Assessment of groundwater-surface water interaction using long-term hydrochemical data and isotope hydrology: Headwaters of the Condamine River, Southeast Queensland, Australia.

A spatial analysis of hydrochemical data of groundwater and surface water was undertaken to identify groundwater-surface water connectivity in the headwaters of the Condamine River catchment, Southeast Queensland, Australia. An assessment of long-term hydrochemical and water level data supplemented by stable- and radioisotope measurements following a prolonged dry period dominated by baseflow, helped in determining patterns of interaction in different tributaries of the upper Condamine catchment. A conceptual hydrological model representing the major hydrochemical processes and their implications for stream-aquifer connectivity was developed and tested using multiple lines of evidence. The results of a multivariate statistical analysis highlight that there are two main regions with distinct hydrochemical facies (salinity, alkalinity, and predominant ions) in surface water. Geomorphology, geology, anthropogenic and climate influence were identified as the most relevant controlling factors of the spatial variability in water quality. Stable isotope data confirmed a clear evaporation trend in almost all surface water samples during baseflow conditions. Two water types can be identified and separated by the degree of evaporation and the proximity of one group to the local meteoric water line. The results confirm the discharge of groundwater from aquifers recharged by rainfall and located upstream of the surface water sampling sites. Overall, 222Rn data show a trend of increased activity in surface water towards the upstream portions of these tributaries, validating the use of this tracer to estimate groundwater input to the local creeks. The proportion of groundwater contribution to stream flow calculated by 222Rn and chloride mass balance is in agreement, and ranges between 20-70% in tributaries in the northern areas, and between 8-50% in the upper reaches of the main river channel. This study shows the efficacy of an integrated approach combining long-term hydrochemical data interpreted via multivariate statistics, hydraulic water level data and stable and radiogenic isotope hydrology for the determination of groundwater-surface interactions in headwater catchments.

Hydrochemical evolution within a large alluvial groundwater resource overlying a shallow coal seam gas reservoir.

A combination of multivariate statistical techniques, simple hydrochemical mixing models and inverse geochemical modelling was used to investigate the major hydrochemical evolutionary pathways of a large alluvial aquifer, the upper Condamine River alluvium, south-east Queensland, Australia. Hydrochemical similarities between alluvium and sedimentary bedrock groundwater imply some mixing between alluvial and sedimentary bedrock aquifers, but spatial assessment showed that this was localised around outcrops of sedimentary bedrock in upstream areas. Within the alluvium, a distinct shift towards a low salinity Na-HCO3 water type and a brackish Na-HCO3-Cl water type was obvious in two separate locations. Both of these water types are unique to the alluvium, and inverse modelling shows that they can evolve via a combination of in situ alluvial processes, including diffuse recharge of rainfall or river water or the evolution of basalt-derived groundwater via gypsum dissolution plagioclase weathering, cation exchange and some carbonate precipitation/dissolution. The evolution of these water types is potentially influenced by overlying sodic alkaline soils, and often is associated with a source of sulfate. Evapotranspiration is the dominant salinization process in the alluvium and increases in calcium cations during salinization indicate that brackish Na-HCO3-Cl groundwater in the underlying Walloon Coal Measures are unlikely to have a major influence on salinization in the alluvium. The most saline water types observed were endemic to shallow zones of the alluvium where evapotranspiration is likely. Results demonstrate that a combination of multivariate statistics and inverse geochemical modelling can be successfully used to delineate hydrochemical pathways in complex hydrogeological settings where a range of environmental and anthropogenic factors may be influencing the evolution of water types with similar hydrochemical compositions.

Hydrochemical evolution and groundwater flow processes in the Galilee and Eromanga basins, Great Artesian Basin, Australia: a multivariate statistical approach.

The Galilee and Eromanga basins are sub-basins of the Great Artesian Basin (GAB). In this study, a multivariate statistical approach (hierarchical cluster analysis, principal component analysis and factor analysis) is carried out to identify hydrochemical patterns and assess the processes that control hydrochemical evolution within key aquifers of the GAB in these basins. The results of the hydrochemical assessment are integrated into a 3D geological model (previously developed) to support the analysis of spatial patterns of hydrochemistry, and to identify the hydrochemical and hydrological processes that control hydrochemical variability. In this area of the GAB, the hydrochemical evolution of groundwater is dominated by evapotranspiration near the recharge area resulting in a dominance of the Na-Cl water types. This is shown conceptually using two selected cross-sections which represent discrete groundwater flow paths from the recharge areas to the deeper parts of the basins. With increasing distance from the recharge area, a shift towards a dominance of carbonate (e.g. Na-HCO3 water type) has been observed. The assessment of hydrochemical changes along groundwater flow paths highlights how aquifers are separated in some areas, and how mixing between groundwater from different aquifers occurs elsewhere controlled by geological structures, including between GAB aquifers and coal bearing strata of the Galilee Basin. The results of this study suggest that distinct hydrochemical differences can be observed within the previously defined Early Cretaceous-Jurassic aquifer sequence of the GAB. A revision of the two previously recognised hydrochemical sequences is being proposed, resulting in three hydrochemical sequences based on systematic differences in hydrochemistry, salinity and dominant hydrochemical processes. The integrated approach presented in this study which combines different complementary multivariate statistical techniques with a detailed assessment of the geological framework of these sedimentary basins, can be adopted in other complex multi-aquifer systems to assess hydrochemical evolution and its geological controls.

Honoring those who have served: how can health professionals provide optimal care for members of the military, veterans, and their families?

With over one million service members separating from the military over the next several years, it seems prudent to ask whether U.S. health care professionals and systems of care are prepared to evaluate and treat the obvious and more subtle injuries ascribed to military deployment and combat. The authors suggest that several systemic interventions-adding military health history sections to electronic health records, history and physical diagnosis textbooks, and licensing exams while also ensuring that this content is adequately covered in undergraduate and graduate health professional training-will enable all health care professionals to provide service members and veterans with the high-quality care that they deserve. The authors also highlight the U.S. Department of Veterans Affairs' recent innovations in education and care delivery, which are enhancing the education of thousands of students and residents, who will be better prepared to care for veterans after receiving this training.

Connecting the dots: interprofessional health education and delivery system redesign at the Veterans Health Administration.

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

High spatial resolution Raman thermometry analysis of TiO2 microparticles.

A new technique of high-resolution micro-Raman thermometry using anatase TiO2 microparticles (0.5-3 µm) is presented. These very high spatial resolution measurements (280 nm) reveal temperature gradients even within individual microparticles. Potential applications of this technique are demonstrated by probing the temperature distribution of a micro-fabricated heater consisting of a thin silicon nitride (Si-N) membrane with a gold coil on top of the membrane. Using TiO2 microparticle micro-Raman thermometry, the temperature from the outer edge of the coil to the inner portion was measured to increase by ~40 °C. These high spatial resolution microscopic measurements were also used to measure the temperature gradient within the 20 µm wide Si-N between the gold heating coils. 2D numerical simulations of the micro heater temperature distribution are in excellent agreement with the experimental measurements of the temperatures. These measurements illustrate the potential to extend applications of micro-Raman thermometry to obtain temperature details on a sub-micrometer spatial resolution by employing microparticles.

Educational outcomes of the Harvard Medical School-Cambridge integrated clerkship: a way forward for medical education.

PURPOSE: The authors report data from the Harvard Medical School-Cambridge Integrated Clerkship (CIC), a model of medical education in which students' entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships. METHOD: The authors compared 27 students completing the first three years of the CIC (2004-2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students' National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness. RESULTS: CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness. CONCLUSIONS: CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

Commentary: building human capital: discovery, learning, and professional satisfaction.

Physician satisfaction is an important contributor to a well-functioning health system. Mohr and Burgess report that physicians in the Veterans Health Administration (VA) who spend time in research have greater overall job satisfaction, that satisfaction tracks with aggregate facility research funding, and that satisfaction is higher among physicians working in VA facilities located on the same campus or within walking distance of an affiliated medical school. An environment conducive to research therefore not only advances science but also seems to be a key element of physician satisfaction. In addition to advancing scientific discovery and promoting greater physician satisfaction, these findings suggest that an environment of discovery and learning may yield benefits beyond specific academic endeavors and contribute more broadly to supporting health system performance.

The Department of Veterans Affairs Nursing Academy (VANA): forging strategic alliances with schools of nursing to address nursing's workforce needs.

In 2007, the Department of Veterans Affairs (VA) established the VA Nursing Academy (VANA), a 5-year, $60-million pilot program funding 15 partnerships between schools of nursing and local VA health care facilities nationwide, to expand nursing faculty, enhance clinical faculty development, increase nursing student enrollment, and promote educational innovations. VA is an ideal setting for educating nursing students owing to a well-educated registered nurse staff, an array of traditional and nontraditional settings, a state-of-the-art computerized electronic health record system, and a unique patient population. Challenges related to the complex nature of VANA partnerships, conceptualized as strategic alliances created between disparate subunits, each embedded in a larger organization, require careful governance to ensure smooth implementation. To ensure the program's aims are met, a 6-year national evaluation has been funded to help identify which strategies best achieve VANA's goals. The speed of economic recovery and the resulting changes in the nursing workforce are important determinants of VANA's future.

Re-evaluating the National Subarachnoid Haemorrhage study (2006) from a Patient-Related-Outcome-Measure perspective: comparing fiscal outcomes of Treatment-as-Usual with an enhanced service.

BACKGROUND: Subarachnoid haemorrhage (SAH) is neurological catastrophe, creating major disruption for patient and family, hence the importance of considering Patient-Related-Outcome-Measures (PROM). This study uses the National Study of SAH (2006) to explore any fiscal benefits to patients and NHS if they had an enhanced Neuro-Vascular-Specialist-Nurse (NVSN) service compared to Treatment-as-Usual (TAU). METHOD: Ensuring total confidentiality, clinical data from the National Study (n=2397) were matched with regional clinical data of a TAU (n=137) and prospective NVSN service (n=184) patients. The TAU and NVSN fiscal outcomes were projected onto the National Study patients to provide estimates of the potential benefits that could accrue nationally from a NVSN service based upon length of stay and earlier return to work of patients and carers. RESULTS: There were substantial benefits for NVSN cohort related to shorter time in hospital, reduced family disruption, earlier return to work and fiscal benefits to family and the NHS. NVSN patients and carers potential savings were estimated at £ 8.097 million and £ 2.492 million to the service, £ 10.497 million overall. PRACTICE IMPLICATIONS: This PROM approach allows the 'patient's voice' to be heard, which facilitates speedier patient and family recovery, showing that an integrated treatment approach in 'high tech' neuro-surgery is cost-effective.

Comparison of problematic behaviours of 10th and 11th year Southern English adolescents. Part 2: Current drink, drug and sexual activity of children with smoking parents.

To determine parental and school influences upon the behaviour and attitudes of adolescents of smoking versus non-smoking parents and of those "liking and disliking" school. Utilising a self-administered confidential standardised questionnaire, a representative sample of Southern English 10th and 11th year secondary school pupils was obtained. Current drink, drug and sexual behaviour were explored and data on adolescents whose parents smoked was extrapolated and compared against adolescents of non-smoking parents. Pupils reporting "liking school" were compared against those "not liking school" and all results statistically analysed. There were 17% smoking mothers [SM] and 23% smoking fathers [SF]. The focus is upon students of SF whose adolescents are significantly more often engaged in substance misuse (38-18%), drinking in pubs (31%-15%), binge drinking (32%-18%), and under-age sexual activity (27%-14%) plus smoking (51%-32%), truanting (43%-23%), vandalism (32%-22%) and stealing (19%-11%). SM students had higher incidence of sexual behaviour (33%-13%) and unprotected sex (21%-6%). Students of smoking parents were less well informed and had significantly more negative attitudes about social behaviour and responsibility. "Liking school" was associated to significantly lower rates of problematic behaviour, which predominately was not related to the social background of the pupils. The smoking father criteria carries a social class bias, nonetheless these parents need to be aware of the particular behaviour of their children and their increased risk. SF do not "cause" the behaviour rather it reflects something of the nature of the adolescent's relationship to parents, school and society.

Comparison of problematic behaviours of 10th and 11th year Southern English adolescents in 1985 and 2005. Part 1: Trends in gender behaviour.

UNLABELLED: To compare the problematic behaviours of 1985 adolescent 10th and 11th year students with that of 2005 pupils, and to examine current drink, drug and sexual activity. METHOD: Utilised a standardised questionnaire from 1985 and replicated the survey in broadly the same area in 2005. The study was self-administered and guaranteed anonymity for pupil and school, and was able to eliminate any bravado reporting. In 1985 it was not possible to inquire about sexual behaviour nor 'binge' drinking but this study was able to explore current respondents drink and sexual behaviour, utilising a linkage analysis to examine any drink-drug-sexual behaviour axis. RESULTS: In 1985 males significantly smoked, truanted, fought, vandalised, stole and 'drugged' more than girls, but by 2005 females significantly smoked, drank, used cannabis more than boys. Current adolescent girls were more often were 'binge drinkers' (29%-15%) and sexually active than boys (23% to 11%). Amongst 10th year 8% of boys and 16% of girls were actively sexually, by the 11th year it was 15% of boys and 31% of girls. DISCUSSION: Over the 20 years the traditional differences in troublesome youth behaviour has changed, with girls behaving similar or worse than boys, which along with Binge Drinking and greater sexual activity, puts them at greater risk, which is a challenge to parents and services, nonetheless, the majority of young people do Not engage in these problematic behaviours.

Distribution of Fe in waters and bottom sediments of a small estuarine catchment, Pumicestone Region, southeast Queensland, Australia.

Dissolved and extractable iron concentrations in surface water, groundwater and bottom sediments were determined for Halls Creek, a small subtropical tidally influenced creek. Dissolved iron concentrations were much higher in fresh surface waters and groundwater compared to the estuarine water. In bottom sediments, iron minerals were determined by X-ray diffraction (XRD); of these, hematite (up to 11%) has formed by precipitation from iron-rich water in the freshwater section of the catchment. Pyrite was only identified in the estuarine reach and demonstrated several morphologies [identified by scanning electron microscopy (SEM)] including loosely and closely packed framboids, and the euhedral form. The forms of pyrite found in bottom sediments indicate in situ production and recrystallisation. In surface waters, pyrite was detected in suspended sediment; due to oxygen concentrations well above 50 micromol/l, it was concluded that framboids do not form in the water column, but are within resuspended bottom sediments or eroded from creek banks. The persistence of framboids in suspended sediments, where oxygen levels are relatively high, could be due to their silica and clay-rich coatings, which prevent a rapid oxidation of the pyrite. In addition to identifying processes of formation and transport of pyrite, this study has environmental significance, as this mineral is a potential source of bioavailable forms of iron, which can be a major nutrient supporting algal growth.

Temporal variations of mineral character of acid-producing pyritic coastal sediments, Southeast Queensland, Australia.

The lower Pimpama River catchment possesses many features of morphology, geology and landuse, typical for Southeast Queensland. Pimpama River and its main tributary Hotham Creek meander over a coastal plain which developed during the last several thousand years as a result of sea level fluctuations and changing fluvial and estuarine regimes which provided ideal conditions for the formation of sedimentary pyrite. A complex mixture of natural and human factors triggers and controls the oxidation and hydrolysis of this pyrite. The consequent production of sulfuric acid and leaching of metals from the pyrite-rich sediments represent main environmental issues of this coastal setting. This study aimed to determine the lithological character of the coastal unconsolidated sediments, and identify changes produced by acidity over a long period of time in a natural system and over a short period of time in a laboratory system. The mineral composition of the estuarine sediments of the coastal plain reflects the lithology of their source, the geological basement, and also the enhanced weathering rate due to acid production. The primary minerals present in the sediments consist of quartz and feldspars (primarily albite, K-feldspars to a lesser extent and minor anorthite) the product of physical weathering of bedrock material, mainly sandstone. Kaolinite is the dominant clay mineral and represents the product of intense leaching of feldspars promoted by acid conditions. Kaolinite is fairly ordered in structure in fresh and weathered bedrock and it becomes disordered in the estuarine sediments. Illite is mainly present in bedrock-related samples and the highest amounts are associated with muscovite. In the tidal sediments, illite is present to a lesser extent and is not found in the lower estuary. The distribution of mixed layers of smectite-illite is highly variable and their deposition is mainly controlled by the hydrodynamic conditions of the environment. Only low energy tidal settings favour the deposition of smectites. Pyrite is present at many sites and is always accompanied by oxidation products such as jarosite and gypsum. The laboratory experiment showed that in the short-term, changes induced by acid production mainly involved the: (1) decomposition of oxidation products such as gypsum and jarosite, (2) weathering of feldspars (mainly plagioclase), and (3) increased amount of kaolinite and possible increased structural disorder. These observations are of significance when considering wetlands as a method of remediating acid-producing areas by re-establishment of reducing conditions. Jarosite is quite widespread and can represent a source of acid over a short period of time in water-saturated, partially oxidized pyrite-rich sediments. The initial several months of a wetland establishment may, however, be dominated by secondary acid production and metal leaching from preexisting oxidation products like jarosite and natrojarosite.

Assessing residents' competency in care management: report of a consensus conference.

BACKGROUND: Residency programs must prepare physicians to practice in the current health care environment. This mandate is reflected in 3 of the 6 competency domains now required by the Accreditation Council for Graduate Medical Education: systems-based practice, interpersonal skills and communication, and practice-based learning and improvement. SUMMARY: An invitational conference was convened, with experts in clinical practice, managed care administration, and education to identify and recommend optimal and promising assessment methods for 4 target areas: physician-patient communication, ethics, teamwork and collaboration, and practice management. Working in small groups, participants considered a range of resident assessment methods and identified current or future methods for each area, based on reliability, validity, use of behaviorally oriented outcomes, feasibility, and cost. Preferred methods of assessment varied by domain and include written examinations, computer-based patient management problems, standardized patients, objective structured clinical examinations, portfolios, 360-degree evaluations, and patient satisfaction surveys. CONCLUSIONS: The use of several practical, scientifically sound, and specific methods for assessing residents' competency in care management are recommended. Assessment instruments will need to be flexible enough to adapt to the rapid changes in the health care delivery system and terminology.

Health care economics, financing, organization, and delivery.

BACKGROUND: The US health care system is in a state of rapid evolution, with changing payment, organizational, and management structures. To learn how to function optimally in a system in which care is increasingly managed and competitive, today's medical students must understand the structural and economic underpinnings of the system within which they will practice. At the outset of the Undergraduate Medical Education for the 21st Century (UME-21) project, the great majority of medical school curricula were lacking in areas of health care financing and organizational structure. The institutions involved in the UME-21 project sought to address curricular deficiencies in two broad areas: (1) the structure and financing of the US health care system ("health policy") and (2) the manner in which this system is reflected in the organization and activities of health care providers ("care delivery"). This article discusses the development, implementation, and evaluation of the first of the two areas. METHODS: Data were abstracted from written reports provided by each of the UME-21 schools to the project's Executive Committee and sponsor. In selected cases, additional data were obtained by personal communications with project directors and evaluators. Local UME-21 project leaders verified all data presented. RESULTS: Curricular philosophy and teaching methods varied widely, but health policy curricula were predominantly preclinical and didactic in nature. At the school level, much was achieved in terms of student knowledge, curricula were generally well received by students, attitudes toward managed care generally moved in a positive direction, and behavior may have been positively influenced as well. At the project level, many potentially interesting changes exist within the 18 schools and between the UME-21 and other schools, but it is not clear whether or what parts of the health policy curricula were responsible for these changes. Nonetheless, as measured by changes in health policy-related items on the Association of American Medical Colleges Graduation Questionnaire, it appears that UME-21 schools outperformed their non-UME-21 counterparts. All of the UME-21 schools were enthusiastic about their health policy innovations, and this extended across all key stakeholders. Most schools avoided focusing on managed care and instead adopted more neutral themes that introduced the same material. Integrating the new material in conjunction with the more traditional aspects of the curriculum was also an effective implementation strategy. CONCLUSIONS: Health policy should be incorporated into both the preclinical and clinical years. The former emphasizes health care economics as one of the foundations of medical practice, whereas the latter provides the opportunity for its use on a daily basis in clinical settings. However, like any new curriculum, to achieve equal status with the traditional biomedical curriculum, it must be presented in a scholarly, rigorous, and reasonably comprehensive fashion. Mounting a scholarly health policy curriculum requires a wide-ranging, interdisciplinary faculty. If it is to become a central component of the medical school curriculum, creative approaches to faculty recruitment and development will be needed. This will require both careful educational policy formulation and new investment.