Flandrian sea-level changes in the Moray Firth area

The Moray Firth area is recognized as an area deficient in data relevant to sea-level change. This thesis attempts to provide a preliminary assessment of the restoration of sea-level following the last glaciation, particularly the last 10,000 years. The methodology used is essentially empirical and analytic, based upon stratigraphic description, micropalaeontological investigation and radiocarbon dating of sites in former tidal flat and lagoonal environments. Three sites at the head of the Beauly and Cromarty Firths, at Barnyards (NH 5247), Moniack (NH 5443) and Arcan Mains (NH 4954) provide stratigraphic and environmental evidence for the interpretation of sea-level change during the Flandrian Age. A preliminary chronological scheme of positive and negative tendencies of sea-level movement and a time-altitude graph is constructed using information from biostratigraphic and lithostratigraphic sea- level indicators and nine new radiocarbon dates. An attempt is made to assess the magnitude of error inherent at all stages of the analysis. Correlation is made with other areas of Scotland and Fennoscandia. A comparison is made between the differing methodologies employed in this thesis and other areas of Scotland where sequences of measured and named shorelines have been established. An isostatic curve for the inner Moray Firth is constructed using eustatic calibration of index point altitude. The results are compared to other published isostatic curves for Scotland

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement.

INTRODUCTION: Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain. METHODS AND ANALYSIS: A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews. ETHICS APPROVAL AND DISSEMINATION: Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country. TRIAL REGISTRATION NUMBER: ISRCTN18010240

Mid-Late Quaternary Fluvial Archives near the Margin of the MIS 12 Glaciation in Southern East Anglia, UK: Amalgamation of Multi-Disciplinary and Citizen-Science Data Sources

This paper presents an updated geological reconstruction of the Quaternary evolution of the River Thames at its downstream extremities, close to the North Sea coast, based on new data from multi-disciplinary and citizen-science sources. In this area, the interaction of the Thames with the MIS 12 (Anglian) glaciation is an important part of the Quaternary archive. The Anglian ice sheet, which reached parts of north and east London, was responsible for diverting the Thames southwards into its present course, although the footprint of the maximum ice sheet(s) does not reach the North Sea coast south of Hollesley, Suffolk. Further south, the coastal zone hosts pre-Anglian and early Anglian river-terrace deposits of the pre-diversion Thames system, superimposed upon which are products of later post-Anglian rivers, of both Middle and Late Pleistocene age. On the peninsula between the Stour and Blackwater–Colne estuaries, the lowest and most recent terrace of the pre-diversion Thames includes evidence directly pertaining to the glacial disruption event, for which geochronological data are reported here for the first time. The first post-diversion terrace of the Thames also reaches this peninsula, the river having essentially re-joined its original valley before crossing the alignment of the modern coastline. This terrace passes beneath Clacton-on-Sea, where it includes the type locality of the Clactonian Palaeolithic Industry. The area of interest to this paper, in NE Essex and southern Suffolk, includes a number of interglacial and Palaeolithic sites, the data from which assist in constraining the chronostratigraphy of the sequence. In some cases, there has been uncertainty as to whether these sites represent pre-Anglian environments and hominin occupations, part of the palaeo-Thames sequence, or whether they are the product of later post-Anglian streams, formed after the Thames had migrated southwards. This paper compiles evidence from a wide range of recent sources, including developer-funded archaeological appraisal and citizen-science activities, to explore and update the evidence from sites at Ipswich, Upper Dovercourt and Thorpe-le-Soken, as well as a number of localities associated with the Clacton Channel Deposits (host to the type-Clactonian), amongst others. The resulting new data are placed within the wider context of the Quaternary fluvial archives in southern Britain, with a discussion of how disparate sources of information, including the work of citizen scientists, have contributed

Patient-reported outcome measures for monitoring primary care patients with depression: the PROMDEP cluster RCT and economic evaluation.

BACKGROUND: Guidelines on the management of depression recommend that practitioners use patient-reported outcome measures for the follow-up monitoring of symptoms, but there is a lack of evidence of benefit in terms of patient outcomes. OBJECTIVE: To test using the Patient Health Questionnaire-9 questionnaire as a patient-reported outcome measure for monitoring depression, training practitioners in interpreting scores and giving patients feedback. DESIGN: Parallel-group, cluster-randomised superiority trial; 1 : 1 allocation to intervention and control. SETTING: UK primary care (141 group general practices in England and Wales). INCLUSION CRITERIA: Patients aged ≥ 18 years with a new episode of depressive disorder or symptoms, recruited mainly through medical record searches, plus opportunistically in consultations. EXCLUSIONS: Current depression treatment, dementia, psychosis, substance misuse and risk of suicide. INTERVENTION: Administration of the Patient Health Questionnaire-9 questionnaire with patient feedback soon after diagnosis, and at follow-up 10-35 days later, compared with usual care. PRIMARY OUTCOME: Beck Depression Inventory, 2nd edition, symptom scores at 12 weeks. SECONDARY OUTCOMES: Beck Depression Inventory, 2nd edition, scores at 26 weeks; antidepressant drug treatment and mental health service contacts; social functioning (Work and Social Adjustment Scale) and quality of life (EuroQol 5-Dimension, five-level) at 12 and 26 weeks; service use over 26 weeks to calculate NHS costs; patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale); and adverse events. SAMPLE SIZE: The original target sample of 676 patients recruited was reduced to 554 due to finding a significant correlation between baseline and follow-up values for the primary outcome measure. RANDOMISATION: Remote computerised randomisation with minimisation by recruiting university, small/large practice and urban/rural location. BLINDING: Blinding of participants was impossible given the open cluster design, but self-report outcome measures prevented observer bias. Analysis was blind to allocation. ANALYSIS: Linear mixed models were used, adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering including practice as random effect. Quality of life and costs were analysed over 26 weeks. QUALITATIVE INTERVIEWS: Practitioner and patient interviews were conducted to reflect on trial processes and use of the Patient Health Questionnaire-9 using the Normalization Process Theory framework. RESULTS: Three hundred and two patients were recruited in intervention arm practices and 227 patients were recruited in control practices. Primary outcome data were collected for 252 (83.4%) and 195 (85.9%), respectively. No significant difference in Beck Depression Inventory, 2nd edition, score was found at 12 weeks (adjusted mean difference -0.46, 95% confidence interval -2.16 to 1.26). Nor were significant differences found in Beck Depression Inventory, 2nd Edition, score at 26 weeks, social functioning, patient satisfaction or adverse events. EuroQol-5 Dimensions, five-level version, quality-of-life scores favoured the intervention arm at 26 weeks (adjusted mean difference 0.053, 95% confidence interval 0.013 to 0.093). However, quality-adjusted life-years over 26 weeks were not significantly greater (difference 0.0013, 95% confidence interval -0.0157 to 0.0182). Costs were lower in the intervention arm but, again, not significantly (-£163, 95% confidence interval -£349 to £28). Cost-effectiveness and cost-utility analyses, therefore, suggested that the intervention was dominant over usual care, but with considerable uncertainty around the point estimates. Patients valued using the Patient Health Questionnaire-9 to compare scores at baseline and follow-up, whereas practitioner views were more mixed, with some considering it too time-consuming. CONCLUSIONS: We found no evidence of improved depression management or outcome at 12 weeks from using the Patient Health Questionnaire-9, but patients' quality of life was better at 26 weeks, perhaps because feedback of Patient Health Questionnaire-9 scores increased their awareness of improvement in their depression and reduced their anxiety. Further research in primary care should evaluate patient-reported outcome measures including anxiety symptoms, administered remotely, with algorithms delivering clear recommendations for changes in treatment. STUDY REGISTRATION: This study is registered as IRAS250225 and ISRCTN17299295. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 17. See the NIHR Funding and Awards website for further award information

Depression follow-up monitoring with the PHQ-9: open cluster-randomised controlled trial.

BACKGROUND: Outcome monitoring of depression is recommended but lacks evidence of patient benefit in primary care. AIM: To test monitoring depression using the PHQ-9 questionnaire with patient feedback. DESIGN AND SETTING: Open cluster-randomised controlled trial in 141 group practices. METHOD: Adults with new depressive episodes were recruited through records searches and opportunistically. EXCLUSION CRITERIA: dementia, psychosis, substance misuse, suicide risk. The PHQ-9 questionnaire was to be administered soon after diagnosis, and 10-35 days later. PRIMARY OUTCOME: Beck Depression Inventory (BDI-II) score at 12 weeks. SECONDARY OUTCOMES: BDI-II at 26 weeks; Work and Social Adjustment Scale and EuroQol EQ-5D-5L quality of life at 12 and 26 weeks; antidepressant treatment, mental health service use, adverse events, and Medical Informant Satisfaction Scale over 26 weeks. RESULTS: 302 intervention arm patients were recruited and 227 controls. At 12 weeks 252 (83.4%) and 195 (85.9%) were followed-up respectively. Only 41% of intervention arm patients had a GP follow-up PHQ-9 recorded. There was no significant difference in BDI-II score at 12 weeks (mean difference -0.46; 95% CI -2.16,1.26), adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering by practice). EQ-5D-5L quality of life scores were higher in the intervention arm at 26 weeks (adjusted mean difference 0.053; 95% CI 0.093,0.013). A clinically significant difference in depression at 26 weeks could not be ruled out. No significant differences were found in social functioning, adverse events, or satisfaction. In a per-protocol analysis, antidepressant use and mental health contacts were significantly greater in intervention arm patients with a recorded follow-up PHQ-9. CONCLUSIONS: No evidence was found of improved depression outcome at 12 weeks from monitoring. The findings of possible benefits over 26 weeks warrant replication, investigating possible mechanisms, preferably with automated delivery of monitoring and more instructive feedback

Depression follow-up monitoring with the PHQ-9: open cluster-randomised controlled trial

Background: Outcome monitoring of depression is recommended but lacks evidence of patient benefit in primary care. Aim: To test monitoring depression using the PHQ-9 questionnaire with patient feedback. Design and setting: Open cluster-randomised controlled trial in 141 group practices. Method: Adults with new depressive episodes were recruited through records searches and opportunistically. Exclusion criteria: dementia, psychosis, substance misuse, suicide risk. The PHQ-9 questionnaire was to be administered soon after diagnosis, and 10-35 days later. Primary outcome: Beck Depression Inventory (BDI-II) score at 12 weeks. Secondary outcomes: BDI-II at 26 weeks; Work and Social Adjustment Scale and EuroQol EQ-5D-5L quality of life at 12 and 26 weeks; antidepressant treatment, mental health service use, adverse events, and Medical Informant Satisfaction Scale over 26 weeks. Results: 302 intervention arm patients were recruited and 227 controls. At 12 weeks 252 (83.4%) and 195 (85.9%) were followed-up respectively. Only 41% of intervention arm patients had a GP follow-up PHQ-9 recorded. There was no significant difference in BDI-II score at 12 weeks (mean difference -0.46; 95% CI -2.16,1.26), adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering by practice). EQ-5D-5L quality of life scores were higher in the intervention arm at 26 weeks (adjusted mean difference 0.053; 95% CI 0.093,0.013). A clinically significant difference in depression at 26 weeks could not be ruled out. No significant differences were found in social functioning, adverse events, or satisfaction. In a per-protocol analysis, antidepressant use and mental health contacts were significantly greater in intervention arm patients with a recorded follow-up PHQ-9. Conclusions: No evidence was found of improved depression outcome at 12 weeks from monitoring. The findings of possible benefits over 26 weeks warrant replication, investigating possible mechanisms, preferably with automated delivery of monitoring and more instructive feedback