The mental health and psychosocial problems of survivors of torture and genocide in Kurdistan, Northern Iraq: A brief qualitative study

Background: From 1986-9, the Kurdish population of Iraqi Kurdistan was subjected to an intense campaign of military action, and genocide by the central Iraq government. This campaign, referred to as the Anfal, included systematic attacks consisting of aerial bombings, mass deportation, imprisonment, torture, and chemical warfare. It has been estimated that around 200,000 Kurdish people disappeared. Purpose: To gain a better understanding of current priority mental health and psychosocial problems among Kurdish survivors of the Anfal, and to inform the subsequent design of culturally appropriate and relevant assessment instruments and services to address these problems. The study examined 1) the nature and cause of current problems of survivors of torture and/or civilian attacks and their families, 2) what survivors do to address these problems, and 3) what they felt should be done. Methods: We used a grounded theory approach. Free list interviews with a convenience sample (n=42) explored the current problems of Kurdish persons affected by torture. Subsequent key informant interviews (n=21) gathered more detailed information on the priority mental health problem areas identified in the free list interviews. Results: Major mental health problem areas emerging from the free list interviews (and explored in the key informant interviews) included 1) problems directly related to the torture, 2) problems related to the current situation, and 3) problems related to the perception and treatment by others in the community. Problems were similar, but not identical, to Western concepts of depression, anxiety, PTSD and related trauma, and traumatic grief. Conclusion: Iraqi Kurdish torture survivors in Iraq have many mental health and psychosocial problems found among torture survivors elsewhere. The findings suggest that the problems are a result of the trauma experienced as well as current stressors. Development of mental health assessment tools and interventions should therefore address both previous trauma and current stressors

Down-Regulation of MiR-127 Facilitates Hepatocyte Proliferation during Rat Liver Regeneration

Liver regeneration (LR) after partial hepatectomy (PH) involves the proliferation and apoptosis of hepatocytes, and microRNAs have been shown to post-transcriptionally regulate genes involved in the regulation of these processes. To explore the role of miR-127 during LR, the expression patterns of miR-127 and its related proteins were investigated. MiR-127 was introduced into a rat liver cell line to examine its effects on the potential target genes Bcl6 and Setd8, and functional studies were undertaken. We discovered that miR-127 was down-regulated and inversely correlated with the expression of Bcl6 and Setd8 at 24 hours after PH, a time at which hypermethylation of the promoter region of the miR-127 gene was detected. Furthermore, in BRL-3A rat liver cells, we observed that overexpression of miR-127 significantly suppressed cell growth and directly inhibited the expression of Bcl6 and Setd8. The results suggest that down-regulation of miR-127 may be due to the rapid methylation of its promoter during the first 24 h after PH, and this event facilitates hepatocyte proliferation by releasing Bcl6 and Setd8. These findings support a miRNA-mediated negative regulation pattern in LR and implicate an anti-proliferative role for miR-127 in liver cells

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Testing the validity and reliability of the shame questionnaire among sexually abused girls in Zambia.

PURPOSE:The aim of the current study is to test the validity and reliability of the Shame Questionnaire among traumatized girls in Lusaka, Zambia. METHODS:The Shame Questionnaire was validated through both classical test and item response theory methods. Internal reliability, criterion validity and construct validity were examined among a sample of 325 female children living in Zambia. Sub-analyses were conducted to examine differences in construct validity among girls who reported sexual abuse and girls who did not. RESULTS:All girls in the sample were sexually abused, but only 61.5% endorsed or reported that sexual abuse had occurred. Internal consistency was very good among the sample with alpha = .87. Criterion validity was demonstrated through a significant difference of mean Shame Questionnaire scores between girls who experienced 0-1 trauma events and more than one traumatic event, with higher mean Shame Questionnaire scores among girls who had more than one traumatic event (p = .004 for 0-1 compared to 2 and 3 events and p = .016 for 0-1 compared to 4+ events). Girls who reported a history of witnessing or experiencing physical abuse had a significantly higher mean Shame Questionnaire score than girls who did not report a history of witnessing or experiencing physical abuse (p<.0001). There was no significant difference in mean Shame Questionnaire score between girls who reported a sexual abuse history and girls who did not. Exploratory factor analysis indicated a two-factor model of the Shame Questionnaire, with an experience of shame dimension and an active outcomes of shame dimension. Item response theory analysis indicated adequate overall item fit. Results also indicate potential differences in construct validity between girls who did and did not endorse sexual abuse. CONCLUSIONS:This study suggests the general utility of the Shame Questionnaire among Zambian girls and demonstrates the need for more psychometric studies in low and middle income countries

The Shame Questionnaire Items and Exploratory Factor Analysis Varimax Rotated Factor Matrix of Shame Questionnaire.

<p>Bold indicates factor loading > .40. Parentheses indicates sub-analyses of factor loadings for girls who endorsed sexual abuse, factor loadings for girls who did not endorse sexual abuse.</p><p>*Factor loadings for girls who did not endorse sexual abuse are only listed in factor 1.</p><p>The Shame Questionnaire Items and Exploratory Factor Analysis Varimax Rotated Factor Matrix of Shame Questionnaire.</p

Female Child Participant Demographics and Scale Scores (n = 325).

<p>Variable codes for trauma event types: Experiencing physical assault or violence-P; Experiencing sexual assault or violence-S; Witnessing physical assault or violence- W.</p><p>Female Child Participant Demographics and Scale Scores (n = 325).</p

Evaluation of Criterion Validity: Analysis of Variance Comparing the Shame Questionnaire Score Between Number of Traumatic Event Types.

<p>Evaluation of Criterion Validity: Analysis of Variance Comparing the Shame Questionnaire Score Between Number of Traumatic Event Types.</p

Sub-Analysis: Multidimensional Rating Scale Model with Unstandardized Parameters for Girls who Endorsed Sexual Abuse vs. Unidimensional Rating Scale Model with Unstandardized parameters for Girls who Did Not Endorse Sexual Abuse.

<p>Sub-Analysis: Multidimensional Rating Scale Model with Unstandardized Parameters for Girls who Endorsed Sexual Abuse vs. Unidimensional Rating Scale Model with Unstandardized parameters for Girls who Did Not Endorse Sexual Abuse.</p

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit