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

The expenses scandal and the politics of electoral reform

The scandal over MPs' expenses that erupted in 2009 was followed by a surge in discussion of electoral reform. A range of reforms to Westminster's existing electoral system are now high on the political agenda. This article examines the extent and the nature of the scandal's impact on the electoral reform debate and draws out comparative implications for the sorts of conditions that can force politicians to accept electoral reforms that they do not want. It finds that the expenses scandal significantly changed debate about some electoral reform topics, but not about others. It proposes three factors likely to increase the impact of scandal in sparking reform: that the scandal is seen as harming ordinary people in their daily lives; that reforms can readily be understood as likely to mitigate the sources of scandal; and that those reforms do not seriously harm politicians' own perceived interests.

Milk, dairy products and consumer health: a short review

There appears to be a large mis-match between (1) the advice given on milk/dairy foods by various authorities, (2) public perceptions of harm from the consumption of milk and dairy products and, (3) the evidence from long-term prospective cohort studies. These studies provide convincing evidence that increased consumption of milk can lead to reductions in the risk of vascular disease and possibly some cancers and provide an overall survival advantage. The volume of evidence available for milk products such as cheese and butter is however surprisingly limited and too small to come to any clear conclusions as to their effects on health.

The future of lean construction: a brave new world

Lean construction is considered from a human resource management (HRM) perspective. It is contended that the UK construction sector is characterised by an institutionalised regressive approach to HRM. In the face of rapidly declining recruitment rates for built environment courses, the dominant HRM philosophy of utilitarian instrumentalism does little to attract the intelligent and creative young people that the industry so badly needs. Given this broader context, there is a danger that an uncritical acceptance of lean construction will exacerbate the industry's reputation for unrewarding jobs. Construction academics have strangely ignored the extensive literature that equates lean production to a HRM regime of control, exploitation and surveillance. The emphasis of lean thinking on eliminating waste and improving efficiency makes it easy to absorb into the best practice agenda because it conforms to the existing dominant way of thinking. 'Best practice' is seemingly judged by the extent to which it serves the interests of the industry's technocratic elite. Hence it acts as a conservative force in favour of maintaining the status quo. In this respect, lean construction is the latest manifestation of a long established trend. In common with countless other improvement initiatives, the rhetoric is heavy in the machine metaphor whilst exhorting others to be more efficient. If current trends in lean construction are extrapolated into the future the ultimate destination may be uncomfortably close to Aldous Huxley's apocalyptic vision of a Brave New World. In the face of these trends, the lean construction research community pleads neutrality whilst confining its attention to the rational high ground. The future of lean construction is not yet predetermined. Many choices remain to be made. The challenge for the research community is to improve practice whilst avoiding the dehumanising tendencies of high utilitarianism.

The impact of an insecticide on insect flower visitation and pollination in an agricultural landscape

1 Pesticides are considered a threat to pollinators but little is known about the potential impacts of their widespread use on pollinators. Less still is known about the impacts on pollination, comprising the ecosystem service that pollinators provide to wildflowers and crops. 2 The present study measured flower visitation and pollination in an agricultural landscape, by placing potted flowering plants (Petunia sp.) in vine fields sprayed with a highly toxic insecticide (fenitrothion). During two sampling rounds, insect visitors to the petunias were observed and measures of pollination were recorded by counting and weighing seeds. 3 In the earlier sampling round, a lower species richness of insect visitors was observed in fields that had received an early application of insecticide. No negative impacts were found from later applications. The results obtained suggest a greater potential harm to insect pollinators and flower visitation as a result of insecticide application early in the season. 4 No reduction in pollination was found in fields that received an early insecticide application. Pollination was greater with two insecticide applications between sampling rounds rather than one application. 5 In the present study system, insecticide application had a negative effect on pollinators but a possible positive effect on pollination services. In some cases, it may be that actions for conserving biodiversity will not benefit pollination services to all plants.

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis

Background: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. Methods: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to general practices, patients, pharmacists, researchers, and statisticians. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-eff ectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. Findings: 72 general practices with a combined list size of 480 942 patients were randomised. At 6 months’ follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0∙58, 95% CI 0∙38–0∙89); a β blocker if they had asthma (0∙73, 0∙58–0∙91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0∙51, 0∙34–0∙78). PINCER has a 95% probability of being cost eff ective if the decision-maker’s ceiling willingness to pay reaches £75 per error avoided at 6 months. Interpretation: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. Funding: Patient Safety Research Portfolio, Department of Health, England.

Clothing consumption in two recent EU Member States: a cross-cultural study

Marketing research efforts across Eastern European countries continue growing since the introduction of market reforms in this region. Nonetheless, questions remain unanswered as to cross-cultural differences in Eastern Europeans' consumer behavior. The present research addresses this knowledge gap by developing and testing hypotheses about cross-cultural variations in a number of clothing-related consumer behavior phenomena in the Czech Republic and Bulgaria. Our findings indicate significant differences regarding consumer interest in clothing, preference for utilitarian, self-expressive and hedonic meanings of clothing artifacts, preference for well-known clothing brands, brand loyalty, and importance of clothing attributes. The study advances research in marketing by investigating clothing value-expressive symbolism and consumption in the tworecentEUMember States. The study provides valuable insights to marketers for developing effective marketing strategies.

Priority setting in healthcare: from arbitrariness to societal values

This paper develops an account of the normative basis of priority setting in health care as combining the values which a given society holds for the common good of its members, with the universal provided by a principle of common humanity. We discuss national differences in health basket in Europe and argue that health care decision-making in complex social and moral frameworks is best thought of as anchored in such a principle by drawing on the philosophy of need. We show that health care needs are ethically ‘thick’ needs whose psychological and social construction can best be understood in terms of David Wiggins's notion of vital need: a person's need is vital when failure to meet it leads to their harm and suffering. The moral dimension of priority setting which operates across different societies’ health care systems is located in the demands both of and on any society to avoid harm to its members.

A copyright exception for private copying in the United Kingdom

This paper discusses the proposed copyright exception for private copying in the UK in the aftermath of the Hargreaves Review. It explores the options by which the exception shall retain a realistic scope without significantly impacting on the interests of the rightholders and addresses the concept of possible harm that may arise due to private copying. It concludes that an exception for copying of content legally owned by an individual to another medium or device for private use corresponds to consumers’ reasonable expectations without causing more than minimal harm to the rightholders’ interests and without requiring an accompanying introduction of a fair compensation scheme.

Attacking human implants: a new generation of cybercrime

Human ICT implants, such as RFID implants, cochlear implants, cardiac pacemakers, Deep Brain Stimulation, bionic limbs connected to the nervous system, and networked cognitive prostheses, are becoming increasingly complex. With ever-growing data processing functionalities in these implants, privacy and security become vital concerns. Electronic attacks on human ICT implants can cause significant harm, both to implant subjects and to their environment. This paper explores the vulnerabilities which human implants pose to crime victimisation in light of recent technological developments, and analyses how the law can deal with emerging challenges of what may well become the next generation of cybercrime: attacks targeted at technology implanted in the human body. After a state-of-the-art description of relevant types of human implants and a discussion how these implants challenge existing perceptions of the human body, we describe how various modes of attacks, such as sniffing, hacking, data interference, and denial of service, can be committed against implants. Subsequently, we analyse how these attacks can be assessed under current substantive and procedural criminal law, drawing on examples from UK and Dutch law. The possibilities and limitations of cybercrime provisions (eg, unlawful access, system interference) and bodily integrity provisions (eg, battery, assault, causing bodily harm) to deal with human-implant attacks are analysed. Based on this assessment, the paper concludes that attacks on human implants are not only a new generation in the evolution of cybercrime, but also raise fundamental questions on how criminal law conceives of attacks. Traditional distinctions between physical and non-physical modes of attack, between human bodies and things, between exterior and interior of the body need to be re-interpreted in light of developments in human implants. As the human body and technology become increasingly intertwined, cybercrime legislation and body-integrity crime legislation will also become intertwined, posing a new puzzle that legislators and practitioners will sooner or later have to solve.

Assessment and management of anxiety disorders in children and adolescents

Anxiety disorders in childhood and adolescence are extremely common and are often associated with lifelong psychiatric disturbance. Consistent with DSM-5 and the extant literature, this review concerns the assessment and treatment of specific phobias, separation anxiety disorder, generalised anxiety disorder, social anxiety disorder, panic disorder and agoraphobia. Evidence-based psychological treatments (cognitive behaviour therapy; CBT) for these disorders have been developed and investigated, and in recent years promising low-intensity versions of CBT interventions have been proposed that offer a means to increase access to evidence-based treatments. There is some evidence of effectiveness of pharmacological treatments for anxiety disorders in children and young people, however, routine prescription is not recommended due to concerns about potential harm.

Bacterial motility confers fitness advantage in the presence of phages

Dispersal provides the opportunity to escape harm and colonize new patches, enabling populations to expand and persist. However, the benefits of dispersal associated with escaping harm will be dependent on the structure of the environment and the likelihood of escape. Here, we empirically investigate how the spatial distribution of a parasite influences the evolution of host dispersal. Bacteriophages are a strong and common threat for bacteria in natural environments and offer a good system with which to explore parasite-mediated selection on host dispersal. We used two transposon mutants of the opportunistic bacteria, Pseudomonas aeruginosa, which varied in their motility (a disperser and a nondisperser), and the lytic bacteriophage ФKZ. The phage was distributed either in the central point of colony inoculation only, thus offering an escape route for the dispersing bacteria; or, present throughout the agar, where benefits of dispersal might be lost. Surprisingly, we found dispersal to be equally advantageous under both phage conditions relative to when phages were absent. A general explanation is that dispersal decreased the spatial structuring of host population, reducing opportunities for parasite transmission, but other more idiosyncratic mechanisms may also have contributed. This study highlights the crucial role the parasites can play on the evolution of dispersal and, more specifically, that bacteriophages, which are ubiquitous, are likely to select for bacterial motility.

The efficacy of shopping value in predicting destination loyalty

Recognizing the importance of tourism's experiential aspects, this research examines how hedonic and utilitarian values relate to tourist's overall shopping experience satisfaction and destination loyalty. Study findings suggest both hedonic and utilitarian shopping values are strongly linked to overall shopping satisfaction. Overall shopping satisfaction fully mediates utilitarian shopping value's effect on destination repatronage intention (DRI), destination word-of-mouth (DWoM), and partially mediates hedonic shopping value's (HSV) effect on DRI and DWoM. Study results advance consumer behavior theory and offer managerial implications for retailers operating in a rapidly maturing tourism destination in Turkey's Mediterranean region.

Traditional medicine use by cancer patients in Thailand

Ethnobotanical relevance Cancer patients commonly use traditional medicines (TM) and in Thailand these are popular for both self-medication and as prescribed by TM practitioners, and are rarely monitored. A study was conducted at Wat Khampramong, a Thai Buddhist temple herbal medicine hospice, to document some of these practices as well as the hospice regime. Materials and methods Cancer patients (n=286) were surveyed shortly after admission as to which TMs they had previously taken and perceptions of effects experienced. They were also asked to describe their current symptoms. Treatment at the hospice is built upon an 11-herb anti-cancer formula, yod-ya-mareng, prescribed for all patients, and ideally, its effects would have been evaluated. However other herbal medicines and holistic practices are integral to the regime, so instead we attempted to assess the value of the patients׳ stay at the hospice by measuring any change in symptom burden, as they perceived it. Surviving patients (n=270) were therefore asked to describe their symptoms again just before leaving. Results 42% of patients (120/286; 95% CI 36.4%, 47.8%) had used herbal medicines before their arrival, with 31.7% (38/120; 95% CI 24%, 40.4%) using several at once. Mixed effects were reported for these products. After taking the herbal regime at Khampramong, 77% (208/270 95% CI; 71.7%, 81.7%) reported benefit, and a comparison of the incidence of the most common (pain, dyspepsia, abdominal or visceral pain, insomnia, fatigue) showed statistical significance (χ2 57.1, df 7, p<0.001). Conclusions A wide range of TMs is taken by cancer patients in Thailand and considered to provide more benefit than harm, and this perception extends to the temple regime. Patients reported a significant reduction in symptoms after staying at Khampramong, indicating an improvement in quality of life, the aim of hospices everywhere. Based on this evidence, it is not possible to justify the use of TM for cancer in general, but this study suggests that further research is warranted. The uncontrolled use of TMs, many of which are uncharacterised, raises concerns, and this work also highlights the fact that validated, robust methods of assessing holistic medical regimes are urgently needed.