Post-traumatic stress, depression, and anxiety during the 2021 Myanmar conflict: a nationwide population-based survey.

Background: The UN warns that Myanmar faces the 'triple crises' of mass conflict, uncontrolled COVID-19, and economic collapse. Therefore, we aimed to assess the population mental health burden, healthcare needs, and the associated risk factors in Myanmar. Methods: We established a nationwide random sample and recruited 1038 adults via random digit dialling from July 3-Aug 9, 2021, during the ongoing conflict since Feb 1, 2021, and surge in SARS-CoV-2 infections. Probable post-traumatic stress disorder (PTSD) was assessed using the PTSD Checklist-Civilian Version. Probable depression and anxiety were assessed using the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2. We calculated population attributable fractions for probable mental disorders using multivariable logistic regression models. Based on the mental health burden and healthcare-seeking patterns, we projected the need for mental health services. Findings: During the 'triple crises', a third of adults in Myanmar (34.9%, 95% CI 32.0-37.7) reported a probable mental disorder. Prevalence of probable PTSD, depression, and anxiety were 8.1% (6.6-9.7), 14.3% (12.0-16.6), and 22.2% (19.7-24.7), respectively. We estimated that up to 79.9% (43.8-97.9) of probable PTSD was attributable to political stress. This corresponds to 2.1 million (1.1-3.2 million) fewer adults with probable PTSD if political stress was removed from the population. The mental health burden could translate into roughly 5.9 million adults seeking mental health services. Interpretation: The mental health burden in Myanmar is substantial, and population mental health might only be restored when the three crises have ended. An accelerated peace process is critical to protecting Myanmar's population mental health. Funding: This research was supported the Research Grants Council of the Hong Kong Special Administrative Region, China (Project No. HKU 17606122) and the Michele Tansella Award.

Development of Upper Extremity Deep Vein Thrombosis in a Patient With Seronegative Myasthenia Gravis: A Case Report and Review of Literature.

We present the case report of a patient with seronegative myasthenia gravis (MG) who was admitted for metabolic encephalopathy and acute on chronic hypoxic respiratory failure secondary to an MG crisis three days after an intravenous immunoglobulin treatment. In the intensive care unit, her MG was managed with intravenous immunoglobulin, plasmapheresis, prednisone, and pyridostigmine. During the course of her visit, she had urosepsis along with a left chest port that had cultured positive for Pseudomonas aeruginosa and developed a right upper extremity deep vein thrombosis (UEDVT) and superficial thrombosis in the left upper extremity despite being on heparin therapy. She had a transient drop in platelets to below 150,000 that resolved within a day. We analyzed the variables of this case report and reviewed the literature of similar cases to elucidate the factors that may have led to the development of the UEDVTs. The patient had many factors in her past medical history that could have contributed to her thrombosis including morbid obesity and prior history of pulmonary embolisms. It is hypothesized that MG disturbs the endothelial cell lining through an increased inflammatory state that could also be a causative factor. There is no definitive way we could link MG as a causative factor due to a lack of testing to assess alteration in the integrity or functionality of her endothelium. A case report we reviewed showed a presentation of UEDVT in an MG patient due to a thymoma compressing the subclavian vein. However, this is not the case in this example due to the patient having a history of thymectomy. She was also at risk due to her hospital stay which led to immobility and placement of a central venous catheter. We conclude the formation of the UEDVT was likely a combination of these factors.

Relationship Between Severity and Length of Exposure to COVID-19 Parameters and Resulting Government Responses and the Suicide Crisis Syndrome (SCS).

OBJECTIVE: The COVID-19 pandemic has had a globally devastating psychosocial impact. A detailed understanding of the mental health implications of this worldwide crisis is critical for successful mitigation of and preparation for future pandemics. Using a large international sample, we investigated in the present study the relationship between multiple COVID-19 parameters (both disease characteristics and government responses) and the incidence of the suicide crisis syndrome (SCS), an acute negative affect state associated with near-term suicidal behavior. METHODS: Data were collected from 5528 adults across 10 different countries in an anonymous web-based survey between June 2020 and January 2021. RESULTS: Individuals scoring above the SCS cut-off lived in countries with higher peak daily cases and deaths during the first wave of the pandemic. Additionally, the longer participants had been exposed to markers of pandemic severity (eg, lockdowns), the more likely they were to screen positive for the SCS. Findings reflected both country-to-country comparisons and individual variation within the pooled sample. CONCLUSION: Both the pandemic itself and the government interventions utilized to contain the spread appear to be associated with suicide risk. Public policy should include efforts to mitigate the mental health impact of current and future global disasters.

Associations between recorded loneliness and adverse mental health outcomes among patients receiving mental healthcare in South London: a retrospective cohort study.

PURPOSE: Loneliness disproportionately affects people with mental disorders, but associations with mental health outcomes in groups affected remain less well understood. METHOD: A cohort of patients receiving mental healthcare on 30th June 2012 was assembled from a large mental health records database covering a south London catchment area. Recorded loneliness within the preceding 2 years was extracted using natural language processing and outcomes were measured between 30th June 2012 until 30th December 2019, except for survival which applied a censoring point of 6th December 2020 according to data available at the time of extraction. The following mental healthcare outcomes: (i) time to first crisis episode; (ii) time to first emergency presentation; (iii) all-cause mortality; (iv) days active to service per year; and (v) face-to-face contacts per year. RESULTS: Loneliness was recorded in 4,483 (16.7%) patients in the study population and fully adjusted models showed associations with subsequent crisis episode (HR 1.17, 95% CI 1.07-1.29), emergency presentation (HR 1.30, 1.21-1.40), days active per year (IRR 1.04, 1.03-1.05), and face-to-face contacts per year (IRR 1.28, 1.27-1.30). Recorded loneliness in patients with substance misuse problems was particularly strongly associated with adverse outcomes, including risk of emergency presentation (HR 1.68, 1.29-2.18) and mortality (HR 1.29, 1.01-1.65). CONCLUSION: Patients receiving mental healthcare who are recorded as lonely have a higher risk of several adverse outcomes which may require a need for higher service input.

The role of family and individual factors in going through adolescence having a disabled sibling - analysis of a healthy child's functioning. A case-control study protocol.

BACKGROUND: Having a disabled sibling can be a source of extremely important and enriching experiences that foster the development of social and emotional competences, as well as broadening the child's perspective and knowledge. On the other hand, it also poses many challenges for the siblings, especially in adolescence. Thus, the aim of the proposed project is to investigate the specificity of the growing up process in young people with disabled siblings. PARTICIPANTS AND PROCEDURE: A total of 160 dyads (320 participants) - an adolescent and one of his/her parents - will take part in this cross-sectional case-control study. Participants will be assigned to four groups, having a sibling with: 1) intellectual disability, 2) motor disability, 3) chronic somatic disease, and 4) the control group - having a sibling without any disability. Both the healthy adolescent and one of the parents will fill out a set of questionnaires regarding the study variables: Questionnaire of Relationships with Siblings, Parental Attitude Scale-2, KidScreen-27, Parentification Questionnaire for Youth, Teenage Rebellion Questionnaire, Child Behavior Checklist 6-18. RESULTS: The primary outcomes include investigating the healthy adolescent functioning in three environments: family, peers and school. The proposed research model focuses both on the difficulties associated with having a disabled sibling (e.g. possible occurrence of disorders) and resources (e.g. higher quality of relationships in the family, especially in the sibling subsystem). CONCLUSIONS: The proposed comprehensive approach to the issue of disability in the family from the perspective of a healthy child will allow for a better understanding of the mechanisms underlying the process of growing up with disabled siblings.

Gastric paraganglioma: a case report and review of literature.

Paragangliomas (PGLs) are rare neuroendocrine tumors which overproduce catecholamines (CAs). They are extra-adrenal, catecholamine-secreting tumors occurring outside the adrenal glands. Gastric PGLs originating from extra-adrenal paraganglia are exceptionally rare, and their presentation in geriatric patients further adds to the complexity of diagnosis and management. A 72-year-old male patient presented with enduring left upper abdominal pain and anemia persisting for over a year, and hypertension for six months. Physical examination revealed epigastric discomfort and pallor. Computed tomography scans revealed enlarged lymph nodes in the lesser curvature of the stomach and thickening of the gastric antrum wall with concavity. The patient underwent three cycles of neoadjuvant therapy before radical gastrectomy for gastric cancer. These imaging findings were confirmed during surgery and intraoperative blood pressure was in fluctuation. After the successful resection of the tumor, postoperative pathology confirmed paraganglioma. During postoperative examination, it was observed that the patient's CAs and their metabolites had returned to within the normal range. Combined with the existing ten literatures, we retrospective report the clinical and pathological characteristics and treatment strategies of the rare gastric paraganglioma.

Brexit - the EU membership crisis that wasn't?

This introduction to the special issue recalls the alarm raised in EU capitals and Brussels after the UK's in-out referendum delivered a Leave vote in June 2016. The fear was of a domino effect and the further fragmentation of an already divided EU. Seven years later, it is clear that there was rapid attrition of Eurosceptic triumphalism, and the EU-27 showed remarkable unity. This required a sustained collective effort to contain a membership crisis and maintain the EU polity. Yet, the issue contributors challenge the notion that the alarm was unfounded and explain why this counter-factual did not materialise, even though potential for future membership crises of different sorts was revealed. Theoretically, this supports an understanding of the EU as a polity that is fragile, yet able to assert porous borders, exercise authority over a diverse membership, and mobilise a modicum of loyalty when the entire integration regime is under threat.

The Brexit puzzle: polity attack and external rebordering.

Brexit constitutes a puzzle for integration theory. Functionalist analyses have not only failed to predict the UK's exit but have also underestimated the disintegrative dynamics of the withdrawal negotiations. By contrast, postfunctionalism accounts for the disintegrative Brexit process but struggles to explain the unity and defence of supranational integration among the EU-27. This article tries to make sense of the Brexit puzzle. First, it argues that Brexit constitutes an attack on the EU polity rather than a policy failure - the type of crisis that functionalist theories explain best. Second, it complements the postfunctionalist account of domestic politicisation with an analysis of the reactions and strategies of the defenders of supranational integration. According to this expanded postfunctionalist analysis, the interaction of polity attack and polity defence has produced 'external rebordering': extreme disintegration of the UK from the EU, on the one hand, and strengthened integration of the EU-27, on the other.

The energy crossroads: Exploring the moderating role of the energy crisis on the acceptance of the development of a uranium mine.

The energy crisis caused by the lack of supply from some countries involved in armed conflicts, coupled with society's continuous demand for energy production, is leading to the proposal of new energy sources, such as the development of uranium mines to increase nuclear energy production. Mine projects (MPs) trigger numerous conflicts in the local societies involved. While for some people, they represent an opportunity for development and benefits, for others these proposals are perceived as a threat and a health risk. However, energy scarcity and price increases create a social dilemma that moderates the established relationships between the perceived risks and benefits and the valuation of energy proposals. This research aims to analyze both the weight of the factors influencing the acceptance of a uranium MP and the moderating role of the energy crisis on these factors. A total of 629 people participated in this study (371 before and 258 after the energy crisis). The participants answered a questionnaire assessing their socio-demographic characteristics, beliefs about the environment, the perceived risks and benefits, and their emotional balance, as well as their level of knowledge and acceptance of the uranium mine proposal. The results show that age, gender, and level of education and knowledge both directly and indirectly influence the acceptance of a mine. In addition, the perception of risks and benefits is associated with the emotional balance generated, explaining the level of final acceptance of the proposal. The moderation-mediated energy crisis hypothesis influences the relationship between the perceived risks and acceptance of the uranium mine. The results are discussed in order to determine factors for intervention to alleviate the social conflicts created by new energy proposals.

The impact of cultural stress on family functioning among Puerto Rican displaced families and the effect on mental health.

Hurricane María caused significant devastation on the island of Puerto Rico, impacting thousands of lives. Puerto Rican crisis migrant families faced stress related to displacement and relocation (cultural stress), often exhibited mental health symptoms, and experienced distress at the family level. Although cultural stress has been examined as an individual experience, little work has focused on the experience as a family. To address this gap, we conducted a mixed-methods study designed to examine the predictive effects of cultural stress on family conflict and its mental health implications among Puerto Rican Hurricane María parent and child dyads living on the U.S. mainland. In the quantitative phase of the study, 110 parent-child dyads completed an online survey assessing cultural stress, family dynamics, and mental health. As part of our primary analysis, we estimated a structural equation path model. Findings from the quantitative phase showed a significant positive relationship between family cultural stress and family conflict, as well as individual parent and child mental health symptoms. In the qualitative phase of the study, 35 parent-child dyads participated in individual interviews. Findings from the interviews revealed variations in difficulties related to language, discrimination, and financial burdens, with some participants adapting more quickly and experiencing fewer stressors. Findings also highlight the impact on mental health for both parents and youth, emphasizing the family-level nature of cultural stress, while noting a potential discrepancy between qualitative and quantitative findings in the discussion of family conflict.

Alkindi Sprinkle for Pediatric Patients With Primary Adrenocortical Insufficiency: A Narrative Review.

Adrenocortical insufficiency, also known as adrenal insufficiency (AI), is an endocrine disorder characterized by inadequate production of adrenal hormones, including glucocorticoids and mineralocorticoids (MCs). The condition can be categorized as primary, secondary, or tertiary AI, depending on the location of the defect. Classical symptoms of AI include weakness, fatigue, abdominal pain, tachycardia, hypotension, electrolyte imbalances, and hyperpigmentation. In children, the most common cause of AI is classical congenital adrenal hyperplasia, which results from a deficiency in the 21-hydroxylase enzyme. The 21-hydroxylase enzyme produces all steroids, such as cortisol and aldosterone. AI management primarily involves hormone replacement therapy, typically with oral hydrocortisone and MC supplementation. However, the administration of hydrocortisone to pediatric patients presents challenges related to the lack of available dose-appropriate formulations. Historically, crushed or split adult tablets were used for the pediatric treatment of AI, although this poses an increased risk of under- or overtreatment. Inadequate dosing in the pediatric population can adversely affect growth, development, and metabolic health. Alkindi Sprinkle is a pediatric-specific hydrocortisone oral granule preparation that manages cortisol levels to help facilitate accurate therapeutic dosing. Alkindi offers several advantages, including accurate dosing, taste masking, and ease of administration. The present investigation describes AI, the management of AI, and the treatment of pediatric AI using Alkindi Sprinkle, including clinical efficacy.

Determinants of Referral Outcomes for Victim-Survivors Accessing Specialist Sexual Violence and Abuse Support Services.

Sexual violence and abuse (SVA) is highly prevalent globally, has devastating and wide-ranging effects on victim-survivors, and demands the provision of accessible specialist support services. In the UK, Rape Crisis England & Wales (RCEW), a voluntary third sector organization, is the main provider of specialist SVA services. Understanding the profile of victim-survivors who are referred to RCEW and their referral outcomes is important for the effective allocation of services. Using administrative data collected by three Rape Crisis Centres in England between April 2016 and March 2020, this study used multinomial regression analysis to examine the determinants of victim-survivors' referral outcomes, controlling for a wide range of potentially confounding variables. The findings demonstrate that support needs, more so than the type of abuse experienced, predicted whether victim-survivors were engaged with services. Particularly, the presence of mental health, substance misuse and social, emotional, and behavioral needs were important for referral outcomes. The referral source also influenced referral outcomes, and there were some differences according to demographic characteristics and socioeconomic factors. The research was co-produced with stakeholders from RCEW, who informed interpretation of these findings. That victim-survivors' engagement with services was determined by their support needs, over and above demographic characteristics or the type of abuse they had experienced, demonstrates the needs-led approach to service provision adopted by RCEW, whereby resources are allocated effectively to those who need them most.

Methodological approaches to measuring mental health in a cost-of-living crisis: A rapid review.

BACKGROUND: Cost-of-living crises are damaging to population mental health and require a public health response. It is important to assess whether public health interventions are effective. We aimed to identify population-level methods and measures and the appropriateness of the measures for vulnerable populations. METHODS: A rapid evidence review was undertaken. Nineteen databases, including grey literature, were searched for evidence published between 1970 and April 2023. RESULTS: Seven reviews, nine primary studies and two reports from grey literature were identified. Methods consisted of analyses of existing data from national or regional cohort studies, household panel surveys, repeated cross-sectional surveys, routine medical data, or data on suicide death rates. Twelve brief validated mental health measurement tools, embedded in population-level surveys, were identified. Two quasi-experimental studies used data from a UK household panel survey to examine the impact of the introduction of specific welfare policies on mental health. Studies identified socio-economic vulnerabilities, but it was not possible to determine whether data were effectively captured from people from minority ethnic groups. CONCLUSION: Population-level surveys can be used in quasi-experimental studies to measure the effects of a public health initiative with specific roll out dates to tackle cost-of-living impacts. It is unclear as to whether the identified methods and tools are suitable for use with people from minority ethnic groups.

Psychiatric diagnoses, somatic disorders, and emergency dispatches among individuals who used a national suicide crisis line.

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care.

[Opioid-free anesthesia : Wrong track or meaningful exit from the era of opioid-based analgesia?] / Opioidfreie Anästhesie : Irrweg oder sinnvoller Ausweg aus der Ära der opioidbasierten Analgesie?

The limitations and disadvantages of opioids in anesthesia are very well known but the advantages combined with a lack of effective alternatives even now still prevents refraining from using opioids as part of an adequate pain therapy. For decades, pain research has had the declared goal of replacing opioids with new substances which have no serious side effects; however, currently this goal seems to be a long way off. Due to the media coverage of the "opioid crisis" in North America, the use of opioids for pain management is also increasingly being questioned by the patients. Measures to contain this crisis are only slowly taking effect in view of the increasing number of deaths, which is why the triggers are still being sought. The perioperative administration of opioids is not only a possible gateway to addiction and abuse but it can also cause outcome-relevant complications, such as respiratory depression, postoperative nausea and vomiting and an increase in postoperative pain. Therefore, these considerations gave rise to the idea of an opioid-free anesthesia (OFA), i.e., opioids are not administered as part of anesthesia to carry out surgical procedures. Although this idea may make sense at first glance, a rapid introduction of this concept appears to be risky as it entails significant changes for the entire anesthesiological management. Based on relatively robust data from clinical studies, this concept can now be evaluated and discussed not only emotionally but also objectively. This review article presents arguments for or against the complete avoidance of intraoperative or even perioperative opioids. The current conditions in Germany are primarily taken into account, so that the perioperative pain therapy is transferable to the established standards. The results from current clinical studies on the implementation of an opioid-free anesthesia are summarized and discussed.

Climate crisis risks to elderly health: strategies for effective promotion and response.

The climate crisis significantly impacts the health and well-being of older adults, both directly and indirectly. This issue is of growing concern in Canada due to the country's rapidly accelerating warming trend and expanding elderly population. This article serves a threefold purpose: (i) outlining the impacts of the climate crisis on older adults, (ii) providing a descriptive review of existing policies with a specific focus on the Canadian context, and (iii) promoting actionable recommendations. Our review reveals the application of current strategies, including early warning systems, enhanced infrastructure, sustainable urban planning, healthcare access, social support systems, and community engagement, in enhancing resilience and reducing health consequences among older adults. Within the Canadian context, we then emphasize the importance of establishing robust risk metrics and evaluation methods to prepare for and manage the impacts of the climate crisis efficiently. We underscore the value of vulnerability mapping, utilizing geographic information to identify regions where older adults are most at risk. This allows for targeted interventions and resource allocation. We recommend employing a root cause analysis approach to tailor risk response strategies, along with a focus on promoting awareness, readiness, physician training, and fostering collaboration and benchmarking. These suggestions aim to enhance disaster risk management for the well-being and resilience of older adults in the face of the climate crisis.

A rare case of Philadelphia-positive (P210BCR-ABL1) T-cell acute lymphoblastic leukemia/lymphoma associated with minimal residual disease persistence after intensive chemotherapeutic approaches.

T-cell acute lymphoblastic leukemia/lymphoma (T-ALL/LBL) is a rare and aggressive leukemia. Philadelphia chromosome-positive cytogenetic abnormality is most common in CML. It is difficult to differentiate between de novo Ph+ T-ALL/LBL and T-cell lymphoblastic crises of CML. We present a case of adult Ph+ T-ALL/LBL with a likely history of antecedent CML. Initially thought to be a case of chronic-phase CML, a diagnostic quandary led to the pursuit of a lymph node biopsy that established the diagnosis of Ph+ T-LBL or T lymphoblastic blast crisis of CML, a clinical presentation extremely rare and only the second of its kind from our review of the literature. The patient was treated with an intensive chemotherapy regimen for over a year due to persistent minimal residual disease (MRD) positivity indicating aggressive disease.

Displacement in Place and the Financial Crisis in Lebanon.

Displacement is underway in Lebanon after financial collapse, but not as events of migration, rather, as processual disruption to people's lives that begins in place, preceding the potential outcome of forced migration. Financial collapse has shifted the population into extremes of constraint, dispossessing them of assets needed to live in valued ways. Widely circulated claims of an exodus are premature. Historic mass emigration from Lebanon occurred in times of capital availability whilst today's financial collapse denies most people of the capital needed to emigrate. Migration remains limited to the few with social and cultural capital unaffected by the crisis. This article was prompted by the author's observations of financial collapse whilst living in Lebanon in 2020 and long-standing engagement with the country. Regardless of whether mass emigration occurs, perhaps after the economy's recapitalization, the displacement process already underway warrants attention from refugee and forced migration studies.