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Abstract Introduction Attacks on healthcare have been committed throughout the Syrian conflict in violation of International Humanitarian Law (IHL), contributing to the devastation of the country’s healthcare system. The conflict has also forcibly displaced over half of Syria’s pre-conflict population, 7.2 million of whom are internally displaced. In this retrospective analysis, we aim to assess the relationships between (1) healthcare attacks and general conflict and (2) healthcare attacks and forced displacement between 2016 and 2022. Methods Data on healthcare attacks, conflict events, and displacement were extracted from the Syrian American Medical Society (SAMS), Uppsala Conflict Data Project, and OCHA Türkiye, respectively. The analysis addresses three research questions: the associations between (1) healthcare attacks and conflict events, (2) healthcare attacks and conflict events in the week after an attack on a healthcare facility, and (3) healthcare attacks and forced displacement. For each, we used generalized additive models with a negative binomial distribution that also accounted for spatial and temporal factors. Results SAMS recorded a total of 541 attack events, comprising 650 attack rounds over 235 facilities between 2016 and 2022. Conflict events were significantly associated with healthcare attacks in the same week (IRR: 1.14, 95% CI 1.12–1.17), and healthcare attacks in one week were associated with a maximum of 1.44 greater risk (95% CI 1.08–1.91) of conflict events in the following week, even when accounting for general conflict levels in the previous weeks. Healthcare attacks were also significantly associated with increased displacement up to three months following the attacks. Discussion We find that healthcare facilities are not avoided during conflict (as obliged under IHL), and that healthcare attacks significantly precede an escalation of general conflict in the same area. Healthcare attacks are also significantly associated with displacement for months following the attacks, even when accounting for conflict levels. Based on these findings, we present a framework outlining one pathway through which healthcare attacks may contribute to larger conflict tactics. Our findings highlight the critical role of healthcare infrastructure in conflict and reaffirm calls to hold perpetrators of these attacks accountable.

Abstract Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis in children between the ages of 10 and 16. Nevertheless, risk factors for AIS, especially adjustable ones, are still poorly understood. This study seeks to examine the associations of lifestyle and social environment factors with AIS in Syrian schoolchildren. This matched case-control study uses survey data from a school-based scoliosis screening approach. We utilized logistic regression models to estimate the relative risk of AIS prevalence for each variable in the analysis. A multivariate logistic regression was performed to investigate the independent influence of each component on AIS development, with odds ratios (ORs) adjusted for the important factors. Overall, 1102 participants from 22 schools were included in this study, comprising 551 AIS cases and 551 controls. Mean age of the study population was 13.5 years ± 1.08. Six hundred and twenty (56.3%) of the study subjects were girls. After adjusting for other significant factors, age between 13 and 15 years (OR = 2.45; 95% CI, 1.37–6.17), inappropriate desk heights, either too low (OR = 1.53, 95% CI 1.12–1.85) or too high (OR = 1.46, 95% CI 1.13–1.87), standing with anterior pelvic tilt (OR = 1.97, 95% CI 1.46–3.43), and sleeping on the right side (OR = 1.92, 95% CI 1.54–2.23), remained associated with elevated AIS risks. In contrast, sitting normally and classroom sitting positions change regularly were associated with lower odds of AIS. The adjusted ORs were 0.73 (95% CI 0.43–0.94) for sitting normally, and 0.63 (95% CI 0.31–0.97) for sitting positions change. This study investigated the correlation between desk heights and AIS and revealed that incorrect desk heights were associated with more AIS risk. To prevent schoolchildren from developing AIS, stakeholders should consider installing height-adjustable desks in the classroom, changing students’ sitting positions on an ongoing basis, and establishing training courses that assist students in keeping proper sitting postures.

Abstract Background Migraine is the most common primary headache. It’s alone responsible for 1.3% of disability in the world. Migraine both worsen quality of life of individuals and place a significant burden on the society. Despite this, there exists a knowledge gap regarding its repercussions on the Syrian population. Methods This cross-sectional study enrolled 679 migraine-diagnosed patients from all over Syria through electronic questionnaires disseminated on official social media platforms. Depending on demographic characteristics, physical and mental debility assessed using the Chalder scale, the Migraine Specific Quality of Life Questionnaire (MSQ) and the Generalized Anxiety Disorder 2-item (GAD_2) scale. Results Our study included 679 participants (mean age: 29.49 years; BMI: 24.55). The sample was predominantly female (74.7%) and mostly single (52%). Females reported higher fatigue (mean = 21.48) than males (mean = 19.22; p

Abstract Background The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway. Methods This cross-sectional study is based on survey data collected from 353 quota refugees in 2018–19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience. Results Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0–4.7)), moderate (1.8 (1.1–2.8)), strong (1.7 (1.1–2.6)), and prescription painkillers; mild (4.6 (2.2–9.5)), moderate (5.6 (3.2–10.0)), strong (6.7 (3.9–11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2–3.5), 3.9 (2.1–7.0) and 2.4 (1.3–4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6–13.49)), moderate (6.7 (4.3–10.5)) and strong (6.6 (4.3–10.4)). Conclusion Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Abstract Background The EQ-5D is one of the most commonly used tools to establish health-related quality of life (QoL). EQ-5D data in atrial fibrillation (AF) patients in the Middle East are lacking. Objectives This study aims to evaluate the reliability and validity of the Arabic version of the EQ-5D in AF inpatients in Syria. Methods The study involved patients admitted to the emergency department of Tishreen’s University Hospital in Latakia with AF as the primary diagnosis between the 1st of June 2021 and the 1st of June 2023. Arabic versions of the EQ-5D, EQ-VAS and SF36 questionnaires were administered to patients. Validation was done using convergent, discriminant, and known-groups validity, while reliability was conducted using EQ-5D retesting within 2–4 weeks. Results 432 participants were included in the study with a mean ± standard deviation of 63 ± 15. Males represented 242 (56%) of the participants. All hypotheses relating EQ-5D responses to external variables were satisfied. All three validation hypotheses demonstrated that the EQ-5D had the convergent, discriminant and known group validity to assess QoL in this cohort. The intraclass correlation coefficient (ICC) for test-retest reliability ranged between 0.74 and 0.88, while Cohen’s κ ranged between 0.72 and 0.86. Cronbach’s α value for internal consistency was 0.73. Conclusion The Arabic version of EQ-5D was valid and reliable in measuring QoL in AF inpatients in Syria. This validation opens the door for more widespread use of the EQ-5D in Arabic-speaking regions, facilitating better-informed healthcare decisions and improving patient care strategies in Syria and other Middle Eastern countries.

Objective: Cutaneous leishmaniasis is a parasitic skin disease transmitted by the bite of sandflies. In our region, which is endemic for this disease, there has been a great migration from a much more endemic region and population movements from our area to Türkiye and abroad. Afterward, a pandemic was experienced. Due to these two extraordinary events and the possible epidemic potential in our region, it is useful to follow-up on the disease. We aimed to contribute to the evaluation of the disease in these processes by analyzing the data of our laboratory in recent years. Methods: Between January 2019 and December 2022, samples from patients who came to our laboratory with suspected cutaneous leishmaniasis were taken, stained and examined under a microscope. Patients were evaluated in terms of age, gender, nationality, place of residence, lesion site and duration. Results: Out of the 144 examined cases, 64 (44.4%) were positive for cutaneous leishmaniasis. Among these positive cases, 40 (62.5%) were women, 24 (37.5%) were men, and 54 (84.3%) belonged to the 0-9 age group. Of those who tested positive, 54 (84.3%) were Turkish citizens and 23 (35.9%) were Syrian citizens. Fifty-four (84.3%) patients had only single lesion. While the number of applications and positivity rates remained within normal levels in 2019 and 2020, a significant decrease was observed in both from 2021 and 2022. Conclusion: Cutaneous leishmaniasis is carried by migration, decreases in large-scale isolations such as pandemics, and its spread can be prevented with correct diagnosis and treatment. Although the number of patients may change over time and place, cutaneous leishmaniasis is a disease that threatens the health of societies and should always be monitored.

Abstract Background Effective vaccination governance in conflict-affected regions poses unique challenges. This study evaluates the governance of vaccination programs in northwest Syria, focusing on effectiveness, efficiency, inclusiveness, data availability, vision, transparency, accountability, and sustainability. Methods Using a mixed-methods approach, and adapting Siddiqi’s framework for health governance, data were collected through 14 key informant interviews (KIIs), a validating workshop, and ethnographic observations. Findings were triangulated to provide a comprehensive understanding of vaccination governance. Results The study highlights innovative approaches used to navigate the complex health governance landscape to deliver vaccination interventions, which strengthened sub-national vaccination structures such as The Syria Immunisation Group (SIG). The analysis revealed several key themes. Effectiveness and efficiency were demonstrated through cold-chain reliability and extensive outreach activities, though formal reports lacked detailed analysis of vaccine losses and linkage between disease outbreak data and coverage statistics. Key informants and workshop participants rated the vaccination strategy positively but identified inefficiencies due to irregular funding and bureaucracy. Inclusiveness and data availability were prioritised, with outreach activities targeting vulnerable groups. However, significant gaps in demographic data and reliance on paper-based systems hindered comprehensive coverage analysis. Digitalisation efforts were noted but require further support. The SIG demonstrated a clear strategic vision supported by international organizations such as the World Health Organization, yet limited partner participation in strategic planning raised concerns about broader ownership and engagement. While the SIG was perceived as approachable, the lack of public documentation and financial disclosure limited transparency. Internal information sharing was prevalent, but public communication strategies were insufficient. Accountability and sustainability faced challenges due to a decentralized structure and reliance on diverse donors. Despite stabilizing factors such as decentralization and financial continuity, fragmented oversight and reliance on donor funding remained significant concerns. Discussion The study highlights the complexities of vaccination governance in conflict-affected areas. Comparisons with other conflict zones underscore the importance of local organisations and international support. The SIG’s role is pivotal, but its legitimacy, transparency, and inclusivity require improvement. The potential transition to early recovery in Syria poses additional challenges to SIG’s sustainability and integration into national programs. Conclusion The governance of vaccination in northwest Syria is multifaceted, involving multiple stakeholders and lacking a legitimate government. Enhancing transparency, local ownership, and participatory decision-making are crucial for improving governance. The role of international bodies is essential, emphasising the need for structured feedback mechanisms and transparent monitoring processes to ensure the program’s success and sustainability.

Abstract Background Mental health and psychosocial support (MHPSS) is increasingly considered vital for addressing the needs of displaced communities. The mental health of young people in Lebanon, including members of the host community and refugees, has been severely affected by multiple crises. Physical activity (PA) is an effective means for enhancing mental health, but evidence of PA’s impact on mental health among forcibly displaced populations is still emerging and often varies widely across studies. Method In this waitlist-controlled study, we examined the effectiveness of an 8-week psychosocial bouldering group intervention offered by the nonprofit organization ClimbAID on psychological well-being, distress, self-efficacy, and social cohesion in a group of mostly Syrian refugee adolescents residing in the Bekaa Valley, Lebanon. The intervention consisted of 8 sessions and took place once a week for 2 h in a group of up to 12 adolescents with 2 trained facilitators and up to 2 volunteers, supervised by a climbing instructor and a social worker. Multilevel analyses were performed for all outcomes. Results 233 people were included in the study. The dropout rate was approximately 33%. The IG improved significantly more than the waitlist group in terms of overall mental well-being and psychological distress. Group allocation was a significant predictor of improvements in mental well-being and psychological distress and showed a trend toward predicting self-efficacy. There was no positive impact of the intervention on social cohesion. Conclusions Even in complex humanitarian settings of forced displacement, a psychosocial bouldering intervention reduces psychological distress and increases well-being in a mixed group of host and refugee youth in Bekaa, Lebanon. Trial registration Prospectively registered with ISRCTN 13005983, registered April 1st, 2022.

Abstract Background Conflict in Syria since 2011 led to over one million Syrians fleeing to Lebanon, predominantly from economically disadvantaged areas with low literacy and high child marriage rates. Over 90% live in extreme poverty, in informal tented settlements with minimal access to education, healthcare or employment. Displacement and poverty have further increased early marriages and unplanned pregnancies, and curtailed access to sexual and reproductive healthcare (SRH) in the Bekaa valley. This is exacerbated by increasing rates of sexual and gender-based violence (SGBV), intimate partner violence and domestic violence. Study design We aimed to explore SRH beliefs and practices and teach on key SRH topics through focus group discussions (FGD) and questionnaires, co-designed with Syrian practitioners, conducted with Syrian men and women. FGD were recorded, transcribed and thematically analysed. Questionnaires collected demographics and explored SRH beliefs and practices. Findings 24 FGD with 203 participants, 72.4% female and 27.6% men. 90.1% participants were married with an average age-gap of 6.3 years between partners. Teenage marriage rates were 55.6% for women, and 47.4% delivered their first child before the age of 20. 43.6% participants were not using any contraception. Findings demonstrate the impacts of SRH cultural norms and changes due to displacement, financial crisis, and increased exposure to technology and NGOs. Conclusions SRH is multifaceted and contested, requiring systemic improvements in access to care, employment and education. This small but important proof-of-concept study demonstrates the possibility of engaging men and women in SRH discussion; paramount to empowering communities and challenging intergenerational SGBV.

Abstract Chronic diseases and pain exacerbate depressive symptom in Syria. Limited research on hospital-induced depressive symptom among Syrian patients with chronic diseases warrants further study. A cross-sectional study in four Damascus hospitals revealed high rates of pain and depressive symptom. This study aims to investigate the prevalence and severity of chronic pain and hospital-induced depressive symptom in Syrian patients, as well as the relationship between pain, depressive symptom, and medication behavior. This study analyzes the impact of pain, hospitalization, and medication on patients with chronic diseases. The four Damascus hospitals included 453 patients from various departments. Data were collected through structured interviews and internationally recognized scales such as the PSEQ, HADS, and MMAS. These findings offer insights into pain management and psychological well-being, with implications for patient care and support strategies. The study involved 453 patients with chronic diseases, with gender distribution showing 46.6% females and 53.4% males. The age range was from 7 to 87 years, with an average of 46.87 years. Chi-square tests revealed a significant connection between gender and HADS-A scores, where 48.3% of females had abnormalities (χ2 (1, N = 453) = 7.125, p = 0.028). Marital status was significantly associated with anxiety and depressive symptom levels, particularly among widowed and divorced patients. Employment status, education, and comorbidity were linked to abnormal HADS-A scores, while education level showed a positive correlation with HADS-D scores. ANOVA tests showed significant differences in MMAS scores across income groups (F (3, 449) = 3.167, p = 0.024), with a notable difference between low-income and lower-middle-income groups (mean difference = 0.389, p = 0.031. Chronic pain and HID are prevalent among Syrian patients with chronic diseases and influenced by socio-demographic factors. Personalized interventions are needed to address psychological symptoms and medication behavior.

Abstract Background Medications are commonly found in every household. In Syria, where healthcare infrastructure faces significant challenges, improper storage can lead to reduced medication efficacy and increased health risks. Additionally, inappropriate disposal practices pose serious environmental concerns, especially in a region already grappling with environmental degradation. This study aimed to evaluate the knowledge, and practices of Syrian individuals regarding the appropriate storage and disposal of home medications. Method A cross-sectional study was conducted from September 22 to October 20, 2023, using an online survey distributed via social media apps (WhatsApp, Facebook, and Telegram) in Syria. The questionnaire, adapted from a similar study in Saudi Arabia, was translated to Arabic using the forward–backward translation technique. A convenience sampling technique was used. Inclusion criteria were participants over eighteen with expired or unused medications at home. Descriptive statistics, Chi-square tests, and binary logistic regression analysis were performed using SPSS version 27, with statistical significance defined as p

The rise of the cyber domain and social media platforms has profoundly impacted the socio-political landscape in Syria, enabling cyber-activism to emerge as a potent force against authoritarian regimes. This qualitative research examines the evolution, impact, and challenges Syrian cyberactivists face, drawing from professional reports, interviews, and scholarly literature. While online platforms empower activists by facilitating mobilization and information dissemination, activists also face significant obstacles, including surveillance, censorship, and cyberattacks within a statecontrolled digital environment. Despite these challenges, cyber-activism in Syria played a crucial role in shaping narratives, fostering solidarity, challenging the regime, influencing international perceptions, and highlighting the transformative potential of the cyber domain in repressive contexts.

Abstract Study objective This study aims to assess the prevalence of both classic and non-classic pain sites in patients with ischemic heart disease, emphasizing the importance of recognizing and not disregarding non-classic symptoms. Methods This cross-sectional study included 100 patients diagnosed with coronary artery disease (CAD) who were admitted to two major hospitals in Syria. classic pain was identified as pain located in the precordial area, with or without radiation to the neck, jaw, left shoulder or arm. Patients’ demographics and previous medical history were documented to investigate any potential associations with non-classic pain. Results 62% of the patients experienced non-classic pain, while 12% had no precordial pain. For those without precordial pain, the most common pain site was the left chest (66.7%). Non-classic pain was significantly associated with smoking, with 72.2% of smokers experiencing non-classic pain compared to 35.7% non-smokers (p = 0.001). Additionally, patients with previous heart disease were more likely to have non-classic pain (71.7%), compared with patients with no history of heart disease (51.1%) (p = 0.03). Other factors such as age, sex, and diabetes were not statistically significant. Conclusion Non-classic pain is common, affecting 62% of individuals, primarily in the right shoulder, right arm, and back. This type of pain could be associated with smoking and prior heart disease. Misdiagnosing coronary artery disease can have serious consequences, as patients with non-classic symptoms may miss important pre-hospital procedures like ECG.

Abstract Background The COVID-19 pandemic has had a significant impact on the education sector, leading to the closure of colleges and schools and disrupting the learning process for an uncertain duration. In response, electronic learning has emerged as a suitable method for continuing the educational process during the lockdown. This study aimed to assess the attitudes, practices, and barriers to e-learning among medical students at Syrian Private University. Methods A cross-sectional survey study was conducted at the Faculty of Medicine of the Syrian Private University (SPU) in Damascus, Syria. The study used a convenience sampling approach and was carried out from June 2021 to January 2022. Data were collected using a self-administered questionnaire structured into two sections. The first section included 12 sociodemographic questions. The second section assessed students’ attitudes, practices, and barriers related to e-learning, and consisted of 14 questions on attitudes, 11 questions on practices, and 9 questions on barriers. Results Of the 519 participating students, over half (55.1%) exhibited a negative attitude towards e-learning. However, more than 60% reported engaging in e-learning activities such as downloading educational content and participating in virtual study groups. The main barriers identified were unstable internet connections (92.7%) and challenges in communication with educators (82.7%). Bionomical logistic regression revealed that negative attitudes were predicted by housing status, academic year, health status, lack of engagement with colleagues in e-learning practices, and the reported barriers of difficulty adjusting learning style, lack of technical skills, poor communication with educators, limited access to devices, and limited space conducive for studying (P

Abstract The prevalence of overactive bladder (OAB) is known to be higher in patients with type 2 diabetes (T2DM). However, few studies have examined specific risk factors contributing to its progression among diabetes mellitus (DM) patients, so this study aimed to investigate the risk factors specific to diabetes mellitus that influence overactive bladder in the Syrian population. This cross-sectional study was conducted at four endocrinology centers in four Syrian provinces: Damascus, Aleppo, Homs, Hama, and Latakia. The study was comprised of patients who had been diagnosed with both T2DM and OAB and had visited these centers from February 2020 to January 2023. The Arabic version of the Overactive Bladder Symptom Score (OABSS) scale was used to categorize the participants based on the severity score into two groups: the mild OAB group and the moderate-severe OAB group. A logistic analysis was conducted to assess the risk factors associated with the OAB among patients with diabetes. Among the 153 patients diagnosed with both DM and OAB, significant distinctions were found between the two groups concerning the severity of overactive bladder, age, duration of diabetes, symptomatic diabetic peripheral neuropathy (DPN), and ankle reflex (P

Abstract Background Eating disorders (EDs) are a complex group of disorders that affect mental and physical health and pose a challenge for medical professionals to diagnose. This study aims to screen for eating disorders among Syrian university undergraduates. Methods and materials A cross-sectional study was conducted among Syrian university students using a self-administered questionnaire. The questionnaire consisted of three sections: socio-demographic characteristics, dietary habits and barriers to healthy eating, and the Sick, Control, One, Fat, Food (SCOFF) score. The chi-square test was used to evaluate the factors related to eating disorders. Results Of 728 students, 45.3% were males and 54.7% females. The majority of participants studied medicine 32.3%, followed by pharmacy 25.7% and dentistry 17.6%. Overweight and obese participants represented 21.4% and 6.8% respectively. Merely 36% of students reported adopting a healthy diet, a greater percentage of females 58.8% reported having snacks compared to males 48.5% (P = 0.006), a higher percentage of females 38.8% reported consuming fast food compared to males 26.6% (P

Abstract Stroke is a global public health concern, contributing to high rates of morbidity and mortality. In Syria, the current conflict and associated challenges have had a profound impact on healthcare infrastructure, including education and awareness programs related to stroke. An essential aspect of preventing stroke is the awareness of individuals. The study aimed to investigate factors associated with knowledge and awareness of stroke among Syrian people. A cross-sectional national representative study was conducted in Syria. The questionnaire was created on Google form and disseminated as a link through online platform social media like Facebook, WhatsApp, and Twitter. The population of the study was divided using proportionate random sampling into the 14 governorates. A random sample was selected from each area. The STROBE reporting guideline for cross-sectional studies was followed. Logistic regression analysis was performed to identify the factors associated with poor knowledge of stroke. A total of 1013 Syrian adults participated in the study. With more than half of them were females (53.5%) and employed (55.6%). Significant associations were found between ability to identify at least one correct risk factor and employability status (p = 0.029), single group (p = 0.036) and smokers (p

The purpose of this study is to identify the characteristics of Kurachine Dolomite reservoir rocks (KD), and the Kurachine Anhydrite cover rocks (KA) in the (Abo-Rabah) hydrocarbon field in the Ad-Daw Basin (central Syria). The reservoir and covering rocks, being the most important elements necessary for the presence of hydrocarbon traps. The study focuses on the reservoir Kurachine Dolomite rocks (KD), and the covering Kurachine Anhydrite rocks (KA) in the Abo-Rabah area in the Ad-Daw Basin (central Syria). The mentioned Kurachine formations consider to be favorite traps for hydrocarbon ac- cumulation in the (Abo Rabah) and adjacent area. A litho-stratigraphic model has been proposed for the study field, through analytical integration and interpretation processing. This model reveals differences between litho-stratigraphic relations in the concerned field. Most of significant reflectors in the district were investigated by transmitting the integrated seismic data into geological formations. Two Way Time (TWT) map of the reservoir formation (KD) has been originated. The comparison results of this study are with the previous results. It has been found that, the current prepared time map (TWT) is different from the previous maps, where the current (TWT) seems to be more realistic, because it is based on a larger number of boreholes, that are recently drilled in the study area. So, the reliability of the present results enabled to suggest three new promised hydrocarbon borehole locations favorable for drilling. Also, the current study exposed the relation between the clarity of the seismic signal and the thickness of kurachine anhydrite (KA) cover rocks.

Background: On 6 February 2023, an earthquake with a 7.8 magnitude wreaked destruction in northern Syria to add a new emergency status in the country. This study aims to evaluate the mental health status of the Syrian population in the immediate phase of the earthquake.Methods: This nationwide cross-sectional study was conducted in Syria from 17 February to 6 April. Data were collected on socio-demographics, trauma exposure characteristics, and levels of acute stress, depression, and anxiety. The NSESSS Checklist for the APA was used to assess ASD symptoms, PHQ-9 for depression, and GAD-7 for anxiety. Linear mixed-effects models were employed to identify predictive factors while accounting for governorate as a random effect and time elapsed as a fixed factor.Results: The rate of probable ASD symptoms was significant, with 55.3% of participants exhibiting these symptoms, including 10.3% reporting severe-to-extreme levels of severity. Similarly, 71.6% of participants exhibited symptoms of depression and 59.1% showed symptoms of anxiety. Furthermore, 40.4% of participants displayed a co-occurrence of ASD along with anxiety and depression. Linear mixed effects models indicated that symptoms were predicted by female sex, displacement, poor economic status, and a positive mental health history time elapsed, physical trauma, belief in the ongoing risk of earthquakes, feelings of dizziness, recurrent night-time fear arousal, and a continued sensation of seismic activity.Conclusion: This study demonstrated the high rates of symptoms of ASD, anxiety, and depression across the Syrian population during the immediate aftermath of the earthquake. High portions of people may acquire co-occurring symptoms represented by different mental health problems. These findings highlight the need for immediate actions to enhance mental health support in Syria.

RESTRICTION OF FREEDOMS AND RIGHTS VS. MIGRATION OF SYRIAN KURDS This article focuses on analysing the factors pushing Kurds out of Syria. The starting point for the research is the analysis of negative, positive, and political freedom. The article puts forward the thesis that the restriction of freedom and rights of Kurds in Syria was a decisive factor pushing them out of the country. In this context, an attempt is made to answer the following questions: 1) what is positive and negative freedom?, 2) what freedoms and rights were guaranteed to the citizens by the constitution of Syria?, 3) how were the freedom and rights of Kurds restricted in Syria?, 4) how many Kurds emigrated from Syria and where did they go?

Food security has always been the main goal of Syrian agricultural strategy. Therefore, the main objective of this study is to examine the dynamic relationship between selected climatic and non-climatic variables and food security in Syria from 1961 to 2018. The autoregressive distributed lag (ARDL) bounds testing approach is applied to estimate the association among the study variables with evidence of long-run and short-run analysis. The long-run estimates revealed that non-climatic variables including crop production, agricultural land, land under cereal production, and population, positively affected food security. Moreover, climatic variables including temperature and CO2 emissions positively affected food security in the long-run. The findings revealed that in the short-run, fertilizer affected food security positively. However, in the long run, the effect of fertilizer consumption turned out to be negative and significant. This study suggests that governments may consider measures to improve food security in Syria. Governments should focus on the issue of using climate-adapted plant varieties. Increasing the area under cereal crops and reducing agricultural land degradation could be an important long-term strategy for the government. There is a need to properly train farmers regarding fertilizer usage and switch from chemical fertilizer to organic fertilizer.

Background: The impact on the physical and mental health of those who survived torture and their close circles in the Syrian regime’s detention facilities remains under-studied.Objective: This qualitative study explored Syrian refugees’ narrations of captivity and torture, and the consequences of such extreme traumatic events on their physical and psychosocial health.Method: Thirteen audio-recorded interviews were conducted in Arabic with Syrian refugees. Study participants were at least 19 years of age, resided in diverse urban areas of Jordan, had experienced captivity and torture in Syrian detention facilities, and voluntarily agreed to participate in the study. Participation was anonymous, only oral consent was required, and no incentives were provided to participants. Interviews were transcribed and translated into English by a team of researchers, followed by analysis of repetitive themes according to the narrative paradigm.Results: Analysis of interviews elicited three major themes: extreme traumatic experiences of torture, and its physical and psychosocial health consequences. The first major theme was divided into two sub-themes: torture experienced by the participants themselves, and torture experienced by participants’ close circles. The second major theme, pertaining to physical health, was divided into two sub-themes: acute and chronic health sequelae. The third major theme, related to psychosocial health, was divided into four sub-themes: mental health symptomatology, impacts on professional life, impacts on interpersonal relationships, and social consequences.Conclusions: Torture experiences of Syrian refugees had adverse consequences for the physical and psychosocial health, functioning, and the overall well-being of survivors and their close circles. Interventions may seek to improve both the acute and chronic health consequences, as well as the mental health symptoms and associated impacts on livelihood, professional, and relationship dynamics. They should span clinical, legal, and advocacy spheres, given that a holistic approach may contribute immensely to survivors’ healing process.

Syria has been struggling with a prolonged and brutal war for over a decade, leaving much of the country in devastation and its forests severely degraded. While many studies have identified logging for firewood as a significant driver of deforestation during the war, there is a notable absence of research specifically addressing logging behavior within the context of war. This research seeks to address this gap by examining the changes in logging behavior among local communities, the effects of violence and socioeconomic variables on wood harvesting, the contribution of wood income to people's survival during the war. To do that, we conducted survey questionnaires in two coastal villages in Syria—Blouta and Nehel al Annaze—which experienced high and low levels of violence, respectively. Our findings reveal that logging activities increased once the war began, with more people involved in forest harvesting and average days spent logging per week significantly increasing from 1.5 to 4. Additionally, the war appeared to reduce the gender disparity in logging activities: before the conflict, women engaged in logging significantly more frequently than men, but this difference became insignificant during the war. The level of violence alone did not significantly affect the amount of wood logged per month. Furthermore, income generated from wood harvesting played a substantial role in bridging the gap between the monthly income needed to cover their basic necessities and the actual income of families in both villages by 46.94 % and 84.83 % of the gap in Nehel al Annaze and Blouta, respectively. These results highlight the crucial role of forest resources in supporting rural livelihoods during times of war. Post-war effective forest management will be vital to ensure the sustainable use and recovery of forest resources, supporting both ecological restoration and economic stability for the rural communities.

The recent introductory of e-payment services in Syria and the overwhelming interest of such new services call for thorough investigation of their quality and venues for improvement to unleash their full potential. This study investigates the quality of e-payment services offered by mobile network operators in Syria by adopting the E-SERVQUAL metric based on four dimensions: ease of use, reliability, security and privacy, and responsiveness. This study presents the responses of 133 users of these services in Syria from October to December 2023. The results indicate that e-payment services were of high quality in terms of reliability, security and privacy, and responsiveness dimensions. However, they are of lower quality in terms of ease of use. It is recommended that mobile companies increase the flexibility of e-payment services by widening the top-up options and offering more payment categories as well as relaxing the ceiling set for any single e-payment transaction. These companies were also encouraged to increase the number of kiosk machines to credit customer balances and improve the distribution of these machines into more selective locations. Furthermore, mobile companies may increase their share in the e-payment market by offering rewards and cash discounts for transactions conducted through their e-payment platforms.

AbstractPolycystic 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.

Introduction In Syria, specialist dentists undergo five years of undergraduate education and four years of postgraduate education. In the latter, students engage in treating complex cases as part of their professional training. This study aimed to obtain in-depth qualitative understanding of the clinical learning environment at Damascus University Faculty of Dental Medicine, Syria. Methods Semi-structured interviews were held with eight postgraduate dental students at Damascus University Faculty of Dental Medicine. The faculty has eight clinical departments; therefore, a single participant was purposively sampled from each department. The male-female ratio of the eight interviewed participants was 1:1. All interviews were conducted between 26th April 2020 and 8th January 2021. Data were analyzed inductively using reflective thematic analysis. Pragmatic saturation was discussed during the analysis and the authors made an interpretative judgement to stop data collection at the eighth interview. Results Major themes which emerged covered different aspects of the clinical learning environment such as clinical training, social interaction and assessment procedures. Faculty’s negligence of their teaching duties was one of the most recurrent themes. In clinical training and due to faculty inaccessibility, students had to rely on themselves or their senior peers in training. The social climate was perceived negatively and assessment was described as unfair and biased. Discussion This study employed Gruppen’s conceptual framework to conduct a theory informed analysis of the clinical learning environment in a dental school with limited resources. The findings highlight important areas of improvement that needs addressing, including the unavailability of teaching staff, neglect of student needs, a competitive social atmosphere, and inconsistent assessment practices. Future research ought to focus on understanding the perspectives of teaching faculty and decision makers regarding the obstacles to implementing substantial reforms aimed at enhancing the clinical learning experience.

Introduction In Syria, specialist dentists undergo five years of undergraduate education and four years of postgraduate education. In the latter, students engage in treating complex cases as part of their professional training. This study aimed to obtain in-depth qualitative understanding of the clinical learning environment at Damascus University Faculty of Dental Medicine, Syria. Methods Semi-structured interviews were held with eight postgraduate dental students at Damascus University Faculty of Dental Medicine. The faculty has eight clinical departments; therefore, a single participant was purposively sampled from each department. The male-female ratio of the eight interviewed participants was 1:1. All interviews were conducted between 26th April 2020 and 8th January 2021. Data were analyzed inductively using reflective thematic analysis. Pragmatic saturation was discussed during the analysis and the authors made an interpretative judgement to stop data collection at the eighth interview. Results Major themes which emerged covered different aspects of the clinical learning environment such as clinical training, social interaction and assessment procedures. Faculty’s negligence of their teaching duties was one of the most recurrent themes. In clinical training and due to faculty inaccessibility, students had to rely on themselves or their senior peers in training. The social climate was perceived negatively and assessment was described as unfair and biased. Discussion The findings of this study were framed within Gruppen et al. (2019) theory of the learning environment wherein four dimensions emerge: the personal, the social, the organizational and the material. The findings of this study showcased the continuing deterioration of the clinical learning environment at Damascus University. It is hoped that these findings will encourage decision makers to introduce a comprehensive reform that addresses the curriculum, teaching practices and assessment procedures in clinical professional training.

The lungs and liver are the most common sites of hydatid cysts, but they may also be found in other organs. We report the case of a lady in her 50s who presented to a hospital in northwest Syria with a large swelling in the right gluteal region. This was diagnosed as a gluteal abscess, and an incision and drainage were performed. Intraoperatively, a hydatid cyst germinal membrane was noted. She had the required imaging to exclude other cysts, which revealed a liver hydatid cyst of 7.5 cm, which was treated with PAIR (puncture, aspiration, injection, and re-aspiration) and albendazole. The residual wound was closed using a manual vacuum-assisted closure (VAC) pump for seven days. A key lesson is that a hydatid cyst in the gluteal muscles, though rare, should be considered in the differential diagnosis. We also show that the innovative use of a manual VAC pump can be used to support closure of large hydatid cyst cavities in muscles.

The Turkomans are considered to be the integral part of a political space often reflexively labeled as “Turkic World.” Following the collapse of the Ottoman Empire, the Turkoman communities in Syria and Iraq have undergone a complex evolution leading to their current status as politically organized distinct ethnic groups. This transformation has been predetermined by the policies of the colonial powers and the rise of Arab nationalism that was aimed to establish the united “Arab Homeland.” It was only with the decline of Baathist regimes that Turkomans started to gain political recognition. How have the Turkomans in Syria and Iraq evolved culturally and politically over time? Do they perceive their future as being closely linked to their Arab “host” countries, or do they harbor aspirations of coming back to their historical Turkic legacy? What support do they receive from Turkey, and what is offered by Syrian and Iraqi authorities? We have analyzed the Turkoman issue through a structural and identity-based lens, examining how these communities have navigated their relationships with the Arab states they reside in and their historical ties to Turkey. The framework proposed by R. Brubaker, which examines the interactions between marginalized ethnic minorities, nationalizing states, and external homelands, provides a valuable tool for understanding the complex dynamics involving Turkoman communities in Syria and Iraq. The research findings indicate that Turkoman identity remains robust, albeit with a notable shift towards a more inclusive national-state dimension. Despite constituting a minority group, Turkomans in both countries are actively advocating for recognition within society and asserting their cultural rights. The primary Turkoman political factions in both countries have garnered backing from Turkey, although the nature of this support is complex. In Iraq, Turkomans are inclined towards seeking Turkish patronage while also demonstrating a willingness to engage with the Iraqi government. Conversely, in Syria, Turkomans residing along the border have successfully established a self-governing region with the Turkey’s assistance. Furthermore, a segment of Turkomans place emphasis on their religious affiliations, such as identifying as Shiite or Alawite.

Abstract Introduction Migrant women might be cannot benefit from health services sufficiently. The unmet need for family planning is among the pivotal indicators for measuring progress toward improving maternal and child health. The aim of this study was to identify the unmet need for family planning (UMNFP) among Syrian migrant women living in Mardin and its determinants. Material and methods The study was conducted in Mardin. Data were gathered during home visits Data collection tools were socio-demographic and reproductive health questionnaires. The statistical analysis was performed using SPSS software. Qualitative variables were presented by number and percentage. Quantitative variables were presented by means (standard deviation). To determine, the determinants of UMNFP binary logistic regression was used. Results The result of this study showed that prevalence of UMNFP was 35%. Woman’s low educational level (OR:5.42, CI95%:2.43–8.94), history of un intended pregnancy(OR:1.43, CI95%:1.1–1.94) and induced abortion (OR:1.76, CI95%: 1.41–2.21), not having husband’s regular job(OR: 2.24, CI95%:1.92–3.78) and lack of woman`s autonomy in decision related to use of contraception methods(OR:3.21, CI95%: 1.78–6.12) were determinants of UMNFP. Conclusion The prevalence of UMNFP among Syrian immigrants living in Mardin was considerable. Understanding the challenges and the barriers impacting use of contraception including cultural norms as well, as social and language obstacles are essential to decrease UMNFP.

Abstract Background Assessment of the clinical learning environment (CLE) is an essential step that teaching hospitals routinely undertake to ensure the environment is conducive, learning-oriented and supportive of junior doctors’ education. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an internationally recognized tool for assessing the CLE with evidence of high reliability and validity. Translation of PHEEM into other languages such as Spanish, Japanese and Persian enabled wider adoption of the instrument in the world. However, in Syria and other Arabic countries, a validated Arabic translation of PHEEM is still not available, making it difficult to adopt it and use it in Arabic contexts. This study aims to translate and culturally adapt the PHEEM from English into Arabic. Methods This study followed the structured translation and validation process guideline proposed by Sousa & Rojjanasrirat 2010. First, the PHEEM went through forward translation by three translators, then reconciled with the aid of a fourth translator. Afterwards, two professional bicultural and bilingual translators conducted back translation into English and compared it with the original version. This formed the Pre-final Version (PFV) which was then pretested for clarity on a sample of medical residents in Damascus, Syria. Following appropriate modifications, the PFV was sent to a panel of experts for a comprehensive review of language clarity and to assess content validity. Results A total of thirty-five medical residents were recruited. Ten items with language clarity issues were identified and modified according to the elicited suggestions. Thereafter, the modified PFV was presented to ten subject experts who identified three items in need of revision. The item-content Validity Index (CVI) was over 0.78 for all of the 40 items; the calculated scale-CVI was 0.945. Discussion This study provided the first linguistically valid Arabic translation of the widely used PHEEM inventory. The next step is to conduct a full psychometric analysis of the Arabic PHEEM to provide further evidence of validity and reliability.

Abstract Introduction The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions. Materials and methods This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts. Results A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress. Conclusion The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

Climate change leads to altered spatial and temporal patterns of precipitation due to activating the hydrological cycle. This study analyzes the distribution of precipitation concentration over the Levant in 1970–2018 for the first time at various time scales. The precipitation concentration index (PCI) was calculated using a quality-controlled time series from 167 meteorological stations. Trends were calculated using a Mann–Kendall nonparametric test, and a nonparametric Mann–Whitney test was used to determine the statistical significance of the differences between the mean sub-periods. The Levant can be divided into three regions, a strongly irregular concentration in south Palestine and Jordan as well as east Jordan; an irregular concentration in center/north Palestine, north Jordan, and east Syria; and a moderately irregular concentration over the Syrian coast. The annual precipitation concentration index (PCI) for the Levant, Palestine, and Syria non-significantly increased by 0.33, 0.32, and 0.22 unit/decade, respectively. Significant increasing trends occurred in the northwest of the West Bank, with averages of 0.75 unit/decade. The seasonal rainfall distribution tends to be uniform in winter and spring, mainly for south Levant, whereas the annual rainfall tends to be more concentrated. The autumn PCI significantly decreased for the Levant, Palestine, and Syria by −0.46, −0.61, and −0.54 units/decade, respectively. HIGHLIGHTS The PCI was calculated using a quality-controlled time series.; A moderately irregular concentration was found in the Syrian coastal area.; An irregular concentration was found in the center/north Palestine, Jordan, and east Syria whereas a strongly irregular was found in the south Levant.; The annual rainfall tends to be more concentrated.; The autumn PCI significantly decreased in the Levant and its sub-regions.;

As an organization committed to working with and standing alongside those who have been forcibly displaced from their homes, advocacy is a core element of Jesuit Refugee Service’s work around the world. With policymakers, donor governments, and host communities, JRS advocates for, and with, those who seek safety and the opportunity to rebuild a life for themselves and their families. Through a network of staff across the globe implementing programs each and every day, JRS identifies the challenges faced in meeting the basic needs of those we serve, and which policies can improve those circumstances. In this article, we share examples of three areas where JRS has exerted influence and action on such policies. This includes access to refugee education, protecting the right to asylum, and placing a spotlight on one of the world’s most forgotten crises, the conflict in Syria.

Abstract 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

Geoelectrical survey was conducted by using vertical electrical sounding technique (VES) with adapting Schlumberger configuration, to locate and drill a borehole for groundwater extraction in the Kodana station for the Shami goats, Southern Syria. An integrated approach is proposed to increase the efficacy of the VES technique and to reduce the uncertainties and the high failures in locating and drilling a successful groundwater borehole. The approach is essentially based on analyzing the Dar-Zarrouk (D-Z) parameters with constraining several conditions to obtain the optimum hydro-geophysical model.The 1D inversion quantitative interpretation of twelve VES sounding points and the (D-Z) parameters allowed the characterization of the study area in terms of depth and the Neogene pyroclastic basalt aquifer. The result showed that VES point (V6) has the optimum and favorable properties for drilling a successful borehole in the area. The V6 has GPS coordinates of E: 3589614, N: 3301961 and Z: 770835m. The Neogene (fractured pyroclastic layer with rocks of basaltic composition) aquifer at this V6 point is characterized by a thickness (h) of 217m, a resistivity (ρ) of 227Ωm, a transverse resistance (R) of 49259 Ωm2, and an anisotropy parameter (λ) of 1.15. The advantages of the proposed approach are well proven and documented, in comparing with other techniques that require the combination of VES technique with other available geophysical techniques. The VES technique within the proposed approach is therefore recommended to be easily applied for groundwater investigations, and locating the suitable positions for drilling boreholes in similar worldwide basaltic environments.

Key Clinical Message In patients with anomalous origin of the left main coronary artery, accurate classification is essential for effective management. Despite surgical refusal, successful stenting and medication can lead to favorable outcomes. Regular monitoring ensures ongoing cardiac health. Abstract Coronary artery anomalies, including anomalous origin of the left main coronary artery from the right sinus of Valsalva, are rare occurrences with varying clinical significance. Accurate classification of these anomalies is crucial for determining their implications and guiding management. A 50‐year‐old man presented with chest pain and was diagnosed with an anomalous origin of the left main coronary artery. Despite refusing surgery, successful stenting and medication led to a favorable outcome. Regular monitoring is scheduled. Accurate classification of coronary anomalies, such as the left main coronary artery anomaly described, is vital for effective management. Even when surgical intervention is declined, alternative treatments, such as stenting, can be successful. Regular monitoring ensures ongoing cardiac health.

BackgroundAdvanced breast cancer (ABC) is a heterogeneous disease with varied prognoses, that is affected by many clinicopathological features. This study aimed to investigate the clinicopathological characteristics, first-line treatment (FLx), and prognostic impact of these features on survival among Syrian patients with ABC.Materials and methodsThis retrospective cohort study included patients with ABC. The association of clinicopathological factors with survival was assessed using Kaplan-Meier curves and the log-rank test, as well as the Cox proportional hazards regression model to calculate the hazard ratio (HaR).ResultsA total of 423 patients with ABC were included in the study, with a median age (range) of 47 years (23-82). 83% of metastases were metachronous. Most patients (91.8%) received chemotherapy as the FLx. The median progression-free survival (PFS) and overall survival (OS) of all the patients were 7 and 16 months, respectively. The median PFS was associated with four factors, which were time of metastasis (adjusted HaR=1.861, 95% CI 1.420-2.438, P

Objectives: Little work has been done investigating the prevalence and impact of comorbidities on cholera outcomes within conflict settings. We describe the clinical outcomes of patients treated for cholera in Latakia, Syria, during the 2022–2023 cholera outbreak. Methods: We performed a single-centre retrospective observational cohort study of patients admitted to the hospital with suspected cholera between 15th December 2022 and 15th February 2023 at National Hospital, Latakia, Syria. Multivariable negative binomial regression analysis was used to investigate the variables’ relationship to hospital length of stay. Results: The study involved 89 patients admitted to the hospital; none were vaccinated against cholera. Cholera rapid diagnostic test was positive in 91 % of patients. Half of the patients (51 %) were male; a third (35 %) had hypertension, and a fifth (19 %) had diabetes. One patient passed away during admission. Patients who were male, had diabetes and were hypertensive tended to have longer hospital stays in univariable analysis. When these factors were added to a multivariable negative binomial model (consisting of age, gender, hypertension and diabetes), male sex (IRR: 4.1, 95 % CI: 1.28–6.2, p = 0.001), the presence of hypertension (IRR: 2.1,95 % CI: 1.14 to 4.1, p = 0.004) and diabetes (IRR: 2, 95 % CI: 1.2 to 2.7, p = 0.001) were independent predictors of longer hospital stays. Conclusion: In conflict settings, hypertension and diabetes are common in patients admitted to hospital with cholera and are associated with longer hospital stays. Mortality from cholera, however, was low. Our findings highlight the importance of comorbidity control in mitigating excess morbidity during infectious disease outbreaks within conflict areas.

Key Clinical Message Down syndrome (DS), characterized by trisomy 21, significantly increases susceptibility to leukemia, although the occurrence of multiple myeloma (MM) in DS is exceedingly rare. This report details the case of a 45‐year‐old female with DS who was diagnosed with MM, highlighting diagnostic and therapeutic complexities. It emphasizes the importance of tailored therapeutic strategies for treating MM in individuals with DS and the need for specialized approaches in these cases.

Awassi is a fat-tailed sheep breed, and the best breed in Syria is famous. Awassi sheep are Syria's main source of red meat and milk production. In this study, we estimated the influence of various factors on sheep meat and milk production using time-series data from 1961 to 2020. This study employed the Cobb-Douglas production function to analyze the data. The results obtained indicate that Awassi meat production in Syria was positively and significantly influenced by carcass weight (p

The main goal of this paper is to present and compare the main developments in the Russian wars in Ukraine and Syria by considering the main patterns, parallels, and changing trajectories that could shed more light onto both of these war zones, which are highly interlinked due to Russia’s leading role in both. It analytically, comparatively, and contemplatively approaches those developments by highlighting multiple similarities and the main differences in global responses to these conflicts. Both conflicts should be seen as highly unpredictable, dynamic, and unnecessarily extended asymmetric proxy wars in which global powers test their new military doctrines and their competitors' responses to their unconventional actions and other unsolicited and indirect interferences in the local dynamism of both wars. Unlike in Syria, the Ukrainian war zone is wholly transformative and ready for the adoption of partial hybridization and the utilization of the new software-defined warfare in combination with conventional weapons.

The Arab Spring that began in Tunisia in 2010 quickly spread throughout the Middle East, fueling protests in many countries of the region, including Libya and Syria. While in Libya the UN Security Council supported NATO’s military intervention against the Gaddafi regime, the Syrian case caused disparity in views, with Russia and China vetoing the Western countries’ attempt to intervene in the conflict and topple Syria’s President Bashar al-Assad. The US intention to intervene directly in the Syrian civil war, triggered by the 2013 chemical weapons crisis, was successfully halted by Russian diplomatic efforts. Yet, the rising threat of terrorism in Syria and Iraq prompted the establishment of the US-led Global coalition against Daesh/ISIS, which conducted airstrikes in 2014, forcing Assad, who at that time had lost control over a significant part of Syria’s territory, to appeal to Russian President Vladimir Putin for assistance. As a result, Russia began its counterintervention in Syria to support Assad’s struggle to remain in power, fight terrorism and regain control of the country. This article discusses US and Russian objectives in the Syrian crisis, the limited results of the US-led military intervention and the success of the Russian counterintervention.

Abstract Introduction The COVID-19 outbreak devastated the fragmented health system in Syria, a war-torn country, and exaggerated the demands for humanitarian assistance. COVID-19 vaccination was rolled out in Northwest Syria, an area out of government control, in May 2021. However, vaccine acceptance rates are still minimal, which is reflected in the meager percentage of vaccinated people. The study aims to investigate the effectiveness of the humanitarian actors’ plans to address the COVID-19 vaccine hesitancy and conclude practical strategies for boosting vaccine uptake in Northwest Syria. Methods and materials Two questionnaires were developed to collect data from humanitarian organizations involved in the COVID-19 vaccination campaign and people from northwest Syria. Data analysis was performed using SPSS 22 data analysis program. Results According to the findings, 55.5% of people refused the COVID-19 vaccine. The results showed a knowledge gap and lack of evidence regarding humanitarian actors’ strategies to address the vaccine’s low uptake. Besides, it was found that doctors and medical workers were reliable sources of information about the vaccine. However, they were not systematically engaged in community mobilization and risk communication to promote people’s perspectives on the vaccine. Conclusion Risk communication and community engagement programs were not significantly associated with increasing the COVID-19 acceptance rate. Humanitarian actors must reconsider their strategies to address vaccine hesitancy in Northwest Syria. These strategies should engage medical professionals through dialogue sessions on the realities of the pandemic and vaccine development mechanism based on a compelling and evidence-based approach.

The authors consider the potential of a loose coalition in curbing US global influence, ie. the implications of its formation and strengthening on the final establishment of multipolarity. Based on the view that international relations are increasingly defined by multipolarity and that the opposition is increasingly speaking out against yesterday's hegemon, the authors point out that the US insists on an increasingly harsh global polarization, while Russia and China strive to initiate global "dedollarization" mechanisms. The joining of African and Middle Eastern countries to the anti-American bloc initiates international processes that potentially lead to the strengthening of existing and the formation of new units of collective security. After a period of soft balancing of US power, in the period from the coming to power of the Putin administration until the conflict in Georgia in 2008, the Russian Federation began an era of hard balancing, and the conflicts in Syria and the current one in Ukraine are the best indicators. By intervening in Syria, Russia secured the supply of its own gas to Europe and regained its international reputation, while by launching military operations in Ukraine, it rejected immediate military threats to NATO from its borders. The balance of power is currently emerging as the most realistic concept of international relations, although Russia and China are waiting for the moment when the inevitability of economic growth will change the balance of power in their favor.

Abstract Background The recent earthquake in Syria has caused widespread devastation, leading to extensive damage and loss of life. Considering the diverse range of disasters and conflicts that have affected Syrian society, health workers must possess essential competencies to effectively manage various types of disasters, including earthquakes. Therefore, this study was undertaken to identify the specific competencies required by Syrian health workers to respond efficiently and effectively to earthquakes. Methods An exploratory qualitative study was conducted at the Medical Education Program MEP of the Syrian Virtual University SVU. Nine members of the research team of the MEP, who represent various health specializations in medicine, dentistry, nursing, and pharmacy, accepted to take part in this study. Among these, three members have been actively involved in providing health care in hospitals and the field during the Syrian earthquake on 6 February 2023. The Delphi process was adopted to identify competencies. Health workers involved in earthquake response were categorized into nine groups including medical doctors, dentists, pharmacists, nurses, psychological support professionals, medical students, allied healthcare professionals, on-site disaster teams, and managers. The final list was accepted if it achieved more than 80% agreement among the participants in the first, second, and final rounds. Results The study identified 74 competencies (12 knowledge items, 35 skills, and 27 attitudes) essential for health workers to respond effectively to earthquakes. They are categorized into five domains: "Preparing the team for the rescue process during and, after earthquakes, Implementation of the rescue process, Education and psychological support, Research, and development". Conclusion A list of earthquake competencies was identified for health workers. It is hoped that this list will enhance a country’s resilience and will enable decision–makers to support health workers in acquiring these competencies within a very strained health system in Syria and other countries.

Abstract Background The genus Beauveria (Bals.) Vuill. includes many species, some of which are limited to specific regions while others are distributed worldwide. The diversity of Beauveria species is poorly investigated in Syria and most studies lack proper diagnosis of species. Entomopathogenic isolates of this genus were obtained using the Galleria Bait Method. This study aimed to identify these isolates based on morphological characterizations combined with molecular data, using nuclear ribosomal internal transcribed spacer (ITS) and elongation factor 1-alpha (EF1-α) sequences. The diversity of this genus in Syria has also been evaluated using a phylogenetic analysis of available ITS sequences of Syrian isolates in the GenBank. Results Two entomopathogenic isolates, B195 and B243, were detected in the soil of agro-ecosystems in the Syrian coastal region. Morphological and molecular information revealed that these two isolates belong to Beauveria bassiana (Bals.) Vuill. (Hypocreales: Cordycipitaceae) with 514 bp and 284 bp for the sequences of each isolate for ITS and EF1-α, respectively. Pathogenicity test showed 100% mortality of Galleria mellonella L. larvae 2–3 days post-fungal exposure for both isolates. The phylogenetic tree showed that all Syrian sequences of Beauveria clustered within the species B. bassiana, with a considerable intraspecific diversity, except for two isolates previously identified as B. bassiana, which are closely related to Beuveria pseudobassiana S.A. Rehner and Humber. Conclusions This study presents a morpho-molecular characterization of two Syrian soil-sourced B. bassiana isolates highly pathogenic to G. mellonella larvae and clarifies their phylogenetic placement. Depending on our findings, further exploration studies of the genus Beauveria in Syria are still needed to better our understanding of the diversity and distribution of this entomopathogen in Syria.

The main objective of this paper is basically to calibrate and compare the different geoelectrical results obtained by the three interpretative techniques of the inverse slope method (ISM), Pichgin and Habibuleav (PHT) and concentration-number (C-N) fractal modeling with the well lithology of an existing known ditch in the Al-Sharquieh phosphate mine in Syria. Those interpretative techniques are applied herein to interpret the vertical electrical soundings (VES) points measured along a parallel profile to the ditch. ISM reveals the presence of four to five geoelectrical layers in the study region. The PHT allows the determination of the tectonic subsurface features of the study region, by analyzing the non homogeneity points and their distributions along a given geoelectrical profile. The fractal C-N modeling provides the different apparent resistivity ranges dominating in the study region. Good agreements are obtained between the direct observed field lithological descriptions of both wall sides of this ditch, and the results obtained by those three interpretative geoelectrical techniques. The high radioactive readings exceeding four hundred count per second (cps) are due to the presence of secondary uranium accompanied with fractures, cracks and joints. The secondary uranium occurrences accompanied by phosphate deposits are found in the study area in the fractured zones, as determined by the geoelectrical PHT technique. The three mentioned geoelectrical methodologies are therefore used as indirect techniques for delineating the radioactive zones related to uranium prospecting. It is a successful application of the joint use of those three techniques, that could be applied in mining to delimit the subsurface geological structure. The reliability and efficacy of (ISM), (PHT), and (C-N) fractal modeling techniques are consequently well confirmed, and it is therefore recommended to use and apply them for characterizing and describing similar lithological phosphatic sequences, and for several shallow mining, environmental and civil engineering applications.

The usage of private military companies (PMCs) has remained rampant among significant powers of the world since the Cold War. Historically, PMCs emerged as small contractors in the beginning but gradually attained multiplicity with distinctive capabilities. The Russian Wagner Group provides multi-dimensional and sophisticated support to the Putin Administration. The Group accounts for an operational latitude which is advanced, diplomatic, and target-oriented, and maneuvers Russian strength in both Syria and Ukraine. Russian mercenaries are state-specific, i.e., the use of Wagner Group in Syria and Ukraine, making it challenging for the opposition to understand the functioning and administration of these companies. By 2019, the Group remained covert yet precarious for its enemies. However, the new advancements suggest that the idea of plausible deniability is now shifting towards overt use as well as far-reaching proprietorship of the Group as a branch of Russian military interests. The research focuses on the private structure of Wagner Group paving the way for new challenges towards the NATO countries, shifting from conventional military threats from Russia towards overt, opportunist, and task-oriented PMCs.

This article adopts a socio-economic and political lens to elucidate the interplay of factors that heighten the vulnerability of Syrian refugee agricultural workers and their exposure to pesticides in Lebanon. It provides a comprehensive understanding for the interconnected social, political and economic factors at the global, regional, national and local levels and how they increase the vulnerability of Syrian refugee agricultural workers, particularly their exposure to pesticides. The global factors highlight the shifts from colonialism to state-controlled economies to neoliberal policies. These changes have prioritized the interests of large agricultural schemes and multinationals at the expense of small and medium-sized agriculture. Consequently, there has been a boost in pesticides demand, coupled with weak regulations and less investment in agriculture in the countries of the Global South. The article explains how the dynamic interaction of climate change and conflicts in the Middle East and North Africa region has negatively impacted the agriculture sector and food production, which led to an increased potential for pesticide use. At the national and local levels, Lebanon’s social, political and economic policies have resulted in the weakening of the agricultural sector, the overuse of pesticides, and the intensification of the Syrian refugee agricultural workers’ vulnerability and exposure to pesticides. The article recommends that researchers, policymakers, and practitioners adopt a political-economic-social lens to analyze and address the full dynamic situation facing migrant and refugee workers in Lebanon and other countries and promote equity in the agricultural sector globally.