Healthcare workers' perceptions of postoperative care and implementation challenges in conflict-affected northwest Syria: a mixed-methods analysis

Introduction

Protracted violent conflict has severely reduced healthcare provision in northwest Syria (NWS), and this is especially concerning for postoperative care as conflict-related injuries have further compounded this strain. Without sufficient postoperative care, minor complications can evolve into life-threatening events. In this study, we aim to understand healthcare workers' attitudes, practices and perceptions regarding postoperative care in NWS and identify key barriers to postoperative care.

Methods

Individuals with experience in health leadership positions in NWS were identified using purposive and snowball sampling and interviewed using a semistructured interview guide. Interview summaries were analysed using a standardised codebook to identify potential themes. In addition to these interviews, an online survey on hospital practices was sent to hospital administrators and non-governmental organisation leadership who disseminated the survey to all employees engaging in clinical work.

Results

Eighteen key informants were interviewed, and 466 survey responses from doctors (39%), nurses (37%), medical technicians (13%) and administrators (11%) were recorded. Through key informant interviews, we demonstrate several barriers to postoperative care, including health system fragmentation, limited healthcare workforce, insufficient resources due to conflict, disinterest, and lack of clinical documentation and discharge standards. Survey respondents reported poor patient compliance (66%), lack of routine follow-up visits (42%) and non-sterile operating room instruments (42%) as primary reasons for postoperative complications. Identified pathways to improve postoperative care included increased staffing and training, improved operating room sterilisation, and enhanced patient follow-up and discharge processes.

Conclusion

In conclusion, the health system in NWS is extremely overburdened from over a decade of violent conflict, increased demand for health services and insufficient resources. This has made implementing consistent and adequate postoperative care nearly impossible, contributing to unnecessary complications and mortality. Solutions to address postoperative complications in NWS must account for these complex realities and the broader context in which this system exists.

Pediatric traumatic brain injuries in war zones: a systematic literature review

Background

Pediatric casualties in war zones are a devastating consequence of armed conflicts, causing significant challenges for affected children, especially in the context of poor access to care. This study aimed to understand traumatic brain injuries (TBIs) in this high-risk population and to identify and provide information for the stakeholders, as well as to recognize severe long-term consequences and develop strategies to prevent them, thus minimizing their burden while aiding in the management of these cases.

Methods

We carried out a systematic literature review following PRISMA guidelines to identify publications discussing traumatic brain injuries in children in the context of war zones, and we analyzed all the collected data.

Results

Our study showed that head injuries were the most common casualty in war zones; male and female children were affected, and the mean age was 8-10 years. Most children were reported to be from Afghanistan, and blasts were the most common mechanism of injury. The mortality fluctuated from 3 to 47%.

Conclusion

There is a lack of evidence-based information regarding the characterization, approach, and management of children with TBI in conflict zones. While the world finds ways to live in peace, there is an urgency to research, train, and deploy enough specialists to these areas, if governments are serious about improving outcomes for this population.

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.

Emergency calls from migrants to an emergency call centre: A retrospective epidemiological study

OBJECTIVE

The study aims to evaluate migrants' inclination to call emergency call centres. Records of calls made to an emergency call centre by migrants of different age groups and nationalities were reviewed retrospectively.

MATERIALS AND METHODS

A total of 4481 emergency call records from migrants of 33 different nationalities was evaluated between 2017 and 2021.

RESULTS

Migrants called the emergency call centres mostly for medical reasons, and most of their calls resulted in referrals to hospitals. Pain, fever, nausea, and vomiting were among the most common medical reasons for emergency calls. The majority of the calls were in the green triage category, and the calls spread over the week.

CONCLUSION

The results showed that migrants use emergency call services in non-emergency situations. The study recommended enhancing migrants' knowledge of when and how to utilise emergency call centres and making health planning to meet their specific needs.

Cross-border strategies for access to healthcare in violent conflict - A scoping review

Background

The geographical reconfiguration of healthcare systems in times of violent conflict is increasingly being recognised in academic literature. This includes conflict-induced, cross-border travel for medical treatment. Yet the conceptual approach to this healthcare-seeking behaviour, by a population here referred to as cross-border population, remains poorly understood. This scoping review identifies academic literature on cross-border populations to map the current approach to cross-border populations and to propose a research agenda.

Methods

The study used a scoping review following the Joanna Briggs Institute Scoping Review methodology. We included articles on conflicts between 1980 and 2019.

Results

A total of 53 articles met the inclusion criteria. From these articles, we distinguished four types of studies on cross-border healthcare: Direct analysis, implicit analysis, clinical research, and identification. The 45 articles belonging to the first three categories were then searched for themes specifically relevant to healthcare for cross-border populations and linked with sub-themes such as border crossing time and the types of healthcare available. These themes were structured into three main areas: access to care; quality of care; and governance of care. Our analysis then describes the available knowledge, documented practices, and challenges of cross-border healthcare specifically in conflict settings.

Conclusions

A better understanding of cross-border healthcare systems is required to inform local practices and develop related regional and international policies. While the reviewed literature provides some highlights on various practices of cross-border healthcare, there are many gaps in available knowledge of this topic. To address these gaps, our study proposes a research framework outlining key themes and research questions to be investigated by signposting where major research and operational gaps remain. This facilitates well-directed future work on cross-border therapeutic geographies in the context of armed conflict and furthers understanding of a hitherto largely ignored area of the international healthcare system.

Incidence and demographic characteristics of Syrian Civil War-related amputations: A multi-center study

Objectives

The aim of this study was to identify the causes, levels, and rates of amputations performed in civilians during the Syrian Civil War and to present epidemiological data of the amputees.

Patients and methods

Between August 2017 and February 2019, a total of 363 amputations of 307 amputees (266 males, 41 females; mean age 29.9±13.3 years; range, 6 to 86 years) were retrospectively analyzed in four prosthesis and orthosis centers managed by an international non-governmental organization and serving to individuals who experienced amputation during Syrian Civil War. Level, etiology, number of amputations and distribution of the amputations by years were investigated.

Results

Of the patients, 25.4% were under the age of 18 years. A total of 74% of all amputations were of the lower extremities. Transtibial and transfemoral amputations were the most common amputation levels. Of the amputees, 89.3% reported the cause of amputation as bombing.

Conclusion

Civil amputations during the Syrian Civil War are different from those in other civil wars due to the high rate of bombing-induced amputations and also the high rate of victims under the age of 18 years. Our study results show a high ratio of both lower and upper extremity amputations in these civilians.

Evaluation of Syrian refugees' emergency service admissions in the western region of Turkey

Immigration increases physical, mental, and social health problems. Emergency departments constitute resources that refugees can easily access and where they frequently present. Physicians from every specialty (chest diseases, thoracic surgery, internal diseases, etc.) may be consulted if needed. We aimed to compare demographic data and clinical characteristics of Syrian refugees and Turkish citizens in our emergency department. This study was an observational cross-sectional study. It included patients who presented to the Adult Emergency Department between April 1 and July 1, 2018. The patients were grouped into Syrian refugee and Turkish citizen groups. Patient age, gender, International Statistical Classification of Disease and Related Health Problems (ICD-10) diagnostic codes, and judicial case status were recorded from physician-patient outpatient clinic data records. Disease diagnoses and judicial cases were statistically compared between the two groups. A total of 30,749 patients presented to the emergency department during the study period. Of these, 999 were Syrian refugees. The mean ages of the Syrian refugees and Turkish citizens were significantly different. There were also differences between the two groups in the top five diagnostic codes (M79-Soft tissue disorders, J39-Other disorders of the upper respiratory tract; R51-Headache; R10-Abdominal and pelvic pain; M54-Dorsalgia). A comparison of the judicial cases also revealed a difference in mean age between the groups. Fewer specific disease diagnoses were identified among Syrian refugees. This may be explained by difficulties related to language barriers between the refugees and healthcare personnel.

Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war

Background

In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty.

Methods

This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery.

Results

Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant.

Conclusions

An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.

What is the emergency application differences concerning diseases pertinent to the chest between Turkish citizens and Syrian refugees: A cross-sectional study

AIM

Millions of Syrians were displaced after the Syrian civil war broke in 2011. Turkey hosts the largest number of refugees. This study aimed to describe the disease patterns of Syrian refugees applying to an emergency department.

MATERIAL AND METHODS

The study included patients who presented to an emergency department between 2017 and 2018. Study data were retrieved from the hospital's electronic medical records registry. The main study outcome was the ICD-10 codes pertinent to "chest diseases." Additionally, analyzed data were nationality, age, sex, triage status on admission, hospitalization status, and examination date.

RESULTS

The number of emergency department admissions included in the study period was 378 487 persons, of which 14 262 (3.8%) were Syrian refugees. A total of 62 345 diagnoses (16.5%) were related to the respiratory system. Turkish patients had a significantly higher median age than Syrian refugees. Also, there were significantly more women among Syrian applicants, and acute bronchitis and asthma were more common among Syrian patients. However, the hospitalization rates were similar between the two groups. Moreover, Syrian patients had more applications during the summer seasons and had higher "Yellow" labels in the emergency triage.

CONCLUSION

There are differences in the disease patterns of Syrian refugees and Turkish citizens applying to the emergency department. This may be explained by the difficulty in communication which, to our opinion, may be reversed as language barriers are overcome and adaptation to the society is completed over time.

Undeclared civil war? Urban violence in major city in Brazil

PURPOSE

Civil violence is responsible for 2.5% of deaths worldwide; it killed more people in the 21st century than the sum of all wars. This study describes violence victims treated at a trauma reference hospital in Salvador, Brazil and analyzes the impact of different types of interpersonal violence.

METHODS

Interpersonal violence victims admitted between July 2015 and July 2017 were included. The 1,296 patients (mean age: 30.3 years; 90% male) were divided into three groups according to the mechanism of interpersonal violence: 1) beating, 2) firearm injury and 3) stab wound (STW) injury. The groups were compared for the following variables: age, gender, trauma mechanism, Revised Trauma Score (RTS) at admission, need for intensive care unit (ICU) attention, length of hospital stay, need for transfusion of blood products and death.

RESULTS

Gunshot wounds (GSW) were the primary mechanism of injury (59%), followed by beating (24%) and STW (17%). Gunshot wound victims had a lower mean RTS upon admission, increased need for blood products and more Intensive Care Unit (ICU) admissions. Beating victims had the longest mean hospital stay (11.6 ± 19.6 days). The GSW group accounted for 77.4% of all deaths. The in-hospital mortality rate was significantly higher in the GSW group (12.7%) than in the beating group (5.4%) and in the STW group (4.9%).

CONCLUSIONS

Gunshot wound victims are more critical: they require longer ICU stays, more transfusions of blood products and exhibit increased mortality compared with STW and beating victims.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017

OBJECTIVES

Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality.

METHODS

We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017.

RESULTS

Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%).

CONCLUSIONS

The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

Orthopedic treatment, complications, and cost analysis of 67 soldiers injured in a three-month period

OBJECTIVES

This study aims to analyze the musculoskeletal injury types, injury mechanisms, treatment modalities, complications, and costs of 67 consecutive soldiers wounded in the battlefield in Syria civil war over a period of three months.

PATIENTS AND METHODS

This retrospective study was conducted between January 2018 and March 2018 at Kilis State Hospital. The study included 67 male patients (median age 28.5 years; range, 15 to 46 years). Patients' ages, injury mechanisms, fracture types, fracture locations, injury severity scores, mangled extremity severity scores, complications, and treatment costs were evaluated.

RESULTS

Twenty-three patients were injured due to handmade explosives, 21 patients due to gunshots, 16 patients due to landmines, five patients due to rockets, and two patients due to grenades. A total of 35.8% of the patients (n=24) had concomitant trauma. The mean hospitalization period was 10.2 days (range, 1-45 days). A total of 88 treatments were performed on these patients. Thirty-six of these treatments were external fixators, 21 were amputations, 12 were open reduction internal fixations, seven were closed reduction internal fixations, five were intramedullary nailings, three were cannulated screws, three were fasciotomies, and one was an arthrodesis. The treatment costs ranged from 1,577 to 296,286 Turkish Liras. Complications were observed in 17 patients and 11 of them developed infections, three of them had compartment syndrome, and three died during the hospitalization period.

CONCLUSION

The increase in warfare technology is correlated with the severity of military injuries in the battlefields. These injuries still lead to high traumatic amputation rates, high-risk complications, and high costs.

The use of emergency department and outpatient clinics by Syrian refugees

BACKGROUND

Displacement after a war or an armed conflict always leads to unexpected health problems, both among migrating people and in places to which new people have migrated. This study aimed to determine the health care needs and trends of Syrian patients.

METHODS

This retrospective study was conducted in a secondary care hospital in the city of Nevşehir, in central Turkey, between January 2013 and December 2017. All Syrian patients who visited the outpatient clinics and emergency department (ED) were enrolled in the study.

RESULTS

Over a span of five years, 41 723 Syrian patients visited the hospital's outpatient clinics and ED. The patients' median age was 23 (inter-quartile range (IQR) = 7-34), and 57.7% of them were female. In 2017, one-third of the Syrian patients visited the ED, a rate that was higher than that found among local patients (30.3% vs 25.0%, P < 0.001, respectively). The rate of pediatric clinic admissions among Syrian patients was about four times greater than the rate of local patients (20.1% vs 5.2%, P < 0.001, respectively), and Syrians' rate of admission to the obstetrics and gynecology clinic was about three times greater than the rate of local patients' admissions (12.3% vs 4.3%, P < 0.001, respectively).

CONCLUSIONS

This study showed that Syrian patients' visits to the hospital, and especially the ED, are increasing. Further, the needs and expectations of these patients in terms of health care are different from local demands. New approaches should be applied to provide an appropriate use of health care facilities.

Assessment of the health needs of Syrian refugees in Lebanon and Syria's neighboring countries

Background

Health needs of displaced Syrians in refugee hosting countries have become increasingly complex in light of the protracted Syrian conflict. The primary aim of this study was to identify the primary health needs of displaced Syrians in Iraq, Jordan, Lebanon, Turkey, and Syria.

Methods

A systematic review was performed using 6 electronic databases, and multiple grey literature sources. Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was Syrian individuals displaced due to conflict in Syria and its neighboring countries. The outcomes of interest were health needs (i.e. health problems that can be addressed by health services), gaps in health services, training, and workforce. Studies on mixed refugee populations and Syrians displaced prior to the conflict were excluded.

Results

The Lebanon-specific results of the review were validated through two stakeholder roundtable discussions conducted with representatives from primary healthcare centers, non-governmental organizations and humanitarian aid agencies. A total of 63 articles were included in the analysis. Mental health and women's health were identified as the greatest health needs in the region. The most common health problems were Non-communicable diseases in Jordan, women's health in Lebanon and mental health in Turkey. Studies addressing gaps in services found the highest gap in general healthcare services, followed by women's health, mental health, and vaccinations. Sub-optimal training and availability of health workers was also noted particularly in Syria.Results from the stakeholders' discussions in Lebanon showed communicable diseases, women's health and mental health as the main health needs of Syrian refugees in Lebanon. Reported barriers to accessing health services included geographical barriers and lack of necessary awareness and education.

Conclusion

There is a need for an enhanced synchronized approach in Syria's refugee hosting neighboring countries to reduce the existing gaps in responding to the needs of Syrian refugees, especially in regards to women's health, mental health, and communicable diseases. This mainly includes training of healthcare workers to ensure a skilled workforce and community-based efforts to overcome barriers to access, including lack of knowledge and awareness about highly prevalent health conditions.

Emergency Medical Service (EMS) Utilization by Syrian Refugees Residing in Ankara, Turkey

Introduction

Many Syrians have left their country and migrated to other countries since March 2011, due to the civil war. As of March 2016, a total of 2,747,946 Syrian refugees had immigrated to Turkey. Some Syrian refugees have been living in camps, while 2,475,134 have been living in metropolitan areas, such as Ankara.

Study Objective

This study investigated Emergency Medical Service (EMS) utilization among Syrian refugees residing in Ankara.

Methods

This study was a descriptive, cross-sectional database analysis using data obtained from the Department of EMS of the Ankara Provincial Health Directorate.

Conclusion

Five stations in the Altındağ region of Ankara responded to 42% of all calls from Syrian refugees. Prehospital EMS in Ankara have been used mostly by Syrian refugees younger than 18-years-old. Study findings also suggest that medical staff in regions where Syrian refugees are likely to be treated should be supported and provided with the ability to overcome language barriers and cultural differences.

AltınerAO, Tekeli YeşilS. Emergency Medical Service (EMS) utilization by Syrian refugees residing in Ankara, Turkey. Prehosp Disaster Med. 2018;33(2):160–164.

Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations

Policy Points: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror.

CONTEXT

Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. Based on an 18-month follow-up of the Israeli civilian population following the 2014 war in Gaza, we describe and analyze the medical costs associated with rocket attacks and review the demography of the victims who filed claims for disability compensation. We then propose practical lessons to help health care authorities prepare for future confrontations.

METHOD

Using the National Insurance Institute of Israel's (NII) database, we conducted descriptive and comparative analyses using statistical tests (Fisher's Exact Test, chi-square test, and students' t-tests). The costs were updated until March 30, 2016, and are presented in US dollars. We included only civilian expenses in our analysis.

FINDINGS

We identified 5,189 victims, 3,236 of whom presented with acute stress reactions during the conflict. Eighteen months after the conflict, the victims' total medical costs reached $4.4 million. The NII reimbursed $2,541,053 for associated medical costs and $1,921,792 for associated mental health costs. A total of 709 victims filed claims with the NII for further support, including rehabilitation, medical devices, and disability pensions.

CONCLUSION

We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror.

Outpatient admissions and hospital costs of Syrian refugees in a Turkish university hospital

OBJECTIVES

To examine the most frequent admitted polyclinics, diagnoses, and the costs of Syrian refugee patient in a Turkish university hospital in the metropolitan city of Istanbul, Western part of Turkey. 

METHODS

Research methodology consist of analyzing outpatient admissions to the Hospital Polyclinics of Faculty of Medicine, Istanbul University, Cerrahpasa, Istanbul, Turkey from January-June 2014. We carried out diagnosis groups as classified in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification, and analyzed the hospital cost of first admission through records based in the hospital information system. 

RESULTS

Median age of 251 Syrian refugee patients is 19 years, inter quartile rate 7-34 years. Patients aged 65 and older compared with those until 18 years and 19 to 64 years aged groups have made statistically significant (p less than 0.001) less hospital admissions. The Most frequented clinic was the emergency clinic. On June there have been significantly (p less than 0.001) more admissions compared with other months. The most common diagnoses were diseases of the respiratory system. The costs of per admission was estimated nearly 48 US Dollar/per patient and the total amount of hospital admissions was 12,031.93 US Dollar. 

CONCLUSION

On the specified dates, the clinics were mostly frequented from Syrian refugees until 18 years group. The most common presenting symptoms are respiratory diseases and most frequented clinic is emergency.

Emergency department visits of Syrian refugees and the cost of their healthcare

The aim of this study was to evaluate the demographic and clinical characteristics of Emergency Department (ED) visits made by Syrian refugees and to assess the cost of their healthcare. This retrospective study was conducted in adult Syrians who visited the ED of Adiyaman University Training and Research Hospital, Adiyaman Province, Turkey, between 01 January and 31 December 2015. We evaluated 10,529 Syrian refugees who visited the ED, of whom 9,842 were included in the study. The number of ED visits significantly increased in 2015 compared with 2010; the increase in the proportion of total ED visits was 8% (n = 11,275, dif: 8%, CI 95%: 7.9- 8.2, p < 0.001). Of this 8%, 6.5% were visits made by Syria refugees and the remaining 1.5% accounted for the visits made by other individuals. Upper respiratory tract infections (URTI) were the diseases most frequently presented (n = 4,656; 47.3%), and 68.5% of ED visits were inappropriate (n = 6,749). The median ED length of stay (LOS) of the Syrian refugees was significantly longer than that of the other individuals visiting the ED (p < 0.001). The total cost of the healthcare of the Syrian refugees who visited the ED was calculated as US$ 773,374.63. This study showed that Syrian refugees have increased the proportion of ED visits and the financial healthcare burden. The majority of ED visits made by Syrian refugees were inappropriate. In addition, their ED LOS was longer than that of other individuals making ED visits.

Retrospective analysis of patients with burn injury treated in a burn center in Turkey during the Syrian civil war

Objectives:

To report the management of burn injuries that occured in the Syria civil war, which were referred to our burn center.

Methods:

Forty-three patients with burns, injured in the civil war in Syria and whom were referred to Dr. Lütfi Kırdar Kartal Educating and Training Hospital Burn Centre of İstanbul, Turkey between 2011-2015 were analyzed in a retrospective study.

Results:

Most of our patients were in major burn classification (93%; 40/43) and most of them had burns >15% total on body surface area. Most of them were admitted to our center late after first management at centers with improper conditions and in cultures of these patients unusual and resistant strains specific to the battlefield were produced.

Conclusion:

Immediate transfer of the patients from the scene of incidence to burn centers ensures early treatment, this factor may be effective on the outcome of these patients.

The Syrian civil war: The experience of the Surgical Intensive Care Units

Objective:

Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre.

Methods:

The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality.

Results:

A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission.

Conclusion:

The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.

Refugees of the Syrian Civil War: Impact on Reemerging Infections, Health Services, and Biosecurity in Turkey

After the Arab Spring uprising, Syria descended into a civil war in 2011. By March 2016, the United Nations reported that 13.5 million Syrians required humanitarian assistance, including 6.6 million internally displaced persons and more than 4.8 million refugees outside of Syria. Turkey is currently hosting the largest number of Syrian refugees-more than 2.7 million. A limited number of refugees are living in camps settled around the border, and others are spread throughout Turkey. This explosive and unexpected increase in the Syrian population in Turkey has had several negative impacts on health and social determinants. The overload of healthcare facilities has led to shortages in childhood immunization programs, drugs, and access to clean water and food supplies. According to Ministry of Health data, more than 7.5 million Syrians were examined at outpatient clinics, and 299,240 were hospitalized; most of those hospitalized were injured and wounded victims who require and have been occupying intensive care units. The refugees generally live in crowded and unsanitary conditions, which may lead to the spread of respiratory, skin, gastrointestinal, and genital system infections. Currently, measles, poliomyelitis, leishmaniasis, and multidrug-resistant tuberculosis are the reemerging infections being most frequently recorded. Multidrug-resistant gram-negative bacterial infections seem to be an increasing problem in gunshot or surgical wounds. Hepatitis A, malaria, and varicella have been seen with a high incidence among the refugees. There are many problems waiting to be resolved for health and living standards in Turkey.

Abdominal injuries in communal crises: The Jos experience

Background:

Abdominal injuries contribute significantly to battlefield trauma morbidity and mortality. This study sought to determine the incidence, demographics, clinical features, spectrum, severity, management, and outcome of abdominal trauma during a civilian conflict.

Materials and Methods:

A prospective analysis of patients treated for abdominal trauma during the Jos civil crises between December 2010 and May 2012 at the Jos University Teaching Hospital.

Results:

A total of 109 victims of communal conflicts with abdominal injuries were managed during the study period with 89 (81.7%) males and 20 (18.3%) females representing about 12.2% of the total 897 combat related injuries. The peak age incidence was between 21 and 40 years (range: 3–71 years). The most frequently injured intra-abdominal organs were the small intestine 69 (63.3%), colon 48 (44%), and liver 41 (37.6%). Forty-four (40.4%) patients had extra-abdominal injuries involving the chest in 17 (15.6%), musculoskeletal 12 (11%), and the head in 9 (8.3%). The most prevalent weapon injuries were gunshot 76 (69.7%), explosives 12 (11%), stab injuries 11 (10.1%), and blunt abdominal trauma 10 (9.2%). The injury severity score varied from 8 to 52 (mean: 20.8) with a fatality rate of 11 (10.1%) and morbidity rate of 29 (26.6%). Presence of irreversible shock, 3 or more injured intra-abdominal organs, severe head injuries, and delayed presentation were the main factors associated with mortality.

Conclusion:

Abdominal trauma is major life-threatening injuries during conflicts. Substantial mortality occurred with loss of nearly one in every 10 hospitalized victims despite aggressive emergency room resuscitation. The resources expenditure, propensity for death and expediency of timing reinforce the need for early access to the wounded in a concerted trauma care systems.

Surgical outcomes of a civil war in a neighbouring country

OBJECTIVES

The civil war in Syria began on 15 March 2011, and many of the injured were treated in the neighbouring country of Turkey. This study reports the surgical outcomes of this war, in a tertiary centre in Turkey.

METHODS

159 patients with civilian war injuries in Syria who were admitted to the General Surgery Department in the Research and Training Hospital of the Medical School of Mustafa Kemal University, Hatay, Turkey, between 2011 and 2012 were analysed regarding the age, sex, injury type, history of previous surgery for the injury, types of abdominal injuries (solid or luminal organ), the status of isolated abdominal injuries or multiple injuries, mortality, length of hospital stay and injury severity scoring.

RESULTS

The median age of the patients was 30.05 (18-66 years) years. Most of the injuries were gunshot wounds (99 of 116 patients, 85.3%). Primary and previously operated patients were transferred to our clinic in a median time of 6.28±4.44 h and 58.11±44.08 h, respectively. Most of the patients had intestinal injuries; although a limited number of patients with colorectal injuries were treated with primary repair, stoma was the major surgical option due to the gross peritoneal contamination secondary to prolonged transport time. Two women and 21 men died. The major cause of death was multiorgan failure secondary to sepsis (18 patients).

CONCLUSIONS

In the case of civil war in the bordering countries, it is recommended that precautions are taken, such as transformation of nearby civilian hospitals into military ones and employment of experienced trauma surgeons in these hospitals to provide effective medical care. Damage control procedures can avoid fatalities especially before the lethal triad of physiological demise occurs. Rapid transport of the wounded to the nearest medical centre is the key point in countries neighbouring a civil war.