The Acute Care Undergraduate TEaching (ACUTE) initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom

Background: The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation. Design: Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale. Results: A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation. Conclusions: We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Bridging the Faraoni and Selli oceanic anoxic events: late Hauterivian to early Aptian dysaerobic to anaerobic phases in the Tethys.

A detailed geochemical analysis was performed on the upper part of the Maiolica Formation in the Breggia (southern Switzerland) and Capriolo sections (northern Italy). The analysed sediments consist of well-bedded, partly siliceous, pelagic carbonate, which lodges numerous thin, dark and organic-rich layers. Stable-isotope, phosphorus, organic-carbon and a suite of redox-sensitive trace-element contents (RSTE: Mo, U, Co, V and As) were measured. The RSTE pattern and Corg:Ptot ratios indicate that most organic-rich layers were deposited under dysaerobic rather than anaerobic conditions and that latter conditions were likely restricted to short intervals in the latest Hauterivian, the early Barremian and the pre-Selli early Aptian. Correlations are both possible with organic-rich intervals in central Italy (the Gorgo a Cerbara section) and the Boreal Lower Saxony Basin, as well as with the facies and drowning pattern in the Helvetic segment of the northern Tethyan carbonate platform. Our data and correlations suggest that the latest Hauterivian witnessed the progressive installation of dysaerobic conditions in the Tethys, which went along with the onset in sediment condensation, phosphogenesis and platform drowning on the northern Tethyan margin, and which culminated in the Faraoni anoxic episode. This episode is followed by further episodes of dysaerobic conditions in the Tethys and the Lower Saxony Basin, which became more frequent and progressively stronger in the late early Barremian. Platform drowning persisted and did not halt before the latest early Barremian. The late Barremian witnessed diminishing frequencies and intensities in dysaerobic conditions, which went along with the progressive installation of the Urgonian carbonate platform. Near the Barremian-Aptian boundary, the increasing density in dysaerobic episodes in the Tethyan and Lower Saxony Basins is paralleled by a change towards heterozoan carbonate production on the northern Tethyan shelf. The following return to more oxygenated conditions is correlated with the second phase of Urgonian platform growth and the period immediately preceding and corresponding to the Selli anoxic episode is characterised by renewed platform drowning and the change to heterozoan carbonate production. Changes towards more humid climate conditions were the likely cause for the repetitive installation of dys- to anaerobic conditions in the Tethyan and Boreal basins and the accompanying changes in the evolution of the carbonate platform towards heterozoan carbonate-producing ecosystems and platform drowning.

Rapid changes in the redox conditions of the western Tethys Ocean during the early Aptian oceanic anoxic event

The early Aptian (125 to 121 Ma) records an episode of severe environmental change including a major perturbation of the carbon cycle, an oceanic anoxic event (OAE 1a, 122.5 Ma), a platform drowning episode and a biocalcification crisis. We propose to trace changes in the oxygenation state of the ocean during the early Aptian anoxic event using the redox-sensitive trace-element (RSTE) distribution, phosphorus accumulation rates (PARs) and organic-matter characterization in three different basins of the western Tethys. The following sections have been investigated: Gorgo a Cerbara (central Italy) in the Umbria Marche basin, Glaise (SE France) in the Vocontian basin and Cassis/La Bédoule (SE France) located in the Provencal basin. In the Gorgo a Cerbara section, RSTE distributions show a low background level along the main part of the section, contrasted by different maxima in concentrations within the Selli level. In the Glaise section, the Goguel level displays a weak increase in RSTE contents coeval with moderate TOC values. At Cassis/La Bédoule, no significant RSTE enrichments have been observed in sediments equivalent to the Selli level. These differences in the records of the geochemical proxies of the Selli level or its equivalent indicate the deposition under different redox conditions, probably related to the paleogeography. Our data indicate the development of anoxic–euxinic conditions in the deeper part of the Tethys during OAE 1a, whereas in the shallower environments, conditions were less reducing. Moreover, at Gorgo a Cerbara, the Selli level is characterized by rapid changes in the intensity of reducing conditions in the water column. Ocean eutrophication seems to be a major factor in the development and the persistence of anoxia as suggested by the PAR evolution. Higher PAR values at the onset of OAE 1a suggest an increase in nutrient input, whereas the return to lower values through the first part of the OAE 1a interval may be related to the weakened capacity to retain P in the sedimentary reservoir due to bottom-water oxygen depletion. This general pattern is contrasted by the data of Gorgo a Cerbara, where the sediments deposited during the OAE 1a interval show P-enrichments (mainly authigenic P). This is associated with maxima in TOC values and Corg:Ptot ratios, suggesting that a part of the remobilized P was trapped in the sediments and as such prevented from returning to the water column.

Late Barremian-Early Aptian palaeoenvironmental change: the Cassis-La Bedoule section (SE France)

The well-dated section of Cassis-La Bédoule in the South Provencal Basin (southern France) allows for a detailed reconstruction of palaeoenvironmental change during the latest Barremian and Early Aptian. For this study, phosphorus (P) and clay-mineral contents, stable-isotope ratios on carbonate (δ13Ccarb) and organic matter (δ13Corg), and redox-sensitive trace elements (RSTE: V, U, As, Co, and Mo) have been measured in this historical stratotype. The base of the section consists of rudist limestone, which is attributed to the Urgonian platform. The presence of low P and RSTE content, and content of up to 30% kaolinite indicate deposition under oligotrophic and oxic conditions, and the presence of warm, humid climatic conditions on the adjacent continent. The top of the Urgonian succession is marked by a hardground with encrusted brachiopods and bivalves, which is interpreted as a drowning surface. The section continues with a succession of limestone and marl containing the first occurrence of planktonic foraminifera. This interval includes several laminated, organic-rich layers recording RSTE enrichments and high Corg:Ptot ratios. The deposition of these organic-rich layers was associated with oxygen-depleted conditions and a large positive excursion in δ13Corg. During this interval, a negative peak in the δ13Ccarb record is observed, which dates as latest Barremian. This excursion is coeval with negative excursions elsewhere in Tethyan platform and basin settings and is explained by the increased input of light dissolved inorganic carbon by rivers and/or volcanic activity. In this interval, an increase in P content, owing to reworking of nearshore sediments during the transgression, is coupled with a decrease in kaolinite content, which tends to be deposited in more proximal areas. The overlying hemipelagic sediments of the Early Aptian Deshayesites oglanlensis and D. weissi zones indicate rather stable palaeoenvironmental conditions with low P content and stable δ13C records. A change towards marl-dominated beds occurs close to the end of the D. weissi zone. These beds display a long decrease in their δ13Ccarb and δ13Corg records, which lasted until the end of the Deshayesites deshayesi subzone (corresponding to C3 in Menegatti et al., 1998). This is followed by a positive shift during the Roloboceras hambrovi and Deshayesites grandis subzones, which corresponds in time to oceanic anoxic event (OAE) 1a interval. This positive shift is coeval with two increases in the P content. The marly interval equivalent to OAE 1a lacks organic-rich deposits and RSTE enrichments indicating that oxic conditions prevailed in this particular part of the Tethys ocean. The clay mineralogy is dominated by smectite, which is interpreted to reflect trapping of kaolinite on the surrounding platforms rather than indicating a drier climate.