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This study uniquely explores the impact of militarization on carbon emissions in North Atlantic Treaty Organization (NATO) countries from 1985 to 2019 using panel econometric techniques. NATO countries, characterized by substantial defense budgets, advanced technologies, high industrialization, and significant energy consumption, offer a unique context for examining these factors. Employing the Pooled Mean Group Autoregressive Distributed Lag (PMG-ARDL) and FMOLS models, the research analyzes the long-term and short-term dynamics across three groups: traditional NATO members (Group 1), new NATO members (Group 2), and a combined group (Group 3). Relevant variables used in the estimation are industrialization, technological innovation, energy consumption, and economic growth. Findings reveal that in Group 1, military expenditure and energy consumption significantly increase carbon emissions, while industrialization and technological innovation reduce them. In Group 2, increased military spending and industrialization reduce emissions, but energy consumption and technological innovation increase them. For Group 3, economic growth significantly drives emissions, whereas industrial advancements and selective technological innovations mitigate them. The study underscores the need for tailored environmental policies and technological advancements to reduce carbon emissions, contributing to sustainable development within military alliances. These insights are crucial for policymakers aiming to balance defense needs with environmental sustainability in NATO countries.
Specialists globally employ various clinical scales and instruments to assess balance, gait, and motor functions in children with cerebral palsy (CP). Selecting appropriate assessment tools is essential for planning studies, developing effective treatment strategies, and tracking clinical outcomes. Given the diversity in assessment needs – whether evaluating dynamic, functional, or static balance – there is a need to identify the most suitable tools for each aspect. Therefore, the primary objective of this review is to critically analyze current clinical and instrument-based assessment methods in the literature to determine the most effective approaches for pediatric CP. This systematic review retrieved 1,812 papers, of which only 23 met the inclusion criteria and presented assessment methods for evaluating balance and motor functions in pediatric CP. These methods were further organized into clinical and instrument-based assessment groups. Among clinical examinations, the Pediatric Balance Scale and Gross Motor Function Measures were considered gold standards and featured in eight studies. In contrast, postural sway measured with the Biodex Balance System, Gait Stability Indices from the GAITRite system, and EMG sensing were the predominant instrument-based observations. Despite this variety, a consensus on the best assessment methods remains lacking. This review highlights the potential of integrating AI-driven metrics that combine clinical and instrument-based data to enhance precision and individualized care. Future research should focus on creating integrated, individualized profiles to better capture the unique capabilities of children with CP, enabling more personalized and effective intervention strategies.
Aims: The Default Mode Network (DMN) is a network of brain regions that are functionally connected and become active during self-directed thought, introspection, and rumination. Rumination refers to the repetitive and passive focus on distressing thoughts, often linked to negative emotional states. Specifically, an increase in the brooding type of rumination is associated with severity of depression. Functional magnetic resonance imaging (fMRI) research offers a unique perspective on how the functional connectivity of the DMN is involved in rumination, shedding light on its neurobiological underpinnings. This systematic review aims to synthesise existing literature that explored the functional connectivity of the DMN in individuals with depressive disorders during episodes of rumination.
Methods: This systematic review investigated activity in DMN in patients with depression using resting state fMRI scans. Literature search was done on PubMed, Medline and Cochrane using search terms “depression OR Major Depressive Disorder OR depressive episode” AND “ruminat*” AND “functional MRI OR fMRI”. 324 studies were identified from the three databases, and after removing 42 duplicates, 274 studies were selected for title and abstract screening.
Abstracts were assessed for eligibility using the following inclusion criteria: original studies in peer-reviewed journals, clinical diagnosis of depressive disorder, measurement of rumination using a validated scale and resting state or task-based fMRI. 193 studies were excluded, and 58 studies were moved to full-text review. Intervention studies were also excluded at this stage. Following the above criteria, 25 studies were selected for full-text review.
Results: Out of the 25 studies, 9 used task-based fMRI and 16 used resting state fMRI. Only resting state fMRI studies were included for data extraction. Results from the 16 studies showed that depressed people had both increased and decreased functional connectivity between different regions of the brain during brooding rumination. The connectivity within the DMN was increased, while connectivity between DMN and other areas of brain, including between DMN and TPN (task-positive network) was reduced, when compared with healthy controls.
Conclusion: This review shows widespread associations between depression, rumination and functional connectivity within and between various brain regions. Increase of functional connectivity within the DMN during depression might be responsible for the increase in brooding rumination seen in depressed individuals. A decrease in connectivity of DMN to other areas of the brain might result in difficulties for depressed individuals to switch from a ruminating state into the executive network mode. Overall, this review provides an overview of the neurobiological underpinnings for the increase in brooding rumination in depression.
Aims: Changes in the hippocampus and amygdala are associated with psychotic illnesses. However, there is little research examining the output tracts of these regions in psychosis. The fornix connects the hippocampus to the basal forebrain anteriorly and to the hypothalamus posteriorly, while the stria terminalis (ST) connects the amygdala to these same areas. The anterior commissure divides these tracts into anterior (pre-commissural) and posterior (post-commissural) fibres. This study investigates these two tracts and their pre- and post-commissural fibres in young adolescents with psychotic experiences (PEs) as compared with controls across two timepoints (TP), 2 years apart.
Methods: 51 young adolescents with PEs (37 female) and 43 healthy controls (25 female) underwent high angular diffusion imaging at TP1, while 39 adolescents with PEs and 29 healthy controls underwent same at TP2. Images were processed using ExploreDTI and, using a bespoke method, the fornix and ST were separated and pre-commissural and post-commissural fibres isolated. Analysis of covariance was performed correcting for age, sex and intracranial volume.
Results: Right pre-commissural fornical Mean Diffusivity (MD) (p=0.035) and Radial Diffusivity (RD) (p=0.009) were increased, with decreased Fractional Anisotropy (FA) (p=0.045) at TP1. There was increase across MD (p=0.004), RD (p=0.005) and Axial Diffusivity (AD) (p=0.042) at TP2. Only right pre-commissural fornix MD and RD increases at TP2 survived Bonferroni correction at p=0.0083. No ST differences survived correction for multiple comparisons.
Conclusion: This study uses a novel method to separate the stria terminalis and fornix, using an anatomically driven approach. The results show that the hippocampal output fibres are involved in early psychosis, while the amygdala fibres are not affected. Of the hippocampal fibres, it is the fibres going to the basal forebrain, responsible for motivation and behaviour, that are specifically impacted. These changes in adolescents are entirely right sided, reflecting similar right sided hippocampal changes found in adults with psychotic illnesses. The right basal forebrain is known to influence vigilance, attention and emotional processing, which are affected in patients with psychosis. The findings from this study suggest that the right basal forebrain is affected in children and adolescents with psychotic experiences, which are common in people who go on to develop psychotic illnesses, and thus supports the neurodevelopmental theory of psychosis.
Law & Society scholars often dismiss Law & Economics (L&E) as insoluble with our core beliefs about distributive justice, culture, and social solidarity. This reaction has yielded missed opportunities for new theory emergent between the fields. One such opportunity came in 1978, when Guido Calabresi and Philip Bobbitt argued that societies make “tragic choices” about scarce resource allocations so as to reconcile such choices with core culture, ethics, and values. In Calabresi’s later words, their book was a “more or less explicit appeal to anthropology for help.”1 Today, sociolegal studies remain well-poised to answer this appeal. Taking theory about moral costs from Calabresi in L&E and adding anthropological thought on the meaning of “value,” this essay presents situated valuation – a contextualized notion of value that accounts for the moral costs of inequalities while supporting principled scrutiny of redistributive policies meant to reduce inequality but sometimes worsening it. This discussion highlights the importance of interpretive social science in the study of distributive inequality, while showcasing a neglected but generative link between mutually imbricated interdisciplinary communities.
The world is facing a global plastics crisis with more than 50% of plastics produced only being used once and then discarded. If nothing is done to put an end to plastic pollution, it is projected that by 2050, there will be more plastic (by weight) than fish in the ocean, affecting natural ecosystems, biodiversity and human health. While solutions often target governments and corporations, a crucial group is frequently ignored: informal waste pickers. Despite the limitations of recycling alone, waste pickers significantly impact the plastic recycling chain. This review addresses the gap in our understanding of their role. It argues that waste pickers are an essential component of the larger portfolio of solutions for the plastic crisis but face significant challenges.
How does the decline of traditional news outlets affect political polarization? We provide novel evidence on this question by examining the link between local newspaper exits, media consumption, and electoral behaviour in a multiparty setting. Our empirical analysis combines a unique panel of all German local newspapers between 1980 and 2009, electoral returns, and an annual media consumption survey of more than 670,000 respondents. Using a difference-in-differences design, we demonstrate that local newspaper exits increase electoral polarization. Additional analysis points to changes in media consumption as the underlying mechanism driving this result: following local news exits, consumers substitute local news with national tabloid news. Our findings extend prior results in the US context to a multiparty setting and shed new light on the causal chain running from changing local news landscapes to electoral behaviour.
Beaumont Hospital is the National Neurosurgical Centre in Ireland. Due to the high numbers of referrals from Neurology and Neurosurgery, The Department of Psychiatry established a specialist Neuropsychiatry inpatient Liaison service and a weekly Neuropsychiatry outpatient clinic. Many of the referrals that the service receive involve the management of delirium. Delirium is a common medical complication, particularly in neurosurgical settings. Delirium causes significant symptom burden which can lead to distress to all involved and impacts quality of life.
Objectives
The aim was to improve the rates of referrals for delirium presentations and referral rates overall from Neurology and Neurosurgery. The neuropsychiatry service have implemented a delirium protocol for all medical and surgical teams in Beaumont Hospital. This protocol can be accessed through the Beaumont hospital phone app, or on site on each ward. For this reason, delirium can be managed by medical teams in the first instance. If this is not successful, neuropsychiatry can be contacted for further advice or review of patients with more complicated presentations.
Methods
The neuropsychiatry service receives referrals through the Patient Information Profile Explorer system which is accessed through the Beaumont Hospital online portal. In the event of an urgent referral, neurology or neurosurgery teams can contact the neuropsychiatry service directly by phone. Referrals are logged on the team referral log book, and details of the referral are recorded along with diagnosis and management. Data was collected retrospectively from the PIPE and log book to measure the rates and reasons for referrals over a one year period. Rates and details of referrals were initially recorded between July-December 2022. An educational intervention was provided where psychoeducation was provided to junior hospital doctors during protected teaching times and further education was provided over the phone when referrals were discussed between team members. Rates and details of referrals were then recorded between January-July 2023.
Results
There was a reduction in referrals when comparing the two six month periods. There were 115 neuropsychiatry referrals from July to December 2022 and 78 referrals from January to July 2023. Rates of delirium referrals also reduced from 31% to 25% after psychoeducation was provided to junior doctors.
Conclusions
This audit highlights the importance of communication and education for medical and surgical trainees in the management of delirium. There is a high rate of turnover of junior doctors throughout the year in Beaumont Hospital. For this reason, it is imperative that continued education is provided to allow them to follow the delirium protocol independently before seeking tertiary service assistance. Ultimately, early and rapid intervention of delirium can have a positive impact on patient care and prognosis
The concept of digital psychiatry, encompassing technologies such as mental health apps, Virtual Reality (VR), Artificial Intelligence (AI), and telepsychiatry, emerges as a potential solution to bridge the existing gaps in the mental health system of Pakistan. However, one of the major barriers to the implementation of these technologies is hesitancy to adopt digital tools by psychiatrists.
Objectives
This study aims to explore the current understanding of digital psychiatry, the barriers faced by psychiatrists in its’ widespread implementation, and their willingness to adopt these services in clinical practice.
Methods
This cross-sectional study surveyed psychiatrists’ knowledge, attitudes, and practices on digital psychiatry from 39 public hospitals across Pakistan using an online validated questionnaire from January to July 2023. Participants included psychiatry residents, fellows, and consultants practicing in Pakistan. Responses were analyzed with Raosoft software, Quirkos, and SPSS 26 using thematic analysis and correlation.
Results
A total of 200 participants responded to the questionnaire, primarily in the age range of 20-30 years (56%). The gender distribution was 55% male (N = 111) and 45% female (N = 89). Among the professional roles, 23% were consultants, 7% were registrars, 54% were psychiatry residents, and 17% were medical officers. Respondents came from both rural (N = 148, 74%) and urban (N = 52, 26%) practice settings. Regarding telepsychiatry, 46% strongly agreed that they are familiar with telepsychiatry, while 58% agreed that telepsychiatry can save time and money. Additionally, 22% strongly agreed that it’s a viable approach for patient care. Concerning perspectives on Artificial Intelligence (AI) in digital psychiatry readiness, only 40% of participants had received AI training. However, 55% expressed interest in collaborating with international centers on AI-related projects. In terms of mental health apps, 62% of respondents reported limited familiarity with them. Nevertheless, 65% believed that these apps could potentially save time and money for psychiatric health systems. Lastly, concerning Virtual Reality (VR) in psychiatric care, 57% of participants were familiar with VR technology, but only 43% were acquainted with its applications in psychiatry. Notably, 71% did not view VR as a viable replacement for in-person psychiatric management.
Conclusions
This is the first study conducted on understanding digital psychiatry in Pakistan’s healthcare system, which revealed multiple challenges to digital health competency among psychiatrists. This emphasizes on the need for formal training and funding towards resources to overcome obstacles in utilizing mental health technologies.
The thalamus, a dual grey matter formation within the diencephalon is thought to be involved in psychosis. It consists of distinct nuclei with specific functions. To date no study has investigated the volumes of the thalamic nuclei in young adolescents with Psychotic Experiences (PEs).
Methods
This study used T1 imaging with Freesurfer analysis to investigate the differences in thalamic nuclei in 98 young people (53 with PEs) over three time points, from ages 11 to 18. A linear mixed effects (LME) model was used to examine the longitudinal nature of the data.
Results
The findings were entirely left sided – specifically a smaller left whole thalamus (p = 0.04), significant reduction in the size of the left pulvinar (p = 0.008) and a slight increase in the size of left ventral nucleus (p = 0.005).
Conclusion
This study found significant volumetric differences in thalamic functional composite nuclei between adolescents with a history of PE compared with healthy controls. Two such nuclear groups survived post-hoc DTR testing, the left ventral and left pulvinar nuclei. The pulvinar nucleus demonstrated a reduced volume over time in PE groups compared with healthy controls whilst the left ventral nucleus demonstrated an increased volume over time in PE groups compared with controls. The thalamus has been shown to be actively involved in the modulation of cortico-cortical communication via cortico-thalamo-cortical pathways, thus synchronizing the activity of the cortex during tasks that require attention. One of the core deficits believed to be a part of psychotic illnesses is the inappropriate modulation of attention through various cortical networks. This disrupted modulation results in a lack of control of goal-directed behaviour and can be attributed to the changes seen in pulvinar in psychotic illnesses, thus resulting in impairment in the integrity of sensory information and context processing. The affiliation of the ventral thalamic nucleus to the dopaminergic system, particularly the substantia nigra, may aid in explaining why this nucleus demonstrates larger volumes in adolescents with PEs compared with healthy controls over time.
More research needs to be done on following this cohort up, specifically investigating changes in thalamic nuclei in those who develop a diagnosable psychotic disorder.
To quantify and evaluate the gender differences regarding the development of PTSD. This meta-analysis calculates (a) the difference between males and females who develop PTSD, and (b) the difference in gendered relative risk of PTSD development.
Methods
Study selection criteria included participant mean age above 18 years, single and direct exposure to a terrorism related traumatic event, and a confirmed diagnosis based on Diagnostic and Statistical Manual of Mental Disorders 5th edition. Data extraction included year and location of terrorist event, the total number of participants in the study, the total numbers of males and females diagnosed with PTSD, and time (in months) of diagnosis following the traumatic event. The number of males and females affected by PTSD was pooled using random effects inverse variance weighted meta-analysis and relative risks (95% confidence interval) were calculated.
Results
Twenty-seven studies met the inclusion criteria of which five had significant information to be included in the meta-analysis. The total number of males in the pooled sample size was 328, and the total number of females was 354 out which a total number of 34 males and 66 females met the PTSD criteria. The mean average of males and females affected by PTSD was 6 and 11, respectively. An independent samples Mann Whitney U test rejected the null hypothesis (p < 0.05) and concluded that the distribution of PTSD between males and females was significantly different. The meta-analysis found an overall relative risk of a diagnosis of PTSD in females to be 1.82 (95% CI 1.25–2.65) compared with males.
Conclusion
This meta-analysis found females to have an elevated risk of developing PTSD following a single terrorism traumatic event. The results of our study are supported by previously published research, which has found females to be at higher risks of developing PTSD. However, such research has proposed gender differences secondary to the types of stressful events experienced, which does not apply to our meta-analysis given the uniformity of the traumatic event we explore. Other factors, therefore, need investigating to understand this phenomenon.
We acknowledge that researching psychological consequences in communities affected by terrorism is complicated and limited by lack of healthcare access, trained clinicians, cultural diversity in the expression and articulation of a community's traumatic experience and of course, the instability of the ground fabric. Other limitations of the included studies are the binary of gender reporting, which limits a fuller understanding of a minoritized community.
A cross-sectional, mixed-method study was conducted in Badin, a rural area in southern Sindh, which is considered a high-risk disaster zone, to assess the vulnerability, preparedness, and disaster experiences of the coastal population. A multistage sampling technique was employed to select the villages, study area, and 3 distinct populations (I, II, and III). Family heads of households were recruited for population I, village heads for population II, and community support group leaders from selected clusters for population III. The survey was conducted through face-to-face interviews. The results revealed that the population of rural southern Sindh, Pakistan, is highly vulnerable to disasters and exhibits lower levels of preparedness. The statistics about the vulnerable population may prove helpful in designing policies targeting specific groups to mitigate hazards in the future.
Balochistan, Pakistan's largest province, faces a concerning rise in self-harm and suicide, exacerbated by socioeconomic challenges, political instability and events such as climate change and recent suicide bombings. Despite the alarming suicide mortality rate, it remains a neglected public health issue. This perspective paper highlights the need for a comprehensive approach, including suicide prevention initiatives, community-based mental health services, education and research. We also suggest establishing a suicide prevention task force, inclusion of life skills and mental health education in school and undergraduate curricula, conducting research into self-harm, and fostering empathetic media reporting. Additionally, suggestions for sustainable economic change include job creation, development of marketable skills and interest-free microfinance initiatives to empower the community economically.
Psychosocial health problems are major public health burdens for adolescents. Identifying risk factors is essential to containing negative health implications.
Aims
This study aimed to estimate the burden of psychosocial health problems among adolescents, and identify potential risk and protective factors.
Method
We used the Global School-based Student Health Survey data from 68 countries across six World Health Organization regions. We computed the overall, national- and regional-level weighted estimates of the mean number of psychosocial health problems. Adjusted Poisson regression models examined the factors associated with psychosocial health problems.
Results
Our sample totalled 202 040 adolescents aged 11–17 years (mean age 14.6 [s.d. 1.18] years), composed of 95 589 (47.31%) boys and 104 191 (51.57%) girls (2260 (1.12%) missing answers). Samoa had the highest mean number of psychosocial health problems (mean 2.64 [s.d. 1.41]), and Niue had the lowest (mean 0.33 [s.d. 0.72]). In the pooled analysis, the following factors were associated with higher rates of psychosocial health problems in adolescents globally: ≥13 years of age, being female, experiencing food insecurity, experiencing physical violence, having been bullied, engagement in physical altercation, experiencing serious injury, missing school without parental permission, lack of parental support or monitoring, parents who were not understanding of their child's problems and high sedentary behaviour. Being female, food insecurity, bullying, physical attacks or serious injury were all significantly associated with higher rates of psychosocial health problems in each of the six regions separately.
Conclusions
The prevalence of psychosocial health problems is high among adolescents, although there are country-level variations. Health promotion strategies should consider the identified factors to promote adolescents’ health and well-being.
To assess the current status of implementation of the Antimicrobial Stewardship Program (ASP) across Tertiary Care Hospitals in Karachi, Pakistan.
Design:
Exploratory qualitative case study.
Setting:
Public and private tertiary care hospitals in Karachi, Pakistan
Participants and Methods:
The study data were collected from 3 public and 4 private tertiary care hospitals. Twenty-eight in-depth interviews were conducted from the Chief Executive Officer, Chief Medical Officer, Medical Superintendent, and departmental heads of internal medicine, general surgery, and pediatric, respectively. Purposive sampling was done to include higher and middle managers, whereas the infectious diseases consultant, infectious diseases/clinical pharmacist, and clinical microbiologist were interviewed through snowball sampling methodology. Analysis was done using NVivo. Data were source-triangulated within and among the study setting and study participants.
Results:
We found that more than two-thirds (n = 5, 71%) of tertiary care hospitals in Karachi do not have a structured ASP which includes major public sector hospitals (n = 3, 43%) and half of the private sector hospitals (n = 4, 29%). The study results led to four broad themes, (1) ASP structure, (2) ASP interventions, (3) hospital medical record-keeping system, and (4) structured way for analyzing and reporting mechanism of data related to the ASP. At H1 and H2, there was a consistency in ASP structure and interventions, whereas paucity seen among remaining tertiary care hospitals.
Conclusion:
There is an alarming need for ASP in the public and private sector hospitals in Karachi. This study can inform future stakeholders regarding ASP and strategies for structural change at hospitals.
Adverse effects are a common concern when prescribing and reviewing medication, particularly in vulnerable adults such as older people and those with intellectual disability. This paper describes the development of an app giving information on side-effects, called Medichec, and provides a description of the processes involved in its development and how drugs were rated for each side-effect. Medications with central anticholinergic action, dizziness, drowsiness, hyponatraemia, QTc prolongation, bleeding and constipation were identified using the British National Formulary (BNF) and frequency of occurrence of these effects was determined using the BNF, product information and electronic searches, including PubMed.
Results
Medications were rated using a traffic light system according to how commonly the adverse effect was known to occur or the severity of the effect.
Clinical implications
Medichec can facilitate access to side-effects information for multiple medications, aid clinical decision-making, optimise treatment and improve patient safety in vulnerable adults.
The recent flood crisis in Pakistan has had significant impacts on the physical, mental and socioeconomic fabric of almost 33 million people. Floods in Pakistan are leading to a range of negative impacts on health and major disruptions to healthcare services. The lack of mental health and psychosocial support services (MHPSS) is a significant concern in rural areas of Pakistan in providing support to communities affected by floods. It is important for the government and mental health policymakers to work with academic coalitions and non-governmental organisations to replicate low-resource MHPSS models that will develop and advocate for effective, gender-sensitive mental healthcare throughout the country.
The sharp bound for the third Hankel determinant for the coefficients of the inverse function of convex functions is obtained, thus answering a recent conjecture concerning invariance of coefficient functionals for convex functions.
Can wars breed nationalism? We argue that civilians’ indirect exposure to war fatalities can trigger psychological processes that increase identification with their nation and ultimately strengthen support for nationalist parties. We test this argument in the context of the rise of the Nazi Party after World War 1 (WW1). To measure localized war exposure, we machine-coded information on 7.5 million German soldiers who were wounded or died in WW1. Our empirical strategy leverages battlefield dynamics that cause plausibly exogenous variation in the county-level casualty fatality rate—the share of dead soldiers among all casualties. We find that throughout the interwar period, electoral support for right-wing nationalist parties, including the Nazi Party, was 2.6 percentage points higher in counties with above-median casualty fatality rates. Consistent with our proposed mechanism, we find that this effect was driven by civilians rather than veterans and areas with a preexisting tradition of collective war commemoration.