Novel fluorinated surfactants tentatively identified in firefighters using liquid chromatography quadrupole time-of-flight tandem mass spectrometry and a case-control approach

Fluorinated surfactant-based aqueous film-forming foams (AFFFs) are made up of per- and polyfluorinated alkyl substances (PFAS) and are used to extinguish fires involving highly flammable liquids. The use of perfluorooctanesulfonic acid (PFOS) and other perfluoroalkyl acids (PFAAs) in some AFFF formulations has been linked to substantial environmental contamination. Recent studies have identified a large number of novel and infrequently reported fluorinated surfactants in different AFFF formulations. In this study, a strategy based on a case-control approach using quadrupole time-of-flight tandem mass spectrometry (QTOF-MS/MS) and advanced statistical methods has been used to extract and identify known and unknown PFAS in human serum associated with AFFF-exposed firefighters. Two target sulfonic acids [PFOS and perfluorohexanesulfonic acid (PFHxS)], three non-target acids [perfluoropentanesulfonic acid (PFPeS), perfluoroheptanesulfonic acid (PFHpS), and perfluorononanesulfonic acid (PFNS)], and four unknown sulfonic acids (Cl-PFOS, ketone-PFOS, ether-PFHxS, and Cl-PFHxS) were exclusively or significantly more frequently detected at higher levels in firefighters compared to controls. The application of this strategy has allowed for identification of previously unreported fluorinated chemicals in a timely and cost-efficient way.

Mandatory reporting of health professionals: the case for a Western Australian style exemption for all Australian practitioners

This article discusses the current mandatory reporting obligations for health practitioners in Australia under the Health Practitioner Regulation National Law. It provides a summary of the mandatory notification legislation, and contextualises the introduction of this law. The details of the Western Australian exemption, under which a treating doctor is exempt from mandatory reporting of a doctor-patient, and the rationale for its introduction are examined. This is followed by a consideration of the potential impact of the mandatory reporting obligations. The authors argue that the Western Australian exemption has merit and should be considered for adoption throughout Australia.

Caring for refugees in general practice: perspectives from the coalface

This qualitative research project explored the experiences of primary health care providers working with newly arrived refugees in Brisbane. Data from 36 participants (20 general practitioners, five practice nurses and 11 administrative staff) involved in five focus groups and four semi-structured interviews were analysed. The results indicated that despite difficulties, providers are committed and enthusiastic about working with refugees. The flexibility of the general practice setting enables innovative approaches. The establishment of a specialised refugee health service in Brisbane has improved providers’ capacity to deliver refugee health care. However, most practices continue to feel isolated as they search for solutions, and the need for greater supports and a more coordinated approach to care were emphasised. The themes of communication, knowledge and practice and health care systems encapsulated the factors that influence health care providers’ ability to care for refugees and provide a framework for improving available supports. Australian primary health care is currently undergoing great change, which provides an opportunity to make significant gains in the provision of care for refugees and other minority groups within our community. As health care reforms are implemented it is essential that they are responsive to the expressed needs of health care providers working in these areas.

A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination

INTRODUCTION

Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care.

METHODS

A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service - Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included.

RESULTS

Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters.

CONCLUSION

The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.

Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study

BACKGROUND

Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories.

METHODS

In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees (n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011.

RESULTS

16.5% of participants had Vitamin B12 deficiency (<150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%.

CONCLUSION

Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes, treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities.

Developing a framework for understanding doctors' health access: a qualitative study of Australian GPs

Health access behaviours of doctors need to be understood if the profession is to adequately respond to concerns raised about doctors' health. There has been limited investigation of these issues and most qualitative studies have focussed on doctors who have been seriously unwell. This research project was designed to explore doctors' attitudes to health access and the barriers they experience using six independently facilitated focus groups (37 general practitioners) in Brisbane, Australia. Themes that emerged using inductive thematic analysis were grouped into three key categories. The findings challenge current representations of doctors' health within the medical literature. Doctors in this study reported positive attitudes towards their own health care. Health access, however, was difficult because of the barriers they encountered. These barriers are described in detail revealing the rationale used by doctors seeking care. A framework of patient, provider and profession barrier domains is developed to enable a comparison between the health access barriers of the doctor and those experienced by the general community. The complexity is highlighted as the socio-cultural factors woven through these barrier domains are recognised. The potential for this framework to provide a structure for future interventions to enhance doctors' health access is discussed.

Invisible populations: parallels between the health of people with intellectual disability and people of a refugee background

When considering the delivery of primary health care in the community, some populations remain virtually invisible. While people with intellectual disability might seem to share few characteristics with refugees and humanitarian entrants, there are a number of difficulties that both groups share when accessing and receiving primary health care. Commonalities include communication barriers, difficulties accessing past medical records and the complexity of health needs that confront the practitioner providing health care. These issues and additional systemic barriers that prevent the delivery of optimal health care to both groups are explored. Integrated multidisciplinary care is often required for the delivery of best practice care; however, such care can be difficult for each group to access. In May 2010, the specific Medicare Health Assessment Item numbers for both of these groups were incorporated into a group of more generic Item numbers. This has resulted in a lost opportunity to enhance the evidence surrounding health care delivery to these vulnerable populations. This paper recognises the importance of health policy in leading affirmative action to ensure these populations become visible in the implementation of the National Primary Health Care Strategy.

What doctors want? A consultation method when the patient is a doctor

Doctors face many barriers accessing health care. Even after a doctor has adopted the patient role, quality health care can remain elusive. This study investigated the consultation between the treating doctor and the doctor-patient. We aimed to determine what doctors want within the consultation, their preferred consultation method. This qualitative study involved 37 GPs who participated in one of six independently facilitated focus groups. Data were recorded, transcribed and analysed for recurrent themes using an iterative inductive framework. Participants emphasised the importance of, and the difficulty in, establishing a relationship with a GP. This involved determining who to see and when to go to the doctor. Specific ways of strengthening the doctor-patient relationship were discussed, including understanding the illness experience, acknowledging the whole patient, setting boundaries, providing holistic care, developing rapport and participating in shared decision making. Empathy was especially important. Analysis revealed strong similarities with the 'patient-centred consultation method'. Understanding the preferred consultation method for doctors will assist doctors in providing quality care to their peers. This is an important step in enhancing health access for doctors. Doctors want what patients want: care delivered within a patient-centred consultation. These insights may help other health professionals when treating or receiving care from their colleagues.

Neurobehavioral abnormalities in first-degree relatives of individuals with autism

CONTEXT

Studying sensorimotor and neurocognitive impairments in unaffected family members of individuals with autism may help identify familial pathophysiological mechanisms associated with the disorder.

OBJECTIVE

To determine whether atypical sensorimotor or neurocognitive characteristics associated with autism are present in first-degree relatives of individuals with autism.

DESIGN

Case-control comparison of neurobehavioral functions.

SETTING

University medical center.

PARTICIPANTS

Fifty-seven first-degree relatives of individuals with autism and 40 age-, sex-, and IQ-matched healthy control participants (aged 8-54 years).

MAIN OUTCOME MEASURES

Oculomotor tests of sensorimotor responses (saccades and smooth pursuit); procedural learning and response inhibition; neuropsychological tests of motor, memory, and executive functions; and psychological measures of social behavior, communication skills, and obsessive-compulsive behaviors.

RESULTS

On eye movement testing, family members demonstrated saccadic hypometria, reduced steady-state pursuit gain, and a higher rate of voluntary response inhibition errors relative to controls. They also showed lateralized deficits in procedural learning and open-loop pursuit gain (initial 100 milliseconds of pursuit) and increased variability in the accuracy of large-amplitude saccades that were confined to rightward movements. In neuropsychological studies, only executive functions were impaired relative to those of controls. Family members reported more communication abnormalities and obsessive-compulsive behaviors than controls. Deficits across oculomotor, neuropsychological, and psychological domains were relatively independent from one another.

CONCLUSIONS

Family members of individuals with autism demonstrate oculomotor abnormalities implicating pontocerebellar and frontostriatal circuits and left-lateralized alterations of frontotemporal circuitry and striatum. The left-lateralized alterations have not been identified in other neuropsychiatric disorders and are of interest given atypical brain lateralization and language development associated with the disorder. Similar oculomotor deficits have been reported in individuals with autism, suggesting that they may be familial and useful for studies of neurophysiological and genetic mechanisms in autism.

Refugee health: a new model for delivering primary health care

Providing health care to newly arrived refugees within the primary health care system has proved challenging. The primary health care sector needs enhanced capacity to provide quality health care for this population. The Primary Care Amplification Model has demonstrated its capacity to deliver effective health care to patients with chronic disease such as diabetes. This paper describes the adaption of the model to enhance the delivery of health care to the refugee community. A ‘beacon’ practice with an expanded clinical capacity to deliver health care for refugees has been established. Partnerships link this practice with existing local general practices and community services. Governance involves collaboration between clinical leadership and relevant government and non-government organisations including local refugee communities. Integration with tertiary and community health sectors is facilitated and continuing education of health care providers is an important focus. Early incorporation of research in this model ensures effective feedback to inform providers of current health needs. Although implementation is currently in its formative phase, the Primary Care Amplification Model offers a flexible, yet robust framework to facilitate the delivery of quality health care to refugee patients.

Impaired inhibitory control is associated with higher-order repetitive behaviors in autism spectrum disorders

BACKGROUND

Impairments in executive cognitive control, including a reduced ability to inhibit prepotent responses, have been reported in autism spectrum disorders (ASD). These deficits may underlie patterns of repetitive behaviors associated with the disorder.

METHOD

Eighteen individuals with ASD and 15 age- and IQ-matched healthy individuals performed an antisaccade task and a visually guided saccade control task, each with gap and overlap conditions. Measures of repetitive behaviors were obtained using the Autism Diagnostic Inventory-Revised (ADI-R) and examined in relation to neurocognitive task performance.

RESULTS

Individuals with an ASD showed increased rates of prosaccade errors (failures to inhibit prepotent responses) on the antisaccade task regardless of task condition (gap/overlap). Prosaccade error rates were associated with the level of higher-order (e.g. compulsions, preoccupations) but not sensorimotor repetitive behaviors in ASD.

CONCLUSIONS

Neurocognitive disturbances in voluntary behavioral control suggest that alterations in frontostriatal systems contribute to higher-order repetitive behaviors in ASD.

Endoscopic deployment of the wireless capsule using a capsule delivery device in pediatric patients: a case series

The aim of this study was to review the use of the AdvanCE capsule endoscopy delivery device (US Endoscopy, Mentor, Ohio, USA) in pediatric patients who are too young to safely follow the wireless capsule swallowing instructions. Nine patients (mean age 6.6 years; SD +/- 1.8 years) underwent capsule deployment. Indications for the procedure were the evaluation of suspected inflammatory bowel disease in eight patients and evaluation of protein-losing enteropathy in one patient. The capsule was successfully deployed in the first part of the duodenum in seven patients and in the pyloric canal in one patient. In another patient the capsule was deployed in the gastric antrum and required endoscopic retrieval due to abdominal pain and failure of the capsule to traverse the pylorus. The wireless capsule successfully passed in the remaining eight patients without any complications. The AdvanCE capsule endoscopy delivery device appears to be a safe and technically easy method of wireless capsule delivery in pediatric patients. Capsule deployment should be in the duodenum whenever possible. Further studies of the use of this device in pediatric patients are warranted.

Emergency brake response time after first metatarsal osteotomy

BACKGROUND

There is sparse information upon which to recommend a return to activity after foot surgery. The purpose of this study was to determine whether six weeks is sufficient time for the emergency brake response time to return to preoperative levels after a first metatarsal osteotomy for symptomatic hallux valgus.

METHODS

We conducted a prospective, observational study to assess the effect of surgery on emergency brake response time in a group of twenty-eight patients undergoing a unilateral first metatarsal osteotomy on the right side for symptomatic hallux valgus. A custom-made driving simulator was used to assess total brake response time, reaction time, and brake time. Patients were assessed preoperatively and at two and six weeks postoperatively. A control group of twenty-eight individuals matched for age, driving status, and sex was included for baseline comparison.

RESULTS

Total brake response time, reaction time, and brake time were significantly lower for the control cohort compared with the preoperative values recorded in the study cohort (p < 0.05). Only seven of the twenty-eight study patients were able to complete the assessment at two weeks; the remainder were not able to complete it because of postoperative pain. All patients were able to comfortably complete the study at six weeks. In the study cohort, the total brake response time, reaction time, and brake time had significantly improved compared with preoperative recordings (p < 0.05).

CONCLUSIONS

By six weeks after surgery, emergency braking time in patients undergoing a first metatarsal osteotomy is similar to that of healthy individuals.