Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States.

Rural health disparities have attracted increased national attention, compelling an expanded focus on rural health research. In this article, we deconstruct the definitions and narratives of "rural" communities and suggest that a paradigm shift is needed that centers the complexity and strength of rural places. We discuss the relevance of health equity frameworks, implementation science, and community-engaged approaches to promote rural well-being. Focusing on rural in its own right will lead to intervention innovations and reinvention with implications beyond rural areas. We conclude with suggestions for research and practice to inspire renewed interest in partnering with rural communities to promote health equity.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics.

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking.

Waterpipe tobacco usage is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world, waterpipe usage surpasses cigarette smoking. Waterpipes and cigarettes are both mechanisms for inhalation of tobacco smoke and therefore have serious health consequences. However, because of the many differences between the two products, prevention and control strategies that have proven effective for cigarettes may not transfer readily to waterpipe. This report highlights the differences between waterpipes and cigarettes in toxicant exposure and physiologic effects, patterns of use, social norms, the extent of evidence, and the policy environment. There is little evidence to date around effective interventions for waterpipe prevention and control. The current state of evidence for intervention to curb or control waterpipe is at ground zero and critically needs attention from both scientists and policy makers. National and global efforts aimed at cigarette prevention have succeeded, particularly in developed countries. We suggest the time has come to harness what we know works for cigarette prevention and control and adapt it to tackle the growing epidemic of waterpipe tobacco use.

Incidence and Clinical Features of Bleeding Peptic Ulcers in Acute Upper Gastrointestinal Bleeding: -Experience of Moroccan University Hospital Unit

Introduction: Peptic ulcer disease (PUD) has been recognized as the leading cause of acute upper gastrointestinal bleeding (AUGIB). This study aims to report general features of bleeding peptic ulcers in patients who benefit of urgent endoscopy in our department after an acute upper gastrointestinal hemorrhage. Results: A total of 1809 patients were explored for acute upper gastrointestinal bleeding in our unit since 2003 to 2008. Gastroduodenal peptic ulcers were the most frequent diagnosed etiology. They present 38% of all reported causes of bleeding (n=527) (table I). 25% were located at duodenal mucosa (n= 347) and 13% were gastric ulcers (n=180). No esophageal ulcers were reported. Incidence of both duodenal and gastric ulcers decreases during the last years. Conclusion: In our department; incidence of bleeding peptic ulcer disease is decreasing but they continue to be the first cause of AUGIB

Parental smoking and exposure to environmental tobacco smoke are associated with waterpipe smoking among youth: results from a national survey in Lebanon.

OBJECTIVES: Waterpipe tobacco smoking (WTS) is a growing public health concern worldwide yet little is known about the epidemiology of use among young people. The objectives of this study were to examine the prevalence, patterns and correlates of WTS among students across Lebanon. STUDY DESIGN: The study design was a cross sectional survey. METHODS: 126-item tobacco questionnaire was conducted among 1128 sixth and seventh grade students across Lebanon. Current patterns of use were descriptively analysed, and logistic regression models examined correlates of WTS. RESULTS: Ever WTS prevalence was 44.3%, current WTS prevalence was triple that of cigarettes (22.1% vs 7.4%), and 40.0% of current users were at least weekly or daily smokers. Initiation and patterns of use, as well as addiction and cessation attitudes have been reported. Significant correlates of current WTS included older age, reduced religiosity, peer and parent tobacco use, recent waterpipe advertisement exposure, increased pluralistic ignorance and current cigarette use. Significant correlates of ever WTS were similar to current WTS, but included second hand waterpipe tobacco smoke exposure at home and did not include recent waterpipe advertisement exposure. Neither gender nor socio-economic status were significant correlates of current or ever WTS. CONCLUSIONS: Waterpipe is the most common form of tobacco smoking, and is used regularly, among sixth and seventh grade Lebanese students. It should be considered a public health priority with increased tobacco surveillance and legislation. Widespread educational and policy interventions might help denormalize the social acceptability of WTS. Meanwhile, more research is needed to understand the changing paradigm of WTS epidemiology and the health outcomes among young smokers.

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally.

OBJECTIVE: The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review. DATA SOURCES: The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms. STUDY SELECTION: Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10-29 years. DATA EXTRACTION: Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results. DATA SYNTHESIS: The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels. CONCLUSIONS: The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

Can video aids increase the validity of patient consent?

The objective of this study is to identify the value of using video to communicate and share information with patients, and assess the role of video in aiding decision-making and consent in urogynaecological surgery. The patients with the need for urogynaecological surgery who were seen in Weston Hospital from November 2003 to December 2008 were offered a video of the proposed procedure to watch prior to decision-making and consenting. Patients were then sent a questionnaire assessing the role of the video in their understanding of the need for and method of the procedure, and the impact of this on their decision-making. A total of 96 questionnaires were sent out, and 71 forms were returned and analysed. Our study shows that women's understanding of the method and purpose of their operation was significantly increased by using the video.

Waterpipe tobacco and cigarette smoking among university students in Jordan.

SETTING: While waterpipe and cigarette smoking have been well studied in Syria and Lebanon, data from Jordan are limited. OBJECTIVES: To characterize the relative prevalence of waterpipe tobacco and cigarette smoking among university students in Jordan, and to compare the demographic and environmental factors associated with each form of tobacco use. DESIGN: We surveyed 1845 students randomly recruited from four universities in Jordan. We used multivariable logistic regression controlling for clustering of individuals within universities to determine associations between demographic and environmental covariates and waterpipe tobacco and cigarette use. RESULTS: Waterpipe tobacco smoking rates were 30% in the past 30 days and 56% ever, while cigarette smoking rates were 29% in the past 30 days and 57% ever. Past 30-day waterpipe tobacco smoking rates were 59% for males and 13% for females. Females had substantially lower odds than males of being current waterpipe (OR 0.12, 95%CI 0.10-0.15) or cigarette (OR 0.08, 95%CI 0.05-0.14) smokers. Current cigarette smoking was more significantly associated with markers of high socio-economic status (SES) than waterpipe tobacco smoking. CONCLUSION: Waterpipe tobacco smoking is as common as cigarette smoking among Jordanian university students. While cigarette smoking is consistently associated with high SES, waterpipe tobacco smoking is more evenly distributed across various populations.

Acute upper gastro-intestinal bleeding in morocco: what have changed?

Objective. In the present study, we aimed to investigate epidemiological, clinical, and etiological characteristics of acute upper gastro-intestinal bleeding. Materials and Methods. This retrospective study was conducted between January 2003 and December 2008. It concerned all cases of acute upper gastroduodenal bleeding benefited from an urgent gastro-intestinal endoscopy in our department in Morocco. Characteristics of patients were evaluated in terms of age, gender, medical history, presenting symptoms, results of rectal and clinical examinations, and endoscopy findings. Results. 1389 cases were registered. As 66% of the patients were male, 34% were female. Mean age was 49. 12% of patients had a history of previous hemorrhage, and 26% had a history of NSAID and aspirin use. Endoscopy was performed in 96%. The gastroduodenal ulcer was the main etiology in 38%, followed by gastritis and duodenitis in 32.5%. Conclusion. AUGIB is still a frequent pathology, threatening patients' life. NSAID and aspirin are still the major risk factors. Their impact due to peptic ulcer remains stable in our country.

Bioactivity as an options value of sea cucumbers in the Egyptian Red Sea.

The utility of a species can be divided into its direct, indirect, and options values. In the marine environment, direct consumptive values predominate and often lead to overexploitation at the expense of significant options values derived through bioprospecting for natural products. We surveyed the waters of the Egyptian Red Sea coast (Gulf of Aqaba [north] and the Red Sea [south]) for species of sea cucumbers and analyzed extracts from species for a range of bioactivities with potential biomedical applications. All habitat types were surveyed within these regions. We found 22 species of sea cucumber of which two, Holothuria fuscogilva and Holothuria flavomaculata, were recorded in Egypt for the first time. Although none of the species identified were unique to the Gulf of Aqaba, 10 species were only found in the Red Sea sector. Bioassay results showed that although no species had antibacterial activity, most extracts exhibited activity against Candida and Leishmania but were most active against a LoVo mammalian carcinoma cell line. Our most significant finding was the intraspecific variation in bioactivity in individuals collected from different habitat types and sectors of the coast. This variation may reflect the effect of environment on secondary metabolite production or may indicate significant genetic diversity between populations within a species. Our results indicate a potentially significant options value to sea cucumbers through bioprospecting. Given the importance of economic development in countries such as Egypt and the perceived low conservation value of invertebrates such as sea cucumbers, the linking of these factors to conservation is vital for the maintenance and sustainable exploitation of these animals.

Clinicovirologic analysis of hepatitis C infection in transfusion-dependent beta-thalassemia major children.

Regular blood transfusion puts beta-thalassemia major patients at a higher risk of developing hepatic iron overload and hepatitis C virus (HCV) infection. The association between several transfusion-related factors and an increased risk of developing HCV viremia has been reported. The effect of HCV infection on liver damage in transfusion-dependent thalassemia patients has been poorly described. A sample of 100 Egyptian transfusion-dependent beta-thalassemia major children were studied. Individual patients underwent full history taking, clinical examination and a panel of laboratory tests including HCV ribonucleic acid polymerase chain reaction (HCV-PCR) in blood samples. Liver biopsy was performed for 24 patients. HCV-PCR was positive in 64% of patients. A statistically significant correlation was found between HCV-PCR positivity (HCV viremia) and shorter inter-transfusion interval. There was a significant positive correlation between mean serum ferritin level and mean levels of alanine aminotransferase and aspartase aminotransferase. Histopathologic features of both chronic hepatitis and siderosis were present in 91.7% of biopsy specimens, and fibrosis was present in 41.67%. A higher risk of HCV viremia is noted with a shorter inter-transfusion interval. The reduced role of HCV infection in chronic liver injury in this group of patients may be surpassed by the associated effects of iron overload because of the chronic transfusion. However, the latter finding should be verified in larger studies.

Obtaining informed consent: observations from community research with refugee and impoverished youth.

This paper presents challenges facing researchers in applying basic ethical principles while conducting research with youth in a developing country context. A discussion of the cultural and social challenges to adherence to the elements of informed consent: disclosure, comprehension, capacity, voluntariness and consent is presented. The authors argue that the current institutional review board requirements that guide research reflect values and stem from western contexts that may not be fully applicable to non-western contexts. More dialogue is needed among researchers in developing world contexts on challenges of and possible revisions to requirements that maintain respect for persons, beneficence, autonomy and justice, particularly when working with youth.

Domestic violence against women during pregnancy: the case of Palestinian refugees attending an antenatal clinic in Lebanon.

OBJECTIVES: To determine the factors associated with domestic violence against pregnant Palestinian refugee women residing in Lebanon and currently using the United Nation Relief and Work Agency's (UNRWA) primary healthcare services. METHODS: This was a cross-sectional study conducted at a polyclinic of primary healthcare of the UNRWA in South Lebanon during the years 2005-2006. The sample was 351 pregnant women who were 15-42 years of age and not accompanied by their husbands or relatives. All women were invited by the midwife to participate in the study during their visit to the clinic for their first checkup or during a follow-up visit. The Abuse Assessment Screen instrument was used to screen for past and recent history of physical and emotional abuse among the participants. RESULTS: Domestic violence was significantly associated with education, gestational age, fear of husband or someone else in the house, and unintended pregnancy. The odds of abuse for women with an elementary or lower education were 6.86 (95% CI 1.2-38.1) and for women with an intermediate or secondary education 6.84 (95% CI 1.4-33.3) compared with women with a university education. The odds of abuse during pregnancy for women whose husbands did not desire their pregnancy were 3.80 (95% CI 1.5-9.7) compared with other women. CONCLUSIONS: Domestic violence against women in Lebanon was associated with educational level, gestational age, fear of husband or someone else in the house, and unintended pregnancy.

Patterns of tobacco use: results from the 2005 Global Youth Tobacco Survey in Lebanon.

We report the results of the 2005 Global Youth Tobacco Survey in Lebanon which investigated the self-reported attitudes and behaviours related to tobacco among 3314 Lebanese schoolchildren aged 13-15 years. Current use of any tobacco product was 60.1%; the use of cigarettes was 10% and other tobacco products 59% with male predominance in all areas. About 80% of students lived in homes where others smoked. About 60% of current smokers wanted to quit smoking and 51% of all students had learned about the effects of tobacco in class. Over a quarter (27%) thought that boys who smoke have more friends and 17% believed that smoking makes boys more attractive. The majority of students had been exposed to both anti-smoking media messages and pro-smoking advertisements.

Patterns of tobacco use: results from the 2005 Global Youth Tobacco Survey in Lebanon

We report the results of the 2005 Global Youth Tobacco Survey in Lebanon which investigated the self-reported attitudes and behaviours related to tobacco among 3314 Lebanese schoolchildren aged 13-15 years. Current use of any tobacco product was 60.1%; the use of cigarettes was 10% and other tobacco products 59% with male predominance in all areas. About 80% of students lived in homes where others smoked. About 60% of current smokers wanted to quit smoking and 51% of all students had learned about the effects of tobacco in class. Over a quarter [27%] thought that boys who smoke have more friends and 17% believed that smoking makes boys more attractive. The majority of students had been exposed to both anti-smoking media messages and pro-smoking advertisements

Genomic stability prevails in North-African hepatocellular carcinomas.

The molecular pathogenesis of hepatocellular carcinoma, a tumour characterized by a vast clinical heterogeneity, remains unexplored outside Europe and Eastern Asia. We analysed by direct sequencing or loss of heterozygosity assay, the common targets of genomic alterations in 42 hepatocellular carcinomas collected in western North-Africa. Overall, genomic instability was uncommon, allelic losses affecting mostly chromosomes 1p, 4q, 8p and 17p (24-28% of cases). CTNNB1 and TP53 were infrequently mutated (9 and 17% of cases, respectively). Surprisingly, TP53 mutation R249S, diagnostic of aflatoxin B1 exposure, usually frequent in Africa, was exceptional (one case), indicating that in western North-Africa, hepatocellular carcinoma genetics differs markedly from that of the remainder of the continent.