Cervical priming before surgical abortion between 14 and 24 weeks: a systematic review and meta-analyses for the National Institute for Health and Care Excellence-new clinical guidelines for England.

OBJECTIVE: This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14+0 and 24+0 weeks' gestation. DATA SOURCES: Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included. METHODS: Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I2<50%), random effects models were used for moderate heterogeneity (I2≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I2≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grades of Recommendation Assessment, Development, and Evaluation. RESULTS: A total of 15 randomized controlled trials (N=2454) were included and showed decreased difficulty of procedure and/or increased cervical dilation and decreased patient acceptability with regimens that included dilators compared with those that did not include dilators; increased preoperative expulsion of the pregnancy with sublingual misoprostol and mifepristone compared with sublingual misoprostol alone; increased difficulty of procedure with dilators and misoprostol compared with dilators and mifepristone; decreased difficulty of procedure with dilators and mifepristone compared with dilators alone; and increased cervical dilation when dilators were placed the day before abortion compared with the same day. CONCLUSION: Considered alongside clinical expertise, the published data support the use of osmotic dilators, misoprostol, or mifepristone before abortion for pregnancies at 14+0 to 16+0 weeks' gestation; osmotic dilators or misoprostol for pregnancies at 16+1 to 19+0 weeks' gestation; and osmotic dilators alone or with mifepristone for pregnancies at 19+1 to 24+0 weeks' gestation. The effectiveness of pharmacologic agents alone beyond 16+0 weeks' gestation and the optimal timing of dilator placement remain important questions for future research.

Cervical priming before surgical abortion up to 13+6 weeks' gestation: a systematic review and metaanalyses for the National Institute for Health and Care Excellence-new clinical guidelines for England.

OBJECTIVE: This study aimed to determine the optimal cervical priming regimen before surgical abortion up to and including 13+6 weeks' gestation. DATA SOURCES: Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA: This study included randomized controlled trials published in English after 2000 that compared the following: (1) mifepristone and misoprostol against each other, placebo, or no priming; (2) different doses of mifepristone or misoprostol; (3) different intervals between priming and abortion; or (4) different routes of misoprostol administration. STUDY APPRAISAL AND SYNTHESIS METHODS: Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were metaanalyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no substantial heterogeneity (I2<50%), random effects models were used for moderate heterogeneity (I2≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I2≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: A total of 18 randomized controlled trials (n=8538) were included and showed the following: decreased incomplete abortion rate (risk ratio=0.44; 95% confidence interval, 0.21-0.9) and force required to dilate the cervix (mean difference= -7.08 N; 95% confidence interval, -11.67 to -2.49) and increased preoperative bleeding (risk ratio=5.90; 95% confidence interval, 5.08-6.86) with misoprostol compared with no priming; decreased preoperative bleeding when sublingual misoprostol was given 1 hour before abortion compared with 3 hours before (risk ratio=0.14; 95% confidence interval, 0.03-0.56); and increased force required to dilate the cervix (mean difference=14.3 N; 95% confidence interval, 2.13-26.47) when mifepristone was given 24 hours before abortion compared with 48 hours before. The quality of the evidence base was limited by low event rates and risk of bias in included studies. CONCLUSION: Cervical priming with misoprostol decreases the force needed to dilate the cervix for first trimester surgical abortion and reduces the risk of incomplete abortion. Considered alongside clinical expertise, this evidence supports the use of routine cervical priming before first trimester surgical abortion with 400 µg misoprostol or, if misoprostol cannot be used, 200 mg oral mifepristone.

Access to and sustainability of abortion services: a systematic review and meta-analysis for the National Institute of Health and Care Excellence-new clinical guidelines for England.

BACKGROUND: Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances. OBJECTIVE AND RATIONALE: This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times. SEARCH METHODS: Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE. OUTCOMES: Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services. WIDER IMPLICATIONS: Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services.

HIV screening in the dental setting in New York State.

While primary care providers in New York State (NYS) are mandated to offer all patients a HIV test, still many NYS residents miss the HIV screening opportunity. To fill the gap, and as the CDC recommends, this study aimed to examine the feasibility of implementing HIV screening in dental setting, identify patient characteristics associated with acceptance of HIV rapid testing, and discuss best practices of HIV screening in dental setting. New York State Department of Health (NYSDOH) collaborated with the Northeast/Caribbean AIDS Education and Training Center (NECA AETC) and three dental schools in New York State to offer free HIV screening tests as a component of routine dental care between February 2016 and March 2018. Ten clinics in upstate New York and Long Island participated in the study. HIV screening was performed using the OraQuick™ In-Home HIV Test. 14,887 dental patients were offered HIV screening tests; 9,057 (60.8%) were screened; and one patient (0.011%) was confirmed HIV positive and linked to medical care. Of all dental patients, 33% had never been screened for HIV; and 56% had not had a primary care visit or had not been offered an HIV screening test by primary care providers in the previous 12 months. Multi-level generalized linear modeling analysis indicated that test acceptance was significantly associated with patient's age, race/ethnicity, gender, country of origin, primary payer (or insurance), past primary care visits, past HIV testing experiences, and the poverty level of patient's community. HIV screening is well accepted by dental patients and can be effectively integrated into routine dental care. HIV screening in the dental setting can be a good option for first-time testers, those who have not seen a primary care provider in the last 12 months, and those who have not been offered HIV screening at their last primary care visit.

Structured assessments for imminent aggression in mental health and correctional settings: Systematic review and meta-analysis.

BACKGROUND: Structured risk assessment schemes can aid violence reduction in mental health and correctional settings. However, the properties and effectiveness of schemes for predicting imminent (within 24-h) violence have not been comprehensively reviewed. OBJECTIVES: To systematically review the properties and predictive performance of structured schemes that have been used to predict imminent aggression. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Multiple electronic databases were searched, relevant reference lists and journals were hand-searched. REVIEW METHODS: Thirty-two structured risk assessment schemes were identified and used in a search for evidence about the prediction of imminent violence, or their psychometric properties when used for that purpose. Study findings were synthesised narratively and, where statistics about predictive validity were available, subjected to meta-analyses. RESULTS: Five schemes (Brøset Violence Checklist, HCR-20: Assessing Risk for Violence version 2.0 clinical subscale, Dynamic Appraisal of Situational Aggression and its variants for youth and for women) have been subject to relevant research. Fifty papers were included in a narrative review, and 31 comprising 26 samples involving 282,238 assessments for 2723 individuals were included in meta-analyses. Only the Dynamic Appraisal of Situational Aggression and the Brøset Violence Checklist were subject to implementation research in which the tools were largely rated as having utility for, and being acceptable to, user-participants. Many studies have not established interrater reliability of the tools in the field. After removing outliers, pooled effect sizes for prediction of aggression against people and for any aggression were, respectively: Hedges' g = 1.35[1.15-1.56]) and g = 1.24[0.99, 1.50] for the Brøset Violence Checklist and g = 1.04 [0.69, 1.39] and 0.88 [0.62, 1.15] for the Dynamic Appraisal of Situational Aggression. Moderator analyses revealed pooled effect sizes for both schemes were decreased by low study bias risk and increased by patient forensic vs. civil legal status. CONCLUSIONS: Research supports the value of both the Brøset Violence Checklist and the Dynamic Appraisal of Situational Aggression. Both are generally acceptable and feasible to implement, and their predictive value is broadly equivalent producing large pooled effect sizes. There is less evidence about the Dynamic Appraisal of Situational Aggression. variants for women and youth though initial studies are promising.

Examining the relationship between sepsis and oropharyngeal dysphagia in hospitalised elderly patients: a retrospective cohort study.

INTRODUCTION: Elderly people are recognised to be at increased risk of oropharyngeal dysphagia (OPD), the causes of which are multifactorial. Our aim was to identify if sepsis is associated with OPD in the elderly during hospitalisation in the absence of known other risk factors for OPD. METHODS: A hospital electronic database was searched for elderly patients (≥65 years) referred for assessment for suspected dysphagia between March 2013 and 2014. Exclusion criteria were age <65 years, pre-existing OPD or acute OPD secondary to acute intracranial event, space-occupying lesion or trauma. Data were collected on factors including age, sex, comorbidities, existing OPD, sepsis, microbiology, recovery of OPD and medication. Sepsis was defined as evidence of a systemic inflammatory response syndrome with a clinical suspicion of infection. RESULTS: A total of 301 of 1761 screened patients referred for dysphagia assessment met the inclusion criteria. The prevalence of sepsis and subsequent OPD was 16% (51/301). The mean age was 83 years (median 81 years). The most common comorbidity was dementia (31%). The majority (84%) failed to recover swallowing during their hospital stay, 12% had complications of aspiration and 35% died. The most common source of sepsis was from the chest (55%). Other factors contributing to the risk for dysphagia included delirium (22%) and neuroactive medication (41%). However, 10% of patients had sepsis and subsequent OPD without other identified risk factors. CONCLUSION: The prevalence of sepsis and subsequent dysphagia is significant and should be taken into account in any elderly person in hospital with new-onset OPD without other predisposing risk factors.

Structured risk assessment for reduction of multiple risk outcomes in a secure mental health setting: Use of the START.

BACKGROUND: Structured risk assessment is commonly used in secure settings to aid prediction and prevention of risky behaviours; the expected benefits have rarely been investigated. AIMS: The aim of the study is to determine whether adverse outcomes (physical and verbal aggression, self-harm, victimisation, self-neglect, unauthorised leave and substance abuse) reduced after patients were assessed with the Short-term Assessment of Risk and Treatability (START). METHODS: In a naturalistic study, anonymised demographic and clinical information was collected from 50 male patients. Data included START assessment and frequency of target behaviour for 3 months before and after first assessment. Chi-square and linear mixed models analyses were used to determine whether there was any change in the behaviours of interest. RESULTS: There were no significant changes in physical or verbal aggression over time, although a tendency towards fewer incidents was apparent. Other adverse behaviours were very infrequent at baseline, precluding adequate analysis. CONCLUSIONS: In this small sample, START did not achieve its primary purpose of significant reduction in adverse behaviours. Although our sample size was informed by a power calculation, we may have over-estimated the size of anticipated change. Further, the 3-month comparison periods before and after the assessment follow-up period were rather short. Accordingly, we recommend more research on the value of this tool in practice rather than discontinuing its use. Copyright © 2017 John Wiley & Sons, Ltd.

Predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes: The effect of diagnosis.

The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N = 527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.

Role of assessment components and recent adverse outcomes in risk estimation and prediction: Use of the Short Term Assessment of Risk and Treatability (START) in an adult secure inpatient mental health service.

The Short Term Assessment of Risk and Treatability is a structured judgement tool used to inform risk estimation for multiple adverse outcomes. In research, risk estimates outperform the tool's strength and vulnerability scales for violence prediction. Little is known about what its'component parts contribute to the assignment of risk estimates and how those estimates fare in prediction of non-violent adverse outcomes compared with the structured components. START assessment and outcomes data from a secure mental health service (N=84) was collected. Binomial and multinomial regression analyses determined the contribution of selected elements of the START structured domain and recent adverse risk events to risk estimates and outcomes prediction for violence, self-harm/suicidality, victimisation, and self-neglect. START vulnerabilities and lifetime history of violence, predicted the violence risk estimate; self-harm and victimisation estimates were predicted only by corresponding recent adverse events. Recent adverse events uniquely predicted all corresponding outcomes, with the exception of self-neglect which was predicted by the strength scale. Only for victimisation did the risk estimate outperform prediction based on the START components and recent adverse events. In the absence of recent corresponding risk behaviour, restrictions imposed on the basis of START-informed risk estimates could be unwarranted and may be unethical.

The Predictive Validity of the Short-Term Assessment of Risk and Treatability (START) for Multiple Adverse Outcomes in a Secure Psychiatric Inpatient Setting.

The Short-Term Assessment of Risk and Treatability (START) aims to assist mental health practitioners to estimate an individual's short-term risk for a range of adverse outcomes via structured consideration of their risk ("Vulnerabilities") and protective factors ("Strengths") in 20 areas. It has demonstrated predictive validity for aggression but this is less established for other outcomes. We collated START assessments for N = 200 adults in a secure mental health hospital and ascertained 3-month risk event incidence using the START Outcomes Scale. The specific risk estimates, which are the tool developers' suggested method of overall assessment, predicted aggression, self-harm/suicidality, and victimization, and had incremental validity over the Strength and Vulnerability scales for these outcomes. The Strength scale had incremental validity over the Vulnerability scale for aggressive outcomes; therefore, consideration of protective factors had demonstrable value in their prediction. Further evidence is required to support use of the START for the full range of outcomes it aims to predict.

Predictive validity of the HCR-20 for violent and non-violent sexual behaviour in a secure mental health service.

BACKGROUND: Violent and non-violent sexual behaviour is a fairly common problem among secure mental health service patients, but specialist sexual violence risk assessment is time-consuming and so performed infrequently. AIMS: We aimed to establish whether a commonly used violence risk assessment tool, the Health Clinical Risk management 20(HCR-20), has predictive validity specifically for inappropriate sexual behaviour. METHODS: A pseudo-prospective cohort design was used for a study in the adult wards of a large provider of specialist secure mental health services. Routine clinical team HCR-20 assessments were extracted from records, and incidents involving inappropriate sexual behaviour were recorded for the 3 months following assessment. RESULTS: Of 613 patients, 104 (17%) had engaged in at least one inappropriate sexual behaviour; in 65 (10.6%), the sexual act was violent. HCR-20 total score, clinical and risk management subscales, predicted violent and non-violent sexual behaviour. The negative predictive value of the HCR-20 for inappropriate sexual behaviour was over 90%. CONCLUSIONS: Prediction of violent sexual behaviour may be regarded as well within the scope of the HCR-20 as a structured professional judgement tool to aid violence risk prediction, but we found that it also predicts behaviours that may be of concern but fall below the violence threshold. High negative predictive values suggest that HCR-20 scores may have some utility for screening out patients who do not require more specialist assessment for inappropriate sexual behaviour. Copyright © 2015 John Wiley & Sons, Ltd.

The HCR-20 as a measure of reliable and clinically significant change in violence risk among secure psychiatric inpatients.

OBJECTIVE: Periodic structured violence risk assessment is the principle method underlying treatment planning for mentally disordered offenders but little is known about how risk changes over time. We aimed to determine whether hospitalised patients underwent reliable clinical change in assessed risk. METHOD: We used a pseudo-prospective longitudinal study design. Demographic, clinical and risk assessment data of adult inpatients (N=480) who had been routinely assessed with the HCR-20 on two to four occasions over a mean period of 17 months (SD=2) were collated. Linear mixed models regression was conducted to determine change over time on total, subscale, and individual item scores, and relative change between clinical and demographic groups. The Reliable Change Index was calculated to examine whether change was greater than that expected by measurement error; clinically significant change was defined as the extent to which HCR-20 scores reduced below previously reported scores for patients not requiring hospitalisation. RESULTS: HCR-20 total score (Estimate -0.42, 95% CI=-0.84, -0.01, p<.05; d=.20) and clinical score (Estimate=-0.42, 95% CI=-0.64, -0.20, p<.001; d=.36) reduced over assessments. Significant differences in change were evident between clinically and demographically defined groups. A maximum of 3% of individuals showed clinically significant reliable reductions in HCR-20 total scores. The scores of patients whose overall level of risk was judged to have decreased did not reduce between assessments. CONCLUSION: Violence risk changes very little over the course of treatment although there is some variation between groups. Most change cannot be demonstrated to be reliable or clinically significant. Important clinical management decisions should not depend solely on evidence from changes in HCR-20 risk assessment.

Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR-20.

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR-20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3-month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR-20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item-outcome analysis revealed that impulsivity, negative attitudes, and non-compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients.

Predictive validity of the START for unauthorised leave and substance abuse in a secure mental health setting: a pseudo-prospective cohort study.

BACKGROUND: Risk assessment and management is central to the nursing role in forensic mental health settings. The Short Term Assessment of Risk and Treatability (START) aims to support assessment through identification of risk and protective factors. It has demonstrated predictive validity for aggression; it also aims to aid risk assessment for unauthorised leave and substance abuse where its performance is relatively untested. OBJECTIVES: To test the predictive validity of the START for unauthorised leave and substance abuse. DESIGN: A naturalistic, pseudo-prospective cohort study. SETTINGS: Four centres of a large UK provider of secure inpatient mental health services. PARTICIPANTS: Inpatients resident between May 2011 and October 2013 who remained in the service for 3-months following assessment with the START by their clinical team. Exclusion criteria were missing assessment data in excess of prorating guidelines. Of 900 eligible patients 73 were excluded leaving a final sample size of n=827 (response rate 91.9%). Mean age was 38.5 years (SD=16.7); most participants (72.2%) were male; common diagnoses were schizophrenia-type disorders, personality disorders, organic disorders, developmental disorders and intellectual disability. METHODS: Routinely conducted START assessments were gathered. Subsequent incidents of substance abuse and unauthorised leave were coded independently. Positive and negative predictive values of low and elevated risk were calculated. Receiver Operating Characteristic analysis was conducted to ascertain the predictive accuracy of the assessments based on their sensitivity and specificity. RESULTS: Patient-based rates of unauthorised leave (2.4%) and substance abuse (1.6%) were low. The positive and negative predictive values for unauthorised leave were 5.9% and 98.4%; and for substance abuse 8.1% and 99.0%. The START specific risk estimate for unauthorised leave predicted its associated outcome (Area under the curve=.659, p<.05, 95% CI .531, .786); the substance abuse risk estimate predicted its outcome with a large effect size (Area under the curve=.723, p<.01, 95% CI .568, .879). CONCLUSIONS: The study provides limited support for the START by demonstrating the predictive validity of its specific risk estimates for substance abuse and unauthorised leave. High negative predictive values suggest the tool may be of most utility in screening out low risk individuals from unnecessary restrictive interventions; very low positive predictive values suggest caution before implementing restrictive interventions in those rated at elevated risk. Researchers should investigate how multidisciplinary teams formulate risk assessments for these outcomes since they outperform the quantitative element of this tool.

Predictive validity of the HCR-20 for inpatient self-harm.

BACKGROUND: Few instruments have been developed to assess the risk of self-harm by psychiatric patients and the evidence for their predictive validity is limited. Given that individuals who self-harm may also engage in other-directed aggression, and that the behaviour can be a precursor to violence, we tested whether, and for which groups, the commonly used violence risk assessment HCR-20 demonstrated predictive validity for self-harm. PROCEDURES: A pseudo-prospective cohort study (N=504) was conducted in a UK secure/forensic mental health setting using routinely collected data. HCR-20 assessments were completed by the clinical team and incidents of self-harm during the 3months following assessment were coded from patient records. FINDINGS: The HCR-20 total score, H10 and R5 subscales, and SJ for violence significantly predicted self-harm; however, AUC values did not demonstrate large effect sizes (range .345 to .749). Personality disorder and impulsivity were the strongest predictors of self-harm, but the R5 scale contained the greatest proportion of relevant items. Predictive efficacy was superior for women compared with men and for those with schizophrenia or personality disorder compared with organic and developmental disorders. CONCLUSIONS: The HCR-20 appears to be a significant predictor of self-harm. It may be possible to supplement HCR-20 ratings with case specific knowledge and additional known risk factors for self-harm to make a valuable summary judgement about the behaviour and thus minimise the need for multiple assessment tools.

Differential predictive validity of the Historical, Clinical and Risk Management Scales (HCR-20) for inpatient aggression.

The Historical, Clinical and Risk Management Scales (HCR-20) may be a better predictor of inpatient aggression for selected demographic and clinical groups but homogeneity of study samples has prevented definitive conclusions. The aim of this study, therefore, was to test the predictive validity of the HCR-20 as a function of gender, diagnosis, age, and ethnicity while controlling for potential covariates. A pseudo-prospective cohort study (n=505) was conducted in a UK secure/forensic mental health setting using routinely collected data. The HCR-20 predicted aggression better for women than men, and for people with schizophrenia and/or personality disorder than for other diagnostic groups. In women, the presence of the risk management items (R5) was important while men׳s aggression was best predicted solely by current clinical features from the C5 scale. R5 items were better than C5 items for predicting aggression in people with organic and developmental diagnoses. Our data provide additional information on which HCR-20 raters can formulate overall summary judgements about risk for inpatient aggression based on important demographic and clinical characteristics.

Short-Term Assessment of Risk and Treatability (START): systematic review and meta-analysis.

This article describes a systematic review of the psychometric properties of the Short-Term Assessment of Risk and Treatability (START) and a meta-analysis to assess its predictive efficacy for the 7 risk domains identified in the manual (violence to others, self-harm, suicide, substance abuse, victimization, unauthorized leave, and self-neglect) among institutionalized patients with mental disorder and/or personality disorder. Comprehensive terms were used to search 5 electronic databases up to January 2013. Additional articles were located by examining references lists and hand-searching. Twenty-three papers were selected to include in the narrative review of START's properties, whereas 9 studies involving 543 participants were included in the meta-analysis. Studies about the feasibility and utility of the tool had positive results but lacked comparators. START ratings demonstrated high internal consistency, interrater reliability, and convergent validity with other risk measures. There was a lack of information about the variability of START ratings over time. Its use in an intervention to reduce violence in forensic psychiatric outpatients was not better than standard care. START risk estimates demonstrated strong predictive validity for various aggressive outcomes and good predictive validity for self-harm. Predictive validity for self-neglect and victimization was no better than chance, whereas evidence for the remaining outcomes is derived from a single, small study. Only 3 of the studies included in the meta-analysis were rated to be at a low risk of bias. Future research should aim to investigate the predictive validity of the START for the full range of adverse outcomes, using well-designed methodologies, and validated outcome tools.

Postpartum outcomes in supine delivery by physicians vs nonsupine delivery by midwives.

CONTEXT: Clinically preferred maternal position during childbirth has varied between supine and nonsupine over time and from patient to patient. Preferred maternal birthing position is coming under increasing scrutiny. OBJECTIVE: To compare postpartum maternal and infant outcomes resulting from supine and nonsupine positions maintained during the second stage of labor. DESIGN AND METHODS: Nonrandomized clinical trial comparing low-risk women (N=198) in two separate obstetrics practices. In one practice, parturients (n=100) used only the supine position as their birthing position. In the other practice, parturients (n=98) used any or all of three nonsupine positions (sitting, squatting, or kneeling/hands-and-knees). Data collection took place immediately after birth by provider survey and included: Apgar scores, demographics, estimated blood loss, neonatal weight, perineal integrity, position during second-stage labor and birth, and vulvar edema. RESULTS: Infants born to mothers in nonsupine positions were delivered with significantly less tearing of the perineum (P<.001) and less vulvar edema (P<.001). Although the length of second-stage labor was shorter among the women who were nonsupine, this result lacked statistical significance. There did not appear to be increased risk to the infant from the mother's nonsupine posture. CONCLUSION: Nonsupine positions during labor and delivery were found to have clinical advantages without risk to mother or infant. Enhanced maternal outcomes included improved perineal integrity, less vulvar edema, and less blood loss.