Implementing a multisite shared haemodialysis care programme.

Adults receiving centre-based haemodialysis (HD) have low levels of patient activation which are associated with poorer outcomes. Shared haemodialysis care (SHC) describes an intervention whereby individuals are supported to undertake elements of their treatment to improve their activation levels and promote better self-care. This project aimed to increase the proportion of those performing SHC in seven HD centres within the Oxford Kidney Unit's catchment area. Sequential Plan-Do-Study-Act (PDSA) cycles effected change first in two central HD centres, in cycles 1 and 2, before rolling out to five satellite HD centres, in cycles 3 and 4. Cycle 1 explored and transformed staff perceptions regarding SHC using a questionnaire and teaching sessions while in cycle 2, staff partnered with patients to develop leaflets and noticeboards to improve awareness and participation. These interventions were then rolled out to the remaining HD centres in PDSA cycles 3 and 4. Other interventions included: Enrolling staff and patients in virtual training courses; designating SHC 'Champions'; engagement with a national SHC forum; and changes to the electronic patient record to enable the monitoring of patient SHC opportunity and to promote sustainable change. Outcome measurement data on the number of patients performing SHC and the number at different defined stages of SHC competency were captured monthly. In April 2022, only 4% (19/483) of those receiving centre-based HD performed any aspect of SHC. By the end of the project in December 2023, this had increased to 43% (220/511). There was a significant and sustained growth in the stage of patient SHC competency as well as the number of patients performing SHC in each HD centre. The project demonstrated that it is possible to implement, scale-up and maintain a multisite SHC programme even with little baseline staff and patient SHC experience.

Field observations to establish the impact of fluvial flooding on potentially toxic element (PTE) mobility in floodplain soils.

Inundation of river water during flooding deposits contaminated sediments onto floodplain topsoil. Historically, floodplains were considered an important sink for potentially toxic elements (PTEs). With increasing flood frequency and duration, due to climate change and land use change, it is important to understand the impact that further flooding may have on this legacy contamination. In this study a field-based approach was taken, extracting soil pore waters by centrifugation of soils sampled on multiple occasions from multiple locations across a floodplain site, which lies adjacent to the River Loddon in southeast England. Flooding generally decreased pore water PTE concentrations and significantly lower pore water concentrations of Cd, Cu, and Cr were found post-flood compared to pre-flood. The dominant process responsible for this observation was precipitation with sulphides resulting in PTE removal from the pore water post-flood. The changes in pH were found to be associated with the decreased pore water concentration of Cu, which suggests the pH rise may have aided adsorption mechanisms or precipitation with phosphates. The impact of flooding on the release and retention of PTEs in floodplain soils is the net effect of several key processes occurring concurrently. It is important to understand the dominant processes that drive mobility of individual PTEs on specific floodplains so that site-specific predictions can determine the impact of future floods on the environmental fate of legacy contaminants.

The impact of increased flooding occurrence on the mobility of potentially toxic elements in floodplain soil - A review.

The frequency and duration of flooding events is increasing due to land-use changes increasing run-off of precipitation, and climate change causing more intense rainfall events. Floodplain soils situated downstream of urban or industrial catchments, which were traditionally considered a sink of potentially toxic elements (PTEs) arriving from the river reach, may now become a source of legacy pollution to the surrounding environment, if PTEs are mobilised by unprecedented flooding events. When a soil floods, the mobility of PTEs can increase or decrease due to the net effect of five key processes; (i) the soil redox potential decreases which can directly alter the speciation, and hence mobility, of redox sensitive PTEs (e.g. Cr, As), (ii) pH increases which usually decreases the mobility of metal cations (e.g. Cd2+, Cu2+, Ni2+, Pb2+, Zn2+), (iii) dissolved organic matter (DOM) increases, which chelates and mobilises PTEs, (iv) Fe and Mn hydroxides undergo reductive dissolution, releasing adsorbed and co-precipitated PTEs, and (v) sulphate is reduced and PTEs are immobilised due to precipitation of metal sulphides. These factors may be independent mechanisms, but they interact with one another to affect the mobility of PTEs, meaning the effect of flooding on PTE mobility is not easy to predict. Many of the processes involved in mobilising PTEs are microbially mediated, temperature dependent and the kinetics are poorly understood. Soil mineralogy and texture are properties that change spatially and will affect how the mobility of PTEs in a specific soil may be impacted by flooding. As a result, knowledge based on one river catchment may not be particularly useful for predicting the impacts of flooding at another site. This review provides a critical discussion of the mechanisms controlling the mobility of PTEs in floodplain soils. It summarises current understanding, identifies limitations to existing knowledge, and highlights requirements for further research.

Dual stresses of flooding and agricultural land use reduce earthworm populations more than the individual stressors.

Global climate change is leading to a significant increase in flooding events in many countries. Current practices to prevent damage to downstream urban areas include allowing the flooding of upstream agricultural land. Earthworms are ecosystem engineers, but their abundances in arable land are already reduced due to pressure from farming practices. If flooding increases on agricultural land, it is important to understand how earthworms will respond to the dual stresses of flooding and agricultural land use. The earthworm populations under three land uses (pasture, field margin, and crops), across two UK fields, were sampled seasonally over an 18-month period in areas of the fields which flood frequently and areas which flood only rarely. Earthworm abundance in the crop and pasture soils and total earthworm biomass in the crop soils was significantly lower in the frequently flooded areas than in the rarely flooded areas. The relative percentage difference in the populations between the rarely and frequently flooded areas was greater in the crop soils (-59.18% abundance, -63.49% biomass) than the pasture soils (-13.39% abundance, -9.66% biomass). In the margin soils, earthworm abundance was significantly greater in the frequently flooded areas (+140.56%), likely due to higher soil organic matter content and lower bulk density resulting in soil conditions more amenable to earthworms. The findings of this study show that earthworm populations already stressed by the activities associated with arable land use are more susceptible to flooding than populations in pasture fields, suggesting that arable earthworm populations are likely to be increasingly at risk with increased flooding.

The Effect of Flooding and Drainage Duration on the Release of Trace Elements from Floodplain Soils.

Floodplains downstream of urban catchments are sinks for potentially toxic trace elements. An intensification of the hydrological cycle and changing land use will result in floodplains becoming inundated for longer durations in the future. We collected intact soil cores from a floodplain meadow downstream of an urban catchment and subjected them to an inundation/drainage cycle in the laboratory to investigate the effect of flood duration on trace element concentrations in the soil porewater. The porewater concentrations of Ni, Cr, and Zn increased, whereas Cu and Pb decreased with flood duration. All the Cr present in porewaters was identified as Cr(III). Copper concentrations increased after drainage but Pb mobility remained suppressed. Both pH and dissolved organic carbon (DOC) increased with flood duration but were lower in treatments that were drained for the longest duration (which were also the treatments flooded for the shortest duration). The porewater concentrations of Cr and Ni decreased after drainage to levels below those observed before inundation, mirroring the DOC concentrations. We concluded that the duration of floodplain inundation does have an influence on the environmental fate of trace elements but that flooding does not influence all trace elements in the same way. The implications of an intensification of the hydrological cycle over the coming decades are that floodplains may become a source of some trace elements to aquatic and terrestrial ecosystems. Environ Toxicol Chem 2020;39:2124-2135. © 2020 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.