Laparoscopic repair of internal hernia in one anastomosis gastric bypass (OAGB): a case report.

One anastomosis gastric bypass (OAGB), considered an alternative to Roux-en-Y gastric bypass, is becoming an increasingly common procedure. It shows excellent results in terms of weight reduction and remission of metabolic disease. Among the advantages of OAGB is the lack of internal hernia due to the absence of jejuno-jejunal anastomosis. However, internal herniation in OAGB is not impossible, and multiple cases have been mentioned in the literature. We describe a laparoscopic revisional surgery of internal hernia in a patient with a 2-month history of OAGB.

Increased airway resistance among exclusive waterpipe smokers detected using impulse oscillometry.

INTRODUCTION: Waterpipe smoking is increasing in popularity, yet the evidence implicating waterpipe smoking in lung disease is limited. We hypothesized that impulse oscillometry (IOS) would detect airway abnormalities in waterpipe smokers (WPS). METHODS: We studied 210 participants, 40 years or older, from the community, of whom 92 were exclusive WPS and 118 were never-smokers. Waterpipe smoking history was assessed using a validated questionnaire. All participants underwent spirometry, and IOS and absolute and percentage predicted results (for age, sex, height, and weight) were compared between WPS and nonsmokers. The association of IOS parameters with waterpipe smoking duration and extent (waterpipe smoked/day * smoking duration) was evaluated using linear regression. RESULTS: WPS smoked on average 1.8 ± 1.2 waterpipes/day, over an average duration of 23.3 ± 39.8 years. WPS and nonsmokers were largely asymptomatic and had similar age, body mass index, sex distribution, and spirometric values. Nevertheless, WPS had higher IOS measured resistance at 5Hz compared to nonsmokers, (0.53 ± 0.2 vs. 0.48 ± 0.2 kPa/L/s, P = 0.03) and higher percentage-predicted resistance (124.5 ± 36.3 vs. 115.7% ± 35.6%, P = 0.04). Waterpipe smoking duration was also associated with resistance (ß = 0.04 kPa/L/s/year, P = 0.01) and with percentage-predicted resistance (ß = 0.05/year, P = 0.02). Waterpipe smoking extent was associated with resistance (ß = 0.009 kPa/L/s/waterpipe-year, P = 0.04), while the association with percentage-predicted resistance was near significance (ß = 0.009/waterpipe-year, P = 0.07). CONCLUSIONS: Waterpipe smoking is associated with increased airway resistance assessed by IOS but not by spirometry in largely asymptomatic individuals from the community.

A successful endoscopic extraction of accidently ingested toothbrush in an adult: a case report.

Toothbrush ingestion is a rare phenomenon. It is usually found in psychiatric, elderly and mentally disabled patients. Foreign bodies usually pass spontaneously and uneventfully through the gastrointestinal tract. Nevertheless, larger objects may require early intervention to avoid complications. This report describes the course of treatment for a 25-year-old woman with an accidentally ingested toothbrush.

Successful laparoscopic extraction of trichobezoar due to Rapunzel syndrome: first reported case in Kuwait.

Rapunzel syndrome is a rare condition typically found in young female patients with mental or psychiatric disorders. It manifests as a large trichobezoar extending beyond the pylorus into the small intestine and leads to various adverse conditions. Early diagnosis and prompt management are crucial to avoiding complications. These bezoars are extracted endoscopically, laparoscopically and via open surgery (most common). In this current report, we discuss a successful laparoscopic extraction of a trichobezoar in a 12-year-old girl with acute abdominal pain due to small-bowel obstruction. We describe our technique compared with others' techniques and include a literature review on this topic.

Swirl sign in post-Roux-en-Y gastric bypass patients: a case series.

Bariatric surgeries have been increasing with the rising numbers of obese patients. Roux-en-Y is one of the safest and effective bariatric procedures worldwide. Internal hernia is one of laparoscopic Roux-en-Y gastric bypass complications. Its vague symptoms and late presentation may lead to adverse outcomes. Swirl sign in computed tomography scan has proven to be a particular and sensitive finding to detecting internal hernia in patients with an ambiguous presentation.

The association of waterpipe smoking with arterial stiffness and wave reflection in a community-based sample.

PURPOSE: The evidence linking waterpipe smoking to cardiovascular disease is limited. We evaluated the association of waterpipe smoking (WPS) with arterial stiffness and wave reflection measured by augmentation pressure (AP), augmentation index (AIx), and carotid-femoral pulse wave velocity (CFPWV), which are validated predictors of cardiovascular disease. MATERIALS AND METHODS: Community-based, cross-sectional study including 205 exclusive waterpipe smokers and 199 matched never-smokers aged 35 years or older (mean age 51.7 ± 8.9 years, 36% females). Smoking and its extent were assessed using a validated questionnaire and urine cotinine levels. CFPWV, AP, AIx (AP/aortic pulse pressure) and heart rate adjusted AIx (AIx@75) were determined using tonometry and compared between smokers and non-smokers, and the association of WPS with tonometry measures was assessed using linear regression adjusting for possible confounders. RESULTS: Waterpipe smokers and non-smokers had similar mean age and sex distribution. Compared to non-smokers, waterpipe smokers had significantly higher adjusted AP (10.5 ± 3.9 vs. 9.4 ± 3.9 mmHg respectively; p = 0.01), AIx (28.1 ± 8.4 vs. 25.7 ± 8.5% respectively; p = 0.01) and AIx@75 (24.2 ± 8.7 vs. 21.8 ± 8.9% respectively; p = 0.01). AIx was significantly associated with WPS extent, measured by a number of waterpipe smoked/day (ß = 1.04/waterpipe, 95%CI:[0.50-1.58]), duration of waterpipe smoking (ß = 0.77/10-years, 95%CI:[0.16-1.38]), their products in waterpipe-years (ß = 0.30/10-waterpipe-year, 95%CI:[0.12-0.47]) and plasma cotinine (ß = 0.56/100 ng/ml, 95%CI:[0.14-0.98]), adjusting for possible confounders, and so were AP and AIx@75. CFPWV however, was not associated with waterpipe smoking. CONCLUSION: In a community-based sample, exclusive WPS and its extent were associated with a dose-dependent increase in AIx and AP, accounting for other risk factors, suggesting that waterpipe smokers are at increased risk of cardiovascular disease.

Laparoscopic Roux-en-Y Gastric Bypass After Gastroesophageal Reflux Disease Surgical Procedure: Analysis of 85 Consecutive Patients with Pre- and Post-Operative Endoscopy Control.

Background: Most of the obese patients undergoing an anti-reflux operation experience recurrence of gastroesophageal reflux disease (GERD). Laparoscopic Roux-en-Y gastric bypass (LRNYGB) has been accepted as the bariatric surgery of choice for a previous GERD-operated obese patients. Methods: We present 85 consecutive patients from a single institution, previously submitted to antireflux surgery and then to LRNYGB. Preoperative endoscopy was carried out in all patients; 49 (57.64%) patients had findings of fundoplication failure or signs of persistent GERD, of those 20 (40.81%) with esophagitis. Results: From the bypass, per or postoperative minor to moderate complications occurred in 12 patients (14.11%): 2 (2.35%) conversions to laparotomy, 1 (1.17%) melena, 8 (9.41%) stenosis of gastrojejunostomy, treated by a simple endoscopic dilatation with a balloon, and 1 (1.17%) gastrogastric fistula. A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB. Eight of 79 (10.12%) patients had persistent esophagitis that represented 40% (8 of 20 patients) of persistent reflux esophagitis even after LRNYGB. All of them were men. Conclusion: LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. Nevertheless esophagitis still persisted in many of those patients.

Lung health in the Eastern Mediterranean Region: the need to end designated smoking areas in public places (Editorial).

Tobacco use is a fatal habit that causes harm to almost all organs of the human body and kills up to half of its users. Studies have shown that tobacco contains a poisonous mix of more than 7000 chemicals that have major consequences, including heart attacks and strokes , and are considered major risk factors for many types of cancer (4) and the leading cause of lung cancer. Moreover, tobacco use dramatically affects the respiratory system, damaging its airways and alveoli, and leading to chronic obstructive lung diseases1 including emphysema and chronic bronchitis.

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon.

Waterpipe tobacco smoking (WTS) is spreading worldwide. Research has indicated health consequences of WTS similar to cigarettes. Prevalence of WTS is high among young people. In Lebanon, current use rates of 35% have been documented among 13⁻15 year olds. We evaluated a school-based intervention. Method: We conducted a randomized-controlled-trial of a theory-informed WTS intervention. The intervention consisted of ten sessions based on social cognitive theory and the social influences approach. Thirty-one schools participated: 14 intervention and 17 control; a total of 1279 students completed pre and post assessments. We measured knowledge, attitudes and self-reported behaviors related to WTS using Chi-square tests and regression analyses to compare results between the two study arms. Results: The intervention increased knowledge of intervention group compared to control group participants-about WTS constituents and health consequences; and shifted attitudes of intervention group participants to be even more unfavorable towards WTS. We found no impact of the intervention on WTS behaviors. Discussion: The effectiveness of the intervention on knowledge and attitudes supports previous research. The lack of intervention effect on behavior is not surprising given the timing of the post assessment immediately after the intervention, and the social context that was supportive of waterpipe use.

Effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: a randomized controlled trial.

BACKGROUND: Cigarette smoking is one of the major preventable causes of death and diseases in Qatar. The study objective was to test the effect of a structured smoking cessation program delivered by trained pharmacists on smoking cessation rates in Qatar. METHODS: A prospective randomized controlled trial was conducted in eight ambulatory pharmacies in Qatar. Eligible participants were smokers 18 years and older who smoked one or more cigarettes daily for 7 days, were motivated to quit, able to communicate in Arabic or English, and attend the program sessions. Intervention group participants met with the pharmacists four times at 2 to 4 week intervals. Participants in the control group received unstructured brief smoking cessation counseling. The primary study outcome was self-reported continuous abstinence at 12 months. Analysis was made utilizing data from only those who responded and also using intent-to-treat principle. A multinomial logistic regression model was fitted to assess the predictors of smoking at 12 months. Analysis was conducted using IBM-SPSS® version 23 and STATA® version 12. RESULTS: A total of 314 smokers were randomized into two groups: intervention (n = 167) and control (n = 147). Smoking cessation rates were higher in the intervention group at 12 months; however this difference was not statistically significant (23.9% vs. 16.9% p = 0.257). Similar results were observed but with smaller differences in the intent to treat analysis (12.6% vs. 9.5%, p = 0.391). Nevertheless, the daily number of cigarettes smoked for those who relapsed was significantly lower (by 4.7 and 5.6 cigarettes at 3 and 6 months respectively) in the intervention group as compared to the control group (p = 0.041 and p = 0.018 respectively). At 12 months, the difference was 3.2 cigarettes in favor of the intervention group but was not statistically significant (p = 0.246). Years of smoking and daily number of cigarettes were the only predictors of smoking as opposed to quitting at 12 months (p = 0.005; p = 0.027 respectively). CONCLUSIONS: There was no statistically significant difference in the smoking cessation rate at 12 months between the groups. However, the smoking cessation program led to higher (albeit non-significant) smoking cessation rates compared with usual care. More research should be conducted to identify factors that might improve abstinence. TRIAL REGISTRATION: Clinical Trials NCT02123329 . Registration date 20 April 2014.

Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon.

INTRODUCTION: Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated. METHODS: This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries. RESULTS: The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children's participation as 'positive and active' in 77.9% of the sessions. CONCLUSIONS: Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

Cancer risk in waterpipe smokers: a meta-analysis.

OBJECTIVES: To quantify by meta-analysis the relationship between waterpipe smoking and cancer, including cancer of the head and neck, esophagus, stomach, lung and bladder. METHODS: We performed a systematic literature search to identify relevant studies, scored their quality, used fixed and random-effect models to estimate summary relative risks (SRR), evaluated heterogeneity and publication bias. RESULTS: We retrieved information from 28 published reports. Considering only highquality studies, waterpipe smoking was associated with increased risk of head and neck cancer (SRR 2.97; 95 % CI 2.26-3.90), esophageal cancer (1.84; 1.42-2.38) and lung cancer (2.22; 1.24-3.97), with no evidence of heterogeneity or publication bias. Increased risk was also observed for stomach and bladder cancer but based mainly on poor-quality studies. For colorectum, liver and for all sites combined risk estimates were elevated, but there were insufficient reports to perform a meta-analysis. CONCLUSIONS: Contrary to the perception of the relative safety of waterpipe smoking, this meta-analysis provides quantitative estimates of its association with cancers of the head and neck, esophagus and lung. The scarcity and limited quality of available reports point out the need for larger carefully designed studies in well-defined populations.

Assessing the effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: study protocol for a randomized controlled trial.

BACKGROUND: It had been reported that up to 37% of the adult male population smokes cigarettes in Qatar. The Global Youth Tobacco Survey also stated that 13.4% of male school students aged 13 to 15 years in Qatar smoke cigarettes. Smoking cessation is key to reducing smoking-related diseases and deaths. Healthcare providers are in an ideal position to encourage smoking cessation. Pharmacists are the most accessible healthcare providers and are uniquely situated to initiate behavior change among patients. Many studies have shown that pharmacists can be successful in helping patients quit smoking. Studies demonstrating the effectiveness of pharmacist-delivered smoking cessation programs are lacking in Qatar. This proposal aims to test the effect of a structured smoking cessation program delivered by trained ambulatory pharmacists in Qatar. METHODS/DESIGN: A prospective, randomized, controlled trial is conducted at eight ambulatory pharmacies in Qatar. Participants are randomly assigned to receive an at least four-session face-to-face structured patient-specific smoking cessation program conducted by the pharmacist or 5 to 10 min of unstructured brief smoking cessation advice (emulating current practice) given by the pharmacist. Both groups are offered nicotine replacement therapy if feasible. The primary outcome of smoking cessation will be confirmed by an exhaled carbon monoxide test at 12 months. Secondary outcomes constitute quality-of-life adjustment as well as cost analysis of program resources consumed, including per case and patient outcome. DISCUSSION: If proven to be effective, this smoking cessation program will be considered as a model that Qatar and the region can apply to decrease the smoking burden. TRIAL REGISTRATION: Clinical Trials NCT02123329 .

Secondhand smoke emission levels in waterpipe cafes in Doha, Qatar.

BACKGROUND: Exposure to the emissions of a tobacco waterpipe is associated with increased health risks among its users as well as those exposed to its secondhand smoke. Waterpipe use is an emerging concern to the tobacco control community, particularly among countries of the Eastern Mediterranean Region. In 2002, Qatar adopted legislation that prohibited cigarette smoking inside public venues, but exempted tobacco waterpipe smoking. To inform the development and enforcement of effective policy, the impact of cigarette and waterpipe use on indoor air quality was monitored in waterpipe cafes in Doha, Qatar. METHODS: Particulate matter (PM2.5) levels were measured inside and outside of a sample of 40 waterpipe cafes and 16 smoke-free venues in Doha, Qatar between July and October 2012. In addition, the number of waterpipes being smoked and the number of cigarette smokers were counted within each venue. Non-paired and paired sample t tests were used to assess differences in mean PM2.5 measurements between venue type (waterpipe vs smoke-free) and environment (indoor vs outdoor). RESULTS: The mean PM2.5 level inside waterpipe venues (476 µg/m(3)) was significantly higher than the mean PM2.5 level inside smoke-free venues (17 µg/m(3); p<0.001), and significantly higher than the mean PM2.5 level found immediately outside waterpipe venues (35 µg/m(3); p<0.001). In smoke-free venues, the outside mean PM2.5 level (30 µg/m(3)) did not differ significantly from the mean PM2.5 inside levels inside these venues (p=0.121). CONCLUSIONS: Elevated levels of particulate pollution were found in waterpipe cafes in Doha, Qatar, potentially endangering the health of employees and patrons. To protect the public from the dangers of secondhand tobacco smoke, and to change social norms around tobacco use, smoke-free policies that apply to all forms of combusted tobacco products, including the waterpipe, are needed.

Challenges to obtaining parental permission for child participation in a school-based waterpipe tobacco smoking prevention intervention in Qatar.

BACKGROUND: Involving children in research studies requires obtaining parental permission. A school-based intervention to delay/prevent waterpipe use for 7th and 8th graders in Qatar was developed, and parental permission requested. Fifty three percent (2308/4314) of the parents returned permission forms; of those 19.5% of the total (840/4314) granted permission. This paper describes the challenges to obtaining parental permission. No research to date has described such challenges in the Arab world. METHODS: A random sample of 40 schools in Doha, Qatar was selected for inclusion in the original intervention. Permission forms were distributed to parents for approval of their child's participation. The permission forms requested that parents indicate their reasons for non-permission if they declined. These were categorized into themes. In order to understand reasons for non-permission, interviews with parents were conducted. Phone numbers of parents were requested from the school administration; 12 of the 40 schools (30%) agreed to provide the contact information. A random sample of 28 parents from 12 schools was interviewed to reach data saturation. Thematic analysis was used to analyze their responses. RESULTS: Reasons for non-permission documented in both the forms and interviews included: poor timing; lack of interest; the child not wanting to participate; and the child living in a smoke-free environment. Interviews provided information on important topics to include in the consent forms, parents' decision-making processes regarding their child's participation, and considerations for communicating with parents. Many parents also indicated that this was the first time they had been asked to give an informed consent for their child's participation in a study. CONCLUSIONS: Results indicate that more attention needs to be given to the informed parental consent process. Researchers should consider enhancing both the methods of communicating information as well the specific information provided. Before embarking on recruitment of children for studies, formative research on the parental consent process is suggested.

Prevalence of tobacco use among students aged 13-15 years in Health Ministers' Council/Gulf Cooperation Council Member States, 2001-2004.

BACKGROUND: This article examines differences and similarities in adolescent tobacco use among Member States of the Health Ministers' Council for the Gulf Cooperation Council (HMC/GCC) using Global Youth Tobacco Survey (GYTS) data. METHODS: Nationally representative samples of students in grades associated with ages 13-15 in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen. Schools were selected proportional to enrollment size, classes were randomly selected within participating schools, and all students in selected classes were eligible to participate. RESULTS: GYTS results confirmed that boys are significantly more likely than girls to smoke cigarettes or use shisha (water pipe). Students had higher rates of tobacco use than adults in Bahrain, Oman, and United Arab Emirates. For boys and girls, shisha use was higher than cigarette smoking in almost all countries. Susceptibility to initiate smoking among never smokers was higher than current cigarette smoking in all countries. Exposure to secondhand smoke in public places was greater than 30%, direct protobacco advertising exposure was greater than 70% on billboards and in newspapers, and more than 10% of students were influenced by indirect advertising. Finally, less than half of the students were taught in school about the dangers of tobacco use in the past year. CONCLUSIONS: For boys and girls, high prevalence of cigarette smoking, high prevalence of shisha use, and high susceptibility of never smokers to initiate smoking in the next year are troubling indicators for the future of chronic disease and tobacco-related mortality in the Member States of the HMC/GCC.

Strategy to improve road safety in developing countries.

OBJECTIVE: To review the road safety situation in developed and developing countries compared with the Arabian Gulf countries and suggest a strategy to improve it. The role of road engineers in reducing accidents is highlighted. METHODS: This is a retrospective study of road traffic accidents (RTAS) for a period from 1988 to 1998 in Arabian Gulf Countries. The data was taken from the Directorate of Traffic and Ministry of Health records in Gulf Countries. Additional data was obtained from other sources including the World Health Organizations Statistics Annuals, International Road Federation, Transport Road Research Laboratory and accident facts publications. Overall fatality and injury rates of RTAs were calculated. RESULTS: The lack of reliable data is a serious problem in most of the developing countries. It is quite reasonable to assume that the incidence of accidents is much larger than actually reported. A comparison of vehicle ownership levels and safety parameters in both developed and developing countries is presented to highlight the relative seriousness of the road safety situation in different countries. The fatality rates (per population and per vehicles) are selected for comparison purposes from developed and developing countries. CONCLUSION: Road traffic accidents continue to be a major cause of mortality and morbidity in the Arabian Gulf Countries leading to substantial wastage of life and national resources. Further investigation is essential and will require close inter-sectoral collaboration between, traffic police, health, law, and transport authorities. Developing a research strategy for prevention will reduce casualties and death on the road.