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While evidence exists supporting the potential for aerosol transmission of SARS-CoV-2, the infectious dose by inhalation remains unknown. In the present study, the probability of infection following inhalation of SARS-CoV-2 was dose-dependent in a nonhuman primate model of inhalational COVID-19. The median infectious dose, assessed by seroconversion, was 52 TCID50 (95% CI: 23–363 TCID50), and was significantly lower than the median dose for fever (256 TCID50, 95% CI: 102–603 TCID50), resulting in a group of animals that developed an immune response post-exposure but did not develop fever or other clinical signs of infection. In a subset of these animals, virus was detected in nasopharyngeal and/or oropharyngeal swabs, suggesting that infected animals without signs of disease are able to shed virus and may be infectious, which is consistent with reports of asymptomatic spread in human cases of COVID-19. These results suggest that differences in exposure dose may be a factor influencing disease presentation in humans, and reinforce the importance of public health measures that limit exposure dose, such as social distancing, masking, and increased ventilation. The dose-response data provided by this study are important to inform disease transmission and hazard modeling, and, ultimately, mitigation strategies. Additionally, these data will be useful to inform dose selection in future studies examining the efficacy of therapeutics and vaccines against inhalational COVID-19, and as a baseline in healthy, young adult animals for assessment of the importance of other factors, such as age, comorbidities, and viral variant, on the infectious dose and disease presentation., Author summary SARS-CoV-2 infection and subsequent disease presentation are dependent on exposure dose in a nonhuman primate model of inhalational COVID-19.

BACKGROUND: The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging.OBJECTIVES: The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings.METHODS: Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model.RESULTS AND CONCLUSIONS: We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.

Environmental gradients or biophysical parameters such as climate, topography and geology drive landscape-scale vegetation structure, species distribution and productivity. These gradients have the potential to provide detailed, fine-scale spatial prediction of the accumulation of bushfire fuels and hence fire hazard by elucidating patterns in field information in a consistent and repeatable way. Rapid visual assessment of bushfire fuel hazard via ratings provides fire and land management agencies with a measure of the probability of first attack success and general suppression difficulty of bushfires at a location. This study used generalised additive modelling to examine how measures of fuel hazard, recorded for locations in New South Wales, Australia, varied in response to environmental gradients and whether these gradients could be used to predict fuel hazard at a landscape scale. We found that time since last fire, temperature and precipitation were strong predictors of fuel hazard. Our model predictions for fuel hazard outperformed current operational methods, however, both methods tended to overestimate lower fuel hazard and underestimate higher fuel hazard. Biophysical modelling of fuel hazard provides significant advancement for predicting fuel hazard. These models have the capability to be improved and developed as additional fuel hazard data, fire history mapping and remote sensing of environmental variables advance both spatially and temporally.

Fire management agencies undertake a range of fire management strategies in an attempt to reduce the risk posed by future wildfires. This can include fuel treatments (prescribed burning and mechanical removal), suppression and community engagement. However, no agency has an unlimited budget and numerically optimal solutions can rarely be implemented or may not even exist. Agencies are trying to quantify the extent to which their management actions reduce risk across multiple values in the most cost-effective manner. In this paper, we examine the cost-effectiveness of a range of prescribed burning strategies across multiple landscapes in south-eastern Australia. Landscapes considered include vegetated areas surrounding the cities of Hobart, Melbourne, Adelaide, Canberra, and Sydney. Using a simulation approach, we examine the potential range of fires that could occur in a region with varying levels of edge and landscape prescribed burning treatment regimes. Damages to assets are measured for houses, lives, transmission lines, carbon and ecological assets. Costs of treatments are estimated from published models and all data are analyzed using multi-criteria decision analysis. Cost-effectiveness of prescribed burning varies widely between regions. Variations primarily relate to the spatial configuration of assets and natural vegetation. Regions with continuous urban interface adjacent to continuous vegetation had the most cost-effective fuel treatment strategies. In contrast, those regions with fragmented vegetation and discontinuous interfaces demonstrated the lowest cost-effectiveness of treatments. Quantifying the extent to which fuel treatments can reduce the risk to assets is vital for determining the location and extent of treatments across a landscape.

Spotting during wildfires can significantly influence the way wildfires spread and reduce the chances of successful containment by fire crews. However, there is little published empirical evidence of the phenomenon. In this study, we have analysed spotting patterns observed from 251 wildfires from a database of over 8000 aerial line scan images capturing active wildfire across mainland southeast Australia between 2002 and 2018. The images were used to measure spot fire numbers, number of &ldquo, long-distance&rdquo, spot fires (&gt, 500 m), and maximum spotting distance. We describe three types of spotting distance distributions, compare patterns among different regions of southeast Australia, and associate these with broad measures of rainfall, elevation, and fuel type. We found a relatively high correlation between spotting distance and numbers, however, there were also several cases of wildfires with low spot fire numbers producing very long-distance spot fires. Most long-distance spotting was associated with a &ldquo, multi-modal&rdquo, distribution type, where high numbers of spot fires ignite close to the source fire and isolated or small clumps of spot fires ignite at longer distances. The multi-modal distribution suggests that current models of spotting distance, which typically follow an exponential-shaped distribution, could underestimate long-distance spotting. We also found considerable regional variation in spotting phenomena that may be associated with significant variation in rainfall, topographic ruggedness, and fuel descriptors. East Victoria was the most spot-fire-prone of the regions, particularly in terms of long-distance spotting.

Air pollution with PM2.5 (particulate matter smaller than 2.5 micro-metres in diameter) is a major health hazard in many cities worldwide, but since measuring instruments have traditionally been expensive, monitoring sites are rare and generally show only background concentrations. With the advent of low-cost, wirelessly connected sensors, air quality measurements are increasingly being made in places where many people spend time and pollution is much worse: on streets near traffic. In the interests of enabling members of the public to measure the air that they breathe, we took an open-source approach to designing a device for measuring PM2.5. Parts are relatively cheap, but of good quality and can be easily found in electronics or hardware stores, or on-line. Software is open source and the free LoRaWAN-based "The Things Network" the platform. A number of low-cost sensors we tested had problems, but those selected performed well when co-located with reference-quality instruments. A network of the devices was deployed in an urban centre, yielding valuable data for an extended time. Concentrations of PM2.5 at street level were often ten times worse than at air quality stations. The devices and network offer the opportunity for measurements in locations that concern the public.

Wildfires continue to destroy houses, but an understanding of the complex mix of risk factors remains elusive. These factors comprise six themes: preparedness actions (including defensible space), response actions (including defence), house construction, landscape fuels, topography and weather. The themes span a range of spatial scales (house to region) and responsible agents (householders through government to entirely natural forces). We conducted a statistical analysis that partitions the contribution of these six themes on wildfire impact to houses, using two fires that destroyed 200 houses in New South Wales (Australia) in October 2013 (the Linksview and Mt York fires). We analysed 85 potential predictor variables using Random Forest modelling. The best predictors of impact were whether the house was defended and distance to forest toward the direction of fire spread. However, predictors from all four of the other themes had some influence, including distance to the nearest other burnt house (indicating house-to-house transmission) and vegetation cover up to 40 m from the house. The worst-placed houses (undefended, without adequate defensible space, with burnt houses nearby and with a westerly aspect) were 10 times more likely to be impacted than the best-placed houses in our study. The results indicate that householders are the agents most able to mitigate risk in the conditions experienced in these fires through both preparation and active defence.

Aim Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings. Background De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher-risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect. Design Descriptive qualitative research using semi-structured interviews and Framework Analysis. Methods Inpatient interviews (N=26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis. Results Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behavior. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants’ identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation. Conclusion This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behavior change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques. This article is protected by copyright. All rights reserved.

Background\ud \ud Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The ‘Six Core Strategies’ developed in America, underpinned by prevention and trauma informed principles, is one such approach.\ud \ud \ud Objective\ud \ud An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as ‘REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period.\ud \ud \ud Design\ud \ud A non-randomised controlled trial design was employed.\ud \ud \ud Setting\ud \ud Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems.\ud \ud \ud Method\ud \ud As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption).\ud \ud \ud Results\ud \ud In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoption phase (6.62 events/1000 bed-days, 95% CI 5.53-7.72) compared to the baseline phase (9.38, 95% CI 8.19-10.55). Across all implementation wards there was an average reduction of restraint by 22%, with some wards showing a reduction of 60% and others less so (8%). The association between ward type and study phase was statistically significant.\ud \ud \ud Conclusion\ud \ud In conclusion, it is possible that reductions in the use of physical restraint are achievable using a model such as the Six Core Strategies. This approach can be adapted for global settings and changes can be sustained over time with continued support.

Workplace violence is a significant problem for health service personnel, with National Health Service (NHS) workers subject to 68 683 physical assaults between 2013 and 2014. Almost 70% of assaults occur in the mental health sector, and although serious, non-fatal injury is rare, the individual and economic impact can be substantial. In the present study, we analysed mandatory incident reports from a national database to examine whether there were identifiable precursors to incidents leading to staff injury, and whether staff characteristics were associated with injury. In line with previous descriptions, we found injury occurred either as a direct result of patient assault or during physical interventions employed by staff to contain aggression. Importantly, we found little evidence from staff reports that patients' symptoms were driving aggression, and we found less evidence of patient perspectives among reports. We make several recommendations regarding the reporting of these events that could inform policy and interventions aimed at minimizing the likelihood of injury.

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient-staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression-rule breaking, aggression-medication, and aggression-containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression-containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.

Recent decades have witnessed an escalation in the social, economic, and ecological impacts of wildfires worldwide. Wildfire losses stem from the complex interplay of social and ecological forces at multiple scales, including global climate change, regional wildfire regimes altered by human activities, and locally managed wildland-urban interface (WUI) zones where homes increasingly encroach upon wildland vegetation. The coupled nature of the human-ecological system is precisely what makes reducing wildfire risks challenging. As losses from wildfire have accelerated, an emerging research and management objective has been to create fire-adapted communities where ecologically functional levels of wildfire are preserved but risks to human lives and property are minimized. Realizing such a vision will require widespread and decentralized action, but questions remain as to when and how such a transformation could take place. We suggest that the period following a destructive wildfire may provide a “hot moment” for community adaptation. Drawing from literature on natural hazard vulnerability, disaster recovery, and wildfire ecology, this paper proposes a linked social-ecological model of community recovery and adaptation after disaster. The model contends that changes during post-wildfire recovery shape a community's vulnerability to the next wildfire event. While other studies have highlighted linked social-ecological dynamics that influence pre-fire vulnerability, few studies have explored social-ecological feedbacks in post-fire recovery. This model contributes to interdisciplinary social science research on wildfires and to scholarship on community recovery by integrating hazard vulnerability reduction with recovery in a cyclical framework. Furthermore, it is adaptable to a variety of hazards beyond wildfire. The model provides a basis for future empirical work examining the nature and effectiveness of recovery efforts aimed at long-term vulnerability reduction.

Fire agencies are moving towards planning systems based on risk assessment; however, knowledge of the most effective way to quantify changes in risk to key values by application of prescribed fire is generally lacking. We present a quantification and inter-regional comparison of how risk to management values responds to variations in prescribed burning treatment rate. Fire simulations were run using the PHOENIX RapidFire fire behaviour simulator for two case study landscapes in interface zones in Tasmania and the Australian Capital Territory (ACT), Australia. A Bayesian network approach used these data to explore the influence of treatment and weather on risk from wildfire. Area burnt, length of powerline damaged and length of road damaged responded more strongly to treatment in the ACT than in Tasmania, whereas treatment mitigated house loss and life loss more strongly in Tasmania than the ACT. The effect of prescribed burning treatment rate on area burnt below minimum tolerable fire interval was similar in each case study landscape. Our study shows that the effectiveness of prescribed burning at mitigating area burnt by wildfire and other key values varies considerably across landscapes and values.

BackgroundService user (patient) involvement in care planning is a principle enshrined by mental health policy yet often attracts criticism from patients and carers in practice.AimsTo examine how user-involved care planning is operationalised within mental health services and to establish where, how and why challenges to service user involvement occur.MethodSystematic evidence synthesis.ResultsSynthesis of data from 117 studies suggests that service user involvement fails because the patients' frame of reference diverges from that of providers. Service users and carers attributed highest value to the relational aspects of care planning. Health professionals inconsistently acknowledged the quality of the care planning process, tending instead to define service user involvement in terms of quantifiable service-led outcomes.ConclusionsService user-involved care planning is typically operationalised as a series of practice-based activities compliant with auditor standards. Meaningful involvement demands new patient-centred definitions of care planning quality. New organisational initiatives should validate time spent with service users and display more tangible and flexible commitments to meeting their needs.

Wildfires will continue to reach people and property regardless of management effort in the landscape. House-based strategies are therefore required to complement the landscape strategies in order to reduce the extent of house loss. Here we use a Bayesian Network approach to quantify the relative influence of preventative and suppressive management strategies on the probability of house loss in Australia. Community education had a limited effect on the extent to which residents prepared their property hence a limited effect on the reduction in risk of house loss, however hypothetically improving property preparedness did reduce the risk of house loss. Increasing expenditure on suppression resources resulted in a greater reduction in the risk of loss than preparedness. This increase had an interaction effect with increasing the distance between vegetation and the houses. The extent to which any one action can be implemented is limited by social, environmental and economic factors. Bayesian Network models provide a powerful tool for analysing fire risk scenarios.Combining multiple data sources allow for the exploration of a range of scenarios that cannot be empirically tested.Fire risk reduction strategies can reduce risk, but other factors limit their implementation.Approaches used here are broadly applicable to other natural hazards.

Background Obsessive-compulsive disorder (OCD) is prevalent and without adequate treatment usually follows a chronic course. “High-intensity” cognitive-behaviour therapy (CBT) from a specialist therapist is current “best practice.” However, access is difficult because of limited numbers of therapists and because of the disabling effects of OCD symptoms. There is a potential role for “low-intensity” interventions as part of a stepped care model. Low-intensity interventions (written or web-based materials with limited therapist support) can be provided remotely, which has the potential to increase access. However, current evidence concerning low-intensity interventions is insufficient. We aimed to determine the clinical effectiveness of 2 forms of low-intensity CBT prior to high-intensity CBT, in adults meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for OCD. Methods and findings This study was approved by the National Research Ethics Service Committee North West–Lancaster (reference number 11/NW/0276). All participants provided informed consent to take part in the trial. We conducted a 3-arm, multicentre randomised controlled trial in primary- and secondary-care United Kingdom mental health services. All patients were on a waiting list for therapist-led CBT (treatment as usual). Four hundred and seventy-three eligible patients were recruited and randomised. Patients had a median age of 33 years, and 60% were female. The majority were experiencing severe OCD. Patients received 1 of 2 low-intensity interventions: computerised CBT (cCBT; web-based CBT materials and limited telephone support) through “OCFighter” or guided self-help (written CBT materials with limited telephone or face-to-face support). Primary comparisons concerned OCD symptoms, measured using the Yale-Brown Obsessive Compulsive Scale–Observer-Rated (Y-BOCS-OR) at 3, 6, and 12 months. Secondary outcomes included health-related quality of life, depression, anxiety, and functioning. At 3 months, guided self-help demonstrated modest benefits over the waiting list in reducing OCD symptoms (adjusted mean difference = −1.91, 95% CI −3.27 to −0.55). These effects did not reach a prespecified level of “clinically significant benefit.” cCBT did not demonstrate significant benefit (adjusted mean difference = −0.71, 95% CI −2.12 to 0.70). At 12 months, neither guided self-help nor cCBT led to differences in OCD symptoms. Early access to low-intensity interventions led to significant reductions in uptake of high-intensity CBT over 12 months; 86% of the patients allocated to the waiting list for high-intensity CBT started treatment by the end of the trial, compared to 62% in supported cCBT and 57% in guided self-help. These reductions did not compromise longer-term patient outcomes. Data suggested small differences in satisfaction at 3 months, with patients more satisfied with guided self-help than supported cCBT. A significant issue in the interpretation of the results concerns the level of access to high-intensity CBT before the primary outcome assessment. Conclusions We have demonstrated that providing low-intensity interventions does not lead to clinically significant benefits but may reduce uptake of therapist-led CBT. Trial registration International Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN73535163., Karina Lovell and colleagues reveal that low-intensity computerised cognitive behaviour therapy provides no clinical benefit to OCD patients., Author summary Why was this study done? Many people suffer from obsessive-compulsive disorder (OCD), and if they do not get treatment, it can be a long-term problem. Although cognitive-behaviour therapy (CBT) with a therapist is effective, many people struggle to get access because of limited numbers of therapists. Low-intensity versions of CBT (written or web-based materials with limited therapist support) may increase access to care, but evidence of their effectiveness is limited. What did the researchers do and find? We tested 2 low-intensity versions of CBT in a trial (guided self-help and supported computerised cognitive-behaviour therapy [cCBT]), testing their impact on patients with OCD when provided prior to CBT with a therapist. Neither low-intensity version of CBT led to clinically significant benefits in patient outcomes. Access to “low-intensity” interventions led to significant reductions in uptake of CBT with a therapist over 12 months. More patients were satisfied with guided self-help than supported cCBT. What do these findings mean? Providing low-intensity interventions does not lead to clinically significant benefits but may reduce uptake of therapist-led CBT. These findings from a large pragmatic trial showing no clinical benefit from low-intensity treatments are in contrast to other studies published recently.

BackgroundThe Obsessive–Compulsive Treatment Efficacy randomised controlled Trial emerged from a research recommendation in National Institute for Health and Care Excellence obsessive–compulsive disorder (OCD) guidelines, which specified the need to evaluate cognitive–behavioural therapy (CBT) treatment intensity formats.ObjectivesTo determine the clinical effectiveness and cost-effectiveness of two low-intensity CBT interventions [supported computerised cognitive–behavioural therapy (cCBT) and guided self-help]: (1) compared with waiting list for high-intensity CBT in adults with OCD at 3 months; and (2) plus high-intensity CBT compared with waiting list plus high-intensity CBT in adults with OCD at 12 months. To determine patient and professional acceptability of low-intensity CBT interventions.DesignA three-arm, multicentre, randomised controlled trial.SettingImproving Access to Psychological Therapies services and primary/secondary care mental health services in 15 NHS trusts.ParticipantsPatients aged ≥ 18 years meetingDiagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for OCD, on a waiting list for high-intensity CBT and scoring ≥ 16 on the Yale–Brown Obsessive Compulsive Scale (indicative of at least moderate severity OCD) and able to read English.InterventionsParticipants were randomised to (1) supported cCBT, (2) guided self-help or (3) a waiting list for high-intensity CBT.Main outcome measuresThe primary outcome was OCD symptoms using the Yale–Brown Obsessive Compulsive Scale – Observer Rated.ResultsPatients were recruited from 14 NHS trusts between February 2011 and May 2014. Follow-up data collection was complete by May 2015. There were 475 patients randomised: supported cCBT (n = 158); guided self-help (n = 158) and waiting list for high-intensity CBT (n = 159). Two patients were excluded post randomisation (one supported cCBT and one waiting list for high-intensity CBT); therefore, data were analysed for 473 patients. In the short term, prior to accessing high-intensity CBT, guided self-help demonstrated statistically significant benefits over waiting list, but these benefits did not meet the prespecified criterion for clinical significance [adjusted mean difference –1.91, 95% confidence interval (CI) –3.27 to –0.55;p = 0.006]. Supported cCBT did not demonstrate any significant benefit (adjusted mean difference –0.71, 95% CI –2.12 to 0.70). In the longer term, access to guided self-help and supported cCBT, prior to high-intensity CBT, did not lead to differences in outcomes compared with access to high-intensity CBT alone. Access to guided self-help and supported cCBT led to significant reductions in the uptake of high-intensity CBT; this did not seem to compromise patient outcomes at 12 months. Taking a decision-making approach, which focuses on which decision has a higher probability of being cost-effective, rather than the statistical significance of the results, there was little evidence that supported cCBT and guided self-help are cost-effective at the 3-month follow-up compared with a waiting list. However, by the 12-month follow-up, data suggested a greater probability of guided self-help being cost-effective than a waiting list from the health- and social-care perspective (60%) and the societal perspective (80%), and of supported cCBT being cost-effective compared with a waiting list from both perspectives (70%). Qualitative interviews found that guided self-help was more acceptable to patients than supported cCBT. Professionals acknowledged the advantages of low intensity interventions at a population level. No adverse events occurred during the trial that were deemed to be suspected or unexpected serious events.LimitationsA significant issue in the interpretation of the results concerns the high level of access to high-intensity CBT during the waiting list period.ConclusionsAlthough low-intensity interventions are not associated with clinically significant improvements in OCD symptoms, economic analysis over 12 months suggests that low-intensity interventions are cost-effective and may have an important role in OCD care pathways. Further research to enhance the clinical effectiveness of these interventions may be warranted, alongside research on how best to incorporate them into care pathways.Trial registrationCurrent Controlled Trials ISRCTN73535163.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 37. See the NIHR Journals Library website for further project information.

Clients in acute mental health wards are at risk of weight gain associated with antipsychotic treatment, other adverse effects of medication, trauma associated with seclusion and restraint, and threats or assaults by others. Managing these risks is based on improving physical health, refining medication, reviewing ward culture and reducing incidents of conflict, violence, seclusion and restraint by behavioural interventions. Adequate training is essential, and research into outcomes is urgently needed.

Service users, staff and carers have long expressed dissatisfaction with the quality of acute mental health inpatient care, particularly with perceived staff inaccessibility and poor environments. Recovery-orientated organisational policies and staff training and practice have been shown to improve the situation. These have centred on integration with other services and collaboration with service users and their families. Whereas on wards, good risk management, therapeutic relationships, meaningful activities, attention to physical health and social inclusion all promote recovery and are cost-effective.

Suppression activities on large wildfires are complicated. Existing suppression literature does not take into account this complexity which leaves existing suppression models and measures of resource productivity incomplete. A qualitative descriptive analysis was performed on the suppression activities described in operational documents of 10 large wildfires in Victoria, Australia. A five-stage classification system summarises suppression in the everyday terms of wildfire management. Suppression can be heterogeneous across different sectors with different stages occurring across sectors on the same day. The stages and the underlying 20 suppression tasks identified provide a fundamental description of how suppression resources are being used on large wildfires. We estimate that at least 57% of resource use on our sample of 10 large wildfires falls outside of current suppression modelling and productivity research.

The number of houses at risk from wildfire continues to increase around the world as populations continue to expand into fire-prone areas. Creating defensible space (managing fuels within a 30-m zone around a house) is a key strategy for mitigating risk, but there is a need to evaluate the key components of defensible space. This study examined house impact in 27 independent forest fires from New South Wales, Australia, between 2001 and 2009, comprising 309 houses destroyed or damaged and 618 unburnt houses. A range of spatial measures of vegetation, nearby buildings, waterbodies and topography were measured around each house. Principle Components Analysis and Generalised Additive Mixed Model analysis was used to derive the best and supported alternative models to explain the determinants of housing impact. The best model contained positive effects of vegetation touching the house and estimated Radiant Heat Flux and negative effects of distance to the nearest building and the number of nearby waterbodies on the probability of impact. The results suggest that risk could be effectively reduced by providing waterbodies, maintaining defensible space and ensuring separation between houses.

Compared with the rest of the population, older people receive inequitable care for faecal incontinence. Good care improves symptoms and minimises the effects of this common problem on quality of life. Faecal incontinence is a symptom rather than a diagnosis and there are a number of options for investigation and treatment depending on the suspected underlying cause. Although there are clear guidelines for assessment and management, there are significant gaps in the evidence base and in service provision. There are many opportunities for improving care and nurses should be encouraging, supporting and leading these improvements.

Poor practice associated with pro re nata (PRN) prescriptions in mental health is common and has serious health consequences for mental health service users. Patient group directions (PGDs) are structured prescribing protocols which increase nurses' accountability for practice associated with the supply of medicines and may improve practice in this area. Attempts to replace PRN with the PGD throughout two mental health trusts were met with significant resistance by registered mental health nurses. The reasons for this were associated with anxieties over increased responsibility for practice, concerns related to the 'medicalization' of the nursing role and the increased paperwork associated with the PGD. Poor practice associated with pro re nata (PRN) prescriptions in mental health is known to be common and can increase the risk of serious and potentially fatal side effects. A contributing factor to poor practice is the lack of a clear chain of accountability between the decision to prescribe and administer PRN prescriptions. To address this problem, a patient group direction (PGD) for acute behavioural disturbance (lorazepam 0.5-2mg) and staff training materials were developed. The intention was to replace PRN prescriptions with the PGD in two mental health trusts. One of the potential benefits of this would be the removal of the contribution of PRN to high and combined dose antipsychotic prescriptions. This proposal, however, was met with significant resistance in both trusts and did not replace PRN as a result. A series of interviews and focus groups were conducted with 16 RMNs working in the two trusts, to explore the reasons why the PGD was met with resistance. Senior nurses perceived resistance to be associated with anxieties over increased responsibility for decision making. Junior nurses reported concerns regarding the medicalization of the nursing role, the paperwork associated with the PGD and the training approach used. Future efforts to implement PGDs in mental health settings must carefully consider the methods for engaging effectively with participating organizations, in terms of managing change and completing the necessary groundwork for successful implementation.

Wildfires pose significant risks to people and human infrastructure worldwide. The treatment of fuel in landscapes may alter these risks but the magnitude of this effect on risk is poorly understood. Evidence from Australian Eucalyptus forests suggests that mitigation of risk using prescribed burning as a fuel treatment is partial because weather and fuel dynamics are conducive to regular high intensity fires. We further examine the response of risk to treatment in eucalypt forests using landscape simulation modelling. We model how five key measures of wildfire activity that govern risk to people and property may respond to variations in rate and spatial pattern of prescribed fire. We then model effects of predicted climate change (2050 scenarios) to determine how the response of risk to treatment is likely to be altered in the future. The results indicate that a halving of risk to people and property in these forests is likely to require treatment rates of 7-10% of the area of the landscape per annum. Projections of 2050 weather conditions under climate change further substantially diminished the effect of rate of treatment. A large increase in rates of treatment (i.e. circa. 50% over current levels) would be required to counteract these effects of climate change. Such levels of prescribed burning are unlikely to be financially feasible across eucalypt dominated vegetation in south eastern Australia. Despite policy imperatives to expand fuel treatment, a reduction rather than an elimination of risk will result. Multi-faceted strategies will therefore be required for the management of risk.

The role conflict experienced by forensic psychiatric nurses between their therapeutic responsibilities and their responsibility to operationalize security procedures is well established in the literature. There has been less investigation into how this role conflict is played out specifically in the management of inpatient substance misuse in forensic units. This study, therefore, aimed to explore the views of nurses working in one medium secure unit of the impact of the procedures used to manage substance misuse (partial strip searching, room searching, canine searching, 'pat' (or 'rubdown') searching, urine drug screening) on their relationships with patients. Ten interviews of registered mental health nurses working in a medium secure unit in the Northwest were carried out. The interview data were transcribed verbatim and framework analysis used to identify emergent themes. The impact of the procedures on nurse-patient relationships was reported as largely negative by the participants. They reported that the intrusion of the procedures had a detrimental effect on their relationships with patients. The relative degree of intrusion posed by each of the procedures was an important factor in determining the extent and duration of damage to nurse-patient relationships, as was the communication skills of the nurse conducting the procedure.

The Task-Taxon-Task method (Anno et al. DNA-TR-95-115, 1996) is a statistical modeling approach to predict performance decrements on behavioral tasks in response to various stressors. We describe the basics of the T3 method and our approach to adapting it to handle more acute stressors, which can require decomposition into task networks via logical or empirical analysis. We provide an illustrative example showing how the method can be used to account for performance decrements in manual tasks associated with wearing protective gloves. This illustration provides a substantive application in which the current T3 method can be augmented to account for performance decrements in a new sub-domain, while additionally providing lessons for extending the method to new stressors, performance domains, and behavior modeling systems.

On October 22, 2005, a preventive medicine team deployed with the 212th Mobile Army Surgical Hospital to assist with earthquake relief efforts in Pakistani-controlled Kashmir. These efforts included core field preventive medicine but quickly extended into other efforts. In collaboration with the host nation and other organizations, the preventive medicine team performed additional support for operations outside the U.S. compound, including water and sanitation assessments of camps for internally displaced persons, communicable disease investigation and control, and vaccination programs. Preventive medicine personnel were vital to health diplomacy efforts in this operation, particularly because of security concerns that prevented other U.S. medical assets from leaving the compound. Comparisons with the U.S. responses during other humanitarian operations are made. Preventive medicine missions in health diplomacy will continue to increase. Training and collaborative relationships with other government agencies, such as the U.S. Agency for International Development, and with nongovernmental organizations should continue to be developed.

Fuel load is a primary determinant of fire spread in Australian forests. In east Australian forests, litter and canopy fuel loads and hence fire hazard are thought to be highest at and beyond steady-state fuel loads 15-20 years post-fire. Current methods used to predict fuel loads often rely on course-scale vegetation maps and simple time-since-fire relationships which mask fine-scale processes influencing fuel loads. Here we use Light Detecting and Remote Sensing technology (LiDAR) and field surveys to quantify post-fire mid-story and crown canopy fuel accumulation and fire hazard in Dry Sclerophyll Forests of the Sydney Basin (Australia) at fine spatial-scales (20 × 20 m cell resolution). Fuel cover was quantified in three strata important for crown fire propagation (0.5-4 m, 4-15 m, >15 m) over a 144 km(2) area subject to varying fire fuel ages. Our results show that 1) LiDAR provided a precise measurement of fuel cover in each strata and a less precise but still useful predictor of surface fuels, 2) cover varied greatly within a mapped vegetation class of the same fuel age, particularly for elevated fuel, 3) time-since-fire was a poor predictor of fuel cover and crown fire hazard because fuel loads important for crown fire propagation were variable over a range of fire fuel ages between 2 and 38 years post-fire, and 4) fuel loads and fire hazard can be high in the years immediately following fire. Our results show the benefits of spatially and temporally specific in situ fuel sampling methods such as LiDAR, and are widely applicable for fire management actions which aim to decrease human and environmental losses due to wildfire.

Wildfires are complex adaptive systems, and have been hypothesized to exhibit scale-dependent transitions in the drivers of fire spread. Among other things, this makes the prediction of final fire size from conditions at the ignition difficult. We test this hypothesis by conducting a multi-scale statistical modelling of the factors determining whether fires reached 10 ha, then 100 ha then 1000 ha and the final size of fires >1000 ha. At each stage, the predictors were measures of weather, fuels, topography and fire suppression. The objectives were to identify differences among the models indicative of scale transitions, assess the accuracy of the multi-step method for predicting fire size (compared to predicting final size from initial conditions) and to quantify the importance of the predictors. The data were 1116 fires that occurred in the eucalypt forests of New South Wales between 1985 and 2010. The models were similar at the different scales, though there were subtle differences. For example, the presence of roads affected whether fires reached 10 ha but not larger scales. Weather was the most important predictor overall, though fuel load, topography and ease of suppression all showed effects. Overall, there was no evidence that fires have scale-dependent transitions in behaviour. The models had a predictive accuracy of 73%, 66%, 72% and 53% accuracy at 10 ha, 100 ha, 1000 ha and final size scales. When these steps were combined, the overall accuracy for predicting the size of fires was 62%, while the accuracy of the one step model was only 20%. Thus, the multi-scale approach was an improvement on the single scale approach, even though the predictive accuracy was probably insufficient for use as an operational tool. The analysis has also provided further evidence of the important role of weather, compared to fuel, suppression and topography in driving fire behaviour.

BackgroundDe-escalation techniques are a recommended non-physical intervention for the management of violence and aggression in mental health. Although taught as part of mandatory training for all National Health Service (NHS) mental health staff, there remains a lack of clarity around training effectiveness.AimsTo conduct a systematic review of the learning, performance and clinical safety outcomes of de-escalation techniques training.MethodThe review process involved a systematic literature search of 20 electronic databases, eligibility screening of results, data extraction, quality appraisal and data synthesis.ResultsA total of 38 relevant studies were identified. The strongest impact of training appears to be on de-escalation-related knowledge, confidence to manage aggression and de-escalation performance (although limited to artificial training scenarios). No strong conclusions could be drawn about the impact of training on assaults, injuries, containment and organisational outcomes owing to the low quality of evidence and conflicting results.ConclusionsIt is assumed that de-escalation techniques training will improve staff's ability to de-escalate violent and aggressive behaviour and improve safety in practice. There is currently limited evidence that this training has these effects.

The purpose of this study was to evaluate the role of interferon as initial and maintenance therapy in patients with newly diagnosed follicular lymphoma. Between 1984 and 1994, 204 patients with newly diagnosed Stage III or Stage IV follicular lymphoma were randomized to receive either, Chlorambucil (CB): 10 mg daily for 6 weeks, followed by a 2-week interval, with 3 subsequent 2-week treatment periods at the same dose, separated by 2-week intervals, or, CB given concurrently with interferon (IFN). IFN was given at a dose of 3 × 106units thrice weekly, subcutaneously, throughout the 18-week treatment period. Responding patients were subsequently randomized to receive maintenance IFN at the dose and schedule described above, or to expectant management. The overall response rate was 161/204 (78%), complete remission being achieved in 24% of patients. Neither the addition of IFN to the initial treatment, nor the use of maintenance IFN influenced response rate, remission duration or survival. This study was undertaken to determine whether IFN, given in combination with, and then subsequent to, CB would alter the clinical course of patients with follicular lymphoma. Disappointingly, this objective was not achieved, no advantage having been demonstrated for the addition of IFN. © 2001 Cancer Research Campaign http://www.bjcancer.com

Large budgets are spent on both suppression and fuel treatments in order to reduce the risk of wildfires. There is little evidence regarding the relative contribution of fire weather, suppression and fuel treatments in determining the risk posed from wildfires. Here we undertake a simulation study in the Sydney Basin, Australia, to examine this question using a fire behaviour model (Phoenix Rapidfire). Results of the study indicate that fire behaviour is most strongly influenced by fire weather. Suppression has a greater influence on whether a fire reaches 5 ha in size compared to fuel treatments. In contrast, fuel treatments have a stronger effect on the fire size and maximum distance the fire travels. The study suggests that fire management agencies will receive additional benefits from fuel treatment if they are located in areas which suppression resources can respond rapidly and attempt to contain the fires. No combination of treatments contained all fires, and the proportion of uncontained fires increased under more severe fire weather when the greatest number of properties are lost. Our study highlights the importance of alternative management strategies to reduce the risk of property loss.

Measures of phylogenetic diversity have been used to establish conservation priorities amongst groups of taxa. We adapt one such measure (‘Phylogenetic Diversity’ or ‘PD’) to a hierarchical environmental classification and use its algorithm to design a conservation reserve system (using the Northern Territory of Australia as a case study). This approach accords priority selection to sites which are most dissimilar to the environments already secured in the existing conservation network, and hence rapidly increases equitability in reservation percentage at higher levels of the hierarchy (broad environmental groups). Variation within these broad classes (i.e. environmental classes defined at a lower level of the hierarchy) is included in selections, but this inclusion tends to occur later in the selection process. This approach results in an eventual complete solution (to the goal of 5% reservation of all recognised environmental classes), which is 18% more expensive than a minimum-set solution which treats all environmental classes as equally distinct, but its advantage of rapid securement of main environments would be compelling where only a limited number (less than the minimum set) of additions to the existing conservation network is achievable in the forseeable future. The approach is further contrasted with a prioritisation mechanism (‘irreplaceability’) associated with minimumset approaches. Irreplaceability is largely a measure of limited distribution, and we argue that this may not be an important ranking criterion if the limited environment is defined at a low classification level and closely related environments are already well-represented in the existing conservation network.

To meet the demands required for safe and effective care, nurses must be able to integrate theoretical knowledge with clinical practice (Kohen and Lehman, 2008; Polit and Beck, 2008; Shirey, 2006). This should include the ability to adapt research in response to changing clinical environments and the changing needs of service users. It is through reflective practice that students develop their clinical reasoning and evaluation skills to engage in this process. This paper aims to describe the development, implementation and evaluation of a project designed to provide a structural approach to the recognition and resolution of clinical, theoretical and ethical dilemmas identified by 3rd year undergraduate mental health nursing students. This is the first paper to describe the iterative process of developing a 'blended' learning model which provides students with an opportunity to experience the process of supervision and to become more proficient in using information technology to develop and maintain their clinical skills. Three cohorts of student nurses were exposed to various combinations of face to face group supervision and a virtual learning environment (VLE) in order to apply their knowledge of good practice guidelines and evidenced-based practice to identified clinical issues. A formal qualitative evaluation using independently facilitated focus groups was conducted with each student cohort and thematically analysed (Miles & Huberman, 1994). The themes that emerged were: relevance to practice; facilitation of independent learning; and the discussion of clinical issues. The results of this study show that 'blending' face-to-face groups with an e-learning component was the most acceptable and effective form of delivery which met the needs of students' varied learning styles. Additionally, students reported that they were more aware of the importance of clinical supervision and of their role as supervisees.

[Figure][1] PHOTO: © NPS PHOTO/ALAMY STOCK PHOTO In their Policy Forum “Reform forest fire management” (18 September, p. [1280][2]), M. P. North et al. commendably advocate a more rational strategy for managing fire in U.S. forests. However, their prediction that the extent and

Wildfires can have devastating effects on life, property and the environment. Official inquiries following major damaging fires often recommend management actions to reduce the risk of future losses from wildfires. Understanding where wildfires are most likely to occur in the landscape is essential to determining where wildfires pose the greatest risk to people and property. We investigated the spatial patterns of wildfire ignitions at a bioregional scale in New South Wales and Victoria using generalised linear models. We used a combination of social and biophysical variables and examined whether different categories of ignitions respond to different explanatory variables. Human-caused ignitions are the dominant source of ignitions for wildfires in south-eastern Australia and our results showed that for such ignitions, population density was the most important variable for the spatial pattern of ignitions. In future years, more ignitions are predicted in the coastal and hinterland areas due to population increases and climate change effects.

Approaches to management of fireprone forests are undergoing rapid change, driven by recognition that technological attempts to subdue fire at large scales (fire suppression) are ecologically and economically unsustainable. However, our current framework for intervention excludes the full scope of the fire management problem within the broader context of fire−vegetation−climate interactions. Climate change may already be causing unprecedented fire activity, and even if current fires are within the historical range of variability, models predict that current fire management problems will be compounded by more frequent extreme fire-conducive weather conditions (eg Fried et al. 2004). Concern about climate change has also made the mitigation of greenhouse-gas (GHG) emissions and increased carbon (C) storage a priority for forest managers.

Wildfire can result in significant economic costs with inquiries following such events often recommending an increase in management effort to reduce the risk of future losses. Currently, there are no objective frameworks in which to assess the relative merits of management actions or the synergistic way in which the various combinations may act. We examine the value of Bayes Nets as a method for assessing the risk reduction from fire management practices using a case study from a forested landscape. Specifically, we consider the relative reduction in wildfire risk from investing in prescribed burning, initial or rapid attack and suppression. The Bayes Net was developed using existing datasets, a process model and expert opinion. We compared the results of the models with the recorded fire data for an 11-year period from 1997 to 2000 with the model successfully duplicating these data. Initial attack and suppression effort had the greatest effect on the distribution of the fire sizes for a season. Bayes Nets provide a holistic model for considering the effect of multiple fire management methods on the risk of wildfires. The methods could be further advanced by including the costs of management and conducting a formal decision analysis.

A nine year fire history for the Darwin region was created from Landsat imagery, and examined to describe the fire regime across the region. 43% of the region burned each year, and approximately one quarter of the fires occur in the late dry season, which is lower than most other studied areas. Freehold land, which covers 35% of the greater Darwin region, has 20% long-unburnt land. In contrast, most publicly owned and Aboriginal owned land has very high fire frequency (60-70% per year), and only 5% long unburnt. It seems that much of the Freehold land is managed for fire suppression, while the common land is burnt either to protect the Freehold or by pyromaniacs. Generalized Linear Modelling among a random sample of points revealed that fire frequency is higher among large blocks of savannah vegetation, and at greater distances from mangrove vegetation and roads. This suggests that various kinds of fire break can be used to manage fire in the region. The overall fire frequency in the Darwin region is probably too high and is having a negative impact on wildlife. However, the relatively low proportion of late dry season fires means the regime is probably not as bad as in some other regions. The management of fire is ad-hoc and strongly influenced by tenure. There needs to be a clear statement of regional fire targets and a strategy to achieve these. Continuation of the fire mapping is an essential component of achieving the targets.

Mission grasses Pennisetum polystachion (L.) Schult. and P. pedicellatum (Trin) and Gamba Grass Andropogon gayanus (Kunth) are three weed species that are thought to be spreading rapidly in the vicinity of Darwin and may pose a major threat to ecosystems in northern Australia. The distribution of the species was assessed from a vehicle along 913 km of roads near Darwin. The study provided data on the potential source of further spread and an analysis of the potential habitat of the weeds. For analysis, roadsides were divided up into 200 m cells and the distributions of the grasses were compared against land tenure and broad land unit maps, Mission grasses were present in approximately 52% of cells, and were particularly common around the rural residential/horticultural area of Humpty Doo. They occurred equally commonly in all broad land units, but differed among tenures, being particularly common on freehold land. Gamba Grass occurred in 15% of cells, with hot spots in a number of areas. It was most common on freehold land, and was rare on conservation reserves. It also showed an association with broad land units reflecting wetter areas. Mission grasses are so widespread in the Darwin region that control can only be contemplated in very small areas requiring frequent treatment of re-invading plants. It may be possible to control Gamba Grass in conservation reserves and Crown land if prompt action is taken. For all three species, preventing their spread to new areas should be a high priority.

Patient Group Directions (PGDs) have been used in clinical practice for a decade. They enable non-medical practitioners to supply medicines to patients, in certain legally defined circumstances, without a doctor's prescription and in accordance with a pre defined protocol. The authors aimed to review the existing literature in order to identify and evaluate the evidence regarding the quality, safety and acceptability of PGDs within care systems and their impact on health outcomes. Searches of relevant databases were conducted, articles screened against eligibility criteria and relevant data extracted. A number of key issues emerged from the data including quality and safety of practice, acceptability to patients and practitioners, access to treatment and implications for professional roles and responsibilities. There were no data related to health outcomes. The review concludes that while PGDs may be an acceptable way to deliver care, their impact on patient outcomes and health status has been poorly studied.