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As the Boko Haram insurgency heads into its second decade, it seems no quick end is in sight. What are the possible scenarios for the future trajectory of Boko Haram, and in particular what is its endgame? While predicting the future is a very hazardous business, plausible endgame scenarios can be envisioned based on reflection on the metamorphoses of Boko Haram, careful analysis of the dynamics of its current situation, and prognosis of its emergent trends. The formal declaration of the Boko Haram Caliphate and its territorial control over much of Borno State are no more. Yet the ‘technical military defeat’ proclaimed by President Muhammad Buhari in 2015 has not prevented Boko Haram from carrying out attacks not only in rural areas, but in big towns and even military bases, often killing Nigerian soldiers – as many as 100 soldiers in one attack. Negotiations leading to the release of Boko Haram captives in exchange for freeing incarcerated leaders of the insurgency came about more than a year after the proclamation of the technical defeat. It seems that decisive defeat leading to complete surrender and total cessation of hostilities is not on the immediate horizon. Yet what scenario is likely to unfold?
This chapter explores this question by drawing insights from the literature on the growth, decline, and end of past insurgent insurgencies and civil wars. Theoretically, one may argue that there are only a few possible outcomes to an insurgency: the government may defeat the insurgents; the insurgents may defeat the government; both parties may reach a negotiated settlement; there may be a stalemate; or the insurgency may transform into something else, such as organized crime. We suggest that rather than one distinct ending, Boko Haram is likely to continue its previous patterns of transformations and factionalization, precluding decisive outcomes. Unless distinctively different approaches are taken by the state, likely endgames include a negotiated settlement with some factions, the further entrenchment of the war economy with its continuous menacing of rural areas by others, and some elements potentially becoming absorbed into the global terrorist networks of the Islamic State.
Mental health problems have a significant impact globally in terms of social and economic costs. Increasing access to and uptake of mental health interventions (particularly by men) remains a challenge for service providers. The current study sought to examine the efficacy of a delivering a Stress Control intervention in partnership with a community sporting organisation (the Gaelic Athletic Assocaition, GAA) in ameliorating mental health difficulties in a general population. Measures of anxiety, depression and quality of life were administered before and after the delivery of the 6-week programme. A focus group was conducted afterwards to gather qualitative data on participants’ experiences of the intervention. Statistically significant decreases in depression scores were found following attendance at the course: t (94) = 3.14, p = .002, with a large effect size (0.5) (n = 95). There was an increase in the number of male attendees compared with clinic-based courses. Thematic analysis of the focus group data revealed a number of key themes including increased accessibility in terms of the scale and context of the delivery of the course. Delivering large-scale psychoeducational courses like Stress Control in partnership with the GAA represents a promising avenue for increasing access (for males in particular) to an effective intervention for improving mental health outcomes
Key learning aims
(1) To gain an understanding of the impact of delivering a large-scale psychological intervention in partnership with a community sports organisation on accessibility and stigma reduction for participants.
(2) To become aware of the potential benefits of considering non-clinic-based locations in running public mental health interventions.
(3) To understand the key role of the normalisation of the experience of common mental health problems and the impact on intervention uptake.
Impairments of contextual processing and theory of mind (ToM) have both been offered as accounts of the deviant language characterising formal thought disorder (FTD) in schizophrenia. This study investigated these processes in patients' dialogue. We predicted that FTD patients would show a decrement in linguistic alignment, associated with impaired ToM in dialogue.
Speech samples were elicited via participation in an interactive computer-based task and a semi-structured interview to assess contextual processing abilities and ToM skills in dialogue, respectively, and from an interactive card-sorting task to measure syntactic alignment. Degree of alignment in dialogue and the syntactic task, and evidence of ToM in (i) dialogue and (ii) a traditional ToM task were compared across schizophrenia patients with FTD (n = 21), non-FTD patients (n = 22) and healthy controls (n = 21).
FTD patients showed less alignment than the other two groups in dialogue, and than healthy controls on the syntactic task. FTD patients showed poorer performance on the ToM task than the other two groups, but only compared to the healthy controls in dialogue. The FTD group's degree of alignment in dialogue was correlated with ToM performance in dialogue but not with the traditional ToM task or with syntactic alignment.
In dialogue, FTD patients demonstrate an impairment in employing available contextual information to facilitate their own subsequent production, which is associated with a ToM deficit. These findings indicate that a contextual processing deficit impacts on exploiting representations via the production system impoverishing the ability to make predictions about upcoming utterances in dialogue.
Empirical research demonstrates the short- to medium-term efficacy and effectiveness of cognitive behavioural group therapy (CBGT) for social anxiety disorder (SAD). Little is known about the durability of gains beyond 1 year following treatment in real-life clinical settings. Literature regarding the impact of aftercare programs as an adjunct to CBGT treatment on SAD is scarce.
To evaluate the long-term effectiveness of CBGT for SAD in a community sample and to explore the relationship between long-term treatment outcomes and aftercare support group attendance.
A longitudinal cohort design evaluated changes in standardized psychological measures assessing aspects of SAD, anxiety and depression. Questionnaires were completed before the program (time 1, N = 457), after the program (time 2, n = 369) and at an average of 4.6 years follow-up (time 3, n = 138).
Large treatment effect sizes at post-intervention were maintained at long-term follow-up on measures of SAD, anxiety and depression. There was no statistically significant relationship between frequency of attendance at an aftercare support group and degree of improvement from post-treatment severity on any measure.
CBGT is an effective intervention in the long-term in a routine clinical setting and should be considered a viable treatment option for SAD. Recommendations for future research, treatment implications and study limitations are considered.
IAU Commission 19 began in 1919 with the birth of the IAU at the Brussels Conference, where Standing Committee 19 on Latitude Variations was established as one of 32 standing committees. At the first IAU General Assembly in 1922, Standing Committee 19 became Commission 19 “Variation of Latitude”. In the beginning, the main topic of the Commission was the investigation of polar motion. Later, its activities included observations and theory of Earth rotation and connections between Earth orientation variations and geophysical phenomena. As a result, in 1964 at the XII IAU General Assembly, the Commission was renamed “Rotation of the Earth”. The investigation of Earth orientation variations is primarily based on observations of natural and artificial celestial objects. Therefore, maintenance of the international terrestrial and celestial reference frames, as well as the coordinate transformation between the frames and the improvement of the model of precession/nutation, have always been among the primary Commission topics. In 1987, the IAU through Commissions 19 and 31 “Time” established, jointly with the International Union of Geodesy and Geophysics, what is now known as the International Earth Rotation and Reference Systems Service. Commission 19 continued to work to develop methods to improve the accuracy and understanding of Earth orientation variations and related reference systems and frames as well as theoretical studies of Earth rotation. In 2015, Commission 19 was renewed as Commission A2 “Rotation of the Earth” continuing Commission 19’s functions and linking the astronomical community to other scientific organizations such as the International Association of Geodesy, International VLBI Service for Geodesy and Astrometry, International GNSS Service, International Laser Ranging Service and International DORIS Service. During its entire history, IAU Commission 19/A2 has always worked in close cooperation with these and other related services to improve the accuracy and consistency of the Earth orientation parameters and celestial and terrestrial reference frames.
The management of patients in primary care is often complicated by the presence of multiple chronic conditions and psychosocial issues that increase the complexity of the encounter and have important impacts on care. There is a paucity of literature on this subject in the pediatric population.
The aim of this study was to quantify the burden of chronic conditions in pediatric primary care.
The problem lists of 3995 randomly selected patients from a community pediatric clinic and an academic hospital-based pediatric clinic in the same metropolitan area were analyzed for the presence and number of any chronic condition.
In total, 53% of patients suffered from at least one chronic problem, 25% had two or more chronic conditions and 5.1% had four or more conditions. Compared with the community clinic, the academic clinic had significantly more children with catastrophic complex conditions (P<0.001). A regression analysis showed a significant positive correlation between the number of chronic medical conditions and mental health diagnoses.
The burden of chronic disease in the pediatric primary care setting may be significantly higher than has been previously suggested. To ensure optimal quality of care, health planners should take into account the high burden of chronic illness, psychosocial issues and multimorbidity among patients in the pediatric primary care setting, as well as the higher complexity profile of patients attending academic clinics.
There is little evidence to guide pharmacological treatment in adults with Down syndrome and Alzheimer's disease.
To investigate the effect of cholinesterase inhibitors or memantine on survival and function in adults with Down syndrome and Alzheimer's disease.
This was a naturalistic longitudinal follow-up of a clinical cohort of 310 people with Down syndrome diagnosed with Alzheimer's disease collected from specialist community services in England.
Median survival time (5.59 years, 95% CI 4.67–6.67) for those on medication (n = 145, mainly cholinesterase inhibitors) was significantly greater than for those not prescribed medication (n = 165) (3.45 years, 95% CI 2.91–4.13, log-rank test P<0.001). Sequential assessments demonstrated an early effect in maintaining cognitive function.
Cholinesterase inhibitors appear to offer benefit for people with Down syndrome and Alzheimer's disease that is comparable with sporadic Alzheimer's disease; a trial to test the effect of earlier treatment (prodromal Alzheimer's disease) in Down syndrome may be indicated.
Declaration of interest
A.S. has undertaken consulting for Ono Pharmaceuticals, outside the submitted work. Z.W. has received a consultancy fee and grant from GE Healthcare, outside the submitted work.
Studies indicate that DSM-5 criteria for delirium are relatively restrictive, and identify different cases of delirium compared with previous systems. We evaluate four outcomes of delirium (mortality, length of hospital stay, institutionalization, and cognitive improvement) in relation to delirium defined by different DSM classification systems.
Prospective, longitudinal study of patients aged 70+ admitted to medical wards of a general hospital. Participants were assessed up to a maximum of four times during two weeks, using DSM-5 and DSM-IV criteria, DRS-R98 and CAM scales as proxies for DSM III-R and DSM III.
Of the 200 assessed patients (mean age 81.1, SD = 6.5; and 50% female) during hospitalization, delirium was identified in 41 (20.5%) using DSM-5, 45 (22.5%) according to DSM-IV, 46 (23%) with CAM positive, and 37 (18.5%) with DRS-R98 severity score >15. Mortality was significantly associated with delirium according to any classification system, but those identified with DSM-5 were at greater risk. Length of stay was significantly longer for those with DSM-IV delirium. Discharge to a care home was associated only with DRS-R98 defined delirium. Cognitive improvement was only associated with CAM and DSM-IV. Different classification systems for delirium identify populations with different outcomes.
According to the priority view, or prioritarianism, it matters more to benefit people the worse off they are. But how exactly should the priority view be defined? This article argues for a highly general characterization which essentially involves risk, but makes no use of evaluative measurements or the expected utility axioms. A representation theorem is provided, and when further assumptions are added, common accounts of the priority view are recovered. A defence of the key idea behind the priority view, the priority principle, is provided. But it is argued that the priority view fails on both ethical and conceptual grounds.
Textured voices include both voices heard as interpolated into a musical texture and voices heard as having their own textured character, whether as a ‘voice’ with a ‘timbre’ or as a ‘collective voice’ with a ‘composite timbre’ made up of many voices, each textured itself. They have often been heard as performances of ethical life. Comparisons between these performances can be misleading because the contingencies characterizing the textured voice for a listener who listens in a particular way can make each performance irreducible. A pair of articles and cartoons in TV Guide from the summer of 1966 depict the making of a textured laugh track as a contradictory activity. Yet they seem to resolve contradictions into surface conflicts between individuated parties. Listening for textured voices in this case was itself a political activity because it was productive of more than one distinct form of ethical life.
The recently published DSM-5 criteria for delirium may lead to different case identification and rates of delirium than previous classifications. The aims of this study are to determine how the new DSM-5 criteria compare with DSM-IV in identification of delirium in elderly medical inpatients and to investigate the agreement between different methods, using CAM, DRS-R98, DSM-IV, and DSM-5 criteria.
Prospective, observational study of elderly patients aged 70+ admitted under the acute medical teams in a regional general hospital. Each participant was assessed within 3 days of admission using the DSM-5, and DSM-IV criteria plus the DRS-R98, and CAM scales.
We assessed 200 patients [mean age 81.1±6.5; 50% female; pre-existing cognitive impairment in 63%]. The prevalence rates of delirium for each diagnostic method were: 13.0% (n = 26) for DSM-5; 19.5% (n = 39) for DSM-IV; 13.5% (n = 27) for DRS-R98 and 17.0%, (n = 34) for CAM. Using tetrachoric correlation coefficients the agreement between DSM-5 and DSM-IV was statistically significant (ρtetr = 0.64, SE = 0.1, p < 0.0001). Similar significant agreement was found between the four methods.
DSM-IV is the most inclusive diagnostic method for delirium, while DSM-5 is the most restrictive. In addition, these classification systems identify different cases of delirium. This could have clinical, financial, and research implications. However, both classification systems have significant agreement in the identification of the same concept (delirium). Clarity of diagnosis is required for classification but also further research considering the relevance in predicting outcomes can allow for more detailed evaluation of the DSM-5 criteria.
The dramatic rise in childhood obesity has driven the demand for tools better able to assess and define obesity and risk for related co-morbidities. In addition, the early life origins of non-communicable diseases including type 2 diabetes are associated with subtle alterations in growth and body composition, including total and regional body fatness, limb/trunk length and skeletal muscle mass (SMM). Consequently improved tools based on national reference data, which capture these body components must be developed as the limitations of BMI as a measure of overweight and obesity and associated cardiometabolic risk are now recognised. Furthermore, waist circumference as a measure of abdominal fatness in children is now endorsed by the International Diabetes Federation and National Institute for Clinical and Health Excellence for diagnostic and monitoring purposes. The present paper aims to review the research on growth-related variations in body composition and proportions, together with how national references for percentage body fat, SMM and leg/trunk length have been developed. Where collection of these measures is not possible, alternative proxy measures including thigh and hip circumferences are suggested. Finally, body ratios including the waist:height and muscle:fat ratios are highlighted as potential measures of cardiometabolic disease risk. In conclusion, a collection of national references for individual body measures have been produced against which children and youths can be assessed. Collectively, they have the capacity to build a better picture of an individual's phenotype, which represents their risk for cardiometabolic disease beyond that of the capability of BMI.
This study examines the effectiveness of a group CBT (CBGT) intervention in reducing a variety of symptoms and problem areas associated with social anxiety disorder. A longitudinal cohort design assessed changes in standardized psychological scales assessing general mood and specific aspects of social anxiety. Questionnaires were completed pre-programme (time 1, n = 252), post-programme (time 2, n = 202), and at 12 months follow-up (time 3, n = 93). A consistent significant pattern was found for all variables: pre-intervention scores were significantly higher than both post-intervention scores and 12-month follow-up scores. Large effect sizes were found and rates of clinical significant changes varied, with over half of the participants recording clinically significant changes in general mood. Individual CBT can be translated successfully into a group format for social anxiety. Given the high completion rate, the intervention is acceptable to participants, feasible, and effective in a routine clinical service.