Pediatric mock codes (PMC) were first introduced to the Burn Trauma ICU (BTICU) in Fall 2020. The goal of the PMCs were to increase efficiency in a code situation and to increase nursing confidence. However, due to the unique timing of initiation, this hospital also chose to look at how turnover rates affected the outcomes of the PMCs. The time period chosen was during the COVID crisis and the unit had an increasing number of nurses leaving for contract positions.The PMCs created were specifically designed to replicate the pediatric population the team cares for. A different PMC scenario was presented every six months for a total of four mock codes. The nurses completed the PMCs with a team approach, with each team consisting of two to six nurses. During the mock code, the nurse educator kept track of time, monitored role assignments and completion of major tasks, and ensured pre and post surveys were completed. The pre and post surveys evaluated the nurse’s self-confidence, biggest concern regarding a pediatric code, and if they had previously participated in a PMC.Over the period of two years, 82 participants were captured. However, these were not unique individuals, as some nurses participated in all four mock codes. It was expected that each time the mock code was completed, the number of nurses who had participated in PMC would increase. However, as time progressed, the rate of previous participation actually decreased.Instead of improving on time to compressions or medication administration time, the times stayed the same over the two-year time frame. When evaluating the comments on the survey, the staff concerns also did not change over time. Medication administration remained the number one concern across all four mock codes. Even though the PMC did not improve skills, 100% of those who participated expressed an increase in confidence level.Nursing units depend on novice nurses gaining knowledge and skills and progressing into the expert nurses on the unit. However, the loss of permanent staff and the hiring of new nurses has had an impact on this cycle. The unit lost many of its expert nurses before the new nurses had time to advance. This can be directly seen in the turnover rate and the previous participation in the PMC. Essentially this halted the unit as a whole from growing their skill set in the pediatric population. However, as the nursing market stabilizes, there are future plans to continue to evaluate the PMC skills and outcomes.As nursing turnover rates increase, patient complications and outcomes should also be evaluated to see if a correlation is present.


Physician-coded verbal autopsy (PCVA) is the most widely used method to determine causes of death (COD) in countries where medical certification of death is low. Computer-coded verbal autopsy (CCVA), an alternative method to PCVA for assigning the COD is considered to be efficient and cost-effective. However, the performance of CCVA as compared to PCVA is yet to be established in the Indian context.We evaluated the performance of PCVA and three CCVA methods i.e., InterVA 5, InSilico, and Tariff 2.0 on verbal autopsies done using the WHO 2016 VA tool on 2,120 reference standard cases developed from five tertiary care hospitals of Delhi. PCVA methodology involved dual independent review with adjudication, where required. Metrics to assess performance were Cause Specific Mortality Fraction (CSMF), sensitivity, positive predictive value (PPV), CSMF Accuracy, and Kappa statistic.In terms of the measures of the overall performance of COD assignment methods, for CSMF Accuracy, the PCVA method achieved the highest score of 0.79, followed by 0.67 for Tariff_2.0, 0.66 for Inter-VA and 0.62 for InSilicoVA. The PCVA method also achieved the highest agreement (57%) and Kappa scores (0.54). The PCVA method showed the highest sensitivity for 15 out of 20 causes of death.Our study found that the PCVA method had the best performance out of all the four COD assignment methods that were tested in our study sample. In order to improve the performance of CCVA methods, multicentric studies with larger sample sizes need to be conducted using the WHO VA tool. Verbal autopsy (VA) is a method of ascertaining cause of death (COD) from information on signs/symptoms and circumstances preceding death through interviewing the deceased's caretakers  for comparison with the underlying cause derived from PCVA or any of the CCVA methods. For the same death. The reference UCOD can be derived from the pathological autopsy, which is considered as a “gold standard,” or from clinical records which are considered as the next best alternative  which would be compared with the reference standard for validation.The key objective of the study was to establish the most accurate approach for assigning the COD to Verbal Autopsy tool. The parameter of accuracy or estimating the sample size was chosen to be the sensitivity of a COD assignment method in correctly assigning diagnoses from a specific cause of interest when compared to the set of cases with reference standard diagnoses from that cause. Based on the literature review, it was estimated that to establish a sensitivity of 70% with an absolute margin of 5–6% with a confidence of 95%, an estimated sample size of 250 cases with reference diagnoses for the cause of interest would be required. Since the study proposed to validate 20 specified causes of death, a total sample of 5,000 cases was required, with equal distribution across these 20 causes of interest. Considering the potential for attrition and loss to follow-up due to various reasons, the size of this primary sample was inflated by 40% to 7,000 cases.In each hospital, a nominated team member prepared medical record files during the study time period by de-identification, assignment of the study case number, and removal of the medical certificate of COD, which were then sent for blind physician review. A team of trained physicians in medical certification of COD and basic rules for selection of the underlying COD as per ICD  procedures reviewed the case records in each hospital. All cases that met the criterion for the confirmed diagnosis and were from the list of 20 selected causes of interest were selected into the study sample. Confirmatory evidence comprised of either an appropriate laboratory test, imaging investigation, surgical notes or documented clinical history and observations suggestive of the diagnosis of interest, similar to criteria used in other studies  are available for download from the WHO Verbal autopsy website  was developed for the training purpose. A 10-day training program of the field investigators was conducted which included 6 days of in-house training on the VA tool followed by 4-day field level training. The training was imparted by physicians having prior field experience in conducting VA and analyzing verbal autopsy data. They underwent a training program that included classroom sessions on VA methodology, detailed instruction and focus group discussions on questionnaire content and interviewing skills, VA ethics, as well as field practice interviews with feedback sessions. The sessions focused on highlighting the concept, importance and purpose of VA along with an in-depth understanding about the procedures, principles and communication techniques for conducting VA interviews. The in-house training also included mock role plays along with dedicated sessions for identification of signs and symptoms related to common illnesses. The practical sessions were facilitated by several of the co-authors on the manuscript, as well as other technical officers from the institute with previous experience in conducting VA studies. VA data was collected using tablet computer devices, for which interviewers were also familiarized with their use, which included instructions on program control, troubleshooting, and data storage and transmission. The cases were allotted to interviewer teams according to geographical clusters within suburban areas of Delhi. The project management team provided on-site supervision and troubleshooting tips to improve interviewing skills, monitored field progress and data quality, and arranged data storage.The study protocol and all procedures were approved by the ICMR-NIMS- Institutional Ethical Committee and approved by the ICMR-NIMS Scientific Advisory Committee.Electronic data from all VAs were merged into a single data file which was cleaned and prepared for further analysis. The OpenVA package was used for analysis with the interVA-5 and InSilico CCVA diagnostic programs, and the Smart VA application was used for the Tariff method Thomas, . Each CCA range of statistical indicators were used to measure and compare the accuracy of different techniques (PCVA and CCVA) for assigning causes of death. For accuracy of individual causes, the indicators used are the Percentage Relative Difference between proportions from the reference standard cases and the test method cases, as well as Sensitivity and Positive Predictive Values. The overall accuracy of a COD diagnostic method across all causes in comparison with the reference standards was evaluated using three indicators.Cause-Specific Mortality Fraction Accuracy (CSMF Accuracy) is defined as the average value of differences between CSMFs for each cause by a particular COD assignment method and the CSMF for the same causes in the reference dataset  is a measure of agreement between the two independent ratings for the same observation  for PCVA. In regard to perinatal causes of death, however, the PCVA alone showed high scores of sensitivity for both stillbirths and prematurity and a moderate score for birth asphyxia. In contrast, the CCVA methods did not perform adequately for perinatal causes of death. Finally, for deaths from road traffic accidents, two of the CCVA methods—InterVA5 and InSilicoVA showed low validation scores, although these deaths are relatively straightforward to identify through VA. Similarly, for deaths from falls, all methods showed poor positive predictive values which is indicative of over-identification of this cause by VA.The diagnostic accuracy of each method can also be understood from the misclassification patterns between the method being tested and the reference diagnoses for the study sample, as presented in The indicators for the overall comparison of the performance of each COD assignment method are presented in With the advent of computerized methods for assigning causes of death from VA, this study provides important evidence of the performance of these methods in the Indian context. The principal finding that PCVA appears to be the most accurate COD assignment method from VA data is not unexpected, particularly since physician reviewers have access to and can wholly utilize information from the open narrative section of the VA questionnaires, which has been proved from previous research to provide valuable and accurate evidence to establish the probable COD. Nevertheless, the quantification of computer diagnostic performance using well-defined reference diagnoses as well as standard statistical indicators for performance evaluation, along with the detailed symptom-cause information compiled from this study, will be a valuable resource for further development of the diagnostic logic of the CCVA programs. In parallel, the diagnostic errors noted for PCVA in Validation of verbal autopsy diagnosis is challenging in terms of obtaining reference diagnosis. Several studies have used causes of death based on medical records as the reference standard  have been misclassified to accidental falls. This could be simply because the family member could only recall and report the fall associated with the sudden unconsciousness that occurs from an acute stroke without having the opportunity to observe unilateral paralysis, which is the cardinal sign of stroke. Similarly, there are specific patterns of misclassification in regard to the COD assignment for deceased individuals with diabetes. Some physicians nominate diabetes as the underlying cause when present along with ischaemic heart disease and stroke, while others consider such co-morbidity as an association rather than a causal relationship and hence nominate the cardiovascular condition as the underlying cause. The ICD rules permit physicians to exercise their individual preferences for these situations, which therefore explains the observed cross-classification patterns observed from PCVA. However, it is interesting to note similar cross-classification patterns between diabetes and cardiovascular diseases even from CCVA methods in A potential limitation of the study was the relatively large number of cases (74%) that were lost to follow-up by VA, arising from incomplete or wrong address details provided on case records. Field supervisors made follow-up visits to search for houses not identified by VA interviewers in about 10% of cases, but these visits, too, were largely unsuccessful, hence confirming the loss to follow-up. However, as demonstrated in For assigning causes of death, we selected a set of 20 causes of death that we considered important for the epidemiological profile of India. However, our target list did not include other less frequent but still important conditions such as dengue fever, leishmaniasis, and hypertensive/congestive heart disease. Validation of VA diagnoses for these conditions would require specially designed studies that separately target these conditions, given their seasonality or geographical specificity. Nevertheless, the conduct of this study has established a standard methodology for VA validation studies in India, which could be replicated in other settings with varying epidemiological profiles across India.In conclusion, our study found that the PCVA method had the best performance out of all the four COD assignment methods that were tested in our study sample. While the CCVA algorithms have not yet achieved an appropriate level of accuracy for them to be directly taken as alternatives to physician assignment of causes of death, the data compiled from studies such as this one could be very useful for improving both PCVA and CCVA programs.dr_vishnurao@yahoo.com.The datasets presented in this article are not readily available because, the datasets generated and/or analyzed during the current study are not publicly available, as we are a Government of India research organization; approvals from the competent authority need to be taken for data sharing, but the data may be available from the corresponding author on reasonable request, subject to approval from the competent authority. Requests to access the datasets should be directed to MR, The studies involving human participants were reviewed and approved by ICMR-NIMS Ethics Committee on Health Research. The patients/participants provided their written informed consent to participate in this study.MR, SB, SS, and CR conceived and designed the analysis and wrote the paper. MR, SB, SS, SN, AJ, LS, and BG conduct of study. SN, KS, SS, LS, SN, AJ, VY, and BG contributed to data analysis and interpretation. MR, KS, LS, and AJ performed the analysis. All authors contributed to the article and approved the submitted version.


Cannibalism, the consumption of another by an individual of the same species, is a widespread practice amongst many animal groups. Human cannibalism or anthropophagy, however, is less common but has been found in many diverse groups ranging from hominids to Crusaders and soldiers in World War II. Although the existence of human cannibalism has been vigorously debated in recent times, it seems clear that well-described cases have occurred. The motivation for consuming human tissues may be (1) nutritional, (2) ritual and (3) pathological. A case of alleged cannibalism involving one of the victims of the so-called Snowtown serial killings in South Australia, Australia, is reported with an analysis of the history and features of cannibalism. Forensic problems may occur in accurately identifying remains that have been cannibalized; however, if ritualistic, serial and/or sadistic homicides are encountered, cannibalism should be considered, particularly if body parts are missing. Caníbales, the Spanish name for the Caribe Indians of the Lesser Antilles who were believed to indulge in this practice [Cannibalism refers to the consumption of another by an individual of the same species. The word cannibal derives from practice . It is wpractice .Human cannibalism or anthropophagy, however, is far less common, although it has occurred for millennia in a wide range of human societies and cultural groups. Anthropological studies have identified cut marks on 780,000-year-old hominid bones and on 100,000-year-old bones from Neanderthal populations that existed in the Middle Paleolithic era , 4. AccoSimilar remains Fig.  from GouCharacteristic features of cannibalism in archeological material include the finding of admixed fragments of human and animal bones, all showing similar features with typical signs of butchery, often alongside stone implements . The bonWhile cannibalism may simply take place for nutritional purposes, there are also cases that occur for ritual and pathological reasons. During the investigation of a series of bodies found stored in large plastic barrels in the vault of a disused bank in the South Australian village of Snowtown Fig. , a descrFollowing a detailed police investigation, six barrels that were discovered in the vault of a bank in Snowtown, South Australia, in May 1998 were transported to the Forensic Science Centre in Adelaide where a team led by pathologists John Gilbert and Roger Byard examined the contents. The barrels contained eight intact and partially dismembered adult bodies consisting of seven males and one female, along with hand cuffs, thumb cuffs, disposable gloves, duct tape, gags and rope. At the end of the investigation, it transpired that there were 12 victims in all, with 4 bodies being disposed of at other sites. The causes of death were often difficult to determine given the state of decomposition of the bodies, with a number of pathological conclusions of ‘undetermined’ being made; however, there was evidence of strangulation, choking and drug ingestion in several of the victims. The killings had taken place between 1992 and 1999 with John Bunting, Robert Wagner and James Vlassakis subsequently being convicted of multiple counts of murder .During the trial, it was asserted by Vlassakis that Wagner had removed flesh from the final victim, David Johnson which was then cooked in a frying pan and eaten , 11. He Determining whether cannibalism has occurred may not be possible based on autopsy findings, as was demonstrated in the Snowtown case where only a tissue defect that could correspond to a portion removed for consumption was found. As the early stages of dismemberment consist of taking slices of thigh and/or buttock muscle, this could be obscured by subsequent putrefactive changes. This has been termed ‘survival cannibalism’. Later, more intensive searching for nutritive material, ‘end stage cannibalism’, may leave detectable markings such as cut marks on the bone Fig.  or the bIt has been suggested based on animal studies that the transmission of pathogens from victims to consumers may account for the rarity of cannibalism in human populations ; howeverWhile the existence of cannibalism has been disputed, particularly in tribal societies, there appears no doubt from multiple historical records that there have been many reliably reported cases. Cannibalism occurs for a wide variety of reasons and may be separated into two broad categories of exo- and endocannibalism . With exA more functional classification is based on motivations for consuming human tissues and has the following subgroups: 1) nutritional or gastronomic, (2) ritual and (3) pathological  nutritio and alsoHistorical examples of nutritional cannibalism have included survivors of shipwrecks who either fed on the bodies of those who had died, so-called necro-cannibalism, or who killed other survivors for food . A well-known example is the French frigate Méduse that sank off Mauritania in 1816. Of the 147 passengers and crew who were on a raft, only 15 survived. The Donner party of settlers trying to cross the Sierra Nevada mountains in the 1840s are another example of cannibalism in extremis .The fate of the members of the Franklin expedition trying to discover the North-West passage in 1845 has been argued, with a number of proposed theories ranging from lead poisoning from soldered tins of preserved food to botulism and scurvy . There aNutritional cannibalism by necessity may progress to cannibalism by choice as was demonstrated by the nineteenth-century convict, Alexander Pearce who was imprisoned on Sarah Island on the west coast of the colony of Van Diemen’s Land. He survived during his escape with a group of fellow convicts in 1821 by resorting to killing and eating the others. Following his return to the island, he again escaped and murdered and consumed parts of his fellow escapee prior to recapture, putting him into the rare category of a serial opportunistic cannibal [On occasion, the consumption of human tissues and blood has been promoted for medical purposes. In Europe, particularly in the sixteenth and seventeenth centuries, remedies were dispensed that contained human, blood, fat and bones derived from recent graves or from Egyptian mummies . The ‘KiThe Encyclopaedia Brittannica of 1797 specified that ‘We have two different fubftances preferved for medicinal ufe under the name of mummy. . . The one is the dried and preferved flefh of human bodies, embalmed with myrrh and fpices; the other is the liquor running from fuch mummies’ .bulutoko, were used by priests and chieftains in Fiji for eating human flesh  or whether instead the victim was killed prior to consumption . Removal of tissues or limbs prior to death may be associated with bruising and hemorrhage. Harvesting flesh from prisoners while they were alive by Japanese soldiers in World War II led to convictions in trials after the war .The ‘rule of the sea’ was sometimes evoked to excuse shipwrecked sailors who had decided to sacrifice victims and resort to cannibalism. In 1884 when the yacht Mignonette sank off the Cape of Good Hope, two of the four survivors in a life raft decided to kill a cabin boy . After rThus, although cannibalism is now rare in most Western societies, it has had an extensive history occurring in many communities and cultures over millennia. Its association with sexual serial murders , however


Cannabis sativa L. in the form of hemp (< 0.3% THC by dry weight) into the US agricultural sector has been complex and remains confounded by its association with cannabis (> 0.3% THC by dry weight). This has been further exacerbated by inconsistent hemp regulations in the US since the 2014 Farm Bill’s reintroduction.The reintroduction of A content analysis was performed to analyze the terms and definitions presented by state and tribal hemp production plans, the USDA Hemp producer license, and the 2014 state pilot plans. A total of 69 hemp production plans were analyzed.Results suggest significant discrepancies between hemp production plans, which have been exacerbated by extending the 2014 Farm Bill language into the 2018 Farm Bill timeframe.Findings from this study point to areas in need of uniformity and consistency as the regulatory framework is modified and provides a starting point for change for federal policymakers. The results may also be useful to companies attempting to market products across state boundaries. Suggestions for how to mitigate these inconsistencies are provided based on the content analysis findings.The online version contains supplementary material available at 10.1186/s42238-023-00181-0. Cannabis sativa L. (cannabis), discouraging its production due to the failure of the Act to differentiate between hemp and cannabis  content, which is the primary psychoactive component of the Cannabis sativa L. plant (U.S Drug Enforcement Administration The United States Department of Agriculture (USDA) formally distinguishes the two plants based on THC , regulations for hemp are also state and tribal government dependent but are not addressed by any of these plans. There are no federal-level retail regulations or industry standards that regulate the final hemp-based products in terms of consistency, quality, or analysis of claimed attributes of a hemp product in the retail sector. However, the US Food and Drug Administration (FDA) has launched a Data Acceleration Plan to learn more about the safety of cannabis-derived products, indicating that regulations for this sector are in progress , to ensure coding consistency and accelerate data coding efficiently once intercoder reliability was assured. While intercoder reliability is essential to establish whenever research involves more than one coder, this is especially true when quantifying qualitative data  were given incongruous definitions, demonstrating different understandings of the term. The findings of this study highlight the persistent inconsistencies in hemp production regulations among US states and tribal governments.While the varying terminology in state and tribal plans is likely due to different colloquialisms across the country, these disparities can create regulatory confusion. Since hemp is highly likely to be transported and marketed across state and tribal boundaries, differences in regulatory language at such an early stage create challenges for actors throughout the supply chain, including producers, input suppliers, processors, marketers, and consumers. In addition, inconsistencies limit future expansion by creating additional barriers such as new market entry, customer loyalty and acquisition of new and valuable venture capital (Mark et al. It is important to note that while our team has concluded that the independent state and tribal hemp plans are noticeably inconsistent, the presence of this varying terminology is not indicative of a true discrepancy in the production of hemp between these entities. Without being familiar with the intricacies of each hemp production plan, we are unable to say for certain the degree to which the practices of each entity differ. However, the findings of this study suggest that there is likely some discordance between hemp production in each state and tribal government that has an approved independent plan.Cannabis sativa L. and cultivate cannabis instead of hemp, it is reasonable to believe that the incongruent composition of state and tribal plans makes this challenging to prevent. By allowing states and plans to determine different windows for post-test harvest, for example, the current regulations may unintentionally allow for the distribution of cannabis (Pearce et al. As highlighted by its tumultuous history, a major barrier to the success of the reintroduction of hemp in the US agricultural sector is its association with cannabis (Campbell et al. Findings from this study point to areas in need of uniformity and consistency as the regulatory framework is modified and provides a starting point for federal policymakers. Based on the conclusions of our analysis, it appears that current regulatory flexibility has created an environment that fosters competitive advantages among state and tribal governments depending upon the content of their independent plans. However, more research is needed to fully understand the scope and depth of any potential competitive advantage. Further, the democratic process will have to play out as states and tribal governments will most likely be interested in maintaining any current advantage, whether intentional or unintentional. Lastly, it is likely that states and tribal governments have had newly developed and approved hemp production plans since the cutoff date for this analysis, July 14, 2021. As a result, there is an opportunity for further research to analyze if these changes have enhanced, or further weakened, the overall consistency of plans.Based on the findings of this study, there are significant areas for improvement in federal policy guidelines for hemp production. The research team has curated two suggestions for how to mitigate the inconsistencies seen in state and tribal hemp programs. First, we recommend that the USDA provide and define the basic regulatory language for independent plans to follow. While the USDA Hemp Producer License provides some terminologies and definitions, it is not required that plans choosing to operate under individually approved plans adhere to them. By creating an expanded list of terms and corresponding definitions that must be ubiquitous among all state and tribal plans, the USDA can provide a lexicon for hemp producers to alleviate discrepancies in how production is approached and defined.Additionally, we suggest the creation of regulations for the rest of the hemp supply chain. While we are aware that the USDA does not have jurisdiction over the processing of hemp or any other steps post-harvest, we feel that it will be beneficial to provide these regulations to ensure that, once cleared on the pre-harvest side, the integrity of the hemp programs is maintained and are not allowed to infiltrate the cannabis business. By creating clear separations between hemp and cannabis supply chains, hemp producers may find relief from the longstanding erroneous association between the two crops. For the USA to steward a victorious reemergence of hemp in the agricultural sector, the industry must work with policymakers and regulators to attenuate pre-existing barriers and provide a way for hemp to safely and equitably make its way to consumers who have confidence in purchasing various hemp-derived products.Additional file 1: Table S1. Form used to document term, definition, and state/tribal government. Description of Data: Example format of the form used to document the term, the corresponding definition, and which state or tribal government’s plan the term was found in. Table S2. List of terms included in only one plan. Description of Data: A comprehensive list of the terms included in only one plan at the research study cutoff date of July 14, 2021.


Cats and dogs share human environments and habits which in the last decades have extended life expectancy in pets as in man, and they will do more in the next . This istheir importance in knowledge advancement is all the more recognized, the less we know about.” Contrarily to the Editorial policy of many scientific journals, we are also pleased that Frontiers included Case Reports.This Research Topic includes two case reports and two original researches. The high-quality description and the originality of the case reports confirm how much medicine science and specifically feline medicine need them to add details and information in a broader context or to create a new context of focus. I owe it to Dr. Robert J. Higgins of UC of Davis in California (USA), who left us just over a year ago, to have taught us, when we were young people entering the world of research, to not neglect the value of case reports since, as he said, “Chen et al. the identification of pseudo-Homer-Wright rosettes characterizing the neuroblastoma-like schwannoma is really an intriguing issue. In this study negative immunolabelling for synaptophysin definitely excluded typical figures of neuroblastoma, while periaxin , thanks to detailed histological descriptions, in the first case also supported by electron microscopy analysis, and wide immunohistochemistry investigations in both. In the paper of periaxin –4 and SOperiaxin  have properiaxin  assumed Foiani et al. rises up a couple of questions: (1) based on the only case of feline embryonal tumor of the central nervous system (CNS) reported in the literature, can really this species be assumed as not predisposed to juvenile CNS tumor? (2) what should “juvenile” mean in cats? Less than 2 years or < 1 year? Or rather generically < 5 years, considering five as the line beyond which the incidence of neoplastic diseases tends to increase in pets? Whatever our answers are, as from today ETANTR must be included in differential diagnosis of non-cerebellar PNET in cats and domestic animals, and classification of CNS tumors should be updated in veterinary medicine. Of course, we are long way from made diagnosis by genetic investigations as in humans, but we think that for juvenile tumors a greater effort may be worth making in veterinary oncology. As for the feline lymphoma , one of the most common tumors of the nervous system, the anatomical patterns have been confirmed to be numerous, as in the past review  it is worth appreciating the collaborative effort among clinic, imaging, surgery, and neuropathology made to add more information about the most common spinal cord tumor in this species. Collecting data in all these fields from each case is not always an easy task. Combining localization of tumors, clinical findings, cerebrospinal fluid analysis, magnetic resonance imaging characteristics and their possible correlations with histopathological findings, especially for the presence of necrosis, have provided useful markers for both final diagnosis and prognosis of the cases.Again, human neuropathology shows us many histological variants of tumors of the nervous system which, far from having to simply be assumed in veterinary classification, represent a continuous pressure for comparative and behavioral studies in veterinary neuropathology. Embryonal Tumor with Multilayered Rosettes (ETMR) is a clear example of this, encouraging us to reconsider the large group of non-cerebellar Primitive Neuroectodermal Tumors in pets. The paper by t review , and theUpon completion of this editorial project, we want to thank all the contributing authors since new interesting and updated information on feline tumors of the nervous system have been provided for use by scientific community and veterinary neurologists, and their daily work progress.MM wrote the body of the editorial. MP wrote part of comments and added references. Both authors contributed to the article and approved the submitted version.


The high percentage of carbon emissions, which leads to various environmental problems such as air pollution and global warming, is one of the critical issues resulting from the growth of cities. International agreements are being established to prevent these negative effects. Non-renewable resources are also being depleted and may become extinct in future generations. Due to the extensive use of fossil fuels by automobiles, data show that the transportation sector is responsible for roughly a quarter of worldwide carbon emissions. On the other hand, in developing nations, energy is scarce in many neighborhoods and districts because the governments are unable to meet the community's need for power supply. This research aims to work on techniques that will reduce the carbon emissions produced by roadways while also building environmentally friendly neighborhoods by electrifying the roads using (RE). A novel component called "Energy-Road Scape" (ERS) elements will be used to demonstrate how to generate (RE) and, hence, reduce carbon emissions. This element is the result of integrating streetscape elements with (RE). This research presents a database for ERS elements and properties as a tool for architects and urban designers to design ERS elements instead of utilizing regular streetscape elements. Nowadays, it is not only a problem, but a threat to life on planet earth with its natural balance of the ecosystem3. The reason for that is if the threatening reasons persist, then, corrections will be definitely ineffective. Therefore, the most important task is to eliminate the reasons for this blow of carbon emissions on earth. According to the EIA, the first reason for Carbon emissions resulting from fuel combustion is electricity and heat, while the second one is the resultant exhaust from transportation. These two reasons add up collectively to about 65%4.Thus, the research community has a viable task of performing both corrective and preventive measures. The corrective actions start by improving and developing operations of filtration and purifying of the air and water of our planet. However, only preventive measures are to crown any corrective measures with successThis research addresses both aspects in an attempt to prevent and eliminate causes that lead to increase in carbon emissions. The novelty of this study is presenting new elements called “Energy-RoadScape” (ERS). These elements integrate RE devices with streetscape elements to generate clean energy and create sustainable neighborhoods. This research intends to reduce the amount of energy taken from the governments of developing countries, which are already facing shortage in their base needs for energy supply. In addition, using ERS elements will impact the neighborhoods’ economic, social, public health, and environmental stated, as well as it will slow the spread of global issues like carbon emissions, ozone depletion, and climate change which is produced from generating energy using fossil fuel.The hypothesis of this research is that the high level of carbon emissions produced from roads is from electricity production and the heavy use of vehicles and tucks for fossil fuels. Integrating Streetscape elements with RE sources will create Enery-RoadScape elements, in which it will produce clean and efficient energy that can be used for lighting the neighbourhood’s streets and could be used to generate electricity for electric spencer that charge the electric vehicles.5. The impact of these elements on human health, social life, economy, environment, and psychology of human actions was discovered by researchers through their research path6, which is why many streetscape designers, architects, and urban designers regarded them as aesthetic, healthy, and special features in their designs7. This encouraged individuals to consider the significance of streetscape components deeply8. Various academics have categorized the streetscape components in various ways over time, the components shown in Fig. To retain the aesthetic and functional qualities of the streetscape, different streetscape fittings are positioned in public or communal areas9. The industry for (RE) has shown tremendous technological advancement during the past fifteen years10. The rising level of competition with conventional power plants provided momentum to the global market for (RE) technology11. According to previous research statistics within the field of (RE), the use of sun, wind, hydropower, geothermal, and biomass can generate enough energy to serve the world's population more than a few times over12. However, this is considered anticipatory if compared to the actually practical usage. In fact, few technologies for harnessing (RE) have proven to be effective, while the economic viability of this technology is restricted to a small number of countries worldwide13. Markets are frequently drastically changed by grants in favour of fossil fuels, which push (RE) to the back burner14. Early "entrance into the (RE) technologies market, aimed to start a transformation to an energy system based on (RE) technologies and building of production capacities and installations of (RE) technologies, and benefit from their macroeconomic development15. Additionally, as more technological advancements are made, (RE) technologies are becoming competitive without investment support16. As shown in Fig. Human efforts to use (RE) sources have altered because of the current energy crisisThis research consists of two parts: theoretical and empirical. The theoretical part presents streetscape elements and introduces (RE) sources. The empirical part presents the properties of new sustainable elements called Energy-RoadScape elements, which integrate (RE) devices with streetscape elements as a tool for reducing CO2 emissions from roads. In which it will solve the infrastructure problem facing the spreading of the electric vehicle industry in developing nations. The research will present a database to help the designers calculate the amount of energy produced from using ERS as well as the properties of each element. The properties of the ERS elements are divided into the initial cost of installing this element, the area needed to operate efficiently, and the life-time and annual maintenance cost of each element.The goal of the research is to identify the Energy-RoadScape ERS) Elements and properties, which result from integrating streetscape elements with (RE) devices. The characteristics of the ERS elements are identified, analyzed, and presented in three phases as shown in Fig. The relation matrix identifies the streetscape elements such as sidewalks, trees and landscape strips, etc. that can be integrated with (RE) devices, such as solar, wind, biomass, hydropower, kinetic energy, and geothermal energy generators. The results of this phase is a new elements called ERS. Depending on previous studies and real-life applications that integrated Streetscape elements with (RE) devices, this research created a relation matrix as illustrated in Table This research was able to identify the categories of streetscape features that can be integrated with RE to create new elements called (ERS). This study focused on the small types of renewables that can be integrated with streetscape elements such biomass, kinetic energy (piezoelectric cells), PV, tiny hydropower plants, geothermal, and small wind turbines that can be installed in small spaces. Massive wind turbines and enormous hydropower plants were excluded from this study due to their excessively large footprints. Table 17. In this research, the data was gathered from Egyptian firms that are specialized in constructing streetscapes elements such as “Curve Streetscape Company” and RE contactors such as “I-Solar Company”, “3 M company”, Three Brothers Company, etc. Since there is still a scarcity in utilizing some types of RE devices in Egypt. For example, there is no local companies installing kinetic energy harvesting systems such as piezoelectric cells in Egypt. Hence, popular online marketing websites such as Alibaba and Amazon were employed to gather information on these materials. In this study, two cross-sectional surveys were conducted: The first cross-sectional survey focused on collected data regarding streetscape elements. While the second cross-sectional survey, was targeting RE devices as shown in Fig. The Cross-sectional surveys are used to gather data about the characteristics of RE devices and streetscape elements. In cross-sectional surveys, questionnaires are used to gather data from a population or a representative sample about a specific subject at a specific time periodA number of meetings were held with twelve directors from various Egyptian corporations to get information on the characteristics of (RE) devices between May 2022 and October 2022. A list of data summarized the characteristics of each RE device available in the companies, was provided to the research. The data provided by the managers was gathered and summarized in Table In comparison to the energy produced by piezoelectric cells for roads, Table In April 2022, an interview was conducted with “Curve” Landscape Company's general and financial managerS. 38 questions were posed to the head manager of the Company, 34 of which concerned the costs and characteristics of streetscape elements, that the company had previously built, and 4 of which reiterated the company history. The information in Table 2 area, whereas geothermal energy produces 24 kWh for a 1.5 m2. Although geothermal energy is an uncommon source of energy and doesn't occur in most locations, it can be considered the element that produces the most energy per day.The ERS elements database was created using the information gathered from relational matrix and the two cross-sectional surveys. The area of RE devices and the area of streetscape elements were compared in order to recalculate the properties of ERS elements. The area of streetscape elements was used as the smallest area that could be used for this integration, and the researchers recalculated the cost and the power generated for the larger area. The cost of ERS elements were calculated by sum the initial costs of the streetscape elements, the initial costs of the RE device, and the costs of the accessories required to use this device. While the cost of annual maintenance was calculated by adding the cost of the annual maintenance of RE device and streetscape elements. Regarding the lifetime, the research compared the lifetime of streetscape elements to the RE device and chose whichever is less. Table 18. in addition, ERS affect the economic state by increasing the property values since that people prefer to buy a property in a sustainable city and it reduce the electricity bills in public facilities due to the usage of (RE)7. Moreover, ERS reduced the environmental negative impact for energy generation since fossil fuels will not burn to generate energy which will reduce the production of GHG. Although, some CO2 is still produced during the manufacture and construction of (RE) devices15. ERS create clean and health environment and reduce the carbon emissions15.Energy-RoadScape (ERS) is a sustainable element and it could be considered as the new generation of Streetscape elements, it is the product of integrating streetscape elements with (RE) devices. ERS share the benefit of streetscape elements and (RE) device. It affects the social state by increase the quality of life in the city offering more job opportunities, developing the community, and giving it its identity, they also help in making the neighbourhoods more liveable place; they give the families and children a place to express their feelings and an outdoor space to play and enjoy their timeEvery economic development requires energy as a vital input. Oil, petroleum, coal, and natural gas are the primary non-renewable sources of energy used today, but their availability are declining. In the future, it was determined that RE is going to be a vital field and have been strongly recommended in the field of research and production of its equipment's based on the new trend in the growth of populated areas, taking into account the high ratio of residential activity in energy consumption. The biggest problem with adopting RE is that it is more expensive than fossil fuels. This type of energy produces low net energy ratios, but it is always available. In spite of potential cost reductions from research on this technology, RE costs may not soon be comparable with the cost of fossil fuels. The economic and environmental implications of employing RE sources were the focus of this study. It demonstrates that ERS elements may be used effectively in every city, but it also demonstrates that ERS elements increase the initial cost of the road, and the payback period will take almost 3–4 years. Additionally, ERS elements can generate more energy than the road itself might use. If third-world nations promote the use of ERS elements in their roads, their cities will be able to support their own energy needs and will be able to sell this continuous energy generation for a profit. These underdeveloped nations, which are underdeveloped because of the energy issue, can be developed with the aid of ERS elements. This research is valuable because it provides a brand-new component called ERS elements that can be used anywhere and contributes to addressing major environmental issues like lowering carbon emissions, ozone depletion, and climatic changes.The research proposed an integration between streetscape elements with (RE) sources, to result in Enery-RoadScape elements that were proved theoretically to reduce Carbon emissions. However, it is strongly recommended that these elements undergo industrial development processes so that the theory becomes policy.


The majority of patients born with congenital heart disease (CHD) need lifelong surveillance with serial clinical attendance and examinations. However, loss of follow-up (namely no documented follow-up for 3 years or more) is a recognised common problem since it is often related to remarkable worsening in the health of CHD patients with increased morbidity and mortality. Transitioning from paediatric to adult care has proven to be the most vulnerable point in the care of these subjects. As such, a systematic review was carried out to ask the following questions: What is the percentage of loss of follow-up worldwide? Are there regional fluctuations in the percentage? Is there a link between loss of follow-up and the complexity of CHD? What strategies should be employed to lower the risk of discontinuity in care? The most recent worldwide averaged loss of follow-up is 26.1%, with significant fluctuations across continents and countries. This percentage is even higher (31.9%) when one includes all untraceable patients, presuming that they are not having any cardiac follow-up. The highest discontinuity of care was reported in the USA and in patients with simple CHD. Planning the rules of transition seems to be one of the most reliable tools to minimise the number of CHD patients who are lost in transition. Recalling patients, with general practitioners who are crucial in readdressing half of the lost to follow-up CHD patients to adult CHD specialists, and a good relationship between paediatric cardiologists and the adult CHD team are two other valuable strategies in aiding successful transition. Congenital heart disease (CHD) represents the most commonly seen congenital defect, which frequently evolves from a life-threatening to a chronic lifespan condition. In fact, as a consequence of progress in the care of subjects with CHD, the survival rates have dramatically increased over the last few decades, with about 95% of children with CHD surviving into adulthood ,2. ConseACHD patients may develop late cardiac complications and need serial examinations throughout their whole life ,8. In adEven though steady care is suggested for CHD subjects , unfortunately a large number of them present with care gaps or loss to follow-up , which mPlanning the rules of transition has a likely key role in preventing these risks . InformiThe number of CHD patients experiencing discontinuity in care varies a lot across studies, countries, and disease complexities. Again, it is still debatable as to what extent transition programs are able to prevent the loss of follow-up from occurring . This review asks the questions (a) What is the percentage of loss of follow-up world- wide? (b) Are there any regional fluctuations? (c) Is there a link between the loss of follow-up and the severity of the heart disease? and (d) What strategies should be employed to lower the risk of discontinuity in care?A literature review was conducted investigating the electronic databases PubMed, Scopus, and Web of Science from their establishment up to 31 December 2022  were removed after the screening of their title and abstract. Thus, 1199 studies were encompassed with a view of full-text assessment on the basis of title and abstract. A total of 1134 were removed as they did not meet the inclusion criteria, and 12 were not available from online libraries. As such, 53 studies met the inclusion criteria, and six additional papers were encompassed after checking the references of the first 53. A flowchart of the study selection process is shown in Three manuscripts focused on question (a), 17 articles had question (b) as a target, 8 articles analysed question (c), and 31 articles on question (d) were found.As above stated, the risk of loss of follow-up is likely to be the foremost weakness of transition during adolescence. Discontinuation may begin at an early age, even for CHD patients with defects of high complexity, with percentages showing ups and downs worldwide, but with an average value of 26.1%, as shown in the most recent meta-analysis released in the field. The percentage is even higher (31.9%) when including all untraceable patients and supposing that they did not have any follow-up. The true discontinuity value is expected to be within this range . In addiDiscontinuation in the care of CHD shows ups and downs around the world. Regarding Europe, even on a small island such as Malta, with easy access to the health care system, the loss to follow-up was 21%. Nevertheless, following being recalled from hospitals, more than 80% of the initially lost patients accepted being examined and had their regular follow-up . In BelgConcerning the USA, in a single centre study , the detected loss of follow-up was 37.6%, thus highlighting a suboptimal maintenance of care, even in a single setting . The higThe highest outlined percentage of loss of follow-up was in Canada, with an astonishing 53% in the research by Reid and Coll. They carried out their study at the largest paediatric cardiac centre in the country . The prevalence halved (24%) after recalling the patients . A similData from Australia are limited to the form of an abstract showing a loss of follow-up of 24% in patients with CHD of moderate and high complexity, with a slight female prevalence . No dataAs per the AHA/ACC classification, CHD are subdivided into three classes on the basis of the degree of complexity  see Tab.It is generally accepted that those affected by complex CHD are more likely to discontinue their follow-up ,31,42. TThe results of the meta-analysis are very important, since single centre or regional studies keep sharing the idea that patients with less severe CHD have an increased likelihood to be lost in follow-up. For example, this was outlined by a recent American study carried out in North Carolina  . HoweverReducing the number of CHD patients who are lost in their care is extremely important, since they have a marked tendency to turn up in the Emergency Department due to a sudden worsening in their clinical state. About 20% of those urgently admitted pass away or require heart transplantation by 3 years from the initial admission . This waSocial determinants of health such as poverty, lack of private insurance, difficulties in housing, low level of parental education, being an immigrant, belonging to ethnic minorities, shortage of food supply, and transport barriers are linked to a number of adverse outcomes, missed examinations, with loss to follow-up included . As suchOverbooked paediatric cardiology clinics with a lack of time to address the multiple issues concerning transition is another possible explanation of lapse in the continuity of care that should be amended. This often implies transferring patients when they are still too immature or also after too few paediatric outpatient examinations in the pretransfer period. A survey carried out among CHD caregivers reported that only 31% thought that their adolescent patients had been appropriately prepared for transition . For theLikewise, adolescent patients who are at risk of or inappropriate behaviours such as drug abuse may necessitate more aggressive programs to make significant progress in their way of acting, which may lead to successful transfer .The involvement of a nurse in the transition clinic (multidisciplinary team), with the aim of spending time in helping CHD adolescents develop a comprehensive understanding of their condition, self-care management, and the skills that are needed to take part in adult life is another reliable strategy to prevent any lapse in care .General practitioners are crucial in returning half of the lost to follow-up subjects to specialised supervision. Intensifying cooperation with them may be a way to further lower lapses in care .A structured transition programme ensuring a planned and coordinated transfer has been suggested to be the most important tool to prevent any discontinuity in care from occurring. Unfortunately, in the clinical setting, even when some resources for transition are available, they are often represented by non-tailored educational leaflets about CHD and do not address the preparation to transition appropriately during this high-risk process . ConversIn an ideal tertiary care centre, joined facilities for paediatric and adult cardiology should be offered. Proposing joint appointments with paediatric cardiologists and ACHD specialists for a formal handover of care should reduce the risk of losing the care of CHD patients . If thisInterestingly, a study highlighted that the main cause for loss to follow-up is represented by the fact that the CHD patients were told that there was no need for any further examination. This occurred in about a third of the samples . Lack ofSome patients have a very poor knowledge of their CHD and related needs, which may explain, at least in part, why they are lost to follow-up. When specifically giving insights into the problem, among the male patients, the highest knowledge deficit was about medical problems whilst among the females, the highest deficit concerned lifestyle issues. Lack of knowledge in pregnancy-related risk, probability of disease recurrence, and family planning was alarming as it involved approximately half of the samples. Teenagers and young adults suffering from simple CHD had the lowest knowledge deficit . The latCHD represents a significant stressor triggering psychological disturbances since birth. Prolonged hospital stay as a neonate as well as social limitations and bullying as a child or adolescent may cause anxiety and depression, which can even be exacerbated when transitioning from paediatric to adult services. In this respect, psychologists may help both patients and their parents and reduce the loss of follow-up .Creating a tailored app with a few things such as a specific diagram for each patient, a transition checklist, a way to monitor progress throughout the list, a past medical history background, notifications of appointments, and therapeutic changes;Establishing education for patients with video clips for each specific disease with links to learning topics such as the way to recognise an emergency;Promoting mentorship from peers and ACHD patients suffering from the same condition and enabling connection with each other by means of chats;Creating blog spaces and forums for patients to share their experience, ask medical questions, and make comments about the other patients’ observations .As previously mentioned, there is a considerable number of international transition projects such as formal education programmes, nurse-led actions aimed at ameliorating ACHD patients’ knowledge, or the establishment of a mobile app to reach young patients. All of them show promising results and are focused on trying to set up a smooth and properly working transition process . SpecifiSince CHD is the most commonly seen congenital abnormality, and, as previously mentioned, living ACHD patients outnumber patients surviving childhood, giving teenagers the power of properly transitioning care is extremely important. It has been previously outlined that personally managing chronic diseases requires five main skills: problem solving, decision making, resource utilisation, patient–doctor bonding, and taking action . The mobIn Quebec (Canada), due to the high number of ACHD patients missing appropriate care, a national media campaign called “Wanted! 8000 Heart Patients” was launched by means of billboards displayed all over the country. The publicity campaign generated close awareness from ACHD individuals and the media. After a short time, many articles were released in newspapers and magazines and attention was generated via national radio and TV. As such, 800 more ACHD patients were referred to appropriate care. The successful campaign represents an example of a commendable effort to raise awareness among people and regain those ACHD individuals who were not on any follow-up .Another way to retrieve ACHD patients who are experiencing a lapse in their care might be that suggested by Diallo et al. . Since lFeatures that are specific to ACHD populations including the influence of social factors determining health, well-being, and neurological status;The additional costs for the health care system and potential health complications that are related to inadequate transition to ACHD care including the increased access to the Emergency Department;The need to set up tailored transition programmes addressing and implementing the participation of CHD adolescents in face-to-face and online appointments with care givers, adopting a family-centred approach .In the recent document released by the AHA on transition for CHD individuals, three bullet points were identified as the most important in the whole process of the transition of care, namely:Even in the most recent (and so far only) meta-analysis released in the field, the loss to follow-up number was clearly lower in those subjects formally involved in a transition program in comparison to those who were not. Nonetheless, this differentiation was not statistically significant. This is likely to be related to the fact that only three studies comparing CHD patients with or without the provision of transitional supervision were considered. Further research on the transition in ACHD patients will likely shed light on this interesting point ,70,71,72The process of transition is really important, since the number of teenagers who are in the transition age is estimated to account about 15–20% of the overall population with CHD . This nuHowever, as mentioned, in a not negligible percentage of CHD individuals, discontinuity of care represents an issue. The reported numbers are unacceptably high, as they are significantly related to a high risk of health deterioration, the need for a heart transplant, and death. Some strategies involving multiple stakeholders seem to be promising in lowering the lapse in care, but further prospective research will be needed to confirm this. For instance, having a CHD-specific transition program will save families and adolescents the stress of figuring out the process themselves. Professional advice and progressive health care transition from early adolescence, in addition to obtaining information and encouragement from patient family organisations, will undoubtedly have a positive effect on the outcomes for those suffering from CHD and their parents, including reducing the loss of follow-up .Health care transition is made up of two interconnected factors: the transfer of medical follow-up from paediatric to adult health care professionals, and the transfer of medical responsibility from parents to young patients . A good An important concept that is linked with transition is the so called “quality of life” (QoL). In fact, well-being is another goal of transition. The ultimate goal of a smooth transition programme is increasing the QoL of young patients, along with their life expectancy. QoL has the potential to be implemented through continuous health care. The latter minimises admission to hospitals and promotes physical and psychosocial well-being and QoL. A recently published review showed that appropriate transition interventions lead to psychosocial benefits such as improving QoL, CHD self-management, and the state of being fully prepared for transition. Additionally, the likelihood of an appropriate transition increases when CHD patients judge life positively and feel good .Many tools are available to measure the adolescents’ transition readiness with time , of whicCurrent data on the loss of follow-up are quite complete regarding North America, whereas Europe is under-represented with only two studies from Sweden and Belgium, as included in the only meta-analysis in the field. These are not necessarily representative of Europe. As an obvious consequence, more research in Europe will be required to check whether the apparently reduced loss to follow-up is also confirmed in other European regions, especially in the south of the continent. Furthermore, robust research in the field should be carried out in South America, Asia, and Africa, since so far, data are missing for all. Specific funding for such studies in low-income regions must be allocated.What is sure is that the CHD population is living longer, growing in terms of number, and represents a vulnerable group. Though the problem is underestimated around the world, with some exceptions, implementing and refining protective measures aimed at reducing the loss of follow-up and related consequences in terms of morbidity and mortality is a burden that cannot be ignored any longer. With a synchronised and multidisciplinary endeavour, ultimately, subjects suffering from CHD should be able to achieve the goal of a smooth transition to adult-oriented follow-up  85,86].,86.85,86


Although the impact of adverse childhood experiences (ACEs) on healthy behaviors of adulthood is largely investigated, the role of these adversities in a wide variety of impulsive and risky behaviors (RBs) as well as the role of mediating variables has been rarely studied. Therefore, the present study aimed to investigate the mediating role of positive-negativeemotional motivations in the relationship between ACEs and RBs.In a cross-sectional study, 401 adults of the general population of Kermanshah  and Kurdistan  were selected and they were assessed using the Risky, Impulsive, & Self-destructive behavior Questionnaire (RISQ) and the Childhood Trauma questionnaire (CTQ). Data were analyzed using latent profile analysis (LPA), the correlation tests and structural equation modeling.The prevalence of ACEs using LPA was estimated 37.7%. There was a significant correlation between all types of child abuse (not child neglect) and RBs. Emotional motivations played a mediating role in the relationship between ACEs and RBs . The proposed model could explain about 11% of the variance of emotional motivations and around 70% of the variance of RBs.Considering the impact of ACEs on emotional motivations and the impact of emotional motivations on RBs, intervention on emotional motivations may help to reduce RBs in people who suffer from ACEs. Some people may put themselves at risk by committing aggressive acts, injuring themselves for a purpose other than suicide, or driving recklessly, for example, while others may risk financially by taking part in large bets or risky investments; some people expose their health to risks by consuming illegal substances or overeating, and others may engage in risky sexual behaviors or commit criminal acts.2 Regardless of diversity, by enhancing the likelihood of premature death, long-term disability and mental health consequences, these behaviors, in general, impose great costs on the individual and society.4 Involvement in risky and impulsive behaviors, no matter they are inherently criminal or not, increases the likelihood of being involved in the judicial system.5Risky and self-destructive behaviors involve making behavioral choices that may expose people to serious risks of being harmed and they reflect a tendency to engage in harmful behaviors regardless of the potential negative consequences.8 which is defined as potentially traumatic events that can have long-term negative effects on health and well-being.9 ACEs were first defined by Felitti et al.10 They describe such experiences as exposure to mental, physical, or sexual abuse and disorders in domestic function, including substance abuse by family members, having members with mental illnesses in the family, witnessing violence against the mother or stepmother and committing criminal behaviors at home during the first 18 years of life. Other studies mention emotional and physical neglect, parental separation, loss of family members or friends, prolonged financial distresses, bullying, community violence, and mass violence or war as ACEs along with other cases named above.11Severity of the problems that risky and impulsive behavior imposes on the individual and, on a larger scale, on society highlights the significance of assessing such behaviors and identifying the factors affecting them. One of the factors considered in recent years to recognize the initiation and procedure of RBs is the adverse childhood experiences (ACEs)12 or another study with 12288 participants in the same country found that about 53% of people had experienced at least one childhood trauma13 In studies conducted in other countries, the prevalence of ACEs is reported as 46.2% -66.2% in the adult population16 and 75% -85% among the adolescent population.18 These statistics reveal the high prevalence of ACEs among adolescents and adults in different countries and cultures, which will have serious consequences for the growth and health of the victims.20Studies report the high prevalence of ACEs among the general population. A study on 214157 people in the United States, for example, found that over half of the respondents (61.55%) had experienced at least one adverse childhood experience, 11 for example, in a review of 12 studies that have previously been conducted in the United States revealed that the prevalence of ACE was higher in the population using drugs compared to the general population, and that there was a positive relationship between the number of ACEs and the development and severity of substance abuse in adolescents and adults. This relationship was also depicted in different countries, cultures and groups.24 The relationship between ACEs and some other RBs, such as risky sexual behavior,26 violence and aggression,28 and alcohol consumption and dependence20 was also presented in other studies.The relationship between ACEs and some RBs, including substance and alcohol abuse, has been well reflected in various studies in recent years. Leza, Siria,29 In this way, the existing theoretical models identified two initial triggers to reduce or alleviate negative emotional states such as anxiety, sadness or extreme anger31 and to increase positive emotional states such as pleasing or thrilling experiences32 as the triggers of RBs. Outstanding models of motivation suggest that there are two primary systems of approach motivation (which involves following rewarding consequences) and avoidance motivation (which involves avoiding disturbing consequences) in which risky and impulsive behaviors are associated with alterations in activation of one or both systems.33 For example, studies indicate that substance use is positively related to the approach tendencies such as preparation to seek new rewards or tendencies to thrilling or pleasing states, despite negative consequences.34Involvement in RBs occurs in a wide range of situations, for instance, when people are in a negative mood or under the influence of immediate temptations.35On the other hand, avoidance tendencies such as the need to confront with negative emotions are also recognized as the primary motivation for RBs.3 These systems may also be influenced by childhood experiences. In fact, the evidence suggests that ACEs, affecting the self-regulation processes in general and the emotion regulation process in particular, will lead to an inability to healthy and adaptive adjustment of disturbing emotions and impulses.36 Self-regulation processes in childhood and consequently the individual's interactions with the environment are formed in growing children in a way that can profoundly affect the subsequent development and health and longevity in them.37 Self-regulation are associated with the brain development in the prefrontal cortex, which are strengthened during several developmental stages and are sensitive to the effects of the upbringing environment.38 According to the organizational model of development, behavior regulation is influenced by the characteristics of the upbringing environment at levels of home, school and community.39 Children who grow up in stable, responsive, and sensitive domestic environments will develop higher levels of self-regulation, while exposure to inadequate and turbulent upbringing environments would erode self-regulation development and may lead to making decisions based on emotions and impulses in adulthood.40These two emotional triggers are not independent of each other and these two systems, either alone or in interaction with each other, may lead to RBs.24 and some studies have attempted to examine mediating variables,42 the mechanism through which childhood experiences can influence RBs is not yet completely known. Therefore, the present study was conducted with three hypotheses to address these deficiencies: first, the amount of reporting ACEs in the present sample is higher than in western studies; second, there is a positive correlation between the number and intensity of ACEs and adult RBs; and third, ACEs lead to an increase in RBs by affecting emotional motivations.Examining the adverse experiences of childhood is highly significant not only because of the wide prevalence, but also due to the extensive impact of such experiences on the growth and health of those experiencing them. The importance of this study becomes doubled particularly when it focuses on the relationship between these experiences and RBs, which can have serious consequences for individuals and society. Although evaluation of such relationships has been highly considered in various studies in recent years, there are still some restrictions. First, those studies mainly focus on a few cases of particular RBs, such as substance and alcohol abuse, and not all RBs have been fully and simultaneously taken into consideration. Second, such studies were mostly conducted in developed countries, and the absence of such studies can still be observed in developing countries, including Iran. Third, although there is a consensus that such experiences do not directly affect health-related consequences,The population, the sample and the sampling methodThe present study was cross-sectional and 401 adults  participated in it. Sampling was performed in the spring 2021 in Kermanshah  and Sanandaj , western cities in Iran. The convenience sampling method was applied and the questionnaires were only presented to those who were inclined to complete them and there were no coercions or financial incentives to complete the questionnaires.Tools The Childhood Trauma Questionnaire-Short Form (CTQ): this questionnaire is a 28 items screening tool to identify people with childhood abuse and neglect. It measures five types of childhood misbehavior, including sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect on a 5-point scale from 1 (never) to 5 . Its validity and reliability were confirmed in various studies.44Risky, Impulsive, and Self-destructive behavior Questionnaire (RISQ): this self-report questionnaire contains 38 items that measure the general tendency to engage in risky and self-destructive behaviors in 9 areas of illegal/criminal behavior, substance abuse, aggression, self-harm, gambling, risky sexual behavior, excessive alcohol use, impulsive eating, and driving or spending recklessly.2 In each item, participants are asked to report the number of times they have committed these behaviors both in the past month and during their lifetime. In order to reduce the positive skewness, participants' responses to each item are first graded based on five classes , and then the scores of the items in each area are added together to achieve the participant's score in that area. In the questionnaire the participants are also asked to indicate, for each behavior, whether they agree with the statements: " I do this behavior to stop feeling upset, distressed, or overwhelmed" and " I do this behavior to feel excitement, to get a thrill, or to feel pleasure" based on a 5-point Likert scale, from zero (strongly disagree) to 4 (strongly agree). The sum of the participant's answers to the first question of different items would result in the total score of negative emotional trigger of RB and the sum of the participant's answers to the second question of different items would result in the total score of positive emotional trigger of RB. Its validity and reliability were confirmed in Sadeh and Baskin-Sommers2 study.Procedure After preparing the questionnaires, they were presented to the participants (in Persian) in the parks and recreation centers of Kermanshah and Kurdistan, along with some explanations provided about the general objective of the research and that the people were not obliged to participate in the research. Considering that the number of parks and recreation centers in the mentioned cities is not high and in order for the selected sample to be representative of all the people of the city, all parks and recreation centers (with the exception of places where it is not possible to fill out the questionnaire due to the lack of places to sit) were considered as sampling locations. In each of these places, questionnaires were given to people who looked healthy, were willing to fill out the questionnaires, and had sufficient literacy to fill out the questionnaires. In this study, it was attempted to use short questionnaires as much as possible in order not to consume much time to answer them and to avoid respondent fatigue. Data Analysis45 LPA is a model-based technique that provides various statistical indicators based on which individuals can be placed into separate categories according to their behaviors or other traits46 and by using this method, we can determine the behavior patterns of people in groups. Structural equation modeling with robust maximum likelihood estimation was used in Mplus software to investigate the mediator role. The reason for using this method is that the normality of the distribution of scores is not required. To increase the simplicity, subscale scores were used as indicators of the factors instead of items. In fact, using 28 items as indicators of ACEs, 76 items as indicators of emotional motivation, and 38 items as indicators of RBs could make it difficult to understand the model. When developing the final model, impulsive eating and physical neglect were excluded from the model due to their low association with own factor. The factor loading of impulsive eating on its respective factor was 0.25  and the factor loading of physical neglect on its respective factor was 0.35 . Positive and negative emotional motivation were also used as two indicators of a latent variable due to high correlation (r=0.80). Positive and negative emotional motivations were also used as two indicators of a latent variable due to high correlation (r=0.80). The data collected were analyzed using latent profile analysis (LPA), Spearman correlation test and structural equation modeling by SPSS version 26 and Mplus version 7. In the present study, LPA was used to estimate the prevalence of ACEs. LPA is a kind of person-centered research strategy based on the assumption that there might be several subgroups with distinct characteristics in a particular population and samples extracted from it.1=335.12, P=0.007)  were male and 178 (44.4%) were female. The average age of participants was 31.61 with a standard deviation of 10.55. Data on ACE (Table 1) revealed that emotional neglect  had been reported as the most prevalent, and sexual abuse  as the least common ACE. Men had experienced more physical abuse  and physical neglect  compared to women. Latent profile analysis (LPA) was used to assess the prevalence of ACEs with regard to the fact that the questionnaire used did not have a cutoff point. The results of this analysis led to the extraction of three groups (LMRP=0.007) . The firThe results of Spearman correlation test   indicatResults of structural equation modeling using the robust maximum likelihood estimation   confirme1. adjusted Lo–Mendell–Rubin likelihood ratio test16 In comparison to women, men reported more experiences in the two areas of physical abuse and neglect, which is consistent with previous studies.21 This finding can indicate a higher prevalence of this type of ACE in men, or it may indicate that men are more likely than women to reveal such experiences.In the present study, LPA was used to estimate the prevalence of ACEs. Applying this method led to extraction of one group with low ACEs and two groups with medium and high ACEs . Considering that 62.3% of people were categorized in the group with low ACEs and the rest of individuals were placed in the other two groups, it can be concluded that the prevalence of ACEs in the present sample is at least 37.7%. Despite using a different method to estimate the prevalence of ACEs in the present study, this percentage is relatively similar to the value obtained in other studies.10 The relationship between ACEs and RBs was confirmed, but what is more important is the path and mechanism by which ACEs lead to RBs. The correlation results showed that the ACEs, especially childhood abuses compared to neglect, have a high correlation with emotional motivations and probably lead to RBs through the change of these motivations. This finding is consistent with the results of structural equation modeling in which the mediating role of emotional motivations was confirmed in the relationship between ACEs and RBs suggests that ACEs, particularly child abuse, would lead to appearing disorders in the growing child's tendency system (towards rewards) and avoidance (of punishments), which in turn will show itself as RBs in the adulthood.The correlation test indicated that there is a relationship between ACEs and most of RBs. But not all ACEs did play the same role in forming these behaviors; so that there was the highest correlation between the physical and emotional abuse and different types of RBs while emotional neglect showed the lowest correlation with these behaviors. Although these differences were not statistically significant, it still seems logical that child abuse, due to the severity of the trauma, has a higher correlation with RBs compared to neglect. So that early studies focused mainly on the role of abuse in developmental disorders in children and its consequences in their life.47 In a stressful environment where there is resource and opportunity scarcity and they are unpredictable to appear, there is little or no reinforcement to delay satisfaction in the hope of greater rewards in the future. Over time, the growing child learns to prefer instant rewards and this would result in a tendency to make impulsive decisions.38 It is assumed that this tendency for instant reward in people along with ACEs would make them seek excitement or pleasing states constantly, despite the negative consequences, on the one hand,34 and, on the other hand, it would cause them to be unable to tolerate negative emotions and to seek the quickest solution to relieve;35 both these problems can result in RBs. In this regard, emerging developmental approaches suggest that children and adolescents that are exposed to tough and unpredictable environments of upbringing would develop cognitive preferences for short-term versus long-term rewards.24 aggression,28 risky sexual behavior26 and alcohol use20 has been shown in previous studies, the association of ACEs with other behaviors such as gambling, criminal acts, and self-harm has been less investigated. These results indicate a wide range of consequences associated with ACEs. Intervening on these behaviors requires considering and neutralizing these consequences. Furthermore, some of these behaviors were specifically related to certain types of ACEs; compared to other behaviors, risky sexual behavior, for instance, had the highest correlation with having the experience of sexual abuse. This finding shows the specific action mechanism of some ACEs, but how and in what way childhood sexual abuse leads to adult sexual behavior needs further study. Perhaps using interviews to find out the beliefs of people with these experiences can be helpful. RBs were different from each other in terms of the degree of being influenced by ACEs. For example, aggression, criminal acts, and self-injury are more likely to be influenced by ACEs than impulsive eating. Although the association of ACEs with some RBs such as substance use,There are limitations in present study that can restrict its generalizability: first, regarding the fact that participation in the present study was voluntary, the participants may not present real examples of society; second, considering the data collection method, which was self-reporting, samples might not have provided accurate information about their behaviors and experiences; Also, considering that the current research was cross-sectional and correlational, longitudinal research is needed for causal conclusions.As expected, the results indicated a high prevalence of ACEs. Although many people, especially women, may not be willing to share their childhood experiences with others, about 38% of people reported varying degrees of ACEs. This finding highlights the need to pay attention to parenting and parent education in the country. It also shows the importance of the government's attention to the family and support for families that are dysfunctional for various reasons, and legal support for the children who live in these families. In addition, providing support and treatment facilities for women who suffer from these experiences can reduce the effects of these experiences on their own parenting style and prevent the intergenerational transmission of defective parenting style. The fact that these experiences are less reported in women than in men can also be a tip that the reported statistics may be much lower than the actual amount and it points out the need to pay attention to the signs of these abuses in women in clinical settings.The findings also showed that ACEs are related to a wide variety of RBs and lead to these behaviors through changes in emotional motivations. RBs include a wide range of behaviors, most of which are closely related and are influenced by ACEs. But there are exceptions here, for example, impulsive eating had little correlation with other RBs and was therefore excluded from structural equation modeling. This behavior had little connection with ACEs, and the reason for doing this should be looked for somewhere else. In the structural equation modeling, emotional neglect was also removed from the model because its correlation with the total score of RB was insignificant. This shows that all ACEs are not of equal importance in predicting RBs, and all types of abuse are more difficult experiences than emotional neglect. The implications of these results are that, first, professionals who work with children should be sensitive to the signs of possible child abuse. This is especially important in Iran, where professionals may not want to enter the privacy of the family and report possible abuses. This is especially important in our country, where professionals may not want to enter the privacy of the family and do not want to report possible abuses. In addition, the treatment services that are provided for people with RBs should be accompanied by considering and neutralizing the effects of childhood abuse. In this regard, it is recommended for future researches to investigate the relationship between adverse childhood experiences and emotional motivations in more depth and if possible with longitudinal studies. Also, designing interventions to reduce the effects of adverse childhood experiences on emotional motivations can be useful.AcknowledgementsH. J. conceived and designed the evaluation and drafted the manuscript. S. D. &R. R. participated in designing the evaluation, performed parts of the statistical analysis and helped to draft the manuscript. H. J. re-evaluated the clinical data, revised the manuscript and performed the statistical analysis and revised the manuscript. S. D. &R. R. collected the data. H. J. re-analyzed the clinical and statistical data and revised the manuscript. All authors read and approved the final manuscript.