Microplastics in human blood: Polymer types, concentrations and characterisation using µFTIR.

Microplastics (MPs) are an everyday part of life, and are now ubiquitous in the environment. Crucially, MPs have not just been found within the environment, but also within human bodies, including the blood. We aimed to provide novel information on the range of MP polymer types present, as well as their size and shape characteristics, in human whole blood from 20 healthy volunteers. Twenty-four polymer types were identified from 18 out of 20 (90 %) donors and quantified in blood, with the majority observed for the first time. Using an LOQ approach, five polymer types met the threshold with a lower mean ± SD of 2466 ± 4174 MP/L. The concentrations of plastics analysed in blood samples ranged from 1.84 - 4.65 µg/mL. Polyethylene (32 %), ethylene propylene diene (14 %), and ethylene-vinyl-acetate/alcohol (12 %) fragments were the most abundant. MP particles that were identified within the blood samples had a mean particle length of 127.99 ± 293.26 µm (7-3000 µm), and a mean particle width of 57.88 ± 88.89 µm (5-800 µm). The MPs were predominantly categorised as fragments (88 %) and were white/clear (79 %). A variety of plastic additive chemicals were identified including endocrine disrupting-classed phthalates. The procedural blank samples comprised 7 polymer types, that were distinct from those identified in blood, mainly resin (25 %), polyethylene terephthalate (17 %), and polystyrene (17 %) with a mean ± SD of 4.80 ± 5.59 MP/L. This study adds to the growing evidence that MPs are taken up into the human body and are transported via the bloodstream. The shape and sizes of the particles raise important questions with respect to their presence and associated hazards in terms of potential detrimental impacts such as vascular inflammation, build up within major organs, and changes to either immune cell response, or haemostasis and thrombosis.

Narrative review: what constitutes contemporary, high-quality end-of-life care and can lessons be learned from medieval history?

BACKGROUND AND OBJECTIVE: In modern Britain, palliative and end-of-life care is governed by quality standards and guidance, which should consider spiritual and psychological needs. However, there are significant gaps in provision of services which was highlighted during the coronavirus disease 2019 (COVID-19) pandemic where many individuals and families suffered profound spiritual and existential distress. Significant gaps remain in the provision of services to support patients with spiritual and psychological needs which can affect the management of physical symptoms. During the medieval period in Western Europe, it was important to prepare well for death throughout life. It has been suggested that lessons may be learned from medieval preparations for death which might benefit those approaching end-of-life in contemporary society. It is therefore timely to consider medieval attitudes to death and reflect on how these might inform modern end-of-life care. The objective of this review is to synthesise literature addressing modern end-of-life care in the UK and contrast this with literature on preparations for death during the medieval period in Western Europe. Our aim is to determine whether there is wisdom to be gained from history which could inform our approaches to end-of-life care today. METHODS: Using online databases and broad keyword searches along with experts in the field of medieval history, we identified literature and translations of texts with a focus on preparations for death during both periods. These were narratively synthesised and discussed. KEY CONTENT AND FINDINGS: A key finding is that the medieval attitude to death was as an integral part of life, whereas in modern society death is not usually considered until the situation arises. The review highlights a need for a better understanding of the individuality of spiritual and existential needs during end-of-life care in modern society, which will vary according to individual choice, culture, societal group, religion, and belief. CONCLUSIONS: The lessons we can learn from our medieval counterparts include the need for lifelong and individual preparations for the end of life, with emphasis on spiritual needs. Alongside palliative interventions, we need to take time to appreciate what gives individuals spiritual support and provide the resources to facilitate this.

Microplastics in human urine: Characterisation using µFTIR and sampling challenges using healthy donors and endometriosis participants.

Microplastics (MPs) are found in all environments, within the human food chain, and have been recently detected in several human tissues. The objective herein was to undertake an analysis of MP contamination in human urine samples, from healthy individuals and participants with endometriosis, with respect to their presence, levels, and the characteristics of any particles identified. A total of 38 human urine samples and 15 procedural blanks were analysed. MPs were characterised using µFTIR spectroscopy (size limitation of 5 µm) and SEM-EDX. In total, 123 MP particles consisting of 22 MP polymer types were identified within 17/29 of the healthy donor (10 mL) urine samples, compared with 232 MP particles of differing 16 MP polymer types in 12/19 urine samples from participants with endometriosis. Healthy donors presented an unadjusted average of 2589 ± 2931 MP/L and participants with endometriosis presented 4724 ± 9710 MP/L. Polyethylene (PE)(27%), polystyrene (PS)(16%), resin and polypropylene (PP)(both 12%) polymer types were most abundant in healthy donor samples, compared with polytetrafluoroethylene (PTFE) (59%), and PE (16%) in samples from endometriosis participants. The MP levels within healthy and endometriosis participant samples were not significantly different. However, the predominant polymer types varied, and the MPs from the metal catheter-derived endometriosis participant samples and healthy donors were significantly smaller than those observed in the procedural blanks. The procedural blank samples comprised 62 MP particles of 10 MP polymer types, mainly PP (27%), PE (21%), and PS (15%) with a mean ± SD of 17 ± 18, highlighting the unavoidable contamination inherent in measurement of MPs from donors. This is the first evidence of MP contamination in human urine with polymer characterisation and accounting for procedural blanks. These results support the phenomenon of transport of MPs within humans, specifically to the bladder, and their characterisation of types, shapes and size ranges identified therein.

The contamination of in situ archaeological remains: A pilot analysis of microplastics in sediment samples using µFTIR.

BACKGROUND: Microplastics (MPs) are found in all environments: aquatic, airborne, and terrestrial. While their presence is not disputed, their potential impacts are not yet known. OBJECTIVE: To undertake a pilot analysis of MP contamination in archaeological sediment samples, taken in the late 1980s from two archaeological excavation sites in the historic city of York (UK) as well as contemporary sources close to the same sites, with respect to the presence (if any), levels, and characteristics of any particles identified. METHODS: This study analysed pre-digested sediment samples as follows: n = 3 from Queens Hotel (QH) site and n = 3 Wellington Row (WR) contemporary core-source, and n = 3 QH and n = 3 WR archival-source samples, alongside procedural controls (n = 8), using µFTIR spectroscopy (size limitation of 5 µm) to detect and characterise any MPs present. RESULTS: In total, 66 MP particles consisting of 16 MP polymer types were identified across both site and contemporary/archived samples. The highest levels of MP particles, 20,588 MP/kg was identified at the lowest sample depth (∼7.35 m) at archived WR, 5910 MP/kg in the mid depth layer (∼5.85 m) at the contemporary QH site. Of the MPs detected in sediment samples overall, polytetrafluoroethylene (PTFE), polybutylene sulfone (PSU), and polypropylene: polyethylene (PE:PP) copolymer polymer types were most abundant; mainly fragmented and irregular shape. CONCLUSIONS: This is believed to be the first evidence of MP contamination in archaeological sediment (or soil) samples with polymers and size ranges measured and while accounting for procedural blanks. These results support the phenomenon of transport of MPs within archaeological stratigraphy, and the characterisation of types, shapes and size ranges identified therein. Through contamination, MPs may compromise the scientific value of archaeological deposits, and environmental proxies suspended within significant sediment, and as such represent a new consideration in the dynamism of, as well as arguments for preserving, archaeological deposits in situ.

The COVID-19 response and accountability in South Africa.

South Africa is a country that has undergone massive societal changes in the last 30 years. At the time coronavirus disease 2019 (COVID-19) struck, the country was still facing challenges in terms of inequality and the disaster vulnerability of its population. During COVID-19, the provision of lifesaving personal protective equipment and other resources was marred by corruption and failings of the governmental officials. At the same time, the complexity of the COVID-19 pandemic required operational changes in the public health and disaster risk management systems. This study provides an overview of the public service accountability legislation and framework. Flexibility of the disaster management structures at the local government level and flexible information sharing as well as cooperation of all relevant stakeholders are critical for efficient management of the coronavirus pandemic and the maintenance of accountability in that space. Those experiences are captured at local and district municipality levels in the Western Cape Province of South Africa. Best practices and lessons should be taken forward and identified.

Gastrointestinal parasites in captive olive baboons in a UK safari park.

From the safety inside vehicles, Knowsley Safari offers visitors a close-up encounter with captive olive baboons. As exiting vehicles may be contaminated with baboon stool, a comprehensive coprological inspection was conducted to address public health concerns. Baboon stools were obtained from vehicles, and sleeping areas, inclusive of video analysis of baboon­vehicle interactions. A purposely selected 4-day sampling period enabled comparative inspections of 2662 vehicles, with a total of 669 baboon stools examined (371 from vehicles and 298 from sleeping areas). As informed by our pilot study, front-line diagnostic methods were: QUIK-CHEK rapid diagnostic test (RDT) (Giardia and Cryptosporidium), Kato­Katz coproscopy (Trichuris) and charcoal culture (Strongyloides). Some 13.9% of vehicles were contaminated with baboon stool. Prevalence of giardiasis was 37.4% while cryptosporidiosis was <0.01%, however, an absence of faecal cysts by quality control coproscopy, alongside lower than the expected levels of Giardia-specific DNA, judged RDT results as misleading, grossly overestimating prevalence. Prevalence of trichuriasis was 48.0% and strongyloidiasis was 13.7%, a first report of Strongyloides fuelleborni in UK. We advise regular blanket administration(s) of anthelminthics to the colony, exploring pour-on formulations, thereafter, smaller-scale indicator surveys would be adequate.

ON LIVER FLUKE (FASCIOLA HEPATICA) IN CAPTIVE VICUÑAS (VICUGNA VICUGNA) AT KNOWSLEY SAFARI, PRESCOT, UNITED KINGDOM.

Knowsley Safari (KS), Prescot, United Kingdom houses a variety of captive exotic ungulates. As part of their animal welfare plan, a prospective coprological survey was undertaken for liver fluke. In June 2021, 330 fecal samples, representative of 18 exotic ungulate species, were processed by sedimentation and filtration, with examination by coproscopy. Finding fascioliasis in all five vicuña alone, with fecal egg counts ranging from one to eight eggs per gram, anthelminthic treatment was attempted twice, with three coprological reviews. While the first anthelminthic treatment (oxyclozanide) was equivocal, the second anthelminthic treatment (triclabendazole) was proven effective upon two later follow-ups. An initial malacological survey of 16 freshwater sites in KS, first found Galba truncatula at two sites in June 2021, then upon more extensive searching subsequently within the vicuña's enclosure. It appears that F. hepatica was locally acquired, being the first report of fascioliasis within captive vicuñas in the United Kingdom. To develop a better fluke-management plan, regular coprological and malacological surveillance is justified, perhaps with molecular xenomonitoring of snails, alongside prompt administration of appropriate flukicide as required.

Non-pharmacological interventions to manage psychological distress in patients living with cancer: a systematic review.

BACKGROUND: Psychological distress is common in patients with cancer; interfering with physical and psychological wellbeing, and hindering management of physical symptoms. Our aim was to systematically review published evidence on non-pharmacological interventions for cancer-related psychological distress, at all stages of the disease. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered on PROSPERO (CRD42022311729). Searches were made using eight online databases to identify studies meeting our inclusion criteria. Data were collected on outcome measures, modes of delivery, resources and evidence of efficacy. A meta-analysis was planned if data allowed. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Fifty-nine studies with 17,628 participants were included. One third of studies included mindfulness, talking or group therapies. Half of all studies reported statistically significant improvements in distress. Statistically significant intervention effects on distress were most prevalent for mindfulness techniques. Four of these mindfulness studies had moderate effect sizes (d = -0.71[95% CI: -1.04, -0.37] p < 0.001) (d = -0.60 [95% CI: -3.44, -0.89] p < 0.001) (d = -0.77 [CI: -0.146, -1.954] p < 0.01) (d = -0.69 [CI: -0.18, -1.19] p = 0.008) and one had a large effect size (d = -1.03 [95% CI: -1.51, -0.54] p < 0.001). Heterogeneity of studies precluded meta-analysis. Study quality was variable and some had a high risk of bias. CONCLUSIONS: The majority of studies using a mindfulness intervention in this review are efficacious at alleviating distress. Mindfulness-including brief, self-administered interventions-merits further investigation, using adequately powered, high-quality studies. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered on PROSPERO, number CRD42022311729.

Heat induces multiomic and phenotypic stress propagation in zebrafish embryos.

Heat alters biology from molecular to ecological levels, but may also have unknown indirect effects. This includes the concept that animals exposed to abiotic stress can induce stress in naive receivers. Here, we provide a comprehensive picture of the molecular signatures of this process, by integrating multiomic and phenotypic data. In individual zebrafish embryos, repeated heat peaks elicited both a molecular response and a burst of accelerated growth followed by a growth slowdown in concert with reduced responses to novel stimuli. Metabolomes of the media of heat treated vs. untreated embryos revealed candidate stress metabolites including sulfur-containing compounds and lipids. These stress metabolites elicited transcriptomic changes in naive receivers related to immune response, extracellular signaling, glycosaminoglycan/keratan sulfate, and lipid metabolism. Consequently, non-heat-exposed receivers (exposed to stress metabolites only) experienced accelerated catch-up growth in concert with reduced swimming performance. The combination of heat and stress metabolites accelerated development the most, mediated by apelin signaling. Our results prove the concept of indirect heat-induced stress propagation toward naive receivers, inducing phenotypes comparable with those resulting from direct heat exposure, but utilizing distinct molecular pathways. Group-exposing a nonlaboratory zebrafish line, we independently confirm that the glycosaminoglycan biosynthesis-related gene chs1 and the mucus glycoprotein gene prg4a, functionally connected to the candidate stress metabolite classes sugars and phosphocholine, are differentially expressed in receivers. This hints at the production of Schreckstoff-like cues in receivers, leading to further stress propagation within groups, which may have ecological and animal welfare implications for aquatic populations in a changing climate.

Characteristics of good home-based end-of-life care: analysis of 5-year data from a nationwide mortality follow-back survey in England.

BACKGROUND: Recently, there has been an emphasis on providing good-quality end-of-life care; however, little is known about it and its determinants for patients living at home. AIM: To determine what characterises good-quality end-of-life care for patients living at home. DESIGN AND SETTING: An observational study using 5-year data from the National Survey of Bereaved People (Views of Informal Carers - Evaluation of Services [VOICES]) in England. METHOD: Analysis was based on data for 63 598 decedents, who were cared for at home in the last 3 months of life. Data were drawn from 110 311 completed mortality follow-back surveys of a stratified sample of 246 763 deaths registered in England between 2011 and 2015. Logistic regression analyses were used to identify independent variables associated with overall quality of end-of-life care and other indicators of end-of-life care quality. RESULTS: Patients who received good continuity of primary care (adjusted odds ratio [AOR] 2.03; 95% confidence interval [CI] = 2.01 to 2.06) and palliative care support (AOR 1.86; 95% CI = 1.84 to 1.89) experienced better overall quality of end-of-life care than those who did not, as perceived by relatives. Decedents who died from cancer (AOR 1.05; 95% CI = 1.03 to 1.06) or outside of hospital were more likely to receive good end-of-life care, as perceived by relatives. Being older, female (AOR 1.16; 95% CI = 1.15 to 1.17), from areas with least socioeconomic deprivation, and White (AOR 1.09; 95% CI = 1.06 to 1.12) were associated with better overall end-of-life care, as perceived by relatives. CONCLUSION: Better quality of end-of-life care was associated with good continuity of primary care, specialist palliative care support, and death outside of hospital. Disparities still exist for those from minority ethnic groups and those living in areas of socioeconomic deprivation. Future commissioning and initiatives must consider these variables to provide a more-equitable service.

Detection of microplastics in human saphenous vein tissue using µFTIR: A pilot study.

Microplastics (MPs) are ubiquitous in the environment, in the human food chain, and have been recently detected in blood and lung tissues. To undertake a pilot analysis of MP contamination in human vein tissue samples with respect to their presence (if any), levels, and characteristics of any particles identified. This study analysed digested human saphenous vein tissue samples (n = 5) using µFTIR spectroscopy (size limitation of 5 µm) to detect and characterise any MPs present. In total, 20 MP particles consisting of five MP polymer types were identified within 4 of the 5 vein tissue samples with an unadjusted average of 29.28 ± 34.88 MP/g of tissue (expressed as 14.99 ± 17.18 MP/g after background subtraction adjustments). Of the MPs detected in vein samples, five polymer types were identified, of irregular shape (90%), with alkyd resin (45%), poly (vinyl propionate/acetate, PVAc (20%) and nylon-ethylene-vinyl acetate, nylon-EVA, tie layer (20%) the most abundant. While the MP levels within tissue samples were not significantly different than those identified within procedural blanks (which represent airborne contamination at time of sampling), they were comprised of different plastic polymer types. The blanks comprised n = 13 MP particles of four MP polymer types with the most abundant being polytetrafluoroethylene (PTFE), then polypropylene (PP), polyethylene terephthalate (PET) and polyfumaronitrile:styrene (FNS), with a mean ± SD of 10.4 ± 9.21, p = 0.293. This study reports the highest level of contamination control and reports unadjusted values alongside different contamination adjustment techniques. This is the first evidence of MP contamination of human vascular tissues. These results support the phenomenon of transport of MPs within human tissues, specifically blood vessels, and this characterisation of types and levels can now inform realistic conditions for laboratory exposure experiments, with the aim of determining vascular health impacts.

Sex and gametogenesis stage are strong drivers of gene expression in Mytilus edulis exposed to environmentally relevant plasticiser levels and pH 7.7.

Plastic pollution and changes in oceanic pH are both pressing environmental issues. Little emphasis, however, has been placed on the influence of sex and gametogenesis stage when investigating the effects of such stressors. Here, we examined histology and molecular biomarkers of blue mussels Mytilus edulis exposed for 7 days to a pH 7.7 scenario (- 0.4 units) in combination with environmentally relevant concentrations (0, 0.5 and 50 µg/L) of the endocrine disrupting plasticiser di-2-ethylhexyl phthalate (DEHP). Through a factorial design, we investigated the gametogenesis cycle and sex-related expression of genes involved in pH homeostasis, stress response and oestrogen receptor-like pathways after the exposure to the two environmental stressors. As expected, we found sex-related differences in the proportion of developing, mature and spawning gonads in histological sections. Male gonads also showed higher levels of the acid-base regulator CA2, but females had a higher expression of stress response-related genes (i.e. sod, cat, hsp70). We found a significant effect of DEHP on stress response-related gene expression that was dependent on the gametogenesis stage, but there was only a trend towards downregulation of CA2 in response to pH 7.7. In addition, differences in gene expression between males and females were most pronounced in experimental conditions containing DEHP and/or acidified pH but never the control, indicating that it is important to consider sex and gametogenesis stage when studying the response of mussels to diverse stressors.

Thermoresponsive Block Copolymer Core-Shell Nanoparticles with Tunable Flow Behavior in Porous Media.

With the purpose of investigating new polymeric materials as potential flow modifiers for their future application in enhanced oil recovery (EOR), a series of amphiphilic poly(di(ethylene glycol) methyl ether methacrylate-co-oligo(ethylene glycol) methyl ether methacrylate) [P(DEGMA-co-OEGMA)]-based core-shell nanoparticles were prepared by aqueous reversible addition-fragmentation chain transfer-mediated polymerization-induced self-assembly. The developed nano-objects were shown to be thermoresponsive, demonstrating a reversible lower-critical solution temperature (LCST)-type phase transition with increasing solution temperature. Characterization of their thermoresponsive nature by variable-temperature UV-vis and dynamic light scattering analyses revealed that these particles reversibly aggregate when heated above their LCST and that the critical transition temperature could be accurately tuned by simply altering the molar ratio of core-forming monomers. Sandpack experiments were conducted to evaluate their pore-blocking performance at low flow rates in a porous medium heated at temperatures above their LCST. This analysis revealed that particles aggregated in the sandpack column and caused pore blockage with a significant reduction in the porous medium permeability. The developed aggregates and the increased pressure generated by the blockage were found to remain stable under the injection of brine and were observed to rapidly dissipate upon reducing the temperature below the LCST of each formulation. Further investigation by double-column sandpack analysis showed that the blockage was able to reform when re-heated and tracked the thermal front. Moreover, the rate of blockage formation was observed to be slower when the LCST of the injected particles was higher. Our investigation is expected to pave the way for the design of "smart" and versatile polymer technologies for EOR applications in future studies.

Microplastics in the surgical environment.

Atmospheric microplastics (MPs) have been consistently detected within indoor and outdoor air samples. Locations with high human activity are reported to have high MP levels. The aim was to quantify and characterise the MPs present within the surgical environment over a one-week sampling period. MPs were collected in samplers placed around an operating theatre and adjoining anaesthetic room at 12 h intervals. Particles were filtered onto 0.02 µm membranes and analysed using micro-Fourier-transform infrared spectroscopy. The number of MPs identified during the working day sampling period varied, with a mean of 1,924 ± 3,105 MP m-2 day-1 and a range of 0 - 9,258 MP m-2 day-1 observed in the theatre, compared with a mean of 541 ± 969 MP m-2 day-1 and a range of 0 - 3,368 MP m-2 day-1 for the anaesthetic room. Across both rooms and at all sampling points, an increase in levels with a decrease in MP size was observed. Identified particles consisted of mainly fragment shaped MPs (78 %) with polyethylene terephthalate (37 %), polypropylene (25 %), polyethylene (7 %) and nylon (13 %) representing the most abundant polymer types. MPs were not detected in the theatre during non-working hours. The results provide novel information on defining polymer levels and types, in a room environment where the use of single plastics has been regarded as beneficial to practice. These results can inform cellular toxicity studies, investigating the consequences of human MP exposure as well as represent a potentially novel route of exposure for humans for this emerging contaminant of concern, via surgery.

Patient experiences of living with cancer before interaction with palliative care services in Zimbabwe: A qualitative secondary data analysis.

OBJECTIVE: Cancer patients in Zimbabwe typically access health services with advanced disease, limiting treatment choices and lessening the likelihood of positive treatment outcomes. We outline experiences of patients with advanced cancer prior to interaction with palliative care services to identify targets for future intervention development to enhance care delivery in Zimbabwe. METHODS: Participants were purposively sampled adult patients with advanced cancer. We adopted a thematic approach to guide a qualitative secondary data analysis exploring factors influencing support sought by participants, external factors influencing decision making across the disease trajectory and the process for seeking and accessing palliative care. RESULTS: Participants reported fragmented and uncoordinated care, from initial symptom experience and throughout disease progression. A recurring notion of disjuncture was present through participants' experiences of gaps, breaks and discontinuity across the disease trajectory. Each step had a beginning and end without clear routes for transition with movement between steps as a result of happenstance or informal encounters. CONCLUSION: Targets for intervention development at the patient and family level exist that may reduce the disjuncture currently experienced between need and care provision. A holistic response that incorporates engagement with policy actors is critical to addressing prominent financial constraints for patients.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries.

BACKGROUND: Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups. METHODS: Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed. RESULTS: Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping. CONCLUSIONS: There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns. TRIAL REGISTRATION: PROSPERO- CRD42020167890 .

Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) face limited treatment options and inadequate access to palliative care. AIM: To provide a pragmatic overview of clinical guidelines and produce evidence-based recommendations for severe COPD. Interventions for which there is inconsistent evidence to support their use and areas requiring further research were identified. DESIGN: Practice review of guidelines supported by scoping review methodology to examine the evidence reporting the use of guideline-recommended interventions. DATA SOURCES: An electronic search was undertaken in MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Database of Systematic Reviews, complemented by web searching for guidelines and publications providing primary evidence (July 2021). Guidelines published within the last 5 years and evidence in the last 10 years were included. RESULTS: Severe COPD should be managed using a multidisciplinary approach with a holistic assessment. For stable patients, long-acting beta-agonist/long-acting muscarinic antagonist and pulmonary rehabilitation are recommended. Low dose opioids, self-management, handheld fan and nutritional support may provide small benefits, whereas routine corticosteroids should be avoided. For COPD exacerbations, systematic corticosteroids, non-invasive ventilation and exacerbation action plans are recommended. Short-acting inhaled beta-agonists and antibiotics may be considered but pulmonary rehabilitation should be avoided during hospitalisation. Long term oxygen therapy is only recommended for patients with chronic severe hypoxaemia. Short-acting anticholinergic inhalers, nebulised opioids, oral theophylline or telehealth are not recommended. CONCLUSIONS: Recommended interventions by guidelines are not always supported by high-quality evidence. Further research is required on efficacy and safety of inhaled corticosteroids, antidepressants, benzodiazepines, mucolytics, relaxation and breathing exercises.

Conceptualising effective symptom management in palliative care: a novel model derived from qualitative data.

BACKGROUND: Pain, breathlessness and fatigue are some of the most challenging symptoms to manage in patients with advanced disease. Specialist palliative care leads to better symptom management, but factors contributing to successful symptom management in this context have not been explored. Our aim was to understand what facilitates effective symptom management in specialist palliative care within UK hospices and investigate what barriers are experienced. METHODS: This was a grounded theory study using qualitative semi-structured focus groups and interviews. Participants were recruited from multidisciplinary specialist palliative care teams (doctors, nurses, healthcare assistants, physiotherapists, occupational therapists, complementary therapists, social workers and chaplains) working in inpatient, outpatient and community services provided by five hospices in the United Kingdom. RESULTS: We present a novel qualitative data-derived model of effective symptom management in specialist palliative care. We describe a co-ordinated, multi-faceted, sequential approach involving a process of engagement, partnership, decision-making, and delivery. Interventions to manage symptoms are less effective in psychologically distressed patients. Our data highlights that families of patients have a key role in determining effectiveness of symptom management interventions A holistic approach by a co-ordinated, multi-disciplinary team, including support to recognise and minimise psychological distress might facilitate more effective symptom management. Barriers to symptom management include team discordance and lack of understanding about symptom management by patient and families. CONCLUSIONS: Shared decision-making between patients and professionals and co-ordination of care by a multi-disciplinary team are key components of effective symptom management. Actions to address psychological distress and evaluate the understanding and expectations of patients and their families would enable more effective symptom management. A more effective multi-disciplinary approach would be facilitated by discussion within teams about role competencies and boundaries.

Gonadal Atresia, Estrogen-Responsive, and Apoptosis-Specific mRNA Expression in Marine Mussels from the East China Coast: A Preliminary Study.

This preliminary survey analysed mussel atresia incidences, estrogen-responsive and apoptotic-specific molecular end points, and aqueous and gonadal levels of selected estrogens from the East China coast. Estrogen levels were low (e.g. < LOD-28.36 ng/L, < LOD-3.88 ng/g wet weight of tissue for BPA) relative to worldwide freshwater environments, but high oocyte follicle atresia incidences (up to 26.6%) occurred at selected sites. Expression of estrogen-responsive ER2 was significantly increased in males relative to females at sites with high atresia incidences in females. A second estrogen-responsive gene, V9, was significantly increased at two sites in April in females relative to males; the opposite was true for the remaining two sites. Apoptosis-specific genes (Bcl-2, fas) showed elevated expression in males relative to females at the site with the highest atresia incidence. These results provide coastal estrogen levels and the utility of several estrogen-specific molecular-level markers for marine mussels.