Seroprevalence and risk factors of HBV, HCV and HIV among hemodialysis patients: a multicenter cross-sectional study from Damascus Syria.

OBJECTIVE: The aim of this study is to determine the prevalence rates of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among hemodialysis (HD) patients as well as to identify associated risk factors. METHODOLOGY: A multicenter cross-sectional study involved patients who had been on HD for at least three months. The study was conducted at five HD centers in Damascus, Syria from August 2019 to September 2021. HBsAg, HCV-Ab and HIV (antibody/antigen) seropositivity were identified using the third generation ELISA technique. Patients' information was extracted from their records and by face-to-face interview. Multiple logistic regression models were applied to identify risk factors associated with HBV or HCV seropositivity. The significance level was set at 5%. RESULTS: A total of 637 patients were included in the study with a mean age (SD) of 50.5 (15.6) years and 56.7% of them were men. The dialytic age ranged from one to thirty years with a mean (SD) of 6.10 (5.6) years. The prevalence of positive hepatitis B surface antigen, anti-HCV, co-infection of HBV and HCV, and anti-HIV (antibody/antigen) were 3.2%, 22.1%, 0.7%, and 0%, respectively. After controlling for co-variables, hepatitis B vaccine was the only predictor of seropositivity of HBV (OR: 0.15, 95% CI: 0.057-0.393, P < 0.001), as it significantly protected against contracting HBV. On the other hand, the dialytic age (OR: 1.42, 95% CI: 1.12-1.94, P = 0.032) and the dialysis center were significant factors affecting the prevalence of HCV. CONCLUSIONS: The prevalence of HCV and HBV infections among HD patients in Damascus, Syria has decreased remarkably compared with the results from 2001. Nevertheless, it is still considered relatively high. Thus, there is an urgent need to strengthen the prevention and control measures for viral infection transmission in HD centers in Damascus.

Risk factors associated with overactive bladder severity in patients with type 2 diabetes.

BACKGROUND: The prevalence of overactive bladder (OAB) is known to be higher in patients with type 2 diabetes (T2DM) however there are not many studies about specific risk factors contributing to its progression among diabetes mellitus (DM) patients, so this study aimed to investigate the risk factors specific to DM that influence the progression of OAB in Syrian population. METHODS: This cross-sectional study was carried out at five endocrinology centers situated in four Syrian provinces: Damascus, Aleppo, Homs, Hama, and Latakia. The study comprised patients who were diagnosed with both T2DM and OAB and had visited these centers from March 2020 and February 2024. The Arabic version of the OAB Symptom Score (OABSS) scale was used to categorize the participants based on the severity score into two groups: the mild OAB group and the moderate-severe OAB group. A logistic analysis was conducted to assess the risk factors associated with the progression of OAB among patients with diabetes. RESULT: Among the 186 patients diagnosed with both DM and OAB, significant distinctions were found between the two groups concerning the severity of OAB, age, duration of diabetes, symptomatic diabetic peripheral neuropathy (DPN), and ankle reflex (p < 0.05). Furthermore, a multivariate analysis revealed that age (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.68-1.58), duration of diabetes (OR 2.14, 95% CI 1.75-3.74), and symptomatic DPN (OR 2.47, 95% CI 1.17-3.54) independently acted as risk factors for the advancement of OAB. CONCLUSION: The progression of OAB in Syrian patients with diabetes is closely associated with the severity of DM. Factors such as age, duration of diabetes, and symptomatic DPN are independent predictors of the severity of OAB. Patients who experience symptomatic DPN are at an increased risk of developing OAB.

Prevalence of classic and non-classic pain sites of coronary artery disease: a cross-sectional study.

STUDY OBJECTIVE: This study aims to assess the prevalence of both classic and non-classic pain sites in patients with ischemic heart disease, emphasizing the importance of recognizing and not disregarding non-classic symptoms. METHODS: This cross-sectional study included 100 patients diagnosed with coronary artery disease (CAD) who were admitted to two major hospitals in Syria. classic pain was identified as pain located in the precordial area, with or without radiation to the neck, jaw, left shoulder or arm. Patients' demographics and previous medical history were documented to investigate any potential associations with non-classic pain. RESULTS: 62% of the patients experienced non-classic pain, while 12% had no precordial pain. For those without precordial pain, the most common pain site was the left chest (66.7%). Non-classic pain was significantly associated with smoking, with 72.2% of smokers experiencing non-classic pain compared to 35.7% non-smokers (p = 0.001). Additionally, patients with previous heart disease were more likely to have non-classic pain (71.7%), compared with patients with no history of heart disease (51.1%) (p = 0.03). Other factors such as age, sex, and diabetes were not statistically significant. CONCLUSION: Non-classic pain is common, affecting 62% of individuals, primarily in the right shoulder, right arm, and back. This type of pain could be associated with smoking and prior heart disease. Misdiagnosing coronary artery disease can have serious consequences, as patients with non-classic symptoms may miss important pre-hospital procedures like ECG.

The validity and reliability of the Arabic version of the EQ-5D in atrial fibrillation patients in a conflict country: a study from Syria.

BACKGROUND: The EQ-5D is one of the most commonly used tools to establish health-related quality of life (QoL). EQ-5D data in atrial fibrillation (AF) patients in the Middle East are lacking. OBJECTIVES: This study aims to evaluate the reliability and validity of the Arabic version of the EQ-5D in AF inpatients in Syria. METHODS: The study involved patients admitted to the emergency department of Tishreen's University Hospital in Latakia with AF as the primary diagnosis between the 1st of June 2021 and the 1st of June 2023. Arabic versions of the EQ-5D, EQ-VAS and SF36 questionnaires were administered to patients. Validation was done using convergent, discriminant, and known-groups validity, while reliability was conducted using EQ-5D retesting within 2-4 weeks. RESULTS: 432 participants were included in the study with a mean ± standard deviation of 63 ± 15. Males represented 242 (56%) of the participants. All hypotheses relating EQ-5D responses to external variables were satisfied. All three validation hypotheses demonstrated that the EQ-5D had the convergent, discriminant and known group validity to assess QoL in this cohort. The intraclass correlation coefficient (ICC) for test-retest reliability ranged between 0.74 and 0.88, while Cohen's κ ranged between 0.72 and 0.86. Cronbach's α value for internal consistency was 0.73. CONCLUSION: The Arabic version of EQ-5D was valid and reliable in measuring QoL in AF inpatients in Syria. This validation opens the door for more widespread use of the EQ-5D in Arabic-speaking regions, facilitating better-informed healthcare decisions and improving patient care strategies in Syria and other Middle Eastern countries.

Idiopathic nephrotic syndrome in Syrian children: clinicopathological spectrum, treatment, and outcomes.

BACKGROUND: Idiopathic nephrotic syndrome (INS) is the most common glomerular disease in children. We performed this study to report histopathological findings, the correlation between clinical and histopathological features, and the response to steroids and other immunosuppressive drugs and outcomes in Syrian children with INS. METHODS: A single-center retrospective observational cohort study was conducted at Children's University Hospital in Damascus, and included all patients aged 1-14 years, admitted from January 2013 to December 2022, with INS and who underwent kidney biopsy. RESULTS: The study included 109 patients, with a male/female ratio of 1.13:1, and a median age of 5 years with interquartile range (2.8-10). The main indication of kidney biopsy was steroid-resistant nephrotic syndrome (SRNS) (57.8%). The main histopathological patterns were minimal change disease (MCD) (45%) and focal segmental glomerulosclerosis (FSGS) (37.6%). FSGS was the most common histopathological pattern in SRNS (44.3%). In SRNS, we used calcineurin inhibitors to induce remission. Tacrolimus was used in 49 patients with response rate (complete remission of proteinuria) of 69.4% and cyclosporine in 20 patients with response rate of 50%. In steroid-dependent nephrotic syndrome (SDNS), we used mycophenolate mofetil (MMF) and cyclophosphamide to prevent relapses; MMF was used in 9 patients with response rate (maintaining sustained remission) of 89% and cyclophosphamide in 3 patients with response rate of 66.7%. Rituximab was used in four patients with FSGS, two SRNS patients and two SDNS patients, with sustained remission rate of 100%. Fifteen patients (13.7%) progressed to chronic kidney disease stage 5. Of them, 7 patients had FSGS and 8 patients had focal and global glomerulosclerosis;14 of them were steroid-resistant and one patient was steroid-dependent with persistent relapses. The most common outcome was sustained remission (47%) in MCD and frequent relapses (31.7%) in FSGS. CONCLUSIONS: FSGS was the most common histopathological pattern in idiopathic SRNS and had the worst prognosis. Calcineurin inhibitors could be an effective therapy to induce complete remission in SRNS. Rituximab may be an effective treatment to achieve sustained remission in SDNS and frequently relapsing NS and may have a potential role in SRNS with further studies required.

Assessing pre-eclampsia awareness among pregnant women in Syria: a cross-sectional study on knowledge and perceptions.

BACKGROUND: Pre-eclampsia (PE) is a major contributor to morbidity and mortality in mothers worldwide. Adequate understanding of this condition improves treatment, control, and prevention. This study evaluated preeclampsia awareness among pregnant women in Syria, and the characteristics related to awareness adequacy. METHODS: This national cross-sectional study was conducted in Syria between 25 October and November 19, 2022. We included pregnant females of all age groups from all Syrian governorates. The questionnaire consisted of sociodemographic characteristics and knowledge of pre-eclampsia and its associated factors, symptoms, and complications. RESULTS: Overall, 706 participants were involved in this research, with a mean age of 38.22. Only 52.1% of them reported that they had heard of preeclampsia. Among the participants, 56.5% stated that they would not terminate a pregnancy if they were determined to be likely to develop preeclampsia, while nearly 55.2% agreed to continue the pregnancy rather than deliver prematurely even if their where a potential risk on their health risks. Participants who reported a family history of PE or had already experienced PE were more likely to have appropriate preeclampsia knowledge than those who did not (OR = 2.27, OR = 3.18, respectively). Respondents aged 25 to 35 years had the highest knowledge scores, and participants living in cities scored higher knowledge than rural residents. CONCLUSION: According to our findings, pregnant women in Syria have a awareness gaps regarding the PE topic. This highlights the need to enhance women's preeclampsia understanding for better pregnancy outcomes. Education through organizations, the media, and national programs is a significant aspect that promotes an adequate understanding of preeclampsia.

Health information management systems and practices in conflict-affected settings: the case of northwest Syria.

BACKGROUND: In conflict settings, as it is the case in Syria, it is crucial to enhance health information management to facilitate an effective and sustainable approach to strengthening health systems in such contexts. In this study, we aim to provide a baseline understanding of the present state of health information management in Northwest Syria (NWS) to better plan for strengthening the health information system of the area that is transitioning to an early-recovery stage. METHODS: A combination of questionnaires and subsequent interviews was used for data collection. Purposive sampling was used to select twenty-one respondents directly involved in managing and directing different domains of health information in the NWS who worked with local NGOs, INGOs, UN-agencies, or part of the Health Working Group. A scoring system for each public health domain was constructed based on the number and quality of the available datasets for these domains, which were established by Checci and others. RESULTS & CONCLUSIONS: Reliable and aggregate health information in the NWS is limited, despite some improvements made over the past decade. The conflict restricted and challenged efforts to establish a concentrated and harmonized HIS in the NWS, which led to a lack of leadership, poor coordination, and duplication of key activities. Although the UN established the EWARN and HeRAMS as common data collection systems in the NWS, they are directed toward advocacy and managed by external experts with little participation or access from local stakeholders to these datasets. RECOMMENDATIONS: There is a need for participatory approaches and the empowerment of local actors and local NGOs, cooperation between local and international stakeholders to increase access to data, and a central domain for planning, organization, and harmonizing the process. To enhance the humanitarian health response in Syria and other crisis areas, it is imperative to invest in data collection and utilisation, mHealth and eHealth technologies, capacity building, and robust technical and autonomous leadership.

The crosstalk between subjective fibromyalgia, mental health symptoms and the use of over-the-counter analgesics in female Syrian refugees: a cross-sectional web-based study.

Suboptimal fibromyalgia management with over-the-counter analgesics leads to deteriorated outcomes for pain and mental health symptoms especially in low-income countries hosting refugees. To examine the association between the over-the-counter analgesics and the severity of fibromyalgia, depression, anxiety and PTSD symptoms in a cohort of Syrian refugees. This is a cross-sectional study. Fibromyalgia was assessed using the patient self-report survey for the assessment of fibromyalgia. Depression was measured using the Patient Health Questionnaire-9, insomnia severity was measured using the insomnia severity index (ISI-A), and PTSD was assessed using the Davidson trauma scale (DTS)-DSM-IV. Data were analyzed from 291. Among them, 221 (75.9%) reported using acetaminophen, 79 (27.1%) reported using non-steroidal anti-inflammatory drugs (NSAIDs), and 56 (19.2%) reported receiving a prescription for centrally acting medications (CAMs). Fibromyalgia screening was significantly associated with using NSAIDs (OR 3.03, 95% CI 1.58-5.80, p = 0.001). Severe depression was significantly associated with using NSAIDs (OR 2.07, 95% CI 2.18-3.81, p = 0.02) and CAMs (OR 2.74, 95% CI 1.30-5.76, p = 0.008). Severe insomnia was significantly associated with the use of CAMs (OR 3.90, 95% CI 2.04-5.61, p < 0.001). PTSD symptoms were associated with the use of CAMs (ß = 8.99, p = 0.001) and NSAIDs (ß = 10.39, p < 0.001). Improper analgesics are associated with poor fibromyalgia and mental health outcomes, prompt awareness efforts are required to address this challenge for the refugees and health care providers.

Knowledge and practices on home medication storage and disposal in Syria: a population-based, cross-sectional study.

BACKGROUND: Medications are commonly found in every household. In Syria, where healthcare infrastructure faces significant challenges, improper storage can lead to reduced medication efficacy and increased health risks. Additionally, inappropriate disposal practices pose serious environmental concerns, especially in a region already grappling with environmental degradation. This study aimed to evaluate the knowledge, and practices of Syrian individuals regarding the appropriate storage and disposal of home medications. METHOD: A cross-sectional study was conducted from September 22 to October 20, 2023, using an online survey distributed via social media apps (WhatsApp, Facebook, and Telegram) in Syria. The questionnaire, adapted from a similar study in Saudi Arabia, was translated to Arabic using the forward-backward translation technique. A convenience sampling technique was used. Inclusion criteria were participants over eighteen with expired or unused medications at home. Descriptive statistics, Chi-square tests, and binary logistic regression analysis were performed using SPSS version 27, with statistical significance defined as p < 0.05. RESULTS: A total of 2,217 responses were analyzed, with the majority of participants being female (79%) and aged between 21-30 years (56%). The study found that 90.7% of respondents dispose of expired medications in the garbage, while 95% keep medications in their original containers. Additionally, 30% consult pharmacists for storage instructions, and 64% read storage information on medication leaflets. Logistic regression analysis revealed that males were less likely to check expiration dates before use (OR: 0.58, 95% CI: 0.40-0.84) and periodically (OR: 0.68, 95% CI: 0.54-0.85). Participants aged 31-40 years were less likely to check expiration dates periodically (OR: 0.46, 95% CI: 0.31-0.68), while those with children under six years old were more likely to do so (OR: 1.29, 95% CI: 1.01-1.67). Males were also less likely to read storage instructions (OR: 0.61, 95% CI: 0.50-0.76) but more likely to ask pharmacists about them (OR: 1.26, 95% CI: 1.01-1.57). There was no significant difference in these practices between medical professionals and the general population. CONCLUSION: This study reveals gaps in the practices related to the storage and disposal of medications among the Syrian public. The findings suggest a need for targeted public education and awareness programs to improve these practices and reduce the associated health and environmental risks.

Assessment the awareness of vitamin D deficiency among the general population in Syria: an online cross-sectional study.

BACKGROUND: Vitamin D deficiency is an importance preventable problem in the global and associates with lack levels of awareness about vitamin D. According to prior studies, in the Arab world, there is low of knowledge and awareness toward vitamin D deficiency. The target of our study is evaluating the knowledge level about vitamin D deficiency and determining the associated factors with levels of awareness of its. METHOD: This online cross-sectional study was performed in Syria between 25 February to 29 March 2023 to assess the levels of knowledge about vitamin D deficiency among general Syrian population. The study's survey was obtained from previously published research and we conducted a pilot study to assure the validity and clarity questionnaire. All Syrian individuals aged 18 or older who were able to read and write and willing to participate were included, while, non-Syrian nationality individuals and all medical staff (doctors, nurses, and medical students…), as well, those under 18 age were excluded. The questionnaire consisted of 23 questions separated into four categories. The first section was sociodemographic information of the study population. The second section measured the level awareness of the study population regarding the benefits of vitamin D. In addition, the third and fourth part evaluated knowing of the respondents about sources of and toxicity consequences of vitamin D. The data were analyzed by utilizing multivariate logistic regression in IBM, SPSS V.28 version. RESULTS: Overall, 3172 of the study population accepted to participate in this research and 57.9% the majority of them were aged in the range among 18 and 28. While, the average age of the respondents were 30.80 ± 11.957. Regarding with the awareness toward knowledge of advantages and source of vitamin D and outcomes of vitamin D toxicity. Most of the participants mentioned that vitamin D is used to treat bone disease and rickets and contributes in maintaining calcium and phosphates (91.4% and 84.6%, respectively). Whereas, more than half of them reported that sun exposure does not cause vitamin D poisoning and that vegetarians are more likelihood to have vitamin D than non-vegetarians, (54.1% and 54.9%, respectively). Only, age and occupation out of nine predictors variables were significantly correlated with adequate knowledge of Vitamin D (p-value < 0.05). The respondents aged more than 60 years were high probability to have good recognition of Vitamin D than participants aged between 18 and 28 years. (OR = 7.95). Retired participants have shown lower aware of Vitamin D 0.38 times than students. CONCLUSION: Our research revealed that most of the participated individuals have sufficient comprehension about vitamin D, despite, there were significant gap. Health education via programs by government health-care agencies, NGOs and social workers is necessary to increase the awareness and knowledge toward benefits, source, deficiency and toxicity of vitamin D to avoid injury several diseases such as rickets.

A scoping review of post-earthquake healthcare for vulnerable groups of the 2023 Turkey-Syria earthquakes.

BACKGROUND: Identifying healthcare services and also strengthening the healthcare systems to effectively deliver them in the aftermath of large-scale disasters like the 2023 Turkey-Syria earthquakes, especially for vulnerable groups cannot be emphasized enough. This study aimed at identifying the interventions undertaken or proposed for addressing the health needs or challenges of vulnerable groups immediately after the occurrence of the 2023 Turkey-Syria earthquakes, as well as for prioritizing their healthcare service delivery in the post-Turkey-Syria earthquake. METHODS: In this scoping review compiled with the five steps of the Arksey and O'Malley framework, five databases, including PubMed, Science Direct, Web of Science, OVID, and Google Scholar, were searched for studies published between March and April 2023 in line with the eligibility criteria. Interventions for enhancing post-earthquake healthcare services (PEHS) were grouped into seven (7) categories, adopted from previous guidelines and studies. Each one was assigned a default score of a value equal to one (1), which, in the end, was summed up. RESULTS: Of the 115 total records initially screened, 29 articles were eligible for review. Different interventions they reported either undertaken or proposed to address the healthcare needs and challenges, especially faced by the most vulnerable groups in the aftermath of the Turkey-Syria earthquakes, were categorized into 7 PEHS. They were ranked with their scores as follows: humanitarian health relief (25); medical care (17); mental health and psychosocial support (10); health promotion, education, and awareness (9); disease surveillance and prevention (7); disability rehabilitation (7); and sexual and reproductive health (5). CONCLUSION: Since there are no proper guidelines or recommendations about the specific or most significant PEHS to prioritize for vulnerable groups after the occurrence of large-scale earthquakes, this scoping review provides some insights that can help inform healthcare service delivery and prioritization for vulnerable groups in the post-2023 Turkey-Syria earthquakes and other similar disasters.

Chronic pain and use of painkillers, healthcare services and long-term impairment among Syrian refugees: a cross-sectional study.

BACKGROUND: The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway. METHODS: This cross-sectional study is based on survey data collected from 353 quota refugees in 2018-19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience. RESULTS: Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0-4.7)), moderate (1.8 (1.1-2.8)), strong (1.7 (1.1-2.6)), and prescription painkillers; mild (4.6 (2.2-9.5)), moderate (5.6 (3.2-10.0)), strong (6.7 (3.9-11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2-3.5), 3.9 (2.1-7.0) and 2.4 (1.3-4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6-13.49)), moderate (6.7 (4.3-10.5)) and strong (6.6 (4.3-10.4)). CONCLUSION: Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Individual and social determinants of COVID-19 vaccine hesitancy and uptake in Northwest Syria.

INTRODUCTION: The COVID-19 outbreak devastated the fragmented health system in Syria, a war-torn country, and exaggerated the demands for humanitarian assistance. COVID-19 vaccination was rolled out in Northwest Syria, an area out of government control, in May 2021. However, vaccine acceptance rates are still minimal, which is reflected in the meager percentage of vaccinated people. The study aims to investigate the effectiveness of the humanitarian actors' plans to address the COVID-19 vaccine hesitancy and conclude practical strategies for boosting vaccine uptake in Northwest Syria. METHODS AND MATERIALS: Two questionnaires were developed to collect data from humanitarian organizations involved in the COVID-19 vaccination campaign and people from northwest Syria. Data analysis was performed using SPSS 22 data analysis program. RESULTS: According to the findings, 55.5% of people refused the COVID-19 vaccine. The results showed a knowledge gap and lack of evidence regarding humanitarian actors' strategies to address the vaccine's low uptake. Besides, it was found that doctors and medical workers were reliable sources of information about the vaccine. However, they were not systematically engaged in community mobilization and risk communication to promote people's perspectives on the vaccine. CONCLUSION: Risk communication and community engagement programs were not significantly associated with increasing the COVID-19 acceptance rate. Humanitarian actors must reconsider their strategies to address vaccine hesitancy in Northwest Syria. These strategies should engage medical professionals through dialogue sessions on the realities of the pandemic and vaccine development mechanism based on a compelling and evidence-based approach.

Vaccination governance in protracted conflict settings: the case of northwest Syria.

BACKGROUND: Effective vaccination governance in conflict-affected regions poses unique challenges. This study evaluates the governance of vaccination programs in northwest Syria, focusing on effectiveness, efficiency, inclusiveness, data availability, vision, transparency, accountability, and sustainability. METHODS: Using a mixed-methods approach, and adapting Siddiqi's framework for health governance, data were collected through 14 key informant interviews (KIIs), a validating workshop, and ethnographic observations. Findings were triangulated to provide a comprehensive understanding of vaccination governance. RESULTS: The study highlights innovative approaches used to navigate the complex health governance landscape to deliver vaccination interventions, which strengthened sub-national vaccination structures such as The Syria Immunisation Group (SIG). The analysis revealed several key themes. Effectiveness and efficiency were demonstrated through cold-chain reliability and extensive outreach activities, though formal reports lacked detailed analysis of vaccine losses and linkage between disease outbreak data and coverage statistics. Key informants and workshop participants rated the vaccination strategy positively but identified inefficiencies due to irregular funding and bureaucracy. Inclusiveness and data availability were prioritised, with outreach activities targeting vulnerable groups. However, significant gaps in demographic data and reliance on paper-based systems hindered comprehensive coverage analysis. Digitalisation efforts were noted but require further support. The SIG demonstrated a clear strategic vision supported by international organizations such as the World Health Organization, yet limited partner participation in strategic planning raised concerns about broader ownership and engagement. While the SIG was perceived as approachable, the lack of public documentation and financial disclosure limited transparency. Internal information sharing was prevalent, but public communication strategies were insufficient. Accountability and sustainability faced challenges due to a decentralized structure and reliance on diverse donors. Despite stabilizing factors such as decentralization and financial continuity, fragmented oversight and reliance on donor funding remained significant concerns. DISCUSSION: The study highlights the complexities of vaccination governance in conflict-affected areas. Comparisons with other conflict zones underscore the importance of local organisations and international support. The SIG's role is pivotal, but its legitimacy, transparency, and inclusivity require improvement. The potential transition to early recovery in Syria poses additional challenges to SIG's sustainability and integration into national programs. CONCLUSION: The governance of vaccination in northwest Syria is multifaceted, involving multiple stakeholders and lacking a legitimate government. Enhancing transparency, local ownership, and participatory decision-making are crucial for improving governance. The role of international bodies is essential, emphasising the need for structured feedback mechanisms and transparent monitoring processes to ensure the program's success and sustainability.

The impact of humanitarian aid on financial toxicity among cancer patients in Northwest Syria.

INTRODUCTION: The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions. MATERIALS AND METHODS: This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts. RESULTS: A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress. CONCLUSION: The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

Monitoring war destruction from space using machine learning.

Existing data on building destruction in conflict zones rely on eyewitness reports or manual detection, which makes it generally scarce, incomplete, and potentially biased. This lack of reliable data imposes severe limitations for media reporting, humanitarian relief efforts, human-rights monitoring, reconstruction initiatives, and academic studies of violent conflict. This article introduces an automated method of measuring destruction in high-resolution satellite images using deep-learning techniques combined with label augmentation and spatial and temporal smoothing, which exploit the underlying spatial and temporal structure of destruction. As a proof of concept, we apply this method to the Syrian civil war and reconstruct the evolution of damage in major cities across the country. Our approach allows generating destruction data with unprecedented scope, resolution, and frequency-and makes use of the ever-higher frequency at which satellite imagery becomes available.

Risk factors Associated with Pain Severity in Syrian patients with non-specific low back Pain.

BACKGROUND: Low back pain (LBP) majorly contributes to activity limitations and work absences worldwide. Therefore, a comprehensive knowledge of the risk factors linked to non-specific low back pain (NSLBP) can enable early and timely interventions to achieve long-term improvements. Current study aimed to assess the risk factors associated with the severity of NSLBP patients in Syria. METHODS: This study used a cross-sectional design and a self-assessment questionnaire to collect data on NSLBP, as well as personal and physical factors, across four provinces in Syria (Damascus, Aleppo, Homs, and Latakia) from November 2021 to September 2022. The assessments incorporated the Short Form 36-Item Health Survey (SF-36), the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). Then we examined the relationship between the severity of NSLBP and these potential risk factors. Descriptive statistics were employed to summarize the demographic characteristics of the participants. Additionally, multiple logistic regression analysis was performed to evaluate the risk factors for non-specific low back pain. RESULTS: The study included a total of 875 patients with NSLBP. The results indicated that patients with primary school education, a high body mass index (BMI), prolonged driving and sitting durations, smoking habits, and recurrent low back pain had higher VAS and ODI scores, as well as lower SF-36 scores (p < 0.01). Additionally, workers and drivers had higher VAS and ODI scores and lower SF-36 scores compared to waiters and patients who lifted objects heavier than 10 kg for more than a quarter of their work time for over 10 years (p < 0.01). The multiple logistic regression analysis revealed that lower education levels, low back pain lasting 1-7 days, chronic low back pain in the past year, smoking, driving for prolonged time, and higher BMI were associated with more severe VAS scores. CONCLUSION: The severity of NSLBP is related to lower education levels, poor living conditions, strenuous physical labor, inactive lifestyle, and driving for a long time. Additionally, patients with recurrent NSLBP experience more intense pain. To manage these issues, potential interventions could include reducing obesity rates, limiting the duration of hard physical work, limiting driving duration and reducing sedentary behaviors and smoking. These measures may help alleviate the overall burden of NSLBP.

Humanitarianism as a tool of statecraft: contested authority, sovereign violence, and humanity in the Syrian civil war.

This research explores the dynamics of interaction between the sovereign state and international humanitarian organisations in alleviating human suffering in the Syrian civil war. Considering civil wars as a rupture in sovereignty, its focus is on the practices of the sovereign state within its social context and the resulting implications for aid organisations. I argue that the Syrian regime has employed state violence, in tandem with administrative and bureaucratic impediments, to reassert its sovereign authority in humanitarian decision-making processes. This exercise of sovereign power is intertwined with the actions of aid organisations, thereby reshaping power dynamics among the state, aid organisations, and vulnerable populations. Through a qualitative method, I show that the deployment of state violence concomitantly pushes aid organisations, specifically the United Nations, towards enforcing the state sovereignty defined by the regime. As an effect of assertive sovereignty, interpretations of humanitarian principles and practices are continuously negotiated and constructed differently by aid organisations, even though they share a common overarching goal.

The attitudes of Syrian Private University Medical Students towards E-Learning during the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic has had a significant impact on the education sector, leading to the closure of colleges and schools and disrupting the learning process for an uncertain duration. In response, electronic learning has emerged as a suitable method for continuing the educational process during the lockdown. This study aimed to assess the attitudes, practices, and barriers to e-learning among medical students at Syrian Private University. METHODS: A cross-sectional survey study was conducted at the Faculty of Medicine of the Syrian Private University (SPU) in Damascus, Syria. The study used a convenience sampling approach and was carried out from June 2021 to January 2022. Data were collected using a self-administered questionnaire structured into two sections. The first section included 12 sociodemographic questions. The second section assessed students' attitudes, practices, and barriers related to e-learning, and consisted of 14 questions on attitudes, 11 questions on practices, and 9 questions on barriers. RESULTS: Of the 519 participating students, over half (55.1%) exhibited a negative attitude towards e-learning. However, more than 60% reported engaging in e-learning activities such as downloading educational content and participating in virtual study groups. The main barriers identified were unstable internet connections (92.7%) and challenges in communication with educators (82.7%). Bionomical logistic regression revealed that negative attitudes were predicted by housing status, academic year, health status, lack of engagement with colleagues in e-learning practices, and the reported barriers of difficulty adjusting learning style, lack of technical skills, poor communication with educators, limited access to devices, and limited space conducive for studying (P < 0.05). CONCLUSION: While medical students at SPU were actively engaged in e-learning, over half held negative attitudes. These negative attitudes were associated with the various barriers that students reported. The findings can inform stakeholders in our institution and other Syrian universities about the challenges of implementing e-learning in medical colleges.

Translation, cultural adaptation and linguistic validation of the postgraduate hospital educational environment measure into Arabic.

BACKGROUND: Assessment of the clinical learning environment (CLE) is an essential step that teaching hospitals routinely undertake to ensure the environment is conducive, learning-oriented and supportive of junior doctors' education. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an internationally recognized tool for assessing the CLE with evidence of high reliability and validity. Translation of PHEEM into other languages such as Spanish, Japanese and Persian enabled wider adoption of the instrument in the world. However, in Syria and other Arabic countries, a validated Arabic translation of PHEEM is still not available, making it difficult to adopt it and use it in Arabic contexts. This study aims to translate and culturally adapt the PHEEM from English into Arabic. METHODS: This study followed the structured translation and validation process guideline proposed by Sousa & Rojjanasrirat 2010. First, the PHEEM went through forward translation by three translators, then reconciled with the aid of a fourth translator. Afterwards, two professional bicultural and bilingual translators conducted back translation into English and compared it with the original version. This formed the Pre-final Version (PFV) which was then pretested for clarity on a sample of medical residents in Damascus, Syria. Following appropriate modifications, the PFV was sent to a panel of experts for a comprehensive review of language clarity and to assess content validity. RESULTS: A total of thirty-five medical residents were recruited. Ten items with language clarity issues were identified and modified according to the elicited suggestions. Thereafter, the modified PFV was presented to ten subject experts who identified three items in need of revision. The item-content Validity Index (CVI) was over 0.78 for all of the 40 items; the calculated scale-CVI was 0.945. DISCUSSION: This study provided the first linguistically valid Arabic translation of the widely used PHEEM inventory. The next step is to conduct a full psychometric analysis of the Arabic PHEEM to provide further evidence of validity and reliability.