To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive.
To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis.
Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening.
Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37–20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33–10.10).
The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.
Declaration of interest
D.S. is an expert advisor to the National Institute for Health and Care Excellence (NICE) centre for guidelines and a member of the current NICE guideline development group for rehabilitation in adults with complex psychosis and related severe mental health conditions; a board member of the National Collaborating Centre for Mental Health (NCCMH); views are personal and not those of NICE or NCCMH. G.S. was the National Clinical Director for Mental Health at NHS England and played a lead role in setting up the physical health CQUIN (Commissioning for Quality and Innovation framework) for people with psychosis. M.J.C. is Director of the College Centre for Quality Improvement which was commissioned by NHS England to collect data for the CQUIN and commissioned by HQIP to conduct the National Clinical Audit of Psychosis. S.J.C. is Clinical Lead for the National Clinical Audit of Psychosis. E.C., K.Z. and A.Q. are employed by the Royal College of Psychiatrists which was commissioned by NHS England to collect data for the CQUIN and commissioned by HQIP to conduct the National Clinical Audit of Psychosis.
We conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive.
Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive–behavioural therapy.
CTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.
To better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program.
Information on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change.
In total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders.
The use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.
Empirical data on the use of services due to mental health problems in older adults in Europe is lacking. The objective of this study is to identify factors associated with service utilization in the elderly.
As part of the MentDis_ICF65+ study, N = 3,142 people aged 65–84 living in the community in six European and associated countries were interviewed. Based on Andersen's behavioral model predisposing, enabling, and need factors were analyzed with logistic regression analyses.
Overall, 7% of elderly and 11% of those with a mental disorder had used a service due to mental health problems in the last 12 months. Factors significantly associated with underuse were male sex, lower education, living in the London catchment area, higher functional impairment and more comorbid mental disorders. The most frequently reported barrier to service use was personal beliefs, e.g. “I can deal with my problem on my own” (90%).
Underutilization of mental health services among older people in the European community is common and interventions are needed to achieve an adequate use of services.
The dynamics of steady detonation propagation in a two-dimensional, high explosive circular arc geometry are examined computationally using a reactive flow model approach. The arc is surrounded by a low impedance material confiner on its inner surface, while its outer surface is surrounded either by the low impedance confiner or by a high impedance confiner. The angular speed of the detonation and properties of the steady detonation driving zone structure, i.e. the region between the detonation shock and sonic flow locus, are examined as a function of increasing arc thickness for a fixed inner arc radius. For low impedance material confinement on the inner and outer arc surfaces, the angular speed increases monotonically with increasing arc thickness, before limiting to a constant. The limiting behaviour is found to occur when the detonation driving zone detaches from the outer arc surface, leaving a region of supersonic flow on the outer surface. Consequently, the angular speed of the detonation becomes insensitive to further increases in the arc thickness. For high impedance material confinement on the outer arc surface, the observed flow structures are significantly more complex. As the arc thickness increases, we sequentially observe regions of negative shock curvature on the detonation front, reflected shock formation downstream of the reaction zone, and eventually Mach stem formation on the detonation front. Subsequently, a region of supersonic flow develops between the detonation driving zone and the Mach stem structure. For sufficiently wide arcs, the Mach stem structure disappears. For the high impedance material confinement, the angular speed of the detonation first increases with increasing arc thickness, reaches a maximum, decreases, and then limits to a constant for sufficiently large arc thickness. The limiting angular speed is the same as that found for the low impedance confiner on the outer arc surface.
The fluid mechanics of the interaction between a porous material confiner and a steady propagating high explosive (HE) detonation in a two-dimensional slab geometry is investigated through analytical oblique wave polar analysis and multi-material numerical simulation. Two HE models are considered, broadly representing the properties of either a high- or low-detonation-speed HE, which permits studies of detonation propagating at speeds faster or slower than the confiner sound speed. The HE detonation is responsible for driving the compaction front in the confiner, while, in turn, the high material density generated in the confiner as a result of the compaction process can provide a strong confinement effect on the HE detonation structure. Polar solutions that describe the local flow interaction of the oblique HE detonation shock and equilibrium state behind an oblique compaction wave with rapid compaction relaxation rates are studied for varying initial solid volume fractions of the porous confiner. Multi-material numerical simulations are conducted to study the effect of detonation wave driven compaction in the porous confiner on both the detonation propagation speed and detonation driving zone structure. We perform a parametric study to establish how detonation confinement is influenced both by the initial solid volume fraction of the porous confiner and by the time scale of the dynamic compaction relaxation process relative to the detonation reaction time scale, for both the high- and low-detonation-speed HE models. The compaction relaxation time scale is found to have a significant influence on the confinement dynamics, with slower compaction relaxation time scales resulting in more strongly confined detonations and increased detonation speeds. The dynamics of detonation confinement by porous materials when the detonation is propagating either faster or slower than the confiner sound speed is found to be significantly different from that with solid material confiners.
Except for dementia and depression, little is known about common mental disorders in elderly people.
To estimate current, 12-month and lifetime prevalence rates of mental disorders in different European and associated countries using a standardised diagnostic interview adapted to measure the cognitive needs of elderly people.
The MentDis_ICF65+ study is based on an age-stratified, random sample of 3142 older men and women (65–84 years) living in selected catchment community areas of participating countries.
One in two individuals had experienced a mental disorder in their lifetime, one in three within the past year and nearly one in four currently had a mental disorder. The most prevalent disorders were anxiety disorders, followed by affective and substance-related disorders.
Compared with previous studies we found substantially higher prevalence rates for most mental disorders. These findings underscore the need for improving diagnostic assessments adapted to the cognitive capacity of elderly people. There is a need to raise awareness of psychosocial problems in elderly people and to deliver high-quality mental health services to these individuals.
Scholars of political behavior increasingly embed experimental designs in opinion surveys by randomly assigning respondents alternative versions of questionnaire items. Such experiments have major advantages: they are simple to implement and they dodge some of the difficulties of making inferences from conventional survey data. But survey experiments are no panacea. We identify problems of inference associated with typical uses of survey experiments in political science and highlight a range of difficulties, some of which have straightforward solutions within the survey-experimental approach and some of which can be dealt with only by exercising greater caution in interpreting findings and bringing to bear alternative strategies of research.
Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.
Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.
PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.
Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.
We study the physics of steady detonation wave propagation in a two-dimensional circular arc via a Detonation Shock Dynamics (DSD) surface evolution model. The dependence of the surface angular speed and surface spatial structure on the inner arc radius (
), the arc thickness (
is the outer arc radius) and the degree of confinement on the inner and outer arc is examined. We first analyse the results for a linear
model, in which the normal surface velocity
is the planar Chapman–Jouguet velocity,
is the total surface curvature and
is a length scale representative of a reaction zone thickness. An asymptotic analysis assuming the ratio
is conducted for this model and reveals a complex surface structure as a function of the radial variation from the inner to the outer arc. For sufficiently thin arcs, where
, the angular speed of the surface depends on the inner arc radius, the arc thickness and the inner and outer arc confinement. For thicker arcs, where
, the angular speed does not depend on the outer arc radius or the outer arc confinement to the order calculated. It is found that the leading-order angular speed depends only on
, and corresponds to a Huygens limit (zero curvature) propagation model where
, assuming a constant angular speed and perfect confinement on the inner arc surface. Having the normal surface speed depend on curvature requires the insertion of a boundary layer structure near the inner arc surface. This is driven by an increase in the magnitude of the surface wave curvature as the inner arc surface is approached that is needed to meet the confinement condition on the inner arc surface. For weak inner arc confinement, the surface wave spatial variation with the radial coordinate is described by a triple-deck structure. The first-order correction to the angular speed brings in a dependence on the surface curvature through the parameter
, while the influence of the inner arc confinement on the angular velocity only appears in the second-order correction. For stronger inner arc confinement, the surface wave structure is described by a two-layer solution, where the effect of the confinement on the angular speed is promoted to the first-order correction. We also compare the steady-state arc solution for a PBX 9502 DSD model to an experimental two-dimensional arc geometry validation test.
This paper presents radiocarbon results from a single Goniastrea favulus coral from Papua New Guinea which lived continuously between 13.0 and 13.1 kyr BP. The specimen was collected from a drill core on the Huon Peninsula and has been independently dated with 230Th. A site-specific reservoir correction has been applied to the results, and coral growth bands were used to calibrate individual growth years. Alternating density bands, which are the result of seasonal growth variations, were subsampled to provide 2 integrated 6-month 14C measurements per year. This allows for 20 independent measurements to be averaged for each decadal value of the 14C calibration, making these results the highest resolution data set available for this brief time range. The finestructure of the data set exhibits 14C oscillations with frequencies on the order of 4 to 10 yr, similar to those observed in modern coral 14C records.