Arsenic in groundwater: a threat to sustainable agriculture in South and South-east Asia.

The problem of arsenic pollution of groundwater used for domestic water supplies is now well recognised in Bangladesh, India and some other countries of South and South-east Asia. However, it has recently become apparent that arsenic-polluted water used for irrigation is adding sufficient arsenic to soils and rice to pose serious threats to sustainable agricultural production in those countries and to the health and livelihoods of affected people. This paper reviews the nature of those threats, taking into account the natural sources of arsenic pollution, areas affected, factors influencing arsenic uptake by soils and plants, toxicity levels and the dietary risk to people consuming arsenic-contaminated rice.

Using national health policies to improve access to palliative care medications in the community.

Access to affordable priority palliative care medicines needs to be informed by good clinical data from well-conducted clinical trials designed to address efficacy, cost-effectiveness, and safety. Availability of priority palliative care symptom control medicines improves the provision of palliation in the place of patient's choice including the community. Within Australia, a National Medicines Policy and a Palliative Care Strategy endorsed by Federal and State and Territory health ministers have facilitated a process to improve the evidence for palliative clinical practice and, through this, improve community availability of key medications for people at the end of life. The initiative, coordinated by a working party under government auspices, has brought together medicine regulators, the pharmaceutical industry, government, policy makers, and clinicians. The brief was to improve availability of key palliative care medications within the current national drug regulatory and funding frameworks. The results to date include: a palliative care section within the Pharmaceutical Benefits Scheme generating the first ever patient-defined section; medicines not previously listed now available; commitment of AU$9.46 M for a national multisite collaborative clinical study network to improve the evidence for clinical interventions in the palliative care setting through systematic investigation with rigorous Phase III and IV studies to inform registration and subsidy applications; and establishing a national Communication Network of the Palliative Care Medications Working Group for the health workforce and community to improve the quality use where improved access has been achieved.

Medically assisted nutrition for palliative care in adult patients.

BACKGROUND: Many palliative care patients have a reduced oral intake during their illness. The management of this can include the provision of medically assisted nutrition with the aim of prolonging the length of life of a patient, improving their quality of life, or both. OBJECTIVES: To determine the effect of medically assisted nutrition on the quality and length of life of palliative care patients. SEARCH STRATEGY: Studies were identified from searching The Cochrane Library, MEDLINE (1966 to 2008), EMBASE (1980 to 2008), CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible trials, key textbooks, and previous systematic reviews. The date of the latest search was July 2008. SELECTION CRITERIA: All relevant randomised controlled trials (RCTs) or prospective controlled trials (if no RCTs were found). DATA COLLECTION AND ANALYSIS: There were no RCTs or prospectively controlled trials found that met the inclusion criteria. MAIN RESULTS: There were four prospective non-controlled trials (including one qualitative study) that studied medically assisted nutrition in palliative care participants, and one Cochrane systematic review (on Motor Neurone disease), but no RCTs or prospective controlled studies. AUTHORS' CONCLUSIONS: There are insufficient good quality trials to make any recommendations for practice with regards to the use of medically assisted nutrition in palliative care patients.

Survey of bereavement support provided by Australian palliative care services.

OBJECTIVE: To determine the prevalence, staffing, methods, timing and allocation of bereavement programs in Australian palliative care services. DESIGN: Questionnaire-based postal survey. SETTING AND PARTICIPANTS: The questionnaire was mailed in January 2007 to all 324 palliative care centres identified from the Australian Palliative care national directory 2004. RESULTS: 236 of the 324 centres responded (73%), and 95% of these undertook bereavement follow-up, with similar prevalence in metropolitan and regional areas. Staff from a range of disciplines were involved in coordinating and delivering these services, with nurses taking on these roles in most regional centres. Common types of bereavement follow-up included individual sessions and visits, telephone contact, letters, anniversary cards and memorial services. Most centres (74%) approached the bereaved within 2 weeks of the death, and 83% of centres offered bereavement support to families or "significant others" of all patients who died under their care. Some form of risk assessment for complicated grief was performed by 69% of participating centres. CONCLUSION: Bereavement care is an integral part of Australian palliative care services. Given the multidisciplinary staffing demonstrated, it is important that those coordinating and delivering these programs are adequately trained and supported. There is a need for further research to guide the development of bereavement support practice.

Effect of tubing on loss of clonazepam administered by continuous subcutaneous infusion.

Previous studies have reported loss of clonazepam from solutions administered intravenously from plastic infusion bags and administration sets. In palliative care, clonazepam is sometimes administered through syringe drivers using polyvinyl chloride (PVC) infusion tubing. No data currently exist to show whether use of PVC tubing affects the amount of clonazepam actually received by the patient. This study compared the use of two different types of PVC tubing with a non-PVC tubing. Solutions containing clonazepam or clonazepam and morphine were prepared with either normal saline or water for injection as diluent. Concentrations of morphine and clonazepam were determined using high-performance liquid chromatography. Significant loss of clonazepam (up to 50%) was observed in all solutions infused through PVC tubing. Solutions infused through non-PVC tubing retained greater than 90% of the initial concentration of clonazepam. It is recommended that when administering clonazepam using a syringe driver, non-PVC tubing be used.

What are the essential medications in pallative care? - a survey of Australian palliative care doctors.

BACKGROUND: There is a disparity of availability and cost of drugs in the community for palliative care patients through the Pharmaceutical Benefits Scheme (PBS) compared to those available to inpatients in public hospitals. METHODS: The Joint Therapeutics Committee of the Australian and New Zealand Society of Palliative Medicine, Palliative Care Australia and the Clinical Oncological Society of Australia surveyed palliative care practitioners in Australia to compile a list of drugs they considered essential. RESULTS: Drugs nominated generally had good levels of evidence for use in palliative care, although many practitioners still used some without evidence of benefit. DISCUSSION: We are now working with the Commonwealth Department of Health and Ageing to agree on a list of drugs for specific palliative care indications. As a result, the first ever section in the PBS for a specific patient population has been created. There is a need for high quality studies in palliative care to determine the best drugs to add to the list.

Cancer patients' attitudes toward euthanasia and physician-assisted suicide: the influence of question wording and patients' own definitions on responses.

OBJECTIVES: The aims of this study were to: (1) investigate patients' views on euthanasia and physician-assisted suicide (PAS), and (2) examine the impact of question wording and patients' own definitions on their responses. DESIGN: Cross-sectional survey of consecutive patients with cancer. SETTING: Newcastle (Australia) Mater Hospital Outpatients Clinic. PARTICIPANTS: Patients over 18 years of age, attending the clinic for follow-up consultation or treatment by a medical oncologist, radiation oncologist or haematologist. MAIN OUTCOME MEASURES: Face-to-face patient interviews were conducted examining attitudes to euthanasia and PAS. RESULTS: 236 patients with cancer (24% participation rate; 87% consent rate) were interviewed. Though the majority of participants supported the idea of euthanasia, patient views varied significantly according to question wording and their own understanding of the definition of euthanasia. CONCLUSIONS: Researchers need to be circumspect about framing and interpreting questions about support of 'euthanasia', as the term can mean different things to different people, and response may depend upon the specifics of the question asked.

The compatibility and stability of midazolam and dexamethasone in infusion solutions.

The delivery of subcutaneous medication by continuous infusion is common in palliative medicine. Many centers combine multiple medications, but the analytical confirmation of the compatibility and stability of these combinations has rarely been performed. This study examined the compatibility and stability of midazolam and dexamethasone using high performance liquid chromatography. Nine different solutions were prepared in polypropylene syringes by combining these two drugs with 0.9% sodium chloride. When these two drugs were combined in a syringe, there was significant loss of midazolam over 48 hours, with only 60-80% of the initial concentration remaining in syringes stored at 35-39 degrees C. This study demonstrates that cloudiness of a solution is not the only predictor of drug loss and that drug loss may occur even in solutions that remain clear at time of preparation. The clinical implications of these results are that dexamethasone and midazolam should not be combined in syringe driver solutions.

Survival after enrollment in an Australian palliative care program.

Palliative care services aim to achieve the best quality of life for patients by controlling pain and other physical symptoms and attending to their psychospiritual needs. There have been many studies across different countries looking at timing of referral to palliative care services. Almost universally, timing of referral to palliative care is 'late' in the course of the patients' illness. This study looked at survival of patients after enrollment in an Australian integrated palliative care service that consists of inpatient beds (hospice), community care and consultation services. We analyzed the survival of 1138 patients enrolled over a 30-month period. The mean age was 70.1 years and 55% of the patients were male. The most common cancers were lung (19.1%), colorectal (13.4%) and prostate (5.8%), with nonmalignant disease accounting for 5.6% of all patients. The median length of survival was 54 days, with 9.3% of the patients dying within 7 days and 16.96% of patients living longer than six months. Perhaps more importantly than median survival is the time spent on a palliative care program in the overall context of diagnosis till death. The median percentage of time since diagnosis spent on the program was 17%. Timing of referral should be dependent on the need for intervention for physical or psychological symptoms. This can be meaningful whether the number of days till death is small or large.