Wood heater smoke and mortality in the Australian Capital Territory: a rapid health impact assessment.

OBJECTIVES: To estimate the number of deaths and the cost of deaths attributable to wood heater smoke in the Australian Capital Territory. STUDY DESIGN: Rapid health impact assessment, based on fine particulate matter (PM2.5 ) data from three outdoor air pollution monitors and published exposure-response functions for natural cause mortality attributed to PM2.5 exposure. SETTING: Australian Capital Territory (population, 2021: 454 000), 2016-2018, 2021, and 2022 (2019 and 2020 excluded because of the impact of extreme bushfires on air quality). MAIN OUTCOME MEASURES: Proportion of PM2.5 exposure attributable to wood heaters; numbers of deaths and associated cost of deaths (based on the value of statistical life: $5.3 million) attributable to wood heater smoke. RESULTS: Wood heater emissions contributed an estimated 1.16-1.73 µg/m3 to the annual mean PM2.5 concentration during the three colder years (2017, 2018, 2021), or 17-25% of annual mean exposure, and 0.72 µg/m3 (15%) or 0.89 µg/m3 (13%) during the two milder years (2016, 2022). Using the most conservative exposure-response function, the estimated annual number of deaths attributable to wood heater smoke was 17-26 during the colder three years and 11-15 deaths during the milder two years. Using the least conservative exposure-response function, an estimated 43-63 deaths per year (colder years) and 26-36 deaths per year (milder years) were attributable to wood heater smoke. The estimated annual equivalent cost of deaths was $57-136 million (most conservative exposure-response function) and $140-333 million (least conservative exposure-response function). CONCLUSIONS: The estimated annual number of deaths in the ACT attributable to wood heater PM2.5 pollution is similar to that attributed to the extreme smoke of the 2019-20 Black Summer bushfires. The number of wood heaters should be reduced by banning new installations and phasing out existing units in urban and suburban areas.

The effects on mortality and the associated financial costs of wood heater pollution in a regional Australian city.

OBJECTIVES: To estimate the annual burden of mortality and the associated health costs attributable to air pollution from wood heaters in Armidale. DESIGN: Health impact assessment (excess annual mortality and financial costs) based upon atmospheric PM2.5 measurements. SETTING: Armidale, a regional Australian city (population, 24 504) with high levels of air pollution in winter caused by domestic wood heaters, 1 May 2018 - 30 April 2019. MAIN OUTCOME MEASURES: Estimated population exposure to PM2.5 from wood heaters; estimated numbers of premature deaths and years of life lost. RESULTS: Fourteen premature deaths (95% CI, 12-17 deaths) per year, corresponding to 210 (95% CI, 172-249) years of life lost, are attributable to long term exposure to wood heater PM2.5 pollution in Armidale. The estimated financial cost is $32.8 million (95% CI, $27.0-38.5 million), or $10 930 (95% CI, $9004-12 822) per wood heater per year. CONCLUSIONS: The substantial mortality and financial cost attributable to wood heating in Armidale indicates that effective policies are needed to reduce wood heater pollution, including public education about the effects of wood smoke on health, subsidies that encourage residents to switch to less polluting home heating (perhaps as part of an economic recovery package), assistance for those affected by wood smoke from other people, and regulations that reduce wood heater use (eg, by not permitting new wood heaters and requiring existing units to be removed when houses are sold).

Five Years of Accurate PM2.5 Measurements Demonstrate the Value of Low-Cost PurpleAir Monitors in Areas Affected by Woodsmoke.

Low-cost optical sensors are used in many countries to monitor fine particulate (PM2.5) air pollution, especially in cities and towns with large spatial and temporal variation due to woodsmoke pollution. Previous peer-reviewed research derived calibration equations for PurpleAir (PA) sensors by co-locating PA units at a government regulatory air pollution monitoring site in Armidale, NSW, Australia, a town where woodsmoke is the main source of PM2.5 pollution. The calibrations enabled the PA sensors to provide accurate estimates of PM2.5 that were almost identical to those from the NSW Government reference equipment and allowed the high levels of wintertime PM2.5 pollution and the substantial spatial and temporal variation from wood heaters to be quantified, as well as the estimated costs of premature mortality exceeding $10,000 per wood heater per year. This follow-up study evaluates eight PA sensors co-located at the same government site to check their accuracy over the following four years, using either the original calibrations, the default woodsmoke equation on the PA website for uncalibrated sensors, or the ALT-34 conversion equation (see text). Minimal calibration drift was observed, with year-round correlations, r = 0.98 ± 0.01, and root mean square error (RMSE) = 2.0 µg/m3 for daily average PA PM2.5 vs. reference equipment. The utitilty of the PA sensors without prior calibration at locations affected by woodsmoke was also demonstrated by the year-round correlations of 0.94 and low RMSE between PA (woodsmoke and ALT-34 conversions) and reference PM2.5 at the NSW Government monitoring sites in Orange and Gunnedah. To ensure the reliability of the PA data, basic quality checks are recommended, including the agreement of the two laser sensors in each PA unit and removing any transient spikes affecting only one sensor. In Armidale, from 2019 to 2022, the continuing high spatial variation in the PM2.5 levels observed during the colder months was many times higher than any discrepancies between the PA and reference measurements. Particularly unhealthy PM2.5 levels were noted in southern and eastern central Armidale. The measurements inside two older weatherboard houses in Armidale showed that high outdoor pollution resulted in high pollution inside the houses within 1-2 h. Daily average PM2.5 concentrations available on the PA website allow air pollution at different sites across regions (and countries) to be compared. Such comparisons revealed major elevations in PA PM2.5 at Gunnedah, Orange, Monash (Australian Capital Territory), and Christchurch (New Zealand) during the wood heating season. The data for Gunnedah and Muswellbrook suggest a slight underestimation of PM2.5 at other times of the year when there are proportionately more dust and other larger particles. A network of appropriately calibrated PA sensors can provide valuable information on the spatial and temporal variation in the air pollution that can be used to identify pollution hotspots, improve estimates of population exposure and health costs, and inform public policy.

Bicycle helmet wearing is associated with closer overtaking by drivers: A response to Olivier and Walter, 2013.

There is a body of research on how driver behaviour might change in response to bicyclists' appearance. In 2007, Walker published a study suggesting motorists drove closer on average when passing a bicyclist if the rider wore a helmet, potentially increasing the risk of a collision. Olivier and Walter re-analysed the same data in 2013 and claimed helmet wearing was not associated with close vehicle passing. Here we show how Olivier and Walter's analysis addressed a subtly, but importantly, different question than Walker's. Their conclusion was based on omitting information about variability in driver behaviour and instead dividing overtakes into two binary categories of 'close' and 'not close'; we demonstrate that they did not justify or address the implications of this choice, did not have sufficient statistical power for their approach, and moreover show that slightly adjusting their definition of 'close' would reverse their conclusions. We then present a new analysis of the original dataset, measuring directly the extent to which drivers changed their behaviour in response to helmet wearing. This analysis confirms that drivers did, overall, get closer when the rider wore a helmet. The distribution of overtaking events shifted just over one-fifth of a standard deviation closer to the rider - a potentially important behaviour if, as theoretical frameworks suggest, near-misses and collisions lie on a continuum. The paper ends by considering wider issues surrounding this topic and suggests public health research might be best served by shifting focus to risk elimination rather than harm mitigation.

Safety in numbers in Australia: more walkers and bicyclists, safer walking and bicycling.

ISSUE ADDRESSED: Overseas research shows that fatality and injury risks per cyclist and pedestrian are lower when there are more cyclists and pedestrians. Do Australian data follow the same exponential 'growth rule' where (Injuries)/(Amount of cycling) is proportional to ((Amount of cycling)-0.6)? METHOD: Fatality and injury risks were compared using three datasets: 1) fatalities and amounts of cycling in Australian States in the 1980s; 2) fatality and injury rates over time in Western Australia as cycling levels increased; and 3) deaths, serious head injuries and other serious injuries to cyclists and pedestrians in Victoria, before and after the fall in cycling with the helmet law. RESULTS: In Australia, the risks of fatality and injury per cyclist are lower when cycling is more prevalent. Cycling was safest and most popular in the Australian Capital Territory (ACT), Queensland and Western Australia (WA). New South Wales residents cycled only 47% as much as residents of Queensland and WA, but had 53% more fatalities per kilometre, consistent with the growth rule prediction of 52% more for half as much cycling. Cycling also became safer in WA as more people cycled. Hospitalisation rates per 10,000 regular cyclists fell from 29 to 15, and reported deaths and serious injuries from 5.6 to 3.8 as numbers of regular cyclists increased. In Victoria, after the introduction of compulsory helmets, there was a 30% reduction in cycling and it was associated with a higher risk of death or serious injury per cyclist, outweighing any benefits of increased helmet wearing. CONCLUSIONS: As with overseas data, the exponential growth rule fits Australian data well. If cycling doubles, the risk per kilometre falls by about 34%; conversely, if cycling halves, the risk per kilometre will be about 52% higher. Policies that adversely influence the amount of cycling (for example, compulsory helmet legislation) should be reviewed.

Air pollution in Australia: review of costs, sources and potential solutions.

ISSUE ADDRESSED: Estimated health costs and principal sources of air pollution are reviewed, together with estimated costs of reducing pollution from major sources in Australia. METHOD: Emissions data from the Australian National Pollutant Inventory were compared with published estimates of pollution costs and converted to the cost per kilogram of emissions. Costs per kg of emissions (and, for the two main sources of pollution, diesel vehicles and wood heaters, costs per heater and per vehicle) are relatively easy to understand, making it easier to compare health costs with costs of pollution-control strategies. RESULTS: Estimated annual costs of morbidity/mortality exceed $1,100 per diesel vehicle and $2,000 per wood heater. Costs of avoiding emissions (about $2.1/kg PM2.5 for phasing out wood heaters and upwards of $70/kg for reducing diesel emissions) are considerably less than the estimated health costs ($166/kg) of those emissions. CONCLUSIONS: In other countries, smokeless zones (for domestic heating), heavy vehicle low-emission zones, and lower registration charges for low-emission vehicles reduce pollution and improve health. Similar 'polluter-pays' taxes in Australia to encourage retrofitting of existing diesels and incentives to choose new ones with lowest emissions would provide substantial benefits. Adopting Christchurch's policy of phasing out wood heaters and 'polluter-pays' levies to discourage their use would be extremely cost-effective.

Tumors with intrahepatic bile duct differentiation in cirrhosis: implications on outcomes after liver transplantation.

BACKGROUND: The role of liver transplantation (LT) in the management of cirrhotic patients with tumors exhibiting intrahepatic bile duct differentiation remains controversial. The objective of this study was to characterize the spectrum of these tumors and analyze post-LT outcomes. METHODS: Retrospective pathology database search of explant histology analysis of liver transplants between April 1993 and November 2013. RESULTS: Thirty-two patients were analyzed, 75% were men with a mean age of 60 years. Seven patients had nodules demonstrating intrahepatic cholangiocarcinoma (I-CCA), nine had I-CCA nodules occurring concomitantly with hepatocellular carcinoma (HCC), and 16 had mixed HCC-CCA nodules. The median number of tumors was 1 and size was 2.5 cm. Overall patient survival post-LT at 1 and 5 years was 71% and 57%, respectively. Patients within Milan criteria, especially with I-CCA features, showed a 5-year tumor recurrence rate (10%) and 5-year survival rate (78%) comparable with other patients having HCC within Milan criteria. CONCLUSION: This series showed that patients with CCA within Milan criteria may be able to achieve acceptable long-term post-LT survival.

Experiencias de padres de adultos con síndrome de Down

Las autoras de este artículo exponen de manera sencilla un conjunto de reflexiones basadas en un estudio que llevaron a cabo durante 10 años, en el que analizaron la situación, estilos de vida y grado de satisfacción de más de 400 familias en las que había un adulto con discapacidad intelectual, más de un tercio con síndrome de Down. Destacan el alto grado de estabilidad y flexibilidad encontrado en las familias de adultos con síndrome de Down, así como un mayor grado de satisfacción y un menor nivel de relaciones conflictivas cuando se las compara con las familias cuyo hijo adulto tiene otro tipo de discapacidad. Nuestra investigación sugiere que la flexibilidad, la cuidadosa planificación del futuro, el mantenimiento de unas redes activas de apoyo social y el saber afrontar las estrategias de modo activo van a ser los recursos clave de los padres que han de conseguir una mayor satisfacción y bienestar en la vida de todos los miembros de la familia (AU)