Acute liver failure occurs when many cells in the liver die in a short period of time or the liver becomes damaged.

Definition

Acute liver failure occurs when many cells in the liver die in a short period of time or the liver becomes damaged. Pediatric liver failure is not as common as liver failure in adults and liver failure in children is typically very rare. If the features occur in individuals with prior hepatic disease, it is considered acute-on-chronic liver failure.

The most common causes are infections (e.g., viral hepatitis) and drug toxicity (e.g., acetaminophen ingestion). Hepatic encephalopathy may be accompanied by jaundice and nonspecific symptoms such as nausea, vomiting, and fatigue. The diagnosis is confirmed by identifying an elevation of hepatic enzymes and an altered coagulation panel in patients with encephalopathy.

Clinicians should maintain a high index of suspicion and aim to confirm the diagnosis as quickly as possible in order to start management early. Patients with ALF are usually critically ill and require admission to a critical care unit for extensive supportive treatment. The prognosis is poor, and most patients require urgent liver transplantation as definitive treatment.

Pathophysiology of acute liver failure

The exact pathophysiology of ALF depends on the underlying aetiology leading to liver dysfunction. Most cases of ALF are associated with a direct insult to the liver leading to massive hepatocyte necrosis (death of tissue) and/or apoptosis (programmed cell death), which prevents the liver from carrying out its normal function.

As the condition progresses it can lead to a hyperdynamic circulatory state with low systemic vascular resistance due to a profound inflammatory response. Collectively, this causes poor peripheral perfusion and multi-organ failure. Patients also develop significant metabolic derangements (e.g. hypoglycaemia, electrolyte derangement) and are at increased risk of infection.

Marked cerebral oedema occurs, which is a major cause of morbidity and mortality in ALF. This is thought to be due to hyperammonaemia causing cytotoxic oedema and increased cerebral blood flow that disrupts cerebral autoregulation.

Epidemiology

In developed nations, acute liver failure has an estimated incidence of fewer than 10 cases per million people per year. Acetaminophen (paracetamol) overdoses are prominent causes of fulminant hepatic failure in Europe and, in particular, Great Britain. Hepatitis delta virus (HDV) superinfection is much more common in developing countries than in the United States because of the high rate of chronic hepatitis B virus (HBV) infection. Hepatitis E virus (HEV) is associated with a high incidence of fulminant hepatic failure in women who are pregnant and is of concern in pregnant patients living in or traveling through endemic areas. These regions include, but are not limited to, Mexico and Central America, India and the subcontinent, and the Middle East.

Causes of acute liver failure

The exact cause of acute liver failure may be unknown, or it may be caused by any of the following:

Certain medicines, herbal supplements, and illegal drugs can cause liver damage. An acetaminophen overdose may cause acute liver failure. An overdose can happen by taking too much acetaminophen at one time or overtime. Other medicines that can cause liver failure include antiseizure medicines and certain antibiotics. Illegal drugs, such as cocaine, can also cause liver damage.

A viral infection may cause hepatitis. Hepatitis causes your liver to swell. Hepatitis can lead to acute liver failure.

Autoimmune diseases may cause your body to attack and damage your liver cells.

Health conditions, such as Wilson disease or Reye syndrome, may cause acute liver failure. Heart failure, heatstroke, and blood vessel diseases such as Budd-Chiari syndrome, can also cause acute liver failure.

Pregnancy-related conditions, such as fatty liver and HELLP syndrome, may cause acute liver failure.

Cancer metastasis is cancer that has spread and reached your liver from other parts of your body.

Risk factors

You are at risk for acute liver failure if you:

Take too much acetaminophen

Have certain diseases or infections, such as hepatitis, Wilson disease, and herpes simplex virus

Drink a lot of alcohol

Have poor blood flow to the liver

Complications

Abnormal bleeding: The liver plays an important role in producing proteins, called blood clotting factors, which help the blood to clot. If the liver isn’t working properly, these may not be produced which can lead to bleeding in any part of the body. Measuring the rate of blood clotting is a useful way to assess whether the liver is getting better or worse. Blood clotting may only be treated if there is bleeding or your child needs any procedures that may put him/her at risk of bleeding. Blood clotting factors may need to be given to treat this.

Infection: The liver plays an important part in fighting infection. Acute liver failure makes it more likely for a child to get an infection. Your child may be given intravenous (through the vein) antibiotics and anti-fungal medicines to prevent infection. Any specific infection identified will be treated.

Encephalopathy: Encephalopathy can occur because the liver is unable to clear toxins from the blood properly. This can lead to irritation and swelling of the brain. If there is a decrease in your child’s level of consciousness, leading to drowsiness, irritability, or behavior which is out of character, they may need to be cared for in an intensive care. A ventilator (breathing machine) may need to be used to allow a child to completely rest and enable additional treatment to be given.

Other treatments such as a form of dialysis may also be needed to try and rid the body of toxins.

Encephalopathy can be very difficult to assess and it can change from one minute to the next. For example, one minute a young child can be very sleepy and the next minute they may be sitting up in bed drinking a bottle.

Poor Kidney Function: When the liver fails the kidneys may not work as well as they should. In this case children are given fluids via a drip and a medicine to help them pass urine. They may also need a urinary catheter to accurately measure their urine output. Some children may need help from kidney dialysis for a short time.

Symptoms of acute liver failure

Signs and symptoms of acute liver failure may include:

Yellowing of your skin and eyeballs (jaundice)

Pain in your upper right abdomen

Abdominal swelling (ascites)

Nausea

Vomiting

A general sense of feeling unwell (malaise)

Disorientation or confusion

Sleepiness

Breath may have a musty or sweet odor

Tremors

Diagnosis and test

The following are the most common ways to diagnose acute liver failure:

Blood Tests: These will determine how well the liver is functioning. A prothrombin time test, which measures how long it takes blood to clot, is the most common exam. Other tests may measure levels of bilirubin, albumin, lactate (lactic acid), and phosphate.

Imaging Tests: This will usually include an ultrasound, which uses soundwaves to form an image of the liver so that doctors can detect liver damage. Other tests may include a computerized tomography (CT) scan and magnetic resonance imaging (MRI). Both help doctors look for other causes of acute liver failure when the ultrasound is negative.

Liver Biopsy: This is a surgical procedure that removes a tiny portion of liver tissue so that doctors can examine it under a microscope to determine what is wrong.

In addition to these tests, doctors may also ask about recent symptoms, medications, and factors that put the patient at risk of viral hepatitis, such as intravenous drug use and tattoos.

Treatment

Because ALF often involves rapid mental deterioration and the potential for multiorgan failure, patients should be managed in a dedicated Intensive Liver Therapy Unit (ILTU). For patients admitted in a non-transplant centre, the possibility of rapid progression of ALF makes early consultation with a transplant facility critical. Accordingly, plans for transfer to a transplant centre should begin in patients with any sort of abnormal mentation. Early institution of antidotes or specific antiviral therapy, liver dialysis and plasma purification techniques may prevent the need for liver transplantation and reduce the likelihood of a poor outcome after transplant.

Modes of treatment available

Medical management: This should happen in a dedicated Intensive Liver Therapy Unit (ILTU), providing supportive care to the liver and organs which may get damaged in ALF, especially the brain. Specific antidotes to counter the cause of liver insult are available for select cases like paracetamol poisoning, Viral hepatitis B, autoimmune hepatitis.

Plasma purification techniques: Once ALF sets in, there is spillover of inflammatory mediators into blood plasma which may damage other organ systems. Therapeutic plasma exchange and plasmapheresis are helpful in certain situations.

Liver dialysis: MARS (Molecular adsorption in a recirculating system) dialysis serves as a stabilisation technique as well as a bridge to transplant until a new liver is available from the dead organ donation pool.

Regenerative Hepatology: The liver has immense power to regenerate and during ALF, the bone marrow supplies stem cells to the ailing liver to recuperate. These stem cells reach the liver from the marrow and transform themselves into liver cells. There are special regenerative medicines/techniques to facilitate this.

Liver transplantation: If medical management fails or when there are clear pointers in lab tests and clinical features which would tell us that medical management won’t be efficacious, then urgent liver transplantation is the way to go.

Medications

When acute liver failure is caused by ingesting toxic substances, acetaminophen overdose, or viral hepatitis, it can often be treated through medication. These include the following:

Activated Charcoal: This is carbon that has been exposed to high temperatures, which increases its surface area and makes it effective at absorbing toxins.

Antiviral Therapy: This encompasses a variety of medications that will slow down the effects of the hepatitis virus. They may include entecavir (Baraclude), tenofovir (Viread), lamivudine (Epivir), adefovir (Hepsera), and telbivudine (Tyzeka).

N-Acetyl Cysteine: This is a derivative of amino acid that is highly effective in treating the effects of acetaminophen overdoses, as well as mushroom poisoning.

Penicillin: When given in high doses, this common antibiotic can combat toxins such as mushrooms.

Prevention of acute liver failure

You can prevent some of the underlying causes of acute liver failure. Make sure you:

Always follow the directions on the label when taking a medicine that has acetaminophen. Be very careful not to mix medicines that contain acetaminophen. Talk with your pharmacist or healthcare provider if you have questions.

Stop drinking alcohol if you have a liver problem.

Talk with your healthcare provider about the hepatitis A and B vaccines. You may need these if you are at risk for coming into contact with the blood or feces of a person who has viral hepatitis. If you visit other countries, particularly developing nations, don’t drink local tap water.

Atrial septal defect (ASD) is a congenital heart disease in which there is an opening in the wall.

Definition

Atrial septal defect (ASD) is a congenital heart disease in which there is an opening in the wall (the atrial septum) between the heart’s two upper chambers (the right and left atria). An ASD is one of the defects referred to as “a hole in the heart.”

Normally, the heart has two sides, which are separated by a muscular wall called the septum. Each side of the heart also has two parts the upper chamber, called an atrium, and the lower chamber, called a ventricle. The right side of the heart carries deoxygenated blood back into the heart and the left side carries oxygenated blood back out to the body.

An ASD allows the oxygenated blood to pass from the left atrium, through the opening in the septum, and into the right atrium, causing the two to mix. This leads to increased blood flow through the right side of the heart and lungs. Over time, this “extra” blood volume stresses the heart and causes the right atrium, ventricle and pulmonary arteries to dilate (become wider). This can eventually lead to heart failure, pulmonary hypertension or heart rhythm abnormalities.

Prevalence

ASDs are common and can present at any age. Females constitute 65% to 75% of patients with secundum ASDs, but the gender distribution is equal for sinus venosus and ostium primum ASDs.

Atrial septal defect pathophysiology

In most cases of atrial septal defect, blood shunts from the left atrium to the right atrium, causing a volume overload of the right-sided chambers. The magnitude of shunting depends on the size of the defect, the ratio of pulmonary to systemic vascular resistance, and the relative compliance of the two ventricles. Excessive blood flow through the right-side chambers results in their dilation and hypertrophy.

Pulmonary vasoconstriction and development of pulmonary hypertension may occur as a consequence of excessive pulmonary blood flow and may precipitate right-side CHF. In conditions associated with high right atrial pressure (eg, pulmonic stenosis), shunting may occur from right-to-left across a patent foramen ovale or atrial septal defect, potentially resulting in cyanosis and polycythemia.

Types of Atrial septal defect

Atrial septal defects fall into three categories. Within each type of defect, the severity may vary. It may be small or large and may require surgery or close without surgical intervention. Only a cardiologist or cardiothoracic surgeon can determine the severity of the heart problem.

Secundum ASD (ASD 2 or ASD II): The most common type of ASD, where the defect is located in the middle of the atrial septum.

Primum ASD (ASD 1 or ASD I): The second most common type of ASD, where the defect is located in the endocardial cushion area of the septum. This type of ASD is often accompanied by other problems, including an endocardial cushion ventricular septal defect, which means that the defect includes the lower portion of the heart as well as the upper portion.

Sinus Venosus ASD (Sinus Venus): This type of ASD occurs in the upper portion of the septum, in close proximity to where the vena cava brings blood to the heart from the body.

Risk factors

Atrial septal defect (ASD) occurs as the baby’s heart is developing during pregnancy. Certain health conditions or drug use during pregnancy may increase a baby’s risk of atrial septal defect or other congenital heart defect. These things include:

German measles (rubella) infection during the first few months of pregnancy

Diabetes

Lupus

Alcohol or tobacco use

Illegal drug use, such as cocaine

Use of certain medications, including some anti-seizure medications and drugs to treat mood disorders

Some types of congenital heart defects occur in families (inherited). If you have or someone in your family has congenital heart disease, including ASD, screening by a genetic counselor can help determine the risk of certain heart defects in future children.

Causes

Congenital heart defects can run in families. Talk to your doctor about genetic testing if you or a family member has an atrial septal defect.

Some conditions that occur during pregnancy can increase the risk of a baby having ASD, including:

Diabetes

Drug, tobacco, or alcohol use

Lupus

Obesity

Rubella, also known as German measles

Phenylketonuria (PKU)

Symptoms

You may not have symptoms if your ASD is very small. If you do have symptoms, they may not appear until you are age 20 or older. You may have any of the following:

Not having any energy, or feeling very tired (fatigue)

Feeling your heart skip a beat or flutter

Shortness of breath that is worse during exercise

Lips and fingernails turn blue with activity

Colds or lung infections that happen often

Chest pain

Atrial septal defect complications

Over time, if an ASD isn’t repaired, the extra blood flow to the right side of the heart and lungs may cause heart problems. Usually, most of these problems don’t show up until adulthood, often around age 30 or later. Complications are rare in infants and children.

Possible complications include:

Right heart failure: An ASD causes the right side of the heart to work harder because it has to pump extra blood to the lungs. Over time, the heart may become tired from this extra work and not pump well.

Arrhythmias: Extra blood flowing into the right atrium through an ASD can cause the atrium to stretch and enlarge. Over time, this can lead to arrhythmias (irregular heartbeats). Arrhythmia symptoms may include palpitations or a rapid heartbeat.

Stroke: Usually, the lungs filter out small blood clots that can form on the right side of the heart. Sometimes a blood clot can pass from the right atrium to the left atrium through an ASD and be pumped out to the body. This type of clot can travel to an artery in the brain, block blood flow, and cause a stroke.

Pulmonary hypertension (PH): PH is increased pressure in the pulmonary arteries. These arteries carry blood from your heart to your lungs to pick up oxygen. Over time, PH can damage the arteries and small blood vessels in the lungs. They become thick and stiff, making it harder for blood to flow through them.

These problems develop over many years and don’t occur in children. They also are rare in adults because most ASDs either close on their own or are repaired in early childhood.

Diagnosis and test

Your child’s doctor may have heard a heart murmur when listening to your child’s heart with a stethoscope. The heart murmur is from the abnormal flow of blood through the heart.

Your child may need to see a pediatric cardiologist for a diagnosis. This is a doctor with special training to treat heart problems in children. The doctor will examine your child and listen to your child’s heart and lungs. The doctor will find out where the murmur is best heard and how loud it is. Your child may have some tests, such as:

Chest X-ray: This test may show an enlarged heart or it may show changes in your child’s lungs because of the blood flow changes caused by an atrial septal defect.

Electrocardiogram (ECG): This test records the electrical activity of the heart. It shows abnormal rhythms (arrhythmias) that may be caused by an atrial septal defect. It can also find heart muscle stress caused by an atrial septal defect.

Echocardiogram: This test uses sound waves to make a moving picture of the heart and heart valves. An echo can show the blood flow through the atrial septal opening and find out how big the opening is.

Cardiac catheterization: This tests uses a thin, flexible tube called a catheter put near the heart. Contrast dye is used during a cardiac catheterization to get even clearer pictures. In some children, this procedure may be used to close the atrial septal defect.

Treatment and medications

About half of ASDs close without treatment. One in five ASDs will close naturally during the first year of life. Your child’s doctor may suggest careful monitoring to see if the opening closes on its own before recommending further treatment.

While some ASDs close over time, others require treatment. Options include:

Careful monitoring: Depending on the diagnosis, doctors may monitor children who have ASD without symptoms of heart failure. This could require regular check ups and tests to see if the defect gets smaller or closes on its own.

Cardiac catheterization: Often done under general anesthesia, an interventional cardiac catheterization uses a small, flexible tube threaded through a blood vessel. Through this tube, a small device can plug the hole in the atrial septum. Once secured in place, normal tissue grows around the device and no further procedures are required. Patients usually spend one night in the hospital after having ASD closure during a cardiac catheterization.

Device closure: Doctors use a small, flexible tube called a catheter along with another tool called a septal occluder. The doctor will carefully push the catheter through your child’s blood vessels all the way into her heart. Then, your doctor will use the septal occluder to stop blood from flowing through the ASD hole.

Surgery: In some cases, open-heart surgery is needed to repair the ASD. While your child is asleep for the repair, a heart-lung bypass machine maintains the body’s flow of blood and oxygen. Your child may spend two to four days in the hospital afterward. Outcomes from surgery are typically very good, although there are risks from possible complications and limits on activity during recovery.

Medicine: Many children with ASD don’t have symptoms and don’t need medication. But it still might be a good idea for some children to take it. Medicine can help some children’s hearts work better. For example, water pills (diuretics) help a child’s heart work better by flushing extra fluid out of a child’s body through their kidneys.

Prevention of Atrial septal defect

In most cases, ASD cannot be prevented. If a woman is planning to conceive, she needs to schedule a pre-conception visit with their doctor. This visit should include:

Getting tested for immunity to Rubella: If a woman is not immune, consult the doctor about getting vaccinated.

Going over one’s current health conditions and medications: An individual needs to carefully monitor certain health problems during pregnancy. The doctor may also recommend adjusting or stopping certain medications before one gets pregnant.

Reviewing family medical history: If one has a family history of heart defects or other genetic disorders, she must consider talking with a genetic counsellor to determine what the risk might be before getting pregnant.

Alexei Zhuravlev has offered a dire warning to the United States.

Russian official Alexei Zhuravlev has offered a dire warning to the United States, claiming that President Vladimir Putin could wipe both the East and West coasts with just four nuclear missiles.

Alexei Zhuravlev, a member of Russia’s parliament, declared on state TV station Russia-1 on Monday that the country is capable of launching a devastating nuclear assault on the US in response to its assistance for Ukraine in the conflict.

I will tell you perfectly competently that two Sarmat missiles are required to destroy the entire East Coast of the United States, the pro-Kremlin commentator stated, referring to Russia’s latest intercontinental ballistic missiles, dubbed as Satan-2 among NATO nations.

And the same is true for the West Coast, Zhuravlev added.

Four rockets, and nothing will be left.

The ultra-hawkish legislator was commenting on a CBS News story from April that discussed what a nuclear assault on New York City would look like.

According to Russian official Alexei Zhuravlev, four Satan-2 missiles could strike the US East and West coastlines.

The ardent Putin admirer then shifted his focus to Ukraine, reiterating the erroneous Kremlin statement that around 5% of the neighboring country’s population, or approximately 2 million people, are “incurable” Nazis.

Zhuravelv, who, like many in the Russian establishment, sees Ukraine as a renegade region of Russia, went on to assert that the continuing conflict officially referred to as a special military operation by the Kremlin is a civil war.

This is not the first time Zhuravlev has vowed to destroy Western countries that are assisting Ukraine in its fight against Russia.

A month ago, the legislator bragged on state television that one Sarmat and the British Isles are gone.

Dmitry Rogozin, the president of Russia’s official space agency, Roscosmos, tweeted a week ago that 50 new Sarmat-2 ballistic missiles will be combat-ready shortly.

I propose that aggressors address us more gently, Rogozin stated.

Following the successful test flight of Sarmat, or Satan-2, last month, Putin stated in a televised address that the missile would make Russia’s adversaries think twice before issuing threats.

The Kremlin leader further warned that the Satan-2 missile is capable of defeating all contemporary anti-missile defense systems.

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Macron said nothing could be ruled out in terms of additional sanctions against Russia in the coming weeks.

French President Emmanuel Macron said on Tuesday (May 31) that, following a sixth European Union package of sanctions against Russia, nothing could be ruled out in terms of additional sanctions in the coming weeks.

Speaking to reporters following an EU summit in Brussels, he also said he hoped that in the next days and weeks agreement could be reached with Russia to allow more exports of food from Ukraine.

He said recent talks on the matter between the Russian and Turkish presidents had produced positive conclusions.

I hope that the next few days or weeks will make it possible to resolve this situation, Macron added.

During his last conversation with Russian President Vladimir Putin and German Chancellor Olaf Scholz, Macron said he had made an offer to Putin to draft a UN Security Council resolution providing a framework for the release of grain from Ukraine’s blocked seaports.

Security guarantees must be given to the Ukrainians so their ships are not attacked, Macron said.

We are now waiting for a reply from Russia on this point and are liaising with the UN secretary general.

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Biden to hold meeting with head of Fed Reserve over inflation.

President Joe Biden on Tuesday (May 31) holds a rare White House meeting with the head of the Federal Reserve, Jerome Powell, to discuss soaring inflation and White House attempts to tame the politically damaging price surge ahead of midterm elections.

In their first such meeting this year, Biden and Powell will discuss the state of the American and global economy, the White House said, with an emphasis on inflation.

This is Biden’s top economic priority, the White House said, as we transition from a historic economic recovery to stable, steady growth that works for working families.

Inflation of more than 8 per cent is casting a heavy shadow on Biden’s claims to be steering the US economy back to health after the COVID-induced crash.

Employment is back near pre-pandemic levels and growth is strong, but savage price increases for essentials including food and fuel are driving growing public dissatisfaction.

The Fed has raised rates three quarters of a percentage point, kicking off what central bank officials say could be a series of hikes aimed at calming down the economy, although there are fears that the unintended result may be recession.

Federal Reserve Governor Christopher Waller said Monday that he backs several more half-point rate hikes – “until I see inflation coming down closer to our 2 per cent target. 

Biden is scrambling to ease the pressure on American consumers ahead of November midterm elections in which his Democrats are forecast to lose control of Congress to the Republicans.

Biden’s own approval ratings are barely in the 40 per cent range, reflecting his inability to sell voters on his upbeat message of US economic recovery.

As the election approaches, Biden has pivoted to more aggressively trying to explain the inflation phenomenon as a byproduct of forces beyond his control.

These include the Russian invasion of Ukraine, which triggered Western sanctions disrupting the huge Russian energy industry.

President Vladimir Putin’s invading forces, meanwhile, have all but put a halt to Ukraine’s important wheat exports.

Biden calls the effect Putin’s price hike.

Writing in the Wall Street Journal on Monday, Biden underlined the independence of the Federal Reserve, but noted that the central bank has a primary responsibility to control inflation. 

Biden recalled that his predecessor Donald Trump frequently launched political attacks on the Fed and that other presidents had also sought to influence its decisions inappropriately during periods of elevated inflatio. 

I won’t do this, he pledged.

In the op-ed, Biden said his long-term plan for economic health includes easing the pace of post-COVID recovery to more sustainable levels, boosting economic productivity and reducing the federal budget deficit.

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China backed Myanmar rebel group.

A powerful Myanmar ethnic rebel group with close ties to China called on Tuesday (May 31) for the junta to engage in dialogue with anti-coup fighters to end 15 months of bloodshed.

With a standing force of around 25,000, the United Wa State Army is one of the world’s largest non-state militaries, manufacturing its own guns and conscripting a member from each household in areas under its control.

But the UWSA largely sticks to its autonomous enclave on Myanmar’s northern border with China, and has so far had little involvement in the fighting sparked by the toppling of Aung San Suu Kyi’s government by the military last year.

The UWSA made an appeal to all parties in the conflict for resolving it by negotiation as soon as possible, it said in a statement following talks with junta officials in the capital Naypyidaw.

Internal conflicts in the borderlands that have plagued Myanmar since independence from Britain have proved that any fundamental problems cannot be solved by military force, it said.

It added the UWSA would remain outside the conflict between the junta and its opponents, which has plunged the country into turmoil and displaced hundreds of thousands of people.

Myanmar has about 20 ethnic rebel armies many of which control swathes of remote border territory – that have fought each other and the military for decades over the drug trade, natural resources and autonomy.

Some have condemned the ouster of Aung San Suu Kyi’s government and offered shelter and weapons training to the People’s Defence Forces (PDF) that sprung up after the coup.

Analysts say the PDFs have surprised junta forces with their effectiveness.

Wa forces dwarf the collage of other ethnic rebel groups, posing a deterrent to the military and providing Beijing with a useful bridgehead into its resource-rich neighbour.

China remains a major ally of the Myanmar junta and has refused to label the military’s power grab a coup.

In April, Beijing said it would help safeguard Myanmar’s sovereignty, independence and territorial integrity no matter how the situation changes.

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Bomb blast in Myanmar killed one and left nine others with severe injuries.

A bomb blast in a busy neighbourhood of Myanmar’s commercial hub Yangon killed one person and injured nine others on Tuesday (May 31), police and junta authorities said.

The Southeast Asian country has been in turmoil since a military coup that ousted Aung San Suu Kyi’s civilian government, with anti-junta groups clashing regularly with the military.

The blast occurred around 3.20pm local time near a bus stop in Yangon’s Downtown district, a police source said, requesting anonymity.

Pictures published by local media showed passers-by tending to several injured people as they lay on the ground, and what appeared to be blood on the pavement.

A local volunteer paramedic who arrived on the scene shortly after the explosion told AFP his team had taken two seriously injured people to hospital.

Security forces later found an unexploded grenade near the site of the blast, the police source said.

One man in his 30s died from his injuries after being taken to a hospital and nine others were receiving treatment, the junta’s information team said in a statement.

The blast came from a “homemade mine”, it said, blaming the attack on “People’s Defence Force” fighters – groups that have sprung up to fight the military’s bloody crackdown on dissent.

No group has claimed responsibility for the attack.

A shadow government dominated by lawmakers from Aung San Suu Kyi’s ousted party, and which is working to reverse the coup, condemned the blast.

We strongly condemn this terrorist act targeting civilians, its defence ministry said in a statement.

Across the country, there are almost daily killings of low-level junta officials or alleged informers, with details murky and reprisals from the military often following quickly.

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In a separate statement, the junta said a bombing in Nawnghkio in northern Shan state had killed the head teacher of a primary school and injured seven others.

Local media also reported the blast, with images showing damaged walls and debris strewn across the floor.

AFP was unable to verify the reports.

Most of the violence has occurred in rural areas, although anti-coup fighters have also targeted officials and infrastructure in towns and cities.

Last November, a top executive from Mytel – a telecom venture between Myanmar’s military and Viettel, itself operated by Vietnam’s army – was gunned down outside his Yangon home.

And in August, anti-coup fighters shot dead five policemen on a commuter train in Yangon.

More than 1,800 people have been killed and more than 13,000 arrested in the junta’s crackdown on dissent since the coup, according to a local monitoring group.

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Popular French Journalist killed in Russia-Ukraine conflict.

US refused to aide Ukraine with rocket launcher that strike in Russia.

The battle for eastern Ukraine is heating up as the Russian forces are trying to surround the towns under Ukrainian control, the ground troops are outnumbered and outgunned and the United States has backed off from helping Ukraine with rocket systems.

The US president was asked to update on plans to send larger military aid to Ukraine and the President said.

We’re not going to send Ukraine rocket systems that can strike in Russia.

Earlier, the American media had reported that Biden administration was mulling to send rocket systems to Ukraine and the Russians had warned that this attempt will cross a red line.

Just hours before Biden’s announcement, the Russian Foreign Minister, Sergey Lavrov, appeared on a French news network to talk about their new plans in Ukraine and said.

Russian troops have entered the outskirts of the Ukrainian city of Sievierodonetsk, it is the largest city in Luhansk which is partly under Ukrainian control.

Witnesses say that the city is being bombed at least 200 times in an hour and all the critical infrastructure has been turned to dust.

The Ukrainian President says that they are doing everything to hold off Moscows’s advances.

The invasion so far has killed thousands of civilians, over 6.7 million people have been displaced and more than 14,000 cases of alleged war crimes are being probed by Ukraine, several Russian soldiers have pleaded guilty in cases of shelling and killing civilians.

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