A blueprint for learning: How NHS England (London) learned during its response to the Covid-19 pandemic

Identification and sharing of lessons is a key aspect of emergency preparedness, resilience and response (EPRR) activity in the national health service (NHS) in England (NHS England, 2022). The overall intent of the lessons identification and implementation process is to improve readiness and response to future major incidents and emergencies, such that, wherever possible, patient harm is minimised and staff well-being is maximised. In this commentary, we draw on international literature to outline some of the major challenges in healthcare organisations to learning from major incidents and emergencies. We describe our experience of identifying lessons and set out the approach used by NHS England (London) to identifying lessons from the NHS response to the Covid-19 pandemic in the capital. We describe the knowledge garnered in our organisation about learning methods during the Covid-19 pandemic. The commentary considers the different approaches to identifying lessons, and the subsequent challenges of learning and implementation. This paper places its focus on the learning processes followed rather than what was learned as a result. It also explores whether the learning process undertaken by NHS England (London) demonstrates the hallmarks of a learning organisation.

Is colour vision impairment associated with cognitive impairment in solvent exposed workers?

AIMS

To determine whether acquired colour vision deficits in solvent exposed individuals are associated with cognitive impairment.

METHODS

A sample of 82 painters and 38 other subjects were studied. Alcohol, drug, and smoking histories were obtained. Colour vision was tested using the Lanthony D-15-d colour vision test. Cognitive impairment was measured using the Benton visual retention test, Trail making A, and Trail making B tests. Pre-morbid IQ was estimated using the National Adult Reading Test. Solvent exposure in all subjects was estimated using a previously validated, structured subjective assessment methodology.

RESULTS

After exclusion of subjects with competing causes of colour vision impairment the final group of men numbered 78. There was a significant association on multiple linear regression between the mean colour confusion index (CCI) and three measures of cognitive impairment, the Benton visual retention test, Trail making A, and Trail making B tests after adjusting for the effects of age (or IQ as appropriate), alcohol, and smoking.

CONCLUSION

Acquired colour vision loss is associated with cognitive impairment in solvent exposed workers. However, given the prevalence of acquired colour vision losses in the adult population, colour vision testing is unlikely to be of value as a screening test.

Chronic fatigue and organophosphate pesticides in sheep farming: a retrospective study amongst people reporting to a UK pharmacovigilance scheme

The Department of Health has recently published a report from the CFS/ME Working Group which concluded that chronic fatigue syndrome (CFS) should be recognized as a chronic illness. Symptoms consistent with CFS are often reported by people who consider their health has been affected by exposure to pesticides, but the Working Group concluded that this type of exposure is not a common trigger for the syndrome. The Veterinary Medicines Directorate (VMD) collects self-assessed reports of ill health in humans associated with veterinary medicines under their Suspected Adverse Reaction Surveillance Scheme. The reporters have mainly been sheep farmers. These reports were used to investigate the possible relationship between chronic fatigue (CF) and exposure to organophosphate pesticides in sheep farming. The overall aim of the study was to investigate a possible association between exposure to organophosphates and the development of CF amongst people who consider their health has been affected by pesticides in sheep farming. The hypothesis investigated was that repeated exposure to organophosphate pesticides in sheep dip may increase the probability of developing CF. A group of mostly sheep farmers who had reported to the VMD surveillance scheme were identified. We planned to use a retrospective case-control study design but the initial symptoms reports were not sufficiently reliable to enable this. The study population was asked to complete two questionnaires. The first questionnaire was designed to identify the history of exposure of subjects to organophosphate pesticides, and their exposure was then reconstructed using a metric specifically developed for this purpose. The second questionnaire collected detailed information to identify whether the subjects had CF when they originally reported to the VMD and at the time of the survey. The questionnaire was sent to a total of 206 subjects, of whom 28 had moved home. A total of 37% of the remaining 178 subjects participated. There was a high prevalence of CF amongst those who completed the questionnaire and this has generally persisted since the subjects reported to the VMD. Higher CF scores were associated with higher exposure to organophosphate pesticides. CF is very common amongst those who consider their health was affected by pesticides and we have shown there is limited evidence of an association between exposure to organophosphates and CF. Further research is needed to investigate the cause of this syndrome amongst farmers exposed to pesticides.

Organic solvent exposure, genes, and risk of neuropsychological impairment

BACKGROUND

Subtle cognitive and neurological impairments have been found in some workers exposed to organic solvents. Whether these effects occur at or below current legal limits for occupational exposure is controversial.

AIM

To determine whether occupational solvent exposure is associated with neuropsychological impairment and whether such risk is modified by polymorphisms in the genes for enzymes involved in detoxification.

DESIGN

Retrospective case-control analysis.

METHODS

We studied 78 former dockyard painters and 42 community controls. Individual respiratory and dermal exposures to solvents were estimated. Neuropsychological tests were administered, including paper and pencil tests, tests from the Neurobehavioural Evaluation System (NES2), together with a structured neurological examination and genotyping of polymorphic enzymes involved in detoxification: GSTM1, GSTT1, GSTP1, NAT1, NAT2, SOD1 and CYP1A1.

RESULTS

While initial case-control analyses failed to identify any significant differences between symptomatic and asymptomatic painters, in regression analyses increasing solvent exposure was associated with increasing risk of cognitive impairment, after adjustment for IQ (or age, where appropriate), smoking and alcohol. There was also an association between exposure and reduction in grip strength. There was limited evidence of risk modification by some enzyme polymorphisms.

DISCUSSION

This association between increasing intensity of solvent exposure and neuropsychological impairment may be important at current exposure levels in the UK.

Use of patches and whole body sampling for the assessment of dermal exposure

There has been a growing awareness of the importance of dermal exposure in recent years. A wide range of techniques are employed to measure exposure, of which surrogate skin techniques such as patch sampling and whole body sampling are frequently used. One of the problems associated with dermal sampling is that different methods often produce different results due to differences in the principles involved in sample collection. As a consequence little progress towards establishing dermal exposure limits has been made. Both patches and clothing act as passive samplers and are intended to collect all of a substance deposited on them. This paper details the principles underlying patch and whole body sampling and outlines some of the advantages and disadvantages of each. A conceptual model has recently been proposed for dermal exposure and the role that surrogate techniques may play in the application of this model is discussed. Finally, suggestions are made as to how these techniques may be made more relevant and areas of future research highlighted.

Impairment of colour vision in workers exposed to organic solvents

OBJECTIVES

To investigate loss of colour vision related to exposure to solvents and the role of three enzyme polymorphisms in modifying the risk in exposed workers.

METHODS

A sample was studied of 68 male dockyard workers and 42 male community controls with and without neuropsychological symptoms from a previous cross sectional study. Indices of cumulative and intensity based exposure to solvents were calculated for all subjects. Alcohol, drug, and smoking histories were obtained. Colour vision was tested by Lanthony D15d colour vision test. Genotype of glutathione S-transferase M1 and T1 and N-acetyltransferase 2 polymorphisms were determined.

RESULTS

The relation between impairment of colour vision and exposure to solvents was investigated with multiple regression techniques. Increasing annual exposure to solvents was significantly associated with reduced colour vision (p=0.029). Impairment of colour vision was not associated with neuropsychological symptoms as measured by the Q16 solvent symptom questionnaire. No significant association was found between acquired impairment of colour vision and genetic polymorphisms when GSTM1, GSTT1 or NAT2 phenotypes were included in the analyses.

CONCLUSIONS

Exposure to mixed solvents is associated with impairment in colour vision, the risk increases with increasing exposure. The risk of impairment of colour vision was not altered in this study by the presence of different GSTM1, GSTT1 or NAT2 polymorphisms.

Particulate air pollution and the blood

BACKGROUND

Particulate air pollution has been associated with excess deaths from, and increases in hospital admissions for, cardiovascular disease among older people. A study was undertaken to determine whether this may be a consequence of alterations in the blood, secondary to pulmonary inflammation caused by the action of fine particles on alveolar cells, by repeatedly measuring haematological factors in older people and relating them to measurements of exposure to airborne particles.

METHODS

One hundred and twelve individuals aged 60+ years in two UK cities provided repeated blood samples over 18 months, 108 providing the maximum of 12 samples. Estimates of individual exposure to particles of less than 10 microm diameter (PM(10)), derived from a mathematical model based on activity diaries and comparative measurements of PM(10) at multiple sites and during a variety of activities, were made for each three day period prior to blood sampling. The relationships between blood values and estimates of both personal exposure and city centre measurements of PM(10) were investigated by analysis of covariance, adjusting for city, season, temperature, and repeated individual measurements.

RESULTS

Estimated personal exposure to PM(10) over the previous three days showed negative correlations with haemoglobin concentration, packed cell volume (PCV), and red blood cell count (p<0.001), and with platelets and factor VII levels (p<0.05). The changes in red cell indices persisted after adjustment for plasma albumin in a sample of 60 of the subjects. City centre PM(10) measurements over three days also showed negative correlations with haemoglobin and red cell count (p<0.001) and with PCV and fibrinogen (p<0.05), the relationship with haemoglobin persisting after adjustment for albumin. C reactive protein levels showed a positive association with city centre measurements of PM(10) (p<0.01). Based on a linear relationship, the estimated change in haemoglobin associated with an alteration in particle concentration of 100 microg/m(3) is estimated to have been 0.44 g/dl (95% CI 0.62 to 0.26) for personal PM(10) and 0.73 g/dl (95% CI 1.11 to 0.36) for city centre PM(10) measurements.

CONCLUSIONS

This investigation is the first to estimate personal exposures to PM(10) and to demonstrate associations between haematological indices and air pollution. The changes in haemoglobin adjusted for albumin suggest that inhalation of some component of PM(10) may cause sequestration of red cells in the circulation. We propose that an action of such particles either on lung endothelial cells or on erythrocytes themselves may be responsible for changing red cell adhesiveness. Peripheral sequestration of red cells offers an explanation for the observed cardiovascular effects of particulate air pollution.

Bronchial reactivity and dietary antioxidants

BACKGROUND

It has been postulated that dietary antioxidants may influence the expression of allergic diseases and asthma. To test this hypothesis a case-control study was performed, nested in a cross sectional study of a random sample of adults, to investigate the relationship between allergic disease and dietary antioxidants.

METHODS

The study was performed in rural general practices in Grampian, Scotland. A validated dietary questionnaire was used to measure food intake of cases, defined, firstly, as people with seasonal allergic-type symptoms and, secondly, those with bronchial hyperreactivity confirmed by methacholine challenge, and of controls without allergic symptoms or bronchial reactivity.

RESULTS

Cases with seasonal symptoms did not differ from controls except with respect to the presence of atopy and an increased risk of symptoms associated with the lowest intake of zinc. The lowest intakes of vitamin C and manganese were associated with more than fivefold increased risks of bronchial reactivity. Decreasing intakes of magnesium were also significantly associated with an increased risk of hyperreactivity.

CONCLUSIONS

This study provides evidence that diet may have a modulatory effect on bronchial reactivity, and is consistent with the hypothesis that the observed reduction in antioxidant intake in the British diet over the last 25 years has been a factor in the increase in the prevalence of asthma over this period.

Implication of a repression system, homologous to those of other bacteria, in the control of arginine biosynthesis genes in Streptomyces coelicolor

As with most amino acid biosynthetic pathways in streptomycetes, enzymes of arginine biosynthesis in Streptomyces coelicolor show only slight derepression in minimal medium without, as opposed to with, exogenous arginine. However, when an arginine auxotroph was cultured in limiting arginine, ornithine carbamoyltransferase (OCT) activities rose by as much as 100-fold. The response was not due to a general starvation effect. To elucidate the repression-derepression mechanism, a DNA fragment containing the upstream region of the previously isolated S. coelicolor argCJB cluster was cloned into a multicopy vector and transformed into wild-type S. coelicolor; a slight transient derepression of OCT was observed in minimal medium without, though not with, added arginine, consistent with titration by the insert of a negatively acting macromolecule such as a repressor. A subfragment carrying the 5' end of argC and the region immediately upstream showed specific binding, in mobility shift assays, to purified AhrC, the repressor/activator of genes of arginine metabolism in Bacillus subtilis. It is therefore likely that in S. coelicolor, expression of arginine biosynthesis genes is controlled by a protein homologous to the well-characterised B. subtilis and Escherichia coli repressors.

The increase in hay fever: pollen, particulate matter and SO2 in ambient air

To investigate whether the rise in allergic disease is explicable on the basis of an increase in the concentrations of allergen and urban air pollutants to which the population has been exposed, we compared the concentrations of grass pollen, sulphur dioxide and black smoke to which two samples of children with previously measured prevalences of hay fever had been exposed, in Cardiff, South Glamorgan. In these studies there had been a 59% increase in the prevalence of hay fever among 12 year old school children between 1973 and 1988. Exposures to grass pollen of the two populations had been no different, but the earlier sample, with the lower prevalence of hay fever, had been exposed to substantially higher concentrations of ambient particulate matter and sulphur dioxide. The rise in prevalence of hay fever, occurring without a rise in grass pollen concentrations, supports the hypothesis that the population has become more susceptible to airborne allergen. This increased susceptibility is unlikely to be a consequence of concomitant exposure to sulphur dioxide and particulate air pollution.

Oilseed rape and bronchial reactivity

OBJECTIVES

To investigate atopy and changes in symptoms, peak flow rate, and bronchial reactivity in people complaining of symptoms during the oilseed rape flowering season.

METHODS

37 people who had given positive answers to questions about the presence of symptoms in relation to the flowering season of oilseed rape and 24 controls with no such symptoms were studied, although not all took part in all parts of the study. All had been previously identified in a cross sectional survey of a random sample of a rural population. Atopy was assessed by means of skin prick tests, total immunoglobulin E (IgE), and radioallergosorbent test (RAST) assays. Bronchial reactivity (PC20) was measured by histamine challenge. Total IgE and bronchial reactivity were measured both before and during the oilseed rape flowering season. Day to day changes were monitored by subjects who kept a record of their symptoms and peak flow morning and evening, starting before the flowering season and continuing during it and into the grass pollen season.

RESULTS

Only two cases, of 23 tested, showed evidence of allergy to oilseed rape and only 10 of 23 tested, including these two, were atopic. Eye, nasal, and headache symptoms increased in the season in cases, which validated the questionnaire used in the previous cross sectional survey. 12 of 16 cases tested and seven of 15 controls showed a seasonal fall in PC20; the fall in the cases was significantly greater than in the controls. Peak flow charts showed no evidence of fall or of increased variability during the season.

CONCLUSIONS

People who complained of symptoms in relation to the flowering of oilseed rape were rarely allergic to the plant and fewer than half were atopic. Nevertheless, they usually showed increased bronchial reactivity during the season, which may have been due in some cases to other allergens but in others to non-specific irritant effects of the air. Whether these are due to chemicals released by the crop, to rising summer ozone levels, or to other factors remains unclear.

Oilseed rape and seasonal symptoms: epidemiological and environmental studies

BACKGROUND

There is widespread concern that the cultivation of oilseed rape leads to seasonal epidemics of respiratory symptoms in populations living in the neighbourhood, and it has been suggested that the plant is a potent allergen. A study was therefore undertaken to determine the prevalence of seasonal symptoms in rural populations close to and far from areas of oilseed rape cultivation, and to measure the levels of allergen and other potentially harmful substances released by the crop.

METHODS

Random samples of 1000 adults from the general practice populations of two villages surrounded by oilseed rape fields, and 1000 adults from one village far from such cultivation, were taken. The subjects completed a previously validated questionnaire on respiratory and other symptoms, including questions on symptom seasonality, occupation, and smoking habits. Pollen and fungal spore counts were made around fields of oilseed rape and in the villages. The chemicals released by oilseed rape were measured in the field.

RESULTS

Overall, 86.8% of the subjects completed the questionnaires and the populations of the two samples were generally comparable. Spring and summer exacerbations of symptoms occurred equally in the two areas in approximately 25% of the population. There were small but significant excesses of cough, wheeze, and headaches in spring in the oilseed rape area (2.3% v 1.1%, 6.8% v 4.6%, and 4.8% v 2.8%, respectively), and cough, wheeze, and itchy skin were more prevalent in smokers. Counts of oilseed rape pollen were generally low except adjacent to fields, and counts of fungal spores were mostly higher in the rape than the non-rape areas. Oilseed rape was shown to give off terpenes and these were detected close to fields.

CONCLUSIONS

While it is likely that a proportion of the spring symptoms occurring in people living in close proximity to oilseed rape is caused by the plant, the excess of such symptoms is small. This, together with the low levels of pollen in the area, suggests that allergy to oilseed rape pollen is uncommon. The general prevalence of seasonal symptoms in rural areas is of interest, and a proportion of these cases is likely to be caused by factors other than allergy. Release of chemicals by plants and natural rises in summer ozone levels may be contributors.

Identification of the 664 proline to leucine mutation in the low density lipoprotein receptor in four unrelated patients with familial hypercholesterolaemia in the UK

Mutations in the gene for the low density lipoprotein (LDL) receptor cause Familial Hypercholesterolaemia (FH). One such mutation, a cytosine to thymine change in the codon for amino acid 664, causes proline (CCG) to be replaced by leucine (CTG) at this position, and creates a Pst I site in exon 14 of the gene. This mutation, previously identified in an FH homozygote of Asian Indian origin, results in a receptor with a reduced binding affinity for LDL and in delayed processing of the precursor form of the protein in cultured cells. A total of 224 unrelated heterozygous and 4 homozygous FH patients from London was screened for this mutation using direct amplification of genomic DNA by the polymerase chain reaction (PCR) and restriction digestion of the PCR product. Four patients were identified who were heterozgous for this mutation and the C to T base change was confirmed by sequencing. Affected relatives of these patients were also found to have the mutation. The effect of the mutation on LDL-receptor function in lymphoblastoid cell lines obtained from two of these patients was similar to that observed in heterozygous relatives of the original proband (MM). Eight polymorphisms of the LDL receptor gene were used to determine the haplotype of the defective allele carried by the patients and the individual (MM) in whom the mutation was first discovered. Two different haplotypes were found, suggesting that the mutation, which occurs at a CpG 'hotspot', has arisen independently at least twice. The presence of the same single base change in the LDL-receptor gene in several unrelated patients has not previously been reported in a population which is not geographically or culturally isolated.

Anthelmintic resistance and the control of ovine ostertagiasis: a drug action model for genetic selection

A site-specific genetic prediction model is presented, which examines the influences of different anthelmintic treatment regimens on selecting for drug resistance within a sheep management system. The model exploits the power of modern microcomputers to integrate factors such as parasite strain, geographic location, management practice and genetic fitness to identify effective control regimens which do not lead to resistant Ostertagia circumcincta strains over a 30-year horizon. The potential use of the model as a farm level management-support tool is discussed.

Level of benzimidazole resistance in a strain of Ostertagia circumcincta studied over several infections in lambs

A benzimidazole-resistant strain of Ostertagia circumcincta (HFRO) was used experimentally to infect lambs. The level of resistance, measured by an egg hatch assay, was studied throughout each infection and also after treatment of the lambs with fenbendazole. The HFRO strain was highly resistant to benzimidazoles. There was day-to-day variation in the level of resistance throughout a single infection with a high level of resistance in the early part of the infection, around Day 27 post-inoculation of infective larvae, falling to a lower level later in the infection. Egg hatch assays on the 3 days immediately post-treatment with fenbendazole showed the resistance level was high then resistance fell to the pre-treatment level after 7 days. Selection for benzimidazole resistance using fenbendazole treatment at the normal dose rate of 5 mg kg-1 over five passages of the HFRO strain in lambs failed to increase the resistance level. Storage of larvae over a 5-month period at 4 degrees C, prior to infection of lambs, did not produce any alteration in the resistance level. The possible reasons for the variations in resistance found with the HFRO strain are discussed along with the implications for sheep parasite control and further development of benzimidazole resistance.

Deposition of DDE and polychlorinated biphenyls in dated sediments of the Santa Barbara basin

Analysis of dated oceanic sediments from the Santa Barbara Basin of the Southern California Bight has shown that deposition of polychlorinated biphenyls (PCB) began about 1945 and that DDE [1,1-dichloro-2-2-bis(p-chloro-phenyl)ethylene] first appeared in sediments deposited about 1952. Concentrations of both show a progressive increase through 1967; estimated deposition rates (in grams per square meter per year) in 1967 of DDE and PCB were 1.9 x 10(-4) and 1.2 x 10(-4), respectively.

Contemporary Phosphorites on the Continental Margin of Peru

Phosphorite nodules occurring along the biologically productive continental margin of Peru have been dated by uranium-series methods. The radiometric ages range from late Pleistocene to Recent, indicating that phosphorities are currently forming in this area.

Lead pollution: records in Southern California coastal sediments

The present anthropogenic lead fluxes into sediments from the Santa Monica, San Pedro, and Santa Barbara basins of Southern California are, respectively, 0.9, 1.7, and 2.1 micrograms of lead per square centimeter of sea bottom per year; the natural (prepollution) rates for these three basins were, respectively, 0.24, 0.26, and 1.0 microgram of lead per square centimeter per year. Studies of isotopic composition indicate that lead pollutants in coastal sediments are derived mainly from the combustion of lead additives in gasoline.

Planktonic Foraminifera: field experiment on production rate

In a study of the rate of production of four species of planktonic Foraminifera in the region of the California Current it was found that their life spans are of the order of 1 month. Reproduction seems to take place mainly in the upper hundred meters. Results are in contrast to previous evidence presented in favor of yearly life cycles and maturing at great depth in other species of planktonic Foraminifera.