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This study examines more than 5.8 million bed days of data from private and National Health Service care providers who contribute to the Mental Health Services Monthly Statistics in the UK. The use of oral chemical restraint is compared with provider size, and the relative use of oral chemical restraint as opposed to seclusion is investigated.
Results
The data-set has large amounts of missing data. The use of oral chemical restraint is proportional to provider size in terms of bed days. Analysis of those providers who reliably submit data demonstrates patterns of reported use of oral chemical restraint versus use of seclusion.
Clinical implications
Further research is required into the institutional characteristics that are correlated with increased use of oral chemical restraint. Efforts to investigate the use of restrictive interventions in mental health settings are frustrated by inconsistent reporting.
Patients referred to a Personality Disorder (PD) Service are frequently not offered treatment. This has profound implications for patients (who feel dismissed or rejected), referrers (who are perplexed as they have clearly diagnosed a PD) and the PD services themselves (their raison d'etre being to treat PD patients). A systematic search identified no literature on reasons for non-acceptance. This study aimed to describe reasons for not offering therapy in patients, after a specialist assessment.
Methods
We conducted a case series of 50 patients assessed in a specialist PD service. We collected data from routine service notes, using thematic analysis to identify categories of the reasons identified for treatment unsuitability.
Results
Reasons for assessing treatment unsuitability (in descending order) were:
1. (20%) – Lack of engagement (e.g. repeated non-attendance of appointments) and motivation to change (e.g. externalising all responsibility, or believing they completely lacked agency in their actions).
2. (18%) – Extremely harmful substance misuse or dependence.
3. (13%) – The underlying diagnosis (e.g. not meeting diagnostic criteria for a personality disorder or a severe psychopathy) and level of severity (e.g. too mild for a specialist service).
4. (11%) – Identified areas of psychological work has very little to no relation to interpersonal difficulties or relationships.
1. To accept that many patients with PD will fail to actively engage in psychotherapy.
2. To consider whether severity is of a level requiring specialist PD treatment; or if the patient needs a forensic psychotherapy service rather than a non-forensic PD service.
3. To consider whether the comorbid conditions (e.g. dependent alcohol use) are in fact the primary diagnosis and thus require treatment before the PD service intervention.
PD services
1. Need to develop novel interventions to help patients become more active and engaged in the assessment and thus progress onto treatment.
2. Need to inform referrers on their criteria for not offering treatment, allowing referrers the ability to gauge more accurately when to refer the patient.
The aim of this paper is to describe key findings and recommendations of SUI reports regarding patients with a diagnosis of PD in East London NHS Foundation Trust (ELFT). Patients with a diagnosis of PD are often involved in SUIs with regards to risk to themselves or others. Contributing factors might be the nature of their disorder in terms of mood instability and impulsivity, self-harming or antisocial behaviour, and the difficulties posed to assessing clinicians in predicting risk.
Background
Patients with PD present severe challenges to services. SUI findings thus serve as a lightning rod for issues in their management. With the emergence of NICE guidelines for borderline PD [2009] and antisocial PD [2009] regarding risk assessments, there has been greater optimism for management of PDs.
Method
A case series of 50 SUI reports of patients with a diagnosis of PD were identified from the governance and risk management team of ELFT. Themes were categorized as positive practice, contributory factors, and recommendations. Findings are related to guidelines in NICE and RCPsychiatry. Any patient with a diagnosis of PD (of any sub-type) that was involved in a SUI in ELFT met the inclusion criteria. There were no exclusion criteria.
Result
The most frequent themes in positive practice were ‘continuity of care’ and ‘clinical practice’. The most frequent subthemes in clinical practice were ‘assessments’ and ‘follow-up’. ‘Continuity of care’ included examples of collaborative working between various teams, as in joint assessments, good communication, and timely referrals. In contributory factors ‘poor documentation’ was the most frequent theme. 14 reports found no contributory factors. In recommendations the most frequent theme was the need for development and implementation of PD policies and for improved risk management.
Conclusion
NICE guidelines stress the importance of continuity of care and good clinical care and it is commendable that these were findings in positive practice. The importance of documentation being accurate and timely needs underlining in hard pressed time poor clinicians. Services would do well to review PD policies specifically regarding risk management at a wider Trust and local service level. Our findings point to the ongoing need for workforce development as recommended in the RCPSych position statement on PD published in January 2020.
Ecosystems across the globe are vulnerable to the effects of climate change, as are the communities that depend on them. However, ecosystems can also protect people from climate change impacts. As the evidence base strengthens, nature-based solutions (NbS) are increasingly prominent in climate change policy, especially in developing nations. Yet intentions rarely translate into measurable, evidence-based targets. As Paris Agreement signatories revise their Nationally Determined Contributions, we argue that NbS are key to meeting global goals for climate and biodiversity, and we urge researchers to work more closely with policy-makers to identify targets that benefit both people and ecosystems.
Koch’s postulates originally proposed a one microorganism–one disease approach to disease; however, it is now clear that many diseases of plants and animals are associated with changes in the taxonomic composition and function of the microbiome, and that health and disease are mediated by a dynamic interplay between host factors, environmental factors, the host microbiota and pathogenic microorganisms. Commensal microbes can become pathogenic under certain conditions, and disease can arise from complex polymicrobial infections. Although causation and correlation can be difficult to untangle, it is clear that the host microbiome plays a key role in resisting colonisation by pathogens across all host taxa, from plants to animals to humans. This offers exciting possibilities for manipulating microbiomes in order to reduce pathogenic infection in a range of contexts, including agriculture, wildlife and human health, through the use of probiotics, prebiotics and microbiome transplants, among other approaches.
A classic example of microbiome function is its role in nutrient assimilation in both plants and animals, but other less obvious roles are becoming more apparent, particularly in terms of driving infectious and non-infectious disease outcomes and influencing host behaviour. However, numerous biotic and abiotic factors influence the composition of these communities, and host microbiomes can be susceptible to environmental change. How microbial communities will be altered by, and mitigate, the rapid environmental change we can expect in the next few decades remain to be seen. That said, given the enormous range of functional diversity conferred by microbes, there is currently something of a revolution in microbial bioengineering and biotechnology in order to address real-world problems including human and wildlife disease and crop and biofuel production. All of these concepts are explored in further detail throughout the book.
Host-associated microbiomes are ubiquitous in nature, but highly variable in both space and time, and shaped by a diverse range of biotic and abiotic factors. This chapter summarises the numerous drivers of variation in microbiome structure and function across both plants and animals. Plants harbour distinct microbial communities in their rhizosphere, phyllosphere and endosphere. These communities interact with hosts in a different way, and in turn are shaped by a unique set of environmental factors. For example, the rhizosphere supports a particularly diverse microbial community shaped by plant exudates and signalling molecules to facilitate nutrient transfer to the host. Similarly, variation in animal microbiomes is driven by host genetic, life-history and environmental traits, including phylogeny, diet, age, metabolism and sociality. Several of these factors are also given more detailed treatment in later chapters. Particular attention is given to our current state of knowledge concerning initial colonisation and subsequent succession in microbial community composition in juveniles, the consequences of which remain one of the major outstanding questions in microbiome research.
Many ecological relationships that are inherently reciprocal are often studied from one perspective only (Agrawal et al. 2007). One example is the interaction between tropical forests and nearctic-neotropical migratory songbirds (hereafter migrants). Several studies have determined that some migrant populations are limited by conditions at their tropical wintering grounds in Central America, South America and the Caribbean (Marra et al. 1998, Mills 2006); however, the ecological role of migrants in these tropical forests is poorly understood.
A simple numerical method is presented for solving the eigenvalue problem which governs the stability of Couette flow. The method is particularly useful in obtaining the eigenfunctions associated with the various modes of instability. When the cylinders rotate in opposite directions, these eigenfunctions exhibit an exponentially damped oscillatory behaviour for sufficiently large values of − μ, where μ = Ω2/Ω1. In terms of the stream function which describes the motion in planes through the axis of the cylinders, this means that weak, viscously driven cells appear in the outer layes of the fluid which, according to Rayleigh's criterion, are dynamically stable. For μ = − 3, for example, four cells are present, the amplitudes of which are in the ratios 1·0:0·0172:0·013:0·00125.
In the present study, we have investigated the viability of using tetrodotoxin (TTX) to induce selective blockade of myelinated fibre conduction in rabbit sural nerve, and explored some aspects of reflexes evoked by non-myelinated sural nerve afferents before and after application of TTX. In rabbits decerebrated under halothane-nitrous oxide anaesthesia, application of 30 nM TTX to the desheathed sural nerve completely blocked Aβ and Aδ waves of the compound action potential evoked by electrical stimulation of the nerve at 95 times threshold. The amplitude of C-fibre volleys evoked by these stimuli was reduced to a mean of 60 % of pre-treatment values. Reflexes evoked in medial gastrocnemius motoneurones by sural nerve stimulation showed corresponding changes after TTX treatment, with activation latency increasing from 5-7 ms in the control state to > 100 ms after TTX application. Temporal summation (wind up) in long latency reflexes (> 100 ms) was significantly enhanced after application of TTX. These data show that low concentrations of TTX can selectively block conduction in rabbit sural nerve A-fibres, providing a method for studying the central actions of non-myelinated C-fibres in isolation. Experimental Physiology (2003) 88.1, 13-18.
We describe detailed studies of ionically self-assembled monolayer (ISAM) photovoltaic (PV) devices incorporating various electron acceptor materials, such as fullerenes and phthalocyanines. Excitons are generated when the conducting polymer is irradiated, and the electron acceptors aid in dissociating the electron/hole pairs before they can radiatively recombine, thus improving the efficiency of the PV process. The ISAM technique allows the deposition of conducting polymer and electron acceptor materials in alternating layers of nanometer-scale thickness. This ensures that every photoexcited electron-hole pair is in proximity to an electron acceptor, thus minimizing electron-hole recombination and increasing the photocurrent. The individual thickness of each monolayer and the interpenetration of adjacent layers can be precisely controlled through the parameters of the electrolyte solutions. Using the ISAM technique, we have demonstrated that it is possible to create ultrathin films (100 nm) of PV material that have enhanced efficiencies.
GaAs layers were grown in recessed silicon trenches for monolithic integration of GaAs and silicon devices. These layers were examined using cathodoluminescence (CL) and transmission electron microscopy (TEM). The CL showed no dependence on distance from the sidewall edge within its limit of resolution. Cross-sectional TEM micrographs showed the GaAs grown on the sidewall to depend on the sidewall orientation. Material grown on the near-{111} sidewalls was comparable to that grown on the well bottom, while the GaAs grown on the near-{110} sidewalls showed poorer crystal quality. A photodetector was fabricated in the recessed GaAs/Si; this device could be easily adapted to a monolithically integrated structure.
Spatial homogeneity of the luminescence and electrical properties of gallium arsenide films grown directly on silicon substrates (GaAs/Si) by molecular beam epitaxy (MBE) have been investigated with microscopic scanning photoluminescence (PL), cathodoluminescence (CL), electron beam induced current (EBIC), and scanning deep level transient spectroscopy (SDLTS). It was found that GaAs/Si exhibits a highly nonuniform lateral distribution of speckled appearance in CL and PL images. These centers are also responsible for short minority carrier lifetimes as determined by EBIC. The observed nonuniformities appear to be a fundamental material property which is not altered by post-growth annealing. Correlations between the luminescence and electrical inhomogeneities and structural defects will be discussed.
Deep electron traps were investigated in MBE GaAs grown directly on Si substrates with orientations a few degrees off the <100> axis. Capacitance Deep Level Transient Spectroscopy (CDLTS) revealed the presence of eleven electron traps in the GaAs epilayer. Their activation energies ranged from 0.21 eV to 0.83 eV below the conduction band. Most of these traps were previously observed in homoepitaxial GaAs films grown under As-rich conditions (VPE, MBE), or in electron irradiated bulk GaAs. Trap concentrations tracked Si dopant density and MBE growth conditions. Observed deep levels are not introduced by metals or other contaminants present at the GaAs-Si interfaces. Rather, they are caused by defect complexes. These complexes involve native point defects, whose formation is favoured by As-rich environments, by lattice mismatch, and by different thermal expansion coefficients. Si dopant atoms may also participate in the formation of these defects. A similar deep level generation mechanism is proposed for the electron traps in homoepitaxial MBE GaAs layers.