Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial

Objectives To evaluate the effectiveness of integrated motivational interviewing and cognitive behaviour therapy in addition to standard care for patients with psychosis and a co-morbid substance use problem. Design Two-centre, open, rater-blind randomised controlled trial Setting UK Secondary Care Participants 327 patients with clinical diagnoses of schizophrenia, schizophreniform or schizoaffective disorder and DSM-IV diagnoses of drug and/or alcohol dependence or abuse Interventions Participants were randomly allocated to integrated motivational interviewing and cognitive behaviour therapy or standard care. Therapy has two phases. Phase one – “motivation building” – concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two –“Action” – supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year. Main outcomes The primary outcome was death from any cause or admission to hospital in the 12 months after therapy. Secondary outcomes were frequency and amount of substance use (Timeline Followback), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, global assessment of functioning and deliberate self harm, at 12 and 24 months, with additional Timeline Followback assessments at 6 and 18 months. Analysis was by intention-to-treat with robust treatment effect estimates. Results 327 participants were randomised. 326 (99.7%) were assessed on the primary outcome, 246 (75.2%) on main secondary outcomes at 24 months. Regarding the primary outcome, there was no beneficial treatment effect on hospital admissions/ death during follow-up, with 20.2% (33/163) of controls and 23.3% (38/163) of the therapy group deceased or admitted (adjusted odds-ratio 1.16; P= 0.579; 95% confidence interval 0.68 to 1.99). For secondary outcomes there was no treatment effect on frequency of substance use or perceived negative consequences, but a statistically significant effect of therapy on amount used per substance-using day (adjusted odds-ratios: (a) for main substance 1.50; P=0.016; 1.08 to 2.09, (b) all substances 1.48; P=0.017; 1.07 to 2.05). There was a statistically significant treatment effect on readiness to change use at 12 months (adjusted odds-ratio 2.05; P=0.004; 1.26 to 3.31), not maintained at 24 months. There were no treatment effects on assessed clinical outcomes. Conclusions Integrated motivational interviewing and cognitive behaviour therapy for people with psychosis and substance misuse does not improve outcome in terms of hospitalisation, symptom outcomes or functioning. It does result in a reduction in amount of substance use which is maintained over the year’s follow up. Trial registration Current Controlled Trials: ISRCTN14404480

Model predictive control using dynamic integrated system optimisation and parameter estimation (DISOPE)

DISOPE is a technique for solving optimal control problems where there are differences in structure and parameter values between reality and the model employed in the computations. The model reality differences can also allow for deliberate simplification of model characteristics and performance indices in order to facilitate the solution of the optimal control problem. The technique was developed originally in continuous time and later extended to discrete time. The main property of the procedure is that by iterating on appropriately modified model based problems the correct optimal solution is achieved in spite of the model-reality differences. Algorithms have been developed in both continuous and discrete time for a general nonlinear optimal control problem with terminal weighting, bounded controls and terminal constraints. The aim of this paper is to show how the DISOPE technique can aid receding horizon optimal control computation in nonlinear model predictive control.

An integrated study of urban microclimates in Chongqing, China: historical weather data, transverse measurement and numerical simulation

Chongqing is the largest central-government-controlled municipality in China, which is now under going a rapid urbanization. The question remains open: What are the consequences of such rapid urbanization in Chongqing in terms of urban microclimates? An integrated study comprising three different research approaches is adopted in the present paper. By analyzing the observed annual climate data, an average rising trend of 0.10◦C/decade was found for the annual mean temperature from 1951 to 2010 in Chongqing,indicating a higher degree of urban warming in Chongqing. In addition, two complementary types of field measurements were conducted: fixed weather stations and mobile transverse measurement. Numerical simulations using a house-developed program are able to predict the urban air temperature in Chongqing.The urban heat island intensity in Chongqing is stronger in summer compared to autumn and winter.The maximum urban heat island intensity occurs at around midnight, and can be as high as 2.5◦C. In the day time, an urban cool island exists. Local greenery has a great impact on the local thermal environment.Urban green spaces can reduce urban air temperature and therefore mitigate the urban heat island. The cooling effect of an urban river is limited in Chongqing, as both sides of the river are the most developed areas, but the relative humidity is much higher near the river compared with the places far from it.

Securing participation : experiments in a one-day introduction to economics

Classroom experiments and exercises served as a one-day introduction to economics for students who felt insecure about taking first-year business classes. The first experiment addresses demand in isolation, while the second addresses supply. Supply, demand and equilibrium are integrated in a pit market in which all students have equal expected profits. A monopoly pricing exercise addresses market failure. Exercises use many incremental questions to reveal principles of microeconomics. Evaluations show that at the end of the program, students were familiar with economic results and concepts, and were more comfortable with talking economics.r />

Violent offender rehabilitation and the therapeutic community model of treatment : towards integrated service provision?

Rehabilitation programs for violent offenders are at an early stage in their development, and there is currently only a very limited empirical base from which to draw any conclusions about treatment effectiveness (Jolliffe and Farrington, 2007). Therapeutic communities for offender populations have a much longer history, although the effects of applying this model of treatment to violent offenders have not been systematically investigated. This paper reviews the content and evidence supporting both violent offender treatment programs and therapeutic community models, concluding that approaches to treatment which combine features of both may prove to be most successful, and warrant further development and evaluation.r />

Process and impact evaluation of the romp & chomp obesity prevention intervention in early childhood settings : lessons learned from implementation in preschools and long day care settings

Background: The Romp & Chomp controlled trial, which aimed to prevent obesity in preschool Australian children, was recently found to reduce the prevalence of childhood overweight and obesity and improve children’s dietary patterns. The intervention focused on capacity building and policy implementation within various early childhood settings. This paper reports on the process and impact evaluation of this trial and the lessons learned from this complex community intervention.r />Methods: Process data was collected throughout and audits capturing nutrition and physical activity-related environments and practices were completed postintervention by directors of Long Day Care (LDC) centers (n = 10) and preschools (n = 41) in intervention and comparison (n = 161 LDC and n = 347 preschool) groups.r />Results: The environmental audits demonstrated positive impacts in both settings on policy, nutrition, physical activity opportunities, and staff capacity and practices, although results varied across settings and were more substantial in the preschool settings. Important lessons were learned in relation to implementation of such community-based interventions, including the significant barriers to implementing health-promotion interventions in early childhood settings, lack of engagement of for-profit LDC centers in the evaluation, and an inability to attribute direct intervention impacts when the intervention components were delivered as part of a health-promotion package integrated with other programs.r />Conclusions: These results provide confidence that obesity prevention interventions in children’s settings can be effective; however, significant efforts must be directed toward developing context-specific strategies that invest in policies, capacity building, staff support, and parent engagement. Recognition by funders and reviewers of the difficulties involved in implementing and evaluating such complex interventions is also critical to strengthening the evidence base on the effectiveness of such public health approaches to obesity prevention.r />

Influence of cyclosporin A on quality of bone around integrated dental implants: a radiographic study in rabbits

To evaluate the influence of cyclosporin A (CsA) administration on bone around integrated dental implants assessed by a bone quality index and by quantitative subtraction radiography.A total of 36 machine surface commercial implants were placed in 18 adult rabbits. After a 3-month healing period without any disturbance, the animals were randomly divided into three groups of six animals each. Group A was sacrificed at this time. CsA was injected subcutaneously in an immunosuppressive dose of 10 mg/kg/day in a test group (Group T), and a Group B served as a control, receiving only vehicle. After 3 months of cyclosporin administration, the animals of both Groups B and T were sacrificed. Radiographs were obtained at implant surgery and at the day of sacrifice with a CMOS sensor. Bone quality around the implants was compared between the groups using a bone quality index and quantitative subtraction radiography.The bone analysis showed that in Group T, the bone quality changed dramatically from a dense cortical to a loose trabecular bone structure (P < 0.0001, chi(2) test) while in Groups A and B there were no significant differences. Quantitative digital subtraction radiography showed significantly (P < 0.05) lower gray shade values (radiographic density) in a region of bone formation around the implants in Group T (118 +/- 12) than in Groups A (161 +/- 6) and B (186 +/- 10).Within the limits of this study, CsA administration has a negative effect on the quality of bone around integrated dental implant.

Adopting an integrated, flexible approach to reducing the birdstrike risk from Canada geese

Canada Geese overflying the runways at London’s Heathrow Airport have been struck on eleven occasions by aircraft during the last ten years. Four of these occurred during the pre-breeding season and seven during the post moult period. A monitoring study was initiated in 1999 to evaluate the movements of geese around the airport and determine appropriate mitigation strategies to reduce the risk of birdstrike. Moult sites within 13km of the airport were identified. 4,900 moulting geese were caught and fitted with colour rings and radio-transmitters between 1999 and 2004. 2,500 visits were made to over 300 sites resulting in over 10,000 sightings of known individuals. Birds that crossed the airport approaches whilst moving between roost sites and feeding areas in newly harvested cereal crops were identified. Throughout the monitoring period efforts were made to control the risk, but by 2003 it was estimated that 10,000 bird transits of the approaches involving almost 700 individuals occurred during a 50 day period. The knowledge of the movements of ringed and tagged birds was used to inform a revised habitat management, daily roost dispersal and on-airfield bird deterrence programme in 2004. By adopting a flexible approach to management, an estimated 70% reduction in bird transits was achieved. This paper discusses the techniques used to achieve this reduction.

Registry for the Evaluation of the Prognostik value of a novel integrated imaging approach combining Single Photon Emission Computed Tomography with coronary calcification imaging (REPROSPECT)

AIMS: Although an added diagnostic and prognostic value of the global coronary artery calcification (CAC) score as an adjunct to single-photon emission computed tomography (SPECT)-myocardial perfusion image (MPI) has been repeatedly documented, none of the previous studies took advantage of the anatomic information provided by the unenhanced cardiac CT. Therefore, no co-registration has so far been used to match a myocardial perfusion defect with calcifications in the subtending coronary artery. To evaluate the prognostic value of integrating SPECT-MPI with CAC images were obtained from non-enhanced cardiac computed tomography (CT) for attenuation correction to predict major adverse cardiac events (MACE). METHODS AND RESULTS: Follow-up was obtained in 462 patients undergoing a 1-day stress/rest (99m)Tc-teterofosmin SPECT and non-enhanced cardiac CT for attenuation correction. Survival free of MACE was determined using the Kaplan-Meier method. After integrating MPI and CT findings, patients were divided into three groups (i) MPI defect matched by calcification (CAC ≥ 1) in the subtending coronary artery (ii) unmatched MPI and CT finding (iii) normal finding by MPI and CT. At a mean follow-up of 34.5 ± 13 months, a MACE was observed in 80 patients (33 death, 6 non-fatal myocardial infarction, 9 hospitalizations due to unstable angina, and 32 revascularizations). Survival analysis revealed the most unfavourable outcome (P < 0.001 log-rank test) for patients with a matched finding. CONCLUSION: In the present study, a novel approach using a combined integration of cardiac SPECT-CAC imaging allows for refined risk stratification, as a matched defect emerged as an independent predictor of MACE.

[Community-integrated acute psychiatric care. Options and limitations]

The shift of psychiatric care from the hospital to the community has been accompanied by a reduction of hospital beds and shortened durations of inpatient treatment, but also by an increase in admissions. This evolution may be largely attributed to the prime focus of community mental health institutions on rehabilitation. The continued implementation of reforms in psychiatric care is contingent upon effectively halting the "revolving door phenomenon" by incorporating community-integrated treatment approaches into the care of acutely ill patients. Since the mid-1960s, a series of studies have established the efficacy of two community-integrated modalities for the treatment of acute psychiatric illness, i.e. home-based and day hospital treatment. In general, these approaches not only seem to be as effective as inpatient care for certain groups of patients but also reduce their need of hospitalisation, thereby contributing towards a cost effective, comprehensive psychiatric care system.

Patient classification system: An integrated method for measuring nursing intensity and optimizing resource allocation

A patient classification system was developed integrating a patient acuity instrument with a computerized nursing distribution method based on a linear programming model. The system was designed for real-time measurement of patient acuity (workload) and allocation of nursing personnel to optimize the utilization of resources.^ The acuity instrument was a prototype tool with eight categories of patients defined by patient severity and nursing intensity parameters. From this tool, the demand for nursing care was defined in patient points with one point equal to one hour of RN time. Validity and reliability of the instrument was determined as follows: (1) Content validity by a panel of expert nurses; (2) predictive validity through a paired t-test analysis of preshift and postshift categorization of patients; (3) initial reliability by a one month pilot of the instrument in a practice setting; and (4) interrater reliability by the Kappa statistic.^ The nursing distribution system was a linear programming model using a branch and bound technique for obtaining integer solutions. The objective function was to minimize the total number of nursing personnel used by optimally assigning the staff to meet the acuity needs of the units. A penalty weight was used as a coefficient of the objective function variables to define priorities for allocation of staff.^ The demand constraints were requirements to meet the total acuity points needed for each unit and to have a minimum number of RNs on each unit. Supply constraints were: (1) total availability of each type of staff and the value of that staff member (value was determined relative to that type of staff's ability to perform the job function of an RN (i.e., value for eight hours RN = 8 points, LVN = 6 points); (2) number of personnel available for floating between units.^ The capability of the model to assign staff quantitatively and qualitatively equal to the manual method was established by a thirty day comparison. Sensitivity testing demonstrated appropriate adjustment of the optimal solution to changes in penalty coefficients in the objective function and to acuity totals in the demand constraints.^ Further investigation of the model documented: correct adjustment of assignments in response to staff value changes; and cost minimization by an addition of a dollar coefficient to the objective function. ^