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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.

Background: In today's healthcare systems, physiotherapists are one of the most important providers of care services to patients with disabilities including those with epilepsy. The aims of this systematic scoping review were to identify, summarize, and present narrative synthesis of qualitative evidence on knowledge, attitudes, and practices of physiotherapists toward epilepsy and patients with epilepsy., Methods: Primary studies were searched in Medline/PubMed, Embase, Science Direct, SpringerLink, CInAHL/EBSCO, Cochrane library, and Scopus as late as July 02, 2021. Appraisal of the methodological quality was conducted for the studies included in this systematic scoping review. Due to the heterogenous nature of the collected data, results of this study are presented as narrative synthesis., Results: A total of 11 were finally included in the qualitative synthesis. The selected studies were published in the period between 2016 and 2020. The studies included in this review had acceptable methodological quality in many of the 11 domains of the quality assessment tool. Contents of the included studies were grouped into the 11 themes and 8 subthemes. The major themes were related education/access to information, interaction with patients, witnessing seizures, barriers and promoters of adequate knowledge and attitudes, and interventions to improve knowledge and attitudes., Conclusion: Currently, high-quality interventional studies are needed to improve knowledge, attitudes, and practices of physiotherapists with regard to epilepsy and patients with epilepsy. Future studies are still needed to investigate if improving knowledge, attitudes, and practices of physiotherapists with regard to epilepsy and patients with epilepsy can improve health-related outcomes of the patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Overactive bladder (OAB) is a popular distressing health condition that has negative impact on health-related quality of life (HRQoL) of the inflicted individuals. This multicenter study was conducted to determine the prevalence of OAB symptoms and their impact on the HRQoL of medical and dentistry students., Methods: This study was conducted in a cross-sectional design in the 3 main universities in Palestine. In addition to the sociodemographic, health, and academic characteristics of the medical and dentistry students, the questionnaire also contained the OAB symptom bother (6-items) and HRQoL (13-items) Short-Form (OAB-q SF) scales. Kruskal-Wallis test, Mann-Whitney U test, Pearson Chi-Square/Fisher's Exact Test, Spearman's rank correlations, and a multiple linear regression model were used to analyze the data., Results: Responses were collected from medical and dentistry students (n = 402). The median OAB symptom bother score was 54.1 [44.8, 81.9] and the median HRQoL score was 94.4 [88.4, 94.4]. There was a strong negative correlation between the OAB and HRQoL scores (Spearman's rho = 64.4%, p value < 0.001). OAB scores were significantly higher among dentistry students, females, who had chronic disease, and those who reported stressful life. HRQoL scores were significantly higher among medicine students, those who reported less stressful life, and those who reported satisfaction with their social life. Dentistry students, female, and those who self-reported high stress were 1.94-fold (95% CI 1.05, 3.56), 1.91-fold (95% CI 1.16, 3.14), and 1.88-fold (95% CI 1.21, 2.91) more likely to report less than optimal HRQoL compared to medicine students, male, and those who self-reported low stress, respectively., Conclusions: Our findings suggested that OAB symptoms were prevalent among medical and dentistry students across Palestinian universities. Decision makers in academia, healthcare authorities, and advocacy groups might need to design appropriate interventions to address health and wellbeing issues of medical and dentistry students. Using appropriate diagnostic procedures, reducing stress, and improving the social life might help in reducing the burden on OAB and improve the HRQoL of medical and dentistry students. More investigations should be conducted to investigate if such interventions are effective in reducing OAB symptoms and improving HRQoL., (© 2021. The Author(s).)

Objective: This qualitative exploratory study was conducted to explore how anesthesiologists in Palestine provide perioperative care for patients with epilepsy and how they account for the unique challenges relevant to epilepsy while planning perioperative care for patients with epilepsy., Methods: This study was conducted in an explorative qualitative design. Purposive and snowball sampling approaches were used to recruit the study participants. Qualitative semi-structured in-depth interviews were conducted with anesthesiologists (n = 10) and a neurologist (n = 1). The qualitative data collected in this study were thematically analyzed using the interpretive description methodology to generate themes, subthemes, and patterns., Results: Three major themes emerged from the collected qualitative data with a total of 18 subthemes. The 3 themes were: 1) considerations/challenges while assessing patients, 2) anesthetic considerations, and 3) recovery considerations. Lack of epilepsy-specific assessment and anesthesia protocols, underuse of neurology referral services, and lack of neuromonitoring were identified., Conclusion: Findings of this study highlighted the need to develop specific anesthesia protocols for patients with epilepsy. Anesthesiologists and planners of perioperative care should improve collection of patient information and assessment methods, ensure control over seizures, reduce triggers of seizures, and improve patient monitoring approaches. Findings of this study might be used to inform anesthesiologists and decision makers in professional groups, patient advocacy groups, and healthcare authorities to benchmark and improve anesthesia care and services offered to patients with epilepsy. More studies are still needed to quantitatively assess the quality of anesthesia care and services provided to patients with epilepsy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (© 2021. The Author(s).)

Background: This scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain., Methods: The databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively., Results: Twenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items)., Conclusion: Communication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2021 Ramzi Shawahna et al.)

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., (© 2021. The Author(s).)

Background: Medical students are the future workforce of physicians in primary, secondary, tertiary, and highly specialized care centers. The present study was undertaken to assess familiarity, knowledge, confidence, of medical students with regard to autism spectrum disorders (ASDs)., Methods: This multicenter study was conducted in a cross-sectional design among medical students in the 3 main universities in Palestine. In addition to the sociodemographic and academic details, the questionnaire measured familiarity (8-items), knowledge (12-items), confidence and willingness to learn (5-items) with regard to ASDs., Results: The questionnaire was completed by309 medical students (response rate = 77.3 %). The median familiarity, knowledge, and confidence scores were 50 % (42.5 %, 57.5 %), 50 % (41.7 %, 66.7 %), and 60.0 % (54.0 %, 68.0 %), respectively. There was a positive moderate correlation between familiarity and knowledge scores (Spearman's rho = 0.29, p-value < 0.001) and familiarity and confidence scores (Spearman's rho = 0.34, p-value < 0.001). Medical students who have received a course on autism were 3.08-fold (95 % C.I. of 1.78-5.31) more likely to score ≥ 50 % on the familiarity items compared to those who did not receive a course. The medical students who were in their clinical academic stage, who received a course on ASDs, and those who interacted with individuals with ASDs were 2.36-fold (95 % C.I. of 1.34-4.18), 2.66-fold (95 % C.I. of 1.52-4.65), and 2.59-fold (95 % C.I. of 1.44-4.63) more likely to score ≥ 50 % on the knowledge items. Medical students who reported high satisfaction with their social life were 2.84-fold (95 % C.I. of 1.15-7.00) more likely to score ≥ 50 % on the confidence items., Conclusions: The present study identified considerable awareness and knowledge gaps among medical students with regard to ASDs. Medical students in this study reported low confidence in their ability to provide healthcare services to individuals with ASDs. Appropriately designed educational interventions might improve familiarity, knowledge, and confidence of medical students. More studies are still needed to investigate if such interventions can improve healthcare services for individuals with ASDs., (© 2021. The Author(s).)

Objectives: This study aimed to quantitatively, qualitatively, and visually analyze, describe, evaluate, and identify trends of the published scholarly documents on physical activity/exercise in epilepsy., Methods: Scopus database was systematically searched using the keywords relevant to "exercise" and "epilepsy". The Bibliometrix R-Tool was used to quantify, analyze, visualize, and describe the data set of the scholarly documents identified through the systematic search. Data collected from the retrieved documents were synthesized qualitatively., Results: Search of the database resulted in 182 scholarly documents reporting on physical activity/exercise in epilepsy. The scholarly documents were obtained from 93 indexed sources, authored by 516 researchers, indexed by 1311 keywords, and cited 4648 references. Epilepsy and Behavior was the fastest growing source for documents on physical exercise in epilepsy and the Universidade Federal De So Paulo in Brazil was the most productive institution in the field. Thematic analysis showed that epilepsy and physical exercise were basic themes, quality of life and depression were motor themes, and yoga was a niche theme. Quality of life and sport were trendy topics after the year 2015. A total of 14 barriers and 2 promoters of physical activity/exercise were qualitatively synthesized., Conclusion: Findings of this analysis might be helpful to librarians, institutions, and professionals interested in the field of physical activity/exercise in epilepsy. Researchers might be informed of collaboration opportunities, trendy topics, and emerging themes in the field., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: History courses are "required" elements among the didactic elements of the medical and pharmacy curricula in many schools around the world. The aim of this study was to develop consensus-based aims, contents, intended learning outcomes, teaching, and evaluation methods of a history of medicine and pharmacy course for medical and pharmacy students in the Arab World., Methods: A systematic search of PubMed, ScienceDirect, SpringerLink, Scopus, and Google Scholar was conducted to identify course aims, contents, intended learning outcomes from the literature. The search was supplemented by semi-structured in-depth interviews with 5 educators/academicians, 3 pharmacists, and 3 physicians. The Delphi technique was used among panelists (10 educators/academicians, 4 physicians, and 4 pharmacists) to develop consensus-based course aims, contents, intended learning outcomes, teaching, and evaluation methods., Results: The vast majority of the panelists agreed on the 10 items (agreement ≥88.9%) on the importance of teaching history to medical and pharmacy students. Consensus-based aims (n = 4) and intended learning outcomes (n = 13) were developed in the 1st and 2nd iterative Delphi rounds. The panelists suggested that 16 dedicated meeting hours (1 credit hour) would be required to cover the course. Bloom's verbs were used to target the lower and higher orders of the cognitive domain. The course could be taught through face-to-face lectures, provision of reading materials, video documentaries, case studies, group discussions and debates. Multiple-choice questions, written reflections, portfolios, group projects, and engagement in discussions and debates might be used to evaluate performance of students., Conclusion: Consensus-based course of history of medicine and pharmacy course was developed for medical and pharmacy students in the Arab World. Well-designed course aims, contents, intended learning outcomes, teaching, and evaluation methods are more likely to meet the accreditation requirements and might improve performance of medical and pharmacy students. Future studies are still needed to investigate if such consensus-based courses can improve performance of the students., (© 2021. The Author(s).)

Objective: Pediatric acute lymphoblastic leukemia (ALL) is the most prevalent type of cancer among children. This study was conducted to describe and correlate the clinical characteristics and outcomes of treatment of patients with pediatric ALL in the main referral hospital in Palestine., Results: Complete data of 69 patients were included in this analysis. The majority (79.7%) of the patients had B-ALL phenotype. After induction chemotherapy, remission was experienced by the vast majority of the patients and 5 (7.2%) experienced relapses. Cytogenetics for patients with B-ALL phenotype indicated that 10 (18.2%) patients had t(12, 21) translocation, 5 (9.1%) had hyperdiploidy, 4 (7.3%) had t(1, 19) translocation, and 2 (3.6%) had t(9, 22) translocation. The initial white blood cells (p value < 0.001), absolute neutrophils (p value = 0.011), and hemoglobin (p value < 0.001) were significantly lower in patients with B-cell ALL. Platelet counts were significantly lower (p value = 0.012) in patients with splenomegaly and those with bleeding symptoms (p value = 0.008). Presence of palmar pollar was positively associated (p value = 0.035) with T-cell ALL. Presence of hepatomegaly was positively associated (p value < 0.001) with splenomegaly.

Objective: This study assessed preparedness of Palestinian medical students as future physicians to care for patients with epilepsy through assessing their knowledge and attitude., Methods: The current study was conducted in a cross-sectional design. A pre-validated study tool was used to collect sociodemographic and academic details of the students, test their knowledge using a 16-item test, and test their attitude using a 13-item test., Results: A total of 386 medical students completed the study tool. The median knowledge score was 75.0% (range: 62.5% to 87.5%). The median attitude score was 81.5% (range: 73.8% to 89.2%). Knowledge and attitude scores correlated positively (Spearman's rho = 0.25, p-value < 0.001). Students who were in their clinical training stage (OR = 4.22, 95% CI of 2.54 to 7.01), who had received a course/part of a course on epilepsy (OR = 2.55, 95% CI of 1.26 to 5.17), who perceived their knowledge of epilepsy as moderate (OR = 3.14, 95% CI of 1.87 to 5.28), and those who perceived their knowledge of epilepsy as high (OR = 11.91, 95% CI of 2.47 to 57.41) were more likely to score ≥ 70% in the knowledge test compared to those who were in their basic training stage, who had not received a course/part of a course on epilepsy, and who perceived their knowledge of epilepsy as low, respectively., Conclusion: Findings of the current investigation may indicate that inclusion of courses on epilepsy early in the medical curriculum might promote knowledge of medical students with regard to epilepsy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for the treatment of various types of inflammatory conditions. Diclofenac is a very common NSAID that is utilized to relieve pain and reduce fever and, most importantly, inflammation. However, it suffers from low water solubility and a low dissolution profile. Therefore, we aim to develop a new drug delivery system based on the synthesis of amphiphilic structures that are capable of self assembling into nano-micelles which will be a water-soluble delivery system for the diclofenac. The amphiphilic structure consists of a hydrophilic moiety of triethylene glycol (TEG), polyethylene glycol PEG 400, or PEG 600 linked with the hydrophobic drug diclofenac through an ester linkage. The diclofenac derivatives were successfully synthesized as confirmed by nuclear magnetic resonance. Moreover, the formation of the micellar structure of the synthesized amphiphilic derivatives was confirmed by atomic force microscopy obtaining a spherical shape of the micelles with average diameters of 200 nm for Dic-PEG400-Dic, and 110 nm for Dic-PEG600-Dic. The critical micelle concentration has been determined as 2.7 × 10 -3 mg mL -1 for Dic-PEG400-Dic, and 1 × 10 -4 mg mL -1 for Dic-PEG600-Dic. The in vitro diclofenac release profile by esterase enzyme was conducted and showed almost complete conversion to free diclofenac within 35 h in the case of Dic-PEG400-Dic micelles and more than 85% of Dic-PEG600-Dic micelles. Then the anti-inflammatory activity was determined by testing the TNF-α production in LPS-stimulated Balb/c mice. Diclofenac micelles significantly suppressed TNF-α production after a 5 mg kg -1 dose was given. The developed micelles showed TNF-α inhibition up to 87.4% and 84% after 48 hours of treatment in the case of Dic-PEG400-Dic and Dic-PEG600-Dic micelles respectively in comparison to 42.3% in the case of diclofenac alone. Dic-PEG400-Dic micelles showed the most potent anti-inflammatory activity with improved TNF-α suppression through time progress. Therefore, the developed nano-micelles provide a facile synthetic approach to enhance diclofenac water solubility, improve the anti-inflammatory effect and achieve a sustained release profile to get better patient compliance., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Background: Among all cancers, breast cancer is the most prevalent cancer and the leading cause of mortality among women in developing countries including Palestine. Community pharmacists are trusted and easily accessible healthcare providers who could be engaged in breast cancer health promotion. This study was conducted with the aim of exploring knowledge, attitudes, beliefs, and barriers toward breast cancer health promotion among community pharmacists in the Palestinian territories., Methods: This study was conducted in a cross-sectional design using a questionnaire among community pharmacists. Knowledge of community pharmacists of breast cancer was tested using a 26-item knowledge test. Attitudes and beliefs of the community pharmacists with regard to breast cancer promotion were explored using 14 items. Barrier to breast cancer health promotion were explored using 9 items., Results: Data were collected from 200 community pharmacists. The median knowledge score was 69.2 % with and IQR of 15.2 %. Of the community pharmacists, 67.5 % scored 50 % and above in the knowledge test. Multivariate logistic regression showed that community pharmacists who were female in gender were more likely to score 50 % and above in the knowledge test compared to the community pharmacists who were male in gender (OR = 4.73, 95 % CI of 2.26-9.89). The community pharmacists had positive attitudes toward breast cancer health promotion. There was a significant moderate positive correlation between knowledge and attitudes scores (Spearman's rho = 0.37, p-value < 0.001). Lack of reimbursement, lack of enough personnel, lack of time, and fear of offending the patients were the main barriers to breast cancer health promotion (percentage of agreement > 60.0 %)., Conclusions: This study shed light on the role of community pharmacists in breast cancer health promotion. Pharmacists had good knowledge of breast cancer and positive attitudes toward promoting the health of patients with breast cancer. Further studies are still needed to determine how to integrate community pharmacists in the team of healthcare providers caring for patients with breast cancer.

Background: In Palestine, type 2 diabetes mellitus (T2DM) is a rapidly growing health concern. This study evaluated knowledge, attitude, and practice of patients with T2DM with regard to their disease. The study also investigated association and correlation between knowledge, attitude, and practice with sociodemographic and clinical characteristics of the patients. Predictors of higher knowledge, positive attitude, and good practice were also identified., Methods: This cross-sectional study was conducted in primary healthcare facilities frequently visited by patients with T2DM across the West Bank of Palestine in the period of October 2018 to January 2019. An interviewer administered questionnaire was used to determine knowledge, attitude and practice of patients with T2DM with regard to their disease., Results: Out of 300 patients invited, 220 (73.3%) patients responded. In this study, the median age was 57.0 years (51.0, 65.0), the median time elapsed since diagnosis with T2DM was 7.0 years (4.0, 14.0), the median fasting blood glucose was 150.0 mg/dL (128.8, 180.0), the median postprandial glucose was 230.0 mg/dL (200.0, 270.0), the median HbA 1c was 7.8% (7.0, 8.53), and the median BMI was 28.8 kg/m 2 (25.5, 33.1). The median knowledge score was 6.0/13.0 (4.5/13.0, 7.5/13.0), the median attitude score was 3.0/4.0 (2.0/4.0, 4.0/4.0), and the median practice score was 3.0 (1.0/5.0, 4.0/5.0). Having university education was strongly associated with having higher knowledge scores (p-value = 0.001). Additionally, having attended an educational program on diabetes was moderately associated with higher practice scores (p-value = 0.026)., Conclusions: Findings of this study highlighted the need for appropriately designed interventions to increase knowledge about T2DM among patients with low educational level. Well-designed educational programs might promote healthy practice among patients with T2DM. Future studies are still needed to assess if such interventions could be effective in improving health outcomes and quality of life of patients with T2DM in Palestine.

Prediction of performance of traditional, reformulated, and novel oral formulations in adults and pediatrics is of great importance. This study was conducted to assess solubility of celecoxib in age-appropriate fasted- and fed-state gastric and intestinal biorelevant media, classify celecoxib into biopharmaceutical classification system (BCS), and assess the effects of age-related developmental changes in the composition and volume of gastrointestinal fluids on the solubility and performance of oral formulations containing celecoxib. Solubility of celecoxib was assessed at 37°C in the pH range specified by the BCS-based criteria in 13 age-appropriate biorelevant media reflective of the gastric and proximal small intestinal environment in both fasted and fed states in adults and different pediatric subpopulations. A validated HPLC-UV method was used to quantify celecoxib. Experimental and computational molecular descriptors and in vivo pharmacokinetic data were used to assign the permeability class of celecoxib. Celecoxib belonged to BCS class 2. The pediatric to adult solubility ratios were outside the 80-125% boundaries in 3 and borderline in 1 biorelevant media. Significant age-related variability could be predicted for oral formulations containing celecoxib intended for pediatric use. Findings of this study indicated that the criteria used in the adult BCS might not be directly applied to pediatric subpopulations.

Background and Aims: Type 2 diabetes mellitus (T2DM) is a rapidly growing public health issue. This systematic review aimed to narrate and qualitatively synthesize evidence and recommendations of physical activity/exercise for patients with T2DM., Methods: The databases Medline through Pubmed, Cochrane, and Scopus were systematically searched from inception to February 08, 2020 using MeSH terms related to "diabetes mellitus" and "physical activity/exercise". Studies were included if they reported on the roles of physical activity/exercise in managing patients with T2DM or effects of physical activity/exercise on glycemic control. Documents identified through the search were analyzed and evidence and recommendations were synthesized qualitatively., Results: Data were extracted from 16 original articles and 11 systematic reviews with meta-analyses. A qualitative summary of evidence included general items (n = 6) and recommendations for physical activity/exercise (n = 12). Physical activity/exercise can reduce incidence of T2DM, hyperinsulinemia, fasting plasma/blood glucose, HbA1c, body fats, cholesterol, blood pressure, heart rate, cardiovascular risk, and dosage of antidiabetic medications. Physical activity/exercise can improve sensitivity to insulin, muscle strength, oxygen consumption, aerobic capacity, and mental health of patients with T2DM., Conclusion: Despite the increasing interest in incorporating physical activity/exercise in the management of T2DM and improving healthcare delivery, there are still limited clear instructions and guidelines for both the patient and the healthcare provider., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

This study aimed to develop a topical emulgel formulation from olive oil and lemongrass (LG) extracts and to evaluate its in vitro and in vivo (sensorial) properties in addition to its sun protection factor (SPF) value. The primary emulsion and the gel were prepared separately, and then they were levigated together to formulate the emulgel. The produced emulgel was evaluated for its physical appearance, pH, spreadability, and stability. The SPF value of emulgel was evaluated by applying the Mansur equation. Moreover, an in vivo sensorial assessment was conducted on the emulgel through a crossover study by including 20 volunteers. The results confirm good stability for emulgel formulations because there was no significant change in the pH value, no micelle inversion, or phase separation detected. The emulgel recorded a moderate SPF value (5.5) which can be useful for daily use, especially in tanned skin subjects. Moreover, the sensorial assessment of LG and blank emulgels showed a significant change in the cooling effect, odor, and smoothness and add some kind of moisture. In fact, there was a significant difference in overall properties between the two formulations where the p -value was less than 0.05. It is concluded the emulgel formulation containing LG and olive oil could be beneficial in terms of applicability and stability and can be easily formulated in pharmaceutical facilities. Besides, it would be useful for daily use because of the overall suitable properties, especially odor, feel, and SPF value.

Background: Therapeutic drug monitoring (TDM) can play a major role in optimizing pharmacotherapy of epilepsy. This study was conducted to explore views and opinions of clinicians who care for patients with epilepsy (PWE) in Palestine and to develop consensus-based recommendations with regard to importance, justification, technical, and analytical issues of TDM of antiepileptic drugs (AEDs)., Methods: The study was conducted in three phases: (1) the published literature was thoroughly searched for an initial list of items relevant to TDM of AEDs, (2) the list was supplemented by items provided by key experts (n = 8) through semi-structured in-depth interviews, (3) views and opinions of clinicians (n = 20) on TDM of AEDs were explored, and (4) a two-round Delphi technique was followed among a panel of experts (n = 27) to develop consensus-based recommendations to guide TDM of AEDs in Palestine., Results: Consensus was achieved on items related to importance (8 items) of TDM of AEDs, clinical justifications of TDM of AEDs (19 items), guidelines for optimal TDM of AEDs (11 items), TDM of some AEDs (21 items), TDM practice (24 items), and some technical and analytical issues in TDM of AEDs (13 items)., Conclusion: Consensus-based recommendations that might be used in guiding TDM of AEDs in Palestine were developed. Future studies are still needed to investigate if these consensus-based recommendations can improve healthcare of PWE in Palestine., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This study was conducted to assess the degree of agreement of Palestinian nursing students with recommendations and key messages to eliminate/reduce epilepsy stigma and change perception of the general public about epilepsy and people with epilepsy (PWE)., Methods: A cross-sectional observational study was conducted among undergraduate nursing students. The study tool was a questionnaire with 24 items which collected the sociodemographic and academic characteristics of the participants (6 items) and agreements with 18 recommendations and key messages to eliminate/reduce epilepsy stigma., Results: A total of 342 nursing students completed the questionnaire with a response rate of 68.4%. The participants agreed with the 6 recommendations to inform media, improve awareness, and educate the general public on epilepsy (agreement rates: 87.7% to 92.4%), 4 recommendations to coordinate efforts to improve awareness and educate the general public on epilepsy and PWE (agreement rates: 89.8% to 93.0%), and 8 key messages to eliminate/reduce epilepsy stigma (agreement rates: 70.2% to 93.9%). In general, female students tended to express significantly higher levels of agreement with the recommendations and key messages (p-value < 0.05)., Conclusion: Results of the present study highlighted the importance of involving nurses and future nurses in eliminating/reducing epilepsy stigma and changing perception of the general public about epilepsy and PWE. Further studies are to be conducted to investigate if these recommendations and messages can eliminate or significantly reduce epilepsy stigma and change perception of the general public about epilepsy and PWE., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Physicians and complementary alternative medicine (CAM) specialists are not formally educated/trained on the benefits of exercises for people living with epilepsy (PWE). This study was performed to develop a consensus-based knowledge items on the benefits of exercises for PWE that physicians and CAM specialists need to know., Methods: Knowledge items were collected after an extensive review of the scientific literature and from in-depth interviews with key contacts in the domain (6 primary healthcare providers, 4 neurologists, 4 exercise and medicine specialists, 4 CAM practitioners, 4 researchers who did studies on the benefits of exercise for PWE, and 4 PWE). Items collected were reviewed by 12 researchers who did studies on exercise for PWE. A Delphi technique was followed among a panel of 50 members to develop the consensus-based core list., Results: The final consensus-based core list contained 64 items that were grouped into the following categories: 1) general items recommending exercise for PWE, 2) benefits of exercise on prevention of seizures, 3) benefits of exercise on antiepileptic therapy, 4) benefits of exercise in preventing comorbidities associated with epilepsy, 5) benefits of exercise in improving quality of life of PWE, and 6) psychosocial benefits of exercise for PWE., Conclusion: This consensus-based core list might guide educators, trainers, or authorities while designing educational or training courses to increase knowledge of physicians in primary healthcare and CAM specialists with regard to the benefits of exercise for PWE. Further investigations are needed to determine if such consensus-based core list might improve care and wellbeing of PWE., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The current study was performed to develop a consensus-based core inventory of key performance indicators (KPIs) to be used in capturing the impact of pharmaceutical care in healthcare facilities that employ integrative medicine paradigm in Palestine., Methods: A panel of healthcare professionals and risk/quality assurance managers was composed employing a judgmental sampling technique. The study tool was a questionnaire. Views and opinions of the panelists on the roles of pharmacists in caring for patients admitted to or visiting healthcare facilities that employ integrative medicine were collected using 11 statements. An initial inventory of activities and services that potentially can be used as KPIs was compiled from the literature and interviews with key contact experts in the domain. Three iterative Delphi rounds were conducted among the panelists ( n  = 50) to achieve formal consensus on the KPIs that should be used. The consensus-based KPIs were ordered by the scores of the panelists., Results: A total of 8 consensus-based KPIs were developed. The KPIs related to the number of problems related to medications and complementary and alternative medicine (CAM) that were resolved by pharmacists and CAM practitioners ( p  < 0.0001), number of patients for whom reconciliations were documented ( p  < 0.0001), number of patients receiving direct, comprehensive, and/or collaborative care ( p  < 0.0001), and number of patients for whom pharmacists and CAM practitioners were involved in implementing a therapeutic plan ( p  < 0.05) were rated significantly higher than the KPI (#8) related to the participation in multi-healthcare provider discussions/deliberations., Conclusions: Consensus-based KPIs that can be used in capturing the impact of evidence-based CAM and pharmaceutical care of patients in healthcare facilities that employ integrative medicine paradigm were developed. Future studies are still needed to investigate if implementing these KPIs might promote evidence-based CAM and pharmaceutical care in healthcare facilities that employ the integrative medicine paradigm., Competing Interests: The author declares no conflicts of interest., (Copyright © 2020 Ramzi Shawahna.)

Background: Co-existence of depression and anxiety can be associated with severe detrimental consequences to the physical, mental and social wellbeing of the affected populations. This study was conducted to determine prevalence of depressive and anxiety symptoms among Palestinian medical students and to investigate associations between sociodemographic factors of the students with depressive and anxiety symptoms., Methods: This study was conducted in a cross-sectional observational design using a questionnaire in the period between September 2018 and April 2019 in a major university in the West Bank of Palestine. Depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II) and anxiety symptoms were assessed using the Beck Anxiety Inventory (BAI). The questionnaire also collected the sociodemographic characteristics of the students. Reliability of the questionnaire was tested using the test re-test method. A total of 425 medical students were invited to participate in the study., Results: Of those invited, 286 students completed the questionnaire, giving a response rate of 67.3%. More than half (56.6%) of the students had minimal depression, 20.3% had mild depression, 14.0% had moderate depression, 9.1% had severe depression, 23.4% had no anxiety, 29.7% had mild to moderate anxiety, 25.5% had moderate to severe anxiety, and 21.3% had severe anxiety. Multiple linear regression analysis showed that academic stage (p-value < 0.01), Grade Point Average (p-value < 0.01), mental health status (p-value < 0.001), ever attempted suicide (p-value < 0.05), and religious commitment (p-value < 0.01) were predictors of BDI-II scores. Multiple linear regression analysis showed that academic stage (p-value < 0.05) and mental health status (p-value < 0.001) were predictors of BAI scores., Conclusions: Depressive and anxiety symptoms were prevalent among Palestinian medical students in a major university in the West Bank of Palestine. Interventions might be designed to improve self-rated mental health of medical students in their academic years, ameliorate study conditions, and provision of counseling services to improve spirituality might be effective in reducing symptoms of depression and anxiety among medical students in Palestine. Future studies are still needed to investigate if these interventions could be useful in reducing depressive and anxiety symptoms among Palestinian medical students.

Background: Recently, there has been shifts from providing large volumes to providing higher quality of healthcare services. This qualitative exploratory study was conducted to explore the views of different stakeholders on activities and services that could serve as quality indicators of pharmaceutical care in Palestinian integrative healthcare facilities., Methods: A judgmental sampling technique was used to invite and recruit stakeholders for this study. Semistructured in-depth interviews were conducted with the stakeholders. Data collected during the interviews were qualitatively analyzed using the interpretive description methodology. Themes, subthemes, and patterns were recognized using the Qualitative Analysis Guide of Leuven. The data were coded using RQDA software., Results: Interviews ( n  = 22) were conducted with 9 complementary and alternative medicine practitioners, 8 pharmacists, 2 physicians, 2 nurses, and 1 risk/quality assurance manager. The interview median duration was 41 with an IQR of 22 min. Following the thematic analysis adopted to achieve the objectives of this study, six major themes emerged from the data collected from the interviews. The themes emerged from the data were (1) provision of collaborative, direct, and comprehensive patient care services; (2) common services and activities at the time of admission, during stay, at transition between wards/services/hospitals, and at discharge to home or community care; (3) screening for, identifying, and resolving problems; (4) collaboration with other healthcare providers; (5) professional development; and (6) performance and efficiency., Conclusions: Quality indicators are invaluable for informing decisions relevant to justifying allocation of scarce resources, securing funds, and demonstrating value in activities and services within integrative healthcare facilities. Further studies are still needed to develop a set of measurable indicators to measure the impact of pharmaceutical care in integrative healthcare facilities., Competing Interests: The author declares no conflicts of interest., (Copyright © 2020 Ramzi Shawahna.)

Objectives: Yoga is believed to play a role in stabilizing the electroencephalogram and the autonomic nervous system, thus might help control seizures in people with epilepsy (PWE). This qualitative study was conducted to explore experiences of Palestinian PWE with regard to benefits, motives, barriers, and recommendations of prescribing yoga exercises as a nonpharmacological intervention., Methods: Purposive and snowball sampling techniques were used to recruit PWE who practiced yoga. Semi-structured in-depth interviews (n = 18) were conducted with the study participants. The interpretive description method was used to qualitatively analyze the data collected during the interviews., Results: Following the thematic analysis adopted for this study, four major themes emerged. These themes were as follows: perceived benefits of yoga, motives to practice yoga, barriers to practice yoga, and recommendations on effective yoga practice for PWE. The perceived benefits included improvements in management of seizures, psychological, physical, and social well-being. People with epilepsy were motivated by the health benefits of yoga. Barriers of adherence to practice included personal and logistic factors. The interviewees recommended tailoring yoga sessions to the needs of PWE., Conclusion: This explorative qualitative study reported perceived benefits, motives, barriers, and recommendations of yoga as a nonpharmacological intervention for PWE. People with epilepsy used yoga as a beneficial nonpharmacological intervention to improve their health and reduce the negative effects of epilepsy on their physical and psychosocial well-being. Future studies are needed to investigate the health benefits of yoga when sessions are tailored to the needs of PWE., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This study was conducted to investigate if crossword puzzles as active learning tools can improve the knowledge retention of nursing students in pharmacology of epilepsy and improve their performance in writing the correct spelling of antiepileptic drugs (AEDs)., Methods: The present study was a randomized controlled prospective parallel study in which a control group design with pretests and posttests were used among nursing students. Students were randomly allocated to either control group (n = 114) who received routine learning or intervention group (n = 110) who received crossword puzzles. Both control and intervention groups had to complete multiple-choice question (MCQs) and spelling pretests and posttests., Results: Scores of the MCQs and spelling pretests were not statistically different (p-value > 0.05) for participants in all achievement categories in both control and intervention groups. In the intervention group, scores in the first and second MCQs and spelling posttests were significantly higher than their corresponding scores in the pretest scores for participants from the all achievement categories (p-value < 0.05) and scores of the first and second MCQs and spelling posttests were not significantly different (p-value > 0.05). Data analyses showed that there were significant normalized changes between scores of students in across all achievement categories., Conclusion: Findings of this study suggested that crossword puzzles were effective in improving the learning of nursing students about the pharmacology of epilepsy and writing correct spelling of AEDs. Educators should consider using crossword puzzles as active learning tools to improve knowledge of nursing students about the pharmacology of epilepsy., Competing Interests: Declaration of competing interest The authors report no relationships that could be construed as a conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recently, measuring and benchmarking provision of healthcare services has drawn a considerable attention. This scoping review was conducted to identify, describe, and summarize studies in which the Delphi technique was used to develop quality indicators of pharmaceutical care. The study also aimed to identify activities and services that could be used to capture the impact of pharmacist in integrative medicine., Methods: Databases were searched from inception to February 2020 using key terms that were combined using Boolean operators. Studies were included if they were relevant to development of quality indicators of pharmaceutical care with regard to medications or complementary and alternative medicine (CAM) modalities. Full text of the selected studies was imported into EndNote. Studies were screened and data were extracted into a standard extraction form., Results: Data were extracted from 31 studies. Of those, 24 (77.4%) were related to provision of pharmaceutical services relevant to medications and 7 (22.6%) were related to provision of care using CAM modalities. Most of the studies (67.7%) were published in 2010 and beyond. Almost half of the studies (48.4%) originated from the United States, United Kingdom, and Canada. A total of 42 different activities and services that could be used as quality indicators were identified from the studies included in this review. Activities and services were related to history taking, performing reconciliations, identifying and resolving therapy problems, providing collaborative care, designing care plans, optimal performance, and continuing education., Conclusions: Although there is an increasing interest in improving healthcare delivery, quality indicators of pharmaceutical services and those relevant to CAM provision in healthcare facilities adopting the integrated healthcare paradigm are still limited. Future studies are needed to develop validated quality indicators that could be successfully used in measuring and benchmarking quality of services in integrated healthcare facilities., Competing Interests: The author declares no conflicts of interest., (Copyright © 2020 Ramzi Shawahna.)

Background: Hen eggs contaminated with lead can be harmful to the health of children and adults. The objective of this pilot study was to investigate if sub-chronic treatment with ascorbic acid can reduce lead levels in the different parts of hen eggs after intentionally exposing the laying hens to a concentrated source of lead., Methods: Clinically normal mixed-breed egg laying hens (n = 18) were used in this pilot study. Hens were exposed to a concentrated source of lead (200 mg/kg body weight /day lead acetate) for 1 week. Subsequently, egg laying hens were either treated with sub-chronic doses of ascorbic acid (500 mg/kg body weight /day) or left untreated for 4 weeks. Lead levels were assessed in egg-shell, egg-albumen, and egg-yolk samples using a graphite furnace atomic absorption spectrophotometer., Results: Lead levels increased significantly (p-value < 0.01) from baseline in egg-yolk, egg-albumen, and egg-shell samples following 1 week exposure to lead acetate. Sub-chronic treatment of egg laying hens with high doses of ascorbic acid could bring statistically significant reduction (p-value < 0.01) in lead levels in egg-yolk, egg-albumen, and egg-shell samples after intentional exposure to a concentrated source of lead., Conclusions: Findings of this pilot study showed that sub-chronic treatment of egg laying hens with ascorbic acid can reduce lead levels in different egg parts after intentional exposure to a concentrated source of lead. Supplementing feedstuffs and water with sources of ascorbic acid could be beneficial in reducing lead levels in hen egg tissues following environmental exposure. Further studies are still required to investigate if ascorbic acid can reduce lead levels in other chicken tissues.

Objective: This study assessed knowledge and attitudes of undergraduate nursing students toward epilepsy and patients with epilepsy (PWEs). Associations between different sociodemographic and academic variables and knowledge and attitude scores were also assessed., Methods: The present study was conducted in a cross-sectional observational design among Palestinian undergraduate nursing students using a prevalidated and reliable questionnaire of 38 items. After collecting sociodemographic and academic characteristics, students answered a knowledge test (16 items) and attitude test (13 items)., Results: The questionnaire was completed by 342 nursing students. The median knowledge score was 65.6 with an interquartile range (IQR) of 31.3, and the median attitude score was 81.5 with an IQR of 20.0. Multiple linear regression analyses showed that higher knowledge scores were predicted by being female in gender (p-value <0.05), had a course/studied about epilepsy (p-value <0.001), self-rated knowledge about epilepsy as high (p-value <0.05), and ever witnessing a PWE experiencing seizures (p-value <0.001). Higher attitude scores were predicted by self-rated knowledge about epilepsy as high (p-value <0.001), had a course/studied about epilepsy (p-value <0.05), and ever witnessed a PWE experiencing seizures (p-value <0.05)., Conclusion: Nursing students had moderate knowledge of epilepsy and had generally positive attitudes toward PWEs. Findings of this study highlighted knowledge gaps and areas for improvement. As knowledge scores were positively correlated with attitudes, probably, findings of this study might suggest that educational/training interventions can improve knowledge as well as positive attitudes of nursing students with regard to epilepsy and PWEs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The present study was conducted among pharmacy students to use an 8-step systematic approach to facilitate discussions, deliberations, and decision-making on what to do when facing a dilemma of a patient with epilepsy who drives while having breakthrough seizures., Methods: A hypothetical case was developed using the 12-tips for developing dilemma case-based assessments in health education. A mixed method was used in this study. A serial group discussions based on the nominal group technique (NGT) method were applied. A thorough review of the literature and interviews with key experts in the domain (n = 12) were conducted to obtain pertinent data to inform discussions, deliberations, and decision-making. The analytic hierarchy process (AHP) was used to pairwise compare countervailing arguments and alternative courses of action., Results: In this study, 3 nominal groups were held, and for each 3, discussion rounds were conducted. A total of 27 panelists took part in the nominal groups. Compared with other alternative courses of action, significantly higher weight scores (p-value < 0.001) were given to the course action, "the pharmacist could counsel/educate the patient on the dangers/risks of driving while experiencing breakthrough seizures, inform the patient to refrain from driving in this period, and make a shared decision with the patient to refrain from driving in this period and inform the state authorities"., Conclusion: This study demonstrates that the 8-step approach when combined with the AHP can be a handy method in facilitating decision-making while addressing and resolving ethical/legal/professional dilemmas in daily healthcare practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Electronic health records (EHRs) with embedded clinical decision support systems (CDSSs) have the potential to improve healthcare delivery. This study was conducted to explore merits, features, and desiderata to be considered when planning for, designing, developing, implementing, piloting, evaluating, maintaining, upgrading, and/or using EHRs with CDSSs., Methods: A mixed-method combining the Delphi technique and Analytic Hierarchy Process was used. Potentially important items were collected after a thorough search of the literature and from interviews with key contact experts (n = 19). Opinions and views of the 76 panelists on the use of EHRs were also explored. Iterative Delphi rounds were conducted to achieve consensus on 122 potentially important items by a panel of 76 participants. Items on which consensus was achieved were ranked in the order of their importance using the Analytic Hierarchy Process., Results: Of the 122 potentially important items presented to the panelists in the Delphi rounds, consensus was achieved on 110 (90.2%) items. Of these, 16 (14.5%) items were related to the demographic characteristics of the patient, 16 (14.5%) were related to prescribing medications, 16 (14.5%) were related to checking prescriptions and alerts, 14 (12.7%) items were related to the patient's identity, 13 (11.8%) items were related to patient assessment, 12 (10.9%) items were related to the quality of alerts, 11 (10%) items were related to admission and discharge of the patient, 9 (8.2%) items were general features, and 3 (2.7%) items were related to diseases and making diagnosis., Conclusions: In this study, merits, features, and desiderata to be considered when planning for, designing, developing, implementing, piloting, evaluating, maintaining, upgrading, and/or using EHRs with CDSSs were explored. Considering items on which consensus was achieved might promote congruence and safe use of EHRs. Further studies are still needed to determine if these recommendations can improve patient safety and outcomes in Palestinian hospitals.

Background: Medication transcription errors (MTEs) are frequent in hospitalized patient settings. Definitions and scenarios that represent potential MTEs in the Palestinian nursing practice were not previously approached using formal consensus techniques. This investigation was conducted to develop a consensual definition of MTEs and scenarios that represent different MTE situations by a panel of nurses and other healthcare professionals., Methods: In this observational study, consensus was sought using the Delphi technique. Panelists (n = 64) were invited and recruited from different hospitals in Palestine and a two-iterative rounds Delphi technique was used to achieve consensus on a proposed definition of MTEs and 76 different scenarios representing potential MTEs., Results: Consensus was achieve to accept the definition and to consider 69 of the 76 proposed scenarios (77.6%) as MTEs, exclude 3 scenarios (3.9%), and 4 scenarios (5.3%) remained equivocal. Equivocal scenarios might be considered as MTEs or not depending on the clinical situation., Conclusions: Consensus was achieved on a definition of MTEs and scenarios representing MTEs by a panel of nurses and other healthcare professionals. This study showed that it was possible to develop and achieve consensus on a definition and scenarios representing MTE situations using formal consensus techniques. Such consensual definitions could be useful in future epidemiological studies investigating MTEs. Using consensual definitions might reduce methodological variations, promote congruence in error counting and reporting, and permit comparing error rates in different hospital settings.

Objective: This study was conducted to develop and achieve formal consensus on a core set of key performance indicators (KPIs) that can be captured in measuring the impact of pharmacists in caring for patients with epilepsy (PWE) visiting epilepsy clinics as outpatients in primary healthcare practice., Methods: In this study, a comprehensive literature search and review was conducted to extract candidate KPIs. Interviews with key contacts (6 pharmacists, 2 neurologists, 3 nurses, and 3 PWE) were also conducted to supplement the inventory set of KPI candidates. A three-round Delphi technique was followed among a panel of 40 members to achieve formal consensus on a core list of KPIs. Consensual KPIs were ranked by the ratings of the panelists., Results: The final consensual core set contained 8 KPIs in the thematic activity areas of pharmaceutical care, medication reconciliation and best possible medication history, patient education/counseling, interprofessional patient care, competence, and performance efficiency/patient satisfaction. The KPIs related to therapy problems identified and resolved by pharmacist and provision of proactive comprehensive direct patient care by a pharmacist received significantly higher (p-value: 0.0001) scores compared to the KPI related to complaints about pharmacists received., Conclusion: Eight consensual KPIs to capture in measuring the impact of pharmacists in caring for PWE visiting epilepsy clinics as outpatients in primary healthcare practice were developed using the Delphi technique. If successfully adopted, implemented, captured, and analyzed, these consensual KPIs might help advance pharmaceutical care of PWE in primary healthcare practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Exercise has physiologic and psychological benefits for cancer patients and survivors. Today, various exercises are recommended as adjunct to therapies for cancer patients and survivors. This study was conducted to develop a consensual core list of important knowledge items that primary healthcare providers and complementary and alternative medicine (CAM) practitioners need to know on the role of exercises and physical activities in stimulating anticancer immunity., Methods: Knowledge items were collected following interviews with key contact experts (4 oncologists, 3 exercise and medicine specialists, 2 researchers, 2 cancer patients, and 3 survivors) and extensive literature review. The collected knowledge items were rated by 9 researchers who conducted research on exercise and cancer. A modified two-iterative Delphi technique was employed among a panel ( n = 65 ) of healthcare providers and CAM practitioners to develop the consensual core list of knowledge items., Results: Of the 49 knowledge items, consensus was achieved on 45 (91.8%) items in 6 categories. Of those, 9 (20.0%) were general items on recommending moderate to vigorous habitual exercises and physical activities. The rest of items were related to the effects of habitual exercises and physical activities on the functions of immune system and exposure to carcinogens 16 (35.6%), anticancer therapies 12 (26.7%), metastasis of cancer 3 (6.7%), metabolism within tumors 3 (6.7%), and myokines release 2 (4.4%)., Conclusion: Formal consensus was achieved for the first time on a core list of knowledge items on how exercises and physical activities might stimulate anticancer immunity. This core list might be considered at the time of developing training/educational interventions and/or continuing education for primary healthcare providers and CAM practitioners. Future studies are still needed to investigate if such consensual lists might improve congruence in cancer care continuum and improve survival rates and wellbeing of cancer patients and survivors.

Background: Dyslipidemia is among the most significant risk factors of cardiovascular disease. Many patients with dyslipidemia fail to meet certain therapeutic targets as a result of clinical inertia., Aims: To explore the views and opinions of physicians who often see and provide healthcare to patients with dyslipidemia on clinical inertia and to achieve consensus on the factors they believed promote clinical inertia in the Palestinian clinical practice., Methods: This study was conducted in an observational design using the Delphi technique as a formal consensus method. A panel of fifty physicians participated this study. A two Delphi rounds were followed to achieve consensus on a list of factors they believed promoted clinical inertia., Results: The majority (86%) of the panelists believed that clinical inertia was prevalent in caring for patients with dyslipidemia. Of the 40 factors initially included in the questionnaire, consensus was achieved on 21 (52.5%) factors related to the physician, 10 (25.0%) factors related to the patient, and 5 (12.5%) factors related to the office and healthcare system as promoters of clinical inertia in the first and second Delphi rounds., Discussion: This study highlights factors promoting clinical inertia in managing dyslipidemia from the views of physicians who often provide healthcare to patients with dyslipidemia., Conclusion: Consensus was achieved on factors related to the physician, patient, and healthcare system that promote clinical inertia in caring for patients with dyslipidemia in the Palestinian clinical practice by a panel of physicians who often provide healthcare to those patients. Further studies are still needed to design strategies to eliminate or reduce the phenomenon of clinical inertia in caring for patients with dyslipidemia and improve patient outcomes., (Copyright © 2019 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Background: In daily practice, healthcare practitioners face many challenges in ethical and professional decision making. Currently, little is known on the ethical and professional deliberations and weighing benefits against risks in daily complementary and alternative medicine (CAM) practice. The aim of this study was to combine the Utrecht method and the Analytic Hierarchy Process (AHP) in deliberations, weighing benefits against risks of using ginger for a pregnant woman suffering nausea and vomiting of pregnancy (NVP) along with other comorbidities., Methods: A hypothetical case was constructed using the twelve tips for constructing dilemma case-based assessment. Three CAM practitioners, two physicians, three pharmacists, and two patients were recruited, and the Utrecht and the AHP methods were combined and used to deliberate and weigh benefits against risks of using ginger for the presented case., Results: Responses from the ten panelists were obtained. Priority ratings showed significantly higher scores ( p -value < 0.001) for alleviating symptoms of NVP (30.7%  ± 16.6%) compared to other potential benefits. Increasing the risk of bleeding was given significantly higher ( p -value < 0.0001) weight scores (24.7%  ± 13.5%) than other potential side effects. Potential risk of spontaneous abortion and risk of impairment of fetal development were given higher ( p -value < 0.001) weight scores than risk of fetal hypoglycemia. When benefits were compared against side effects and risks to the fetus and pregnancy, potential benefits were given higher ( p -value < 0.001) weight scores (72.3%  ± 5.2%)., Conclusions: Considering the anticipated benefits and risks, a shared decision was made to use ginger in the case presented. The woman should also be informed of the potential side effects and risks of using ginger. The use of this combined method might promote openness and transparency in making shared decisions for healthcare providers and patients.

Inflammation is a nonspecific response of tissues to diverse stimuli and/or insults associated with the release of various mediators that induce pain, fever, and general sense of illness. Such responses can be reduced by the administration of non-steroidal or steroidal anti-inflammatory drugs. These anti-inflammatory drugs are associated with various side effect. However, the combination of non-steroidal anti-inflammatory drugs (NSAIDs) with glucocorticoids provides a synergistic anti-inflammatory and pain relief with less side effects. In this study, we aimed to synthesize a novel twin-drug of Dexamethasone-Diclofenac formulated into polylactide (PLA) nanoparticles to improve their solubility and provide a sustained release system. The twin-drug was synthesized through an esterification reaction which was then encapsulated into PLA nanoparticles. The hydrolysis of the synthesized twin-drug and drug release from PLA nanoparticles were studied in vitro with and without esterase enzyme. The anti-inflammatory activity was studied in BALB/c mice. After the successful synthesis of the twin-drug, its water solubility was improved by its encapsulation into PLA nanoparticles with a loading capacity of 66%. The in vitro release showed a sustained release profile of the twin-drug up to 52 h. The esterase hydrolysis showed a rapid release with a maximum hydrolysis after 1.5 h. Moreover, the anti-inflammatory activity exhibited a synergistic effect with a higher percentage of inhibition for the TNF-α level in comparison to the parent drugs after 6 h treatment. In conclusion, the prepared nano twin-drug is a novel therapy that showed a sustained release profile with an excellent anti-inflammatory activity., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: The current study was carried out to examine prevalence of complications related to diabetes mellitus (DM) and to investigate association between clinical variables and biochemical factors with complications of DM in patients treated in primary healthcare settings in the West Bank of Palestine., Materials and Methods: Sociodemographic, clinical, and biochemical variables were collected from 385 patients visiting 17 primary healthcare settings in the West Bank. Patients provided blood and urine samples, responded to a questionnaire interview, and were subjected to ophthalmic examination., Results: HbA 1c levels were predicted by duration of DM (p < 0.001), HDL (p = 0.011), alkaline phosphatase (p = 0.001), blood urea (p = 0.006), and LDL (p = 0.008). Triglycerides levels were predicted by blood urea (p = 0.002), HDL (p < 0.001), and total cholesterol (p < 0.001). GOT levels were predicted by LDL (p = 0.002) and GPT (p < 0.001). GPT levels were predicted by HDL (p = 0.003) and blood urea (p = 0.025). Urine albumin were predicted by total cholesterol (p = 0.001), LDL (p = 0.005), and blood urea (p = 0.036). CD ratio was predicted by the IOP and the IOP was predicted by the CD ratio (p = 0.001)., Conclusions: Prevalence of complications related to DM was high among patients with DM treated in primary healthcare practice. These complications and risk factors were predicted by certain clinical characteristics and biochemical factors. Policies and programs are needed to manage these modifiable risk factors., (Copyright © 2018 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Pregnant and nursing women are at higher risk of zinc deficiency which can have detrimental consequences on health. We assessed blood zinc levels in 72 nursing women from the West Bank of Palestine and investigated the association between sociodemographic variables and blood zinc levels. Blood samples were analyzed for their zinc contents using graphite furnace atomic absorption spectrophotometry. Blood and data collection were performed between July and December 2016. The median blood zinc level was 4.53 mg/L (interquartile range of 0.38 mg/L). In unadjusted analyses, blood zinc levels were higher in nursing women who lived in cities (p-value <.001), had higher household income (p-value <.001), whose husbands had a white collar job (p-value <.05), were nonsmokers (p-value <.05), did not use hair dyes (p-value <.05), and consumed energy beverages (p-value <.001). Multiple linear analysis showed that living in cities and consuming energy beverages remained significantly associated with higher blood zinc levels (p-value <.05). Blood zinc levels were in the range previously reported for similar non-malnourished populations. Nursing women living in cities and those consuming energy beverages tended to have higher blood zinc levels. Urbanized lifestyle might have enhanced blood zinc levels in nursing women.

Background: Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations., Methods: A two-iterative round Delphi technique was used in two separate panels of breastfeeding women ( n = 65) and healthcare providers ( n = 56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek., Results: About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations., Conclusion: Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended.

Objective: The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy., Methods: This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP)., Results: Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%)., Conclusion: Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE)., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: Lithium chloride (LiCl) has been shown to improve the tightness of brain endothelial cell monolayers in vitro by inhibition of the GSK-3β enzyme, activation of the Wnt/beta-catenin pathway and regulation of tight junction (TJ) protein expression. However, the effect of LiCl on the drug transporters and drug-metabolizing enzymes has not been addressed so far. The hCMEC/D3 cell line is a validated in vitro BBB model expressing transporters and drug-metabolizing enzymes (phase 1 and 2). The present study was conducted to compare the mRNAs levels corresponding to several BBB endothelial markers in hCMEC/D3 cells with and without incubation in LiCl., Methods: We used quantitative real-time polymerase chain reaction (qRT-PCR) to quantify the mRNA expression of 5 tight junction (TJ) proteins, 4 adhesion proteins, 5 solute carriers, 7 ATP-binding cassette (ABC) transporters, 8 cytochrome P450 (CYP) and 17 phase 2 conjugation enzymes in hCMEC/D3 cells with and without incubation in LiCl., Results: Our study showed that LiCl treatment for 6 days at a concentration of 10 mM induced the TJ protein claudin-3, the ABC transporter BCRP/ABCG2, the cytochrome P-450 CYP1A1 and the glutathione-S-transferase GSTM3, while the other selected markers were not significantly affected., Conclusions: Our findings provide new insights into the effects of lithium on some drug transporters and drug-metabolizing enzymes in the BBB that may have consequences in pharmacotherapy.

Background: Complementary and alternative medicine (CAM) utilization is dramatically increasing among patients. As community pharmacies are a major provider of CAM products, community pharmacists need to have the sufficient knowledge and information to advice their patients, answer their inquiries and to be proactive in the healthcare process to ensure optimal therapy outputs and minimize both drug-drug and drug-herb interactions. Therefore, the main objective of this study was to assess the knowledge, beliefs, and practices of community pharmacists in Palestine about CAM., Methods: The study was conducted in a cross-sectional design in which a questionnaire was administered on a sample of licensed community pharmacists from Palestine. The questionnaire was of 5 sections: demographic and practice details of the participants, practice, beliefs, and knowledge about CAM. Mann-Whitney-U or Kruskal-Wallis tests were used to comparison of different issues as appropriate. P-values of <0.05 were considered significant., Results: A total of 284 community pharmacists were surveyed, however, 281 were included in the analysis as they met inclusion criteria. Out of the 281, 149 (53.0%) of the participants were males and the rest were females. About 40% of the participants were between 20 to 29 years old. Pharmacists frequently recommended CAM modalities. Exercises (84.0%) and food supplements (82.6%) were the most commonly recommended modalities. In the last year, vitamin B 12 was the most frequently prescribed supplement. The median knowledge score was 5 out of 8 and the median beliefs about CAM score was 4.0 out of 7.0., Conclusions: CAM recommendations by pharmacists appear to be commonplace. Although their knowledge scores were fair to average, pharmacists still need more education and training about CAM in order to be more qualified to provide better pharmaceutical care and improve their patient's outcome.

Pharmacists are trusted and easily accessible healthcare providers. We assessed awareness and knowledge of symptoms, etiology, and treatment of autism spectrum disorders (ASDs) among pharmacists practicing in Palestine. The pharmacists reported low familiarity with ASDs. The median score on the 12-item knowledge section was 50.0% with an interquartile range of 16.7%. Having course(s) or lecture(s) on ASDs during pharmacy degree program was significantly associated with familiarity (p value <0.001), knowledge (p value <0.001), and confidence (p value <0.05) scores. Nearly 62% of the pharmacists reported as not feeling confident enough in their ability to counsel parents about medications used for their children with ASDs and their side effects. This study revealed gaps in awareness and knowledge of ASDs among pharmacists.

Purpose: The purpose of this study was to assess the knowledge of pharmacists practicing in Palestine of issues related to using psychotropic medications in older people., Methods: The study was conducted with a cross-sectional observational design using a questionnaire. A total of 400 pharmacists responded to a 19-statement knowledge test related to the use of psychotropic medications in older people. The study was conducted from July 2016 to February 2017. The reliability and internal consistency of the study tool was assessed using the test-retest method and the Cronbach alpha. Categorical groups were compared using the chi-square test and the Spearman rank correlation., Results: On the 19-statement knowledge test, the median score was 55.3% with an interquartile range of 21.9%. In a comparison of the demographic and practice-related variables of the pharmacists who scored ≥ 50% on the 19-statement knowledge test with those who scored < 50%, age, gender, and having taken a course on psychotropic medications were found to be significantly associated with performance, as shown by the chi-square test and Spearman correlation., Conclusion: Pharmacists practicing in Palestine possess less than optimal knowledge of issues related to the use of psychotropic medications in older people. Continuing educational interventions and/or training might be helpful in improving pharmacists' knowledge of issues related to using psychotropic medications in older people.

Background: Nausea and vomiting of pregnancy (NVP) affect approximately 80-90% of the pregnant women. Ginger (Zingiber officinale Roscoe) is the most widely used herbal therapy in the management of NVP. Like conventional therapies, herbal therapies have potential harms and benefits that patients need to be informed about in order to develop their therapy preferences. The aim of this study was to achieve consensus among women who suffered NVP and physicians often consulted by pregnant women on a core list of potential harms and benefits of using ginger to manage NVP to be addressed during clinical consultations., Methods: In this study, the Delphi technique was used to achieve consensus on a core list of important harms and benefits of using ginger in the management of NVP to be addressed during the clinical consultation. A Delphi process was followed in two panels in parallel sessions. One panel was composed of 50 gynecologists and other physicians who are often consulted by pregnant women suffering NVP and the other panel was composed of 50 women who suffered NVP., Results: Consensus was achieved on 21 (75%) of the 28 potential harms presented to the panelists. Panelists agreed that potential harms of the anticoagulant effects of ginger, risk with other co-morbidities, and risk of potential allergic reactions are important to address during the clinical consultation. Of the 14 potential benefits presented to the panelists in both panels, consensus was achieved on 13 (92.9%). Partial consensus on 7 potential harms and 1 potential benefit was achieved in both panels., Conclusions: Addressing important potential harms and benefits of using ginger for the management of NVP during the clinical consultations is important in promoting congruence and reducing patient dissatisfaction in clinical practice. Consensus was achieved on a core list of important harms and benefits of using ginger for the management of NVP to be addressed during the clinical consultations by a panel of women and a panel of physicians. Further studies are still needed to investigate what is being addressed during clinical consultations.

Purpose: Pharmacists are key players in providing healthcare for patients with chronic diseases including women with epilepsy. The purpose of this study was to assess pharmacist's knowledge of women's issues in epilepsy in the Palestinian pharmacy practice., Method: The study was conducted in a cross-sectional observational design using a 12-item test on women's health in epilepsy. Demographic details were collected. Scores were calculated as percentage of correct answers for each pharmacist., Results: The sample consisted of 408 pharmacists. The median correct score was only 53.8% with an IQR of 30.8. Pharmacists who interacted with ≥10 patients with epilepsy per month were 1.61 (95% C.I of 1.04-2.49) more likely to score ≥60% in the test than those who interacted with <10 patients with epilepsy per month. The difficulty index ranged from very easy to difficult. Nearly 91% of the pharmacists answered correctly the question on the role of folic acid in reducing teratogenesis and only 46% answered correctly the question on exposure to valproic acid and the risk of giving birth to a child with autism., Conclusion: Although pharmacists could be knowledgeable and in key position to provide essential information to patients with chronic diseases, there are many knowledge gaps in women's health issues in epilepsy that need bridging. Greater exposure to and interaction with people with epilepsy might be helpful in enhancing knowledge of pharmacists of specific issues pertaining to women's health in epilepsy., (Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objective: Antiepileptic drugs (AEDs) are mainstay in controlling epileptic seizures. As experts in medications, pharmacists should be able to ensure accuracy of dosing regimens, explain adverse effects, and screen for and alert people with epilepsy (PWE) and their physicians to possible drug-drug interactions (DDIs). The aim of this study was to evaluate pharmacists' knowledge of issues in pharmacotherapy of epilepsy using AEDs., Methods: This was a cross-sectional observational study conducted in the Palestinian pharmacy practice. A 10-item case-based questionnaire was used to determine actions taken by pharmacists in theoretical situations in pharmacotherapy of epilepsy. Demographic and practice details of the study participants were also collected. Scores were calculated as percentage of correct answers for each participant., Results: The number of participants was 394. The majority (approximately 75%) identified themselves as community pharmacists. The median score was 33.4% with an IQR of 33.3. Pharmacists who received training on epilepsy and AEDs during their pharmacy degree program were 4.78-fold (95% C.I. of 1.82-12.60) more likely to score ≥50% in the test than those who did not receive training on epilepsy and AEDs. Despite gaps in knowledge, pharmacists tended to perform the necessary action in cases of adverse effects and aggravated seizures associated with AEDs., Conclusion: Pharmacists can play a crucial role in providing essential information on AEDs to patients and prescribers. There are many knowledge gaps that need to be filled. Specifically designed pedagogic and/or training interventions might be helpful in filling these gaps., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Psoriasis is a frequent skin inflammatory disorder that inflicts millions of patients around the globe. To meet their healthcare needs, patients with psoriasis often seek treatment outside the allopathic paradigm. Use of medicinal plants has emerged as one of the most common and preferred modalities of complementary and alternative medicine (CAM). The aim of this study was to investigate the use of medicinal plants by patients with psoriasis in the West Bank of Palestine., Methods: The current study was a questionnaire based cross-sectional descriptive study on the use of medicinal plants by psoriasis patients in the West Bank of Palestine. A sample of 149 patients with psoriasis who were visiting outpatient clinics responded to the questionnaire in face to face interviews., Results: Medicinal plants were used by 81 (54.4%) patients with psoriasis. Patients used 33 medicinal plants belonging to 26 families. Plants belonging to Lamiaceae and Leguminosae were the most commonly used by the study patients. Aloe vera, Trigonella arabica, Catharanthus roseus and Anthemis cotula were the most frequently used medicinal plants to treat psoriasis. Leaves and fruits were the most commonly used parts by the study patients. Paste was the most commonly used form of preparation. The use of medicinal plants was significantly associated with age and monthly household income of the patients. Enhancement of immunity, improving conventional therapy and reduction of side effects were the most commonly self-reported reasons for using medicinal plants., Conclusions: Patients with psoriasis in Palestine seem to use medicinal plants as a CAM modality to manage their psoriasis. Many medicinal plants were commonly used by patients with psoriasis. More randomized clinical trials are needed to demonstrate safety and efficacy for the majority of these medicinal plants reported to be used by patients with psoriasis in Palestine.

Background Medication dispensing errors (MDEs) are frequent in community pharmacy practice. A definition of MDEs and scenarios representing MDE situations in Palestinian community pharmacy practice were not previously approached using formal consensus techniques. Objective This study was conducted to achieve consensus on a definition of MDEs and a wide range of scenarios that should or should not be considered as MDEs in Palestinian community pharmacy practice by a panel of community pharmacists. Setting Community pharmacy practice in Palestine. Method This was a descriptive study using the Delphi technique. A panel of fifty community pharmacists was recruited from different geographical locations of the West Bank of Palestine. A three round Delphi technique was followed to achieve consensus on a proposed definition of MDEs and 83 different scenarios representing potential MDEs using a nine-point scale. Main outcome measure Agreement or disagreement of a panel of community pharmacists on a proposed definition of MDEs and a series of scenarios representing potential MDEs. Results In the first Delphi round, views of key contact community pharmacists on MDEs were explored and situations representing potential MDEs were collected. In the second Delphi round, consensus was achieved to accept the proposed definition and to include 49 (59 %) of the 83 proposed scenarios as MDEs. In the third Delphi round, consensus was achieved to include further 13 (15.7 %) scenarios as MDEs, exclude 9 (10.8 %) scenarios and the rest of 12 (14.5 %) scenarios were considered equivocal based on the opinions of the panelists. Conclusion Consensus on a definition of MDEs and scenarios representing MDE situations in Palestinian community pharmacy practice was achieved using a formal consensus technique. The use of consensual definitions and scenarios representing MDE situations in community pharmacy practice might minimize methodological variations and their significant effects on the number and rate of MDEs reported in different studies.