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ORIGINAL RESEARCH INVESTIGACIÓN ORIGINAL
Reacciones psicológicas y psicopatológicas en Honduras después del huracán Mitch: implicaciones para la planificación de los servicios
Robert KohnI, *; Itzhak LevavII; Irma DonaireIII; Miguel MachucaIV; Rita TamashiroV
IBrown University, Department of Psychiatry and Human Behavior, Providence, Rhode Island, United States of America
IIIsrael, Ministry of Health, Jerusalem, Israel
IIIHonduras, Ministry of Health, Tegucigalpa, Honduras
IVRepresentation, Pan American Health Organization/World Health Organization, Quito, Ecuador
VUniversidad Nacional Autónoma, Department of Psychology, Tegucigalpa, Honduras
BACKGROUND: Posttraumatic stress disorder (PTSD) and other psychopathological outcomes have not been sufficiently studied in community-based samples in Latin America. This study explored various psychopathological reactions and their respective risk factors two months after Hurricane Mitch struck Honduras in October 1998.
METHODS: In the Honduran capital of Tegucigalpa, 800 respondents age 15 and older were selected from residential areas of high, middle, or low socioeconomic status that had suffered either high or low impact from the devastating effects of the hurricane. The Composite International Diagnostic Interview was used to diagnose PTSD. Depression, alcohol misuse, and grief reaction were examined using screening instruments, and the SelfReporting Questionnaire was used to measure demoralization. The Impact of Event Scale was administered to ascertain the severity of the posttraumatic reaction.
RESULTS: PTSD was present in 10.6% of the sample. Respondents from the high-impact residential areas were more distressed, had higher scores on the grief inventory, and showed greater severity in PTSD symptoms. The respondents from the high-impact residential areas also had higher prevalence rates of major depression, alcoholism, and prior emotional problems. The best explanatory model for the risk of developing PTSD included the degree of exposure based on reported traumatic events, and associated increased demoralization. Among the persons with PTSD, its severity was predicted by being female and by the degree of exposure to hurricane-related traumatic events.
CONCLUSIONS: Out of a total population of 3.3 million adults (age 15 and older) in Honduras, it is estimated that over 492 000 of them may have developed PTSD due to Hurricane Mitch. Adequate health disaster preparedness and response requires full acknowledgement of the multiple psychological effects that victims experience.
Key words: Disasters; mental health; mental disorders; stress disorders, post-traumatic; Honduras.
OBJETIVOS: En América Latina no se han estudiado suficientemente los trastornos por estrés postraumático (TSP) y otras afecciones piscopatológicas mediante muestras basadas en la comunidad. El presente estudio explora varias reacciones psicopatológicas y sus respectivos factores de riesgo dos meses después de que el huracán Mitch azotó Honduras en octubre de 1998.
MÉTODOS: En Tegucigalpa, capital de Honduras, se seleccionó a 800 personas de 15 años de edad o más que vivían en áreas residenciales consideradas de estatus socioeconómico alto, medio o bajo y que habían sufrido los devastadores efectos del huracán en mayor o en menor medida. Para diagnosticar los casos de TSP se utilizó la Entrevista Diagnóstica Internacional Compuesta. La depresión, el abuso de alcohol y la reacción de dolor se evaluaron mediante encuestas de tamizaje, mientras que para la desmoralización se empleó el Cuestionario de Síntomas. Se aplicó la Escala de Impacto de Eventos para establecer la gravedad de la reacción postraumática.
RESULTADOS: Se encontró TSP en 10,6% de la muestra. Los encuestados de las áreas residenciales más afectadas estaban más angustiados, tuvieron una mayor puntuación en la evaluación de sufrimiento, y presentaron síntomas de TSP de mayor gravedad. También presentaron mayores tasas de prevalencia de depresión mayor, alcoholismo y problemas emocionales previos. El mejor modelo explicativo del riesgo de sufrir TSP tomó en cuenta el grado de exposición según los eventos traumáticos informados y el incremento de la desmoralización asociada con ellos. Entre las personas con TSP, los factores pronóstico de la gravedad de los trastornos fueron el pertenecer al sexo femenino y el grado de exposición a los eventos traumáticos relacionados con el huracán.
CONCLUSIONES: Se calcula que del total de 3,3 millones de adultos (de 15 años de edad o más) habitantes de Honduras, más de 492 000 han sufrido TSP debido al huracán Mitch. Para contar con una adecuada preparación sanitaria y ofrecer una apropiada respuesta ante los desastres es necesario reconocer en profundidad los múltiples efectos psicológicos que experimentan las víctimas.
Palabras clave: Desastres, salud mental, trastornos mentales, trastornos por estrés postraumático, Honduras.
The scientific literature has repeatedly shown that natural and human-made disasters leave in their wake short-, medium-, and long-term psychopathological reactions (1, 2). Post-traumatic stress disorder (PTSD) is the most commonly studied disorder in mental health disaster outcome research, although it is not the only psychopathological reaction. The role of culture in PTSD is complex, and so are the relationships that dose response, depression, demoralization, and substance use have with PTSD (3).
Most of the research on PTSD has been conducted in industrialized Western nations, with little research coming from developing regions, including Latin America. However, when natural disasters are measured by economic loss or the number of deaths and injuries, Asia is the most vulnerable region in the world, followed by Latin America. Of the 20 countries where the most deaths from disasters occurred between 1966 and 1990, 6 are located in Latin America (4).
To date, the mental health consequences of seven disasters in Latin America have been studied. In deriving a diagnosis of PTSD, most of these studies applied symptoms checklists rather than structured diagnostic instruments. In addition, the community was not the basis for the sampling framework. Investigations following the volcano eruption in Armero, Colombia, included persons from shelters and primary care clinics (5). Using a PTSD symptom checklist and clinical assessment, those researchers found a PTSD rate of 32% in the shelters and of 42% in the clinics. One published study on the effects of Hurricane Mitch on Nicaragua included an investigation of adolescents from three public schools who had had different degrees of exposure to the impact of the hurricane on their community (6). Assessment for PTSD was made using the Child Posttraumatic Stress Disorder Index. A second study in Nicaragua, which targeted adults, was based on consecutive patients in four primary health care centers (7). PTSD symptoms were measured using the Harvard Trauma Questionnaire. This study found a prevalence rate of 4.5% in the least-damaged area and of 9.0% in the most-damaged area (7).
A study examining the effects of Hurricane Paulina in Mexico utilized the Revised Civilian Mississippi Scale in the community; however, a quota rather than a random sample was employed (8). De la Fuente (9) conducted two studies on the impact that victims living in shelters had suffered from an earthquake in Mexico. These studies used a questionnaire probing psychiatric symptoms based on the Diagnostic and Statistical Manual, third edition (DSMIII), and found rates of PTSD of 32%. To date, only three studies following natural disasters in Latin America have used structured diagnostic interview schedules to make a diagnosis of PTSD. The Diagnostic Interview Schedule (DIS) and Structured Clinical Interview for DSM-III were used to make a diagnosis of PTSD among 524 individuals following an earthquake in Mexico. A rate of 32% was found; women had higher rates than did men (10). In Puerto Rico the DIS was readministered to 521 persons previously interviewed in a representative national sample after a flood. The group who had been exposed to the flood had a rate of PTSD of 3.7%, and the unexposed group had a rate of 0.7% (11, 12).
Several studies have suggested that Hispanic populations may be more vulnerable to PTSD. Using the DIS, Durkin examined the rate of PTSD among victims of earthquakes in the country of Chile and in the state of California in the United States (13); the rate in Chile was 19%, versus 3% in California. The Chilean sample was based on residents of a housing complex, while the California sample was based on a household survey. In a study of Hurricane Andrew in the United States, Spanish-speaking Latinos had higher rates of PTSD symptoms than did either Hispanics who choose to be interviewed in English or non-Hispanics (14).
Despite the relative scarcity of current research on Latin America, the available data suggest that disasters lead to considerable mental health morbidity. However, health officials and decisionmakers often overlook the mental health impact of disasters. This occurs, for example, because the authorities are overwhelmed by the immediate human and material losses, environmental consequences, destruction of health centers, and risk of epidemics. In addition, the mental health impact of disasters may be ignored due to the stigma of psychiatric disorders.
The objective of this community-based study was to investigate the risk of PTSD and other psychopathological reactions, including demoralization, depression, grief, and alcohol misuse, several months after Honduras was struck by Hurricane Mitch in 1998. The study was done in Tegucigalpa, the capital city of the country. Several measures of dose response were employed, and, unlike other studies, the sampling design was developed to specifically study the role of socioeconomic status as a risk factor for developing psychopathology.
Hurricane Mitch hit Central America on 25 October 1998 with wind speeds up to 285 km/hr (150 mi/hr). This was the most devastating disaster to affect Central America in a century.
Honduras suffered the brunt of the disaster. The Pan American Health Organization (PAHO) and the Honduran Government estimated that 1.5 million of Honduras' population of 6.4 million were displaced by the hurricane, 5 657 were killed, and 8 058 more were never found. Another 112 272 persons were reported injured. Approximately 1 375 shelters had to be established to accommodate 285 000 persons who were evacuated (15). In the region where Tegucigalpa is located, 404 225 individuals were displaced; of those, 22 429 were housed in 165 shelters (16). Fifteen of the 29 hospitals in the country were rendered inoperable by the hurricane. Thirty percent of the country's health infrastructure was damaged. Eighty percent of the population had difficulty accessing drinking water. Marked increases in intestinal diseases, cholera, malaria, and dengue were seen.
The study was conducted in December 1998 and January 1999. A sample of 800 adults (age 15 and older) stratified by the socioeconomic status (SES) of the neighborhood was selected. One-half of the adults were from lowSES neighborhoods, one-fourth from middle-SES neighborhoods, and one-fourth from high-SES neighborhoods. The SES groups were stratified by high-impact and low-impact neighborhoods. The selection and determination of which neighborhoods were considered to be high and low impact was done in consultation with the Secretariat of Health in Honduras. A neighborhood was considered to have suffered high impact if nearly all the homes were destroyed. Individuals in the low-SES highly impacted strata were further subdivided into two groups: those remaining in the community (either still residing in their original homes or having moved elsewhere in the community) and those temporarily housed in shelters.
For the persons remaining in the community, the housing units were selected from predetermined neighborhoods based on SES and impact. The number of homes in each neighborhood was counted regardless of whether the house was intact or not. The first house selected was at the beginning of each street. The subsequent house selected was based on the number of homes in the area divided by the number of interviews needed for the respective strata. Homes were selected regardless of whether or not they were destroyed or occupied. If a house was unoccupied or destroyed, the residents of the home prior to it were located if they resided in Tegucigalpa by asking neighbors and reconstruction workers. If the residents of the designated house could not be located, the subsequent house was selected. Consecutive households were selected in the districts where houses were destroyed and in the poor neighborhoods where it was extremely difficult to ascertain the individual unit, such as with a slum dwelling where one family unit was built next to or on top of another. For individuals living in the sampled shelters, all families were included.
In a brief interview the initial household resident who was contacted provided a description of the exposure of the hurricane on the home and the family. This informant provided a list of all the individuals, including the informant, who resided in the home at the time of the hurricane, in order for us to select for a more-extensive interview one target respondent per household, according to the Kish procedure (17). Those age 15 and older were eligible.
The Secretary of Health of Honduras and the Representation of the Pan American Health Organization in Honduras approved both the interview schedule and the consent forms for human rights safeguard. Written informed consent was obtained from the person providing the information about the residents of the home and also from the subject who underwent the more-extensive interview. Each of the interviewers was provided a letter of introduction from the Secretary of Health identifying them as an interviewer for this study.
The interview of the target respondent included sections on demographic information, demoralization, depression, posttraumatic stress, alcohol abuse, help-seeking, and exposure to trauma. A psychiatrist and a Honduran psychologist translated the scales that did not have an available Spanish version. All items were evaluated for cultural validity by the team and modified for the local usage, and to fit the events related to the hurricane.
Demoralization was measured using the SelfReporting Questionnaire (SRQ) (18). Since the objective of the study was to determine current psychiatric and psychological problems, the SRQ was modified to inquire about the last seven days rather than the past month. The SRQ had been validated in neighboring Nicaragua, with a cutoff of nine positive symptom items being found to be appropriate as a screen for probable psychiatric cases in the general community (19). The SRQ schedule also included five items on alcohol abuse, which were modified to tap into behaviors that occurred since the hurricane. This scale had been used globally, including in Latin America (20). To measure losses resulting from the hurricane, five items from the Texas Inventory of Grief were used (21). The Texas Inventory of Grief was administered in only half of the interviews.
To evaluate for the presence of current major depression a DSM-IV/ International Classification of Diseases Tenth Revision symptom checklist inquiring into the presence of diagnostic symptoms in the past two weeks was used. This instrument had been previously used in a multicenter study of primary care practices throughout Latin America (22). DSM-IV diagnosis of PTSD was obtained using the Spanish-language version 2.1 of the Composite International Diagnostic Interview Schedule (CIDI) PTSD module, a diagnostic interview schedule (23). The module obtained the current diagnosis, and each question was modified so that it only referred to the hurricane and to no other traumatic event. Presence of current PTSD symptoms and their severity in the past seven days was further evaluated by using the Impact of Event Scale (IES) (24). The total score on the IES is derived by the sum of positive responses. The IES consists of two subscales, one for intrusion and one for avoidance. Again, the items were linked directly to the hurricane rather than being left open to other traumatic events.
A single item was included in the interview schedule to control for the presence of any predisaster psychological problem: "Did you have problems with your nerves before the hurricane?" This was followed by questions evaluating the degree of traumatic exposure that occurred during the hurricane (see Table 2 for a list of items). Positive responses to these items were summed to form an exposure index (Chronbach's alpha = 0.58).
The interview also asked about exposure to violence following the hurricane (witnessing violence, being assaulted, someone assaulting your child, or assaulting someone). The interview concluded with a series of items about the utilization of any medical or mental health assistance after the disaster, and the resources that might be used in the future.
Risk factors for psychopathology were examined using both univariate and multivariate analyses. Chi-square tests and t tests were used in the univariate analysis. Logistic regression was used to determine the odds ratios (ORs) and the 95% confidence intervals (CIs) for potential risk of PTSD. Multivariate regression analysis was used to examine predictors of severity of PTSD. Backwards regression analyses were utilized to determine the best-fitting models. Low SES, middle SES, and high SES plus high-impact or low-impact neighborhood were included in each of the regression models since they were basic stratification variables in the sample design. Statistical tests were considered to be significant at the P < 0.05 level. The statistical analysis was conducted using the SUDAAN software program to adjust the standard errors (SEs) for the stratified sample design (25).
Exposure and psychopathology
Eight hundred interviews were completed, stratified as follows: low impact and high SES, 100; low impact and middle SES, 101; low impact and low SES, 199; high impact and high SES, 100; high impact and middle SES, 100; high impact and low SES not in a shelter, 98; and high impact and low SES in a shelter, 102. Females constituted 61.4% of the sample. The average age of the subjects was 37.0 years (standard deviation, 16.8 years). Residence in a high-impact or low-impact neighborhood was not significantly associated with any of the demographic variables other than having to undergo a change in occupation following the hurricane. The demographic characteristics of the sample are shown in Table 1.
Table 2 reports the proportion of persons who experienced any of six traumatic events whose occurrence during the hurricane we asked about, for all the respondents, the low-impact stratum, and the high-impact stratum. The six events were: the house was damaged, witnessed someone being injured, witnessed someone die, was injured, lost one's belongings, and lost a pet. Each event was reported at a statistically higher rate in the high-impact group. Twelve individuals, including two from the low-impact group, reported witnessing someone die. The high-impact group had a significantly increased exposure index (t = 13.79, degrees of freedom (df) = 793, n = 793, P < 0.0001) in contrast to the low-impact group.
Exposure to violence following the hurricane, reported by over one-third of the population, did not differ significantly by impact group.
PTSD, as diagnosed by the CIDI, was present in 10.6% (SE = 1.1%) of the sample two months following the hurricane. Table 3 shows the prevalence rates by high-impact and low-impact neighborhood, and Table 4 presents the rates by the three levels of SES. Each of the three disorders was significantly higher among those in the high-impact group, and that was also true for those in the low-SES group. The relationship between SES and the three diagnoses was not a result of higher exposure to the traumatic events in the low-SES group, given that the interaction between SES and the exposure index was not statistically significant. The proxy one-item measure of predis-aster psychopathology, "prior nerves," was also more prevalent among those in the high-exposure group (23.5%) than in the low-exposure group (16.6%) (chi-square = 5.86, df = 1, P < 0.02). The prevalence of "prior nerves" was inversely related to SES (chi-square = 16.26, df = 2, P < 0.0003).
There were significant differences between the two impact groups in the degree of demoralization as measured by the SRQ. Respondents in the high-impact group were more distressed (t = 4.45, df = 793, n = 772, P < 0.0001) and had higher scores in the Texas Inventory of Grief (t = 4.88, df = 793, n = 394, P < 0.0001). The IES also was elevated in the high-impact group, including the intrusion subscale (t = 4.55, df = 793, n = 783, P < 0.0001), the avoidance subscale (t = 4.10, df = 793, n = 786, P < 0.0001), and the total score (t = 4.74, df = 793, n = 773, P < 0.0001).
About one-fourth of the total sample sought medical consultation in the two months following the hurricane, but the 28.9% proportion among the high-impact group and the 24.2% among the low-impact group were not significantly different. Nor were there statistical differences with regard to those who sought assistance for emotional problems, with that being 10.3% among the high-impact group and 7.4% among the low-impact group.
Risk factors for posttraumatic stress disorder
Each logistic regression analysis that examined risk factors for CIDI-PTSD included impact group and SES since these characteristics were used to stratify the sample. Females were at a markedly increased risk (OR = 2.1, 95% CI: 1.23.4). Increasing age appeared to have a small but statistically significant increased risk for PTSD (OR = 1.02; 95% CI: 1.001.03). Living in a common-law relationship (in contrast to being married) had an increased risk for PTSD (OR = 2.1; 95% CI: 1.14.1). Level of education and being unemployed (prior to or since the hurricane) were not significantly associated with increased risk for PTSD. When gender, age, and marital status were all included in the model along with impact group and SES, each of these three variables remained statistically significant.
Exposure to the traumatic events due to the hurricane that were risk factors for PTSD included: house being damaged (OR = 3.4; 95% CI: 2.05.7); seeing someone injured (OR = 2.9; 95% CI: 1.17.4); losing one's belongings (OR = 3.0; 95% CI: 1.55.9); and loss of a pet (OR = 3.6; 95% CI: 1.97.0). Being injured during the hurricane did not reach statistical significance (OR = 2.2; 95% CI: 0.95.1). The exposure index was predictive of PTSD (OR = 1.9; 95% CI: 1.52.5).
As for violent events following the hurricane, witnessing violence (OR = 3.4; 95% CI 1.86.4) increased the risk of developing PTSD related to the hurricane. However, having been assaulted (OR = 2.2; 95% CI: 0.85.9) or having a child who was assaulted (OR = 1.2; 95% CI: 0.91.7) were not associated with PTSD due to the hurricane.
Comorbid psychopathological reactions and conditions were in part associated with increased risk for the diagnosis of PTSD following the hurricane. Major depression (OR = 11.1; 95% CI: 6.518.9) and predisaster problems with nerves (OR = 1.4; 95% CI: 1.31.6) were associated risk factors, but not alcoholism (OR = 1.9; 95% CI: 0.84.3). Alcoholism was associated with increased risk for PTSD, controlling for gender (OR = 3.4; 95% CI: 2.48.2). Demoralization was also comorbid with PTSD, based on the SRQ (OR = 1.3; 95% CI: 1.31.4). The Texas Inventory of Grief scale was not associated with PTSD. A logistic regression model that included only the possible comorbid conditions, demoralization, major depression, and "prior nerves," along with the stratification variables, was created. This model resulted in demoralization (OR = 1.3; 95% CI: 1.21.4) and major depression (OR = 2.1; 95% CI: 1.04.5) remaining significant covariates, but not "prior nerves."
A backward logistic regression analysis was conducted using impact group, SES, gender, marital status, age, demoralization based on the SRQ, major depression, alcoholism, "prior nerves," and exposure index to determine the best-fitting model of the studied risk factors for PTSD. Only demoralization (OR = 1.3; 95% CI: 1.21.4) and the exposure index (OR = 1.6; 95% CI: 1.22.1) remained statistically significant. Gender, age, "prior nerves," major depression, and alcoholism did not remain in the model; neither SES nor impact group remained statistically significant.
Individuals with CIDI-PTSD were much more likely to use health services following the hurricane compared to those without PTSD (48.5% versus 23.5%; OR = 2.8; 95% CI: 1.74.5), as well as to consult for psychological issues (30.1% versus 6.1%; OR = 5.7; 95% CI: 3.110.3).
Severity of posttraumatic stress disorder
An increased score on the IES was moderately associated with increased CIDI-PTSD risk for the total score (OR = 1.1; 95% CI: 1.11.1), the avoidance subscale (OR = 1.1; 95% CI: 1.11.1), and the intrusion subscale (OR = 1.2; 95% CI: 1.11.2). Severity was examined using the IES total score among those who had PTSD, using multiple regression models. The stratification variables, impact group, and SES were not related to severity of PTSD. Females with PTSD had higher scores than did men on the IES (b = 8.37, SE = 4.23, P < 0.05). Age, marital status, and unemployment prior to or after the hurricane were not related to PTSD severity. Seeing someone being injured (b = 10.59, SE = 4.21, P < 0.02), getting injured during the hurricane (b = 11.31, SE = 3.95, P < 0.0002), and losing one's belongings (b = 10.43, SE = 3.20, P < 0.002) were events significantly associated with increased severity of the disorder. The exposure index also predicted more severe PTSD (b = 4.47, SE =1.17, P < 0.0001). Exposure to post-hurricane violence was not related with severity of PTSD. Major depression, alcoholism, and prior problems with nerves did not correlate with severity. Increased demoralization (b = 0.99, SE = 0.33, P < 0.004) was significantly associated with more severe PTSD, but not for the measure for grief. Seeking medical or mental health services was not associated with severity of PTSD.
A backward regression analysis was conducted to determine which factors were predictive of severity of PTSD. Gender, demoralization, exposure index, and the two stratification variables were included in the initial model. The significant variables in the final model included being female (b = 9.56, SE = 3.54, P < 0.008) and the exposure index (b = 4.66, SE = 1.13, P < 0.0001).
PTSD appeared in 10.6% of the respondents. This rate of PTSD was much lower than in most Latin American studies examining disasters. This finding may be explained by the utilization of a diagnostic instrument that was clearly linked to the event, and to the community-based sampling design that we used. As noted, previous studies used symptoms checklists rather than diagnostic tools and relied on selected populations.
Latin American studies on PTSD have also led to mixed results concerning whether a dose response is related to an increased risk of de veloping PTSD. A study of Guatemalan refugees living in Mexico found no association between the number of war-related trauma events reported and symptoms of PTSD (26). In contrast, Caldera et al. (7), who conducted a research study on the effects that Hurricane Mitch had in the neighboring country of Nicaragua, suggested that there was a dose response that depended on the degree of impact on the different communities from which the samples were drawn. Two measures of impact/exposure were employed in our study of Honduras: (1) impact on neighborhood, an ecological measure, and (2) an exposure index, which reflected the individual's own experience based on the number of trauma events. Although both were associated with an increased risk for PTSD, in the final model only the individual's own exposure experience remained significant. Importantly, the severity of PTSD was associated only with individual exposure factors.
Major depression, demoralization, prior emotional disorder, and alcoholism in men were all associated with PTSD. However, following control for other covariates, only demoralization remained significant in the analysis. Curiously, comorbidity was not predictive of severity of PTSD. Our measure of major depression and alcoholism was based on symptom scales and not on a diagnostic instrument, unlike the procedure that we followed to ascertain PTSD. This is a limitation of this study, and conceivably the relationship with comorbidity might have been different. Furthermore, our study could not differentiate incident cases of major depression and alcoholism following the hurricane from those with a preexisting condition. We did use a proxy measure for prior psychopathology, although its validity is open to interpretation.
Prior research has suggested that socioeconomic status is a risk factor for disaster-related PTSD (2), yet SES has been less often investigated than other issues such as dose response or comorbidity. Disasters have the potential to affect people differentially. Disasters may have a higher impact the lower the social class of the victim is. That is because poorer people have fewer resources before a disaster, and are thus more likely to exhaust their assets before the disaster situation ends. Furthermore, the risk of being affected by a disaster is not equal across SES groups; the lower the socioeconomic level of a neighborhood, the higher the impact. Our Honduras study found mixed results for the role of SES. Those in the low-SES group have markedly higher rates of PTSD, suggesting an increased risk. Increased risk of exposure itself did not explain the inverse relationship between PTSD and SES, suggesting that lower SES itself increases the risk for PTSD. SES, however, is not a strong predictor for PTSD and was not significant in the final model. In addition, SES did not predict severity of PTSD.
The magnitude of the mental health reactions associated with Hurricane Mitch was considerable. Based on the census of Honduras, which indicated a total population of 3.3 million age 15 and older in 1998, we estimated that over 492 000 adults may have developed PTSD from Hurricane Mitch alone. We also noted in our study the post-disaster violence that may have been a result of community disorganization and deprivation. Our findings do not reflect post-disaster PTSD from secondary trauma.
In our study a sizable proportion (30%) of those individuals with PTSD attempted to get assistance for their psychiatric problems. Unfortunately, this study did not ascertain the type or quality of the assistance provided. Although not all those affected may require direct intervention, some large-scale interventions may be needed. Such an intervention might reduce the risk of secondary reactions by turning non-understandable symptoms into understandable ones and by suggesting ways of coping with psychiatric symptoms, including seeking help from mental health services.
Mental health disaster response requires an understanding of the nature of the disaster and its impact on the individual (Figure 1). This includes the type and extent of the loss, the cause of the disaster, the involvement of the individual (central versus peripheral), impact of the disaster, whether the person was evacuated, and if physical injury occurred. Taken together, these factors constitute the individual's disaster experience. Three broad types of mediating factors should be accounted for in addressing an individual's needs following a disaster (27): those that preceded the disaster, those that arose after the disaster, and those that are related to situations involving bereavement. From the public health perspective, each of these mediating factors needs to be taken into account. For example, our study suggested that personal losses, in particular property losses, have a great impact on acute psychopathology. This might suggest that public health action focused on restoring housing and other essential goods and in supporting the process of financial recovery might alone result in a positive mental health outcome for many. Mental health services need to be designed to address the complexity of the disaster experience, and the services need to include surveillance of the affected population over time.
Little research is available on the long-term outcome of disasters, particularly for low-income populations. Mental health outcomes are diverse, and they may include bereavement, demoralization, psychosocial concerns (such as parental well-being, quality of life, family functioning, and academic performance), physical health problems, psychiatric disorders, and disabilityas well as no adverse outcome. Mental health planning should not cease with just the conclusion of the acute event; health care providers must be prepared to treat those who remain in protracted vulnerability and have long-term chronic conditions as a result of trauma.
Acknowledgments. We thank our interviewers for their dedication and Beth Hott for her assistance with the data management and the manuscript.
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19. Penayo U, Kullgren G, Caldera T. Mental disorders among primary health care patients in Nicaragua. Acta Psychiatr Scand. 1990;82: 825.
20. Climent CE, Arango MV. Manual de psiquiatría para trabajadores de atención primaria. Washington, D.C.: Organización Panamericana de la Salud; 1983. (Serie PALTEX para técnicos medios y auxiliares, n. 1).
21. Faschingbauer TR, Devaul RA, Zisook S. Development of the Texas Inventory of Grief. Am J Psychiatry. 1977;134:6968.
22. Levav I, Kohn R, Montoya I, Palacio C, Rozic P, Salano I, et al. Training Latin American primary care physicians in the WPA module on depression: results of a multicenter trial. Psychol Med. 2005;35(1):3545.
23. World Health Organization. Composite International Diagnostic Interview, version 2.1. Geneva: WHO; 1997.
24. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979; 41:20918.
25. Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual. Release 7.5. Research Triangle Park: Research Triangle Institute; 1997.
26. Sabin M, Lopes Cardozo B, Nackerud L, Kaiser R, Varese L. Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. JAMA. 2003;290:63542.
27. Kohn R, Levav I. Bereavement in disaster: an overview of the research. Int J Ment Health. 1990;19:6176.
Manuscript received 24 August 2004. Accepted for publication 14 June 2005.
Suggested citiation Kohn R, Levav I, Donaire I, Machuca M, Tamashiro R. Psychological and psychopathological reactions in Honduras following Hurricane Mitch: implications for service planning. Rev Panam Salud Publica. 2005;18(4/5):28795.
* Send correspondence to: Robert Kohn, Butler Hospital, 345 Blackstone Blvd., Providence, Rhode Island 02906, United States of America; telephone 401-455-6277; fax: 401-455-6566; e-mail: RobertKohn@brown.edu

domain: literature


Green Construction Homes for Sale in Metro Denver
The future of home construction is green. The homes for sale here have all been constructed to save energy. These “green homes” may include solar panels and many are Energy Star certified, which means they offer better energy efficiency than other homes. Energy Star certified homes meet strict requirements set by the U.S. Environmental Protection Agency (EPA). Many of these homes have energy-saving appliances, high-efficiency heating and cooling, energy-efficient lighting and other features that make them environmentally friendly. This data is updated continually with information from the MLS. If you can’t find the perfect home, let us help. Call David and Tom at 720-408-7409.


China's top planning body, the National Development and Reform
Commission (NDRC), has warned of a surplus in coal supply if no
measures are taken to check new investments.
The NDRC issued the warning following an analysis of performance
of the coal industry in the first half of the year.
By the end of last May, there were 2,743 coal-related investment
projects being carried out in China, involving a total investment
of 343 billion yuan (US$43 billion), Xinhua-run China Securities
Journal reported on Wednesday.
These projects, when completed, will increase the country's coal
production by 800 million tons to over 2.1 billion tons. In 2005,
demand was 2.1 billion tons.
The risk of oversupply is also evident in rising inventory at
coalmines and major ports, the report said.
By the end of June, the amount of coal in stock had hit 153
million tons, the highest since 2003.
Coal prices have also declined in some regions, the report
Some industry analysts, however, disagree with the NDRC,
believing that the growth of China's coal demand over the next few
years could exceed the current 10 percent, which would then not
result in a serious oversupply.
(Xinhua News Agency August 30, 2006)


Hello again! The Extra Rotation is back on air after a short hiatus and we have a slight format change. This episode we will recap the news and reviews from March 2017.
We discuss the very recently released It teaser trailer, the building hype towards the Justice League and the state of their franchises, and then something different in Atomic Blonde and David Ayer’s Bright. We give CHiPs more time than it deserves, Kong Skull Island less than it deserves, and we balanced the time for Logan just right.
This episode of The Extra Rotation is now available on your favorite podcast app. We can be found on iTunes or Google Play, or if you prefer to listen while browsing The Daily Rotation there is a media player below just for you!
And as always, feel free to email any feedback or comments to firstname.lastname@example.org.


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We found 128 alternative medicine practitioners near Fishers, IN.
Dr. Nancy Cooper is a chiropractor in Carmel, IN. She is in-network for Medicare insurance. Dr. Cooper has received professional recognition including the following: Angies List Super Service award 2013, Nominated for Indy's A list 2014. She is accepting new patients.
Dr. William Nall's areas of specialization are pain medicine, family medicine, and neuromuscular medicine. He accepts Medicare insurance. He studied medicine at Pikeville College School of Osteopathic Medicine.
Dr. David Dunham's areas of specialization are physical therapy and chiropractic. He is an in-network provider for Most Insurance Plans insurance. Dr. Dunham is accepting new patients.
Clinical interests: Chiropractor Physical Therapist Pain Management
Dr. Thomas Cittadine is an orthopedist and osteopathic manipulative medicine specialist in Noblesville, IN. Dr. Cittadine is professionally affiliated with Riverview Health. After attending Indiana University School of Medicine, he completed his residency training at Fort Wayne Medical Education Program. His average rating from his patients is 5.0 stars out of 5. Dr. Cittadine honors Medicare insurance.
Dr. Ann Nelson's areas of specialization are family medicine and osteopathic manipulative medicine; she sees patients in Indianapolis, IN and Carmel, IN. Dr. Nelson's clinical interests include osteopathic manipulation. She takes Medicare insurance. She graduated from New York College of Osteopathic Medicine. Dr. Nelson is professionally affiliated with Riley Physicians, Indiana University Health Physicians, and IU Health Methodist/IU Health University. She is not currently accepting new patients.
Clinical interests: Routine and preventive care, Health and wellbeing, Care coordination with specialists, Osteopathic ... (Read more)
Dr. Roger Spahr sees patients in Indianapolis, IN and Carmel, IN. His medical specialties are family medicine and complementary and alternative medicine. Patients rated him highly, giving him an average of 4.0 stars out of 5. Dr. Spahr is in-network for Out of Network and Medicare insurance. He welcomes new patients. Dr. Spahr studied medicine at Indiana University School of Medicine.
Dr. Mary Pennella's specialty is chiropractic. She is especially interested in X-rays. Dr. Pennella takes Self-Pay/Uninsured insurance. She has received professional recognition including the following: Palmer Class of 2000, Most Outstanding Student Award.
Clinical interests: X-Ray, Insight 2000 Subluxation Station, Palmer Package, Atlas Orthogonal, Sacro Occipital ... (Read more)
Dr. Todd McDougle is a chiropractor in Noblesville, IN and Fishers, IN. Dr. McDougle's areas of expertise include scoliosis and general care. He honors Self-Pay/Uninsured insurance. He has received professional recognition including the following: Deans List.
Clinical interests: Scoliosis, Family Practice, Exercise & Fitness, Extremities, Full Spine, Pro Adjuster, Impulse ... (Read more)
Dr. Ronald Sheppard is a chiropractor in Indianapolis, IN. He is especially interested in general care, spine problems, and carpal tunnel syndrome. He is rated highly by his patients. Dr. Sheppard accepts Self-Pay/Uninsured, Medicaid, and Medicare insurance.
Clinical interests: Full Spine, Extremities, Whiplash, Carpal Tunnel Syndrome, Deep Muscle, Family Practice, ... (Read more)

domain: medical


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Leslie Schinella Collection of Gene Krupa Materials, 1945-1972
Goodman, Benny (Benjamin David) 1909-1986
Lombardo, Guy 1902-1977
Krupa, Gene 1909-1973
.3 cu. ft. : 1 box
Printed materials relating to Krupa and other big band musicians and band leaders, including Guy Lombardo and Benny Goodman. The collection includes a photograph of Krupa, concert programs (one with several autographs), a biographical publication and concert programs.
Leslie Schinella Collection of Gene Krupa Materials, 1945-1972, Archives Center, National Museum of American History

domain: library


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Philanthropist George Soros and UConn alumnus Gary Gladstein ’66 with his wife, Dr. Phyllis Gladstein, announced a $4 million gift to the UConn Human Rights Institute, the largest donation to the internationally renowned program. The gift, which requires the UConn Foundation to raise an additional $2 million in matching funds, would give the Institute a $6 […]
WNPR spots part of effort to double amount raised for scholarships over next five years. Jan. 27 – Serving as a physician for the VA Connecticut Healthcare System in West Haven since 1992, Dr. Lindsay Schine is about to gain statewide recognition as part of the UConn Foundation’s efforts to raise $150 million over the […]
Lab and conference room at the School of Pharmacy named for three donors who made gifts to support research and teaching Several longtime donors to the University of Connecticut are receiving a unique honor for their contributions to the School of Pharmacy. UConn’s Board of Trustees has unanimously approved the naming of two academic spaces […]
The Board of Directors of the UConn Foundation endorsed a five-year, $150 million fundraising initiative last week that will double the amount of financial support—including merit and need-based scholarships—that the Foundation raises for the benefit of the UConn student body.
Five-year plan will double money Foundation raises for scholarships and fellowships, ensure UConn attracts best and brightest STORRS—On Nov. 7, the Board of Directors of the UConn Foundation endorsed a five-year, $150 million fundraising initiative that will double the amount of financial support—including merit and need-based scholarships—that the Foundation raises for the benefit of the […]
Nearly 250 donors, student-athletes, coaches and administrators gathered inside Rome Ballroom in October for the UConn Athletics Annual Endowed Scholarship Dinner. Throughout the evening, which featured a social hour, dinner and speaking program, those in attendance heard about the importance of endowed scholarships on the lives of UConn’s student-athletes and the success of its programs.

domain: news


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Gender Neutral This term can be used to spell it out facilities that anyone may use aside from their sex ( ag e.g. gender basic restrooms). This term can be used to also describe someone who will not sign up for any socially built sex (often known as вЂњGender QueerвЂќ). Gender Non Conforming an individual who is, or perhaps is discerned to have sex traits which do not adapt to conventional or expectations that are societal.
Gender/Sexual Reassignment Surgery relates to a procedure that is surgical transition a person from a single biological intercourse to a different. This is combined with hormones treatment and emotional help. a вЂњtranssexualвЂќ individual must undergo many years of hormones and mental evaluation and reside while the вЂњoppositeвЂќ or вЂњdesiredвЂќ gender just before getting the surgery (see intersex).
Gender Role A societal expectation of just just how a person should work, think, and/or feel based upon an assigned sex in terms of societyвЂ™s binary biological intercourse system. Heterosexual An adjective utilized to explain individuals whoever enduring real, intimate and/or psychological attraction would be to folks of the sex that is opposite. Also right.
Homosexual (see Offensive Terms to Avoid) Outdated term that is clinical derogatory and offensive by numerous homosexual and lesbian individuals. The Associated Press, nyc circumstances and Washington Post restrict usage associated with term. Gay and/or lesbian accurately describe those people who are interested in folks of the exact same intercourse.
Homophobia concern with lesbians and homosexual guys. Prejudice is normally a far more description that is accurate of or antipathy toward LGBT individuals.
Intersex those who obviously (that is, without the medical interventions) develop main and/or additional sex faculties that don’t fit nicely into societyвЂ™s definitions of female or male. Numerous visibly intersex babies/children are surgically modified by health practitioners to produce their intercourse faculties conform to societal binary norm expectations. Intersex individuals are reasonably typical, although societyвЂ™s denial of these presence has permitted really room that is little intersex dilemmas become talked about publicly. Has changed вЂњhermaphrodite,вЂќ which can be inaccurate, outdated, problematic, and usually unpleasant, because it means вЂњhaving both sexesвЂќ and this just isn’t fundamentally real, as you can find at the very least 16 other ways to be intersex.
When you look at the full life often employed by communities of color to denote addition when you look at the LGBTQ communities.
Kinsey Scale Alfred Kinsey, a celebrated sociologist, described a range on a scale of 0 6 to spell it out the sort of libido within someone. 0 Entirely Heterosexual 6: Completely Homosexual. In their 1948 work intimate Behavior when you look at the Human Male. The Kinsey Scale can be utilized to dissect the bisexual community and explain the differences between intimate orientation and preference that is sexual.
Lesbian a lady whose enduring real, intimate and/or psychological attraction is to many other females. Some lesbians may choose to determine as homosexual (adj.) or as homosexual females.
LGBTQQIA An acronym utilized to mention to all the intimate minorities: вЂњLesbian, Gay/Gender Neutral/Gender Queer, Bisexual/Bigender, Transgender/Transvestite/Transsexual, Questioning/Queer, Intersex, and Allies/Androgynous/Asexual.вЂќ Life style (see Offensive Terms to Avoid) Inaccurate term employed by anti extremists that are gay denigrate lesbian, gay, bisexual and transgender everyday lives. As there isn’t any one lifestyle that is straight there is certainly no one lesbian, homosexual, bisexual or transgender lifestyle.
Guys Loving Men (MLM) Commonly used by communities of color to denote the attraction of males to guys.
Guys whom Have Intercourse with Guys males, including those that usually do not determine on their own as homosexual or bisexual, whom take part in intercourse along with other men (used in public places wellness contexts in order to avoid excluding males whom identify as heterosexual). Openly Gay Describes those who self determine as lesbian or arab live cam homosexual inside their individual, general public and/or lives that are professional. Additionally freely lesbian, freely bisexual, openly transgender.
Outing The work of publicly declaring (often according to rumor and/or speculation) or revealing another personвЂ™s sexual orientation or sex identification without that personвЂ™s permission. Considered inappropriate by way of a big part of the LGBT community. Pansexual not restricted in sexual choice pertaining to sex that is biological sex, or sex identity. Queer usually a pejorative term, queer was appropriated by some LGBT people to explain by themselves. But, it’s not universally accepted also inside the LGBT community and really should be prevented unless some body self identifies by doing this.
Questioning the entire process of considering or exploring oneвЂ™s orientation that is sexual sex identification.
Sexual Orientation The term that is scientifically accurate an individualвЂ™s enduring real, romantic and/or psychological attraction to people in the exact same and/or opposite sex, including lesbian, homosexual, bisexual and heterosexual (right) orientations. Prevent the term that is offensive choice,вЂќ which will be utilized to declare that being homosexual or lesbian is voluntary therefore вЂњcurable.вЂќ Sexual Behavior relates to an individualвЂ™s intimate activities or actions ( exactly just what an individual does intimately). Though often an individualвЂ™s intimate orientation is consistent with their intimate behavior, it’s not constantly the scenario.
Sexual Minority An all inclusive, politically oriented term talking about people who identify by having a minority intimate orientation, intercourse identification, or gender expression/gender identity.
Intimate choice (see Offensive Terms in order to avoid) This term identifies an individualвЂ™s option when it comes to attraction. Intimate choice is predicated on gender/sex, appearance (height, fat, competition, ethnicity), or connection that is emotional. You will need to observe that intimate choice denotes a вЂњchoiceвЂќ and it has a bad connotation whenever utilized to explain the population that is LGBTQ.
Right Pop tradition term utilized to individuals who identify being a heterosexual, meaning having an intimate, psychological, real and attraction that is relational people of the вЂњoppositeвЂќ gender/sex. The definition of вЂњstraightвЂќ frequently possesses connotation that is negative the LGBTQ population, as it recommended that non heterosexual people are вЂњcrookedвЂќ or вЂњunnaturalвЂќ.

domain: sociology


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Buying Inexpensive Majorca Genuine Estate
Have you at any time wished to go on a holiday in Tennessee but you can't simply because of financial factors? Do you believe that going on holiday is awfully costly? Nicely, you may want to think once more as there are ways on how you will be in a position to make your Tennessee holiday downturn proof. How? For starters, you've received to consider your accommodation.
Developers can usually release more land but they can never build more shoreline. Although some of them attempt to develop artificial canals in an attempt to produce much more waterfront land. It's costly to do and such qualities will by no means compare to one located straight on ocean frontage.
Are you a Snowbird? Do you have a Grafton Mill or 2nd home in las vegas? All Below One Roof provides all inclusive packages to provide preventive upkeep on your house while you are absent. They might also come and thoroughly clean your home prior to you arrive and after you depart, so that all you have to fret about is taking pleasure in your vacation in Vegas!
To discover the very best mortgage to fit you and your pocket, seek the advice of a certified mortgage advisor, but never be railroaded into paying fees, big or or else, till you know what you are obtaining for your cash. You would not be the initial person to pay a large fee on the promise of a hefty forthcoming mortgage, only to discover it never comes, and your charge is non-refundable.
With the assist of the web, you can effortlessly remain in touch with your home nation for family members, friends and any business or cash related actions that you need to attend to. You can also remain on top of the information and even watch your favored tv programmes and listen to your favorite radio station.
There are numerous different types of home loans but they all slip into one of two teams. Both a reimbursement mortgage or an interest only home loan. With a repayment mortgage, your month-to-month payments not only include the interest, but also gradually spend off the loan itself. With an curiosity more info only mortgage, as the name indicates, you are only paying the interest back again. Therefore, you will require to established aside additional monies, either a savings coverage, or an insurance coverage, to build up a lump sum, to pay off the home loan at the end of the phrase. That is your responsibility.
This is just a snippet of what you can find on the doorstep of your COSTA BLANCA Home. You will drop in adore with the beautiful scenery and tranquility of the location. The pleasant locals will be make you really feel at home.

domain: finance


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The difference between natural and purified CBD. CBD products can be used for different purposes depending on the composition. So they can be purchased in the form of dietary supplements, cosmetic products or as medicines.
The strength and type of effect depend on various factors, including whether it is natural CBD derived from plants or so-called purified or synthetic CBD. So what exactly is the difference between natural and purified CBD?
“Natural CBD” means that the active ingredient was obtained directly from the plant and that the natural ratio of the other contained cannabinoids in the final product has been preserved. Synthetic CBD, on the other hand, has an altered active ingredient content and, for example, generally contains only minor amounts of the psychoactive THC.
CBD is usually obtained by various extraction processes from commercial or industrial hemp. The products often have a CBD content of more than 4% and contain less than 0.2% THC. This THC limit is set by the legislation for over-the-counter CBD products.
However, the problem here is that it is hardly possible to breed hemp varieties that have such a high CBD content and at the same time a negligible THC content. It is therefore very difficult to obtain natural CBD that complies with the legal limits for THC. For this reason, methods have been developed to reduce the THC content of such naturally extracted extracts. With these methods, however, it may happen that the potentially healing effect of the product is partly lost.
For example, in the recent past, several scientists have begun studies on the mode of action of natural and purified CBD. For example, a research team from the Hebrew University of Jerusalem investigated the effect of the two different types of CBD on their suitability as pain and anti-inflammatory agents. Initially, experiments were performed on mice and later on humans, and the results showed that the differences can sometimes be serious.
The administration of purified CBD showed an increasing effect by increasing the dosage, but only up to a certain limit point. From a certain dose, the effect could not be increased by increased addition of the purified CBD.
On the contrary, sometimes even after this point, a reduction of the effect could be observed despite increasing the dose. The effect diagram was therefore bell-shaped because the effect increased to a limit point and then fell off again just as. The study was named ” Overcoming the Bell-Shaped Dose-Response of Cannabidiol by Using Cannabis Extract Enriched in Cannabidiol .”
To improve comparability, the scientists then used a natural CBD of the variety Avidekel to treat the same symptoms, which has a very high CBD content of 18% and a THC content of 1%. When increasing the dose administered, it could be observed that the magnitude of the effect was directly proportional to the increase in the dose.
No limit point was observed over 24 hours as with the administration of purified CBD. The researchers were thus able to show with this experiment that natural CBD is significantly better suited for the treatment of inflammatory diseases as synthetic or purified CBD. You suspect that this is because the natural CBD product includes the entire natural cannabinoid spectrum.
Thus, the researchers were able to demonstrate that contained in naturally extracted extracts of hemp plant substances that can influence the mode of action of CBD and improve its effect or strengthen. It is therefore spoken of so-called synergy between the respective cannabinoids.
Overall it can, therefore, be said that with natural CBD a higher dosage and thus a stronger effect of the respective product is possible. By contrast, the effect of purified or synthetic CBD can only be increased to a certain extent by an increase in the dose, after which the effect may even be retrograde. For conditions requiring a high dose of CBD, it is therefore advised to use products containing natural CBD from CBD-rich and low-THC cannabis strains.

domain: chemistry


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2 cups uncooked Lotus Foods Carnaroli Rice
1 teaspoon kosher salt
1 teaspoon grated fresh ginger
1/2 teaspoon minced garlic
1 cup seedless cucumber (cut into small diced pieces)
1/4 cup mined red onion (cut into small diced pieces)
1 tablespoon brown sesame seeds
1/2 cup unseasoned Japanese rice vinegar
3 tablespoons canola or other flavorless vegetable oil
1 tablespoons tamari or soy sauce
2 tablespoons toasted sesame oil
Combine the rice, 2 3/4 cups water, and the salt in a rice cooker and cook according to the manufacturer’s directions. Or combine 2 3/4 cups water, rice and the salt in a saucepan. Bring to a boil over high heat. Cover, reduce the heat and simmer for 15 – 20 minutes. Let the rice cool to room temperature.
For the dressing: Whisk the rice vinegar, oil, tamari, sesame oil, ginger, and garlic in a small bowl until blended.
Combine the cooled rice, cucumber, red onion, and sesame seeds in a large bowl. Add the dressing; toss gently until blended. Serve at room temperature.
Recipe from Lotus Foods website

domain: food


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Halloween Border Coloring
If you are making a collage art with small children it will be a good idea to view the pictures to make sure the images are kid safe. Second buy some card stock with a Halloween autumn or spooky theme. Use it as the background or paint a canvas stretcher board dark or midnight blue. You can also make it more ingenious by having your own or the kids drawing on the collage art. It will convey a touch of your personality. Third is find pictures again you could find several online. Many art collage designers use Victorian photos but you may use family pictures or cutouts from books and magazines. Excellent resources for photos are thrift shops and yard sales. Some graphic designers advertise collage sheets for download and printed or shipped in the mail. Pictures from Halloween greeting cards are also available in this format.
You can use a cardboard box in making a scary coffin. Also get a large-size cardboard piece and cut out the shape of a coffin for the opening/cover. Paint a red or white cross over the top of the coffin. You can imitate the sound of stepping over a mass of bones by drying bread in the oven and placing them under an area rug. Cut out stone hedges out of Styrofoam paint them gray and write R.I.P. over them with a marker. You can also write your names or guest s names for that spooky feeling. Make body parts by stuffing rubber/latex gloves with cotton and painting the opening red for that bloody effect. For a realistic touch to your home decor you can fill goblets with blood and display them in hallways and your dining area! This will enhance that vampire-in-coffin feel.
You can either give them a list of things to collect or have a treasure hunt that leads them from place to place looking for clues. 7. Halloween costumes can be expensive but if you get creative they don t have to be. Let the kids do some research and find what they d like to be then let them start working on creating their own costumes. They ll be so proud when they dress up for Halloween because they will have made the costume themselves. Well these are just a few Halloween games and activities that you might like to try this Halloween. Remember homemade is always the best and Halloween doesn t have to be expensive. Do a little bit of planning and the kids can enjoy making Halloween games decorations costumes cards and food.
Of course kids can also draw or design their own pictures as well and this can greatly help them explore their own creativity. One of the problems with a number of games and activities designed for kids is the fact that they are seemingly lacking in creativity and that does not provide much for the kids in terms of helping them to think analytically and creatively. Whoa! That statement seems like a huge stretch in terms of describing the value of printable Halloween bingo cards. Well if you look at the cards as mere paper cut outs then yes it is somewhat understandable how you could arrive at such a conclusion. However if you look at the underlying creativity beneath the design of the cards then the value of the cards becomes obvious. By exploring creativity in the arts and crafts realm youngsters get a break from "button pushing" electronic games and instead explore talents that they may not knew they had. Of course this can be the start of something much more expansive down the road.

domain: hobby


Welcome to Prestige Construction Company, your go-to destination for top-of-the-line boom trucks. When it comes to lifting and transporting heavy materials for construction projects, our boom trucks are the epitome of reliability, durability, and efficiency. With years of experience in the industry, we understand the importance of having the right equipment to get the job done efficiently and safely. Our collection of boom trucks is designed to cater to the diverse needs of construction companies, contractors, and more.
Why Choose Our Boom Trucks?
At Prestige Construction Company, we take pride in offering the best-in-class boom trucks that are built to exceed industry standards. Here's why our boom trucks stand out:
Durability and Strength
Our boom trucks are manufactured using high-quality materials and advanced engineering techniques to ensure remarkable durability and strength. These trucks are specifically designed to withstand the rigorous demands of construction projects, offering long-lasting performance even in harsh working conditions.
Wide Range of Capacities
We understand that every construction project comes with unique lifting and transportation requirements. That's why our boom truck collection includes a wide range of capacities, allowing you to choose the one that perfectly matches your needs. From small-scale residential projects to large-scale commercial ventures, we've got you covered.
Advanced Features and Technology
Our boom trucks are equipped with the latest technology and advanced features to ensure optimum functionality and safety. From state-of-the-art control systems to enhanced stability mechanisms, our trucks are designed to provide a seamless user experience while adhering to the highest safety standards.
Experienced and Skilled Operators
Prestige Construction Company takes pride in our team of experienced and skilled boom truck operators. Each operator is trained to handle our trucks with precision and efficiency, ensuring smooth operations and minimizing the risk of accidents. Our operators prioritize the safety of your crew and assets while delivering exceptional results.
The Benefits of Using Boom Trucks
Using boom trucks for your construction projects offers numerous benefits:
Boom trucks are designed to streamline the lifting and transportation process, allowing for more efficient project completion. With their ability to reach great heights and maneuver easily, they reduce the time and effort required to lift and move heavy materials, resulting in increased productivity.
With their advanced safety features and trained operators, boom trucks offer enhanced safety during lifting and transportation tasks. These trucks minimize the risk of accidents, protecting your crew and materials from potential harm. Safety is always a top priority for us, and we ensure that our boom trucks are equipped with the necessary safety measures.
Boom trucks are incredibly versatile, making them suitable for various construction projects. Whether you're working on a residential, commercial, or industrial site, our boom trucks can adapt to different environments and lift materials of various shapes and sizes. They offer the flexibility and versatility needed to tackle diverse construction challenges.
Increased Cost Savings
By utilizing boom trucks for your lifting and transportation needs, you can significantly reduce labor costs and time-consuming manual handling. The efficiency and productivity offered by these trucks translate into cost savings in the long run. Moreover, our reliable and durable boom trucks require minimal maintenance, further adding to your savings.
Contact Us Today
Don't compromise on the quality and reliability of your construction equipment. Choose Prestige Construction Company's boom trucks for your lifting and transportation needs. Our team is dedicated to providing exceptional customer service, tailored solutions, and reliable products. Contact us today to discuss your requirements and explore our range of boom trucks!
© 2022 Prestige Construction Company. All rights reserved.


Panasonic is a well-known brand of electronics and is known for its range of camera options. Apart from cameras Panasonic also manufactures wide range of televisions, mobile phones etc. Panasonic Company was earlier known as Matsushita electronics industrial co. ltd., which was later changed to Panasonic in 2008. Panasonic offers wide range of cameras and camcorders and one can choose them on the basis of their requirements and usage. They Panasonic lumix LX5 cameras are the new replacement to LX 3 which is a great camera in itself. These ranges of cameras are great for both the professional and for people who have a passion of photography.
Features of Panasonic Lumix DMC-LX5
The model Panasonic Lumix DMC- LX 5 is very similar to LX3 with some minor and better changes in the model. The good features of the camera include:
– Better lens with 3.8x zoom
– Larger photo cells with enhanced color saturation
– Faster signal processing
– Improved optical image stabilization system from Mega OIS to Power OIS
– Great picture quality
– Sharp pictures
– Great designs
– Amazing results on still photography
Lumix series advantages
The advantages of the Lumix series camera is the Leica brand lens used in the camera. Other advantages include the various in- built shoot modes. These include,
– Intelligent mode: This mode includes automatic adjustments by the camera itself.
– My color mode: This mode offers you a range of palette color options to choose from.
– Scene mode: More than 23 in built scene mode settings for specific scene.
– Manual mode: This is a manual setting mode, where the user takes charge and picks settings for taking pictures.
– Movie mode: Captures motion JPEG video at pixel resolution of 1280 x 720.
Panasonic Lumix Lx5 is certainly a great option for people who like to have great pictures with light weight camera models for the ease of operation. The various in built modes gives you a free hand to experiment and enhance the photography experiences. Overall, it is a great addition to the LX series of Panasonic cameras.


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There are numerous choices available. It takes a lot of time and effort to select the best one. So, in this article, we have a review of the top products. Each has a ton of fantastic functions that will make your life a little bit simpler. By doing this, you can be sure that you’re getting the best 1000 watt grow lights for your needs while saving the most money.
How we choose
We spent hundreds of hours researching various products to determine which of these 1000 watt grow lights exhibits the highest performance and functionality. To generate precise numbers, we collected data from various metrics. These products were evaluated using our rating metrics. Before making your purchase, you should consider the potential difficulty of the tasks you will use as one of these 1000 watt grow lights. Depending on your needs, one feature or function may be crucial to you while being useless to others. Because of this, we’ve compiled a list of the top products below so you can pick the one that best suits your requirements. We selected these 10 products using several research metrics, including:
- Brand value
- Consumer ratings, reviews & many more
10 Best 1000 watt grow lights on The Market
There are a lot of 1000 watt grow lights on the market, but not all of them are equal in terms of quality. If you’re looking to buy a new one, you’ll want to know what features to look for.
We’ve compiled this list to help you find the best 1000 watt grow lights for your needs. We’ve also included some helpful information about how each 1000 watt grow lights works and what it can do (or not do).
In this article, we will be looking at some of the best 1000 watt grow lights reviews. These are reviews that can help you decide which 1000 watt grow lights to invest in and which ones not to waste your money on.
- Full spectrum: the light include red,blue,yellow,white,and so on etc. which is similar to the sunshine,ideal for all kinds of indoor plants veg and flower at all growth stages.
- Most LED lights are rated at somewhere 50000 hours of use. For comparison, many other grow lights tend to last for around 20,000 hours before needing to be replaced.Protecting diodes are added to make sure one chip out, others still work.
- Perfectly help you to save the energy and improve the environment of plant growing. DOUBLE SWITCH- Veg and Bloom button have different function. Veg switch: It's blue led and white led. For seeding or young vegetative growth,you can use Veg switch only. Bloom switch: It's red led and white led.for flowering/blooming,you can use both Veg and Bloom switches.
- 【Warranty and Customer Service】24 monthes quality guarantee and 30 days refund
- New Upgrades: Compare with the traditional 1000 watt grow lamps, this new Dual-Chips 10w led lights is bigger, brighter and efficient, but consuming only 110 watts.
- NEW UPGRADES: Compare with the traditional 1000 watt grow lamps, this new Dual-Chips 10w led lights is bigger, brighter and efficient.
- FULL SPECTRUM LIGHT For INDOOR PLANTS: Our LED grow lights provides full spectrum lighting from 380 nm to 780 nm (including UV + IR) of natural light for plants needed of all growing stages from vegetables to flowers. Achieve greater yield while saving you on energy costs!
- VEG/BLOOM DOUBLE SWITCH -- This special switch design was made to provide proper light for plants in different growth stages , and gives your plants more better living environment.Perfectly help you to care plants and save you more time.
- DURABLE LED GROW LIGHT:Multiple high-speed mute fans and upgraded aluminum radiators enable the light bulb to work at 50°F to 60°F that is lower than other lamps. In a lower temperatures, your plant won’t be burned which could increase your lighting time and promote plant growth, Super long use time, so that you do not have to change the light frequently.
- WORRY-FREE WARRANTY: Plug and Play. No installation required. Product quality and friendly customer service are always our top priority. We offer worry-free 36-month warranty and professional guidance to help you and your plants grow better.
- VEG & BLOOM SWITCHES: Different bands of LEDs make up our true full spectrum light, which helps plants, vegetables and flower indoor growing at all stages.VEG for growing, BLOOM for seedling / flowering.
- LOW-PRICED & UPGRADE LED CHIPS: It is the perfect grow light for beginners since it is simple to use and affordable. With its newer technology, the new 216 Leds provides much brighter and improved efficiency. In fact, It is more efficient than the outdated 1000 watt grow lamps. As well, it offers the highest PAR/Lumen output per watt.
- OUTSTANDING COVERAGE: Twice effective coverage area than any Reflector Series lights, perfect for a 7.9' x 7.6' growing area at 25" height. LUYIMIN LED grow lights provides full spectrum lighting from 380 nm to 780 nm (including UV + IR) of natural light for plants needed of all growing stages from vegetables to flowers.
- TOP FULL SPECTRUM GROW LIGHTS: The proportion of the spectrum has been adjusted in order to provide more matching spectrum for plant growth.The light include red,blue,white,IR which can replace natural sunlight,IR chips can promote plant growth and defend insects and disease,ideal for all kinds of indoor plants veg and flower at all growth stages.
- 5 YEARS WARRANTY: Plus 90 days satisfaction or return guarantee. We are so confident in our products' quality control, if any question pls contact us, we will offer you professional guidance to help your plants grow better,Lifespan: 100,000 hours.
- ✅【Veg & Bloom Switch】: Through a wide plant growth testing, the Veg and Bloom switch, which designed to provide proper light for plants in different growth stages to greatly increase your harvest. Veg switch is the blue LED and white LED designed for seed or seedling growth; Bloom switch is the red LED and white LED designed for flowering/blooming; Both Veg and Bloom switches can for maximum per formance to plants.
- ✅【Energy-saving Technology】: Different from the traditional HPS, our LED plant grow lamp adopts a high-tech double chips, our 1000w grow light can replace the traditional HPS. Achieved the balance between efficient utilization and energy-saving. Effectively reduce light loss and ensure the utilization of light up to 90%. Our indoor grow lights can save a lot of electricity bill for you.
- ✅【Efficient Cooling System】: 1000W led grow lights are adopted 2 high-speed cooling fans and built-in aluminum heat-sink, both of them constitute a powerful cooling system which can dissipate the heat from the growing lamp inside to outside efficiently. Enable the light bulb to work at 50°F to 60°F. Your plant won’t be burned which could increase your lighting time and promote plant growth. Totally protect the led board and ensure the long service life.
- ✅【Daisy Chain Design】The led grow lamp with daisy chain design allows multiple greenhouse lights to connect in parallel at the same time. The included power cable serves a double purpose and can be either plugged into a standard outlet or into the daisy chain outlet of another grow lights. To ensure safety, not more than 5 lights together per chain. It's recommend that you connect 3 units, this is the safest way to use. Meet the light demand of large area plants.
- ✅【Full Spectrum】: New Upgraded 1000W led grow light should provide the proper spectrum of light for photosynthesis, which key to plant growth. We specialized design 54pcs RED light to ensure the yield will be increased up to 40%-60%. With this led grow lights, you can grow delicate tropicals that will bloom year-round, as well as letting you harvest easy-to-grow vegetables and herbs in the coldest winter day.
- High efficiency diode： the highest light output LED available at present, create the better canopy light penetration, get 40% higher yields with less energy compared with other red blue lights. In addition, most of the LED lights have a rated service life between 50000 and 100000 hours. In contrast, many other growth lights can only last for about 20000 hours.
- Blue,Red,Yellow, White, and IR (410-440, 660-665nm,3000-3500K, 5000-6500K and IR 740-760nm), infinite close to natural light, best for all plants all stages growing, rapid plant response from seed to flower and increase yield & crop quality
- No Fan ZERO Noise, large areas of solid aluminium heat sink, special protective covers for cables, waterproof LED board, high safety performance MEAN WELL Driver. 50% longer lifespan compare with other brand lights.
- New Upgrades: High Energy Efficiency with 2.7 umol/J, only consume 100w, but has same yield as 1000W BlurpleHQB led grow lights. Footprint is 2 x 2 ft
- CXHOME LED Grow Light provides 24 monthes quality guarantee and 30 days refund.If the goods you receive are damaged or defective, please contact us, you will get a new light for free.
Things to Consider When Buying 1000 watt grow lights
When it comes to buying 1000 watt grow lights, there are a few things that you should keep in mind. Not just any product will do, and not just any price is worth paying. The following tips will help you buy the right product at the right price.
- Is it worth it? The first thing you should do is decide whether it’s worth buying at all. Look at your budget and decide what you can afford. If the price is too high, then it probably isn’t worth it.
- Do I need this? Sometimes, when we see something new and exciting, we get carried away and buy something without thinking about whether or not we need it. If you have doubts about whether or not you need something, don’t buy it until you’ve had time to think about it and talk with someone else who can also give their opinion!
- Is there a better option out there? Another thing to consider is whether or not there are other options out there that might be better suited for your needs than the one that caught your eye initially. While the first thing may be pretty or flashy, there could be something else that would work just as well, if not better, at a lower cost, so don’t be afraid.
- Is there a warranty? If a product has a warranty, it’s made well enough to last for years. If not, then you can expect to either buy replacements or spend time fixing broken parts yourself.
Buying a product that doesn’t meet your needs can be frustrating and expensive. Before you buy, make sure you consider the following:
This is probably the most important factor when buying 1000 watt grow lights. The price of a product is usually determined by its quality and brand name, but it can also depend on other factors, such as supply and demand in the market. The higher the demand, the higher the price for an item.
This refers to how durable an item is and whether or not it will last long enough for your needs. Quality products are more expensive than those not made well because they are more durable and will last longer without needing maintenance or repairs.
Look at reviews from other customers to see how long the 1000 watt grow lights has lasted, especially if it’s something like 1000 watt grow lights that will often be used over time. Ask yourself whether it’s worth paying more for something durable rather than replacing it after just a few months or years of use because it broke down quickly or was cheaply made from low-quality materials that failed unexpectedly.
Check user reviews
A great way to get unbiased opinions about 1000 watt grow lights is by reading reviews from other consumers who have bought them. User reviews are an excellent source of information because they’re written by people who use the product, not just someone trying to sell it to you. They also provide useful information about what to expect from a particular product, so you know whether or not it’s worth buying.
Know what you want
You can’t expect to find 1000 watt grow lights just by looking randomly around. You need to know what you’re after before you start shopping. Make a list of features, functions, and price ranges that match your needs, then shop around until you find something that matches your criteria.

domain: agronomy


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May 30, 2013 | CUNY School of Law
Alum Lori Nessel (’92), director of the Center for Social Justice at Seton Hall Law School, is quoted in a recent Associated Press article examining the process of “medical repatriation,” which allows hospitals to deport undocumented immigrant patients, often while they are still unconscious. A report from the Center for Social Justice at Seton Hall Law School and the Health Justice Program at New York Lawyers for the Public interest, Discharge, Deportation, and Dangerous Journeys: A Study on the Practice of Medical Repatriation, concluded that at least 600 immigrants were removed over a five-year period. “The problem is it’s all taking place in this unregulated sort of a black hole … and there is no tracking,” said Nessel.
Read the report [pdf]


text: HomePoliticsWhy Do Certain Interracial Relationships Piss Off Liberals? ©2015 Black & Right March 20, 2013 Politics, Race 6 Comments A New First Couple in Sports: Woods and Vonn Should Black Women Care Whom Tiger Dates? Flashbacks: Do You Agree That 99.99% Of White Women Who Vote Republican Would Never Date A Black Man?, Republican VP Nominee’s College Sweetheart Is A Black Woman Kardashian sisters consistently hook up with black men, black professional athletes marry their white cheerleader sweeties, actors and musicians inter-racially hook up all the time and as long as they’re liberal, few seem to have a problem with it: many black women complain that the only good black men available are either gay or Republican. But when Republicans of different races mix, all hell breaks loose. Love is hard enough to find as it is so where’s this progressive tolerance we hear so much about? koala It pisses off the liberals because liberals are racisits. Richmedia Is Woods a conservative? The only thing that I know about Voon is I heard she skied once. Igor Yes, you could say that Vonn skis quite well…. ;P Igor Hypocrisy knows no bounds, Bob. It also requires lack of cogent thinking, which Progressives are famous for. Cognative dissonance is so much easier to do if you are ignorant, uninformed, and (dare I say it?!) stupid. Tallyman There’s good racism and there’s bad racism for Progressives, dependent upon whether it leads to the promised utopia. Consistency requires conscious mental intervention of the brain instead of trained emotional responses. For Liberals, it’s only “I emote therefore I am.” http://www.facebook.com/profile.php?id=1410598313 facebook-1410598313 The world is TOTALLY upside down Bob. People today attack the NRA, the oldest civil rights organization in the country. They were formed to protect freed slaves. Are the gun grabbing democrats racists? The NRA is one of the good guys, yet they have been vilified while the country has no recollection of the racist history of the democratic party. Why isn;t anyone addressing getting guns out of the hands of criminals?

domain: politics


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On inner streets and roads in the neighborhood, the Lekki Phase I Residents Association has outlawed commercial motorcycle operators, also known as Okada riders.
Mr. Yomi Idowu, Chairman of LERA, announced the ban on Thursday while speaking to journalists about security lapses in the area.
During the press conference, some people demonstrated against Okada riders’ activity in the region, holding placards with various messages.
Idowu urged the Lagos State Government to implement the law prohibiting Okada riders from operating within the state.
Governor Babajide Sanwo-Olu has banned Okada riders in Ikeja, Surulere, Eto-Osa, Lagos Mainland, Lagos Island, and Apapa, effective June 1.
“We in Lekki Phase I cannot continue to put our people’s lives in danger.” As a result, we are taking preventive actions by prohibiting Okada riders from riding with immediate effect. “On our roadways and inner streets, we choose to live and say no to ‘Okada,” he remarked.
He also urged the Ministry of Physical Planning and Urban Development and the New Towns Development Authority to remove hoodlums and miscreants from the community’s unfinished buildings.
The shooting of a sound engineer, David Imoh, in Lekki, was described by Idowu as “dastardly, animalistic, and mindless.”
According to intelligence inputs reaching us, following the raid on Okada riders and subsequent confiscation of their bikes by officers of the Lagos State Taskforce in Lekki Phase 1, the riders, believing the action was prompted by Lekki residents, are plotting to assault the locals,” he added.
“This isn’t the first time people in Lekki Phase I have been terrorized by motorbike riders.” Indeed, Okada has been a nuisance to the environment, with many people engaging in reckless behavior. The security situation in Lekki Phase I has obviously deteriorated.
“It is imperative that we all take a collective stance and formulate joint initiatives to avert a total exposure to imminent security threats to the lives and assets of our residents.”
Chief Emeka Nweze, a member of the Board of Trustees, noted that the Okada riders’ customers are mostly domestic workers and construction workers.
Chief Nweze has urged the state administration to guarantee that people who own underdeveloped properties begin to improve them or face having their assets confiscated.
“We can’t keep harboring criminals in such unfinished structures.” Residents are at risk, “he stated.


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Motor Trend is reporting Subaru's version of the Toyota FT-86 (aka Toyoburu) will be underpinned by a revised Legacy platform with an Impreza rear suspension. This should result in a comfortable chassis that isn't too soft when the roads turn twisty.
While the FT-86 will feature a naturally aspirated 2.0-liter boxer engine with approximately 200 hp (149 kW /203 PS), the Subaru model is expected to use an updated 2.0-liter turbo with 260 hp (194 kW / 264 PS). Both models will have a six-speed manual (from the Impreza), but an automatic transmission will likely be offered as well. Unfortunately, all-wheel drive doesn't seem like part of the package.
Styling is expected to be virtually identical to the Toyota FT-86, as all body panels will be shared, but the Subaru version will feature a unique grille, modified bumpers, and different wheels.
The car will likely go on sale in 2013 with a base price of $25,000+.


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August 9, 2022
Several pharmacologic interventions for insomnia disorder appear to be more effective than others, according to a new systematic review and meta-analysis. Some drugs are more reliable for short-term treatment, and some may produce substantial side effects.
Eszopiclone (Lunesta) and lemborexant (Dayvigo) had the most favorable profiles. Doxepin (Silenor), seltorexant, and zaleplon (Sonata) were tolerated well but lacked some data for efficacy and other important outcomes.
Overall, many licensed drugs (such as benzodiazepines, daridorexant [Quvivic], suvorexant [Belsomra], and trazodone [Oleptro]) were effective for acute treatment of insomnia but were associated with poor tolerability or lacked sufficient data on long-term outcomes.
In addition, melatonin, ramelteon (Rozerem), and other nonlicensed drugs didn't show overall material benefits.
"Clearly, the need to treat insomnia as effectively as possible is very important, as it can have knock-on effects for a patient's health, their home lives, and the wider health system," senior author Andrea Cipriani, MD, PhD, professor of psychiatry at the University of Oxford, United Kingdom, told Medscape Medical News.
"We hope our analysis will be of great help to clinicians seeking the most appropriate treatment for their patients," he said. "We looked at all information published and unpublished — in journals and in online registries — to achieve the most transparent and comprehensive picture of all the data available."
The study was published July 16 in The Lancet.
Systematic ReviewCipriani and colleagues conducted a systematic review and network meta-analysis to estimate the comparative effectiveness of pharmacologic interventions for the acute and long-term treatment of adults with insomnia disorder, excluding trials for secondary insomnia.
The systematic review included 170 randomized clinical trials, with 47,950 participants who were randomly assigned to one of 36 licensed or nonlicensed drugs or placebo. The network meta-analysis included 154 double-blind randomized controlled trials that encompassed 44,089 participants randomly assigned to 30 interventions or placebo. The primary outcomes were efficacy (defined as patient-reported sleep quality), all-cause discontinuation, tolerability, and safety (defined as adverse events such as dizziness, nausea, fatigue, headache, sedation, and drowsiness).
For acute treatment, benzodiazepines, doxylamine, eszopiclone, lemborexant, seltorexant, zolpidem, and zopiclone were more effective than placebo. In addition, benzodiazepines, eszopiclone, zolpidem, and zopiclone were more effective than melatonin, ramelteon, and zaleplon.
For long-term treatment, eszopiclone and lemborexant were more effective than placebo, and eszopiclone was more effective than ramelteon and zolpidem.
Intermediate-acting benzodiazepines, long-acting benzodiazepines, and eszopiclone had fewer discontinuations than ramelteon due to any cause. However, zopiclone and zolpidem had more dropouts than placebo because of adverse events, and zopiclone had more dropouts, compared with eszopiclone, daridorexant, and suvorexant.
Benzodiazepines Entail Risks In terms of the number of participants with side effects at the study endpoint, benzodiazepines, eszopiclone, zolpidem, and zopiclone were worse than placebo, doxepin, seltorexant, and zaleplon. Zopiclone also had more than lemborexant, melatonin, ramelteon, and suvorexant.
Generally, eszopiclone and lemborexant had the best efficacy, acceptability, and tolerability profiles, though eszopiclone was associated with adverse events such as dizziness and nausea. The safety data for lemborexant were inconclusive but showed a higher risk for headaches. Overall, there was insufficient evidence to support the prescription of benzodiazepines and zolpidem for long-term treatment, particularly since benzodiazepines entail risks for tolerance, dependence, and withdrawal effects.
"This study of pharmacologic treatments is not a recommendation that drugs should always be used as the first line of support to treat insomnia, not least because some of them can have serious side effects," said Cipriani. "However, our research shows that some of these drugs can also be effective and should be used in clinical practice when appropriate. For example, where treatments such as improved sleep hygiene and cognitive behavioral therapy have not worked, or where a patient wants to consider taking medication as part of their treatment."
The study authors noted that more recently developed drugs target novel pharmacologic mechanisms through the orexin neurotransmitter system. Lemborexant appeared to be the most effective orexin antagonist for short-term and long-term treatment, while seltorexant and suvorexant had better tolerability. Daridorexant didn't show an overall material benefit. Future research with more selective targeting of the pathway and orexin receptors could lead to better pharmacologic treatments for insomnia, they concluded.
The research team also noted the potential limitations of a systematic review and meta-analysis, particularly because patients tend to have problems with long-term interventions for insomnia. In this review, only eight studies looked at the long-term effects.
"Not a Unitary Presentation""Insomnia disorder is a highly prevalent condition with a significant amount of morbidity, and no one treatment suits all or is effective for everybody. Identifying a range of treatments that tend to be more effective is important for those who suffer chronically," Jack Edinger, PhD, an insomnia specialist and professor of sleep medicine at National Jewish Health, Denver, Colorado, told Medscape Medical News.
"The results aren't overly surprising in the sense that the usual suspects are more effective," he said. "These data don't conflict with what I hear incidentally from patients, and they also gel pretty well with the individual clinical trials I've read over the years."
Edinger, who wasn't involved with this study, has researched the effects of lemborexant, particularly among older adults with insomnia. He noted the importance of considering a patient's factors related to sleep quality, such as total sleep time, sleep onset, and sleep maintenance. For instance, some drugs may appear effective but only increase sleep time by 20 minutes per night, whereas others increase sleep time by 1 hour per night, he said.
"Since insomnia is not a unitary presentation, it's important to know what particular insomnia pattern you're trying to address," he said. "But overall, I'm glad this study does demonstrate that many of these tested drugs work better than what people may resort to with nonlicensed, over-the-counter options."
The study was funded by the UK National Institute for Health Research (NIHR) Oxford Health Biomedical Research Centre. Cipriani is supported by the NIHR Oxford Cognitive Health Clinical Research Facility and is the chief and principal investigator of two trials about seltorexant for depression, sponsored by Janssen. Edinger has received support from Eisai, which makes lemborexant.
*Lancet. Published online July 16, 2022. Full text

domain: psychology


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As per reports, Walt Disney Co’s (DIS) cruise line has announced mandatory Covid-19 vaccination proof of all passengers above 12 years of age, traveling from Florida to the Bahamas as COVID-19 Delta variant cases across the United States surge. Travelers below the age of 12 will need a negative COVID-19 test, the cruise operator informed. Disney also plans to cancel the “Disney Fantasy” sailing on Sept. 4.
Disney’s cruise line earlier did not insist on vaccinations, but the change comes after the U.S. health regulator asked people to avoid cruises irrespective of vaccination status, as infections rise. Also, the Bahamas, which is a major hub for cruises would not allow those ships to dock in the country unless all passengers 12 years of age and above provide vaccination proof.
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domain: travel