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Stuart Grossman, M.D.

• Co-Director, Brain Cancer Research Program, Sidney Kimmel Cancer Center
• Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0003883/stuart-grossman

Mechanism Kudzu + Benzodiazepines Kudzu markedly reduces the elimination of methotrexate pain research treatment journal buy azulfidine 500mg on-line. This might occur because of competition for renal of biliary excretion pain medication for dogs metacam generic azulfidine 500mg mastercard, No data for kudzu found menstrual pain treatment natural buy 500mg azulfidine free shipping. Importance and management Evidence is limited to data in rats pain management for dying dog buy cheap azulfidine 500 mg on line, and the doses of kudzu used in this study are very high. Nevertheless, the findings suggest that kudzu might markedly increase the effects of methotrexate. The Kudzu + Cardiovascular drugs; Miscellaneous risks are likely to be greatest with high-dose methotrexate (for neoplastic diseases) and in patients with impaired renal function, but less in those given low doses (5 to 25mg weekly) for psoriasis or No data for kudzu found. For a discussion of the evidence that rheumatoid arthritis and with normal kidney function. Note that the puerarin, an isoflavone present in kudzu, might inhibit platelet use of methotrexate requires routine monitoring. Kudzu + Digoxin Life-threatening interaction between the root extract of Pueraria lobata and methotrexate in rats. For the possibility that high-dose biochanin A, an isoflavone present in kudzu, might increase digoxin levels, see Isoflavones + Digoxin, page 261. Kudzu + Nicotine For discussion of a study showing that daidzein and genistein Kudzu + Fexofenadine present in kudzu caused a minor decrease in the metabolism of nicotine, see Isoflavones + Nicotine, page 261. For the possibility that high-dose biochanin A, an isoflavone in kudzu, may slightly decrease fexofenadine levels in rats, see Isoflavones + Fexofenadine, page 261. Kudzu + Oestrogens or Oestrogen K antagonists Kudzu + Food Kudzu contains oestrogenic compounds. This may result in additive effects to oestrogens or it may oppose the effects of No interactions found. Similarly, kudzu may have additive effects to oestrogen antagonists or oppose the effects of oestrogen antagonists. Evidence, mechanism, importance and management Kudzu + Herbal medicines Kudzu has a long history of use for menopausal symptoms, and is known to contain isoflavones (plant oestrogens). Numerous in vitro and animal studies have demonstrated oestrogenic effects for the No interactions found. Comparison of Pueraria lobata with hormone replacement therapy in treating the symptoms or lipids or hormone levels, and was less effective than adverse health consequences of menopause. Theoretically, the isoflavones from kudzu might have oestrogen antagonistic effects when they are given with potent oestrogenic drugs, as their oestrogenic effects are weaker and they might Kudzu + Paclitaxel competitively inhibit the conventional oestrogenic drugs. Conversely, because of their oestrogenic effects it is possible that they might reduce the efficacy of potent oestrogen antagonists. For the possibility that the isoflavones Although many studies have been carried out, clinical information biochanin A and genistein present in kudzu might increase paclitaxel on the potential interaction of kudzu with oestrogens or oestrogen levels, see Isoflavones + Paclitaxel, page 261. On the basis of the postulated oestrogenic used intravenously, and the effect of biochanin A on intravenous effects of kudzu and the theoretical mechanisms of antagonism, paclitaxel does not appear to have been evaluated. However, isoflavones from plants are widely consumed as part of the traditional diet in many parts of the world, and there is no clear evidence that this affects response to Kudzu + Theophylline hormonal contraceptives or oestrogen antagonists such as tamoxifen. For further information on the oestrogenic effects of isoflavone No data for kudzu found. For the possibility that high doses of supplements, see Isoflavones + Tamoxifen, page 262. Efficacy and safety of Pueraria mirifica (Kwao Kruea levels, see Isoflavones + Theophylline, page 263. Lapacho is used traditionally for infectious diseases of Tabebuia impetiginosa, Tabebuia pentaphylla, Tabebuia bacterial, protozoal, fungal and viral origin, to enhance the rosea Bertol. It is also used as an anticancer therapy, especially in South America, Constituents and, although there is experimental evidence to support some Naphthoquinones are the major active constituents of the of these uses, good clinical evidence is not available. Other constituents that may contribute to the pharmacoPharmacokinetics logical activity of lapacho include: iridoid glycosides such as No relevant pharmacokinetic data found. L 270 Lapacho 271 Importance and management Lapacho + Anticoagulants Evidence is extremely limited, but the fact that lapachol was withdrawn from clinical studies due to its anticoagulant effects adds Lapacho may have anticoagulant effects and therefore, theorweight to the theoretical mechanism. Until more is known it would etically, concurrent use of conventional anticoagulants may be seem prudent to discuss the possible increase in anticoagulant effects additive. However, it has been stated that lapachol (the main active constituent of lapacho) was originally withdrawn 1. Lapachol inhibition of vitamin K epoxide reductase and vitamin from clinical study because of its anticoagulant adverse effects,1 but K quinine reductase. Experimental evidence An in vitro study in rat liver microsomes found that lapachol is a Lapacho + Food potent inhibitor of vitamin K epoxide reductase. Mechanism Anticoagulants such as warfarin exert their effects by antagonising the effects of vitamin K, which is necessary to produce some clotting factors. They do this by inhibiting vitamin K epoxide reductase, Lapacho + Herbal medicines which reduces the synthesis of vitamin K. This action appears to be shared by lapachol, and therefore the concurrent use of lapacho and anticoagulants may be additive. Pharmacokinetics Persian or Turkish liquorice is Glycyrrhiza glabra L var Prolonged intake of high doses of liquorice extract, or its violacea Boiss. These findings therefore suggest that the effect of liquorice might be less Constituents than that of pure glycyrrhizin at the same dose. Liquorice has a great number of active compounds of different classes that act in different ways. The most Interactions overview important constituents are usually considered to be the Liquorice appears to diminish the effects of antihypertenoleanane-type triterpenes, mainly glycyrrhizin (glycyrrhizic sives and may have additive effects on potassium depletion or glycyrrhizinic acid), to which it is usually standardised, if given in large quantities with laxatives and corticosteroids. There are also numerIron absorption may be decreased by liquorice, whereas ous phenolics and flavonoids of the chalcone and isoflavone antibacterials may diminish the effects of liquorice. A case type, and many natural coumarins such as liqcoumarin, report describes raised digoxin levels and toxicity in a patient umbelliferone, glabrocoumarones A and B, herniarin and taking liquorice. See Use and indications under bupleurum, page 89, for possible interactions of the dried root and stolons of liquorice are used as an liquorice given as part of these preparations. L 272 Liquorice 273 Liquorice + Antihypertensives Liquorice + Caffeine Liquorice may cause fluid retention and therefore reduce the For mention that sho-saiko-to (of which liquorice is one of 7 effects of antihypertensives. Additive hypokalaemia may also constituents) only slightly reduced the metabolism of caffeine in one occur with loop and thiazide diuretics. Clinical evidence In 11 patients with treated hypertension, liquorice 100g daily for 4weeks (equivalent to glycyrrhetinic acid 150mg daily) increased Liquorice + Carbamazepine mean blood pressure by 15. The group taking the largest quantity of liquorice experienced the greatest rise in systolic blood pressure, and was the only group to have a statistically significant rise in diastolic blood pressure. Clinical evidence Experimental evidence (a) Dexamethasone Because of the quality of the clinical evidence, experimental data In a parallel group study, 6 patients were given glycyrrhizin 225mg have not been cited. There is an extensive literature, which has been daily for 7days, and 6 patients were given the same dose of the subject of a review. The mineralocorticoid effects of glycyrrhizin were significantly reduced by dexamethasone; cortisol plasma concentrations and urinary Mechanism excretions were reduced by up to 70%. Note that glycyrrhizin had no effect on addition, the potassium-depleting effect of liquorice would be endogenous cortisol levels in 7 control subjects without adrenal expected to be additive with loop and thiazide diuretics. Nevertheless, in patients with poorly Experimental evidence controlled blood pressure it may be prudent to ask about liquorice Several experimental studies have found that glycyrrhizin and consumption to establish whether this could be a factor. Deglycyrrhizinated liquorice would not be In vitro, glycyrrhetinic acid (the aglycone of glycyrrhizin), expected to have these effects. Sigurjonsdottir HA, Franzson L, Manhem K, Ragnarsson J, Sigurdsson G, Wallerstedt Mechanism S. Licorice-induced hypertension and syndromes of apparent acid may slightly delay the clearance of hydrocortisone and mineralocorticoid excess. Dexamethasone appears to attenuate the mineralocorticoid effects Importance and management of glycyrrhizin because it suppresses endogenous cortisol secretion Evidence appears to be limited to one case. Other corticosteroids would be of the elevated digoxin levels were exacerbated by the hypokalaemia expected to interact similarly if given in adrenal-suppressant doses. The theoretical basis for an Deglycyrrhizinated liquorice would not have these effects. Any herbal preparation that can reduce Importance and management potassium levels would be expected to increase the risk of digoxin the clinical importance of these observations is uncertain. This is likely to be additive with other concurrent corticosteroids sufficient to cause adrenal suppression would be medications that a patient may also be taking that can cause expected to reduce the mineralocorticoid activity of liquorice, but hypokalaemia, such as loop diuretics. Glycyrrhizin (an active caution in patients who are taking digitalis glycosides and who constituent of liquorice) and its metabolite glycyrrhetinic acid regularly use/abuse laxatives including liquorice and/or anthraquislightly increased the plasma levels of hydrocortisone and none-containing substances such as rhubarb.

Thomas Duncan had walked into the Emergency Department at Dallas Presbyterian Hospital on 25 September complaining of abdominal pain and nausea herbal treatment for shingles pain buy azulfidine 500mg otc, but despite his telling staf that he had recently visited Liberia cape fear pain treatment center lumberton nc generic azulfidine 500 mg online, no one thought to screen him for Ebola and he was sent home with Tylenol and a course of antibiotics pain medication for dogs at home order genuine azulfidine line. Next heel pain treatment webmd buy discount azulfidine on-line, he set up an information management system to log cases and trace contacts who may have been exposed to the virus. For most of the fve-anda-half weeks he was in Guinea, Rollin stayed in Conakry, the better to monitor cases at Donka Hospital, but he also found time to tour prefectures close to the capital and dispatch staf to Gueckedou to report from the epicentre of the outbreak. By the end of April Conakry had not seen a new patient in over a week, and Rollin noted that cases had also slowed to a trickle in Guinee Forestiere. And why, even as Ebola spread across the border to Sierra Leone and Liberia, threatening urban outbreaks, were health agencies so slow to respondfi One is that while Ebola had previously been amplifed in hospital settings and, on occasion, had sparked urban outbreaks, those outbreaks had been rapidly contained by the institution of strict barrier nursing controls and the isolation of infectious contacts. This was because for all that the reservoir of the virus was unknown, each of the fve identifed subtypes showed a high degree of genomic stability. Moreover, while theYambuku outbreak had seen case mortality rates as high as 90 per cent, in Kikwit the mortality rate had been 78 per cent, while in an outbreak in Gabon the following year the mortality rate had been 57 per cent. Nor had they factored in the mobility of local populations living at the border of three countries or the fact that new highways had greatly reduced travel times to urban areas. Nor had they considered the impact that the widespread distrust of foreigners and government elites might have on the willingness of afected communities to accept that Ebola was real, and not a hoax. Nor had medical research agencies and pharmaceutical companies shown much interest in conducting safety studies of Ebola vaccines and drugs that had shown promise in animal models, much less in advancing the medications to license. But perhaps the biggest lesson of theWest African Ebola epidemic was that Zaire ebolavirus had most likely been circulating undetected in the tri-border zone for years. Moreover, phylogenetic analysis suggested that the outbreak had been triggered by a single spillover event, a fnding consistent with the epidemiological evidence and reports that the index case had originated in Meliandou in December 2013. There was one other intriguing fnding: the Makona variant had diverged from other Zaire ebolavirus variants only about a decade earlier. The question is, how did Zaire ebolavirus get all the way to Guinea and why Gueckedoufi These bats are common across sub-Saharan Africa, including Guinea, and some are thought to be capable of migrating long distances. Perhaps a wayward fruit bat introduced the virus to Guinee Forestiere, from where it spread to local bat populations, including the colony of Mops condylurus sheltering in the tree stump in Meliandou. As for why Gueckedou, one need look no further than the clearance of formerly forested areas by loggers and farmers. Clear-cutting in particular has had a devastating impact, driving bats from their roosts and forcing them ever closer to human habitations. Without further ecological investigations and a better understanding of Ebola transmission patterns and where the virus goes between outbreaks, it is difcult to say. Or perhaps Emile and his friends had a knack for extracting the lolibelo and were simply unlucky. However, frst impressions can be misleading, and as you turn your back on the lavishly gilded Capela Dorada and head west toward BoaVista, you enter a world of modern apartment buildings and outsized shopping malls, and, in the gaps and crevices between, the places the poor call home. They hug the highways running parallel to the coast and encroach on the canals that feed into the Beberibe and other tributaries that drain from what used to be a massive mangrove swamp. One of the largest, Jaboatao dos Guararapes, lies south of the seaside resort of Boa Viagem, a fve-mile stretch of prime beachfront lined with international hotels and luxury condominiums. In August of that year several women from Jaboatao dos Guararapes and adjacent communities gave birth to babies with an unusual congenital syndrome. Many of the babies cried continually, as if they were in constant pain, and could only be comforted by being bathed in warm water or by resting their stomachs on pilate balls. One of the frst physicians to recognize the new syndrome wasVanessa van der Linden, a neuro-paediatrician of Dutch descent who practices at Hospital Barao de Lucena, a public hospital in the northeast of the city. Puzzled, van der Linden ordered tests for rubella, syphilis and toxoplasmosis, a parasite harboured by cats that is extremely common in Brazil and which, like rubella and syphilis, is known to be associated with congenital birth defects, but all the tests were negative. However, for all that van der Linden was concerned, the twin was just one of hundreds of children delivered in Recife hospitals every month. Then, two weeks later, while doing her usual maternity rounds, she came across three more babies with microcephaly, and the following week two more. At a loss to explain the pattern of neurological damage, she shared her concern with her mother, Ana van der Linden, also a paediatrician. In a normal year, physicians in Pernambuco might see fve cases across the whole state. In all, ffty-eight had been registered in hospitals across the state, most of them within the space of four weeks. At a loss to explain the pattern, the Pernambuco Health Department did the only thing it could: it called a disease detective, Carlos Brito. Trained as an infectious disease clinician, he seems never happier than when parsing epidemiological data or tapping furiously at his laptop. The Ministry of Health was concerned that physicians needed better guidelines to help them diagnose and recognize the mosquito-borne disease. As it turned out, this experience would make Brito the ideal person to investigate the mysterious cases of microcephaly in Pernambuco two years later. The deadliest arbovirus, yellow fever, was most likely introduced to Brazil in the late seventeenth century when slave ships fromWest Africa began arriving at Recife and other coastal ports with slave labourers for the sugar plantations. Those ships also brought the Aedes aegypti mosquito, the main vector of yellow fever, dengue and chikungunya. The mosquito prefers to lay its eggs in fresh water (during the slave trade, the Aedes larvae would have bred in the casks of drinking water kept below decks, next to the slaves whose chains made them sitting targets for the mature mosquitoes). Ideally, Aedes looks for a shady uncovered container with a wide opening, but it is not fussy and its larvae have been found in everything from fowerpots to water bowls, to car tires and discarded plastic bottles. Their preferred mode of attack is to sneak up from behind and insert their sharply pointed proboscises into ankles or elbows, though knees will also do. The bad news is that one bite is usually sufcient to transmit whatever virus the mosquito happens to be harbouring.

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Discuss the relationship among the kinematic quantities of angular distance and displacement unifour pain treatment center purchase 500mg azulfidine with amex, angular velocity cape fear pain treatment center 500 mg azulfidine otc, and angular acceleration kneecap pain treatment buy azulfidine discount. Discuss the relationship between angular and linear motions pain treatment bone metastases discount azulfidine online american express, particularly displacement, velocity, and acceleration. The subset of kinematics that deals with angular motion is angular kinematics, which describes angular motion without regard to the causes of the motion. Pick any point close to the center of the wheel and any point close to the edge of the wheel. The point close to the edge travels farther than the point close to the center as the wheel rotates. The gymnast simultaneously undergoes both translaFor example, the bicycle wheel spins about its axle which is tion and rotation. The axle is perpendicular to the plane of rotation described by the rim of the wheel. An understanding of angular motion is critical to Measurement of Angles comprehend how one moves. The segments Angle rotate about the joint centers that form their axes of rotation. For example, the forearm segment rotates about An angle is composed of two lines, two planes, or a combithe elbow joint during flexion and extension of the nation that intersects at a point called the vertex. When an individual moves, the segments generIn a biomechanical analysis, the intersecting lines are generally undergo both rotation and translation. If the longitudinal axis of the leg segcombinations of angular motion of multiple segments ment is one side of an angle and the longitudinal axis of the can result in linear motion of the segment end point seen thigh segment is the other side, the vertex is the joint cenin throwing and many other movements in which end ter of the knee. Coordinate points rotation and translation occurs, it is described as general describing the joint centers determine the sides and vertex motion. The vertex It is important to use the correct units to communicate of the angle is the knee joint center. It is also essential to use the correct subject at the joint centers makes a technically incorrect units because angle measurements may be used in further assumption that the joint center at the vertex of the angle calculations. At the knee joint, the second unit of measurement describes the number the medial and lateral femoral condyles are asymmetrical. For example, along its long axis and rotates about an axis through the a triple jump in skating requires the skater to complete knee from front to back. The skater completes a rotation therefore, changes throughout any motion of the knee. This unit of measurement is useful in qualitative center of rotation of a joint at an instant in time is called the descriptions of movements in figure skating, gymnastics, instantaneous joint center. It is difficult to locate and diving but is not useful in a quantitative analysis. These measurements are not and the revolution is often used, the most appropriate unit practical in most situations; thus, the assumption of a static for angular measurement in biomechanics is the radian. A radian is defined as the measure of an angle at the center Using MaxtraQ, import the first video file of the golfer. That is: u = s/r = 1 rad where u = 1 rad, s = arc of length r along the diameter, and r = radius of the circle. Because both s and r have units of length (m), the units in the numerator and denominator cancel each other out with the result that the radian is dimensionless. In further calculations, the radian is not considered in determining the units of the result of the calculation. Degrees have a dimension and must be included in the unit of the product of any calculation. It is necessary, therefore, to use the radian as a unit of angular measurement instead of the degree in any calculation involving linear motion because the radian is dimensionless. The absolute angle of a segment relative Angular measurement in radians is often determined in to the right horizontal is also called the segment angle. The angle in question is not the right angle in the unit must be used in further calculations, the angular triangle. If the leg and thigh segment coordinate positions motion concepts presented in the remainder of this chapare considered, the absolute angles of both the thigh and ter will use the degree for ease of understanding. To calculate the absolute leg angle, the distal end coordinate values are subtracted from the proximal end coordinate values and the ratio of y to x defines the tantypes of Angles gent of the angle: AbsOlute Angle In biomechanics, two types of angles are generally calculated. The first is the absolute angle, which is the angle of inclination of a body segment relative to some fixed reference in the environment. One involves placing a coordinate system at the proximal end point of the segment. The most frequently used convention for calculating absolute angles, however, places a coordinate system at the distal end point of the segment. The angle using this convention is also measured counterclockwise from the right horizontal. The absolute angles calculated using these two conventions are related and give comparable information. This is called finding the inverse tangent and is written as follows: u tan 1 3. This orientation indicates that the leg horizontal requires adjustments when the orientation is such that is positioned so that the knee is farther from the vertical (y) the differences between the proximal and distal end points indicate axis of the coordinate system than the ankle. Similarly, to calculate the thigh angle, the coordinate An absolute thigh angle of 105. The differences in right foot touchdown (black) and 0 right foot toe-off (blue) phases of a walking gait are 0 500 1,000 1,500 apparent. For our purposes, the triangle is made up angles so they are taken counterclockwise with respect to of the two segments B and C and a line, A, joining the the right horizontal. For example, the leg orientation in distal end of one segment to the proximal end of the touchdown results in a negative x-position and positive other. To toe-off, however, both x and y are positive, so there is no calculate the relative angle at the knee (u), the lengths adjustment. These adjustments provide a consistent reference for the computation of the absolute angles. Using MaxtraQ, import the first video file of the woman walking (representing right heel contact). Digitize the right shoulder, right greater trochanter, right knee, and the right ankle. This is the angle between longitudinal axes of two segments and is also referred to as the joint angle or the intersegmental angle. Relative angles, however, do not describe the position of the segments or the sides of the angle in space. Digitize the right iliac crest, right greater trochanter, right knee, and the right ankle. A relative angle can be calculated from the absolute values to obtain a result similar to computations using the law of cosines. The relative angle between two segments can be calculated by subtracting the absolute angle of the distal segment from the proximal segment. Several organizations, such as the Canadian Society of Biomechanics and the International Society of 3(1.

Recent reduced in many areas knee pain treatment yoga purchase azulfidine cheap online, particularly those indications suggest it has since worsened pain management in uti discount azulfidine 500mg on-line. People in Syria services are among their primary concerns are adopting reduced coping strategies due as afected people seek to rebuild their lives treatment guidelines for diabetic neuropathic pain discount 500mg azulfidine. Protracted displacement shoulder pain treatment exercises discount azulfidine 500 mg otc, the depletion of productive assets and savings, limited economic opportunities and the widespread destruction and contamination of agriculture-related infrastructures have had a profound socioeconomic impact on the population. Hostilities and insecurity are expected to continue, most notably in the north-west and in parts of the north-east of the country, which will generate additional civilian displacement. Contingency plans are being put in place for up to 100,000 displacements per month (1. Twenty per cent of households expect to integrate into their place of displacement, and 44 per cent remain undecided about their future plans. Existing monitoring and assessment methodologies in Syria cannot ascertain the voluntariness and sustainability of these returns, or whether they have been adequately informed and took place in safety and with dignity. Twenty per cent of returns in 2019 are expected to be in the governorate of Rural Damascus. In the current situation, the impact of funding-related cuts to assistance to vulnerable Palestine refugees will threaten the lives and livelihoods of this disadvantaged population. Due to their exposure to multiple risk factors, many of these people belong to more than one group. As a result the overall number of people in need is lower than the cumulative total of these groups. People in acute need refers to those facing more severe forms of deprivation in terms of their security, basic rights and living conditions and face life-threatening needs requiring urgent humanitarian assistance. Countless civilians have been killed and injured as a direct result of hostilities, with 45 per cent of the injured expected to sustain a permanent impairment. Extensive explosive hazard contamination is a deadly reminder of the indiscriminate and protracted effects of hostilities. Civilian infrastructure lies destroyed or in disrepair, limiting access to shelter, basic services and livelihood opportunities. Close to eight years of crisis have triggered immediate suffering and at the same time severely undermined the ability of communities to recover. Escalation of hostilities in 2018 facing restrictions on their movement both towards Aleppo city and back towards Afrin. In 2018, an escalation in hostilities in several areas, including In other areas, active hostilities were still ongoing as 2018 East Ghouta, southern Damascus, Afrin, southern Syria and ended, most notably in north-west Syria and south-eastern Deir-ez-Zor, caused signifcant loss of human life, large-scale Deir-ez-Zor. Despite the announcement of a demilitarized displacement and extensive destruction of civilian property zone in the so-called Idleb de-escalation area in September and infrastructure. The and villages saw signifcant destruction and explosive hazard fghting lef thousands of individuals trapped near front lines contamination. Over the course of 2018, the Health sector recorded International Coalition and Turkey. At the start of 2018 and 142 attacks on health care personnel and facilities, claiming 16 afer four years of the deconfiction mechanism being in efect, the lives of 102 people and injuring 189. By the end of 2018 this signifcant increase from the 122 attacks confrmed over the fgure had risen to 1,047 deconficted humanitarian facilities, course of 2017, which claimed the lives of an estimated 73 including schools, medical facilities and humanitarian sites. Tere have been particular concerns or abducted in the frst six months of the year. Verifed criminal prosecution by parties in control due to actual or data on humanitarian actors killed and injured is not presumed political afliation or loyalties. However, multiple sources indicate that scores of existential threat to the viability of the humanitarian operation humanitarian staf have lost their lives since the beginning of and continuity of services. Grave signifcant decline in institutional educational capacity, while violations against children, as monitored and reported the psychological distress sufered by many children will likely through the Monitoring and Reporting Mechanism for Syria have profound and long-lasting implications. The major monitored violations include In addition, many youth and adolescents lack meaningful the killing and maiming of children, recruitment and use of opportunities within their communities, with limited access children in confict, detention of children associated to parties to learning, resulting in high rates of unemployment. Despite the hostilities in southern high in Idleb, with some 610,000 arrivals tracked from Syria, which resulted in a rapid cycle of displacement locations both inside and outside the governorate from followed by return, the second half of the year saw a Rural Damascus, Hama and Aleppo among others. This significant decline in the overall number of displacements, followed an escalation in military operations by the with some 380,000 movements recorded between July Government of Syria in southern and south-eastern and December. Many of these people, electricity and overcrowding as their main concerns, exposing particularly in north-west Syria, are likely to have been them to potential protection risks. Sixty per cent of people are believed to have been of poverty and unemployment, with many living below the internally displaced at least once in Palestine refugee camps poverty line. Despite drastic changes in the fndings estimate that 90 per cent of the Palestinian the situation on the ground in 2018, thousands of Palestine population in Syria were in absolute poverty while 80 per cent refugees are still afected by constrained humanitarian access 29 were in extreme poverty. At present, the inter-agency are estimated to have spontaneously returned to various community is not facilitating or promoting returns, but locations in Syria so far in 2018. As per community feedback, number of spontaneous returns in 2018 was to Deir-ez-Zor de-escalation of hostilities, the reduction of risks associated Governorate, with 295,000 individuals estimated to have 31 with military activities and the improvement in availability returned in the frst nine months of the year. A similar pattern of short-term specifc needs as a result of having been outside their country displacement was observed in southern Syria, where several for a signifcant amount of time, including issues related to hundred thousand people displaced by the military ofensive civil documentation, education and social reintegration. However, the overall scale of returns among households in Damascus and Idleb, and at a lower level for Aleppo, Lattakia and Rural Damascus is expected to remain limited relative to the overall refugee governorates. The survey found that gender-related displacement in areas with ongoing hostilities in north-west vulnerabilities, income and livelihoods opportunities, and north-east Syria. Extravulnerable households with multiple vulnerabilities, such as children-headed households with no or limited 24 livelihood opportunities, continue to remain the most undecided about their intentions for the future. Households who are aware that their property is intact or only partially damaged at their place of origin, are more inclined to return home. Hostilities have caused widespread only 31 per cent of returnees of secondary school age are damage and destruction to the civilian infrastructure reportedly enrolled in school, indicating a dearth of education upon which many of these services depend. In terms of sanitation facilities, at least 70 per cent in some areas, further compromising the provision of of sewage is untreated and at least half of the sewerage systems quality medical assistance. Measles, indicate that only 9 per cent of the population is still served by acute bloody diarrhoea and typhoid fever were reported functional wastewater treatment plants. Dysfunctionality of in Al-Hasakeh, Ar-Raqqa, Deir-ez-Zor, Aleppo and Idleb existing wastewater treatment plants and sewerage networks governorates during 2018. Tousands of cases were identifed across the country measures such as sanctions and export controls. In addition, some places expressed specifc concern about the ability of humanitarian used for garbage dumping are inadequately managed which actors to access humanitarian exemptions under the current could contribute to increased vector breeding. Older people are also more likely to have a physical disability, face barriers to accessing assistance and Almost 850,000 people are estimated to be services, and may be at increased risk of violence and family above the age of 60 in Syria, which represents separation if they are unable to fee during hostilities. As the Syria crisis has by the erosion of both formal and informal social support continued, elderly people have become increasingly vulnerable systems. Tese factors contribute to making older people and face specifc risks, especially for those who have been particularly vulnerable and at increased risk of abuse and displaced and have no family or community support. Programmes that address the specifc needs and the people face particular risks and have specifc needs during conditions of older people are therefore critical and need to be humanitarian crises, including the likely deterioration of their scaled up in 2019. Furthermore, many communities not access to food, high prices and infation, reduced purchasing served through water networks have serious issues with water power and continuous livelihood depletion of the most afordability that impact needs across other sectors. The situation is even more dire of a monthly food ration has reduced if compared to the peak for people living in informal settlements, where families can of the crisis, but still remains very high for Syrians. The availability of food in Syria has also been signifcantly impacted by the crisis, as well as the drought. The impact of Tese coping strategies are ultimately unsustainable and, the drought and unseasonal downpours afected the cereal in the absence of humanitarian interventions or an overall yield. The implication of lowest recorded production in the improvement in the socioeconomic situation, may continue last three decades is that the availability of wheat and barley, to lead people to resort to increasingly exploitative and major staples, are further constrained and there is a signifcant hazardous activities as their fnancial and material resources shortfall of wheat and barley to meet national cereal are exhausted.