Displaying publications 81 - 100 of 128 in total

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  1. Elghazaly H, Aref AT, Anderson BO, Arun B, Yip CH, Abdelaziz H, et al.
    Int J Cancer, 2021 08 01;149(3):505-513.
    PMID: 33559295 DOI: 10.1002/ijc.33506
    In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.
    Matched MeSH terms: Middle East/epidemiology
  2. Phillips KP, Pokushalov E, Romanov A, Artemenko S, Folkeringa RJ, Szili-Torok T, et al.
    Europace, 2018 06 01;20(6):949-955.
    PMID: 29106523 DOI: 10.1093/europace/eux183
    Aims: Long-term results from catheter ablation therapy for atrial fibrillation (AF) remain uncertain and clinical practice guidelines recommend continuation of long-term oral anticoagulation in patients with a high stroke risk. Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the initial results of combining catheter ablation procedures for AF and LAAC in a multicentre registry.

    Methods and results: Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 139 subjects at 10 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful Watchman implantation was achieved in 100% of patients. The overall 30-day serious adverse event (SAE) rate was 8.7%, with the device and/or procedure-related SAE rate of 1.4%. One pericardial effusion required percutaneous drainage, but there were no strokes, device embolization, or deaths at 30 days. The 30-day bleeding SAE rate was 2.9% with 55% of patients prescribed NOAC and 38% taking warfarin post-procedure.

    Conclusion: The outcomes from these international, multicentre registries support the feasibility and safety of performing combined procedures of ablation and Watchman LAAC for patients with non-valvular AF and high stroke risk. Further data are needed on long-term outcomes for the hybrid technique on all-cause stroke and mortality.

    Matched MeSH terms: Middle East/epidemiology
  3. Lim CC, Woo PCY, Lim TS
    Sci Rep, 2019 Apr 15;9(1):6088.
    PMID: 30988390 DOI: 10.1038/s41598-019-42628-6
    Antibody phage display has been pivotal in the quest to generate human monoclonal antibodies for biomedical and research applications. Target antigen preparation is a main bottleneck associated with the panning process. This includes production complexity, downstream purification, quality and yield. In many instances, purified antigens are preferred for panning but this may not be possible for certain difficult target antigens. Here, we describe an improved procedure of affinity selection against crude or non-purified antigen by saturation of non-binders with blocking agents to promote positive binder enrichment termed as Yin-Yang panning. A naïve human scFv library with kappa light chain repertoire with a library size of 109 was developed. The improved Yin-Yang biopanning process was able to enrich monoclonal antibodies specific to the MERS-CoV nucleoprotein. Three unique monoclonal antibodies were isolated in the process. The Yin-Yang biopanning method highlights the possibility of utilizing crude antigens for the isolation of monoclonal antibodies by phage display.
    Matched MeSH terms: Middle East Respiratory Syndrome Coronavirus/immunology*
  4. AlKasseh AS, Zaki NM, Aljeesh YI, Soon LK
    East Mediterr Health J, 2014 Jan 09;19 Suppl 3:S12-8.
    PMID: 24995734
    To determine the risk factors of gestational diabetes mellitus in refugee populations in the Gaza Strip, a retrospective case-control study was performed between March and June 2011 in the United Nations Relief and Works Agency (UNRWA) primary health care clinics. Data were collected on maternal sociodemographics and the prevalence of diagnosed GDM according to World Health Organization criteria from clinics where postnatal Palestinian refugee women had been diagnosed with GDM during previous pregnancies, and non-GDM women were used as controls. Sociodemographic characteristics, pre-pregnancy body-mass index (BMI), obstetrics history and family history of diabetes were used as study variables. In total, 189 incident cases of GDM were identified. The most significant risk factors for GDM were: history of miscarriage more than once; overweight before pregnancy; history of stillbirth; history of caesarean birth; and positive family history of diabetes mellitus.
    Matched MeSH terms: Middle East
  5. Ahmad SZ, Ahamad MS, Yusoff MS
    Waste Manag Res, 2014 Jan;32(1):24-33.
    PMID: 24241167 DOI: 10.1177/0734242X13507313
    Proper implementation of landfill siting with the right regulations and constraints can prevent undesirable long-term effects. Different countries have respective guidelines on criteria for new landfill sites. In this article, we perform a comparative study of municipal solid waste landfill siting criteria stated in the policies and guidelines of eight different constitutional bodies from Malaysia, Australia, India, U.S.A., Europe, China and the Middle East, and the World Bank. Subsequently, a geographic information system (GIS) multi-criteria evaluation model was applied to determine new suitable landfill sites using different criterion parameters using a constraint mapping technique and weighted linear combination. Application of Macro Modeler provided in the GIS-IDRISI Andes software helps in building and executing multi-step models. In addition, the analytic hierarchy process technique was included to determine the criterion weight of the decision maker's preferences as part of the weighted linear combination procedure. The differences in spatial results of suitable sites obtained signifies that dissimilarity in guideline specifications and requirements will have an effect on the decision-making process.
    Matched MeSH terms: Middle East
  6. Alagha JS, Said MA, Mogheir Y
    Environ Monit Assess, 2014 Jan;186(1):35-45.
    PMID: 23974533 DOI: 10.1007/s10661-013-3353-6
    Nitrate concentration in groundwater is influenced by complex and interrelated variables, leading to great difficulty during the modeling process. The objectives of this study are (1) to evaluate the performance of two artificial intelligence (AI) techniques, namely artificial neural networks and support vector machine, in modeling groundwater nitrate concentration using scant input data, as well as (2) to assess the effect of data clustering as a pre-modeling technique on the developed models' performance. The AI models were developed using data from 22 municipal wells of the Gaza coastal aquifer in Palestine from 2000 to 2010. Results indicated high simulation performance, with the correlation coefficient and the mean average percentage error of the best model reaching 0.996 and 7 %, respectively. The variables that strongly influenced groundwater nitrate concentration were previous nitrate concentration, groundwater recharge, and on-ground nitrogen load of each land use land cover category in the well's vicinity. The results also demonstrated the merit of performing clustering of input data prior to the application of AI models. With their high performance and simplicity, the developed AI models can be effectively utilized to assess the effects of future management scenarios on groundwater nitrate concentration, leading to more reasonable groundwater resources management and decision-making.
    Matched MeSH terms: Middle East
  7. Lim JN
    Asian Pac J Cancer Prev, 2011;12(6):1627-9.
    PMID: 22126510
    Psychosocial and cultural factors influencing cancer health behaviour have not been systematically investigated outside the western culture, and qualitative research is the best approach for this type of social research. The research methods employed to study health problems in Asia predominantly are quantitative techniques. The set up of the first psychosocial cancer research network in Asia marks the beginning of a collaboration to promote and spearhead applied qualitative healthcare research in cancer in the UK, Southeast Asia and the Middle East. This paper sets out the rationale, objectives and mission for the UK-SEA-ME Psychosocial-Cultural Cancer Research Network. The UK-SEA-ME network is made up of collaborators from the University of Leeds (UK), the University of Malaya (Malaysia), the National University of Singapore (Singapore) and the University of United Arab Emirates (UAE). The network promotes applied qualitative research to investigate the psychosocial and cultural factors influencing delayed and late presentation and diagnosis for cancer (breast cancer) in partner countries, as well as advocating the use of the mixed-methods research approach. The network also offers knowledge transfer for capacity building within network universities. The mission of the network is to improve public awareness about the importance of early management and prevention of cancer through research in Asia.
    Matched MeSH terms: Middle East
  8. Hilles AH, Abu Amr SS, Hussein RA, Arafa AI, El-Sebaie OD
    Water Sci Technol, 2016;73(1):102-12.
    PMID: 26744940 DOI: 10.2166/wst.2015.468
    The objective of this study was to investigate the performance of employing H2O2 reagent in persulfate activation to treat stabilized landfill leachate. A central composite design (CCD) with response surface methodology (RSM) was applied to evaluate the relationships between operating variables, such as persulfate and H2O2 dosages, pH, and reaction time, to identify the optimum operating conditions. Quadratic models for the following two responses proved to be significant with very low probabilities (<0.0001): chemical oxygen demand (COD) and NH3-N removal. The obtained optimum conditions included a reaction time of 116 min, 4.97 g S2O8(2-), 7.29 g H2O2 dosage and pH 11. The experimental results were corresponding well with predicted models (COD and NH3-N removal rates of 81% and 83%, respectively). The results obtained in the stabilized leachate treatment were compared with those from other treatment processes, such as persulfate only and H2O2 only, to evaluate its effectiveness. The combined method (i.e., /S2O8(2-)/H2O2) achieved higher removal efficiencies for COD and NH3-N compared with other studied applications.
    Matched MeSH terms: Middle East
  9. Gilbert D
    Links, 1993;9(5):6-8, 30.
    PMID: 12159278
    Matched MeSH terms: Middle East
  10. Kazi S
    Pak Dev Rev, 1994;33(4 Pt 2):1333-44.
    PMID: 12346198
    Matched MeSH terms: Middle East
  11. Nair AM, Shilpa PH, Shekhar V, Tiwari RVC, Shaik I, Dasari B, et al.
    J Family Med Prim Care, 2020 Jul;9(7):3200-3204.
    PMID: 33102270 DOI: 10.4103/jfmpc.jfmpc_496_20
    Recently coronavirus outbreak which started in Wuhan, China, has caused international concern that has affected more than 29 lakh people worldwide and with no vaccine or specific antiviral drugs present as well as oblivious testing of carriers who are generally asymptomatic, the use of general health intervention techniques are failing to comply. As compared to other epidemics like severe acute respiratory syndrome-coronavirus (SARS-CoV) and the Middle-East respiratory syndrome (MERS-CoV), coronavirus (also named as COVID-19) exhibit mild symptoms in the majority of cases. But in the case of a vulnerable population, it can prove to be life-threatening. Relying on proper barrier technique, use of chest computed tomography scans, managing co-morbid conditions of susceptible patients, identifying the pattern of disease spread as well as the use of polymerase chain reaction to assess the specificity of cases will eventually prove to be efficacious since most of the positive cases are asymptomatic at the beginning which poses a challenge to the primary health care physicians. The development of vaccines will also take some time so it is better to know about COVID-19 better and also follow quarantine restrictions properly till then. In this review, we try to put forward all the relevant studies which have been published by the end of March 2020 so as to summarize the natural history, diagnosis as well as treatment strategies for eradicating COVID-19, which will help in managing this pandemic.
    Matched MeSH terms: Middle East Respiratory Syndrome Coronavirus
  12. Xi S, Li Y, Yue L, Gong Y, Qian L, Liang T, et al.
    Front Pharmacol, 2020;11:582322.
    PMID: 33192523 DOI: 10.3389/fphar.2020.582322
    Viral pneumonia is one kind of acute respiratory tract infection caused by the virus. There have been many outbreaks of viral pneumonia with high contagiousness and mortality both in China and abroad, such as the great influenza in 1918, the severe acute respiratory syndrome (SARS) coronavirus in 2003, the Influenza A (H1N1) virus in 2009, and the Middle East Respiratory Syndrome coronavirus (MERS-CoV) in 2012 and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2019. These outbreaks and/or pandemic have significant impact on human life, social behaviors, and economic development. Moreover, no specific drug has been developed for these viruses. Traditional Chinese medicine (TCM) plays an important role in the treatment of viral pneumonia during these outbreaks especially in SARS and SARS-CoV-2 because studies suggest that TCM formulations may target several aspects of the disease and may have lesser side effects than manufactured pharmaceuticals. In recent years, a lot of clinicians and researchers have made a series of in-depth explorations and investigations on the treatment of viral pneumonia with TCM, which have understood TCM therapeutic mechanisms more specifically and clearly. But critical analysis of this research in addition to further studies are needed to assess the potential of TCM in the treatment of viral pneumonia.
    Matched MeSH terms: Middle East Respiratory Syndrome Coronavirus
  13. Alshahrani NZ, Alshahrani SM, Alshahrani AM, Leggat PA, Rashid H
    J Travel Med, 2021 02 23;28(2).
    PMID: 33146380 DOI: 10.1093/jtm/taaa205
    Matched MeSH terms: Middle East
  14. Rahman S, Singh K, Dhingra S, Charan J, Sharma P, Islam S, et al.
    Ther Clin Risk Manag, 2020;16:1007-1022.
    PMID: 33116550 DOI: 10.2147/TCRM.S272908
    COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient's caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.
    Matched MeSH terms: Middle East Respiratory Syndrome Coronavirus
  15. Alrashdan MS, Alazzam M, Alkhader M, Phillips C
    BMC Med Educ, 2018 Nov 26;18(1):283.
    PMID: 30477562 DOI: 10.1186/s12909-018-1386-9
    BACKGROUND: Differences between dental students in terms of social, economic and cultural backgrounds are likely to impact their professional career plans. The aim of this study was to explore the professional career plans among final year dental students from different backgrounds at a single Middle Eastern institution (Jordan university of Science and Technology-JUST).

    METHODS: Fifth year dental students at JUST were invited to fill out a paper based self-administered questionnaire. Data was collected on students` demographics, their future career plans and the impact of social and economic changes on such plans, their interest in postgraduate studies and the specialty of choice in addition to the influence of a group of factors on that choice. Data was also collected on the value of non-academic workshops, guidance regarding career plans, participants` preferred pattern of work (full-time versus part-time) and retirement plans. Students were categorized according to their nationalities. Pearson's chi squared test, one way ANOVA and post hoc tests were used to measure statistical significance between measured variables and backgrounds of participants. The level of significance was set at P ≤ 0.05.

    RESULTS: A total of 227 students completed the survey (response rate = 84%). 47% of the participants were Jordanians, 27% were Malaysians, 11% were from Gulf States (Saudi Arabia, Bahrain, Kuwait and Qatar), 10% were from conflict zones in the Middle East (Syria, Iraq, Palestine and Yemen) and 5% comprised students from other nationalities. Significant differences were found between students from different backgrounds in their funding sources (Chi square = 132, P 

    Matched MeSH terms: Middle East
  16. Anderson D, Nathoo N, Lu JQ, Kowalewska-Grochowska KT, Power C
    J Neurovirol, 2018 06;24(3):376-378.
    PMID: 29508303 DOI: 10.1007/s13365-018-0620-x
    Sarcocystosis is a zoonotic infection that causes intestinal and muscular illnesses in humans. Sarcocystosis was until recently considered rare in humans. To complete their life cycle, Sarcocystis species require both a definitive and an intermediate host. Humans are the definitive host when infected by one of two species: Sarcocystis hominis (from eating undercooked beef) or Sarcocystis suihominis (from eating uncooked pork). Infection with either of these species results in intestinal sarcocystosis, causing a self-limited disease characterized by nausea, abdominal pain, and diarrhea. Humans act as the intermediate host when infected by Sarcocystis nesbitti, resulting in the markedly different clinical picture of muscular sarcocystosis. Most documented cases of muscular sarcocystosis were assumed to be acquired in Malaysia, in addition to other regions of Southeast Asia and India. Published cases of muscular sarcocystosis from the Middle East, Central and South America, and Africa are all rare. Although the clinical presentation of muscular sarcocystosis remains to be fully characterized, fever, myalgia, and headache are among the most common symptoms. Here, we report a patient from sub-Saharan Africa with chronic Sarcocystis myopathy and well-controlled HIV-AIDS.
    Matched MeSH terms: Middle East
  17. Mat-Rahim NA, Rashid TRTA, Suppiah J, Thayan R, Yusof AM, Sa'at Z
    Asian Pac J Trop Dis, 2015 Jul;5(7):543-546.
    PMID: 32289031 DOI: 10.1016/S2222-1808(15)60833-7
    Objective: To describe the complete nucleocapsid (N) gene region of Middle East respiratory syndrome coronavirus (MERS-CoV) from imported case in Malaysia and the relations with human- and camel-derived MERS-CoV.

    Methods: Combination of throat and nasal swab specimens was subjected to viral RNA extraction. For screening, the extracted RNA was subjected to real-time RT-PCR targeting upstream of E gene, open reading frame 1b and open reading frame 1a. For confirmation, the RNA was subjected to RT-PCR targeting partial part of the RNA-dependent RNA polymerase and nucleocapsid, followed by amplification of complete N gene region. Nucleotide sequencing of the first Malaysian case of MERS-CoV was performed following the confirmation with real-time RT-PCR detection.

    Results: Initial analysis of partial RNA-dependent RNA polymerase and N gene revealed that the nucleotides had high similarity to Jeddah_1_2013 strain. Analysis of complete N gene region (1 242 nucleotides) from the case showed high similarity and yet distinct to the nucleotide sequences of camel-derived MERS-CoV.

    Conclusions: From the finding, there are possibilities that the patient acquired the infection from zoonotic transmission from dromedary camels.

    Matched MeSH terms: Middle East Respiratory Syndrome Coronavirus
  18. Falavigna A, Quadros FW, Teles AR, Wong CC, Barbagallo G, Brodke D, et al.
    Global Spine J, 2018 May;8(3):303-310.
    PMID: 29796379 DOI: 10.1177/2192568217735804
    Study Design: Cross-sectional study.

    Objectives: To continue the line of a previous publication using steroid for acute spinal cord injury (SCI) by spine surgeons from Latin America (LA) and assess the current status of methylprednisolone (MP) prescription in Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine targets for educational activities suitable for each region.

    Methods: The English version of a previously published questionnaire was used to evaluate opinions about MP administration in acute SCI in LA, EU, AP, NA, and ME. This Internet-based survey was conducted by members of AOSpine. The questionnaire asked about demographic features, background with management of spine trauma patients, routine administration of MP in acute SCI, and reasons for MP administration.

    Results: A total of 2659 responses were obtained for the electronic questionnaire from LA, EU, AP, NA, and ME. The number of spine surgeons that treat SCI was 2206 (83%). The steroid was used by 1198 (52.9%) surgeons. The uses of MP were based predominantly on the National Acute Spinal Cord Injury Study III study (n = 595, 50%). The answers were most frequently given by spine surgeons from AP, ME, and LA. These regions presented a statistically significant difference from North America (P < .001). The number of SCI patients treated per year inversely influenced the use of MP. The higher the number of patients treated, the lower the administration rates of MP observed.

    Conclusions: The study identified potential targets for educational campaigns, aiming to reduce inappropriate practices of MP administration.

    Matched MeSH terms: Middle East
  19. Hassanein M, Al Sifri S, Shaikh S, Raza SA, Akram J, Rudijanto A, et al.
    Diabetes Ther, 2021 Jun;12(6):1703-1719.
    PMID: 33974216 DOI: 10.1007/s13300-021-01067-1
    INTRODUCTION: To analyse the safety and effectiveness of gliclazide modified release (MR) in adults with type 2 diabetes mellitus participating in Ramadan from three geographically and culturally different regions of the world included in the DIA-RAMADAN study.

    METHODS: DIA-RAMADAN was a real-world, observational, international, non-comparative study. The global study population was divided into three regional subgroups, with data gathered at inclusion 6-8 weeks prior to Ramadan (V0), during Ramadan (4.5 weeks) and 4-6 weeks after Ramadan (V1). Primary endpoint was the proportion of patients reporting ≥ 1 symptomatic hypoglycaemic events (HE), which were collected using a patient diary along with other adverse events.

    RESULTS: Patient numbers from the three regions were n = 564 (46.5%; Indian sub-continent), n = 354 (29.1%; Middle East) and n = 296 (24.4%; South-East Asia). Patient baseline characteristics, demographics, fasting habits and antidiabetic treatments varied between regions. There were similar proportions of symptomatic HE between regions, with no severe HE. Significant weight reductions were observed in all regions following Ramadan, along with reductions in HbA1c and fasting plasma glucose.

    CONCLUSION: These real-world study data indicate that gliclazide MR is safe and effective for management of type 2 diabetes during Ramadan in all three regions studied as part of DIA-RAMADAN.

    TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT04132934. INFOGRAPHIC.

    Matched MeSH terms: Middle East
  20. Dwekat IMM, Tengku Ismail TA, Ibrahim MI, Ghrayeb F
    Women Birth, 2021 Jul;34(4):344-351.
    PMID: 32684342 DOI: 10.1016/j.wombi.2020.07.004
    BACKGROUND: Respectful care during childbirth is a universal right for each woman in every health system, and mistreatment of women during childbirth is a major breach of this right.

    AIM: This study aimed to explore the views of Palestinian women and healthcare providers regarding factors contributing to the mistreatment of women during childbirth at childbirth facilities in the West Bank, Palestine.

    METHODS: A qualitative study was conducted in the West Bank, Palestine, from February 2019 to April 2019. In-depth interviews were conducted with six Palestinian women and five healthcare providers. Consent was obtained individually from each participant, and the interviews ranged from 40 to 50min. Data collection was continued until thematic saturation was reached. Open-ended questions were asked during interviews. Thematic analysis was used to interpret the data collected from the interviews.

    RESULTS: Four themes were identified with regards to the women and healthcare providers' views about factors contributing to the mistreatment of women during childbirth in the West Bank, Palestine: limitation in childbirth facilities, factors within the healthcare providers, the women themselves, and barriers within the community.

    DISCUSSION: Mistreatment of women during childbirth may occur due to the limitations of resources and staff in childbirth facilities. Some women also justified the mistreatment, and certain characteristics of the women were believed to be the factors for mistreatment.

    CONCLUSION: As the first known study of its kind in West Bank, the identified contributing factors especially the limitations of resources and staff are essential to provide good quality and respectful care at childbirth facilities.

    Matched MeSH terms: Middle East
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