 Sgwrth i amlwg, mae'r cyntaf o gweithio i'r ffordd ddim yn ymwneud. Byddai'n meddwl ystod baiad yn ysgolw'r rhagorau a'r cyfrifwyr sy'n ddiddordeb hwnnw. Dyma'r rhagorau sy'n ddiddordeb hwnnw i gweithio'r ysgolwyr sy'n ei wneud i gael'r cyfrifwyr sy'n ddiddordeb hwnnw. Mae'n bosbwysig cyfrifwyr yma'r ysgolwyr ar y cyfrifwyr mewn cyfrifwyr ac rwy'n meddwl ysgolwyr. systematig review. As we move forward we realise that we didn't actually have sufficient information to do justice to that title. So for the time being we have some provisional findings to discuss with you and we'll talk a little bit about the gaps surrounding current reporting and current evidence to support this particularly interesting topic. I should give thanks to the co-authors particularly Sylvia here and Bayard who has done a lot of work on this in the last couple of weeks. Since I'm the first to speak I'm going to dwell a little on this particular slide. This is really just, as I'm sure most of you are aware, a little bit of justification with regards to why we're doing work on this topic and why we think today is so important. It's also a good opportunity for those of you who unfortunately are meant to be next door to slowly pick up your things and relocate unless you wish to stay which I would recommend. So this is some data from the WHO, a country reported data that was submitted to the WHO in the last couple of years. These are a selected number of conflict affected countries and you can see that in each and every country there is quite a substantial burden of NCDs. The problem that we face and the reason that we wanted to look at this in a little bit more detail is that the specifics and the finer details are very poorly understood. I'm sure it goes without saying for most of you that we see now that the burden of NCDs is certainly growing. Greater number of middle income countries are affected by non-communicable diseases. We also see a global demographic shift, aging populations and so on, which are proportionally more affected by NCDs. But also in crisis specific contexts, some of the stressors related to crisis, the relationship between health seeking behaviour, the relationship between unhealthy practices, alcohol use, smoking, drug use and so on, and also the burden of mental health and the relationship between mental health and non-communicable diseases, which is well established, is something that I think we need to explore in more detail. Of course, in these crisis contexts, the breakdown of health services and the treatment gap is also a very interesting area for further research. Back to the systematic review. This is the aim of the review and the overarching objectives. You'll see as we discuss some of the findings that we haven't really yet been able to do justice to some of the objectives. But as we move forward and as we work towards completing the review, we hope to have some further details to share with you. So it goes without saying that the systematic review followed the Prisma guidelines. We employed three arms in terms of the search terms, looking at crisis-related terms, terms related to non-communicable diseases and terms related to the burden of disease. And we searched the usual databases plus grey literature sources. So we had some of the co-authors that work for humanitarian agencies were supplying grey lit sources themselves and we approached other agencies and other databases. But this is an ongoing process and I will come back to that as the end as we solicit more papers from you. So we were looking specifically at crisis-affected populations, specifically civilians, so we didn't look at veterans. That was quite a significant number of papers that looked at combat veterans who were back in their home countries. We were looking specifically at low and middle income countries and also NCDs and their complications. And we only looked at quantitative studies. We had no language restrictions and no time restrictions. So we picked up initially just over 12,000 papers. We settled on 71 published studies and a further 10 studies from the grey literature. This slide shows you the trend in publication over time. So the first study that we found was published back in 1990. You see a reasonably positive trend towards further publication in the last five to ten years. Most of these studies since 2010 are from the Middle East. Many of the more recent studies related to the Syria crisis more specifically. Here we have broken down some of the papers by context. There are some interesting observations to be made here. The first on the left here is really the lack of published work coming out related to the African continent, which is quite dramatic. Only one paper from the chosen studies. Likewise, only two papers that looked at IDP populations specifically. And just over three quarters of the papers were focused on conflict crises. This is another interesting observation certainly for those of you that are doing work or that intend to go on and do research in this particular area. Currently the evidence is very reliant on very poor quality data. Lots of routine data reporting from hospital databases and so on. These sort of retrospective studies which are methodologically quite poor. Only a handful of case control studies and a lot of descriptive work. This is perhaps the most interesting of the slides. What sort of diseases have people been investigating? Some of the studies I should say were reporting on multiple different disease outcomes. You'll see the total number here is more than the 81. You see the big three there, cardiac disease, hypertension, diabetes. Quite an interesting number of papers related to cancer as well. And the seven other papers. We had one paper that looked at dermatological problems. Another paper that looked at GI disease. Only one paper actually that looked at GI disease which was quite interesting. And then a couple of renal papers as well. Some stuff on arthritis, COPD and asthma. So where are the gaps? You can see from the early findings that we've presented here that there are certainly a great number of gaps. One of the major problems that we've identified thus far is that there is a real lack of population level data. There are very few studies that are reporting at a population level. And this makes it very difficult to look at issues related to access to care and the treatment gap and to really make strong statements regarding the burden of disease in this particular population. As I mentioned briefly, there's currently an over-reliance on very basic study methodologies, lots of descriptive work, reliance on the retrospective analysis of routine hospital data. Very rarely are we finding the use of control groups. And often also some of these studies are making fairly tenuous and quite interesting causative links based on this fairly poor quality data. There was one study in particular that looked at retrospectively at some data from the conflict in the Balkans and made some interesting correlations between the conflict and the incidence of right-sided colon cancer, which was quite an interesting study. And the quality of data. So less than half of the papers are using validated diagnostic tools, which is something worth bearing in mind. And as I've just mentioned, only one third of the paper are making conclusions that we think they can really make based on the data that they have access to. So next steps, as I've said a couple of times, this is very provisional data. There is still more work to be done. We still need to go through with the second screening of the data and the full quality appraisal, which is pending. We would certainly like to identify more Cray literature. We do feel that there is more out there. And this is a call to you. If you do have information that you think would be useful to us, please do get in touch with Bayard directly. And similarly, as we're still in the fairly early stages of this study, we're really interested to hear what sort of research questions and what sort of information you would like to be extracted from this study. We have our own aims and objectives, but if there's anything that you think is missing from there, then now is a good time to discuss that. So we do hope to ultimately publish the final results in a paper or a series of papers. So thank you very much. Please do get in touch with Bayard if you have any further information and I'm happy to answer any questions. Thank you. Any quick questions and clarification? Hi, thanks very much. I'm Amy Banagie from UCL. I wanted to ask if there was any articles referring to training or degree of workforce expertise in these areas because as well as Burden wants to know about the resource to tackle it because there usually aren't even the doctors in health. Professionals who go out there, there isn't expertise to deal with NCDs usually more often. So I just wondered if that was tackled both in the humanitarian forces and in the country level as well. Thank you. Sure, and that's a very interesting question. I don't think that any of the papers that we have picked up as part of this review approach that issue directly, but it's possible that we have missed some of those papers that we were screening particularly looking at burden of disease. So some of the search terms we used may actually have filtered out some of those studies. So it's difficult to say if there is any work that has been done on that. Slim Slammer from WHO MRO. I did myself a review, I need to share, actually we were discussing with Philippa to share some of the papers that were never been publishing this, but about five to six years ago. What was interesting is before the Syria crisis, the papers that you missed partially were coming from Rita and Katrina and mainly on disaster, not on conflict. But since five to six years we have seen emerging now a number of papers that are mainly on conflict. But before that, most of the papers that you can find out are mainly on disaster, not on conflicts, and mainly coming from hurricanes, some of the earthquake related to Pakistan. So you probably have found those ones as well. But I think that there is something now happening also with always a delay between some of the events and the publication of course. But I think that something is changing in the last years, mainly related to conflict in the Middle East. Thank you. Thanks very much, James.