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IntroductionSecure forensic mental health services are low volume, high cost services. They offer care and treatment to mentally disordered offenders who pose a high risk of serious violence to others. It is therefore incumbent on these services to systematically evaluate the outcomes of the care and treatment they deliver to ensure patient benefit in multiple domains. These should include physical and mental health outcomes, as well as offending related outcomes. The aim of Dundrum Forensic Redevelopment Evaluation Study (D-FOREST) is to complete a structured evaluation study of a complete national forensic mental health service, at the time of redevelopment of the National Forensic Mental Health Service for the Ireland.Methods and analysisD-FOREST is a multisite, prospective observational cohort study. The study uses a combination of baseline and repeated measures, to evaluate patient benefit from admissions to forensic settings. Patients will be rated for physical health, mental health, offending behaviours and other recovery measures relevant to the forensic hospital setting at admission to the hospital and 6 monthly thereafter.Lagged causal model analysis will be used to assess the existence and significance of potential directed relationships between the baseline measures of symptomatology of schizophrenia and violence risk and final outcome namely length of stay. Time intervals including length of stay will be measured by median and 95% CI using Kaplan-Meier and Cox regression analyses and survival analyses. Patient related measures will be rated as changes from baseline using general estimating equations for repeated measures, analysis of variance, analysis of covariance or logistic regression.Ethics and disseminationThe study has received approval from the Research Ethics and Effectiveness Committee of the National Forensic Mental Health Service, Ireland. Results will be made available to the funder and to forensic psychiatry researchers via international conferences and peer-reviewed publications.Trial registration numberNCT05074732.

Background People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence. Method We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence. Results Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence. Conclusions Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

Background Treatment completion difficulties are common in forensic mental health settings and may have a profound impact on recidivism rates. Aims To test for associations between measures of risk and of security needs on the one hand and treatment non-completion on the other among male offender-patients in one medium security hospital. Methods We conducted a retrospective file study in a Flemish medium security hospital. A random sample of 25 treatment non-completers was compared to a random same-size sample of completers, each rated, blind to outcome, on the DUNDRUM-1 security needs scale from data recorded at the time of admission to the unit. 'Non-completion' was defined as any failure to complete treatment, whether staff-terminated or self-terminated; in Flanders, failure to comply with the judicial conditions of placement can result in re-imprisonment. We used binary logistic regression to test relationships between treatment completion/non-completion and security need, measured with the DUNDRUM-1, together with a range of possible confounding variables. Results Most patients had psychosis and/or personality disorder and often substance use disorders also. Treatment non-completion was invariably staff ordered because of security breaches. DUNDRUM-1 and PCL-R Facet 4 scores at the time of admission and HCR-20 scores during admission were significantly higher among non-completers than completers, but after binary logistic regression, only the DUNDRUM-1 rating was independently associated with non-completion. Conclusions Our study showed that an admission DUNDRUM-1 rating, indicating levels of security need, co-varies only to a small extent with the historical items of the HCR-20, so may be regarded as measuring complementary domains. While conditions in Flanders at the time of the study complicated it in that medium security hospital units offered the highest level of hospital security available, the finding that non-completion of treatment was particularly likely when the DUNDRUM-1 indicated a higher security need than facilities could provide may have implications for all secure hospital services.

Routine outcome measurement in forensic mental health has a history as long as the subject itself, though as yet this has seldom been reviewed. In forensic mental health, the outcome measurements of greatest relevance are those relating to risk of violence, need for therapeutic security and responses to interventions and treatments.

The reformulated learned helplessness model proposes that people who tend to make internal, stable, and global attributions in response to uncontrollable aversive events are more likely to develop depression. The present study sought to investigate the nature of the relationship between attributional style and depression in a male prison sample. One hundred and one adult male prisoners from four medium security prisons in Ireland completed the Attributional Style Questionnaire and measures of depression (BDI-II) and anxiety (BAI). Severity of self-reported depressive symptoms in the present sample was comparable to other prison and clinical samples, but higher than community samples. Participants were more severely affected by depressive symptoms than anxiety. The original attributional dimensions (i.e. internal, stable, and global) predicted a significant amount of variance in depression, but the model was not significant after controlling for anxiety. A subsequent regression model, comprising attributional dimensions for both negative events and positive events including a measure of 'uncontrollability', accounted for 35% of the variance in depression and the model retained significance while controlling for anxiety. An attributional model of depression may be relevant to the prison population and could provide a valid insight into the development and treatment of depressive symptoms in prisoners. The findings are interpreted in relation to previous research and implications for theory, clinical practice, and rehabilitation are discussed.

Forensic patients with schizophrenia who had carried out a homicide scored higher on a measure of moral cognition (MFQ-30) than other violent patients. Neurocognitive impairment was associated with homicide by mediation via higher scores for in-group loyalty.

In this study a 29-item version of the systemic clinical outcome and routine evaluation (SCORE), which contained all items from the SCORE-15 and SCORE-28, was used to develop norms for both the 15 and the 28 versions of the SCORE from the same sample. In a random digit dialling telephone survey, a stratified national random sample of 403 adults living in the Republic of Ireland and Northern Ireland completed the SCORE and brief measures of family and personal adjustment. Using receiver operating characteristic curve analyses, cut-off points for the SCORE-28 and 15 were found to identify families of children with significant emotional and behavioural problems. We also established 90th percentile points and percentages of cases falling above each scale point for both versions of the SCORE. Confirmatory factor analyses showed that, for both versions of the SCORE, the data fit the three factor solutions found in previous studies. The SCORE scales also had significant correlations with measures of family, parental and child adjustment, and negligible correlations with socioeconomic variables and social desirability response set.

This article describes the development, in an Irish context, of a three-factor, twenty-eight-item version of the Systemic Clinical Outcome and Routine Evaluation (SCORE) questionnaire for assessing progress in family therapy. The forty- item version of the SCORE was administered to over 700 Irish participants including non-clinical adolescents and young adults, families attending family therapy, and parents of young people with physical and intellectual disabilities and cystic fibrosis. For validation purposes, data were also collected using brief measures of family and personal adjustment. A twenty-eight-item version of the SCORE (the SCORE-28) containing three factor scales that assess family strengths, difficulties and communication was identified through exploratory principal components analysis. Confirmatory factor analysis showed that the factor structure of the SCORE-28 was stable. The SCORE-28 and its three factor scales were shown to have excellent internal consistency reliability, satisfactory test-retest reliability and construct validity. The SCORE-28 scales correlated highly with the General Functioning Scale of the Family Assessment Device, and moderately with the Global Assessment of Relational Functioning Scale, the Kansas Marital and Parenting Satisfaction Scales, the Satisfaction with Life Scale, the Mental Health Inventory – 5, and the total problems scale of the Strengths and Difficulties Questionnaire. Correlational analyses also showed that the SCORE-28 scales were not strongly associated with demographic characteristics or social desirability response set. The SCORE-28 may routinely be administered to literate family members aged over 12 years before and after family therapy to evaluate therapy outcome.

Background Patients admitted to a secure forensic hospital are at risk of a long hospital stay. Forensic hospital beds are a scarce and expensive resource and ability to identify the factors predicting length of stay at time of admission would be beneficial. The DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale are designed to assess need for therapeutic security and urgency of that need while the HCR-20 predicts risk of violence. We hypothesized that items on the DUNDRUM-1 and DUNDRUM-2 scales, rated at the time of pre-admission assessment, would predict length of stay in a medium secure forensic hospital setting. Methods This is a prospective study. All admissions to a medium secure forensic hospital setting were collated over a 54 month period (n = 279) and followed up for a total of 66 months. Each patient was rated using the DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale as part of a pre-admission assessment (n = 279) and HCR-20 within 2 weeks of admission (n = 187). Episodes of harm to self, harm to others and episodes of seclusion whilst an in-patient were collated. Date of discharge was noted for each individual. Results Diagnosis at the time of pre-admission assessment (adjustment disorder v other diagnosis), predicted legal status (sentenced v mental health order) and items on the DUNDRUM-1 triage security scale and the DUNDRUM-2 triage urgency scale, also rated at the time of pre-admission assessment, predicted length of stay in the forensic hospital setting. Need for seclusion following admission also predicted length of stay. Conclusions These findings may form the basis for a structured professional judgment instrument, rated prior to or at time of admission, to assist in estimating length of stay for forensic patients. Such a tool would be useful to clinicians, service planners and commissioners given the high cost of secure psychiatric care.

Background There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed. Methods We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB). Results Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence. Conclusions Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence. Electronic supplementary material The online version of this article (doi:10.1186/s12888-015-0548-0) contains supplementary material, which is available to authorized users.

Interviews were conducted with clinicians and 22 participants who had completed treatment with the Northside Inter-Agency Project (NIAP), a community based treatment programme for adolescent sexual abusers. Clinicians reported that a majority of adolescents completed all steps of the programme and a majority of families had been highly supportive of adolescents’ participation in treatment. Difficulties with the management of conflict. the regulation of negative emotions, and cognitive deficits were the principal areas in which clinicians judged these adolescents to have problems in addition to their sexually abusive behaviour patterns. Despite having these difficulties, two thirds of cases were judged by therapists to be at low risk of reoffending following treatment. In just over half of cases, adolescents reported entering situations, following treatment, which placed them at risk for reoffending, but in an anonymous questionnaire none reported sexually re-offending.

In the present study a group of sexually abusive adolescents who had completed a community based treatment programme were compared with a group of non-offending peers matched for age, sex, and socio-economic status. Physical abuse, parental separation, and school related educational and behavioural difficulties were more common in the histories of the sexually abusive adolescents than in the histories of their control group counterparts. Despite this, compared with the control group, the sexually abusi ve adolescents were found to have the same level of psychological and psychosocial functioning following treatment. This was interpreted tentatively as evidence for treatment effectiveness. However, not all cases responded to treatment. When the sexually abusive adolescents were classified by treatment staff as those at high and low risk for reoffending following treatment, high risk cases who failed to respond to treatment were found to have lower ability levels, lower levels of maternal and paternal care,...

A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …

Background: Despite the availability of proven therapies, outcomes in patients with heart failure (HF) remain poor. In this 2-stage, multicenter trial, we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF. MethodsandResults: In Stage 1, a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme (ACE) inhibitors and other HF medications. Before discharge (Stage 2), patients were randomized to a patient support program (PSP) (education about HF, self-monitoring, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge) or usual care. In Stage 1 (766 patients) ACE inhibitor use increased from 58% on admission to 83% at discharge (P .0001), and the daily dose (in enalapril equivalents) increased from 11.3 8.8 mg to 14.5 8.8 mg (P .0001). In Stage 2 (276 patients) there was no difference in ACE inhibitor adherence, but a reduction in cardiovascular-related emergency room visits (49 versus 20, P .030), hospitalization days (812 versus 341, P .003), and cost of care ($CDN 2,531 less per patient) in favor of the PSP. Conclusion: Simple interventions can improve ACE inhibitor use and patient outcomes.

Tissue Doppler guided optimization of A-V and V-V delay of biventricular pacemaker improves response to cardiac resynchronization therapy in heart failure patients

204 Impact of A-V and LV-RV delay of biventricular pacemaker for resynchronisation therapy in nonresponder heart failure patients demonstrated by tissue doppler. M. Gaballa ~ , M. Chart 2, W. Hui 2, P. Cheung ~ , R. Williams ~, N. Brass ~, S. Sivakumaren 2, K. O'Reilly a, J. Van der Linder ~, L.A. Brodin 3 Cardiology department, Edmonton, Canada; Z Royal Alexandria Hospital, Cardiology, Edmonton, Alberta, Canada; S Huddinge University Hospital, Cardiology Dept., Stockholm, Sweden