Paramedics and their role in end-of-life care: perceptions and confidence

Background: Studies have highlighted paramedics are inadequately prepared to care for patients who are at the end of their life, due to the historical focus of their training on acute medical management. This appears to cause conflict with paramedic perceptions of their role. Objective: To gain an understanding of paramedics' perceptions, confidence and concerns towards dealing with end of life care patients and their families. Design: An online survey comprising open and closed questions was distributed to all paramedics in a regional ambulance service in the north of England. Demographic data included: National Health Service (NHS) grade, personal experience, education and training to contextualise the data. A total population sample across differing organisational roles was used for paramedics in a regional ambulance service in the north of England. Responses were obtained from 182 staff. Results: NHS grade and length of service as a paramedic influenced the participant's confidence and concerns when dealing with end of life patients. A large number of participants (n=126, 70%) identified validity of documentation as a concern with 83 (46%) highlighting fear of litigation and 90 (50%) identifying that conflict with families was a concern. Support from other services was viewed as a contributing factor to increased paramedic involvement in end of life care. Conclusion: Most paramedics viewed end of life care as central to their role, but there was a need for further specific education to help enable paramedics to feel more confident, competent and supported in ensuring patients receive optimal care. </jats:sec

Data linkage to national Australian health insurance data to investigate exposure to environmental hazards: the example of residential asbestos

Introduction The enrolment data for Medicare, the Australian universal health insurance provider, covers almost the entire population. Medicare data are commonly used for data linkage, usually to access national medical and pharmaceutical data. However, the enrolment data also enable the identification of geographical cohorts for studies analysing exposure to environmental hazards. Objectives and Approach One example of this was the ACT Asbestos Health Study examining the health risks associated with living in houses insulated with loose-fill asbestos in the Australian Capital Territory. The Medicare Enrolment File contains the personal details and addresses of all people enrolled since 1984, including all updates to these details. We linked these data to a register of ~1100 affected properties, with subsequent linkage to the national death index and the Australian Cancer Database. We estimated Standardized Incidence Ratios (SIR) for selected cancers in people living in these houses to obtain a measure of exposure to environmental risk within the population. Results After intensive cleaning and standardisation, nearly all (99.8%) of the affected addresses were linked. There were over one million people who had at least one ACT address between 1983 and 2013, and 2% of these had lived at an affected address and classified as exposed. The adjusted incidence of mesothelioma in exposed males was 2·5 times that of unexposed males (SIR 2·54, 95% CI 1·02–5·24), and there were some statistically significant results. The study population, number of deaths and cancers of interest were validated against the ACT census and registry figures. There were some limitations in coverage due to the period of available data, the frequency of address updates, and records with postal rather than residential addresses, but these were tested by sensitivity analyses. Conclusion/Implications The study demonstrates the power of data linkage to (a) obtain a measure of exposure to an environmental risk within a population, and (b) obtain outcomes for the resulting case and control cohorts. This method could be applied in other risk studies where exposure is based on geography

Quantitative biomonitoring of polycyclic aromatic compounds (PACs) using the Sydney rock oyster (Saccostrea glomerata)

Increasing our understanding of the bioavailable fractions of polycyclic aromatic compounds (PACs) in an aquatic environment is important for the assessment of the environmental and human health risks posed by PACs. More importantly, the behaviour of polar polycyclic aromatic hydrocarbons (polar PAHs), which are metabolites of legacy PAHs, are yet to be understood. We, therefore, carried out a study involving Sydney rock oysters (Saccostrea glomerata) sourced from two locations, that had been exposed to PAH contamination, within an Australian south-east estuary. Biomonitoring of these oysters, following relocation from the estuary to a relatively isolated waterway, was done at 24 and 72 h after deployment and subsequently at 7, 14, 28, 52 and 86 days. Control samples from Camden Haven River were sampled for PAC analyses just before deployment, after 28 days and at the end of the study (day 86). Lipid-normalised concentrations in oyster tissues across the 86-day sampling duration, elimination rate constants (k2), biological half-lives (t1/2) and time required to reach 95% of steady-state (t95) were reported for parent PAHs and the less-monitored polar PAHs including nitrated/oxygenated/heterocyclic PAHs (NPAHs, oxyPAHs and HPAHs) for the three differently sourced oyster types. Most of the depurating PAHs and NPAHs, as well as 9-FLO (oxyPAH), had k2 values significantly different from zero (p < 0.05). All other oxyPAHs and HPAHs showed no clear depuration, with their concentrations remaining similar. The non-depuration of polar PAHs from oyster tissues could imply greater human health risk compared to their parent analogues

Bioavailability of polycyclic aromatic compounds

Improving risk assessment and remediation rests on better understanding of contaminant bioavailability. Despite their strong toxicological attributes, little is known about the partitioning behaviour and bioavailability of polar polycyclic aromatic hydrocarbons (PAHs) in aquatic environments. The present study provides an insight into the bioavailable fractions of polar PAHs and their parent analogues in the tissues of the Sydney rock oyster, Saccostrea glomerata, a model aquatic bio-indicator organism. The concentration and distribution patterns of parent and polar PAHs including oxygenated PAHs (oxyPAHs), nitrated PAHs (NPAHs) and heterocyclic PAHs (HPAHs) were determined in water, sediment and oysters from an ecologically and economically important estuary of New South Wales, Australia. Total concentrations of PAHs, oxyPAHs, NPAHs and HPAHs were higher in sediments compared to oyster tissue and water. For most polar PAHs, total concentrations for water, sediment and oyster samples were 1). BSAF individual computation showed that bioaccumulation of nine investigated HPAHs in oyster tissues were relatively low and only 2-EAQ (oxyPAH) and 1N-NAP (NPAH) showed high levels of accumulation in oyster tissues, similar to parent PAHs. To the best of our knowledge, this is the first known study on the bioavailability of polar and non-polar PAHs in an Australian aquatic environment. The outcome of this study might be a useful indicator of the potential risks of polar PAHs to humans and other living organisms

Risk of cancer associated with residential exposure to asbestos insulation: a whole-population cohort study

Background The health risks associated with living in houses insulated with asbestos are unknown. Loose-fill asbestos was used to insulate some houses in the Australian Capital Territory (ACT). We compared the incidence of mesothelioma and other cancers in residents of the ACT who did and did not live in these houses. Methods Our cohort study included all ACT residents identified using Medicare enrolment data. These data were linked to addresses of affected residential properties in the ACT to ascertain exposure. We followed up residents by linking data to the Australian Cancer Database and National Death Index. Outcomes were diagnosis of mesothelioma and selected other cancers. Effects were estimated for males and females separately using standardised incidence ratios (SIRs), adjusting for age and calendar time of diagnosis. Findings Between Nov 1, 1983, and Dec 31, 2013, 1 035 578 ACT residents were identified from the Medicare database. Of these, 17 248 (2%) had lived in an affected property, including seven (2%) of 285 people diagnosed with mesothelioma. The adjusted incidence of mesothelioma in males who had lived at an affected property was 2·5 times that of unexposed males (SIR 2·54, 95% CI 1·02–5·24). No mesotheliomas were reported among females who had lived at an affected property. Among individuals who had lived at an affected property, there was an elevated incidence of colorectal cancer in women (SIR 1·73, 95% CI 1·29–2·26) and prostate cancer in men (1·29, 1·07–1·54); colorectal cancer was increased, although not significantly, in males (SIR 1·32, 95% CI 0·99–1·72), with no significant increase in the other cancers studied. Interpretation Residential asbestos insulation is likely to be unsafe. Our findings have important health, social, financial, and legal implications for governments and communities in which asbestos has been used to insulate houses.This work was funded by the ACT Government

Dense Cores in Perseus: The Influence of Stellar Content and Cluster Environment

We present the chemistry, temperature, and dynamical state of a sample of 193 dense cores or core candidates in the Perseus Molecular cloud and compare the properties of cores associated with young stars and clusters with those which are not. The combination of our NH3 and CCS observations with previous millimeter, sub-millimeter, and Spitzer data available for this cloud enable us both to determine core properties precisely and to accurately classify cores as starless or protostellar. The properties of cores in different cluster environments and before-and-after star formation provide important constraints on simulations of star-formation, particularly under the paradigm that the essence of star formation is set by the turbulent formation of prestellar cores. We separate the influence of stellar content from that of cluster environment and find that cores within clusters have (1) higher kinetic temperatures and (2) lower fractional abundances of CCS and NH3. Cores associated with protostars have (1) slightly higher kinetic temperatures (2) higher NH3 excitation temperatures), (3) are at higher column density, have (4) slightly more non-thermal/turbulent NH3 linewidths, have (5) higher masses and have (6) lower fractional abundance of CCS. We find that neither cluster environment nor protostellar content makes a significant difference to the dynamical state of cores as estimated by the virial parameter -- most cores in each category are gravitationally bound. Overall, cluster environment and protostellar content have a smaller influence on the properties of the cores than is typically assumed, and the variation within categories is larger than the differences between categories.Comment: 28 pages, 17 figures. Accepted to Ap

Prenatal exome sequencing in anomalous fetuses: new opportunities and challenges

We investigated the diagnostic and clinical performance of exome sequencing (ES) in fetuses with sonographic abnormalities with normal karyotype, microarray and, in some cases, normal gene specific sequencing