Deceased Organ Donation in Syria: Challenges and Solutions.

The first living-donor kidney transplant in Syria was performed 41 years ago; by 2019, 5407 renal transplants had been performed there. Three heart transplants from deceased donors were performed in the late 1980s; cardiac transplant activities have since discontinued. In 2003, a new, national Syrian legislation was enacted authorizing the use of organs from living unrelated donors and from deceased donors. This important law was preceded by another big stride in this regard: the acceptance by the higher Islamic religious authorities in Syria in 2001 of the principle of procurement of organs from deceased donors, provided that consent is given by a first- or second-degree relative. After the enactment of this law, kidney transplant rates increased from 7 per million population in 2002 to 17 per million population in 2007. Kidney transplants performed abroad for Syrian patients declined from 25% in 2002 to < 2% in 2007. Kidney transplants continued at comparable rates until 2010, before the beginning of the political crisis in 2011. Four decades after the first successful kidney transplant in Syria, however, patients needing an organ transplant must rely on living donors only. Moreover, 17 years after the law authorizing use of organs from deceased donors, a program is still not in place in Syria, and additional improvement of the legal framework is needed. The war, limited resources, and lack of public awareness about the importance of organ donation and transplant appear to be major factors inhibiting initiation of a deceased-donor program in Syria. A concerted and ongoing education campaign is needed to increase awareness of organ donation, change negative public attitudes, and gain societal acceptance. Every effort must be made to initiate a deceased-donor program to lessen the burden on living donors and to enable national self-sufficiency in organs for transplant.

The mental, reproductive, and physical health impacts of female children's association with armed forces and groups.

BACKGROUND: Globally, over 300,000 children are being used in armed groups, including young girls some as young as eight years old. These young girls often called female children associated with armed groups and armed forces (CAAFAG), are exposed to high levels of violence and experience extensive abuse. OBJECTIVE: This review aimed to understand the unique health consequences of association on female CAAFAG and the factors associated with their increased health vulnerability. METHODS: The research utilized a review protocol, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The search yielded 449 unique articles, 53 (12 %) of which were included for final analysis to identify health concerns for female CAAFAG. Qualitative literature was also analyzed using thematic analysis to identify factors and experiences associated with female CAAFAG's increased risk of experiencing adverse health outcomes. RESULTS: Internalizing and functional impairment presented unique challenges for females, largely due to their distinct experiences with stigma upon return to communities and returning with children. CONCLUSIONS: Based on the findings of this review, female CAAFAG are at a unique risk for internalizing, functional impairment, and reduced adaptive behaviors. This review also highlights girls' post-conflict experiences of stigma, internal tensions, and returning with a child as modifiable risk factors for poor mental health.

How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country's infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

Acciones de familias de personas con discapacidad víctimas de desplazamiento forzado / Family actions of people with disabilities victims of forced displacement

RESUMEN Objetivo Identificar las acciones concretas y significativas que establecen las familias de personas con discapacidad víctimas de desplazamiento forzado para la (re)construcción de sus redes sociales en la localidad de Ciudad Bolívar de la ciudad de Bogotá. Metodología Estudio cualitativo con enfoque etnográfico. Se realizaron 5 encuentros para el diálogo sentido con un grupo focal de 28 personas víctimas de desplazamiento, entre personas con discapacidad y cuidadores y otros miembros del núcleo familiar, que participan en procesos de inclusión social, habitantes de la localidad de Ciudad Bolívar. La información se registró en diarios de campo, fotografías, videos y material construido por los participantes. Resultados Los resultados muestran que los procesos que permiten la reconstrucción de tejido social están preponderantemente enmarcados en la satisfacción de necesidades concretas como el trabajo, la vivienda, la educación y la alimentación, dejando invisibles los aspectos significativos de la vida de los participantes. Conclusiones La percepción que existe sobre la discapacidad, aunada a la situación de desplazamiento, dibuja un panorama de mayor exclusión social frente a las relaciones de normalidad establecidas por la sociedad. Así mismo, se refleja la invisibilización de la doble situación de fragilidad, dada por los mecanismos de exclusión social a los cuales son sometidas las personas con discapacidad.(AU)

ABSTRACT Objective To identify concrete and meaningful actions that establish the families of people with disabilities victims of forced displacement for (re)construction of social networks in the locality of Ciudad Bolivar in Bogota. Methodology Qualitative study with ethnographic approach. 5 meetings were heald with a focus group of 28 people victims of forced displacement, including people with disabilities and their caregivers and other members of their familes involved in social inclusion processes, inhabitants of the locality of Ciudad Bolivar. Results The results Indicate that the processes that allow the reconstruction of social networks there are framed in satisfaction of specific needs such as work, housing, education and nutrition, leaving significant aspects of participants life invisible. Conclusion Perception that exists about disability and displacement situation increases the social exclusion actions towards this population group by the regular society, which reflects the invisibility of the double situation of fragility.(AU)

Trends and patterns of deaths, injuries and intentional disabilities within the Libyan armed conflict: 2012-2017.

BACKGROUND: The consequences of armed conflicts impose considerable burdens on the economy and health care services, particularly in countries that are not equipped to deal with them, such as in the Middle-East, and North African countries. Little is known about the burden of mortality and injury resulting from the Libyan armed conflict. This study aimed to determine the trends and patterns of mortality, injury and disabilities directly associated with the Libyan armed conflict and analyze the geographic variation within the country during 2012-2107. METHODS: Data on conflict-related deaths, injuries, and disabilities were obtained from the national registry offices. The information included date, place, and demographic information. A questionnaire was also used to obtain information from the affected individuals and their families. National and regional trends of mortality, injury and disabilities were calculated. Spatial analysis was performed using geographic data available on all documented cases to analyze clustering of mortality and injury. RESULTS: A total of 16,126 deaths and 42,633 injuries were recorded with complete information during the Libyan conflict from 2012 till 2017. The overall mortality rate was 2.7/1000 population and injury rate was 7.1/1000. The overall male-to-female ratio of mortality and injury was 4.4:1; 42.3% were single and aged 20-30 years old, and 26.4% were aged 31-40 years. Moreover, injuries resulted in death in 20.1% of cases and disability in 33.5% of the cases. Most of the disabilities were caused by blasts, while gun shots resulted in more deaths. The overall mortality and injury rates were highest during 2015-2017. These rates were highest in the eastern region. Injuries were most concentrated in Benghazi and Derna in the east, followed by Sert and Musrata in the central region. CONCLUSIONS: Conflict-related mortality, injury and disability has inflicted a heavy burden on the Libyan society that may persist for a long time. The rates of these casualties varied in time and place. National, well-planned efforts are needed to address this serious situation and its consequences.

Fundamental patterns and predictions of event size distributions in modern wars and terrorist campaigns.

It is still unknown whether there is some deep structure to modern wars and terrorist campaigns that could, for example, enable reliable prediction of future patterns of violent events. Recent war research focuses on size distributions of violent events, with size defined by the number of people killed in each event. Event size distributions within previously available datasets, for both armed conflicts and for global terrorism as a whole, exhibit extraordinary regularities that transcend specifics of time and place. These distributions have been well modelled by a narrow range of power laws that are, in turn, supported by some theories of violent group dynamics. We show that the predicted event-size patterns emerge broadly in a mass of new event data covering all conflicts in the world from 1989 to 2016. Moreover, there are similar regularities in the events generated by individual terrorist organizations, 1998-2016. The existence of such robust empirical patterns hints at the predictability of size distributions of violent events in future wars. We pursue this prospect using split-sample techniques that help us to make useful out-of-sample predictions. Power-law-based prediction systems outperform lognormal-based systems. We conclude that there is indeed evidence from the existing data that fundamental patterns do exist, and that these can allow prediction of size distribution of events in modern wars and terrorist campaigns.

The Neuropsychological Consequences of Armed Conflicts and Torture.

PURPOSE OF REVIEW: At any point in time, there are hundreds of armed conflicts throughout the world. Neuropsychological disorders are a major cause of morbidity during and after armed conflicts. Conditions such as closed and open head injuries, acute stress disorder, post-traumatic stress disorder, depression, anxiety, and psychosis are prevalent among survivors. Herein, we summarize information on the various forms of torture, the resultant neuropsychological pathology, and treatment strategies to help survivors. RECENT FINDINGS: Strategies to address the needs of individuals who experienced neuropsychological trauma due to armed conflicts and torture include pharmacological and psychological interventions. The former includes antidepressant, antianxiety, and antipsychotic medications. The latter includes narrative exposure therapy and trauma-focused cognitive-behavioral therapy. Neuropsychological disorders are major causes of morbidity among survivors of armed conflicts and torture. Treatment strategies must be affordable, applicable across cultures, and deliverable by individuals who understand the victims' psychosocial and ethnic background.

Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda.

BACKGROUND: Limited knowledge exists to inform the selection and introduction of locally relevant, feasible, and effective mental health interventions in diverse socio-cultural contexts and health systems. We examined stakeholders' perspectives on mental health-related priorities, help-seeking behaviors, and existing resources to guide the development of a maternal mental health component for integration into non-specialized care in Soroti, eastern Uganda. METHODS: We employed rapid ethnographic methods (free listing and ranking; semi-structured interviews; key informant interviews and pile sorting) with community health workers (n = 24), primary health workers (n = 26), perinatal women (n = 24), traditional and religious healers (n = 10), and mental health specialists (n = 9). Interviews were conducted by trained Ateso-speaking interviewers. Two independent teams conducted analyses of interview transcripts following an inductive and thematic approach. Smith's Salience Index was used for analysis of free listing data. RESULTS: When asked about common reasons for visiting health clinics, the most salient responses were malaria, general postnatal care, and husbands being absent. Amongst the free listed items that were identified as mental health problems, the three highest ranked concerns were adeka na aomisio (sickness of thoughts); ipum (epilepsy), and emalaria (malaria). The terms epilepsy and malaria were used in ways that reflected both biomedical and cultural concepts of distress. Sickness of thoughts appeared to overlap substantially with major depression as described in international classification, and was perceived to be caused by unsupportive husbands, intimate partner violence, chronic poverty, and physical illnesses. Reported help-seeking for sickness of thoughts included turning to family and community members for support and consultation, followed by traditional or religious healers and health centers if the problem persisted. CONCLUSION: Our findings add to existing literature that describes 'thinking too much' idioms as cultural concepts of distress with roots in social adversity. In addition to making feasible and effective treatment available, our findings indicate the importance of prevention strategies that address the social determinants of psychological distress for perinatal women in post-conflict low-resource contexts.

To Do No Harm: Humanitarian Aid in Conflict Demands Political Engagement.

Humanitarian aid in settings of conflict has always been fraught with challenges. In the absence of political engagement, however, manipulation by state authorities, however, have the potential to pervert aid intervention to inflict harm. South Sudan exemplifies how states may abuse the humanitarian response to retreat from public responsibility, divert funds to further violence and conflict and dictate the distribution of aid. Recent trends toward nationalist policies in the West that favor disengagement and limited military strikes have the very effect of allowing this abuse to transform humanitarian aid into a tool for harm. (Disaster Med Public Health Preparedness. 2018;12:567-568).

Identifying youth-friendly service practices associated with adolescents' use of reproductive healthcare services in post-conflict Burundi: a cross-sectional study.

BACKGROUND: Very little is known about reproductive health service (RHS) availability and adolescents' use of these services in post-conflict settings. Such information is crucial for targeted community interventions that aim to improve quality delivery of RHS and outcomes in post-conflict settings. The objectives of this study therefore was to examine the density of RHS availability; assess spatial patterns of RHC facilities; and identify youth-friendly practices associated with adolescents' use of services in post-conflict Burundi. METHODS: A cross-sectional survey was conducted from a full census of all facilities (n = 892) and provider interviews in Burundi. Surveyed facilities included all public, private, religious and community association owned-centers and hospitals. At each facility efforts were made to interview the officer-in-charge and a group of his/her staff. We applied both geospatial and non-spatial analyses, to examine the density of RHS availability and density, and to explore the association between youth-friendly practices and adolescents' use of RHS in post-conflict Burundi. RESULTS: High spatial patterning of distances of RHC facilities was observed, with facilities clustered predominantly in districts exhibiting persistent violence. But, use of services remained undeterred. We further found a stronger association between use of RHS and facility and programming characteristics. Community outreach, designated check-in/exam rooms, educational materials (posters, print, and pictures) in waiting rooms, privacy and confidentiality were significantly associated with adolescents' use of RHS across all facility types. Cost was associated with use only at religious facilities and youth involvement at private facilities. No significant association was found between provider characteristics and use of RHS at any facility. CONCLUSIONS: Our findings indicate the need to improve youth-friendly service practices in the provision of RHS to adolescents in Burundi and suggest that current approaches to provider training may not be adequate for improving these vital practices. Our mixed methods approach and results are generalizable to other countries and post-conflict settings. In post-conflict settings, the methods can be used to identify service availability and spatial patterns of RHC facilities to plan for targeted service interventions, to increase demand and uptake of services by youth and young adults.

The Alcohol Use Disorders Identification Test (AUDIT): Exploring the Factor Structure and Cutoff Thresholds in a Representative Post-Conflict Population in Northern Uganda.

AIMS: Despite increased use of the Alcohol Use Disorders Identification Test (AUDIT) in sub-Saharan Africa, few studies have assessed its underlying conceptual framework, and none have done so in post-conflict settings. Further, significant inconsistencies exist between definitions used for problematic consumption. Such is the case in Uganda, facing one of the highest per-capita alcohol consumption levels regionally, which is thought to be hindering rebuilding in the North after two decades of civil war. This study explores the impact of varying designation cutoff thresholds in the AUDIT as well as its conceptual factor structure in a representative sample of the population. METHODS: In all, 1720 Cango Lyec Project participants completed socio-economic and mental health questionnaires, provided blood samples and took the AUDIT. Participant characteristics and consumption designations were compared at AUDIT summary score thresholds of ≥3, ≥5 and ≥8. Confirmatory factor analyses (CFA) explored one-, two- and three-factor level models overall and by sex with relative and absolute fit indicators. RESULTS: There were no significant differences in participant demographic characteristics between thresholds. At higher cutoffs, the test increased in specificity to identify those with hazardous drinking, disordered drinking and suffering from alcohol-related harms. All conceptual models indicated good fit, with three-factor models superior overall and within both sexes. CONCLUSION: In Northern Uganda, a three-factor AUDIT model best explores alcohol use in the population and is appropriate for use in both sexes. Lower cutoff thresholds are recommended to identify those with potentially disordered drinking to best plan effective interventions and treatments. SHORT SUMMARY: A CFA of the AUDIT showed good fit for one-, two, and three-factor models overall and by sex in a representative sample in post-conflict Northern Uganda. A three-plus total AUDIT cutoff score is suggested to screen for hazardous drinking in this or similar populations.

Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties.

Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.

Participación de terapia ocupacional en contextos de conflicto armado y postconflicto / The role of occupational therapy in contexts of armed conflict and the post-conflict

Objetivos Identificar experiencias profesionales de terapia ocupacional en contextos nacional e internacional de conflicto armado y postconflicto. Métodos Revisión sistemática cualitativa de literatura 2005-2014, según cinco categorías analíticas: experiencias profesionales; problemáticas; poblaciones; referentes teóricos; y procedimientos. Resultados Se recuperaron 78 trabajos. Contexto nacional: los modelos más empleados son ocupación humana y desempeño ocupacional realizante; la problemática más tratada es desplazamiento forzado. Contexto internacional: 19 países documentan experiencias; los modelos canadiense y rehabilitación basada en comunidad se emplean en mayor número; las principales problemáticas tratadas son desplazamiento forzado, condición de refugiados y atención a integrantes de la fuerza pública. En ambos contextos se destacan procedimientos como las actividades artísticas e intervenciones en bienestar social e inclusión sociolaboral. Conclusiones Los trabajos de grado son la principal fuente de experiencias nacionales, aunque pocos están publicados; son escasos los trabajos con población victimaria (desmovilizados, desvinculados); cobra relevancia el sector rural como escenario típico del conflicto armado y contexto expulsor; se han introducido frecuentes categorías conceptuales y prácticas al quehacer, desde la perspectiva de la terapia ocupacional crítica, que afianzan el papel profesional en fenómenos de exclusión social y violencias, como agente de transformación que acude a la dimensión sociopolítica de la ocupación humana. Estos hallazgos plantean retos gremiales y académicos para publicar, abordar poblaciones no sólo en condición de víctimas, incursionar en la formación y ejercicio en contextos rurales y reconocer el papel profesional como agente que trasciende más allá de la dimensión salubrista de la ocupación humana.(AU)

Objective To identify professional experiences of Occupational Therapy in Colombian and international contexts of armed conflict and post-conflict. Methods A qualitative systematic review of the literature between 2005-2014 in five analytical categories: professional experiences, problem situations, populations, theoretical frameworks, and procedures. Results 78 papers were retrieved. Colombian context: the models most used are human occupation and occupational performance; the most frequent problem is forced displacement. International context: 19 countries documented experiences; the Canadian model and the community-based rehabilitation model are most used; the main problem situations are forced displacement, refugee status, and attention to members of the armed forces. Both contexts highlight procedures such as artistic activities and interventions related to social welfare and social-inclusion. Conclusions Graduate these are the main source of Colombian experiences, though few are published; there are a few studies about victim population (demobilized). The rural sector as a typical scenario of armed conflict and a context of displacement have been seen as relevant. Frequent conceptual categories and practices have been introduced from the critical perspective of Occupational Therapy which reinforce the role of the professional in phenomena of social exclusion and violence, as a transformational agent that addresses the socio-political dimension of human occupation. These findings posit challenges for professionals and academics to publish, to work with populations (victims or not), to approach training and practice in rural contexts, and to recognize the role of the professional as an agent that transcends the public health dimension of human occupation.(AU)