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Background: There are no processes that routinely assess end-of-life care in Australian general practice. This study aimed to develop a data collection process which could collect observational data on end-of-life care from Australian general practitioners (GPs) via a questionnaire and clinical data from general practice software., Methods: The data collection process was developed based on a modified Delphi study, then pilot tested with GPs through online surveys across three Australian states and data extraction from general practice software, and finally evaluated through participant interviews., Results: The developed data collection process consisted of three questionnaires: Basic Practice Descriptors (32 items), Clinical Data Query (32 items) and GP-completed Questionnaire (21 items). Data extraction from general practice software was performed for 97 decedents of 10 GPs and gathered data on prescriptions, investigations and referral patterns. Reports on care of 272 decedents were provided by 63 GPs. The GP-completed Questionnaire achieved a satisfactory level of validity and reliability. Our interviews with 23 participating GPs demonstrated the feasibility and acceptability of this data collection process in Australian general practice., Conclusions: The data collection process developed and tested in this study is feasible and acceptable for Australian GPs, and comprehensively covers the major components of end-of-life care. Future studies could develop an automated data extraction tool to reduce the time and recall burden for GPs. These findings will help build a nationwide integrated information network for primary end-of-life care in Australia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We investigated the association of allergic diseases and epilepsy with risk of brain tumours, in Interphone, a 13-country case-control study. Data were obtained from 2693 glioma cases, 2396 meningioma cases, and 1102 acoustic neuroma cases and their 6321 controls. Conditional logistic regression models were used to estimate pooled odds ratios (ORs) and their respective 95% confidence intervals (CIs), adjusted for education and time at interview. Reduced ORs were observed for glioma in relation to physician-diagnosed asthma (OR = 0.73; CI 0.58-0.92), hay fever (OR 0.72; CI 0.61-0.86), and eczema (OR 0.78, CI 0.64-0.94), but not for meningioma or acoustic neuroma. Previous diagnosis of epilepsy was associated with an increased OR for glioma (2.94; CI 1.87-4.63) and for meningioma (2.12; CI 1.27-3.56), but not for acoustic neuroma. This large-scale case-control study adds to the growing evidence that people with allergies have a lower risk of developing glioma, but not meningioma or acoustic neuroma. It also supports clinical observations of epilepsy prior to the diagnosis of glioma and meningioma., (© 2022. Springer Nature B.V.)

Objectives: To describe general practitioners' (GPs) involvement in end-of-life care, continuity and outcomes of care, and reported management challenges in the Australian context., Methods: Sixty-three GPs across three Australian states participated in a follow-up survey to report on care provided for decedents in the last year life using a clinic-based data collection process. The study was conducted between September 2018 and August 2019., Results: Approximately one-third of GPs had received formal palliative care training. Practitioners considered themselves as either the primary care coordinator (53.2% of reported patients) or part of the management team (40.4% of reported patients) in the final year of care. In the last week of life, patients frequently experienced reduced appetite (80.6%), fatigue (77.9%) and psychological problems (44.9%), with GPs reporting that the alleviation of these symptoms were less than optimal. Practitioners were highly involved in end-of-life care (eg, home visits, consultations via telephone and family meetings), and perceived higher levels of satisfaction with communication with palliative care services than other external services. For one-third of patients, GPs reported that the last year of care could potentially have been improved., Conclusion: There are continuing needs for integration of palliative care training into medical education and reforms of healthcare systems to further support GPs' involvement in end-of-life care. Further, more extensive collection of clinical data is needed to evaluate and support primary care management of end-of-life patients in general practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We aimed to evaluate and compare the prevalence and profile of musculoskeletal symptom (MSS) outcomes across cohorts of university music students with different 'majors': (i) performance and nonperformance students, and (ii) classical and non-classical performance students. Data were collected using a cross-sectional questionnaire survey, and regression analyses were used to compare the groups. Of the 166 participating students, 92.5% reported experiencing MSSs in the last 12 months, and 72.6% in the last 7 days. Few significant differences were identified between groups. Musculoskeletal symptoms are a problem for all types of university music students, and all should have access to support to prevent and manage their MSSs, regardless of their majors.

Recent research highlights an overlap of gender diversity and autism spectrum disorders (ASD); however, data on individuals who are trans and also on the autism spectrum are largely from clinical samples and may not be representative of individuals who are trans with ASD in the general population. In addition, there is scant literature on the mental health of these individuals and their experiences in accessing gender-affirming care. We investigated the prevalence of ASD in trans young people, their mental health (psychiatric diagnoses and self-harm and suicidal behaviors) and experiences in accessing gender-affirming care. This is an analysis of data collected in an Australian cross-sectional mixed methods survey (N = 859) of trans young people aged 14-25 years. Overall, 22.5% of participants had ever received a diagnosis of ASD from a health professional. This group was more likely to exhibit current psychopathology, have engaged in self-harming and suicidal behaviors, and was also more likely than the non-ASD diagnosed reference group to have received a psychiatric diagnosis. The ASD-diagnosed group were also more likely to experience barriers in accessing gender-affirming care. This is the first large population-based sample of trans individuals with ASD to report on mental health outcomes and experiences in accessing gender-affirming care. We highlight the necessity for clinicians working with either trans or ASD populations to have awareness of the co-occurrence, and to cultivate skills to work with individuals who are both trans and on the autism spectrum., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: General practitioners (GPs) do not typically receive education regarding gender diversity despite the increasing number of trans, gender diverse and non‑binary (TGDNB) patients presenting to general practice. It is important for GPs, as the first point of entry into the healthcare system, to provide a safe and affirming environment for TGDNB patients to reduce ill-health later in life., Objective: The aim of this article is to clarify how GPs can improve their care of TGDNB patients to be more inclusive and thereby promote a positive relationship with the health system, assist in gender-affirming care and reduce illness within this population. The authors provide simple suggestions for clinical practice and encourage clinicians to seek professional development in this rapidly developing field., Discussion: Care of TGDNB patients extends beyond gender-affirming care to include mental health and community supports to ensure the overall wellbeing of the patient. Central to this care is respect of the patient's gender identity and expression.

Background: Trans and gender diverse (TGD) young people worldwide experience high rates of poor mental health; however, these rates were unknown in Australia. In addition, how negative life events affect the mental health of TGD young people has been largely unexplored., Methods: This paper reports on novel mental health findings of Trans Pathways, the largest study ever conducted in Australia with trans (transgender) and gender diverse young people (N = 859; aged 14-25 years). The study was an anonymous online cross-sectional survey undertaken in 2016. Logistic and linear regression models were used to test associations between mental health outcomes and negative life experiences., Results: TGD young people in Australia experience high levels of mental distress, including self-harming (79.7%), suicidal thoughts (82.4%), and attempting suicide (48.1%). Three in four participants had been diagnosed with depression and/or anxiety (74.6% and 72.2%, respectively). Many TGD young people had been exposed to negative experiences such as peer rejection (89.0%), precarious accommodation (22.0%), bullying (74.0%), and discrimination (68.9%). Most poor mental health outcomes were associated with negative experiences. The strongest associations were found for precarious accommodation and issues within educational settings. For example, participants with a prior suicide attempt were almost six times more likely to have experienced issues with accommodation, including homelessness., Conclusions: The current results highlight the urgent need for better mental health care and provide insight into areas for targeted mental health interventions. These findings are pertinent for clinicians working with trans young people and wider society.

Defining the linkages between landscape change, disease ecology and human health is essential to explain and predict the emergence of Plasmodium knowlesi malaria, a zoonotic parasite residing in Southeast Asian macaques, and transmitted by species of Anopheles mosquitos. Changing patterns of land use throughout Southeast Asia, particularly deforestation, are suggested to be the primary drivers behind the recent spread of this zoonotic parasite in humans. Local ecological changes at the landscape scale appear to be increasing the risk of disease in humans by altering the dynamics of transmission between the parasite and its primary hosts. This paper will focus on the emergence of P. knowlesi in humans in Malaysian Borneo and the ecological linkage mechanisms suggested to be playing an important role.

Objective Studies of loud noise exposure and vestibular schwannomas (VS) have shown conflicting results. The population-based INTERPHONE case‒control study was conducted in 13 countries during 2000-2004. In this paper, we report the results of analyses on the association between VS and self-reported loud noise exposure. Methods Self-reported noise exposure was analyzed in 1024 VS cases and 1984 matched controls. Life-long noise exposure was estimated through detailed questions. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using adjusted conditional logistic regression for matched sets. Results The OR for total work and leisure noise exposure was 1.6 (95% CI 1.4-1.9). OR were 1.5 (95% CI 1.3-1.9) for only occupational noise, 1.9 (95% CI 1.4-2.6) for only leisure noise and 1.7 (95% CI 1.2-2.2) for exposure in both contexts. OR increased slightly with increasing lag-time. For occupational exposures, duration, time since exposure start and a metric combining lifetime duration and weekly exposure showed significant trends of increasing risk with increasing exposure. OR did not differ markedly by source or other characteristics of noise. Conclusion The consistent associations seen are likely to reflect either recall bias or a causal association, or potentially indicate a mixture of both.

Aim: This study sought to identify clinical, demographic and service-related factors associated with psychological distress amongst outpatient chemotherapy patients., Background: Distress in cancer patients leads to increased risk of psychological comorbidity, contributing to sub-optimal treatment adherence and potentially leading to poorer health outcomes. Screening and recognition of distress and risk factors is an important aspect of holistic care within a multidisciplinary team environment., Methods: Data were obtained via survey and chart review of ambulatory chemotherapy patients at three public tertiary referral hospitals in Perth, Western Australia. The DASS-21 was used to screen for psychological distress. Regression analyses were used to assess the relationship between distress and a range of cancer, socioeconomic and treatment factors., Results: Patients with a Karnofsky Performance Score≤80 (OR 3.8, 95% CI [1.7, 78.7]) and average waiting time (between oncology outpatient appointment and commencement of chemotherapy infusion) >60min (OR 2.4, 95% CI [1.04, 5.5]) were at increased risk of moderate-severe distress. Patients with a household income between $AU 50-75,000 p.a. had a lower risk of distress compared to <$25,000 p.a. (OR 0.05, 95% CI [0.01, 0.52]). On sub-scale analysis, depression and anxiety contributed more to overall distress than the stress subscales., Conclusions: Performance status, waiting times and household income were key predictors of distress. Findings could assist clinicians to identify higher-risk population subsets that could benefit from targeted screening and additional psychological and social work support. Findings could also assist administrators to consider the contribution of modifiable factors such as waiting times to patient distress., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Spring water therapies have been used since at least 1550 BC. Despite the growing body of evidence supporting these therapies for a range of conditions, including musculoskeletal, dermatological, respiratory and cardiovascular conditions, they do not currently form part of mainstream healthcare in many countries. The protocol established in this paper aims to support systematic reviews that examine the health outcomes associated with human exposure to regional spring waters, using the Australia and New Zealand context as a case study., Methods/design: The protocol searches for studies in eight health/medical databases, searches three local health/medical journals, and includes forwards and backwards searching. Standard systematic review methods are used including: specifying pre-determined inclusion criteria and data management plans, appraising the studies for bias, and allocation to a hierarchy of evidence., Discussion: The protocol supports a review and comprehensive synthesis of the current evidence regarding the health effects of natural spring water, and can be adapted for reviews in other regions. From this evidence, recommendations regarding practice and future research can be made on the therapeutic role of spring water.

Our hypothesis is that symptoms of high altitude syndromes are detectable even at intermediate altitudes, as commonly encountered under Australian conditions (<2500 m above sea level). High altitude medicine has long recognised several syndromes associated with rapid ascent to altitudes above 2500 m, including high altitude pulmonary oedema (HAPE), high altitude cerebral oedema (HACE) and high altitude flatus expulsion (HAFE). Symptoms of high altitude syndromes are of growing concern because of the global trend toward increasing numbers of tourists and workers exposed to both rapid ascent and sustained physical activity at high altitude. However, in Australia, high altitude medicine has almost no profile because of our relatively low altitudes by international standards. Three factors lead us to believe that altitude sickness in Australia deserves more serious consideration: Australia is subject to rapid growth in alpine recreational industries; altitude sickness is highly variable between individuals, and some people do experience symptoms already at 1500 m; and there is potential for an occupational health and safety issue amongst workers. To test this hypothesis we examined the relationship between any high altitude symptoms and a rapid ascent to an intermediate altitude (1800 m) by undertaking an intervention study in a cohort of eight medical clinic staff, conducted during July of the 2012 (Southern Hemisphere) ski season, using self-reporting questionnaires, at Mansfield (316 m above sea level) and at the Ski Resort of Mt Buller (1800 m), Victoria, Australia. The intervention consisted of ascent by car from Mansfield to Mt Buller (approx. 40 min drive). Participants completed a self-reporting questionnaire including demographic data and information on frequency of normal homeostatic processes (fluid intake and output, food intake and output, symptoms including thirst and headaches, and frequency of passing wind or urine). Data were recorded in hourly periods extending over 18 h before and 18 h after ascent. We found that the frequency of flatus production more than doubled following ascent, with a post-ascent frequency of approximately 14 expulsions per person over the 18 h recording period (Rate Ratio 2.31, CI 1.33-3.99, p=0.003). The frequency and severity of headaches also increased following ascent. These results support the hypothesis that high altitude symptoms can be significant issues even at the relatively lower altitudes encountered in Australian alpine regions. Increased awareness amongst clinicians of this possibility could contribute to a reduction in the disease burden from high altitude syndromes at intermediate altitudes., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Fetal growth restriction has been inconsistently associated with maternal exposure to elevated levels of traffic-related air pollution., Objective: We investigated the relationship between an individualised measure of fetal growth and maternal exposure to a specific marker for traffic-related air pollution., Methods: We estimated maternal residential exposure to a marker for traffic-related air pollution (nitrogen dioxide, NO2) during pregnancy for 23,452 births using temporally adjusted land-use regression. Logistic regression was used to investigate associations with small for gestational age and sex (SGA) and fetal growth restriction, defined as proportion of optimal birth weight (POBW) below the 10th percentile. Sub-populations investigated were: women who spent most time at home, women who did not move house, women with respiratory or circulatory morbidity, women living in low/middle/high socio-economic areas, women who delivered before 37 weeks gestation, and women who delivered from 37 weeks gestation., Results: An IQR increase in traffic-related air pollution in the second trimester across all women was associated with an OR of 1.31 (95% CI 1.07 to 1.60) for fetal growth restriction. Effects on fetal growth restriction (low POBW) were highest among women who subsequently delivered before 37 weeks of gestation. Effects on SGA were highest among women who did not move house: OR 1.35 (95% CI 1.08 to 1.69)., Conclusions: Larger effect sizes were observed for low POBW than for SGA. Exposure to traffic-related air pollution in mid to late pregnancy was associated with risk of SGA and low POBW in this study.

Simulated lung fluids are solutions designed to mimic the composition of human interstitial lung fluid as closely as possible. Analysis of mineral dusts using such solutions has been used to evaluate the respiratory bioaccessibility of various elements for which solubility in the lungs is a primary determinant of reactivity. The objective of this study was to employ simulated lung fluid analysis to investigate the respiratory bioaccessibility of nickel in soils. Current occupational guidelines in Australia regulate nickel compounds in terms of water solubility, though this may not be an accurate estimation of the total nickel that will dissociate in the lungs. Surface soils were collected from the city of Kalgoorlie in Western Australia, the site of an operational nickel smelter and metal mining activities. The fraction of the samples less than 10 μm was extracted from the soil, and it was this sub-10-μm fraction that was found to hold most of the total nickel present in the soil. The fine fraction was analyzed using a simulated lung fluid (modified Gamble's solution) to isolate the nickel phases soluble in the lungs. In addition, a sequential extraction was employed to compare the bioaccessible fraction to those dissolved from different binding forms in the soil. In all samples, the simulated lung fluid extracted more nickel than the two weakest leaches of the sequential extraction combined, providing a more representative nickel bioaccessibility value than the current water leach method.

Previous studies have linked poor mental human health with environmental degradation, but none have assessed additional diseases that may co-exist with these mental disorders. In previous work, depression was found to be associated with a major form of environmental degradation; dryland salinity. However, little is known about diseases co-morbid with depression in this environmental setting. In rural Australia, dryland salinity is a major form of environmental degradation contributing widely to deterioration and non-viability of farmland. Using georeferenced health record data, Bayesian spatial methods were used to determine the relationship between dryland salinity and a range of human health outcomes. Initial modelling found an increased relative risk for asthma, suicide and ischaemic heart disease in relation to dryland salinity (adjusted for Indigenous and socio-economic status). However, in this follow-up study, a further evaluation of the role of co-morbidities in this population revealed that: (i) the presence of depression was consistently linked to residence in areas with high salinity and (ii) the association of asthma, suicide and heart disease with salinity was most likely attributable to the co-morbidity of the conditions with depression. Given the predicted increase in dryland salinity and the elevated relative risk of depression in impacted areas, the relative risk of the co-morbid conditions can be expected to increase in rural areas in the future, further adding to the burden of disease associated with environmental degradation.

Australia is currently experiencing a process of escalating ecosystem degradation. This landscape degradation is associated with many outcomes that may directly or indirectly impact on human health. This study used a Bayesian spatial method to examine the effects of environmental degradation (measured as dryland salinity) on the mental health of the resident rural population. An association was detected between dryland salinity and depression, indicating that environmental processes may be driving the degree of psychological ill-health in these populations.

Bushfire smoke contains an array of organic and inorganic compounds, including respirable and inspirable particles, aldehydes, and carbon monoxide. These compounds have been found to be a health hazard for firefighters in the United States. Despite the high frequency of bushfires in Australia, analyses of bushfire smoke components are scarce. As part of an occupational health study investigating the respiratory health effects of bushfire smoke in firefighters, air toxics sampling was undertaken in a smoke chamber and during prescribed burns. Levels of formaldehyde and acrolein were demonstrated at respectively 60% and 80% of the Short Term Exposure Limit in the smoke chamber. Carbon monoxide levels exceeded the peak limit of 400 ppm significantly. Although concentrations were lower during the prescribed burns, the study shows that Australian bushfire smoke contains air toxics of concern and provides justification for further research into the levels of air toxics measured at bushfires and the associated health impacts.

Background: By international standards, water supplies in Perth, Western Australia, contain high trihalomethane (THM) levels, particularly the brominated forms. Geographic variability in these levels provided an opportunity to examine cross-city spatial relationships between THM exposure and rates of birth defects (BDs)., Objectives: Our goal was to examine BD rates by exposure to THMs with a highly brominated fraction in metropolitan locations in Perth, Western Australia., Methods: We collected water samples from 47 separate locations and analyzed them for total and individual THM concentrations (micrograms per liter), including separation into brominated forms. We classified collection areas by total THM (TTHM) concentration: low (< 60 microg/L), medium (> 60 to < 130 microg/L), and high (> or = 130 microg/L). We also obtained deidentified registry-based data on total births and BDs (2000-2004 inclusive) from post codes corresponding to water sample collection sites and used binomial logistic regression to compare the frequency of BDs aggregately and separately for the TTHM exposure groups, adjusting for maternal age and socioeconomic status., Results: Total THMs ranged from 36 to 190 microg/L. A high proportion of the THMs were brominated (on average, 92%). Women living in high-TTHM areas showed an increased risk of any BD [odds ratio (OR) = 1.22; 95% confidence interval (CI), 1.01-1.48] and for the major category of any cardiovascular BD (OR = 1.62; 95% CI, 1.04-2.51), compared with women living in low-TTHM areas., Conclusions: Brominated forms constituted the significant fraction of THMs in all areas. Small but statistically significant increases in risks of BDs were associated with residence in areas with high THMs.

The causes of term pre labor rupture of membranes (term PROM) remain poorly defined. The authors conducted a record-based prevalence study to explore a possible relation between disinfection by-products in drinking water and term PROM in an Australian community with spatially variable trihalomethane and nitrate levels. A multilevel statistical model was used to examine the relation between factors operating at the levels of the individual, district, and water distribution zone and the prevalence of PROM at term among 16,229 women in Perth, Western Australia (2002-2004). Adjusted odds ratios for term PROM increased with increasing tertiles of nitrate exposure (moderate exposure: odds ratio = 1.23, 95% confidence interval: 1.03, 1.52; high exposure: odds ratio = 1.47, 95% confidence interval: 1.20, 1.79), but there was no significant relation with exposure to trihalomethanes. This study raises the possibility that water contaminants may promote the development of PROM at term.

The very rapid worldwide increase in mobile phone use in the last decade has generated considerable interest in the possible health effects of exposure to radio frequency (RF) fields. A multinational case-control study, INTERPHONE, was set-up to investigate whether mobile phone use increases the risk of cancer and, more specifically, whether the RF fields emitted by mobile phones are carcinogenic. The study focused on tumours arising in the tissues most exposed to RF fields from mobile phones: glioma, meningioma, acoustic neurinoma and parotid gland tumours. In addition to a detailed history of mobile phone use, information was collected on a number of known and potential risk factors for these tumours. The study was conducted in 13 countries. Australia, Canada, Denmark, Finland, France, Germany, Israel, Italy, Japan, New Zealand, Norway, Sweden, and the UK using a common core protocol. This paper describes the study design and methods and the main characteristics of the study population. INTERPHONE is the largest case-control study to date investigating risks related to mobile phone use and to other potential risk factors for the tumours of interest and includes 2,765 glioma, 2,425 meningioma, 1,121 acoustic neurinoma, 109 malignant parotid gland tumour cases and 7,658 controls. Particular attention was paid to estimating the amount and direction of potential recall and participation biases and their impact on the study results.

Human health often depends on environmental variables and is generally subject to widespread and comprehensive surveillance. Compared with other available measures of ecosystem health, human disease incidence may be one of the most useful and practical bioindicators for the often elusive gauge of ecologic well-being. We argue that many subtle ecosystem disruptions are often identified only as a result of detailed epidemiologic investigations after an anomalous increase in human disease incidence detected by routine surveillance mechanisms. Incidence rates for vector-mediated diseases (e.g., arboviral illnesses) and direct zoonoses (e.g., hantaviruses) are particularly appropriate as bioindicators to identify underlying ecosystem disturbances. Outbreak data not only have the potential to act as a pivotal warning system for ecosystem disruption, but may also be used to identify interventions for the preservation of ecologic health. With this approach, appropriate ecologically based strategies for remediation can be introduced at an earlier stage than would be possible based solely on environmental monitoring, thereby reducing the level of "ecosystem distress" as well as resultant disease burden in humans. This concept is discussed using local, regional, and global examples, thereby introducing the concept of multilevel ecosystem interventions. Key words: bioindicators, disease control, disease outbreaks, ecologic management, ecosystem health, surveillance.

Aim: The objective of this study was to determine whether incidence rates of head and neck malignancies in New Zealand have varied since the introduction of cellular telephones in 1987. In particular, we sought to compare trends in tumour rates in anatomical sites that receive high, medium and low levels of cellular telephone radiation (based on dosimetry data)., Methods: We investigated whether trends in tumour incidence rates in New Zealand have varied since the introduction of cellular telephones in 1987. The exposure measure used was the proportion of cellular telephone subscribers within the national population, calculated using the number of subscribers over the study period., Results: The graphs for high, medium and low exposure sites did not display any significant changes in trend patterns for either gender over the years 1986 to 1998., Conclusions: Incidence rates for malignancies arising in the head and neck, including those sites that hypothetically receive the highest levels of radio frequency radiation during cellular telephone use, have not changed materially since the introduction of cellular telephones to New Zealand. However, ecological studies of this nature are limited in many ways and a stronger study design is clearly needed to establish more exactly any elevation in risk.