Building referral mechanisms for neonatal care in humanitarian emergency settings: A systematic review.

AIM: During humanitarian emergencies, women and children are particularly vulnerable to health complications and neonatal mortality rates have been shown to rise. Additionally, health cluster partners face challenges in coordinating referrals, both between communities and camps to health facilities and across different levels of health facilities. The purpose of this review was to identify the primary referral needs of neonates during humanitarian emergencies, current gaps and barriers, and effective mechanisms for overcoming these barriers. METHODS: A systematic review was performed using four electronic databases (CINAHL, EMBASE, Medline, and Scopus) between June and August 2019 (PROSPERO registration number CRD42019127705). Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was neonates born during humanitarian emergencies. Studies from high-income countries and prior to 1991 were excluded. The STROBE checklist was used to assess for risk of bias. RESULTS: A total of 11 articles were included in the analysis; these were mainly cross-sectional, field-based studies. The primary needs identified were referrals from homes to health facilities before and during labour, and inter-facility referrals after labour to more specialised services. Some of the main barriers included a lack of roads and infrastructure for transport, staff shortages-especially among more specialised services, and a lack of knowledge among patients for self-referral. Mechanisms for addressing these needs and gaps included providing training for community healthcare workers (CHWs) or traditional birth attendants to identify and address antenatal and post-natal complications; education programmes for pregnant women during the antenatal period; and establishing ambulance services in partnership with local Non-Governmental Organizations. CONCLUSION: This review benefited from a strong consensus among selected studies but was limited in the quality of data and types of data that were reported. Based on the above findings, the following recommendations were compiled: Focus on local capacity-building programmes to address programmes acutely. Recruit CHWs to raise awareness of neonatal complications among pregnant women. Upskill CHWs to provide timely, appropriate and quality care during humanitarian emergencies.

Rebuilding health post-conflict: case studies, reflections and a revised framework.

War and conflict negatively impact all facets of a health system; services cease to function, resources become depleted and any semblance of governance is lost. Following cessation of conflict, the rebuilding process includes a wide array of international and local actors. During this period, stakeholders must contend with various trade-offs, including balancing sustainable outcomes with immediate health needs, introducing health reform measures while also increasing local capacity, and reconciling external assistance with indigenous legitimacy. Compounding these factors are additional challenges, including co-ordination amongst stakeholders, the re-occurrence of conflict and ulterior motives from donors and governments, to name a few. Due to these complexities, the current literature on post-conflict health system development generally examines only one facet of the health system, and only at one point in time. The health system as a whole, and its development across a longer timeline, is rarely attended to. Given these considerations, the present article aims to evaluate health system development in three post-conflict environments over a 12-year timeline. Applying and adapting a framework from Waters et al. (2007, Rehabilitating Health Systems in Post-Conflict Situations. WIDER Research Paper 2007/06. United Nations University. http://hdl.handle.net/10419/63390, accessed 1 February 2018.), health policies and inputs from the post-conflict periods of Afghanistan, Cambodia and Mozambique are assessed against health outputs and other measures. From these findings, we developed a revised framework, which is presented in this article. Overall, these findings contribute post-conflict health system development by evaluating the process holistically and along a timeline, and can be of further use by healthcare managers, policy-makers and other health professionals.

Assessment of the health needs of Syrian refugees in Lebanon and Syria's neighboring countries.

BACKGROUND: Health needs of displaced Syrians in refugee hosting countries have become increasingly complex in light of the protracted Syrian conflict. The primary aim of this study was to identify the primary health needs of displaced Syrians in Iraq, Jordan, Lebanon, Turkey, and Syria. METHODS: A systematic review was performed using 6 electronic databases, and multiple grey literature sources. Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was Syrian individuals displaced due to conflict in Syria and its neighboring countries. The outcomes of interest were health needs (i.e. health problems that can be addressed by health services), gaps in health services, training, and workforce. Studies on mixed refugee populations and Syrians displaced prior to the conflict were excluded. RESULTS: The Lebanon-specific results of the review were validated through two stakeholder roundtable discussions conducted with representatives from primary healthcare centers, non-governmental organizations and humanitarian aid agencies. A total of 63 articles were included in the analysis. Mental health and women's health were identified as the greatest health needs in the region. The most common health problems were Non-communicable diseases in Jordan, women's health in Lebanon and mental health in Turkey. Studies addressing gaps in services found the highest gap in general healthcare services, followed by women's health, mental health, and vaccinations. Sub-optimal training and availability of health workers was also noted particularly in Syria.Results from the stakeholders' discussions in Lebanon showed communicable diseases, women's health and mental health as the main health needs of Syrian refugees in Lebanon. Reported barriers to accessing health services included geographical barriers and lack of necessary awareness and education. CONCLUSION: There is a need for an enhanced synchronized approach in Syria's refugee hosting neighboring countries to reduce the existing gaps in responding to the needs of Syrian refugees, especially in regards to women's health, mental health, and communicable diseases. This mainly includes training of healthcare workers to ensure a skilled workforce and community-based efforts to overcome barriers to access, including lack of knowledge and awareness about highly prevalent health conditions.

Exploring the role of locomotor sensitization in the circadian food entrainment pathway.

Food entrainment is the internal mechanism whereby the phase and period of circadian clock genes comes under the control of daily scheduled food availability. Food entrainment allows the body to efficiently realign the internal timing of behavioral and physiological functions such that they anticipate food intake. Food entrainment can occur with or without caloric restriction, as seen with daily schedules of restricted feeding (RF) or restricted treat (RT) that restrict food or treat intake to a single feeding time. However, the extent of clock gene control is more pronounced with caloric restriction, highlighting the role of energy balance in regulating clock genes. Recent studies have implicated dopamine (DA) to be involved in food entrainment and caloric restriction is known to affect dopaminergic pathways to enhance locomotor activity. Since food entrainment results in the development of a distinct behavioral component, called food anticipatory activity (FAA), we examined the role of locomotor sensitization (LS) in food entrainment by 1) observing whether amphetamine (AMPH) sensitization results in enhanced locomotor output of FAA and 2) measuring LS of circadian and non-circadian feeding paradigms to an acute injection of AMPH (AMPH cross-sensitization). Unexpectedly, AMPH sensitization did not show enhancement of FAA. On the contrary, LS did develop with sufficient exposure to RF. LS was present after 2 weeks of RF, but not after 1, 3 or 7 days into RF. When food was returned and rats regain their original body weight at 10-15 days post-RF, LS remained present. LS did not develop to RT, nor to feedings of a non-circadian schedule, e.g. variable restricted feeding (VRF) or variable RT (VRT). Further, when RF was timed to the dark period, LS was observed only when tested at night; RF timed to the light period resulted in LS that was present during day and night. Taken together our results show that LS develops with food entrainment to RF, an effect that is dependent on the chronicity and circadian phase of RF but independent of body weight. Given that LS involves reorganization of DA-regulated motor circuitry, our work provides indirect support for the role of DA in the food entrainment pathway of RF. The findings also suggest differences in neuronal pathways involved in LS from AMPH sensitization and LS from RF.

Glucocorticoids and Stress-Induced Changes in the Expression of PERIOD1 in the Rat Forebrain.

The secretion of glucocorticoids in mammals is under circadian control, but glucocorticoids themselves are also implicated in modulating circadian clock gene expression. We have shown that the expression of the circadian clock protein PER1 in the forebrain is modulated by stress, and that this effect is associated with changes in plasma corticosterone levels, suggesting a possible role for glucocorticoids in the mediation of stress-induced changes in the expression of PER1 in the brain. To study this, we assessed the effects of adrenalectomy and of pretreatment with the glucocorticoid receptor antagonist, mifepristone, on the expression of PER1 in select limbic and hypothalamic regions following acute exposure to a neurogenic stressor, restraint, or a systemic stressor, 2-Deoxy-D-glucose (2DG) in rats. Acute restraint suppressed PER1 expression in the oval nucleus of the bed nucleus of the stria terminalis (BNSTov) and the central nucleus of the amygdala (CEAl), whereas 2DG increased PER1 in both regions. Both stressors increased PER1 expression in the paraventricular (PVN) and dorsomedial (DMH) nuclei of the hypothalamus, and the piriform cortex (Pi). Adrenalectomy and pretreatment with mifepristone reversed the effects of both stressors on PER1 expression in the BNSTov and CEAl, and blocked their effects in the DMH. In contrast, both treatments enhanced the effects of restraint and 2DG on PER1 levels in the PVN. Stress-induced PER1 expression in the Pi was unaffected by either treatment. PER1 expression in the suprachiasmatic nucleus, the master circadian clock, was not altered by either exposure to stress or by the glucocorticoid manipulations. Together, the results demonstrate a key role for glucocorticoid signaling in stress-induced changes in PER1 expression in the brain.

Stress-induced changes in the expression of the clock protein PERIOD1 in the rat limbic forebrain and hypothalamus: role of stress type, time of day, and predictability.

Stressful events can disrupt circadian rhythms in mammals but mechanisms underlying this disruption remain largely unknown. One hypothesis is that stress alters circadian protein expression in the forebrain, leading to functional dysregulation of the brain circadian network and consequent disruption of circadian physiological and behavioral rhythms. Here we characterized the effects of several different stressors on the expression of the core clock protein, PER1 and the activity marker, FOS in select forebrain and hypothalamic nuclei in rats. We found that acute exposure to processive stressors, restraint and forced swim, elevated PER1 and FOS expression in the paraventricular and dorsomedial hypothalamic nuclei and piriform cortex but suppressed PER1 and FOS levels exclusively in the central nucleus of the amygdala (CEAl) and oval nucleus of the bed nucleus of the stria terminalis (BNSTov). Conversely, systemic stressors, interleukin-1ß and 2-Deoxy-D-glucose, increased PER1 and FOS levels in all regions studied, including the CEAl and BNSTov. PER1 levels in the suprachiasmatic nucleus (SCN), the master pacemaker, were unaffected by any of the stress manipulations. The effect of stress on PER1 and FOS was modulated by time of day and, in the case of daily restraint, by predictability. These results demonstrate that the expression of PER1 in the forebrain is modulated by stress, consistent with the hypothesis that PER1 serves as a link between stress and the brain circadian network. Furthermore, the results show that the mechanisms that control PER1 and FOS expression in CEAl and BNSTov are uniquely sensitive to differences in the type of stressor. Finally, the finding that the effect of stress on PER1 parallels its effect on FOS supports the idea that Per1 functions as an immediate-early gene. Our observations point to a novel role for PER1 as a key player in the interface between stress and circadian rhythms.