The health of internally displaced people in Syria: are current systems fit for purpose?

INTRODUCTION: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. METHODS: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. FINDINGS: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. CONCLUSION: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria

Regional contributions of six preventable risk factors to achieving the 25 × 25 non-communicable disease mortality reduction target: a modelling study

Background Countries have agreed to reduce premature mortality from the four main non-communicable diseases (NCDs) by 25% from 2010 levels by 2025 (referred to as the 25 × 25 target). Countries also agreed on a set of global voluntary targets for selected NCD risk factors. Previous analyses have shown that achieving the risk factor targets can contribute substantially towards meeting the 25 × 25 mortality target at the global level. We estimated the contribution of achieving six of the globally agreed risk factor targets towards meeting the 25 × 25 mortality target by region. Methods We estimated the eff ect of achieving the targets for six risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) on NCD mortality between 2010 and 2025. Our methods accounted for multicausality of NCDs and for the fact that, when risk factor exposure increases or decreases, the harmful or benefi cial eff ects on NCDs accumulate gradually. We used data for risk factor and mortality trends from systematic analyses of available country data. Relative risks for the eff ects of individual and multiple risks, and for change in risk after decreases or increases in exposure, were from reanalyses and meta-analyses of epidemiological studies. Findings The probability of dying between the ages 30 years and 70 years from the four main NCDs in 2010 ranged from 19% in the region of the Americas to 29% in southeast Asia for men, and from 13% in Europe to 21% in southeast Asia for women. If current trends continue, the probability of dying prematurely from the four main NCDs is projected to increase in the African region but decrease in the other fi ve regions. If the risk factor targets are achieved, the 25 × 25 target will be surpassed in Europe in both men and women, and will be achieved in women (and almost achieved in men) in the western Pacifi c; the regions of the Americas, the eastern Mediterranean, and southeast Asia will approach the target; and the rising trend in Africa will be reversed. In most regions, a more ambitious approach to tobacco control (50% reduction relative to 2010 instead of the agreed 30%) will contribute the most to reducing premature NCD mortality among men, followed by addressing raised blood pressure and the agreed tobacco target. For women, the highest contributing risk factor towards the premature NCD mortality target will be raised blood pressure in every region except Europe and the Americas, where the ambitious (but not agreed) tobacco reduction would have the largest benefi t. Interpretation No WHO region will meet the 25 × 25 premature mortality target if current mortality trends continue. Achieving the agreed targets for the six risk factors will allow some regions to meet the 25 × 25 target and others to approach it. Meeting the 25 × 25 target in Africa needs other interventions, including those addressing infectionrelated cancers and cardiovascular disease

Context-led capacity building in time of crisis: fostering non-communicable diseases (NCD) research skills in the Mediterranean Middle East and North Africa.

BACKGROUND: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project's end (2015), the entire region was engulfed in crisis. OBJECTIVE: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil. METHODS: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH). RESULTS: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs. CONCLUSIONS: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB

Religion-based tobacco control interventions: how should WHO proceed?

Using religion to improve health is an age-old practice. However, using religion and enlisting religious authorities in public health campaigns, as exemplified by tobacco control interventions and other activities undertaken by WHO's Eastern Mediterranean Regional Office, is a relatively recent phenomenon. Although all possible opportunities within society should be exploited to control tobacco use and promote health, religion-based interventions should not be exempted from the evidence-based scrutiny to which other interventions are subjected before being adopted. In the absence of data and debate on whether this approach works, how it should be applied, and what the potential downsides and alternatives are, international organizations such as WHO should think carefully about using religion-based public health interventions in their regional programmes

Isolated Congenital Absence of Lumbosacral Facet Joint

A congenital absence of the lumbar facet joint is a rare reported condition. This is the case of a 32-year-old male patient presenting with severe low back pain radiating to his right lower limb. Physical examination revealed no motor deficits, but right lower limb numbness was reported over dorsum aspect of the right foot. No other sensory or motor disturbances were reported or found on exam. Imaging studies, consisting of a spine MRI and spine CT scan with 3D reconstruction, revealed the absence of the right L5-S1 zygapophyseal joint. The patient was treated conservatively with resolution of his symptoms on one-month follow-up

Expression of HIF-1α and Markers of Angiogenesis Are Not Significantly Different in Triple Negative Breast Cancer Compared to Other Breast Cancer Molecular Subtypes: Implications for Future Therapy.

Triple negative breast cancer lacks estrogen, progesterone and epidermal growth factor receptors rendering it refractory to available targetedtherapies. TNBC is associated with central fibrosis and necrosis, both indicators of tumor hypoxia. Hypoxia inducible factor 1α is up-regulated under hypoxia and its expression is associated with induction of angiogenesis resulting in proliferation, aggressive tumor phenotype and metastasis. In this study we evaluate the potential use of HIF-1α as aTNBC-specific marker.62 TNBC, 64 HER2+, and 64 hormone-receptors positive breast cancer cases were evaluated for central fibrosis and necrosis, HIF-1α, HIF-1β, VEGFR3, CD31 expression and microvessel density. RNA extraction from paraffin-embedded samples, followed by quantitative real-time polymerase chain reaction (qRT-PCR) evaluation of HIF-1α and VEGF transcripts was performed on 54 cases (18 from each subtype).HIF-1α protein was expressed in 35.5% TNBC, 45.3% HER2+and 25.0% ER+/PR+ (p = 0.055; χ2 test). PCRanalysis of subgroup of breast cancers, 84.2% expressed HIF-1α protein and its transcripts, while only 66.7% expressed VEGF transcripts simultaneously with the HIF-1α protein and its transcripts. Central fibrosis and necrosis was highest in TNBC (p = 0.015; χ2 test), while MVD was comparable among all groups (p = 0.928; χ2 test). VEGFR3 was highest in TNBC expressing HIF-1α. HIF-1β protein was expressed in 32.0% of HIF-1α(+), and in (44.3%) of HIF-1α(-) breast cancer cases (p = 0.033; χ2 test). Moreover, HIF-1α expression in cases with central fibrosis and necrosis was highest in the HER2+ followed by the TNBC (p = 0.156; χ2 test).A proportion of TNBC express HIF-1α but not in a significantly different manner from other breast cancer subtypes. The potential of anti-HIF-1α targeted therapy is therefore not a candidate for exclusive use in TNBC, but should be considered in all breast cancers, especially in the setting of clinically aggressive or refractory disease

Sacral Anatomical Orientation in the Lebanese Population

Introduction. PI is currently used as the gold standard measurement in spinopelvic anatomy. There is a need for a reliable method to calculate sacral anatomic orientation (SAO) independent of posture and to establish its association with PI, which was previously established in a single study (Peleg et al., 2007). Therefore, the aim of our study is the application and verification of this association on a Lebanese sample. Methods. Methods for measuring SAO and PI on living individuals are described. The study was carried out on 200 adult individuals using CT 3D images (volume-rendering method). Reliability (intratester and intertester) was evaluated using the intraclass correlation test. A regression analysis was carried out to evaluate the association between the two measurements. Results. There were 103 females (51%) and 97 males (49%) with a mean age of 58.68 ± 19.6 years (min = 20; max = 93). The mean SAO and PI in our population were found to be 52.65° (SD = 8.16°) and 59.08° (SD = 12.53°), respectively. SAO and PI measurements were highly correlated (Pearson correlation test; r = −0.296, P<0.0001 for our general population). PI can be predicted via SAO, i.e., SAO = (−0.193 × PI) + 64.057. Conclusions. SAO may be an important tool, alongside PI, in defining the sagittal shape of the spine and useful for understanding its association with spinal diseases as they are not affected by postural changes

Long-term evolution of slipped capital femoral epiphysis treated by in situ fixation: a 26 years follow-up of 11 hips

Slipped capital femoral epiphysis (SFCE) may lead to femoro acetabular impingement and long-term function impairment, depending on initial displacement and treatment. There are several therapeutic options which include <em>in situ f</em>ixation (ISF). The objective of this study was to evaluate long-term functional and radiographic outcomes of patients with SFCE treated with ISF. We conducted a single-center, retrospective study evaluating the clinical and radiographic outcomes of SCFE<em> in situ</em> fixation with a mean follow-up of 26 years (10- 47). Analysis of preoperative and last follow up radiographs was performed. The functional status of the hip was evaluated according to the Oxford hip score-12 and the radiographic osteoarthritis stage was rated according to Tönnis classification. Signs of femoro acetabular impingement were sought. Ten patients (11 hips) were included. The average initial slip was 33.5° (10-62). At final follow up, the average Oxford hip score was 19.3 (12-37), it was good for groups who had a small initial slip (16.7) or moderate (17) and fair for the severe group (27). Average Tönnis grade was 1.3 (0- 3). The average alpha angle was 65.3° (50- 80°). Femoro acetabular impingement was likely in 100% of patients with severe slip, in 50% of patients with moderate slip and in 33% of patients with a slight slip. <em>In situ</em> fixation generated poor functional results, substantial hip osteoarthritis and potential femoro acetabular impingement in moderate to severe SCFE’s. However, in cases with minor displacement, functional and radiographic results are satisfactory. The cut off seems to be around 30° slip angle, above which other treatment options should be considered