Assessment of the response to kidney patients' needs in disaster-stricken Syria.

PURPOSE OF REVIEW: The major fighting activities in the Syrian conflict have subsided, but the country continues to deal with significant political, economic, and psychosocial consequences that gravely impact the healthcare system, including the care of patients with kidney disease. The purpose of this manuscript is to review some of the problems faced by kidney patients in postconflict Syria and their available and proposed remedies. RECENT FINDINGS: Many challenges, such as unfair, poorly planned, and poorly organized distribution of resources, suboptimal quality-monitoring infrastructure, psychosocial barriers, and workforce shortages, impede the delivery of quality care and negatively impact outcomes. The negative impact of these problems is not uniform and tends to affect certain areas more than others because of geopolitical factors imposed by the conflict. SUMMARY: After prolonged conflicts, healthcare resources remain limited for prolonged periods, leading to inadequate care, poor outcomes, and worsening inequities. Involvement of the international community and expatriate nephrologists is essential to guide care delivery and improve outcomes. The lessons learned from the Syrian conflict apply to many limited resources and disaster situations.

Providing Hemodialysis in Unstable Areas: An Assessment and Framework for Effective Care.

Introduction: Providing hemodialysis to patients with kidney failure (KF) in conflict-affected areas poses a significant challenge. Achieving and sustaining reasonable quality hemodialysis operations in such regions necessitates a comprehensive approach. Methods: In the conflict area of Northwest (NW) Syria, a 3-phase project was initiated to address the quality of hemodialysis operations. The assessment phase involved the examination of infection prevention and control (IPC) protocols, staff training, medical protocols, individualized hemodialysis prescriptions, and laboratory testing capabilities. The second phase involved activities toward capacity building and implementing an action plan based on feasibility and sustainability. Results: The assessment phase revealed that only 7 of 14 centers had IPC protocols, and 8 centers provided IPC training for their staff. Furthermore, only 7 centers had medical protocols, and 5 used individualized hemodialysis prescriptions. Difficulties in testing for potassium was reported in 7 centers and the inability to perform hepatitis B and C serologies was reported in 3 centers. Only 2 centers adhered to machine and water treatment system maintenance guidelines, and 4 conducted daily water quality checks. Recommendations were formulated, and an action plan was developed for implementation in the second phase. The plan encompassed enhancements in IPC practices, medical protocols, record-keeping, laboratory testing, and equipment maintenance. Conclusion: This project underscores that hemodialysis services in conflict-affected areas do not meet the standards for quality care. It emphasizes the necessity of implementing a comprehensive framework that engages relevant stakeholders in defining and upholding quality care, a model that should be extended to other protracted conflict-affected regions.

Telemedicine interventions in six conflict-affected countries in the WHO Eastern Mediterranean region: a systematic review.

BACKGROUND: The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps. MAIN BODY: A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. CONTEXT: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. INTERVENTIONS: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. EVALUATION: most papers were observational or descriptive with few describing quality measures of interventions. CONCLUSIONS: Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.

End-Stage Kidney Disease in Areas of Armed Conflicts: Challenges and Solutions.

Violent and protracted conflicts are disastrous to civilian populations and their health care systems. The complex requirements of caring for end-stage kidney disease (ESKD) dialysis patients in such contexts pose unique challenges. Dialysis is procedurally complex and resource-intensive. Delivering ESKD care in man-made conflict settings presents added challenges beyond what is required in natural disasters and resource-limited situations. In this article, we review the medical literature on, and document experience with, managing dialysis ESKD patients in conflict zones. We discuss the impact of war on patient outcomes, dialysis system infrastructure, operational funding, and risks to providers and organizations. This article provides recommendations to health care providers, educators, and policymakers on how to mitigate associated challenges.

Challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west Syria.

Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.

Care and outcomes of end-stage kidney disease patients in times of armed conflict: recommendations for action.

BACKGROUND: Conflicts can lead to significant disruption in the care of endstage kidney disease (ESKD) patients. The purpose of this paper is to review the available literature on the care of ESKD patients in times of armed conflict and make recommendations for action. METHOD: A review of all PubMed-published reports between 1965 and 2015 about the care of ESKD patients at the time of conflict. We excluded articles that reported on acute kidney injury and natural disasters. RESULTS: We found a total of 12 reports on dialysis care and/or kidney transplant care from five armed conflicts and resulting refugee crises. These conflicts led to significant shortage of staff and resources and caused several obstacles in providing adequate dialysis to ESKD patients. In one study, the mortality rate of patients on automated peritoneal dialysis was as high as 95%. The kidney transplantation rate decreased in all but one of the reports about kidney transplant care and patients had difficulties securing their immunosuppressive medications. CONCLUSIONS: ESKD patients, especially dialysis patients, comprise a severely vulnerable population during conflicts. Their care can be disrupted and altered leading to a substantial increase in their mortality rate. Efforts to improve their care during conflicts are needed.

Incidence of childhood brain tumors in Syria (1993-2002).

OBJECTIVE: To determine whether the incidence and location of childhood CNS tumors in Syria follows the same pattern described in Western and Far Eastern countries. PATIENTS AND METHODS: We analyzed the data compiled from 367 children with brain tumors operated on in our Department of Neurosurgery between 1993 and mid-2002. We excluded all vascular and metastatic lesions and adopted the latest WHO classification in grouping all glial tumors. RESULTS: We found that 47% of brain tumors were located in the supratentorial, and 53% in the infratentorial region. The ratio of male to female occurrence was 1:1.2 (52% males, 48% females). For lesions in the supratentorial space, the distribution was 56% males and 44% females, while in the posterior fossa, the distribution was 61% males and 39% females. Low-grade tumors (WHO I/II) constituted 53.5% of all lesions, and the rest were high grade tumors (WHO III/IV) 46.5%. The most common tumor found in our childhood population was medulloblastoma (27.5%), followed by astrocytoma (25.8%), then craniopharyngioma (14.1%). The most common tumor in the posterior fossa was medulloblastoma (53.5%), followed by astrocytoma (22.5%), then ependymoma (17%). The most common tumors in the supratentorial space were astrocytoma and craniopharyngioma. CONCLUSIONS: In our patient population, the incidence and distribution of CNS tumors were somehow different than those reported by authors from the Western and Far Eastern countries. Whether these results are unique to Syria, or reflect a regional difference in the disease distribution between the Middle East region and the rest of the world, remains to be determined.