Search

Background Guidelines recommend that asthma medication should be stepped down to the minimally effective dose that achieves symptom control. Stepping down aims to prevent adverse medication effects and unnecessary costs but is often not implemented in primary care, where most patients with asthma are managed. Little is known about the experiences and views of patients regarding stepping down.Methods Patients with stable asthma, with regular use of a preventer inhaler, from general practitioner practices across England, participated in a survey and/or semi-structured interview. Questions explored the patient’s understanding of their asthma, views and knowledge of preventer inhalers, experiences and perceptions of stepping down asthma medication. Qualitative group-based multidisciplinary thematic analysis by two healthcare professionals and a patient were performed.Results 143 patients responded to the survey, 63% were female, between the ages 18–80 years and including geographical areas across the UK, 17 of whom participated in an interview. Half of these patients with stable asthma, most with asthma for more than 10 years, had never had a discussion regarding stepping down asthma medication. Most stepping down that had occurred was related to seasonal changes in asthma control. Four overarching themes from the interviews were identified, (1) experiences of living with asthma and needing inhalers, (2) insufficient education regarding preventer inhalers, (3) stepping down is agreeable and possible and (4) current asthma care is suboptimal.Conclusion Patients with stable asthma were able to self-manage their asthma well. They had little awareness of medication adverse effects and minimal experience of having their medication stepped down by a healthcare professional. Most were inclined to step down, if clinically safe to do so, indeed some had reduced their medication doses themselves, without professional guidance.

Spatially explicit, near real time information on surface water dynamics is critical for understanding changes in water resources, and for long-term water security planning. The distribution of surface water across the African continent since 1984 and updated as every new Landsat scene becomes available is presented here, and validated for the continent for the first time. We applied the Water Observations from Space (WOfS) algorithm, developed and well-tested in Australia, to every Landsat scene acquired over Africa since the mid 1980s to provide spatial information on surface water dynamics over the past 30+ years. We assessed the accuracy of WOfS using aerial and satellite imagery. Four regional geospatial organisations, coordinated through the Digital Earth Africa Product Development Task Team, conducted the validation campaign and provided both the regional expertise and experience required for a continental-scale validation effort. We assessed whether the point was wet, dry, or cloud covered, for each of the 12 months in 2018, resulting in 34,800 labelled observations. As waterbodies larger than 100 km2 are easy to identify with Landsat resolution data and can thus boost accuracy, these were masked out. The resulting overall accuracy of the water classification was 82%. WOfS in Africa is expected to be used by ministries and departments of agriculture and water across the continent, by international organisations, academia, and the private sector. A large-scale collaborative effort, which included regional and technical skills spanning two continents was required to create a service that is regionally accurate and is both hosted on, and implemented operationally from, the African continent.

Background Singing for lung health (SLH) is an arts-based breathing control and movement intervention for people with long-term respiratory conditions, intended to improve symptoms and quality of life. Online, remotely delivered programmes might improve accessibility; however, no previous studies have assessed the effectiveness of this approach.Methods We conducted an assessor-blind randomised controlled trial comparing the impact of 12 weeks of once-weekly online SLH sessions against usual care on health-related quality of life, assessed using the RAND 36-Item Short Form Health Survey (SF-36) Mental Health Composite (MHC) and Physical Health Composite (PHC) scores.Results We enrolled 115 people with stable chronic obstructive pulmonary disease (COPD), median (IQR) age 69 (62–74), 56.5% females, 80% prior pulmonary rehabilitation, Medical Research Council dyspnoea scale 4 (3–4), forced expiratory volume in 1 s % predicted 49 (35–63). 50 participants in each arm completed the study. The intervention arm experienced improvements in physical but not mental health components of RAND SF-36; PHC (regression coefficient (95% CI): 1.77 (95% CI 0.11 to 3.44); p=0.037), but not MHC (0.86 (95% CI −1.68 to 3.40); p=0.504). A prespecified responder analysis based on achieving a 10% improvement from baseline demonstrated a response rate for PHC of 32% in the SLH arm and 12.7% for usual care (p=0.024). A between-group difference in responder rate was not found in relation to the MHC (19.3% vs 25.9%; p=0.403).Discussion and conclusion A 12-week online SLH programme can improve the physical component of quality of life for people with COPD, but the overall effect is relatively modest compared with the impact seen in research using face-to-face group sessions. Further work on the content, duration and dose of online interventions may be useful.Trial registration number NCT04034212.

ABSTRACTThe technological landscape for managing big Earth observation (EO) data ranges from global solutions on large cloud infrastructures with web-based access to self-hosted implementations. EO data cubes are a leading technology for facilitating big EO data analysis and can be deployed on different spatial scales: local, national, regional, or global. Several EO data cubes with a geographic focus (“local EO data cubes”) have been implemented. However, their alignment with the Digital Earth (DE) vision and the benefits and trade-offs in creating and maintaining them ought to be further examined. We investigate local EO data cubes from five perspectives (science, business and industry, government and policy, education, communities and citizens) and illustrate four examples covering three continents at different geographic scales (Swiss Data Cube, semantic EO data cube for Austria, DE Africa, Virginia Data Cube). A local EO data cube can benefit many stakeholders and players but requires several technical developments. These developments include enabling local EO data cubes based on public, global, and cloud-native EO data streaming and interoperability between local EO data cubes. We argue that blurring the dichotomy between global and local aligns with the DE vision to access the world’s knowledge and explore information about the planet.

Objectives To explore physiotherapists’ opinions of physiotherapy assessment of Breathing Pattern Disorder (BPD).Methods Qualitative study using focus groups (FGs) with reflexive thematic analysis and survey methods. The survey was distributed via social media and email to UK specialist physiotherapy interest groups. Two FGs, conducted in different settings, included physiotherapists based in hospital outpatients/community, private practice and higher education.Results One-hundred-and-three physiotherapists completed the survey. Respondents identified a lack of consensus in how to define BPD, but some agreement in the components to include in assessment. Fifteen physiotherapists participated in the FGs. Three themes emerged from FG discussions: (1) nomenclature and language of breathing, (2) BPD and breathlessness and (3) The value of assessment of breathlessness.Conclusion The inconsistent nomenclature of dysfunctional breathing pattern impacts assessment, management and understanding of the diagnosis. Clarity in diagnosis, informing consistency in assessment, is fundamental to improving recognition and treatment of BPD. The findings are useful in the planning of education, training, future research and guideline development in BPD assessment.

Abstract Background Prior studies support a genetic basis for postoperative acute kidney injury (AKI). We conducted a genome-wide association study (GWAS), assessed the clinical utility of a polygenic risk score (PRS), and estimated the heritable component of AKI in patients who underwent noncardiac surgery. Methods We performed a retrospective large-scale genome-wide association study followed by a meta-analysis of patients who underwent noncardiac surgery at the Vanderbilt University Medical Center (“Vanderbilt” cohort) or Michigan Medicine, the academic medical center of the University of Michigan (“Michigan” cohort). In the Vanderbilt cohort, the relationship between polygenic risk score for estimated glomerular filtration rate and postoperative AKI was also tested to explore the predictive power of aggregating multiple common genetic variants associated with AKI risk. Similarly, in the Vanderbilt cohort genome-wide complex trait analysis was used to estimate the heritable component of AKI due to common genetic variants. Results The study population included 8248 adults in the Vanderbilt cohort (mean [SD] 58.05 [15.23] years, 50.2% men) and 5998 adults in Michigan cohort (56.24 [14.76] years, 49% men). Incident postoperative AKI events occurred in 959 patients (11.6%) and in 277 patients (4.6%), respectively. No loci met genome-wide significance in the GWAS and meta-analysis. PRS for estimated glomerular filtration rate explained a very small percentage of variance in rates of postoperative AKI and was not significantly associated with AKI (odds ratio 1.050 per 1 SD increase in polygenic risk score [95% CI, 0.971–1.134]). The estimated heritability among common variants for AKI was 4.5% (SE = 4.5%) suggesting low heritability. Conclusion The findings of this study indicate that common genetic variation minimally contributes to postoperative AKI after noncardiac surgery, and likely has little clinical utility for identifying high-risk patients.

Background: The recent integration of genomic data with electronic health records has enabled large scale genomic studies on a variety of perioperative complications, yet genome-wide association studies on acute kidney injury have been limited in size or confounded by composite outcomes. Genome-wide association studies can be leveraged to create a polygenic risk score which can then be integrated with traditional clinical risk factors to better predict postoperative complications, like acute kidney injury.Methods: Using integrated genetic data from two academic biorepositories, we conduct a genome-wide association study on cardiac surgery-associated acute kidney injury. Next, we develop a polygenic risk score and test the predictive utility within regressions controlling for age, gender, principal components, preoperative serum creatinine, and a range of patient, clinical, and procedural risk factors. Finally, we estimate additive variant heritability using genetic mixed models.Results: Among 1,014 qualifying procedures at Vanderbilt University Medical Center and 478 at Michigan Medicine, 348 (34.3%) and 121 (25.3%) developed AKI, respectively. No variants exceeded genome-wide significance (p < 5 × 10−8) threshold, however, six previously unreported variants exceeded the suggestive threshold (p < 1 × 10−6). Notable variants detected include: 1) rs74637005, located in the exonic region of NFU1 and 2) rs17438465, located between EVX1 and HIBADH. We failed to replicate variants from prior unbiased studies of post-surgical acute kidney injury. Polygenic risk was not significantly associated with post-surgical acute kidney injury in any of the models, however, case duration (aOR = 1.002, 95% CI 1.000–1.003, p = 0.013), diabetes mellitus (aOR = 2.025, 95% CI 1.320–3.103, p = 0.001), and valvular disease (aOR = 0.558, 95% CI 0.372–0.835, p = 0.005) were significant in the full model.Conclusion: Polygenic risk score was not significantly associated with cardiac surgery-associated acute kidney injury and acute kidney injury may have a low heritability in this population. These results suggest that susceptibility is only minimally influenced by baseline genetic predisposition and that clinical risk factors, some of which are modifiable, may play a more influential role in predicting this complication. The overall impact of genetics in overall risk for cardiac surgery-associated acute kidney injury may be small compared to clinical risk factors.

NaK is a bacterial non-selective cation channel. Here, the authors use solution NMR to show that selectivity filter (SF) in NaK is dynamic, with structural differences between the Na+ and K + -bound states. The conformation of the SF is communicated to the pore-lining helices similarly as in the K + -selective channels.

Introduction Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD.Methods and analysis This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18–40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants’ intervention and trial experiences.Ethics and dissemination This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science’s Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal.Trial registration number This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw).

Non cystic-fibrosis bronchiectasis (NCFB) is a complex chronic respiratory disease, characterised by excessive sputum production and abnormal permanent dilation of bronchi. Mucus accumulation leads to recurrent bacterial infections and increased bacterial load, causing vicious cycles of structural damage and decreased lung function. Respiratory physiotherapy management of NCFB includes airway clearance techniques and use of nebulised, hypertonic saline. Despite advances in treatment, a consistent relationship has been observed between gender and disease occurrence, with a higher prevalence amongst females. Furthermore, NCFB presents most aggressively amongst post-menopausal females, a group likely exposed to higher levels of progesterone (P4) over a longer period of time. The effects of gender-specific hormones on bacterial load and physiotherapy management of people living with NCFB remain unknown. The aim of this narrative review was to discuss the potential influence of gender specific hormones on NCFB disease progression and influence on physiotherapy, medical management and future research. SCOPUS and PUBMED electronic databases were used to conduct searches for relevant studies using specific inclusion and exclusion criteria. Secondary inclusion of relevant literature was obtained from primary paper references. Previous literature suggests that P4 may impair Cilia Beat Frequency (CBF) in airway epithelium. Reduction in CBF may further reduce ability to expectorate amongst individuals with NCFB, increasing bacterial load and likelihood of exacerbations, negatively impacting on disease progression. Furthermore, coadministration of Estrogen has been suggested to offer opposing effects to that of P4 only. These findings question whether hormonal levels may be monitored, controlled and optimised within management and treatment of females with NCFB to improve airway clearance, reduce exacerbations and improve quality of life. Larger scale, long-term trials are required to further explore the effects of gender specific hormones on NCFB and the viability of treatment with hormone replacement therapy. The reviews of this paper are available via the supplemental material section .

Singing is an increasingly popular activity for people with chronic obstructive pulmonary disease (COPD). Research to date suggests that ‘Singing for Lung Health’ may improve various health measures, including health-related quality-of-life. Singing and breathing are closely linked processes affecting one another. In this narrative review, we explore the physiological rationale for ‘Singing for Lung Health’ as an intervention, focusing on the abnormalities of pulmonary mechanics seen in COPD and how these might be impacted by singing. The potential beneficial physiological mechanisms outlined here require further in-depth evaluation.

Introduction Participating in singing is considered to have a range of social and psychological benefits. However, the physiological demands of singing and its intensity as a physical activity are not well understood.Methods We compared cardiorespiratory parameters while completing components of Singing for Lung Health sessions, with treadmill walking at differing speeds (2, 4 and 6 km/hour).Results Eight healthy adults were included, none of whom reported regular participation in formal singing activities. Singing induced acute physiological responses that were consistent with moderate intensity activity (metabolic equivalents: median 4.12, IQR 2.72–4.78), with oxygen consumption, heart rate and volume per breath above those seen walking at 4 km/hour. Minute ventilation was higher during singing (median 22.42 L/min, IQR 16.83–30.54) than at rest (11 L/min, 9–13), lower than 6 km/hour walking (30.35 L/min, 26.94–41.11), but not statistically different from 2 km/hour (18.77 L/min, 16.89–21.35) or 4 km/hour (23.27 L/min, 20.09–26.37) walking.Conclusions Our findings suggest the acute metabolic demands of singing are comparable with walking at a moderately brisk pace, hence, physical effects may contribute to the health and well-being benefits attributed to singing participation. However, if physical training benefits result remains uncertain. Further research including different singing styles, singers and physical performance impacts when used as a training modality is encouraged.Trial registration number ClinicalTrials.gov registry (NCT04121351).

Introduction SARS-CoV-2 has restricted access to face-to-face delivery of pulmonary rehabilitation (PR). Evidence suggests that telehealth-PR is non-inferior to outpatient PR. However, it is unknown whether patients who have been referred to face-to-face programmes can feasibly complete an online-PR programme.Methods This service evaluation used a mixed-methods approach to investigate a rapid PR service remodelling using the University of Gloucestershire eLearn Moodle platform. Quantitative baseline demographic and PR outcome data were collected from online-PR participants, and semistructured interviews were completed with PR staff and participants.Results Twenty-five individuals were eligible from a PR waiting list. Thirteen declined participation and 14 completed PR. Significant pre-post online PR improvements were achieved in 1 min sit-to-stand (CI 2.1 to 9 (p=0.004)), Generalised Anxiety Disorder (CI −0.3 to −2.6 (p=0.023)), Primary Health Questionnaire-9 (CI −0.3 to −5.1 (p=0.029)), Chronic Respiratory Questionnaire dyspnoea (CI 0.5 to 1.3 (p=0.001)), fatigue (CI 0.7 to 2 (p=0.0004)), emotion (CI 0.7 to 1.7 (p=0.0002)), mastery (CI 0.4 to 1.3 (p=0.001)). Interviews indicated that patient PR inclusion was made possible with digital support and a PR introduction session improved participant engagement and safety. Incremental progression of exercise was perceived as more successful online compared with face-to-face PR. However, perceptions were that education sessions were less successful. Online-PR required significant staff time resource.Discussion Online-PR improves patient outcomes and is feasible and acceptable for individuals referred for face-to-face PR in the context of a requirement for social distancing. Face-to-face programmes can be adapted in a rapid fashion with both staff and participants perceiving benefit. Future pragmatic trials are now warranted comparing online-PR including remote assessments to centre-based PR with suitably matched outcomes, and patient and staff perceptions sought regarding barriers and facilitators of online delivery.

Objectives To establish what proportion of patients completing a UK pulmonary rehabilitation (PR) programme meet the 2018 National Institute for Health and Care Excellence (NICE) chronic obstructive pulmonary disease (COPD) guideline (NG115) criteria to have a respiratory review to establish whether referral to a lung volume reduction multidisciplinary team would be appropriate. This respiratory review would include evaluation of the presence of hyperinflation and the presence of emphysema on CT scan. The NICE criteria include measures of breathlessness and exercise capacity but these parameters are not completely defined.Design Observational study.Setting PR programmes across the UK in 2015 (210 centres) and 2017 (184 centres) entering data into the Royal College of Physicians’ National Asthma and COPD Audit Programme.Participants 8295 (55.7%) of 14 889 patients in programmes using incremental shuttle walk test (ISWT) or 6-minute walk test (6MWT) as an outcome measure completed PR, and 4856 (32.6%) had complete data recorded (6MWT/ISWT, baseline spirometry, Medical Research Council (MRC) dyspnoea score).Results Depending on the walking test safety threshold adopted for the ISWT (≥140 m or ≥ 80 m) and the MRC dyspnoea score threshold used (MRC score ≥3 or ≥4 at the end of PR), between 4.9% and 18.1% of PR completers met the NICE criteria for a lung volume reduction-focused respiratory review.Conclusions Lung volume reduction therapies are beneficial in appropriately selected patients with COPD, but few procedures are performed, and treatment pathways are unclear. These data help to inform the feasibility of the approach recommended by NICE and highlight the need for future systematic pathways to reduce inequalities in patients being considered for effective treatments.

Objectives To explore the experiences and perceived impact on health and well-being related to participation in a dance group for people with chronic respiratory disease (CRD).Design An exploratory qualitative study using thematic analysis of semistructured interviews.Setting A community dance group in a UK health centre.Participants Convenience sample of long-term dance group participants.Intervention Weekly community dance sessions designed for people with breathlessness, lasting 75 min, led by a trained community dance leader.Results Convenience sample of eight participants, six females, aged 57–87 years (mean 75), with a median 2-year attendance at weekly dance sessions. Long-term attendance was driven by strongly held beliefs regarding the health and well-being benefits of participation. Four key themes were identified: dance as (1) a holistically beneficial activity, with physical and psychosocial health benefits including improved or maintained physical fitness and psychological well-being, and reduced need for healthcare; (2) an integral part of their life; (3) an enjoyable activity; and (4) a source of deep social cohesion.Conclusions Dance group participants perceived a broad range of health benefits of relevance to the biopsychosocial impacts of their respiratory disease. The themes identified are useful in the ongoing planning and evaluation of dance as a holistic complex intervention for people with CRD. Further research is required to assess the extent of health impacts identified, and how dance might be most effectively placed as an option in the management of CRD.Trial registration number NCT04006015.

Objectives To integrate evidence from randomised controlled trials (RCTs) and observational studies on the efficacy of inhaled treatments for chronic obstructive pulmonary disease using network meta-analyses.Methods Systematic searches MEDLINE and Embase based on predetermined criteria. Network meta-analyses of RCTs investigated efficacy on exacerbations (long-term: ≥20 weeks of treatment; short-term:

Introduction Singing for lung health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions. Participants report biopsychosocial benefits, however, research on impact is limited. The ‘SLH: Improving Experiences of Lung Disease trial’, a randomised controlled, single (assessor) blind, trial of 12 weeks SLH versus usual care for people with chronic obstructive pulmonary disease (COPD) (n=120) was setup to help to address this. The first group (n=18, nine singing and nine controls) started face-to-face (five sessions) before changing to online delivery (seven sessions) due to COVID-19-related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.Methods We conducted semistructured interviews and thematic analysis regarding barriers, facilitators and key considerations for transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, premeasures and postmeasures of quality of life and disease impact (Short Form 36 Health Survey, COPD Assessment Test score), breathlessness (Medical Research Council breathlessness scale, Dyspnoea-12), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalised Anxiety Disorder-7), balance confidence (Activity specific Balance Confidence, ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).Results Attendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semistructured interviews identified three themes regarding participation in SLH delivered face to face and online, these where (1) perceived benefits; (2) digital barriers (online) and (3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect −4.78 PHQ-9 points, p

Harmful algal blooms (HABs) are a naturally occurring global phenomena that have the potential to impact fisheries, leisure and ecosystems, as well as posing a significant hazard to animal and human health. There is significant interest in the development and application of methodologies to study all aspects of the causative organisms and toxins associated with these events. This paper reports the first application of nanopore sequencing technology for the detection of eukaryotic harmful algal bloom organisms. The MinION sequencing platform from Oxford Nanopore technologies provides long read sequencing capabilities in a compact, low cost, and portable format. In this study we used the MinION to sequence long-range PCR amplicons from multiple dinoflagellate species with a focus on the genus Alexandrium. Primers applicable to a wide range of dinoflagellates were selected, meaning that although the study was primarily focused on Alexandrium the applicability to three additional genera of toxic algae, namely; Gonyaulax, Prorocentrum, and Lingulodinium was also demonstrated. The amplicon generated here spanned approximately 3 kb of the rDNA cassette, including most of the 18S, the complete ITS1, 5.8S, ITS2 and regions D1 and D2 of the 28S. The inclusion of barcode genes as well as highly conserved regions resulted in identification of organisms to the species level. The analysis of reference cultures resulted in over 99% of all sequences being attributed to the correct species with an average identity above 95% from a reference list of over 200 species (see Supplementary Material 1). The use of mock community analysis within environmental samples highlighted that complex matrices did not prevent the ability to distinguish between phylogenetically similar species. Successful identification of causative organisms in environmental samples during natural toxic events further highlighted the potential of the assay. This study proves the suitability of nanopore sequencing technology for taxonomic identification of harmful algal bloom organisms and acquisition of data relevant to the World Health Organisations “one health” approach to marine monitoring.

Abstract This article, co-authored by a patient living with chronic obstructive pulmonary disease (COPD) and a respiratory physiotherapist, discusses the patient’s experience of COPD and singing as a form of therapy. The clinician then discusses his experience of Singing for Lung Health in the context of the patient, and how more research is needed in this area.

Digital Earth Africa is now providing an operational Sentinel-1 normalized radar backscatter dataset for Africa. This is the first free and open continental scale analysis ready data of this kind that has been developed to be compliant with the CEOS Analysis Ready Data for Land (CARD4L) specification for normalized radar backscatter (NRB) products. Partnership with Sinergise, a European geospatial company and Earth observation data provider, has ensured this dataset is produced efficiently in the cloud infrastructure and can be sustained in the long term. The workflow applies radiometric terrain correction (RTC) to the Sentinel-1 ground range detected (GRD) product, using the Copernicus 30 m digital elevation model (DEM). The method is used to generate data for a range of sites around the world and has been validated as producing good results. This dataset over Africa is made available publicly as a AWS public dataset and can be accessed through the Digital Earth Africa platform and its Open Data Cube API. We expect this dataset to support a wide range of applications, including natural resource monitoring, agriculture, and land cover mapping across Africa.

The Genus Alexandrium is a widespread dinoflagellate marine phytoplankton that is the primary causative organism causing Paralytic Shellfish Poisoning (PSP) intoxications in European waters. EU food safety directives specify that EU Member States must implement a routine monitoring programme to mitigate risks associated with bio-accumulation of biotoxins by bivalve shellfish, such as those produced by Alexandrium. This strategic drive comprises of both direct testing of bivalve flesh for the presence of regulated toxins and an early warning phytoplankton monitoring programme. In the UK the flesh testing moved away from animal bio-assays to analytical chemistry techniques, whereas phytoplankton monitoring methods have seen little technological advancement since implementation. Methods currently utilize light microscopy and manual enumeration of different algal species. These methods although proven are time consuming, reliant on highly trained staff, have high limits of detection (LOD) with low specificity, unable to reliably identify Alexandrium to species level. The implications of these limitations of the techniques mean that in the case of Alexandrium the LOD is also the action limit and as such it is easy to miss positive samples affecting the efficacy of any early warning strategy. This study outlines the development, preliminary method characterisation, validation and trial implementation of an alternative early warning technique, utilizing quantitative PCR to identify water samples containing Alexandrium cells. The approach outlined in this document, showed an improved correlation with flesh toxicity, improved sensitivity, improved throughput compared to traditional light microscopy methods and there was also good correlation with higher cell abundance samples when compared to the light microscopy results. The application of this approach to routine water samples was explored and was found to demonstrate potential as a corroborative method for use during flesh intoxication episodes. This study offers potential for future improvements in the accuracy and sensitivity of phytoplankton monitoring whilst ensuring continuity of public safety, providing cost savings and offering new research opportunities. Keywords: Harmful algal bloom, Biotoxin, Alexandrium, qPCR assay, Monitoring, TaqMan

The aim of this service improvement project was to gain understanding of the patient experience of lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement, from referral through to post-discharge care. Focus group interviews were carried out in two tertiary centres in London and Leicester, UK. Sixteen patients who had undergone lung volume reduction surgery (LVRS), endobronchial valve (EBV) placement, or both, were recruited. Prior to participation in each focus group, participants completed a questionnaire to guide and focus discussion. Thematic analysis identified common themes to the participant experience of receiving lung volume reduction interventions. Themes included patient focus on declining health and the need to “fight” for a referral; consequences of having procedures and potential unexpected complications; and vulnerability post discharge and limited continuity of care. Participants were clear that the benefits of having had either LVRS or EBV procedures outweighed any difficulties experienced. Participants were keen to have further similar interventions if appropriate. These data confirm the need to develop more systematic lung volume reduction pathways, provide appropriate information, and ensure that post-discharge care is optimal.

Combining data from multiple sensors into a single seamless time series, also known as data interoperability, has the potential for unlocking new understanding of how the Earth functions as a system. However, our ability to produce these advanced data sets is hampered by the differences in design and function of the various optical remote-sensing satellite systems. A key factor is the impact that calibration of these instruments has on data interoperability. To address this issue, a workshop with a panel of experts was convened in conjunction with the Pecora 20 conference to focus on data interoperability between Landsat and the Sentinel 2 sensors. Four major areas of recommendation were the outcome of the workshop. The first was to improve communications between satellite agencies and the remote-sensing community. The second was to adopt a collections-based approach to processing the data. As expected, a third recommendation was to improve calibration methodologies in several specific areas. Lastly, and the most ambitious of the four, was to develop a comprehensive process for validating surface reflectance products produced from the data sets. Collectively, these recommendations have significant potential for improving satellite sensor calibration in a focused manner that can directly catalyze efforts to develop data that are closer to being seamlessly interoperable.

Cyanobacterial blooms in freshwater bodies in England are currently monitored reactively, with samples containing more than 20,000 cells/mL of potentially toxin-producing species by light microscopy resulting in action by the water body owner. Whilst significantly reducing the risk of microcystin exposure, there is little data describing the levels of these toxins present in cyanobacterial blooms. This study focused on the quantitative LC-MS/MS analysis of microcystins in freshwater samples, collected across England during 2016 and found to contain potentially toxin-producing cyanobacteria. More than 50% of samples contained quantifiable concentrations of microcystins, with approximately 13% exceeding the WHO medium health threshold of 20 μg/L. Toxic samples were confirmed over a nine-month period, with a clear increase in toxins during late summer, but with no apparent geographical patterns. No statistical relationships were found between total toxin concentrations and environmental parameters. Complex toxin profiles were determined and profile clusters were unrelated to cyanobacterial species, although a dominance of MC-RR was determined in water samples from sites associated with lower rainfall. 100% of samples with toxins above the 20 μg/L limit contained cell densities above 20,000 cells/mL or cyanobacterial scum, showing the current regime is suitable for public health. Conversely, with only 18% of cell density threshold samples having total microcystins above 20 μg/L, there is the potential for reactive water closures to unnecessarily impact upon the socio-economics of the local population. In the future, routine analysis of bloom samples by LC-MS/MS would provide a beneficial confirmatory approach to the current microscopic assessment, aiding both public health and the needs of water users and industry.

The capillary/channel length is an important factor in capillary electrophoresis (CE) systems since it is directly related to the amount of separation attainable. In this work we present methods to increase the effective channel length without the need to modify the physical channel length. Using an electrode located close to the capillary surface it is possible to dynamically modify zeta-potential and therefore the electroosmotic flow (EOF). By controlling the EOF, certain ionic species within a sample can be held in a short channel whilst other species migrate along the channel. Alternatively the sample can be transported back and forth along the active channel length until sufficient separation has been attained. CE enables detailed analysis of a sample’s composition and this is of interest to a range of applications.