The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip.

BACKGROUND: Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. METHODS: A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. RESULTS: The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. CONCLUSIONS: This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon.

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war. Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis. Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living. Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Responding to the Humanitarian Crisis in Gaza: Damned if You do Damned if You don't!

Palestine, since 1948, has endured frequent military occupations and uprisings, intifadas, in a limited geographic area that has resulted in one of the worst humanitarian crises. The prolonged nature of this military occupation has created a biosphere of war that is uninhabitable, whereby Palestinians suffer from physical, psychological, and social wounds. Israel also imposed restrictive measures in Gaza, making it difficult for Palestinians to obtain permits to work and travel throughout Palestine. Israel continued to intensify the restrictions on Gaza, reaching a blockade on the Gaza Strip, which cut off Palestinians from Jerusalem, where hospitals, banks, and vital services are found. This form of permanent siege resulted in a surge in the unemployment rate, poverty, and poor nutritional and wellbeing status. The siege also resulted in the largest open-air prison, as people became stuck between an incomplete life and the absence of total death. The major challenge is that humanitarian interventions, in the case of Gaza, are ineffective, as they are part of the siege framework. This is because any humanitarian aid meant for Gaza needs to be approved by Israel. Thus, when the emergency becomes chronic and humanitarian interventions become part of the siege framework, how can Gaza rebuild its health capacity in a permanent emergency, and to what extent can the humanitarian sector make a change?

Plastic and Maxillofacial Training for War-Zones - A Systematic Review.

Study Design: Injuries sustained in war-zones are variable and constantly developing according to the nature of the ongoing conflict. Soft tissue involvement of the extremities, head and neck often necessitates reconstructive expertise. However, current training to manage injuries in such settings is heterogenous. This study involves a systematic review. Objective: To evaluate interventions in place to train Plastic and Maxillofacial surgeons for war-zone environments so that limitations to current training can be addressed. Methods: A literature search of Medline and EMBase was performed using terms relevant to Plastic and Maxillofacial surgery training and war-zone environments. Articles that met the inclusion criteria were scored then educational interventions described in included literature were categorised according to their length, delivery style and training environment. Between-group ANOVA was performed to compare training strategies. Results: 2055 citations were identified through this literature search. Thirty-three studies were included in this analysis. The highest scoring interventions were over an extended time-frame with an action-oriented training approach, using simulation or actual patients. Core competencies addressed by these strategies included technical and non-technical skills necessary when working in war-zone type settings. Conclusions: Surgical rotations in trauma centers and areas of civil strife, together with didactic courses are valuable strategies to train surgeons for war-zones. These opportunities must be readily available globally and be targeted to the surgical needs of the local population, anticipating the types of combat injuries that often occur in these environments.

Systematic review of the microbiology of osteomyelitis associated with war injuries in the Middle East and North Africa.

Osteomyelitis is a serious complication associated with war-related limb injuries requiring complicated treatment regimens and management. Few reports have been published from the Middle-East and North-Africa regions about the microbial aetiology of osteomyelitis caused by war injuries. The aim of this review is to collect published data about the microbiology of osteomyelitis in war-related injuries in the region and to derive targeted treatment regimens to manage these serious and limb-threatening infections. A thorough literature search was done using six search engines for pertinent articles. Articles with a minimum of five cases of osteomyelitis from war wounds, citation of microbial aetiology and mention of the timing of cultures obtained in relation to injury were included. Nine studies that met the eligibility criteria were included, involving 1644 patients and a total of 2332 cultures. Gram-negative bacteria were isolated from 1184 cultures, and Gram-positive bacteria were identified from 1148 cultures. Antibiotic coverage should be tailored for Gram-negative organisms in the early stages and Gram-positives in the chronic phase, respectively, with broader coverage reserved for critically ill patients. There is a dire need for further and larger studies about osteomyelitis from war injuries for targeted treatment.

Simulation Training Approach for Cleft Lip and Palate Repair in Low-Income Countries.

BACKGROUND: During periods of civil strife, the need for trauma care and lack of sufficient cleft surgeons causes an increase in children left untreated with cleft lip and palate deformities. During the Syrian war, some cleft care was provided through visiting charities, with surgeries performed both in Syria and neighboring countries. There is a need to increase the number of adequately trained cleft surgeons available in such regions so that care can be achieved beyond mission trips. METHODOLOGY: Cleft lip and palate repair workshops were delivered to 50 doctors in Syria. Pre-workshop, trainees received supplementary learning material. During the workshop, attendees received didactic teaching followed by 2 simulation sessions. Pre- and post-workshop, attendees completed questionnaires regarding their confidence and ability to perform cleft lip and palate repair. RESULTS: Pre-workshop, 96% of workshop attendees had never independently performed cleft lip repair while 100% of attendees had not previously performed cleft palate repair. The mean pre-workshop confidence score was 2.452. Post-workshop, the mean confidence score was 3.503. Confidence rating scores significantly improved (P < .001). CONCLUSION: The workshop delivered in Syria, together with this cleft lip and palate simulator provides an effective training tool that may support surgical training globally, particularly those in low-income countries. Further support is needed by charity organizations to ensure the continued delivery of such training.

Everyone Is Harmed When Clinicians Aren't Prepared.

War and conflict are now common, lingering like an endemic disease in most countries of the Global South. Population displacement, infectious disease outbreaks, food and water shortages, damage to infrastructure, anxiety, and posttraumatic stress are among the phenomena to which clinicians are expected to respond as professionals. Yet curricula in health professions do not prepare trainees to cultivate the skills needed to develop intervention pathways to meet the needs of populations in conflict zones. This article argues that decolonization of curricula in health professions is key to preparing clinicians to respond with care and competence to vulnerabilities and disease burden exacerbated by conflict.

What is the role of incisional vacuum therapy in challenging spinal wounds? A single centre experience.

OBJECTIVE: A surgical approach to the treatment of spinal defects and disorders has become more common because of the medical and technological advancements achieved in the last decade. This rising trend in spinal surgeries is associated with adverse events, most notably wound complications. From its introduction, negative pressure wound therapy (NPWT) has proved to be essential in the management of complex wounds and in speeding up wound recovery. The aim of this study is to investigate the use of incisional NPWT in patients undergoing spinal surgery and its role in the prevention of wound complications. METHOD: This study is a retrospective medical chart review conducted on patients who underwent spinal surgery and received incisional vacuum therapy as part of their treatment. The apparatus was applied intraoperatively following the spinal surgery for all patients included in this study. All surgical procedures were conducted between September 2019 and May 2020. Data entry and analysis were performed between September and October 2020. RESULTS: A total of five patients' records were reviewed. In our healthcare centre, three patients developed seroma, one developed haematoma, four required revision surgery and one patient required re-operation. There was no wound dehiscence and none of the wounds became infected. Mean length of hospital stay was 11.2 days (standard deviation (SD): 9.5 days) and mean operation time was 333 minutes (SD: 86.4 minutes). CONCLUSION: There is a scarcity of data on the role of incisional vacuum therapy in the prevention of wound complications associated with spine surgeries. Our study showed promising results for the use of incisional NPWT in the management of spinal wounds. Further research is required in order to enhance wound care by exploiting this potentially beneficial approach.

The socioeconomic burden of antibiotic resistance in conflict-affected settings and refugee hosting countries: a systematic scoping review.

BACKGROUND: Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review. METHODS: A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline. RESULTS: The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries. CONCLUSION: This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.

The multidimensional burden of COVID-19 on Syrian refugees in Lebanon.

BACKGROUND: The COVID-19 pandemic is a global phenomenon that is spreading at an alarmingly high rate, increasing morbidity, mortality as well as affecting the global economy, education sector and psychological well-being of the public. Measures, taken to mitigate the spread of the virus during this pandemic, created challenges to humanitarian communities preventing them from carrying out their responsibilities towards vulnerable populations. The aim of this study is to assess the burden of COVID-19 by looking at the current living conditions, examining available services provided, and identifying the economic and health challenges of Syrian refugee families living in Lebanon. METHODS: This is a cross-sectional study conducted on 129 Syrian refugee families living in Lebanon during the COVID-19 pandemic. All participants provided consent prior to completion of the standardized questionnaire. RESULTS: During the pandemic, 79% of breadwinners lost their jobs; of those who kept their jobs, 68% had their wages reduced. None of the families was capable of affording all of their basic needs with 55% only partially affording and 45% not able to afford. Thirty percent of Syrian refugee families did not receive support from organizations during the pandemic reflecting the impact of this crisis on humanitarian organizations. Education was also affected as 70% of children did not continue their education at home. Stress and anxiety were the most commonly reported behavioral changes among both children and adults. CONCLUSIONS: The impact of this crisis is multidimensional affecting the economy, global health and education level of the public. Measures should be taken to lessen the detrimental effect of this crisis on the community as a whole and on vulnerable populations in particular.

The Epidemiology of Stunted Growth in Refugee Patients with Chronic Burn Injuries.

The aim of this study is to identify the prevalence of stunted growth in Syrian refugee children with chronic burn injuries and to compare it to other children (±burn) of similar socioeconomic status. This is a retrospective medical chart review conducted on 142 Syrian refugee children (≤18 years of age) who have sustained war-related and nonwar-related chronic burn injuries between 2014 and 2020. Stunted growth was measured using the height-for-age z score. The majority of burn injuries were among children below 5 years of age. The prevalence of stunting was 9.2% in our sample, with an overall mean z-score of -0.491 (SD = 1.1). There was no statistically significant difference in z-scores between males and females. The majority of stunted patients are those who sustain their burn injuries at an early age. Early management of burn injuries is key in preventing adverse outcomes associated with stunting. Further research, planning, funding, and targeted interventions are required by stakeholders to alleviate the burden of stunting in the pediatric refugee population, along with the health and economic consequences that it entails.

The Pericranial Flap as a Salvage Procedure in Pediatric Neurosurgical Complications.

ABSTRACT: The pericranium is a vascularized structure that can be used for the treatment of complex scalp and skull defects. It is also utilized as a prophylactic measure to prevent wound complications in high-risk patients. In this study, we looked at the use of the pericranial flap in pediatric patients. A retrospective chart review was done in the American University of Beirut Medical Center from February 2010 to 2020. Ten pediatric patients were identified who required either prophylactic pericranial flap (n  =  3) or for treatment of a chronic draining sinus (n =  7). Patients were followed up for an average of 23 days. There were no cases of infection, hematoma, seroma, or meningitis. Only 1 case developed dehiscence of the skin. It was managed conservatively and healed within 2 weeks. The pericranial flap is a workhorse flap for scalp and skull reconstruction, with no donor site morbidity and thus should always be considered.

Ecology of War, Health Research and Knowledge Subjugation: Insights from the Middle East and North Africa Region.

In an ecology of war, as experienced in the Middle East and North Africa region, health research faces several interrelated challenges: de-prioritization, paucity in the generation of reliable data, and its securitization. This directly contributes to local knowledge subjugation and research waste as local narratives are disqualified in favor of institutionalized and privileged global unitary knowledge. Huge efforts that require political will and commitment, coupled with multidisciplinary approaches and sustainable collaborations between researchers and humanitarian workers at the local, regional and global levels, are indispensable to give more space for the abandoned local knowledge in order to have contextualized and more impactful interventions where more lives are saved.

Assessing the capacity for conflict and health research in Lebanon: a qualitative study.

BACKGROUND: Conflicts pose new challenges for health systems, requiring rapid and practical approaches to meet emerging needs on the ground. Lebanon has been highly influenced by surrounding conflicts in the Middle East and North Africa (MENA) region, especially the Syrian crisis. Strengthening research capacity to collect evidence on conflict in the MENA region and beyond is crucial to inform healthcare policy and practice. For targeted capacity strengthening interventions, the main objective of this paper is to present key findings of a needs assessment of conflict and health research in Lebanon. This will support recent efforts to scale up context-specific policies, interventions to strengthen the country's health system, and research capacity. METHODS: The study is based on 30 semi-structured interviews with key informants such as specialist academics, humanitarian workers and public sector officials. RESULTS: Despite being ranked third in the number of publications on biomedical and health research per capita in MENA and in hosting reputable universities which are considered central academic hubs in the region, lack of nationwide research culture, insufficient funding and limited access to data were reported to be major challenges for health researchers in Lebanon. Even with the ongoing efforts, poor impact of research on policy continues to be a persistent gap. Large disparities in research capacities and taught skills were reported between different universities in Lebanon, with a disproportionate emphasis on quantitative over qualitative skills. Most medical students are not trained to conduct research or to practice in conflict settings. Concerns were also expressed regarding the ethics of research conducted, specifically by local non-governmental organizations. RECOMMENDATIONS: To conduct contextualized trainings on research skills with a stronger focus on qualitative approaches, medical practice, and ethical research in conflict. To better involve policymakers in designing research agendas by organizing multiple stakeholder meetings. CONCLUSION: The study indicates that health research in Lebanon is characterized by considerable strengths in terms of human capital and research capacities of certain universities. However, the Lebanese research infrastructure needs further development in terms of ensuring sustainable funding, providing access to data, teaching qualitative research skills, conducting ethical and multidisciplinary research, and promoting cross-sectoral knowledge transfer.

Prevalence of Stunting in Syrian Refugee Children With Cleft Lip and/or Cleft Palate in Time of Crisis: A Call for Intervention.

OBJECTIVE: Our study aims to compare the prevalence of stunted growth in Syrian refugee children with cleft lip and/or palate (CL±CP) to other children with CL±CP of similar socioeconomic status. DESIGN: A retrospective medical chart review. SETTING: Center for Cleft and Craniofacial Surgery at a tertiary care hospital in Lebanon in the period between January 2013 and May 2019. PATIENTS, PARTICIPANTS: One hundred three Syrian refugee children and 70 Lebanese children <18 years of low socioeconomic status who have CL, CP, or both. INTERVENTIONS: These patients underwent cleft repair surgeries at our center. MAIN OUTCOME MEASURE(S): Stunted growth measured by calculating the height-for-age z-score (HAZ). RESULTS: Using a confidence interval of 95%, the prevalence of stunting is significantly higher among Syrian refugees (P < .003). The prevalence of stunting and age of presentation were positively correlated (P < .02). There was no difference in stunting between patients with CP and CL (P < .746). There was no difference in stunting between genders. CONCLUSIONS: The majority of Syrian refugee patients with CL±CP fall on the malnourished side of the nutritional spectrum as reflected by the high percentage of stunting as well as a mean of -1 for the HAZ.

The economic burden of cancer care for Syrian refugees: a population-based modelling study.

BACKGROUND: Cancer represents a substantial health burden for refugees and host countries. However, no reliable data on the costs of cancer care for refugees are available, which limits the planning of official development assistance in humanitarian settings. We aimed to model the direct costs of cancer care among Syrian refugee populations residing in Jordan, Lebanon, and Turkey. METHODS: In this population-based modelling study, direct cost per capita and per incident case for cancer care were estimated using generalised linear models, informed by a representative dataset of cancer costs drawn from 27 EU countries. A range of regression specifications were tested, in which cancer costs were modelled using different independent variables: gross domestic product (GDP) per capita, crude or age-standardised incidence, crude or age-standardised mortality, and total host country population size. Models were compared using the Akaike information criterion. Total cancer care costs for Syrian refugees in Jordan, Lebanon, and Turkey were calculated by multiplying the estimated direct cancer care costs (per capita) by the total number of Syrian refugees, or by multiplying the estimated direct cancer costs (per incident case [crude or age-standardised]) by the number of incident cancer cases in Syrian refugee populations. All costs are expressed in 2017 euros (€). FINDINGS: Total cancer care costs for all 4·74 million Syrian refugees in Jordan, Lebanon, and Turkey in 2017 were estimated to be €140·23 million using the cost per capita approach, €79·02 million using the age-standardised incidence approach, and €33·68 million using the crude incidence approach. Under the lowest estimation, and with GDP and total country population as model predictors, the financial burden of cancer care was highest for Turkey (€25·18 million), followed by Lebanon (€6·40 million), and then Jordan (€2·09 million). INTERPRETATION: Cancer among the Syrian refugee population represents a substantial financial burden for host countries and humanitarian agencies, such as the UN Refugee Agency. New ways to provide financial assistance need to be found and must be coupled with clear, prioritised pathways and models of care for refugees with cancer. FUNDING: UK Research and Innovation Global Challenges Research Fund: Research for Health in Conflict-Middle East and North Africa region (R4HC-MENA).

Strengthening capacity for cancer research in conflict settings: key informant insights from the Middle East.

BACKGROUND: Management of cancer in the Middle East and North Africa (MENA) region is accompanied by multiple challenges including heterogeneous access to early detection and treatment options and limited implementation of national cancer control plans. Furthermore, protracted armed conflicts across the region have had dramatic effects, including disruption of healthcare systems and the migration of healthcare professionals. Strengthening capacity for cancer research has been identified as a key intervention to correct data poverty, inform policy, manage limited resources and improve health outcomes. OBJECTIVE: The main objective of this study is to gain insights into the landscape, barriers and enablers of cancer training, research and care in the MENA region. METHOD: We utilised purposive sampling to interview 16 key informants from a diverse academic, medical and research background originating from countries affected by conflicts, such as Lebanon, and from active conflict zones including Iraq and Syria. RESULTS: The themes that emerged from the interviews focused on the barriers to cancer care, barriers to cancer research and training, strengths and importance of cancer research and training recommendations. The detrimental effect of conflict on cancer provision and research was a cross-cutting sub-theme disrupting cancer care provision and research due to unsafe environments, fragmented facilities, absence of drugs and migration of personnel. When asked about perceived optimal training format for cancer research, most informants recommended a post-graduate, face-to-face training focusing on cancer research methods and concepts. CONCLUSION: This study offers a unique insight into the barriers affecting cancer research and capacity-strengthening priorities from oncologists and researchers working in conflict-affected areas of the MENA region. These data will form the base for future capacity-strengthening initiatives addressing specific regional challenges.