Problemas sociales: mucha frecuencia, poca formación / Social problems: high frequency, low training

Introducción: la patología social pediátrica en relación con inequidades socioeconómicas, relaciones disfuncionales familiares, inmigración, adicciones, violencia hacia la infancia, etc. va en aumento. El objetivo de este trabajo es analizar su peso en la labor asistencial del pediatra, la descripción de la formación y los conocimientos en ese ámbito, y las razones que dificultan su implicación en estos temas. Metodología: estudio multicéntrico a través de encuesta online cumplimentada por 407 profesionales médicos. Se analizaron 11 problemas en relación con el entorno familiar, escolar, pobreza, inmigración, adicciones y violencia. Resultados: los problemas del entorno familiar o escolar fueron señalados como frecuentes o muy frecuentes por alrededor del 50% de los profesionales; los relacionados con inmigración, acoso y pobreza, por el 20-30%; y los referidos a violencia o adicciones, por menos del 10%. Sin embargo, los porcentajes de formación recibida (y de conocimientos) fueron muy bajos en todos los temas (la mayor formación se aprecia en violencia de género y abuso). Se desglosan los resultados según el ámbito profesional de trabajo (hospitalario o Atención Primaria), el entorno (urbano o rural) y la edad. La mayor dificultad que alegan los profesionales para el abordaje de estos problemas es precisamente la falta de formación. Conclusiones: la patología social infantil está muy presente en la labor diaria del pediatra. Por ello, se precisa una adecuada formación y actualización en esta materia que permita detectar y atender esta patología como el resto de los problemas de la infancia. Se proponen acciones de mejora. (AU)

Introduction: paediatric social disease in relation to socioeconomic inequities, dysfunctional family relationships, immigration, addiction, violence towards children, etc has been increasing. The aim of this paper is to analyse the importance of social disease in paediatric practice and describe the training and knowledge of providers on this subject and the perceived barriers to their involvement in these issues. Methodology: multicentre study by means of an online survey with participation by 407 medical professionals. We analysed 11 social problems related to the family and school environment, poverty, immigration, substance use and violence. Results: problems in the family or school environment were reported as frequent or highly frequent by approximately 50% of the respondents; problems related to immigration, bullying and poverty, by 20-30%; and problems related to violence or addiction by less than 10%. However, the percentage of respondents that reported receiving training (and having knowledge) were very low for all topics (the frequency of training was highest for gender violence and abuse). We analysed the results based on the care setting (hospital or primary care), geographical setting (urban or rural) and age of the provider. The greatest barrier reported by professionals in tackling these problems was precisely the lack of training. Conclusions: paediatricians encounter social disease frequently in their everyday practice. For this reason, adequate and up-to-date training on the subject is required to detect and treat social disease like any other childhood problems. Some improvement strategies are proposed. (AU)

Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis.

BACKGROUND: Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. METHODS: Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. RESULTS: We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5). INTERPRETATION: Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.

Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness.

BACKGROUND: Given the relative lack of psychiatric information and data on the perpetrators of US mass shootings, the aim of our study was to understand who these "mass shooters" were and whether they had a psychiatric illness. If so, were they competently diagnosed, and if so, were they treated with appropriate medication for their diagnoses before the violence? METHODS: Because a prospective study of diagnosis and treatment could not, for obvious reasons, be carried out, we designed a retrospective, observational study of mass shooters, defined as those who killed 4 or more people with firearms between 1982 and 2012 or who killed 3 or more people with firearms between 2013 and 2019 in the United States. We used the Mother Jones database-a database of 115 persons identified as committing a mass shooting in the United States between January 1982 and September 2019. In the vast majority of the incidents identified in the database, the perpetrator died either during or shortly after the crime, leaving little reliable information about their history-especially psychiatric history. We focused on the 35 mass shooters who survived and for which legal proceedings were instituted because these cases presented the most reliable psychiatric information. For each of these 35 mass shootings, we interviewed forensic psychiatrists and forensic psychologists who examined the perpetrator after the crime and/or collected the testimony and reports by psychiatrist(s) at trial or in the postconviction proceedings contained in the court record. In addition, we reviewed available information from the court proceedings, public records, a videotaped interview of assailant by law enforcement, social media postings of the assailant, and writings of the assailant. After collecting the clinical information from multiple sources on each case to make a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis, we also completed a Sheehan Diagnostic Scale. After this, 20 additional cases where the assailant died at the crime were randomly selected form the remaining 80, to determine whether there were differences in psychiatric diagnoses and treatment between such assailants and those who survived. RESULTS: Twenty-eight of 35 cases in which the assailant survived had a psychiatric diagnosis-18 with schizophrenia, 3 with bipolar I disorders, 2 with delusional disorders, persecutory type, 2 with personality disorders (1 paranoid and 1 borderline), 2 with substance-related disorders without other psychiatric diagnoses, and 1 with posttraumatic stress disorder. Four had no psychiatric diagnosis, and in 3, we did not have enough information to make a diagnosis.Of 15 of 20 cases in which the assailant died, 8 had schizophrenia. None of those diagnosed with psychiatric illnesses were treated with medication. CONCLUSIONS: A significant proportion of mass shooters experienced unmedicated and untreated psychiatric disorder.

Daños colaterales de la pandemia por COVID-19: ¿consecuencias inevitables? / Collateral damage from the COVID-19 pandemic: inevitable consequences?

Esta revisión narrativa describe el daño colateral de la pandemia de COVID-19, tanto en aspectos de la salud, como también sociales, educativos o económicos. Comunicamos el impacto mundial y local. Consideramos que varias de estas consecuencias eran inevitables, especialmente las sucedidas durante los primeros meses de una pandemia que se difundió a gran velocidad y con graves consecuencias directas en la morbimortalidad de la población. Sin embargo, luego de seis meses de su llegada a la Argentina, es oportuno revaluar la situación y replantearse si no se debería cambiar el enfoque para balancear la minimización del impacto directo de COVID-19 junto con la del daño colateral que las medidas para paliarlo produjeron. Es un desafío que no debe limitarse al sistema de salud. Debe encararse con un abordaje intersectorial amplio y con participación activa de la sociedad. Así como aplanamos la curva de COVID-19, cuanto más nos demoremos en aplanar las otras curvas de problemas sanitarios y sociales que se están generando, mayor será su impacto, tanto en el corto como en el largo plazo. (AU)

This narrative review shows the collateral damage of the COVID-19 pandemic, whether in health, social, educational or economic aspects. We report on the impact at the global and local levels. Many of these consequences were inevitable, especially in the first months of a pandemic that spread at great speed and with serious direct consequences on the morbidity and mortality of the population. However, six months after the arrival in our country, it is an opportunity to reassess the situation and rethink whether the approach should not be changed to balance the minimization of the direct impact of COVID-19 with that of the collateral damage that mitigation measures produced. This is a challenge that should not be limited to the health system. It must be addressed with a broad intersectoral approach and active participation of society. Just as we flatten the COVID-19 curve, the longer we delay in flattening the other curves of health and social problems that are being generated, the greater the impact, both in the short and long term. (AU)

Climate Change, Migration, and Civil Strife.

PURPOSE OF REVIEW: In this article, we examine the intersection of human migration and climate change. Growing evidence that changing environmental and climate conditions are triggers for displacement, whether voluntary or forced, adds a powerful argument for profound anticipatory engagement. RECENT FINDINGS: Climate change is expected to displace vast populations from rural to urban areas, and when life in the urban centers becomes untenable, many will continue their onward migration elsewhere (Wennersten and Robbins 2017; Rigaud et al. 2018). It is now accepted that the changing climate will be a threat multiplier, will exacerbate the need or decision to migrate, and will disproportionately affect large already vulnerable sections of humanity. Worst-case scenario models that assume business-as-usual approaches to climate change predict that nearly one-third of the global population will live in extremely hot (uninhabitable) climates, currently found in less than 1% of the earth's surface mainly in the Sahara. We find that the post-World War II regime designed to receive European migrants has failed to address population movement in the latter half of the twentieth century fueled by economic want, globalization, opening (and then closing) borders, civil strife, and war. Key stakeholders are in favor of using existing instruments to support a series of local, regional, and international arrangements to protect environmental migrants, most of whom will not cross international borders. The proposal for a dedicated UN agency and a new Convention has largely come from academia and NGOs. Migration is now recognized not only as a consequence of instability but as an adaptation strategy to the changing climate. Migration must be anticipated as a certainty, and thereby planned for and supported.

Los impuestos como instrumento de salud pública. A propósito de las bebidas azucaradas / Taxes as an instrument of public health. On the subject of sugary drinks

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A methodology for analyzing and forecasting sociopolitical destabilization.

The article presents a methodology for the analysis of political crises meant to assess the current situation of sociopolitical (in)stability of the developing and developed societies in question, provide an inertial forecast of the developing situation in a given period, analyse threats to stability threats, and examine possible measures to counteract such threats and their likely influence on the situation. The methodology is based on modeling sociopolitical stability in the country in question with the help of an elaborate logical-mathematical model.

Mass Panic Disaster Management in COVID-19 Pandemic.

Coronavirus disease (COVID-19) pandemic occurred abruptly. It is an unexpected disaster. Uncertain treatment for this viral infection increases excessive anxiety, which does not occur only in one person but also in majority of people; therefore, it can create mass panic. Mass panic is a serious problem that must be immediately identified and managed. Mass panic management will reduce COVID-19 incidence.

A classification model of homelessness using integrated administrative data: Implications for targeting interventions to improve the housing status, health and well-being of a highly vulnerable population.

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

Prevención del consumo de alcohol: límites de consumo de bajo riesgo y otras actuaciones / No disponible

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Research 101: A process for developing local guidelines for ethical research in heavily researched communities.

BACKGROUND: Marginalized communities often attract more than their share of research. Too often, this research benefits researchers disproportionately and leaves such communities feeling exploited, misrepresented, and exhausted. The Downtown Eastside (DTES) neighborhood of Vancouver, Canada, has been the site of multiple public health epidemics related to injection drug use as well as the site of much community-led resistance and struggle that has led to the development of cutting-edge harm reduction interventions (e.g., North America's first supervised injection facility, Insite) and a strong sense of community organization. This background has made the DTES one of the most heavily researched communities in the world. Amidst ongoing experiences of unethical or disrespectful research engagement in the neighborhood, a collaboration between local academic researchers and community representatives developed to explore how we could work together to encourage more respectful, community-responsive research and discourage exploitative or disrespectful research. METHODS: We developed a series of six weekly workshops called "Research 101." These workshops brought together approximately 13 representatives from peer-based organizations in the DTES with a variety of experiences with research. Research 101 created space for community members themselves to discuss the pitfalls and potential of research in their neighborhood and to express community expectations for more ethical and respectful research. RESULTS: We summarized workshop discussions in a co-authored "Manifesto for Ethical Research in the Downtown Eastside." This document serves as a resource to empower community organizations to develop more equitable partnerships with researchers and help researchers ground their work in the principles of locally developed "community ethics." Manifesto guidelines include increased researcher transparency, community-based ethical review of projects, empowering peer researchers in meaningful roles within a research project, and taking seriously the need for reciprocity in the research exchange. CONCLUSIONS: Research 101 was a process for eliciting and presenting a local vision of "community ethics" in a heavily researched neighborhood to guide researchers and empower community organizations. Our ongoing work involves building consensus for these guidelines within the community and communicating these expectations to researchers and ethics offices at local universities. We also describe how our Research 101 process could be replicated in other heavily researched communities.

Condicionantes y consecuencias sociales del embarazo en la adolescencia / Conditioning Factors and Social Consequences of Teenage Pregnancy

Introducción: Son conocidos los riesgos y consecuencias negativas que para la salud física tiene el embarazo en la adolescencia, pero ellos no actúan aisladamente, sino asociados con factores psicosociales, económicos, políticos, estructurales y de género. Esta situación no puede ser considerada como un problema biológico pues es también un problema social con numerosas aristas y campos de influencia negativa. Objetivo: Actualizar las condicionantes y consecuencias sociales del embarazo en la adolescencia. Métodos: Se realizó una búsqueda bibliográfica utilizando los términos "embarazo en la adolescencia", asociado a problema social. Resultados: Se encontró que la baja escolaridad, pertenecer a una familia disfuncional, vivir en zona rural o marginal, así como dificultades en la percepción de riesgo son condicionantes para el embarazo en la adolescencia. Conclusiones: las mayores consecuencias sociales están en el fracaso escolar, sensación de frustración en la madre, trastornos en la dinámica familiar, dificultades para la crianza del niño y para la inserción en la vida laboral futura de las adolescentes(AU)

Introduction: The risks and negative consequences that adolescent pregnancy has for physical health are known, but they do not act in isolation, but associated with psychosocial, economic, political, structural and gender factors. This situation cannot be considered as a biological problem because it is also a social problem with numerous edges and fields of negative influence. Objective: To update the conditioning and social consequences of pregnancy in adolescence. Methods: A literature search was conducted using the terms "pregnancy in adolescence", associated with "social problem". Results: Our study found that low schooling, belonging to a dysfunctional family, living in a rural or marginal area, as well as difficulties in the perception of risk are conditioning factors for adolescent pregnancy. Conclusions: The greatest social consequences are school dropout, the mother´s feeling of frustration, disturbances in the family dynamics, and difficulties for the upbringing of the child and for the insertion in the future work life of the adolescent mothers(AU)

Prescription opioid misuse and comorbid substance use: Past 30-day prevalence, correlates and co-occurring behavioral indicators in the 2016 National Survey on Drug Use and Health.

BACKGROUND AND OBJECTIVES: Prescription opioid misuse has not been well examined in the context of comorbid substance use in representative samples of substance users. Past 30-day comorbid prescription opioid misuse and recreational substance use (eg, alcohol, marijuana, cocaine, etc.) was studied in a representative sample of substance users in the United States using the 2016 National Survey on Drug Use and Health (NSDUH). METHODS: Prevalence of prescription opioid misuse with and without comorbid substance use was estimated with the 2016 NSDUH. Generalized linear modeling was used to describe demographic correlates of opioid and comorbid substance use and explore the relation of opioid and comorbid substance use with social and behavioral health indicators. RESULTS: The majority of past month prescription opioid misusers reported use of other substances including cigarettes, alcohol, marijuana, or hard drugs (cocaine, methamphetamine, etc.). Males and younger respondents had a significantly higher risk of reporting past month prescription opioid misuse with illicit drug or polydrug use (p's < .01). Prescription opioid and polydrug users had the greatest odds of stealing property, selling drugs, having suicidal ideations, major depressive episode, and perceived treatment need in the past year compared to all other categories of prescription opioid misuse categories. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Prescription opioid misuse is likely a part of a larger set of psychological, behavioral, and mental health problems. More attention should be given to the profiles of recreational (non-medical) substance use involving prescription opioids to curtail the current opioid crisis and prevent other similar epidemics in the future. (Am J Addict 2019;XX:1-8).

Attitudes toward defendants with substance-related charges: An analysis of a national sample of criminal defense attorneys.

BACKGROUND AND OBJECTIVES: While a large percentage of criminal offenders suffer from substance use disorders (SUDs), virtually nothing is known about the attitudes criminal defense attorneys possess toward their clients who are facing substance-related charges. This is a serious concern, as the burden of steering individuals with SUDs into treatment often falls to criminal defense attorneys. The goal of this study was to examine the attitudes of criminal defense attorneys toward individuals who have been accused of drug crimes. METHODS: A questionnaire was sent to criminal defense attorneys (N = 1,933) from all 50 U.S. states and the District of Columbia. It was comprised of (i) demographic information and (ii) a version of the 11-item Medical Condition Regard Scale (MCRS). RESULTS: Criminal defense attorneys held generally positive attitudes toward clients with substance-related charges, but there was a significant divergence in attitudes between private and public attorneys, with the latter showing both greater familiarity with and better attitudes toward this same group of clients. These differences were impactful: worse attitudes toward clients strongly correlated with greater predictions that the clients would reoffend. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Given the magnitude of the incarcerated population with SUDs and the centrality of defense attorneys in the treatment process, especially its initiation, the divergence in attitudes between private and public criminal defense attorneys is concerning. There is a clear need for increased collaboration between physicians and attorneys, with an aim of increasing the number of individuals with SUDs receiving proper treatment (Am J Addict 2018;XX:1-7).