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ADHD is associated with an increased risk of injury. Causal evidence for effects of pharmacological treatment on injuries is scarce. We estimated effects of ADHD medication on injuries using variation in provider preference as an instrumental variable (IV). Using Norwegian registry data, we followed 8051 patients who were diagnosed with ADHD aged 5 to 18 between 2009 and 2011 and recorded their ADHD medication and injuries treated in emergency rooms and emergency wards up to 4 years after diagnosis. Persons with ADHD had an increased risk of injuries compared to the general population (RR 1.35; 95% CI: 1.30-1.39), with higher risk in females (RR 1.47; 95% CI: 1.38-1.56) than males (RR 1.23; 95% CI: 1.18-1.28). The between-clinics variation in provider preference for ADHD medication was large and had a considerable impact on patients' treatment status. There was no causal evidence for protective effects of pharmacological treatment on injuries overall for young individuals with ADHD characterized by milder or atypical symptoms. However, there was an apparent effect of pharmacological treatment over time on the risk of injuries treated at emergency wards in this patient group., (© 2023. The Author(s).)

Objective: Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes., Method: We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference., Results: Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges., Conclusion: This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning., Study Preregistration Information: The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971., (Copyright © 2023 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency., Methods: By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories., Conclusions: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group., (© 2023 The Authors. International Journal of Methods in Psychiatric Research published by John Wiley & Sons Ltd.)

Objective: We studied the point prevalence of suicidal and violent ideation, as well as their co-occurrence and associated characteristics in inpatients with mental health disorders., Methods: Data on suicidal and violent ideation, and sociodemographic and clinical information, were gathered from 1,737 patients when admitted to the acute psychiatric ward., Results: The point prevalence was 51.9% for suicidal ideation and 19.8% for violent ideation. The point prevalence of co-occurring suicidal and violent ideation was 12.3%, which was significantly greater than expected by chance. Logistic regression analyses indicated that both suicidal and violent ideation were associated with young age and the absence of diagnoses of psychotic disorders; in addition, suicidal ideation was associated with female gender, violent ideation, and diagnoses of mood- neurotic and personality disorders, whereas violent ideation was associated with male gender, suicidal ideation, and diagnoses of mood and neurotic disorders., Conclusions: Overall, the findings highlight the need for further research on suicidal and violent ideation in people with mental health problems including, but not limited to, their association with adverse behavioral outcomes, as well as the need to routinely assess both suicidal and violent ideation in clinical practice., (© 2020 The American Association of Suicidology.)

We combine infectious disease transmission and the non-pharmaceutical (NPI) intervention response to disease incidence into one closed model consisting of two coupled delay differential equations for the incidence rate and the time-dependent reproduction number. The model contains three parameters, the initial reproduction number, the intervention strength, and the response delay. The response is modeled by assuming that the rate of change of the reproduction number is proportional to the negative deviation of the incidence rate from an intervention threshold. This delay dynamical system exhibits damped oscillations in one part of the parameter space, and growing oscillations in another, and these are separated by a surface where the solution is a strictly periodic nonlinear oscillation. For the COVID-19 pandemic, the tipping transition from damped to growing oscillations occurs for response delays of about one week, and suggests that, without vaccination, effective control and mitigation of successive epidemic waves cannot be achieved unless NPIs are implemented in a precautionary manner, rather as a response to the present incidence rate. Vaccination increases the quiet intervals between waves, but with delayed response, future flare-ups can only be prevented by establishing a post-pandemic normal with lower basic reproduction number.

We estimate the weekly excess all-cause mortality in Norway and Sweden, the years of life lost (YLL) attributed to COVID-19 in Sweden, and the significance of mortality displacement. We computed the expected mortality by taking into account the declining trend and the seasonality in mortality in the two countries over the past 20 years. From the excess mortality in Sweden in 2019/20, we estimated the YLL attributed to COVID-19 using the life expectancy in different age groups. We adjusted this estimate for possible displacement using an auto-regressive model for the year-to-year variations in excess mortality. We found that excess all-cause mortality over the epidemic year, July 2019 to July 2020, was 517 (95%CI = (12, 1074)) in Norway and 4329 [3331, 5325] in Sweden. There were 255 COVID-19 related deaths reported in Norway, and 5741 in Sweden, that year. During the epidemic period of 11 March-11 November, there were 6247 reported COVID-19 deaths and 5517 (4701, 6330) excess deaths in Sweden. We estimated that the number of YLL attributed to COVID-19 in Sweden was 45,850 [13,915, 80,276] without adjusting for mortality displacement and 43,073 (12,160, 85,451) after adjusting for the displacement accounted for by the auto-regressive model. In conclusion, we find good agreement between officially recorded COVID-19 related deaths and all-cause excess deaths in both countries during the first epidemic wave and no significant mortality displacement that can explain those deaths.

Background: To suppress the COVID-19 outbreak, the Norwegian government closed all schools on March 13, 2020. The kindergartens reopened on April 20, and the schools on April 27 and May 11 of 2020. The effect of these measures is largely unknown since the role of children in the spread of the SARS-CoV-2 virus is still unclear. There are only a few studies of school closures as a separate intervention to other social distancing measures, and little research exists on the effect of school opening during a pandemic., Objective: This study aimed to model the effect of opening kindergartens and the schools in Norway in terms of a change in the reproduction number (R). A secondary objective was to assess if we can use the estimated R after school openings to infer the rates of transmission between children in schools., Methods: We used an individual-based model (IBM) to assess the reopening of kindergartens and schools in two Norwegian cities, Oslo, the Norwegian capital, with a population of approximately 680 000, and Tromsø, which is the largest city in Northern Norway, with a population of approximately 75 000. The model uses demographic information and detailed data about the schools in both cities. We carried out an ensemble study to obtain robust results in spite of the considerable uncertainty that remains about the transmission of SARS-CoV-2., Results: We found that reopening of Norwegian kindergartens and schools are associated with a change in R of 0.10 (95%CI 0.04-0.16) and 0.14 (95%CI 0.01-0.25) in the two cities under investigation if the in-school transmission rates for the SARS-CoV-2 virus are equal to what has previously been estimated for influenza pandemics., Conclusion: We found only a limited effect of reopening schools on the reproduction number, and we expect the same to hold true in other countries where nonpharmaceutical interventions have suppressed the pandemic. Consequently, current R-estimates are insufficiently accurate for determining the transmission rates in schools. For countries that have closed schools, planned interventions, such as the opening of selected schools, can be useful to infer general knowledge about children-to-children transmission of SARS-CoV-2., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is among the most common mental disorders in children and adolescents, and it is a strong risk factor for several adverse psychosocial outcomes over the lifespan. There are large between-country and within-country variations in diagnosis and medication rates. Due to ethical and practical considerations, a few studies have examined the effects of receiving a diagnosis, and there is a lack of research on effects of medication on long-term outcomes.Our project has four aims organised in four work packages: (WP1) To examine the prognosis of ADHD (with and without medication) compared with patients with other psychiatric diagnoses, patients in contact with public sector child and adolescent psychiatric outpatient clinics (without diagnosis) and the general population; (WP2) Examine within-country variation in ADHD diagnoses and medication rates by clinics' catchment area; and(WP3) Identify causal effects of being diagnosed with ADHD and (WP4) ADHD medication on long-term outcomes., Method and Analysis: Our project links several nationwide Norwegian registries. The patient sample is all persons aged 5-18 years that were in contact with public sector child and adolescent psychiatric outpatient clinics in 2009-2011. Our comparative analysis of prognosis will be based on survival analysis and mixed-effects models. Our analysis of variation will apply mixed-effects models and generalised linear models. We have two identification strategies for the effect of being diagnosed with ADHD and of receiving medication on long-term outcomes. Both strategies rely on using preference-based instrumental variables, which in our project are based on provider preferences for ADHD diagnosis and medication., Ethics and Dissemination: The project is approved by the Regional Ethics Committee, Norway (REC number 2017/2150/REC south-east D). All papers will be published in open-access journals and results will be presented in national and international conferences., Trial Registration Numbers: ISRCTN11573246 and ISRCTN11891971., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

As of November 2020, the number of COVID-19 cases was increasing rapidly in many countries. In Europe, the virus spread slowed considerably in the late spring due to strict lockdown, but a second wave of the pandemic grew throughout the fall. In this study, we first reconstruct the time evolution of the effective reproduction numbers R(t) for each country by integrating the equations of the classic Susceptible-Infectious-Recovered (SIR) model. We cluster countries based on the estimated R(t) through a suitable time series dissimilarity. The clustering result suggests that simple dynamical mechanisms determine how countries respond to changes in COVID-19 case counts. Inspired by these results, we extend the simple SIR model for disease spread to include a social response to explain the number X(t) of new confirmed daily cases. In particular, we characterize the social response with a first-order model that depends on three parameters ν1,ν2,ν3. The parameter ν1 describes the effect of relaxed intervention when the incidence rate is low; ν2 models the impact of interventions when incidence rate is high; ν3 represents the fatigue, i.e., the weakening of interventions as time passes. The proposed model reproduces typical evolving patterns of COVID-19 epidemic waves observed in many countries. Estimating the parameters ν1,ν2,ν3 and initial conditions, such as R0, for different countries helps to identify important dynamics in their social responses. One conclusion is that the leading cause of the strong second wave in Europe in the fall of 2020 was not the relaxation of interventions during the summer, but rather the failure to enforce interventions in the fall.

Vitamin D status may be important for stress resilience. This study investigated the effects of vitamin D supplements during winter on biological markers of stress resilience such as psychophysiological activity, serotonin, and cortisol in a placebo-controlled, randomized clinical trial. Eighty-six participants were randomly assigned to the Intervention (vitamin D) or Control (placebo) groups. Before and after the intervention participants were exposed to an experimental stress procedure. Psychophysiological activity was measured during three main conditions: baseline, stress, and recovery. Fasting blood samples were taken in the morning and saliva samples were collected at seven different time points across 24 h. Prior to intervention both groups had normal/sufficient vitamin D levels. Both groups showed a normal pattern of psychophysiological responses to the experimental stress procedure (i.e., increased psychophysiological responses from resting baseline to stress-condition, and decreased psychophysiological responses from stress-condition to recovery; all p < 0.009). Post-intervention, the Intervention group showed increased vitamin D levels ( p < 0.001) and normal psychophysiological responses to the experimental stress procedure ( p < 0.001). Importantly, the Control group demonstrated a classic nadir in vitamin D status post-intervention (spring) ( p < 0.001) and did not show normal psychophysiological responses. Thus, physiologically the Control group showed a sustained stress response. No significant effects of vitamin D were found on serotonin and cortisol.

In a given country, the cumulative death toll of the first wave of the COVID-19 epidemic follows a sigmoid curve as a function of time. In most cases, the curve is well described by the Gompertz function, which is characterized by two essential parameters, the initial growth rate and the decay rate as the first epidemic wave subsides. These parameters are determined by socioeconomic factors and the countermeasures to halt the epidemic. The Gompertz model implies that the total death toll depends exponentially, and hence very sensitively, on the ratio between these rates. The remarkably different epidemic curves for the first epidemic wave in Sweden and Norway and many other countries are classified and discussed in this framework, and their usefulness for the planning of mitigation strategies is discussed.

Background: Contextual variables such as staff characteristics, treatment programs, assessment routines and administrative structures are found to influence patient violence rates in psychiatric forensic wards. The possible effects of current developments in treatment philosophy emphasizing patients' perspective and treatment involvement upon violence rate have not yet been examined. The aim of this paper is to analyse associations between such developments and the occurrence of violent incidents among patients in a high security forensic psychiatric ward., Methods: During a 17-year period with stable ward conditions, incidents of violence were systematically collected together with diagnostic, risk assessment and demographic patient characteristics. Changes in care- and organizational related variables such as nursing staff characteristics, treatment and management routines were collected. Multilevel modelling was applied to estimate the relationship between these variables and changes in violent incidents., Results: A substantial decline in the occurrence of violent incidents paralleled with changes in the ward during the middle phase of the study period. Most of the changes, such as implementation of new treatment and care routines and an increased proportion of female staff and higher education levels, were significantly related to a decrease in the occurrence of violent incidents in the ward., Conclusions: Findings in this study suggest that an increase in individualized, patient-oriented care strategies, delivered by well-educated nursing staff with an equally balanced gender distribution contribute to a low level of violence.

Background: Workplace violence in emergency primary health care is prevalent, but longitudinal studies using validated assessment scales to describe the characteristics of workplace violence in these settings are lacking. The aim of the present study was to determine the characteristics of aggressive incidents in emergency primary health care clinics in Norway., Methods: Incidents of workplace violence were reported with the Staff Observation Aggression Scale - Revised Emergency (SOAS-RE). The study was conducted in ten emergency primary health care clinics over a period of one year., Results: A total of 320 aggressive incidents were registered. The mean overall SOAS-RE score for reported aggressive incidents was 9.7 on a scale from 0 to 22, and 60% of the incidents were considered severe. Incidents of verbal aggression accounted for 31.6% of all reported incidents, threats accounted for 24.7%, and physical aggression accounted for 43.7%. Verbal aggression was most often provoked by long waiting time. Physical aggression was most often provoked when the patient had to go through an involuntary assessment of health condition. Almost one third of the aggressors were females, and nurses were the most frequent targets of all aggression types. No differences in psychological stress were found between types of aggression., Conclusions: This study shows that workplace violence in emergency primary health care clinics is a severe problem. Patterns in provocation and consequences of aggressive incidents can be used to improve our understanding of and prevention and follow-up procedures of such incidents.

Background: Hereditary ichthyosis constitutes a diverse group of cornification disorders. Identification of the molecular cause facilitates optimal patient care., Objective: We wanted to estimate the diagnostic yield of applying whole-exome sequencing (WES) in the routine genetic workup of inherited ichthyosis., Methods: During a 3-year-period, all ichthyosis patients, except X-linked and mild vulgar ichthyosis, consecutively admitted to a university hospital clinic were offered WES with subsequent analysis of ichthyosis-related genes as a first-line genetic investigation. Clinical and molecular data have been collected retrospectively., Results: Genetic variants causative for the ichthyosis were identified in 27 of 34 investigated patients (79.4%). In all, 31 causative mutations across 13 genes were disclosed, including 12 novel variants. TGM1 was the most frequently mutated gene, accounting for 43.7% of patients suffering from autosomal recessive congenital ichthyosis (ARCI)., Conclusion: Whole-exome sequencing appears an effective tool in disclosing the molecular cause of patients with hereditary ichthyosis seen in clinical practice and should be considered a first-tier genetic test in these patients., (© 2018 European Academy of Dermatology and Venereology.)

Background: Many emergency primary health care workers experience aggressive behaviour from patients or visitors. Simple incident-reporting procedures exist for inpatient, psychiatric care, but a similar and simple incident-report for other health care settings is lacking. The aim was to adjust a pre-existing form for reporting aggressive incidents in a psychiatric inpatient setting to the emergency primary health care settings. We also wanted to assess the validity of the severity scores in emergency primary health care., Methods: The Staff Observation Scale - Revised (SOAS-R) was adjusted to create a pilot version of the Staff Observation Scale - Revised Emergency (SOAS-RE). A Visual Analogue Scale (VAS) was added to the form to judge the severity of the incident. Data for validation of the pilot version of SOAS-RE were collected from ten casualty clinics in Norway during 12 months. Variance analysis was used to test gender and age differences. Linear regression analysis was performed to evaluate the relative impact that each of the five SOAS-RE columns had on the VAS score. The association between SOAS-RE severity score and VAS severity score was calculated by the Pearson correlation coefficient., Results: The SOAS-R was adjusted to emergency primary health care, refined and called The Staff Observation Aggression Scale - Revised Emergency (SOAS-RE). A total of 350 SOAS-RE forms were collected from the casualty clinics, but due to missing data, 291 forms were included in the analysis. SOAS-RE scores ranged from 1 to 22. The mean total severity score of SOAS-RE was 10.0 (standard deviation (SD) =4.1) and the mean VAS score was 45.4 (SD = 26.7). We found a significant correlation of 0.45 between the SOAS-RE total severity scores and the VAS severity ratings. The linear regression analysis showed that individually each of the categories, which described the incident, had a low impact on the VAS score., Conclusions: The SOAS-RE seems to be a useful instrument for research, incident-recording and management of incidents in emergency primary care. The moderate correlation between SOAS-RE severity score and the VAS severity score shows that application of both the severity ratings is valuable to follow-up of workers affected by workplace violence.

This study examines the structure of the Comprehensive Assessment of Psychopathic Personality (CAPP) from a card sort perspective. The CAPP is a lexically based construct map of psychopathy comprising 33 symptoms organized by its developers into 6 broad functional domains of personality (i.e., Attachment, Behavioral, Cognitive; Dominance; Emotional, Self). Groups of mental health workers and students were asked to sort the CAPP symptoms into the model's 6 proposed domains. Overall, both mental health workers and students were able to categorize the symptoms speedily and intuitively according to model. This suggests that the CAPP model's hierarchical structure is plausible, and that the lexical nature of the model is successful in facilitating people's ability to understand features of psychopathy in a way that requires limited cognitive effort. Together, these findings support the validity of the CAPP model as a lexically based concept map of psychopathy. Yet, some exceptions to the overall pattern of agreement with model were identified., ((c) 2015 APA, all rights reserved).)

This study is the first to our knowledge to examine the cross-language consistency across the original version of the Comprehensive Assessment of Psychopathy (CAPP) and a translated version. The CAPP is a lexically based construct map of psychopathy comprising 33 symptoms from 6 broad domains of personality functioning. English-language CAPP prototypicality ratings from 124 mental health workers were compared with ratings from 211 Norwegian mental health workers using the Norwegian translation. High agreement was found across languages in regard to which symptoms where perceived as central to psychopathy or not. Multigroup confirmatory factor analyses (MGCFA) indicated that, overall, the symptoms had similar associations with the 6 proposed underlying dimensions across the 2 language versions. Finally, in general, the probability for a given prototypicality rating on an individual symptom was similar across language version samples at the same level of the underlying trait, as analyzed with Item Response Theory (IRT). Together these findings lend support to the validity of the construct of psychopathy, the validity of the CAPP as a concept map of psychopathy, and the validity of the Norwegian translation of the CAPP., ((PsycINFO Database Record (c) 2014 APA, all rights reserved).)

Background: Recent studies have suggested that functional classifications of aggression should be used to improve the understanding of the heterogeneity of aggression and its management, among inpatients in psychiatric hospitals., Aims: Our aim was to examine a theoretically derived three-factor model for conceptualising aggressive incidents by inpatients as irritable, instrumental or defensive., Methods: As part of the routine assessments in a forensic psychiatric high security ward, staff filled out a questionnaire on motives for aggression after all violent incidents. A total of 1652 incidents from 28 patients were analysed by means of exploratory and confirmatory factor analyses., Results: Support was found for the three-factor model. For the most part, the scale items loaded on the factors as predicted, and the model was able to explain 61% of the data variance. Irritable incidents were the most common, but elevated scores for instrumental characteristics were found as well. High psychopathy scores were associated with incidents scoring high values on both irritable and instrumental dimensions, and low values on the defensive dimensions., Conclusions: Confirming these three dimensions of inpatient aggressive incidents may help caregivers' understanding of aggressive behaviour. If confirmed in future studies, this dimensional approach may prove useful for the management of aggressive inpatients., (Copyright © 2013 John Wiley & Sons, Ltd.)

Cooke and colleagues recently developed the lexically based model of psychopathy named the Comprehensive Assessment of Psychopathic Personality (CAPP, Cooke, Hart, Logan, & Michie, 2004). The current study was the first to evaluate aspects of the validity of a translated version of the CAPP model, which comprises 33 symptoms from six domains of personality functioning. Prototypicality ratings from 796 Norwegian community residents, forensic mental health professionals, and corrections professionals were obtained. Most CAPP symptoms were evaluated as highly prototypical of psychopathy by all three groups. Symptoms from the Self, Dominance, and Attachment domains were perceived as more prototypical than those from the Behavioral domain. Confirmatory Factor Analysis (CFA) indicated that two CAPP domains were unidimensional whereas evidence of unidimensionality was somewhat weaker for the other domains, but improved substantially after removal of problematic symptoms. Overall, the findings support the content validity of the CAPP model. This may have relevance to the current considerations regarding reformulation of the criteria for Antisocial Personality Disorder in DSM-V.

Passenger transport affects climate through various mechanisms involving both long-lived and short-lived climate forcers. Because diesel cars generally emit less CO(2) than gasoline cars, CO(2) emission taxes for vehicle registrations and fuels enhance the consumer preference for diesel cars over gasoline cars. However, with the non-CO(2) components, which have been changed and will be changed under the previous and upcoming vehicle emission standards, what does the shift from gasoline to diesel cars mean for the climate mitigation? By using a simple climate model, we demonstrate that, under the earlier emissions standards (EURO 3 and 4), a diesel car causes a larger warming up to a decade after the emissions than a similar gasoline car due to the higher emissions of black carbon and NO(X) (enhancing the O(3) production). Beyond a decade, the warming caused by a diesel car becomes, however, weaker because of the lower CO(2) emissions. As the latter emissions standards (EURO 5 and 6) are phased in, the short-term warming due to a diesel car becomes smaller primarily due to the lower black carbon emissions. Thus, although results are subject to restrictive assumptions and uncertainties, the switch from gasoline to diesel cars encouraged by CO(2) taxes does not contradict with the climate mitigation focusing on long-term consequences., (© 2012 American Chemical Society)

Although the transport sector is responsible for a large and growing share of global emissions affecting climate, its overall contribution has not been quantified. We provide a comprehensive analysis of radiative forcing from the road transport, shipping, aviation, and rail subsectors, using both past- and forward-looking perspectives. We find that, since preindustrial times, transport has contributed approximately 15% and 31% of the total man-made CO2 and O3 forcing, respectively. A forward-looking perspective shows that the current emissions from transport are responsible for approximately 16% of the integrated net forcing over 100 years from all current man-made emissions. The dominating contributor to positive forcing (warming) is CO2, followed by tropospheric O3. By subsector, road transport is the largest contributor to warming. The transport sector also exerts cooling through reduced methane lifetime and atmospheric aerosol effects. Shipping causes net cooling, except on future time scales of several centuries. Much of the forcing from transport comes from emissions not covered by the Kyoto Protocol.