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.

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 (β = 8.99, p = 0.001) and NSAIDs (β = 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.

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.

Seroprevalence of brucellosis antibodies and associated risk factors among the hospitalized patient, Aleppo, Syria: a hospital-based cross-sectional study

Introduction and importance

Brucellosis is one of the most common infectious diseases in the world, especially in developing countries. Recent reports show that Syria is among the top ten countries where brucellosis is most prevalent. The purpose of this study is to estimate the seroprevalence of brucellosis antibodies among the hospitalized patients, in one of the largest hospitals in northern Syria.

Materials and methods

A cross-sectional study was conducted among the hospitalized patients. The authors used a questionnaire to collect sociodemographic and brucellosis-related data from the patients. The authors also collected blood samples from these patients to be screened for brucellosis antibodies using Wright Coombs Agglutination and 2-mercaptoethanol tests, during the period from November 2021 and March 2022.

Results

Among the 776 patients who were recruited in the study, the seroprevalence of brucellosis antibodies was 13.1% (n=776). The highest prevalence was among the female sex (16.7%, n=298), middle aged group 12-40 years (24.1%, n=116), and patients with history of brucellosis (30.1%, n=53). Among the positive samples, the findings of 2-mercaptoethanol tests show that (14.7%, n=102) were positive (presence of IgG Antibodies), and (75.5%, n=102) were negative.

Conclusion

This study is the first to describe the epidemiology of brucellosis in northern Syria. It clearly shows high rates of positivity, which reflects immense challenges facing the public health sector in Syria. The best next step in light of this crisis is to raise awareness among population about brucellosis and its risk factor.

Criminological and Psychiatric Profiles of Immigrant and Refugee Offenders: A Retrospective Analysis of Cases in a Forensic Setting

This study aimed to scrutinize the characteristics of immigrant and refugee offenders within our institution, focusing on factors such as immigrant status, country of birth, duration of residence in Turkey, as well as psychiatric, socio-demographic, and criminal profiles. The data were obtained through a retrospective examination of case records referred to the Observation Department of the Council of Forensic Medicine for the assessment of criminal responsibility between 2017 and 2022. The study categorized the cases into two groups: refugees and immigrants, comprising 35 and 22 offenders, respectively. Significant differences in educational levels were identified between immigrants and refugees within our study group (p < .001). Notably, drug use disorders were more prevalent among refugees, whereas alcohol use disorders were more common among immigrants, with statistical significance (p < .005). During forensic psychiatric assessments, 57.1% of refugees and 54.5% of immigrants required interpretation services. The most prevalent offense in the refugee group was homicide (37.1%), followed by child sexual abuse (28.6%). In contrast, homicide (31.8%) and theft and extortion (22.7%) were the most common offenses for the immigrant group. Six cases (10.5%) were judged to have reduced or no criminal liability. Among the cases, 52.6% had a history of prior outpatient psychiatric referrals, with the most frequent diagnosis being atypical psychosis at 10.5%. The findings underscore the necessity for additional research and targeted interventions to address the mental health and criminological complexities confronted by this vulnerable population.

The frequency of NUDT15 rs116855232 and its impact on mercaptopurine-induced toxicity in Syrian children with acute lymphoblastic leukemia

Introduction

Polymorphisms in NUDT15 may result in differences in mercaptopurine-induced toxicity. This study aimed to identify the frequency of the NUDT15 (c.415C>T; rs116855232) polymorphism and investigate the effect of this polymorphism on mercaptopurine-induced toxicity in a population of Syrian patients with childhood acute lymphoblastic leukemia (ALL).

Methods

This is a retrospective study that included children with ALL reaching at least 6 months of maintenance therapy. The NUDT15 genotyping was determined using standard targeted sequencing of polymerase chain reaction products. The odds ratio (OR) for the association between toxicity and genotype was evaluated.

Results

A total of 92 patients were enrolled. The majority of the patients in the study population were low-risk (63.04%), followed by intermediate-risk (25%), and high-risk (11.96%). There were 5 patients (5.4%) with NUDT15 (c.415C>T; rs116855232) CT genotype, and 1 patient (1.08%) with NUDT15 TT genotype, with allele frequencies of C=0.962 and T=0.038. The mercaptopurine median dose intensity was 100%, 54.69%, and 5% for the genotypes CC, CT, and TT, respectively (P=0.009). Early onset leukopenia was significantly associated with the NUDT15 polymorphism (OR: 6.16, 95% CI: 1.11-34.18, P=0.037). There was no association between the NUDT15 genotype and hepatotoxicity.

Conclusion

Approximately 6.5% of the study population exhibited reduced NUDT15 activity. The mercaptopurine dose intensity was considerably low in NUDT15 rs116855232 TT genotype compared with CT and CC. The dosage of mercaptopurine should be adjusted according to the NUDT15 genotype in pediatric patients with ALL.

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.

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.

The Impact of a Web-Based Restorative Dentistry Course on the Learning Outcomes of Dental Graduates: Pre-Experimental Study

BACKGROUND

Restorative dentistry plays a crucial role in dental practice, necessitating professionals to stay abreast with the latest advancements in the field. The advancement of technology has made web-based learning a widely used method of education delivery in dentistry, providing learners with extensive information and flexibility.

OBJECTIVE

This study aims to evaluate how effective an online educational course in restorative dentistry is for dental graduates in Syria.

METHODS

This study used a pre-experimental study design, with pretest and posttest assessments to measure changes in participants' knowledge and skills. A total of 21 dental graduates completed the online course in restorative dentistry, which was hosted on Moodle, using the learning management system of the Syrian Virtual University. Participants were provided with a suggested learning sequence and had the flexibility to navigate the course on their own and at their own pace. The course was developed based on the principles of web course design and web-based course development using the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) general instructional design model. The pretest and posttest assessments consisted of 50 multiple-choice questions with a single correct answer, aligning with the course content. Furthermore, participants were asked to complete a course acceptance survey upon finishing the course.

RESULTS

The results showed a significant improvement in the participants' knowledge of restorative dentistry, supported by a statistically significant P value of less than .05. The effect size of the difference between the pre and posttest indicated that the effect size, as indicated by ω2, demonstrated a significant 62.1% difference between the pre and posttest, indicating a high and statistically significant effect. Furthermore, the value derived from the Haridy obtained work ratio formula indicated that the educational program was effective, with an effectiveness amount of 3.36%. Additionally, 93% (n=19) of respondents expressed confidence in having gained the expected benefits from the educational course upon its completion.

CONCLUSIONS

The findings indicated a notable enhancement in the participants' understanding of restorative dentistry. The participants' high satisfaction rate and positive feedback from the course acceptance survey further emphasize the favorable reception of the web-based learning approach. This study highlights the potential of web-based learning in dental education, opening the door for future research in this area. The findings of this study carry important implications for the design and implementation of web-based educational programs in dentistry, suggesting that such programs can serve as an effective tool for continuous professional development in the field.

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.

The prevalence of menstrual disorders and their association with psychological stress in Syrian students enrolled at health-related schools: A cross-sectional study

OBJECTIVES

Menstrual disorders are among the most prevalent health issues among young female students studying in health science faculties. This study aimed to provide insights into the menstrual patterns among medical faculty students and determine whether stress can be a risk factor for its various disorders.

METHODS

This cross-sectional study was conducted in the Faculties of Medicine, Dentistry, and Pharmacy at the Syrian Private University, Damascus, Syria, between October and November 2022. A total of 980 female students anonymously completed the identification of menstrual problems and the perceived stress scale (PSS) questionnaire. The data were analyzed using SPSS-25.

RESULTS

The mean age of students was 21.52 ± 2.06 years. The most common menstrual disorders in this study were dysmenorrhea (88%), and premenstrual syndrome (87%). A total of 82% had mild to moderate stress, 10% had high stress, and 8% had low stress. Moderate to high perceived stress was associated with an increased risk of PMS (OR = 1.79, P = 0.0037).

CONCLUSION

These findings stress the importance of universities, especially health science faculties, establishing protocols for early detection and intervention in students with stress and menstrual disorders. Implementing stress reduction education and timely counseling, along with preventive measures, is crucial for students' well-being. Further research is needed to refine interventions for this group.

Exploring Women's Religious Coping Strategies and Psychological Impact After the 2023 Earthquake in Syria

This paper examined gender (N = 1406;77.7% women) patterns of religious coping and psychological impact following the devastating 2023 Syrian earthquakes. Measures in this nation-wide convenience sample study included positive religious coping (PRC) and negative religious coping (NRC) using the Brief Religious Coping Scale (RCOPE), and probable PTSD, depression, and anxiety, using the PCL-5, PHQ-9, and GAD-7, respectively. Women reported higher endorsement of PRC items while men higher endorsement of NRC items. Within the women only sample, lower education and lower income, education and younger age predicted PRC and NRC, respectively. NRC was strongly positively associated with PTSD, depression and anxiety; while, PRC was positively associated only with PTSD. These vulnerable women require targeted support to adopt more adaptive religious coping strategies.

Bridging the first-aid knowledge gap: a cross-sectional study of medical scope students in Syria

INTRODUCTION AND OBJECTIVE

Sufficient knowledge required to deal with emergencies at the accident site may not be found in most medical students due to the lack of effective first-aid training in most medical education curricula. This study aims to assess and evaluate medical students' knowledge level in providing first-aid care, especially first-year students.

METHODS

An electronic questionnaire was distributed via social media to 1,855 medical students in October 2020. The knowledge level was assessed based on scores obtained for each clinical scenario requiring first aid and classified as good, intermediate, or weak. Statistical analysis was performed using SPSS software.

RESULTS

The study found that academic year and specialization significantly influence medical students' first-aid knowledge level. However, demographic factors such as gender, university, marital status, housing status, work status, financial condition, and previous first-aid training did not show any significant effect.

CONCLUSION

The level of knowledge among Syrian medical students in providing first-aid care is somewhat limited. Therefore, first-aid courses should be made more accessible to these students, and their effectiveness should be ensured and maintained through frequent updates. Moreover, more attention should be placed on publicizing first-aid knowledge to make life-saving procedures attainable to anyone, anytime and anywhere.

A cross-sectional study

Background and Aims

Healthcare workers in particular frequently report Work-related musculoskeletal diseases (WRMSDs). The purpose of this study is to evaluate the prevalence and features of WRMSDs in residents from different specialties and trainee nurses from educational hospitals in Damascus, Syria.

Methods

A cross-sectional survey was undertaken aiming at the medical residents and the trainee nurses working in the public health sector in 11 hospitals. The sample size was found to be 2016. In this study, a modified version of the Standardized Nordic Questionnaire was employed.

Results

After the inclusion and exclusion criteria was the number of the participants 1855. In general, musculoskeletal pain was in the past week (69%) and the past 12 months (85%). Musculoskeletal pain in medical care practitioners was found to be linked to higher mean age (p = 0.0053) and body mass index (BMI) (p = 0.0437) in the last year. Females had a higher prevalence of WRMSDs than males (p = 0.0036), and those who were married also had a higher prevalence (p = 0.0218). Working longer hours per week and per month were associated with musculoskeletal pain in the previous 7 days (p = 0.0043 and p = 0.0003, respectively).

Conclusion

WRMSD prevalence was 85% among our study participants in the previous year. The most common complaint was lower back pain. Aging, female gender, and increasing BMI have been associated with higher reporting of WRMSDs. Our results suggested that doctors were twice as susceptible to developing WRMSDs as nurses. These results highlight the increasing urgency for ergonomics training programs and effective interventions to reduce WRMSDs and enhance working conditions for healthcare professionals in Syria.

Efficacy of a 2-week therapy with levofloxacin concomitant versus a levofloxacin sequential regimen for Helicobacter pylori infection in the Syrian population: a study protocol for randomized controlled trial

BACKGROUND

Treating Helicobacter pylori is becoming increasingly difficult with the development of bacterial resistance to many established treatment regimens. As a result, researchers are constantly looking for novel and effective treatments. This trial aims to establish the efficacy of levofloxacin-based sequential treatment regimen and concomitant levofloxacin-based regimen as empirical first-line therapy in the Syrian population.

METHOD

This is an open-label, prospective, single-center, parallel, active-controlled, superiority, randomized clinical trial. The recruitment will target Helicobacter pylori-positive males and females between the ages of 18 and 65 to evaluate the efficacy of empirical first-line therapy in the Syrian population. We are planning to recruit up to 300 patients which is twice the required sample size. One hundred fifty individuals will be randomly assigned to undergo either a sequential levofloxacin-based treatment regimen or a concomitant levofloxacin-based regimen. High-dose dual therapy (proton-pump inhibitor and amoxicillin) will be the rescue therapy in the event of first-line failure. The first-line eradication rate in both groups is the primary outcome, and one of the secondary outcomes is the overall eradication rate of high-dose dual therapy in the event of first-line treatment protocol failure. Intention-to-treat analysis and per-protocol analysis will be used to evaluate the eradication rates of Helicobacter pylori for first-line treatment protocols.

DISCUSSION

For the first time in the Syrian population, this randomized controlled trial will provide objective and accurate evidence about the efficacy of a sequential levofloxacin-based treatment regimen.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06065267 . Registered on October 3, 2023. Prospective registered. Enrollment of the first participant has not started yet.

Dietary and smoking habits during the exam period and their effect on the academic achievement among Syrian medical students

BACKGROUND

Dietary habits are crucial for maintaining overall health and have been shown to impact academic performance. However, little research has been conducted on the specific eating, drinking, and smoking habits during the exam period and their effect on academic performance. Therefore, this study aimed to investigate dietary and smoking habits and their relationship with academic performance among medical students at Damascus University. Findings from this study can inform interventions to improve both dietary habits and academic performance.

METHODS

A cross-sectional design was used to investigate the association between dietary habits during the exam period and academic performance among 608 medical students. Data were collected using a self-administered paper-based questionnaire that was randomly distributed across multiple classes. The statistical analysis employed Spearman's rank correlation and multiple linear regression to examine the relationship between the different amounts of diet behaviour during the exams and the reported average students' grades from the last two semesters. The regression model was adjusted for age, sex, residency type, and residency partners.

RESULTS

In both Spearman's rank correlation and multiple linear regression analyses, we observed consistent negative associations between specific dietary habits and self-reported average grades. These included daily consumption of tea (B = -0.334, p = 0.022), instant coffee (B = -0.682, p = 0.001), and weekly fast food consumption (B = -0.583, p = 0.038). Notably, traditional coffee was found to be significant in the Spearman analysis but did not exhibit significance in the regression analysis. Furthermore, the regression analysis revealed a negative association between water pipe consumption and academic performance (B = -0.700, p = 0.049). No significant association was observed between other dietary habits, cigarette smoking, and academic performance.

CONCLUSIONS

The study highlights a negative, but weak, association between academic achievement and specific dietary habits during the exam period. However, further longitudinal studies are needed to establish causal relationships. Additionally, the study suggests exploring the impact of other habits such as study and sleeping habits, which may have a more significant impact on academic achievement.

Post-quake call for action: developing core competencies matrix for Syrian health workers in emergency time

BACKGROUND

The recent earthquake in Syria has caused widespread devastation, leading to extensive damage and loss of life. Considering the diverse range of disasters and conflicts that have affected Syrian society, health workers must possess essential competencies to effectively manage various types of disasters, including earthquakes. Therefore, this study was undertaken to identify the specific competencies required by Syrian health workers to respond efficiently and effectively to earthquakes.

METHODS

An exploratory qualitative study was conducted at the Medical Education Program MEP of the Syrian Virtual University SVU. Nine members of the research team of the MEP, who represent various health specializations in medicine, dentistry, nursing, and pharmacy, accepted to take part in this study. Among these, three members have been actively involved in providing health care in hospitals and the field during the Syrian earthquake on 6 February 2023. The Delphi process was adopted to identify competencies. Health workers involved in earthquake response were categorized into nine groups including medical doctors, dentists, pharmacists, nurses, psychological support professionals, medical students, allied healthcare professionals, on-site disaster teams, and managers. The final list was accepted if it achieved more than 80% agreement among the participants in the first, second, and final rounds.

RESULTS

The study identified 74 competencies (12 knowledge items, 35 skills, and 27 attitudes) essential for health workers to respond effectively to earthquakes. They are categorized into five domains: "Preparing the team for the rescue process during and, after earthquakes, Implementation of the rescue process, Education and psychological support, Research, and development".

CONCLUSION

A list of earthquake competencies was identified for health workers. It is hoped that this list will enhance a country's resilience and will enable decision-makers to support health workers in acquiring these competencies within a very strained health system in Syria and other countries.

Challenges in diagnosing and managing cystic duct carcinoma: A case report from Syria

INTRODUCTION AND IMPORTANCE

Primary cystic duct carcinoma, an uncommon and aggressive biliary cancer variant, poses a significant challenge in clinical practice. This study examines recent clinical cases, focusing on diagnostics, interventions, and implications in managing this disease, with a prevalence ranging from 0.03 % to 0.05 %, contributing to 2.6-12.6 % of extrahepatic biliary neoplasms.

CASE PRESENTATION

A 57-year-old male, a smoker with hypertension and hyperuricemia, presented symptoms of severe upper right abdominal pain, jaundice, and altered stool color. Diagnosis revealed ulcerated papillary adenocarcinoma invading all gallbladder layers (2.5 cm). Surgical resection and Roux-en-Y anastomosis were performed. Histopathological examination showed invasive tumor proliferation, preserved lymph node architecture, and severe hepatic microsteatosis. Lymph nodes were tumor-free, and a benign hepatic biopsy (0.5 cm) displayed chronic portitis. The final diagnosis confirmed cystic duct carcinoma, emphasizing the complex diagnostic and therapeutic aspects in biliary cases.

CLINICAL DISCUSSION

The clinical discussion unveils the complexities associated with primary cystic duct carcinomas. Emphasizing the necessity of a multidisciplinary approach, this case highlights the importance of efficient management strategies-from initial diagnosis to surgical intervention-in dealing with this challenging malignancy.

CONCLUSION

In conclusion, this case underscores the intricate nature of primary cystic duct carcinomas. It accentuates the essential role of a multidisciplinary approach, urging the need for continuous research endeavors to further comprehend and enhance the treatment methodologies for this rare and complex malignancy.

Decision-Making, Violence, Resistance, and Love: Contested and Complicating Narratives of Syrian Marriages

Within scholarly literature as well as reports from humanitarian actors, including international nongovernmental organizations (NGOs), United Nations agencies and local NGOs, Syrian marriages are often described in static, essentialist ways that reinforce Orientalist assumptions. Based on feminist ethnographic research with Syrian women and men in Jordan, this article explores marriages in historical and intersectional context, before and during displacement. The article challenges common representations of Syrian marriages and advances how Syrian women's power and agency are understood. It emphasizes women's role in deciding to marry (or not) and discusses violence and love in marriage and resistance to proposed love marriages.

Assessing social accountability perspectives among Syrian medical students: a cross-sectional study

BACKGROUND

Social accountability (SA) within medical education signifies a commitment to address critical regional, societal, and national issues through educational, research, and service activities. In resource-limited regions, marginalized communities face barriers to accessing quality healthcare, and the concept of SA is often poorly understood by students. This study aims to investigate the perspectives, awareness, and comprehension of Syrian medical students regarding the concepts and principles of SA.

METHODS

This cross-sectional online study was conducted in Syria from June 1st to July 25th, 2023, to assess the perspectives on SA among medical students enrolled in pre-clinical and clinical phases from the 3rd to the 6th year, encompassing both stream I and stream II. The questionnaire included three parts: consent and introduction, socio-demographic data, and a 12-item survey assessing social accountability. Data were analyzed using Statistical Package for the Social Sciences software version 24 (SPSS 24).

RESULTS

A total of 1312 medical students (62.3% females vs. 37.7% males) participated in our analysis. Less than half of the participants (45.7%) reported that their institution had a limited social mission statement regarding the communities they serve. However, only 39.6% reported that their curriculum partially reflected the needs of the population they serve. A mere 7.5% and 6.8% of respondents indicated that their school had excellent community partners and stakeholders shaping their institution, and they learned significantly about other cultures and social circumstances in the medical context through their curriculum. About 24.1% reported that their institution required them to engage in a substantial amount of community-based learning, and 37.4% believed that their class reflected a good representation of socio-demographic characteristics of the reference population. A significant portion of the participants (44.3%) stated that their school did not encourage them to pursue generalist specialties, and 12.7% felt that their institution did not have a positive impact on the community. Among the included participants, 45.8% had some level of SA status, while 37.7% indicated good SA status. Age, gender, and the phase of study were the only sociodemographic characteristics statistically associated with SA status (p-value < 0.05). The association between the 12 items determining SA and the year of study was statistically significant for seven items (p-value < 0.05). However, adjusted logistic regression revealed no significant correlation between predicting SA status and sociodemographic factors (p-value > 0.05).

CONCLUSION

This study underscores the significant influence of clinical experience and gender on Syrian medical students' perceptions of SA. To enhance these perceptions, medical institutions should tailor support services for different stages of training and target initiatives to engage male students.

Breast cancer quality of care in Syria: screening, diagnosis, and staging

BACKGROUND

The Syrian decade-long war has severely affected the healthcare system, including almost vanishing cancer screening practices, war-destroyed medical facilities, and lack of continuous medical education. This study aims to present data on the affected breast cancer screening practices, methods of diagnosis, and stages distribution in Syria.

METHODS

Medical charts of breast cancer patients treated at Albairouni University Hospital between January 2019 and May 2022 were retrospectively reviewed. Eligible patients were women diagnosed with primary breast cancer. Exclusion criteria included females receiving neoadjuvant chemotherapy and incomplete charts. Data regarding the patient's age, city of residence, marital status, number of children, smoking habits, method of diagnosis, tumor size (T), lymph nodes (N), and distal metastasis (M) were collected. We used Microsoft Excel and Statistical Package for the Social Sciences (SPSS) to analyze data. Descriptive methodology (frequency [n], percentage) was used.

RESULTS

The number of charts reviewed was 4,500. The number of remaining charts after applying the exclusion criteria was 2,367. The mean age was 51.8 (SD = 11.3). More than half of the patients (58.3%) came from outside Damascus -where the hospital is located- and its suburbs. Less than 5% of the population detected cancer by screening mammography. Only 32.4% of patients were diagnosed by a biopsy, while surgical procedures (lumpectomy and mastectomy) were used to diagnose 64.8% of the population. At the time of diagnosis, only 8% of patients presented with local-stage disease (stages 0 & I), 73% had a regional disease (stages II & III), and 19% had metastatic breast cancer (stage IV).

CONCLUSION

Our retrospective chart review analysis is the first comprehensive review in Syria for female breast cancer patients. We found a significant low percentage of patients diagnosed based on a screening mammogram, much higher surgical biopsies rather than a simple imaging-guided biopsy, and much lower than the national average of early-stage disease. Our alarming findings can serve as the base for future strategies to raise the population's health awareness, create more serious national screening campaigns, and adopt a multidisciplinary approach to the disease in Syria.

Assessment of Paediatric Forensic Cases Under the Age of 18 Who Presented to the Emergency Clinic: The Case of Kilis, a Border City with Syria

AIM

This study was conducted to determine the paediatric forensic cases under the age of 18 from of the year of the outbreak of war.

DESING AND METHODS

The population of the study included 16,970 people under the age of 18, who were accepted as forensic cases among 88,052 cases, who presented to the emergency department of Kilis State Hospital between January 2011 and November 2019. The application time of the patients, their nationality, age, gender, their types of application to the emergency department, the event causing the forensic case, and the follow-up and treatment methods in the emergency department were recorded on the standard data entry form.

RESULTS

Among all the paediatric forensic cases, it was determined that 52.0% were Syrian, 70.8% were boys, 30.0% were in the age range of 11 and 15 years and 20.5% had an outpatient treatment.

CONCLUSIONS

In this study, although juvenile forensic rates are consistent with the literature, the higher forensic cases of Syrian nationality was determined as a striking result.

PRACTICE IMPLICATIONS

Today, considering extraordinary situations such as wars and armed conflicts, more refugees may benefit from Turkish healthcare services in the in the forthcoming periods and it is important for community health to conduct studies in this field.

Beyond the scars: a qualitative study on the experiences of mastectomy among young women with breast cancer in a country with crisis

BACKGROUND

As breast cancer incidence rises among younger women, there is a knowledge gap regarding the emotional, physical, and social effects of mastectomy, specifically in a crisis-affected country such as Syria. This study aimed to explore these effects on young women with breast cancer in Syria, taking into consideration the cultural significance of a woman's breast as part of her feminine identity.

METHODS

A qualitative design, using semi-structured in-depth interviews with 10 young women with breast cancer who underwent mastectomy, was conducted between June to December 2022.

RESULTS

Thematic analysis was used to analyze the data, and five main themes were identified: (1) psychological and emotional well-being (altered self-esteem and femininity, impact on sexual life and relationships, psychological distress associated with mastectomy, mirror trauma and the need for psychological care); (2) body image and breast reconstruction (the dilemma over reconstruction decision, body image and clothing and lack of access to prosthetic information/services); (3) social and interpersonal factors (lack of marriage choices and society's view and stigma); (4) coping mechanisms with mastectomy effects (family support; faith in god almighty; comparing their situation to others and use of prosthetics) and (5) physical health and functioning (physical effects on mobility and function).

CONCLUSION

Mastectomy has significant physical, emotional, and social consequences on young women with breast cancer, particularly in crisis-affected Syria where access to breast reconstruction is limited. It is crucial for healthcare professionals to understand these impacts, to raise awareness, encourage early detection, and promote less aggressive treatments to improve women's quality of life.

Using machine learning and remote sensing to track land use/land cover changes due to armed conflict

Armed conflicts have detrimental impacts on the environment, including land systems. The prevailing understanding of the relation between Land Use/Land Cover (LULC) and armed conflict fails to fully recognize the complexity of their dynamics - a shortcoming that could undermine food security and sustainable land/water resources management in conflict settings. The Syrian portion of the transboundary Orontes River Basin (ORB) has been a site of violent conflict since 2013. Correspondingly, the Lebanese and Turkish portions of the ORB have seen large influxes of refugees. A major challenge in any geoscientific investigation in this region, specifically the Syrian portion, is the unavailability of directly-measured "ground truth" data. To circumvent this problem, we develop a novel methodology that combines remote sensing products, machine learning techniques and quasi-experimental statistical analysis to better understand LULC changes in the ORB between 2004 and 2022. Through analysis of the resulting annual LULC maps, we can draw several quantitative conclusions. Cropland areas decreased by 21-24 % in Syria's conflict hotspot zones after 2013, whereas a 3.4-fold increase was detected in Lebanon. The development of refugee settlements was also tracked in Lebanon and on the Syrian/Turkish borders, revealing different LULC patterns that depend on settlement dynamics. The results highlight the importance of understanding the heterogenous spatio-temporal LULC changes in conflict-affected and refugee-hosting countries. The developed methodology is a flexible, cloud-based approach that can be applied to wide variety of LULC investigations related to conflict, policy and climate.

Evaluating physicians' awareness and prescribing trends regarding proton pump inhibitors: a cross-sectional study

Introduction: Proton pump inhibitors (PPIs) are commonly used to treat acid-related disorders. Their appropriate use depends on the correct indications from the clinician. Owing to the high incidence of use and misuse, PPIs have been identified as an essential pharmacological class for developing deprescribing recommendations. Therefore, assessing physicians' knowledge and practice regarding PPI usage is critical for paving the way toward targeted recommendations and efforts. Objective: This study aimed to assess Syrian physicians' perceptions of proton pump inhibitors adverse effects, their benefit in upper gastrointestinal bleeding (UGIB) prophylaxis, and how these perceptions are related to PPI prescription practice. Methods: A cross-sectional study was performed using a web-based questionnaire distributed among Syrian physicians in internal medicine between 28 November and 23 December 2022. The questionnaire assessed perceptions and experiences of PPIs, concerns about specific adverse effects, and their effectiveness for UGIB prophylaxis, in addition to the different scenarios used to determine the best practice for appropriate treatment to manage minimal, mild, moderate, and high-risk UGIB patients. Results: A total of 473 participants completed the questionnaire, with median age ±SD was (28.46 ± 4.58), and most participants (83.3%) were residents. Approximately half of the participants (45.5%) agreed that discussion assistance was provided to continue or terminate PPIs properly. Only 8.9% were very familiar with published evidence of PPI adverse effects. Bone weakening and vitamin B12 deficiency were the most frequently reported side effects (81.8% and 79.7%, respectively). However, dementia (0.4%) and mortality (1.9%) were the least reported adverse effects. More than half of the participants (64%) perceived using PPIs to prevent upper GI bleeding. Non-trainee physicians were less knowledgeable about appropriate GERD management than resident physicians (p < 0.001). Conclusion: The study showed a gap between Syrian physicians' perceptions and practices regarding PPI use, which necessitates spreading awareness of updated guidelines for PPI usage and their side effects.

Knowledge, attitudes and intentions of the Syrian pregnant women toward labour analgesia, and its associated factors: a cross sectional study in Syria (2022)

BACKGROUND

During the reproductive period among pregnant women, the worst pain a woman can experience is labour pain. Untreated labour pain has many detrimental effects on the mother and the fetus. Then, the inadequate levels of awareness and attitudes toward labour analgesia among pregnant women are considered a serious concern that influences no-healthy results for both the mother and the baby. Therefore, this research aimed to define the degree of Awareness, Attitude, and intent to use labour analgesia among pregnant women in Syria.

METHODS

We conducted a cross-sectional study from 7 September to 23 October 2022, in which we included Pregnant Syrian women aged 18 and above. The questionnaire was based on a prior study that included verified and validated scales, which consisted of 23 questions separated into four sections. The sample size was calculated using Fisher's formula; however, our study included 638 participants. The data was analyzed using IBM SPSS Version 28.0, using descriptive and binary logistic regression methods.

RESULTS

Among those who had previous deliveries, 39.4% performed a caesarian delivery, and only 1.9% had a delivery at home. Nearly half of the study participants (50.4%) reported adequate knowledge about analgesia for obstetric pain. The inquired pregnant women who had children had more odds of knowledge than participants who had not. Respondents who were childbearing at the health center were more likely to have a good attitude (Adjusted Odds ratio = 4.728, P-value < 0.05, 95%CI: 1.035-21.589) than those who were childbearing at a national referral hospital. Also, the respondents above 31 years were less likely to desire labour analgesia than those aged 18-24.

CONCLUSION

Our results revealed that Syrian pregnant women have a moderated awareness, attitudes, and desire regarding labour analgesia, indicating a serious health problem among this population group. It is recommended that local and global health organizations address the current condition relevant to this issue by implementing healthy educational programmes for Syrian women through coordination with obstetric and gynaecological professionals.

Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan

BACKGROUND

We evaluated community health volunteer (CHV) strategies to prevent non-communicable disease (NCD) care disruption and promote coronavirus disease 2019 (COVID-19) detection among Syrian refugees and vulnerable Jordanians, as the pandemic started.

METHODS

Alongside medication delivery, CHVs called patients monthly to assess stockouts and adherence, provide self-management and psychosocial support, and screen and refer for complications and COVID-19 testing. Cohort analysis was undertaken of stockouts, adherence, complications and suspected COVID-19. Multivariable models of disease control assessed predictors and non-inferiority of the strategy pre-/post-initiation. Cost-efficiency and patient/staff interviews assessed implementation.

RESULTS

Overall, 1119 patients were monitored over 8 mo. The mean monthly proportion of stockouts was 4.9%. The monthly proportion non-adherent (past 5/30 d) remained below 5%; 204 (18.1%) patients had complications, with 63 requiring secondary care. Mean systolic blood pressure and random blood glucose remained stable. For hypertensive disease control, age 41-65 y (OR 0.46, 95% CI 0.2 to 0.78) and with diabetes (OR 0.73, 95% CI 0.54 to 0.98) had decreased odds, and with baseline control had increased odds (OR 3.08, 95% CI 2.31 to 4.13). Cumulative suspected COVID-19 incidence (2.3/1000 population) was suggestive of ongoing transmission. While cost-efficient (108 US${\$}$/patient/year), funding secondary care was challenging.

CONCLUSIONS

During multiple crises, CHVs prevented care disruption and reinforced COVID-19 detection.

The Spectrum of α-Thalassemia Mutations in Syrian Patients

α-Thalassemia (α-thal) is a globally prevalent genetic disorder of hemoglobin (Hb) structure where the rate of α-globin chain synthesis is reduced or absent due to the presence of α-globin mutation(s). The aim of this study is to define the spectrum of α-globin gene mutations and evaluate their allele frequency in a group of α-thal carriers. A total of 55 individuals with possible α-thal patients were referred from the thalassemia centers in Syria. They have unexplained hypochromia and microcytosis. All patients were genetically tested for 21 common α-globin gene mutations using reverse hybridization kit. Seven different α-globin gene mutations and 13 different genotypes were detected in 55 patients. The two most frequently encountered mutations were -α3.7 deletion (47.1%) and --MED mutation (21.4%). The most commonly observed genotype was -α3.7/αα (40%), followed by --MED/αα genotype (21.8%). We determined the most common α thalassemia mutations in the Syrian patients. α-Thalassemia mutations with deletions were mostly observed in our study.

Using a Modified Delphi Method for Identifying Competencies in a Syrian Undergraduate Neonatology Curriculum

OBJECTIVES

There is a global shift toward competency-based medical education (CBME) to equip medical students with essential competencies required to meet healthcare needs. Syrian medical faculties lack a formal competency-based neonatology curriculum for undergraduate medical students. Therefore, our study aimed to develop a national consensus on the required competencies for undergraduate neonatology curricula in Syria.

METHODS

This study took place at the Syrian Virtual University between October 2021 and November 2021. The authors used a modified Delphi method to determine neonatal medicine competencies. A focus group of three neonatologists and one medical education professional identified initial competencies. In the first Delphi round, 75 pediatric clinicians rated the competencies on a 5-point Likert scale. After formulating the results, a second Delphi round was conducted with 15 neonatal medicine experts. To reach an agreement, 75% of participants must score a competency as 4 or 5. Correlation coefficients were used to compare clinicians' first Delphi ratings with experts' second Delphi ratings. Competencies with a weighted response greater than 4.2 were considered essential.

RESULTS

A list of 37 competencies (22 knowledge, 6 skills, and 9 attitudes) was identified after the second Delphi round, of which 24 were considered core competencies (11 knowledge, 5 skills, and 8 attitudes). The correlation coefficient for knowledge, skills, and attitudes competencies was 0.90, 0.96, and 0.80, respectively.

CONCLUSIONS

Neonatology competencies have been identified for medical undergraduates. These competencies aim to help students achieve the required skills and enable decision-makers to implement CBME in Syria and similar countries.

Massive scar contractures in unique presentation: Case report

INTRODUCTION

Scar contractures are a common complication of burn injuries, especially in the head and neck region. This paper presents a case of a middle-aged female who suffered severe scar contracture after a burn injury during the war in Syria.

PRESENTATION OF CASE

A 33-year-old woman with a severe neck scar contracture resulting from a neglected burn injury presented to a plastic surgery department. The contractures extended to the chin, mandible, chest, and upper limbs. The patient underwent contracture release and reconstruction surgery, which involved the removal of the platysma and the placement of split-thickness skin grafts. The patient was discharged after one month of hospitalization. However, burn injuries require immediate and deliberate treatment, which may include reconstructive surgery.

DISCUSSION

Despite various efforts have been made to prevent the development of contractures, the contraction ratio of burn scars is still a badly controlled process, and reconstructive surgery is often indicated. There are many options to achieving the surgery, which vary in complexity. However, there is no preferable strategy and each option has advantages and disadvantages.

CONCLUSION

Reconstructive is complete and technically demanded surgery, which needs special centers and professionals, this leads to poor results, especially in development countries like Syria.

Stress, depression, anxiety, and quality of life among the healthcare workers during COVID-19 pandemic in Syria: a multi-center study

BACKGROUND

The COVID-19 pandemic emerged as an expected source of stress and anxiety as the healthcare workers had to work for long hours in close contact with infected patients, thus increasing the probability of medical errors and threatening the patients' safety. This study aims to measure the levels of depressive symptoms, anxiety symptoms, and stress among Syrian healthcare workers and their quality of life during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted in six central hospitals in Damascus, Syria. Data were collected from 1 to 30 June-2021. The Depression Anxiety Stress Scale-21 (DASS-21) was used to evaluate depression, anxiety, and stress among healthcare workers. Quality of life was assessed using the EUROHIS-QOL 8-item index.

RESULTS

A total of 700 participants were included in this study. 61.6% (n = 431) were males and 38.4% (n = 269) were females. Younger ages (18-29 years old) were significantly associated with higher levels of depression and stress (p < 0.0083). Female healthcare workers had higher significant levels of anxiety (p < 0.05). Significant anxiety and stress levels were reported when healthcare workers had contact with COVID-19 patients, even if they had protective equipment (p < 0.05). Half of the participants (50%; n = 349) reported a good quality of life.

CONCLUSION

Stress levels and depressive symptoms were remarkably higher in healthcare workers of ages 18 and 29 years old, whereas anxiety levels were significantly higher and more severe in female healthcare workers. Moreover, direct interaction with COVID-19 patients was associated with higher levels of stress and anxiety symptoms.

"Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict

INTRODUCTION

Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.

METHODS

We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed.

RESULTS

A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers.

CONCLUSION

Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.

Fighting with words: humanitarian security and the changing role of law in contemporary armed conflict

Violence against humanitarians is a commonplace phenomenon in contemporary armed conflict. This paper examines how the manipulation of international legal principles for political or military purposes, a practice known as 'lawfare', impacts humanitarian security in conflict-affected areas. Drawing on a case study of the Syrian conflict (2011-), it finds that lawfare has been used to legitimate systematic civilian targeting by pro-government forces and to delegitimise the delivery of aid to opposition-held areas of the country. Efforts to use legal measures to promote civilian welfare-by way of sanctions or demands for cross-border humanitarian access-have been taken as evidence of Western attempts to politicise humanitarian considerations and international law. In practice, this has meant increased security risks for aid workers and impunity for those implicated in the violence. The paper concludes by calling for more critical research on lawfare and politicisation of international law as part and parcel of civilian protection in conflict-affected areas.

Pregnancy and delivery characteristics and outcomes in Northwestern Syria: A prospective cohort study

OBJECTIVE

Detail a picture of the current pregnancy and delivery characteristics and outcomes in Northwestern Syria.

METHODS

This is a prospective observational study, using an electronic health information system, from four healthcare centers in two provinces in Northwestern Syria. We classified the population into two groups: Displaced people are those who live inside refugee camps; and residents are housed outside the camps.

RESULTS

We analyzed data from 21 294 pregnant women. Among them 69.6% were displaced. Less than 1% of all care met the standard WHO's antenatal guidelines, and 3.9% met the focused WHO guidelines. Displaced women were more likely to have no antenatal visits (35.8% vs. 25.4%). We found a high rate of anemia (45.8%), prevalence of adolescent pregnancy (20.7%), cesarean-section (25.2%), preterm birth (4.2%), low birth weight (8.3%), and newborn mortality rate within 24 hours of birth (1.2%). Preterm births were more likely to occur in women who had no record of antenatal visits (4.2%) and the prevalence decreased with the increasing number of antenatal visits.

CONCLUSION

We found huge deficiency in perinatal care among all women in this region. We found high cesarean-section rate, anemia, premature birth, newborn mortality within 24 h of birth, and high adolescent pregnancy.

Reporting on the Status of Nutrition Programs of Higher Education in the Syrian Arab Republic: A Current Snapshot

Background

The Syrian Arab Republic (SAR) is experiencing high rates of malnutrition. While many adults experience overweight and obesity, as a direct result of the continuing conflict, SAR is also noted as one of the most food-insecure regions in the Arab world. To combat the health impacts and outcomes related to diet and dietary behaviors, trained nutrition professionals are needed. We aimed to examine current nutrition-affiliated programs offered in post-secondary institutions in the SAR.

Methods

The search was conducted between Jan and Feb 2021. An electronic review of universities and colleges' websites, department webpages, and academic programs' homepages and resources of all the private and public universities in SAR was conducted to find programs related to nutrition, nutrition sciences, and dietetics.

Results

Only 13%, or 4 out of 30 SAR colleges and universities had bachelor's programs in nutrition or nutrition science, and none had nutrition programs at the graduate or terminal degree levels.

Conclusion

A pathway for integration of graduates from nutrition sciences into the healthcare and public health workforce should be defined and an understanding of the value of those with a degree in nutrition should be cultivated in clinical and community care settings. Partnering with existing or creating independent organizations charged with defining the scope of practice and ensuring educational quality and competence of graduating students, as well as readiness to practice as part of a healthcare team or in a public health nutrition role will be integral to moving the nutrition profession forward in the SAR.

Cholera: An Overview with Reference to the Syrian Outbreak

Cholera is an acute type of diarrheal disease caused by intestinal infection with the toxin-producing bacteria Vibrio cholerae. The disease is still endemic in almost 69 countries, accounting for around 2.86 million cases and 95,000 deaths annually. Cholera is associated with poor infrastructure, and lack of access to sanitation and clean drinking water. The current cholera outbreak in Syria is associated with more than 10 years of conflict, which has devastated infrastructures and health services. There were 132,782 suspected cases reported between August 25, 2022 and May 20, 2023 in all 14 governorates, including 104 associated deaths. The recent earthquake in the region has complicated the situation, with an increase in cholera cases, and hindrance to a response to the disease. Climate change has driven a number of large cholera outbreaks around the world this year. The World Health Organization prequalifies three oral cholera vaccines. Cholera treatment mainly depends on rehydration, with the use of antibiotics in more severe infections. This review gives an overview of cholera bacteriology, pathogenesis, epidemiology, clinical manifestations, diagnosis, management, and prevention in light of global climate change and the ongoing outbreak in Syria, which poses a significant public health threat that requires urgent attention.

Geographical Origin, WASH Access, and Clinical Descriptions for Patients Admitted to a Cholera Treatment Center in Northwest Syria between October and December 2022

Background  On September 10, 2022, a cholera outbreak was declared in Syria for the first time in over a decade of protracted conflict. As of May 20, 2023, 132,782 suspected cases had been reported, primarily in northwest and northeast Syria. We aim to provide a detailed description of water sources and clinical status of a patient cohort seen at a cholera treatment center (CTC) in northwest Syria. Methods  We retrospectively identified patients with confirmed cholera who presented to the CTC in Idlib governorate between October 8 and December 18, 2022. Data were obtained from clinical case records and analyzed in R v4.0.4. Results  Ninety-four patients (55.3% men) were treated at the CTC. Thirty-five patients were severely dehydrated (Plan C treatment), 54 had some dehydration (Plan B), and 5 had no dehydration (Plan A). Most patients were between 11 and 20 years old ( n  = 25, 26.6%) or 31 and 40 years old ( n  = 19, 20.2%). Note that 70.2% ( n  = 66) of patients were seen in November 2022 and most were from Harim district ( n  = 44, 46.8%). Public wells ( n  = 46, 48.9%) and water trucking ( n  = 41, 43.6%) were the most commonly used water sources. Note that 76.6% ( n  = 72) did not have access to chlorine-treated water. Forty-seven patients (50%) had more than five water, sanitation, and hygiene (WASH)-related cholera risk factors. Following treatment, six patients were transferred to another treatment center, three died (case fatality rate: 3.2%), and the remainder were discharged. Conclusion  Most patients reported WASH-related risk factors for cholera, reflecting the poor state of WASH in northwest Syria after over a decade of conflict. This relates to the direct and indirect impacts of urban and periurban violence as well as the underfunded humanitarian response. Strengthening WASH and health promotion are important components to control the outbreak.

Evaluation of the Undergraduate Learning Environment at Dental Schools in Syria

OBJECTIVE

The learning environment plays a vital role in dental education. A positive learning environment could improve students' satisfaction, psychosocial well-being, and academic achievement. This study set out to measure the quality of the learning environment according to the Dundee Ready Educational Environment Measure (DREEM) at different dental schools in Syria.

METHODS

The study included dental schools at Damascus University (DU), Tishreen University (TU), and University of Hama (HU). DU and TU are considered 2 of the largest universities in Syria. Students across all years of study were invited to complete an Arabic version of the DREEM questionnaire.

RESULTS

In total, 1205 students completed the questionnaire: 650 were from DU, 309 from HU, and 243 from TU. Cronbach's alpha value of the DREEM instrument was 0.927. The total DREEM score for all universities was 108.8 ± 31.5 (n = 1205), which is 54.4% of the total score; DU scored the lowest on the DREEM scale (105.9 ± 28.5) followed by TU (111.1 ± 34.3) and HU (113.3 ± 34.4). There was a significant difference amongst the 3 universities (P = .001) with a small effect size (eta-squared = 0.01). At the subscale level, students' perception of learning (SPL) at DU and TU was perceived unfavourably, and the social self-perception of students (SSP) was negatively perceived across all universities. Clinical students scored significantly lower than their preclinical counterparts. No significant difference emerged between male and female students.

CONCLUSIONS

This study provides a baseline data on the learning environment at dental schools in Syria. Although the study suggests a more positive than negative perception of the learning environment, Syrian dental schools scored considerably lower than their Arab and international counterparts. Aspects related to SPL and SSP were the most serious areas requiring improvement, and future research should focus on designing proper interventions to address them.

Psychological Support for Earthquake Survivors in Turkey and Syria

Introduction

Thousands of children and families are in danger after two powerful earthquakes and dozens of aftershocks struck the border between Turkey and Syria. Thus, earthquake survivors in Turkey and Syria have an urgent need for psychological help. The objectives of this study were to (1) describe the mental health support services offered to people affected by the earthquakes that ravaged parts of Turkey and Syria, (2) discuss the challenges faced by the psychological support services, and (3) highlight recommendations for improving mental health services for earthquake survivors.

Methods

A questionnaire with open-ended questions was E-mailed to nongovernmental organizations that provide mental health and psychological support to earthquake-affected individuals in Turkey and Syria. The organizations were requested to describe their activities and the obstacles they had to face to deliver these psychological support services. Using content analysis, the gathered statements were examined.

Results

Mental health professionals from 23 nongovernmental organizations responded. The earthquake survivors were mostly provided with Eye Movement Desensitization and Reprocessing and spiritual support. Human resources and financial issues were the most reported concerns among the organizations that responded to the current study.

Conclusions

While dealing with the long-term consequences of a disaster, it is essential to coordinate the efforts of many organizations.

Assessment of attitudes and practices towards COVID-19 pandemic: a survey on a cohort of educated Syrian population

BACKGROUND

Coronavirus disease (COVID-19) caused the death of millions of people and affected the lives of hundreds of millions worldwide. The WHO recommendations aimed mainly to reduce transmission, minimize infection, and get people vaccinated. Nevertheless, opinions and attitudes about the disease varied. In this study, we evaluated personal attitudes and practices of a cohort of an educated Syrian population, after several waves of infection with COVID-19 and the release of different types of vaccines.

METHODS

A cross-sectional internet-based survey was launched in January 2022.The survey queried the participants' personal experience, attitudes, practices towards COVID-19, and vaccination.

RESULTS

The study included 408 individuals. The respondents were mainly females (72.6%), 20-29 years old (39.2%), and college graduates (59.3%). A large proportion (89.7%) reported having been infected at least once during the pandemic; a significant association was found with age (p = 0.001). Nearly half of the respondents got vaccinated; the majority were > 40 years old. Opinions differed regarding the effectiveness and safety of the vaccines; only a small percentage of the participants (17.4%) thought all vaccines were effective and safe. Remarkably, the level of education did not significantly dominate the participants' attitudes or practices towards the COVID-19 pandemic. Approximately half of the respondents (44.9%) stated their lives were affected by the pandemic and over the third were worried (38%). A significant association was detected with gender in favour of females. Most of the participants have taken at least one precautionary measure to limit the infection.

CONCLUSION

The level of education did not significantly dominate the participants' attitudes or practices towards the COVID-19 pandemic. Female respondents were more cautious, concerned and committed to taking precautionary measures regardless of their education level. However, their unwillingness to receive the vaccine raises significant concerns. Efforts should be made to emphasize the importance of immunization, the safety and effectiveness of vaccines, and encourage vaccination among individuals.

Policy versus practice: Syrian refugee doctors in Egypt

The COVID-19 pandemic has renewed interest in streamlining processes which allow refugee doctors and other healthcare workers to make up for the shortfall in healthcare delivery, which many countries are facing increasingly. The protracted conflict in Syria is the biggest driver of forced displacement internationally with refugees, including healthcare workers seeking safety in host countries, however many face challenges to entering the workforce in a timely manner. The majority are in countries surrounding Syria (Lebanon, Jordan and Turkey) however the restrictive labour policies in these countries, particularly for healthcare workers have forced many to look further afield to Europe or the Gulf. Egypt's context is interesting in this regard, as it hosts a smaller number of registered Syrian refugees and was initially welcoming of Syrian medical students and doctors. However, recent socio-political changes have led to restrictions in training and work, leading doctors who initially considering staying in Egypt to increasingly consider it a transit country rather than a destination country. Here, we explore the processes by which Syrian doctors in Egypt can work and how documented policies may differ to practice. We do this through a document review and from the first-hand experiences of the authors.

Community engagement and adherence to COVID-19 prevention measures in Northwest Syria: a systematic review

The COVID-19 pandemic has increased the burden on the collapsing health system in northwest Syria. The situation was exacerbated by the low rates of adherence to preventive measures and acceptance of the COVID-19 vaccine. In this study, we systematically analysed studies related to Risk Communication and Community Engagement programs, and community awareness in northwest Syria in order to determine the most widespread prevention methods, the community's perspectives and knowledge of epidemic prevention, and the factors that prevent effective community engagement and uptake of COVID-19 prevention precautions in an area that has been suffering from the scourge of conflict for more than ten years. Based on the research findings, low adherence to COVID-19 prevention measures is mainly due to external factors related to socioeconomic status, scarcity of resources, and poor living conditions. Therefore, this study suggested that integrated multi-sectoral humanitarian programs that address these factors holistically are more effective than solely public health interventions in involving the community to become an active part of the Risk Communication and Community Engagement programs and ensuring their effectiveness.

Mediastinal liposarcoma: a case report and review of the literature

BACKGROUND

Mediastinal Liposarcoma (ML) is an exceedingly rare neoplasm, accounting for less than 1% of all liposarcomas. Surgical resection is the most effective therapeutic modality, while adjuvant radiation therapy may be recommended for unresectable tumors.

CASE PRESENTATION

This case report presents a rare case of a 52-year-old Syrian male patient with well-differentiated mediastinal liposarcoma (ML) who presented with exertional dyspnea, cough, and weight loss. Imaging studies revealed a large tumor causing extrinsic compression on the right lung, as well as compression of the heart and great vessels. CT-guided biopsy confirmed a diagnosis of well-differentiated liposarcoma, and the patient underwent surgical resection. The patient had a rapid postoperative recovery and was discharged on the fourth day post-operation, displaying an excellent postoperative status. The patient was followed up for 3 months postoperatively with no recurrence.

CONCLUSION

This report highlights the significance of incorporating ML into the differential diagnosis of mediastinal masses, particularly in individuals presenting with exertional dyspnea and weight loss. Furthermore, this report provides a comprehensive review of previously reported cases of ML in the medical literature.

Health system governance assessment in protracted crisis settings: Northwest Syria

BACKGROUND

Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria.

METHODS AND MATERIALS

A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively.

RESULTS

The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach.

CONCLUSION

Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.

The impacts of the Syrian conflict on child and adolescent health: a scoping review

BACKGROUND

The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population.

METHODS

A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence.

RESULTS

A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health.

CONCLUSIONS

The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

Norwegian citizens' responses to influxes of asylum seekers: comparing across two refugee crises

We compared Norwegians' attitudes to immigration, perspective taking, and intergroup behaviors directed at asylum seekers in 2016 (Syrians and Afghans) and 2022 (Ukrainians). We find evidence for a stronger exclusionary response to the asylum seekers in 2016 than in 2022. Attitudes to immigration were more negative in 2016 than in 2022, and skepticism and avoiding asylum seekers was more common. However, the dominant behavior in both years was prosocial (greeting and donating) and Norwegians' willingness to take asylum seekers perspective was similar in 2016 and 2022. These results may reflect an absence of a symbolic threat in 2022 and may be connected to differences in the political rhetoric about asylum seekers in 2015/2016 and 2022.

Experiences of Egypt as a destination and transit country for Syrian refugee healthcare workers: a qualitative study

BACKGROUND

Refugee healthcare workers (HCWs) can make important contributions in host countries, particularly in the wake of the ongoing COVID-19 pandemic, which has exacerbated existing shortages of frontline HCWs. However, refugee HCWs often face challenges entering the labour markets of such countries even where needs exist. Syria's decade-long conflict has forced thousands of HCWs from their homes; however, data on this population are limited, impeding the formation of policies that can support them. This study explores the experiences of Syrian refugee HCWs in Egypt.

METHODS

Key informants (KIs) were selected using purposive and snowball sampling method and semi-structured interviews were conducted in person in Cairo and remotely from the UK during July 2019. Interviews were conducted in Arabic and analysed using a combined deductive and inductive thematic analysis framework after transcription into English.

RESULTS

Fifteen KI interviews were analysed. The main emerging themes from the qualitative interviews are those relating to 1. Education, training, and licensing 2. Politics and bureaucracy 3. Societal factors 4. Economic factors. Political changes in Egypt altered opportunities for Syrian HCWs over time; however, refugee HCWs broadly reported acceptance among Egyptian patients and colleagues. Bureaucratic factors which impede the ability of Syrian refugee HCWs to obtain a full license to practice and leave to remain and the absence of clearly defined policies were reported as barriers. Economic factors including the risk of economic exploitation e.g. in the informal sector and financial insecurity were noted to have a negative psychosocial impact.

CONCLUSIONS

This is the first qualitative research study which explores the experiences of Syrian refugee HCWs in Egypt. It adds to the sparse literature on the topic of Syrian refugee HCWs but provides evidence for further discussions on how to support refugee HCWs in Egypt and in other host countries in the region. Though interviews were conducted before the COVID-19 pandemic, the pandemic itself lends urgency to the discussion around refugee HCWs on an international level.

Bioinformatic analysis of KIT juxtamembrane domain mutations in Syrian GIST patients: jigsaw puzzle completed

BACKGROUND

The huge number of detected somatic KIT mutations highlights the necessity of in silico analyses that are almost absent in the relevant medical literature. The aim of this study is to report the mutation spectrum analysis of exon 11 encoding the juxtamembrane (JM) domain of the KIT gene in a group of Syrian GIST patients.

METHODS

Forty-eight formalin-fixed paraffin-embedded GIST tissue samples, collected between 2006 and 2016, were retrieved from the pathological archives and analyzed for KIT exon 11 mutations by DNA sequencing. Structural/functional impact of detected variants was predicted using several bioinformatic tools.

RESULTS

Twenty-one different variants have been detected in intron 10, exon 11, and intron 11 of the KIT gene, eight of which were novel changes. Mutations in exon 11 of the KIT gene were detected in 28 of 48 (58.3%) GIST patients and predicted to be pathogenic and cancer promoting. Specifically, age above 60 was very significantly associated with the negative selection of deletion mutations (p = .007), a phenomenon that points to deletion severity.

CONCLUSIONS

Six bioinformatic tools have proved efficient in predicting the impact of detected KIT variations in view of published structural, experimental, and clinical findings.

Gauging the learning environment at Damascus University Pharmacy School in Syria using the DREEM questionnaire: A cross-sectional study

Introduction: This study was undertaken to provide the first record of evaluation of the educational environment of the Bachelor of Pharmacy program at Damascus University (DU), Syria using the internationally adopted Dundee Ready Education Environment Measure (DREEM) tool and compare it with other pharmacy schools around the world. Methods: A cross-sectional study was conducted at DU Pharmacy School in 2022. The validated DREEM 50-item inventory was added to Google Forms and used to collect data electronically. River sampling and snowball sampling methods were used. Data was collected during the second term between April 2022 and June 2022. Students from all years were included. Results: A total of 269 students completed the questionnaire; that is about 6.7% of the total population. The Cronbach's alpha of the DREEM questionnaire was 0.94. The total DREEM score was 89.8±32.1/200. Senior students scored significantly less on the DREEM scale than their younger counterparts. DU Pharmacy School scored significantly less on the total DREEM score than its other counterparts around the world with a large effect size (d>0.80). All subscales scored below 50% and the lowest scoring subscales were students' perception of learning (SPL=41.8%) and students' perception of the social environment (SSP=42.5%). Conclusions: The findings implied that the educational environment is in need of major improvement, especially in areas related to teaching and learning practices and the general social environment; failure to address the current issues in the learning environment might hinder learning and clinical practice of the future generation of pharmacists. This study provides a quality improvement map which could be used preciously address the areas that need most attention at DU Pharmacy School.