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Abstract Background Unsafe surgical practices are a preventable cause of morbidity and mortality. The WHO published its surgical safety checklist (SSC) to help reduce surgical errors and complications and improve patient outcomes. This study aims to audit compliance with the WHO’s SSC and explore attitudes toward its implementation in hospitals within a low- and middle-income country. Methods This was a two-part, cross-sectional study in which a retrospective desk review was used to audit compliance with SSC use, and a questionnaire was used to explore attitudes toward the SSC. The data were collected between September and November 2021 from two major governmental and nongovernmental hospitals. Surgeons, anesthesiologists, and surgical nurses were invited to complete a self-administered questionnaire that measured attitudes across five domains via a 5-point Likert scale. Results The final sample consisted of 340 patients whose records were retrieved from one governmental hospital (n=170) and one nongovernmental hospital (n=170). Among those patients, 93 (27.4%) underwent general surgery, 49 (14.4%) underwent orthopedic surgery, and 45 (13.2%) underwent pediatric surgery. The SSCs were fully completed for 27.9% of the patients, partially completed for 43.2% of the patients, and left blank for 28.8% of the patients. Compliance with the use of the SSC was significantly associated with age (p=0.002), sex (p=0.022), type of surgery (p

Non–small cell lung cancer (NSCLC) is a heterogeneous disease with diverse molecular alterations. Two of the most common genetic abnormalities found in advanced NSCLC are mutations in the epidermal growth factor receptor (EGFR) and rearrangements in the ROS proto-oncogene 1 (ROS-1). Although these two alterations are typically mutually exclusive, there have been reports of their co-occurrence in a small subset of NSCLC patients. The discovery of this comutation has recently become apparent due to the increased use of more sensitive whole genome sequencing. We share our experience with two cases of coexisting EGFR and ROS-1 alterations. The first case is a 60-year-old man diagnosed with advanced adenocarcinoma of the lung with metastasis to bone and left adrenal gland. The second case is a 49-year-old woman diagnosed with stage IV lung adenocarcinoma with metastasis to the contralateral lung and diffuse abdominal lymphadenopathy. The first case was treated with osimertinib, and currently has had a stable disease on this medication for more than 3 years. The second case had a short interval of stable disease on osimertinib; then she developed progressive disease with poor response to anti–ROS-1 therapy. We believe patients with advanced NSCLC may have a higher incidence of coalterations, especially in the areas of the world with higher EGFR mutations and in the era of higher usage of whole genome sequencing. The presence of comutations will allow for a good long-term response to anti-EGFR therapy. This highlights the importance of the use of next-generation sequencing whenever possible and considers variant allele frequency as a factor in directing the therapy. There are many other unanswered questions, such as the best treatment sequencing or even the combined targeted therapy approach. This case series may add some information to the current literature.

Introduction The global pandemic was an emerging challenge that significantly impacted healthcare systems and the delivery of care. Prompt actions and adaptive techniques, such as the virtual clinic, were implemented to ensure the quality and continuity of the care provided. The aim of this quality improvement project was to ensure the smooth implementation and effectiveness of the virtual clinic during the COVID-19 crisis. Methods A specialized team of multidisciplinary healthcare providers was established to systematically ensure the implementation of the virtual clinic within the Department of Oncology. The team used multiple Plan-Do-Study-Act (PDSA) cycles of the quality improvement model to achieve the final goal and facilitate the transition to the virtual clinic. Results A total of 29 weekly virtual clinic sessions were conducted, covering various oncology services. From March to December 2020, 81% of the scheduled patients (3888) responded to virtual clinic calls. Physicians initiated 234 unplanned virtual clinic calls to follow up on a patient’s condition. In addition, 916 medications were shipped to patients as needed. A patient satisfaction survey in May 2020 indicated an overall satisfaction rate of 92% with the virtual clinic process. Staff satisfaction was also high (91%), and 88% of the physicians believed that the virtual clinic would continue beyond the pandemic. Conclusion Implementing the virtual clinic is achievable through following systematic steps and effectively addressing emerging challenges as required. The concept of the virtual clinic was well accepted by patients and staff.

Introduction: Despite extensive studies of the impact of COVID-19 on patients with cancer, there is a dearth of information from the Middle East and North Africa (MENA) region. Our study aimed to report pertinent MENA COVID-19 and Cancer Registry (MCCR) findingson patient management and outcomes. Methods: MCCR was adapted from the American Society of Clinical Oncology COVID-19 Registry to collect data specifically from patients with cancer and SARS-CoV-2 infection from 12 centers in eight countries including Saudi Arabia, Jordan, Lebanon, Turkey, Egypt, Algeria, United Arab Emirates, and Morocco. The Registry included data on patients and disease characteristics, treatment, and patient outcomes. Logistic regression was used to assess associations with mortality. Results: Between November 29, 2020, and June 8, 2021, data were captured on 2008 patients diagnosed with COVID-19 from the beginning of the pandemic. Median age was 56 years (16–98), 56.4% were females, and 26% were current or ex-smokers. Breast cancer (28.5%) was the leading diagnosis and 50.5% had metastatic disease. Delays of planned treatment (>14 days) occurred in 80.3% for surgery, 48.8% for radiation therapy, and 32.9% for systemic therapy. Significant reduction in the delays of all three treatment modalities occurred after June 1, 2020. All-cause mortality rates at 30 and 90 days were 17.1% and 23.4%, respectively. All-cause mortality rates at 30 days did not change significantly after June 1, 2020; however, 90-day mortality increased from 33.4% to 42.9% before and after that date (p = 0.015). Multivariable regression analysis showed the following predictors of higher 30- and 90-day mortality: age older than 70 years, having metastatic disease, disease progression, and being off chemotherapy. Conclusion: Patients with cancer in the MENA region experienced similar risks and outcome of COVID-19 as reported in other populations. Although there were fewer treatment delays after June 1, 2020, 90-day mortality increased, which may be attributed to other risk factors such as disease progression or new patients who presented with more advanced disease.

Introduction The outpatient oncology infusion unit is very busy, serving 60 to 70 patients per day. Due to a limited number of nurses, treatment chairs, only one pharmacy hood for bio-hazardous drug preparation, and other factors, patients wait a long time before starting their treatment, which affects the patient experience negatively. We conducted a quality improvement project to reduce the waiting time before starting the treatment, improve the patients' experience, and allow the unit to work more effectively through better resource utilization and accommodating more patients. Methods A committee was formed with representatives from oncology nursing and the quality specialist, chemotherapy pharmacy supervisor, data manager, and a medical consultant (team leader). We studied baseline data of patient waiting times from January to March 2019 and the factors that contributed to delays before starting the treatment. The charge nurse identified patients who could safely have their medication released early in the morning at 7 am, enabling the pharmacy to dispense at 8 am without their actual presence being required in the infusion suite (i.e., medication early release program or MERP). Multiple plan-do-study-act (PDSA) cycles were implemented to achieve a wait time from check-in to medication administration of less than 60 minutes. Data collected included check-in time, chair time, vital signs time, administration time, and discharge time. Additionally, reasons for drug wastage were assessed for patients who did not receive the prepared medication. A patient satisfaction survey was conducted with the patients before and after being enrolled in the program. Results At baseline, average waiting time for patients receiving similar medications in the MERP was 2 hours and 27 minutes. After the first intervention, average waiting time was reduced to 1 hour and 24 minutes, and small improvements were observed after each PDSA cycl. A major breakthrough occurred after an intensive patient education program and enforcement of strict compliance with the criteria in selecting the patients appropriate for theMERP. Average waiting time wasreduced to ≤ 60 minutes, and in November 2022, it was 30 minutes on average. Drug wastage was identified as a balancing measure. We were successful in reducing drug wastage by implementing several changes and patient education measures and achieved zero wastage. The patient satisfaction survey showed better satisfaction with the new changes. Conclusion A positive impact was achieved in this quality improvement project, with a significant reduction in the average waiting time for patients to start receiving chemotherapy. The outcome of this project has been maintained for 4 years and is still ongoing.

Background: Soft tissue sarcoma (STS) is a rare malignancy that affects soft tissues. It encompasses various subtypes and requires different treatment strategies. Doxorubicin is a commonly used anthracycline in the management of localized and metastatic STS. However, high doses of doxorubicin are associated with cardiotoxicity, which can significantly impact patients’ long-term outcomes. This study aimed to evaluate doxorubicin’s effect on cardiac function in patients with sarcoma and to correlate the frequency of cardiotoxicity with potential risk factors. Methods: A retrospective analysis was conducted on patients with sarcoma who were treated with doxorubicin between 2016 and 2022 at King Abdulaziz Medical City in Saudi Arabia. Patient demographic information, comorbidities, cardiac measurements, laboratory values, systemic therapy, and treatment outcomes were collected from electronic medical records. A statistical analysis was performed to assess the association between cardiotoxicity and various factors. Results: A total of 133 patients were included in the study, with a median age of 30 years. Cardiotoxicity was observed in 9% of the patients. Female patients had a significantly higher risk of developing cardiotoxicity. Patients with a higher Eastern Cooperative Oncology Group (ECOG) performance status and lower troponin I levels also had an increased risk of cardiotoxicity. However, there was no significant association between cardiotoxicity and the number of chemotherapy cycles, total cumulative dose of doxorubicin, or history of radiation. Furthermore, patients with cardiotoxicity had a higher risk of mortality. The overall survival of the patients was 18 months. Conclusion: Doxorubicin-associated cardiotoxicity is a concern for patients with sarcoma. Female patients and patients with a higher ECOG performance status are at an increased risk of developing cardiotoxicity. Careful monitoring and risk assessment are crucial for mitigating the adverse effects of doxorubicin treatment in patients with sarcoma. Future studies are warranted to validate these findings and explore preventive strategies for doxorubicin-induced cardiotoxicity in patients with sarcoma.

Objectives: This study aims to quantify the cross-sectional and prospective associations between quality of life (QoL) and moderate-to-vigorous physical activity (MVPA).Methods: This study was based on the Swiss children’s Objectively measured PHYsical Activity cohort. The primary endpoint is the overall QoL score and its six dimensions. The main predictor is the average time spent in MVPA per day. Linear mixed effects and linear regression models respectively were used to investigate the cross-sectional and prospective associations between MVPA and QoL.Results: There were 352 participants in the study with complete data from baseline (2013–2015) and follow-up (2019). MVPA was positively associated with overall QoL and physical wellbeing (p = 0.023 and 0.002 respectively). The between-subject MVPA was positively associated with the overall QoL, physical wellbeing, and social wellbeing (p = 0.030, 0.017, and 0.028 respectively). Within-subject MVPA was positively associated with physical wellbeing and functioning at school (p = 0.039 and 0.013 respectively). Baseline MVPA was not associated with QoL 5 years later.Conclusion: Future longitudinal studies should employ shorter follow-up times and repeat measurements to assess the PA and QoL association.

University students constitute a target for risk-reduction interventions regarding food poisoning as they are among those with higher exposure to problematic food. This is particularly important since young adults' knowledge regarding measures to prevent foodborne illnesses was found to be inadequate. Therefore, the objectives of this study were to assess knowledge, attitudes, and practices regarding food safety and food poisoning among An-Najah National University Students and to investigate the correlation of their knowledge, attitudes, and practices with various socio-demographic characteristics and academic variables. The cross-sectional design was used, and the study occurred at An-Najah National University in Nablus. Data was collected using a native Arabic language face-to-face questionnaire. Verbal consent was obtained before initiation. The questionnaire has four parts that address students' demographic data, knowledge, attitudes, and practice. A sample of 450 students was invited to complete the questionnaire. Half the respondents were aged 17 to 20, and more than half (57.1%) were females. The median knowledge score was 10.00 [8.75-12.0]. A significant correlation was found between the food poisoning knowledge and attitude scores of students (r = 0.339, p < 0.001), a significant correlation between food poisoning knowledge and attitude scores (r = 0.285, p < 0.001), and a significant correlation between attitude and practice scores (r = 0.429, p < 0.001). The current study found significant correlations between knowledge, attitude, and practices of university students regarding food safety. Female respondents also had better attitudes and more hygienic food practices. The results can help students prepare effective methods to understand food poisoning better and improve their knowledge and awareness. The study also indicates that more comprehensive and focused education regarding food safety is required for this population.

Background and Objective: Cancer survival has improved significantly, which reflects the achievements in screening, diagnosis, and treatment. As a consequence, multiple primary malignancies are diagnosed more frequently, with an incidence ranging from 0.52–11.7%. The types of malignancy that coexist and survival patterns vary notably in different countries and geographical areas. Due to the limited literature in Saudi Arabia, a baseline of prevalent malignancy combinations and their survival patterns would support early detection and disease management. Method: This was a retrospective descriptive study conducted from 1993–2022 at King Abdulaziz Medical City, Department of Medical Oncology, Riyadh, Saudi Arabia. Patients with at least two biopsy-proven solid malignancies were included. Patients with hematological malignancies, missing data, or an uncertain or indecisive pathology report were excluded. Result: In total, 321 patients were analyzed. More than half (57.3%) of the patients were female. A third (33%) of the cases were synchronous, and 67% were metachronous. The most frequent site of the first primary malignancy was breast cancer, followed by colorectal, skin, and thyroid cancers. The most frequent site of the second primary malignancy was colorectal cancer, followed by thyroid, breast, and liver cancers. Only 4% of the cases had a third primary malignancy, with colorectal and appendiceal cancers being the most frequent. The most frequently observed histopathology in the synchronous and metachronous malignancies was adenocarcinoma. Breast–colorectal, breast–thyroid, and kidney–colorectal were the most frequently observed malignancy combinations. Conclusion: The current study offers a baseline of multiple primary malignancies in Saudi Arabia and provides supporting evidence that the pattern of multiple primary malignancies varies among different countries and ethnicities. The possibility of developing another primary malignancy should be considered when treating and monitoring cancer patients.

Background: Unsafe surgical practices are a preventable cause of morbidity and mortality. The WHO published its surgical safety checklist (SSC) to help reduce surgical errors and complications and improve patient outcomes. This study aims to audit compliance with the WHO's SSC and explore attitudes toward its implementation in hospitals within a low- and middle-income country. Methods: This was a two-part, cross-sectional study in which a retrospective desk review was used to audit compliance with SSC use, and a questionnaire was used to explore attitudes toward the SSC. The data were collected between September and November 2021 from two major governmental and nongovernmental hospitals. Surgeons, anesthesiologists, and surgical nurses were invited to complete a self-administered questionnaire that measured attitudes across five domains via a 5-point Likert scale. Results: The final sample consisted of 340 patients whose records were retrieved from one governmental hospital (n=170) and one nongovernmental hospital (n=170). Among those patients, 93 (27.4%) underwent general surgery, 49 (14.4%) underwent orthopedic surgery, and 45 (13.2%) underwent pediatric surgery. The SSCs were fully completed for 27.9% of the patients, partially completed for 43.2% of the patients, and left blank for 28.8% of the patients. Compliance with the use of the SSC was significantly associated with age (p=0.002), sex (p=0.022), type of surgery (p<0.001), classification of surgery (p=0.006) and hospital sector (p<0.001). None of the patients at the governmental hospital had a completely filled the SSC, whereas none of those at the nongovernmental hospital had a blank SSC. Among the final sample of 80 operating room staff members included in the study that explored their attitudes, 41.3%, 40.0%, and 18.8% were surgeons, surgical nurses, and anesthesiologists, respectively. The participants demonstrated positive attitudes toward the SSC across all the attitude domains. The majority said that lack of time (56.3%), staff assertiveness (55.0%), and training (53.8%) were the most important barriers to implementing the SSC. The hospital sector was significantly associated with higher scores across all domains. Conclusions: While the majority of operating room staff used the SSC, only a minority filled the list completely. The attitudes toward using the WHO's SSC trended positively, which encourages the official implementation of the SSC at the national level. Addressing the identified barriers may enhance the quality of implementation by providing educational sessions. Future reaudits are recommended to enhance the adaptability of the SSC. [ABSTRACT FROM AUTHOR]

IntroductionHealthcare workers (HCWs) are seldom involved in balanced scorecard (BSC) deployments. This study aims to incorporate Palestinian HCWs in the BSC to create health policy recommendations and action plans using BSC-HCW1, a survey designed and validated based on BSC dimensions.MethodologyIn this cross-sectional study, the BSC-HCW1 survey was delivered to HCWs in 14 hospitals from January to October 2021 to get them involved in PE. The differences between physicians' and nurses' evaluations were assessed by the Mann–Whitney U-test. The causal relationships between factors were analyzed using multiple linear regression. The multicollinearity of the model was checked. Path analysis was performed to understand the BSC strategic maps based on the Palestinian HCWs' evaluations.ResultsOut of 800 surveys, 454 (57%) were retrieved. No evaluation differences between physicians and nurses were found. The BSC-HCW1 model explains 22–35% of HCW loyalty attitudes, managerial trust, and perceived patient trust and respect. HCWs' workload time-life balance, quality and development initiatives, and managerial performance evaluation have a direct effect on improving HCWs' loyalty attitudes (β = 0.272, P < 0.001; β = 0.231, P < 0.001; β = 0.199, P < 0.001, respectively). HCWs' engagement, managerial performance evaluation, and loyalty attitudes have a direct effect on enhancing HCWs' respect toward managers (β = 0.260, P < 0.001; β = 0.191, P = 0.001; β = 0.135, P = 0.010, respectively). Quality and development initiatives, HCWs' loyalty attitudes, and workload time-life balance had a direct effect on improving perceived patient respect toward HCWs (β = 254, P < 0.001; β = 0.137, P = 0.006, β = 0.137, P = 0.006, respectively).ConclusionThis research shows that it is important to improve low-performing indicators, such as the duration of time HCWs spend with patients, their knowledge of medications and diseases, the quality of hospital equipment and maintenance, and the inclusion of strengths and weaknesses in HCWs' evaluations, so that HCWs are more loyal and less likely to want to leave. For Palestinian hospital managers to be respected more, they must include HCWs in their action plans and explain their evaluation criteria. Patients will respect Palestinian HCWs more if they prioritize their education and work quality, spend more time with patients, and reflect more loyalty. The results can be generalized since it encompassed 30% of Palestinian hospitals from all categories.

Abstract Background Venous thromboembolism (VTE) represents a considerable burden on cancer patients' survival and quality of life, but this burden varies based on the patient's baseline characteristics and cancer‐related factors. Although solid evidence on the predictors and effect of VTE in cancer patients exists. Aim To evaluate VTE rate, morbidity, and mortality to develop parameters that could predict VTEs and their associated mortality in patients with multiple primary malignancies (MPMs). Method and Results This was a retrospective cohort study that took place at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. Two hundred and forty‐two patients with at least two biopsy‐proven malignancies and had at least 3 months of follow‐up after MPMs diagnosis were included. VTE was diagnosed in 14.5% of the cases, two‐thirds of which were deep vein thrombosis. VTE was significantly associated with a higher mortality and worse survival. Predictors of VTE after MPMs diagnosis were a high ECOG performance status at MPMs diagnosis, a metastatic first primary malignancy, and ICU admission after MPMs diagnosis. Having a GI or hematological malignancy as the second primary malignancy, a high D‐dimer at ICU admission, and palliative care referral were significantly associated with a higher mortality in patients who had VTE. Conclusion VTE was diagnosed in 14.5% of patients with MPMs and it significantly compromises their survival. We believe that these results might be of particular benefit since the phenomenon of MPMs is becoming more frequently encountered.

Abstract Malignant peritoneal mesothelioma (MPM) is a rare malignancy, presenting with non‐specific and potentially‐misleading manifestations. It represents a diagnostic pitfall as it mimics ovarian carcinoma. Maintaining a low diagnostic threshold, obtaining a detailed history, and utilizing immunohistochemical markers to diagnose MPM is crucial as early diagnosis and treatment might improve survival.

PURPOSEThe social impact of cancer on patients and their family is well known. Yet, unlike with physical and financial toxicities, no validated tools are available to measure this impact. This study aimed at developing, validating, and implementing a novel social toxicity assessment tool for patients with cancer diagnosis (STAT-C).METHODSQuestions were generated through multiple steps including focus groups of patients, their families, and oncology care professionals. These steps along with relevant literature resulted in the development of an initial 20-item questionnaire. Content validity and relevance of the tool were assessed using Content Validity Index for individual items and Content Validity Index for the entire scale. Following expert examination, the constructed STAT-C tool consisted of 14 items grouped into three domains—social relations, social activities, and economic impact. Based on the total possible score for the survey in 150 patients for all the items, three levels of a socioeconomic toxicity were determined—severe social toxicity, mild social toxicity, and no social toxicity.RESULTSThe 14 items were marked as relevant, and the Content Validity Index for individual items ranged between 0.80 and 1.00. An overall average Content Validity Index for the entire scale of 0.87 showed high content validity of the constructed tool. Exploratory factor analysis revealed retention of 13 items of the constructed STAT-C Tool, which loaded across three factors that mapped groupings into measures of social relations, social activities, and economic impact domains.CONCLUSIONOur study revealed that STAT-C is a valid, reliable tool, and well captures and measures unique and pertinent social toxicity constructs for Arabic-speaking patients. The tool should enable oncology professionals to deliver better patient-centered care as a component of a comprehensive approach.

PURPOSEAs frontline workers facing the COVID-19 pandemic, healthcare providers should be well-prepared to fight the disease and prevent harm to their patients and themselves. Our study aimed to evaluate the knowledge, attitude, and practice of oncologists in response to the COVID-19 pandemic and its impact on them.METHODSA cross-sectional study was conducted using a validated questionnaire disseminated to oncologists by SurveyMonkey. The tool had 42 questions that captured participants’ knowledge, attitude, and practice; their experiences; and the pandemic’s impact on various aspects of their lives. Participants from Middle East and North African countries, Brazil, and the Philippines completed the electronic survey between April 24 and May 15, 2020.RESULTSOf the 1,010 physicians who participated in the study, 54.75% were male and 64.95% were medical or clinical oncologists. The level of knowledge regarding the prevention and transmission of the virus was good in 52% of participants. The majority (92%) were worried about contracting the virus either extremely (30%) or mildly (62%), and 84.85% were worried about transmitting the virus to their families. Approximately 76.93% reported they would take the COVID 19 vaccine once available, with oncologists practicing in Brazil having the highest odds ratio of intention to receive the COVID-19 vaccine (odds ratio, 11.8, 95% CI, 5.96 to 23.38, P < .001). Participants reported a negative impact of the pandemic on relations with coworkers (15.84%), relations with family (27.84%), their emotional and mental well-being (48.51%), research productivity (34.26%), and financial income (52.28%).CONCLUSIONThe COVID-19 pandemic has adverse effects on various personal and professional aspects of oncologists’ lives. Interventions should be implemented to mitigate the negative impact and prepare oncologists to manage future crises with more efficiency and resilience.

Abstract Background This case study documents the first familial case of Blau syndrome (BS) in Palestine characterized with mutation in CARD15/NOD2. Case presentation Eighteen years old female was initially misdiagnosed with Juvenile idiopathic arthritis (JIA). The patient had been on steroids and methotrexate treatment for the last 16 years, but did not respond well to treatment. Initial examination at Saint John of Jerusalem Eye Hospital Group clinic showed bilateral intermediate uveitis with camptodactyly. The patient’s sister (aged 19 years) had bilateral intermediate uveitis and camptodactyly. Both eyes of their father had signs of old posterior uveitis. Father’s left eye showed 360 degrees posterior synechia, mature cataract with old Keratic precipitates (KPs). He also had camptodactyly. The patient was referred to pediatric rheumatologist to rule out sarcoidosis. Lung CT scan showed bronchiectasis, genetic consultation followed. Complete eye examination, full history, refraction, and Optical coherence tomography (oct) were done. Systemic and topical steroid therapy could not control the ocular inflammation. The family then was referred to a geneticist. Genetic analyses showed that the proband and all three family members had an R334q mutation in the CARD15/Nod2 gene. Conclusions BS should be considered in the differential diagnosis of childhood uveitis, especially in low and middle income countries where it is misdiagnosed in many cases, which delay appropriate diagnosis and thus control. Genetic analysis of the CARD15/Nod2 gene is helpful in the diagnosis. Steroids alone are not enough to control the disease, other immunosuppressants and biologics are needed.

Non-small cell lung cancer (NSCLC) is a heterogeneous disease with diverse molecular alterations. Two of the most common genetic abnormalities found in advanced NSCLC are mutations in the epidermal growth factor receptor (EGFR) and rearrangements in the ROS proto-oncogene 1 (ROS-1). Although these two alterations are typically mutually exclusive, there have been reports of their cooccurrence in a small subset of NSCLC patients. The discovery of this comutation has recently become apparent due to the increased use of more sensitive whole genome sequencing. We share our experience with two cases of coexisting EGFR and ROS-1 alterations. The first case is a 60-year-old man diagnosed with advanced adenocarcinoma of the lung with metastasis to bone and left adrenal gland. The second case is a 49-year-old woman diagnosed with stage IV lung adenocarcinoma with metastasis to the contralateral lung and diffuse abdominal lymphadenopathy. The first case was treated with osimertinib, and currently has had a stable disease on this medication for more than 3 years. The second case had a short interval of stable disease on osimertinib; then she developed progressive disease with poor response to anti-ROS-1 therapy. We believe patients with advanced NSCLC may have a higher incidence of coalterations, especially in the areas of the world with higher EGFR mutations and in the era of higher usage of whole genome sequencing. The presence of comutations will allow for a good long-term response to anti-EGFR therapy. This highlights the importance of the use of next-generation sequencing whenever possible and considers variant allele frequency as a factor in directing the therapy. There are many other unanswered questions, such as the best treatment sequencing or even the combined targeted therapy approach. This case series may add some information to the current literature. [ABSTRACT FROM AUTHOR]

Abstract Background The use of complementary and alternative medicine (CAM) is common among cancer patients and it may reflect the individual and societal beliefs on cancer therapy. Our study aimed to evaluate the trends of CAM use among patients with cancer between 2006 and 2018. Methods We included 2 Cohorts of patients with cancer who were recruited for Cohort 1 between 2006 and 2008 and for Cohort 2 between 2016 and 2018. The study is a cross-sectional study obtaining demographic and clinical information and inquiring about the types of CAM used, the reasons to use them and the perceived benefits. We compared the changes in the patterns of CAM use and other variables between the two cohorts. Results A total of 1416 patients were included in the study, with 464 patients in Cohort 1 and 952 patients in Cohort 2. Patients in Cohort 2 used less CAM (78.9%) than Cohort 1 (96.8%). Cohort 1 was more likely to use CAM to treat cancer compared to Cohort 2 (84.4% vs. 73%, respectively, p

Abstract Background Self-efficacy is a widely applied psychosocial concept that is commonly used in association with management of chronic diseases, including hypertension. The aim of this study was to assess self-efficacy of hypertension management and patient-physician communication, as well as the factors associated with self-efficacy and patient-physician communication among patients with hypertension in Palestine. Methods We conducted face-to-face, questionnaire-based interviews using validated instruments to assess self-efficacy in managing hypertension (Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6C)) and patient-physician communication (Perceived Efficacy in Patient-Physician Interaction Questionnaire (PEPPI)) in patients with hypertension at the three main primary healthcare centers in Nablus district in northern West Bank, Palestine. We also performed a multiple linear regression analysis to determine the variables independently associated with PEPPI and SES6C scores. Results We enrolled 377 participants with hypertension in this study. The average age (measured in years) was 56.8 with a standard deviation of 11.6. The mean PEPPI and SES6C scores were 20.0 (SD 4.4) and 41.1 (SD 10.6), respectively. In a multiple linear regression model, subjects who were city dwellers (B=3.597, p=0.004), and subjects with high education levels (B=4.010, p=0.001) achieved higher PEPPI scores, whereas subjects in the normal weight category (B=5.566, p

Abstract Background A health system response to domestic violence against women is a global priority. However, little is known about how these health system interventions work in low-and-middle-income countries where there are greater structural barriers. Studies have failed to explore how context-intervention interactions affect implementation processes. Healthcare Responding to Violence and Abuse aimed to strengthen the primary healthcare response to domestic violence in occupied Palestinian territory. We explored the adaptive work that participants engaged in to negotiate contextual constraints. Methods The qualitative study involved 18 participants at two primary health care clinics and included five women patients, seven primary health care providers, two clinic case managers, two Ministry of Health based gender-based violence focal points and two domestic violence trainers. Semi-structured interviews were used to elicit participants’ experiences of engaging with HERA, challenges encountered and how these were negotiated. Data were analysed using thematic analysis drawing on Extended Normalisation Process Theory. We collected clinic data on identification and referral of domestic violence cases and training attendance. Results HERA interacted with political, sociocultural and economic aspects of the context in Palestine. The political occupation restricted women’s movement and access to support services, whilst the concomitant lack of police protection left providers and women feeling exposed to acts of family retaliation. This was interwoven with cultural values that influenced participants’ choices as they negotiated normative structures that reinforce violence against women. Participants engaged in adaptive work to negotiate these challenges and ensure that implementation was safe and workable. Narratives highlight the use of subterfuge, hidden forms of agency, governing behaviours, controls over knowledge and discretionary actions. The care pathway did not work as anticipated, as most women chose not to access external support. An emergent feature of the intervention was the ability of the clinic case managers to improvise their role. Conclusions Flexible use of ENPT helped to surface practices the providers and women patients engaged in to make HERA workable. The findings have implications for the transferability of evidenced based interventions on health system response to violence against women in diverse contexts, and how HERA can be sustained in the long-term.

PURPOSE ASCO developed the Quality Oncology Practice Initiative (QOPI) to ensure patient safety in oncology outpatient services. We evaluated the impact of participation in QOPI certification on patient care at our institution. METHODS To participate in QOPI, we created a multidisciplinary team, and we chose the required modules and began QOPI participation per program requirement. In the initial round, we scored lower than the required score of 75% to be eligible for QOPI certification. We then implemented multiple measures and interventions, and we conducted multiple Plan, Do, Study, Act cycles (PSDA) cycles to achieve our goal. RESULTS Our score in the initial round was 68%; in the second round, our score remained low at 65%; in the third round, we exceeded the target score by achieving 93%. We completed the certification process with a site visit. In October 2018, we became the first QOPI-certified center in the Middle East and Asia. CONCLUSION We learned many lessons during our journey toward QOPI certification. Essential elements of success included timely assembly of the right multidisciplinary team and clear communication between team members within the institution and with the ASCO QOPI team.

PURPOSEThe COVID-19 pandemic affected health care systems globally and resulted in the interruption of usual care in many health care facilities, exposing vulnerable patients with cancer to significant risks. Our study aimed to evaluate the impact of this pandemic on cancer care worldwide.METHODSWe conducted a cross-sectional study using a validated web-based questionnaire of 51 items. The questionnaire obtained information on the capacity and services offered at these centers, magnitude of disruption of care, reasons for disruption, challenges faced, interventions implemented, and the estimation of patient harm during the pandemic.RESULTSA total of 356 centers from 54 countries across six continents participated between April 21 and May 8, 2020. These centers serve 716,979 new patients with cancer a year. Most of them (88.2%) reported facing challenges in delivering care during the pandemic. Although 55.34% reduced services as part of a preemptive strategy, other common reasons included an overwhelmed system (19.94%), lack of personal protective equipment (19.10%), staff shortage (17.98%), and restricted access to medications (9.83%). Missing at least one cycle of therapy by > 10% of patients was reported in 46.31% of the centers. Participants reported patient exposure to harm from interruption of cancer-specific care (36.52%) and noncancer-related care (39.04%), with some centers estimating that up to 80% of their patients were exposed to harm.CONCLUSIONThe detrimental impact of the COVID-19 pandemic on cancer care is widespread, with varying magnitude among centers worldwide. Additional research to assess this impact at the patient level is required.

PURPOSEProgrammed death-ligand 1 (PD-L1) is a marker for checkpoint inhibitor use in the management of solid tumors, especially in non–small-cell lung cancer (NSCLC). Our study was aimed at determining the patterns of PD-L1 expression and cluster of differentiation 8 (CD8) immunostains in patients with NSCLC in the Arab population.METHODSArchival tumor tissue from patients with a confirmed diagnosis of NSCLC were obtained and stained for PD-L1 with antibody 22C3, using immunohistochemistry staining and giving the tumor proportion score (TPS) as a percentage from 0%-100% of stained tumor cells. Tumors were categorized into negative expressers (TPS < 1%), low positive (TPS, 1%-49%), and high positive (TPS, 50%-100%). Correlation of expression with clinical and pathologic features, including CD8-positive (CD8+) lymphocyte density, was also analyzed.RESULTSTwo hundred patients with NSCLC were included in the study from 6 centers in Saudi Arabia and Algeria. Median age was 65 years (28-93 years), and the majority were men (75%) with stage 4 NSCLC (64%). The TPS was high in 37 patients (18%), low in 60 patients (30%), and negative in 103 patients (52%). In a univariate analysis, the following were significant predictors of any PD-L1 expression (> 1%): male sex, being Saudi national patients, high expression of CD8+, and presence of tumor-infiltrating lymphocytes. In the multivariate analysis, only high expression of CD8+ cells (≥ 2+) was significant, with an odds ratio of 4.4 (95% CI, 1.5 to 12.9; P = .003)CONCLUSIONPD-L1 expression in our population is similar to the published literature and correlated with the density of CD8+ cells. Validation of the predictive value of this marker in our population and identifying easier and reliable methods to test for it are warranted.

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

Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed. [ABSTRACT FROM AUTHOR]

Omar B Da’ar,1 Yasmine A Zaatreh,2 Aida A Saad,2 Mohammad Alkaiyat,3 Tabrez Pasha,3 Anwar E Ahmed,1 Rami Bustami,4 Khaled Alkattan,2 Abdul Rahman Jazieh3 1College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; 3Oncology Department, King Abdulaziz Medical City, National Guards Health Affairs Riyadh, Riyadh, Saudi Arabia; 4College of Business, Alfaisal University, Riyadh, Saudi ArabiaCorrespondence: Omar B Da’arHealth System Management, College of Public Health & Health Informatics, King Saudi bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi ArabiaTel +966-11-4299999 Ext. 95419Email odaar@smumn.eduBackground: Incidence of cancer in Saudi Arabia has increased for the last two decades, ratcheting up to global levels. Yet, there is a dearth of research on the burden of lung cancer. This study examined the association between new cases of lung cancer and factors such as gender, age, and year of diagnosis; and forecast new cases and extrapolated future economic burden to 2030.Methods: This a national-level cohort study that utilized the Saudi Cancer Registry data from 1999 to 2013. Multivariate regression was used; new lung cancer cases forecast and economic burden extrapolated to 20130. Sensitivity analysis was conducted to assess the impact of a range of epidemiologic and economic factors on the economic burden.Results: Of the 166,497 new cancer cases (1999–2013), 3.8% was lung cancer. Males and Saudis had over threefold higher cases compared with females and non-Saudis, respectively. While the age group ≥65 years had 1.14 times or 14% increase in new cases, under-30 years had 97.2% fewer cases compared with age group 45–59. Compared with 1999, the period 2011–2013 had a 106% average increase. The years 2002–2010 registered an average 50% rise in new cases compared to 1999. New cases would rise to 1058 in 2030, an upsurge of 87% from 2013. The future economic burden was estimated at $2.49 billion in 2015 value, of which $520 million was attributable to care management and $1.97 billion in lost productivity. The economic burden for the period 2015–2030 will be $50.16 billion. The present value of this burden in 2015 values will be $34.60 billion, of which 21% will be attributable to care management. Estimates were robust to uncertainty, but the aged-standardized rate and 5-year survival rate would account for much of the variability compared with the economic factors.Conclusion: Findings reveal an upsurge of lung cancer burden in incidence and potential economic burden, which may inform cancer control measures.Keywords: new cases of lung cancer, lung cancer trend, lung cancer projection, the economic burden, Saudi Arabia

Abdul Rahman Jazieh,1 Omar B Da’ar,2 Mohammad Alkaiyat,1 Yasmine A Zaatreh,3 Aida A Saad,3 Rami Bustami,4 Mashael Alrujaib,5 Khaled Alkattan3 1Oncology Department, King Abdulaziz Medical City, National Guards Health Affairs Riyadh, Riyadh, Saudi Arabia; 2Department of Health Systems Management, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Department of Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; 4Department of Healthcare Management, College of Business, Alfaisal University, Riyadh, Saudi Arabia; 5Department of Radiology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi ArabiaCorrespondence: Abdul Rahman JaziehDepartment of Oncology, King Abdulaziz Medical City, National Guards Health Affairs Riyadh, P.O. Box 22490, Riyadh 11426, Saudi ArabiaTel +966-11-801111 Extension 53356Email jaziehoncology@gmail.comBackground: Cancer incidence in Saudi Arabia has increased for the last two decades, ratcheting up to global levels. The study aimed to analyze cancer trends and the contributions of various cancer types, forecast incidence, and estimate the economic burden in 2030.Methods: A national-level cohort study utilizing the Data of Cancer Registry of patients who were diagnosed in 1999–2015. New cases in 2016–2030 were forecast and predicted based on 1999–2015 data. We used growth assumption and regression analysis to predict the trends of cancer cases. We assessed the contributions of cancer types to incidence trends. We carried forecasting of new cases and extrapolation of the potential economic burden. We conducted a sensitivity analysis of the cost of cancer with respect to changes in economic and epidemiologic factors.Results: The findings suggest that the number of known cancer cases increased by 136% from 1999 to 2015 and is projected to rise by 63% in 2030. The forecast indicates female cases will account for higher number of cases and greater proportion increase. The future cost of all cancer types would be estimated at $7.91 billion in 2015 value, of which $3.76 billion will be attributable to care management and $4.15 billion in lost productivity. With the assumption of growth of the aged-standardized incidence rate, the costs of care management and lost productivity are projected to be $5.85 and $6.47 billion, respectively in 2030, an increase of 56% in each component. The future undiscounted total estimated economic burden for the period 2015–2030 would be $159.44 billion, of which 47.5% will be attributable to care management. Estimates were robust to uncertainty, but the 5-year prevalence of cancer survivorship would account for the greatest variability.Conclusion: Our model showed an upsurge of cancer burden in terms of incidence and the potential economic burden, which may inform cancer control measures.Keywords: cancer trends, the 2030 cancer burden projection, cancer economic burden, Saudi Arabia

Abstract Background Cardiac catheterization is performed for both therapeutic and diagnostic reasons, in which the outcome may vary from only medical treatment to the need of percutaneous coronary intervention and ending with coronary artery bypass graft. The primary goal of this study was to determine predictors of revascularization. Methods A retrospective cohort study was conducted on data collected from records of patients who underwent cardiac catheterization at Al-Arabi Heart Center in Palestine in 2017. Multivariate logistic regression analysis was carried out to assess the association of sociodemographic and pre-catheterization clinical predictors with revascularization. Results A total of 1550 patients were included in the study. The participants mean age was 58 with a SD of 11.7 years, 73.6% were males. 50.2% of patients who underwent an interventional cardiac catheterization tested negative for troponin on presentation. Multivariate logistic regression showed Troponin (RR = 4.5), Age (RR = 1.0), Female gender (RR = 0.4) previous catheterization (RR = 2.0), and existence of diabetes as significant predictors for revascularization. The correlation between ECG on presentation and the subsequent need for an interventional cardiac catheterization was significant only in case of ST-Elevation (RR = 1.5), and T wave inversion (RR = 1.6). CK-MB, Hypertension and ECG with ST-depression were not significant predictors. Conclusion This study assessed revascularization predictors in addition to characteristics and outcomes of patients who have undergone cardiac catheterization. The results showed the especially high predictive value of troponin in determining the need for revascularization which outweighed the importance of ECG findings on presentation in making clinical decision regarding catheterization.

Abstract Background Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD). Methods Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM). Results Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression. Conclusion This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.