The family drug & alcohol court (FDAC) evaluation project

This report presents the findings from the evaluation of the first pilot Family Drug and Alcohol Court (FDAC) in Britain. FDAC is a new approach to care proceedings, in cases where parental substance misuse is a key element in the local authority decision to bring proceedings. It is being piloted at the Inner London Family Proceedings Court in Wells Street. Initially the pilot was to run for three years, to the end of December 2010, but is now to continue until March 2012. The work is co-funded by the Department for Education (formerly the Department for Children, Schools and Families), the Ministry of Justice, the Home Office, the Department of Health and the three pilot authorities (Camden, Islington and Westminster). The evaluation was conducted by a research team at Brunel University, with funding from the Nuffield Foundation and the Home Office. FDAC is a specialist court for a problem that is anything but special. Its potential to help break the inter-generational cycle of harm associated with parental substance misuse goes straight to the heart of public policy and professional practice. Parental substance misuse is a formidable social problem and a key factor in around a third of long-term cases in children’s services in some areas. It is a major risk factor for child maltreatment, family separation and offending in adults, and for poor educational performance and substance misuse by children and young people. The parents’ many difficulties create serious problems for their children and place major demands on health, welfare and criminal justice services. For these reasons, parental substance misuse is a cross-cutting government agenda. FDAC is distinctive because it is a court-based family intervention which aims to improve children’s outcomes by addressing the entrenched difficulties of their parents. It has been adapted to English law and practice from a model of family treatment drug courts that is used widely in the USA and is showing promising results with a higher number of cases where parents and children were able to remain together safely, and with swifter alternative placement decisions for children if parents were unable to address their substance misuse successfully. The catalysts for the FDAC pilot were the encouraging evidence from the USA and concerns about the response to parental substance misuse through ordinary care proceedings in England: poor coordination of adult and children’s services; late interventions to protect children; delays in reaching decisions in court; and soaring costs of proceedings, linked to the cost of expert evidence.The work is co-funded by the Department for Education (formerly the Department for Children, Schools and Families), the Ministry of Justice, the Home Office, the Department of Health and the three pilot authorities (Camden, Islington and Westminster).1 The evaluation was conducted by a research team at Brunel University, with funding from the Nuffield Foundation and the Home Office

Characterising the Dense Molecular Gas in Exceptional Local Galaxies

The interferometric facilities now coming online (the Atacama Large Millimetre Array (ALMA) and the NOrthern Extended Millimeter Array (NOEMA)) and those planned for the coming decade (the Next Generation Very Large Array (ngVLA) and the Square Kilometre Array (SKA)) in the radio to sub-millimetre regimes are opening a window to the molecular gas in high-redshift galaxies. However, our understanding of similar galaxies in the local universe is still far from complete and the data analysis techniques and tools needed to interpret the observations in consistent and comparable ways are yet to be developed. I first describe the Monte Carlo Markov Chain (MCMC) script developed to empower a public radiative transfer code. I characterise both the public code and MCMC script, including an exploration of the effect of observing molecular lines at high redshift where the Cosmic Microwave Background (CMB) can provide a significant background, as well as the effect this can have on well-known local correlations. I present two studies of ultraluminous infrared galaxies (ULIRGs) in the local universe making use of literature and collaborator data. In the first of these, NGC\,6240, I use the wealth of available data and the geometry of the source to develop a multi-phase, multi-species model, finding evidence for a complex medium of hot diffuse and cold dense gas in pressure equilibrium. Next, I study the prototypical ULIRG Arp\,220; an extraordinary galaxy rendered especially interesting by the controversy over the power source of the western of the two merger nuclei and its immense luminosity and dust obscuration. Using traditional grid based methods I explore the molecular gas conditions within the nuclei and find evidence for chemical differentiation between the two nuclei, potentially related to the obscured power source. Finally, I investigate the potential evolution of proto-clusters over cosmic time with sub-millimetre observations of 14 radio galaxies, unexpectedly finding little to no evidence for cluster evolution

Modelling the Molecular Gas in NGC 6240

We present the first observations of H$^{13}$CN$(1-0)$, H$^{13}$CO$^+(1-0)$ and SiO$(2-1)$ in NGC\,6240, obtained with the IRAM PdBI. Combining a Markov Chain Monte Carlo (MCMC) code with Large Velocity Gradient (LVG) modelling, and with additional data from the literature, we simultaneously fit three gas phases and six molecular species to constrain the physical condition of the molecular gas, including mass$-$luminosity conversion factors. We find $\sim10^{10}M_\odot$ of dense molecular gas in cold, dense clouds ($T_{\rm k}\sim10$\,K, $n_{{\rm H}_2}\sim10^6$\,cm$^{-3}$) with a volume filling factor $<0.002$, embedded in a shock heated molecular medium ($T_{\rm k}\sim2000$\,K, $n_{{\rm H}_2}\sim10^{3.6}$\,cm$^{-3}$), both surrounded by an extended diffuse phase ($T_{\rm k}\sim200$\,K, $n_{{\rm H}_2}\sim10^{2.5}$\,cm$^{-3}$). We derive a global $\alpha_{\rm CO}=1.5^{7.1}_{1.1}$ with gas masses $\log_{10}\left(M / [M_\odot]\right)=10.1_{10.0}^{10.8}$, dominated by the dense gas. We also find $\alpha_{\rm HCN} = 32^{89}_{13}$, which traces the cold, dense gas. The [$^{12}$C]/[$^{13}$C] ratio is only slightly elevated ($98^{230}_{65}$), contrary to the very high [CO]/[$^{13}$CO] ratio (300-500) reported in the literature. However, we find very high [HCN]/[H$^{13}$CN] and [HCO$^+$]/[H$^{13}$CO$^+$] abundance ratios $(300^{500}_{200})$ which we attribute to isotope fractionation in the cold, dense clouds.Comment: 27 pages, 17 figures, 9 tables. Accepted in Ap

Chemically Distinct Nuclei and Outflowing Shocked Molecular Gas in Arp 220

We present the results of interferometric spectral line observations of Arp 220 at 3.5mm and 1.2mm from the Plateau de Bure Interferometer (PdBI), imaging the two nuclear disks in H$^{13}$CN$(1 - 0)$ and $(3 - 2)$, H$^{13}$CO$^+(1 - 0)$ and $(3 - 2)$, and HN$^{13}$C$(3 - 2)$ as well as SiO$(2 - 1)$ and $(6 - 5)$, HC$^{15}$N$(3 - 2)$, and SO$(6_6 - 5_5)$. The gas traced by SiO$(6 - 5)$ has a complex and extended kinematic signature including a prominent P Cygni profile, almost identical to previous observations of HCO$^+(3 - 2)$. Spatial offsets $0.1''$ north and south of the continuum centre in the emission and absorption of the SiO$(6 - 5)$ P Cygni profile in the western nucleus (WN) imply a bipolar outflow, delineating the northern and southern edges of its disk and suggesting a disk radius of $\sim40$ pc, consistent with that found by ALMA observations of Arp 220. We address the blending of SiO$(6 - 5)$ and H$^{13}$CO$^+(3 - 2)$ by considering two limiting cases with regards to the H$^{13}$CO$^+$ emission throughout our analysis. Large velocity gradient (LVG) modelling is used to constrain the physical conditions of the gas and to infer abundance ratios in the two nuclei. Our most conservative lower limit on the [H$^{13}$CN]/[H$^{13}$CO$^+$] abundance ratio is 11 in the WN, cf. 0.10 in the eastern nucleus (EN). Comparing these ratios to the literature we argue on chemical grounds for an energetically significant AGN in the WN driving either X-ray or shock chemistry, and a dominant starburst in the EN.Comment: 28 pages, 17 figures, accepted to Ap

Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools.

BACKGROUND: Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. METHODS: A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: "uncertainty" AND "palliative care" AND "assessment" OR "care planning". Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. RESULTS: Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. CONCLUSION: The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice

Introducing the highlights from: problem solving in court: current practice in FDACs in England.

The FDAC (Family drug and alcohol court) problem-solving approach in court is about hearing cases in a collaborative rather than an adversarial manner. FDAC’s main features are judicial continuity, fortnightly judge-led review hearings without lawyers present where judges use motivational interviewing techniques with parents, encouraging parents to seize every opportunity to turn their lives around for the benefit of their children. In early 2016, expanding on their 2014 research, Lancaster University and Ryan Tunnard Brown undertook a review of FDAC problem-solving court practices. The study consisted of observations of 46 hearings in 10 FDAC courts. The study had two main aims. The first was to test whether FDAC judges are currently using a problem-solving approach during court hearings. The second was to collect the views of judges about differences between FDAC and ordinary care proceedings, local implementation of the FDAC model, and the value of extending its problem-solving approach to other types of care cases. The findings are very positive. The researchers found clear evidence that adherence to the principles and practice of the FDAC problem-solving approach is at the heart of the FDAC courts, and that the judges were unanimous in their support for the FDAC approach which they described as a more compassionate way of responding to the parental difficulties that put children at risk of harm. The study made a strong case for: continuing to roll out and sustain the FDAC model; ensure fidelity to the FDAC model through initial and ongoing training by the FDAC National Unit; and generate local and national discussion about which other types of care proceedings would benefit from the FDAC approach. Their data collection and analysis focused on evidence of the following principles and practice being in place. Problem-solving principles focusing on the FDAC process: 1. Enhanced information (to and from all parties) 2. A collaborative approach (solving problems through joint thinking and action) 3. Fair decision making (using a non-adversarial and an honest, transparent approach) 4. Judicial review and monitoring (by a specially-trained judge) 5. A focus on outcomes (to achieve the changes needed in parental behaviour and lifestyle). Problem-solving activity focusing on Judges practice: 1. talking to parents 2. inviting their views 3. expressing interest in their progress 4. acknowledging family strengths 5. offering praise to parents 6. explaining the aims of FDAC 7. explaining decisions made 8. urging parents to take responsibility for their actions, including the consequences of prioritising their own needs over those of their children, and 9. using time in court to tackle the range of problems faced by parents (that is, using a problem-solving approach)

Insight, cognition and quality of life in Alzheimer's disease

Background: The detrimental impact of dementia upon patient health-related quality of life (HRQL) is well established, as is the importance of improving HRQL. However, relatively little is known about the natural history of HRQL in dementia and those factors influencing it. This limited knowledge potentially restricts the evaluation of the efficacy of interventions designed to improve HRQL. One such area concerns the relationship between HRQL and patient insight. It remains unclear what impact, if any, impaired insight has upon a patient's HRQL. The present study aimed to investigate the relationship between insight and HRQL in a sample of patients with Alzheimer's disease (AD) and their carers. Methods: 256 patients with AD were recruited as part of AddNeuroMed, a multicentre European AD biomarkers study. Of these, 174 completed a quality-of-life measure in addition to a comprehensive battery of clinical and neuropsychological assessments. Results: Insight was found to be differentially related to patient perceptions of HRQL in mild and moderate dementia. Within moderate dementia, impaired insight was associated with better perceived HRQL. Conversely, cognition, but not insight, was associated with impaired HRQL in mild dementia. Insight was not found to be associated with carer perceptions of patient HRQL. Conclusion: Impairment of insight is associated with better HRQL in moderate dementia. This finding has implications for interventions which focus on increasing patient awareness and orientation, as impairment of insight appears to have a positive impact upon HRQL

Improving implementation of evidence based practice for people with psychosis through training the wider workforce: results of the GOALS feasibility randomised controlled trial

Background and objectives There is a pressing need to improve access to evidence-based practice for people with psychosis. The primary aim of this study was to assess clinical feasibility of a manualised, evidence-based CBT intervention (GOALS) targeting a personalised recovery goal, delivered by the frontline workforce, following brief training. Secondly, we aimed to conduct preliminary statistical analyses of key outcomes and costs. Methods The GOALS study is a feasibility randomised controlled trial (ISRCTN 73188383). 75 participants with current psychosis were recruited and randomly allocated to receive either treatment as usual alone or with GOALS therapy. Results Brief training enabled frontline staff to deliver the therapy according to protocol and 74% of therapy participants partially or fully achieved their goals. There were significant improvements with a moderate effect size of 0.56 on goal attainment. However, preliminary statistical analyses found no significant differences between groups on our primary outcome of activity levels or other secondary outcomes Health economic analysis found that point estimates of costs, controlling for baseline costs, implied savings (even including intervention costs), but the difference was not statistically significant. Limitations The study was designed as a feasibility RCT, and therefore the results of secondary estimates of efficacy effects should be treated with caution. Conclusions This approach holds promise in supporting people with psychosis to reach personal recovery goals, cost effectively

Floating Hem-o-Lok Clips in the Bladder without Stone Formation after Robot-Assisted Laparoscopic Radical Prostatectomy

Hem-o-Lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) are widely used in robot-assisted laparoscopic radical prostatectomy because of their easy application and secure clamping. To date, there have been some reports of intravesical migration of these clips causing urethral erosion, bladder neck contractures, and subsequent calculus formation. We report the first case of bladder migration of Hem-o-Lok clips without stone formation after robot-assisted laparoscopic radical prostatectomy. The Hem-o-Lok clips were found during urethral dilation with a guide wire for bladder neck contracture under cystourethroscopy. The Hem-o-Lok clips were floating in the bladder without stone formation and were removed by a cystoscopic procedure