Breast cancer quality of care in Syria: screening, diagnosis, and staging.

BACKGROUND: The Syrian decade-long war has severely affected the healthcare system, including almost vanishing cancer screening practices, war-destroyed medical facilities, and lack of continuous medical education. This study aims to present data on the affected breast cancer screening practices, methods of diagnosis, and stages distribution in Syria. METHODS: Medical charts of breast cancer patients treated at Albairouni University Hospital between January 2019 and May 2022 were retrospectively reviewed. Eligible patients were women diagnosed with primary breast cancer. Exclusion criteria included females receiving neoadjuvant chemotherapy and incomplete charts. Data regarding the patient's age, city of residence, marital status, number of children, smoking habits, method of diagnosis, tumor size (T), lymph nodes (N), and distal metastasis (M) were collected. We used Microsoft Excel and Statistical Package for the Social Sciences (SPSS) to analyze data. Descriptive methodology (frequency [n], percentage) was used. RESULTS: The number of charts reviewed was 4,500. The number of remaining charts after applying the exclusion criteria was 2,367. The mean age was 51.8 (SD = 11.3). More than half of the patients (58.3%) came from outside Damascus -where the hospital is located- and its suburbs. Less than 5% of the population detected cancer by screening mammography. Only 32.4% of patients were diagnosed by a biopsy, while surgical procedures (lumpectomy and mastectomy) were used to diagnose 64.8% of the population. At the time of diagnosis, only 8% of patients presented with local-stage disease (stages 0 & I), 73% had a regional disease (stages II & III), and 19% had metastatic breast cancer (stage IV). CONCLUSION: Our retrospective chart review analysis is the first comprehensive review in Syria for female breast cancer patients. We found a significant low percentage of patients diagnosed based on a screening mammogram, much higher surgical biopsies rather than a simple imaging-guided biopsy, and much lower than the national average of early-stage disease. Our alarming findings can serve as the base for future strategies to raise the population's health awareness, create more serious national screening campaigns, and adopt a multidisciplinary approach to the disease in Syria.

Prolonged war reverses carbon emissions from an early decline to a late increase - Evidence from Syria.

Given that war can have a serious impact on the climate, this article is aimed to discuss the impact of warfare on carbon emissions by examining changes in CO2 before and during the war in Syria based on the kaya constant equation and the LMDI decomposition method. In the decade before the war, population was the largest contributor, making up 32.64% of the total 51.02% increase in carbon emissions. The only factor that offsetting carbon emissions was energy intensity, making a 22.30% curbing effect. In the early stage of the war, carbon emissions decreased by 56.38%, in which per capita GDP contributed 37.55% of the total CO2 decline. Carbon intensive of energy was the only factor promoting the carbon increase with a 4.67% contribution. In the late war, carbon emissions start to resume slow increase with energy intensity and economy turning negative to positive. It can be speculated that the impact of the war on CO2 emissions: (i) in the first years of the war, CO2 would drop significantly at the cost of significant population decline and economic recession, the least desirable and the worst way to reduce carbon emissions. (ii) if evolves into a prolonged war, it would reverse carbon emissions from decline to increase, although the population and the economy are both falling. This research, therefore contends that once war is triggered, there is no other solution to prevent this worst-case scenario of Population Decline - Economic Recession - Increased Carbon Emissions from happening, unless the war is stopped immediately.

Pediatric cranial injuries: the Syrian civil war.

OBJECTIVE: Kilis, Turkey, a city near Aleppo, Afrin and Azez, Syria, where conflicts are intense, is one of the cities that provides initial emergency treatment. The aim in this study was to analyze the clinical and radiological characteristics of and treatment methods and results in pediatric patients admitted to Kilis State Hospital with cranial gunshot wounds obtained during the Syrian war. MATERIALS AND METHODS: In this study, 62 pediatric patients treated for cranial gunshot wounds obtained during the civil war in Syria between December 2011 and May 2017 at the Neurosurgery Clinic of Kilis State Hospital on the Turkish side of the Turkey-Syria border were retrospectively analyzed. RESULTS: A total of 62 patients were evaluated. Forty-six (74.2%) patients were male and 16 (25.8%) were female. The mean age of the patients was 11.4 ± 6.3 (range: 1 month to 18 years) years. The mean Glasgow coma scale (GCS) score was 7.2 ± 3.8. Surgical treatment was performed in 36 patients (58.1%). Six (16.7%) of the surgically treated patients and 15 (57.7%) of the conservatively treated patients died (p < 0.001). While good clinical results (GOS4-5) were obtained in 24 (66.7%) patients who underwent surgical treatment, only 8 (30.8%) patients who underwent conservative treatment had good clinical results (GOS 4-5). The treatment results in patients with a GCS score of between 9 and 15 who were treated with both methods were significantly better (GOS score of 4-5) (p < 0.05) than those in patients with a GCS score of 8 or lower. The treatment results of the patients aged 10-18 years were significantly better than those of patients aged 0-9 years (GOS 4-5) (p < 0.05). CONCLUSION: In this study, the GCS score on admission was a significant predictive factor for survival in pediatric patients with cranial gunshot wounds. The outcomes of patients aged 0-9 years with severe neurological damage were worse than those in patients aged 10-18 years. On the basis of the analyses of the treatment methods and GCS and GOS scores of the patients in our study, we conclude that surgical treatment should be performed immediately in all patients with radiological indications and a GCS score higher than 3. Additionally, we conclude that child soldiers exist in Syria.

Public health consequences after ten years of the Syrian crisis: a literature review.

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID - 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Assessing the impact of the Lebanese National Polio Immunization Campaign using a population-based computational model.

BACKGROUND: After the re-introduction of poliovirus to Syria in 2013, Lebanon was considered at high transmission risk due to its proximity to Syria and the high number of Syrian refugees. However, after a large-scale national immunization initiative, Lebanon was able to prevent a potential outbreak of polio among nationals and refugees. In this work, we used a computational individual-simulation model to assess the risk of poliovirus threat to Lebanon prior and after the immunization campaign and to quantitatively assess the healthcare impact of the campaign and the required standards that need to be maintained nationally to prevent a future outbreak. METHODS: Acute poliomyelitis surveillance in Lebanon was along with the design and coverage rate of the recent national polio immunization campaign were reviewed from the records of the Lebanese Ministry of Public Health. Lebanese population demographics including Syrian and Palestinian refugees were reviewed to design individual-based models that predicts the consequences of polio spread to Lebanon and evaluate the outcome of immunization campaigns. The model takes into account geographic, demographic and health-related features. RESULTS: Our simulations confirmed the high risk of polio outbreaks in Lebanon within 10 days of case introduction prior to the immunization campaign, and showed that the current immunization campaign significantly reduced the speed of the infection in the event poliomyelitis cases enter the country. A minimum of 90% national immunization coverage was found to be required to prevent exponential propagation of potential transmission. CONCLUSIONS: Both surveillance and immunization efforts should be maintained at high standards in Lebanon and other countries in the area to detect and limit any potential outbreak. The use of computational population simulation models can provide a quantitative approach to assess the impact of immunization campaigns and the burden of infectious diseases even in the context of population migration.

Psychological distress among medical students in conflicts: a cross-sectional study from Syria.

BACKGROUND: Medical education can be a time of great psychological distress for students. The ongoing Syrian conflict represents an additional factor potentially contributing to poor mental health among medical students. Studies revealed high levels of psychological distress among Syrians. We aimed to investigate the prevalence and risk factors of depression, anxiety and stress among medical students at Damascus University during this period of war. METHODS: A cross-sectional study was conducted using the Depression, Anxiety and Stress Scale (DASS-21) in addition to questions about demographic and financial characteristics, and questions about the effects of the ongoing war on the participants' lives. RESULTS: 350 students were included. Prevalence of depression, anxiety and stress was 60.6%, 35.1%, and 52.6%, respectively. Depression was more likely in females and those with "intermediate" or "insufficient" personal income. Anxiety was more likely in females and those with "insufficient" personal income while less likely in fifth- and sixth-year compared to second-year students. Stress was lower in fifth-year compared to second-year students and higher in "insufficient" personal income compared to "sufficient" personal income. CONCLUSIONS: We concluded that Syrian medical students suffer from high rates of psychological distress. Females, second-year students, and those with "insufficient" personal income were the most affected. Students' perception of their own financial status, rather than the financial status per se was related to psychological distress. There was no evidence of a direct relationship between the ongoing conflict and psychological distress. Further investigations of causes and consequences of poor mental health in Syrian medical students are essential.

Impact of Syrian Conflict on the Oral Health of Adolescents: A Cross-Sectional Study.

BACKGROUND: The Syrian conflict has had a negative impact on the psychological and overall health of adolescents. However, little is known about the oral health of those who are internally displaced. AIMS: The purpose of this study was to investigate the relationship between mental health state and self-reported oral health and habits in Syrian adolescents. METHODS: A total of 99 adolescents living in Syria were included in the study. The participants were given four questionnaires: the International Trauma Questionnaire (ITQ), the Depression Anxiety Stress Scale-21 (DASS-21), the Epworth Sleepiness Scale (ESS), and the World Health Organization (WHO) Oral Health Questionnaire for Children (2013). The relationship between self-reported oral and mental health was evaluated. RESULTS: Adolescents with symptoms of mental disturbances or abnormal sleep conditions were statistically more likely to self-report the health of their teeth and gums as below average, less likely to brush their teeth regularly, and reported more frequent smoking (p<0.05). Moreover, symptoms of mental disturbances and abnormal sleep conditions were statistically more likely in adolescents living in rural areas and whose parents' education did not exceed secondary school (p<0.05). CONCLUSION: Syrian adolescents reported mental disturbances, which were reflected in their poor oral health and habits. These findings confirm the need for psychiatric and oral health care programs for Syrians who remain in areas of conflict.

The lived experience of patients with conflict associated injuries whose wounds are affected by antimicrobial resistant organisms: a qualitative study from northwest Syria.

INTRODUCTION: For those with severe conflict-associated wounds which are affected by antimicrobial resistant (AMR) organisms, health systems during protracted conflict are often ill-equipped to respond to their needs. In this study, our aim is to explore the experiences of those with conflict-associated wounds whose wounds have been infected with AMR bacteria and who reside in northwest Syria (NWS). This is with a view to understanding the challenges they face and how the health and humanitarian system can better respond to their needs. METHODS: A qualitative research methodology where in-depth interviews were conducted with patients who are known to have AMR organisms infecting conflict-associated wounds was used. Patients were recruited from Bab Al-Hawa hospital in NWS based on pre-set inclusion criteria. They were invited to participate in remote interviews due to the ongoing COVID-19 pandemic. Interviews were conducted during January and February 2021 and transcribed in Arabic before thematic analysis was undertaken to identify key themes and subthemes. RESULTS: 14 in-depth interviews were conducted of which 12 were with men. The age range was 20-49 years. We categorised the findings into 6 themes: i. those related to the mechanism of injury, ii, the impact of the conflict on health system accessibility, iii. experiences of immediate inpatient management, iv. the experience of outpatient and home management, v. the current impact of the injury on participants, and vi. participant perspectives around improving healthcare access for those with conflict-related wounds affected by AMR organisms. Important findings relate to the quality and capacity for both immediate and longer-term care and the psychosocial and socioeconomic impacts of the injuries which many of the participants continue to grapple with. CONCLUSION: This is the first exploration through qualitative research of the experiences of those with conflict-affected wounds which are infected with AMR organisms in NWS. Emerging themes as told by participants can help stakeholders, including policy makers, humanitarian organisations and those involved with health system planning in NWS consider gaps in current and future care needs (including livelihood opportunities) for this vulnerable group.

The Impact of the Syrian Civil War on One Department in an Israeli Hospital.

During the Syrian civil war, Syrian refugees crossed the Israeli border to receive medical treatment. During this time, Galilee Medical Center (GMC) became the main center for multidisciplinary treatment of these war-wounded patients. This retrospective study compares the demographics of local Israeli and refugee Syrian patients, as well as the volume and types of procedures each group received over a 5-year period. From January 2013 to December 2017, 963 unique patients underwent 1,751 procedures in the GMC Plastic Surgery Department. Of these patients, 176 were Syrian-including 42 children-and 787 were Israeli. These groups underwent 393 and 1,358 procedures, respectively, for a procedure-per-patient ratio of 2.23 versus 1.72, respectively. On average, Syrian patients tended to be younger than Israeli patients (23.6 vs. 49.25 years), had longer median hospitalization time (50 vs. 8 days), longer median operative times (102 vs. 85 minutes), and higher incidence of infection with multidrug-resistant bacteria (52.2 vs. 5.8%). Further, Syrian patients had more trauma-related procedures, such as skin grafts, wound debridement, and microsurgery, than Israeli patients. Through this process, GMC's plastic surgery department gained unprecedented exposure to a variety of complex procedures.

Ageism, an invisible social determinant of health for older Syrian refugees in Lebanon: a service providers' perspective.

BACKGROUND: Older refugees face particular challenges because their health and social needs are largely overlooked in humanitarian programmes, policies and research. The few studies available have shown that older refugees suffer from a high prevalence of non-communicable diseases, including mental health problems, increased social isolation and poverty, and difficulty accessing health and social services. This article aims to provide further in-depth understanding of how service providers perceive health and social challenges of older Syrian refugees living in Lebanon by focusing on (1) their health and social challenges; (2) the available and lacking services; (3) participation; and (4) policy recommendations to improve services. METHODS: This study is based on a qualitative research approach. Fifteen semi-structured interviews were conducted with health and social workers providing services to older Syrian refugees living in Lebanon. All interviews were digitally recorded, transcribed, coded and analysed using thematic analysis. RESULTS: Study results clearly show that older refugees face increased marginalisation and neglect, mainly because of ageism. Ageism experienced at aid agency, family and individual levels, impacts negatively on older refugees. They have a sense of social isolation, neglect and feel they are a burden, consequently their social participation decreases, impacting negatively on their physical and mental health as well as their access to social and health care. Linked to experiences of ageism, study participants noted: (1) high prevalence rates of non-communicable diseases and mental health problems; (2) difficulties accessing care, with inadequate services to support the needs of older refugees; and (3) policy recommendations calling for an holistic approach to aid which takes into consideration the specific needs of older refugees as well as their capabilities. CONCLUDING REMARKS: Ageism is a key determinant of health which negatively impacts the physical, mental and social health, and wellbeing of older Syrian refugees. It pushes them to the margins of society where they are left behind by the humanitarian response, policy makers and researchers, as well as their communities and families. To mitigate this situation, this article calls for directly addressing ageism on social, service and policy levels.

Design and Adoption of Low-Cost Point-of-Care Diagnostic Devices: Syrian Case.

Civil wars produce immense humanitarian crises, causing millions of individuals to seek refuge in other countries. The rate of disease prevalence has inclined among the refugees, increasing the cost of healthcare. Complex medical conditions and high numbers of patients at healthcare centers overwhelm the healthcare system and delay diagnosis and treatment. Point-of-care (PoC) testing can provide efficient solutions to high equipment cost, late diagnosis, and low accessibility of healthcare services. However, the development of PoC devices in developing countries is challenged by several barriers. Such PoC devices may not be adopted due to prejudices about new technologies and the need for special training to use some of these devices. Here, we investigated the concerns of end users regarding PoC devices by surveying healthcare workers and doctors. The tendency to adopt PoC device changes is based on demographic factors such as work sector, education, and technology experience. The most apparent concern about PoC devices was issues regarding low accuracy, according to the surveyed clinicians.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017.

OBJECTIVES: Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality. METHODS: We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017. RESULTS: Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%). CONCLUSIONS: The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

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.

Renal Transplantation in Areas of Armed Conflict.

Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease. KT recipients are considered a vulnerable patient population because of their dependence on expensive immunosuppression drugs from the time of transplantation until graft failure. Management of KT recipients is complex, and therefore requires a sustainable infrastructure that is equipped to provide reliable medical care and continued access to immunosuppressive drugs. This structure, especially in third-world countries, relies on elements that may be easily disrupted during times of armed conflict. This results in a decrease in KT rate and interruption in access to immunosuppressive drugs, which may lead to poor KT outcomes. This review summarizes our experiences and reviews other literature published regarding the status and management of KT recipients in Syrians as an example of an armed conflict zone.

Comparison of retinopathy of prematurity incidence between Turkish citizens and Syrian refugees.

Purpose: More than 3.5 million Syrians came to Turkey seeking refuge and over 470,000 Syrian infants were born since the start of the civil war in 2011. Our aim is to compare the incidence of retinopathy of prematurity (ROP) between Syrian refugees and Turkish citizens. Methods: This multicenter, retrospective study was conducted in Gaziantep University, Faculty of Medicine and Gaziantep Children's Hospital in Turkey. We included the data of patients who were screened for ROP between July 2015 and June 2017. Results: The above-mentioned data of 906 Turkish infants and 199 Syrian infants were included in this study. Mean gestational ages (GAs) were (32.9 ± 2.7) and (32.1 ± 2.8) weeks as well as mean birth weights (BWs) were (1937.5 ± 582.9) and (1696.8 ± 485.5) g, in Turkish and Syrian infants, respectively. GA and BW were significantly lower in Syrian infants while time spent in neonatal intensive care unit was significantly higher. The zone of ROP was lower in the Syrian infants in the first examination and for the most advanced ROP (P = 0.001). Any stage ROP was present in 392 (43.3%) and 81 (40.7%) patients in Turkish and Syrian population, respectively (P = 0.490). The number of patients who required treatment for ROP were 95 (10.5%) and 20 (10.1%) in Turkish and Syrian groups, respectively (P = 0.882). Conclusion: Our findings showed that refugee infants had lower BW and GA than native population but the incidence of ROP did not differ between them. Psychosocial stress is an important risk factor for women at reproductive age as it increases the incidence of prematurity. Additional care and psychological support must be given to refugees during perinatal period to decrease the risk of premature birth.

Post Syrian war impact on susceptibility rates and trends in molecular characterization of Enterobacteriaceae.

OBJECTIVE: Describe susceptibility and molecular profiles among Enterobacteriaceae pathogens and to explore if war, among other factors, can affect antimicrobial resistance. METHODS: Clinical isolates from the Study for Monitoring Antimicrobial Resistance Trends associated with urinary tract and intra-abdominal infections between 2011 and 2015 were identified in Lebanon and Jordan. Susceptibility testing and molecular characterization were performed as per standard methods. RESULTS: A total of 1486 Enterobacteriaceae pathogens (including unusual pathogens) were identified. Incidence rates of  extended spectrum ß-lactamases were high with an overall higher prevalence of resistance in Jordan compared with Lebanon. CTX-M-15 was the most prevalent extended spectrum ß-lactamases produced and OXA-48 the most reported carbapenemases subtype. CONCLUSION: Changes in healthcare system due to war could impact regional resistance patterns and which requires a continuous surveillance program and containment plan.