Experiences of healthcare workers displaced by conflict: lessons from past conflicts and implications

Background

Conflicts cause mass displacement, including of healthcare workers (HCWs). Understanding experiences of HCWs over the displacement trajectory, from push factors out of conflict zones, to barriers and facilitators in transit and host countries, is key to developing support mechanisms and informing policy discussions regarding return and reintegration.

Methodology

We systematically reviewed 6 academic databases and grey literature using combined search terms for HCWs, displacement, conflict, and experiences to identify English-language literature documenting personal or professional experiences of HCWs displaced by conflict, published between 1945 to 2020. Open coding and thematic analysis were used to identify emerging themes. Quality appraisal was conducted.

Results

25 publications from academic journals, snowballed references, and grey literature from 10 geographical contexts and various types of HCW met inclusion criteria, many from conflicts in the Middle-East. 5 themes emerged: Conflict drives displacement: HCWs fled due to direct violence and deteriorating working conditions caused by increased workload, depleting resources, workforce attrition and attacks on healthcare. Giving back: Refugee HCWs were determined to continue working but had to do so informally or by working with humanitarian agencies. Personal and professional integration in host countries: refugee HCWs overcame barriers to relicense after which they reported disadvantage in job applications due to professional gaps and discrimination; many ended up working under-qualified jobs. Psychological toll on HCWs was pronounced. Prospects on return: HCWs desired to return to their home countries but feared political instability and violence.

Conclusions

Policies which support HCW retention during conflict, integration into host health systems, and encourage return post-conflict must be implemented. Further research is required to understand the individual and systemic support mechanisms required.

Key messages

Displaced HCWs experience many personal and professional challenges. Policies that support HCWs across the displacement trajectory and support return and post-conflict system rebuilding are required.

Dapagliflozin in type 2 diabetes: effectiveness across the spectrum of disease and over time

BACKGROUND

Despite many available therapies, patients with type 2 diabetes mellitus (T2DM) frequently do not achieve/maintain glycaemic control. Furthermore, side effects such as hypoglycaemia and weight gain may limit therapy choices. Dapagliflozin, a selective sodium-glucose cotransporter-2 inhibitor, reduces hyperglycaemia by increasing glucosuria independently of insulin, representing a novel approach in T2DM. Dapagliflozin efficacy, safety and tolerability were evaluated across a wide range of clinical trials.

METHODS

Dapagliflozin 10-mg efficacy data from (i) two short-term, active-comparator studies (vs. metformin-XR over 24 weeks and vs. glipizide over 52 weeks), (ii) pooled 24-week analyses of five placebo-controlled trials (as monotherapy or add-on therapy), and (iii) long-term studies over 2 years; dapagliflozin 5- and 10-mg pooled safety data from 12 placebo-controlled trials; and cardiovascular safety and malignancy data from 19 dapagliflozin studies were evaluated.

RESULTS

In treatment-naïve patients (baseline HbA1c 9%), dapagliflozin reduced HbA1c (-1.45%) similarly to metformin-XR (-1.44%). In metformin-treated patients (baseline HbA1c 7.7%), dapagliflozin achieved a clinically significant reduction (-0.52%) similar to glipizide (-0.52%). In pooled 24-week analyses, dapagliflozin vs. placebo differences in HbA1c, weight and systolic blood pressure (SBP) were -0.60%, -1.61 kg and -3.6 mmHg, respectively. At 2 years, dapagliflozin vs. placebo differences in HbA1c and weight were -0.44 to -0.80% and -2.41 to -3.19 kg, respectively, and vs. glipizide, differences in HbA1c, weight, and SBP were -0.18%, -5.06 kg, and -3.89 mmHg, respectively. Major hypoglycaemia with dapagliflozin was rare (< 0.1%). Urinary tract and genital infections were more common with dapagliflozin, but responded to standard care and rarely led to study discontinuation. Events of renal failure/impairment and malignancies were rare and balanced across treatment groups. Pooled analyses did not indicate that dapagliflozin increased cardiovascular event risk.

CONCLUSIONS

Dapagliflozin improved glycaemic control, decreased body weight, and lowered blood pressure across the spectrum of T2DM disease, with maintenance of these benefits over time.

A comparison of glycaemic variability in CSII vs. MDI treated type 1 diabetic patients using CGMS

OBJECTIVE

To evaluate and compare glucose variability, hypoglycaemic events and daily glycaemic control in well-controlled (HbA1c <or= 7%), type 1 diabetic patients treated with either continuous subcutaneous insulin infusion (CSII) using lispro or multiple daily insulin injection (MDI) using glargine once daily and lispro with meals.

RESEARCH DESIGN AND METHODS

A total of 16 patients with type 1 diabetes receiving treatment with either CSII (eight patients) or MDI (eight patients), all with HbA1c levels < 7%, wore a continuous glucose monitoring system sensor for 3 days to compare the number, duration, timing and severity of hyperglycaemic and hypoglycaemic episodes.

RESULTS

There were several more episodes of hyperglycaemic [blood glucose (BG) >or= 180 mg/dl] and hypoglycaemic (BG <or= 60 mg/dl) excursions observed in patients treated with CSII than MDI. Glycaemic exposure over 150 mg/dl was similar between the two groups. Maintenance of near-euglycaemia as determined by the average amount of time spent within the glucose range of 80-140 mg/dl was marginally significantly better for the MDI than for the CSII group. Although the CSII group had significantly more hypoglycaemic episodes below 60 mg/dl, the average duration of hypoglycaemia was not significantly different for the two groups. Similar percentages of nocturnal hypoglycaemia were seen. There were no reported major adverse events throughout the duration of the study.

CONCLUSION

Well-controlled type 1 diabetic patients treated with MDI had fewer hyperglycaemic and hypoglycaemic excursions than patients treated with CSII.

Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon

BACKGROUND

Currently, little is known about argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in the Arab world, despite emerging evidence on the adverse health effects of argileh smoking and well-established knowledge about the health risks of cigarette smoking during pregnancy.

OBJECTIVES

The present study assesses pregnant Arab women's knowledge of chemical contents and related harmful effects of argileh and cigarettes, their attitudes towards smoking argileh and cigarettes, and their actual smoking of argileh and cigarettes, both before and during pregnancy.

METHODS

A stratified sample of 864 women from 23 health care centers in Lebanon completed a structured, interviewer-administered questionnaire. Information was collected on basic demographic variables, women's knowledge, attitudes, and cigarette and argileh smoking.

RESULTS

Women were partially knowledgeable about the health risks of cigarette smoking, knew little about the harmful ingredients of argileh smoking, and had many misconceptions regarding how argileh worked or how it can produce harm. Attitudes were permissive towards all forms of smoking. Almost one quarter (23%) of participants reported smoking during pregnancy, with 17% smoking only cigarettes, 4% smoking only argileh, and 1.5% smoking both cigarette and argileh.

CONCLUSION

A significant and growing percentage of pregnant Arab women are smoking in Lebanon, with four cigarette smokers for every argileh smoker. Smoking behaviors are empirically linked with important gaps in knowledge and with permissive attitudes. These data may be used to design more effective prevention programs targeting this vulnerable population.

Scintigraphic features of autoimmune thyroiditis

The term autoimmune thyroiditis encompasses multiple inflammatory conditions of the thyroid gland, each with variable clinical manifestations. The more acute forms, silent (painless) thyroiditis and postpartum thyroiditis, are associated with transient hyperthyroidism and are sometimes mistaken for Graves disease. The chronic form, Hashimoto thyroiditis (chronic autoimmune thyroiditis), results in goiter and eventual hypothyroidism unless it is recognized and treated promptly. Thyroid uptake measurements and scintigraphic findings (usually obtained with technetium-99m or iodine-123) play a complementary role along with thyroid function testing in differentiating autoimmune thyroiditis from other thyroid diseases, thereby influencing treatment. In some cases, histologic evaluation of biopsy specimens is required to yield the definitive diagnosis. Knowledge of the entire spectrum of these disorders is essential for appropriate case management.

Exercise performance-based outcomes of medically treated patients with coronary artery disease and profound ST segment depression

OBJECTIVES

We sought to determine the relationship between exercise duration and cardiovascular outcomes in patients with profound (> or =2 mm) ST segment depression during exercise treadmill testing (ETT).

BACKGROUND

Patients with stable symptoms but profound ST segment depression during ETT are often referred for a coronary intervention on the basis that presumed severe coronary artery disease (CAD) will lead to unfavorable cardiovascular outcomes, irrespective of symptomatic and functional status. We hypothesized that good exercise tolerance in such patients treated medically is associated with favorable long-term outcomes.

METHODS

We prospectively followed 203 consecutive patients (181 men; mean age 73 years) with known stable CAD and > or =2 mm ST segment depression who are performing ETT according to the Bruce protocol for an average of 41 months. The primary end point was occurrence of myocardial infarction (MI) or death.

RESULTS

Eight (20%) of 40 patients with an initial ETT exercise duration < or =6 min developed MI or died, as compared with five (6%) of 84 patients who exercised between 6 and 9 min and three (3.8%) of 79 patients who exercised > or =9 min (p = 0.01). Compared with patients who exercised < or =6 min, increased ETT duration was significantly associated with a reduced risk of MI/death (6 to 9 min: relative risk [RR] = 0.25, 95% confidence interval [CI] 0.08 to 0.76; >9 min: RR = 0.14, 95% CI 0.04 to 0.53). This protective effect persisted after adjustment for potentially confounding variables. We observed a 23% reduction in MI/death for each additional minute of exercise the patient was able to complete during the index ETT.

CONCLUSIONS

Optimal medical management in stable patients with CAD with profound exercise-induced ST segment depression but good ETT duration is an appropriate alternative to coronary revascularization and is associated with low rates of MI and death.