Dynamic modelling of metals in topsoils of UK and Chinese catchments

Strongly particle–reactive contaminants such as metals may exhibit highly accumulative behaviour when input to soils. This may cause exceedence of threshold concentrations for risk, for example for ecological effects or for crop metal content, if accumulation continues for a sufficiently long period. Since remediation of soils contaminated beyond threshold metal concentrations is likely to be costly and technically difficult, there is a need for tools to predict present and future accumulation of metals given future projections of inputs. The Intermediate Dynamic Model for Metals (IDMM) is an intermediate complexity model for describing and predicting metal accumulation and loss in topsoils over timescales of decades to centuries. The model combines mechanistic and empirical submodels for metal speciation, partitioning and aging in soils to predict solid phase and porewater metal speciation, leaching losses and plant uptake in response to time–varying inputs. The model has been applied both to a set of upland UK catchments, and to the Guanting reservoir catchment of northern China. The latter scenario presents a strongly contrasting environment, in terms of precipitation and soil chemistry, to the UK catchments. The model is driven by time series inputs of metals, starting from a pristine ‘steady state’ where input and output metal fluxes are in balance. Following estimation of historic metal inputs, particularly from atmospheric deposition, the model is able to make robust predictions of present day topsoil metal pools (within a factor of three of observations). The model thus provides a useful tool for predicting future trajectories of metal concentrations in topsoil, allowing assessment of potential risks due to varying scenarios of metal inputs

Outcome measurement in functional neurological disorder: a systematic review and recommendations.

OBJECTIVES: We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. METHODS: A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group. RESULTS: Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years). CONCLUSIONS: There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

BACKGROUND: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. METHODS: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. FINDINGS: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. INTERPRETATION: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. FUNDING: National Institute for Health Research, Health Technology Assessment programme

Characteristics of 698 patients with dissociative seizures: A UK multicenter study

Objective We aimed to characterize the demographics of adults with dissociative (nonepileptic) seizures, placing emphasis on distribution of age at onset, male:female ratio, levels of deprivation, and dissociative seizure semiology. Methods We collected demographic and clinical data from 698 adults with dissociative seizures recruited to the screening phase of the CODES (Cognitive Behavioural Therapy vs Standardised Medical Care for Adults With Dissociative Non‐Epileptic Seizures) trial from 27 neurology/specialist epilepsy clinics in the UK. We described the cohort in terms of age, age at onset of dissociative seizures, duration of seizure disorder, level of socioeconomic deprivation, and other social and clinical demographic characteristics and their associations. Results In what is, to date, the largest study of adults with dissociative seizures, the overall modal age at dissociative seizure onset was 19 years; median age at onset was 28 years. Although 74% of the sample was female, importantly the male:female ratio varied with age at onset, with 77% of female but only 59% of male participants developing dissociative seizures by the age of 40 years. The frequency of self‐reported previous epilepsy was 27%; nearly half of these epilepsy diagnoses were retrospectively considered erroneous by clinicians. Patients with predominantly hyperkinetic dissociative seizures had a shorter disorder duration prior to diagnosis in this study than patients with hypokinetic seizures (P < .001); dissociative seizure type was not associated with gender. Predominantly hyperkinetic seizures were most commonly seen in patients with symptom onset in their late teens. Thirty percent of the sample reported taking antiepileptic drugs; this was more common in men. More than 50% of the sample lived in areas characterized by the highest levels of deprivation, and more than two‐thirds were unemployed. Significance Females with dissociative seizures were more common at all ages, whereas the proportion of males increased with age at onset. This disorder was associated with socioeconomic deprivation. Those with hypokinetic dissociative seizures may be at risk for delayed diagnosis and treatment

Characteristics of 698 patients with dissociative seizures: A UK multicenter study

Objective We aimed to characterize the demographics of adults with dissociative (nonepileptic) seizures, placing emphasis on distribution of age at onset, male:female ratio, levels of deprivation, and dissociative seizure semiology. Methods We collected demographic and clinical data from 698 adults with dissociative seizures recruited to the screening phase of the CODES (Cognitive Behavioural Therapy vs Standardised Medical Care for Adults With Dissociative Non‐Epileptic Seizures) trial from 27 neurology/specialist epilepsy clinics in the UK. We described the cohort in terms of age, age at onset of dissociative seizures, duration of seizure disorder, level of socioeconomic deprivation, and other social and clinical demographic characteristics and their associations. Results In what is, to date, the largest study of adults with dissociative seizures, the overall modal age at dissociative seizure onset was 19 years; median age at onset was 28 years. Although 74% of the sample was female, importantly the male:female ratio varied with age at onset, with 77% of female but only 59% of male participants developing dissociative seizures by the age of 40 years. The frequency of self‐reported previous epilepsy was 27%; nearly half of these epilepsy diagnoses were retrospectively considered erroneous by clinicians. Patients with predominantly hyperkinetic dissociative seizures had a shorter disorder duration prior to diagnosis in this study than patients with hypokinetic seizures (P < .001); dissociative seizure type was not associated with gender. Predominantly hyperkinetic seizures were most commonly seen in patients with symptom onset in their late teens. Thirty percent of the sample reported taking antiepileptic drugs; this was more common in men. More than 50% of the sample lived in areas characterized by the highest levels of deprivation, and more than two‐thirds were unemployed. Significance Females with dissociative seizures were more common at all ages, whereas the proportion of males increased with age at onset. This disorder was associated with socioeconomic deprivation. Those with hypokinetic dissociative seizures may be at risk for delayed diagnosis and treatment

The use of reservoir sediments as environmental archives of catchment inputs and atmospheric pollution

Lakes and reservoirs act as sinks for both catchment and atmospherically derived particulates and so their sediments can provide valuable information on temporal changes in these inputs. While the use of lake sediments as environmental archives is well established, reservoir sediments have less frequently been used as temporal records. Yet, for investigating pollution histories, reservoirs are ostensibly of greater interest: they are generally located close to urban and industrial sources of pollution and accumulate sediment rapidly and over similar time periods to major emissions of pollutants. The lack of interest in reservoir sediments stems from the perception that fluctuating water levels are likely to result in significant sediment disturbance. This perception is sustained, perhaps mistakenly, by a lack of research into reservoir sedimentary systems. There is, therefore, a need to review the available published research on reservoir sedimentation processes and patterns, the relatively few studies that have used reservoir sediments and relevant studies from the lake-sediment literature, and thus critically evaluate the potential and problems of using reservoir sediments as temporal records of pollution. Current understanding of the processes of sedimentation and resulting distributions are reviewed. Some significant differences between sedimentation in lakes and reservoirs are highlighted and the implications for sampling and interpretation of sedimentary records discussed. It is suggested that, at present, a valuable resource is being underutilized and it is demonstrated that, where sediment deposition patterns are taken into account, reservoir sedimentary records can provide important data for reconstructing past atmospheric and catchment pollutant inputs

Sediment Stratigraphy and Heavy Metal Fluxes to Reservoirs in the Southern Pennine Uplands, UK

Reservoir sediments are rarely used as environmental archives because of the potential for sediment disturbance by fluctuating water levels. However, rapid rates of sedimentation, proximity to urban centres and often the existence of management records, may make them potentially important resources for reconstructing recent, anthropogenically-derived environmental change. This project assesses the potential of reservoir sedimentary records for reconstructing past atmospheric and drainage basin fluxes of heavy metals (manganese, iron, nickel, copper, zinc and lead) in the southern Pennines, UK. Five reservoirs were selected on the basis of management history and drainage basin characteristics. Multi-parameter analysis showed sediments to be replicable across the ȁ8accumulating zone’ with reasonably consistent rates of sedimentation. Water level fluctuations were not found to detrimentally affect sediment records in the deepwater area of the reservoirs. In fact, spheroidal carbonaceous particle (SCP) profiles show trends in inputs that closely reflect major changes in industrialisation, indicating the reservoir sediments to be excellent records of particulate inputs. Only lead (Pb) and zinc (Zn) were significantly enriched in the reservoir sediment in comparison to background levels. Manganese (Mn), iron (Fe) and to a limited degree, copper (Cu), appeared to be affected by post-deposition mobility. Preliminary calculations of Pb fluxes indicate that over 80% of the current Pb input to the reservoirs is from Pb deposited onto drainage basin soils in the past, rather than from direct atmospheric deposition or natural background inputs. In Howden reservoir, for example, the total Pb flux to deepwater sediment cores in 2000 was 119 mg m−2 a−1. Of this, an estimated 99 mg m−2 a−1 was from anthropogenically-derived Pb, initially deposited onto drainage basin soils and subsequently entering the reservoir via erosion and leaching processes. There is, therefore, no indication that the flux of Pb to the aquatic system is declining in response to reductions in Pb deposition. The ecotoxicological effects of the high and continuing Pb flux to these reservoirs, despite recent decreases in atmospheric deposition, is an area requiring further investigation

A mass balance approach to quantifying Pb storage and fluxes in an upland catchment of the Peak District, north-central England

A mass balance model of the main Pb stores and fluxes for a typical organic-rich upland catchment in the Peak District, UK, has been produced. The model, based on the Howden reservoir catchment, reveals that the majority of Pb in the catchment is stored within the soil (approximately 8·63 t km-2). Soil Pb levels are extremely high and can only be explained as the result of centuries of atmospheric Pb deposition from surrounding urban-industrial conurbations, and mining and smelting activity within the Peak District National Park. The atmospheric Pb flux onto the Howden catchment is approximately 107 kg a-1. The aquatic Pb flux is estimated at between 29·9 and 71·7 kg a-1; thus, at present, catchment soils are acting as a sink for Pb pollution. The Howden reservoir acts as a secondary store for Pb eroded and leached from catchment soils, with approximately 80% re-deposited in its sediments. It is estimated that 2·3% of the catchment soil Pb pool has been retained in the reservoir sediments over its 91 year lifespan. Although the catchment is currently acting as a Pb sink, the rate of change in the soil Pb pool is very small. Future change in climate or deposition chemistry could, however, transform catchment soils into a significant source of Pb to the aquatic environment and water supply