Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis.

BACKGROUND Panic disorder is characterised by the presence of recurrent unexpected panic attacks, discrete periods of fear or anxiety that have a rapid onset and include symptoms such as racing heart, chest pain, sweating and shaking. Panic disorder is common in the general population, with a lifetime prevalence of 1% to 4%. A previous Cochrane meta-analysis suggested that psychological therapy (either alone or combined with pharmacotherapy) can be chosen as a first-line treatment for panic disorder with or without agoraphobia. However, it is not yet clear whether certain psychological therapies can be considered superior to others. In order to answer this question, in this review we performed a network meta-analysis (NMA), in which we compared eight different forms of psychological therapy and three forms of a control condition. OBJECTIVES To assess the comparative efficacy and acceptability of different psychological therapies and different control conditions for panic disorder, with or without agoraphobia, in adults. SEARCH METHODS We conducted the main searches in the CCDANCTR electronic databases (studies and references registers), all years to 16 March 2015. We conducted complementary searches in PubMed and trials registries. Supplementary searches included reference lists of included studies, citation indexes, personal communication to the authors of all included studies and grey literature searches in OpenSIGLE. We applied no restrictions on date, language or publication status. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) focusing on adults with a formal diagnosis of panic disorder with or without agoraphobia. We considered the following psychological therapies: psychoeducation (PE), supportive psychotherapy (SP), physiological therapies (PT), behaviour therapy (BT), cognitive therapy (CT), cognitive behaviour therapy (CBT), third-wave CBT (3W) and psychodynamic therapies (PD). We included both individual and group formats. Therapies had to be administered face-to-face. The comparator interventions considered for this review were: no treatment (NT), wait list (WL) and attention/psychological placebo (APP). For this review we considered four short-term (ST) outcomes (ST-remission, ST-response, ST-dropouts, ST-improvement on a continuous scale) and one long-term (LT) outcome (LT-remission/response). DATA COLLECTION AND ANALYSIS As a first step, we conducted a systematic search of all relevant papers according to the inclusion criteria. For each outcome, we then constructed a treatment network in order to clarify the extent to which each type of therapy and each comparison had been investigated in the available literature. Then, for each available comparison, we conducted a random-effects meta-analysis. Subsequently, we performed a network meta-analysis in order to synthesise the available direct evidence with indirect evidence, and to obtain an overall effect size estimate for each possible pair of therapies in the network. Finally, we calculated a probabilistic ranking of the different psychological therapies and control conditions for each outcome. MAIN RESULTS We identified 1432 references; after screening, we included 60 studies in the final qualitative analyses. Among these, 54 (including 3021 patients) were also included in the quantitative analyses. With respect to the analyses for the first of our primary outcomes, (short-term remission), the most studied of the included psychological therapies was CBT (32 studies), followed by BT (12 studies), PT (10 studies), CT (three studies), SP (three studies) and PD (two studies).The quality of the evidence for the entire network was found to be low for all outcomes. The quality of the evidence for CBT vs NT, CBT vs SP and CBT vs PD was low to very low, depending on the outcome. The majority of the included studies were at unclear risk of bias with regard to the randomisation process. We found almost half of the included studies to be at high risk of attrition bias and detection bias. We also found selective outcome reporting bias to be present and we strongly suspected publication bias. Finally, we found almost half of the included studies to be at high risk of researcher allegiance bias.Overall the networks appeared to be well connected, but were generally underpowered to detect any important disagreement between direct and indirect evidence. The results showed the superiority of psychological therapies over the WL condition, although this finding was amplified by evident small study effects (SSE). The NMAs for ST-remission, ST-response and ST-improvement on a continuous scale showed well-replicated evidence in favour of CBT, as well as some sparse but relevant evidence in favour of PD and SP, over other therapies. In terms of ST-dropouts, PD and 3W showed better tolerability over other psychological therapies in the short term. In the long term, CBT and PD showed the highest level of remission/response, suggesting that the effects of these two treatments may be more stable with respect to other psychological therapies. However, all the mentioned differences among active treatments must be interpreted while taking into account that in most cases the effect sizes were small and/or results were imprecise. AUTHORS' CONCLUSIONS There is no high-quality, unequivocal evidence to support one psychological therapy over the others for the treatment of panic disorder with or without agoraphobia in adults. However, the results show that CBT - the most extensively studied among the included psychological therapies - was often superior to other therapies, although the effect size was small and the level of precision was often insufficient or clinically irrelevant. In the only two studies available that explored PD, this treatment showed promising results, although further research is needed in order to better explore the relative efficacy of PD with respect to CBT. Furthermore, PD appeared to be the best tolerated (in terms of ST-dropouts) among psychological treatments. Unexpectedly, we found some evidence in support of the possible viability of non-specific supportive psychotherapy for the treatment of panic disorder; however, the results concerning SP should be interpreted cautiously because of the sparsity of evidence regarding this treatment and, as in the case of PD, further research is needed to explore this issue. Behaviour therapy did not appear to be a valid alternative to CBT as a first-line treatment for patients with panic disorder with or without agoraphobia.

Influence of catchment quality and altitude on the water and sediment composition of 68 small lakes in Central Europe

68 lakes (63 Swiss, 2 French and 3 Italian) located in an altitudinal range between 334 and 2339m spanning a wide range of land-use have been investigated. The aim of the study was to discuss influences of geographic location, vegetation and land-use in the catchment area on the water and sediment chemistry of small lakes. Detailed quantitative description of land-use, vegetation, and climate in the watershed of all lakes was established. Surface and bottom water samples collected from each lake were analyzed for major ions and nutrients. Correlations were interpreted using linear regression analysis. Chemical parameters of water and sediment reflect the characteristics of the catchment areas. All lakes were alkaline since they were situated on calcareous bedrock. Concentrations of nitrogen and phosphorus strongly increase with increasing agricultural land-use. Na and K, however, are positively correlated with the amount of urbanization within the catchment area. These elements as well as dissolved organic carbon (DOC), Mg, Ca, and alkalinity, increase when the catchment is urbanized or used for agriculture. Total nitrogen and organic carbon in the sediments decrease distinctly if large parts of the catchment consist of bare land. No correlations between sediment composition and maximum water depth or altitude of the lakes were found.¶Striking differences in the water compositions of lakes above and below approximately 700 m of altitude were observed. Concentrations of total nitrogen and nitrate, total phosphorus, DOC, Na, K, Mg, Ca, and alkalinity are distinctly higher in most lakes below 700 m than above, and the pH of the bottom waters of these lakes is generally lower. Estimates of total nitrogen concentrations, even in remote areas, indicate that precipitation is responsible for increased background concentrations. At lower altitudes nitrogen concentrations in lakes is explained by the nitrogen loaded rain from urban areas deposited on the catchment, and with high percentages of agricultural land-use in the watershed.

Network-based genome-wide association study of Crohn's disease

Genome-wide association studies (GWAS) have rapidly become a standard method for disease gene discovery. Many recent GWAS indicate that for most disorders, only a few common variants are implicated and the associated SNPs explain only a small fraction of the genetic risk. The current study incorporated gene network information into gene-based analysis of GWAS data for Crohn's disease (CD). The purpose was to develop statistical models to boost the power of identifying disease-associated genes and gene subnetworks by maximizing the use of existing biological knowledge from multiple sources. The results revealed that Markov random field (MRF) based mixture model incorporating direct neighborhood information from a single gene network is not efficient in identifying CD-related genes based on the GWAS data. The incorporation of solely direct neighborhood information might lead to the low efficiency of these models. Alternative MRF models looking beyond direct neighboring information are necessary to be developed in the future for the purpose of this study.^

Avances metodológicos del proceso de adopción de los Planes de Ordenamiento de segunda generación frente a los vacios jurídicos de la Legislación Colombiana en materia de Ordenamiento Territorial a la luz del P.O.T. Armenia 2007/2019 “Una Ciudad para la Vida"

Las nuevas realidades territoriales, bajo el innovador panorama constitucional colombiano, requieren de procesos de planificación coherentes, ajustados a las necesidades reales de desarrollo de nuestras sociedades en constante crecimiento. Se requieren acciones inmediatas y contundentes de fortalecimiento, asistencia técnica, desarrollo institucional e implementación de instrumentos de Gestión y financiación del suelo, para responder a la insuficiente capacidad de los entes territoriales para asumir con responsabilidad la formulación e implementación de los instrumentos de planificación y ordenamiento territorial planteados por la ley y la normatividad urbanística vigente. Dicha normatividad, dada su falta de reglamentación y regulación, hace compleja su aplicación en pequeñas y medianas ciudades, debido a la deficiente capacidad operativa y ejecutoria que tienen sus administraciones. El 24 de enero de 1999 el Concejo Municipal de Armenia aprobaba el primer plan de ordenamiento territorial para un municipio Colombiano bajo el marco de la Ley de Desarrollo Territorial 388 de 1997. Veinticuatro horas después se produce un sismo de 6.4 grados (Richter) con epicentro a 24 kilómetros de distancia, generando devastadoras consecuencias en toda la región del eje cafetero, tanto en lo físico como en lo social: “Cuando teníamos las respuestas… cambiaron las preguntas". Las nuevas determinantes territoriales generadas como efecto de la tragedia pondrían el proceso de implementación del plan en un escenario complejo y contradictorio. A pesar de que el concepto de gestión del riesgo había sido abordado por el P.O.T., las realidades del desastre superaban la expectativa planificadora, desbordando cualquier escala de ejecutabilidad de la norma recientemente aprobada. El equipo de formulación del nuevo plan, bajo la coordinación del D.A.P.M. y con apoyo de la academia identificó de manera inmediata la complejidad del proceso. Además, realizó aportes que permitieran a los demás municipios Colombianos evitar cometer los mismos errores, superar los obstáculos, agilizar procesos particulares de planificación territorial y dotar así a sus municipios de unos Planes de Ordenamiento mas aterrizados, realizables y sobretodo mas consecuentes con las necesidades particulares de sus municipios.

Perspectivas sobre el turismo en la Comunidad Andina de Naciones : Análisis comparativo con el Mercosur

El proyecto de integración al que aspiran los países miembros de la Comunidad Andina de Naciones (can) tiene un carácter exhaustivo, que excede el ámbito de los acuerdos comerciales. En este contexto, la integración en materia de turismo ha despertado un interés creciente entre los gobiernos de América Latina y el Caribe, por su capacidad de generar divisas y favorecer la inversión privada, la creación de empleo, la inclusión y el encadenamiento de empresas pequeñas y comunidades locales. Asimismo, la actividad turística puede contribuir a reforzar la identidad regional y subregional de los esquemas de integración. El turismo es uno de los rubros económicos más importantes para los países en desarrollo y, a su vez, se lo reconoce como un factor que contribuye a la reducción de la pobreza y al crecimiento económico. Por ello, se lo debe considerar como una oportunidad para el desarrollo de los países de la can, sobre todo porque los miembros del bloque andino cuentan con una oferta turística diversificada compuesta por recursos naturales y culturales de gran atractivo. En el presente trabajo se analiza la evolución del flujo de turistas en los países de la Comunidad Andina de Naciones y se esboza un estudio comparativo con el bloque del mercosur. Luego, se elabora una matriz que permite observar, a primera vista, la magnitud del turismo emisivo intrarregional en ambos casos, así como determinar ciertas conclusiones a partir de los datos observados y comparados. Finalmente, se presentan algunas propuestas que los cuatro países de la CAN podrían desarrollar en el ámbito de la cooperación horizontal, en relación con la promoción conjunta y con la participación de las ciudades de la región en la red de Mercociudades

Perspectivas sobre el turismo en la Comunidad Andina de Naciones : Análisis comparativo con el Mercosur

El proyecto de integración al que aspiran los países miembros de la Comunidad Andina de Naciones (can) tiene un carácter exhaustivo, que excede el ámbito de los acuerdos comerciales. En este contexto, la integración en materia de turismo ha despertado un interés creciente entre los gobiernos de América Latina y el Caribe, por su capacidad de generar divisas y favorecer la inversión privada, la creación de empleo, la inclusión y el encadenamiento de empresas pequeñas y comunidades locales. Asimismo, la actividad turística puede contribuir a reforzar la identidad regional y subregional de los esquemas de integración. El turismo es uno de los rubros económicos más importantes para los países en desarrollo y, a su vez, se lo reconoce como un factor que contribuye a la reducción de la pobreza y al crecimiento económico. Por ello, se lo debe considerar como una oportunidad para el desarrollo de los países de la can, sobre todo porque los miembros del bloque andino cuentan con una oferta turística diversificada compuesta por recursos naturales y culturales de gran atractivo. En el presente trabajo se analiza la evolución del flujo de turistas en los países de la Comunidad Andina de Naciones y se esboza un estudio comparativo con el bloque del mercosur. Luego, se elabora una matriz que permite observar, a primera vista, la magnitud del turismo emisivo intrarregional en ambos casos, así como determinar ciertas conclusiones a partir de los datos observados y comparados. Finalmente, se presentan algunas propuestas que los cuatro países de la CAN podrían desarrollar en el ámbito de la cooperación horizontal, en relación con la promoción conjunta y con la participación de las ciudades de la región en la red de Mercociudades

Perspectivas sobre el turismo en la Comunidad Andina de Naciones : Análisis comparativo con el Mercosur

El proyecto de integración al que aspiran los países miembros de la Comunidad Andina de Naciones (can) tiene un carácter exhaustivo, que excede el ámbito de los acuerdos comerciales. En este contexto, la integración en materia de turismo ha despertado un interés creciente entre los gobiernos de América Latina y el Caribe, por su capacidad de generar divisas y favorecer la inversión privada, la creación de empleo, la inclusión y el encadenamiento de empresas pequeñas y comunidades locales. Asimismo, la actividad turística puede contribuir a reforzar la identidad regional y subregional de los esquemas de integración. El turismo es uno de los rubros económicos más importantes para los países en desarrollo y, a su vez, se lo reconoce como un factor que contribuye a la reducción de la pobreza y al crecimiento económico. Por ello, se lo debe considerar como una oportunidad para el desarrollo de los países de la can, sobre todo porque los miembros del bloque andino cuentan con una oferta turística diversificada compuesta por recursos naturales y culturales de gran atractivo. En el presente trabajo se analiza la evolución del flujo de turistas en los países de la Comunidad Andina de Naciones y se esboza un estudio comparativo con el bloque del mercosur. Luego, se elabora una matriz que permite observar, a primera vista, la magnitud del turismo emisivo intrarregional en ambos casos, así como determinar ciertas conclusiones a partir de los datos observados y comparados. Finalmente, se presentan algunas propuestas que los cuatro países de la CAN podrían desarrollar en el ámbito de la cooperación horizontal, en relación con la promoción conjunta y con la participación de las ciudades de la región en la red de Mercociudades

Urban forest health survey on Roznik in Ljubljana in 2013 by two methods

Urban forest health was surveyed on Roznik in Ljubljana (46.05141 N, 14.47797 E) in 2013 by two methods: ICP Forests and UFMO. ICP Forests is most commonly used monitoring programme in Europe - the International Co-operative Programme on the Assessment and Monitoring of Air Pollution Effects on Forests, which is based on systematic grid. UFMO method - Urban Forests Management Oriented method was developed in the frame of EMoNFUr Project - Establishing a monitoring network to assess lowland forest and urban plantations in Lombardy and urban forest in Slovenia (LIFE10 ENV/IT/000399). UFMO is based on non-linear transects (GPS tracks). ICP forests monitoring plots were established in July 2013 in the urban forest Roznik in Ljubljana .The 32 plots are located on sampling grid 500 × 500 m. The grid was down-scaled from the National Forest Monitoring survey, which bases on national sample grid 4 × 4 km. With the ICP forests method the following parameters for each tree within the 15 plots were gathered according to the ICP forests manual for Visual assessment of crown condition and damaging agents: tree species, percentage of defoliation, affected part of the tree, specification of affected part, location in crown, symptom, symptom specification, causal agents / factors, age of damage, damage extent, and damage extent on the trunk. With the UFMO method, the following parameters for each tree that needed sylviculture measure (felling, pruning, sanitary felling, thinning, etc.) were recorded: tree species, breast diameter, causal agent / damaging factor, GPS waypoint and GPS track. For overall picture in the urban forest health problems, also other biotic and abiotic damaging factors that did not require management action were recorded.

Snow height on sea ice and sea ice drift from autonomous measurements from buoy 2013S1, deployed during Antarctic Fast Ice Network 2013 (AFIN 2013)

Snow height was measured by the Snow Depth Buoy 2013S1, an autonomous platform, installed close to Neumayer III Base, Antarctic during Antarctic Fast Ice Network 2013 (AFIN 2013). The resulting time series describes the evolution of snow height as a function of place and time between 2013-02-11 and 2013-04-29 in sample intervals of 1 hour. The Snow Depth Buoy consists of four independent sonar measurements representing the area (approx. 10 m**2) around the buoy. The buoy was installed on the ice shelf. In addition to snow height, geographic position (GPS), barometric pressure, air temperature, and ice surface temperature were measured. Negative values of snow height occur if surface ablation continues into the sea ice. Thus, these measurements describe the position of the sea ice surface relative to the original snow-ice interface. Differences between single sensors indicate small-scale variability of the snow pack around the buoy. The data set has been processed, including the removal of obvious inconsistencies (missing values). Records without any snow height may still be used for sea ice drift analyses. Note: This data set contains only relative changes in snow height, because no initial readings of absolute snow height are available.

Snow height on sea ice and sea ice drift from autonomous measurements from buoy 2014S24, deployed during Antarctic Fast Ice Network 2014 (AFIN 2014)

Snow height was measured by the Snow Depth Buoy 2014S24, an autonomous platform, installed close to Neumayer III Base, Antarctic during Antarctic Fast Ice Network 2014 (AFIN 2014). The resulting time series describes the evolution of snow depth as a function of place and time between 2014-03-07 and 2014-05-16 in sample intervals of 1 hour. The Snow Depth Buoy consists of four independent sonar measurements representing the area (approx. 10 m**2) around the buoy. The buoy was installed on the ice shelf. In addition to snow depth, geographic position (GPS), barometric pressure, air temperature, and ice surface temperature were measured. Negative values of snow depth occur if surface ablation continues into the sea ice. Thus, these measurements describe the position of the sea ice surface relative to the original snow-ice interface. Differences between single sensors indicate small-scale variability of the snow pack around the buoy. The data set has been processed, including the removal of obvious inconsistencies (missing values). Records without any snow depth may still be used for sea ice drift analyses. Note: This data set contains only relative changes in snow depth, because no initial readings of absolute snow depth are available.

Regional Cooperation of Small & Medium Firms in Japanese Industrial Clusters

This study examines the effects of intra-regional cooperation among firms and institutions on the growth of firms, using the unique data set of questionnaire survey collected in the three major industrial clusters in Japan. In contrast to the existing studies on regional innovations or agglomeration economies, this study explicitly focuses on the detailed contents of cooperative activities with two specific viewpoints: 1) the contents of regional cooperation in each of the three production stages of R&D, commercialization, and marketing, and 2) the detailed types of alliance partners. Our results demonstrate three points: 1) positive correlations are observed between the intensity of regional cooperation and the firm growth rate and R&D expenditure, 2) horizontal cooperation such as alliances with universities and cross-industry exchange organizations has positive significant effects on the growth rate of firms, which is in contrast with the previous studies that stressed only the role of vertically integrated inter-firm linkages in Japan, and 3) contents and partners of regional cooperation are different among the three clusters based on different dominant industries.

Migration, labor and business in the worlding cities of the Arabian Peninsula

This short essay, built on a foundation of more than a decade of fieldwork in the hydrocarbon-rich societies of the Arabian peninsula, distills a set of overarching threads woven through much of that time and work. Those threads include a discussion of the social heterogeneity of the Gulf State citizenries, the central role of development and urban development in these emergent economies, the multifaceted impact of migrants and migration upon these host societies, and the role of foreign 'imagineers' in the portrayal of Gulf societies, Gulf values, and Gulf social norms.

Coastal Urban Flood Resislience versus Climate Change

Processes of founding and expanding cities in coastal areas have undergone great changes over time driven by environmental conditions. Coastal settlements looked for places above flood levels and away from swamps and other wetlands whenever possible. As populations grew, cities were extending trying to avoid low and wet lands. No city has been able to limit its growth. The risk of flooding can never be eliminated, but only reduced to the extent possible. Flooding of coastal areas is today dramatically attributed to eustasic sea level rise caused by global climate change. This can be inaccurate. Current climate change is generating an average sea level upward trend, but other regional and local factors result in this trend being accentuated in some places or attenuated, and even reversed, in others. Then, the intensity and frequency of coastal flooding around the planet, although not so much as a unique result of this general eustasic elevation, but rather of the superposition of marine and crustal dynamic elements, the former also climate-related, which give rise to a temporary raising in average sea level in the short term. Since the Little Ice Age the planet has been suffering a global warming change leading to sea level rise. The idea of being too obeying to anthropogenic factors may be attributed to Arrhenius (1896), though it is of much later highlight after the sixties of the last century. Never before, the human factor had been able of such an influence on climate. However, other types of changes in sea levels became apparent, resulting from vertical movements of the crust, modifications of sea basins due to continents fracturing, drifting and coming together, or to different types of climate patterns. Coastal zones are then doubly susceptible to floods. Precipitation immediately triggers pluvial flooding. If it continues upland or when snow and glaciers melt eventually fluvial flooding can occur. The urban development presence represents modifying factors. Additional interference is caused by river and waste water drainage systems. Climate also influences sea levels in coastal areas, where tides as well as the structure and dynamic of the geoid and its crust come into play. From the sea, waters can flood and break or push back berms and other coastline borders. The sea level, controlling the mouth of the main channel of the basin's drainage system, is ultimately what governs flood levels. A temporary rise in sea level acts as a dam at the mouth. Even in absence of that global change, so, floods are likely going to increase in many urban coastal areas. Some kind of innovative methodologies and practices should be needed to get more flood resilience cities

Potential to attract drivers out of their cars in dense urban areas.

Purpose Sustainable mobility urban policies intend reducing car use and increasing walking, cycling and public transport. However, this transfer from private car to these more sustainable modes is only a real alternative where distances are small and the public transport supply competitive enough. This paper proposes a methodology to calculate the number of trips that can be transferred from private car to other modes in city centres. Method The method starts analyzing which kind of trips cannot change its mode (purposes, conditions, safety , etc.), and then setting a process to determine under which conditions trips made by car between given O-D pairs can be transferable. Then, the application of demand models allow to determine which trips fulfil the transferability conditions. The process test the possibility of transfer in a sequential way: firs to walking, then cycling and finally to public transport. Results The methodology is tested through its application to the city of Madrid (Spain), with the result of only some 18% of the trips currently made by car could be made by other modes, under the same conditions of trip time, and without affecting their characteristics. Out of these trips, 75% could be made by public transport, 15% cycling and 10% on foot. The possible mode to be transferred depends on the location: city centre areas are more favourable for walking and cycling while city skirts could attract more PT trips. Conclusions The proposed method has demonstrated its validity to determine the potential of transferring trips out of cars to more sustainable modes. Al the same time it is clear that, even in areas with favourable conditions for walking, cycling and PT trips, the potential of transfer is limited because cars fulfil more properly special requirements of some trips and tours.

Integrated planning for ecological urban regeneration

Considering that the vast majority of housing stock existing in 2011 will be used to satisfy residential needs in the year 2020 and beyond, ecological urban regeneration appears clearly as the key issue in relation to global urban sustainability for the most part of this century. Thus, if the 1992 Rio Summit identified the urban environment as the main arena where the global environmental crisis should be fought, 20 years later we must emphasize that it is mainly to the real cities and territories around us now where we should address our attention