Factors influencing research productivity among Syrian medical professionals amidst conflict: a case-control study.

BACKGROUND: Medical research productivity is globally increasing, with a lagging progress in third-world countries due to significant challenges, including inadequate training and brain drain. Syria had been showing a slow upward trend until the war broke out and severely hindered academic growth and productivity. A deeper understanding of the factors influencing research productivity in this context are fundamental to guide educational policies and resource allocation. Previous cross-sectional studies that evaluated the perspectives of Syrian academics on the issue were limited by the small sample size of published healthcare workers, making it difficult to identify the factors that enabled them to pursue research. METHODS: To address this challenge, we employed a case-control design. We isolated published early-career Syrian healthcare workers and compared their characteristics and perceptions to unpublished matched controls. Authors in the fields of medicine, dentistry, and pharmacy affiliated with any Syrian University were identified through an extensive search of PubMed and Google Scholar.These authors were invited to complete a questionnaire that covered participants' research contributions, alongside their self-assessed knowledge, attitudes, and barriers towards research. The questionnaire was publicly published to recruit an equal sample of matching controls, with half consisting of unpublished researchers and the other half of participants without prior research contributions. RESULTS: Six-hundred-sixteen participants were recruited. Their knowledge, attitudes, and perceived barriers explained 46% and 34% of the variability in research involvement and publication, respectively (P < 0.001). Getting involved in and publishing research studies associated with higher research-related knowledge and attitudes (P < 0.001). Respondents' assessment of research-related barriers and their academic scores did not differ between cases and controls. Superior research-related knowledge and attitudes were associated with male gender, higher English competency, and better internet connectivity. Meanwhile, extracurricular training and mentors' support were associated with more positive research-related attitudes and less perceived barriers. CONCLUSIONS: Research productivity of medical professionals in Syria exhibits a positive correlation with their knowledge and favorable attitudes towards medical research. Noteworthy, the demographic variations are linked to disparities in research-related knowledge and motivation. In conclusion, these results suggest a potential avenue for enhancement through concentrated efforts on improving extracurricular training interventions and mentors' support.

Improving Academic Writing in a Low-Resource Country: A Systematic Examination of Online Peer-Run Training.

Problem: Syrian medical research synthesis lags behind that of neighboring countries. The Syrian war has exacerbated the situation, creating obstacles such as destroyed infrastructure, inflated clinical workload, and deteriorated medical training. Poor scientific writing skills have ranked first among perceived obstacles that could be modified to improve Syrian research conduct at every academic level. However, limited access to personal and physical resources in conflict areas consistently hampers the implementation of standard professional-led interventions. Intervention: We designed a peer-run online academic writing and publishing workshop as a feasible, affordable, and sustainable training method to use in low-resource settings. This workshop covered the structure of scientific articles, academic writing basics, plagiarism, and the publication process. It was also supplemented by six practical assignments to exercise the learned skills. Context: The workshop targeted healthcare professionals and medicine, dentistry, and pharmacy trainees (undergraduate and postgraduate) at all Syrian universities. We employed a systematic design to evaluate the workshop's short- and long-term impact when using different instructional delivery methods and assignment formats. Participants were assigned in a stratified manner to four groups; two groups attended the workshop synchronously, and the other two groups attended asynchronously. One arm in each group underwent a supervised peer-review evaluation for the practical writing exercises (active), while the other arm in each group self-reviewed their work on the same exercises using exemplary solutions (passive). We assessed knowledge (30 questions), confidence in the learned skills (11 questions), and the need for further guidance in academic writing (1 question) before the workshop and one month and one year after it. Impact: One-hundred-twenty-one participants completed the workshop, showing improved knowledge, confidence, and need for guidance. At one-year follow-up, participants showed stability in these gains. Outcomes for the synchronous and asynchronous groups were similar. Completing practical assignments was associated with greater knowledge and confidence only in the active arms. Participants in the active arms engaging in the peer-review process showed greater knowledge increase and reported less need for guidance compared to those who did not engage in the peer-review. Lessons learned: Peer-run interventions can provide an effective, affordable alternative to improving scientific writing skills in settings with limited resources and expertise. Online academic writing training can show improvements regardless of method of attendance (i.e., synchronous versus asynchronous). Participation in supplementary practical exercises, especially when associated with peer-review, may improve knowledge and confidence.

Lung Cancer Diagnoses and Outcomes During the Syrian War, 2011-2018.

Importance: Protracted wars, which disproportionately affect low-resource countries, exacerbate the challenges faced by cancer care systems, with lung cancer being the most affected as the most fatal oncological condition. Objective: To characterize the presentation and survival of patients with lung cancer during the decade-long Syrian war. Design, Setting, and Participants: This cohort study included patients at a large oncology center in Syria during the first 8 years of the Syrian armed conflict (2011-2018). All patients with a new diagnosis of lung cancer were included. Variables investigated included histological subtypes, TNM classification (tumor, lymph nodes, and metastasis), and staging at diagnosis as well as the yearly follow-ups up to 5 years after presentation. Exposure: The Syrian war divided the country into temporary regions with different political influences and heterogeneously impacted health care accessibility among these regions. Main Outcomes and Measures: Change in prevalence of advanced lung cancer cases at presentation; change in overall survival odds. Results: The study included 5160 patients from all Syrian governorates (mean [SD] age, 59.6 [10.8] years; 4399 men [85.3%]). New diagnoses sharply declined during the first 3 years of the war, with partial recovery afterward. Regardless of their tempo-geographical regions, 60% to 80% of the yearly diagnoses presented with metastases. The 1-year and 5-year survival rates were 13.1% (423 of 3238 patients with follow-up results) and 0.1% (2 of 1853 patients), respectively. Patients who presented from regions more involved in the armed conflicts showed poorer survival rates with odds ranging between 0.51 (95% CI, 0.44-0.59) and 0.61 (95% CI, 0.49-0.74) across follow-ups for up to 2 years in comparison with patients presenting from safer regions. War-related health care inaccessibility explained a greater percentage of the variability in survival (Nagelkerke R2 = 7.5%; P < .001) than both patients' age and the stage of the disease combined (Nagelkerke R2 = 3.9%; P < .001). Conclusions and Relevance: The Syrian war has been associated with a marked decline in the management of patients with lung cancer, with limited access to specialized care, delayed diagnoses, and substantial decrease in survival rates correlating with the intensity of armed conflict in the respective regions. The profound repercussions of the prolonged armed conflict on patients with lung cancer in Syria necessitates urgent comprehensive strategies to improve the accessibility and quality of health care services, especially in conflict-ridden zones.

Patterns of War-Related Traumatic Brain Injuries and Predictors of Mortality Among Civilians During the Syrian Armed Conflict.

BACKGROUND AND OBJECTIVES: High-velocity weapons were used against unshielded civilians during the Syrian armed conflict, leading to a variety of combat-related traumatic brain injuries with high fatality and morbidity. Because of the lack of data in the literature about the management and outcomes of similar injuries, we aimed in this study to characterize shrapnel and gunshot injuries in this vulnerable group and to describe the association between the mechanisms, site, and type of injury and the outcomes. METHODS: This was a single-center retrospective cohort study on new traumatic brain injuries in civilians who presented alive to the neurosurgery department at Damascus Hospital between 2014 and 2017. The analyzed data included the mechanism of injury and its type and site based on computed tomography scans. We also studied the neurological status at admission, the major interventions applied, and outcomes including mortality and neurological deficits at discharge. RESULTS: Shrapnel and gunshot injuries more likely affected the frontal and parietal lobes, respectively. While shrapnel led to injuries in multiple body parts, gunshots led to localized but more severe injuries. Despite that, mortality rates were comparable between the two mechanisms. Injuries to the right parietal and right frontal lobes were more fatal with odds ratios of 2.61 (1.23-5.52) and 2.12 (1.00-4.50), respectively. Moreover, mortality was also linked to the radiological findings of loss of brain material with an odds ratio of 3.73 (1.42-9.81), intracerebral hemorrhage with an odds ratio of 3.60 (1.67-7.80), intraventricular hemorrhage with an odds ratio of 5.49 (1.68-17.95), and subdural hemorrhage with an odds ratio of 6.35 (2.29-17.66). CONCLUSION: The unfortunate nature of the Syrian armed conflict, wherein civilians were targeted during their daily routine, seems to manifest a heightened propensity to affect the parietal lobes, potentially resulting in higher morbidity. Although shrapnel and gunshot injuries showed no significant difference in mortality rates, injuries involving loss of brain tissue and intracranial hemorrhage emerged as independent predictors of mortality.

Wavelet-Based Bracketing, Time-Frequency Beta Burst Detection: New Insights in Parkinson's Disease.

Studies have shown that beta band activity is not tonically elevated but comprises exaggerated phasic bursts of varying durations and magnitudes, for Parkinson's disease (PD) patients. Current methods for detecting beta bursts target a single frequency peak in beta band, potentially ignoring bursts in the wider beta band. In this study, we propose a new robust framework for beta burst identification across wide frequency ranges. Chronic local field potential at-rest recordings were obtained from seven PD patients implanted with Medtronic SenSight™ deep brain stimulation (DBS) electrodes. The proposed method uses wavelet decomposition to compute the time-frequency spectrum and identifies bursts spanning multiple frequency bins by thresholding, offering an additional burst measure, ∆f, that captures the width of a burst in the frequency domain. Analysis included calculating burst duration, magnitude, and ∆f and evaluating the distribution and likelihood of bursts between the low beta (13-20 Hz) and high beta (21-35 Hz). Finally, the results of the analysis were correlated to motor impairment (MDS-UPDRS III) med off scores. We found that low beta bursts with longer durations and larger width in the frequency domain (∆f) were positively correlated, while high beta bursts with longer durations and larger ∆f were negatively correlated with motor impairment. The proposed method, finding clear differences between bursting behavior in high and low beta bands, has clearly demonstrated the importance of considering wide frequency bands for beta burst behavior with implications for closed-loop DBS paradigms.

Intelligibility of speech in Parkinson's disease relies on anatomically segregated subthalamic beta oscillations.

BACKGROUND: Speech impairment is commonly reported in Parkinson's disease and is not consistently improved by available therapies - including deep brain stimulation of the subthalamic nucleus (STN-DBS), which can worsen communication performance in some patients. Improving the outcome of STN-DBS on speech is difficult due to our incomplete understanding of the contribution of the STN to fluent speaking. OBJECTIVE: To assess the relationship between subthalamic neural activity and speech production and intelligibility. METHODS: We investigated bilateral STN local field potentials (LFPs) in nine parkinsonian patients chronically implanted with DBS during overt reading. LFP spectral features were correlated with clinical scores and measures of speech intelligibility. RESULTS: Overt reading was associated with increased beta-low ([1220) Hz) power in the left STN, whereas speech intelligibility correlated positively with beta-high ([2030) Hz) power in the right STN. CONCLUSION: We identified separate contributions from frequency and brain lateralization of the STN in the execution of an overt reading motor task and its intelligibility. This subcortical organization could be exploited for new adaptive stimulation strategies capable of identifying the occurrence of speaking behavior and facilitating its functional execution.

Lessons learnt from the first wave of COVID-19 in Damascus, Syria: a multicentre retrospective cohort study.

OBJECTIVES: The decade-long Syrian war led to fragile health infrastructures lacking in personal and physical resources. The public health of the Syrian population was, therefore, vulnerable to the COVID-19 pandemic, which devastated even well-resourced healthcare systems. Nevertheless, the officially reported incidence and fatality rates were significantly lower than the forecasted numbers. DESIGN: A retrospective cohort study. SETTING: The four main responding hospitals in Damascus, which received most of the cases during the first pandemic wave in Syria (i.e., June-August 2020). PARTICIPANTS: One thousand one hundred eighty-four patients who were managed as inpatient COVID-19 cases. PRIMARY AND SECONDARY OUTCOME MEASURES: The records of hospitalised patients were screened for clinical history, vital signs, diagnosis modality, major interventions and status at discharge. RESULTS: The diagnostic and therapeutic preparedness for COVID-19 was significantly heterogeneous among the different centres and depleted rapidly after the arrival of the first wave. Only 32% of the patients were diagnosed based on positive reverse transcription-PCR tests. Five hundred twenty-six patients had an indication for intensive care unit admission, but only 82% of them received it. Two hundred fifty-seven patients needed mechanical ventilation, but ventilators were not available to 14% of them, all of whom died. Overall mortality during hospitalisation reached 46% and no significant difference was found in fatality between those who received and did not receive these care options. CONCLUSIONS: The Syrian healthcare system expressed minor resilience in facing the COVID-19 pandemic, as its assets vanished swiftly with a limited number of cases. This forced physicians to reserve resources (e.g., ventilators) for the most severe cases, which led to poor outcomes of in-hospital management and limited the admission capacity for milder cases. The overwhelmed system additionally suffered from constrained coordination, suboptimal allocation of the accessible resources and a severe inability to informatively report on the catastrophic pandemic course in Syria.

Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment.

BACKGROUND AND PURPOSE: In these guidelines, we aimed to develop evidence-based recommendations for the use of screening questionnaires and diagnostic tests in patients with neuropathic pain (NeP). METHODS: We systematically reviewed studies providing information on the sensitivity and specificity of screening questionnaires, and quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy. We also analysed how functional neuroimaging, peripheral nerve blocks, and genetic testing might provide useful information in diagnosing NeP. RESULTS: Of the screening questionnaires, Douleur Neuropathique en 4 Questions (DN4), I-DN4 (self-administered DN4), and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) received a strong recommendation, and S-LANSS (self-administered LANSS) and PainDETECT weak recommendations for their use in the diagnostic pathway for patients with possible NeP. We devised a strong recommendation for the use of skin biopsy and a weak recommendation for quantitative sensory testing and nociceptive evoked potentials in the NeP diagnosis. Trigeminal reflex testing received a strong recommendation in diagnosing secondary trigeminal neuralgia. Although many studies support the usefulness of corneal confocal microscopy in diagnosing peripheral neuropathy, no study specifically investigated the diagnostic accuracy of this technique in patients with NeP. Functional neuroimaging and peripheral nerve blocks are helpful in disclosing pathophysiology and/or predicting outcomes, but current literature does not support their use for diagnosing NeP. Genetic testing may be considered at specialist centres, in selected cases. CONCLUSIONS: These recommendations provide evidence-based clinical practice guidelines for NeP diagnosis. Due to the poor-to-moderate quality of evidence identified by this review, future large-scale, well-designed, multicentre studies assessing the accuracy of diagnostic tests for NeP are needed.

Pallidal Recordings in Chronically Implanted Dystonic Patients: Mitigation of Tremor-Related Artifacts.

Low-frequency oscillatory patterns of pallidal local field potentials (LFPs) have been proposed as a physiomarker for dystonia and hold the promise for personalized adaptive deep brain stimulation. Head tremor, a low-frequency involuntary rhythmic movement typical of cervical dystonia, may cause movement artifacts in LFP signals, compromising the reliability of low-frequency oscillations as biomarkers for adaptive neurostimulation. We investigated chronic pallidal LFPs with the PerceptTM PC (Medtronic PLC) device in eight subjects with dystonia (five with head tremors). We applied a multiple regression approach to pallidal LFPs in patients with head tremors using kinematic information measured with an inertial measurement unit (IMU) and an electromyographic signal (EMG). With IMU regression, we found tremor contamination in all subjects, whereas EMG regression identified it in only three out of five. IMU regression was also superior to EMG regression in removing tremor-related artifacts and resulted in a significant power reduction, especially in the theta-alpha band. Pallido-muscular coherence was affected by a head tremor and disappeared after IMU regression. Our results show that the Percept PC can record low-frequency oscillations but also reveal spectral contamination due to movement artifacts. IMU regression can identify such artifact contamination and be a suitable tool for its removal.

Neurologic Care of Forcibly Displaced Persons: Emerging Issues in Neurology.

There is a growing number of forcibly displaced persons (FDPs) worldwide. With more than 100 million people forcibly displaced today, there is an urgent mandate to understand the neurologic care needs of this population and how neurologists and other health care workers can most effectively provide that care. In this Emerging Issues in Neurology article, we attempt to (1) define the scope of the problem of providing neurologic care to FDPs, (2) highlight commonly encountered clinical challenges related to neurologic care of FDPs, and (3) provide useful clinical information for neurologists and other clinicians who deliver care to FDPs with neurologic needs. We address the terminology of forcible displacement and how terms may differ across a person's migration journey. Common challenges encountered by FDPs with neurologic needs across settings include loss of support systems, loss of personal health information, language barriers and differing expression of symptoms, differing belief systems, epidemiologic patterns of disease unfamiliar to the clinician, and patients' fear and perceived risks of engaging with health systems. Practical approaches are shared for clinicians who encounter an FDP with a neurologic presentation. Finally, the article discusses many unmet neurologic needs of FDPs, which require significant investment. These include addressing lapses in neurologic care during displacement and understanding the effects of forcible displacement on people with chronic neurologic conditions. Future research and educational resources should focus on improving epidemiologic intelligence for neurologic conditions across geographies, developing curricula for optimizing the neurologic care of FDPs, and evaluating the most appropriate and effective uses of health technologies in humanitarian settings.

War-related traumatic brain injuries during the Syrian armed conflict in Damascus 2014-2017: a cohort study and a literature review.

BACKGROUND: The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital. METHODS: We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales. RESULTS: Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores. CONCLUSIONS: This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources.

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

BACKGROUND: Early detection of breast cancer (BC) is crucial for better prognosis especially in low-income countries, where advanced cancer stages are common. The Syrian war severely affected the healthcare system restraining the proper timely management of BC cases. We aimed to investigate the prevalence of patient- and system-related delays in BC diagnosis and management in Syria in addition to their predisposing characteristics and impact on the staging. METHODS: This is a cross-sectional retrospective cohort study on patients followed by the BC unit at Al-Bairouni main cancer center in Syria. The data were collected through personal interviews and retrospective revision of patients' records. RESULTS: A total number of 519 patients were recruited; A quarter of them (n = 126) reported more than three months intervals between symptoms recognition and presentation to a physician. Additionally, 72 (13.9 %) patients received a confirmed diagnosis more than three months after presentation, and 12 (2.3 %) started treatment at least three months after the diagnosis. Patients who suffered from war-related inaccessibility to healthcare were 2.55 [1.58-4.11] times more likely to report significant delays. Additionally, the most common self-reported reasons for patient delay were the lack of awareness, which was more evident for less common symptoms like the change in breasts size, and shyness. Patients who reported significant delays were more likely to receive an advanced-stage diagnosis. CONCLUSION: War-related inaccessibility to healthcare rendered a significant group of BC patient susceptible to evident delay. This combined with significant system delays because of the overwhelmed hospitals, high costs, and insufficient personnel, equipment, medications, and training. However, personal factors, which might not be directly related to the war, like the inadequate awareness of rare symptoms and shyness still necessitate urgent interventions on the public knowledge and performed screening practices. These delays associated with receiving advanced-stage diagnoses and minimizing them can return better prognoses.

Activated protein C resistance impact on Syrian candidates for in vitro fertilisation and the benefit of anticoagulation therapy: a retrospective cohort study.

Activated protein C resistance (APCR) is a common thrombophilia, caused mainly by a mutation. The impact of APCR on the efficacy of In Vitro Fertilization (IVF) are still unclear, and no solid recommendations for its management were published. To investigate the effect of APCR on IVF outcomes and assess the efficacy of our management protocol, we retrospectively scanned the medical records of women who were tested with APCR assay in 2019 at our fertility centre. The 66 women (12%) positive for APCR had lower odds of reaching clinical pregnancies after IVF 0.18 [95% CI: 0.07-0.47] and fewer live births. The administration of low-molecular-weight heparin and aspirin associated with more implantation in treated compared to untreated APCR-positive women with an odds ratio of 43.2 [7.51-248.6]. In conclusion, APCR negatively affects the number of clinical pregnancies after IVF, but anticoagulation therapy can mitigate this effect and significantly increase clinical pregnancies.Impact StatementWhat is already known on this subject? The evidence about the impact of APCR on IVF outcomes is still inconclusive. According to the Canadian guideline, routine screening for thrombophilia in patients with recurrent pregnancy loss is not recommended. No clear recommendations regarding the management of APCR in the planning for IVF are yet available.What do the results of this study add? APCR significantly increases implantation failure among infertile women who conduct IVF. Management of APCR using LMWH and aspirin was effective in mitigating this effect and increasing successful implantation.What are the implications of these findings for clinical practice and/or further research? Our findings can support the recommendation to include APCR assay in the routine tests for infertile women conducting IVF, and suggest the combination between LMWH and aspirin as an effective therapy to increase successful implantation in APCR positive candidates. However, more controlled clinical trials are still needed to confirm our results.

Medical Research Conduct and Publication during Higher Education in Syria: Attitudes, Barriers, Practices, and Possible Solutions.

Background: The huge workload on doctors especially residents, who are the main health care providers in public hospitals, in addition to the vanishing incomes and lack of personal safety during the decade-long Syrian crisis, led to further hurdles in the focus on research. Postgraduate students in the medical and paramedical fields must conduct original research projects as part of their graduation requirements. However, this does not reflect on research publications coming from Syria. Methods: This is a nation-wide cross-sectional study targeting medical, dental, and pharmacy postgraduate students who are at the phase of planning for their required projects. The questionnaire aimed to capture their attitudes toward research, perceived barriers, and previous research experiences in order to suggest evidence-based recommendations. Results: The sample consisted of 429 residents representing about 22% of the target population. Nearly all the participants had positive opinion toward the important role of medical research and the significance of their participation. Agreement was also clear regarding perceived barriers, including the lack of adequate training and research facility. Seventy-one percent of the participants were not involved in any research before the time of their master theses, less than 13% of them had submitted an article for publication, and less than 5% had submitted more than one paper. Despite that, high-quality internet connectivity and rich English writing skills were associated with further research experiences. Additionally, mentors' support and self-paced learning of research skills had significant positive impact on students' research contributions with odds ratios of 2.04 [[95% Confidence Interval]: 1.02-4.06] and 2.68 [1.48-4.84], respectively. Conclusion: Lack of training and mentorship, in addition to several common barriers to medical research, hampered residents' capacity of conducting and publishing research despite their positive attitudes toward it. Nevertheless, the variance within our sample exposed a promising window for implementing low-cost institutional and individual solutions such as peer-run self-paced training opportunities and long-distance mentoring.

Use of a Fascial Pad to Help Electrode Insertion During Cochlear Implantation in Incomplete Partition Type III.

Cochlear implantation surgery in the rare cases of incomplete partition type III is constrained by intraoperative difficulties that result from the deformed cochlea. Our case study describes the use of a supporting fascia pad that served as a track to preserve the direction of the electrode during insertion into the cochlear lumen.

A Fully-Immersive Virtual Reality Setup to Study Gait Modulation.

Objective: Gait adaptation to environmental challenges is fundamental for independent and safe community ambulation. The possibility of precisely studying gait modulation using standardized protocols of gait analysis closely resembling everyday life scenarios is still an unmet need. Methods: We have developed a fully-immersive virtual reality (VR) environment where subjects have to adjust their walking pattern to avoid collision with a virtual agent (VA) crossing their gait trajectory. We collected kinematic data of 12 healthy young subjects walking in real world (RW) and in the VR environment, both with (VR/A+) and without (VR/A-) the VA perturbation. The VR environment closely resembled the RW scenario of the gait laboratory. To ensure standardization of the obstacle presentation the starting time speed and trajectory of the VA were defined using the kinematics of the participant as detected online during each walking trial. Results: We did not observe kinematic differences between walking in RW and VR/A-, suggesting that our VR environment per se might not induce significant changes in the locomotor pattern. When facing the VA all subjects consistently reduced stride length and velocity while increasing stride duration. Trunk inclination and mediolateral trajectory deviation also facilitated avoidance of the obstacle. Conclusions: This proof-of-concept study shows that our VR/A+ paradigm effectively induced a timely gait modulation in a standardized immersive and realistic scenario. This protocol could be a powerful research tool to study gait modulation and its derangements in relation to aging and clinical conditions.

The impact of non-extraction orthodontic treatment on oral health-related quality of life: clear aligners versus fixed appliances-a randomized controlled trial.

OBJECTIVE: To assess the impact of clear aligner treatment on oral health-related quality of life (OHRQoL) compared to fixed appliance treatment. TRIAL DESIGN: Two-arm parallel group single-centre randomized controlled trial. METHODS: Forty-four adult patients (8 males, 36 females) were randomly and equally assigned to either the fixed appliances group (FA) or the clear aligners group (CA). Randomization with an allocation ratio of 1:1 was performed by a researcher who is not involved in the study using a random sample table. Non-extraction cases were included in this study. Outcome measures were the OHRQoL of patients and the duration of orthodontic treatment. The OHRQoL of patients was assessed by the short-form Oral Health Impact Profile (OHIP-14) at the following assessment times: before the start of treatment (T0), 1 week (T1), 1 month (T2), 3 months (T3), and 6 months (T4) after the start of orthodontic treatment and post-treatment (T5). The assessor was blinded during outcomes assessment and statistical analysis. RESULTS: Two hundred and eighteen patients were evaluated for eligibility, 44 of them fulfilled the inclusion criteria and were randomly allocated to treatment groups. None of the patients was lost to follow-up. Accordingly, the results of 44 patients were statically analysed. The total OHIP-14 score was not statistically different between the FA and the CA groups at T0 (P = 0.91) and T5 (P = 0.16), whereas it was significantly lower in the CA group as compared to the FA group at T1 (mean difference [MD] = 11.04, 95% CI 8.7 to 13.42, P < 0.001), T2 (MD = 6.00, 95% CI: 4.3 to 7.7, P < 0.001), T3 (MD = 3.37, 95% CI: 1.5 to 5, P < 0.01), and T4 (MD = 3.32, 95% CI: 1.7 to 4.9, P < 0.001). Treatment duration in the CA group was significantly shorter than in the FA group (MD = 4.18, 95% CI: 2.8 to 5.5, P < 0.001). No harms were observed. LIMITATIONS: The results were limited to the non-extraction treatment of mild to moderate crowding cases. CONCLUSIONS: Patients treated with clear aligners reported higher OHRQoL and shorter treatment duration as compared to those treated with fixed appliances. TRIAL REGISTRATION: Retrospectively registered (DRKS-ID: DRKS00023977).

Herniation of the Mastoid Segment of the Facial Nerve During Cochlear Implantation Surgery.

BACKGROUND: We aim to report a rare case of a herniated mastoid segment of the facial nerve that was accidently discovered during cochlear implantation surgery and how altering the surgery plan could achieve the implantation while preserving the nerve. CASE PRESENTATION: A four-year-old girl presented with profound bilateral sensorineural hearing loss that did not completely resolve after 2 years of using hearing aids was scheduled for cochlear implantation surgery in the right ear. During surgery, a herniated mastoid segment of the facial nerve took an anterior course and obstructed the access to the round window. CONCLUSION: When a traditional posterior tympanotomy approach in cochlear implantation surgery is limited in cases of a herniated facial nerve, a tunnel created near the inferior part of the posterior wall of the auditory canal provided safe insertion of the electrode. It also permitted placement of a piece of fascia between the electrode and the facial nerve, therefore, protecting the facial nerve from electrical stimuli.

Breast cancer screening during the Syrian crisis: A cross-sectional study.

INTRODUCTION: Although breast cancer has a lower incidence in developing countries, mortality rates are higher, mainly due to delay in diagnosis and the poor diagnostic and therapeutic capacities. Although screening tests have been available for quite a long time, delayed and advanced presentation is still common, especially in developing countries. The decade-long Syrian crisis has severely crippled the healthcare system and depleted the already-limited capacities of the healthcare services, which under prioritized the care provided to unurgent cases like breast cancer. This study aimed to investigate the practices of breast cancer screening among breast cancer patients. METHODS: A cross-sectional study conducted in Al-Beiruni Hospital at Damascus University in 2019, through personal interviews using a structured questionnaire. RESULTS: The sample consisted of 519 patients with breast cancer. One-hundred twenty (23.2%) of them reported undergoing one or more of the different screening methods at least once every six months prior to diagnosis. Several factors had a statistically significant association with the probability of undergoing or performing screening methods including living in large cities, having fewer children, having a full-time or part-time job, and the level of education. Patients who reported having a relative diagnosed previously with breast cancer or any other malignancies were also more likely to screen themselves. Inaccessibility to healthcare services, which was exaggerated by the armed conflicts, had a significant association with less practicing of the screening methods too (OR: 0.4 [0.3-0.7]). CONCLUSION: The Syrian war and its direct and indirect consequences negatively affected screening practices of breast cancer.

Idiopathic intracranial hypertension with juvenile idiopathic arthritis-associated uveitis: A case report.

A 14-year-old girl with juvenile idiopathic arthritis (JIA)-associated uveitis who also had optic disc edema, was later diagnosed with Idiopathic intracranial hypertension (IIH). To our knowledge, this is the fifth case of the coexistence of uveitis and IIH among children, and the only one with no obvious risk factors for IIH.