Crisis Settings Research Articles

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Abstract The application of machine translation (MT) in crisis settings is of increasing interest to humanitarian practitioners. We collaborated with industry and non-profit partners: (1) to develop and test the utility of an MT system trained specifically on crisis-related content in an under-resourced language combination (French-to-Swahili); and (2) to evaluate the extent to which speakers of both French and Swahili without post-editing experience could be mobilized to post-edit the output of this system effectively. Our small study carried out in Kenya found that our system performed well, provided useful output, and was positively evaluated by inexperienced post-editors. We use the study to discuss the feasibility of MT use in crisis settings for low-resource language combinations and make recommendations on data selection and domain consideration for future crisis-related MT development.

The dual crisis in Irish foreign policy: the economic crash and Brexit in a volatile European landscape

ABSTRACTThis article considers the impact of the 2008–10 financial crisis and the UK’s 2016 Brexit decision as a ‘dual crisis’ which impacted significantly on Irish foreign policy over the past decade. It argues that though Ireland’s foreign policy has remained remarkably consistent over time, the ‘dual crisis’ placed considerable pressure on state capacity and institutional resources. Ireland’s financial implosion carried with it potentially catastrophic consequences for the Eurozone and thus successive governments placed a particular priority on restoring Ireland’s tarnished reputation within the European Union. At the same time, Irish foreign policy was ‘rebooted’ to take on a more muscular promotion of Irish economic interests across the globe. Brexit constituted an existential threat to the island of Ireland, and, in particular the peace process marked by the 1998 Good Friday Agreement. The Brexit crisis set in train a determined effort by Irish policy-makers to both confirm the EU as Ireland’s ‘geopolitical centre of gravity’ and re-position the country within the Union, as the need for new allies and coalition partners became evident following the United Kingdom’s planned departure.

White Paper: How Malaysian Banks can Elevate B40 and MSME Lending

The B40 (Bottom 40% of Household Income) and MSME (Micro Small Medium Enterprise) are a critical component of the Malaysian economy and financial system. They are supported by a complex financial market ecosystem. MSMEs tend to lack financial market and technological sophistication and demand for external financing is driven by mature firms typically older than 5 years. Younger firms rely on personal savings and informal financing networks. There are opportunities in the domestic market for lenders to overcome known supply-side impediments. Malaysia’s situation is not unique. Internationally, while shifting demand and supply side impediments affect MSME access to finance, credit supply side factors dominate. Since most MSMEs are family owned firms, agency considerations may also underpin the preference for external financing by informal or private lenders. However, in the post Global Finance Crisis setting, supply-side impediments have provided the funding opportunity for alternative non-bank financial intermediaries. In the European Union, which has the benefit of a single currency, the alternative finance market is growing. Importantly, participation is characterized by younger and more financial literate and technology savvy borrowers. In Malaysia, well known demand and supply-side impediments along with poor technical infrastructure and financial literacy, especially in remote and agriculturally based areas, limit what is easily achieved in terms of expanding the B40 and MSME loan portfolio. Option-like risk management products could also be made available to reduce earnings volatility and improve credit quality, especially for MSMEs, although these will need to be designed (in the case of Malaysia) to be shariah compliant. Demand side improvements could focus on improving the bank-customer relationship with engagement at the early business stage, while supply side improvements could focus on alternate methods of credit scoring and more granular loan segmentation, especially for urban-based B40 borrowers. Nonetheless, there is still scope for innovative financing solutions for loan book growth using (a) partnerships with digital data providers and Fintech operations; (b) underwriting lending services directly by government; and (c) indirectly through the reevaluation of current regulatory capital requirements that further support B40 and MSME lending. Also, a more activist banking agenda including community outreach could form the centerpiece of any new lending strategy to support a financially inclusive society.

Rapid Forecasting of Cholera Risk in Mozambique: Translational Challenges and Opportunities.

Disasters, such as cyclones, create conditions that increase the risk of infectious disease outbreaks. Epidemic forecasts can be valuable for targeting highest risk populations before an outbreak. The two main barriers to routine use of real-time forecasts include scientific and operational challenges. First, accuracy may be limited by availability of data and the uncertainty associated with the inherently stochastic processes that determine when and where outbreaks happen and spread. Second, even if data are available, the appropriate channels of communication may prevent their use for decision making.In April 2019, only six weeks after Cyclone Idai devastated Mozambique's central region and sparked a cholera outbreak, Cyclone Kenneth severely damaged northern areas of the country. By June 10, a total of 267 cases of cholera were confirmed, sparking a vaccination campaign. Prior to Kenneth's landfall, a team of academic researchers, humanitarian responders, and health agencies developed a simple model to forecast areas at highest risk of a cholera outbreak. The model created risk indices for each district using combinations of four metrics: (1) flooding data; (2) previous annual cholera incidence; (3) sensitivity of previous outbreaks to the El Niño-Southern Oscillation cycle; and (4) a diffusion (gravity) model to simulate movement of infected travelers. As information on cases became available, the risk model was continuously updated. A web-based tool was produced, which identified highest risk populations prior to the cyclone and the districts at-risk following the start of the outbreak.The model prior to Kenneth's arrival using the metrics of previous incidence, projected flood, and El Niño sensitivity accurately predicted areas at highest risk for cholera. Despite this success, not all data were available at the scale at which the vaccination campaign took place, limiting the model's utility, and the extent to which the forecasts were used remains unclear. Here, the science behind these forecasts and the organizational structure of this collaborative effort are discussed. The barriers to the routine use of forecasts in crisis settings are highlighted, as well as the potential for flexible teams to rapidly produce actionable insights for decision making using simple modeling tools, both before and during an outbreak.

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers.

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health-related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.

Who Wants to Talk About Refugees and Why? Foreign Interventions in German Elections

We use this the crisis set off by the arrival of asylum-seekers in Germany to test a theory of the use of propaganda as a strategy by a non-democratic state against a democratic state. We argue that a non-democracy on a collision course with a democracy will use propaganda discourse to punish recalcitrant elite, and will do so especially near elections while promoting frames that weaken the opponent’s institutions. We test these propositions on a corpus of half a million publications, covering Kremlin-backed media channels broadcasting in German, and German media. We find that Kremlin-backed channels are more likely to publish refugee stories near elections in Germany and that they push conspiracy theories at the expense of discussing economic or crime-related aspects of immigration. Our work has implications for the rise of propaganda discourse in Europe and beyond, and for democratic politics under foreign autocratic pressure.

THE JEWISH SALAD BOWL WITHIN THE AMERICAN MELTING POT: A LITERARY CONTEMPLATION

Human history has always been characterized by repeated cycles of crisis and transitional periods bringing about transformation in various aspects of people’s coexistence and interaction with each other be it on the individual, ethnic, national, or even the international level. Currently, we have become eyewitnesses of what can be called the modern times crusades and exodus. The present free movement of people imposed by the globalization trend in contemporary society and particularly the new wave of migration with its relevant migrant crisis set in motion by numerous armed conflicts in the Middle East, will undoubtedly establish new relations among them, among ethnicities, among groups of different religious affiliation and even between migrants and host countries. In the course of these historical transitional periods, the concerned entities have always tried to define and explain such human relations and interactions that can vary from assimilation to multiculturalism. The two prevailing metaphors used to give a definition to the new forms of language, customs and cultural coexistence are those related to the notions of melting pot and salad bowl, which will be contemplated over with literary reference to Grace Paley’s “The Loudest Voice” and Cynthia Ozick’s “Envy; or Yiddish in America”. In both these writings, the need to transcend alienation, as well as the preoccupation to express belongingness in some naturalistic American premises, will hint at a relevant, analogous strive for identification to that of the migrants roaming the streets of Western Europe in search of a peaceful place to dwell and cohabitate with the host country and the implied culture.

059 Takotsubo cardiomyopathy and myasthenic crises: a case series

IntroductionTakotsubo cardiomyopathy (TCM) is an acute, reversible cardiomyopathy that can mimic acute coronary syndrome.1 It is characterised by left ventricular dysfunction, electrocardiogram (ECG) changes and transient apical ballooning in the absence of significant coronary artery disease.1 It is usually triggered by acute stress with catecholamine surge but the exact pathogenesis is not known.1 Takotsubo cardiomyopathy has been described in patients with myasthenic crisis. We present the first and largest case series of four patients with TCM in the setting of myasthenic crisis and discuss possible causes.MethodsTwo patients from each tertiary neurologic centre were identified by their treating neurologist for inclusion in the series. We performed a review of their case notes with respect to history, examination, investigations and management. A brief literature review was also completed.ResultsThe mean age was 78 with a 1:1 female to male ratio. Three of the patients were newly diagnosed with myasthenia gravis (MG) at the time of their TCM. All patients were AChRab positive. One patient had a previous thymectomy but the others had no evidence of thymoma.On review of the literature most cases of TCM in myasthenic crisis occurred in older females. Abnormalities of the ECG were universal. Most cases did not have a thymoma or history of thymectomy.ConclusionTakotsubo cardiomyopathy may be easily overlooked in those presenting with myasthenic crises as they share overlapping clinical features. Rigorous attention to the cardiac status of these patients, especially the ECG, may help to avoid missing this important diagnosis.ReferenceAkashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008;118:2754–2762.

Contagious Runs in Money Market Funds and the Impact of a Government Guarantee

Despite a vast theoretical literature on contagious behavior of investors, little is known about its empirical evidence in a real financial crisis setting. This paper examines evidence for contagious runs in money market funds during the 2008 financial crisis, drawing on a rich data set tracking U.S. money market funds’ daily flows and their enrollment statuses in the Treasury Department’s Temporary Guarantee Program (TGP). Evaluating the positive externality effect from a peer fund’s enrollment in the TGP on non-enrolled funds, we show that panic-driven runs were contagious across funds. We find that funds’ stability due to their enrollment in the guarantee program spilled over and enhanced daily flows to a non-enrolled fund by $1.8 million (compared to already-enrolled funds). Moreover, we find that retail investors were less likely than institutional investors to return to prime money market funds even after enrollment in the guarantee program, implying that the latter benefited more from the government backstop. Results are germane to policies seeking to rebuild investor confidence in times of financial crisis and reduce the chance of future contagion in this industry.

Assessment of disease specific immune responses in enteric diseases using dried blood spot (DBS).

BackgroundBlood collection, transportation and storage remain a problem in countries where infrastructure, laboratory facilities and skilled manpower are scarce. This limits evaluation of immune responses in natural infections and vaccination in field studies. We developed methods to measure antigen specific antibody responses using dried blood spot (DBS) in cholera, ETEC and typhoid fever patients as well as recipients of oral cholera vaccine (OCV).Methodology/Principle findingsWe processed heparinized blood for preparing DBS and plasma specimens from patients with, cholera, ETEC and typhoid as well as OCV recipients. We optimized the conventional vibriocidal method to measure vibriocidal antibody response in DBS eluates. We measured responses in DBS samples and plasma (range of titer of 5 to 10240). Vibriocidal titer showed strong agreement between DBS eluates and plasma in cholera patients (ICC = 0.9) and in OCV recipients (ICC = 0.8) using the Bland-Altman analysis and a positive correlation was seen (r = 0.7, p = 0.02 and r = 0.6, p = 0.006, respectively). We observed a strong agreement of lipopolysaccharide (LPS) and cholera toxin B (CTB)-specific antibody responses between DBS eluates and plasma in cholera patients and OCV recipients. We also found agreement of heat labile toxin B (LTB) and membrane protein (MP)-specific antibody responses in DBS eluates and plasma specimen of ETEC and typhoid patients respectively.ConclusionOur results demonstrate that dried blood specimens can be used as an alternate method for preservation of samples to measure antibody responses in enteric diseases and vaccine trials and can be applied to assessment of responses in humanitarian crisis and other adverse field settings.

Preventing excess narcotic prescriptions in MIS urologic oncology discharges (PENN): A prospective cohort quality improvement initiative.

6502 Background: In the setting of the national opioid crisis, there is increasing interest in non-narcotic pain strategies, particularly for oncology patients. Robotic urologic surgeries for cancer have been shown to result in less pain than open approaches. We hypothesized that the majority of these patients could be safely discharged with adequate analgesia without opioids. Methods: This prospective cohort study aimed to reduce narcotics prescribed at discharge after robotic radical prostatectomy (RARP), robotic radical nephrectomy (RARN) and robotic partial nephrectomy (RAPN). Prior to 9/2018, 100% of patients were discharged on varying amounts of oxycodone (range: 75-337.5 oral morphine milligram equivalents [MME]). We implemented a standard non-opioid analgesia pathway with escalation options across the continuum of care. Patients received gabapentin 300 mg and acetaminophen 975 mg once PO pre-operatively, as well as gabapentin 300 mg every 8 hours, acetaminophen 975 mg every 8 hours PO, and ketorolac 15 mg every 6 hours IV post-operatively. If complaining of persistent pain despite the standing regimen, patients were given 50 mg or 100 mg of tramadol every 6 hours as needed for pain level 5-7 or 8-10 on the visual analog scale, respectively. If requiring further escalation, patients were given 5 or 10 mg of oxycodone every 6 hours as needed on the aforementioned scale. Regardless of escalation status, all patients were discharged on the standing non-narcotic protocol. If escalated, ten pills of tramadol 50 mg or oxycodone 5 mg were prescribed accordingly. Results: Our cohort (n = 170) consisted of patients undergoing RARP (n = 87), RARN (n = 25), RAPN (n = 58) between 9/1/2018-1/9/2019. Overall, 67.7% were discharged without opioids, 24.4% with ten pills of tramadol 50 mg (50 MME) and 8.2% with ten pills of oxycodone 5 mg (75 MME). On multivariate analysis, older age (OR: 0.961, 95% CI: 0.923-0.995, p = 0.026) was associated with lower odds of needing opioids at discharge. There was no difference in postoperative telephone encounters between those discharged with or without opioids. Conclusions: The majority of robotic surgery patients do not require opioids upon discharge. An escalation protocol allows for a patient centered approach to reduce narcotic prescribing while still addressing cancer and surgical pain.

Newborn and Child Health Care in Humanitarian Crisis Settings: Piloting of Training Package for Primary Health Care Workers in Rural Nepal

Introduction:The community-based integrated management of newborn and childhood illness (CBIMNCI) training package has been widely used throughout Nepal. Adding a component of disaster response and management to this program would greatly impact the community, and could improve the knowledge and skills of community workers for the management of children during a disaster.Aim:Describe the development and implementation of a community-based training for children in disasters.Methods:Using expertise from emergency and pediatric emergency physicians, pediatricians, and psychiatrists, we developed a two-day training and facilitator manual covering topics such as trauma, resuscitation, burn, drowning, disaster, nutrition, and care of the newborn. The information and manuals were presented to the Nepal Division of Child Health for approval. Four pilot trainings were conducted in Bardia and Bardibas in Nepal in September 2017, including knowledge and skill-based sessions. Knowledge was tested pre- and post-training using multiple choice questions (MCQ) and self-reflections. Skills were evaluated by direct observation and marked using a Likert scale. Confidence was assessed using a confidence matrix before and after the course. Overall feedback was taken at the end of the session.Results:Of 82 participants, 74 participants from four trainings were included for analysis. Post-test Cronbach’s alpha for MCQ was 0.82 and the confidence matrix was 0.86. Mean score for the pre-test MCQ was 6.12 (SD 2.22) compared to the post-test mean of 10.97 (SD 2.97), which was a statistically significant improvement (p<0.05). Trainees reported that the trauma teaching was helpful. They felt that it improved confidence regarding trauma and disasters.Discussion:Adding this training to current CBIMNCI can be an effective tool to reach out to primary health care workers, and provide further knowledge and skills on care of children during a disaster or humanitarian crisis.

The Syrian refugee crisis: how local governments and NGOs manage their image via social media.

This study, based on situational crisis communication theory and set in the context of the Syrian refugee crisis, seeks first to conduct a comparative analysis of the management of online citizen engagement by local governments and non-governmental organisations (NGOs). Second, it aims to examine the relationship between certain factors pertaining to the types of responses submitted by citizens via the social media of the aforementioned actors. The sample is composed of several Spanish local governments and NGOs belonging to Red de Municipios de Acogida de Refugiados (Local Government Network for Refugee Allocation). The main findings are that NGOs' online engagement with citizens is more than that of local governments. Notably, NGOs are much more active on their Facebook pages than are local governments. The two actors converge, though, in terms of disseminating instructive information and paying less attention to 'basic crisis response options'. Moreover, the factors 'content type', 'reputation', and 'woman' affect the type of response messages sent by citizens.

Collaborative Public Health Management of Ebola in Africa

This essay considers the management of infectious disease through the prism of recent Ebola epidemics on the African continent. A review of country experiences suggests that securing working relationships among multiple actors within a global infrastructure of collaborative health governance offers a productive means for redressing viral spread. It is further argued that as various domains and sectors of the international system become more tightly interlaced to face common health threats, the ability to grow what Galtung referred to as “positive peace” increases. In this context, positive peace is conceptualized as bonds of support emerging from crisis settings that expand politically, socially and economically beyond disease events. Ultimately these bonds chasten a variety of forms of violence. This is opposed to “negative peace,” which reflects an absence of personal violence. The recent history of Ebola in Africa offers observers the opportunity to explore these themes in greater detail, and provides evidence of efforts to build infrastructure that can create more peaceful, mutually beneficial relationships on the common ground of pursuing public health. It also displays how direct human aggression rooted in long standing structural and cultural chains of violence can interrupt, impede and even destroy such efforts, ultimately leading to the possible letting loose of an illness that could reach transnational and even pandemic proportions.

The Increasing Burden of Psychiatric Emergencies: A Call to Action.

* Abbreviation: ED — : emergency department Kalb et al1’s article “Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US” is a crucial national perspective on the increasing burden of pediatric and young adult psychiatric emergencies, which has continued to rise above and beyond previous numbers reported in the National Hospital Ambulatory Medical Care Survey.2,3 A national perspective is vital because most emergency care for children in this country occurs in emergency departments (EDs) with small pediatric volumes and limited pediatric resources.4 Kalb et al1’s work contributes additional information that adolescents and young adults, especially from multiracial populations or people of color, account for the most significant increase. With suicide as the second leading cause of death for youth in the age group of 10 to 19 years, EDs are a critical link to screening, risk identification, and care. Lack of access to mental health services, and the role of EDs as de facto mental health crisis settings, has led to the 2.5-fold increase in suicidal chief complaints. Compounding this is a significant increase in the proportion … Address correspondence to Thomas H. Chun, MD, MPH, Pediatric Emergency Medicine, Rhode Island Hospital, Claverick 246, 593 Eddy St, Providence, RI 02903. E-mail: thomas_chun{at}brown.edu

Utilization of modern contraceptives and predictors among women in Shimelba refugee camp, Northern Ethiopia.

Women living in refugee camps, in addition to the common hardships, such as drought, and famine, are also prone to another peculiar problem: an unintended pregnancy. The impact of unintended pregnancy is so severe that the rate of women who die or suffer an injury while giving birth in crisis settings is almost double the world average death rate. Thus, this study was aimed to investigate the utilization of modern contraceptive and associated factors among women in the reproductive age group in Shimelba refugee camp, Northern Ethiopia. A community-based cross-sectional study was employed and 329 study subjects were selected using simple random sampling technique with a face-to-face interview. The prevalence of using modern contraceptive was 47.7% and the study showed that being older [AOR = 0.017, 95%CI: 0.001, 0.467], being single [AOR = 0.17, 95%CI:0.031,0.914], being unemployed [AOR = 0.21, 95% CI:0.001,0.392], having no partner support [AOR = 0.006, 95% CI:0.001,0.044], and inconvenient service site AOR = 0.089,95% CI:0.013, 0.595] were factors that contributed to women not using modern contraceptive methods. Receipt of counseling on family planning utilization was more likely to helps women to use it [AOR = 3.37, 95% CI: 1.1095, 10.236]. Our study concluded that the current prevalence rate of contraceptive use is fairly good. However, much effort has to be made to improve this result. The situations in refugee can exacerbate the existing barriers to the use of contraceptives. Given its grave consequence on the livelihood of women, the contraceptive issue should be given due emphasis using several techniques including education to expand the awareness on modern contraceptive so as to augment access to family planning.

How to improve organisational staff support? Suggestions from humanitarian workers in South Sudan

Humanitarian workers experience high symptom burdens of common mental health problems. This requires action from the organisations they are employed with. However, many studies have documented continuing weaknesses in organisational staff support, as well as disparities in access to the services for national and international staff. Systematic data capturing suggestions from humanitarian workers on how to tackle this situation within a specific crisis setting is rarely available. This study addresses this gap through qualitative content analysis of the suggestions from the 210 humanitarian workers based in South Sudan collected through an online survey in 2017. Five major themes emerged regarding proposed improvements: ‘Competitive benefit and salary packages’; ‘internal work climate and organisational culture’; ‘equality within and between organisations’; ‘skill enhancement and personal development’ and ‘physical safety and security’. For both national and international staff, improved access to psychosocial support services was the most frequent proposal. Apart from this suggestion, their top priorities for improvement of staff support differed greatly. National staff emphasised improvements related to training and greater equality between employees. International staff emphasised improvements related to time off and team cohesion. Findings provide a clear case for organisations to assess their services and offer a potential framework to inform future interventions that better address the priorities of the humanitarian community as a whole. Key implications for practice Organisations need to ensure staff have adequate access to psychosocial support services National and international staff have different priorities regarding staff support and organisations need to reflect these in their provision of services A unified understanding of staff support is required to manage expectations of staff and hold organisations accountable.

Momentum Trading with the ℓ1‐Filter: Are the Markets Efficient?*

AbstractThis paper explores the possibility of generating consistent momentum profits by trading on nine major indices across the globe using the ℓ1‐filter. This methodology penalizes slope reversion of the filtered trend and identifies piecewise linear trends in the asset prices. We find the buy strategy to offer considerably higher momentum returns compared to the sell strategy. Our strategy beats the buy‐and‐hold (BH) strategy on all fronts and, thus, highlights the inefficiencies in financial markets in recent years (2000–2016). Comparing the momentum profits across a set of advanced economies (AEs) and emerging market economies (EMEs), we find that the developed and efficient financial markets of the AEs provide lower opportunities for momentum profits. The momentum profits are more than double in the EMEs as compared to the AEs. Highlighting the instability of the momentum strategy in different market states by using the global financial crisis (GFC) as a turning point, we further find that considerable opportunity exists for momentum strategies in the bullish runs that precede the crisis, as happened before the GFC. However, the momentum profits reduce significantly as the crisis sets in, increasing the degree of market uncertainty, fear, and risk‐aversiveness.

What influenced provision of non-communicable disease healthcare in the Syrian conflict, from policy to implementation? A qualitative study

BackgroundThere has been increasing focus on tackling the growing burden of non-communicable diseases (NCD) in crisis settings. The complex and protracted crisis in Syria is unfolding against a background of increasing NCD burden. This study investigated factors influencing implementation of NCD healthcare in Syria.MethodsThis is a qualitative study, whereby semi-structured interviews were conducted with fourteen humanitarian health staff working on NCD healthcare in Syria.ResultsChallenges to NCD care implementation were reflected at several stages, from planning services through to healthcare delivery. There was a lack of information on unmet population need; little consensus among humanitarian actors regarding an appropriate health service package; and no clear approach for prioritising public health interventions. The main challenges to service delivery identified by participants were conflict-related insecurity and disruption to infrastructure, hampering continuity of chronic illness care. Collaboration was a key factor which influenced implementation at all stages.ConclusionsThe historical context, the conflict situation, and the characteristics of health actors and their relationships, all impacted provision of NCD care. These factors influenced each other, so that the social views and values (of individuals and organisations), as well as politics and relationships, interacted with the physical environment and security situation. Infrastructure damage has implications for wider healthcare across Syria, and NCD care requires an innovative approach to improve continuity of care. There is a need for a transparent approach to resource allocation, which may be generalisable to the wider humanitarian health sector.

Takotsubo Cardiomyopathy Mimicking Myocardial Infarction in a Man with Myasthenic Crisis: A Case Report and Literature Review.

Takotsubo Cardiomyopathy is a syndrome characterized by transient and reversible regional myocardial dysfunction in the absence of obstructive coronary artery disease classically resulting in ventricular apical ballooning. It has a strong female predominance with onset generally in seventh decade of life, with hypothesized pathophysiology related to excess of catecholaminergic stimulation, particularly during episodes of physical or emotional stress. Takotsubo cardiomyopathy has been previously reported during myasthenic crisis, the acute deterioration of myasthenia gravis typically involving respiratory failure that is also associated with physical or emotional stress. We present the case of an atypically young male patient with classical takotsubo cardiomyopathy in the setting of myasthenic crisis after thymectomy initially concerning for ST segment elevation myocardial infarction, and a review of the literature of takotsubo cardiomyopathy in myasthenic crisis.