Adapting dialectical behaviour therapy in forensic learning disability services: A grounded theory informed study of "what works".

BACKGROUND: Emerging evidence indicates effectiveness of dialectical behaviour therapy (DBT) for people with intellectual disabilities (PWID) in forensic settings; however, little is known about "what works" facilitating engagement and change. METHODS: Eleven interviews were conducted with nine service users across two secure inpatient services. Grounded theory was used to develop a model of perceived engagement and change. RESULTS: The model provides insights into how change occurs during DBT delivered in forensic settings. DBT constitutes a challenging journey, yet provides the motivation and means to address individual's intra-/interpersonal aggression and progress towards release. Participants experienced engaging with DBT as difficult and coercive, moving from compliance and avoidance to acceptance and change. Key factors included participants' motivation, beliefs about safety and ability to change, and interactions with staff. CONCLUSION: Recommendations are made for increasing intrinsic motivation, reducing perceived coercion and distress, and for future research to address potential aversive elements and enhance effectiveness.

In Silico Prediction of the Effects of Mutations in the Human Mevalonate Kinase Gene: Towards a Predictive Framework for Mevalonate Kinase Deficiency.

Mevalonate kinase (MVK) catalyses the phosphorylation of mevalonate. Deficiency of MVK is associated with two rare periodic fever syndromes, mevalonic aciduria (MA), a severe form and hyper-immunoglobulin-D syndrome (HIDS), a milder form. An in silico approach was used to analyse the physicochemical and structural effects of 47 disease-associated variants of MVK. A further 20 variants, which are present in human genome databases, were also analysed. Variants associated with MA are clustered into a "hotspot" consisting of residues 8-35 and 234-338 and tended to result in a prediction of severely reduced protein stability. Four of the uncharacterised variants, p.H24P, p.G198R, p. R253W, and p.G335S, were likely to be associated with MA. This method could be used as the basis for initial predictions of severity when new MVK variants are discovered.

A Rare Case of Inflammatory Myofibroblastic Tumor Causing Left Pulmonary Artery Stenosis and Successfully Treated with Localized Radiotherapy in a Patient with Perinuclear Antineutrophil Cytoplasmic Antibody Vasculitis.

Inflammatory myofibroblastic tumor (IMT) of the lung is a rare neoplasm that commonly behaves in an indolent fashion and is generally treated with complete surgical excision. The management of unresectable IMT presents a significant challenge, especially in cases with multiple comorbidities, and a consensus has yet to be reached on the most appropriate first-line modality. We present a case of unresectable IMT causing severe stenosis of the left pulmonary artery in a patient on immunosuppressive therapy for perinuclear antineutrophil cytoplasmic antibody vasculitis. The patient was successfully treated with localized radiotherapy to a total dose of 45 Gy in five weeks, and has been followed for more than seven years since treatment. In this case report, we review the pertinent literature and illustrate the difficulties in diagnosing and treating rare neoplasms in a patient with significant medical comorbidities.

Trauma history in a high secure male forensic inpatient population.

There is an increasing focus on trauma within forensic services. This study aimed to investigate exposure to trauma among a high secure male forensic population. Based on the Childhood Trauma Questionnaire (CTQ) and the Trauma History Questionnaire (THQ) data capture sheets were developed. Patients' own offending behaviour was included as a source of potential trauma. Records for all patients placed within the hospital (n = 194) were reviewed. All patients had been exposed to a traumatic event over the lifespan, with 75% having been exposed to trauma during childhood. Sixty-five percent of patients had experienced more than one type of trauma during childhood; the mean number of trauma types experienced during this period being 2.31. In adulthood 63% had been exposed to one trauma type while 29% had been exposed to two or more trauma types. No significant difference was found between those with and those without childhood trauma histories on hospital variables including admission length, seclusion and incidents. The implications of these results in the context of adopting a trauma informed care approach to treatment in forensic settings are discussed, and recommendations for future clinical and research directions are made.

Mentalization-based treatment and its evidence-base status: A systematic literature review.

PURPOSE: This study reviewed the evidence-base status of mentalization-based treatment (MBT), its quality, strengths, and limitations. The aim was to pave the way for further MBT research. METHOD: An electronic database and reference lists search identified MBT outcome papers, and these were systematically reviewed. The quality of the studies and the risk of bias were determined using two validated checklist tools. RESULTS: Twenty-three studies were included in the review. This included nine randomized controlled trials, seven uncontrolled pre- and post-effectiveness studies, three retrospective cohort studies, two uncontrolled randomized trials, and two case studies. The methodological quality of almost half of the papers was assessed as fair (43%), followed by good (34%), poor (17%), and excellent (4%) ratings. Nevertheless, the review identified risk of confounding bias across the majority of studies (60%) and fidelity to treatment was poorly reported in almost half of the studies (47%). Most of the studies focused on borderline personality disorder (BPD), showing positive clinical outcomes for this population but the evidence-base for other presentations was still developing. The treatment of adolescents who self-harm and at-risk mothers in substance abuse treatment showed particularly promising results, as these are client groups that have previously shown limited positive response to psychological interventions. CONCLUSIONS: Mentalization-based treatment is a potentially effective method across a wide range of clinical presentations but further research should focus on increasing the quality and the quantity of the MBT evidence outside the treatment of BPD. PRACTITIONER POINTS: MBT can be a particularly effective intervention for the treatment of adults with a diagnosis of BPD and of adolescents who self-harm and mothers enrolled in substance abuse treatments. MBT can be an effective intervention for depression and eating disorders but the evidence is currently limited. Professionals supporting mothers of children at risk may benefit from receiving training in the principles of MBT.

Falls prevention focused medication review by a pharmacist in an acute hospital: implications for future practice.

BACKGROUND: Patients at risk of falling are regularly prescribed medicines which increase falls risk. Medication review is a widely advocated risk reduction strategy. OBJECTIVE: The objectives of this descriptive study were to determine the number and types of falls risk medicines suitable for intervention, and to develop guidance to optimise the effectiveness of future medication related falls prevention initiatives. SETTING: An Irish acute teaching hospital and tertiary referral centre. METHOD: 50 hospital in-patients at risk of falls underwent medication review focused on falls prevention by a pharmacist. Falls risk medicines were identified, and reviewed. If scope to discontinue, dose reduce or switch to a safer alternative was identified by the pharmacist, the suggested medication changes were communicated to the patient's care team. MAIN OUTCOME MEASURE: Identification of the classes of falls risk medicines and types of prescriptions with greatest potential for intervention. Results The mean number of falls risk medicines prescribed to each patient was 4.8 (± 2.8) and the total number prescribed to the 50 patients was 238. Following medication review, the pharmacist identified 48 (20 %) as suitable for intervention. Consequently, 34 medication changes (70.8 %) were implemented. Four medication classes accounted for over 80 % of medication changes. These were anti-emetics, opioid analgesics, anti-cholinergic agents acting on the bladder and benzodiazepines/hypnotics. Intervention was statistically significantly more likely to be possible in the case of p.r.n. medicines compared to regular medicines (p < 0.001, Chi square test). Medication reviews focused on falls prevention took an average of 23.5 min per patient to complete. CONCLUSION: Medication reviews focused on falls prevention involve striking a balance between minimising medicines associated with falls and effectively treating medical conditions. We found only 20 % of falls risk medicines were suitable for change, and reviews were time consuming and resource intensive. However, targeting four medication classes, and being particularly alert to the potential to discontinue 'as required' medicines, has the potential to achieve most of the benefits of more comprehensive reviews. This information will guide the development of future falls risk medicine review initiatives in our hospital, increasing their feasibility in the acute hospital setting.