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Introduction Bipolar disorder (BD) is a source of marked disability, morbidity, and premature death. There is a paucity of research on personalized psychosocial interventions for BD, especially in lowresource settings. A previously published pilot randomized controlled trial (RCT) of a Culturally adapted PsychoEducation (CaPE) intervention for BD in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes towards BD, and improvement in mood symptom scores and health-related quality of life measures compared to treatment-as-usual (TAU). Objectives This protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan. Methods A multicentre individual, parallel arm, RCT of CaPE in 300Pakistani adults with BD. Participants over the age of 18, with adiagnosis of bipolar I and II and who are currently euthymic, will berecruited from seven sites including Karachi, Lahore, Multan, Rawalpindi,Peshawar, Hyderabad and Quetta. Time to recurrence will be the primaryoutcome assessed using Longitudinal Interval Follow-up Evaluation(LIFE). Secondary measures will include mood symptomatology, qualityof life and functioning, adherence to psychotropic medications, andknowledge and attitudes towards BD. Results Full ethics approval has been received from National Bioethics Committee (NBC) of Pakistan and Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The study has completed sixty-five screening across the seven centres, of which forty-eight participants have been randomised. Conclusions A successful trial will lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority patients with BD. Disclosure of Interest None Declared

Introduction Low and middle-income countries (LMICs) hold the majority of disease burden attributed to major depressive disorder (MDD). Despite this, there remains a substantial gap for access to evidence-based treatments for MDD in LMICs like Pakistan. Measurement-based care (MBC) incorporates systematic administration of validated outcome measures to guide treatment decision making and is considered a low-cost approach to optimise better clinical outcomes for individuals with MDD but there is a paucity of evidence on the efficacy of MBC in LMICs. Objectives This protocol highlights a randomized trial which will include Pakistani outpatients with moderate to severe major depression. Methods Participants will be randomised to either MBC (guided by schedule), or standard treatment (guided by clinicians’ judgement), and will be prescribed with paroxetine (10–60mg/day) or mirtazapine (7.5–45mg/day) for 24 weeks. Outcomes will be evaluated by raters blind to study protocol and treatment. Results National Bioethics Committee (NBC) of Pakistan has given full ethics approval. The trial is being conducted and reported as per recommendation of the CONSORT statement for RCTs. Conclusions With increasing evidence from high-income settings supporting the effectiveness of MBC for MDD, it is now necessary to explore its feasibility, utility. and efficacy in low-resource settings. The results of the proposed trial could inform the development of a low-cost and scalable approach to efficiently optimise outcomes for individuals with MDD in Pakistan. Disclosure of Interest None Declared

Abstract Background Psychosis treatment guidelines recommend cognitive behaviour therapy (CBT) and family intervention (FI), for all patients with first episode psychosis (FEP), though guidance borrows heavily from literature in adults from high income countries. To our knowledge, there are few randomized controlled trials (RCTs) examining the comparative effect of these commonly endorsed psychosocial interventions in individuals with early psychosis from high-income countries and no such trials from low and middle-income countries (LMICs). The present study aims to confirm the clinical-efficacy and cost-effectiveness of delivering culturally adapted CBT (CaCBT) and culturally adapted FI (CulFI) to individuals with FEP in Pakistan. Method A multi-centre, three-arm RCT of CaCBT, CulFI, and treatment as usual (TAU) for individuals with FEP (n = 390), recruited from major centres across Pakistan. Reducing overall symptoms of FEP will be the primary outcome. Additional aims will include improving patient and carer outcomes and estimating the economic impact of delivering culturally appropriate psychosocial interventions in low-resource settings. This trial will assess the clinical-efficacy and cost-effectiveness of CaCBT and CulFI compared with TAU in improving patient (positive and negative symptoms of psychosis, general psychopathology, depressive symptoms, quality of life, cognition, general functioning, and insight) and carer related outcomes (carer experience, wellbeing, illness attitudes and symptoms of depression and anxiety). Conclusions A successful trial may inform the rapid scale up of these interventions not only in Pakistan but other low-resource settings, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority groups with FEP. Trial registration NCT05814913.

Background: Pediatric obstructive sleep apnea (OSA) poses a significant health concern, affecting the well-being and quality of life of affected children. This study focuses on the translation, adaptation, and validation of the OSA-18 questionnaire for Arabic-speaking pediatric patients, aiming to contribute to the understanding of OSA and its implications on the quality of life in this population., Methods: A study was conducted at Jordan University Hospital, involving 186 Arabic-speaking pediatric patients with suspected OSA. The OSA-18 questionnaire was translated and culturally adapted following the World Health Organization guidelines. Overnight polysomnography was conducted to assess OSA severity. Internal consistency, construct validity, convergent validity, and predictive/discriminant validity were analyzed., Results: The study sample (68.8% of males, median age: 10.87) showed a median Apnea-Hypopnea Index (AHI) of 7.0, OSA-18 score of 46.5, and Pediatric Sleep Questionnaire (PSQ) score of 7.0. Internal consistency of OSA-18 was acceptable, except for the "physical symptoms" domain. Exploratory and confirmatory factor analyses revealed five factors corresponding to different OSA-18 domains. Convergent validity was supported by significant correlations between OSA-18 and PSQ scores. However, no correlation was found between OSA-18 scores and AHI. OSA severity was associated with higher PSQ scores but not with AHI., Conclusion: This study provides valuable insights into pediatric OSA in Arabic-speaking children. While the translation and validation of the OSA-18 questionnaire demonstrated acceptable reliability and convergent validity, the lack of correlation between OSA-18 scores and AHI raises questions about the survey's ability to capture the full impact of OSA objectively. Future research should focus on developing more reliable diagnostic tools, especially in resource-limited settings., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Annals of Thoracic Medicine.)

Background: Mental health Applications (Mhealth Apps) can change how healthcare is delivered. However, very little is known about the efficacy of Mhealth Apps. Currently, only minimum guidance is available in Assessment and Evaluation Tools (AETs). Therefore, this project aims to understand AET developers' perspectives and end users' experiences and opinions on "how to choose a Mhealth App"., Objective: The primary objectives were: (1) obtaining stakeholder's opinions and experiences of development and use of AETs for Mhealth Apps, their weaknesses and strengths, and barriers in their implementation of Mhealth Apps; (2) the experiences of App users, their analyzation and, obstacles in the use of apps; and (3) to quantify themes related to choosing a Mhealth App., Methods: This qualitative study, used a sampling method to recruit six stakeholders (one App developer, two AET developers, an individual with lived experience of mental health illness, and two physicians) who were interviewed using a topic guide. These were examined by researchers (CT, WK, & FN) using thematic content analysis. Additionally, an anonymous online survey of 107 individuals was conducted., Findings: Our analyses revealed six main themes: (a) needs and opportunities; (b) views on Mhealth apps; (c) views & opinions on AETs; (d) implementation barriers; (e) system of evaluation and; (f) future directions. The first key concept was, all stakeholders agreed that Apps could significantly impact mental health and that end-users were unaware of mental health AETs and Apps. Secondly, due to commercial interests, end-users reliability of App evaluations requires clear conflict-free guidelines. Thirdly, AETs should be evaluated and developed through a rigorous methodology. Finally, stakeholders shared insights into future developments for AETs and Mhealth Apps. Additionally, online survey respondents chose a "health professional" as their preferred source of guidance in selecting a Mhealth app (84%) and best suited to develop guidelines (70%)., Conclusion: The interviews and survey highlight the need for Mhealth Apps to be regulated and the importance of health professionals' engagement in the implementation process. Similarly, without well-defined roles for App evaluations within the health care system, it is unlikely that AETs will have wider spread use and impact without risk., Competing Interests: KK, SW, and MAb were employed by Mental Health Commission of Canada. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Khan, Jebanesan, Ahmed, Trimmer, Agic, Safa, Ashraf, Tuck, Kavic, Wadhawan, Abbott, Husain, Husain, Akhter Hamid, McKenzie, Quintana and Naeem.)

Suicide is a serious global public health problem and the third leading cause of death in those 15-35 years old. Self-harm is the major predictor of future suicide attempts and completed suicide yet remains poorly understood. There is limited evidence on effective interventions for adolescents who present with self-harm. To identify and develop acceptable preventive and therapeutic interventions it is essential to understand the factors that contribute to self-harm and suicide in young people, in the context of their emotions, interpersonal difficulties, available support and prevention strategies. This qualitative study aimed at exploring the lived experiences of adolescents presenting with self-harm and their views about potential prevention strategies. Semi-structured interviews with 16 adolescents (12-18 years) presenting with a self-harm episode in a public hospital in Pakistan. A topic guide was developed to facilitate the interviews. The following themes emerged using the framework analysis; predisposing factors (interpersonal conflicts, emotional crisis etc.), regret and realization that self-harm is not the only option, perceived impact of self-harm, and suggestions for suicide prevention strategies (sharing, distraction techniques, involvement of family). This study may help in refining a contextual and culturally based explanatory model of self-harm in adolescents and in informing development of culturally acceptable interventions.

Cognitive flexibility, the ability to adapt behavior to changing outcomes, is critical to survival. The prefrontal cortex is a key site of cognitive control, and chronic pain is known to lead to significant morphological changes to this brain region. Nevertheless, the effects of chronic pain on cognitive flexibility and learning remain uncertain. We used an instrumental paradigm to assess adaptive learning in an experimental model of chronic pain induced by tight ligation of the spinal nerves L5/6 (spinal nerve ligation model). Naive, sham-operated, and spinal nerve ligation (SNL) rats were trained to perform fixed-ratio, variable-ratio, and contingency-shift behaviors for food reward. Although all groups learned an initial lever-reward contingency, learning was slower in SNL animals in a subsequent choice task that reversed reinforcement contingencies. Temporal analysis of lever-press responses across sessions indicated no apparent deficits in memory consolidation or retrieval. However, analysis of learning within sessions revealed that the lever presses of SNL animals occurred in bursts, followed by delays. Unexpectedly, the degree of bursting correlated positively with learning. Under a variable-ratio probabilistic task, SNL rats chose a less profitable behavioral strategy compared with naive and sham-operated animals. After extinction of behavior for learned preferences, SNL animals reverted to their initially preferred (ie, less profitable) behavioral choice. Our data suggest that in the face of uncertainty, chronic pain drives a preference for familiar associations, consistent with reduced cognitive flexibility. The observed burst-like responding may represent a novel learning strategy in animals with chronic pain.

Electrohydrodynamic atomization (EHDA) is a key research area for producing micro and nano-sized structures. This process can be categorized into two main operating regimes: electrospraying for particle generation and electrospinning for fibre production. Producing particles/fibres of the desired size or morphology depends on two main factors; properties of the polymeric solution used and the processing conditions including flow rate, applied voltage and collection distance. In this work the particle-fibre transition region was analyzed by changing the polymer concentration of PLGA poly (lactic-co-glycolic acid) in acetone between 2 and 25wt%. Subsequently the processing conditions were adjusted to study the optimum transition parameters. Additionally the EHDA configuration was also modified by adding a metallic plate to observe the deposition area. The diameter and the distance of the plate from the capillary tip were adjusted to investigate variations in particle and fibre morphologies as well. It was found that complete transition from particles to fibres occurs at 20wt% indicating concentration to be the dominant criterion. Low flow rates yielded fibres without beads. However the applied voltage and distance between the tip of the nozzle jetting the polymer solution and collector (working distance) did not yield definitive results. Reducing the collector distance and increasing applied voltages produces smooth as well as beaded fibres. Addition of a metal plate reduces particle size by ~1μm; the fibre size increases especially with increasing plate diameter while bead density and size reduces when the disc is fixed closer to the capillary tip. Additionally, the deposition area is reduced by 70% and 57% with the addition of metal plates of 30mm and 60mm, respectively. The results indicate that a metal plate can be utilized further to tune the particle/fibre size and morphology and this also significantly increases the yield of EHDA process which is currently a limitation in adopting it as a mass production technique., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

In this article, I discuss a case study of a patient with depression, paranoid ideation, and other psychiatric difficulties who presented in a state of acute crisis. I review the Swiss Lausanne model of Rorschach and Thematic Apperception Test (TAT) interpretation, focusing on a psychoanalytic understanding of special contents and verbalizations. I then present a review of Comprehensive System (Exner, 2003) Structural Summary variables based on a modified Rorschach administration, while qualifying the meanings of these variables in light of the modified procedure. I conclude with a review of Winnicott's (1969) ideas on the paranoid potential, tie it to the main points of the case, and offer a 5-year follow-up of the patient's treatment. The case offers an approach to personality assessment that is informed by an international theory built on psychology and philosophy, and offers support for the use of an alternative theory-based, psychoanalytic method of data analysis.

Psychodynamically oriented assessment using the Rorschach (Exner, 1974, 1978) or Thematic Apperception Test (TAT; Murray, 1943) understands the testing situation as a 3-way interaction in which the examinee talks to the examiner about the inkblot or the TAT picture. In an attempt to define what is at the heart of assessment, I review the following permutations among these components: the participant and the test, the examiner and the participant, and the examiner and the test. In addition, I focus on some of Paul Lerner's contributions, especially on his unwavering stance regarding the importance of the examiner-examinee dimension as an information-gathering tool.

Lysosomal naphthylamidase activity has been measured microdensitometrically in cells in samples obtained by cervical and vaginal irrigation from 22 cases cytologically graded I and II, 28 graded III (moderate to severe dysplasia), 22 graded IV (carcinoma in situ), and 15 cases (grade V) of invasive carcinoma. There was a statistically significant difference in this activity in the cells from cases of grade V as against those in the relatively normal samples (grades I and II; p < 0.001) and as against those of grade IV (p < 0.005). The method is sufficiently robust for routine use provided that it is recognised that elevated activities can be found as a consequence of other factors such as previous surgical intervention and infection with herpes simplex.

Human papillomavirus antigen was found in 39 (16%) of 253 colposcopic biopsies from a group of women at high risk for cervical cancer who had been examined in the early 1970s. Immunohistochemical evidence of papillomavirus infection was found in 20 (30%) of 67 cervical intraepithelial neoplasia lesions infected with wart virus from these patients. When these results were compared with results of a similar study carried out in the early 1980s there was no significant difference in the prevalence of human papillomavirus antigen in cervical intraepithelial neoplasia lesions infected with wart virus from women who had been examined over a decade apart.

A cluster of five self selected cytodiagnostic laboratories circulated 70 cervical/vaginal smears and 50 sputum smears in a series of five week cycles. Histological sections related to the abnormal smears were also circulated. Proportions of agreement and disagreement were analysed for cervical and sputum smear reports against the original report (and by implication against the consensus); corresponding calculations were made for the histological reports. Cytological and histological correlation was also examined. Agreement for major categories (benign, intraepithelial neoplasia, malignant) was 87% for cervical cytology and 83% for sputum. When the effect of potential random agreement was compensated for by the use of kappa statistics the values of kappa were +0.79 and +0.65, respectively. The corresponding kappa values for gynaecological and respiratory tract histology were +0.78 and +0.82, respectively. Agreement on finer degrees of abnormality was, predictably, less good. Problems arising in this pilot scheme are discussed and suggestions for a simplified scheme are made.

The accuracy and stability of self-image of 21 mentally retarded adults and 24 nonretarded adults were studied. The subjects were confronted with a distorting mirror that made their faces look either fatter or slimmer. Results showed that retarded adults saw themselves as more distorted than did non-retarded adults. Significant sex differences in the retarded population were found. Both the precision and the stability of retarded adults' self-image were significantly correlated with IQ. Results were interpreted within a cognitive framework.