An Algorithmic Approach to Dual-System Venous Drainage for DIEP Flap Breast Reconstruction.

BACKGROUND: Few studies compared the use of the deep venous system alone versus combined superficial and deep venous drainage in DIEP flaps. The objective of this study is to compare DIEP flap breast reconstruction using either the deep venous system alone versus dual-system venous drainage and to propose an algorithm for flap design and orientation and veins selection to facilitate consistent use of dual-system venous drainage. METHODS: Patients undergoing DIEP flap breast reconstruction between March 2017 and April 2021 were retrospectively reviewed. Flaps were divided into two groups: deep venous system only (Group 1) or dual-system (Group 2). Outcomes included takeback to the operating room (OR), flap loss and thrombosis and operative time. RESULTS: A total of 244 DIEP flaps in 162 patients met inclusion criteria. A total of 130 flaps were included in Group 1 (53.3%) and 114 flaps were included in Group 2 (46.7%). Sixteen flaps (6.6%) required immediate takeback to the OR and takeback rates were not significantly different between groups (p=0.606). Flap loss rate was significantly higher in Group 1: 2.5% vs Group 2: 0%; p=0.031. Flap thrombosis occurred in 8 flaps (3.3%) and tended to occur more frequently in Group 1 but this finding did not reach significance (Group 1: 5.4% vs Group 2: 0.9%; p=0.071). CONCLUSIONS: The use of dual-system venous drainage in DIEP flap breast reconstruction decreases the rate of flap loss. Our algorithm can be used to guide selection of flap laterality, rotation, and veins and recipient vessels to facilitate routine use of dual-system venous drainage.

Barriers to sustainable health research leadership in the Global South: Time for a Grand Bargain on localization of research leadership?

BACKGROUND: Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges. FINDINGS: GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges. CONCLUSIONS: Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN-GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South-South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

The health of internally displaced people in Syria: are current systems fit for purpose?

INTRODUCTION: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. METHODS: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. FINDINGS: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. CONCLUSION: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria.

Auricular pseudocysts: a systematic review of the literature.

BACKGROUND: Auricular pseudocysts are benign fluid accumulations of the ear of uncertain etiology. Little is known about the optimal modality to successfully treat these lesions. No systematic review addressing auricular pseudocysts have been published to date. OBJECTIVES: The aim of this study is to summarize all the published data regarding diagnostic and therapeutic challenges of auricular pseudocysts. METHODS: On May 28, 2020, a systematic search of Medline, Embase, and Cochrane databases was conducted. All the studies describing treatment of auricular pseudocysts, procedure description, outcome, and follow-up period were included in this review. RESULTS: After full-text article review, 74 articles were included, representing a total of 1,011 lesions. The commonly used treatments for auricular pseudocysts were deroofing (493 lesions), aspiration (284 lesions), incision and drainage (171 lesions), intralesional steroids (53 lesions), and observation (10 lesions). The highest cure rate was found with the deroofing procedure (97.2%) followed by incision and drainage (95.9%). The mean follow-up period was 6.7 months. CONCLUSION: Surgical procedures (anterior deroofing or incision and drainage) showed the highest cure rates and should be considered as first-line treatment for auricular pseudocysts. Future adequately designed randomized controlled trials are warranted to compare the efficacy of the techniques described.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria.

BACKGROUND: The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict. METHODS: As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria. RESULTS: Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria. CONCLUSIONS: Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

Simple to Extreme: Following the Reconstructive Ladder for Complex Posterior Trunk Reconstruction.

Reconstruction of the posterior trunk and torso defects presents unique challenges to the reconstructive surgeon, particularly in the setting of oncologic resection and adjuvant multimodality therapy such as chemotherapy and radiation. The operation can be more complicated in the setting of hardware exposure. Although local flaps represent the primary workhorse option, reconstruction using a microvascular free tissue transfer should be considered when local flap options have been exhausted. Here, we present a unique case reconstructing a complex, radiated back wound with exposed hardware that failed prior bilateral paraspinous, latissimus dorsi, and trapezius muscle flaps. A unilateral free TRAM flap was used and revascularized through an arteriovenous loop to provide stable coverage of the 15 × 25 cm defect. The patient also had preexisting upper extremity ischemia, which limited flap perfusion and positioning options. The usage of arteriovenous loops and free musculocutaneous flaps can provide another potential adequate option for the treatment of these complex defects.

An unusual tell sign of botulinum toxin injection in patients with facial flushing: incorporating a new questionnaire in the evaluation of botulinum toxin patients.

Lately it has been established that intra-dermal botulinum toxin is also effective in treating many dermatological conditions including refractory erythematous-telangiectatic rosacea, post - menopausal facial flushing and other similar conditions.However, the desired effect of treating the reddening in patients suffering from facial flushing can become an undesirable and embarrassing side effect when these same patients present to the clinic for esthetic concerns such as upper face rhytids. In this case, intramuscular botulinum toxin injections used for wrinkles treatment will also secondarily treat the facial reddening in their localized skin diffusion zones and result in embarrassing white patches all over the face. The patchy appearance following botulinum toxin injections for esthetic purposes could be bothersome for some patients and could be a tell-tale sign of botulinum toxin injections.

Mapping University-Based Master of Public Health Programs in the Arab world.

Background: The Arab world faces numerous health challenges that mandate a competent public health workforce and strengthening public health education. Objective: To analyze university-based Master of Public Health (MPH) programs offered at Faculties of Public Health (FPH) and of Medicine (FM) in Arab countries. Methods: We searched a regional database of academic public health institutions, conducted a search of university websites, and reviewed websites of the Association of Arab Universities and World Directory of Medical Schools. A factsheet for each MPH program was emailed to deans of respective faculties for validation and completion. We examined associations between presence of such programs and population size and Human Development Index (HDI). Findings: A total of 19 FPH and 10 FM at 28 universities offer MPH programs (7 programs per 100 million population). Ten countries offer no MPH programs; the remaining 12 offer 1-5 programs each. Ten MPH programs were initiated over 45 years (1965-2009) and another 19 over 10 years (2010-2019). No correlation was observed between offering an MPH program and the country's HDI or population size. Less than half of the programs admit students from fields outside health. FPH and FM-based programs are comparable in offering core disciplines but FPH programs offer more Social and Behavioral Sciences (83% vs. 60%). More FM-based programs provide practicum training (78% vs. 53%); 10 programs offer none. Epidemiology, alone or with Biostatistics, and Health Management and Policy are the two most frequently offered MPH concentrations. None of the MPH programs offer a concentration on public health in conflict or humanitarian crises; only one offers a certificate on the theme. Only three programs, all FPH-based, reported international accreditation. Conclusions: The recent increase in MPH programs in Arab countries is encouraging. Critical gaps are absence of MPH programs in 10 countries, less coverage of the social sciences, and lack of practicum experience in 10 programs. Upgrading and promoting public health education across the region to fill these gaps calls for collaboration among existing MPH programs. More in-depth analysis of the history and mission of these programs, as well as their admission criteria and curricula, is needed.

Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria.

BACKGROUND: War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period. METHODS: We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework. RESULTS: We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs. CONCLUSIONS: Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

'We need someone to deliver our voices': reflections from conducting remote qualitative research in Syria.

The need to generate evidence in spaces considered insecure and inhabited by potentially extremely vulnerable individuals (e.g. conflict-affected people who may not have means to move) has led researchers to study conflict-affected settings remotely. Increased attention to remote research approaches from social scientists, due to COVID-19-related travel restrictions, is sparking interest on appropriate methods and tools. Drawing on several years' experience of remotely conducting qualitative research in Syria, we discuss challenges and approaches to conducting more inclusive, participatory, and meaningful research from a distance. The logistics, ethics, and politics of conducting research remotely are symptomatic of broader challenges in relation to the decolonisation of global and humanitarian health research. Key to the success of remote approaches is the quality of the relationships researchers need to be able to develop with study participants without face-to-face interactions and with limited engagement 'in the field'. Particularly given overdue efforts to decolonise research institutions and methods, lead researchers should have a meaningful connection with the area in which they are conducting research. This is critical both to reduce chances that it will be extractive and exploitative and additionally for the quality of interpretation.

Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study.

BACKGROUND: Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty. METHODS: Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups. RESULTS: Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg; p = 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p < 0.0001). CONCLUSIONS: Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Acquired ungual fibrokeratoma: a systematic review of the literature.

BACKGROUND: Acquired ungual fibrokeratomas (AUFKs) are benign recurrent fibrokeratotic tumors of the nail unit of uncertain etiology. Little is known about the optimal modality to successfully treat these lesions. No systematic review addressing ungual fibrokeratomas has been published to date. OBJECTIVES: The aim of this study is to summarize all the published data regarding diagnostic and therapeutic challenges of AUFKs. METHODS: On August 9, 2019, a systematic search of Medline and Cochrane databases was conducted. All the studies describing the treatment of ungual fibrokeratomas, procedure description, pathological findings, outcome, and follow-up period were included in this review. RESULTS: After full-text article review, 103 articles were included, representing a total of 78 lesions. The commonly used treatments for fibrokeratomas were complete tumor resection (90.5%), shave excision (8.3%), and cryotherapy (1.2%). Complete surgical excision yielded the highest cure rate among all treatment modalities (90.8%) compared to partial surgical excision (28.6%) and cryotherapy (0%). The mean follow-up period was 12.1 months (1-144). CONCLUSION: Complete surgical removal preserving the matrix showed the highest cure rates and should be considered as first-line treatment for AUFKs. Future adequately designed randomized control trials are warranted to compare different treatment modalities.

Health-related articles on Syria before and after the start of armed conflict: a scoping review for The Lancet-American University of Beirut Commission on Syria.

INTRODUCTION: Armed conflict may influence the size and scope of research in Arab countries. We aimed to assess the impact of the 2011 Syrian conflict on health articles about Syria published in indexed journals. METHODS: We conducted a scoping review on Syrian health-related articles using seven electronic databases. We included clinical, biomedical, public health, or health system topics published between 1991 and 2017. We excluded animal studies and studies conducted on Syrian refugees. We used descriptive and social network analyses to assess the differences in rates, types, topics of articles, and authorship before and after 2011, the start of the Syrian conflict. RESULTS: Of 1138 articles, 826 (72.6%) were published after 2011. Articles published after 2011 were less likely to be primary research; had a greater proportion reporting on mental health (4.6% vs. 10.0%), accidents and injuries (2.3% vs. 18.8%), and conflict and health (1.7% vs. 7.8%) (all p < 0.05); and a lower proportion reporting on child and maternal health (8.1 to 3.6%, p = 0.019). The proportion of research articles reporting no funding increased from 1.1 to 14.6% (p < 0.01). While international collaborations increased over time, the number of articles with no authors affiliated to Syrian institutions overtook those with at least one author affiliation to a Syrian institution for the first time in 2015. CONCLUSION: To our knowledge, this is the first study to examine the impact of armed conflict on health scholarship in Syria. The Syrian conflict was associated with a change in the rates, types, and topics of the health-related articles, and authors' affiliations. Our findings have implications for the prioritization of research funding, development of inclusive research collaborations, and promoting the ethics of conducting research in complex humanitarian settings.