High-stress Situations Research Articles

Why the Utilization of Ready-to-Administer Syringes During High-Stress Situations Is More Important Than Ever.

The COVID-19 pandemic has led to a high-stress environment causing a significant impact on frontline workers, including pharmacists and nurses. In addition to the increased workload, scarcity of resources, and emotional challenges, the frontline health care workers are required to wear additional personal protective equipment that can further limit their range of movement and decrease efficiency. The potential for errors can increase in these types of high-stress situations. One way to reduce the risk of errors is to use manufacturer-prepared, ready-to-administer (RTA) prefilled syringes, when appropriate. The use of RTA prefilled syringes is supported by literature evidence, recommendations, and guidelines from various professional organizations and societies.

Severe Burnout and Poor Mental Health Among Healthcare Workers 6 Months After COVID-19 Pandemic Declaration: What Can We Learn for Future Emergencies?

The aim of this study was to examine the predictors associated with severe burnout and poor mental health among healthcare workers during the COVID-19 pandemic as a learning opportunity for future emergent situations. Modifiable predictors of mental health need to be further examined and quantified to prioritize human resource support in organizations as healthcare workers confront stressful situations. A cross-sectional survey was conducted among 271 healthcare workers from September 8 to October 10, 2020. Approximately one-third reported severe burnout, as well as moderate/severe anxiety and depression. Feeling protected working with COVID-19 patients, high family functioning, and spirituality were associated with 2- to 4-fold lower odds of severe burnout. Satisfaction with the organization's communications predicted 2-fold lower odds of anxiety, whereas high resilience was associated with almost 4-fold lower odds of stress and depression. Healthcare organizations may consider adopting programs to foster resilience, family and spiritual support, and effective communication strategies to reduce burnout and poor mental health among healthcare workers during pandemics and other situations of high stress.

High take-off of coronary arteries contributing to lethal myocardial ischemia: report of two cases

Abstract Introduction/Objective High take-off coronary arteries (HTO) are defined by coronary ostia arising above the sinotubular junction (STJ). Although asymptomatic in most individuals, there is increasing evidence that HTO is a risk factor for sudden cardiac death. Here we present two patients where HTO contributed to death. Methods/Case Report Patient A was a 52 year old morbidly obese male with atypical chest pain, new inferior ST elevations and troponinemia. Multiple coronary angiographies did not reveal any stenosis, but 3 stents were placed in the RCA due to concern for vasospasm. 3 days later the patient died. Autopsy revealed cardiac tamponade and non- atherosclerotic ischemic heart disease with remote apical LV scar and diffuse patchy interstitial fibrosis in the myocardium, which could be attributed to HTO of the RCA 0.5 cm above the STJ and early intramuscular courses of both coronaries. Multiple angiographies likely caused iatrogenic coronary injury and subsequent tamponade. Patient B was a healthy 33 year old female at 34 weeks gestation, who developed anaphylaxis during IV iron infusion for severe iron deficiency anemia. She was transferred to the OR for emergent C-section. Minutes after delivery she died. Autopsy revealed HTO, with coronary ostia being 0.4 cm and 0.7 cm above the STJ, respectively and acute angle take-off of LCA. No atherosclerosis was noted. The inability to increase myocardial perfusion through the coronary arteries during a high stress situation due to pregnancy, iron deficiency anemia and anaphylaxis likely contributed to lethal myocardial ischemia. Results (if a Case Study enter NA) NA Conclusion HTO and other coronary artery anomalies (CAAs) should be considered in cases of cryptogenic acute and chronic myocardial ischemia. Hemodynamic characterization of HTO, including those < 1 cm above the STJ in presence and absence of other CAAs may help better understand their pathophysiologic significance. Antemortem diagnosis requires high clinical suspicion and appropriate surgical intervention could be life-saving.

Cardiac Arrest in an Adolescent with Pulmonary Embolism.

The target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 13-year-old female who presented with seizures and hypoxia and was ultimately diagnosed with pulmonary embolism. The case highlights diagnosis and management of an adolescent with new onset seizures, deterioration in status, and treatment options in pediatric cardiac arrest due to pulmonary embolism. Pulmonary embolism (PE) is an uncommon cause of hypoxia in children making diagnosis difficult. A study looking at 23 years of admission and autopsy data on children found the incidence of clinically significant pulmonary embolism to be 25 per 100,000.1 However, when children present to the emergency department with hypoxia and altered mental status, a diagnosis of pulmonary embolism cannot be excluded. Risk factors such as use of estrogen containing oral contraceptives, immobilization, and recent surgery should raise suspicion for pulmonary embolism in the clinically deteriorating adolescent patient.2,3. By the end of the simulation, learners will be able to:1) develop a differential diagnosis for an adolescent presenting with hypoxia and seizure-like activity2) discuss the utility of bedside ultrasound in helping to differentiate causes of hypoxia3) discuss management of cardiac arrest due to PE in the pediatric patientSecondary learning objectives include:4) discuss indications for emergent use of thrombolytics and Extracorporeal Membrane Oxygenation (ECMO) while becoming aware of institution-based limitations5) demonstrate interpersonal communication with family, nursing, pharmacy, and consultants during high stress situations. This is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of pulmonary embolism in an adolescent patient. Participants participated in a debriefing after the simulation.Research Methods:The effectiveness of this case was evaluated by surveys given to learners after debriefing. Learners gave quantitative and qualitative results of their feedback using a 1-5 rating scale and leaving written feedback. This case was performed with residents in their first and second years of training. Feedback was overall positive, with many of the residents giving the case high scores on effectiveness of the simulation in their education. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future. Pulmonary embolism is an uncommon but important diagnosis for emergency medicine physicians to consider in pediatric cardiac arrest. This case has multiple parts and was based on a real case in our emergency department in which a patient presenting with new seizure-like activity followed by cardiac arrest was ultimately diagnosed with a PE. The case was well received by our learners who felt it improved their identification of this diagnosis and its management. Pulmonary embolism, oral contraceptives, altered mental status, pediatric, adolescent, cardiac arrest, ECMO, thrombolytic, hypoxia, emergency medicine, medical simulation.

The Silent Pandemic: The Psychological Burden on Frontline Healthcare Workers during COVID-19.

This narrative review explores the full scope of harmful psychological effects of the COVID-19 (Coronavirus Disease of 2019) pandemic on FLHCWs (Frontline healthcare workers). Additionally, we highlight the risk factors for worse outcomes. A literature review identified 24 relevant papers included in this synthesis. The majority of studies reported a high number of mental health conditions in HCWs (Healthcare workers) overall. Working in the frontline setting was repeatedly identified as an independent risk factor for poorer mental health. Additional risk factors, such as gender, occupational pressure, and low level of support from hospital administration, family, and the community, were also commonly identified. In the past, defined interventions have been shown to mitigate the psychological impact of high-stress situations on frontline workers. This review is aimed at identifying individuals at higher risk to help effectively target preventative measures in future stress situations in our healthcare system.

A-117 Strategic Memory and Advanced Reasoning Training for Rehabilitation of Warfighters with Mild Traumatic Brain Injury

Abstract Background Military personnel require a level of cognitive readiness that ensures they function safely and effectively in high-stress situations. Warfighters who experienced a mild traumatic brain injury (mTBI) often complain of persistent cognitive issues that may impact those abilities. This study presents preliminary data on the efficacy of a 4-week Strategic Memory Advanced Reasoning Training (SMART) for warfighter rehabilitation. SMART improves executive functioning in order to enhance overall cognitive abilities. Methods This is part of a randomized clinical trial (Validation of Cognitive Enhancement Therapy for mTBI). 22 Marines with prior mTBI and current cognitive complaints; 7 of whom completed SMART and were included in the analysis. Cognitive tests of interest included the Delis-Kaplan Executive Function System Color Word (CW) and Trail Making (TM). Results Improvements were observed on TM Number Sequencing (Pre: M = 9.71, SD = 2.06; Post: M = 11.86, SD = 1.35, p = 0.011, d = 1.37) and approached significance on Letter Sequencing (Pre: M = 10.29, SD = 1.81; Post: M = 12.57, SD = 1.13, p = 0.066, d = 1.26). Though non-significant, a large clinically-relevant effect size was found for Number-Letter Switching (Pre: M = 8.14, SD = 1.95; Post: M = 9.57, SD = 2.15, p = 0.106, d = 0.72). CW performance improved on Inhibition (Pre: M = 5.29, SD = 3.86; Post: M = 8.86, SD = 2.34, p = 0.034, d = 1.03) and Inhibition/Switching (Pre: M = 4.86, SD = 4.06; Post: M = 8.43, SD = 4.12, p = 0.015, d = 1.26). Conclusions The SMART program resulted in large improvements in the executive functioning of a small sample of warfighters with persistent cognitive complaints following a mTBI. The results support further examination of the efficacy of SMART for warfighter rehabilitation.

Therapeutic virtual reality in prison: Participatory design with incarcerated women

Upon release from prison, women face barriers in every step of their journey home, with most reentry services designed for men. With virtual reality (VR) headsets increasingly affordable and normalized as a mental health treatment modality, VR is being adopted by prisons around the United States. We argue that the risks and affordances of VR in this political context necessitate centering those with lived experience as creative agents to avoid designing media that re-traumatizes, reduces the complexities of reentry, and reproduces oppressive prisoner–guard dynamics. This article documents and analyzes the design process of a VR reentry program for a state prison to help incarcerated women practice responding to high-stress reentry situations, prior to their release. The resulting VR prototype draws on therapeutic VR work but takes a community-based participatory design approach. We conclude by discussing the institutional and cultural tensions of implementing a participatory design process in a US state prison system.

A Qualitative Study of Stress and Coping to Inform the LEADS Health Promotion Trial for African American Adolescents with Overweight and Obesity.

The purpose of this study was to conduct in-depth individual interviews with 30 African American adolescents with overweight and obesity and their families (caregiver/adolescent dyads) to gain a better understanding of how to integrate stress and coping essential elements into an existing family-based health promotion program for weight loss. Interview data from 30 African American adolescents with overweight and obesity (Mage = 15.30 ± 2.18; MBMI%-ile = 96.7 ± 3.90) were transcribed and coded for themes using inductive and deductive approaches by two independent coders. Inter-rater reliability was acceptable (r = 0.70–0.80) and discrepancies were resolved to 100% agreement. The themes were guided by the Relapse Prevention Model, which focuses on assessing barriers of overall coping capacity in high stress situations that may undermine health behavior change (physical activity, diet, weight loss). Prominent themes included feeling stressed primarily in response to relationship conflicts within the family and among peers, school responsibilities, and negative emotions (anxiety, depression, anger). A mix of themes emerged related to coping strategies ranging from cognitive reframing and distraction to avoidant coping. Recommendations for future programs include addressing sources of stress and providing supportive resources, as well as embracing broader systems such as neighborhoods and communities. Implications for future intervention studies are discussed.

Platelet Desialylation Is a Novel Mechanism of Thrombocytopenia during Mechanical Circulatory Assistance

Introduction: Although bleeding associated with thrombocytopenia often complicates mechanical circulatory assistance (MCA), the mechanisms of thrombocytopenia observed in this high shear stress situation remain poorly understood. Recent studies have highlighted that platelet desialylation, a process in which terminal sialic acids are cleaved from glycoconjugates on the platelet surface, leads to accelerate platelet clearance via asialoglycoprotein receptors on hepatocytes and subsequent thrombocytopenia. Moreover, it was demonstrated that platelet receptor GPIba occupancy by plasma protein von Willebrand factor (VWF) under physiological shear stress induces platelet desialylation. As MCA promotes, in the majority of patients, high shear-induced VWF/GPIba interactions, we aimed to investigate whether the thrombocytopenia observed during MCA depends on platelet desialylation.Methods: The effects of MCA on platelet desialylation were assessed i) in vitro using human whole blood or platelets rich plasma (PRP) and an Impella (Abiomed Europe GmbH, Aachen, Germany) circulatory assistance pump providing flow rate of 5 liters by minute and inserted in a loop and ii) in 11 adult patients requiring arteriovenous extracorporeal membrane oxygenation (ECMO) circulatory assistance. Platelet desialylation was measured by flow cytometry using fluorescent lectin, at baseline and after initiation (5, 30, 60, 120 and 180 minutes and 24 hours for patients) of MCA. The blood platelet count and the immature platelet fraction (IPF), a new parameter that reflects the activity of thrombopoiesis, were also determined in patients at baseline and daily after ECMO initiation.Results: In vitro, platelet desialylation levels in whole blood and in PRP increased after 5 minutes of circulatory assistance pump compared to baseline (+216%, p<0.05 and +132%, p<0.05, respectively) and the difference persists over time (at 180 minutes: +244%, p<0.05 in whole blood and +292%, p<0.05 in PRP). In all patients, platelet desialylation levels were higher after 5 minutes of ECMO compared to baseline (+197%, p<0.001) and as in vitro, the difference persist over time (at 180 minutes: +187%, p<0.05 and at 24 hours: +223%, p<0.05). In parallel, a decrease of platelet counts and an increase of IPF were observed in all these patients after 2 days under ECMO with a nadir at 4 days for platelet counts (73 G/L, range: 27-119 G/L) and a zenith at 3 days for IPF (13.75%, range: 5.5-22.0%).Conclusion: The present study is the first to show that MCA increases platelet desialylation within minutes after pump initiation. Thus, thrombocytopenia observed in this context seems dependent on platelet desialylation. Giving these results, further studies evaluating the potential beneficial effects of desialylation inhibitors to prevent or treat MCA associated thrombocytopenia could be valuable. DisclosuresNix:Abiomed: Employment.

Neurocognitive Profiles in Adolescence Predict Subsequent Anxiety Trajectories During the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic has created increased stress and anxiety for many; however, some individuals are particularly prone to heightened anxiety. It is unclear if and how prestress neurocognitive factors moderate risk for anxiety during high-stress situations. Enhanced error monitoring and a cognitive control strategy of more instantaneous (reactive) control have both been independently related to anxiety. We examined if a specific neurocognitive profile characterized by heightened error monitoring and a more reactive cognitive control strategy in adolescence predicts young adults’ anxiety trajectories across 3 early months of the COVID-19 pandemic. MethodsAs part of a longitudinal study (N = 291), data were acquired in adolescence (13 years) on error monitoring (n = 124) and cognitive control strategy (n = 119). In young adulthood (18 years), anxiety was assessed three times during the COVID-19 pandemic (n = 162). ResultsOn average, participants experienced greater anxiety in the first COVID-19 pandemic assessment, then anxiety decreased in the following months. Error monitoring and cognitive control strategy interacted to predict anxiety trajectories, such that among adolescents with an increased reliance on reactive control, error monitoring predicted greater anxiety in the first assessment but greater decreases the following months as stay-at-home orders were lifted and families adapted to the restrictions. ConclusionsResults suggest that neurocognitive profiles in adolescence predict young adults’ anxiety responses during a highly stressful period, such as the initial months of the COVID-19 pandemic. Our findings have implications for the early identification of individuals at greater risk for anxiety.

P.116 Assessment of patient safety culture in the theatre unit of an Irish tertiary maternity hospital

Introduction: The practice of obstetrics requires effective multidisciplinary teamwork and systems to achieve optimal patient outcomes in high stress situations. Patient safety culture (PSC) is a core contributor to teamwork and communication. The Safety Attitudes Questionnaire (SAQ) has been validated to measure PSC. High scores in this questionnaire are associated with reduced staff turnover, infection rates and mortality. [1] Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA. 2006;296:696-9. Google Scholar

P.76 Introduction of an obstetric simulation programme to meet training needs during the COVID-19 pandemic

Introduction: Training and service delivery in hospitals across the UK has been profoundly impacted by the COVID-19 pandemic. Continuing multidisciplinary team (MDT) training has been shown to be highly beneficial, particularly in obstetric departments where large numbers of staff work together in high-stress situations.1 Social distancing restrictions have made existing organised training programmes impossible to deliver effectively, therefore we established an in-situ simulation training programme.

Perceived organizational support and emotional labour among police communicators: what can organizational context tell us about posttraumatic stress?

As central members of the emergency response system, communicators are regularly exposed to potentially traumatic events and experience some of the highest rates of posttraumatic stress. Given elevated rates of distress, they are regularly called upon to manage emotions-their own and others'-during high-risk and high-stress situations, within a highly controlled organizational context. Emotional labour (EL) theory suggests that many individuals faced with this challenge utilize a strategy in which emotions are suppressed or faked (surface acting-SA) in keeping with organizational expectations. This study was designed to examine the relationships among reported EL, perceived organizational support, job stress, and severity of posttraumatic stress among a population of communicators. Job pressure and perceived lack of organizational support were positively associated with posttraumatic stress. Although the highest reported levels of SA occurred when interacting with members of the public, this SA was not associated with posttraumatic stress, unlike SA with co-workers and supervisors. SA with co-workers and supervisors was further related to perceptions of lack of organizational support. Thus, an organization perceived as unsupportive may create a culture in which individuals are dissuaded from expressing true emotions with colleagues and supervisors, potentially magnifying the traumatic effects of exposure to critical incidents.

A 36-Hour Unplugged Full-Scale Exercise: Closing the Gaps in Interagency Collaboration between the Disaster Medical Assistance Team and Urban Search and Rescue Team in Disaster Preparedness in Taiwan.

Introduction Disaster medical assistance team (DMAT) and urban search and rescue team (USAR) need to cooperate seamlessly to save lives in disasters, but related research is limited. Objectives To estimate the disaster preparedness of the DMAT and the barriers affecting interagency cooperation between the DMAT and the USAR team. Methods This was an observational study of a full-scale exercise conducted in Taiwan from November 16 to 18, 2018. The exercise scenario simulated a magnitude 7 earthquake in Tainan City. DMATs from other counties were deployed and cooperated with local USAR teams to carry out disaster relief. Our study invited 7 experts to evaluate DMATs on disaster preparedness capabilities and the interagency collaboration between DMATs and USAR. Results A total of eight DMATs, consisting of 30 physicians, 65 nurses, 74 logisticians, 5 health bureau personnel, and 85 USAR teams, participated in this exercise. During the mission, 176 patients were treated. The capabilities of each team were generally consistent with the basic technical standards for type I emergency medical teams, but the compliance rates for basic local anesthesia, cold chain equipment for medication, rapid blood test tools, and sterilization devices were only 50%, 12.5%, 12.5%, and 9%, respectively. In addition, 53% of participants reported abnormal vital signs, indicating that it was a high-stress situation. Moreover, the main barriers to interagency collaboration were differing perspectives and poor mutual understanding. Conclusion A full-scale exercise carried out jointly with DMATs and USAR teams was valuable for disaster preparedness, particularly in terms of understanding the weaknesses of those teams and the barriers to interagency collaboration.

Estresse Ocupacional, qualidade do sono e obesidade em Policiais Militares - Revisão narrativa

Stress was considered by the United Nations as the disease of the 20th Century, being present in more than 90% of the world population, including military police officers. This group of professionals has been in the front-line of the pandemic caused by the Coronavirus and is exposed to daily situations of high emotional stress and traumatic work events, which can cause several health problems, namely occupational stress, sleep problems and obesity. This study aims to conduct a narrative review of the influence of psychosocial environment on the development of occupational stress and consequences on the military police officer´s health. Two platforms, namely PubMed and Google Scholar were used to search for relevant scientific publications on the topic; 148 publications from 2010 to 2020 were analyzed, 71 of which were included in this review. It is estimated that 25% to 35% of the global burden of disease may be due to environmental factors. The stress prevalence in military police officers is higher than the average in the civilian population worldwide; due to an alternate work schedule that does not always respect the circadian characteristics of each individual, and with direct influence on sleep quality and obesity incidence. Public health policies should be taken in the short term in order to improve life quality of these professionals.

Women demonstrate lower markers of stress and oxidative stress during active shooter training drill

It has been well documented that police officers are frequently engaged in a variety of high stress situations during their normal daily tasks, such as civilian encounters where force is needed or domestic violence situations, that cause significant increases in a variety of physiological and psychological stress markers. Chronic exposure to stressors increases risk for cardiovascular disease (CVD) progression. The purpose of this study was to compare male and female salivary and blood markers of stress in response to an active shooter training drill (ASD) to determine if acute stress differentially impacts men and women to better understand if interventions should be targeted. Thirty-one participants (males ​= ​15 [mean age: 23], females ​= ​16 [mean age: 21]) participated in an ASD involving professional actors playing the role of one active gunman, as well as four victims. The ASD lasted approximately 50 seconds. Blood samples were collected 15 ​min prior as well as after the ASD and analyzed for epinephrine (EPI), norepinephrine (NE), and hydrogen peroxide (H2O2) levels. Saliva samples were collected 30 and 5 ​min prior to the ASD and 5 and 30 ​min after the ASD, and were analyzed for cortisol, α-amylase, uric acid, and secretory immunoglobulin-A (SIgA). Our analysis revealed that acute (~50 ​sec) psychological stress in the form of an ASD resulted in significant increases in blood and salivary stress and oxidative stress markers in both men and women. However, four of the seven markers were lower in female participants (cortisol, uric acid, H2O2, and α-amylase presented significant main effects for sex). In addition, SIgA was significantly lower in women compared to men 30 ​min prior to, and five min post ASD. These findings suggest females may be at a lower risk to stress induced oxidative stress and CVD.

Pandemic Nightmares: COVID-19 Lockdown Associated With Increased Aggression in Female University Students' Dreams.

The COVID-19 pandemic and its associated stressors have impacted the daily lives and sleeping patterns of many individuals, including university students. Dreams may provide insight into how the mind processes changing realities; dreams not only allow consolidation of new information, but may give the opportunity to creatively “play out” low-risk, hypothetical threat simulations. While there are studies that analyze dreams in high-stress situations, little is known of how the COVID-19 pandemic has impacted dreams of university students. The aim of this study was to explore how the dream content of students was affected during the university COVID-19 lockdown period (March–July, 2020). Using online survey methods, we analyzed dream recall content (n = 71) using the Hall-Van de Castle dream coding system and Fisher's exact tests for sex comparisons. Preliminary results indicate that female students experienced more nightmares as compared to male students. Dream analysis found that, relative to normative American College Student (ACS) samples generated pre-COVID-19, women were more likely to experience aggressive interactions in their dream content, including increased physical aggression. Results indicate that university students did experience changes in dream content due to the pandemic lockdown period, with women disproportionally affected. These findings can aid universities in developing support programs for students by bringing forth an understanding of students' concerns and anxieties as they process the “new normal” of social distancing.

Lateral Violence of Nurses in the Hospital Environment: The Need for Caring

Abstract Nurses today are plagued with doing more with less and are forced to work in high-stress situations. These conditions lead to a stressful situation and contribute to lateral violence. While lateral violence has the potential to be present in any setting, it is more prevalent in healthcare. The adage of “nurses eat their young” is still in effect today. With a change in focus from a to-do list with a focus on genuine caring, not only the nurse but the patient as well will benefit. The purpose of this analytical review of research literature was to evaluate the prevalence of lateral violence experienced by nurses, determine ways to identify and eradicate it and educate the medical community on the incidence and eradication of lateral violence. Jean Watson’s Theory of Human Caring was determined to be the most comprehensive approach for guiding this review. For nurses to provide optimal care to patients, nurses must be able to work in a positive team-like atmosphere. Future strategies for improving lateral violence in the hospital environment include more educational workshops and nursing residency programs. Scholars suggested educating nursing students early in their nursing curriculum on lateral/horizontal violence to reduce the effects of lateral/horizontal violence for the future.

Increased Misuse of Alcohol and Drugs among Unemployed during COVID-19 Pandemic

Rampant unemployment in the United States brought on by the COVID-19 pandemic has had an enormous detrimental effect on the financial well-being of millions of Americans and their families. Personal concerns about these financial disruptions and social isolation as a precaution against the pandemic have heighted stress particularly among vulnerable groups like the unemployed. High stress situations are known triggers for maladaptive coping behaviors like use/overuse of alcohol, prescription medications, and street drugs. This study of 600 unemployed individuals found substantial increases in all three categories of mood-altering substances. Using adapted addiction symptom measurement items from the most recent Diagnostic and Statistical Manual (DSM-5), the researchers established comparative addiction risk profiles for each substance category. Further, the results of the study offer preliminary insights into substance abuse patterns across two and even all three of the substance categories.

The Role of Neuroscience in the Effects of Adverse Childhood Experiences in Relation to Risk Taking, with Specific Reference to Risk Assessment During a Pandemic, a Review of the Literature

Multiple Adverse Childhood Experiences (ACEs) are frequently associated with cognitive, social, and behavioural impairments in adulthood. Many studies have shown that there is an increased probability of being involved with risky behaviours including involvement with the justice systems, drugs, alcohol, and a lifestyle that can lead to unhealthy choices. Multiple ACEs increase the risk of cardiovascular disease and type 2 diabetes. In this review we will look at the evidence for the physical changes within the brain structure that have been attributed to ACEs. We consider how these might affect the choices towards riskier behaviour and whether this will influence the thought processes of the ACE population during a high stress situation, such as a pandemic.