An interesting D-lemma: what is all the excitement about vitamin D?

There has been a dramatic interest in the importance of vitamin D, “the sunshine vitamin”, in the past few years with regard to its impact on various aspects of health and disease. Research into well-known skeletal effects, as well as extraskeletal effects, has been overwhelming. At times it has been difficult to make informed clinical decisions regarding replacement, if needed at all. This article aims to provide the physician with a summary of the most important clinical effects of vitamin D, as well as give guidelines on testing for possible deficiency and consideration of replacement thereof

Leiomyoma: A rare cause of adrenal incidentaloma

A 40-year-old, treatment-naïve, human immunodeficiency virus- (HIV) positive male was found to have a large right adrenal incidentaloma on ultrasound of the abdomen, which was confirmed on adrenal computed tomography imaging. The laboratory workup excluded functionality of the mass lesion. As the radiological examination of the mass raised the suspicion of a non-benign lesion, the patient underwent a right adrenalectomy. Histology, supported by a panel of immunohistochemical stains, confirmed the diagnosis of an adrenal leiomyoma. Most of the reported cases of adrenal leiomyomas in the literature are of patients with HIV and/or latent Epstein-Barr virus infections. This case illustrates that benign tumours, such as leiomyomas, can mimic the imaging phenotype of adrenal cortical carcinomas, and should be included in the differential diagnosis of adrenal incidentalomas, especially in the HIV-positive population

Groundwater quality into the future: workshop summary

This report details the findings of a workshop held by the British Geological Survey and the Environment Agency on “Groundwater Quality into the Future” in February 2022. The workshop was attended by over 60 delegates, and was a part of a short scoping study aimed at improving understanding of the impacts of climate and land use change on groundwater quality. Four cross-cutting themes emerged from the workshop: 1. The high level of uncertainty associated with potential impacts of climate and land use change on groundwater quality over the next century 2. The need for holistic, systems approaches to the science and management of groundwater quality and resources in the terrestrial water cycle 3. Further education related to groundwater amongst the general public 4. The need for continued monitoring to characterise the impacts of environmental change on groundwater quality A number of focus areas were also identified by the workshop delegates: nutrients, emerging substances, changing rainfall characteristics, changing temperature, groundwater rebound, urban development and construction, changing salinity and groundwater ecosystems. The cross-cutting themes and focus areas identified in the workshop will be used to feed in to future work to improve our scientific understanding and management of the impacts of climate and land use change on groundwater quality

Regulatory practice and transport modelling for nitrate pollution in groundwater

This report forms the first deliverable of a project jointly funded by BGS and the Environment Agency to consider the potential for incorporating the outputs from the BGS unsaturated zone travel time work in assessing the risks to water from nitrate. This is to help to inform the nitrate vulnerable zones (NVZs) designation process. In England, the Environment Agency advises Defra on identifying areas for designation as NVZs. Over time, the designation process has developed and become more complex since the first round of designations in 1996. The designation process for groundwater initially used only public supply monitoring data and the associated source catchment area. In December 2000, the European Court of Justice held that the UK had failed to designate sufficient NVZs for the protection of all waters, not just for drinking water sources. This resulted in the development of revised methodologies for the designation of NVZs which separately address surface waters, groundwater and waters at risk of eutrophication. This was implemented in 2002. Further reviews have been carried out in 2008 and 2012 and as a result, modifications and improvements to methods have been made at each designation round. For groundwater the Environment Agency developed a numerical risk assessment procedure that uses a range of risk factors including both nitrate concentration data and nitrate-loading data to assess the risk of nitrate pollution. The loading data is based on farm census returns made to Defra and combined using the NEAP-N methodology developed by ADAS (Lord and Anthony, 2000). The overall risk assessment considers both current observed concentrations and predicted future concentrations as well as current loadings. However, this approach has a number of disadvantages including a lack of a specific term for the time of travel to the water table and emergence of pollutant both into groundwater and to groundwater discharge points that support surface water features. Instead, these issues are considered at the conceptual level in workshops with local EA hydrogeologists. A key question for Defra and the Agency is how long it will take for nitrate concentrations to peak and then stabilise at an acceptable, lower level, in response to existing and future land management control measures. This is most important for soils, for aquifers, for lakes and for groundwater-fed wetland systems that respond less quickly to changes in loading. Groundwater and lake catchment numerical models can provide first-order estimates of likely response times, but can be difficult and costly to set-up for many different situations and are difficult to apply consistently at the national scale. A previous review of nitrate vulnerable zones suggests a range of further needs: • to understand the recent developments in nitrate pollution simulation and particularly the potential to understand/characterise past nitrate loading from changing land management practices and correlate these with observed nitrate concentrations over time; • to evaluate the retention of nitrate in catchments, particularly in the unsaturated zone of soils and aquifers; • to simulate the recent and future anticipated decreases in nitrate loading by sectors within the UK; • to understand the likely time taken for nitrate concentrations to peak and then stabilise at an acceptable, lower level, in response to existing and future control measures. Without evidence of how long it may take systems to recover it is difficult to evaluate the effectiveness of existing measures or decide whether additional measures are necessary. The aim of this project is to investigate the use of new models to inform decision-making on nitrate pollution in groundwater and the potential for incorporating unsaturated zone processes in future NVZ designations. The work described here forms the first task of this project and aims to review NVZ methodology and recent designation experience. As part of this we will: • collate information from the Agency on the recent application of the methodology; • provide case study examples of designation in different time-lag settings and/or where these are not corroborated by water quality

Source protection zones in the Chalk (open version)

The aim of this report is to provide some general observations on the problem of delineating Source Protection Zones (SPZs) in the Chalk aquifer with particular consideration of the karstic nature of the Chalk. The SPZ delineation methodology for England is outlined in Environment Agency (2019), and the Source Protection Zone definitions are provided in Appendix 1. The high vulnerability of karst aquifers and the challenges of SPZ delineation in karst are highlighted in Environment Agency (2019); which details a bespoke manual approach to SPZ delineation for karst sources. This has been applied to sources where karst is obvious; principally in the Carboniferous Limestone. However, karst has not generally been considered for the majority of Chalk SPZs, which are mostly based on standard porous medium groundwater modelling approaches. Understanding of karst in the Chalk is rapidly evolving and in recent years considerable evidence of karst and rapid groundwater flow has become apparent, and the aim of this report is to consider the implications of this for source protection

Pulmonary hypertension and thyrotoxicosis

Thyrotoxicosis is listed as a cause of pulmonary arterial hypertension (PAH). The aetiopathogenesis remains largely uncertain, but an autoimmune mechanism has been postulated, among others. In this setting, other causes of PAH need to be actively sought and excluded prior to attributing it to the thyrotoxicosis. The importance of recognising this condition is that it is usually reversible with restoration of a euthyroid state. We describe three patients who presented with thyrotoxicosis and features of PAH in whom other causes were excluded with various investigations. We also demonstrated reversibility of the pulmonary hypertension upon restoration of a normal thyroid state

Association between eczema and major cardiovascular outcomes in population-based studies: a systematic review protocol.

INTRODUCTION: Chronic inflammatory diseases such as eczema (also known as atopic dermatitis) have been inconsistently linked to cardiovascular disease and stroke in both mechanistic and epidemiological studies. There is a need to review the existing epidemiological data examining the association between eczema and major cardiovascular outcomes, including angina, myocardial infarction, coronary revascularisation, heart failure, cardiac arrhythmias, stroke and cardiovascular death, in order to improve our understanding of the comorbidities of eczema. METHODS AND ANALYSIS: We will systematically review population-based studies, including cohort, case-control and cross-sectional studies, reporting on the association between eczema and cardiovascular outcomes. We will search Medline, Embase and Global Health, from their date of inception to April 2017, using a comprehensive search strategy formulated with the help of a librarian. Two reviewers will independently screen titles and abstracts in duplicate, followed by independent data extraction and quality assessment. We will group studies by the cardiovascular outcome under study and synthesise them narratively. If sufficient numbers of homogeneous studies are returned, we will perform meta-analyses to obtain pooled effect estimates. Preferred Reporting Items for Systematic Review and Meta-Analysis will be used to inform the reporting of this study. TRIAL REGISTRATION NUMBER: CRD42017060359

Case Study: Telangiectatic osteosarcoma, a rare complication of Paget’s disease of bone

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Modelling the groundwater nitrate legacy

This report details the findings of a project jointly funded by the British Geological Survey (BGS)and Defra through the Environment Agency. The overall aim of the work was to investigate the use of new models to inform decision-making on nitrate pollution in groundwater and the potential for incorporating unsaturated zone processes into the model currently used by the Environment Agency to delineate Nitrate Vulnerable Zones (NVZs). The potential application as supporting evidence for the Water Framework Directive has also been considered as nitrate pollution of groundwater remains the most significant reason for failure of WFD environmental objectives across England. The background to the nitrate legacy in groundwater and to the approaches to NVZ designation is described in Stuart et al. (2016). A series of developments to the BGS Nitrate Time Bomb (NTB) model have been made to improve a number of areas and approaches used in the first version of the model. The improvements included a spatially and temporally distributed nitrate input function, improved unsaturated zone thickness estimation, travel time attribution using a 1:250,000 geological map, estimating nitrate velocity in the unsaturated zone using groundwater recharge and aquifer properties, and introducing nitrate transport processes in low permeability superficial deposits and the saturated zones. These now allow the model to be applied at sub national scale. Using the improved model we have also made the first estimate of the mass of nitrate stored within the unsaturated zone and how this will change over time to improve UK nitrate budget estimates. The new version of the BGS NTB approach was applied in three case studies at different scales which compared its outcomes to the results from other modelling to demonstrate that the model can be benchmarked against the other nitrate modelling approaches: • For a basin-scale model of the Thames Chalk (Howden et al., 2010 & 2011). The NTB model gave comparable results to the original study back to 1925 provided that the same nitrate input function was used. Both models failed to predict nitrate concentrations in the Thames after the mid-1980s. • At the multi-borehole scale in the Permo-Triassic. A similar approach was used to the BGS model in the Eden Valley. This replicated the existing model for the area used by the Environment Agency both in terms of trend assessment and in the lack of dilution available within the aquifer block for blending purposes. • At the single borehole scale in the Chalk of the South Downs. The existing Environment and National Park model constructed by AMEC treated the unsaturated zone very similarly to the NTB model. This model provided a good fit to observed concentrations and confirmed the importance of estimating unsaturated zone delays. The assessment of modelled travel time from different areas of the catchment clearly illustrated the arable areas that would give a relatively rapid respond to changes in nitrate management. To illustrate the potential application of the BGS NTB model to support the Environment Agency’s NVZ designation methodology, areas of England were identified where unsaturated zone lags may be significant and where there is uncertainty in the NVZ designation. A major advantage of the BGS NTB model is that it covers the whole of England (and Wales) in a consistent way. A national overview of areas of designation uncertainty identified large areas of England, in particular the chalk outcrop of southern and eastern England. These were compared to areas with significant unsaturated zone travel time indicating where travel time may be contributing to designation uncertainty. The results suggest that the model may be useful both for identifying currently impacted groundwater which reflects legacy fertilizer application and also where additional designation could be needed as impacts have not yet emerged. Application of the model to support implementation of the WFD has also been considered and whilst no quantitative analysis has yet been carried out there are a number of ways that the model could be of significant benefit. For example, the model could be used to estimate when trend reversal would be expected to occur as a result of measures (at a specific location or across a groundwater body) and the time required to achieve good chemical status (alternative objective setting). A further application could be for scenario testing such as evaluating the effects of different land use/management measures as part of cost benefit analysis or considering the long term impacts of climate change through changing fertiliser use and/or recharge