Patterns of War-Related Traumatic Brain Injuries and Predictors of Mortality Among Civilians During the Syrian Armed Conflict.

BACKGROUND AND OBJECTIVES: High-velocity weapons were used against unshielded civilians during the Syrian armed conflict, leading to a variety of combat-related traumatic brain injuries with high fatality and morbidity. Because of the lack of data in the literature about the management and outcomes of similar injuries, we aimed in this study to characterize shrapnel and gunshot injuries in this vulnerable group and to describe the association between the mechanisms, site, and type of injury and the outcomes. METHODS: This was a single-center retrospective cohort study on new traumatic brain injuries in civilians who presented alive to the neurosurgery department at Damascus Hospital between 2014 and 2017. The analyzed data included the mechanism of injury and its type and site based on computed tomography scans. We also studied the neurological status at admission, the major interventions applied, and outcomes including mortality and neurological deficits at discharge. RESULTS: Shrapnel and gunshot injuries more likely affected the frontal and parietal lobes, respectively. While shrapnel led to injuries in multiple body parts, gunshots led to localized but more severe injuries. Despite that, mortality rates were comparable between the two mechanisms. Injuries to the right parietal and right frontal lobes were more fatal with odds ratios of 2.61 (1.23-5.52) and 2.12 (1.00-4.50), respectively. Moreover, mortality was also linked to the radiological findings of loss of brain material with an odds ratio of 3.73 (1.42-9.81), intracerebral hemorrhage with an odds ratio of 3.60 (1.67-7.80), intraventricular hemorrhage with an odds ratio of 5.49 (1.68-17.95), and subdural hemorrhage with an odds ratio of 6.35 (2.29-17.66). CONCLUSION: The unfortunate nature of the Syrian armed conflict, wherein civilians were targeted during their daily routine, seems to manifest a heightened propensity to affect the parietal lobes, potentially resulting in higher morbidity. Although shrapnel and gunshot injuries showed no significant difference in mortality rates, injuries involving loss of brain tissue and intracranial hemorrhage emerged as independent predictors of mortality.

War-related traumatic brain injuries during the Syrian armed conflict in Damascus 2014-2017: a cohort study and a literature review.

BACKGROUND: The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital. METHODS: We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales. RESULTS: Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores. CONCLUSIONS: This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources.

Medical Research Conduct and Publication during Higher Education in Syria: Attitudes, Barriers, Practices, and Possible Solutions.

Background: The huge workload on doctors especially residents, who are the main health care providers in public hospitals, in addition to the vanishing incomes and lack of personal safety during the decade-long Syrian crisis, led to further hurdles in the focus on research. Postgraduate students in the medical and paramedical fields must conduct original research projects as part of their graduation requirements. However, this does not reflect on research publications coming from Syria. Methods: This is a nation-wide cross-sectional study targeting medical, dental, and pharmacy postgraduate students who are at the phase of planning for their required projects. The questionnaire aimed to capture their attitudes toward research, perceived barriers, and previous research experiences in order to suggest evidence-based recommendations. Results: The sample consisted of 429 residents representing about 22% of the target population. Nearly all the participants had positive opinion toward the important role of medical research and the significance of their participation. Agreement was also clear regarding perceived barriers, including the lack of adequate training and research facility. Seventy-one percent of the participants were not involved in any research before the time of their master theses, less than 13% of them had submitted an article for publication, and less than 5% had submitted more than one paper. Despite that, high-quality internet connectivity and rich English writing skills were associated with further research experiences. Additionally, mentors' support and self-paced learning of research skills had significant positive impact on students' research contributions with odds ratios of 2.04 [[95% Confidence Interval]: 1.02-4.06] and 2.68 [1.48-4.84], respectively. Conclusion: Lack of training and mentorship, in addition to several common barriers to medical research, hampered residents' capacity of conducting and publishing research despite their positive attitudes toward it. Nevertheless, the variance within our sample exposed a promising window for implementing low-cost institutional and individual solutions such as peer-run self-paced training opportunities and long-distance mentoring.

A successful treatment of severe lupoid cutaneous leishmaniasis in an elderly man: a case report.

Lupoid cutaneous leishmaniasis (LCL) is a rare, atypical presentation of cutaneous leishmaniasis (CL). In this report, the authors present the case of a severe LCL in an elderly patient who presented to our dermatology department with severe, painful ulcerated lesion on his midface with cosmetic deformity to his nose. He had a history of CL 3 years ago at the same place. Histopathologic examination showed epidermal and dermal changes with chronic inflammatory infiltrate and no leishmaniasis bodies were detected. He was admitted and treated with systemic glucantime (60 mg/kg) for a month followed by hydroxychloroquine (200 mg twice a day) for another month with favorable outcome. Countries with endemic CL should consider LCL in patients with a history of leishmaniasis and a similar clinical presentation, especially that it could be misdiagnosed with other granulomatous cutaneous conditions, thus leading to cosmetic deformities that can be avoided with early adequate treatment.