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Objective: To determine the feasibility of implementing cessation interventions in Syria. Methods: We randomized 50 smokers to either a brief or intensive behavioral cessation intervention. Adherence to treatment and cessation through 3 months postcessation were calculated. Results: Adherence in the intensive group was only moderate and was associated with smoking for more years and higher self-efficacy. Cessation rates in the brief and intensive intervention groups were 16% and 4%, respectively. Nicotine dependence predicted abstinence at 3 months. Conclusion: Important barriers to cessation included perceived dependence, lack of access to pharmacotherapy, poor social support, and water pipe smoking. [ABSTRACT FROM AUTHOR]

Objectives: To summarize the efficacy of midodrine as an adjunctive therapy in critically ill patients. Safety of midodrine was assessed as a secondary outcome., Data Sources: We performed a systematic review and meta-analysis using a peer-reviewed search strategy combining the themes of vasopressor-dependent shock, critical care, and midodrine and including MEDLINE, Ovid Embase, CINAHL, and Cochrane library databases until September 14, 2023., Study Selection: We included studies if they: 1) included patients with vasopressor-dependent shock, 2) were performed in the ICU, 3) evaluated oral midodrine therapy compared with placebo or usual care, and 4) evaluated one of the outcomes of interest., Data Extraction: We extracted data independently in duplicate using standardized data abstraction forms, which included the following specific variables: patient characteristics, age, sex, type of ICU, etiology of shock, number of patients, study inclusion and exclusion criteria, and geographical location. We also captured the type, dose, and duration of IV vasopressors, any cointervention used, and outcome data., Data Synthesis: We identified seven randomized controlled trials (six included in the pooled analysis) and ten observational studies (four included in the pooled analysis) that met eligibility criteria. Adjunctive midodrine may decrease ICU length of stay (LOS) and there is low certainty of effect on hospital LOS. Midodrine may decrease IV vasopressor support duration, ICU mortality, and hospital mortality. Pooled observational data was based on very low certainty data for all outcomes of interest. The trial sequential analysis-informed required sample size was not met for ICU LOS or IV vasopressor duration and this contributed to Grading of Recommendations, Assessment, Development, and Evaluations assessments of imprecision for both outcomes., Conclusions: Adjunctive midodrine may decrease ICU LOS, duration of IV vasopressor therapy, and mortality in critically ill patients. However, required sample sizes was not met to determine our outcomes of interest. Midodrine may increase risk of bradycardia. While midodrine may provide benefit for patient-centered outcomes, due to increased risk of adverse events, further large-scale studies are needed to inform and guide its routine use in the ICU., Competing Interests: Mr. Kilcommons and Dr. Rewa disclosed the off-label product use of midodrine used for orthostatic hypotension and intradialytic hypotension. Dr. Bagshaw received funding from Baxter, Novartis, Sea Star Medical, BioPorto, and bioMerieux. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Background: Intravenous (IV) vasopressors are the mainstay of physiological support for hemodynamically unstable patients. However, the role of oral vasopressors remains unclear. The objective of our study was to evaluate the feasibility of evaluating midodrine for critically ill patients with IV vasopressor-dependent shock., Methods: We conducted a single-center, concealed-allocation, parallel-group, blinded feasibility randomized controlled trial (RCT) evaluating the effect of oral midodrine versus placebo on IV vasopressor-dependent shock in the intensive care unit (ICU). The study was performed in a medical-surgical ICU at the University of Alberta Hospital from April 2021 to July 2022. We included patients aged 18 years or older admitted to the ICU with ongoing vasopressor support with decreasing vasopressor dose(s). Patients were randomly assigned 1:1 to midodrine or a placebo for the duration of their IV vasopressor therapy. The primary outcome was study feasibility and secondary outcomes included patient-centered outcomes. Feasibility was assessed through rate of recruitment, adherence to study protocol, and patient safety., Results: Twenty patients were enrolled in the study and underwent randomization (n = 11 midodrine, n = 9 control). Recruitment was recorded at 1.2 participants per month, protocol adherence was 90%, and allocation remained concealed. No adverse events were reported in either group. Sepsis was the most common cause of shock in both groups. The midodrine group had a shorter length of ICU stay of 9.6 (SD 8.7) vs 10.4 (SD 14.5) days. Hospital mortality was lower for the midodrine group (n = 2, 18.2% vs n = 4, 37.5%). Vasopressor re-initiation after 24 h was more frequent in the midodrine group (n = 4, 36.4% vs n = 2, 25%). There were no readmissions to the ICU following discharge in either group., Conclusions: The evaluation of midodrine for patients in the ICU is feasible and safe. This trial will inform future large-scale RCTs regarding the utility of midodrine in critically ill patients with IV vasopressor-dependent shock., Trial Registration: This pilot RCT was registered at clinicaltrials.gov (NCT04489589). Registered July 27, 2020. https://clinicaltrials.gov/study/NCT04489589., Competing Interests: Declarations. Ethics approval and consent to participate: This trial was approved by the local Research Ethics Board (REB) in August 2020 (Pro00096716). Informed consent was obtained from the patient or surrogate decision-maker (SDM) prior to being enrolled in the study. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests., (© 2024. The Author(s).)

Study Objective: Rib fractures (RF) are common injuries. Multiple analgesia strategies are available for treatment of pain associated with RF. However, the optimal multimodal technique for pain management is not known. The primary aim of this review was to evaluate the status of evidence derived from randomized clinical trials (RCTs) on the effectiveness of pain management modalities for rib fracture pain. Other patient-centered outcomes were secondary objectives., Methods: Searches were conducted in MEDLINE, Embase, Scopus, and Cochrane Library. The screening process involved two phases, two researchers independently screened the title and abstract and subsequently screened full text. RCT data were extracted independently by two research team members. Consensus was achieved by comparison and discussion when needed. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 tool., Results: A total of 1344 citations were identified. Title and abstract screening excluded 1128 citations, and full text review excluded 177 articles. A total of 32 RCTs were included in the full review. Multiple analgesia techniques and medications were identified and their effect on pain score and need for rescue opioid analgesia. None of the included studies were judged to have a high risk of bias, while only 10 studies were assessed as having a low risk of bias., Conclusions: This systematic review found that studies are of low quality with diverse methodologies and outcomes. A reduction in pain scores was found for epidural analgesia when compared with other modalities. However, the low quality of the evidence necessitates cautious interpretation of this finding. PROSPERO registration: CRD42022376298 (Nov, 16, 2022)., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Intergenic transcription in normal and cancerous tissues is pervasive but incompletely understood. To investigate this, we constructed an atlas of over 180,000 consensus RNA polymerase II (RNAPII)-bound intergenic regions from 900 RNAPII chromatin immunoprecipitation sequencing (ChIP-seq) experiments in normal and cancer samples. Through unsupervised analysis, we identified 51 RNAPII consensus clusters, many of which mapped to specific biotypes and revealed tissue-specific regulatory signatures. We developed a meta-clustering methodology to integrate our RNAPII atlas with active transcription across 28,797 RNA sequencing (RNA-seq) samples from The Cancer Genome Atlas (TCGA), Genotype-Tissue Expression (GTEx), and Encyclopedia of DNA Elements (ENCODE). This analysis revealed strong tissue- and disease-specific interconnections between RNAPII occupancy and transcriptional activity. We demonstrate that intergenic transcription at RNAPII-bound regions is a novel per-cancer and pan-cancer biomarker. This biomarker displays genomic and clinically relevant characteristics, distinguishing cancer subtypes and linking to overall survival. Our results demonstrate the effectiveness of coherent data integration to uncover intergenic transcriptional activity in normal and cancer tissues., Competing Interests: The authors declare no competing interests., (© 2023 The Authors.)

Introduction: Tobacco vendor training is recognized as an essential element to reduce youth access to tobacco. The TRAC training program was developed utilizing best-practices in tobacco retailer training, adult instruction, and e-learning. The objective of this mixed-methods study is to evaluate the acceptability, usability and knowledge impact of an online tobacco retailer program., Methods: An interview guide and evaluation questionnaire were used to collect data on usability and acceptability. To test learner knowledge, each module included a final set of 15 questions randomly chosen and posed to participants before and after the training. Content analysis, chi-squared tests, Student's t-tests, and paired tests were utilized for data analysis. The evaluation was conducted in Alberta, Canada in 2020., Results: A total of 128 participants enrolled in the study. The main themes revealed in the qualitative aspect of the evaluation were: the training was easy to navigate, engaging, informative, and beneficial to the staff's daily work. Compared with the pre-training test, a significantly higher post-training test score, mean and (SD), was recorded for clerks who completed the clerk training module [59.1 (12.8) vs 75.5 (11.1), t=8.6378, p<0.001], and managers who completed the managers training module [51.5 (11.1) vs 73.1 (12.3), t=7.6446, p<0.001]. Similarly, a higher number of participants achieved the passing score of 80% in the post-training test in all three groups., Conclusions: The online training was found to be acceptable and effective in increasing the mean individual score in the knowledge test and in increasing the percentage of participants achieving the passing score. The TRAC training is the first known tobacco retailer training course to employ best practices in tobacco retailer training, adult instruction, and e-learning. Further evaluation of long-term outcomes on employee behavior and on overall compliance with tobacco legislation is recommended., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2022 Hammal F. and Hagen L.)

Objective: Robot-assisted surgery is a minimally invasive approach for repairing the mitral valve. This study aimed to assess its safety and clinical efficacy when compared with conventional sternotomy, partial sternotomy, and right minithoracotomy., Methods: A systematic review of peer-reviewed studies comparing robot-assisted mitral valve repair with conventional sternotomy, partial sternotomy, and right minithoracotomy was conducted following Cochrane Collaboration guidelines. Meta-analyses were performed where possible., Results: The search strategy yielded 15 primary studies, of which 12 compared robot-assisted with conventional sternotomy, 2 compared robot-assisted with partial sternotomy, and 6 compared robot-assisted with right minithoracotomy. The overall quality of evidence was low, and there was a lack of data on long-term outcomes. Individual studies and pooled data demonstrated that robotic procedures were comparable to conventional sternotomy and other minimally invasive approaches with respect to the rates of stroke, renal failure, reoperation for bleeding, and mortality. Robot-assisted mitral valve repair was superior to conventional sternotomy with reduced atrial fibrillation, intensive care unit and hospital stay, pain, time to return to normal activities, and physical functioning at 1 year. However, robot-assisted mitral valve repair had longer cardiopulmonary, aortic cross-clamp, and procedure times compared with all other surgical approaches., Conclusions: Based on current evidence, robot-assisted mitral valve repair is comparable to other approaches for safety and early postoperative outcomes, despite being associated with longer operative times. Ideally, future studies will be randomized controlled trials that compare between robot-assisted surgery, conventional surgery, and other minimally surgery approaches focusing on hard clinical outcomes and patient-reported outcomes.

Background: Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey- or laboratory-based studies. This study employed qualitative methods to explore WP users' perceptions of dependence in Aleppo, Syria., Methods: A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis., Findings: Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included positively reinforced features, such as smoking's association with social gatherings and cultural connectedness, and negatively reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting one's behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at the expense of other reinforcers such as social interaction., Conclusion: The general and specific features of WP dependence need to be considered in developing instruments to measure WP dependence, in clinical assessment of WP dependence, and in developing cessation programs., Competing Interests: Conflict of Interests Thomas Eissenberg is a paid consultant in litigation against the tobacco industry and also the electronic cigarette industry. He is named on one patent for a device that measures the puffing behavior of electronic cigarette users and on another patent for a smartphone app that determines electronic cigarette device and liquid characteristics. Other co-authors have declared no conflict of interest., (© 2022 Kerman University of Medical Sciences.)

ReMap (https://remap.univ-amu.fr) aims to provide manually curated, high-quality catalogs of regulatory regions resulting from a large-scale integrative analysis of DNA-binding experiments in Human, Mouse, Fly and Arabidopsis thaliana for hundreds of transcription factors and regulators. In this 2022 update, we have uniformly processed >11 000 DNA-binding sequencing datasets from public sources across four species. The updated Human regulatory atlas includes 8103 datasets covering a total of 1210 transcriptional regulators (TRs) with a catalog of 182 million (M) peaks, while the updated Arabidopsis atlas reaches 4.8M peaks, 423 TRs across 694 datasets. Also, this ReMap release is enriched by two new regulatory catalogs for Mus musculus and Drosophila melanogaster. First, the Mouse regulatory catalog consists of 123M peaks across 648 TRs as a result of the integration and validation of 5503 ChIP-seq datasets. Second, the Drosophila melanogaster catalog contains 16.6M peaks across 550 TRs from the integration of 1205 datasets. The four regulatory catalogs are browsable through track hubs at UCSC, Ensembl and NCBI genome browsers. Finally, ReMap 2022 comes with a new Cis Regulatory Module identification method, improved quality controls, faster search results, and better user experience with an interactive tour and video tutorials on browsing and filtering ReMap catalogs., (© The Author(s) 2021. Published by Oxford University Press on behalf of Nucleic Acids Research.)

JASPAR (http://jaspar.genereg.net/) is an open-access database containing manually curated, non-redundant transcription factor (TF) binding profiles for TFs across six taxonomic groups. In this 9th release, we expanded the CORE collection with 341 new profiles (148 for plants, 101 for vertebrates, 85 for urochordates, and 7 for insects), which corresponds to a 19% expansion over the previous release. We added 298 new profiles to the Unvalidated collection when no orthogonal evidence was found in the literature. All the profiles were clustered to provide familial binding profiles for each taxonomic group. Moreover, we revised the structural classification of DNA binding domains to consider plant-specific TFs. This release introduces word clouds to represent the scientific knowledge associated with each TF. We updated the genome tracks of TFBSs predicted with JASPAR profiles in eight organisms; the human and mouse TFBS predictions can be visualized as native tracks in the UCSC Genome Browser. Finally, we provide a new tool to perform JASPAR TFBS enrichment analysis in user-provided genomic regions. All the data is accessible through the JASPAR website, its associated RESTful API, the R/Bioconductor data package, and a new Python package, pyJASPAR, that facilitates serverless access to the data., (© The Author(s) 2021. Published by Oxford University Press on behalf of Nucleic Acids Research.)

Background: Mapped the sources and types of evidence available on psychosocial interventions in the treatment of opioid use disorder (OUD), with and without pharmacotherapies., Methods: Six electronic databases were searched for research published until July 1, 2019. Included studies were coded on publication characteristics, evidence sources, treatment settings and modalities, study populations and patient characteristics, intervention(s) offered to patients, research questions addressed in experimental studies, and outcomes investigated., Results: We identified 305 empirical studies of 54,607 patients. Most studies (64 %; n = 194) compared psychosocial interventions to alternative treatment(s) (183 RCTs and 11 quasi-experiments) while 28 % (n = 86) used observational designs, and 8% (n = 25) used qualitative methods. Trials infrequently investigated effects of stand-alone psychosocial interventions without pharmacotherapies (20% of all RCTs). Regardless of research question or study design, program retention and illicit drug use were the most common outcomes investigated (> 81% of all studies and RCTs), typically among longstanding male heroin users attending specialty outpatient addiction services. Studies rarely examined (a) OUD treatment in general health care or prescription OUD (each < 6 % of all studies and RCTs), (b) effects of social assistance (employment, education, social support) and harm reduction (each < 6 % of studies; < 7 % of RCTs), and (c) health-related quality of life and satisfaction with care (each < 10 % and < 15 % of all studies and RCTs, respectively)., Conclusions: Scant evidence is available on the putative rehabilitative effects of psychosocial interventions, either as stand-alone treatments or in an adjunct role to pharmacotherapies., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease., Methods: We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate., Results: We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small., Conclusion: Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Introduction: We compared smoking cessation outcomes between those who used a pharmacist-led community-based smoking cessation intervention and those who did not, prior to total joint replacement (TJR) surgery. Also, we examined intervention characteristics (e.g. number/duration of sessions attended, recommended therapy) and smoking cessation outcomes., Methods: This prospective evaluation was nested within a comparative study from a centralized clinic that prepares over 3000 patients annually for TJR and focused on participants referred to the community-based smoking cessation program preoperatively. Pharmacists offered an individualized evidence-based intervention and collected visit, duration and intervention data. Smoking cessation, the primary outcome, was ascertained independently of participating pharmacists at 6 weeks post-operative using exhaled CO monitoring and at 6 months post-recruitment via telephone interview., Results: Of 286 eligible candidates, 104 agreed to participate, with one subsequently withdrawing (n=103). At 6 weeks post-operatively, 66/103 (64%) participants returned for study re-assessment while 63/103 (61%) participants completed the post-recruitment interview at 6 months; non-respondents to study follow-up were considered smokers. Of 103 participants, 58 (56%) consulted with a pharmacist; those who did not consult a pharmacist (n=45) were slightly younger (p=0.02) with significantly higher CO level (p=0.02) on study entry. Validated 7-day point prevalence abstinence (PPA) at 6 weeks post-operative was 11/58 (19%) in pharmacist-compliant participants compared to 2/45 (4%) in non-compliant participants (p=0.04). At 6 months post-recruitment, 19/58 (33%) pharmacistcompliant participants self-reported a 7-day PPA compared to 2/45 (4%) by non-compliant participants (p<0.001). For pharmacist-compliant participants, 33/58 (54%) saw the pharmacist 4 times; the mean overall pharmacist time was 71.8±24.4 minutes/patient with 26/58 (45%) and 19/58 (33%) prescribed nicotine replacement therapy and varenicline, respectively, and 13/58 (22%) not using medication; post hoc analysis suggested varenicline was marginally more effective for smoking cessation than no medication (p=0.04)., Conclusions: Community-based pharmacist-led smoking cessation programs are an effective addition to usual preoperative care for smokers awaiting elective TJR. Using existing community resources led to higher smoking cessation rates in smokers waiting for TJR relative to those not using these resources., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. All the authors report grants from Pfizer, during the conduct of the study., (© 2020 Beaupre L.A. et al.)

Introduction: Smokers undergoing total joint replacement (TJR) are more likely to develop infections and be re-admitted than non-smokers. The primary purpose of this study was to evaluate the effectiveness of standardized preoperative referral to a community-based pharmacist-led smoking cessation program compared to usual care for patients undergoing TJR. Secondarily, we evaluated the use of the smoking cessation program., Methods: A pre-post quasi-experimental study was conducted at a central intake clinic that prepares approximately 3000 TJR patients annually. Participants were recruited at a mean of 13±11.1 weeks preoperatively and provided informed consent. Participants in the 'pre' observational phase (OP) received usual care for smoking cessation. For 'post' intervention phase (IP) participants, a referral was sent to a community-based pharmacist-led smoking cessation program. Smoking status was validated on study entry using exhaled carbon monoxide. Participants' smoking status was re-assessed using self-reported point prevalence abstinence at 6 months post-recruitment., Results: We enrolled 120/150 (80%) potential OP candidates and 104/286 (36%) potential IP candidates. The groups were similar on study entry; overall, the mean age of participants was 58.7±9.1 years and 103 (47%) were male. They reported medium nicotine dependence with 37±11.6 mean years smoked. At 6 months post-recruitment, 8 (7%) OP participants self-reported 30-day point prevalence abstinence compared to 21 (20%) IP participants (p=0.003). Only 58 (56%) IP participants complied with the pharmacist referral, with 19 (33%) of those seeing the pharmacist reporting point prevalence abstinence at 6 months compared to only 2 (4%) of the 45 participants who did not see the pharmacist (p<0.001)., Conclusions: Referral to a community smoking cessation program as preoperative standard of care is feasible and can enhance long-term quit rates, but voluntary participation led to low recruitment to the program., Competing Interests: The authors declare that they have no competing interests, financial or otherwise, related to the current work. BA Finegan reports grants from Pfizer, during the conduct of the study and personal fees from Pfizer, outside the submitted work. The rest of the authors have also completed and submitted an ICMJE form for disclosure of potential conflicts of interest., (© 2019 Beaupre L. A.)

Quality Problem: For smokers, hospital admission is accompanied by forced involuntary nicotine abstinence due to smoke-free site/grounds policies. An audit of patients admitted to our surgical wards revealed that identification of smoking status was inadequate and that nicotine addiction management (NAM) was infrequently offered. The project aimed to enhance both these metrics by initiating NAM in the post anesthesia care unit (PACU)., Initial Assessment: Out of 744 patients admitted to our PACU in August 2015, 54% had their smoking status documented. The 200 patients (27%) out of the 744 were smokers and only 50% were offered NAM before discharge., Choice of Solution: PACU unit staff to determine the smoking status of every patient before discharge from the PACU (later changed to OR nursing staff) and, if a patient was identified as a smoker, to offer NRT (patch and mouth spray only) and initiate therapy prior to transfer of the patient to the ward., Implementation: Data about number of patients admitted, presence of documented smoking status, number of identified smokers, and number offered/accepted nicotine replacement therapy (NRT) were collected at baseline and thereafter quarterly. Engaging video education sessions addressed the education gaps highlighted in a needs assessment. Identification of smoking status was made part of preoperative checklist and NRT was made available in post-operative recovery room., Results: These interventions resulted in an increase in screening for tobacco use from 54% at baseline to 95% and the offer of NRT to smokers from 50 to 89%.

Purpose: To determine if a non-exercise algorithm-derived assessment of cardiorespiratory fitness (CRF A ) accurately predicted estimated values obtained using a six-minute walk test (CRF 6MWD ) and the Duke Activity Status Index (CRF DASI )., Methods: Following research ethics board approval, an observational cohort study was conducted in selected, consenting patients undergoing elective surgery. Participants completed questionnaires assessing their self-reported exercise capacity. Their height, weight, waist circumference, and vital signs were measured. A six-minute walk test was performed twice with a 45-min rest interval between tests. The correlation between CRF A and both CRF 6MWD and CRF DASI was determined., Results: Two hundred forty-two participants were included. Mean age was 62 (range 45-88 yr); 150 (62%) were male, 87 (36%) self-reported walking or jogging > 16 km per week, and 49 (20%) were current smokers. The CRF A and CRF 6MWD were highly correlated (Pearson r = 0.878; P < 0.001). CRF A and CRF DASI were less strongly correlated (Pearson r = 0.252; P < 0.001). Among patients capable of walking > 427 m in the six-minute walk test, CRF A , CRF 6MWD , and CRF DASI were equivalent., Conclusion: A non-exercise algorithm can estimate cardiorespiratory fitness in patients presenting for elective surgery. The variables required to compute CRF A can be obtained in a clinic setting without the need to engage in formal exercise testing. Further evaluation of CRF A as a predictor of long-term outcome in patients is warranted.

The purpose of this study is to explore electronic cigarettes (EC) use among youth. Focus group sessions with youth (aged 12-17) were held to explore their knowledge and attitudes about EC use. Content analysis techniques were used. There has been an increase in the visibility and accessibility of EC in the past few years among youth. Compared with conventional cigarettes (CC), youth indicated that they would be more willing to use EC under their peer influence. This was motivated by the perception that EC were less harmful. Among youth EC are perceived as less harmful, easier to access and use than CC. Youth do not appear to have received much education about EC. However, they were not convinced that EC were risk free. Clear and unambiguous education about the risk of engaging in any form of smoking/vaping and enforcement of access restrictions appear to be required.

Waterpipe (WP) use has surged in popularity since the introduction of flavoured shisha. It is now an increasingly popular form of smoking among youth in North America. Health professionals/educators knowledge about the WP may well be inadequate. This study, using qualitative methods, sought to explore the knowledge and attitude of leaders in the community toward the WP. Family physicians, pharmacists, tobacco counsellors, social workers and educators were invited to participate in a one-one interview using open-ended questions. A total of 27 interviews were conducted. Individuals from Eastern Mediterranean backgrounds raised doubt about the overemphasised cultural significance of the WP and perceived this as a marketing strategy by industry. Most felt that WP smokers believed the WP to be less harmful than cigarettes and that the use of flavoured tobacco was motivating people to smoke. Participants believed that education should be directed at the general public and healthcare professionals, suggesting school programs and the use of social media to inform young smokers. Most thought that the current practices regarding packaging and second hand smoke exposure are confusing. They identified the lack of knowledge, poor enforcement procedures, "so called cultural aspects" and the economic impact of banning the WP on small businesses as barriers to change. Despite the awareness of an increase in WP use, our participants recognized that little has been done to curb this problem. Our findings emphasize the need for further education and better legislation to regulate WP use and availability.

Introduction: When asserting the right of individuals to be free to smoke a hookah (waterpipe [WP]) in public places, the "cultural" importance of the practice is often cited. The purpose of this study was to explore the cultural significance of WP smoking., Methods: Qualitative methods were used to elicit the views of groups of WP smokers from different cultural backgrounds., Results: Sixteen group discussion sessions with a total of 75 WP smokers aged between 18 and 30 were conducted. A few participants saw culture as a factor supporting WP smoking initiation and maintenance. The vast majority indicated that WPs being perceived as "healthier" than cigarettes, and the availability of flavored shisha as important factors in their initiation and ongoing use. Most started smoking before the age of 18 calling it a "high school thing" and admitted that they had easy access to WP cafés. Many indicated that they did not know if they were smoking tobacco or a "herbal" substance., Conclusion: Peer influence, availability of flavored products and facile access to WP cafés are major factors in WP initiation. Ethno-cultural traditions play only a minor role. The assertion that cultural traditions and practice are inherent in WP smoking as implied by media and marketing was not supported by our findings. Contemporary use of WP is spreading among new non-traditional users. Lack of knowledge about the harms of WP smoking indicates a need for education and regulation to require packaging and health warning labels and restrictions on access, especially to minors., (© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In Canada, although there are periodic media campaigns to raise awareness of Quitlines, these services are underused. We sought to determine if a dedicated kiosk, similar to that used in the retail industry but staffed by volunteers trained in smoking cessation techniques, would be effective method to enhance Quitline reach., Methods: We located a kiosk in the foyer of two hospitals and in two shopping malls in Edmonton, Canada between Feb/2012 and July/2014. The cessation intervention was based on the 5 A's approach. Outcome was assessed by number of visits to the kiosk and referral rates to the Quitline. A cross sectional survey among small sample of visitors was used for evaluation. Descriptive statistics were used to summarize visitors' data., Results: Of 1091 kiosk visitors, 53.3 % were current smokers, of whom 93.3 % indicated a willingness to quit. Of these, 32.1 % requested a Quitline referral at the time of the kiosk visit. Referral requests to the Quitline were greater when the kiosk was located in the non-hospital setting 39.1 % compared to 31.1 % in hospitals (P = 0.2). Referrals from the kiosk represented 6 % of total referrals received by the provincial Quitline during the study period. Following referral the Quitline was able to reach 50 % of those referred, of those, 17 % refused to proceed. At seven month follow up 30 day abstinence rate was 3.8 % of smokers who wished quit. Visitors agreed that the kiosk design was interesting (89.3 %) and increased their knowledge about tobacco and cessation options (88.8 %) and encouraged them to take action to quit (85.7 %)., Conclusions: A "volunteer manned kiosk" can increase awareness of smoking cessation resources in the community and increase referral rates to Quitline services.

Background: There are limited data on the composition and smoke emissions of 'herbal' shisha products and the air quality of establishments where they are smoked., Methods: Three studies of 'herbal' shisha were conducted: (1) samples of 'herbal' shisha products were chemically analysed; (2) 'herbal' and tobacco shisha were burned in a waterpipe smoking machine and main and sidestream smoke analysed by standard methods and (3) the air quality of six waterpipe cafés was assessed by measurement of CO, particulate and nicotine vapour content., Results: We found considerable variation in heavy metal content between the three products sampled, one being particularly high in lead, chromium, nickel and arsenic. A similar pattern emerged for polycyclic aromatic hydrocarbons. Smoke emission analyses indicated that toxic byproducts produced by the combustion of 'herbal' shisha were equivalent or greater than those produced by tobacco shisha. The results of our air quality assessment demonstrated that mean PM2.5 levels and CO content were significantly higher in waterpipe establishments compared to a casino where cigarette smoking was permitted. Nicotine vapour was detected in one of the waterpipe cafés., Conclusions: 'Herbal' shisha products tested contained toxic trace metals and PAHs levels equivalent to, or in excess of, that found in cigarettes. Their mainstream and sidestream smoke emissions contained carcinogens equivalent to, or in excess of, those of tobacco products. The content of the air in the waterpipe cafés tested was potentially hazardous. These data, in aggregate, suggest that smoking 'herbal' shisha may well be dangerous to health., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Smoking is an undertreated risk factor for coronary artery disease (CAD) and is associated with adverse outcomes after myocardial infarction. Aims of our study were to determine if management of CAD by medical therapy (MT) alone or with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) influence smoking status at one year following angiography and if a change in smoking status at one year influences long term survival., Methods: Prospective cohort study using the APPROACH registry. Two cohorts were examined: (1) 11,334 patients who returned a one year follow-up questionnaire; (2) 4,246 patients propensity-matched based on their post-angiography treatment - MT or revascularization (RV). Multivariate modeling and survival analysis were used., Results: In the propensity-matched cohort, quit rates at one year were greater among CABG patients (68%) than PCI (37%) or MT patients (47%). Smokers in the RV group, who self-reported quitting at one year, had a significantly reduced mortality compared to those who continued to smoke., Conclusions: CABG patients were more likely to quit smoking than those treated with MT alone or PCI. Quitting smoking was associated with improved long-term survival; smoking remains a key risk factor for mortality in patients with CAD. These data underscore the importance of nicotine addiction management in patients with CAD and the need to emphasize cessation particularly in those patients undergoing MT or PCI.

Waterpipe tobacco smoking (WTS) is on the rise globally, particularly among vulnerable populations such as youth and women. Increasing knowledge about toxicant yield from waterpipe tobacco and deleterious health effects points to the potential for a health epidemic. WTS is often viewed as a safe alternative to cigarette smoking. Though the original objective of the research was to explore the social norms and attitudes that lead to waterpipe being a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean Region, the use of a qualitative research methodology resulted in rich data that helped to understand more generally the phenomenon of waterpipe smoking. Both focus group discussions (FGDs) and key informant interviews were used. Participants were recruited to represent genders, various age groups, socioeconomic status, waterpipe smoking status, and residents of urban and rural areas. A total of 81 FGDs and 38 in-depth interviews were conducted in 2007. Thematic analysis was used to analyze the transcripts. A total of ten themes emerged: socio-cultural norms, gender differences, motivation to smoke, sensory characteristics of waterpipe, metaphors, consumerism, indicators of dependence, comparison between cigarettes and waterpipe, health effect of smoking, and intervention. Results indicated that WTS has socio-cultural dynamics associated with it that are far more pronounced than health considerations. An increased socio-cultural acceptability, the perceived reduced harm and the advent of the fruity Moassel tobacco are among the many reasons for WTS acceptability. Findings point to the need for a unified strategy to address this health issue at all levels of the ecological framework and have important implications for future policy and practice., (Copyright © 2013. Published by Elsevier Ltd.)

Background: Little is known about the knowledge and attitudes towards tobacco use among medical students in Canada. Our objectives were to estimate the prevalence of tobacco use among medical students, assess their perceived level of education about tobacco addiction management and their preparedness to address tobacco use with their future patients., Methods: A cross-sectional online survey was administered to University of Alberta undergraduate medical school trainees. The 32-question survey addressed student demographics, tobacco use, knowledge and attitudes around tobacco and waterpipe smoking, tobacco education received in medical school, as well as knowledge and competency regarding tobacco cessation interventions., Results: Of 681 polled students, 301 completed the survey. Current (defined as "use within the last 30 days") cigarette, cigar/cigarillo and waterpipe smoking prevalence was 3.3%, 6% and 6%, respectively. One third of the respondents had ever smoked a cigarette, but 41% had tried cigars/cigarillos and 40% had smoked a waterpipe at some time in the past. Students reported moderate levels of education on a variety of tobacco-related subjects but were well-informed on the role of tobacco in disease causation. The majority of students in their final two years of training felt competent to provide tobacco cessation interventions, but only 10% definitively agreed that they had received enough training in this area., Conclusions: Waterpipe exposure/current use was surprisingly high among this sample of medical students, a population well educated about the role of tobacco in disease causation. The majority of respondents appeared to be adequately prepared to manage tobacco addiction but education could be improved, particularly training in behavioral modification techniques used in tobacco use cessation.

The prevalence of waterpipe tobacco smoking is increasing worldwide, despite evidence indicating its adverse health effects. Women and young people seem more likely to be choosing waterpipe tobacco smoking over cigarettes. The objective of this qualitative study was to understand better whether and why waterpipe smoking is a more acceptable form of tobacco use than cigarettes for women in the Eastern Mediterranean Region, and to understand whether the strategies used by multi-national corporations to attract women to cigarette smoking were perceived to be relevant in the context of waterpipe tobacco use. Focus groups (n = 81) and in-depth interviews (n = 38) were conducted with adults in Lebanon, Egypt, Palestine, and Syria. Discussions were thematically analyzed and recurrent themes identified. One of the themes which emerged was the negative image of women smoking waterpipes. Moreover, the sexual allure conveyed through waterpipe smoking as well as waterpipe tobacco smoking as a symbol of emancipation was illustrated. The latter was mainly expressed in Lebanon, in contrast with Egypt where traditional gender roles depict women smoking waterpipes as disrespectful to society. Understanding the social aspects of waterpipe tobacco smoking is crucial to planning future interventions to control waterpipe tobacco smoking among women and in society at large.

Purpose: Brief intervention (BI) to encourage patients who smoke to quit is effective and should occur at every patient interaction. If smokers receive a motivational interview in addition to BI and are offered pharmacotherapy to treat nicotine withdrawal, cessation rates may be improved. We compared the uptake, implementation, and effectiveness of these two approaches in the delivery of a smoking cessation intervention during assessments in a pre-admission clinic (PAC)., Methods: The study was performed in the PAC at two tertiary care hospitals. At both hospitals, PAC patients were screened for smoking status, and current smokers were offered the opportunity to participate in a cessation program. Those who agreed were asked to consent to participate in an evaluation of program effectiveness that included a telephone interview about smoking status six months after hospital discharge. A cohort design was used to compare cessation outcomes across PACs during a one-year period of patient recruitment. The primary outcome measure was a self-reported continuous quit rate six months following hospitalization. Secondary outcomes included the number of patients willing to participate and the completeness of the delivery of program components., Interventions: A BI delivered at one PAC consisted of brief advice and self-help materials, including handing the patient a business card with an available 1-800 Quit line (a telephone smoking cessation help line). The other PAC offered an intensive intervention (II) that included augmenting the BI with an in-hospital and post-discharge motivational interview and access to nicotine replacement therapy (NRT) during admission., Results: At follow-up, we were able to contact 147 of the 288 smokers who agreed to participate in the evaluation of the program, and the self-reported quit rates for the BI and II interventions were 11.4% and 19.5%, respectively. More than 1,200 current smokers were identified and approached at both PACs during the 12-month patient recruitment period, and 60% of those were willing to accept the offered smoking cessation intervention (either BI or II). Implementation of II was uneven, particularly the delivery of the in-hospital motivational interview and prescription of NRT. Uptake of the 1-800 Quit service after discharge was inadequate., Conclusion: The PAC is a feasible location to identify smokers and offer a cessation intervention. There are considerable logistical barriers to the development of an II intervention program as described. A program that incorporates elements of BI and II could offer a practical approach to the implementation of a hospital-wide smoking cessation intervention.

Waterpipe smoking has increased dramatically worldwide in recent years, with an estimated 100 million daily users. Research on this traditional Middle Eastern tobacco use method is in its infancy, and little is known about users' cessation-related attitudes and experiences. A random sample of 268 narghile (waterpipe) smokers (40% female; mean age = 30 years; range = 18-68) was obtained from cafes and restaurants in Aleppo, Syria. The majority of users (86.5%) believed they could quit using waterpipes at any time, but that belief was inversely related to perceived dependence, with only 48.7% of those who thought they were "very hooked" believing they could quit. Interest in quitting was expressed by 28.4% of subjects, with the majority (89.2%) reporting health concerns as a primary reason, and 59.2% having made an unsuccessful quit attempt in the past year. In a logistic regression model, independent predictors of interest in quitting included being married, having smoked for fewer years, not increasing the frequency of smoking over time, and having family members who do not smoke a waterpipe and disapprove of its use. Results indicate that a sizable percentage of waterpipe users express interest in quitting and have tried unsuccessfully in the past to quit. Waterpipe use needs to be considered in developing effective tobacco use cessation programs in the Middle East.

Purpose: To assess the beliefs and attitudes related to narghile (waterpipe) smoking that are likely to contribute to its increased popularity among young people in Syria., Methods: In 2003, a cross-sectional survey was administered to university students in Aleppo, using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 +/- 2.1; response rate 98.8%)., Results: The most common positive perceptions of narghile were related to its smell and taste. Negative perceptions of narghile included the smoke produced, the pollution, and perceived adverse health effects. Students believed the popularity of narghile to be part of a rising regional trend in its use, due to its being an appealing way to spend leisure time socializing with friends. More students (49.7%) believed narghile to be more harmful to health than cigarettes, compared with 30% who believed the opposite. Respiratory disease was the most commonly cited health effect of narghile smoking. Family attitudes regarding tobacco use by younger members were more permissive about narghile compared with cigarettes, and, surprisingly, were more permissive about females smoking narghile than males doing so., Conclusions: The rise in narghile smoking as a trendy social habit appears to be occurring despite considerable appreciation of its potential health risks. Permissiveness of adult family members towards narghile use by young female members, especially in the presence of a strong taboo against female cigarette smoking may contribute to the continuous spread of narghile smoking among women in Syria.

Setting: Narghile (waterpipe) smoking is increasing in all Arab societies, but little is known about its pattern of use., Methods: In 2003, a cross-sectional survey was conducted among students at Aleppo University using an interviewer-administered questionnaire. A representative sample of 587 students participated (278 males, 309 females; mean age 21.8 +/- 2.1 years; response rate 98.8%)., Results: Ever narghile smoking was seen among 62.6% of men and 29.8% of women, while current smoking was seen among 25.5% of men and 4.9% of women. Only 7.0% of the men used narghile daily. Age of initiation was 19.2 +/- 2.2 and 21.7 +/- 3.2 years for men and women, respectively (P < 0.001). The salient feature of narghile smoking was its social pattern, where most users initiated and currently smoked narghile with friends. Narghile and cigarette smoking were related among students, with narghile smoking most prevalent among daily cigarette smokers. Multivariate correlates of narghile smoking were being older, male, originating from the city, smoking cigarettes, having friends who smoke narghile, and coming from a household where a greater number of narghiles were smoked daily., Conclusions: Narghile smoking is prevalent among university students in Syria, where it is mainly practiced by men, intermittently, and in the context of social activities with friends.