An investigation into the clinical utility of ipsilateral/contralateral asymmetries in bone-conduction auditory steady-state responses.

OBJECTIVE: To determine whether ipsilateral/contralateral asymmetries in the bone-conduction (BC) ASSR are robust enough in infants to be used clinically to isolate the test ear. DESIGN: Retrospective investigation of three two-channel BC ASSR datasets. SUBJECTS: Forty-eight adults (mean age 26.7 years), 49 infants (mean age 29.6 weeks). METHODS: BC ASSR stimuli were presented as amplitude/frequency modulated sinusoidal tones with carrier frequencies of 500, 1000, 2000, and 4000 Hz (-10 to 45 dB HL). RESULTS: Infants showed greater differences in ipsilateral/contralateral mean amplitudes and phase delays for all experimental conditions compared to adults. Ninety percent of infants had ipsilateral/contralateral asymmetries at 500 and 4000 Hz (20-35 dB HL) using an "amplitude or phase delay" criterion, and at 4000 Hz (20-25 dB HL) using an "amplitude and phase delay" criterion. CONCLUSIONS: As ipsilateral/contralateral asymmetries are not consistently present for 1000- and 2000-Hz BC ASSRs in infants, clinical masking would be needed at these frequencies to isolate the test ear. For 500- and 4000-Hz BC ASSRs, the accuracy of using these asymmetries requires clinical confirmation in a group of infants with hearing loss.

Exploring the perceptions and experiences of community rehabilitation for Long COVID from the perspectives of Scottish general practitioners' and people living with Long COVID: a qualitative study.

OBJECTIVES: To explore the experience of accessing Long COVID community rehabilitation from the perspectives of people with Long COVID and general practitioners (GPs). DESIGN: Qualitative descriptive study employing one-to-one semistructured virtual interviews analysed using the framework method. SETTING: Four National Health Service Scotland territorial health boards. PARTICIPANTS: 11 people with Long COVID (1 male, 10 female; aged 40-65 (mean 53) and 13 GPs (5 male, 8 female). RESULTS: Four key themes were identified: (1) The lived experience of Long COVID, describing the negative impact of Long COVID on participants' health and quality of life; (2) The challenges of an emergent and complex chronic condition, including uncertainties related to diagnosis and management; (3) Systemic challenges for Long COVID service delivery, including lack of clear pathways for access and referral, siloed services, limited resource and a perceived lack of holistic care, and (4) Perceptions and experiences of Long COVID and its management, including rehabilitation. In this theme, a lack of knowledge by GPs and people with Long COVID on the potential role of community rehabilitation for Long COVID was identified. Having prior knowledge of rehabilitation or being a healthcare professional appeared to facilitate access to community rehabilitation. Finally, people with Long COVID who had received rehabilitation had generally found it beneficial. CONCLUSIONS: There are several patient, GP and service-level barriers to accessing community rehabilitation for Long COVID. There is a need for greater understanding by the public, GPs and other potential referrers of the role of community rehabilitation professionals in the management of Long COVID. There is also a need for community rehabilitation services to be well promoted and accessible to the people with Long COVID for whom they may be appropriate. The findings of this study can be used by those (re)designing community rehabilitation services for people with Long COVID.

Investigating Scottish Long COVID community rehabilitation service models from the perspectives of people living with Long COVID and healthcare professionals: a qualitative descriptive study.

OBJECTIVES: This study aimed to explore the perceptions and experiences of barriers and facilitators to accessing Long COVID community rehabilitation. DESIGN: We used a qualitative descriptive design over two rounds of data collection with three participant groups: (1) people with experience of rehabilitation for Long COVID (PwLC); (2) National Health Service (NHS) staff delivering and/or managing community rehabilitation services (allied health professionals (AHPs)) and (3) NHS staff involved in strategic planning around Long COVID in their health board (Long COVID leads). SETTING: Four NHS Scotland territorial health boards. PARTICIPANTS: 51 interviews: eight Long COVID leads (11 interviews); 15 AHPs (25 interviews) and 15 PwLC (15 interviews). RESULTS: Three key themes were identified: (1) accessing care for PwLC, (2) understanding Long COVID and its management and (3) strengths and limitations of existing Long COVID rehabilitation services. CONCLUSIONS: Organisational delivery of Long COVID community rehabilitation is complex and presents multiple challenges. In addition, access to Long COVID community rehabilitation can be challenging. When accessed, these services are valued by PwLC but require adequate planning, publicity and resource. The findings presented here can be used by those developing and delivering services for people with Long COVID.

Patterns in nutrient concentrations and biological quality indices across the upper Thames river basin, UK.

This paper examines the nutrient chemistry and biological quality indices [Mean Trophic Rank (MTR) and Trophic Diatom Index (TDI)] for rivers within the upper Thames basin. The predominant sources of nitrogen within the rivers monitored were diffuse and agricultural in nature. However, phosphorus showed both diffuse and point source signals. MTR surveys undertaken both upstream and downstream of major STWs indicate that these rivers are 'at risk' of eutrophication or 'badly damaged'. MTR surveys also indicate increased trophic status downstream of STWs, whereas TDI does not indicate such a consistent pattern. Phosphorus treatment at selected major sewage treatment works in the upper Thames basin resulted in significant reductions in in-stream P concentrations and reductions in fluxes by a half to two thirds. However, the effects of P-reduction on in-stream ecology (measured as MTR and TDI) were more difficult to ascribe, owing to: (1) the high variability in river flow rates experienced since P-reduction was introduced; (2) lag effects related to P stores in river bed sediments; and (3) diffuse and smaller point source inputs upstream. The results of this study indicate that control of upstream sources of phosphorus may prove critical in improving the biological quality status of UK lowland rivers, including ecological responses to P-source controls on the major sewage treatment works downstream. Upstream sources include both diffuse (agricultural) sources and small point source inputs which, at present, are not classified as 'qualifying discharges' under the Urban Wastewater Treatment Directive (UWWTD) and are thus not subject to phosphorus control measures. These results are of relevance for integrated, sustainable management and protection of European freshwater resources, particularly in terms of new ecological targets for water quality management under the new Water Framework Directive.

General Practitioners' perceptions of their role in cancer care and factors which influence this role.

Effective cancer care depends on inter-sectoral and inter-professional communication. General Practitioners (GPs) play a pivotal role in managing the health of most Australians, but their role in cancer care is unclear. This qualitative study explored GPs' views of this role and factors influencing their engagement with cancer care. Twelve metropolitan and non-metropolitan GPs in Queensland, Australia, were recruited between April and May 2008, and three focus groups and one interview were conducted using open-ended questions. The transcripts were analysed thematically. The first theme, GPs' perceptions of their role, comprised subthemes corresponding to four phases of the trajectory. The second theme, Enhancing GPs' involvement in ongoing cancer care, comprised subthemes regarding enhanced communication and clarification of roles and expectations. GPs' role in cancer care fluctuates between active advocacy during diagnosis and palliation, and ambivalent redundancy in between. The role is influenced by socioeconomic, clinical and geographical factors, patients' expectations and GPs' motivation. Not all participants wanted an enhanced role in cancer care, but all valued better specialist-GP communication. Role clarification is needed, together with greater mutual trust between GPs and specialists. Key needs included accessible competency training and mentoring for doctors unfamiliar with the system. Existing system barriers and workforce pressures in general practice must be addressed to improve the sharing of cancer care. Only one metropolitan focus group was conducted, so saturation of themes may not have been reached. The challenges of providing cancer care in busy metropolitan practices are multiplied in non-metropolitan settings with less accessible resources and where distance affects specialist communication. Non-metropolitan GPs learn from experience how to overcome referral and communication challenges. While the GPs identified solutions to their concerns, the role can be daunting. GPs are motivated to provide long-term care for their patients, but need to be acknowledged and supported by the health system.

Declines in phosphorus concentration in the upper River Thames (UK): links to sewage effluent cleanup and extended end-member mixing analysis.

Phosphorus concentrations in the upper River Thames Basin (southeastern England) are described and linked to sewage effluent sources. Weekly surveys between 1997 and 2007 of the Thames and two of its major tributaries, the Thame and the Kennet indicated that phosphorus was mainly in soluble reactive (SRP) form. Baseflow concentrations in the Thames reduced from 1584microg/l in 1998 to 376microg/l in 2006 and from 2655 to 715microg/l for the Thame. Flow response, flux and endmember mixing analysis indicated that these declines resulted from SRP reductions in sewage treatment works (STW) effluent following phosphorus stripping for the major STWs in the region. This was confirmed by comparing our analysis with direct measurements of SRP in the effluents based on Environment Agency data. A within-river loss under baseflow of approximately 64% (range 56-78%) of the SRP-effluent input was estimated for the Thames, with a near balance for the Thame. SRP concentrations in the Kennet were an order of magnitude lower than the Thames/Thame: non-point sources dominated and were important for all the rivers at high flows. It was concluded that removal of SRP from effluents would be insufficient SRP in the Thames and Thame to meet annual average environmental targets of 50 to 120microg/l. The paper flags the value of combining hydrological/chemical tracing and concentration/flux approaches to data interrogation and the bonus of having actual measurements of the effluent. It highlights the need for fuller assessment of water storage/sediment/biota interactions for phosphorus and for caution in using boron as a long-term tracer for effluent inputs, its concentrations having declined markedly in response to reduced usage in washing powders: the value of using sodium as a tracer for examining SRP changes is shown.