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Purpose: Engineering and dredging strategies to manage sediment, along with river-scouring, can reveal older sediments. These present a unique opportunity to assess past sources of phosphorus (P) inputs into river sediments. We used the sediment concentrations of P, lead (Pb) and 206/207Pb isotopes to produce 'first-order' estimates of the source (diffuse agricultural or sewage treatment) of phosphorus. Materials and methods: Sediment cores (n = 30) were collected from the length of the non-tidal River Nene, a lowland river in eastern England. Cores were analysed for sediment elemental concentrations and Pb isotopes. Principal component analysis and linear regression modelling were used to assess the relationships between P, Pb and Pb isotopes. Monte-Carlo simulations and boot-strapping were undertaken to estimate, with 95% confidence intervals, the source of P in these sediments. Results and discussion: Analysis of the relationships between PTotal, PbTotal and 206/207Pb isotope ratios suggested that sediments were deposited largely prior to the phasing out of tetra-ethyl Pb (PbBHT) from petrol. Regression models showed positive correlations between PTotal and PbTotal (R2 = 0.85). Principal component analysis suggested a strong sewage treatment signal for Pb and P enrichment. In the rural upper three water bodies, little sewage treatment work (STW)-derived P was found in the sediment, a consequence of limited STW input and greater sediment transport. In the more urbanised water bodies 4–6, 'first-order estimates' of STW P suggest that median concentrations were 30–40% of PTotal. Conclusions: The strong relationships between Pb and P concentrations in river water provided the opportunity to use 206/207Pb isotope ratios to calculate 'first-order' estimates of the proportion of P released from STWs in the historical sediment. Understanding the sources of historical sediment P can be used to assess the success of current sediment management strategies and to base further mitigation measures. Results suggest that whilst much recent sediment P is removed, the legacy sediment remains to contribute P to the water body. Thus, options regarding the practical removal of these sediments and the extent to which this would improve water P status need to be assessed and balanced against options such as further decreasing soil P or STW P stripping. [ABSTRACT FROM AUTHOR]

Professional control in the selection of treatment options for patients is changing. In light of social and legal developments emphasising patient choice and autonomy, and restricting medical paternalism and judicial deference, this article examines how far patients and families can demand NHS treatment in England and Wales. It considers situations where the patient is an adult with capacity, an adult lacking capacity and a child. In all three cases, there is judicial support for professional autonomy, but there are also inconsistencies that have potential to elevate the importance of patient and family preferences. In combination, they may be perceived by healthcare professionals as an obligation to follow patient preferences, even where doing so conflicts with other professional obligations. It is argued that a more nuanced approach to shared decision-making could help clarify the boundaries of decision-making responsibility. [ABSTRACT FROM AUTHOR]

Predictive linear regression (LR) modelling between bioaccessible Pb and a range of total elemental compositions and soil properties was executed for the Glasgow, London, Northampton and Swansea urban areas in order to assess the potential for developing a national urban bioaccessible Pb dataset for the UK. LR indicates that total Pb is the only highly significant independent variable for estimating the bioaccessibility of Pb. Bootstrap resampling shows that the relationship between total Pb and bioaccessible Pb is broadly the same in the four urban areas. The median bioaccessible fraction ranges from 38% in Northampton to 68% in London and Swansea. Results of this study can be used as part of a lines of evidence approach to localised risk assessment but should not be used to replace bioaccessibility testing at individual sites where local conditions may vary considerably from the broad overview presented in this study. [Copyright &y& Elsevier]

Background General practitioners in the UK play a key role in prevention but provision of preventive services is variable. The 2004 General Medical Services contract allows Primary Care Trusts (PCTs) to address health needs through providing locally agreed payments for Local Enhanced Services (LESs). This study identifies how this contractual flexibility is used for preventive services and explores its perceived effectiveness. Methods Semi-structured interviews were carried out (2008–09) in 10 purposively selected case study sites in England. Details of LESs for these sites were collected (2009) through Freedom of Information requests or local contacts. A national on-line survey of PCTs (2009) provided a national context for case study findings. Results LESs were considered to be effective in incentivizing preventive activity. However, specifications and performance management were often weak, awareness of how to optimize incentives was low and, as optional services, LESs were perceived to be at risk in a financial downturn. Conclusions Using LESs for preventive services highlights gaps in ‘core’ primary care responsibilities and in the national pay-for-performance framework. Current incentive arrangements are complex, could increase inequalities and provide only a partial, short-term solution to developing a proactive approach to prevention in primary care. [ABSTRACT FROM PUBLISHER]

Objectives: Shifting the focus of health-care systems towards prevention has proved difficult to achieve. Governance structures are complex, incentives may conflict and there are many competing priorities. We explored the influence of governance and incentive arrangements on commissioning for health and wellbeing in the English National Health Service (NHS) and the governance paradoxes which emerge. Methods: Qualitative and quantitative methods were employed. We carried out one national and two regional focus groups; a national online survey of primary care trusts (PCTs); and 99 semi-structured interviews in 10 purposively selected case study sites across England. Interviewees included decision-makers in PCTs, practice-based commissioners, Chairs of Local Involvement Networks (LINks) and of Overview and Scrutiny committees (OSCs) and Voluntary and Community Sector (VCS) members of local health and wellbeing partnerships. Results: Case study sites differed in the extent to which they reflected a public health ethos throughout the commissioning cycle, incentivized preventive services through contractual flexibilities or prioritized investment in health and wellbeing. Practice-based commissioners were tangentially involved in the commissioning cycle, public health partnerships or local health needs assessment. While commissioning for health and wellbeing involves working through partnerships, performance management regimes favoured single organizational success. Preventive services were considered at increased risk in times of financial stringency. Conclusions: As the NHS in England undergoes further reorganization, it is important to ensure that a systematic, strategic and population-based approach to commissioning is not lost. Governance and incentive arrangements should be critically assessed for their impact on population health and wellbeing. [ABSTRACT FROM AUTHOR]

Polycyclic aromatic hydrocarbon (PAH) concentrations were determined in 16 topsoils (0-10 cm) collected across the site of a former tar works in NE England. The soils were prepared in the laboratory to two different particle size fractions: <250 μm (fraction A) and >250 μm to <2 mm (fraction B). Sixteen priority PAHs were analysed in the soils using in situ pressurised fluid extraction (PFE) followed by gas chromatography-mass spectrometry (GC-MS). The average total PAH concentration in the soils ranged from 9.0 to 1,404 mg/kg (soil fraction A) and from 6.6 to 872 mg/kg (soil fraction B). These concentrations are high compared with other industrially contaminated soils reported in the international literature, indicating that the tar works warrants further investigation/remediation. A predominance of higher-molecular-weight compounds was determined in the samples, suggesting that the PAHs were of pyrogenic (anthropogenic) origin. Statistical comparison ( t-test) of the mean total PAH concentrations in soil fractions A and B indicated that there was a significant difference (95% confidence interval) between the fractions in all but two of the soil samples. Additionally, comparisons of the distributions of individual PAHs (i.e. 16 PAHs × 16 soil samples) in soil fractions A and B demonstrated generally higher PAH concentrations in fraction A (i.e. 65.8% of all individual PAH concentrations were higher in soil fraction A). This is important because fraction A corresponds to the particle size thought to be most important in terms of human contact with soils and potential threats to human health. [ABSTRACT FROM AUTHOR]

Abstract: The authors took part in an independent review of competition and innovation in the water industry in England and Wales, undertaken for United Kingdom and Welsh government ministers. Privatised twenty years ago, subject to a price control regime which has permitted high levels of investment, and unchanged as a set of vertically integrated regional monopolies, the sector now faces fresh challenges associated in particular with the consequences of climate change. The review identified a programme for the introduction of competition and use of market-type instruments into the sector, beginning with opening up retailing to business customers and reforms of the arrangements for abstraction and discharge which are intended to achieve a more rational use of water resources and to stimulate trading across company boundaries. Then, subject to an appropriate governance structure, competition would be introduced into upstream treatment activities, either by the creation of a single buyer of wholesale water or through a common carriage regime. At the same time, the balance of risk of and return to companies’ remaining regulated activities would be changed to encourage more innovative approaches, especially those which avoid heavy capital investment. Heightened stimuli to investment would also flow from relaxing restrictions on mergers and takeovers, and measures to enhance the innovative capabilities of companies. The paper explains the logic of the proposed measures and of their sequencing. [Copyright &y& Elsevier]

Objectives: To identify views of key stakeholders on public health governance. Study design: Focus groups and interviews. Methods: Key national and regional stakeholders in England were invited to participate in focus groups. Three focus groups and four additional interviews were transcribed and a thematic analysis was carried out. Results: Focus groups and interviewees identified points of transition in public health governance including changes in the notion of stewardship, governance across a local public health system and a shift from organizational governance to 'governance of place'. Conclusions: Different governance arrangements and approaches to governance can influence health outcomes through their impact on commissioning strategies, public health practice and performance management regimes. Failure to address these issues will hamper the development of a stewardship role in local organizations and across a local public health system. [ABSTRACT FROM AUTHOR]

The relationship of the total arsenic content of a soil and its bioaccumulation by earthworms ( Lumbricus rubellus and Dendrodrilus rubidus) to the arsenic fraction bioaccessible to humans, measured using an in vitro physiologically-based extraction test (PBET), was investigated. Soil and earthworm samples were collected at 24 sites at the former arsenic mine at the Devon Great Consols (DGC) in southwest England (UK), along with an uncontaminated site in Nottingham, UK, for comparison. Analysis of soil and earthworm total arsenic via inductively coupled plasma mass spectrometry (ICP-MS) was performed following a mixed acid digestion. Arsenic concentrations in the soil were elevated (204–9,025 mg kg−1) at DGC. The arsenic bioaccumulation factor (BAF) for both earthworm species was found to correlate positively with the human bioaccessible fraction (HBF), although the correlation was only significant ( P ≤ 0.05) for L. rubellus. The potential use of both in vitro PBETs and earthworms as complementary tools is explored as a holistic and multidisciplinary approach towards understanding risk at contaminated sites. Arsenic resistant earthworm species such as the L. rubellus populations at DGC are presented as a valuable tool for understanding risk at highly contaminated sites. [ABSTRACT FROM AUTHOR]

This article empirically validates an existing content analysis scheme and addresses a main concern of researchers about text-based, online transcripts in the form of code-recoding by mapping our scheme to the practical inquiry, cognitive presence model's five phases directly to realise higher-order thinking or critical thinking aspects for our software engineering students at London Metropolitan University. Two case studies are presented from final year undergraduate students. We also evaluated a semi-structured CMC environment called SQUAD, developed in-house for scaffolding small group collaborative learning. We argue that the empirical study conducted with software engineering students in Hong Kong and London gives an indication that critical thinking or higher-order thinking certainly exists within online collaborative learning teams where knowledge emerges and is shared. We claim that responses in the integration and resolution categories are more pertinent to critical thinking or higher-order thinking in the context of online, small group, collaborative learning environments when using the cognitive presence model as a framework for measurement purpose. [ABSTRACT FROM AUTHOR]

A self-modelling mixture algorithm was used to convert raw NIR spectra of soils, developed over Jurassic ironstones, into five underlying spectral components (SC) and associated coefficients. The five SCs were shown to be significantly correlated to the total As, bioaccessible As and total Fe contents of the soils and tentatively assigned to crystalline Fe oxides, Fe oxyhydroxides and clay components in the soils. A linear regression model, using the SC coefficients associated with the clay fraction, the Fe oxyhydroxides and the total As content of the soils as independent variables, was shown to predict the bioaccessible As content of the soils (as measured by an in vitro laboratory test) with a 95% confidence limit of ± 1.8 mg kg-1 and a median R2 value of 0.80. The approach could be extended to other soil types but the model presented here only applies to the Jurassic ironstone soils from Lincolnshire UK. [ABSTRACT FROM AUTHOR]

Twenty samples from soils developed over the Northampton Sand ironstone formation were collected from, in and around the town of Wellingborough, Northamptonshire, UK. The total arsenic (As) content ranged from ca. 20-100 mg kg- 1and the bioaccessible As content, as measured by a physiologically based in vitro extraction test, ranged from 1 to 6 mg kg- 1. A chemometric algorithm for mixture resolution, when applied to total element and total organic carbon concentration of the soils, was able to identify chemically distinct soil constituents and their associated As content. Multiple linear regression (MLR) modelling, using the As content of the intrinsic soil constituents and their first order interactions as independent variables, was able to predict the bioaccessible As content of the soils (R2 = 0.85) with an uncertainty of 1.33 mg kg- 1. Although the MLR model showed that the interactions between the soil constituents were the key factors controlling the bioaccessible fraction in each soil most of the total As was found to be bound to an Fe oxide soil constituent. The model predictions shown are currently only valid for the geological and soil chemical setting investigated here, extrapolation to other geological settings would require additional investigations. [ABSTRACT FROM AUTHOR]

Jurassic ironstones outcropping over parts of eastern England give rise to soils with arsenic concentrations in excess of the UK soil guideline value of 20 mg kg−1 for residential areas. Total arsenic concentrations were determined for 73 ironstone derived soils and bioaccessible arsenic determined using an in vitro physiologically based extraction test. The bioaccessible arsenic concentration for these soils was found to be well below the soil guideline value with a mean concentration of 4 mg kg−1 and a range of 2–17 mg kg−1. The bioaccessible fraction ranges from 1.2 to 33%. Data from a sequential extraction test based on the use of aqua regia as the main extractant is presented for a subset of 20 of the soils. Chemometric data reduction is used to demonstrate that the bioaccessible arsenic is mainly contained within calcium iron carbonate (sideritic) assemblages and only partially iron aluminosilicates, probably berthierine, and iron oxyhydroxide phases, probably goethite. It is suggested that the bulk of the non-bioaccessible arsenic is bound up with less reactive iron oxide phases. [ABSTRACT FROM AUTHOR]

The present water quality of the Humber rivers and coastal zone depends on a complex interplay of factors, including physical ones, such as the underlying geology, which influences soil type, climatic ones, such as the rainfall, which influences runoff, socio-economic ones, which influence present-day human activities in the catchment, and the legacy of former activities, such as contaminated sediments from mining. All of these factors affect the fluxes of nutrients and other contaminants to the rivers and coastal zone. The Water Framework Directive (WFD) requires the production of a river basin management plan intended to lead to the achievement of good chemical and ecological status for all water bodies in the catchment over the next two decades. This paper provides an overview of the current environmental and socio-economic state of the Humber catchment and coastal zone, and broadly examines how socio-economic drivers affect the fluxes of nutrients and contaminants to the coastal zone, using the driver–pressure–state–impact–response (DPSIR) approach. This is followed by an overview of future research, describing the use of scenarios to simulate future fluxes and provide a consistent framework to evaluate potential policies to improve water quality in the estuary. The Humber catchment is one of eight case studies within a European research project, EUROCAT (EVK1-CT-2000-00044), which aims to achieve integrated catchment and coastal zone management by analysing the response of the coastal sea to changes in fluxes of nutrients and contaminants from the catchments. For the Humber case study, the research focuses on the fluxes of two nutrient elements, N and P, and four metal contaminants, As, Cu, Pb and Zn. The project requires the integration of scientific and socio-economic approaches, bringing together quantitative environmental data garnered for individual river catchments and coastal zones in previous research programmes, and local and regional socio-economic data, to aid decision-makers in their search for integrated and sustainable coastal zone management strategies. [Copyright &y& Elsevier]

Presents a comparative study of three techniques of taking antenatal history on the quality of maternal care in Leeds, England. Obtainment of histories by midwives via unstructured questionnaires; Classification of actions as medical, surgical and personal associated to maternal age; Efficacy of structured questionnaire in providing better information.

A retrospective, multi-source screening study has detected 148 users (110 males, 38 females) of intravenous drugs who presented to all relevant agencies between 1971 and 1973 in Bristol, a city where maintenance therapy is a very infrequent practice. The peak prevalence was found in the age group 20-24 years, and it appeared that the chief sources of drugs were burglaries of chemists' shops and general practitioner prescriptions. Sixty-four per cent of our users had not been notified to the Home Office. Suggestions are made for the future monitoring and development of services. [ABSTRACT FROM AUTHOR]

Design A randomised blinded crossover trial. Sample selection Forty local primary care dentists in the south west of England were recruited using a variety of methods. Dentists from NHS, mixed practice, private practice and community services were included. Participants were allocated to four balanced experimental test groups of equal numbers. Block randomisation was used for allocation. The principle researcher was blind to which group a participant was from. The trial was completed using a purpose-made weblink which contained a clinical decision-making exercise. The participants repeated the exercise under increasing time pressure. Data analysis Data analysis was performed independently by the principle researcher. The diagnostic sensitivity and specificity of the decisions made were calculated and statistical analysis preformed. This included paired t-tests to assess differences in self-reported stress and difficulty when the exercise was performed under different time constraints. Mann-Whitney U tests were used to compare differences in the sensitivity and specificity values achieved under the varying time constraints. Results One hundred percent (n = 40) of GDPs who responded to the invitation were eligible and included in the study. Results showed a statistical difference (p <0.001) of both perceived difficulty of the task, and stress experienced when under time pressure. Results showed diagnostic sensitivity to pathological features was significantly worse (p <0.001) under time pressure. Conversely, the specificity of identification of pathology free sites were not affected by the different circumstances. Conclusions Time pressure negatively impacted diagnostic performance and decreased diagnostic sensitivity for all pathological features. Sensitivity to caries-related pathology and periodontal disease-related pathology deteriorated by 40% and 67%, retrospectively. [ABSTRACT FROM AUTHOR]

Background: Long-term, low-level exposure to toxic elements in soil may be harmful to human health but large longitudinal cohort studies with sufficient follow-up time to study these effects are cost-prohibitive and impractical. Linkage of routinely collected medical outcome data to systematic surveys of soil quality may offer a viable alternative. Methods: We used the Geochemical Baseline Survey of the Environment (G-BASE), a systematic X-ray fluorescence survey of soil inorganic chemistry throughout England and Wales to obtain estimates of the concentrations of 15 elements in the soil contained within each English and Welsh postcode area. We linked these data to the residential postcodes of individuals enrolled in The Health Improvement Network (THIN), a large database of UK primary care medical records, to provide estimates of exposure. Observed exposure levels among the THIN population were compared with expectations based on UK population estimates to assess representativeness. Results: Three hundred seventy-seven of three hundred ninety-five English and Welsh THIN practices agreed to participate in the linkage, providing complete residential soil metal estimates for 6,243,363 individuals (92% of all current and former patients) with a mean period of prospective computerised medical data collection (follow-up) of 6.75 years. Overall agreement between the THIN population and expectations was excellent; however, the number of participating practices in the Yorkshire & Humber strategic health authority was low, leading to restricted ranges of measurements for some elements relative to the known variations in geochemical concentrations in this area. Conclusions: The linked database provides unprecedented population size and statistical power to study the effects of elements in soil on human health. With appropriate adjustment, results should be generalizable to and representative of the wider English and Welsh population. [ABSTRACT FROM AUTHOR]

Abstract: We describe the use of a fully volumetric geophysical imaging approach, three-dimensional electrical resistivity (3D ERT), for bedrock detection below mixed sand and gravel deposits typical of fluvial valley-fill terraces. We illustrate the method through an analysis of terrace deposits of the Great Ouse River (UK), where up to 4m of sand and gravel have filled the valley bottom during the latest Pleistocene. We use an edge detector to identify the steepest gradient in first-derivative resistivity profiles, which yields an estimate of bedrock depth (verified by drilling) to a precision better than 0.2m (average) and 0.4m (standard deviation). Comparison of a range of drilling techniques at the site has revealed that borehole derived interface depths suffered from levels of uncertainty similar to those associated with the 3D ERT — indicating that the reliability of bedrock interface depths determined using these two approaches is comparable in this case. The 3D ERT method provides a high spatial resolution that enabled a previously unknown erosional bedrock structure, associated with the change from deeper first terrace to second terrace deposits, to be identified in the Great Ouse valley. The method provides a relatively quick method to quantify terrace fill volume over large sites to a greater degree of precision than currently available. [Copyright &y& Elsevier]

Background: Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care.This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters., Methods: Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral)., Results: Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of 'past medical history' (from 71% to 84%, p < 0.001) and 'medication history' (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods., Conclusion: Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement.