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PurposeThis paper gives the background to the ISO 18404:2015 standard and explains its rationale. It aims to correct misconceptions and erroneous statements about the standard appearing in the paper by Antony et al. (2021) and to demonstrate the usefulness of the standard in a wide range of application sectors.Design/methodology/approachA review of recently reported misconceptions and erroneous statements is presented and clarifications are provided. A qualitative interview approach was utilised to obtain the views of leading academics and practitioners familiar with Six Sigma and Lean in a range of sectors and from different parts of the world. This includes the results of a survey for capturing expectations and requirements for the next ISO18404 version.FindingsClarifications were needed to correct some misconceptions and erroneous statements in recently published work. However, on review, the reports of the interviews in Antony et al. (2021) indicate that most Lean Six Sigma professionals have positive experiences with ISO 18404:2015 and see the advantages of a common standard in helping continuous improvement deployment. Possible causes of some reported negative results are already scheduled to be addressed in the forthcoming review of ISO 18404:2015.Research limitations/implicationsA very real constraint when conducting research into ISO 18404:2015 is to obtain a balanced view of the standard from those who have a vested interest in its continuation and evolution, or not. Whilst the authors cannot claim to be any more objective than Antony et al.’s (2021) authors and commentators, they are, in contrast to that group, highly knowledgeable about the reality of the standard, rather than speculating in ignorance.Practical implicationsA very real constraint when conducting research into ISO 18404:2015 is to obtain a balanced view of the standard which is balanced with respect from those who have a vested interest in its continuation and evolution, or not. Whilst the current authors cannot claim to be any more objective than previous authors, Antony et al.’s (2021) authors and commentators, they are, in contrast to that group, highly knowledgeable about the reality of the standard, rather than speculating in ignorance.Originality/valueThe paper gives a clear description of the ISO standard development process and provides a resource for people to obtain insight into the value or non-value add of a standard in Six Sigma and Lean, and the appropriate details of such a standard. These results can form the basis of a case for the implementation of the standard for those organisations currently trying to decide whether or not to implement it.

Patients and their caregivers incur numerous out-of-pocket costs while receiving oncologic treatments. These expenses are often overlooked by clinicians, even in countries with publicly funded healthcare systems. Parking fees are one such category of expenses that contribute to financial toxicity in cancer care. Patients with cancer often have protracted treatment courses, especially if they are receiving external beam radiation therapy. It is not clear if cancer center parking fees influence city-specific indices such as city-specific cost of living. The aim of this study was to evaluate cancer center parking fees in Western Canada and to elucidate any correlation between daily cost of parking and the city-specific indices.This was a cross sectional study conducted from February 1st, 2022, to March 1st, 2022. An online search was undertaken to obtain the publicly available parking information for the regional and community cancer centers in the provinces of British Columbia, Alberta, Manitoba, and Saskatchewan. Telephone calls were made with parking offices or switchboards to obtain this information for the cancer centers that did not have online information on parking. Cancer center address transit scores, median city household income, and city-specific cost of living scores were obtained online for the cities where the cancer centers were located. Pearson correlation and a zero-inflated negative binomial model were used for statistical analysis.Data was collected from 115 community and regional cancer centers distributed across the 4 provinces. The median hourly parking fee across all provinces was 2.00 Canadian Dollars (CAD) (Interquartile range (IQR), 0-4.25), whereas the median daily cost of parking was 9.50 CAD (IQR, 0-13.13). The median cancer center address transit score was 41.00 (IQR, 12.00-50.50). There was a statistically significant (p=0.029) positive correlation between the daily cost of parking and city cost of living. The correlation coefficient between the two variables was 0.412. Furthermore, there was a statistically significant (p0.001) positive correlation between daily cost of parking and cancer center address transit score. The correlation coefficient between the two variables was 0.676. In addition, there was a strong negative correlation between the cancer center address transit score and the presence of free parking with a correlation coefficient of -0.613 (p0.001). There was a nonsignificant (p=0.88) negative correlation between cost of living and the presence of free parking with a correlation coefficient of -0.028.The results of this study demonstrate that daily cost of parking for community and regional cancer centers in Western Canada significantly influences city-specific cost of living and cancer center address transit scores to a varying degree. This demonstrates that the influence of parking fees on patients with cancer is multilayered with significant direct and indirect effects. This can contribute to loss of wage and added financial burden on patients and their caregivers in higher-cost provinces. The presence of free parking at community and regional cancer centers had a statistically significant negative correlation with the cancer center address transit score. This suggests that cities with more free parking also have less robust public transit systems. Conversely, the presence of an extensive public transit system leads to a lower likelihood of free parking being available at cancer centers.The presence of a strong public healthcare system does not necessarily address all aspects of cancer-related financial toxicity. There is strong evidence of both positive and negative correlations between city specific indices and cancer center parking fees in Western Canada. Policy makers and stakeholders should be cognizant of this interplay between the various city specific indices and parking fees for patients with cancer. Policies on provincial and federal levels should be implemented to address this increasingly problematic burden on oncologic patients.

Oman is a high-income Middle Eastern country. Over the past 50 years, the country's health care system has undergone revolutionary changes to meet the health care needs of its population, driven by high oil and gas revenues. It currently has a very efficient universal health care system. There are 2 linear accelerators in the country and 6 radiation oncologists. A new cancer research center is currently under construction. The major challenge that could affect the delivery of radiation therapy in the future is sustenance of the health care achievements in view of a growing population and the reliance on public funding for health care delivery.

3 Background: Concurrent chemoradiation (CRT) with 2 doses of 5-fluorouracil (5-FU) and mitomycin C (MMC) is the standard of care for anal canal cancer (ACC) in North America while 1 dose of MMC is an acceptable practice. Given the lack of randomized data of 1 vs 2 doses of MMC on disease outcomes, we have conducted a population-based study to elucidate the impact of 1 vs. 2 doses of MMC on patterns of treatment failure (POF) and outcomes in ACC treatment. Zainab Al Habsi, Aswin Abraham, Mustafa Al Balushi, Gabriella Tankel, Karen Mulder, Heather Warkentin, Dan Schiller, Keith Tankel, Nawaid Usmani, Diane Severin, Kim Paulson, Hatim Karachiwala, Clarence Wong, Tirath Nijjar, Kurian Joseph. Methods: Data was collected from the provincial cancer registry of patients with stage I-III ACC who were treated with concurrent CRT from 2000 to 2018. Recurrence free survival (RFS), overall survival (OS), and ACC specific survival were calculated. Results: 428 patients with a median age of 58 years (29-88 years) were included in this analysis. 234 (54.7%) patients received 1 dose of MMC and 194 (45.3%) received 2 doses of MMC. At a median follow-up of 78.5 months (5-252 months), 89 (20.8%) patients developed disease recurrence: 44 (10.3%) loco-regionally, 39 (9.1%) distally and 6 (1.4%) had both local and distant recurrences. Cox Regression analysis showed that the dosage of MMC did not have an impact on overall recurrence (HR = 0.883, p = 0.561), whereas stage III was associated with increased risk for recurrence (HR = 5.238, p = 0.021). Subgroup analysis showed an association of stage IIIb and IIIc with recurrence (HR = 13.33, p = 0.008 and HR = 6.933, p = 0.011 respectively), but was not impacted by the use of 1 vs. 2 doses of MMC. The dosage of MMC did not show any association with local recurrence (HR = 1.136, p = 0.655) or distant recurrence (HR = 0.743, p = 0.267). However, in Stage IIIc patients, 2 doses of MMC showed a trend towards improved distant RFS (HR = 0.626,p = 0.084). Conclusions: Our analysis showed that the patterns of failure and the risk of loco-regional and distant failures were similar between patients who received 1 vs. 2 doses of MMC for stage groups I to IIIc. These finding support routine use of single dose of MMC along with 5FU and radiotherapy for definite chemoradiation. However, a trend towards better RFS was demonstrated with a second dose of MMC in patients with stage IIIc disease.

Introduction/background It is not clear if online radiotherapy patient educational materials that are published by the Canadian Cancer Society (CCS) and the various provincial health authorities meet the appropriate readability levels. The aim of this study is to determine the readability of online Canadian radiotherapy patient educational materials. Methods The publicly available educational materials were acquired from the provincial health authorities' and the CCS's websites. Only English language materials were included. Documents which mainly contained instructions or were part of interactive modules were excluded. The materials were transferred to Microsoft Word documents and labelled by source and category. Editing was then performed and the readability scores were acquired for each document. Results A total of 67 documents were included and 4 were excluded. The overall mean Flesch-Kincaid Grade Level from all sources was 7.5 (range, 3.6–13.2; 95% confidence interval [CI] 7.1–7.9), while the overall mean Flesch Reading Ease from all sources was 64.0 (range, 44.2–78.1; 95% confidence interval [CI] 62.0–66.1). The mean Flesch-Kincaid Grade Level scores from all sources were higher than the grade 6 recommended reading level for patient educational materials. This difference was found to be statistically significant (p ≤ 0.05) for Alberta, New Brunswick, Quebec, and Nova Scotia. Discussion/conclusions Overall, the readability levels of online Canadian radiotherapy patient educational materials exceed the recommended grade 6 readability for patient educational resources. It is hoped that the findings of this study would inform and guide the future development and distribution of materials that meet the appropriate readability standards.

Pulmonary embolism (PE) is a life-threatening condition that mandates prompt identification and management. The protean and atypical symptomatology of PE can mislead the physician and pose a diagnostic dilemma. Abdominal pain is one such rare symptom that is not commonly encountered in the clinical setting. With the limited availability of literature describing abdominal pain as a symptom of this acute disease, it is pivotal that healthcare workers are aware of this presentation. Herewith, we report a 36-year-old man with no co-morbidities who presented with abdominal pain and subsequent cardiac arrest. He was diagnosed and managed in the emergency department and made a complete recovery.

Evidence suggests that specifically designed frameworks to implement Lean Six Sigma (LSS) projects to tackle particular problems are more effective than ‘generic’ versions. This paper proposes an implementation framework to effectively deploy LSS to improve a key operation and performance indicator, i.e. ship loading commercial time, of one of the largest world producer of iron ore. This article therefore contributes with a refined framework to effectively implement LSS, and documents its successful application and effectiveness within the context of the case organisation. The LSS framework and project contributed in helping the studied organisation to improve both the capability of its ship loading process and commercial time by more than 30%, resulting in operational savings in the range of $300,000 USD per year. The systematic nature of the framework proposed also helped the organisation to establish a standardised routine to improve its operations. Managerial implications exposing the challeng...

Objectives: To determine and explore the potential use of uHear as a screening test for determining hearing disability by evaluating its accuracy in a clinical setting and a soundproof booth when compared to the gold standard conventional audiometry. Methods: Seventy Sultan Qaboos University students above the age of 17 years who had normal hearing were recruited for the study. They underwent a hearing test using conventional audiometry in a soundproof room, a self-administered uHear evaluation in a side room resembling a clinic setting, and a self-administered uHear test in a soundproof booth. The mean pure tone average (PTA) of thresholds at 500, 1000, 2000 and 4000 Hz for all the three test modalities was calculated, compared, and analyzed statistically. Results: There were 36 male and 34 female students in the study. The PTA with conventional audiometry ranged from 1 to 21 dB across left and right ears. The PTA using uHear in the side room for the same participants was 25 dB in the right ear and 28 dB in the left ear (3–54 dB across all ears). The PTA for uHear in the soundproof booth was 18 dB and 17 dB (1–43 dB) in the right and left ears, respectively. Twenty-three percent of participants were reported to have a mild hearing impairment (PTA > 25 dB) using the soundproof uHear test, and this number was 64% for the same test in the side room. For the same group, only 3% of participants were reported to have a moderate hearing impairment (PTA > 40 dB) using the uHear test in a soundproof booth, and 13% in the side room. Conclusion: uHear in any setting lacks specificity in the range of normal hearing and is highly unreliable in giving the exact hearing threshold in clinical settings. However, there is a potential for the use of uHear if it is used to rule out moderate hearing loss, even in a clinical setting, as exemplified by our study. This method needs standardization through further research.