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The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = -0.90 (CBT; k = 27, 95% CI -1.11 to -0.68; moderate quality) to g = -1.26 (EMDR; k = 4, 95% CI -2.01 to -0.51; low quality). CBT and EA each had moderate-large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

In the UK almost 60% of people with a diagnosis of schizophrenia who use mental health services say they are not involved in decisions about their treatment. Guidelines and policy documents recommend that shared decision-making should be implemented, yet whether it leads to greater treatment-related empowerment for this group has not been systematically assessed. To examine the effects of shared decision-making on indices of treatment-related empowerment of people with psychosis. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of shared decision-making concerning current or future treatment for psychosis (PROSPERO registration CRD42013006161). Primary outcomes were indices of treatment-related empowerment and objective coercion (compulsory treatment). Secondary outcomes were treatment decision-making ability and the quality of the therapeutic relationship. We identified 11 RCTs. Small beneficial effects of increased shared decision-making were found on indices of treatment-related empowerment (6 RCTs; g = 0.30, 95% CI 0.09-0.51), although the effect was smaller if trials with >25% missing data were excluded. There was a trend towards shared decision-making for future care leading to reduced use of compulsory treatment over 15-18 months (3 RCTs; RR = 0.59, 95% CI 0.35-1.02), with a number needed to treat of approximately 10 (95% CI 5-∞). No clear effect on treatment decision-making ability (3 RCTs) or the quality of the therapeutic relationship (8 RCTs) was found, but data were heterogeneous. For people with psychosis the implementation of shared treatment decision-making appears to have small beneficial effects on indices of treatment-related empowerment, but more direct evidence is required.

This paper presents a novel approach to estimate major ion concentrations in estuaries from a known specific conductance. Assuming two-source conservative mixing at steady state, we propose an extension of the Practical Salinity Scale 1978 to estimate concentrations of major ions and total dissolved solids as functions of the conductivity ratio, which is the ratio of sample conductivity and seawater conductivity. We employ an extensive salinity data set that includes measurements of specific conductance and concentrations of major ions and total dissolved solids to demonstrate its validity and limitations for the San Francisco estuary. We show the proposed extension to be valid in waters influenced by seawater intrusion at specific conductance values greater than or equal to 0.25 mS/cm and propose adjusted model constants to account for ionic composition under less saline conditions. We observed evidence of seasonal bias in model residuals and hypothesize that this bias is related to the simplified assumption of fixed upstream end member concentrations. This finding of seasonal bias suggests that upstream end member concentrations are more reflective of high alkalinity freshwater contributions from December through June, compared to other months.

Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs. We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16–65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432. 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of −6·52 (95% CI −10·79 to −2·25; p=0·003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed. National Institute for Health Research.

In this case study, we used the Delta Simulation Model II (DSM2) to study the salt balance at the land–water interface in the river delta of California’s San Francisco Estuary. Drainage, a source of water and salt for adjacent channels in the study area, is affected by channel salinity. The DSM2 approach has been adopted by several hydrodynamic models of the estuary to enforce water volume balance between diversions, evapotranspiration and drainage at the land–water interface, but does not explicitly enforce salt balance. We found deviations from salt balance to be quite large, albeit variable in magnitude due to the heterogeneity of hydrodynamic and salinity conditions across the study area. We implemented a procedure that approximately enforces salt balance through iterative updates of the baseline drain salinity boundary conditions (termed loose coupling). We found a reasonable comparison with field measurements of drainage salinity. In particular, the adjusted boundary conditions appear to capture the range of observed interannual variability better than the baseline periodic estimates. The effect of the iterative adjustment procedure on channel salinity showed substantial spatial variability: locations dominated by large flows were minimally impacted, and in lower flow channels, deviations between baseline and adjusted channel salinity series were notable, particularly during the irrigation season. This approach, which has the potential to enhance the simulation of extreme salinity intrusion events (when high channel salinity significantly impacts drainage salinity), is essential for robustly modeling hydrodynamic conditions that pre-date contemporary water management infrastructure. We discuss limitations associated with this approach and recommend that—for this case study—further improvements could best be accomplished through code modification rather than coupling of transport and island water balance models.

This paper presents the history and evolution of the California Department of Water Resources’ Municipal Water Quality Investigations (MWQI) program. This program tracks source water quality in the Sacramento–San Joaquin Delta (Delta) for drinking water supply for nearly two-thirds of California. The program provides early warning of changing conditions in source water quality, provides data and knowledge-based support for operational decision making, and provides scientific support to a variety of urban water users. This retrospective (i) documents program formation, (ii) describes its evolution in response to regulations and technological advances in water treatment and field monitoring, and (iii) notes how the development of federal drinking water quality regulations such as the Disinfection By-Products Rule impacted the program. The MWQI program is believed to be the first drinking water supply program in the United States to conduct continuous, real-time monitoring of organic carbon, bromide, and other anions and to report these data on the internet. In addition to its regular use for operational decision making, the data may be used for evaluating long-term trends and responses to specific changes in the Delta and its watershed. Future program directions will likely be guided by factors that may trigger changes in treatment plant processes and operations, such as emerging contaminants, changes in land and water management practices, permanent Delta island flooding, sea level rise, and climate change. While this retrospective focuses on one region, its multi-decade interplay of science, treatment and monitoring technology, and regulations (as well as practical aspects of managing such a large-scale program) are broadly relevant to professionals engaged in drinking water quality management in other urbanized and developed regions of the world.

This work presents updated reconstructions of watershed runoff to San Francisco Estuary from tree-ring data to AD 903, coupled with models relating runoff to freshwater flow to the estuary and salinity intrusion. We characterize pre-development freshwater flow and salinity conditions in the estuary over the past millennium and compare this characterization with contemporary conditions to better understand the magnitude and seasonality of changes over this time. This work shows that the instrumented flow record spans the range of runoff patterns over the past millennium (averaged over 5, 10, 20 and 100 years), and thus serves as a reasonable basis for planning-level evaluations of historical hydrologic conditions in the estuary. Over annual timescales we show that, although median freshwater flow to the estuary has not changed significantly, it has been more variable over the past century compared to pre-development flow conditions. We further show that the contemporary period is generally associated with greater spring salinity intrusion and lesser summer–fall salinity intrusion relative to the pre-development period. Thus, salinity intrusion in summer and fall months was a common occurrence under pre-development conditions and has been moderated in the contemporary period due to the operations of upstream reservoirs, which were designed to hold winter and spring runoff for release in summer and fall. This work also confirms a dramatic decadal-scale hydrologic shift in the watershed from very wet to very dry conditions during the late 19th and early 20th centuries; while not unprecedented, these shifts have been seen only a few times in the past millennium. This shift resulted in an increase in salinity intrusion in the first three decades of the 20th century, as documented through early records. Population growth and extensive watershed modification during this period exacerbated this underlying hydrologic shift. Putting this shift in the context of other anthropogenic drivers is important in understanding the historical response of the estuary and in setting salinity targets for estuarine restoration. By characterizing the long-term behavior of San Francisco Estuary, this work supports decision-making in the State of California related to flow and salinity management for restoration of the estuarine ecosystem.

The evidence on factors that may influence treatment decisional capacity ('capacity') in psychosis has yet to be comprehensively synthesised, which limits the development of effective strategies to improve or support it. To determine the direction, magnitude and reliability of the relationship between capacity in psychosis and a range of clinical, demographic and treatment-related factors, thus providing a thorough synthesis of current knowledge. We conducted a systematic review, meta-analytical and narrative synthesis of factors that help or hinder treatment decision-making capacity in psychosis, assessing the direction, magnitude, significance and reliability of reported associations. We identified 23 relevant studies ( = l823). Psychotic symptoms had small, moderate and strong associations with appreciation, understanding and reasoning respectively. Both verbal cognitive functioning and duration of education had small to moderate correlations with understanding and reasoning. Better capacity was also associated with better insight, better metacognitive ability, higher anxiety and lower perceived coercion. No linear relationship with depression was observed. Interventions linked to improved capacity over time were in-patient care, information simplification, shared decision-making and metacognitive training. Although much is known about the role of symptoms and other clinical variables, effective and acceptable psychological interventions to support capacity in this group are lacking.

Immediate-release (IR) quetiapine has been used to treat schizophrenia since 1997, although all the principal placebo-controlled trials have >50% missing outcome data. New studies with relatively lower rates of participant withdrawal have since been published. To assess the efficacy and adverse effects of quetiapine IR for schizophrenia, with consideration of outcome quality and clinical meaningfulness of results, and to examine the potential impact of missing data on the main efficacy findings. We conducted a systematic review and meta-analysis of randomised controlled trials comparing quetiapine IR and placebo (or subtherapeutic dose in relapse prevention trials) for the treatment of schizophrenia (PROSPERO registration CRD4201100165). Primary outcomes were change in overall symptoms and response rates. We also examined whether high rates of participant withdrawal (≥50%) attenuated effect sizes, and assessed the impact of making different assumptions about these people's outcomes. We identified 15 relevant trials (including 2 unpublished), providing the first 12-week data for this drug and the first data on self-reported quality of life. We found quetiapine IR to have a weighted mean difference (WMD) of 6.5 points (95% CI -8.9 to -4) on Positive and Negative Syndrome Scale (PANSS) total scores, which corresponds to a standardised mean difference (SMD) of -0.33 (95% CI -0.46 to -0.21). Longer trials reported larger mean differences favouring quetiapine IR, but the overall estimate was smaller if more conservative assumptions about the outcomes of people who left the trial early were made. Approximately 21 people needed to take quetiapine IR for 1 person to experience at least a 50% improvement in PANSS score. No difference in quality of life was observed (two RCTs), although small to moderate improvements in social functioning were found (three RCTs). Quetiapine IR caused sedation and increased rates of clinically significant weight gain, but no extrapyramidal effects were observed. Quetiapine IR has a small beneficial effect on overall psychotic symptoms over 2-12 weeks, but also leads to weight gain and sedation.

Las Guerras Apaches fueron el conflicto más largo librado por Estados Unidos, que se prolongó durante un cuarto de siglo y marcó la historia del suroeste americano y el norte de México. Una tierra de frontera inhóspita y desolada, infestada de bandoleros, donde cada planta tenía una púa, cada insecto un aguijón, cada pájaro una garra y cada reptil un colmillo: la Apachería. Durante más de dos décadas, los guerreros apaches, duros como su tierra, fogueados por siglos de lucha contra los españoles, pelearon contra los intentos mexicanos y estadounidenses por acabar con su forma de vida. Su conocimiento del terreno, su movilidad y una cultura guerrera que no conocía la misericordia, les convirtieron en un enemigo terrible y formidable. En Las Guerras Apaches. Polvo y sangre en la última frontera del salvaje Oeste , Paul Andrew Hutton relata este legendario conflicto, tan presente en el imaginario popular, tan pleno de heroísmo como de brutalidad, con un pulso que consigue trasladar la intensidad del drama y ponerse en la piel de ambos bandos, haciendo justicia a los nombres legendarios de Gerónimo, Mangas Coloradas, Cochise o Victorio. Como hilo vertebrador, Hutton revive la experiencia de individuos cuya vida discurrió a medio camino entre los dos mundos, como el legendario explorador y cazarrecompensas tuerto Micky Free o como Apache Kid, el último indio libre. Cuando el humo de la pólvora se disipó y Gerónimo se entregó, resignado a una vida en la reserva, para acabar siendo expuesto como una atracción en la Exposición Universal de San Luis en 1904, la mítica era del salvaje Oeste había terminado.