Prevalence and knowledge of polycystic ovary syndrome (PCOS) and health-related practices among women of Syria: a cross-sectional study

Polycystic Ovarian Syndrome (PCOS) is a prevalent metabolic and hormonal disorder affecting women of reproductive age. Limited data exists on Syrian women's PCOS awareness and health behaviors. This study aimed to gauge PCOS prevalence, knowledge, awareness, and health-related practices among Syrian women. A cross-sectional online survey was conducted from 11 February to 27 October 2022, targeting Syrian women aged 18-45. Collaborators from specific medical universities distributed a questionnaire adapted from a Malaysian paper through social media platforms. Out of 1840 surveyed Syrian women, 64.2% were aged 21-29, and 69.6% held bachelor's degrees. Those with a bachelor's degree exhibited the highest mean knowledge score (12.86), and women previously diagnosed with PCOS had a higher mean knowledge score (13.74) than those without. Approximately 27.4% were confirmed PCOS cases, and 38.9% had possible cases. Women with PCOS were 3.41 times more likely to possess knowledge about the condition. The findings suggest a moderate level of PCOS knowledge and health-related practices among Syrian women, emphasizing the need for increased awareness. Consistent local PCOS screening programs, in collaboration with obstetrics and gynecology professionals, are crucial for improving understanding and clinical symptom recognition of this condition among Syrian women.

Behavioral difficulties and associated factors among the 'lost generation' of Syrian children and adolescents

Childhood and adolescence, vital in shaping adult life and society, are profoundly impacted during conflicts like Syria's devastating war. This study explores the prevalence of behavioral disorders in Syrian children and adolescents, examining the influence of war and family-related factors. This cross-sectional study was conducted on children aged 2-17 years at a children's outpatient clinic in Damascus, Syria. We assessed parents' quality of life, war and family-related factors, and behavioral difficulties through parental interviews using two questionnaires: the Arabic version of the Strengths & Difficulties Questionnaire (SDQ) and the brief Arabic version of the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF). 74.67% of children aged 2-4 years and 61.29% of children aged 5-17 years were experiencing behavioral difficulties, with emotional difficulties being the most prevalent ones. Children exposed to kidnapping, family losses, lack of school enrollment, and those with parents having lower education, lower socioeconomic status, and poorer quality of life exhibited higher Total SDQ scores. The high prevalence of behavioral difficulties among children and adolescents in Syria is a major concern, with both direct and indirect war-related factors contributing to this issue.

Exploring associations with depressive and anxiety symptoms among Syrian patients with ankylosing spondylitis undergoing biological treatment: A cross-sectional study

People with ankylosing spondylitis (AS) are vulnerable group to experience mood disorders. It is crucial to identify factors that contribute to depression and anxiety in order to improve outcomes. This study seeks to determine the rates of depression and anxiety in Syrian AS patients, as well as identify potential predictors for these conditions. This cross-sectional study was conducted using convenience sampling at the Biological Treatment Unit of the Rheumatology Department of the Damascus Hospital. Data were collected from face-to-face interviews with patients using validated structural questionnaire. A multivariate linear regression model was used to investigate potential predictive factors of depressive and anxiety symptoms. Of the 103 patients, 49.5% showed clinically significant depressive symptoms, and 36.9 % showed clinically significant anxiety symptoms. Multivariate linear regression indicated that depressive and anxiety symptoms were predicted by job layoff, hip pain, positive history of mental distress, poor quality of life, severe fatigue, and high frequency of sleep disturbance with relatively high explanatory powers. depressive and anxiety symptoms were predicted by disease activity scores but with low explanatory power. This study demonstrated high levels of that depressive and anxiety symptoms among Syrian patients with AS undergoing biological treatment. Poor quality of life, severe fatigue, and high-frequency sleep disturbances are major predictive factors for depressive and anxiety symptoms. Screening for depression and anxiety holds significant importance in the comprehensive management of ankylosing spondylitis even in the context of concurrent biological treatment administration.

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.

Measles Outbreak in Lebanon: July 2023

After the beginning of the Syrian crisis, increased rates of infectious diseases were reported. Lebanon, a neighboring country with a major socioeconomic crisis, witnessed a measles outbreak since July 2023, with 519 reported suspected cases. Half of the cases were under 5 y of age, most of them were unvaccinated. The mass displacement of refugees from conflict areas in Syria to Lebanon and the low vaccination coverage have made the situation more challenging. Further efforts are required in Lebanon to address identified gaps to prevent or at least better control future outbreaks.

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.

Prevalence of fibromyalgia and irritable bowel syndrome and its association with studying medicine, a cross-sectional study in Al-Baath University, Syria

BACKGROUND

The aim of this study is to assess the prevalence rate of fibromyalgia (FM) and irritable bowel syndrome (IBS) among Al-Baath University students and find out whether studying medicine has an association with a higher prevalence rate.

METHODS

The participants of this observational cross-sectional study were students aged 18-30 years from Al-Baath University. A structured self-estimated electronic questionnaire developed by Google Forms was distributed using social media platforms from 15 February to 15 March, 2023. We used The American College of Rheumatology (ACR) 2016 and Fibromyalgia Rapid Screening Tool criteria to assess the prevalence rate of FM. We used The ROME IV criteria to asses IBS prevalence rate.

RESULTS

The final sample size was 800 individuals. The prevalence of IBS in the study population was 26.8%. Overall, IBS-Constipation was the most common subtype, and the prevalence rate was higher among medical students (14%) compared to other colleges (12.8%) (p = .002). The difference in IBS prevalence between males and females was (9.3% vs. 17.5%, p = .283), but this did not reach the statistical significance. The prevalence of FM according to The ACR in the study population was 3.6%. Females had higher prevalence rate than males (3.1% vs. 0.5%, p = .007). The prevalence of FM was also higher in other colleges compared to medicine (2.3% vs. 1.4%, p = .547), but this did not reach statistical significance.

CONCLUSION

We found an increased prevalence of IBS among medical students. The prevalence of FM did not show any relation to studying medicine. We recommend additional prospective studies to assess whether studying medicine could be a risk factor for these disorders or not.

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.

The Ayounkon project: visual impairment, eye diseases and unmet eye care needs in the Syrian refugee population and the hosting community in Lebanon

AIM

To report on the distribution of eye diseases, aetiologies of severe visual impairment/blindness (SVI/BL) and unmet eye care needs of the Syrian refugee population and the Lebanese host community.

METHODS

This retrospective study analysed the data of patients that were examined during the Ayounkon project -an eye health care project offering medical and surgical treatment for Syrian refugees and Lebanese host community in the Bekaa Valley in Lebanon. The project took place in three different primary health care centres and involved cooperation between several NGOs and ophthalmologists working on a voluntary basis. Data was analysed for distribution of eye diseases and aetiologies responsible for monocular and binocular SVI/BL.

RESULTS

A total of 2067 patients were included, 677 were children < 18 years. The most frequent pathologies were ocular allergy (10%), and cataract (7.4%). 158 patients (7.6%) were referred for surgery. Glasses were prescribed for 1103 patients (53.4%), of whom 242 (21.9%) were children of school age. SVI/BL was found in 276 patients (13%). The condition was bilateral in 116 patients (42%). SVI/BL was significantly more frequent in the Syrian population than in the Lebanese (186 patients, 14.8% versus 86 patients, 11.3%; p = 0.04). The main causes for SVI/BL were cataract, keratoconus/corneal decompensation and amblyopia.

CONCLUSION

The Syrian refugee population and the Lebanese host community have a high prevalence of ophthalmic pathologies and SVI/BL. Visual impairment is more prevalent in the refugee population. Our findings underscore the importance of targeted interventions and access to eye care services for these populations.

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.

Benign prostatic hyperplasia and metabolic syndrome; prevalence and association: a cross-sectional study in Syria

BACKGROUND

Benign Prostatic Hyperplasia (BPH) is considered the most common cause of lower urinary tract symptoms in men aged 40 years and older. BPH is related to sex steroids, but there are increasing studies investigating the relationship between the urinary symptoms and the metabolic syndrome. They still have inconsistent results; some reported a significant positive association, while others found no significant association. In this study, we aim to assess the prevalence rate of metabolic syndrome in BPH patients and whether there is an association between symptoms linked to BPH and metabolic syndrome in the Syrian community.

METHODS

The participants of this observational cross-sectional study were benign prostatic hyperplasia patients aged 40-year-old and older from Homs, Syria. An interview questionnaire was performed to collect data from all patients who visited the urology clinic of Homs Military Hospital in the period of January 10 to March 10, 2023. We used the International Prostate Symptom Score (IPSS) to assess the urinary symptoms, and we used the US National Cholesterol Education Program Adult Treatment Panel (NCEP ATPIII) criteria to define the metabolic syndrome.

RESULTS

The final sample size was 426 patients. The overall prevalence of metabolic syndrome was 46.2%. Patients with metabolic syndrome had higher International Prostate Symptom Score compared to patients without metabolic syndrome (21 vs. 18, P < 0.001), and 59.3% of patients with metabolic syndrome suffered from severe symptoms compared to 36.2% of patients without metabolic syndrome who suffered from severe lower urinary tract symptoms (P < 0.001). There was a positive association between (waist circumference, diabetes, triglycerides) (P < 0.001), HDL (P = 0.014) and higher International Prostate Symptom Score. However, there was no statistically significant association between blood pressure and International Prostate Symptom Score (P = 0.879).

CONCLUSION

Our results showed that patients with metabolic syndrome had a higher International Prostate Symptom Score. This idea should be used to design a new benign prostatic hyperplasia/lower urinary tract symptoms treatment.

Communicable diseases in northwest Syria in the context of protracted armed conflict and earthquakes

The earthquakes in Türkiye and Syria in February, 2023, have caused further devastation in northwest Syria-an area already affected by protracted armed conflict, mass forced displacement, and inadequate health and humanitarian provision. The earthquake damaged infrastructure supporting water, sanitation, and hygiene, and health-care facilities. The disruptions to epidemiological surveillance and ongoing disease control measures resulting from the earthquake will accelerate and expand ongoing and new outbreaks of many communicable diseases including measles, cholera, tuberculosis, and leishmaniasis. Investing in existing early warning and response network activities in the area is essential. Antimicrobial resistance, which had already been an increasing concern in Syria before the earthquake, will also be exacerbated given the high number of traumatic injuries and breakdown of antimicrobial stewardship, and the collapse of infection prevention and control measures. Tackling communicable diseases in this setting requires multisectoral collaboration at the human-animal-environment nexus given the effect of the earthquakes on all these sectors. Without this collaboration, communicable disease outbreaks will further strain the already overburdened health system and cause further harm to the population.

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.

The effect of secondhand smoke exposure on dental caries and gingival health among schoolchildren in Damascus, Syria: a cross-sectional study

OBJECTIVE

This study aimed to evaluate the effect of secondhand smoke on dental caries and gingival health among schoolchildren in Damascus, Syria.

MATERIALS AND METHODS

This was a cross-sectional study. It was carried out at government schools in Damascus, Syria. This study included healthy children aged 10 to 13 years old. Schoolchildren were interviewed to answer the researcher-administered questionnaire to obtain answers regarding demographic information and family smoking behavior. A dental examination was performed by a dentist, and the number of decayed (D), missing (M), and filled (F) permanent teeth (DMFT) was scored based on the World Health Organization (WHO) 1997. A gingival examination was performed using the modified gingival index (MGI) and Silness-Leo plaque index (PI) to assess gingival inflammation and plaque accumulation, respectively.

RESULTS

A total of 284 schoolchildren participated. More than half (61.26%) of them were exposed to secondhand smoke (SHS), and about half of them (52.11%) resided in a house with at least one cigarette smoked in a day. About one-third of the passive smokers (33.30%) had poor plaque control, with a statistically significant difference from non-passive smokers (p < 0.05). The multivariate regression model showed that the number of smokers at home was significantly associated with the DMFT score, dental plaque accumulation, and gingival inflammation (p < 0.1). However, the number of cigarettes smoked at home in a day was not a predictor for dental caries and gingival status (p = 1.000).

CONCLUSIONS

Within the limitations of this study, the number of smokers at home appears to have more adverse effects on children's oral health compared to the quantity of smoke inhaled. In addition, SHSe was associated with more dental plaque accumulation among schoolchildren.

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.

Seroprevalence of Hepatitis A, B, and C in Syrian Refugee Children Newly Diagnosed With Cancer

Adult survivors of childhood cancer have an increased incidence of hepatitis due to immunosuppression and frequent blood transfusions. The immunization of children with cancer is critical for hepatitis prevention, however, access to vaccination may be restricted during times of war, such as the Syrian armed conflict. The goal of this study was to assess the pretreatment serological status of hepatitis A, B, and C in 48 Syrian refugee children with cancer diagnosed in our center between 2014 and 2021. The control group consisted of 48 Turkish children with cancer who were age, sex, and disease-matched. Fifty-eight boys and 38 girls, with a median age of 4.8 years, were included. There were 42 patients with hematological malignancies, 20 with central nervous tumors, and 34 with other solid tumors. The frequency of hepatitis A seroprevalence was not statistically different between Syrian and Turkish patients, whereas hepatitis B seroprotectivity was found to be significantly lower in Syrian children with cancer than in Turkish children. Two Syrian patients were hepatitis C virus-positive. Thirty-seven percent and 45% of all patients were seronegative for hepatitis B and hepatitis A, respectively. Our findings support the need for hepatitis screening and, if necessary, vaccination of this vulnerable population before chemotherapy.

Prevalence and risk factors of peri-implant diseases at patient-level: A cross-sectional study in Syria

OBJECTIVES

This research aims to assess the prevalence of peri-implant diseases and to analyze variables of the probable risk at the patient level associated with the occurrence of peri-implant diseases in Syrian patients.

MATERIALS AND METHODS

A cross-sectional study has been carried out on 142 patients with 380 dental implants placed between 2015 and 2021. Patients were invited by phone to return to Damascus University's Periodontology Department for clinical and radiological examination. A descriptive statistical analysis was implemented for the prevalence of peri-implant diseases at the level of the patients. Also, the peri-implant diseases' factors of risk were determined by the multivariate analytical model.

RESULTS

The prevalence rate of peri-implant mucositis and peri-implantitis in patients was 58.5% and 25.4%, respectively. Peri-implant disease is associated with multivariate risk indices, gender female (peri-implant mucositis [OR = 0.269; 95% CI: 0.131-0.552] and peri-implantitis [OR = 0.561; 95% CI: 0.561-0.216]), diabetes (peri-implant mucositis [OR = 3.4; 95% CI: 1.73-12.73]), periodontitis (peri-implant mucositis [OR = 2.409; 95% CI: 1.760-2.613], peri-implantitis [OR = 10.445; 95% CI: 4.097-26.629]).

CONCLUSIONS

Peri-implant diseases are common in the Syrian community. Several patient-level variables (gender female, diabetes, and periodontitis) are associated with peri-implant disease.

Prevalence and Management of Transfusional Iron Overload in Syrian Beta Thalassemia Major Patients Pre and during the Syrian Conflict

Objectives

The primary aim of this study was to evaluate the prevalence of iron overload and the real-world clinical effectiveness of the iron chelation therapies (ICTs) in Syrian patients with transfusion-dependent beta thalassemia major (BTM) prior to and during the ongoing Syrian conflict.

Methods

This single-center, two-stage observational study was conducted at Homs National Thalassemia Center (HNTC) prior to (2009) and during (2019) the armed conflict. The prevalence and the severity of iron overload, as well as the effectiveness of four iron chelation regimens, were assessed using serum ferritin (SF) concentrations as a means of monitoring in two cohorts of BTM patients receiving deferoxamine (DFO), deferiprone (DFP), deferasirox (DFX), or a combination of DFO and DFP therapy in both years. Statistical analyses encompassed one-way ANOVA, Kruskal-Wallis, Mann-Whitney U, and chi-square (χ2) tests for the comparisons of the variables and the frequencies between the two cohorts and subgroups.

Results

We included all eligible BTM patients at HNTC in 2009 (n = 205) and 2019 (n = 172). Only 84 patients from the 2009 cohort were accessible in 2019. Our findings revealed that 98% and 89% of the patients had iron overload (SF ≥ 1500 ng/mL) and comparable elevated median SF concentrations (3868 and 3757 ng/mL) in 2009 and 2019, respectively (P = 0.275). Furthermore, patients on DFO demonstrated the poorest control of iron overload and the highest SF concentrations (4319 and 5586 ng/mL), whereas those on DFX achieved superior outcomes and the lowest SF concentrations (3355 and 2152 ng/mL) in both years. Twenty-six patients from the 2019 cohort received no ICT for six years (from 2012 to 2018) and experienced extremely severe iron overload with SF levels ranging between 4481 and 16,000 ng/mL.

Conclusions

Our findings prove a high prevalence of iron overload and suboptimal chelation outcomes in Syrian BTM patients, both prior to and during the ongoing armed conflict, despite the provision of free ICTs at HNTC. Poor adherence and older age of patients may explain the unfavorable outcomes of DFO and (DFO+DFP) regimens, whereas younger age and higher socioeconomic status may have contributed to the lowest SF and superior outcomes in patients on DFX. This study also demonstrates the crucial role of the National Thalassemia Centers, namely HNTC, in providing health services to BTM patients in times of peace and conflict.

Impact of the Syrian conflict and forced displacement on respiratory health: an analysis of primary data from a humanitarian organisation

BACKGROUND

Despite a decade of conflict, there has been little exploration of respiratory health in Syria, notwithstanding the known impacts of conflict on lung health. Our aim is to explore the burden and trends of respiratory consultations in Syrian American Medical Society (SAMS) facilities in northwest Syria through an ecological analysis.

METHODS

We performed a retrospective review of routinely collected data relating to respiratory presentations in SAMS' facilities between March 2017 and June 2020; we compared data by facility type, infectious versus non-infectious aetiologies and age.

RESULTS

Data were available for 5 058 864 consultations, of which 1 228 722 (24%) were respiratory presentations, across 22 hospitals, 22 primary healthcare centres, 3 mobile clinics and 1 polyclinic. The median number of respiratory consultations per month was 30 279 (IQR: 25 792-33 732). Key findings include: 73% of respiratory consultations were for children; respiratory presentations accounted for up to 38% of consultations each month, seasonal variation was evident; respiratory tract infections accounted for 91% of all respiratory presentations. A steep decrease in consultations occurred between the end of 2019 (160 000) and the first quarter of 2020 (90 000), correlating with an escalation of violence in Idlib governorate.

CONCLUSION

This study presents the largest quantitative analysis of respiratory data collected during the Syrian conflict. It supports the need for improved measures to aid the prevention, diagnosis and management of respiratory conditions during conflict as well as further research to explore the impact of conflict on respiratory health.

Impact of Earthquake on Cardiovascular Health: What Should Cardiovascular Healthcare Providers Anticipate After the Devastating Earthquakes in Turkey and Syria?

Natural disasters like earthquakes have direct and indirect association with major adverse cardiac events. They can impact cardiovascular health by multiple mechanisms not to mention their impact on cardiovascular care and services. Besides the humanitarian tragedy that calls attention globally, we as part of cardiovascular community are concerned with the short and long outcomes of those who survived the recent Turkey and Syria earthquake tragedy. Therefore, in this review, we aimed to draw attention of cardiovascular healthcare providers to the anticipated cardiovascular issues that may arise in survivors on short- and long-term postearthquakes to ensure proper screening and earlier management of this population. With the anticipated increase in natural disasters in future considering climate changes, geological factors, and human activities, the cardiovascular healthcare providers as part of medical community should be aware of the high rate of cardiovascular disease burden that can occur among survivors of earthquakes and other natural disasters, so, they should act accordingly in terms of preparedness measures, adequate response planning starting from services re-allocation to personnel training and enhancing access to medical and cardiac care in both acute and chronic contexts, not to mention screening and risk-stratifying the patients to optimize their management.

Implications for future humanitarian aid missions: Lessons from point-of injury and hospital care for Syrian refugees

BACKGROUND

Warzone humanitarian medical aid missions are infrequent and applying lessons from these missions is vital to ensuring preparedness for future crises. Between 2013-2018, the Israel Defense Forces Medical Corps (IDF-MC) provided humanitarian medical aid to individuals injured in the Syrian Civil War who chose to seek medical assistance at the Israeli-Syrian border. Patients requiring care surgical or advanced care were transferred to civilian medical centers within Israel. This study aims to describe the injury characteristics and management of hospitalized Syrian Civil War trauma patients over a five-year period.

METHODS

Retrospective cohort analysis cross-referencing data from the IDF trauma registry, documenting prehospital care, and the Israel National Trauma Registry, documenting in-hospital care, between 2013 and 2018. Syrian trauma patients hospitalized in Israeli hospitals were cross-referenced between the two registries. Multivariable logistic regression was applied to identify independent factors associated with in-hospital mortality.

RESULTS

Overall, 856 hospitalized trauma patients were included following definitive cross-matching. The median age was 23 years, and 93.3% were males. Blast (n = 532; 62.1%) and gunshot (n = 241; 28.2%) were the most common injury mechanisms. Injury Severity Score was ≥25 for 28.8% of patients and most common body regions with severe injury (Abbreviated Injury Scale≥3) were the head (30.7%) and thorax (25.0%). Intensive care unit admission was required for 40.1% of patients, and the median hospital stay was 13 days. In-hospital mortality was recorded for 73 (8.5%). Signs of shock upon emergency department admission and severe head injury were significantly associated with mortality in the adjusted model whereas age of <18 years was associated with decreased odds for in-hospital mortality.

CONCLUSIONS

Trauma patients hospitalized in Israel following injuries sustained in the Syrian Civil War were characterized by a high prevalence of blast injuries with concomitant involvement of several body regions. Future missions should ensure preparedness for complex multi-trauma, often involving the head, and ensure high intensive care and surgical capacities.

Risk factors for mortality and morbidity in Syrian refugee children with penetrating abdominal firearm injuries: an 1-year experience

BACKGROUND

Despite improvements in technology and surgical techniques, abdominal injuries caused by firearms in children are traumatic with high complication rates and mortality. In this study, factors affecting mortality and complications in penetrating abdominal firearm injuries caused by high-velocity bullets and shrapnel in children as a result of the civil war in Syria were evaluated.

METHODS

This study was conducted as a case series with 53 patients admitted to Kilis State Hospital with penetrating abdominal firearm injuries between January 2016 and February 2017. Patients aged between 6 months and 17 years who suffered penetrating abdominal firearm injuries (PAFI) as a result of the civil war in Syria in the state hospital in Kilis Türkiye border province with Syria and were transferred to our hospital and operated on were included in the evaluation. Patients' sociodemographic information, time to surgery, number of abdominal organs injured, type of firearm causing injury, presence of large vessel injury and extremity injury, presence of thoracic injury requiring thoracotomy in addition to laparotomy, colostomy, penetrating abdominal trauma index, pediatric trauma score (PTS), and shock status were evaluated.

RESULTS

In our study, it was found that a high penetrating abdominal trauma index significantly increased complication rates and mortality (P<0.001 and P=0.002, respectively). In addition, it was found that lower PTSs significantly increased the development of complications and mortality (P=0.001 and P<0.001, respectively). Mortality was not observed in any of the patients with a PTS>8, whereas mortality was observed in 27.3% of patients with a PTS≤8, and this result was statistically significant (P=0.003). Shock sig-nificantly increased mortality, and no patient who was not in shock died (P<0.001). In our study, it was determined that the increase in the number of injured intra-abdominal organs had a significant effect on both complications and mortality (P<0.001 and P=0.002, respectively).

CONCLUSION

The penetrating abdominal trauma index and PTS were found to be effective in predicting mortality and morbidity in pediatric patients with PAFI. It is crucial in this patient group to provide appropriate transport after the first intervention is done rapidly and effectively in conflict zones.

Risk factors for common mental disorders in young refugees from Iran, Somalia and Syria to Sweden

BACKGROUND

Our primary aim was to determine sociodemographic and health-related risk factors for diagnosed common mental disorders (CMDs) among young refugees in Sweden.

METHODS

All young adult refugees from Iran, Somalia and Syria (n = 7192), who were residents in Sweden in 2009, were followed from 2010 to 2013 regarding diagnosed CMDs. Cox regression models were used to compute hazard ratios (HRs) of CMDs with 95% confidence intervals (CIs).

RESULTS

Those arriving as unaccompanied refugee minors had a lower risk of being diagnosed with CMDs (HR: 0.7; 95%CI: 0.6-0.9) than those arriving as accompanied refugee minors. A higher risk of being diagnosed with CMDs was also found in female refugees (HR: 1.3; 95%CI: 1.1-1.5) compared with male refugees. In addition, individuals with a low (HR: 1.7; 95%CI: 1.3-2.3) or a medium (HR: 1.4; 95%CI: 1.1-1.8) educational level were found to have a higher risk of being diagnosed with CMDs compared with individuals with a high educational level. Refugees from Iran (HR: 2.3; 95%CI: 1.8-2.9) had a higher risk of a diagnosis of a CMD than refugees from Somalia. Moreover, refugees with a diagnosis of a mental disorder other than a CMD (HR: 4.2; 95%CI: 2.8-6.1), digestive (HR: 1.5; 95%CI: 1.0-2.2) or musculoskeletal diseases (HR: 1.5; 95%CI: 1.0-2.2) had a higher risk of being diagnosed with subsequent CMDs, compared with those with no such disorders.

CONCLUSIONS

Pre-existing diagnoses of mental disorders other than CMDs, and digestive and musculoskeletal disorders should be carefully considered in clinical assessments to initiate early interventions to prevent CMDs.

The impact of forced displacement: trauma, increased levels of inflammation and early presentation of diabetes in women Syrian refugees

BACKGROUND

Forced displacement and war trauma cause high rates of post-traumatic stress, anxiety disorders and depression in refugee populations. We investigated the impact of forced displacement on mental health status, gender, presentation of type 2 diabetes (T2D) and associated inflammatory markers among Syrian refugees in Lebanon.

METHODS

Mental health status was assessed using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25). Additional metabolic and inflammatory markers were analyzed.

RESULTS

Although symptomatic stress scores were observed in both men and women, women consistently displayed higher symptomatic anxiety/depression scores with the HSCL-25 (2.13 ± 0.58 versus 1.95 ± 0.63). With the HTQ, however, only women aged 35-55 years displayed symptomatic post-traumatic stress disorder (PTSD) scores (2.18 ± 0.43). Furthermore, a significantly higher prevalence of obesity, prediabetes and undiagnosed T2D were observed in women participants (23.43, 14.91 and 15.18%, respectively). Significantly high levels of the inflammatory marker serum amyloid A were observed in women (11.90 ± 11.27 versus 9.28 ± 6.93, P = 0.036).

CONCLUSIONS

Symptomatic PTSD, anxiety/depression coupled with higher levels of inflammatory marker and T2D were found in refugee women aged between 35 and 55 years favoring the strong need for psychosocial therapeutic interventions in moderating stress-related immune dysfunction and development of diabetes in this subset of female Syrian refugees.

[Analysis of Mycobacterium tuberculosis Complex Strains Isolated from the Samples of Patients Living in Northern Syria]

Tuberculosis causes serious mortality and morbidity worldwide each year. A lot of effort and money is spent for the diagnosis and treatment of tuberculosis all over the world. The importance that countries give to health policies and public health is inversely proportional to the incidence of tuberculosis and multidrug resistant tuberculosis. The aim of our study was to evaluate the resistance profiles of Mycobacterium tuberculosis complex strains which were isolated from sputum samples, collected by World Health Organisation from patients living in the northern region of Syria, where health services were disrupted due to the civil war. According to the protocol signed between the World Health Organization and our hospital; sputum samples taken from tuberculosis patients living in Afrin, Azez and Idlib regions or suspected of being resistant to anti-tuberculosis drugs were studied in our hospital. The cultivation process was performed in our laboratory using Löwenstein Jensen media and MGIT-960 system. The susceptibility tests for primary anti-tuberculosis drugs were performed using MGIT-960 system for M.tuberculosis complex isolates. The isolates identified as MDR/RD-TB (multi-drug-resistant-rifampicin-resistant tuberculosis) were sent to National Tuberculosis Reference Laboratory of Public Health Institution of Türkiye for susceptibility testing to first and second line drugs. Mutation and wild-type determination were studied by "Line Probe Assay (LPA)" method to investigate the susceptibility of the isolates to isoniazid, rifampicin, fluoroquinolone and aminoglycoside/cyclic peptide. The results obtained from the patients were collected and evaluated retrospectively from the records. Growth was observed in 18 samples out of 171 sputum samples from 67 patients; 13 isolates were detected as MDR-TB while one isolate was detected as mono RR-TB. The rate of mono RR-TB was 1.5% and the rate of MDR-TB was 19.4%. MUT3 causing rifampicin resistance was detected in 17.9% of the patients, katG/MUT1 causing isoniazid resistance in 17.9% and WT loss causing aminoglycoside/cyclic peptide resistance were detected in 19.4% of the patients. Neither fluoroquinolone resistance nor a mutation leading to fluoroquinolone resistance was detected in the study. When the sputum samples taken from the patients living in Northern Syria were examined, the frequency of MDR-TB was found to be quite high. MDR-TB, which is an important public health problem, was found at high rates due to the internal turmoil in the region and poor accessibility to health services. Since the gene mutations causing drug resistance with the LPA method differ with the conducted studies, it is important to evaluate the dominant gene mutations for determining the TB treatment strategies in the region.

The impact of crisis and COVID-19 on Syrian children growth, health awareness and nutritional practices. a cross-sectional study

BACKGROUND

Despite the great steadfastness that Syria has achieved in the face of more than a decade of stifling crisis followed by the global COVID-19 pandemic, the heavy impacts of these long rough years are certain and crucial on the health and nutrition levels, specially on vulnerable groups like women and children. Moreover, the lack of research and data on health and nutritional status of children within Syria makes it very difficult to draw conclusions and act effectively. The purpose of the current study was to evaluate growth development and give an insight about the public health awareness and nutritional practices among Syrian primary schools children.

METHODS

A cross-sectional study was conducted among private and public primary schools' students aged 6 to 9 years old in Homs governorate in January to April 2021, anthropometric measures were taken and data assessment of socioeconomic background, nutritional practices, and health awareness was achieved by conducting two surveys answered by parents and students.

RESULTS

We defined the total prevalence of obesity (11.8%), underweight (5.6%) and stunting (13.8%), with a significant increased in underweight and stunting prevalence ,(9%, 21.6%) respectively, among public schools' students compared to private schools' students. Differences in nutritional practices and health awareness were recorded between public and private schools' students under socioeconomic impact.

CONCLUSIONS

This study contributes to evaluate the burden of crisis and COVID-19 pandemic on Syrian children growth and health practices in Syria. Improving health awareness and nutritional support among Syrian families to help children meet their growth needs is recommended. Moreover, additional research should be conducted to evaluate micro-nutrients deficiencies and provide appropriate medical support effectively.

Prevalence of cutaneous Leishmaniasis in the Middle East: a systematic review and meta-analysis

Cutaneous leishmaniasis (CL), caused by an obligate intracellular protozoan parasite from the genus Leishmania, imposing a significant burden on underdeveloped countries especially those located in the Middle East. Four electronic databases were searched to evaluate the prevalence of CL in the Middle East. The random effects model (95% confidence intervals (CI)) were applied to determine the overall and subgroup pooled prevalence. Heterogeneity was assessed by Cochran's Q test and I2 statistics. Among 2424 peer-reviewed papers, 37 datasets from 34 studies were included in the current meta-analysis. 285560 individuals were assessed across 9 Middle Eastern countries. The pooled prevalence of CL was estimated at 12% (95% CI 9-15 %; 10718/285560). The highest prevalence rate was observed in Syria (39%, 37-42%), and the lowest one was found in Iraq and Lebanon (0%, 0-1%). The prevalence of CL in studies that applied LST assays had the highest rate (48%, 17-80%). The infection rate in males was similar to females (7%, 4-10%). The prevalence of infection in individuals living in urban areas was higher than in rural areas (14%, 10-19%). The prevalence of CL in the age group 0-15 years was higher than in individuals 16-40 and >40 years (9%, 6-13%). Most of the lesions were found on the face, and single lesions were more prevalent than two and three ones. In conclusion, the occurrence of CL was considerable in Middle Eastern countries. Therefore, more efforts should be made to precisely report the CL in this region for developing appropriate preventive and controlling strategies.  .

Mortality and risk factors associated with peptic ulcer bleeding among adult inpatients of Damascus Hospital, Syria: A cross-sectional study

Peptic ulcer bleeding is associated with significant morbidity and mortality, while monitoring mortality is extremely beneficial to public health, and the latest estimates date back to 2010 for the Syrian population. This study aims to estimate the in-hospital mortality rate and risk factors associated with peptic ulcer bleeding among adult inpatients at Damascus Hospital, Syria. A cross-sectional study with systematic random sampling. Sample size (n) was calculated using the proportional equation: [n = Z2P (1 - P)/d2], with the following hypothesis: Z = 1.96 for the 95% confidence level, P = .253 for mortality in patients hospitalized with complicated peptic ulcers, a margin of error (d) = 0.05, 290 charts were reviewed, and the Chi-square test (χ2 test) was used for categorical variables, and the t test for continuous data. We reported the odds ratio in addition to mean and standard deviation with a 95% confidence. A P value less than .05 was considered statistically significant. Data were analyzed using a statistical package for the social sciences (SPSS). The mortality rate was 3.4%, and the mean age was 61.76 ± 16.02 years. The most frequent comorbidities were hypertension, diabetes mellitus, and ischemic heart disease. The most commonly used medications were NSAIDs, aspirin, and clopidogrel. 74 patients (25.52%) were using aspirin with no documented indication P < .01, odds ratio = 6.541, 95% CI [2.612-11.844]. There were 162 (56%) Smokers. Six patients (2.1%) suffered from recurrent bleeding, and 13 (4.5%) needed surgery. Raising awareness about the risks of using non-steroidal anti-inflammatory drugs may reduce the occurrence of peptic ulcers and, as a result, peptic ulcer complications. Larger, nationwide studies are needed to estimate the real mortality rate in complicated peptic ulcer patients in Syria. There is a lack of some critical data in the patients' charts, which necessitates action to correct.

Impact of comorbidities on hospitalised Syrian patients with COVID-19: a retrospective study

OBJECTIVES

This study aims to compare the clinical manifestations, laboratory findings, outcomes and overall survival time of patients with COVID-19 with and without comorbidities.

DESIGN

Retrospective design.

SETTING

This study was undertaken at two hospitals in Damascus.

PARTICIPANTS

A total of 515 Syrian patients met the inclusion criterion, laboratory-confirmed COVID-19 infection following the Centers for Disease Control and Prevention. Exclusion criteria were suspected and probable cases that were not confirmed with a positive reverse transcription-PCR assay, and patients who self-discharged from the hospital against medical advice.

PRIMARY AND SECONDARY OUTCOME MEASURES

First, assess the impacts of comorbidities on COVID-19 infection in four areas (clinical manifestations, laboratory findings, severity and outcomes). Second, calculate the overall survival time for patients with COVID-19 with comorbidities.

RESULTS

Of 515 patients included, 316 (61.4%) were male and 347 (67.4%) had at least one coexisting chronic disease. Patients with comorbidities compared with no comorbidities were more vulnerable to poor outcomes such as severe infection (32.0% vs 9.5%, p<0.001), severe complications (34.6% vs 9.5%, p<0.001), the need for mechanical ventilation (28.8% vs 7.7%, p<0.001) and death (32.0% vs 8.3%, p<0.001). Multiple logistic regression showed that age ≥65 years old, positive smoking history, having ≥2 comorbidities and chronic obstructive pulmonary disease were risk factors linked to severe COVID-19 infection in patients with comorbidities. Overall survival time was lower among patients with comorbidities (vs no comorbidities), patients with ≥2 comorbidities (vs one comorbidity), and patients with hypertension, chronic obstructive pulmonary disease, malignancy or obesity (vs other comorbidities) (p<0.05).

CONCLUSION

This study revealed that COVID-19 infection had poor outcomes among those with comorbidities. Severe complications, mechanical ventilation usage and death were more prevalent among patients with comorbidities compared with those with no comorbidities.

Epidemiology of poisoning in Syria (1999 through 2020)

INTRODUCTION

Acute poisoning is a significant international public health issue and one of the leading causes of death in the emergency department (ED). In the absence of any previous reports describing the poisoning profile in Syria, we present this study to assess the epidemiological and clinical characteristics of poisoning over 21 years.

METHODS

We collected the data retrospectively from the Syrian Poisons Information Centre (SPIC) from January 1999 until December 2020. The data included patients who had accidental or non-accidental exposure to poisons, either by drugs, medicaments, and biological substances or substances chiefly nonmedicinal sources such as soaps and detergents, corrosive substances, pesticides, and other miscellaneous products.

RESULTS

We collected the data of 120,972 poisoned patients, of whom 52.6% were females, and 47.4% were males. Aleppo governorate reported the highest number of poisoned cases (28.6%), followed by Damascus governorate (19.9%). The highest poisoning rates were recorded in 2020, 2014, and 2010. Pharmaceutical (37.0%) and animal (33.8%) sources were the most common causative agents. The oral route was the route of poisoning in 58.3% of patients, and 33.4% through the skin. The most common poison was scorpion stings 19.5% while the most common cause of death was organophosphates 15.7%.

DISCUSSION

The differences in socioeconomic status, cultural habits, and agricultural and industrial activities between countries have led to a state of fluctuation regarding the most common poisoning agents.

CONCLUSION

Damascus and Aleppo, the two major governorates in Syria, had the highest poisoning cases. Oral administration of pharmaceutical agents was responsible for most of the poisoning cases. The most common individual poison was the scorpion poison, while the top killer was organophosphates.

The culturally and contextually sensitive assessment of mental health using a structured diagnostic interview (MINI Kid) for Syrian refugee children and adolescents in Lebanon: Challenges and solutions

Elevated rates of mental health difficulties are frequently reported in conflict-affected and displaced populations. Even with advances in improving the validity and reliability of measures, our knowledge of the performance of assessment tools is often limited by a lack of contextualization to specific populations and socio-political settings. This reflective article aimed to review challenges and share lessons learned from the process of administering and supervising a structured clinical interview. We administered the MINI International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and used the Clinical Global Impression (CGI) severity scale with N = 119 Syrian refugee children (aged 8-17) resident in ITSs in Lebanon. Qualitative data were derived from supervision process notes on challenges that arose during assessments, analyzed for thematic content. Five themes were identified: (1) practical and logistical challenges (changeable nature of daily life, competing demands, access to phones, temporary locations, limited referral options); (2) validity (lack of privacy, trust, perceptions of mental health, stigma, false positive answers); (3) cultural norms and meaning (impact of different meanings on answers); (4) contextual norms (reactive and adaptive emotional and behavioral responses to contextual stress); and (5) co-morbidity and formulation (interconnected and complex presentations). The findings suggest that while structured assessments have major advantages, cultural and contextual sensitivity during assessments, addressing practical barriers to improving accessibility, and consideration for inter-connected formulations are essential to help inform prevalence rates, treatment plans, and public health strategies.

The delay of breast cancer diagnosis and management during the Syrian war

BACKGROUND

Early detection of breast cancer (BC) is crucial for better prognosis especially in low-income countries, where advanced cancer stages are common. The Syrian war severely affected the healthcare system restraining the proper timely management of BC cases. We aimed to investigate the prevalence of patient- and system-related delays in BC diagnosis and management in Syria in addition to their predisposing characteristics and impact on the staging.

METHODS

This is a cross-sectional retrospective cohort study on patients followed by the BC unit at Al-Bairouni main cancer center in Syria. The data were collected through personal interviews and retrospective revision of patients' records.

RESULTS

A total number of 519 patients were recruited; A quarter of them (n = 126) reported more than three months intervals between symptoms recognition and presentation to a physician. Additionally, 72 (13.9 %) patients received a confirmed diagnosis more than three months after presentation, and 12 (2.3 %) started treatment at least three months after the diagnosis. Patients who suffered from war-related inaccessibility to healthcare were 2.55 [1.58-4.11] times more likely to report significant delays. Additionally, the most common self-reported reasons for patient delay were the lack of awareness, which was more evident for less common symptoms like the change in breasts size, and shyness. Patients who reported significant delays were more likely to receive an advanced-stage diagnosis.

CONCLUSION

War-related inaccessibility to healthcare rendered a significant group of BC patient susceptible to evident delay. This combined with significant system delays because of the overwhelmed hospitals, high costs, and insufficient personnel, equipment, medications, and training. However, personal factors, which might not be directly related to the war, like the inadequate awareness of rare symptoms and shyness still necessitate urgent interventions on the public knowledge and performed screening practices. These delays associated with receiving advanced-stage diagnoses and minimizing them can return better prognoses.

Stunting and Overweight Prevalence Among Resettled Yazidi, Syrian, and Iraqi Pediatric Refugees

This cohort study compares growth abnormalities between Yazidi and non-Yazidi pediatric refugees.

The epidemiology of in-hospital burn patients in a tertiary hospital in Damascus, Syria. A retrospective cohort study

BACKGROUND

Syria has been facing a dreadful crisis for the past 11 years, which has had a significant toll on the healthcare system of the country, and its ability to adequately manage acute injuries. In this research, we study the epidemiology and outcomes of burn patients admitted to the burn center of Al-Mouwasat Hospital in Damascus, Syria.

METHODS

A retrospective cohort research was conducted from January 2017 to December 2021. All accessible paper-based medical records of burn injury patients admitted to the hospital were evaluated. ABSI score was used to classify injury degrees. Chi-square test and logistic regression model were used to study the association between demographic variables and outcomes.

RESULTS

Of the 641 patients, 367 (57.3%) were males and 274 (42.7%) were females. Children represented more than half of our sample 377 (58.8%). The most common cause of burns was flame 393 (61.3%), followed by scalding 199 (31.0%). Most of the patients had a more than 10% TBSA of burns 511 (79.7%). 209 (32.6%) patients had a moderate ABSI score, followed by moderately severe in 149 (23.2%) patients. Children, patients who had high ABSI scores, and those who needed respiratory support were more likely to die than others 2.545 (1.079-6.004), 9.208 (4.061-20.879), respectively.

CONCLUSION

Death was the outcome of third of the hospitalized patients. Furthermore, Children made up more than half of the sample, and had the highest rates of leaving the hospital against medical advice. These results underline the importance of an updated nationally uniformed protocol for the management of burn patients.

Assessment of the Possible Correlation between the Presence of Helicobacter Pylori Infection and Hairy Tongue Lesion in a Group of Patients in Syria: A Cross-Sectional and Pilot Study

BACKGROUND

This study aimed to evaluate the correlation between the presence of hairy tongue and H. pylori infection in patients referring to their blood test based on the serum levels of anti-H pylori IgG antibodies.

METHODS

This cross-sectional study was conducted in the Department of Oral Medicine, University of Damascus Dental School, between February 2021 and January 2022. The sample size of 40 patients (23 males, 17 females), whose ages ranged from 20-79 years with a mean age of 41.5 ± 12 years, was calculated using the G*power 3.1.3, with a statistical power of 80% and a significance level of 0.05. The hairy tongue index was assessed by a visual method based on observing the dorsum tongue appearance. Then, a blood test was performed to detect the presence of H. pylori by Immulite 2000 XPi. Statistical analysis was performed using SPSS software 22.0, Chi-square.

RESULTS

The prevalence of hairy tongue was higher among males (75%) as compared to females (25%) and was found to be statistically significant (p = 0.026). The hairy tongue lesions were found to be least in the 20-39 age group and most prevalent in the 40-59 age group, without statistically significant correlation. H. pylori infection was detected positive in 70% and negative in 30% of hairy tongue patients, compared to the control group, where the rates were 15% and 85%, respectively, with a statistically significant correlation between infection with H. pylori and hairy tongue (p = 0.001).

CONCLUSION

Our results strongly suggest that the hairy tongue might be considered an indicator of H. pylori infection.

Prevalence of internet addiction among Syrian undergraduate medical students

The purpose of this study is to determine the prevalence and risk factors for internet addiction disorder among Syrian medical students. Syrian medical students from 8 different universities participated in an online cross-sectional questionnaire study between May 13 and June 16, 2022. DASS-21 Depression, Anxiety, Stress Scale, and Internet Addiction Test were the 3 main determinants of the questionnaire. One thousand nine hundred fifty-three medical students from 8 different Syrian universities have participated in our cross-sectional. Half of the participants were from the Syrian private and Damascus universities. 62.1% were females, and most participants had good academic degrees (70-90/100). Sixty-nine percent of the study participants thought that COVID19 increased internet use rates. The Internet Addiction Scale's average score was 33.48 ± 16.29 (1-100). The total young internet addiction test score was high among medical students from the faculty of medicine university, students from Damascus University, males, smokers, and medical students with lower academic credentials than other subgroups. Both the relationship between internet addiction and DASS-21 subgroups and the correlation between DASS-21 subgroups were statistically significant. Our research showed that internet addiction was widespread among Syrian medical students, particularly when used more for entertainment than educational purposes. Additionally, it was linked to poor academic degrees in the exams at the university and mental health conditions, including depression, anxiety, and stress.

Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon

HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.

The forgotten threat of cholera in Syria

Cholera is an ancient disease that persists as an issue of public health in many conflict-affected countries worldwide. Cholera is a diarrheal infection caused by ingested water or food contaminated with the bacterium Vibrio cholerae. On 10 September 2022, the Ministry of Health in Syria declared a cholera outbreak. Poor water and sanitation systems, disease surveillance breakdown, the collapse of the health system, and deteriorated socioeconomic conditions are potential risk factors for the outbreak's spread. Identifying the context-related factors associated with the spread of disease is a core to developing practical response mechanisms. In this study, we suggested a multisectoral approach that addresses context-specific elements contributing to the cholera outbreak spread in Syria; public health determinants, geopolitics, risk factors, and pandemic fatigue.

Does Time Heal Trauma? 18 Month Follow-Up Study of Syrian Refugees' Mental Health in Iraq's Kurdistan Region

The findings of longitudinal studies on traumatized refugees have shown that factors related to premigration, migration, and post-migration experiences determine changes in mental health over time. The primary aim of this follow-up study was to examine the potential change in the prevalence rates of probable PTSD and depression among Syrian refugees in Iraq. An unselected group of N = 92 Syrian adult refugees was recruited from Arbat camps in Sulaymaniyah Governorate in Iraq's Kurdistan Region, and then interviewed at two different time points between July 2017 and January 2019. Locally validated instruments were used to assess traumatic events and mental health symptoms. The primary results showed no significant change in the mean scores of PTSD and depression symptoms from the first measurement to the second measurement over the course of 18 months. On the individual level, no reliable change was found for either PTSD or depression symptoms in more than three-quarters of the participants (78.3% and 77.2%, respectively). New adversities and traumatic events that occurred over the 18 months between the interviews were a significant predictor of increasing trauma-related symptoms. After the flight from conflict settings, trauma-related disorders seem to be chronic for the majority of Syrian refugees. Further longitudinal studies are needed in order to identify specific risk factors that lead to maintaining or worsening mental health symptoms over time, and to explore effective therapeutic intervention methods for this traumatized population.

"They cannot afford to feed their children and the advice is to stay home. How‥?": A qualitative study of community experiences of COVID-19 response efforts across Syria

Introduction

COVID-19 highlighted the importance of meaningful engagement between communities and health authorities. This is particularly challenging in conflict-affected countries such as Syria, where social protection and food security needs can hinder adherence to non-pharmaceutical interventions (NPIs) and vaccine uptake. This study explored community perspectives of COVID-19 and health authority responses across the three main areas of control in Syria, i.e. Syrian government-controlled areas (GCA), autonomous administration-controlled areas (AACA), and opposition-controlled areas (OCA).

Methods

We conducted a qualitative study, interviewing 22 purposively-sampled Syrians accessing health services in AACA, GCA, or OCA in 2021 to provide approximately equal representation by governance area and gender. We analysed data thematically using deductive and inductive coding.

Findings

Interviewees in all areas described how their fears of COVID-19 and willingness to adhere to NPIs decreased as their local COVID-19 epidemics progressed and NPIs disrupted access to household essentials such as work and food. Community-level responses were minimal and ad hoc, so most people focused on personal or household protective efforts and many mentioned relying on their faith for comfort. Misinformation and vaccine hesitancy were common in all areas, linked to lack of transparency from and mistrust of local health authorities and information sources.

Conclusions

The COVID-19 pandemic has increased health actors’ need to engage with communities to control disease spread, yet most NPIs implemented in Syria were inappropriate and adherence decreased as the pandemic progressed. This was exemplified by lockdowns and requirements to self-isolate, despite precarious reliance on daily wages, no subsidies for lost income, individual self-reliance, and mistrust/weak communication between communities and health authorities. We found minimal community engagement efforts, consisting entirely of informing with no efforts to consult, involve, collaborate, or empower. This contributed to failures of health actors to contextualise interventions in ways that respected community understandings and needs.

Development of a Prediction Model for the Management of Noncommunicable Diseases Among Older Syrian Refugees Amidst the COVID-19 Pandemic in Lebanon

IMPORTANCE

Older Syrian refugees have a high burden of noncommunicable diseases (NCDs) and economic vulnerability.

OBJECTIVES

To develop and internally validate a predictive model to estimate inability to manage NCDs in older Syrian refugees, and to describe barriers to NCD medication adherence.

DESIGN, SETTING, AND PARTICIPANTS

This nested prognostic cross-sectional study was conducted through telephone surveys between September 2020 and January 2021. All households in Lebanon with Syrian refugees aged 50 years or older and who received humanitarian assistance from a nongovernmental organization were invited to participate. Refugees who self-reported having chronic respiratory disease (CRD), diabetes, history of cardiovascular disease (CVD), or hypertension were included in the analysis. Data were analyzed from November 2021 to March 2022.

MAIN OUTCOMES AND MEASURES

The main outcome was self-reported inability to manage any NCD (including CRD, CVD, diabetes, or hypertension). Predictors of inability to manage any NCD were assessed using logistic regression models. The model was internally validated using bootstrapping techniques, which gave an estimate of optimism. The optimism-adjusted discrimination is presented using the C statistic, and calibration of the model is presented using calibration slope (C slope).

RESULTS

Of 3322 older Syrian refugees, 1893 individuals (median [IQR] age, 59 [54-65] years; 1089 [57.5%] women) reported having at least 1 NCD, among whom 351 (10.6% overall; 18.6% of those with ≥1 NCD) had CRD, 781 (23.7% overall; 41.4% of those with ≥1 NCD) had diabetes, 794 (24.1% overall; 42.2% of those with ≥1 NCD) had history of CVD, and 1388 (42.3% overall; 73.6% of those with ≥1 NCD) had hypertension. Among individuals with NCDs, 387 participants (20.4%) were unable to manage at least 1 of their NCDs. Predictors for inability to manage NCDs were age, nonreceipt of cash assistance, household water insecurity, household food insecurity, and having multiple chronic diseases, with an adjusted C statistic of 0.650 (95% CI, 0.620-0.676) and C slope of 0.871 (95% CI, 0.729-1.023). The prevalence of nonadherence to medication was 9.2%, and the main reasons for nonadherence were unaffordability of medication (40.8%; 95% CI, 33.4%-48.5%) and the belief that they no longer required the medication after feeling better (22.4%; 95% CI, 16.4%-29.3%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the predictors of inability to manage NCDs among older Syrian refugees in Lebanon were mainly related to financial barriers. Context-appropriate assistance is required to overcome financial barriers and enable equitable access to medication and health care.

Prevalence of Keratoconus and Keratoconus Suspect among Patients Seeking Refractive Surgery in Syria

PURPOSE

The purpose of this study was to determine the prevalence of keratoconus (KC) and keratoconus suspect (KCS) among patients seeking refractive surgery in Syria.

METHODS

This is a retrospective multicenter screening study. The study was conducted in Damascus University, Tishreen University, and Tartous Specialist Eye Center (a private center). Data were collected from refractive surgery candidates referred for preoperative evaluation before laser in situ keratomileusis, photorefractive keratectomy, intrastromal corneal rings, and phakic intraocular lens implantation. Corneal parameters were obtained by Scheimpflug-Placido tomography, Sirius (CSO, Italy).

RESULTS

A total of 1479 patients were included in this analysis. The prevalence rates of KC and KCS were 18.19% (269/1479) and 13.52% (200/1479), respectively. In addition, patients with KC were found to have higher percentages of eye rubbing and astigmatism than suspect and normal (P < 0.0001).

CONCLUSION

High prevalence rate of KC was found among patients seeking refractive surgery in Syria. Although this study was carried out on a highly selective population, it may reflect a high prevalence rate in a general population in Syria.

Syndromic surveillance of respiratory infections during protracted conflict: experiences from northern Syria 2016-2021

OBJECTIVE

Northern Syria faces a large burden of influenza-like illness (ILI) and severe acute respiratory illness (SARI). This study aimed to investigate the trends of Early Warning and Response Network (EWARN) reported ILI and SARI in northern Syria between 2016 and 2021 and the potential impact of SARS-CoV-2.

METHODS

We extracted weekly EWARN data on ILI/ SARI and aggregated cases and consultations into 4-week intervals to calculate case positivity. We conducted a seasonal-trend decomposition to assess case trends in the presence of seasonal fluctuations.

RESULTS

It was observed that 4-week aggregates of ILI cases (n = 5,942,012), SARI cases (n = 114,939), ILI case positivity, and SARI case positivity exhibited seasonal fluctuations with peaks in the winter months. ILI and SARI cases in individuals aged ≥5 years surpassed those in individuals aged <5 years in late 2019. ILI cases clustered primarily in Aleppo and Idlib, whereas SARI cases clustered in Aleppo, Idlib, Deir Ezzor, and Hassakeh. SARI cases increased sharply in 2021, corresponding with a severe SARS-CoV-2 wave, compared with the steady increase in ILI cases over time.

CONCLUSION

Respiratory infections cause widespread morbidity and mortality throughout northern Syria, particularly with the emergence of SARS-CoV-2. Strengthened surveillance and access to testing and treatment are critical to manage outbreaks among conflict-affected populations.

Epidemiology and risk factors of colorectal cancer in Syria: a single-center retrospective study

OBJECTIVE

Colorectal cancer represents the third most common malignancy and the second leading cause of cancer deaths worldwide. Many factors contribute to the risk of developing colorectal carcinoma including diet, lifestyle, age, and genetic abnormalities.  Recent findings have shown a considerable increase in the incidence rate of CRC in developing countries. However, there is little information regarding its incidence in the Middle East countries, including Syria. With our manuscript we aimed at presenting the first large epidemiological study regarding colorectal carcinoma incidence in Syria.

PATIENTS AND METHODS

We conducted a retrospective study on colorectal carcinoma cases at our institution from 2014 to 2018. The data include the cases that were diagnosed and recorded based on multiple parameters including gender, age, year of diagnosis, city of origin, and profession.

RESULTS

The number of colorectal cancer cases was 1,117 out of 13,589 cases of all malignant tumors recorded from 2014 to 2018, with an annual average incidence of 8.2%. There was a statistically significant difference in CRC cases according to age and gender. We also found a statistically significant difference according to physical activity and occupation.

CONCLUSIONS

These results demonstrate that risk factors related to colorectal cancer incidence in Syria mainly include male sex, age over 50 years old, and occupation with no physical activity.

Post-traumatic stress disorder (PTSD), anger and mental health of school students in Syria after nine years of conflict: a large-scale school-based study

BACKGROUND

The Syrian crisis has entered its ninth year with many being affected by the war. This is the largest-scale study that aims to evaluate the psychological profile of secondary school students in Syria.

METHODS

This is a cross-sectional study in schools in Damascus, Syria. The surveys assessed working habits, smoking, war exposure, grades, socioeconomic status (SES), social support, health-related quality of life (HRQL), post-traumatic stress disorder (PTSD), problematic anger, and other parameters.

RESULTS

This study included 1369 students of which 53% suffered from PTSD and 62% from problematic anger. Around 46% declared a fair or worse general health and 61% had moderate or severe mental health. Only 9.3% did not report exposure to any war-related variable. War exposure had an impact on PTSD, anger, and HRQL, but not on students' grades. Smoking, having consanguineous parents, and working did not have a clear association with grades or anger. Social support weakly reduced PTSD and anger scores. Interestingly, working was associatedwith lowerPTSD scores but was associated with a worse physical component of HRQL.

CONCLUSION

This is the largest study on school students in Syria that reports the psychological ramifications of war. Although the direct effects of war could not be precisely described, the high burden of PTSD and anger distress was a strong reflection of the chronic mental distress.