Risk Of Serious Harm Research Articles

P3 How Much Did the COVID-19 Shielding Policy Cost in Wales? Results of a Cost Analysis Within the EVITE Immunity Evaluation

The quasi-experimental EVITE Immunity study investigates the effects of shielding clinically extremely vulnerable (CEV) people during the COVID-19 pandemic on health outcomes, healthcare costs and immunity in Wales to help prepare the United Kingdom for future pandemics. Shielding was intended to protect those at highest risk of serious harm from becoming infected with COVID-19. We report the cost of implementing shielding in Wales. The number of people shielding was identified from the Secure Anonymised Information Linkage (SAIL) Databank. Resource costs of shielding between March and June 2020 were collated using published reports, documents and web pages, freedom of information requests to the Welsh Government and personal communications (e.g. with the office of the Chief Medical Officer for Wales, clinicians and staff involved). When shielding began, 117,543 people were on the shielding list (46% male, 54% female). The total cost of administering the shielding programme and supporting people advised to stay at home in Wales during the initial fourteen weeks of the pandemic was £13,308,159 or £113 per person shielding. This included new resources required to compile the shielding list, inform CEV people of the shielding intervention and support and provide prescription and food deliveries. Since the list was adjusted weekly over the 3-month period (with approximately 130,000 people identified by June 2020), the cost per person shielded lies between £102 and £113. This is the first evaluation of the cost of implementing measures to meet the needs of those identified to shield in Wales. However, at the time of analysis, no opportunity cost data were available. The true cost of shielding, including its budget impact and opportunity cost and the intended and unintended effects and consequences of shielding need to be investigated and weighed up to inform whether shielding is a worthwhile policy for future health emergencies.

PO143 / #288 EFFECTS OF 10 KHZ SPINAL CORD STIMULATION ON PAIN AND OPIOID CONSUMPTION IN CHRONIC NEUROAXIS AND/OR EXTREMITY PAIN: A RETROSPECTIVE REVIEW: E-POSTER VIEWING

Long-term opioid therapy remains a common treatment for patients with chronic pain, despite a lack of supporting evidence.1Given the risk of serious harms associated with long-term opioid use,2 alternative pain relief therapies that can reduce or eliminate opioids are required. The aim of this retrospective review was to evaluate the effect of 10 kHz spinal cord stimulation (SCS) on pain and opioid consumption in patients with chronic neuroaxis and/or extremity pain treated at the Lawrence + Memorial Hospital (L+MH), New London, CT.

부패범죄 공익신고자 보호 및 보상에 관한 형사법적 제언

Corruption, which is prevalent in Korean society, is having a significant negative impact on national competitiveness as well as on the happiness index of citizens. Although our society has made great efforts to eradicate such corruption, it is not easy to find tangible results indicating that corruption is decreasing in our society. This is because it is difficult to detect corruption crimes because they are done secretly among insiders. In addition, even if corruption crimes occur due to the culture of loyalty or paternalistic and closed organizational selfishness in Korean society, they try to hide it from within the organization. In order to overcome the secrecy and concealment of corruption crimes, this study intends to suggest ways to improve criminal law by examining the Public Interest Reporter Protection Act that protects and supports whistleblowers reporting corruption crimes within the organization and its problems. First, under the current law, there is a possibility that public interest reporters and collaborators may be subject to criminal punishment, disciplinary action, or administrative sanctions, so it is not possible to provide a realistic incentive to lead them to public interest reporting. This is because the current law selects a voluntary reduction or exemption, stating that “the punishment can be reduced or exempted” when criminal acts by the public interest reporter and collaborators are found in relation to public interest reporting. In order to move forward to a more active public interest report, it will need to be amended to reduce the sentence as necessary. Public interest whistleblowers and collaborators go out as witnesses in the investigation process or trial process. It is necessary to establish an explicit regulation to protect public interest reporters and collaborators who appear as witnesses in investigation or trial procedures, and it is necessary to establish a procedure for investigating evidence that can harmonize the protection of public interest whistleblowers, etc. and the guarantee of the defendant's right to cross-examination. Under the Public Interest Whistleblower Protection Act, personal protection measures can be applied only when serious harm to life or body has been suffered or is likely to be sustained. It is unclear what the obvious harm is, and there may be cases where there is a delay in proving it, resulting in serious harm. As in the Anti-Corruption Act, it should be changed to a case where there is a risk of serious harm to life or body. In addition, without delay, apply for personal protection measures to the Anti-Corruption and Civil Rights Commission, and immediately apply to the police agency, which is specialized in identity protection, so that they can receive protection measures promptly. In addition, the compensation system such as compensation, bounty, and relief money under the current law is not compensated enough for public interest whistleblowers to actively report to public interest because the amount is low in reality. should be raised significantly.

Algorithmic Assessments in Deciding on Voluntary, Assisted or Involuntary Psychiatric Treatment.

The challenges in assessing whether psychiatric treatment should be provided on voluntary, assisted or involuntary legal bases prompted the development of an assessment algorithm that may aid clinicians. It comprises a part that assesses the incapacity to provide informed consent to treatment, care or rehabilitation. It also captures the patient’s willingness to receive these treatments, the risk posed to the patient’s health or safety, financial interests or reputation and risks of serious harm to self or others. By following various decision paths, the algorithm yields one of four legal states: a voluntary, assisted, or involuntary state or that the proposed intervention should be declined. This study examined the predictive validity and the reliability of this algorithm. It was applied 4052 times to 135 clinical case narratives by 294 research participants. The legal states yielded by the algorithm had high statistical significance when matched with the gold standard (Chi-squared = 6963; df = 12; p < 0.001). It was accurate in yielding the correct legal state for the voluntary, assisted, involuntary and decline categories in 94%, 92%, 88% and 86% of the clinical case narratives, respectively. For internal reliability, a correspondence model accounted for 99.8% of the variance by which the decision paths clustered together fittingly with each of the legal states. Inter-rater reliability testing showed a moderate degree of agreement among participants on the suitable legal state (Krippendorff’s alpha = 0.66). These results suggest the algorithm is valid and reliable, which warrant a subsequent randomised controlled study to investigate whether it is more effective in clinical practice than standard assessments.

Workplace violence against emergency health care workers: What Strategies do Workers use?

BackgroundWorkplace violence by patients and bystanders against health care workers, is a major problem, for workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence.Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing violence.To design better interventions to prevent and minimize workplace violence, more information is needed on those strategies emergency health care workers currently use to prevent or minimize violence.The objective of the study was to identify and discuss strategies used by prehospital emergency health care workers, in response to violence and aggression from patients and bystanders. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers.In this study the following research questions were addressed: (1) What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders? (2) What is their experience with these strategies?MethodsFive focus groups with paramedics and dispatchers were held at different urban and rural locations in Canada. The focus group responses were transcribed verbatim and analyzed using thematic analysis.ResultsIt became apparent that emergency healthcare workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and within.ConclusionThe study results support the move away from focusing on the individual worker, who is the victim, to a systems-based approach to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in healthcare organizations and legitimized through professional bodies, unions, public policies, and regulations.

The Ethics of Head Transplant from the Confucian Perspective of Human Virtues.

Head transplantation has ignited intense discussions about whether it should be done scientifically and ethically. This paper examines the ethics of head transplantation from a Confucian perspective and offers arguments against the permissibility of head transplantation. From a Confucian point of view, human beings are the most precious organisms in the world, and ren (benevolence) and li (propriety) are the basic moral principles of human beings. As long as head transplant technology remains underdeveloped, this procedure should not be done because it will pose a serious risk of harm to humans and thus violate the principles of Confucian ren and li. If head transplant technology matures to the point that it would be safe to try in humans, it still should not be performed because it would change the selfhood or identity of the head donor and the body donor and create a new person. Confucian personal virtues greatly depend on selfhood or personal identity, and selfhood or personal identity depend on one's body cultivation and mind rectification. Through the hard effort of body cultivation and mind rectification, one transforms one's selfhood or identity and personality. This selfhood, identity, and personality cannot be separated from one's body but are embedded in one's body. Thus, head transplant would destroy two persons' identities and result in a new person, and the characteristics of this new person's identity are still unknown.

Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study

Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid ‘undue’ levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers’ attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.

Overdose prevention centres in the UK

Overdose prevention centres in the UK

Child Abuse – A Review Article

Any purposeful act of physical, emotional, or sexual abuse, including acts of neglect, done by a person responsible for the child's care has come to be known as child abuse. Violence against children, according to UNICEF, can take many forms "Neglect or negligent care, exploitation, and sexual assault are all examples of physical and mental abuse. Violence can occur in a variety of settings, including homes, schools, orphanages, residential care facilities, the streets, the workplace, jails, and other detention facilities." Such violence can disrupt a child's normal development, affecting their mental, physical, and social well-being. Abuse of a child might result in death in extreme situations. Child abuse and neglect are defined as "at a minimum, any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act that poses an imminent risk of serious harm" according to the Child Abuse Prevention and Treatment Act1.

Impact of Antipsychotic Use on Readmission Rates in Children and Adolescents With Autism Spectrum Disorder and Irritability.

BackgroundRisperidone and aripiprazole have been established as standard pharmacological treatments for irritability and associated aggressive behaviors in individuals with autism spectrum disorder (ASD), and are the only drugs approved by the United States Food and Drug Administration for those purposes. However, the rates of readmission with the use of these drugs in the pediatric population have not been studied, leaving a gap in the knowledge of antipsychotic effects. Readmission rates are a valuable metric of treatment efficacy that also reflect the financial burden, morbidity, and medical complications associated with multiple hospitalizations.MethodologyA retrospective study was conducted in 65 Hospital Corporation of America Healthcare hospitals within the United States from 2016 to 2019. Patients aged 6-17 years with a diagnosis of ASD with irritability were included. The primary outcome was 30-, 60-, and 90-day readmission rates. Chi-square tests of independence and post-hoc analyses were used to assess the relatedness between readmission rate and antipsychotic use, as well as the type of antipsychotic medication if used. A binary regression analysis was used to analyze the relationship between demographic characteristics and readmission rate in this population. Patients on antidepressants, anxiolytics, or medications primarily used as mood stabilizers were excluded from the study to reduce confounding effects of such medications.ResultsA total of 2,375 patients aged 6-17 years were admitted for irritability and a diagnosis of ASD. In total 323 (13.8%) patients were readmitted from this group within 30 days of discharge. After controlling for age, sex, and gender, the use of antipsychotic medication was found to decrease 30- and 90-day readmission rates with an odds ratio of 1.2 to 1.4 times compared to no antipsychotic use (p < 0.04). In patients with autism not on antipsychotics, regression analysis revealed that older age (p = 0.0471) and White race (p = 0.0471) were associated with 30-day readmission (a = 0.05). For these patients, race was also significantly associated with 60-day (p = 0.0494) and 90-day (p = 0.0416) readmission rates. In patients with autism on either risperidone or aripiprazole, age (p = 0.0393) and race (p = 0.0316) were significantly associated with 30-day readmission rate.ConclusionsAntipsychotic use reduced readmission rates within 30 days and 90 days in patients with irritability and ASD. Additionally, oral aripiprazole and oral risperidone were found to be equally effective in reducing the 30-day readmission rate, and neither was superior in comparison to the other in 30-, 60-, or 90-day readmission rates. The reduced 30- and 90-day readmission rates seen in our study with the use of antipsychotic medications emphasize the importance of antipsychotic use for individuals with ASD and irritability, even if the antipsychotic is not risperidone or aripiprazole. Groups who can particularly benefit from antipsychotic use include individuals who are refractory to first- and second-line therapies, such as behavioral interventions, or for those who present with persistent and serious risk of harm to themselves or others. Additionally, the use of antipsychotic medications in this scenario may reduce hospitalizations within 30 days of discharge, allowing reduction of the financial and emotional strain associated with these readmissions.

Conceptualising morally permissible risk imposition without quantified individual risks

We frequently engage in activities that impose a risk of serious harm on innocent others in order to realise trivial benefits for ourselves or third parties. Many moral theories tie the evidence-relative permissibility of engaging in such activities to the size of the risk that an individual agent imposes. I argue that we should move away from such a reliance on quantified individual risks when conceptualising morally permissible risk imposition. Under most circumstances of interest, a conscientious reasoner will identify a gap between the factors they deem potentially relevant to the riskiness of an agent’s behaviour, and the factors they are reasonably able to quantify. This then leads a conscientious reasoner to conclude that they cannot, in good faith, come up with a quantitative risk estimate that is genuinely tailored to the agent’s particular situation. Based on this, I argue that principles of morally permissible risk imposition fail to provide us with practical guidance if they ask us to take into account our agent-specific risks in a quantified manner. I also argue that principles of permissible risk imposition which appeal to quantified individual risks implausibly imply that it is frequently indeterminate whether engaging in some risky activity is morally permissible. For both of these reasons, I contend that principles of morally permissible risk imposition should make no reference to quantified individual risks. They should instead acknowledge that any quantitative estimates that an agent might usefully be able to consider will likely not be tailored to the agent’s idiosyncratic situation.

The association between involuntary alcohol treatment and subsequent emergency department visits and hospitalizations: a Bayesian analysis of treated patients and matched controls.

Many nations have provisions for involuntary treatment of alcohol dependence where the person is at serious risk of harm to themselves. To date, there has been little thorough evaluation of its effectiveness. This study aimed to determine if there were differences between involuntary and voluntary treatment for alcohol dependence on subsequent emergency and hospital care. A retrospective cohort design using linked routinely collected administrative data on health-care utilization. Hospital and community-based alcohol treatment, New South Wales, Australia. A total of 231 patients who were involuntarily treated for alcohol dependence and 231 matched controls who received treatment as usual within the period May 2012 to April 2018. Involuntary treatment comprised a 28-day mandated hospital admission which included supervised withdrawal, comprehensive assessment, rehabilitation and support followed by voluntary aftercare support for up to 6months. Treatment as usual comprised three not mutually exclusive forms of intensive voluntary alcohol treatment: withdrawal management, rehabilitation and pharmacotherapies for alcohol dependence. Outcome measures: changes in the number of emergency department (ED) visits and number of unplanned hospital admissions 12 months before and 12 months after completion of index treatment. Both groups showed a reduction in ED visits (incidence rate ratio (IRR) = 0.56, 95% credible intervals (CrI) = 0.39-0.78) and unplanned hospital admissions (IRR = 0.49, 95% CrI = 0.37-0.65). There was no statistically significant difference between the two groups (IRR = 0.77, 95% CrI = 0.58-1.03 for ED visits and IRR = 0.79, 95% CrI = 0.62-1.01 for hospital admissions). The Bayes factors were 0.925 and 0.936 for ED visits and unplanned hospital admissions, respectively, interpreted as weak evidence in support of the null hypothesis of no difference between the interventions. Involuntary treatment of alcohol dependence was associated with reduced health service utilization in the year following treatment, and the outcomes did not differ from those of a matched control group.

Impact and Return on Investment of the Take Kare Safe Space Program-A Harm Reduction Strategy Implemented in Sydney, Australia.

Safe spaces are increasingly utilized to reduce alcohol-related harm, violence, crime and improve public safety in nightlife settings. This study aimed to determine the impact and return on investment of the Take Kare Safe Space (TKSS) program—a harm reduction program implemented to address alcohol-related violence and disorder in three locations in Sydney’s night-time economy between 2014 and 2019. TKSS ambassadors provided support at static safe spaces and patrolled designated nightlife precincts to provide practical assistance to vulnerable and intoxicated people. Ambassadors recorded information relating to these interactions including ‘client’ age, gender, perceived level of intoxication, time and length of engagement with the program. Costs of program implementation and benefits of major incidents averted were obtained to allow calculation of return on investment. From December 2014 to April 2019, 66,455 people were supported by TKSS ambassadors. Most users were male (62%) and aged 18–25 years (66%). Of 3633 interventions by ambassadors, serious risk of harm was averted in 735 cases (20%). The program’s return on investment is estimated at 2.67, suggesting that a $1 investment results in $2.67 in benefits. Safe Spaces are extensively utilized, particularly by young males with high levels of intoxication, and represent a positive return on investment. Despite the growth of such services, there remains a notable absence of rigorous, independent evaluation regarding the outcomes and/or social benefit of safe space programs. From a policy perspective, there is a need for more high-quality economic evaluations to better inform decisions about competing uses of limited resources.

Prioritizing Healthcare Interventions: A Comparison of Multicriteria Decision Analysis and Cost-Effectiveness Analysis

ObjectivesTo investigate the extent to which stated preferences for treatment criteria elicited using multicriteria decision analysis (MCDA) methods are consistent with the trade-offs (implicitly) applied in cost-effectiveness analysis (CEA), and the impact of any differences on the prioritization of treatments. MethodsWe used existing MCDA and CEA models developed to evaluate interventions for knee osteoarthritis in the New Zealand population. We established equivalent input parameters for each model, for the criteria “treatment effectiveness,” “cost,” “risk of serious harms,” and “risk of mild-to-moderate harms” across a comprehensive range of (hypothetical) interventions to produce a complete ranking of interventions from each model. We evaluated the consistency of these rankings between the 2 models and investigated any systematic differences between the (implied) weight placed on each criterion in determining rankings. ResultsThere was an overall moderate-to-strong correlation in intervention rankings between the MCDA and CEA models (Spearman correlation coefficient = 0.51). Nevertheless, there were systematic differences in the evaluation of trade-offs between intervention attributes and the resulting weights placed on each criterion. The CEA model placed lower weights on risks of harm and much greater weight on cost (at all accepted levels of willingness-to-pay per quality-adjusted life-year than did respondents to the MCDA survey. ConclusionsMCDA and CEA approaches to inform intervention prioritization may give systematically different results, even when considering the same criteria and input data. These differences should be considered when designing and interpreting such studies to inform treatment prioritization decisions.

A multitheoretical perspective for addressing domestic and family violence: Supporting fathers to parent without harm

Summary Domestic and family violence remains a significant challenge to family wellbeing. The risk of serious harm from domestic and family violence is disproportionally carried by women and children, yet often the complex reality of family life means that many families have ongoing contact with their abusers. Responses to this problem are frequently siloed across child protection and specialist domestic violence services, leading to a lack of holistic intervention. More recently, there has been increased attention on addressing the role and behavior of abusive fathers, especially where fathers remain in families or have ongoing contact postseparation through coparenting. This paper offers a systemic approach for understanding and addressing such amilies. Findings An integrated theoretical framework is proposed, which draws together key tenets of feminism, family violence, and intersectional theories within a systems-oriented model. It frames families, inclusive of fathers, within their eco-social contexts, highlighting factors that exacerbate domestic and family violence, and those that increase family safety, which has strong applications for social work practice. Applications An integrated theoretical framework offers an approach for social workers for understanding domestic and family violence in a broad-based and holistic manner, and for developing coordinated family focused interventions while concurrently addressing related child welfare concerns and family safety. A range of considerations for case management of families are explored, which, while relevant to most intact families or those who have continuing contact with perpetrators, holds particular relevance for marginalized families that present with complex needs and experiences of disadvantage.

Evaluating the impact of a community‐based livelihood intervention on child protection: A mixed method approach

AbstractGlobally, children face an increasing risk of harm from abuse, violence and neglect. Progress towards securing a safe environment for them is slow and uneven. There is a growing need to understand how innovative community‐driven interventions could address sociocultural practices that harm children. In this paper, we evaluated the impact of the community‐driven urban programme on livelihood, income fortification and socio‐civic transformation intervention (UPLIFT) on child protection in Kampala, Uganda. We used a mixed‐method evaluation approach, which incorporated the difference‐in‐difference analysis and Kernel propensity score matching to estimate the programme's impact, and for the analysis of our qualitative data, we used the thematic approach. There were 663 pre‐intervention participants and 559 post‐intervention participants, aged between 13 and 17 years, in the study. Results showed improvements in various aspects of child protection; for example, there was strengthened community responsibility for child protection services and uptake of policy. However, we found undesirable impacts on situations presenting a serious risk of harm to children. We argue that protecting children against harm is a complex process, often rooted in the sociocultural and religious life of communities, and that child protection interventions must be deliberate about identifying and targeting ingrained sociocultural practices that sustain child abuse.

Health Risk Assessment of Mercury Exposure from Fish Consumption in Munduruku Indigenous Communities in the Brazilian Amazon.

Fish serves as the principal source of animal protein for the indigenous people of the Amazon, ensuring their food and nutritional security. However, gold mining causes mercury (Hg) contamination in fish, and consequently increases health risks associated with fish consumption. The aim of this study was to assess the health risk attributed to the consumption of mercury-contaminated fish by Munduruku indigenous communities in the Middle-Tapajós Region. Different fish species were collected in the Sawré Muybu Indigenous Land to determine mercury levels. The health risk assessment was carried out according to the World Health Organization (WHO 2008) methodology and different scenarios were built for counterfactual analysis. Eighty-eight fish specimens from 17 species and four trophic levels were analyzed. Estimates of Hg ingestion indicated that the methylmercury daily intake exceeds the U.S. EPA (United States Environmental Protection Agency) (2000) reference dose from 3 to 25-fold, and up to 11 times the FAO (Food and Agriculture Organization)/WHO (2003) dose recommendation. In all situations analyzed, the risk ratio estimates were above 1.0, meaning that the investigated Munduruku communities are at serious risk of harm as a result of ingestion of mercury-contaminated fish. These results indicate that, at present, fish consumption is not safe for this Munduruku population. This hazardous situation threatens the survival of this indigenous population, their food security, and their culture.

The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder services

At the beginning of this year, the UK government released a White Paper on Reforms of the 1983 Mental Health Act (MHA) aiming to achieve higher quality, accessible mental health care, as well as empowering people detained under MHA during the process and continuation of detention. In this piece, we focus on the potential impact of the proposal around appropriate care, management and detention of people with Personality Disorder (PD) within the criminal justice system (CJS), psychiatric service provision and community routes. We briefly review the historical context of reforms of PD services in the UK and discuss the proposed changes and issues in relation to the criteria of least restriction, detention and therapeutic benefit. We highlight the complexity around referral routes and logistics barriers for secure PD services that might hamper speeded referral routes and raise concerns around responsibility for authorisation of transfers in the context of risk of serious harm to the public. We emphasise the complex treatment needs of individuals with PDs and how these are potentially not met. We also discuss the shift of focus from reactive care to preventative measures and early intervention in the community for individuals with mild-to-moderate levels of PD. We highlight the need for appropriate integrative services in the community to facilitate assessment across services, identification of complex needs and support options including earlier routine screening and potential digital interventions to optimise specialised care for PD. • Discusses potential impact of the Mental Health Act reform on management of individuals with Personality Disorders (PD). • Discusses criteria of least restriction, detention and therapeutic benefit for management of severe PD in PD services. • Raises concerns around complexity of referral routes, logistic barriers and responsibility for authorisation of transfers. • Discusses the shift of focus from reactive care to preventative measures and early intervention in the community. • Highlight a need for appropriate integrative services in the community for assessment of complex needs and support options.

The opioid-prescribing practices of Australian general practice registrars: an interview study.

Approximately half of the opioids prescribed by Australian GP and GP registrars are for chronic non-cancer pain-despite limited therapeutic benefit, and serious risks of harm. Understanding the factors driving non-evidence-based opioid prescribing may improve GP training and education. To explore attitudes, beliefs, knowledge and self-reported factors influencing the opioid-prescribing decisions of Australian GP registrars. Telephone interviews were undertaken with 20 GP registrars in 2018-19. Interviews were 30-60 minutes in duration, audio-recorded and de-identified. Braun and Clarke's 6-phase framework was adopted for reflexive thematic analysis of data and managed using QSR NVivo software. Twenty registrars were recruited; 8 men and 12 women. Three themes were identified. Difficult chronic pain consultations negatively affected the registrar well-being. Registrars role modelled their supervisors' opioid-prescribing practices, even if they perceived it to be unsafe. Registrars lacked confidence in initiating, prescribing and weaning opioids, recognizing drug-seeking behaviours and declining to prescribe-but felt confident in their knowledge of opioid pharmacology. Registrars were aware of evidence-based prescribing recommendations and risk reduction strategies but struggled to translate this into practice. Non-evidence-based opioid prescribing by Australian GP registrars is multifactorial. Emotionally difficult pain consultations, poor supervision and low prescriber confidence may contribute to unsafe prescribing. Improving registrar prescribing may require interventions to improve risk reduction, training in communication and role modelling by supervisors.

Understanding safety-netting in remote consulting

The COVID-19 pandemic has changed the way health care is delivered. Paul Silverston explains the importance of providing appropriate safety-netting advice in remote consultations In primary care, the COVID-19 pandemic caused a rapid switch from face-to-face to remote consulting, which presented few opportunities for nurses who were unfamiliar with remote consulting to undergo any training in this skill. The clinical assessment and clinical decision-making skills required in remote consulting are different from those in face-to-face consulting and there is also a higher risk of diagnostic and decision-making errors in remote consulting than in face-to-face consulting. Safety-netting is an essential part of safe practice in primary care to reduce the risk of serious harm to patients from these errors. This article discusses the principles and practices of safety-netting in remote consulting.