A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

Background: Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay. Objectives: To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay. Design: A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4). Setting: All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England. Participants: Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4). Results: Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain. Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group. Limitations: We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients. Conclusions: The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain. Future work: To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients. Study registration: The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376. Funding: The NIHR Health Services and Delivery Research programm

A hot and fast ultra-stripped supernova that likely formed a compact neutron star binary

Compact neutron star binary systems are produced from binary massive stars through stellar evolution involving up to two supernova explosions. The final stages in the formation of these systems have not been directly observed. We report the discovery of iPTF 14gqr (SN 2014ft), a type Ic supernova with a fast-evolving light curve indicating an extremely low ejecta mass (≈0.2 solar masses) and low kinetic energy (≈2 × 10^(50) ergs). Early photometry and spectroscopy reveal evidence of shock cooling of an extended helium-rich envelope, likely ejected in an intense pre-explosion mass-loss episode of the progenitor. Taken together, we interpret iPTF 14gqr as evidence for ultra-stripped supernovae that form neutron stars in compact binary systems

The Broad Absorption Line Tidal Disruption Event iPTF15af: Optical and Ultraviolet Evolution

We present multi-wavelength observations of the tidal disruption event (TDE) iPTF15af, discovered by the intermediate Palomar Transient Factory (iPTF) survey at redshift $z=0.07897$. The optical and ultraviolet (UV) light curves of the transient show a slow decay over five months, in agreement with previous optically discovered TDEs. It also has a comparable black-body peak luminosity of $L_{\rm{peak}} \approx 1.5 \times 10^{44}$ erg/s. The inferred temperature from the optical and UV data shows a value of (3$-$5) $\times 10^4$ K. The transient is not detected in X-rays up to $L_X < 3 \times 10^{42}$erg/s within the first five months after discovery. The optical spectra exhibit two distinct broad emission lines in the He II region, and at later times also H$\alpha$ emission. Additionally, emission from [N III] and [O III] is detected, likely produced by the Bowen fluorescence effect. UV spectra reveal broad emission and absorption lines associated with high-ionization states of N V, C IV, Si IV, and possibly P V. These features, analogous to those of broad absorption line quasars (BAL QSOs), require an absorber with column densities $N_{\rm{H}} > 10^{23}$ cm$^{-2}$. This optically thick gas would also explain the non-detection in soft X-rays. The profile of the absorption lines with the highest column density material at the largest velocity is opposite that of BAL QSOs. We suggest that radiation pressure generated by the TDE flare at early times could have provided the initial acceleration mechanism for this gas. Spectral UV line monitoring of future TDEs could test this proposal.Comment: 20 pages, 12 figures, published in Ap

Sart and individual trial mistake thresholds: Predictive model for mobility decline

The Sustained Attention to Response Task (SART) has been used to measure neurocognitive functions in older adults. However, simplified average features of this complex dataset may result in loss of primary information and fail to express associations between test performance and clinically meaningful outcomes. Here, we describe a new method to visualise individual trial (raw) information obtained from the SART test, vis-a-vis age, and groups based on mobility status in a large population-based study of ageing in Ireland. A thresholding method, based on the individual trial number of mistakes, was employed to better visualise poorer SART performances, and was statistically validated with binary logistic regression models to predict mobility and cognitive decline after 4 years. Raw SART data were available for 4864 participants aged 50 years and over at baseline. The novel visualisation-derived feature bad performance, indicating the number of SART trials with at least 4 mistakes, was the most significant predictor of mobility decline expressed by the transition from Timed Up-and-Go (TUG) &lt; 12 to TUG &gt;= 12 s (OR = 1.29; 95% CI 1.14-1.46; p &lt; 0.001), and the only significant predictor of new falls (OR = 1.11; 95% CI 1.03-1.21; p = 0.011), in models adjusted for multiple covariates. However, no SART-related variables resulted significant for the risk of cognitive decline, expressed by a decrease of &gt;= 2 points in the Mini-Mental State Examination (MMSE) score. This novel multimodal visualisation could help clinicians easily develop clinical hypotheses. A threshold approach to the evaluation of SART performance in older adults may better identify subjects at higher risk of future mobility decline

Characteristics and pathways of long-stay patients in high and medium secure settings in England; a secondary publication from a large mixed-methods study

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for “long-stay,” with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group

The face validity of an initial sub-typology of people with autism spectrum disorders detained in psychiatric hospitals

Autistic adults who have a history of committing crimes present a major problem for providers of services in terms of legal disposal options and possible interventions, and greater understanding of this group and their associated needs is required. For this reason, we aimed to investigate the face validity of a proposed sub-typology of autistic adults detained in secure psychiatric hospitals in the United Kingdom. Initially, a focus group was completed with psychiatrists, clinical psychologists, healthcare workers, family members, and autistic adults who had been detained in hospital, leading to revisions of the sub-typology. Following this, a consensus rating exercise of ten clinical vignettes based upon this subtypology with three rounds was completed with fifteen psychiatrists and clinical psychologists; revisions to the vignettes to improve clarity were made following each round. The findings indicated these subtypes possess face validity and raters were able to classify all ten clinical case vignettes into the sub-typology and percentage of agreement ranged from 96% to 100% for overall subtype classification. This study suggests that the further validity of the sub-typology should be investigated within a larger study, as these sub-types have the potential to directly inform the hospital care-pathway such that length of stay can be minimised

Transcriptional profiling of zebrafish identifies host factors controlling susceptibility to Shigella flexneri

Shigella flexneri is a human-adapted pathovar of Escherichia coli that can invade the intestinal epithelium, causing inflammation and bacillary dysentery. Although an important human pathogen, the host response to S. flexneri has not been fully described. Zebrafish larvae represent a valuable model to study human infections in vivo. Here we use a Shigella-zebrafish infection model to generate mRNA expression profiles of host response to Shigella infection at the whole animal level. Immune response-related processes dominate the signature of early Shigella infection (6 hours post-infection). Consistent with its clearance from the host, the signature of late Shigella infection (24 hours post-infection) is significantly changed, and only a small set of immune-related genes remain differentially expressed, including acod1 and gpr84. Using mutant lines generated by ENU, CRISPR mutagenesis and F0 Crispants, we show that acod1- and gpr84-deficient larvae are more susceptible to Shigella infection. Together, these results highlight the power of zebrafish to model infection by bacterial pathogens and reveal the mRNA expression of the early (acutely infected) and late (clearing) host response to Shigella infection

Neoliberalisation and 'lad cultures' in higher education

This paper links HE neoliberalisation and ‘lad cultures’, drawing on interviews and focus groups with women students. We argue that retro-sexist ‘laddish’ forms of masculine competitiveness and misogyny have been reshaped by neoliberal rationalities to become modes of consumerist sexualised audit. We also suggest that neoliberal frameworks scaffold an individualistic and adversarial culture among young people that interacts with perceived threats to men’s privilege and intensifies attempts to put women in their place through misogyny and sexual harassment. Furthermore, ‘lad cultures’, sexism and sexual harassment in higher education may be invisibilised by institutions to preserve marketability in a neoliberal context. In response, we ask if we might foster dialogue and partnership between feminist and anti-marketisation politics

Why is there no queer international theory?

Over the last decade, Queer Studies have become Global Queer Studies, generating significant insights into key international political processes. Yet, the transformation from Queer to Global Queer has left the discipline of International Relations largely unaffected, which begs the question: if Queer Studies has gone global, why has the discipline of International Relations not gone somewhat queer? Or, to put it in Martin Wight’s provocative terms, why is there no Queer International Theory? This article claims that the presumed non-existence of Queer International Theory is an effect of how the discipline of International Relations combines homologization, figuration, and gentrification to code various types of theory as failures in order to manage the conduct of international theorizing in all its forms. This means there are generalizable lessons to be drawn from how the discipline categorizes Queer International Theory out of existence to bring a specific understanding of International Relations into existence