Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning

BACKGROUND

Quality Improvement (QI) training for health professionals is essential to strengthen health systems. However, QI training during medical school is constrained by students' lack of contextual understanding of the health system and an already saturated medical curriculum. The Program for Improvement in Medical Education (PRIME), an extracurricular offered at the Michael G. DeGroote School of Medicineat McMaster University (Hamilton, Canada), addresses these obstacles by having first-year medical students engage in QI by identifying opportunities for improvement within their own education.

METHODS

A sequential explanatory mixed-methods approach, which combines insights derived from quantitative instruments and qualitative interview methods, was used to examine the impact of PRIME on first-year medical students and the use of QI in the context of education.

RESULTS

The study reveals that participation in PRIME increases both knowledge of, and comfort with, fundamental QI concepts, even when applied to clinical scenarios. Participants felt that education provided a meaningful context to learn QI at this stage of their training, and were motivated to participate in future QI projects to drive real-world improvements in the health system.

CONCLUSIONS

Early exposure to QI principles that uses medical education as the context may be an effective intervention to foster QI competencies at an early stage and ultimately promote engagement in clinical QI. Moreover, PRIME also provides a mechanism to drive improvements in medical education. Future research is warranted to better understand the impact of education as a context for later engagement in clinical QI applications as well as the potential for QI methods to be translated directly into education.

Phosphorus removal from secondary sewage and septage using sand media amended with biochar in constructed wetland mesocosms

To improve the performance efficiency of subsurface constructed wetlands (CWs), a variety of media have been tested. Recently, there has been a rising interest in biochar. This research aims to develop the effectiveness of sand media amended with biochar and two plants species (Melaleuca quinquenervia and Cymbopogon citratus) in removing phosphorus from sewage effluent in CWs. The experimental design consisted of vertical flow (VF) mesocosms with seven media treatments based on the proportions of biochar in the sand media which ranged from 0 to 25% by volume. During the first 8months, the mesocosms were loaded with secondary clarified wastewater (SCW) then septage was used for the remaining 8months. Inflow and outflow were monitored for total phosphorus (TP) and PO4-P. Plants were harvested at the end of the experiment and TP biomass was determined. Removal efficiencies of TP in the mesocosms loaded with SCW and septage ranged from 42 to 91% and 30 to 83%, respectively. Removal efficiencies of PO4-P ranged from 43 to -92% and 35 to 85% for SCW and septage, respectively. The results revealed that the sand media performed better than the biochar-amended media; increasing the proportion of biochar in the media decreased removal efficiency of phosphorus. However, after flushing due to major rain event, there was no significant difference between sand and sand augmented with 20% biochar. Total plant P ranged from 1.75g in the 20% biochar mesocosm to 2.10g in the sand only mesocosm. Plant uptake of P, at least in part, may be accredited for the better P removal efficiency in the sand media compared to the biochar-amended media.

Feasibility of a randomized controlled trial to evaluate the impact of decision boxes on shared decision-making processes

Background

Decision boxes (DBoxes) are two-page evidence summaries to prepare clinicians for shared decision making (SDM). We sought to assess the feasibility of a clustered Randomized Controlled Trial (RCT) to evaluate their impact.

Methods

A convenience sample of clinicians (nurses, physicians and residents) from six primary healthcare clinics who received eight DBoxes and rated their interest in the topic and satisfaction. After consultations, their patients rated their involvement in decision-making processes (SDM-Q-9 instrument). We measured clinic and clinician recruitment rates, questionnaire completion rates, patient eligibility rates, and estimated the RCT needed sample size.

Results

Among the 20 family medicine clinics invited to participate in this study, four agreed to participate, giving an overall recruitment rate of 20%. Of 148 clinicians invited to the study, 93 participated (63%). Clinicians rated an interest in the topics ranging 6.4-8.2 out of 10 (with 10 highest) and a satisfaction with DBoxes of 4 or 5 out of 5 (with 5 highest) for 81% DBoxes. For the future RCT, we estimated that a sample size of 320 patients would allow detecting a 9% mean difference in the SDM-Q-9 ratings between our two arms (0.02 ICC; 0.05 significance level; 80% power).

Conclusions

Clinicians’ recruitment and questionnaire completion rates support the feasibility of the planned RCT. The level of interest of participants for the DBox topics, and their level of satisfaction with the Dboxes demonstrate the acceptability of the intervention. Processes to recruit clinics and patients should be optimized.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0134-x) contains supplementary material, which is available to authorized users.

An investigation into the effectiveness of sand media amended with biochar to remove BOD5, suspended solids and coliforms using wetland mesocosms

Constructed wetland ecotechnologies (CWEs) are a promising solution to effectively treat domestic wastewater in developing countries at low cost. This paper reports the findings of the effectiveness of sand media amended with woody biochar and two plants species (Melaleuca quinquenervia and Cymbopogon citratus) in removing biological oxygen demand (BOD5), suspended solids and coliforms. The experimental design consisted of 21 vertical flow (VF) mesocosms. There were seven media treatments using sand amended with varying proportions of biochar. During the first 8 months, the mesocosms were loaded with secondary clarified wastewater (SCW) then septage. The influent had a 4-day hydraulic retention time. Samples were monitored for BOD5, total suspended solids (TSS), total volatile solids (TVS), total coliforms and faecal coliforms. In the first 8 months, there were no significant performance differences between media treatments in the outflow concentrations of BOD5, TSS and TVS. The significant differences occurred during the last 3 months; using septage with biochar additions performed better than pure sand. For coliforms, the significant differences occurred after 6 months. In conclusion, the addition of biochar was not effective for SCW. The VF mesocosms system proved to be more effective in removing BOD5, TSS, TVS and coliforms when septage was loaded into the media.

Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study

Background

Decision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice.

Methods

We used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantages and disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information.

Results

One hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6 ± 1.2, scale 1–7, with 7 being “high”), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P < 0.0001). In focus groups, clinicians mentioned that co-interventions such as patient decision aids and training in shared decision-making would facilitate the use of the Dbox information. Some participants would have liked a clear “bottom line” statement for each Dbox and access to printed Dboxes in consultation rooms.

Conclusions

Dboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0144-6) contains supplementary material, which is available to authorized users.

Bionimbus: a cloud for managing, analyzing and sharing large genomics datasets

Background

As large genomics and phenotypic datasets are becoming more common, it is increasingly difficult for most researchers to access, manage, and analyze them. One possible approach is to provide the research community with several petabyte-scale cloud-based computing platforms containing these data, along with tools and resources to analyze it.

Methods

Bionimbus is an open source cloud-computing platform that is based primarily upon OpenStack, which manages on-demand virtual machines that provide the required computational resources, and GlusterFS, which is a high-performance clustered file system. Bionimbus also includes Tukey, which is a portal, and associated middleware that provides a single entry point and a single sign on for the various Bionimbus resources; and Yates, which automates the installation, configuration, and maintenance of the software infrastructure required.

Results

Bionimbus is used by a variety of projects to process genomics and phenotypic data. For example, it is used by an acute myeloid leukemia resequencing project at the University of Chicago. The project requires several computational pipelines, including pipelines for quality control, alignment, variant calling, and annotation. For each sample, the alignment step requires eight CPUs for about 12 h. BAM file sizes ranged from 5 GB to 10 GB for each sample.

Conclusions

Most members of the research community have difficulty downloading large genomics datasets and obtaining sufficient storage and computer resources to manage and analyze the data. Cloud computing platforms, such as Bionimbus, with data commons that contain large genomics datasets, are one choice for broadening access to research data in genomics.

The effect of clinical teaching on patient satisfaction in rural and community settings

INTRODUCTION

Few studies have examined the effect of clinical teaching on patient satisfaction in rural and community-based settings. We sought to examine whether patient satisfaction differed when patients were seen by a physician alone or by a physician and medical student in these settings.

METHODS

We conducted a cross-sectional study in rural and community-based settings in southern Ontario (3 obstetrician-gynecologist offices and 4 family medicine clinics). Patients seen by a physician with or without a medical student present completed satisfaction and attitudes questionnaires about their experience.

RESULTS

Patient satisfaction was high across both groups and did not differ when segregated by patient age, sex or employment status. Satisfaction scores were similar for patients seen by a physician with or without a student present. Satisfaction scores did not differ based on practice location. Patients' reasons for agreeing to be seen by a medical student included helping to teach students about medical concerns and helping to train future doctors.

CONCLUSION

Patients in rural and community-based outpatient settings were satisfied with their care when a medical student was involved.

Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decisionmaking: a study protocol

BACKGROUND

Decision Boxes are summaries of the most important benefits and harms of health interventions provided to clinicians before they meet the patient, to prepare them to help patients make informed and value-based decisions. Our objective is to explore the barriers and facilitators to using Decision Boxes in clinical practice, more precisely factors stemming from (1) the Decision Boxes themselves, (2) the primary healthcare team (PHT), and (3) the primary care practice environment.

METHODS/DESIGN

A two-phase mixed methods study will be conducted. Eight Decision Boxes relevant to primary care, and written in both English and in French, will be hosted on a website together with a tutorial to introduce the Decision Box. The Decision Boxes will be delivered as weekly emails over a span of eight weeks to clinicians of PHTs (family physicians, residents and nurses) in five primary care clinics located across two Canadian provinces. Using a web-questionnaire, clinicians will rate each Decision Box with the Information Assessment Method (cognitive impacts, relevance, usefulness, expected benefits) and with a questionnaire based on the Theory of Planned Behavior to study the determinants of clinicians' intention to use what they learned from that Decision Box in their patient encounter (attitude, social norm, perceived behavioral control). Web-log data will be used to monitor clinicians' access to the website. Following the 8-week intervention, we will conduct semi-structured group interviews with clinicians and individual interviews with clinic administrators to explore contextual factors influencing the use of the Decision Boxes. Data collected from questionnaires, focus groups and individual interviews will be combined to identify factors potentially influencing implementation of Decision Boxes in clinical practice by clinicians of PHTs.

CONCLUSIONS

This project will allow tailoring of Decision Boxes and their delivery to overcome the specific barriers identified by clinicians of PHTs to improve the implementation of shared decision making in this setting.

Angiogenin levels and ANG genotypes: dysregulation in amyotrophic lateral sclerosis

Objective

To determine whether 5 single nucleotide polymorphisms (SNPs) associate with ALS in 3 different populations. We also assessed the contribution of genotype to angiogenin levels in plasma and CSF.

Methods

Allelic association statistics were calculated for polymorphisms in the ANG gene in 859 patients and 1047 controls from Sweden, Ireland and Poland. Plasma, serum and CSF angiogenin levels were quantified and stratified according to genotypes across the ANG gene. The contribution of SNP genotypes to variance in circulating angiogenin levels was estimated in patients and controls.

Results

All SNPs showed association with ALS in the Irish group. The SNP rs17114699 replicated in the Swedish cohort. No SNP associated in the Polish cohort. Age- and sex-corrected circulating angiogenin levels were significantly lower in patients than in controls (p<0.001). An allele dose-dependent regulation of angiogenin levels was observed in controls. This regulation was attenuated in the ALS cohort. A significant positive correlation between CSF plasma angiogenin levels was present in controls and abolished in ALS.

Conclusions

ANG variants associate with ALS in the Irish and Swedish populations, but not in the Polish. There is evidence of dysregulation of angiogenin expression in plasma and CSF in sporadic ALS. Angiogenin expression is likely to be important in the pathogenesis of ALS.

50bp deletion in the promoter for superoxide dismutase 1 (SOD1) reduces SOD1 expression in vitro and may correlate with increased age of onset of sporadic amyotrophic lateral sclerosis

The objective was to test the hypothesis that a described association between homozygosity for a 50bp deletion in the SOD1 promoter 1684bp upstream of the SOD1 ATG and an increased age of onset in SALS can be replicated in additional SALS and control sample sets from other populations. Our second objective was to examine whether this deletion attenuates expression of the SOD1 gene. Genomic DNA from more than 1200 SALS cases from Ireland, Scotland, Quebec and the USA was genotyped for the 50bp SOD1 promoter deletion. Reporter gene expression analysis, electrophoretic mobility shift assays and chromatin immunoprecipitation studies were utilized to examine the functional effects of the deletion. The genetic association for homozygosity for the promoter deletion with an increased age of symptom onset was confirmed overall in this further study (p=0.032), although it was only statistically significant in the Irish subset, and remained highly significant in the combined set of all cohorts (p=0.001). Functional studies demonstrated that this polymorphism reduces the activity of the SOD1 promoter by approximately 50%. In addition we revealed that the transcription factor SP1 binds within the 50bp deletion region in vitro and in vivo. Our findings suggest the hypothesis that this deletion reduces expression of the SOD1 gene and that levels of the SOD1 protein may modify the phenotype of SALS within selected populations.

Progranulin mutations and amyotrophic lateral sclerosis or amyotrophic lateral sclerosis-frontotemporal dementia phenotypes

OBJECTIVE

Mutations in the progranulin (PGRN) gene were recently described as the cause of ubiquitin positive frontotemporal dementia (FTD). Clinical and pathological overlap between amyotrophic lateral sclerosis (ALS) and FTD prompted us to screen PGRN in patients with ALS and ALS-FTD.

METHODS

The PGRN gene was sequenced in 272 cases of sporadic ALS, 40 cases of familial ALS and in 49 patients with ALS-FTD.

RESULTS

Missense changes were identified in an ALS-FTD patient (p.S120Y) and in a single case of limb onset sporadic ALS (p.T182M), although the pathogenicity of these variants remains unclear.

CONCLUSION

PGRN mutations are not a common cause of ALS phenotypes.

Macrophyte zonation in stormwater wetlands: getting it right! A case study from subtropical Australia

In Australia stormwater wetlands are becoming an increasingly popular component of water sensitive urban design. However, they must be designed to cope with the dynamic nature of urban hydrology, in particular, fluctuations in water level. The concept of macrophyte zonation relies on a thorough understanding of the water regimes of different plant species. Water depth is crucial and the hydroperiod, i.e. duration and frequency of inundation, has a significant impact on the survival of wetland vegetation. The aim of this study was to investigate plant establishment in a newly constructed stormwater wetland in Brisbane, subtropical Australia. Changes in plant distribution and density have been monitored since 2001. Rainfall and water depth data enabled us to use a hydrologic model to predict the extent of inundation of the different macrophytes zones. The field survey showed macrophyte survival was poor with the complete loss of several species in marsh and ephemeral zones. The main reason for the lack of macrophyte establishment and survival was the extended periods of inundation (supported by the hydrologic model) and deeper water levels. Stormwater wetlands must be designed to ensure that ephemeral species are not permanently inundated or the preferred water depths in marsh zones are not exceeded for extended periods.

Removal of dissolved nitrogen, phosphorus and carbon from stormwater by biofiltration mesocosms

Biofiltration systems are becoming a popular stormwater treatment device in water sensitive urban design for the removal of fine particulate and dissolved pollutants from stormwater. However, there is limited published data on the effectiveness of these systems for nutrient removal. We constructed biofiltration mesocosms to assess nutrient removal (nitrogen, phosphorus and carbon) under experimental conditions. Different types of media were compared (gravel, sand, and sandy-loam) in vegetated and non-vegetated mesocosms (six treatments in total). Five plant species were used. Vegetated sand and vegetated sandy-loam provided the best overall treatment. Vegetated mesocosms were very effective in removing nitrogen (63-77% removal) and phosphorus (85-94% removal) from synthetic stormwater, and removed substantially more nutrients than the non-vegetated treatments. All treatments removed a substantial portion of the carbon from the stormwater (28-66%). When flushed with tap water, nitrogen and phosphorus were retained by the vegetated mesocosms, but leached from the non-vegetated mesocosms. Plant growth was most vigorous in the sandy-loam media, indicating that this is a good growth media, even without the addition of organic matter.

Quantification of biofilms in a sub-surface flow wetland and their role in nutrient removal

Subsurface flow wetlands contain gravel or sand substrates through which the wastewater flows vertically or horizontally. The aims of this study were, firstly, to quantify biofilm development associated with different size gravel in sections of a subsurface flow wetland with and without plants, and secondly, to conduct laboratory experiments to examine the role of biofilms in nutrient removal. Techniques to quantify biofilm included: bacterial cell counts, EPS and total protein extraction. Based on comparative gravel sample volume, only EPS was greater on the smaller 5 mm gravel particles. There was no significant difference between biofilm growth in sections with and without plants. Two vertical flow laboratory-scale reactors, one containing fresh wetland gravel, the other containing autoclaved gravel, were constructed to determine nutrient transformations. The autoclaved gravel in the "sterile" reactor rapidly became colonised with biofilm. Both reactors were dosed with two types of influent. Initially the influent contained 7.25 mg/L NO3-N and 0.3 mg/L NH4-N; the biofilm reactor removed most of the ammonium and nitrite but nitrate concentrations were only reduced by 20%. In the "sterile" reactor there was negligible removal of ammonium and nitrite indicating little nitrification, however nitrate was reduced by 72%, possibly due to assimilatory nitrate reduction associated with new biofilm development. When the influent contained 3 mg/L NO3-N and 16 mg/L NH4-N almost 100% removal and transformation of NH4-N occurred in both reactors providing an effluent high in NO3-N. Organic P was reduced but inorganic soluble P increased possibly due to mineralisation.

An assessment of mosquito breeding and control in four surface flow wetlands in tropical-subtropical Australia

In Queensland, Australia, the tropical-subtropical climate is ideal to promote macrophyte growth in surface flow wetlands; however, there have been concerns that constructed wetlands are potential breeding sites for disease-bearing mosquitoes. The aim of this study was to assess whether mosquitoes were breeding in these constructed wetlands, and if so, where they breed, and what parameters might influence breeding: e.g. water quality, vegetation, or macroinvertebrate communities. A study of four surface flow constructed wetlands located in different climatic regions was undertaken. Mosquito larvae were sampled using 240 ml dippers and macroinvertebrates using dip nets. The wetland with the greatest biodiversity of macrophytes and macroinvertebrates had the least number of mosquito larvae (< 1% of all dips). Samples with most mosquito larvae occurred amongst dense mats of Paspalum grass or dead Typha. Despite the presence of larvae in some parts of these wetlands very few late instars or pupae were found i.e. completion of the mosquito life cycle to adult mosquitoes was unsuccessful. This study has shown that the presence of mosquito larvae can be minimised by increasing macroinvertebrate biodiversity, by planting a variety of macrophyte types and species, excluding aggressive plant species, and maintaining at least 30% open water. Macroinvertebrates are probably a crucial factor in the control of mosquito larvae ensuring that predation of the early instars prevents or limits the development of pupae and the emergence of adults.

Suitability of macrophytes for nutrient removal from surface flow constructed wetlands receiving secondary treated sewage effluent in Queensland, Australia

From a botanical perspective the major difference between waste stabilisation ponds and wetlands is the dominance of algae or floating plants in the former and emergent plants in the latter. Algae, floating and submerged plants remove nutrients directly from the water column whereas emergent species remove nutrients from the sediment. Water depth is a crucial factor in determining which plant types will become established. Surface flow constructed wetlands offer the greatest potential to grow a wide variety of different types of macrophytes. In assessing the suitability of plant species for nutrient removal, consideration must be given not only to nutrient uptake for growth but also storage of nutrients as plant biomass. A survey of macrophytes in 15 surface flow constructed wetlands treating secondary effluent was conducted in Queensland; 63 native species and 14 introduced species were found. Emergent species have been able to tolerate deeper water than in their natural environment and permanent waterlogging. All species grew well in the higher nutrient enriched wastewater. Submerged, floating leaved-attached and free floating species had the highest tissue nutrient content, followed by aquatic creepers. All these species remove nutrients from the water column. Emergent species had lower nutrient content but a greater biomass and were therefore able to store more nutrients per unit area of wetland. In order to maximise the efficiency of constructed wetlands for nutrient removal, a range of species should be used. Native species should be selected in preference to introduced/exotic species.

Nutrient removal and plant biomass in a subsurface flow constructed wetland in Brisbane, Australia

Four native plant species (Baumea articulata, Carex fascicularis, Philydrum lanuginosum and Schoenoplectus mucronatus) are being investigated for their suitability in subsurface flow wetlands. The pilot scale Oxley Wetland, Brisbane, consists of 4 cells with different sized gravel (5 mm and 20 mm). The project aims to investigate nutrient removal rates and removal efficiency; nutrient storage in plant biomass; effect of cropping on plant regrowth, and the effect of gravel size on both water treatment and plant growth. Average daily mass removal rates ranged from 7.3 Kgha(-1)d(-1) NH4-N in Cell D to 4.6 Kgha(-1)d(-1) in Cell C i.e. 37%-22% removal efficiency respectively; 5.2 Kgha(-1)d(-1) NOx-N in Cell C to 1.3 Kgha(-1)d(-1) in Cell A (i.e. 75%-22% removal efficiency) and 0.8 Kgha(-1)d(-1) PO4-P in Cell A to 0.1 Kgha(-1)d(-1) in Cell C (i.e. 10%-1% removal efficiency). Cell A was the youngest wetland with new 5 mm gravel. Plant biomass was highest for Baumea and Carex. Gravel size does not appear to have affected biomass and recovery following cropping. Carex consistently had the highest harvested above ground biomass with high re-growth following cropping. Cropping appears to have retarded growth of the other three species with Schoenoplectus consistently having slowest regrowth. Plant biomass and nutrient storage was highest in Cell A and accounted for 11% of nitrogen removal and 3% of phosphorus removal.

Metal accumulation in aquatic macrophytes from southeast Queensland, Australia

To determine the extent of metal accumulation in some aquatic macrophytes from contaminated urban streams in southeast Queensland, plants were sampled from six sites, along with contiguous sediments. In all, 15 different species were collected, the most common genera being Typha (Cattails or Bulrushes) and Persicaria (Knotweeds). Before heavy metal analysis, plants were further separated into various morphological tissues, and five selected samples were separated into various physiological tissues. The cadmium, copper, lead and zinc content of the plants were analysed using flames AAS. In general, plant roots exhibited higher metal concentrations than the contiguous sediments. Of the metals of interest, only for zinc was there a relatively clear pattern of increasing accumulation in aquatic macrophytes with increasing sediment metal concentrations. Comparison between morphological tissues of the sampled plants found that roots consistently presented higher metal concentrations than either the stems or leaves, however unlike previous studies, this investigation revealed no consistent trend of stems accumulating more metals than the leaves. For Typha spp., metal concentrations followed the order of roots > rhizomes > leaves, while for Persicaria spp. the order was roots > leaves > stems. The submerged species Myriophyllum aquaticum accumulated the highest levels of metals overall (e.g. Zn 4300 micrograms g-1 dry weight and Cd 6.5 micrograms g-1), and the emergent macrophytes also exhibited relatively high metal contents in their roots. The leaves of the submerged and floating-leafed species collected contained relatively high quantities of the four metals of interest, compared with the leaves of emergent aquatic macrophytes. In the Typha rhizome and Persicaria stem samples analysed for internal variation in metal content, there was a pattern of increasing metal concentrations towards the external sections of the stem, both for subterranean stems (rhizomes) and above-substrate stems. For Persicaria stems, no clear pattern was observed for cadmium and lead, the two metals investigated that are not required by plants for survival.

Changes in plant biomass and nutrient removal over 3 years in a constructed wetland in Cairns, Australia

The surface flow wetland in Cairns, Australia consists of 3 linear channels each 65 m long. Channels 1 and 2 are 5 m wide and Channel 3 is 15 m wide. The wetland was constructed in 1994 and band planted with emergent macrophyte species and alternating open water sections. The wetland was monitored for plant growth and nutrient removal until 1997. During that period HRT was 16 days in Channel 1 and 10 days in Channels 2 and 3; mass loading rates were 2.4 kg Total N and 2.0 kg Total P ha(-1) d(-1) in Channel 1 and 3.7 kg TN and 3.3 kg TP ha(-1) d(-1) in Channels 2 and 3. The aim of this work was to determine the proportion of nutrient removal that could be attributed to direct uptake by macrophytes and incorporated into plant biomass. Over the 3 year monitoring period reduction in total mass of nutrients was: Channel 1: 26% P, 85% N; Channel 2: 28% P, 87% N; Channel 3: 21% P, 81% N. Percentage reduction of FRP (Filterable Reactive Phosphorus) was similar to TP; NOx removal was 97-98%. Mass removal rates for TN and TP were higher in Channels 2 and 3 despite greater nutrient loading rates and shorter detention times. Total FRP removal was 23 kg P in Channel 1, 33 kg P in Channel 2 and 70 kg P in Channel 3 of which plant biomass accounted for 65%, 44% and 47% respectively. Total nitrogen removal was 92 kg in Channel 1,154 kg in Channel 2 and 386 kg in Channel 3 of which plant biomass accounted for 47%, 27% and 27% respectively. Thus, in this tropical surface flow wetland supporting a mixture of emergent macrophytes and floating duckweed, vegetation is an important mechanism for direct nutrient removal.

General practitioner knowledge of prohibited substances in sport

OBJECTIVES

To assess general practitioner knowledge of banned substances in sport.

METHODS

Postal questionnaire sent to all general practitioners in West Sussex.

RESULTS

Only 55 (35%) of those who responded (157 in total) were aware that guidelines are to be found in the British National Formulary, and 19 (12%) of respondents believed that medical practitioners are allowed to prescribe anabolic steroids for non-medical reasons.

CONCLUSIONS

General practitioner knowledge of which substances are prohibited in sports is poor. There is a lack of awareness of Sports Council guidelines which are to be found in the British National Formulary. Tackling drug abuse in sport requires education of both athletes and doctors.