Forty-five revolutions per minute:a qualitative study of Hybrid Order use in forensic psychiatric practice

Psychiatrists who recommend a Hybrid Order (Section 45A) as a disposal option at the point of sentencing accept that the convicted individual, as well as being mentally disordered and in need of treatment, is also culpable and deserving of criminal punishment. Ethical and clinical concerns have typically limited its clinical use. However, in 2015 the Court of Appeal specified in R v Vowles and others that the Hybrid Order disposal should be considered first in terms of potential mental health disposals. This judgement sets a high threshold for the use of the hospital order which has been the bedrock of inpatient forensic psychiatric practice since 1983. This study sought to explore the attitudes of consultant forensic psychiatrists towards the use of the Hybrid Order in the wake of the Vowles judgement. We interviewed 12 consultant forensic psychiatrists with longstanding experience of psychiatric sentencing recommendations. We found that the majority of consultants considered the Hybrid Order to be a valuable disposal option when used under specific circumstances. However, significant concerns were raised about its use in those with an enduring psychotic illness. Community aftercare arrangements for Hybrid Order disposals were viewed as inferior to community aftercare arrangements for Section 37/41 patients

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

Background Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions. Objectives 1. To locate, appraise and synthesise qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation; 2. To integrate this evidence with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation; 3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used. Search methods We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCO Host, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched the grey literature: the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting those studies and contacted content experts. We reran the search on 3rd July 2016 and found three studies, which are awaiting classification. Selection criteria We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspects of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation. Data collection and analysis At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team, for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytical themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodes of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews. Main results We include 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review. The quality of the evidence was mixed. Of the 35 summary statement, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for share care and consistency in weaning practice; maximising the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a frameowrk for communication with parents. Authors’ conclusions There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximise relevance and acceptability, protocols should be designed with the patient profile and requirement of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritise management of acutely deteriorating and critically-ill patients

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review

Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of the Society of Sarcopenia, Cachexia and Wasting DisordersSkeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or ‘usual care’ programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis

The provision of adult intensive care in Northern Ireland with reference to the role of high dependency care.

In 1991 an audit of Intensive Care Services was carried out by the Northern Ireland Intensive Care Group. In conjunction with this regional overview, all patients in the Regional Intensive Care Unit, (RICU) in the Royal Victoria Hospital were assessed daily, over a 10 month period in 1990-91 and classified as conforming to either intensive care or high dependency status. These data were then used to compare adult intensive care service in Northern Ireland with recent national and international recommendations on intensive care. Ten units in Northern Ireland were surveyed. In regard to national or international guidelines, all ten were deficient to some degree. Four units had significant deficiencies; small patient numbers, lack of 'dedicated' 24 hr medical cover and or deficiencies in the provision of appropriate monitoring and or equipment. There was a large diversity in casemix among the ten units surveyed which suggested differing admission criteria. The bed occupancy of RICU was 100%. Refused admissions constituted a further 13% of unresourced workload. The lack of physically separate, dedicated high dependency unit facilities meant that 26% of bed days were devoted to HDU care (usually for "improved" intensive care unit patients not yet ready for discharge to a general ward. Achieving nationally recommended intensive care standards (on a regional basis) is probably only possible if a number of the smaller intensive care units are redesignated as high dependency units, and patients requiring intensive care are concentrated in a smaller number of larger ICUs. This will increase the frequency of interhospital transfer of critically ill patients

Transformation in a changing climate: a research agenda

The concept of transformation in relation to climate and other global change is increasingly receiving attention. The concept provides important opportunities to help examine how rapid and fundamental change to address contemporary global challenges can be facilitated. This paper contributes to discussions about transformation by providing a social science, arts and humanities perspective to open up discussion and set out a research agenda about what it means to transform and the dimensions, limitations and possibilities for transformation. Key focal areas include: (1) change theories, (2) knowing whether transformation has occurred or is occurring; (3) knowledge production and use; (4), governance; (5) how dimensions of social justice inform transformation; (6) the limits of human nature; (7) the role of the utopian impulse; (8) working with the present to create new futures; and (9) human consciousness. In addition to presenting a set of research questions around these themes the paper highlights that much deeper engagement with complex social processes is required; that there are vast opportunities for social science, humanities and the arts to engage more directly with the climate challenge; that there is a need for a massive upscaling of efforts to understand and shape desired forms of change; and that, in addition to helping answer important questions about how to facilitate change, a key role of the social sciences, humanities and the arts in addressing climate change is to critique current societal patterns and to open up new thinking. Through such critique and by being more explicit about what is meant by transformation, greater opportunities will be provided for opening up a dialogue about change, possible futures and about what it means to re-shape the way in which people live

Political economy of renewable resource federalism

Author Posting. © Ecological Society of America, 2021. This article is posted here by permission of Ecological Society of America for personal use, not for redistribution. The definitive version was published in Ecological Applications 00 (2021): e2276, doi:10.1002/eap.2276.The authority to manage natural capital often follows political boundaries rather than ecological. This mismatch can lead to unsustainable outcomes, as spillovers from one management area to the next may create adverse incentives for local decision making, even within a single country. At the same time, one‐size‐fits‐all approaches of federal (centralized) authority can fail to respond to state (decentralized) heterogeneity and can result in inefficient economic or detrimental ecological outcomes. Here we utilize a spatially explicit coupled natural–human system model of a fishery to illuminate trade‐offs posed by the choice between federal vs. state control of renewable resources. We solve for the dynamics of fishing effort and fish stocks that result from different approaches to federal management that vary in terms of flexibility. Adapting numerical methods from engineering, we also solve for the open‐loop Nash equilibrium characterizing state management outcomes, where each state anticipates and responds to the choices of the others. We consider traditional federalism questions (state vs. federal management) as well as more contemporary questions about the economic and ecological impacts of shifting regulatory authority from one level to another. The key mechanisms behind the trade‐offs include whether differences in local conditions are driven by biological or economic mechanisms; degree of flexibility embedded in the federal management; the spatial and temporal distribution of economic returns across states; and the status‐quo management type. While simple rules‐of‐thumb are elusive, our analysis reveals the complex political economy dimensions of renewable resource federalism.This work was partially supported through the Ecological Federalism working group of the National Institute for Mathematical and Biological Synthesis, an Institute sponsored by the National Science Foundation through NSF Award (No. DBI‐1300426), with additional support from the Howard H. Baker Jr. Center for Public Policy and The University of Tennessee, Knoxville. M. G. Neubert acknowledges support from the U.S. National Science Foundation (DEB‐1558904) and from the J. Seward Johnson Endowment in support of the Woods Hole Oceanographic Institution’s Marine Policy Center. We would like to thank seminar participants at Oregon State University, Nature Policy Lab at U.C. Davis, and the 2019 Association of Environmental and Resource Economists Summer Conference for valuable comments and suggestions on earlier versions of this research

van der Waals coefficients for positronium-atom interactions

The van der Waals coefficients for positronium interactions with a number of rare gases (He, Ne, Ar, Kr, and Xe) and alkali-metal atoms (Li, Na, K, and Rb) are estimated using a variety of ab initio and semiempirical methods. Dispersion coefficients are also presented for atomic hydrogen and a number of rare-gas and alkali-metal atoms for validation purposes

Verbal working memory and functional large-scale networks in schizophrenia

The aim of this study was to test whether bilinear and nonlinear effective connectivity (EC) measures of working memory fMRI data can differentiate between patients with schizophrenia (SZ) and healthy controls (HC). We applied bilinear and nonlinear Dynamic Causal Modeling (DCM) for the analysis of verbal working memory in 16 SZ and 21 HC. The connection strengths with nonlinear modulation between the dorsolateral prefrontal cortex (DLPFC) and the ventral tegmental area/substantia nigra (VTA/SN) were evaluated. We used Bayesian Model Selection at the group and family levels to compare the optimal bilinear and nonlinear models. Bayesian Model Averaging was used to assess the connection strengths with nonlinear modulation. The DCM analyses revealed that SZ and HC used different bilinear networks despite comparable behavioral performance. In addition, the connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area showed differences between SZ and HC. The adoption of different functional networks in SZ and HC indicated neurobiological alterations underlying working memory performance, including different connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area. These novel findings may increase our understanding of connectivity in working memory in schizophrenia

Scratching the scale labyrinth

In this paper, we introduce a new approach to computer-aided microtonal improvisation by combining methods for (1) interactive scale navigation, (2) real-time manipulation of musical patterns and (3) dynamical timbre adaption in solidarity with the respective scales. On the basis of the theory of well-formed scales we offer a visualization of the underlying combinatorial ramifications in terms of a scale labyrinth. This involves the selection of generic well-formed scales on a binary tree (based on the Stern-Brocot tree) as well as the choice of specific tunings through the specification of the sizes of a period (pseudo-octave) and a generator (pseudo-fifth), whose limits are constrained by the actual position on the tree. We also introduce a method to enable transformations among the modes of a chosen scale (generalized and refined “diatonic” and “chromatic” transpositions). To actually explore the scales and modes through the shaping and transformation of rhythmically and melodically interesting tone patterns, we propose a playing technique called Fourier Scratching. It is based on the manipulation of the “spectra” (DFT) of playing gestures on a sphere. The coordinates of these gestures affect score and performance parameters such as scale degree, loudness, and timbre. Finally, we discuss a technique to dynamically match the timbre to the selected scale tuning