism prevalence was 1%, and no overt hyperthyroidism cases were reported. We observed no significant association between thyroid state and age, gender, duration of dialysis, or weight. Discussion. Hypothyroidism (both subclinical and overt type) is commonly seen in dialysis patients, and its symptoms are ordinary complains even in euthyroid dialysis patients, and this warrants screening programs and more studies on the efficacy of thyroid hormone supplements. [ABSTRACT FROM AUTHOR]

Background: Hemodialysis (HD) is one of the treatment modalities for end stage renal disease patients (ESRD). ESRD and dialysis affects the daily lives of many patients and families confronted by changes in health status, lifestyles, and roles, leading to impaired Quality of life. Objective: This study aimed to examine quality of life and affecting factors among patients undergoing hemodialysis. Methods: A descriptive cross-sectional design was employed. A sample of 93 adult male and female patients undergoing HD were purposefully selected from kidney dialysis unit at El-Shifa hospital in Gaza Strip using the kidney disease quality of life short form (KDQoL-SF) version 1.3. Results: Finding of this study indicated that, QoL of patients undergoing HD was significantly impaired. Numerous clinical and demographic factors were found to have a statistically significance difference with QoL dimensions, such as gender, occupation, income, but the most powerful predictors of impaired QoL are physical and psychosocial factors. Conclusion: The result of this study concluded that the factors affecting QoL for those patients were age, sex, occupations, marital status, type of work, socioeconomic status, residence and educational level. The highly affected dimensions of satisfaction are the spiritual; and overall health dimension, while the least affected dimensions of satisfaction are the physical and psychosocial quality of life. [ABSTRACT FROM AUTHOR]

Although the prevalence of obesity has rapidly increased in the low‐ and middle‐income countries of the Middle East and North Africa (MENA) and Latin America and the Caribbean (LAC) regions, child undernutrition remains a public‐health challenge. We examined region‐specific sociodemographic determinants of this double burden of malnutrition, specifically, the co‐occurrence of child stunting and overweight, using Demographic and Health Survey and Multiple Indicator Cluster Survey data (2003–2016) from 11 countries in the MENA (n = 118,585) and 13 countries in the LAC (n = 77,824) regions. We used multiple logistic regressions to model region‐specific associations of maternal education and household wealth with child nutritional outcomes (6–59 months). The prevalence of stunting, overweight, and their co‐occurrence was 24%, 10%, and 4.3% in children in the MENA region, respectively, and 19%, 5%, and 0.5% in children in the LAC region, respectively. In both regions, higher maternal education and household wealth were significantly associated with lower odds of stunting and higher odds of overweight. As compared with the poorest wealth quintiles, decreased odds of co‐occurring stunting and overweight were observed among children from the second, third, and fourth wealth quintiles in the LAC region. In the MENA region, this association was only statistically significant for the second wealth quintile. In both regions, double burden was not statistically significantly associated with maternal education. The social patterning of co‐occurring stunting and overweight in children varied across the two regions, indicating potential differences in the underlying aetiology of the double burden across regions and stages of the nutrition transition. [ABSTRACT FROM AUTHOR]

INTRODUCTION The Gulf Cooperation Council (GCC) member countries include Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates. The current study aims to provide an estimate of the population fractions of cancer cases attributable to tobacco smoking in the GCC countries. METHODS Population attributable fraction (PAF) was calculated for cancers that were listed by the International Agency for Research on Cancer (IARC) to have sufficient evidence of causal association. The estimated number of incident cancer cases in GCC countries were retrieved from the IARC GLOBOCAN database. The prevalence estimates of current tobacco smoking among persons aged ≥15 years were obtained from the World Health Organization report on prevalence of tobacco smoking. Relative risk estimates for various cancers were obtained from published meta-analyses. Summary PAFs and cancer cases attributable to tobacco smoking are reported by country, sex, and cancer type. RESULTS Tobacco smoking was responsible for 2536 (16.3%) of cancer cases in GCC countries in 2018. It accounted for 22.8% (n=2396) and 2.8% (n=140) of cancer cases among males and females, respectively. Among males, the highest number of cancer incident cases attributable to smoking was lung cancer (807) followed by urinary bladder (328), and colorectal cancer (305). Among females, the highest number of cancer cases attributable to smoking was lung cancer (62) followed by lip and oral cavity (13), and cervical cancer (13). CONCLUSIONS Tobacco smoking accounted for a large portion of cancer cases attributable to preventable risk factors in GCC countries. Preventive efforts focusing on reducing tobacco smoking should be a high priority in GCC countries. [ABSTRACT FROM AUTHOR]

Background: Preventing violence is important especially in the Middle East, where many countries are struggling with violence. Knowing the affecting factors could help public policy makers to decrease violence level. Thus, this study is aimed to analyze health and other socio-economic factors that could affect interpersonal violence in middle eastern countries. Methods: From international organization databases, we collected the panel data of Middle Eastern countries from 1990 to 2016 on prevalence of interpersonal violence as dependent variable and per capita income, life expectancy, democracy index (DI), urbanization and unemployment as explanatory factors. Several panel data diagnostic tests were performed for selecting a suitable model of estimation. The variables were entered in the model in logarithmic form. Because of heteroscedasticity, cross-sectional dependence and serial correlation of residuals, feasible generalized least squares (FGLS) was used for estimation of mentioned model using Stata 14.2. Results: The means of interpersonal violence prevalence and life expectancy were 2462.2 (SD = 232.4) per 100 000 population and 73.5 (SD = 4.5) in the Middle East, respectively. Urbanization (β = -0.0925, P < 0.01), life expectancy (β = -0.0362, P < 0.01), per capita income (β = -0.0046, P < 0.01), unemployment (β = 0.0007, P < 0.01) and democracy (β = -5.83e-06, P < 0.01) had significant relation with interpersonal violence. Conclusion: Life expectancy as a proxy for health is one of the main predictors of interpersonal violence, as literature supports. That is, if a society is healthier, the burden of interpersonal violence will be lower. Thus, health policy makers should consider health status as a preventive factor of violence, which is stated in health as a bridge for peace by the world health organization. [ABSTRACT FROM AUTHOR]

Objectives: We sought to estimate the mortality and morbidity in diabetic acute heart failure (AHF) patients stratified by left ventricular ejection fraction. Methods: We analyzed the data of patients with AHF from seven Middle Eastern countries (Bahrain, Oman, Yemen, Kuwait, UAE, Qatar, and Saudi Arabia) from February to November 2012, who were enrolled in a multinational registry of patients with heart failure (HF). Results: A total of 2258 AHF patients had diabetes mellitus. The mean age was 63.0±11.0 years (ranging from 18 to 99 years), and 60.3% (n = 1362) of the patients were males. The mean ejection fraction (EF) was 37.0±13.0%. HF with reduced EF (< 40%) (HFrEF) was observed in 1268 patients (56.2%), whereas 515 patients (22.8%) had mid-range (40-49%) (HFmrEF) and 475 patients (21.0%) had preserved EF (≥ 50%) (HFpEF). The overall cumulative all-cause mortalities at three- and 12-months follow-up were 11.8% (n = 266) and 20.7% (n = 467), respectively. Those with HFpEF were associated with lower three-months cumulative all-cause mortality compared to those with HFrEF (7.6% vs. 5.9%; adjusted odds ratio (aOR) = 0.54, 95% confidence interval (CI): 0.31-0.95; p = 0.031), but not significantly different when compared to those with HFmrEF (aOR = 0.86, 95% CI: 0.53-1.40; p = 0.554). There were largely no significant differences among the groups with regards to the 12-months all-cause cumulative mortality (11% vs. 11% vs. 10%; p = 0.984). There were also no significant differences in re-hospitalization rates between the three HF groups not only at three months (23% vs. 20% vs. 22%; p = 0.520), but at one-year follow-up (28% vs. 30% vs. 32%; p = 0.335). Conclusions: Three-month cumulative all-cause mortality was high in diabetic HFrEF patients when compared to those with HFpEF. However, there were no significant differences in mortality at one-year follow-up between the HF groups. There were also no significant differences in re-hospitalization rates between the HF groups not only at three months but also at one-year follow-up in the Middle East. [ABSTRACT FROM AUTHOR]

Background The aim was to study the effect of country of birth, educational level and county of residence on overweight and obesity among pregnant women in Norway. Methods Observational study based on Medical Birth Registry Norway and Statistics Norway. The study population consisted of 219 555 deliveries in 2006–2014. Body mass index (BMI) was registered at the first antenatal care visit. Multivariate regression analysis was used to explore the study aims. Results Overweight (BMI 25–29.9) was recorded in 22.3% of the women, obesity (BMI ≥30) in 12.2%. Highest rates of overweight (30.8%) and obesity (13.5%) was recorded among women from the Middle East and North Africa or with no education (30.7% and 17.2%). The prevalence of overweight and obesity was 39.5% in sparsely populated counties and 26.4% for women living in Oslo. Adjusted for country of birth, education level, age, parity, smoking and marital status, the relative odds of overweight and obesity were 65% (95% CI 59–72%) higher in sparsely populated counties compared to Oslo. Conclusions The prevalence of overweight (BMI ≥25) was 34.5%. The factors associated with overweight were living in rural districts in Norway, lower education and being born in countries in the Middle East or Africa. [ABSTRACT FROM AUTHOR]

Objectives: As the millennial generation enters the nursing profession, simulation takes on a key role in effective pedagogy. We sought to examine the efficacy of simulation versus case scenario as a teaching method for novice nursing students in the skill of nasogastric tube (NGT) feeding. We assessed the knowledge, competency, self-confidence, and satisfaction among these nursing students. Methods: This quasi-experimental study was used to compare the efficacy of simulation and case scenarios in promoting knowledge, clinical competency, self-learning, and self-confidence among novice nursing students in the Middle East. The study sample included 69 students registered for the Fundamentals of Nursing Laboratory course at the College of Nursing, Sultan Qaboos University, Oman, during the spring and fall 2016 semesters. Thirty-five students were assigned to the intervention group and attended a simulation, while 34 students were assigned to the control group and were given the standard case scenario used in teaching this course. The competency of the students on NGT feeding skill was measured after a simulation or case scenario. Results: In both groups, the majority of students were ≤ 20 years old, female, hailed from rural areas, and had a cumulative grade point average of > 2.5. Data showed a significant improvement in the mean scores ofcompetency between the intervention and control groups (t(67) = 3.869,p < 0.001) suggesting that simulation was effective in gaining competency compared to the case scenario. There was a positive statistical significance between satisfaction and self-confidence among the intervention group. Conclusions: Simulation has an effective role in clinical education for teaching practical skills. However, in this study, there was a statistically significant difference in the mean scores between the two methods of teaching. This helped us to conclude that competency gained by novice students' learning a skill through simulation, was better than the competency gained through case scenario. We recommend simulation as an effective pedagogy among novice nursing students. [ABSTRACT FROM AUTHOR]

Objective: The study was conducted to assess the level of awareness about testicular cancer and the prevalence of the practice of testicular self-examination (TSE) in the Indian expatriates in the Middle East and thereby propose appropriate interventions. Methods: A cross-sectional survey was conducted in a random sample of Indian subjects aged 15- 35 years and working in various sectors in Al-Qassim region of the Kingdom of Saudi Arabia. A questionnaire was self-designed and filled during interviews to study the awareness levels related to testicular cancer and testicular selfexamination. Results: Overall awareness level related to testicular cancer was found to be poor in 89%, fair in 10% and good in 1% of the participants of the study. The practice of correct monthly testicular self-examination was virtually nonexistent. Conclusion: Awareness regarding testicular cancer and testicular self-examination in Indian men aged 15-35 years, working in Saudi Arabia is low. Dedicated efforts are required in order to educate this large segment of at-risk population. Healthcare providers of Indian origin working in the Middle East can play effective role on this front. [ABSTRACT FROM AUTHOR]

INTRODUCTION Cancer of the oral cavity is regarded lethal with a fairly low mean 5-year survival rate. The current systematic review and meta-analysis is the first of its kind to examine, if the evidence from the Middle East and North African region indicates an association between oral cancer and tobacco; and evaluates the quality of the evidence that portrays this relationship. METHODS A search for articles was carried out in October 2017 and then crosschecked at the end of June 2018 using Medline, Web of Science, CINAHL, and Cochrane databases. Retrieved articles were later subjected to eligibility criteria. The search was not limited to any particular research design adopted by the investigators. However, dissertations, theses and opinion-based reviews generated from the search were excluded during the screening of titles and abstracts. Quality of included studies was determined objectively (Newcastle Ottawa Scale) and subjectively. Revman (Version 5.3) was used for conducting the meta-analysis. RESULTS Six studies satisfied the selection criteria of the current review. The New Castle Ottawa evaluation scale suggested that the three cross-sectional studies and the three case-control studies included in the current review were of relatively low to moderate quality. All included studies explored the association of only one form of smokeless tobacco, i.e. shammah. Three case-control studies revealed a pooled estimate odds ratio of 38.74 (95% CI: 19.50-76.96), indicating that the odds for the occurrence of oral cancer among shammah users were nearly 39 times higher compared to the non-users. CONCLUSIONS Shammah is a potential risk factor for oral cancer; thus, it is necessary that public health practitioners design and implement effective strategies to prevent the abuse of shammah. [ABSTRACT FROM AUTHOR]

Background and Aim: Long-term aspirin therapy is crucial for patients at increased risk for cardiovascular diseases. However, differing perceptions among healthcare providers profoundly shape the challenges observed in risk assessment. This study assessed the knowledge, attitudes and current practices of internists who prescribe aspirin as a preventive measure for cardiovascular diseases. Methods: A questionnaire was distributed to a total of 38 internists working at healthcare centres in Nablus, Palestine. Results: The majority of physicians (95%) reported that they prescribe aspirin for patients following a coronary artery bypass graft. About 92% of physicians prescribe aspirin for patients with a peripheral vascular disease or acute myocardial infarction, and 85% of physicians prescribe aspirin if patients have a history of stroke and congestive heart failure, or stable angina. The prescribing of aspirin as prophylaxis for patients without cardiovascular disease, but with one or more risk factors, was reported by 61% to 79% of the physicians depending on the nature and number of risk factors. In some cases, the presence of additional diseases in association with cardiovascular diseases tended to hinder physicians from prescribing aspirin. Conclusions: The majority of Palestinian internal physicians recommend the use of aspirin as a primary prevention tool for cardiovascular disease in spite of its potential negative side effects. Our results revealed that physicians in Palestine tend to prescribe aspirin with varying patterns and therefore a set of evidence-based recommendations should be implemented. [ABSTRACT FROM AUTHOR]

CONTEXT: Asthma control is suboptimal in the Middle East and North Africa (MENA). AIMS: The aim of this study is to assess the level of asthma control in Saudi patients as per the Global Initiative for Asthma 2012 classification and explore its potential predictive factors. SETTINGS AND DESIGN: Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population (ESMAA) is a multicentric, descriptive, epidemiological study assessing asthma management in the MENA region. In this article, we report the results of patients from Saudi Arabia included in the ESMAA study. METHODS: Adult patients diagnosed with asthma at least 1 year before study entry were considered for inclusion. Asthma control level and its predictive factors were explored. Treatment adherence and quality of life (QoL) were assessed by MMAS-4© and Short Form 8 Health Survey QoL questionnaires, respectively. STATISTICAL ANALYSIS USED: Descriptive statistics were done considering two-sided 95% confidence intervals. Logistic regression was used to explore the potential predictive factors of asthma control. All statistical tests were two-sided, and P < 0.05 was considered statistically significant. RESULTS: Data of 1009 patients from Saudi Arabia were analyzed. Less than one-third of patients (30.1%) were found to have controlled asthma with significantly higher QoL. High level of asthma control was reported among male patients and those with high educational level, while age, body mass index, and adherence to treatment were found to have no effect on asthma control. CONCLUSIONS: Asthma control remains suboptimal among Saudi population. This needs huge efforts to achieve acceptable levels of control and better QoL for asthma patients. Further studies are still needed in Saudi Arabia and the Middle East region. [ABSTRACT FROM AUTHOR]

Background Introducing childhood immunization poses challenges in environments of societal fragility. The Palestinian territories (Pt) are considered 'fragile' because of their lack of political, economic and territorial sovereignty. Poverty is rife, infant mortality high, and diseases associated with overcrowding widespread. Under these circumstances the Rostropovich Vishneskaya Foundation (RVF) has assembled a network of public and private stakeholders to introduce a country-wide rotavirus immunization program. Methods The incidence of diarrhea was determined for 18 months before and 18 months after the introduction of rotavirus vaccine among all children younger than 5 years presenting to outpatient clinics in Gaza with three or more loose stools per day. Simultaneously the prevalence of rotavirus was established by rotavirus antigen detection in stool samples collected from children younger than 3 years at Caritas Baby Hospital in Bethlehem during the corresponding time periods. Results Within 12 months 97.4% immunization coverage was achieved. The incidence of diarrhea dropped by 32.2%, while the prevalence of rotavirus in stool samples decreased by 64.6% throughout the following year. Conclusion In environments of economic or political instability private–public partnerships for the introduction of comprehensive vaccination programs can work based on close collaboration, shared vision, flexibility and inter-organizational trust. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to describe the clinical and immunological characteristics of systemic lupus erythematosus (SLE) in the Arab world. Materials and methods: We searched PubMed and Google Scholar for observational studies describing the clinical and serologic features of SLE in adult patients in the Arab world. We used the search terms "lupus in Arabs" and the names of individual Arab countries. Twenty-two articles from 11 countries including 3,273 patients (349 males, 2,924 females; mean age 28.9 years) met the inclusion criteria and were analyzed. Studies that reported on either clinical or serologic data in adult patients were included. Results: The mean age at disease onset was 28.9 years. The female to male ratio was 8.34:1. The most common clinical manifestations were arthralgia/arthritis (81.1%), anemia (55.6%), fatigue (53.4%), malar rash (53.1%) and renal manifestations (50.4%). Antinuclear antibodies were present in 97.2%, anti-double stranded deoxyribonucleic acid in 74.1%, anti-Ro/Sjogren syndrome A in 50.5%, anti-ribonucleoprotein in 43.5%, anti-Smith in 40.7% and anti-La/Sjogren syndrome B in 29.2%. The mortality rate was 7.6%. The frequency of various clinical and immunological manifestations varied between different regions. Conclusion: SLE displays several different clinical and serologic characteristics, both among different Arab populations and in comparison to other ethnic groups. [ABSTRACT FROM AUTHOR]

Objectives: To describe the distribution of social factors, lifestyle habits and anthropometric measurements according to hypertension and Type-2 diabetes. Methods: A cross-sectional study was conducted in Gaza City, Palestine that included 379 patients (20-60 years) who had hypertension and/or diabetes. Three groups of patients were involved; 106 hypertensive (HT), 109 diabetic (T2DM) and 164 hypertensive diabetics (HT + T2DM). Results: The HT + T2DM group were older and had a higher body mass index compared to HT and T2DM groups. There were 62.3% patients who were female, 49.2% were highly educated HT patients, and 49.3% patients had a low level of education and were HT + T2DM. There were 55.8% patients who lived in large families. Patients who were passive smokers or never smoked before were mostly HT + T2DM, while active smokers and past smokers had T2DM. There were 48.2% patients who were highly physically active who had HT, 40.9% whom were moderately active had T2DM, and 53.8% of patients who had a low level of activity were HT + T2DM. Multivariate linear regression showed that having a diseased mother, living in a large family, being a past or passive smoker, or never having smoked, having a low or moderate level of activity, and having HT or HT + T2DM, were significantly associated with an increased body mass index. Conclusion: Parental health/disease conditions and environmental factors (social network and lifestyle habits) played the greatest role in the development of obesity and disease. [ABSTRACT FROM AUTHOR]