Which Surgical Attitude to Choose in the Context of Non-Resectability of Ovarian Carcinomatosis: Beyond Gross Residual Disease Considerations.

BACKGROUND: In ovarian cancer, the increased rate of radical surgery comprising upper abdominal procedures has participated to improve overall survival (OS) in advanced stages by increasing the rate of complete cytoreductions. However, in the context of non-resectability, it is unclear whether radical surgery should be considered when it would lead to microscopic but visible disease (≤1 cm). We aimed to compare the survival outcomes among patients with incomplete cytoreduction according to the extent of surgery. METHODS: Overall, 148 patients presenting with advanced stage ovarian carcinomas were included in this retrospective study, regardless of treatment schedule. These patients were stratified according to the extent of surgery (standard or radical). Complete cytoreduction at the time of debulking surgery could not be carried out in all cases. RESULTS: Among our study population (n = 148), 96 patients underwent standard procedures (SPs) and 52 underwent radical surgeries (RP). Patients in the SP group had a lower Peritoneal Index Cancer (PCI) at baseline (12.6 vs. 14.9; p = 0.049). After PCI normalization, we observed similar OS in the SP and RP groups (39.7 vs. 43.1 months; p = 0.737), while patients in the SP group had a higher rate of residual disease >10 mm (p < 10(-3)). Patients in the RP group had an increased rate of relapse (p = 0.005) but no difference in disease-free survival compared with the SP group (22.2 for SP vs. 16.3 months; p = 0.333). Residual disease status did not impact survival outcomes. CONCLUSIONS: In the context of non-resectable, advanced stage ovarian cancer, standard surgery seems as beneficial as radical surgery regarding survival outcomes and should be considered to reduce surgery-associated morbidity.

Patient responses to research recruitment and follow-up surveys: findings from a diverse multicultural health care setting in Qatar.

BACKGROUND: Health care researchers working in the Arabian Gulf need information on how to optimize recruitment and retention of study participants in extremely culturally diverse settings. Implemented in Doha, Qatar in 2012 with 4 language groups, namely Arabic, English, Hindi, and Urdu, this research documents persons' responses to recruitment, consent, follow-up, and reminder procedures during psychometric testing of the Multicultural Assessment Instrument (MAI), a novel self- or interviewer-administered survey. METHODS: Bilingual research assistants recruited adults in outpatient clinics by approaching persons in particular who appeared to be from a target language group. Participants completed the MAI, a second acculturation instrument used for content-validity assessment, and a demographics questionnaire. Participants were asked to take the MAI again in 2-3 weeks, in person or by post, to assess test-retest reliability. Recruitment data were analyzed by using nonparametric statistics. RESULTS: Of 1503 persons approached during recruitment, 400 enrolled (27%)-100 per language group. The enrollment rates in the language groups were: Arabic-32%; English-33%; Hindi-18%; Urdu-30%. The groups varied somewhat in their preferences regarding consent procedure, follow-up survey administration, contact mode for follow-up reminders, and disclosure of personal mailing address (for postal follow-up). Over all, telephone was the preferred medium for follow-up reminders. Of 64 persons who accepted a research assistant's invitation for in-person follow-up, 40 participants completed the interview (follow-up rate, 63%); among 126 persons in the postal group with a deliverable address, 29 participants mailed back a completed follow-up survey (response rate, 23%). CONCLUSIONS: Researchers in the Arabian Gulf face challenges to successfully identify, enroll, and retain eligible study participants. Although bilingual assistants-often from the persons' own culture-recruited face-to-face, and our questionnaire contained no health care-related content, many persons were reluctant to participate. This occurrence was observed especially at follow-up, particularly among participants who had agreed to follow-up by post.

Validation of a simple tool to assess risk of waterpipe tobacco smoking among sixth and seventh graders in Lebanon.

BACKGROUND: Waterpipe tobacco smoking (WTS) is highly prevalent in the Eastern Mediterranean region. While studies have identified socio-demographic factors differentiating smokers from non-smokers, validated tools predicting WTS are lacking. METHODS: Over 1000 (n = 1164) sixth and seventh grade students in Lebanon were randomly assigned to a prediction model group and validation model group. In the prediction model group, backward stepwise logistic regression enabled the identification of socio-demographic and psychosocial factors associated with ever and current WTS. This formed risk scores which were tested on the validation model group. RESULTS: The risk score for current WTS was out of four and included reduced religiosity, cigarette use and the perception that WTS was associated with a good time. The risk score for ever WTS was out of seven and included an additional two variables: increased age and the belief that WTS did not cause oral cancer. In the validation model group, the model displayed moderate discrimination [area under the curve: 0.77 (current), 0.68 (ever)], excellent goodness-of-fit (P > 0.05 for both) and optimal sensitivity and specificity of 80.1 and 58.4% (current), and 39.5 and 94.4%, (ever), respectively. CONCLUSIONS: WTS use can be predicted using simple validated tools. These can direct health promotion and legislative interventions.

Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students.

BACKGROUND: Pictorial health warnings are more effective than text warnings in enhancing motivation to quit and not to start smoking among youth. In Lebanon, packs still have only a very small text warning. The aim of this study was to evaluate the perceived effectiveness of pictorial health warnings on cigarette packs among Lebanese youth. METHODS: This was a cross-sectional study including school students (n=1412) aged 13-18 years recruited from 28 schools and university students (n=1217) aged 18-25 years recruited from 7 universities. A variety of warnings were adapted from other countries. In all, 4 warnings were tested among school students and 18 among university students. RESULTS: All pictorial warnings were considered more effective than the current text warning on message-related and impact-related variables, including intentions to quit or not to start smoking among school and university students. Selected examples related to the top-ranked pictorial warnings are: among male non-smoking school students, 81% agreed that the 'lung' warning had more impact on their intentions not to start smoking as compared to 57% for the current text warning (p<0.001) with a significant difference compared to the current text warning; among female non-smoking university students, 75% agreed that the 'economic impact' pictorial had more impact on their intentions not to start smoking with significant difference as compared to 43% for the current text warning (p value=0.001); finally, the 'heart attack' pictorial resulted in 52% of male university students smokers stating they intended to quit as opposed to 20% for the current text warning (p value=0.019). CONCLUSIONS: The results of the present study add to the general international literature on the impact of pictorial warnings on youth and young adults. This study is also the first to test a non-health pictorial warning about the negative economic consequences of smoking, and to find that such a warning was effective among specific sociodemographic groups.

Molecular epidemiology and genotype distribution of Human Papillomavirus (HPV) among Arab women in the State of Qatar.

BACKGROUND: Human Papilloma Virus (HPV) infection is the major cause of cervical cancer worldwide. With limited data available on HPV prevalence in the Arab countries, this study aimed to identify the prevalence and genotypic distribution of HPV in the State of Qatar. METHODS: 3008 cervical samples, exclusively of women with Arabic origin residing in Qatar were collected from the Women's Hospital and Primary Health Care Corporation in Doha, State of Qatar. HPV DNA detection was done using GP5+/6+ primers based real time-polymerase chain reaction (RT-PCR) assay followed by the usage of HPV type specific primers based RT- PCR reactions and Sanger sequencing for genotype identification. RESULTS: Similar prevalence rates of HPV infection was identified in both Qatari and non-Qatari women at 6.2% and 5.9% respectively. HPV prevalence rate of 5.8% and 18.4% was identified in women with normal cytology and in women with abnormal cytology respectively. HPV 81, 11 and 16, in decreasing order were the most commonly identified genotypes. HPV 81 was the most frequent low-risk genotype among women with both normal (74.0%) and abnormal (33.3%) cytology. HPV 16 (4.6%) was identified as the predominant high-risk HPV genotype among women with normal cytology and HPV 16, HPV 18, and HPV 56 (22.2% each) were the most common identified high-risk genotypes in women with abnormal cytology. CONCLUSIONS: The overall HPV prevalence in Arab women in Qatar was identified as 6.1% with an increased HPV prevalence seen in women with abnormal cytology results and no significant trends seen with age. In contrast to Western countries, we report a varied genotypic profile of HPV with a high prevalence of low-risk HPV genotype 81 among the Arab women residing in Qatar.

Prevalence of Chlamydia trachomatis infection in the general population of women in Qatar.

OBJECTIVES: The Arabian Gulf region has limited epidemiological data related to sexually transmitted infections. The objective of this study was to estimate the prevalence of Chlamydia trachomatis infection among general population women in Doha, Qatar. METHODS: Endocervical swabs were collected from healthy women attending primary healthcare centres in Doha, June-December 2008. The specimens were tested for C trachomatis by a commercially available PCR-based assay. Data on basic socio-demographic characteristics, medical history and sexual behaviour were obtained using self-administered questionnaires. The prevalence of C trachomatis and of background variables were stratified by nationality, Qatari nationals versus non-Qatari residents. RESULTS: A total of 377 women were enrolled in the study, out of whom 351 (37.9% Qataris, 62.1% non-Qataris) were tested for the presence of C trachomatis in their specimens. The mean age of participants was 41.2 years, and the vast majority (93%, 95% CI 90.3 to 95.7) were married. The mean age at sexual debut was significantly lower among Qatari women compared with non-Qatari women (19.2 vs 22.2 years, respectively p<0.001), but the mean number of reported lifetime sexual partners (1.1 partner) was nearly the same in both groups (p=0.110). The prevalence of C trachomatis infection was 5.3% among Qatari women and 5.5% among non-Qatari women, with no statistically significant difference between both groups (p=0.923). CONCLUSIONS: The prevalence of C trachomatis among women was higher than expected, with no significant difference between Qatari nationals and expatriate residents. The higher prevalence may reflect, in part, the limited access to and use of chlamydia screening and management.

Short-term exposure to ultrafine and fine particulate matter with multipollutant modelling on heart rate variability among seniors and children from the CorPuScula (coronary, pulmonary, sanguis) longitudinal study in Germany.

Background: Short-term exposure particulate matter with a diameter of 10 µm or less (PM10) and fine particulate matter (PM2.5) has been associated with heart rate variability (HRV), but exposure to ultrafine particles (UFP) has been less well examined. We investigated the associations between the HRV outcomes and short-term exposure to UFP, PM10 and PM2.5 among school-aged children and seniors. Methods: CorPuScula (Coronary, Pulmonary and Sanguis) is a longitudinal, repeated-measure panel study conducted in 2000-2002 in Munich, Germany including 52 seniors (58-94 years old) with 899 observations and 50 children (6-10 years old) with 925 observations. A 10-min resting electrocardiogram was performed to assess resting HRV outcomes [Standard Deviation of Normal to Normal Intervals (SDNN), Root Mean Square of Successive Differences between Normal Heartbeats (RMSSD), Low Frequency power (LF), High Frequency power (HF), ration between low and high frequency (LF/HF)]. UFP and PM exposures were measured near the care home and school yard for seniors and children, respectively. Mean exposures during the day of examination (9-21 h) as well as 3-h, 12-h, 24-h, one-day, and two-day lags were assessed. Linear mixed-effect models were used to investigate the associations between short-term air pollution and HRV outcomes separately in children and seniors. The models were adjusted for sex, age, weather conditions (temperature, precipitation, and water vapor pressure), BMI, lifestyle and medical information. Two and multipollutant models adjusted for NO2 and O3 were performed. Results: Among seniors, we observed increases in SDNN, LF, HF and LF/HF ratio after short-term exposure to UFP (hourly and daily lags) in contrast to decreases in SDNN and RMSSD after exposure to PM10. Associations were generally robust to two- and multipollutant adjustment. Among children, we observed increases of the LF/HF ratio after short-term exposures to UFP at lags 12 and 24 h. In contrast, we observed decreases of the ratio after exposure to PM2.5 and PM10. Results were largely unchanged for multipollutant modelling, however we found a more pronounced increase in SDNN and LF/HF (UFP lag 12 and 24 h) after adjusting for NO2. Conclusions: Overall, among seniors, we observed associations of UFP and PM10 exposure with sympathetic responses of the ANS, which play an important role in sudden heart attacks or arrhythmia. Among children we found more inconsistent associations between UFP and a delayed increase in HRV. Adjusting for co-pollutants including NO2 and O3 yielded robust results.

Long-Term Exposure to Traffic-Related Air Pollution and Diabetes: A Systematic Review and Meta-Analysis.

Objectives: We report results of a systematic review on the health effects of long-term traffic-related air pollution (TRAP) and diabetes in the adult population. Methods: An expert Panel appointed by the Health Effects Institute conducted this systematic review. We searched the PubMed and LUDOK databases for epidemiological studies from 1980 to July 2019. TRAP was defined based on a comprehensive protocol. Random-effects meta-analyses were performed. Confidence assessments were based on a modified Office for Health Assessment and Translation (OHAT) approach, complemented with a broader narrative synthesis. We extended our interpretation to include evidence published up to May 2022. Results: We considered 21 studies on diabetes. All meta-analytic estimates indicated higher diabetes risks with higher exposure. Exposure to NO2 was associated with higher diabetes prevalence (RR 1.09; 95% CI: 1.02; 1.17 per 10 µg/m3), but less pronounced for diabetes incidence (RR 1.04; 95% CI: 0.96; 1.13 per 10 µg/m3). The overall confidence in the evidence was rated moderate, strengthened by the addition of 5 recently published studies. Conclusion: There was moderate evidence for an association of long-term TRAP exposure with diabetes.

Process evaluation of a community-based mental health promotion intervention for refugee children.

Public health interventions are complex in nature and composed of multiple components. Evaluation of process and impact is necessary to build evidence of effectiveness. Process evaluation involves monitoring extent of implementation and comparison against the program plan. This article describes the process evaluation of the 'Qaderoon' (We are Capable) intervention; a community-based mental health promotion intervention for children living in a Palestinian refugee camp of Beirut, Lebanon. The manuscript describes the context of Palestinian refugees in Lebanon, the intervention, the process evaluation plan and results. The process evaluation was guided by the literature and by a Community Youth Committee. Findings indicated that attendance was 54 and 38% for summer and fall sessions, respectively. Session objectives and activities were commonly achieved. Over 78.4% of activities were reported to be implemented fully as planned. Over 90% of the children indicated high satisfaction with the sessions. Contextual facilitators and challenges to implementing the intervention are discussed. The most challenging were maintaining attendance and the actual implementation of the process evaluation plan. Findings from process evaluation will strengthen interpretation of impact evaluation results.

Prevalence and determinants of suicide ideation among Lebanese adolescents: results of the GSHS Lebanon 2005.

The current study examined prevalence and risk factors for suicide ideation in 5038 Lebanese adolescents using Global School Health Survey data. Around 16% of Lebanese adolescents thought of suicide. Multivariate logistic regression models showed that risk factors for suicide ideation included poor mental health (felt lonely, felt worried, felt sad or hopeless), substance use (got drunk, used drugs), victimization (was bullied, was sexually harassed), and lack of parental understanding. Recommendations for future research and interventions are discussed.

Determinants of change in paternal smoking trends during pregnancy in Lebanon.

For pregnant women and their fetus, secondhand smoking poses major public health effects. This study analyzes the determinants of change in smoking behavior among fathers whose partners were pregnant. The study is a secondary analysis of a nationally representative Lebanese cross-sectional survey of 1,028 households conducted in 2007. Currently smoking fathers with a child of 5 years of age or less were included. The main outcome was the change in the father's smoking behavior during his wife's last pregnancy. The study concluded that fathers who changed their smoking patterns when their wives were pregnant were significantly more educated, more likely to smoke a lesser number of cigarettes per day (OR = 96, 95% CI (0.93, 0.99)), and more knowledgeable about cigarette constitutes and its health risks (OR = 1.37, 95% CI (1.08, 1.74). Public health practitioners and health professionals are recommended to raise awareness and provide cessation programs for parents and especially fathers.

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.

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.

Trends in the Aggressiveness of End-of-Life Cancer Care in the State of Qatar.

PURPOSE: Quality of end-of-life (EOL) care is a key component of excellence in cancer care, and monitoring indicators for quality of EOL cancer care is crucial to providing excellent care. The aim of the current study is to describe the relative aggressiveness of EOL cancer care in the state of Qatar and to compare it with international figures. METHODS: We analyzed all deaths from cancer in Qatar between January 1, 2009 and December 31, 2013. A total of 784 eligible patients were studied to assess aggressiveness of cancer care at EOL. RESULTS: The average number of intensive care unit admissions per person decreased from 0.44 to 0.22 (P < .001) over the period of study. In addition, patients spent fewer days in the intensive care unit (2.79 to 1.82 days; P = .006) and made fewer visits to the emergency department (1.00 to 0.52 visits; P < .001) in the last 30 days of life. Fewer patients had at least one aggressive treatment measure at EOL during the 5-year period (82.3% to 71.0%; P = .038). The mean composite score for aggressiveness of EOL care decreased from 2.24 to 1.92 (P < .01). CONCLUSION: The aggressiveness of EOL cancer care has significantly decreased over time in Qatar; however, despite this decrease, the rate is still higher than that reported internationally. The integration of community palliative care services in Qatar may further decrease the aggressiveness of cancer care at EOL.

Are Early Relapses in Advanced-Stage Ovarian Cancer Doomed to a Poor Prognosis?

OBJECTIVE: Early recurrence (ER) after completion of therapeutic regimen in advanced-stage ovarian cancer is a challenging clinical situation. Patients are perceived as invariably having a poor prognosis. We investigated the possibility of defining different prognostic subgroups and the parameters implicated in prognosis of ER patients. STUDY DESIGN: We analyzed a multi-centric database of 527 FIGO stage IIIC and IV ovarian cancer patients. We defined patients relapsing within 12 months as ER and investigated using Cox logistic regression the prognostic factors in ER group. We subsequently divided ER patients into good and poor prognosis groups according to a lower or higher overall survival (OS) at 12 months after relapse and determined parameters associated to poor prognosis. RESULTS: The median follow up was 49 months. One hundred and thirty eight patients recurred within 12 months. OS and Disease Free Survival (DFS) were 24.6 and 8.6 months, respectively, in this group of patients. Among the ER patients, 73 had a poor prognosis with an OS after relapse below 12 months (mean OS = 5.2 months) and 65 survived after one year (mean OS = 26.9 months). Residual disease (RD) after debulking surgery and mucinous histological subtype negatively impacted prognosis (HR = 1.758, p = 0.017 and HR = 8.641, p = 0.001 respectively). The relative risk of death within 12 months following relapse in ER patients was 1.61 according to RD status. However, RD did not affect DFS (HR = 0.889, p = 0.5). CONCLUSION: ER in advanced-stage ovarian cancer does not inevitably portend a short-term poor prognosis. RD status after initial cytoreduction strongly modulates OS, that gives additional support to the concept of maximum surgical effort even in patients who will experience early recurrence. The heterogeneity in outcomes within the ER group suggests a role for tumor biology in addition to classical clinical parameters.

Patterns in place of cancer death in the State of Qatar: a population-based study.

BACKGROUND: International studies show that most people prefer to die at home; however, hospitals remain the most common place of death (PoD). This study aims to investigate the patterns in PoD and the associated factors, which are crucial for end-of-life cancer care enhancement. METHOD: This retrospective, population-based study analyzed all registered cancer deaths in Qatar between January 1, 2006 and December 31, 2012 (n = 1,224). The main outcome measures were patient characteristics: age, gender, nationality, cancer diagnosis, year of death, and PoD. Time trends for age-standardized proportions of death in individual PoDs were evaluated using chi-square analysis. Odds ratio (OR) were determined for variables associated with the most preferred (acute palliative care unit [APCU] and hematology/oncology ward) versus least preferred (ICU and general medicine ward) PoDs in Qatar, stratified by nationality. RESULTS: The hematology/oncology ward was the most common PoD (32.4%; 95% CI 26.7-35.3%) followed by ICU (31.4%; 95% CI 28.7-34.3%), APCU (26.9%; 95% CI 24.3-29.6%), and general medicine ward (9.2%; 95% CI 7.6-11.1%). APCU trended upward (+0.057/year; p<0.001), while the hematology/oncology ward trended downward (-0.055/year; p<0.001). No statistically significant changes occurred in the other PoDs; home deaths remained low (0.4%; 95% Cl 0.38-0.42). Qataris who died from liver cancer (OR 0.23) and aged 65 or older (OR 0.64) were less likely to die in the APCU or hematology/oncology ward (p<0.05). Non-Qataris who died from pancreatic cancer (OR 3.12) and female (OR 2.05) were more likely to die in the APCU or hematology/oncology ward (p<0.05). Both Qataris and non-Qataris who died from hematologic malignancy (OR 0.18 and 0.41, respectively) were more likely to die in the ICU or general medicine ward (p<0.05). CONCLUSION: A high percentage of cancer deaths in Qatar occur in hospital. As home was the preferred PoD for most people, effective home care and hospice programs are needed to improve end-of-life cancer care.

Double jeopardy: assessing the association between internal displacement, housing quality and chronic illness in a low-income neighborhood.

PURPOSE: This study analyzed associations between war-related internal displacement, housing quality and the prevalence of chronic illness in Nabaa, a low-income neighborhood on the outskirts of Beirut, Lebanon. METHODS: A cross-sectional survey of sociodemographics, household characteristics and health conditions of the study population was carried out in 2002. Using a structured questionnaire, the research team surveyed 1,151 households representing 4,987 residents of all ages. The survey was administered to a proxy respondent from each household in face-to-face interviews. A multiple logistic regression model using the generalized estimation equation method was constructed to assess the simultaneous effect of displacement and housing quality on reported ill health, while adjusting for potential confounders. RESULTS: Housing quality and internal displacement were strongly associated with occurrences of chronic illness. The most vulnerable respondents were older residents, females and internally displaced people, who reported high rates of chronic illnesses. Residents with high levels of education were less likely to report a chronic illness than those that had elementary education or less. CONCLUSION: Nabaa residents' experience of poor health was associated with inadequate housing quality. Moreover, residents who have been displaced experience worse living conditions and were more likely to experience poor health than those who were not displaced. These results reveal a need for policies to improve housing quality and alleviate war-related consequences in low-income neighborhoods.