Differential Bioaccumulation of Mercury and Selenium in Stomach Contents and Tissues of Three Colorado, USA, Cutthroat Trout Populations.

Total mercury (THg) and selenium (TSe) levels were measured in stomach contents (SC) and twelve tissues of cutthroat trout (Oncorhynchus clarkii) occurring in three high-elevation lakes of Colorado, USA, inhabiting watersheds absent past and current mining activities. For 32 of 36 tissues, including muscle, mean THg wet weight (ww) concentrations were greater than in the diet (SC) for all sites, indicating biomagnification. Ranges of THg (µg/kg ww) for SC and stomach tissue (ST) were 1.23-73.54 and 14.55-61.35, respectively. Selenium concentrations in fish muscle were not greater than in the SC indicating a trophic transfer factor < 1.0. However, in several other tissues, mean Se dry weight (dw) levels were greater than in SC for all three lakes. Ranges of TSe for SC and ST were 166-7544 and 797-7523 (µg/kg dw), respectively. The muscle to egg/ovary ratio for Se averaged 2.30, 4.60, and 2.68 for the three populations. The variability of SC (planktonic vs. benthic) and differential distributions of THg and TSe in SC and organ-tissues generated questions focusing on the seasonal, physiological, and genetic drivers of these organometal(loid)s in subalpine trout.

Providing effective asthma care at a pediatric patient-centered medical home.

BACKGROUND: A recent assessment of the national annual burden of the cost of asthma among school-aged children was nearly $6 million. In a Midwestern county, the incidence of childhood asthma was 15.8%, which was above both state and national levels. LOCAL PROBLEM: Effective asthma care was not being provided at a rural, pediatric patient-centered medical home due to a lack of standardization. This quality improvement (QI) initiative aimed to increase the mean effective asthma care score to 78% for patients with asthma over the course of 90 days. METHODS: This right care initiative was implemented using a rapid-cycle Plan-Do-Study-Act methodology. Tests of change in the areas of team engagement, patient engagement, and two process measures were analyzed through chart audits and run charts over four cycles. Likert scale surveys were used to analyze qualitative data. INTERVENTIONS: Interventions included developing the Asthma Patient Identification Tool, implementing an asthma education protocol with teach-back, creating standardized smart phrases for effective documentation, and initiating asthma care huddles. RESULTS: The delivery of effective asthma care increased to 84%. The number of patients receiving the asthma education protocol increased to 65%, with 80% of the patients participating in effective teach-back sessions. The mean effective documentation score increased to 92%. CONCLUSIONS: A standardized approach to asthma care grounded in evidence-based guidelines positively affected the delivery of care. Nurse practitioners are effective team leaders for clinical QI initiatives.