Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis.

Waterpipe smoking has developed into a major and rapidly growing global tobacco epidemic affecting more than 100 million people worldwide. This study identifies and analyzes comprehensively all available data on the cardiovascular effects of waterpipe smoking. Databases PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for studies published until December 2019 assessing cardiovascular effects of waterpipe smoking. We included experimental, cohort, cross-sectional and case-control studies and excluded systematic reviews, case reports/series and qualitative studies. Studies not conducted in humans or not distinguishing waterpipe smoking from other forms of smoking were also excluded. A total of 42 studies with 46 cardiovascular parameters were eligible for analysis. The meta-analysis included 31 studies with 38,037 individuals. Results showed that one waterpipe smoking session leads to immediate increases in heart rate and blood pressure (P < 0.001). Compared to non-smokers, waterpipe smokers had significantly lower high-density lipoprotein levels (P < 0.001), higher levels of low-density lipoprotein (P = 0.04), triglyceride (P < 0.001) and fasting blood glucose (P = 0.03) and higher heart rate (P = 0.04) with a tendency to have higher blood pressure. Mean heart rate, blood pressure and lipids levels did not differ between waterpipe and cigarette smokers, except for total cholesterol, being higher among waterpipe smokers (P < 0.001). Current level of evidence suggests that waterpipe smoking is associated with substantial adverse effects on cardiovascular system, which seem to be similar to those of cigarette smoking. Longitudinal studies are required to scrutinize the magnitude of these effects.

Reduction of Outflow Tract Obstruction After PCI to Proximal LAD in a Patient With HOCM.

We present a patient with hypertrophic obstructive cardiomyopathy and accompanying aortic valve stenosis who had a myocardial infarction with a significant proximal left anterior descending coronary artery stenosis. The primary percutaneous coronary intervention resulted in a notable improvement in the left ventricular outflow tract gradient and global longitudinal strain. (Level of Difficulty: Beginner.).

Screening for posttraumatic stress disorder in young adult refugees from Syria and Iraq.

INTRODUCTION: In January 2016, 2057 refugees from civil war-torn Syria and Iraq, aged 18.0 to 24.9 years, were first-time entrants into the German unemployment register and thus potentially eligible for the labor market. Civil war and forced migration may affect individuals' mental health. Traumatic experiences in particular are assumed to represent a major barrier, e.g., to labor-market integration. This study aimed to screen the rates of posttraumatic stress disorder (PTSD). Former refugee studies have reported PTSD screening rates between 3% and 44%. METHOD: A total of 8.5% (N = 175 of 2057) of respondents were randomly interviewed either by telephone or web-based interviews. A total of 84 respondents (48% out of 175 respondents) were screened using the Essen Trauma Inventory (ETI) based on the DSM-IV, and 91 (52%) respondents used the Short Screening Scale for Posttraumatic Stress Disorder (SSS-PSD). All respondents were additionally questioned regarding psychological impairment (Symptom Checklist 10) and health status (Short Form 12). RESULTS: Of the respondents, 59.4% reported at least one traumatic experience. The percentage of positive PTSD screenings obtained using the ETI was 9.5% (N = 84) and 6.6% (N = 91) using the SSS-PSD. The percentage of positive PTSD screenings obtained with both screening instruments was 8% (N = 175; 95%-CI: 3.9% to 12.1%). A total of 19.4% of the subjects were above the SCL-10 cut-off for psychiatric caseness. DISCUSSION: The PTSD rate in this sample was in the average range compared to previous estimates from large samples of refugees. Psychiatric caseness was high. The results should be considered for planning labor-market integration programs and the design of supportive schemes.

Building Evidence-Based Tobacco Treatment in the Eastern Mediterranean Region: Lessons Learned by the Syrian Center for Tobacco Studies.

The tobacco epidemic in Syria is characterized by high rates of cigarettes smoking in men and dramatic reemergence of waterpipe smoking, especially among youths and women. The Syrian Center for Tobacco Studies (SCTS), an NIH-funded pioneer research and capacity building institution, has developed a research infrastructure and conducted three randomized clinical trials to develop and rigorously test culturally-appropriate tobacco treatment programs integrated into primary healthcare (PHC) centers. This review aimed to discuss challenges and lessons learned from the Syrian experience. Addressing these challenges may inform future cessation research activities in Syria and other developing countries. To develop a research infrastructure, the SCTS has established Syria's first IRB and trained physicians/medical students in both tobacco treatment and research methods. Main challenges to conduct the cessation trials were difficulties of coordination between the local and international collaborators; high Smoking Rates among PHC providers; lack of pharmacological agents used in tobacco treatment; and difficulties of conducting research in a politically volatile region. Strategies to overcome these challenges were ensuring an active and regular involvement of all investigator; and advocating for a national smoking-cessation plan that involves training health care providers in smoking cessation treatment and make pharmacological agents used in smoking cessation available.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments.

BACKGROUND: Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. METHODS: Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. RESULTS: Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. DISCUSSION: CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

The relationship between waterpipe smoking and body weight: population-based findings from Syria.

INTRODUCTION: Cigarette smoking has well known effects on body weight, with current smokers weighing less than never-smokers, and cessation producing weight gain. Use of waterpipe (or "hookah") is increasing in many parts of the world but its effects on body weight are not known. METHODS: We compared body mass index (BMI) among 2,536 adults (age ≥ 18 years old), who were never, former, current nondaily, or current daily waterpipe smokers, drawn from 2 representative, population-based household surveys of adults in Aleppo, Syria. RESULTS: Overall, 84.1% (n = 2,134) never-smoked waterpipe, 4.6% (n = 116) were former smokers, 9.9% (n = 251) were current nondaily smokers, and 1.4% (n = 35) were current daily smokers. Mean BMI of the sample was 30.2 kg/m(2) (SD = 6.3). Adjusted for cigarette smoking, number of chronic diseases, age, gender, income, and marital status, daily waterpipe users were 2.26 BMI units greater than never-smokers (beta = 2.26, 95% CI = 0.79-3.72), and had nearly threefold odds of being obese (odds ratio = 2.87, 95% CI = 1.06-7.76). Nondaily and former waterpipe users were similar to never-smokers in terms of BMI and obesity risk. CONCLUSION: Results indicate that daily waterpipe users, compared to never-users, have higher BMI, translating into 6 extra kilograms of weight on average, and are 3 times as likely to be obese.

A comparative study of systemic carcinogen exposure in waterpipe smokers, cigarette smokers and non-smokers.

BACKGROUND: In the past decade, waterpipe smoking-also known as hookah, shisha, narghileh-has increased among youth. The scarcity of rigorous studies linking waterpipe smoking to smoking-related diseases has hindered policy and regulatory efforts to confront the waterpipe epidemic. This study compares systemic carcinogen exposure between independent groups of exclusive waterpipe smokers, cigarette smokers and non-smokers. METHODS: This study was conducted at the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria, between 2010 and 2011. First morning urinary samples were collected from three groups of subjects; exclusive daily waterpipe smokers (n=24), exclusive daily cigarette smokers (n=23), and non-smokers (n=28). These samples were analysed for carcinogenic tobacco-specific nitrosamines 4-(methylnitrosamino)-1-(3-pyridyl)-1- butanol (NNAL) using liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS: Our results show that waterpipe smokers are exposed to about 5-10 times greater NNAL than non-smokers. Mean (95% CI) free and total NNAL was 0.7 (0.3 to 1. 4) and 3.9 (1.6 to 9.5) pg/mL urine for non-smokers, 8.4 (4.8 to 14.8) and 33.0 (21.6 to 50.6) pg/mL urine for waterpipe smokers, and 10.7 (5.0 to 22.6) and 46.8 (27.6 to 79.3) pg/mL urine for cigarette smokers (p<0.001 for all comparisons). Daily waterpipe smokers were less exposed to NNAL than daily cigarette smokers, although the difference did not reach statistical significance for all measurements. CONCLUSIONS: These results provide the clearest indication to date about systemic exposure to harmful carcinogens associated with long-term waterpipe smoking. Such evidence can support policy and regulatory efforts designed to confront the emerging global waterpipe epidemic, as well as drive interventions aimed at increasing the public awareness about the cancer risk associated with waterpipe smoking.

Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries.

OBJECTIVES: To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. METHODS: A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. RESULTS: Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100% in each country. The top policies were mostly population level interventions and health systems' level policies. CONCLUSIONS: Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed.

Cost-effectiveness analysis of salt reduction policies to reduce coronary heart disease in Syria, 2010-2020.

OBJECTIVES: This study presents a cost-effectiveness analysis of salt reduction policies to lower coronary heart disease in Syria. METHODS: Costs and benefits of a health promotion campaign about salt reduction (HP); labeling of salt content on packaged foods (L); reformulation of salt content within packaged foods (R); and combinations of the three were estimated over a 10-year time frame. Policies were deemed cost-effective if their cost-effectiveness ratios were below the region's established threshold of $38,997 purchasing power parity (PPP). Sensitivity analysis was conducted to account for the uncertainty in the reduction of salt intake. RESULTS: HP, L, and R+HP+L were cost-saving using the best estimates. The remaining policies were cost-effective (CERs: R=$5,453 PPP/LYG; R+HP=$2,201 PPP/LYG; R+L=$2,125 PPP/LYG). R+HP+L provided the largest benefit with net savings using the best and maximum estimates, while R+L was cost-effective with the lowest marginal cost using the minimum estimates. CONCLUSIONS: This study demonstrated that all policies were cost-saving or cost effective, with the combination of reformulation plus labeling and a comprehensive policy involving all three approaches being the most promising salt reduction strategies to reduce CHD mortality in Syria.

Behavioral cessation treatment of waterpipe smoking: The first pilot randomized controlled trial.

BACKGROUND: Waterpipe use has increased dramatically in the Middle East and other parts of the world. Many users exhibit signs of dependence, including withdrawal and difficulty quitting, but there is no evidence base to guide cessation efforts. METHODS: We developed a behavioral cessation program for willing-to-quit waterpipe users, and evaluated its feasibility and efficacy in a pilot, two arm, parallel group, randomized, open label trial in Aleppo, Syria. Fifty adults who smoked waterpipe ≥3 times per week in the last year, did not smoke cigarettes, and were interested in quitting were randomized to receive either brief (1 in-person session and 3 phone calls) or intensive (3 in-person sessions and 5 phone calls) behavioral cessation treatment delivered by a trained physician in a clinical setting. The primary efficacy end point of the developed interventions was prolonged abstinence at three months post-quit day, assessed by self-report and exhaled carbon monoxide levels of <10 ppm. Secondary end points were 7 day point-prevalent abstinence and adherence to treatment. RESULTS: Thirty percent of participants were fully adherent to treatment, which did not vary by treatment group. The proportions of participants in the brief and intensive interventions with prolonged abstinence at the 3-month assessment were 30.4% and 44.4%, respectively. Previous success in quitting (OR=3.57; 95% CI=1.03-12.43) predicted cessation. Higher baseline readiness to quit, more confidence in quitting, and being unemployed predicted a better adherence to treatment (all p-values <0.05). CONCLUSIONS: Brief behavioral cessation treatment for waterpipe users appears to be feasible and effective.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries.

BACKGROUND: Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. METHODS AND FINDINGS: Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey. CONCLUSION: Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Forecasting future prevalence of type 2 diabetes mellitus in Syria.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is increasingly becoming a major public health problem worldwide. Estimating the future burden of diabetes is instrumental to guide the public health response to the epidemic. This study aims to project the prevalence of T2DM among adults in Syria over the period 2003-2022 by applying a modelling approach to the country's own data. METHODS: Future prevalence of T2DM in Syria was estimated among adults aged 25 years and older for the period 2003-2022 using the IMPACT Diabetes Model (a discrete-state Markov model). RESULTS: According to our model, the prevalence of T2DM in Syria is projected to double in the period between 2003 and 2022 (from 10% to 21%). The projected increase in T2DM prevalence is higher in men (148%) than in women (93%). The increase in prevalence of T2DM is expected to be most marked in people younger than 55 years especially the 25-34 years age group. CONCLUSIONS: The future projections of T2DM in Syria put it amongst countries with the highest levels of T2DM worldwide. It is estimated that by 2022 approximately a fifth of the Syrian population aged 25 years and older will have T2DM.

Randomized trial of the effectiveness of combined behavioral/pharmacological smoking cessation treatment in Syrian primary care clinics.

AIMS: Effectiveness of nicotine replacement therapy (NRT) for smoking cessation has not been evaluated in low income countries, such as Syria, where it is expensive and not widely available. We evaluated whether nicotine patch boosts smoking cessation rates when used in conjunction with behavioral support in primary care clinics in Aleppo, Syria. DESIGN: Two arm, parallel group, randomized, placebo controlled, double-blinded multi-site trial. SETTING: Four primary care clinics in Aleppo, Syria. PARTICIPANTS: Two hundred and sixty-nine adult primary care patients received behavioral cessation counseling from a trained primary care physician and were randomized to receive six weeks of treatment with nicotine versus placebo patch. MEASUREMENTS: Primary end-points were prolonged abstinence (no smoking after a 2-week grace period) at end of treatment, and 6 and 12 months post-quit day, assessed by self-report and exhaled carbon monoxide levels of <10 p.p.m. FINDINGS: Treatment adherence was excellent and nicotine patch produced expected reductions in urges to smoke and withdrawal symptoms, but no treatment effect was observed. The proportion of patients in the nicotine and placebo groups with prolonged abstinence was 21.6% and 20.0%, respectively, at end of treatment, 13.4% and 14.1% at 6 months, and 12.7% and 11.9% at 12 months. CONCLUSIONS: Nicotine patches may not be effective in helping smokers in low-income countries to stop when given as an adjunct to behavioural support.

Explaining the increase in coronary heart disease mortality in Syria between 1996 and 2006.

BACKGROUND: Despite advances made in treating coronary heart disease (CHD), mortality due to CHD in Syria has been increasing for the past two decades. This study aims to assess CHD mortality trends in Syria between 1996 and 2006 and to investigate the main factors associated with them. METHODS: The IMPACT model was used to analyze CHD mortality trends in Syria based on numbers of CHD patients, utilization of specific treatments, trends in major cardiovascular risk factors in apparently healthy persons and CHD patients. Data sources for the IMPACT model included official statistics, published and unpublished surveys, data from neighboring countries, expert opinions, and randomized trials and meta-analyses. RESULTS: Between 1996 and 2006, CHD mortality rate in Syria increased by 64%, which translates into 6370 excess CHD deaths in 2006 as compared to the number expected had the 1996 baseline rate held constant. Using the IMPACT model, it was estimated that increases in cardiovascular risk factors could explain approximately 5140 (81%) of the CHD deaths, while some 2145 deaths were prevented or postponed by medical and surgical treatments for CHD. CONCLUSION: Most of the recent increase in CHD mortality in Syria is attributable to increases in major cardiovascular risk factors. Treatments for CHD were able to prevent about a quarter of excess CHD deaths, despite suboptimal implementation. These findings stress the importance of population-based primary prevention strategies targeting major risk factors for CHD, as well as policies aimed at improving access and adherence to modern treatments of CHD.

Patterns of water-pipe and cigarette smoking initiation in schoolchildren: Irbid longitudinal smoking study.

INTRODUCTION: Tobacco use remains a major public health problem worldwide. Water-pipe smoking is spreading rapidly and threatening to undermine the successes achieved in tobacco control. METHODS: A school-based longitudinal study in the city of Irbid, Jordan, was performed from 2008 to 2010. All seventh-grade students in 19 randomly selected schools, out of a total of 60 schools in the city, were enrolled at baseline and surveyed annually. RESULTS: Of the 1781 students enrolled at baseline 1,701 (95.5%) were still in the study at the end of the second year of follow-up (869 boys, median age at baseline 13 years). Ever and current water-pipe smoking were higher than those of cigarette smoking at baseline (ever smoking: 25.9% vs. 17.6% and current smoking: 13.3% vs. 5.3% for water-pipe and cigarette smoking, respectively; p < .01 for both) but cigarette smoking caught up by the second year of follow-up (ever smoking: 46.4% vs. 44.7%; p = .32 and current smoking: 18.9% vs. 14.9%; p < .01). Water pipe-only smokers at baseline were twice as likely to become current cigarette smokers after 2 years compared with never smokers (relative risk (RR) = 2.1; 95% CI = 1.2, 3.4). A similar pattern was observed for cigarette-only smokers at baseline (RR = 2.0; 95% CI = 0.9, 4.8). CONCLUSIONS: Prevalence of water-pipe and cigarette smoking increased dramatically over the 2-year follow-up period with similar patterns in boys and girls, although girls had lower prevalence in all categories. Water-pipe smoking at baseline predicted the progress to cigarette smoking in the future and vice versa.

Modifiable cardiovascular risk factors among adults in Aleppo, Syria.

OBJECTIVES: This report provides the first comprehensive and standardized assessment of the distribution of cardiovascular disease (CVD) risk factors in Syria, where such data are still scarce. METHODS: A population-based household survey was conducted in Aleppo (population >2.5 million), involving 1,168 subjects ≥25 years old (47.7% men; mean age 44.7 ± 12.7 years). Information about socio-demographics, personal behavior, and other CVD risk factors was collected. Anthropometric measurements and fasting blood samples were obtained. RESULTS: The prevalence of clinical risk factors of CVD (ClinRFs) was 45.6% for hypertension, 43.2% for obesity, 21.9% for hypercholesterolemia and 15.6% for diabetes. The prevalence of behavioral risk factors (BehRFs) was 82.3% for physical inactivity, 39.0% for smoking, and 33.4% for unhealthy diet. All ClinRFs increased with age, while gender was associated only with obesity and smoking. Education was associated with obesity and diabetes (P < 0.05 for all). CONCLUSIONS: Adults in Syria have some of the world's highest prevalence of CVD risk factors. Unhealthy behaviors and social norms unfavorable to women may explain some of such risk profiles.

Are primary health care providers prepared to implement an anti-smoking program in Syria?

OBJECTIVE: To document primary health care (PHC) providers' tobacco use, and how this influences their smoking cessation practices and attitudes towards tobacco-control policies. METHODS: Anonymous questionnaires were distributed to PHC providers in 7 randomly selected PHC centers in Aleppo, Syria. RESULTS: All PHC providers completed the questionnaires (100% response rate). A quarter of these providers smoke cigarettes and more than 10% smoke waterpipes. Physicians who smoke were less likely to advise patients to quit (OR=0.29; 95% CI, 0.09-0.95), assess their motivation to quit (OR=0.13, 95% CI=0.02-0.72), or assist them in quitting (OR=0.24, 95% CI=0.06-0.99). PHC providers who smoke were less likely to support a ban on smoking in PHC settings (68.2% vs. 89.1%) and in enclosed public places (68.2% vs. 86.1%) or increases in the price of tobacco products (43.2% vs. 77.4%) (P<0.01 for all comparisons). CONCLUSIONS: Smoking, including waterpipe, continues to be widespread among PHC providers in Syria and will negatively influence implementation of anti-smoking program in PHC settings. PRACTICE IMPLICATIONS: Smoking awareness and cessation interventions targeted to PHC providers, and training programs to build providers' competency in addressing their patients' smoking is crucial in Syria.

Association between smoking and chronic kidney disease: a case control study.

BACKGROUND: The progression of chronic kidney disease (CKD) remains one of the main challenges in clinical nephrology. Therefore, identifying the pathophysiological mechanisms and the independent preventable risk factors helps in decreasing the number of patients suffering end stage renal disease and slowing its progression. METHODS: Smoking data was analyzed in patients with CKD throughout 2005-2009. One hundred and ninety-eight patients who had recently been diagnosed with stage three CKD or higher according to the National Kidney Foundation (NKF) 2002 Classification were studied. The control group was randomly selected and then matched with the case subjects using a computerized randomization technique. The relative risk was estimated by computing odds ratio (OR) by using multinomial logistic regression in SPSS ® for Windows between the two groups. RESULTS: Smoking significantly increases the risk of CKD (OR = 1.6, p = 0.009, 95% CI = 1.12-2.29). When compared to nonsmokers, current smokers have an increased risk of having CKD (OR = 1.63 p = 0.02, 95% CI = 1.08-2.45), while former smokers did not have a statistically significant difference. The risk increased with high cumulative quantity (OR among smokers with > 30 pack-years was 2.6, p = 0.00, 95% CI = 1.53-4.41). Smoking increased the risk of CKD the most for those classified as hypertensive nephropathy (OR = 2.85, p = 0.01, 95% CI = 1.27-6.39) and diabetic nephropathy (2.24, p = 0.005, 95% CI = 1.27-3.96). No statistically significant difference in risk was found for glomerulonephritis patients or any other causes. CONCLUSION: This study suggests that heavy cigarette smoking increases the risk of CKD overall and particularly for CKD classified as hypertensive nephropathy and diabetic nephropathy.

Epidemiology of Type 2 diabetes mellitus in Aleppo, Syria.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is considerable public health problem, but data on the prevalence and correlates of T2DM in Syria are scarce. The aim of the present study was to establish reliable estimates of the prevalence of T2DM in Syria. METHODS: A cross-sectional, population-based survey was conducted in Aleppo, Syria (population 2.5 million), in 2006. The study was conducted on a random sample of 1168 subjects ≥25 years of age (47.7% men; mean age 44.7 ± 12.7 years). Information regarding a personal history of diabetes and other risk factors was collected, followed by measurement of weight, height, and the waist:hip ratio (WHR). Of the 1168 participants, 806 provided fasting blood samples that were analyzed for fasting plasma glucose (FPG) and HbA1c. RESULTS: The prevalence of T2DM based on FPG ≥126 mg/dL and HbA1c ≥6.5% was 15.6% (11.2% self-reported; 5.0% diagnosed) and 14.8%, respectively. The prevalence of impaired fasting glucose (FPG ≥110 and <126 mg/dL) was 8.6%. There was a significant positive association between T2DM and age, WHR, a family history of T2DM, and body mass index (BMI) and an inverse association between T2DM and physical activity (P < 0.01 for all). Multivariate analysis showed that age, BMI, WHR, and a family history of T2DM were the most important factors associated with T2DM. Only 16.7% of treated cases of T2DM were under control (i.e. HbA1c <7%). CONCLUSIONS: Based on the results obtained in our sample, T2DM is widespread in Syria. Many of those with T2DM are unaware of their disease and most have unsatisfactory control of their disease.

Hepatitis B vaccination status and needlestick injuries among healthcare workers in syria.

BACKGROUND: Although a majority of countries in the Middle East show intermediate or high endemicity of hepatitis B virus (HBV) infection, which clearly poses a serious public health problem in the region, the situation in the Republic of Syria remains unclear. The aim of this study is to determine the hepatitis B vaccination status, to assess the number of vaccinations administered, and to estimate the annual incidence of needlestick injuries (NSIs) among healthcare workers (HCWs) in Aleppo University hospitals. MATERIALS AND METHODS: A cross-sectional design with a survey questionnaire was used for exploring details of NSIs during 2008, hepatitis B vaccination status, and HBV infection among a random stratified sample of HCWs in three tertiary hospitals in Aleppo (n = 321). RESULTS: Two hundred and forty-six (76.6%) HCWs had sustained at least one NSI during 2008. Nine (2.8%) had HBV chronic infection and 75 HCWs (23.4%) were never vaccinated. Anesthesiology technicians had the greatest exposure risk when compared to office workers [OR = 16,95% CI (2.55-100), P < 0.01], doctors [OR = 10,95% CI (2.1 47.57), P < 0.01], and nurses [OR = 6.75,95% CI (1.56-29.03), P = 0.01]. HCWs under 25 and between the age of 25 and 35 years were at increased risk for NSI when compared to HCWs older than 45 years [OR = 3.12,95% CI (1.19-8.19), P = 0.02] and [OR = 3.05,95% CI (1.42-6.57), P < 0.01], respectively. CONCLUSION: HCWs at Aleppo University hospitals are frequently exposed to blood-borne infections. Precautions and protection from NSIs are important in preventing infection of HCWs. Education about the transmission of blood-borne infections, vaccination, and post-exposure prophylaxis must be implemented and strictly monitored.