Predictive validity of the short-term assessment of risk and treatability (START) for aggression and self-harm in a secure mental health service:gender differences

The START predicts aggressive outcomes and to some extent self-harm. However, it is not known whether gender moderates its performance. This study used routinely collected data to investigate the predictive ability of the START for aggression and self-harm in secure psychiatric patients. Utility of the START was examined separately for men and women. The START was a stronger predictor of aggression and self-harm in women than men. The specific risk estimates produced large effect sizes for the prediction of aggression and self-harm in women; none of the AUC values reached the threshold for a large effect size in the male sample

Predictive validity of the START for unauthorised leave and substance abuse in a secure mental health setting:a pseudo-prospective cohort study

Background Risk assessment and management is central to the nursing role in forensic mental health settings. The Short Term Assessment of Risk and Treatability (START) aims to support assessment through identification of risk and protective factors. It has demonstrated predictive validity for aggression; it also aims to aid risk assessment for unauthorised leave and substance abuse where its performance is relatively untested. Objectives To test the predictive validity of the START for unauthorised leave and substance abuse. Design A naturalistic, pseudo-prospective cohort study. Settings Four centres of a large UK provider of secure inpatient mental health services. Participants Inpatients resident between May 2011 and October 2013 who remained in the service for 3-months following assessment with the START by their clinical team. Exclusion criteria were missing assessment data in excess of prorating guidelines. Of 900 eligible patients 73 were excluded leaving a final sample size of n = 827 (response rate 91.9%). Mean age was 38.5 years (SD = 16.7); most participants (72.2%) were male; common diagnoses were schizophrenia-type disorders, personality disorders, organic disorders, developmental disorders and intellectual disability. Methods Routinely conducted START assessments were gathered. Subsequent incidents of substance abuse and unauthorised leave were coded independently. Positive and negative predictive values of low and elevated risk were calculated. Receiver Operating Characteristic analysis was conducted to ascertain the predictive accuracy of the assessments based on their sensitivity and specificity. Results Patient-based rates of unauthorised leave (2.4%) and substance abuse (1.6%) were low. The positive and negative predictive values for unauthorised leave were 5.9% and 98.4%; and for substance abuse 8.1% and 99.0%. The START specific risk estimate for unauthorised leave predicted its associated outcome (Area under the curve = .659, p < .05, 95% CI .531, .786); the substance abuse risk estimate predicted its outcome with a large effect size (Area under the curve = .723, p < .01, 95% CI .568, .879). Conclusions The study provides limited support for the START by demonstrating the predictive validity of its specific risk estimates for substance abuse and unauthorised leave. High negative predictive values suggest the tool may be of most utility in screening out low risk individuals from unnecessary restrictive interventions; very low positive predictive values suggest caution before implementing restrictive interventions in those rated at elevated risk. Researchers should investigate how multidisciplinary teams formulate risk assessments for these outcomes since they outperform the quantitative element of this tool

Role of assessment components and recent adverse outcomes in risk estimation and prediction:use of the Short Term Assessment of Risk and Treatability (START) in an adult secure inpatient mental health service

The Short Term Assessment of Risk and Treatability is a structured judgement tool used to inform risk estimation for multiple adverse outcomes. In research, risk estimates outperform the tool's strength and vulnerability scales for violence prediction. Little is known about what its’component parts contribute to the assignment of risk estimates and how those estimates fare in prediction of non-violent adverse outcomes compared with the structured components. START assessment and outcomes data from a secure mental health service (N=84) was collected. Binomial and multinomial regression analyses determined the contribution of selected elements of the START structured domain and recent adverse risk events to risk estimates and outcomes prediction for violence, self-harm/suicidality, victimisation, and self-neglect. START vulnerabilities and lifetime history of violence, predicted the violence risk estimate; self-harm and victimisation estimates were predicted only by corresponding recent adverse events. Recent adverse events uniquely predicted all corresponding outcomes, with the exception of self-neglect which was predicted by the strength scale. Only for victimisation did the risk estimate outperform prediction based on the START components and recent adverse events. In the absence of recent corresponding risk behaviour, restrictions imposed on the basis of START-informed risk estimates could be unwarranted and may be unethical

Use of the HCR-20 for violence risk assessment:views of clinicians working in a secure inpatient mental health setting

Purpose: To explore how raters combine constituent components of HCR-20 risk assessment for inpatient aggression, and how relevant they rate the tool for different diagnostic and demographic groups.Design/methodology/approach: A cross-sectional survey design was used. N=45 mental health clinicians working in a secure hospital responded to an online survey about their risk assessment practice.Findings: HCR-20 Historical and Clinical sub-scales were rated the most relevant to violence prediction but four of the five items rated most relevant were Historical items. A recent history of violence was rated more important for risk formulation than Historical and Risk management items, but not more important than Clinical items. While almost all respondents believed predictive accuracy would differ by gender, the tool was rated similarly in terms of its relevance for their client group by people working with men and women respectively.Research limitations/ implications: This was an exploratory survey and results should be verified using larger samples.Practical implications: Clinicians judge recent violence and Clinical items most important in inpatient violence risk assessment but may over-value historical factors. They believe that recent violent behaviour is important in risk formulation; however, while recent violence is an important predictor of future violence, the role it should play in SPJ schemes is poorly codified.Social implications: It is important that risk assessment is accurate in order to both protect the public and to protect patients from overly lengthy and restrictive detention.Originality/ value: Despite the vast number of studies examining the predictive validity of tools like HCR-20 very little research has examined the actual processes and decision-making behind formulation in clinical practice

The predictive validity of the short-term assessment of risk and treatability (START) for multiple adverse outcomes in a secure psychiatric inpatient setting

The Short-Term Assessment of Risk and Treatability (START) aims to assist mental health practitioners to estimate an individual’s short-term risk for a range of adverse outcomes via structured consideration of their risk (“Vulnerabilities”) and protective factors (“Strengths”) in 20 areas. It has demonstrated predictive validity for aggression but this is less established for other outcomes. We collated START assessments for N = 200 adults in a secure mental health hospital and ascertained 3-month risk event incidence using the START Outcomes Scale. The specific risk estimates, which are the tool developers’ suggested method of overall assessment, predicted aggression, self-harm/suicidality, and victimization, and had incremental validity over the Strength and Vulnerability scales for these outcomes. The Strength scale had incremental validity over the Vulnerability scale for aggressive outcomes; therefore, consideration of protective factors had demonstrable value in their prediction. Further evidence is required to support use of the START for the full range of outcomes it aims to predict

Did Massive Primordial Stars Preenrich the Lyman Alpha Forest?

We examine the dynamical evolution and statistical properties of the supernova ejecta of massive primordial stars in a cosmological framework to determine whether this first population of stars could have enriched the universe to the levels and dispersions seen by the most recent observations of the Lyman-Alpha forest. We evolve a lambda CDM model in a 1 Mpc^3 volume to a redshift of z = 15 and add ``bubbles'' of metal corresponding to the supernova ejecta of the first generation of massive stars in all dark matter halos with masses greater than 5 times 10^5 solar masses. These initial conditions are then evolved to z = 3 and the distribution and levels of metals are compared to observations. In the absence of further star formation the primordial metal is initially contained in halos and filaments. Photoevaporation of metal-enriched gas due to the metagalactic ultraviolet background radiation at the epoch of reionization (z ~ 6) causes a sharp increase of the metal volume filling factor. At z = 3, ~ 2.5% of the simulation volume (approx. 20% of the total gas mass) is filled with gas enriched above a metallicity of 10^-4 Z_solar, and less than 0.6% of the volume is enriched above a metallicity of 10^-3 Z_solar. This suggests that, even with the most optimistic prescription for placement of primordial supernova and the amount of metals produced by each supernova, this population of stars cannot entirely be responsible for the enrichment of the Lyman-$\alpha$ forest to the levels and dispersions seen by current observations unless we have severely underestimated the duration of the Pop III epoch. However, comparison to observations show that Pop III supernovae can be significant contributors to the very low overdensity Lyman-Alpha forest.Comment: 4 pages, 3 figures (color). Accepted to ApJ Letters. Replaced version has some correction

Predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes:the effect of diagnosis

The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N = 527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.</p

Masks and tubes used to support the neonatal airway – how to improve their fit, seal and correct placement

Despite the many changes in perinatal medicine in the last fifty years, infants still often and unpredictably need assistance with their breathing. Positive pressure delivered through a facemask remains the almost universal initial approach. This is then generally followed by endotracheal intubation if the infant is not responding or if prolonged support is needed. Despite many years of research into mask ventilation, it is still very challenging and leak and airway obstruction remain a problem. The thesis opens with two mask studies that try to solve this problem. The first is a manikin study that compared three different mask holds. It unfortunately found that there was no difference in the mask leak measured using the different holds. It is perhaps reasonable to change holds if the baby isn’t responding as expected. The second study aimed to measure the dimensions of preterm infants’ faces and compare these with the size of the most commonly available face masks. It found that the smallest size of some brands of mask is too large for many preterm infants. Masks of 35mm diameter are suitable for infants <29 weeks PMA or 1000g. Masks of 42 mm diameter are suitable for infants 27-33 weeks PMA or 750-2500g. The thesis then changed focus to neonatal intubation. Intubation is a challenging skill for paediatric trainees to master. In recent years success rates are decreasing. The next studies look at possible ways to change this trend. The first is a Cochrane review that examined if a stylet could improve intubation success. Only one unblended RCT has been performed and found no difference. The most sizable work of the thesis follows and is a RCT that examines if junior trainees intubation success rates are superior if they intubate with a videolaryngoscope. Two hundred and six intubations were randomised to the screen being visible to the supervisor or covered. The success rate when the instructor was able to view the videolaryngoscope screen was 66% (69/104) compared to 41% (42/102) when the screen was covered, (p<0.001), OR 2.81 (95%CI 1.54-5.17). This shows that videolaryngoscopy is a promising tool to help inexperienced trainees become proficient intubators. This study has resulted in videolaryngoscopy becoming a tool commonly used in neonatal intensive cares. The next study looks at recordings of unsuccessful intubations from the RCT. If an attempt is unsuccessful, the intubator and instructor often cannot explain why making it difficult to know what to do differently in the future. The study found that lack of intubation success was most commonly due to failure to recognize midline anatomical structures. Excessive secretions are rarely a factor in elective premeditated and routine suctioning should be discouraged. Better videolaryngoscope blade design may make it easier to direct the tube through the vocal cords. The final work of the thesis is a review that examines devices used during newborn stabilization. Evidence for their use to optimize the thermal, respiratory and cardiovascular management in the delivery room is presented. After completing all this work I think that perhaps it is time to lessen our reliance on facemasks and embrace other airway devices that are showing promise, particularly the laryngeal mask. I feel that universal intubation competency is no longer feasible but universal competency on the use of laryngeal masks probably is. This urgently needs to be addressed in paediatric training programs. Videolaryngoscopy is a promising tool that improves junior intubators’ success rates. To master intubation many intubations are still necessary but the videolaryngoscope allows the slope of the learning curve to steepen. Development is necessary to design scopes of the future that are inexpensive, easily portable and user friendly