Scaling up quality in an anesthesia practice.

The resources necessary to improve anesthesia quality and meet reimbursement and regulatory thresholds are scarce, particularly for smaller practices. We examined how small practice integration into a firm with greater resources can facilitate improvements. A mixed-methods analysis was conducted using the data from the US Anesthesia Partners data warehouse, Merit-based Incentive Payment System (MIPS), commercial insurers' surgery length of stay (LOS) databases, anesthesia-specific patient satisfaction surveys, and interviews with practice leadership before and after integration. All integrated practices improved their quality improvement infrastructure and achieved higher MIPS scores, with increased clinician and leadership satisfaction. Patient satisfaction exceeded national benchmarks in all groups, based on 398 392 returned surveys in 2021. Hospital LOS for common operations was shorter, based on a statewide database. This case study demonstrates that partnership with an organization with greater resources can advance anesthesia quality.

Individualised Estimation of Quality-adjusted Survival Benefit and Cost-effectiveness of Proton Beam Therapy in Intermediate-stage Hodgkin Lymphoma.

AIMS: Radiotherapy for Hodgkin lymphoma leads to the irradiation of organs at risk (OAR), which may confer excess risks of late effects. Comparative dosimetry studies show that proton beam therapy (PBT) may reduce OAR irradiation compared with photon radiotherapy, but PBT is more expensive and treatment capacity is limited. The purpose of this study is to inform the appropriateness of PBT for intermediate-stage Hodgkin lymphoma (ISHL). MATERIALS AND METHODS: A microsimulation model simulating the course of ISHL, background mortality and late effects was used to estimate comparative quality-adjusted life years (QALYs) lived and healthcare costs after consolidative pencil beam scanning PBT or volumetric modulated arc therapy (VMAT), both in deep-inspiration breath-hold. Outcomes were compared for 606 illustrative patients covering a spectrum of clinical presentations, varying by two age strata (20 and 40 years), both sexes, three smoking statuses (never, former and current) and 61 pairs of OAR radiation doses from a comparative planning study. Both undiscounted and discounted outcomes at 3.5% yearly discount were estimated. The maximum excess cost of PBT that might be considered cost-effective by the UK's National Institute for Health and Care Excellence was calculated. RESULTS: OAR doses, smoking status and discount rate had large impacts on QALYs gained with PBT. Current smokers benefited the most, averaging 0.605 undiscounted QALYs (range -0.341 to 2.171) and 0.146 discounted QALYs (range -0.067 to 0.686), whereas never smokers benefited the least, averaging 0.074 undiscounted QALYs (range -0.196 to 0.491) and 0.017 discounted QALYs (range -0.030 to 0.086). For the gain in discounted QALYs to be considered cost-effective, PBT would have to cost at most £4812 more than VMAT for current smokers and £645 more for never smokers. This is below preliminary National Health Service cost estimates of PBT over photon radiotherapy. CONCLUSION: In a UK setting, PBT for ISHL may not be considered cost-effective. However, the degree of unquantifiable uncertainty is substantial.

A circular economic approach to the phytoextraction of Zn from basic oxygen steelmaking filtercake using Lemna minor and CO2.

Two billion tonnes of alkaline metallurgical waste is generated per year as a product of industry, mining, and metal processing. Filtercake is one such residue formed as a bi-product of steelmaking. Metal rich bi-products can be both an environmental concern and potential resource. High concentrations of heavy metals, if accessed, could be utilised and reprocessed reducing both pollution and the demand for raw metal ores. Phytoextraction is one such method of recovering metals from contaminated mediums. Research interest in Lemna sp. has grown due to their phytoremediation potential. Facilitated by rapid growth and accumulation of nutrients and metals, Lemna minor has been described as one of the most effective macrophytes for remediating contaminated water. The present study outlines a system using L. minor to extract Zn from filtercake when submerged in static water. To facilitate phytoremediation, CO2 carbonation can be employed to solubilise elements and utilise this greenhouse gas, another a bi-product of steel industry. The addition of CO2 to vessels of water containing filtercake lowered the pH from as high as 8.8 to 5.6 and significantly increased Zn in solution compared to vessels receiving no CO2. Results suggest the potential of L. minor to accumulating 68.7 kg Zn per year from 20.5 Mt. filtercake ha-1. This system facilitates a circular economy with re-use of multiple existing bi-products. In addition, the potential employment of biomass in biofuel production and use of remediated filtercake in carbon sequestration adds further environmental and socio-economic impact. The extent to which the approach was consistent with circular economy was discussed and its wider integration considered.

BODIES R US: Ethical Views on the Commercialization of the Dead in Medical Education and Research.

With the ongoing and expanding use of willed bodies in medical education and research, there has been a concomitant rise in the need for willed bodies and an increase in the means of supplying these bodies. A relatively recent development to enlarge this supply has been the growth of for- profit willed body companies ("body brokers") in the United States. These companies advertise for donors, cover all cremation and other fees for the donor, distribute the bodies or body parts nationally and internationally, and charge their users for access to the body or body parts. In doing so, they generate substantial profits. This review examines the historical development of willed body programs, the legal and economic aspects of willed body programs, and then provides an ethical framework for the use of willed bodies. The ethical principles described include detailed informed consent from the donors, comprehensive and transparent information about the process from the body donation organizations, and societal input on the proper and legal handling of willed bodies. Based on the ethical principles outlined, it is recommended that there be no commercialization or commodification of willed bodies, and that programs that use willed bodies should not generate profit.

Status of HPV vaccine introduction and barriers to country uptake.

During the last 12 years, over 80 countries have introduced national HPV vaccination programs. The majority of these countries are high or upper-middle income countries. The barriers to HPV vaccine introduction remain greatest in those countries with the highest burden of cervical cancer and the most need for vaccination. Innovation and global leadership is required to increase and sustain introductions in low income and lower-middle income countries.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients.

INTRODUCTION: Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. METHODS: This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups. RESULTS: In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73-1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79-1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71-1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000). CONCLUSION: This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Sustainability and economic investments in animal health systems.

The paper outlines a framework for shaping and prioritising improvements to investments in animal health systems in order to improve their sustainability. The framework includes financial inputs that can be separated between core investments and day-to-day expenditures. The latter financial inputs should differentiate between avoiding losses in production and reducing wider societal impacts such as negative implications for trade and the environment. Overall the framework provides information on the financial costs of the animal health system and the animal health outcomes that, if collected over time, will allow the efficiency of resource use across the system to be measured. It discusses an application of the framework using existing data, which highlighted problems with measuring and costing veterinary inputs, and with quantifying the range of outputs and the impact of veterinary activities. The paper recommends that the framework proposed is reviewed and compared with work that has been carried out on the human health accounting systems. A true application of the framework will require data sets that can differentiate between public-sector, private-sector and non-governmental organisation investments and the cost of day-to-day animal health goods and services paid by animal owners. Data sets are also needed on animal health outcomes in order to compare investments with animal health outcomes and thereby: demonstrate the success of previous investments, identify weaknesses in the investment profile and ensure that future investments sustain an animal health system, which functions well.

Les auteurs exposent les grandes lignes d'un cadre permettant de définir et de hiérarchiser les améliorations à apporter aux investissements dans les systèmes de santé animale en vue d'une meilleure durabilité. Le cadre prévoit les apports financiers à prendre en compte, qui peuvent être répartis en investissements de fond et dépenses de fonctionnement. Ces derniers apports devraient établir une distinction entre les pertes de production qu'ils permettent d'éviter et l'atténuation d'impacts sociétaux plus larges tels que les effets négatifs des maladies sur le commerce et l'environnement. Dans l'ensemble, le cadre fournit des renseignements sur les coûts financiers d'un système de santé animale et sur les résultats obtenus ; collectées sur des durées longues, ces données permettront de mesurer l'efficacité de l'utilisation des ressources au sein du système. Les auteurs analysent les résultats d'une application du cadre à partir de données existantes, qui mettent en évidence les problèmes liés à la mesure et au chiffrage du coût des intrants vétérinaires et à la quantification des divers extrants et de l'impact des prestations vétérinaires. Les auteurs recommandent que le cadre proposé soit réexaminé et comparé à d'autres travaux relatifs aux systèmes de gestion financière de la médecine humaine. Une véritable application du cadre devra faire appel à des séries de données capables de différencier les investissements suivant leur provenance (secteur public, secteur privé, organisations non gouvernementales) et le coût des biens et services courants de santé animale pris en charge par les propriétaires d'animaux. Il faudra également disposer de données sur les résultats obtenus en santé animale afin de comparer les investissements avec ces résultats et de démontrer ainsi le succès des investissements réalisés, identifier les points faibles de la stratégie d'investissement et s'assurer que les investissements à venir soutiennent un système de santé animale qui fonctionne bien.

Los autores describen sucintamente un marco destinado a formular y jerarquizar medidas de mejora de las inversiones en los sistemas de sanidad animal para lograr que estos sean más sostenibles. Dicho marco incluye las aportaciones económicas, que pueden dividirse en inversiones básicas y gastos corrientes. Dentro de estas aportaciones conviene distinguir entre aquellas destinadas a evitar pérdidas productivas y aquellas que apuntan a reducir consecuencias de mayor calado para la sociedad, por ejemplo efectos negativos sobre el comercio o el medio ambiente. Globalmente, el marco ofrece información sobre los costos económicos del sistema de sanidad animal y los resultados zoosanitarios que, cuantificados a lo largo del tiempo, permitirán medir la eficiencia con que el conjunto del sistema utiliza los recursos. Los autores refieren una aplicación del marco en la que se emplearon datos concretos, lo que puso de manifiesto la existencia de problemas para medir las aportaciones veterinarias y evaluar su costo y para cuantificar los diversos resultados y efectos de la actividad veterinaria. Así pues, los autores abogan por revisar el marco propuesto y compararlo con el trabajo ya realizado en relación con sistemas de «contabilidad¼ de la salud humana. Para aplicar realmente este marco harán falta conjuntos de datos que permitan discriminar entre las inversiones del sector público, las del sector privado y las de organizaciones no gubernamentales y determinar el costo que tienen los bienes y servicios zoosanitarios cotidianos para los propietarios de animales. También se necesitan conjuntos de datos sobre los resultados zoosanitarios, que sirvan para comparar las inversiones con los resultados obtenidos en sanidad animal y, de este modo, demostrar el éxito de inversiones previas, detectar deficiencias en los patrones de inversión y asegurarse de que las futuras inversiones vengan a sostener un sistema de sanidad animal que funcione debidamente.

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review.

BACKGROUND: Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents. METHODS: Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose. RESULTS: Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis. CONCLUSIONS: Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Predicting intensive care and hospital outcome with the Dalhousie Clinical Frailty Scale: a pilot assessment.

Frailty may help to predict intensive care unit (ICU) patient outcome. The Dalhousie Clinical Frailty Scale (DCFS) is validated to assess frailty in ambulatory settings but has not been investigated in Australian ICUs. We conducted a prospective three-month study of patients admitted to a tertiary level ICU. Within 24 hours of ICU admission, the next of kin or nurse in charge assigned a DCFS score to the patient. Data were obtained to assess the association between frailty and patient outcome. The DCFS score was completed in 205 of 348 (59%) of eligible patient admissions. The mean DCFS score was 3.2 (±1.6). Overall frailty (DCFS>4) occurred in 28 of 205 patients (13%, confidence interval 9% to 17%), 13 of 93 (15%, confidence interval 10% to 25%) in patients aged >65 years and 5 of 11 (45%, confidence interval 21% to 71%) in those>85 years. Patients with chronic liver disease (P<0.001) and end-stage renal failure (P=0.009) were more likely to be frail. The DCFS score was not significantly associated with ICU or hospital mortality: odds ratio 0.98 (95% confidence interval 0.6 to 1.6) and odds ratio 1.07 (95% confidence interval 0.8 to 1.4), respectively. However, after adjustment for illness severity and requirement for palliative care, the DCFS score was significantly associated with increased (log) hospital length-of-stay (P=0.04) and age (P=0.001). Approximately 1 in 10 ICU patients were frail and this frequency increased with age. The DCFS was associated with patient age and comorbidities and potentially predicts increased hospital length-of-stay but not other outcomes. Strategies to improve compliance with DCFS completion are needed.

Microbiological impact of three commercial laying hen housing systems.

Hen housing for commercial egg production continues to be a societal and regulatory concern. Controlled studies have examined various aspects of egg safety, but a comprehensive assessment of commercial hen housing systems in the US has not been conducted. The current study is part of a holistic, multidisciplinary comparison of the diverse aspects of commercial conventional cage, enriched colony cage, and cage-free aviary housing systems and focuses on environmental and egg microbiology. Environmental swabs and eggshell pools were collected from all housing systems during 4 production periods. Total aerobes and coliforms were enumerated, and the prevalence of Salmonella and Campylobacter spp. was determined. Environmental aerobic and coliform counts were highest for aviary drag swabs (7.5 and 4.0 log cfu/mL, respectively) and enriched colony cage scratch pad swabs (6.8 and 3.8 log cfu/mL, respectively). Aviary floor and system wire shell pools had the greatest levels of aerobic contamination for all eggshell pools (4.9 and 4.1 log cfu/mL, respectively). Hens from all housing systems were shedding Salmonella spp. (89-100% of manure belt scraper blade swabs). The dry belt litter removal processes for all housing systems appear to affect Campylobacter spp. detection (0-41% of manure belt scraper blade swabs) considering detection of Campylobacter spp. was much higher for other environmental samples. Aviary forage area drag swabs were 100% contaminated with Campylobacter spp., whereas enriched colony cage scratch pads had a 93% positive rate. There were no differences in pathogen detection in the shell pools from the 3 housing systems. Results indicate egg safety is enhanced when hens in alternative housing systems use nest boxes. Additionally, current outcomes indicate the use of scratch pads in hen housing systems needs to be more thoroughly investigated for effects on hen health and egg safety.

Public health decisions: actions and consequences.

The goal of public health is to promote the best possible health for the whole population. Public health issues are numerous and can be unbelievably complex in form, scope, and possible consequence. Most public health decisions involve assessing several different options, weighing the respective benefits and risks of those options, and making difficult decisions that hopefully provide the greatest benefit to the affected populations. Many risk management decisions involve a variety of societal factors which modify risk assessment choices. The purpose of this paper is to point out difficulties in making decisions that impact public health. The intent of such decisions is to improve public health, but as illustrated in the paper, there can be unintended adverse consequences. Such unplanned issues require continued attention and efforts for responsible officials in the protection of environmental public health. This article presents examples of such events, when in the past, it was necessary to assess and regulate a number of potentially hazardous chemicals commonly used as insecticides, gasoline additives, and wood preservatives.

A quantitative risk assessment for the safety of carcase storage systems for scrapie infected farms.

AIMS: To determine the risk associated with the use of carcase storage vessels on a scrapie infected farm. METHODS AND RESULTS: A stochastic quantitative risk assessment was developed to determine the rate of accumulation and fate of scrapie in a novel low-input storage system. For an example farm infected with classical scrapie, a mean of 10(3·6) Ovine Oral ID50 s was estimated to accumulate annually. Research indicates that the degradation of any prions present may range from insignificant to a magnitude of one or two logs over several months of storage. CONCLUSIONS: For infected farms, the likely partitioning of remaining prion into the sludge phase would necessitate the safe operation and removal of resulting materials from these systems. If complete mixing could be assumed, on average, the concentrations of infectivity are estimated to be slightly lower than that measured in placenta from infected sheep at lambing. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first quantitative assessment of the scrapie risk associated with fallen stock on farm and provides guidance to policy makers on the safety of one type of storage system and the relative risk when compared to other materials present on an infected farm.

Improved precision in CHARMED assessment of white matter through sampling scheme optimization and model parsimony testing.

PURPOSE: The composite hindered and restricted model of diffusion provides microstructural indices that are potentially more specific than those from diffusion tensor imaging. However, in comparison to diffusion tensor imaging, the acquisition time is longer, limiting clinical applications. Moreover, the model requires several parameters to be estimated whose confidence intervals can be large. Here, the composite hindered and restricted model of diffusion acquisition and data processing pipelines are optimized to extend the utility of this approach. METHODS: A multishell sampling scheme was optimized using the electrostatic repulsion algorithm, combined with optimal ordering. The optimal protocol, using as few measurements as possible, was determined through leave-n-out analyses. Parsimonious model selection criteria were used to select between nested models, comprising up to three restricted compartments. The schemes were evaluated using both through Monte-Carlo simulations and in vivo data. RESULTS: The optimization/model selection procedure resulted in increased accuracy and precision on the estimated parameters, allowing for a reduction in acquisition time and marked improvements in data quality. The final protocol provided whole brain coverage data in only 12 min. CONCLUSION: Through careful optimization of the acquisition and analysis pipeline for the composite hindered and restricted model of diffusion, it is possible to reduce acquisition time for whole brain datasets to a time that is clinically applicable.

Management of raised glucose, a clinical decision tool to reduce length of stay of patients with hyperglycaemia.

OBJECTIVE: To assess whether the introduction of a management of raised glucose clinical decision tool could improve assessment of patients with hyperglycaemia by non-specialist physicians, leading to early discharge and improved quality of inpatient care. METHODS: Participants were adults aged 18 years or over presenting to the Medical Assessment Unit with a capillary blood glucose level > 11.1 mmol/l. Phase 1 of the study (phase 1) evaluated current clinical practice and potential impact of the clinical decision tool. Phase 2 evaluated the effectiveness of the management of raised glucose tool in clinical practice. Primary outcome measures were inpatient length of stay and same-calendar-day discharges. Secondary outcome measures were diabetes specialist input, patient assessment, intravenous insulin infusion use and patient satisfaction. RESULTS: Implementation of the management of raised glucose clinical decision tool allowed safe, same-calendar-day discharges of 40% of patients with hyperglycaemia as their primary reason for attendance. Median length of stay was lower in the phase 1 than in phase 2 (1.0 vs. 3.5 days, P < 0.01). Early discharge did not result in an increase in readmissions. There was improvement in hyperglycaemia assessment for all patients (P < 0.01), a reduction in the use of intravenous insulin infusions (P < 0.01) and high level of patient satisfaction. CONCLUSION: The management of raised glucose clinical decision tool resulted in a significant increase in the number of same-calendar-day discharges and reduction in hospital length of stay without adverse impact on readmission rates. Additionally, the tool was associated with improvements in inpatient diabetes care and patient satisfaction.

Patients' knowledge of pregnancy-related issues in inflammatory bowel disease and validation of a novel assessment tool ('CCPKnow').

BACKGROUND: Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patient's knowledge of IBD and its treatment before and during pregnancy. AIM: To develop a novel tool (Crohn's and Colitis Pregnancy Knowledge Score 'CCPKnow') to assess knowledge of pregnancy-related issues in IBD. The validated tool was then applied to determine knowledge in patients. METHOD: Discriminate ability of 'CCPKnow' was validated in four groups with different levels of IBD knowledge. Reliability and readability were tested by Cronbach-α and Flesch-Kencaid. Construct validity was subsequently assessed against general IBD knowledge (CCKnow) in 145 women with IBD. Associations between patient factors and knowledge were studied. RESULTS: Median CCPKnow scores differed significantly between the validation groups (P < 0.001). CCPKnow displayed excellent internal consistency, reliability (Cronbach-α 0.94), readability (reading age 9 years) and close correlation with CCKnow (Spearman's ρ 0.64; P < 0.001). Of 145 patients, 44.8% had poor, 27.6% adequate, 17.3% good and only 10.3% very good knowledge. Better knowledge was associated with Caucasian ethnicity, higher income, having a partner, having children, Crohn's and Colitis Association membership, longer disease duration and Crohn's disease. CONCLUSIONS: Crohn's and Colitis Pregnancy Knowledge Score, a novel knowledge assessment tool of pregnancy and IBD, demonstrated excellent test characteristics. We found that nearly half of the women with IBD had poor knowledge, identifying a pressing need for better education.

Effect of systemic antibiotics and topical chlorhexidine on meticillin-resistant Staphylococcus aureus carriage in intensive care unit patients.

Antibiotics and antiseptics have the potential to influence carriage and transmission of meticillin-resistant Staphylococcus aureus (MRSA), although effects are likely to be complex, particularly in a setting where multiple agents are used. Here admission and weekly MRSA screens and daily antibiotic and antiseptic prescribing data from 544 MRSA carriers on an intensive care unit (ICU) are used to determine the effect of these agents on short-term within-host MRSA carriage dynamics. Longitudinal data were analysed using Markov models allowing patients to move between two states: MRSA positive (detectable MRSA carriage) and MRSA negative (no detectable carriage). The effect of concurrent systemic antibiotic and topical chlorhexidine (CHX) on movement between these states was assessed. CHX targeted to MRSA screen carriage sites increased transition from culture positive to negative and there was also weaker evidence that it decreased subsequent transition from negative back to positive. In contrast, there was only weak and inconsistent evidence that any antibiotic influenced transition in either direction. For example, whereas univariate analysis found quinolones to be strongly associated with both increased risk of losing and then reacquiring MRSA carriage over time intervals of one day, no effect was seen with weekly models. Similar studies are required to determine the generalisability of these findings.

Open Air Laboratories (OPAL): a community-driven research programme.

OPAL is an English national programme that takes scientists into the community to investigate environmental issues. Biological monitoring plays a pivotal role covering topics of: i) soil and earthworms; ii) air, lichens and tar spot on sycamore; iii) water and aquatic invertebrates; iv) biodiversity and hedgerows; v) climate, clouds and thermal comfort. Each survey has been developed by an inter-disciplinary team and tested by voluntary, statutory and community sectors. Data are submitted via the web and instantly mapped. Preliminary results are presented, together with a discussion on data quality and uncertainty. Communities also investigate local pollution issues, ranging from nitrogen deposition on heathlands to traffic emissions on roadside vegetation. Over 200,000 people have participated so far, including over 1000 schools and 1000 voluntary groups. Benefits include a substantial, growing database on biodiversity and habitat condition, much from previously unsampled sites particularly in urban areas, and a more engaged public.