Respiratory health and quality of life in young exclusive, habitual smokers - a comparison of waterpipe smokers, cigarette smokers and non-smokers.

Purpose: Waterpipe (WP) use has become a global trend in young populations. However, there are few well-controlled studies focusing specifically on the chronic effects of exclusive WP use on young adults' respiratory health. We sought to compare in young adults the burden of respiratory symptoms in regular WP smokers (WPS) relative to regular cigarette smokers (CS, positive controls) and non-smokers (negative controls); and to evaluate differences in health-related quality of life between the three groups. Method: We implemented a cross-sectional survey in college campuses across four countries (Egypt, Jordan, Morocco and Oman). Purposive sampling was employed to identify habitual (regular) healthy WPS (smoked 3 or more WP per week for 3 or more years); CS (smoked 5 or more cigarettes daily for 3 or more years); and non-smokers. Respiratory symptoms were assessed using the European Community Respiratory Health Survey and the American Thoracic Society and the Division of Lung Diseases Questionnaire. Health-related quality of life was measured using the Short-Form 12. Demographic, environmental and lifestyle factors also were measured. Result: The analytic sample included 135 WPS, 303 CS, and 300 non-smokers. Either tobacco group had significantly greater proportions of males than the non-smoker group. A significantly lower proportion of non-smokers (than either tobacco group) was overweight or obese. Average numbers of reported respiratory symptoms were 5.1, 5.8, and 2.9 in WPS, CS, and non-smokers, respectively. In multivariable regressions controlling for environmental exposures, body mass index, and physical activity, WPS and CS exhibited significantly higher rates of respiratory symptoms than non-smokers (1.6 times greater and 1.9 times greater rate of respiratory symptoms than non-smokers, respectively). Non-smokers reported significantly higher scores for general health relative to either WPS or CS. Conclusion: Relative to their young non-smoking counterparts, young habitual WPS exhibit a significant burden of respiratory symptoms that is comparable to that observed with CS. Young WPS (and CS), despite their age, may be well on their way to developing respiratory disease.

Smoking cessation care can translate to lower hazard of death in the short-run in cancer patients - a retrospective cohort study to demonstrate the value of smoking cessation services within the treatment phase of cancer.

BACKGROUND: Smoking cessation is a key step towards improving cancer care and outcomes. However, smoking cessation interventions are underprovided in oncology settings. Within Jordan's only comprehensive oncology center, we sought to evaluate receipt of care at a smoking cessation clinic and the effect of assisted abstinence through the smoking cessation clinic on short-term (two-year) survival after a cancer diagnosis. METHODS: We employed a retrospective cohort study design. Cancer registry and smoking cessation clinic data for adult Jordanian cancer patients diagnosed between 2009 and 2016, who also were cigarette smokers, and who received full treatment at King Hussein Cancer Center, were analyzed. Specifically, descriptive statistics of patients who visited the smoking cessation clinic were generated, and short-term (two-year) hazard of death of patients based on whether or not smoking cessation clinic-assisted abstinence occurred, were evaluated. RESULTS: There were 3403 patients who met our inclusion criteria. Approximately 21% of cancer patients were seen at the smoking cessation clinic, and significant demographic and clinical disparities in who was being seen [at the smoking cessation clinic] existed. In 2387 patients with available survival data, smokers who never went to the smoking cessation clinic (or were seen only once, or seen a year or more from diagnosis) had a hazard of death 2.8 times higher than smokers who had visited the smoking cessation clinic and who also confirmed they had not smoked on atleast two of their 3-, 6- or 12-month follow-up visits (95% confidence interval [CI] = 1.7-4.6). Non-abstainers at the smoking cessation clinic exhibited a similar disadvantage (HR 2.7, 95% CI 1.4-5.0). CONCLUSIONS: Although evidence-based smoking cessation interventions increase the likelihood of abstinence and can lower the short-term hazard of death during cancer treatment, there is a deprioritization of smoking cessation interventions during cancer care, as indicated by low proportions of patients seen at the smoking cessation clinic. Our findings emphasize the importance of promoting interventions to avail smoking cessation interventions in oncology settings within the cancer treatment phase.

Are Jordanian primary healthcare practitioners fulfilling their potential in cancer prevention and community health? Findings from a cross-sectional survey.

INTRODUCTION: Primary healthcare practitioners (PHCPs) can contribute to the control of cancer by promoting healthy lifestyles to patients. Given the scarcity of data in the Middle East on this subject, we sought to determine, through a cross-sectional survey, the status of healthy lifestyle promotion by PHCPs (physicians, nurses, midwives, nurse aids) in Jordan. METHODS: Building on published studies, an Arabic questionnaire was developed to measure knowledge, perceptions and practices of Jordanian PHCPs with regard to healthy lifestyle counselling. A purposive sample of 20 clinics covering the main regions of Jordan was selected and all PHCPs were asked to complete the questionnaire. RESULTS: 322 practitioners (32.3% physicians) responded (a 75.1% response rate). 24.4% of PHCPs were current cigarette smokers (physicians 44.2%). Roughly 58% of physicians and 50% of non-physicians reported advising the majority of patients to quit tobacco, but proportions were lower for providing other services (eg, asking about frequency of tobacco use, inquiring about diet and exercise, providing evidence-based guidance on quitting tobacco or improving diet and activity). Only 8% of the sample reported collectively asking the majority of patients about smoking status, exercise and diet; and providing evidence-based tips to improve these. Among physicians and non-physicians, 14.2% and 40.4% were able to identify the lifestyle-related risk factors associated with breast, colorectal and lung cancer. In multivariable analyses, confidence was the only significant variable associated with provision of counselling on healthy lifestyles. CONCLUSIONS: Among Jordanian PHCPs, primary prevention services are underprovided, and data suggest ample room to improve PHCPs' skills and practices.

Educational Needs of Oncology Practitioners in a Regional Cancer Center in the Middle East-Improving the Content of Smoking Cessation Training Programs.

Little is known with regard to perceptions and information needs of oncology practitioners in the Middle East as they pertain to smoking cessation (SC) support for cancer patients. We sought to assess these in a regional cancer center. A survey was distributed to oncology practitioners (physicians, nurses, pharmacists, and physio- and respiratory therapists) at King Hussein Cancer Center (Amman, Jordan) for self-completion. The survey included SC-related measures of perceptions, knowledge, and practices. Descriptive statistics and cross tabulations were performed to identify misperceptions and knowledge gaps that could be corrected through continuing education. Findings revealed, among 254 practitioners surveyed, low referral rates to the SC clinic. Negative perceptions about cancer patients who smoke existed (e.g., patients needing smoking to control anxiety; patients' willpower sufficient for quitting; patients not wanting to quit and not needing more information). Substantial knowledge gaps were prevalent with regard to the detrimental outcomes associated with continued tobacco use after a cancer diagnosis and with regard to approved SC medication choices. Our results are useful in identifying topics that need to be highlighted during training and educational efforts in the region and also reinforce the need to avail such efforts in order to improve SC-related knowledge and perceptions.

The effect of habitual waterpipe tobacco smoking on pulmonary function and exercise capacity in young healthy males: A pilot study.

BACKGROUND: Evidence regarding the health effects of habitual waterpipe smoking is limited, particularly in young smokers. Respiratory health and cardiopulmonary exercise tests were compared in young male habitual waterpipe smokers (WPS) versus non-smokers. METHODS: 69 WPS (≥3 times/week for three years) and 69 non-smokers were studied. Respiratory health was assessed through the American Thoracic Society and the Division of Lung Diseases (ATS-DLD-78) adult questionnaire. Pulmonary function and cardiopulmonary exercise tests were performed. Self-reported respiratory symptoms, forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, forced expiratory flow between 25 and 75% of FVC (FEF25-75%), peak expiratory flow (PEF), exercise time, peak end-tidal CO2 tension (PetCO2), subject-reported leg fatigue and dyspnea; peak O2 uptake (VO2 max), and end-expiratory lung volume (EELV) change from baseline (at peak exercise) were measured. RESULTS: WPS were more likely than non-smokers to report respiratory symptoms. WPS also demonstrated: shorter exercise time; lower peak VO2; higher perceived dyspnea at mid-exercise; lower values of the following: FEV1, FVC, PEF, and EELV change. CONCLUSION: Habitual waterpipe tobacco smoking in young seemingly healthy individuals is associated with a greater burden of respiratory symptoms and impaired exercise capacity.

Cancer-related knowledge, attitudes, and risk perception among 6 grade students in Jordan.

UNLABELLED: Elementary schools in Jordan have included health education material in curricula to promote healthy lifestyles among younger school children. However, the relation between healthy lifestyles and the prevention of chronic diseases such as cancer has not been an explicit component in school curricula of younger age groups. We sought to explore the level of knowledge among 6th grade students as well as their attitudes with respect to cancer. This comes as part of a pilot project to develop an educational series on cancer prevention that aims to meet knowledge gaps specific to the community of students in this age group in Jordan. METHODS: A questionnaire composed of items measuring knowledge about cancer and cancer prevention through healthy practices, attitudes towards cancer, and intentions to engage in healthy behaviors was developed. Questionnaires previously used in similar age groups elsewhere were used as a reference. Our questionnaire was reviewed and approved by the Ministry of Education - School Health & Nutrition Department. Sixth graders in a convenience sample of four schools selected by the Ministry of Education completed the self-administered questionnaire. RESULTS: Ninety-six 6th graders from four schools answered the baseline survey, but 28% of the surveys were excluded from the analysis (data quality problems) leaving 69 student participants. In the original sample of 96 students, 48 (69.6%) were girls. Among the 69 student participants, 67 (97.1%) had heard of cancer, but fewer than 44 (63.8% knew it was not a contagious disease. Regarding fear, 29 (42%) would not play with a cancer patient. Concerning prevention of the most prevalent cancers in Jordan as research has shown that certain risk factors increase the chance that a person will develop cancer. The most common risk factors are smoking, Poor diet, lack of physical activity, or being overweight, 25 (36.2%) knew breast cancer was preventable, and 28 (40.6%) and 24 (34.8%) knew this regarding lung and colorectal cancers, respectively. About 40 (57.8%) students identified healthy dietary behaviors (e.g., low fat, low sugar), but only six could identify the ideal frequency for exercise (60 minutes daily). Fifty-eight (84.1%) agreed that cigarettes harmed the health. However, only 21 (30.4%) found it easy to avoid exposure to secondhand smoke. Nine (13%) reported smoking water pipes, but only one reported smoking cigarettes. Forty-eight (69.6%) and 47 (68.1%) agreed that daily physical activity and healthy eating were important, respectively. Fifty-two (75.4%) students found it easy to eat healthy at home, but only 37 (53.6%) found it easy to do so at school. Finally, 63 (91.3%) students wanted to learn more about cancer. CONCLUSION: Although a significant number of our sample of students has heard about cancer and students exhibit some knowledge regarding healthy practices, our results show that knowledge gaps exist with regard to the nature of cancer as a noncontagious disease, the preventability of specific cancers, and the link between specific risk factors and cancer.

Diameter, pressure and compliance relationships in dorsal hand veins.

The diameter-pressure characteristics of dorsal hand veins previously have not been characterized. In this study, the effects of distending pressure with and without infused norepinephrine on diameter and compliance were observed. The elevation needed for venous collapse was measured, and the effects of baseline constriction on venous reactivity were assessed. In seven supine subjects, a brachial cuff on an elevated arm was used to generate distending pressures while a linear variable displacement transformer (LVDT) measured changes in venous diameter. Arctangent functions of distending pressure were fitted to the normalized diameter, then compliance functions were calculated. In supine subjects, 5-15 cm of elevation emptied dorsal hand veins. Norepinephrine decreased the venous diameter at any distending pressure by increasing the P50 without significantly changing the midpoint slope. Compliance was a nearly single-valued function of the normalized diameter with a maximum value at about 60% distention. Reactivity depends on distending pressure and baseline P50. Percentage constriction is a function of initial and final P50 and of distending pressure.

Heparin attenuates norepinephrine-induced venoconstriction.

Reversal by heparin of norepinephrine-induced constriction of normal hand veins was studied. Venous size was measured using a linear variable differential transformer (LVDT) during infusions of saline, norepinephrine, insulin and norepinephrine, and graded doses of heparin with norepinephrine. Heparin reduced the venoconstrictive effects of norepinephrine (p < 0.01), with the effects beginning at 18.5 nmol/min (0.05 U/min) and reaching a maximum between 185 nmol/min and 1.85 mumol/min (0.5 and 5 U/min). Maximal heparin-induced venorelaxation correlated with the maximal insulin effect within individuals (r = 0.8, p < 0.01) and was unchanged by the addition of insulin. Methylene blue, a non-specific inhibitor of the nitric oxide cGMP cascade, reduced heparin-induced venorelaxation. In conclusion, heparin in either physiologic or pharmacologic concentration attenuated norepinephrine-induced venoconstriction. A common mechanism of venorelaxation by heparin and insulin is not excluded given the correlation and lack of additivity of maximum effects and their inhibition by methylene blue.

Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure.

In a retrospective, cohort design, clinical usage of digoxin, diuretic, and angiotensin-converting enzyme (ACE) inhibitor was assessed in all patients readmitted over a 36-month period for congestive heart failure (CHF) diagnostic-related group (DRG) 127. ACE inhibitor dose-response analysis used the discharge dose of ACE inhibitor, converted to enalapril-equivalent doses and adjusted for renal function. Principal end points were time-to-readmission and 90-day readmission rate. Of 314 total patients, digoxin was used in 72%, diuretic in 86%, and 67% received an ACE inhibitor. Only 22% of those on an ACE inhibitor received currently recommended doses of enalapril > or = 20 mg/day or equivalent, whereas 41% received enalapril < or = 5 mg/day. Time-to-readmission was increased by an ACE inhibitor (p = 0.002) but not digoxin or diuretic. An ACE inhibitor was the principal covariate of 90-day readmission rate (p <0.05). The readmission rate was not reduced with daily ACE inhibitor doses of < or = 5 mg enalapril, whereas daily doses of > or = 10 mg enalapril reduced 90-day readmission rates by 28% compared to those receiving diuretic or digoxin therapy (p <0.05). Using a dynamic model, the dose required to achieve 90% to 95% of the theoretical maximum ACE inhibitor effect exceeded 100 mg enalapril daily. Thus, CHF readmission rates are lower when daily ACE inhibitor doses exceed 5 mg enalapril or the equivalent daily, but are unaffected by digoxin or diuretic. Modeled maximum ACE inhibitor benefits require doses 8- to 10-fold higher than current usage patterns.