The impact of the Hospital Elder Life Program on the treatment of asymptomatic bacteriuria: An unexpected benefit.

Delirium in older adults is often inappropriately attributed to presumed urinary tract infections (UTIs) leading to unnecessary prescribing of antibiotics for asymptomatic bacteriuria. We sought to examine whether implementation of the Hospital Elder Life Program (HELP), a delirium prevention program, reduced the inappropriate treatment of asymptomatic bacteriuria. We conducted a secondary data analysis of administrative data and electronic health records on a descriptive study in which HELP was implemented at an academic community hospital. Patients aged 70 and older admitted before HELP was implemented (n = 687) were compared to the intervention group after HELP implementation (n = 637). HELP intervention participants, compared to pre-intervention patients, were less likely to receive inappropriate treatment for asymptomatic bacteriuria (3.0% versus 6.7%, adjusted odds ratio=0.46, 95% confidence interval=0.26-0.79, P = 0.005). HELP was associated with a reduction in the treatment of asymptomatic bacteriuria. Therefore, HELP may decrease adverse events and costs related to unnecessary exposure to antibiotics.

Evidence for climate-driven synchrony of marine and terrestrial ecosystems in northwest Australia.

The effects of climate change are difficult to predict for many marine species because little is known of their response to climate variations in the past. However, long-term chronologies of growth, a variable that integrates multiple physical and biological factors, are now available for several marine taxa. These allow us to search for climate-driven synchrony in growth across multiple taxa and ecosystems, identifying the key processes driving biological responses at very large spatial scales. We hypothesized that in northwest (NW) Australia, a region that is predicted to be strongly influenced by climate change, the El Niño Southern Oscillation (ENSO) phenomenon would be an important factor influencing the growth patterns of organisms in both marine and terrestrial environments. To test this idea, we analyzed existing growth chronologies of the marine fish Lutjanus argentimaculatus, the coral Porites spp. and the tree Callitris columellaris and developed a new chronology for another marine fish, Lethrinus nebulosus. Principal components analysis and linear model selection showed evidence of ENSO-driven synchrony in growth among all four taxa at interannual time scales, the first such result for the Southern Hemisphere. Rainfall, sea surface temperatures, and sea surface salinities, which are linked to the ENSO system, influenced the annual growth of fishes, trees, and corals. All four taxa had negative relationships with the Niño-4 index (a measure of ENSO status), with positive growth patterns occurring during strong La Niña years. This finding implies that future changes in the strength and frequency of ENSO events are likely to have major consequences for both marine and terrestrial taxa. Strong similarities in the growth patterns of fish and trees offer the possibility of using tree-ring chronologies, which span longer time periods than those of fish, to aid understanding of both historical and future responses of fish populations to climate variation.

Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home.

INTRODUCTION: Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control. METHODS: The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care. RESULTS: Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care. CONCLUSION: Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.

Developing plant functional groups to identify changes in functional composition and diversity in a dryland river experiencing artificially sustained flows.

Land use and climate changes are driving significant shifts in the magnitude and persistence of dryland stream surface flows. The impact of these shifts on ecological functioning is largely unknown, particularly where streams have become wetter rather than drier. This study investigated relationships between hydrologic regime (including surface water persistence, differences in groundwater depth and altered flooding dynamics) with plant traits and riverine vegetation functional composition. Our study system was a previously ephemeral creek in semi-arid northwest Australia that has received groundwater discharge from nearby mining operations for >15 years; surface flows are now persistent for ∼27 km downstream of the discharge point. We aimed to (i) identify plant functional groups (FGs) associated with the creek and adjacent floodplain; and (ii) assess their distribution across hydrological gradients to predict shifts in ecological functioning in response to changing flow regimes. Seven FGs were identified using hierarchical clustering of 40 woody perennial plant species based on morphometric, phenological and physiologic traits. We then investigated how FG abundance (projective foliar cover), functional composition, and functional and taxonomic richness varied along a 14 km gradient from persistent to ephemeral flows, varying groundwater depths, and distances from the stream channel. Dominant FGs were (i) drought avoidant mesic trees that are fluvial stress tolerant, or (ii) drought tolerant xeric tall shrubs that are fluvial stress intolerant. The drought avoidant mesic tree FG was associated with shallow groundwater but exhibited lower cover in riparian areas closer to the discharge (persistent surface flows). However, there were more FGs and higher species richness closer to the discharge point, particularly on the floodplain. Our findings demonstrate that quantifying FG distribution and diversity is a significant step in both assessing the impacts of mine water discharge on riverine ecosystems and for planning for post-mining restoration.

Tree growth responses to temporal variation in rainfall differ across a continental-scale climatic gradient.

Globally, many biomes are being impacted by significant shifts in total annual rainfall as well as increasing variability of rainfall within and among years. Such changes can have potentially large impacts on plant productivity and growth, but remain largely unknown, particularly for much of the Southern Hemisphere. We investigate how growth of the widespread conifer, Callitris columellaris varied with inter-annual variation in the amount, intensity and frequency of rainfall events over the last century and between semi-arid (<500 mm mean annual rainfall) and tropical (>800 mm mean annual rainfall) biomes in Australia. We used linear and polynomial regression models to investigate the strength and shape of the relationships between growth (ring width) and rainfall. At semi-arid sites, growth was strongly and linearly related to rainfall amount, regardless of differences in the seasonality and intensity of rainfall. The linear shape of the relationship indicates that predicted future declines in mean rainfall will have proportional negative impacts on long-term tree growth in semi-arid biomes. In contrast, growth in the tropics showed a weak and asymmetrical ('concave-down') response to rainfall amount, where growth was less responsive to changes in rainfall amount at the higher end of the rainfall range (>1250 mm annual rainfall) than at the lower end (<1000 mm annual rainfall). The asymmetric relationship indicates that long-term growth rates of Callitris in the tropics are more sensitive to increased inter-annual variability of rainfall than to changes in the mean amount of rainfall. Our findings are consistent with observations that the responses of vegetation to changes in the mean or variability of rainfall differ between mesic and semi-arid biomes. These results highlight how contrasting growth responses of a widespread species across a hydroclimatic gradient can inform understanding of potential sensitivity of different biomes to climatic variability and change.

Children's "euthanasia" in Nazi Germany.

Children with disabilities were killed during the Nazi era, often by nurses. Some nurses killed children, saying that they were under orders. Propaganda about the need for "racial purity" was all pervasive and influenced much of the population, including nurses. The German people accepted the "mercy" killing of children with disabilities. We describe the children's "euthanasia" program, explore the influence of propaganda, ask why it was acceptable to kill children, and provide historical context demonstrating "slippery slopes" which can lead to abrogation of ethical principles. Discussion of such history is essential as the ethical principles which were breached are still the cornerstone of nursing practice today. Only by openly discussing past wrongs can we attempt to ensure that they do not happen again. Archival documents from Germany and Israel, including trial depositions and transcripts, provided material, supplemented by secondary classic sources.

Tree Rings Show Recent High Summer-Autumn Precipitation in Northwest Australia Is Unprecedented within the Last Two Centuries.

An understanding of past hydroclimatic variability is critical to resolving the significance of recent recorded trends in Australian precipitation and informing climate models. Our aim was to reconstruct past hydroclimatic variability in semi-arid northwest Australia to provide a longer context within which to examine a recent period of unusually high summer-autumn precipitation. We developed a 210-year ring-width chronology from Callitris columellaris, which was highly correlated with summer-autumn (Dec-May) precipitation (r = 0.81; 1910-2011; p < 0.0001) and autumn (Mar-May) self-calibrating Palmer drought severity index (scPDSI, r = 0.73; 1910-2011; p < 0.0001) across semi-arid northwest Australia. A linear regression model was used to reconstruct precipitation and explained 66% of the variance in observed summer-autumn precipitation. Our reconstruction reveals inter-annual to multi-decadal scale variation in hydroclimate of the region during the last 210 years, typically showing periods of below average precipitation extending from one to three decades and periods of above average precipitation, which were often less than a decade. Our results demonstrate that the last two decades (1995-2012) have been unusually wet (average summer-autumn precipitation of 310 mm) compared to the previous two centuries (average summer-autumn precipitation of 229 mm), coinciding with both an anomalously high frequency and intensity of tropical cyclones in northwest Australia and the dominance of the positive phase of the Southern Annular Mode.

Measuring concurrent oral hypoglycemic and antidepressant adherence and clinical outcomes.

OBJECTIVES: Many patients experience difficulty in adhering to medication for both physical and mental health. Our objective was to compare selfreported adherence and electronic monitoring of adherence to oral hypoglycemic agents and antidepressants and to examine the relationship of adherence with clinical outcomes. STUDY DESIGN: Primary care-based longitudinal study. METHODS: Adherence was assessed in 180 patients prescribed pharmacotherapy for type 2 diabetes mellitus (T2DM) and depression enrolled in a randomized controlled trial of an integrated intervention for depression and T2DM. Adherence data were collected using self report and electronic monitoring. Glycated hemoglobin (A1C) assays were used to measure glycemic control, and the 9-item patient health questionnaire assessed depression. RESULTS: At 12 weeks, self-reported adherence and electronic monitoring of adherence showed fair agreement (kappa = 0.213, P = .004 for oral hypoglycemic agents and kappa = 0.380, P < .001 for antidepressants). Patients who achieved >80% adherence to oral hypoglycemic agents measured with electronic monitoring were more likely to achieve A1C < 7% compared with patients who did not achieve > 80% adherence at 12 weeks (adjusted odds ratio = 3.52, 95% confidence interval 1.07-11.57). Self-reported adherence to oral hypoglycemic agents was not associated with diabetes outcomes. Measures of adherence for antidepressants were not associated with depression outcomes in models adjusted for potentially influential covariates. CONCLUSIONS: Compared with electronic monitoring of adherence, self-reported adherence tended to overestimate medication adherence. Electronic monitoring of adherence to oral hypoglycemic agents predicted glycemic control, but self-reported adherence did not predict clinical outcomes.

The temporal relationship between anxiety disorders and urinary incontinence among community-dwelling adults.

OBJECTIVE: The purpose of this paper was to carefully examine the temporal relationships between anxiety disorders and urinary incontinence among community-dwelling adults. METHOD: In all, 1071 persons aged 30 and over were the continuing participants in a population-based longitudinal study of community-dwelling adults. Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Condition-specific functional loss secondary to urinary incontinence was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews keyed to the diagnostic criteria. RESULTS: In multivariate models that controlled for potentially influential characteristics the association between urinary incontinence with condition-specific functional loss and newly-incident anxiety disorders was statistically significant (adjusted relative odds (RO)=2.55, 95% confidence interval (CI) [1.05, 6.20]). CONCLUSIONS: Urinary incontinence with condition-specific functional loss predicted onset of newly-incident anxiety disorders among community-dwelling adults.