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Management of opioid use disorder: 2024 update to the national clinical practice guideline [Guideline]

Background

In an evolving landscape of practices and policies, reviewing and incorporating the latest scientific evidence is necessary to ensure optimal clinical management for people with opioid use disorder. We provide a synopsis of the 2024 update of the 2018 National Guideline for the Clinical Management of Opioid Use Disorder, from the Canadian Research Initiative in Substance Matters.

Methods

For this update, we followed the United States Institute of Medicine’s Standards for Developing Trustworthy Clinical Practice Guidelines and used the Appraisal of Guidelines Research and Evaluation—Recommendation Excellence tool to ensure guideline quality. We carried out a comprehensive systematic literature review, capturing the relevant literature from Jan. 1, 2017, to Sept. 14, 2023. We drafted and graded recommendations according to the Grading of Recommendations, Assessments, Development and Evaluation approach. A multidisciplinary external national committee, which included people with living or lived experience of opioid use disorder, provided input that was incorporated into the guideline.

Recommendations

From the initial 11 recommendations in the 2018 guideline, 3 remained unchanged, and 8 were updated. Specifically, 4 recommendations were consolidated into a single revised recommendation; 1 recommendation was split into 2; another recommendation was moved to become a special consideration; and 2 recommendations were revised. Key changes have arisen from substantial evidence supporting that methadone and buprenorphine are similarly effective, particularly in reducing opioid use and adverse events, and both are now considered preferred first-line treatment options. Slow-release oral morphine is recommended as a second-line option. Psychosocial interventions can be offered as adjunctive treatment but should not be mandatory. The guideline reaffirms the importance of avoiding withdrawal management as a standalone intervention and of incorporating evidence-based harm reduction services along the continuum of care.

Interpretation

This guideline update presents new recommendations based on the latest literature for standardized management of opioid use disorder. The aim is to establish a robust foundation upon which provincial and territorial bodies can develop guidance for optimal care.




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Roadside serendipity: an accident can lead to a rare diagnosis




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An elderly woman with acute respiratory failure and diffuse pulmonary changes




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Large-scale education in respiratory medicine: content versus delivery

The respiratory literature, both written and in online formats, is growing exponentially. Capturing quality content, to meet the learning needs of those working in all fields of respiratory medicine and delivering it in a palatable, accessible format is challenging but paramount. In this article we discuss ways to determine the information content and review different methods of delivering this content to those who need it.




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Neom, Saudi Arabia’s Futuristic City, Suddenly Loses Its CEO



Pitched as a mix of ‘Blade Runner’ and ‘Jurassic Park,’ Neom is the world’s biggest construction project. Twenty-one thousand people have died so far to make it happen.




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Secret Level‘s Creator Hopes Concord Episode Showcases Its Lost Potential



Tim Miller hopes Amazon's anthology series will help viewers appreciate the "blood, sweat, and tears" Firewalk Studios put into the scrapped game.




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Can You Really Save a Life? Study Reveals the Impact of Bystander CPR



New research shows that bystander CPR can substantially improve a person's odds of surviving a cardiac arrest while avoiding major brain damage, especially if given immediately.




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Students can be agents of change: Talking about activism in universities with Jade Ho

Jade Ho explains what is possible for university students when they are given opportunities to learn about –and get involved with– social justice and labour issues in their own communities.

The post Students can be agents of change: Talking about activism in universities with Jade Ho appeared first on rabble.ca.









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Column: Why reporting from South Sudan is so difficult — and critically needed

Simona Foltyn walks down a mountain slope shortly after crossing into South Sudan. Photo by Jason Patinkin

In August, fellow reporter Jason Patinkin and I crossed on foot from northern Uganda into rebel-held South Sudan. Over the course of four days, we walked more than 40 miles through the bush, escorted by rebel soldiers, to shed light on one of the world’s most underreported conflicts.

Reporting on South Sudan’s war, which began in 2013, has always been a challenge due to the risk and logistical hurdles associated with accessing remote areas where fighting takes place. But over the past year, covering the war and its humanitarian fallout has become particularly difficult. Since the beginning of this year, South Sudan’s government has banned at least 20 foreign journalists in an apparent effort to silence reporters who had a track record of critically reporting on the government.

The war has had a devastating impact on South Sudanese communities, but much of it has remained out of the limelight of international media.

This systematic crackdown on the foreign press (South Sudanese journalists have long risked imprisonment and death for doing their work) coincided with two important developments. In November 2016, the United Nations warned that the violence being committed against civilians in the southern region of Equatoria risked spiraling into genocide. Then, in February, the UN declared a man-made famine, warning that 100,000 people were at risk of starving to death as a result of civil war.

Journalists seeking to cover these events were left with two equally unsavory options: self-censorship or a risky trip to rebel-held parts of the country. Only a handful of journalists have attempted the latter since fighting escalated in July last year. For us, this was our second embed with the rebels this year.

Martin Abucha (second from right) rests with his troops in rebel-held South Sudan. Photo by Jason Patinkin

We set off from a town in northern Uganda at five in the morning, bouncing along a bumpy dirt track towards the South Sudan border. Crammed into our four-wheel drive were rebel commander Martin Abucha, a dual American and South Sudanese citizen who we planned to profile for our PBS NewsHour Weekend segment, a couple of guides, and several duffle bags stuffed with our tents, sleeping bags, emergency medical kits and provisions to last us four days.

Just as the sun began to rise above a distant range of hills that we aimed to cross later that day, our car came to a halt in front of a stream. Because of the rainy reason, it carried more water than usual. It was time to disembark and start walking, or “footing,” as South Sudanese tend to call it.

We took off our shoes and waded through the stream’s chilly waters. This was the first of a many rivers we’d have to cross along the way, either on foot or in small flimsy canoes dug out from tree trunks. Each time, we dreaded the idea of falling in with our camera gear.

The first part of our journey in northern Uganda felt very much like a hike through a national park. Passing beautiful landscapes and idyllic farming villages, one could almost forget we were headed into a war zone — but we were about to get a reality check.

We had just crossed into South Sudan when out of nowhere, two dozen armed men popped out of the tall grass and surrounded us at gunpoint.

“Stop! Who are you and where are you going?” a soldier called out in Juba Arabic from his hideout no more than 20 yards away, pointing his AK47 at us. Another one next to him had a rocket-propelled grenade propped on his shoulder, also unequivocally aiming it in our direction.

Instinctively, we threw our hands in the air and exchanged a baffled glance. Had we accidentally bumped into government soldiers? Or perhaps we had come onto the “wrong” rebels? Abucha’s group, called the Sudan People’s Liberation Army In Opposition, is the biggest but not the only armed group in Equatoria, an area rife with rival militia and bandits who exploit the security vacuum left by war.

To our relief, and only after Abucha answered a series of questions, this routine security check quickly gave way to a warm welcome. The platoon would be our escort for the next four days as we trekked to their base and to Loa, Abucha’s hometown.

Keeping up with the rebels was no easy task. Given the country’s pervasive lack of basic infrastructure, South Sudanese grow up walking for dozens of miles just to go about their daily lives. For sedentary Westerners, keeping the target pace of “two meters per second” (around five miles an hour) proved challenging amid 90-degree temperatures, all while filming and plowing our way through dense, itchy elephant grass.

The upside of the cumbersome terrain was that it kept us safe. During our four-day trip, we didn’t cross a single road, instead walking along a dizzying network of narrow bush paths the rebels seemed to know like the backs of their hands. An unwanted encounter with government troops, who tended to stick to roads and move around in vehicles as opposed to on foot, was highly unlikely.

The closest we got to government-controlled area was a visit to Loa, located just two kilometers away from a main road frequently patrolled by government soldiers. We couldn’t stay long, but the hour we spent on the ground offered us a glimpse into what villages must look like in many parts of Equatoria: burned mud huts, looted schools and clinics, fallow fields and – most strikingly – no civilians.

The war has had a devastating impact on South Sudanese communities like the one in Loa, but much of it has remained out of the limelight of international media. Our four-day venture into rebel-held South Sudan offered us a rare opportunity to report ground truths, and we are thankful for that.

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Hundreds dead after massive truck bomb strikes Mogadishu

Civilians evacuate from the scene of an explosion in KM4 street in the Hodan district of Mogadishu, Somalia October 14, 2017. Photo By Feisal Omar/Reuters

At least 231 people were killed and hundreds more wounded after a massive truck bomb on Saturday struck Somalia’s capital city of Mogadishu.

The Somali government has blamed the al-Qaida-linked militant group al-Shabab for the attack, and called it the deadliest ever to hit the nation.

The blast took place outside the Safari Hotel, where rescue workers dug through the rubble of collapsed buildings overnight in search of survivors. Witnesses described a devastating scene with large-scale carnage, as doctors worked feverishly to attend to the dead and injured, many badly burned.

“The hospital is overwhelmed by both dead and wounded,” Dr. Mohamed Yusuf, the director of Medina hospital located near the blast, told the Associated Press. “We also received people whose limbs were cut away by the bomb. This is really horrendous, unlike any other time in the past.”

Photos and videos of the bombing, which took place on a busy street near a section of the city housing foreign embassies, showed collapsed walls, twisted metal, and sporadic fires spewing smoke. The Qatari government said its embassy was “severely damaged” in the strike.

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Family members searched through the wreckage and waited at local hospitals with the hopes of finding relatives who survived the bombing.

Somali President Mohamed Abdullahi Mohamed announced three days of mourning. The attacks received international condemnation, including from the United States.

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Iraqi, Kurdish forces in standoff, weeks after Kurdish vote for independence

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HARI SREENIVASAN: The desire of the Kurds along Iraq’s northern border to govern themselves is receiving more resistance from Iraq’s central government. Iraqi army forces are demanding Kurdish troops withdraw from oil fields and military bases around Kirkuk, a city in the Kurdistan region that voted for independence last month. Kirkuk also has 10% of Iraq’s known oil reserves. Washington Post’s Loveday Morris is in Baghdad covering this standoff joins me now via Skype. First of all the significance of this. Why is it so important?

LOVEDAY MORRIS: There’s been a longtime conflict between Baghdad and Kurdistan over these disputed territories. Most significant of which is Kirkuk because of the oil reserves. But the referendum last month has really sharpened these disputes because you have Baghdad opposing independence and so it feels like they have to restate its territorial claims these areas. So that’s why we’re seeing a lot of tension right now.

HARI SREENIVASAN: And just to give people a little bit of a brief timeline – Iraqi forces control this area for a while and then in June ISIS took over the area and now it’s kind of back in Kurdish hands?

LOVEDAY MORRIS: Right. So in June 2014 Iraq lost control of a lot of the areas and we have this huge collapse in the face of an ISIS offensive. Over 100,000 soldiers fled and Kurdish forces moved in some of these areas – some of them maybe took from ISIS and others just moved into into the vacuum. And so Iraqi forces have been in these areas since June 2014. And that’s their main demand that they return to the areas.

HARI SREENIVASAN: What’s the likelihood that this standoff right now turns violent? Into some sort of a civil war?

LOVEDAY MORRIS:: I think at this point both sides don’t want violence. Al-Abadi, the prime minister, is really trying to defuse the situation by saying there’s going to be no military attack. But at the same time there is this buildup of forces so that I think they are trying to, in a way, intimidate the Kurds to withdraw from some areas but they don’t want to see a fight per say. But in this really tense situation there can be a small spark and things can turn violent quite easily.

HARI SREENIVASAN: Thank you.

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News Wrap: Dozens missing after deadly Mogadishu truck bombing

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JUDY WOODRUFF: And in the day’s other news: More than 300 people are now confirmed dead after Saturday’s massive truck bombing in Somalia, one of the world’s worst attacks in years.

Nearly 400 more were wounded. The government blamed the al-Qaida-linked Al-Shabaab group. Rescue crews today searched for survivors at the scene of the bombing, a crowded street in the capital, Mogadishu. With dozens still missing, officials say they expect the death toll to rise.

OSMAN LIBAH IBRAHIM, Deputy Minister for Natural Resources, Somalia (through interpreter): More bodies are gradually being found and removed from the rubble. There are other people who are under the rubble. We have heard them as they scream for help. My biggest worry is that even the wounded are succumbing to their injuries.

JUDY WOODRUFF: The attack happened two days after Somalia’s defense minister and army chief resigned for undisclosed reasons.

There’s been yet another shift to the right in European politics; 31-year-old conservative Sebastian Kurz, Austria’s foreign minister, is set to become that country’s next leader. But he’s short of a majority in Parliament and will likely form a coalition with the far-right Freedom Party. It was founded by ex-Nazis in the 1950s.

Kurz has called for the European Union to focus more on internal trade and securing borders. He celebrated in Vienna.

SEBASTIAN KURZ, Austrian People’s Party (through interpreter): I have a big request for you. Use today to celebrate. You all have earned it through hard work and dedication. At the same time, I need to tell you that tomorrow the work starts. We didn’t just run to win the elections. We did so to bring Austria back to the top. We ran in this election to achieve real change.

JUDY WOODRUFF: A final result in the election is likely to be decided on Thursday.

Wildfires that broke out over the weekend in Portugal have killed at least 35 people, including a one-month-old infant. Today, more than 5,300 firefighters with some 1,600 vehicles were battling the fires, some of which officials say were started by arsonists. Wildfires have also left at least four people dead in neighboring Spain.

Army Sergeant Bowe Bergdahl pleaded guilty today to desertion and misbehavior before the enemy. He was captured by the Taliban in 2009, after leaving his post in Afghanistan. It prompted an intense search and a prisoner swap. Bergdahl appeared before a military judge in Fort Bragg, North Carolina, today. The 31-year-old could be sentenced to life in prison. He said his actions were very inexcusable, adding he didn’t — quote — “think there’d be any reason to pull off a crucial mission to look for one guy.”

The truck driver in deadly immigrant smuggling run has pleaded guilty in court. San Antonio police found at least 39 immigrants, 10 of whom died, packed into a sweltering semi-trailer last year and died. The driver, James Matthew Bradley Jr., pleaded to conspiracy and transporting immigrants, resulting in death. He faces now up to life in prison.

A New Jersey man has been convicted of planting two pressure-cooker bombs on New York City streets last year. Ahmed Khan Rahimi faces a maximum sentence of life in prison for charges including using a weapon of mass destruction. One of the bombs exploded in Manhattan’s Chelsea neighborhood, wounding 30. The second didn’t detonate. Officials said Rahimi was inspired by ISIS and al-Qaida.

JOHN MILLER, Deputy Commissioner, NYPD Intelligence & Counterterrorism: Ahmed Khan Rahimi learned a lesson which we keep reminding people of. This is the wrong place to try and carry out an act of terrorism. Witnesses will come forward, evidence will be developed, arrests will be made, prosecutions will be brought forth, and they will be successful.

JUDY WOODRUFF: Prosecutors said Rahimi also planted a pipe bomb in Seaside Heights, New Jersey, but no one was injured.

Colin Kaepernick has filed a grievance against the national football league. The former San Francisco 49ers quarterback says that he remains unsigned due to collusion by team owners over his national anthem protests. Kaepernick sparked a debate when he kneeled during the anthem last year, protesting police mistreatment of African-Americans.

On Wall Street today, the Dow Jones industrial average gained 85 points to close at 22957. The Nasdaq rose 18. And the S&P 500 added four.

It was a milestone day in the world of astronomy. For the first time, researchers say they have detected gravitational waves with a flash of light from the same cosmic event. The dual observation supports Albert Einstein’s general theory of relativity. The ripples in space and the light burst were caused by the collision of two neutron stars. They were first detected in August.

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Far-right groups gain ground in Sweden and Germany amid migrant influx

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JUDY WOODRUFF: But first: Sunday’s elections Austria were the latest ample of a shift to the right Europe’s politics, as 31-year-old Christian Kurz was elected chancellor on an anti-immigration platform.

He may now form a government with a far-right party founded in the 1950s by former Nazis.

That follows recent elections in Germany, where a far-right party roiled the race and dealt a blow to returning leader Angela Merkel.

In Sweden, too, there is a strong challenge from the right and a neo-Nazi group that looks stand in elections next year.

Special correspondent Malcolm Brabant ha been surveying the political landscape in Germany and Sweden, and he begins his report in Scandinavia.

MALCOLM BRABANT, Special Correspondent: In a Gothenburg parking lot, supporters of the Nordic Resistance Movement form up for what they hope will be their biggest-ever march, to propagate an ideology espoused by mother of eight Paulina Forslund.

PAULINA FORSLUND, Nordic Resistance Movement: When white becomes the minority, they will be destroyed. I want my children to have a secure future. I want them not only for them to have a secure Sweden. I want them to have a secure world. And I want other people to fight for the same thing.

MALCOLM BRABANT: When addressing her fellow neo-Nazis, Forslund’s rhetoric sharpens.

PAULINA FORSLUND (through interpreter): I’m the welder’s daughter, the forester’s grandchild. My line consists of hardworking men and women. It’s people like them we can thank for the welfare system that our lying politicians are now giving away to imported scum.

MALCOLM BRABANT: Clearly expecting trouble, the movement’s leaders have a muscular protection detail, marching past a silent protest. The sign reads “No Nazis on our streets.”

This protester would only give her name as Johanna.

JOHANNA, Anti-Nazi Protester: They are racist people. They are people who think that certain people are better than others, and I will not stand for that. It’s not something I think has a place in a modern society.

MALCOLM BRABANT: Experts say the resistance movement is recruiting aggressively, and believe this demonstration is emblematic of the rise of the far right.

It took place on Yom Kippur, the Jewish day of atonement.

Allan Stutzinky is leader of Gothenburg’s Jewish community.

ALLAN STUTZINKY, Jewish Community Leader (through interpreter): Nazism has returned. The descendants of the murderers are organizing the same marches today, waving the same flags, shouting the same slogans, and have the same racist agenda.

MALCOLM BRABANT: Anna Johansson is a member of the governing Social Democrat Party. It’s considering outlawing the Nordic Resistance Movement.

ANNA JOHANSSON, Swedish Social Democratic Party: In Sweden and in Denmark, and in other countries, extreme parties are growing, and the hatred is spreading around.

MALCOLM BRABANT: “Go home to mama,” he shouts. “Nazi pigs,” chant the anti- fascist protesters, as a bottle flies through the air.

DAMON, Nordic Resistance Movement: If someone calls themselves a Nazi, most of us would dissociate with that person. That’s nothing we stand for ourselves. I never call myself a Nazi. I’m a national socialist.

MALCOLM BRABANT: Hitler’s party was also called National Socialist, but Damon, a 40-year-old welder, insists he’s a nonviolent family man.

DAMON: The demographic landscape of our — of the whole of Europe is changing, so, basically, it’s a concern on preserving my heritage for my family and our kin.

MALCOLM BRABANT: This demonstration has been stopped short of its destination. The Nordic Resistance Movement is currently trapped between a line of police and anti-fascist protesters. And it looks as though this demonstration isn’t going any further.

Violence briefly erupts as the resistance movement tries to break through police lines, and several marchers are arrested.

PAULINA FORSLUND: We are not your enemy. We are the government’s enemy.

They say we live in a democracy, but we have never had an election about if we want to take all these people in.

MALCOLM BRABANT: When Europe’s refugee crisis began in 2015, Sweden copied Germany’s open-door policy, and 160,000 migrants entered the country. Two years on, Sweden has tighter borders and has begun deporting some of the newcomers.

The new atmosphere alarms Floid Gumbo, entertaining an anti-Nazi rally.

FLOID GUMBO, Singer Originally from Zimbabwe: I came to Sweden over 20 years ago. The climate in Sweden, the people were so friendly, and things were completely different, more welcoming. And I feel like things have sort of gradually changed.

I’m very concerned, because I have children, because I’m thinking what I experienced here is not the same kind of climate, atmosphere that they are going to experience here.

ANNA JOHANSSON: It’s not so long ago that the Nazis ruined Europe. And that makes me very worried. The German elections were terrifying, I think.

MALCOLM BRABANT: Johansson is referring to last month’s success of the right-wing Alternative For Germany Party, or AFD, when it entered Parliament for the first time with 13 percent of the vote.

HUGH BRONSON, Alternative For Germany Party: The AFD only came into existence because Merkel deserted the traditional conservative Christian voters. They were looking for a home, and the AFD has offered them a safe place.

MALCOLM BRABANT: Hugh Bronson is deputy leader of the AFD in Berlin.

Now his party, the third largest in Parliament, is demanding that Angela Merkel imposes tougher immigration rules.

Your opponents claim that you are a party of hate. What’s your response to that?

HUGH BRONSON: We embrace foreigners who respect our laws, pay their taxes, send their children to school, and go about their normal life. The problem is with people who abuse the system to have a better life, or let others pay for their better lives, or who are criminals.

MALCOLM BRABANT: Outside the opera house in Dresden, former East Germany, singer Luca Bergelt is dismayed by the political landscape shifting to the right.

LUCA BERGELT, Singer: My fear is that they will tear Europe apart. They are going to raise up the walls again. They’re going to build new walls between the countries, and that Europe will get more close into itself.

MALCOLM BRABANT: Anti-immigrant sentiment is strong in Dresden. The city was the birthplace of a pan-European anti-Islamic movement, and it delivered the largest number of votes for the right-wing party.

On a holiday to celebrate German unification after the fall of communism, retired engineer Wilfried Schmidt explained why he sent a message to Angela Merkel.

WILFRIED SCHMIDT, Retired Engineer (through interpretor): Let’s put it this way. We all need to recognize that Germany is undergoing social changes that are becoming harder to control. For one, there is mass immigration from difficult regions that is increasingly uncontrollable, of people with entirely different concepts of life, from fundamental differently structured societies that are problematic.

MALCOLM BRABANT: About one million migrants poured into Germany in 2015. Chancellor Merkel consistently defended her pro-refugee policies, but now she has been punished by voters who believe she ignored their concerns.

Chancellor Merkel has promised to listen to the people who voted for the AFD, and she says she’s going to try to win them over with what she calls good politics. But she will not countenance having the party in her coalition.

But the chancellor needs to find new partners who are prepared to be tough on immigration.

As she tries to forge a coalition, the chancellor has agreed to put an annual cap of 200,000 on the number of immigrants, something she previously refused to do. But will it be enough to woo back people who deserted her at the election?

A question for Werner Patzelt, a political scientist at Dresden University.

WERNER PATZELT, Dresden University: Since Chancellor Merkel has made so many U-turns in German domestic politics, it wouldn’t be a surprise if she would try to do a U-turn, also winning back AFD voters.

But this is a really hard political task, because so many of them are so much disappointed by the Christian Democratic Union in general, and by Chancellor Merkel in particular, that they will do anything to avoid going back.

MALCOLM BRABANT: Back in Sweden, the governing party is horrified at the concept of conceding ground to right-wingers, and is trying to isolate them.

ANNA JOHANSSON: Experience shows that, when you adopt the ideas from these right-wing parties, they spread. These parties have their agenda implemented by other parties. And I wouldn’t want to see that happen in Sweden.

FLOID GUMBO: We’re all human beings. We share this world. We’re all here. There’s enough space for us all.

MALCOLM BRABANT: But that’s an appeal that an increasing number of Swedes are rejecting, as the country and much of Europe go through a crisis of identity.

For the PBS NewsHour, I’m Malcolm Brabant in Gothenburg.

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The battle for Mosul is over, but this hidden ISIS danger could lurk for years

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HARI SREENIVASAN: But first: The de facto capital of the Islamic State, Raqqa, in Syria fell yesterday to U.S.-backed forces.

However, the largest city the militants once held was Mosul in Iraq. They were ousted from it in July after a brutal 10-month-long fight that killed thousands.

Now a new major task: finding and destroying the ISIS mines, booby-traps and bombs that litter the city.

Special correspondent Marcia Biggs reports from Iraq.

MARCIA BIGGS, Special Correspondent: It was once a center of learning for over 6,000 students of technology, agriculture, and medicine.

Today, Mosul Technical Institute’s classrooms are burnt to the ground, laboratories reduced to rubble, and books charred and shredded. It’s one of the city’s five universities ravaged by the Islamic State and the battle to oust it.

Now that the battle is over, a new danger looms, the trail of land mines and booby-traps left by ISIS.

So this is the wire, and this is where it was buried.

CHRISTIAN, Team Leader, Janus Global Operations: Yes, they would cut the asphalt, and then they lay the wire in and put the main charge here.

MARCIA BIGGS: We spent the day with Christian, a team leader from Janus Global, a security and risk management firm hired by the U.S. government to sweep and clear major areas of unexploded ordnance and mines.

He’s not allowed to show his face or use his last name, for security reasons.

CHRISTIAN: There’s actually two more on that road before we get to the target building that have to be excavated and/or rendered safe.

MARCIA BIGGS: So, the first building you have to clear, you have got to get rid of the IEDs on the road to that building?

CHRISTIAN: Yes.

MARCIA BIGGS: It’s a long process.

CHRISTIAN: It is, but that’s what makes it interesting.

MARCIA BIGGS: The United States has sunk $30 million this year into clearing former ISIS territories all over Northern Iraq. Under this program, Janus has already cleared 727 buildings, removing 3,000 IEDs, which they say ISIS was producing on assembly lines at an industrial scale.

But State Department officials and experts say the number of unexploded ordnance in Mosul itself is unprecedented.

What’s your first line of attack, in terms of trying to clear Mosul?

CHRISTIAN: Our priority is more the community, rather than the individual, you know, infrastructure. You have got schools, power, sewer, water, so that the area can accept people back into it. And then, once this stabilization phase is over, we can move into the individual homes, so that they can be safer.

MARCIA BIGGS: Clearing Mosul is a process that they say could take years, even decades. So Janus is training local Iraqis to do the job, sending them out as a front-line search team, then investigating and removing any suspicious items themselves.

CHRISTIAN: We’re not going to be here the whole time, so when we — it’s our time to leave, they will have the capacity built from us, and the mentoring we have done, so that they can do it on their own.

MARCIA BIGGS: How are they doing?

CHRISTIAN: They’re — a lot of them are very apt to learn. They’re quick. They’re smart.

MARCIA BIGGS: Fawzi al Nabdi is the team leader for the Iraqi local partner. He’s cleared mines all over Iraq for the last six years.

CHRISTIAN: What you got?

FAWZI AL NABDI, Team Leader, Al Fahad Company (through interpreter): We are ready for this, because it’s my job and I love it. The Americans are here to complete our work and to help us. They have greater experience than we do. If we find any mines, we have to stop and they will investigate it and make a plan to remove it.

MARCIA BIGGS: But he says Mosul is the biggest project he has ever seen, and we’re told it could take at least a month to just get the campus cleared of mines. Only then can they start cleaning it up, so that students can resume classes, this itself a huge task.

ISIS fighters closed the university back in 2014, and used it as a military base. As coalition forces pounded ISIS targets, this seat of higher learning became a battleground.

Ghassan Alubaidy is the institute’s dean.

GHASSAN ALUBAIDY, Dean, Mosul Technical Institute (through interpreter): ISIS used our university to manufacture mines and bombs. For this reason, it was the target of airstrikes in the beginning. They struck the institute nine times, and they struck our workshops, too. Now we can’t use them.

MARCIA BIGGS: The former commander of coalition forces in Iraq, Lieutenant General Stephen Townsend, recently listed 81 locations where bombs were dropped, but had not yet exploded.

Facilities used to make weapons were often on the list of high-value targets for the coalition. So now those places are twice as likely to contain dangerous items.

So, this was once a workshop for electrical engineering students. You can still see the lab tables here. It was hit by an airstrike in 2015. Afterwards, members of the university staff found bomb-making instructions among the rubble. This was likely an ISIS bomb-making factory, and judging by the crater, a high-value target.

Despite the damage, Dean Alubaidy says he will hold classes this fall in alternate buildings, until the campus is ready. He’s expecting registration to be in the thousands, students who lost three years of education during the fighting and don’t want to lose another one.

GHASSAN ALUBAIDY (through interpreter): On our Facebook pages, we found a great number of students posting that they were full of encouragement to come back. For us, it was unbelievable. We couldn’t imagine it, to see how many students wanted to start again, how they were dreaming of the first day of classes, when they could sit in front of teachers again and start to live their lives again.

MARCIA BIGGS: Next door, Mosul University has already started classes. Students even volunteered to help in the cleanup.

But across the river, West Mosul was the site of ISIS’ last stand and bore the brunt of the battle. It’s densely packed Old City, with its flattened buildings, is a challenge for mine-sweeping.

FAWZI AL-NABDI (through interpreter): Most of the homes here were full of mines. And just here in front of us, a man with two kids came back to his home, and when he opened the door, the bomb killed him and his kids.

MARCIA BIGGS: Ahmed Younes fled back in early July with only the clothes on his back. Residents have been virtually banned from returning to his neighborhood on the outskirts of the Old City, but Ahmed said he got special permission, in order to retrieve some personal items.

AHMED YOUNES, Local Resident (through interpreter): We came on our own. We got permission to come, but they are not responsible if anything happens to us.

MARCIA BIGGS: Right now, there is no plan to begin clearing the Old City or even to determine how many mines there are. It is still out of bounds to anyone but the Iraqi security forces.

So the Janus team is focusing on progress in the rest of the city, building by building, bomb by bomb.

CHRISTIAN: Whoever made this device had a set goal. And to allow him to win, people get hurt. So you kind of compete against him to be better than him to take it out before it can do any harm.

MARCIA BIGGS: So, you feel like you’re winning the battle against ISIS?

CHRISTIAN: Yes, one IED at a time.

MARCIA BIGGS: For the PBS NewsHour, I’m Marcia Biggs in Mosul, Iraq.

HARI SREENIVASAN: Tune in later.

Frontline’s latest film, “Mosul,” was on the ground filming the fight as it unfolded street by street and house by house. That’s tonight on PBS.

The post The battle for Mosul is over, but this hidden ISIS danger could lurk for years appeared first on PBS NewsHour.




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Pauline Hanson’s ‘pain in her backside’

PAULINE Hanson has described Rod Culleton as a “pain in the backside”, and despite being disqualified from the Senate he’s continuing to cause her pain.




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Shorten: ‘Don’t underestimate Labor’

BILL Shorten believes Labor can still win next Saturday’s election despite new opinion polling predicting his party will struggle.




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Dundee ice hockey player jailed for rape of teen girl in his car

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Nicola Sturgeon has made 'no decision' on standing for Holyrood election in 2026

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SNP MSP welcomes contest with Flynn as she declares bid to restand for seat

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Analysis: The long battle to succeed John Swinney as SNP leader has now begun

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Two runners saved by the same public defibrillator back new appeal

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New research to better understand the biological factors of suicidal behaviour

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Record obesity rates and a dental crisis: Survey lays bare state of nation's health

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Housebuilder completes 'one of the largest' new Highland homes projects since 1970s

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Scottish family-owned distillery launches new ‘dining destination’

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RPG Cast – Episode 542: “Hell House? Hold My Beer”

There's not a ton of news right now, which isn't a big surprise considering the current challenges of making games. Instead we deep dive into our current games, with Jonathan, Josh, Kelley and Peter leading the charge. Anna Marie and Chris share hosting duties to wrap up this week's panel.

The post RPG Cast – Episode 542: “Hell House? Hold My Beer” appeared first on RPGamer.




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RPG Cast – Episode 543: “Go Find Gnome, Dumb***”

It’s a slightly more potty mouthed cast than usual, as Alice joins Peter, Kelley, Anna Marie and Chris to discuss what the cast has been playing for the week. Anna Marie’s 5-hour rule resurfaces and we explore what crazy black holes Chris has been down this week, alongside the news and your feedback.

The post RPG Cast – Episode 543: “Go Find Gnome, Dumb***” appeared first on RPGamer.



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  • Saturday Morning RPG
  • Seiken Densetsu 3
  • Trials of Mana

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RPG Cast – Episode 544: “You Will NOT Bucket Shame Me”

Things are looking grim: we get thrown out cars, assassinated for our kingdoms, drowned underwater, and struck out. If you’re scratching your head, don’t worry! Everything will make sense once you listen to this week’s podcast.

The post RPG Cast – Episode 544: “You Will NOT Bucket Shame Me” appeared first on RPGamer.



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  • RPG Cast
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  • Phantasy Star Online 2
  • Titan Quest: Anniversary Edition
  • Trials of Mana
  • Utawarerumono: Prelude to the Fallen
  • XCOM: Chimera Squad
  • Xenoblade Chronicles

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RPG Cast – Episode 545: “Did You Infect My Game With Harvest Moon?”

With many media events getting pushed back, the news is a little trim this week. But we still manage to pull together our basket of zany personalities for a podcast we hope brings a smile to your face.

The post RPG Cast – Episode 545: “Did You Infect My Game With Harvest Moon?” appeared first on RPGamer.




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RPG Cast – Episode 546: “Sugar Coated Turd”

Before we go pre-order all the games from Steve, we get a podcast up for you. Chris and Kelley complain about Civ 6 on Switch. Johnathan rages in some streets. And Josh is trying to find where to turn all his sidequests into. Ok, we're off to go be feline couriers.

The post RPG Cast – Episode 546: “Sugar Coated Turd” appeared first on RPGamer.




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RPG Cast – Episode 547: “Cancer Inducing External Hardrive”

The best way to predict the review score of a game is to play a demo of it. So never trouble another for what you can do yourself. For every minute you are playing you lose sixty seconds of ignorance. And without Pokémon tooth brushing games, life would be a mistake.

The post RPG Cast – Episode 547: “Cancer Inducing External Hardrive” appeared first on RPGamer.




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RPG Cast – Episode 548: “Do Not Karen on Me”

New Game Plus Expo comprises the bulk of this week’s news, while the crew ponders their love and hate for Phantasy Star Online 2. Just what has Anna Marie been playing the last two weeks? You’ll have to listen to the episode to find out!

The post RPG Cast – Episode 548: “Do Not Karen on Me” appeared first on RPGamer.




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RPG Cast – Episode 549: “What’s in Your Cranny?”

The RPG Cast has dived head first into #JRPGJuly in our now playing, but since the new month has rolled over, that also means new bugs and fish to catch in Animal Crossing as well! We've got a slew of editorial content to discuss and a smattering of news. Stay safe during the holiday weekend!

The post RPG Cast – Episode 549: “What’s in Your Cranny?” appeared first on RPGamer.



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RPG Cast – Episode 550: “Gamer Girl Glue”

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The post RPG Cast – Episode 550: “Gamer Girl Glue” appeared first on RPGamer.



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  • Trials of Mana
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RPG Cast – Episode 551: “I Don’t Want the Moe Future”

Join Anna Marie, Chris, Josh, and Kelley this week, as things get a little weirder than usual. A sticky soda fracas kicks off the show. Meanwhile, Kelley runs the news section for the first time, which is good since Chris stomps off after discovering this is definitely the worst timeline of them all. And don't forget, #JRPGJuly continues for one more week!

The post RPG Cast – Episode 551: “I Don’t Want the Moe Future” appeared first on RPGamer.




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RPG Cast – Episode 552: “Aw ***t, She’s Playing Diablo!”

This week we learn not to disturb Kelley's special demon slaying time, get too attached to dogs in games, or disturb the Harvest Moon plushie announcement. We also get your suggestions for series that need to be resurrected. Enjoy Action RPG August!

The post RPG Cast – Episode 552: “Aw ***t, She’s Playing Diablo!” appeared first on RPGamer.



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  • Fae Tactics
  • Knights of Pen & Paper
  • Phantasy Star Online 2
  • Story of Seasons: Friends of Mineral Town
  • The Legend of Heroes: Trails of Cold Steel III

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RPG Cast – Episode 553: “Greasing the Marbles”

As Chris and Anna Marie work out where the Romulan Neutral Zone is in their bed, Kelley steps in to host the show. There's also marbles. Time to go date some dog owners.

The post RPG Cast – Episode 553: “Greasing the Marbles” appeared first on RPGamer.





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RPG Cast – Episode 555: “Kelley Just Wants to Fight You”

Anna Marie briefly stops by to tell us about what she's been playing while recovering. The Series X has a price now, will the PS5 get one this week? Also, PAX is happening!

The post RPG Cast – Episode 555: “Kelley Just Wants to Fight You” appeared first on RPGamer.



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RPG Cast – Episode 556: “Chris Is Right for Once!”

It’s an extra large podcast this week. Alex, Kelley, Nathan, Chris, and Anna Marie break down all they’ve been playing. A huge news week is covered with colourful commentary. And we go off on more than one tangent. Help us, we’re incorrigible.

The post RPG Cast – Episode 556: “Chris Is Right for Once!” appeared first on RPGamer.




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RPG Cast – Episode 557: “PS5 Crunchwrap Supreme!”

This week we finally figure out if Dark Souls ripped off Breath of the Wild. We also get really worked up over Bethesda. When is Game Pass coming to PS5, again?

The post RPG Cast – Episode 557: “PS5 Crunchwrap Supreme!” appeared first on RPGamer.