Copy-Pasting in Patients' Electronic Medical Records (EMRs): Use Judiciously and With Caution.

An electronic medical record (EMR) is an electronic, comprehensive, and up-to-date compilation of a patient's medical history and information stored in a secure digital format. It provides real-time access to patient data, enabling healthcare providers to make informed decisions quickly and accurately. EMR systems streamline a patient's healthcare journey and enable shared care across the medical practice. By providing a comprehensive view of a patient's medical history, EMRs can be invaluable tools for physicians and healthcare providers, allowing them to collaborate more effectively and provide better care. Additionally, EMRs can help reduce paperwork, improve accuracy, and increase efficiency, ultimately leading to improved patient outcomes. The true potential of EMR systems can be realized when they are used in conjunction with evidence-based medicine methodologies, quality improvement initiatives, and team-based care. This combination of technologies and practices can revolutionize healthcare delivery, improving patient outcomes, greater efficiency, and cost savings. "Copy-pasting" is an essential feature of EMR systems, with physicians relying on it for up to 35.7% of their workflow. By leveraging the copy-pasting feature of their EMR system, physicians can ensure that their data capture is accurate and timely, leading to better patient care. Copy-pasting can be a valuable tool for physicians, saving time and allowing them to focus on practical clinical issues. However, it is essential to note that while most clinicians copy-paste, 25% of them believe it can lead to a high frequency of medical errors, with the potential for a significant number of errors being attributed to this practice. Therefore, physicians must exercise caution when copy-pasting and take the necessary steps to ensure accuracy and reduce the risk of errors. Copy-pasting can cause severe adverse patient events by introducing new inaccuracies, rapidly spreading inaccurate or outdated information, leading to discordant notes, and creating long notes that mask essential clinical information. Despite these risks, copy-pasting has become widely used in EMRs. Additionally, copy-pasting can reduce the time spent on documentation, allowing healthcare providers to focus more on patient care. Inappropriate copy-pasting can have serious consequences, such as compromising data integrity, endangering patient safety, increasing costs, and even leading to fraudulent malpractice claims. In conclusion, copy-pasting can be helpful for healthcare professionals, but it must be used cautiously. Proper education and safeguards should be implemented to ensure accuracy and up-to-date patient data. Additionally, healthcare professionals should be aware of the legal implications of copy-pasting, as it may be considered a form of medical malpractice. With the proper precautions, copy-pasting can be a safe and efficient way to save time and reduce errors in patient records.

COVID-19 Among Omani Pilgrim Returnees From the Ashura Mass Gathering.

Background The annual Ashura pilgrimage is a mass Islamic gathering during which millions of worshippers converge in the city of Karbala in Iraq. We report on the incidence of the coronavirus disease 2019 (COVID-19) in Omani pilgrims returning from Karbala in the month of Muharram (August) 2021 during the COVID-19 pandemic. Methodology This is a retrospective study using an electronic, self-completed, and Arab-language survey, composed of 17 questions, that was distributed to all pilgrims returning from Karbala. Participation was voluntary, and consent with confidentiality was obtained. Data on the demographics including sex, COVID-19 vaccination record, type of vaccine, duration of stay, compliance with wearing a face mask, using hand sanitization, and polymerase chain reaction (PCR) results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus before the departure from Oman, upon the return to Oman, and on the eighth post-quarantine day were collected. The responses were collected from the period between August 28, 2021, and September 25, 2022. Statistical association and analysis were performed using the Statistical Package for Social Sciences (SPSS) software (IBM SPSS Statistics, Armonk, NY). Results Out of 250 pilgrims, 139 responded to the survey. Fifty-two participants (37.4%) were males, and 87 (63.6%) were females. None of the pilgrims had positive SARS-CoV-2 PCR results before their departure from Oman. Only four pilgrims (2.9%) were detected positive on PCR by the end of a compulsory quarantine on the eighth day after arrival to Oman. No hospital admissions were recorded. The vast majority of the pilgrims were vaccinated with two doses of COVID-19 vaccination, while some few pilgrims were not vaccinated at all. Most of the pilgrims were also compliant with mask wearing, and just over half the pilgrims were compliant with hand sanitization. No significant statistical association was found between contracting SARS-CoV-2 virus infection and taking SARS-CoV-2 vaccination, the number of vaccination doses, having had COVID-19 before, wearing a mask, or compliance with hand sanitization. Conclusion The incidence of COVID-19 cases among pilgrims returning from Iraq during the COVID-19 pandemic was low. No significant difference was noted between pilgrims vaccinated and compliant with the protective measures and those who were not vaccinated or compliant. Herd immunity could be a possible explanation for the low incidence of COVID-19 infection. Larger studies are needed to investigate the incidence of COVID-19 in Ashura pilgrims.

Epidemiology of Cancer Among Chronic Kidney Disease Patients Compared to The General Population.

BACKGROUND: Kidney disease has a major effect on global health, both as direct cause of morbidity and mortality and as an important factor for other comorbid diseases including malignancy. Different studies report a higher risk of cancer development in patients with chronic kidney disease (CKD), but the impact of less sever CKD on risk of cancer is uncertain. However, data concerning the cancer risk in Oman CKD including dialysis patients is scarce. More importantly, there is lack of information about the cancer-specific mortality in CKD and dialysis patients. METHODS: During January 2006 to December 2019, all patients with CKD and those on regular dialysis who are admitted or follow up in Royal Hospital were included for evaluation of malignancy. RESULTS: During the study, a total of 2500 patients with CKD were included, of which 25 patients were found to have different types of cancers, of which 13 were male (52%) and 12 were female (48%).Most of patients 13 (52%) were senior adult (>65 years), then 11 (44%) were adult (19:64- ys) and only one case (4%) was child (<18years.). Cancer was detected in the ovaries (16%), stomach, multiple myeloma and renal (12%) each, while breast and colorectal (1 male/1 female) (8%), parathyroid, thyroid, uterus, cervix, prostate, skin, liver, lymphoma, pituitary gland, and myelofibrosis were present in 4% each. In general population, the breast cancer is the most common cancer among females, followed by thyroid cancer, and colorectal cancer while the most common cancer types among males are colorectal cancer followed by the prostate and then the Non-Hodgkin lymphoma disease. CONCLUSION: These epidemiologic findings should prompt clinicians and health authorities to assess strategies for cancer screening in high-risk population of CKD patients. Additional studies are needed to explain the reasons for this association and represent the potential use of cancer screening in patients with CKD in Oman. KEY WORDS: cancer, chronic kidney disease, epidemiology, hemodialysis.

Impact of Screening Programs on Stage Migration in Breast Cancer.

INTRODUCTION: Breast cancer (BC) is the leading malignancy globally with consequent morbidity, mortality and burden on health care resources when diagnosed at an advance stage. Early-stage diagnosis is crucial to the better outcome. Screening is pivotal to early detection at an early stage. It is understood to reduce mortality, improve outcome, and is cost effective. OBJECTIVE: The objective of the study was to see the impact of screening program on Breast cancer stage in Oman. In this study we looked into the trends in stagespecific breast cancer incidence during two pre-specified time periods 2006-2010 and 2015-2017, before and after the introduction of a national screening programme in Oman. PATIENTS AND METHODS: It is a retrospective analysis, where breast cancer patient's data was retrieved from Oman national cancer Registry ministry of health Sultanate of Oman, for two pre-specified time periods 2006-2010 before the introduction of cancer screening programs and 2015-2017. The cases included were those who had confirmed histopathology diagnosis and where a composite stage, based on TNM stage, was available to be analysed and compared in these two pre-specified time periods to find out the difference between these two time periods. The statistical analysis was carried out and p values were determined. Ethical approval obtained from Royal Hospital medical ethics and scientific research committee. RESULTS: There was a 41% reduction in stage IV breast cancer from 23.01% to 13.58 %, and 86.15% increase in stage 0-1 from 6.86 % to 16.98%. (p Value<001). The stage 0 cases increased from 0% to 4.26 %. With regard to tumour size, T0-1 tumours increased from 14.16% to 26.03%, while T4 tumours decreased from 16.59% to 7.69%. There was increase in node negative breast cancer cases in Oman. The N0 increased from 28.43% to 37.64%. The diagnosis as Non-metastatic M0 disease increased from 39.77% to 60.23%, while diagnosis as metastatic M1 disease decreased from 55.32% to 44.68%. DISCUSSION AND CONCLUSIONS: The introduction of national screening programme in Oman resulted in a continued increase in localized cancers and a decline in advanced disease. Screening programmes should be evaluated continuously and systematically to ensure their targeted objectives. The causal link between stage distribution and mortality needs to be investigated further in the context of screening. Health planners, policymakers, and other stakeholders; including clinicians, educators, community members, and advocates, should be aware of the health system requirements, as well as overall costs of these approaches to breast cancer early detection, to make effective investments, plans, and policies. Key Words: Breast Cancer; Screening; Oman; Royal hospital; early detection; early stage; OCA.

COVID-19 amongst cancer patients: An experience from Oman.

OBJECTIVE: To evaluate the extent of coronavirus infection in cancer patients along with their demographics, laboratory findings and outcomes in a tertiary care setting. METHODS: The study was conducted in Muscat, Oman, from March 24 to October 23, 2020. The data was collected from the cancer registry of the Directorate-General of Non-Communicable Diseases, Ministry of Health, Oman. Data of inpatient coronavirus cases were retrieved from the electronic medical records system of the Royal Hospital, Muscat, all tertiary hospitals linked electronically to the registry and the coronavirus registry of Oman. The data of cancer patients infected with coronavirus was analysed and compared with non-cancer coronavirus-infected patients. Data was analysed using IBM SPSS 2019 v26. RESULTS: Of the 16,260 cancer patients, 77(0.47%) were infected with COVID-19 compared to 111,837(2.17%) in the national population. Mortality among cancer patients with COVID-19 was high 27(35.1%) compared to 1,147(1.03%) in the national population. Cancer patients with COVID-19 also had diabetes 15(20%), hypertension 20(26%), renal complications 15(20%) and cardiac issues 9(12%). Of the total, 32(41.6%) cancer patients with COVID-19 had received active cancer treatment within the preceding 4 weeks. CONCLUSIONS: The data on coronavirus infection outcome is emerging at a rapid pace focussing on the impact of underlying diseases, and the capacity of healthcare systems. Oncologists should customise cancer management, while cancer patients must practise social distancing, and seek prompt evaluation of suspicious symptoms.

The Troubling Link Between Non-alcoholic Fatty Liver Disease (NAFLD) and Extrahepatic Cancers (EHC).

Non-alcoholic fatty liver disease (NAFLD) is a fast-spreading epidemic across the globe and has serious implications far beyond that of a "benign" liver condition. It is usually an outcome of ectopic fat storage due to chronic positive energy balance leading to obesity and is associated with multiple health problems. While association with cardiovascular disease and hepatocellular cancer is well recognized, it is becoming clear the NAFLD carries with it an increased risk of cancers of extrahepatic tissues. Studies have reported a higher risk for cancers of the colon, breast, prostate, lung, and pancreas. Fatty liver is associated with increased mortality; there is an urgent need to understand that fatty liver is not always benign, and not always associated with obesity. It is, however, a reversible condition and early recognition and intervention can alter its natural history and associated complications.

Clinicopathological Features and Outcomes of Gastrointestinal Stromal Tumours in Oman: A multi-centre study.

OBJECTIVES: This study aimed to report the clinicopathological features, management and long-term outcomes of patients with gastrointestinal stromal tumours (GISTs) in Oman. METHODS: This retrospective study was conducted on patients treated for GIST between January 2003 and December 2017 at three tertiary referral centres in Muscat, Oman. All patients with confirmed histopathological diagnoses of GIST and followed-up at the centres during this period were included. Relevant information was retrieved from hospital records until April 2019. RESULTS: A total of 44 patients were included in the study. The median age was 55.5 years and 56.8% were female. The most common primary site of disease was the stomach (63.6%) followed by the jejunum/ileum (18.2%). Two patients (4.5%) had c-Kit-negative, discovered on GIST-1-positive disease. A total of 24 patients (54.5%) presented with localised disease and eight (33.3%) were classified as being at high risk of relapse. Patients with metastatic disease received imatinib in a palliative setting, whereas those with completely resected disease in the intermediate and high-risk groups were treated with adjuvant imatinib. Of the six patients (13.6%) with progressive metastatic disease, of which four had mutations on exon 11 and one on exon 9, while one had wild-type disease. Overall, rates of progression-free survival and overall survival (OS) at 100 months were 77.4% and 80.4%, respectively. Rates of OS for patients with localised and metastatic disease were 89.9% and 80.2%, respectively. CONCLUSION: The presenting features and outcomes of patients with GISTs in Oman were comparable to those reported in the regional and international literature.

Needs for Cancer Education In Oman Based on the Breast Cancer Screening Program.

Most breast cancers in Oman are diagnosed at advanced stages and therefore early detection is important. The Oman Cancer Association (OCA) initiated a mobile mammography program in 2009, but no studies have evaluated its impact. This study aimed at estimating the proportion and predictors of OCA-screened women who had repeated mammography (adherence) and the sensitivity and specificity of the program. Demographic, screening, diagnosis, and treatment data of 13,079 women screened in the OCA mammography clinic from 2009 to 2016, and medical records of all breast cancer patients seen at Royal and Sultan Qaboos University hospitals during the same period were retrieved. Logistic regression analysis was conducted to identify predictors of adherence. A total of 8278 screened women over age 42 years (median age of 50 ± 8 years) were included in the study. Only 18% of initially negative screened women were compliant with recommended subsequent screening. Predictors of adherence included age (50-69 years), family history of cancer, family history of breast cancer, and breast self-examination. The overall cancer detection rate was 4.1/1000 screened women. Positive predictive value of screening was 4.7% with a sensitivity rate of 53% and specificity of 92%. This study showed a low mammography adherence among previously screened women. The study revealed low sensitivity, high specificity, and an acceptable cancer detection rate. Future programs should focus on improving data collection of screened women, maintaining the linkage of databases of screening and treatment clinics, and developing guidelines for breast cancer screening in Oman. The recommendations based on the study results should be incorporated into future professional, patient, and public cancer education programs.

National approaches to managing cancer care: responses of countries in the MENA region to the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic presents serious challenges to cancer care because of the associated risks from the infection itself and the disruption of care delivery. Therefore, many professional societies have published recommendations to help manage patients with cancer during the current pandemic. The objective of our study is to assess the national responses of Middle East North Africa (MENA) countries in terms of publishing relevant guidelines and analyse various components of these guidelines. METHODS: A survey based on the preliminary review of the literature regarding cancer care adaptations has been developed and then completed by a group of oncologists from the following Arab countries affected by the pandemic: Algeria, Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Saudi Arabia, Syria, Tunisia, United Arab Emirates and Yemen. The survey inquired about COVID-19 cases, national recommendations regarding general measures of COVID-19 prevention and patient care in oncology as well as their implementation about cancer care adaptations during the pandemic. RESULTS: Analysis of the COVID-19 pandemic-related guidelines revealed at least 30 specific recommendations that we categorised into seven essential components. All included countries had national guidelines except one country. Estimated full compliances with all specific category recommendations ranged from 30% to 69% and partial compliance ranged from 23% to 61%. CONCLUSION: There is a very good response and preparedness in the Arab Middle East and North Africa region surveyed. However, there are inconsistencies in the various components of the guidelines across the region, which reflects the evolving status of the pandemic in each country as well as the lack of clear evidence-based guidelines for many of the issues in question. There is a need for a clear framework on essential components that should be included in these guidelines to assure providing the best guidance to the oncology community.

Hepatocellular Carcinoma in Oman: An analysis of 284 cases.

OBJECTIVES: Hepatocellular carcinoma (HCC) is the most common type of primary liver tumour worldwide and is increasing in incidence. This study aimed to describe the clinical characteristics of HCC among Omani patients, along with its major risk factors, outcomes and the role of surveillance. METHODS: This retrospective case-series study was conducted between January 2008 and December 2015 at the three main tertiary care hospitals in Oman. All adult Omani patients diagnosed with HCC and visited these hospitals during the study period were included. Relevant data were collected from the patients' electronic medical records. RESULTS: A total of 284 HCC patients were included in the analysis. The mean age was 61.02 ± 11.41 years and 67.6% were male. The majority had liver cirrhosis (79.9%), with the most common aetiologies being chronic hepatitis C (46.5%) and B (43.2%). Only 13.7% of cases were detected by the HCC surveillance programme. Approximately half of the patients (48.5%) had a single liver lesion and 31.9% had a liver tumour of >5 cm in size. Approximately half (49.2%) had alpha-fetoprotein levels of ≥200 ng/mL. The majority (72.5%) were diagnosed using multiphase computed tomography alone. Less than half of the patients (48.9%) were offered one or more HCC treatment modalities. CONCLUSION: The majority of Omani HCC patients were male and had cirrhosis due to viral hepatitis. In addition, few patients were identified by the national surveillance programme and presented with advanced disease precluding therapeutic or even palliative treatment.

Increasing Thyroid Cancer Incidence in Oman: A Joinpoint Trend Analysis.

OBJECTIVES: We sought to investigate the epidemiology of thyroid cancer and its trends in Oman over a 20-year period. METHODS: We analyzed all cases of primary thyroid cancer reported to the Oman National Cancer Registry between 1996 and 2015. Age-standardized incidence rates (ASR) were calculated using the World Standard Population. Joinpoint regression was used to assess trends and obtain annual percentage changes (APC) in incidence rates with 95% confidence intervals (95% CI) and p-values at the alpha = 0.050 level. Gender-specific APC was used to project thyroid cancer incidence rates in Oman over the next 20 years. Population attributable fraction was calculated for obesity and current non-smoking. RESULTS: A total of 1285 cases of primary thyroid cancer cases were registered in Oman between 1996 and 2015, with a female to male ratio of 4:1. In men, the ASR was 2.0 per 100 000 while in females it was 7.6 per 100 000 (p < 0.010). Over 80.0% of thyroid tumors were of a papillary type and 19.0% follicular type. Statistically significant trends for thyroid cancer were detected in women from 2008-2015 (APC = 14.3%, 95% CI: 8.0-20.9, p < 0.010) and among both genders (APC = 16.7%, 95% CI: 4.9-29.9, p < 0.010). If current trends continue, thyroid cancer incidence will increase to 3.1, 16.6, and 11.8 per 100 000 by 2040 in men, women, and both genders, respectively. Nearly 10.0% of thyroid cancer can be prevented by controlling obesity in the Omani population. CONCLUSIONS: Oman has had moderate incidence rates of thyroid cancer with an increasing trend among women. Since projections estimate that the rates of this disease will double in women over the next 20 years, health authorities should consider providing sufficient resources to manage this condition and establish prevention programs that address obesity as part of the strategy for the prevention and control of noncommunicable diseases.

Epidemiology of Lung Cancer in Oman: 20-Year Trends and Tumor Characteristics.

OBJECTIVES: We sought to investigate the epidemiology of lung cancer and its trends in Oman over 20 years. METHODS: We analyzed all cases of primary lung cancer reported to the Oman National Cancer Registry between 1996 and 2015. The World Standard Population was used to obtain age-standardized incidence rates (ASR) of lung cancer per 100 000. Analyses were conducted using univariate statistics. RESULTS: A total of 956 cases of primary lung cancer cases were registered in Oman between 1996 and 2015, with a male to female ratio of 3:1. In men, the ASR was 8.2 per 100 000, while in females it was 2.6 per 100 000 over the entire study period. There were no statistically significant differences in the ASR among men or women when the data was divided over three calendar periods (1996-2005, 2006-2015, and 1996-2015) (p = 0.332 and p = 0.577, respectively). There was also no increasing trend in the incidence of lung cancer. The risk of lung cancer onset commenced in the 30-34 year age group and the mean age at diagnosis was 60.0 years for men and 61.0 years for women. Adenocarcinoma was the most common type of lung cancer among Omanis with a higher proportion in females compared to males. CONCLUSIONS: Oman has one of the lowest incidence rates of lung cancer in the world with no evidence of an increasing trend of this cancer type. This could be attributed to low uptake of tobacco smoking among both sexes. National authorities should capitalize on this finding to avoid any future lung cancer epidemics especially those driven by tobacco use.

Awareness, understanding, attitude and barriers toward prescribing modern cancer immunotherapies in the Arabian Gulf countries.

INTRODUCTION: The use of modern immunotherapy has been evolving over the past few years, and various new agents have been developed for new indications at multiple primary sites in oncology. It is important for physicians who are involved in cancer care to be aware and updated about new therapeutic agents and their indications, potential benefits, and side effects. PATIENTS AND METHODS: From October to November 2017, we conducted a survey on the awareness, understanding, attitude, and barriers associated with prescribing modern cancer immunotherapies among physicians in the Arabian Gulf countries. The study included practicing physicians who delivered chemotherapy; trainees were not eligible. A total of 460 physicians were contacted and invited to complete an online survey, of which approximately 74.8% did not respond, and 4 (3.4%) were excluded because they had not recently treated patients with cancer. 112 (24.3%) physicians completed the survey (completion rate = 25.2%). An online electronic survey questionnaire was developed via Planet Surveys. The survey was designed with multidisciplinary inputs of the study investigators practicing in the Arabian Gulf countries, piloted, and subsequently revised on the basis of feedback from 10 additional oncologists. The final survey included 23 questions and took 8-10 minutes for completion. RESULTS: All respondents were aware of modern immunotherapies, but 62.5% reported having limited experience in implementing them, whereas 31.3% reported good experience. The overall physicians' attitudes toward modern immunotherapy were favorable, with a mean score of 7.4 (scale of 1-10, with 10 being extremely favorable). Efficacy, clear indications, and good safety profile were perceived as key potential benefits. Cost, lack of experience, and lack of access to specific testing were the major barriers. DISCUSSION AND CONCLUSION: There was a high level of awareness and an overall positive attitude toward modern cancer immunotherapy among oncologists in the Arabian Gulf countries, but there was a limited experience in prescribing cancer immunotherapeutic agents. Efficacy, clear indications, and good safety profile were perceived as key potential benefits, whereas cost, lack of experience, and lack of access to specific testing prior to prescription were the major barriers. Patients were likely to be receptive to modern immunotherapy as a therapeutic option for cancer treatment. Long-term efficacy data, financial support programs, and educational activities for prescribers may increase the access to modern immunotherapy.

The Need for Regulatory Reforms in the Use of Opioids for Pain Management and Palliative Care in the Middle East.

Palliative Care (PC) is an evolving oncology subspecialty in the Middle East (ME). Justified opioid use is an integral part of palliative care. Often, morphine consumption is taken as a quality indicator of palliative care services, but is it a reliable indicator to reflect the status of palliative care in current Middle East setting? We need to understand that data on morphine consumption, represent the amount distributed of morphine per person in a country and does not refer the actual justified amount utilization of opioids. In addition, the currently used consumption data is not reflective of product and dosage employed. It includes opioid use in other conditions like post-operative pain, traumatic pain, and drug abuse as well. The population and cancer incidence is highly variable amongst countries. The opioid consumption reported at present in Oman is very low 0.5474 mg/person. The opioid prescription must have an appropriate validated policy, well administered and enforced effectively. The policy must be balanced in such a way to eliminate the barriers of availability on one hand, and limit the probability of abuse on the other. Ideally there should be a national empowered competent control authority which should estimate the needs, license, distribute, monitor and report opioid use. There is an additional need to train health care workers in adequate pain assessment, effective pain management, and validated opioid prescribing practices. The issues in the Middle Eastern (ME) countries are erratic and undependable cancer data, limited palliative care programs, non-effective or no palliative care/pain management policies, and almost non-existent prescription policies of controlled drugs. There is an urgent and essential need to work for comprehensive and integrated palliative care programs encompassing the subspecialties. It must include and care for local perspectives of psychological, social, spiritual, and religious issues in PC in addition to pain management. There remains a need for health education for population, advocacy for policy makers, and a political will at the appropriate levels to meet these challenges.

Breast cancer in a patient with Kindlers syndrome.

Breast Cancer (BC) has associated risk factors and genetic factors like BRCA1, and BRCA2. Many benign and malignant disease processes are found concurrently with BC and believed to be additional risk factors like gall bladder stones (cholelithiasis), hypertension, diabetes mellitus, cerebrovascular lesions, arthritis, spine and spinal cord degenerative lesions, infertility, depression, sleep disturbances, obesity, autoimmune diseases (SLE), and thyroid diseases. There are some malignant disease associations like synchronous or metachronous ovarian, colonic and endometrial tumours with Breast cancer. Kindler Syndrome (KS) is a rare autosomal recessive genetic disorder manifesting as generalized dermatoses, described in 1954 by Theresa Kindler. KS is associated with acral skin blistering inducible by trauma, mucosal inflammation, photosensitivity, progressive pigmentation, telangiectasia, and skin atrophy (Poikiloderma). Repeated and progressive inflammation and subsequent fibrosis leads to ectropion, esophageal, anal, urethral, and vaginal stenosis and dryness. About 100 cases of Kindler syndrome have been reported in literature so far some from Arab World as well. Pathobiology of Kindler syndrome is not well understood. There are defects in KIND1 gene on chromosome 20. This gene expresses itself in basal keratinocytes, where it encodes a protein, called Kindlin 1. We report the second only case of Kindler's syndrome having breast cancer. These very very rare combinations have diagnostic issues, management restrictions, prognostic and follow up implications.

Are we prepared to implement a Lean philosophy within cancer-care service in Oman?

Lean, as it applies to business, has come to signify simplicity, swift response, and efficiency. The concept is to do more with less; namely, to use resources in the most productive way possible through the elimination of all types of waste. The Lean approach can be applied to any field, including healthcare, in which the exponential growth of costs is widespread. Hospitals began experimenting with Lean healthcare in 1990s.  Equal accessibility to healthcare is consistent with the tenets of social justice and a society's duty to ensure basic healthcare to everyone. However, the gap between a state's constitutional responsibility and resource availability is widening, creating a need for an evolution in healthcare provision based on relevance, objectivity, and impartiality. Health-services providers must juggle limited resources to ensure even-handed healthcare availability to all in the era of cost explosion.

Minocycline Improves the Efficacy of EGFR Inhibitor Therapy: A Hypothesis.

Skin rash is a side effect of drugs that inhibit epithelial growth factor receptor (EGFR) as a part of targeted therapy of cancer. Its appearance and severity correlates with survival. Minocycline, an oral tetracycline antibiotic, is recommended as treatment (and increasingly, for prevention) of the rash, though infection is seen in only one-third of the patients. Minocycline has additional anticancer properties such as poly(ADP-ribose) polymerase inhibition. It is proposed that such properties contribute to the efficacy of EGFR inhibitors and can also explain the positive correlation between grade of rash and survival as patients with higher grades of rash are more likely to receive minocycline. Early concurrent administration of minocycline is recommended in patients planned for EGFR therapy while awaiting trials proving this hypothesis.