Middle Holocene expansion of Pacific Deep Water into the Southern Ocean.

The Southern Ocean is a key region for the overturning and mixing of water masses within the global ocean circulation system. Because Southern Ocean dynamics are influenced by the Southern Hemisphere westerly winds (SWW), changes in the westerly wind forcing could significantly affect the circulation and mixing of water masses in this important location. While changes in SWW forcing during the Holocene (i.e., the last ∼11,700 y) have been documented, evidence of the oceanic response to these changes is equivocal. Here we use the neodymium (Nd) isotopic composition of absolute-dated cold-water coral skeletons to show that there have been distinct changes in the chemistry of the Southern Ocean water column during the Holocene. Our results reveal a pronounced Middle Holocene excursion (peaking ∼7,000-6,000 y before present), at the depth level presently occupied by Upper Circumpolar Deep Water (UCDW), toward Nd isotope values more typical of Pacific waters. We suggest that poleward-reduced SWW forcing during the Middle Holocene led to both reduced Southern Ocean deep mixing and enhanced influx of Pacific Deep Water into UCDW, inducing a water mass structure that was significantly different from today. Poleward SWW intensification during the Late Holocene could then have reinforced deep mixing along and across density surfaces, thus enhancing the release of accumulated CO2 to the atmosphere.

Adaptation and validation of the patient assessment of chronic illness care in United States community pharmacies.

BACKGROUND: Roles for United States (US)-based community pharmacists in caring for persons with chronic conditions have greatly expanded. The Patient Assessment of Chronic Illness Care (PACIC) was developed to assess patients' perspectives of care received. However, successful application of this instrument in community pharmacies is uncertain. The objective of this study was to adapt the PACIC for use in community pharmacies (CP-PACIC), assess validity of the CP-PACIC and examine CP-PACIC scale score differences relative to patient characteristics. METHODS: This cross-sectional study surveyed chronically ill adults in Indiana, US who receive care from pharmacists in community pharmacies. The modified CP-PACIC scale consisted of 20-items, which were rated on a 5-point Likert scale from 0 (none of the time) to 4 (always). The total possible score ranged from 0 - 80. An exploratory factor analysis (EFA) was conducted to assess performance and dimensionality. CP-PACIC validity, including face validity, construct validity (via exploratory factor analysis) and internal consistency were assessed. Relationships between patient characteristics and scale scores were evaluated using appropriate statistical tests. RESULTS: Five hundred forty-six respondents' data were analyzed. EFA revealed a 2-factor solution (termed advanced pharmacy chronic illness care (AP) and traditional pharmacy chronic illness care (TP) subscales) accounting for 64.7% of variance; all 20 items were retained. The total 20-item CP-PACIC scale had a Cronbach's alpha (internal consistency) of 0.96; with a 12-item AP subscale Cronbach's alpha of 0.97 and 8-item TP subscale Cronbach's alpha of 0.89. Median total score was 12.0 [interquartile range = 27.3]. Median CP-PACIC sores varied across many respondent demographics (i.e., survey administration type, age, sex, education, health condition, number of pharmacy services received, community pharmacy type) such as whether respondents participated in one or more pharmacy service or not (29 vs. 10; p < .001). CONCLUSIONS: Unlike the original 5-subscale (patient activation, delivery system design, goal setting, problem solving, and follow-up/coordination) PACIC, analysis demonstrated a 2-factor (AP, TP) solution for the CP-PACIC scale with good internal consistency. As there are no standardized evaluation tools that exist, community pharmacies could find great value in using this CP-PACIC tool to benchmark performance and inform quality improvement strategies for patient care delivery.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis.

OBJECTIVE: Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls. METHODS: The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group. RESULTS: A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015). CONCLUSION: Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

People living in nursing care facilities who are ambulant and fracture their hips: description of usual care and an alternative rehabilitation pathway.

BACKGROUND: Little is known about treatment provided to people living in nursing care facilities (NCFs) after hospital admission for hip fracture. In addition, there are no clinical guidelines for rehabilitation and recovery following hip fracture for nursing home residents. METHODS: As part of a randomised trial (SACRED trial), which investigated the efficacy of a four week in-reach rehabilitation program, data were collected which described routine care for 240 people living in 76 nursing care facilities in South Australia who fractured their hips. The in-reach rehabilitation provided to 119 intervention participants is described, including intensity, type and methods used to encourage participation in rehabilitation. Adverse events that occurred, in particular falls, are also reported. RESULTS: NCF records indicated that, over the four weeks following discharge from hospital after hip fracture, 76% of patients receiving usual care had a consultation with their general practitioner. Physiotherapy was provided to 79% of patients in usual care (median of 1.96 h over the 4 weeks, which is less than 30 min each week of physiotherapy). In-reach rehabilitation was provided by the hospital team for 13 h over the 4 weeks with almost full attendance at physiotherapy sessions (median of 1 missed session, range 0-7 with a median of 14 physiotherapy sessions attended by participants, range 1-18). Experienced therapists provided a flexible approach to the rehabilitation to account for patients' dementia and associated neuropsychiatric symptoms while providing dietetic support, mobility training and education to nursing home staff. The number of falls experienced by those in the intervention group was higher compared to those in usual care (Relative Risk 1.38 (95%CI 1.04-1.84, p = 0.03). CONCLUSIONS: Rehabilitation can be provided to people living in NCFs following hip fracture, even when they have moderate to severe dementia but the model needs to be flexible. Provision of rehabilitation may increase the rate of falls in this population. Further studies are required to establish the feasibility of the intervention in other long term care settings. (327 words). TRIAL REGISTRATION: ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry (ANZCTR).

Relationship between diurnal patterns in Rapid Response Call activation and patient outcome.

BACKGROUND: The Rapid Response Call (RRC) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. To date, there have been few studies which have explored the relationship between time of day of RRC and patient outcome. OBJECTIVE: To examine the relationship between the time of RRC activations and patient outcome. METHOD: All adult inpatients with a RRC in non-critical care wards of a metropolitan Australian hospital in 2012 were retrospectively reviewed. RRCs occurring between 18:00-07:59 were defined as 'out of hours'. RESULTS: There were 892 RRC during the study period. RRCs out of hours were associated with a higher rate of ICU admissions immediately after the RRC (19.4% vs. 12.3%, p<0.001). Patients experiencing an out-of-hours RRC were more likely to have an in-hospital cardiopulmonary arrest (OR=1.7, p<0.04). In-hospital mortality rate was significantly higher for patients with out-of-hours RRCs (35.5% vs. 25.0%, p=0.014). After adjusting for confounders out-of-hours RRC were independently associated with increased need for ICU admissions and in-hospital mortality. CONCLUSION: The diurnal timing of RRCs appears to have significant implications for patient mortality and morbidity, patient outcomes are worse if RRC occurs out of hours. This finding has implications for staffing and resource allocation.