Experiences of women in secure care who have been prescribed clozapine for borderline personality disorder

Background: Clozapine is an atypical antipsychotic medicine which can cause significant side-effects. It is often prescribed off-license in severe cases of borderline personality disorder contrary to national treatment guidelines. Little is known about the experiences of those who take clozapine for borderline personality disorder. We explored the lived-experience of women in secure inpatient care who were prescribed clozapine for borderline personality disorder. Findings: Adult females (N=20) participated in audio-taped semi-structured interviews. Transcripts were subject to thematic analysis. The central themes related to evaluation, wellbeing, understanding and self-management; for many, their subjective wellbeing on clozapine was preferred to prior levels of functioning and symptomatology, sometimes profoundly so. The negative and potentially adverse effects of clozapine were explained as regrettable but relatively unimportant. Conclusions: When psychological interventions are, at least initially, ineffective then clozapine treatment is likely to be evaluated positively by a group of women with borderline personality disorder in secure care despite the potential disadvantages

Flexible Network Monitoring with FLAME

Increases in scale, complexity, dependency and security for networks have motivated increased automation of activities such as network monitoring. We have employed technology derived from active networking research to develop a series of network monitoring systems, but unlike most previous work, made application needs the priority over infrastructure properties. This choice has produced the following results: (1) the techniques for general infrastructure are both applicable and portable to specific applications such as network monitoring; (2) tradeoffs can benefit our applications while preserving considerable flexibility; and (3) careful engineering allows applications with open architectures to perform competitively with custom-built static implementations. These results are demonstrated via measurements of the lightweight active measurement environment (LAME), its successor, flexible LAME (FLAME), and their application to monitoring for performance and security

Scalable Resource Control in Active Networks

The increased complexity of the service model relative to store-and-forward routers has made resource management one of the paramount concerns in active networking research and engineering. In this paper,we address two major challenges in scaling resource management-to-many-node active networks. The first is the use of market mechanisms and trading amongst nodes and programs with varying degrees of competition and cooperation to provide a scalable approach to managing active network resources. The second is the use of a trust-management architecture to ensure that the participants in the resource management marketplace have a policy-driven "rule of law" in which marketplace decisions can be made and relied upon. We have used lottery scheduling and the Keynote trust-management system for our implementation, for which we provide some initial performance indications

Safety and Performance in an Open Packet Monitoring Architecture

Packet monitoring arguably needs the flexibility of open architectures and active networking. A significant challenge in the design of open packet monitoring systems is how to effectively strike a balance between flexibility, safety and performance. In this paper we investigate the performance of FLAME, a system that emphasizes flexibility by allowing applications to execute arbitrary code for each packet received. Our system attempts to achieve high performance without sacrificing safety by combining the use of a type-safe language, lightweight run-time checks, and fine-grained policy restrictions. Experiments with our prototype implementation demonstrate the ability of our system to support representative application workloads on Bgit/s links. Such performance indicates the overall efficiency of our approach; more narrowly targeted experiments demonstrate that the overhead required to provide safety is acceptable

Virtual Private Services: Coordinated Policy Enforcement for Distributed Applications

Large scale distributed applications combine network access with multiple storage and computational elements. The distributed responsibility for resource control creates new security issues, caused by the complexity of the operating environment. In particular, policies at multiple layers and locations force conventional mechanisms such as firewalls and compartmented file storage into roles where they are clumsy and failure-prone. Our approach relies on two functional divisions. First, we split policy specification and policy enforcement, providing local autonomy within the constraints of the global security policy. Second, we create virtual security domains each with its own security policy. Every domain has an associated set of privileges and permissions restricting it to the resources it needs to use and the services it must perform. Virtual private services ensure security and privacy policies are adhered to through coordinated policy enforcement points

The Price of Safety in an Active Network

Security is a major challenge for "Active Networking," accessible programmability creates numerous opportunities for mischief. The point at which programmability is exposed, e.g., through the loading and execution of code in network elements, must therefore be carefully crafted to ensure security. The SwitchWare active networking research project has studied the architectural implications of various tradeoffs between performance and security. Namespace protection and type safety were achieved with a module loader for active networks, ALIEN, which carefully delineated boundaries for privilege and dynamic updates. ALIEN supports two extensions, the Secure Active Network Environment (SANE), and the Resource Controlled Active Network Environment (RCANE). SANE extends ALIEN's node protection model into a distributed setting, and uses a secure bootstrap to guarantee integrity of the namespace protection system. RCANE provides resource isolation between active network node users, including separate heaps and robust time-division multiplexing of the node. The SANE and RCANE systems show that convincing active network security can be achieved. This paper contributes a measurement-based analysis of the costs of such security with an analysis of each system based on both execution traces and end-to-end behavior

Managing Access Control in Large Scale Heterogeneous Networks

The design principle of maximizing local autonomy except when it conflicts with global robustness has led to a scalable Internet with enormous heterogeneity of both applications and infrastructure. These properties have not been achieved in the mechanisms for specifying and enforcing security policies. The STRONGMAN (for Scalable TRust Of Next Generation MANagement) system [9], [10] offers three new approaches to scalability, applying the principle of local policy enforcement complying with global security policies. First is the use of a compliance checker to provide great local autonomy within the constraints of a global security policy. Second is a mechanism to compose policy rules into a coherent enforceable set, e.g., at the boundaries of two locally autonomous application domains. Third is the "lazy instantiation" of policies to reduce the amount of state that enforcement points need to maintain. In this paper, we focus on the issues of scalability and heterogeneity

The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): A randomised placebo-controlled trial.

Background: Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted. Methods: Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at six months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at six months adjusted for baseline score, allocation group and site. Results: The study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at six months, of whom 21 (72%) were included in the mITT analysis. At six months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at six months was -3.86 (95% Confidence Intervals = -10.04 to 2.32, p=0.22). There were 14 serious adverse events; six in the clozapine arm and eight in the placebo arm of the trial. There was little difference in the cost of care between groups. Interpretation: We recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units. Trial registration ISRCTN18352058. https://doi.org/10.1186/ISRCTN1835205

Lessons Learned from a Decade of Sudden Oak Death in California: Evaluating Local Management

Sudden Oak Death has been impacting California’s coastal forests for more than a decade. In that time, and in the absence of a centrally organized and coordinated set of mandatory management actions for this disease in California’s wildlands and open spaces, many local communities have initiated their own management programs. We present five case studies to explore how local-level management has attempted to control this disease. From these case studies, we glean three lessons: connections count, scale matters, and building capacity is crucial. These lessons may help management, research, and education planning for future pest and disease outbreaks