Safe and just Earth system boundaries.

The stability and resilience of the Earth system and human well-being are inseparably linked1-3, yet their interdependencies are generally under-recognized; consequently, they are often treated independently4,5. Here, we use modelling and literature assessment to quantify safe and just Earth system boundaries (ESBs) for climate, the biosphere, water and nutrient cycles, and aerosols at global and subglobal scales. We propose ESBs for maintaining the resilience and stability of the Earth system (safe ESBs) and minimizing exposure to significant harm to humans from Earth system change (a necessary but not sufficient condition for justice)4. The stricter of the safe or just boundaries sets the integrated safe and just ESB. Our findings show that justice considerations constrain the integrated ESBs more than safety considerations for climate and atmospheric aerosol loading. Seven of eight globally quantified safe and just ESBs and at least two regional safe and just ESBs in over half of global land area are already exceeded. We propose that our assessment provides a quantitative foundation for safeguarding the global commons for all people now and into the future.

Evaluating quality metrics of patients with type 2 diabetes managed by nurse practitioners in two family nurse practitioner-owned clinics.

BACKGROUND: Diabetes is a major health concern in the U.S. with increasing prevalence. There are limited data on nurse practitioner (NP) roles in diabetes management and clinical patient outcomes in relation to national standards of care. This project aimed to identify rates of American Diabetes Association (ADA) guideline adherence of two NP-owned and operated practices during an ongoing four-year quality improvement project. METHODS: Methods: Electronic health records of 83 - 112 patients (depending on the year) ages > 18 years with type 2 diabetes were reviewed. Mean A1C and rates of adherence to ADA standards were compared from 2013 to 2017 and to national and state data. CONCLUSIONS: Findings demonstrated that diabetes management provided by NPs consistently adhered to national ADA standards of care and met or exceeded national data. This four-year ongoing quality improvement project has led to the implementation of practice modifications that continue to improve patient outcomes through increased adherence to ADA guidelines. IMPLICATIONS FOR PRACTICE: Strategies which improve adherence to ADA standards of care by NPs are essential. Identifying rates of adherence and implementing quality improvement strategies can significantly improve the quality of care provided to patients with diabetes.