Laryngopharyngeal reflux in war-torn Syria and its association with smoking and other risks: an online cross-sectional population study

Vocal Health and Vocal Health Knowledge Among Occupational Voice Users in the Province of Quebec

Voice disorders are frequent among occupational voice users such as teachers. Although these disorders can have serious personal and professional consequences, they are not often recognized as occupational diseases and little attention is paid to their prevention. This study aimed to provide a portrait of the self-reported vocal health and vocal health knowledge of occupational voice users in Quebec, Canada, and to identify risk factors associated with voice disorder symptoms. We conducted an online survey targeting occupational voice users in the province of Quebec, Canada, with a focus on those involved in teaching or training. The final sample, after excluding incomplete surveys, included 808 respondents (665 women, M = 41.5 ± 10.4 years old). The survey responses were analyzed using descriptive and inferential statistics. Results indicated that 9.8% of the respondents had a history of a diagnosed voice disorder and 68.8% of the respondents experienced at least one voice symptom on a regular basis. Ordinal logistic regressions revealed that several personal and environmental factors are associated with an increased risk of developing voice disorders symptoms: being a woman, suffering from a breathing disorder, allergies, acid reflux and/or hearing impairment, having less work experience, working with elementary school children and/or with continuous or speech noise in the background. Most of the respondents (94.6%) had never received information regarding voice disorders during their academic training and less than half of them (47.7%) knew which professionals can treat voice disorders. These findings highlight the need for formal vocal health education among both occupational voice users and their employers to improve prevention and treatment for voice disorders in an at-risk population.

Translation and Validation of the Arabic Version of the Reflux Symptom Score, Short Version 12 (RSS-12)

BACKGROUND

The Reflux Symptom Score (RSS) is a patient-related outcomes measure (PROM) that was developed to diagnose Laryngopharyngeal reflux (LPR), by assessing the severity and frequency of specific symptoms and their respective impact on quality of life (QoL).

OBJECTIVE

To develop the Arabic version of RSS-12 (Ar-RSS-12), and to assess its validity and reliability.

METHOD

The RSS-12 was translated from French into Arabic using the forward-backward translation method, and the translated version underwent transcultural validation. A case-control study was conducted at the otolaryngology clinics of a referral hospital, during the period November to December 2022. It included 61 patients with LPR-related symptoms and a Reflux Symptom Index (RSI) score >13, and 61 control without LPR-related symptoms and negative RSI scores ≤13. The internal consistency, internal and external validity, and Test-Retest reliability of Ar-RSS-12 were analyzed.

RESULT

Patients had significantly higher scores than controls in all 12 items and total Ar-RSS and QoL impact scores, with high Z score values. Item scores showed variable correlation levels with total Ar-RSS score, with ear-nose-throat items showing the strongest correlation (Spearman's rho 0.592-0.866). The QoL scores were more strongly correlated to the symptoms' severity than frequency. The internal consistency was high, with Cronbach's alpha = 0.878. Regarding external validity, correlations with RSI score showed high Spearman's rho values for total Ar-RSS (0.905) and QoL total score (0.903). No statistically significant difference was observed between Test and Retest results in any of the 12 items' score or the total score and QoL, indicating the reproducibility of the test.

CONCLUSION

The Ar-RSS is a valid and reproducible tool for the screening, assessment, and monitoring of LPR in Arabic speaking patients. The inclusion of symptoms severity and frequency, as well as their individual effects on patient's QoL, support the superior clinical applications of RSS compared to other existing PROMs.

Smoking habits and the influence of war on cigarette and shisha smoking in Syria

Tobacco smoking might be impacted by various influences, including psychological, socio-cultural, and economic factors. A community-based cross-sectional survey was conducted in Syrian Arab Republic from March to April 2019 using a web-based questionnaire. The survey aimed at assessing tobacco use (shisha and cigarettes) as well as examining the association between current tobacco use and various sociodemographic and war-related factors. The sample comprised 978 participants (251 males: 727 females) and had a mean age of 24.7 years (SD: 7.60). Most participants were single (n = 825, 84.4%), reside in Damascus and Rif-Dimashq (n = 579, 59.2%), and had a college/university education (n = 911, 93.1%). Concerning smoking, a total of 371 participants (37.9%) were identified to be current tobacco smokers, of whom 211, 84, 76 were exclusive shisha smokers, exclusive cigarette smokers, and dual smokers, respectively. The prevalence of cigarette smoking (exclusive and dual) among males and females was found to be 34.7%, and 10.0%, respectively. On the other hand, the prevalence of shisha smoking (exclusive and dual) among males and females was around 34.3% and 27.6%, respectively. Additionally, various factors have predicted a higher likelihood of cigarette smoking including male gender (AOR = 4.152; 95% CI: 2.842-6.064; p<0.001), and losing someone due to the war (AOR = 1.487; 95% CI: 1.028-2.151; p = 0.035), while unemployed individuals were found to have lower odds of being cigarette smokers (AOR = 0.634; 95% CI: 0.429-0.937; p = 0.022). Concerning shisha smoking, married (AOR = 0.622; 95% CI: 0.402-0.963; p = 0.033), and unemployed individuals (AOR = 0.679; 95% CI: 0.503-0.916; p = 0.011) were found to have lower odds of shisha smoking. Amid the tobacco epidemic in the region, rates of tobacco use in Syria are still worrying. The Syrian armed conflicts may possess a double-edged effect on smoking, and tobacco users who adopt smoking to cope with various stressors should be targeted with well-structured health education, along with appropriate psychological services.

Was a forced lockdown adequate for a country in conflict? A psychological perspective from the Syrian population

BACKGROUND

Syria has suffered for nine years from a conflict that left over 11.1 million inhabitants in need of humanitarian assistance and over 80% in poverty. A ten-week-long full lockdown was enforced in Syria and successfully minimized the spread of COVID-19. This study aims to estimate the occurrence of mental health disorders after lockdown termination among the citizens of war-torn Syria.

METHODS

Online questionnaires, which included demographic and war-related questions, Dimensions of Anger Reactions 5 (DAR-5) and the Depression Anxiety Stress Scale-21 (DASS-21) were distributed to different social media groups.

RESULTS

This study recruited 1445 participants, of which 515 (35.6%) were males, the mean age was 24.8 ± 6.3 years, 38% had problematic anger, 64% had moderate to very severe depression, 42.9% had moderate to severe anxiety and 39.7% had moderate to severe stress. Increased living expenses, not being able to go out and a reduced ability to earn income and provide food were significantly associated with the psychological burden after the lockdown (p < 0.05). The association of war variables with mental disorders was weaker than the effect of the deteriorating economy. Other healthcare workers had more severe distress than doctors, who themselves were found to have less distress than the general population (p < 0.05). Anger scores were approximately equal, regardless of the type of work. Finally, shisha smoking was associated with worse mental health (p < 0.05).

CONCLUSION

The psychological burden of the damaged economy surpassed the direct damage due to COVID-19 and the effect of years of conflict. Urgent interventions are required, as this burden may continue for years, if not for decades. A full lockdown in countries with fragile economies may delay the spread of the virus, but it will severely damage the economy, which will lead to a deterioration of the mental health of their citizens.

Mental Distress and Psychological Disorders Related to COVID-19 Mandatory Lockdown

Background: Lockdown restrictions due to COVID-19 have affected many people's lifestyles and ability to earn a living. They add further distress to the lives of people in Syria, who have already endured 9 years of war. This study evaluates distress and the major causes of concerns related to COVID-19 during the full lockdown. Methods: Online questionnaires were distributed using SPTSS, K10, and MSPSS which were used with other demographic, war- and COVID-19-related questions that were taken from The (CRISIS) V0.1 Adult Self-Report Baseline Form. Results: Our sample included 5,588 with the mean age of 26.84 ± 7.815 years. Of those, only one case of COVID-19 was confirmed. Over 42.7% had two or more positive PTSD symptoms, 42.6% had moderate or severe mental disorder, but only 14.9% had low social support. Higher PTSD and K10 scores overall were seen in female participants and with most of war variables (P < 0.05). Relationships with the partner being negatively affected and distress from a decline in ability to work and provide food were the most prominent. Conclusions: The indirect effects of COVID-19 are far more than that of the pathogen itself. A reduced ability to earn and to provide food were the main concerns indicated in this study. Relationships deteriorated in participants with high K10 and PTSD scores who also had more symptoms and used more hypnotics in the last four weeks. Smoking patterns were not related to K10 and PTSD. Social support played a role in reducing stress, but when relationships were affected, lower support was observed.

Allergic rhinitis, asthma and laryngopharyngeal reflux disease: a cross-sectional study on their reciprocal relations

Allergic rhinitis (AR) is a common medical condition worldwide. It is an inflammation in the nasal mucosa due to allergen exposure throughout the year. Laryngopharyngeal reflux (LPR) is another medical condition that can overlap with AR. LPR can be considered an extra oesophageal manifestation of gastro-oesophageal reflux disease (GORD) or a different entity. Its diagnosis imposes a real challenge as it has a wide range of unspecific symptoms. Although AR and LPR are not life-threatening, they can severely affect the quality of life for years and cause substantial distress. Moreover, having AR is associated with having asthma which is also in turn associated with GORD. This is a cross-sectional study which used surveys distributed online on Social Media and targeted people across Syria. All participants who responded to the key questions were included. Reflux symptom index (RSI) was used for LPR, and score for allergic rhinitis (SFAR) was used for AR. Demographic questions and whether the participant had asthma were also included in the survey. We found that there was an association between the symptoms of LPR and AR p < 0.0001 (OR, 2.592; 95% CI 1.846-3.639), and their scores were significantly correlated (r = 0.334). Having asthma was associated with LPR symptoms p = 0.0002 (OR 3.096; 95% CI 1.665-5.759) and AR p < 0.0001 (OR 6.772; 95% CI 2.823-16.248). We concluded that there was a significant association between having LPR, AR, and asthma. We need more studies to distinguish between their common symptoms and aetiologies.

Interactions of Consanguinity and Number of Siblings with Childhood Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) is a common malignancy in children. Consanguinity has a high prevalence in developing countries and increases the probability of homozygosity for many genes which may affect ALL and its prognosis. We conducted a study to explore the impact of consanguinity and number of siblings on ALL as there are currently no studies to describe this effect. Data were collected from patients' records from the Children's University Hospital of Damascus University, which is the major cancer centre for children in Syria. This study included 193 children with ALL over one year. Number of siblings was not with the French-American-British (FAB) classification, gender, ALL subtype, or risk of ALL children. When comparing consanguinity degrees and complete blood counts at diagnosis, significant contradicting data were found in the third-degree and fourth-degree consanguinity when compared to one another and to not having consanguineous parents as third degree consanguinity was associated with normal platelets but lower WBC counts, and fourth-degree consanguinity was associated with normal haemoglobin levels and WBC counts, but lower platelet counts. Having consanguineous parents was also associated with acquiring ALL at an older age, L2 FAB classification, having a positive family history for malignancies, and not having hepatosplenomegaly (P < 0.05). Although L2 is known to be a poor prognosis indicatory, no association was found with consanguinity and risk. Finally, no association was found with ALL subtype or risk (P > 0.05). Although consanguinity and number of siblings have affected some variables and prognostic features of childhood ALL, the aetiology is not clear and we need further studies to clarify such an association as this will help in optimising therapy and accurately determine the risk.

Mental disorder and PTSD in Syria during wartime: a nationwide crisis

BACKGROUND

Syria has experienced war since 2011, leaving over 80% under the poverty line and millions displaced. War and its retaliations have significantly impacted the mental health of Syrians. This study evaluates the post-traumatic stress disorder (PTSD), and the severity of the mental distress caused by war and other factors such as low social support. This study also evaluates other variables and compares the findings with those of multiple studies on Syria and refugees.

METHODS

This is a cross-sectional study that included people who lived in Syria in different governorates. Online surveys were distributed into multiple online groups and included the Kessler 10 (K10) scale which screens for anxiety and depression, the Screen for Posttraumatic Stress Symptoms (SPTSS) tool, the Multidimensional Scale of Perceived Social Support, and questionnaires on demographic and war-related factors.

RESULTS

Our study included 1951 participants, of which, 527 (27.0%) were males and 1538 (78.8%) between the age of 19 and 25. Among participants, 44% had likely severe mental disorder, 27% had both likely severe mental disorder and full PTSD symptoms, 36.9% had full PTSD symptoms, and only 10.8% had neither positive PTSD symptoms nor mental disorder on the K10 scale. Around 23% had low overall support. Half of the responders were internally displaced, and 27.6% were forced to change places of living three times or more due to war. Around 86.6% of the responders believed that the war was the main reason for their mental distress. Those with high SPTSS and K10 scores were found to take more days off from work or school due to negative feelings and having somatic symptoms. Moreover, the number of times changing places of living due to war, educational level, and being distressed by war noise were the most prominent factors for more severe PTSD and mental distress. No differences in PTSD and mental disorder prevalence were noted in participants living in different governorates or among different types of jobs. A strong significant correlation (r = 0.623) was found between SPTSS and K10 scores.

CONCLUSION

The conflict in Syria has left the population at great risk for mental distress which was higher compared to Syrian refugees elsewhere. Many measures with an emphasis on mental health are needed to help the people against a long-term avoidable suffering.