Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

BACKGROUND: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. METHODS: We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. RESULTS: Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). CONCLUSIONS: Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

New Name, New Format, New Publisher, Same Principles and Values

This issue of the Journal of Family Strengths is an opportunity for a fresh start, as the Family Preservation Journal is renewed and revived under a new name and a new format. Still keen on being a definitive record on developments in family strengths and parenting, the Journal is devoted to presenting theory, practice and evaluation articles on the strengths perspective in family preservation practice, all to assure and improve services and programs that promote and sustain family systems.

A High-Altitude Snow Chemistry Record from Amundsenisen, Dronning Maud Land, Antarctica

In this paper a detailed record of major ions from a 20 in deep firn core from Amundsenisen, western Dronning Maud Land, Antarctica, is presented. The core was drilled at 75degreesS, 2degrees E (2900 m.a.s.l.) during austral summer 1991/92. The following ions were measured at 3 cm resolution: Na+, Mg2+, Ca2+, Cl-, NO3-, SO42- and CH3SO3H (MSA). The core was dated back to 1865 using a combination of chemical records and volcanic reference horizons. The volcanic eruptions identified in this core are Mount Ngauruhoe, New Zealand (1974-75), Mount Agung, Indonesia (1963), Azul, Argentina (1932). and a broad peak that corresponds in time to Tarawera, New Zealand (1886), Falcon Island, South Shetlands, Southern Ocean (1885), and Krakatau, Indonesia (1883). There are no trends in any of the ion records, but the annual to decadal changes are large. The mean concentrations of the measured ions are in agreement with those from other high-altitude cores from the Antarctic plateau. At this core site there may be a correspondence between peaks in the MSA record and major El Nino-Southern Oscillation events.

Sea Level Pressure Variability Over the Southern Indian Ocean Inferred from a Glaciochemical Record in Princess Elizabeth Land, East Antarctica

A 250-year, high-resolution, multivariate ice core record from LGB65 (70degrees50'07"S, 77degrees04'29"E; 1850 m asl), Princess Elizabeth Land (PEL), is used to investigate sea level pressure (SLP) variability over the southern Indian Ocean (SIO). Empirical orthogonal function (EOF) analysis reveals that the first EOF (EOF1) of the glaciochemical record from LGB65 represents most of the variability in sea salt throughout the 250-year record. EOF1 is negatively correlated (95% confidence level and higher) to instrumental mean sea level pressure (MSLP) at Kerguelen and New Amsterdam islands, SIO. On the basis of comparison with NCEP/NCAR reanalysis, strong correlations were found between sea-salt variations and a quasi-stationary low that lies to the north of Prydz Bay, SIO. Comparison with a 250-year-long summer transpolar index (STPI) inferred from sub-Antarctic tree ring records reveals strong coherency. Decadal-scale SLP variability over SIO suggests shifting of the polar vortex. Prominent decadal-scale deepening of the southern Indian Ocean low (SIOL) exists circa 1790, 1810, 1835, 1860, 1880, 1900, and 1940 A. D., continuously after the 1970s, and prominent weakening circa 1750, 1795, 1825, 1850, 1870, 1890, 1910, and 1955 A. D. The LGB65 sea-salt record is characterized by significant decadal-scale variability with a strong similar to21-year periodic structure (99.9% confidence level). The relationship between LGB65 sea salt and solar irradiance changes shows that this periodicity is possibly the solar Hale cycle ( 22 years).

Helium transfer from water into quartz crystals: A new approach for porewater dating

Several important fundamental and applied problems require a quantification of slow rates of groundwater flow. To resolve these problems helium appears to be a promising tracer. In this contribution we discuss a new approach, which gives the helium inventory in a rock – pore water system by using the relevant mineral record, i.e., without extraction and investigation of the porewater samples. Some U- and Th-poor minerals such as quartz (quartz separates from Permo-Carboniferous Formation, sandstone–shale interlayering, Molasses Basin, Northern Switzerland, hereafter PCF, are used in this study) contain excessive helium having migrated into their internal helium-accessible volume (HAV) from the surrounding porewater [I.N. Tolstikhin, B.E. Lehmann, H.H. Loosli, A. Gautschi, Helium and argon isotopes in rocks, minerals and related groundwaters: a case study in Northern Switzerland, Geochim. Cosmochim. Acta 60 (1996) 1497–1514]. These volumes are estimated by using helium as a nano-size penetrating tool, i.e., by saturation of the minerals with helium under controlled pressure–temperature conditions and subsequent measurements of the helium-saturated concentrations. In the quartz separates HAV/total volume ratios vary from 0.017% to 0.16%; along with the measured initial (unsaturated) He concentration the HAV gives the internal helium pressure, the mean value obtained for 7 samples (25 sample aliquots) is P=0.45F0.15 atm (1 r). The product of helium pressure and solubility (7.35_10_3 cc STP He/cc H2O for the temperature and salinity of PCF aquifers reported in [F.J. Pearson, W. Balderer, H.H. Loosli, B.E. Lehmann, A. Matter, T. Peters, H. Schmassmann, A. Gautschi, Applied Isotope Hydrogeology–A Case Study in Northern Switzerland, Elsevier Amsterdam, 1991, 439 pp.]) is the mineral-derived He concentration in the respective porewater, CPW=0.0035F0.0017 cc He/cc H2O. This value is in full accord with measured He concentrations in PCF aquifers, CPCF, varying from 0.0045 to 0.0016 cc He/cc H2O. This agreement validates the proposed approach and also shows that the mineral–porewater helium–concentration equilibrium has been established. Indeed, estimates of the He-migration rates through our quartz samples show that in ~6000 years the internal pressure should equilibrate with He-concentration in related porewater of PCF, and this time interval is short compared to independent estimates [I.N. Tolstikhin, B.E. Lehmann, H.H. Loosli, A. Gautschi, Helium and argon isotopes in rocks, minerals and related groundwaters: a case study in Northern Switzerland, Geochim. Cosmochim. Acta 60 (1996) 1497–1514]. The helium inventory in the rock–porewater assemblage shows that helium abundance in pore waters is indeed important. In shale samples (with ~15% porosity) porewaters contain more helium than the host minerals altogether. Porewater heliumconcentration profiles, available from the mineral record, along with helium production rates are input parameters allowing model(s) of helium migration through a hydrological structure to be developed. Quite high helium concentrations in PCF porewaters imply slow removal mechanisms, which will be discussed elsewhere.

An underestimated record breaking event – why summer 1540 was likely warmer than 2003

The heat of summer 2003 in Western and Central Europe was claimed to be unprecedented since the Middle Ages on the basis of grape harvest data (GHD) and late wood maximum density (MXD) data from trees in the Alps. This paper shows that the authors of these studies overlooked the fact that the heat and drought in Switzerland in 1540 likely exceeded the amplitude of the previous hottest summer of 2003, because the persistent temperature and precipitation anomaly in that year, described in an abundant and coherent body of documentary evidence, severely affected the reliability of GHD and tree-rings as proxy-indicators for temperature estimates. Spring–summer (AMJJ) temperature anomalies of 4.7 °C to 6.8 °C being significantly higher than in 2003 were assessed for 1540 from a new long Swiss GHD series (1444 to 2011). During the climax of the heat wave in early August the grapes desiccated on the vine, which caused many vine-growers to interrupt or postpone the harvest despite full grape maturity until after the next spell of rain. Likewise, the leaves of many trees withered and fell to the ground under extreme drought stress as would usually be expected in late autumn. It remains to be determined by further research whether and how far this result obtained from local analyses can be spatially extrapolated. Based on the temperature estimates for Switzerland it is assumed from a great number of coherent qualitative documentary evidence about the outstanding heat drought in 1540 that AMJJ temperatures were likely more extreme in neighbouring regions of Western and Central Europe than in 2003. Considering the significance of soil moisture deficits for record breaking heat waves, these results still need to be validated with estimated seasonal precipitation. It is concluded that biological proxy data may not properly reveal record breaking heat and drought events. Such assessments thus need to be complemented with the critical study of contemporary evidence from documentary sources which provide coherent and detailed data about weather extremes and related impacts on human, ecological and social systems.

Paracetamol for perioperative analgesia. Old substance - new insights

Since paracetamol was first synthesized in 1878 it has become one of the most popular and widely used drugs for the first-line treatment of fever and pain. The reasons for this popularity are a wide variety of formulations, an assumed positive safety record and the wide availability as an over-the-counter drug. However, recently several studies questioned the positive risk-benefit ratio of paracetamol for postoperative pain by observing several possible adverse effects and limitations. The aim of the present review is to give an update of the recent literature on the efficacy of paracetamol for postoperative pain and on the value of the clinical relevance of different adverse effects of paracetamol. Finally, based on the current findings the authors try to assess the role of paracetamol for the treatment of postoperative pain.

Northern Mediterranean climate since the Middle Pleistocene: a 637 ka stable isotope record from Lake Ohrid (Albania/Macedonia)

Lake Ohrid (Macedonia/Albania) is an ancient lake with unique biodiversity and a site of global significance for investigating the influence of climate, geological, and tectonic events on the generation of endemic populations. Here, we present oxygen (δ18O) and carbon (δ13C) isotope data from carbonate over the upper 243 m of a composite core profile recovered as part of the Scientific Collaboration on Past Speciation Conditions in Lake Ohrid (SCOPSCO) project. The investigated sediment succession covers the past ca. 637 ka. Previous studies on short cores from the lake (up to 15 m, < 140 ka) have indicated the total inorganic carbon (TIC) content of sediments to be highly sensitive to climate change over the last glacial–interglacial cycle. Sediments corresponding to warmer periods contain abundant endogenic calcite; however, an overall low TIC content in glacial sediments is punctuated by discrete bands of early diagenetic authigenic siderite. Isotope measurements on endogenic calcite (δ18Oc and δ13Cc) reveal variations both between and within interglacials that suggest the lake has been subject to palaeoenvironmental change on orbital and millennial timescales. We also measured isotope ratios from authigenic siderite (δ18Os and δ13Cs) and, with the oxygen isotope composition of calcite and siderite, reconstruct δ18O of lake water (δ18Olw) over the last 637 ka. Interglacials have higher δ18Olw values when compared to glacial periods most likely due to changes in evaporation, summer temperature, the proportion of winter precipitation (snowfall), and inflow from adjacent Lake Prespa. The isotope stratigraphy suggests Lake Ohrid experienced a period of general stability from marine isotope stage (MIS) 15 to MIS 13, highlighting MIS 14 as a particularly warm glacial. Climate conditions became progressively wetter during MIS 11 and MIS 9. Interglacial periods after MIS 9 are characterised by increasingly evaporated and drier conditions through MIS 7, MIS 5, and the Holocene. Our results provide new evidence for long-term climate change in the northern Mediterranean region, which will form the basis to better understand the influence of major environmental events on biological evolution within Lake Ohrid.

Developing a point-of-care electronic medical record system for TB/HIV co-infected patients: experiences from Lighthouse Trust, Lilongwe, Malawi.

BACKGROUND Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients. METHODS Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing. RESULTS Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period. CONCLUSION Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.

Lake Son Kol geochemistry, µXRF, biogeochemistry and pollen record

In general, a moderate drying trend is observed in mid-latitude arid Central Asia since the Mid-Holocene, attributed to the progressively weakening influence of the mid-latitude Westerlies on regional climate. However, as the spatio-temporal pattern of this development and the underlying climatic mechanisms are yet not fully understood, new high-resolution paleoclimate records from this region are needed. Within this study, a sediment core from Lake Son Kol (Central Kyrgyzstan) was investigated using sedimentological, (bio)geochemical, isotopic, and palynological analyses, aiming at reconstructing regional climate development during the last 6000 years. Biogeochemical data, mainly reflecting summer moisture conditions, indicate predominantly wet conditions until 4950 cal. yr BP, succeeded by a pronounced dry interval between 4950 and 3900 cal. yr BP. In the following, a return to wet conditions and a subsequent moderate drying trend until present times are observed. This is consistent with other regional paleoclimate records and likely reflects the gradual Late Holocene diminishment of the amount of summer moisture provided by the mid-latitude Westerlies. However, climate impact of the Westerlies was apparently not only restricted to the summer season but also significant during winter as indicated by recurrent episodes of enhanced allochthonous input through snowmelt, occurring before 6000 cal. yr BP and at 5100-4350, 3450-2850, and 1900-1500 cal. yr BP. The distinct ~1500-year periodicity of these episodes of increased winter precipitation in Central Kyrgyzstan resembles similar cyclicities observed in paleoclimate records around the North Atlantic, likely indicating a hemispheric-scale climatic teleconnection and an impact of North Atlantic Oscillation (NAO) variability in Central Asia.

Stable oxygen isotope record and Sr/Ca ratios of corals from IODP Holes M0009D and M0023A

We present monthly resolved records of strontium/calcium (Sr/Ca) and oxygen isotope (d18O) ratios from well-preserved fossil corals drilled during the Integrated Ocean Drilling Program (IODP) Expedition 310 'Tahiti Sea Level' and reconstruct sea surface conditions in the central tropical South Pacific Ocean during two time windows of the last deglaciation. The two Tahiti corals examined here are uranium/thorium (U/Th)-dated at 12.4 and 14.2 ka, which correspond to the Younger Dryas (YD) cold reversal and the Bølling-Allerød (B-A) warming of the Northern Hemisphere, respectively. The coral Sr/Ca records indicate that annual average sea surface temperature (SST) was 2.6-3.1 °C lower at 12.4 ka and 1.0-1.6 °C lower at 14.2 ka relative to the present, with no significant changes in the amplitude of the seasonal SST cycle. These cooler conditions were accompanied by seawater d18O (d18Osw) values higher by ~0.8 per mill and ~0.6 per mill relative to the present at 12.4 and 14.2 ka, respectively, implying more saline conditions in the surface waters. Along with previously published coral Sr/Ca records from the island [Cohen and Hart (2004), Deglacial sea surface temperatures of the western tropical Pacific: A new look at old coral. Paleoceanography 19, PA4031, doi:10.1029/2004PA001084], our new Tahiti coral records suggest that a shift toward lower SST by ~1.5 °C occurred from 13.1 to 12.4 ka, which was probably associated with a shift toward higher d18Osw by ~0.2 per mill. Along with a previously published coral Sr/Ca record from Vanuatu [Corrège et al. (2004), Interdecadal variation in the extent of South Pacific tropical waters during the Younger Dyras event. Nature 428, 927-929], the Tahiti coral records provide new evidence for a pronounced cooling of the western to central tropical South Pacific during the Northern Hemisphere YD event.

Deep-sea sediment core PS2644 record from the southern Greenland Sea

The PS2644 deep-sea core sequence, retrieved from the northwestern margin of Iceland and covering the last 86 ka, exhibits high sedimentation rates during the last glacial cycle that allow the clear distinction of Greenland stadial (GS)/ interstadial (GI) cycles in the various proxy records. Abundance records of rhyolitic, basaltic and tachylytic tephra grains reveal several maxima. Tephra grains of all types were geochemically analyzed in 44 levels. A total of 92 tephras with a distinctive character have been defined within the glacial sequence of gravity core PS2644-5, whereas the Holocene record is dominated by reworked Vedde Ash grains and not suitable for tephra stratigraphic work. Of the 92 tephras only 19 geochemical populations have been linked with confidence to previously defined tephras such as from the Vedde Ash, Faeroe Marine Ash Zones (FMAZ) II and III and North Atlantic Ash Zone (NAAZ) II. For the glacial period informal names were given to 78 new tephras, most of which are basaltic tephras. Several of these layers have a unique geochemical character and might become new chronostratigraphic markers in the North Atlantic region. Linking the tephra populations to the volcanic system producing them, respectively, revealed that Icelandic eruptions dominate with 83 tephra geochemical populations and Jan Mayen with 9. Around 48% of the informal tephra layers linked to the Icelandic volcanic province are produced from either the Grimsvötn or the Veidivötn-Bardarbunga volcanic systems. The intervals spanning from Greenland Stadial (GS) 3 to Greenland Interstadial (GI) 4 (24.5-29 ka BP), from GI 8 to GS 10 (36.9-40.5 ka BP) and from GI 14 to GI 15.2 (50-56 ka BP) are the periods with the highest number of eruptions, all of which are associated with known tephra zones.

(Table 2) B/Ca, d11B, Mg/Ca and d18O record for ODP Hole 130-806B samples

We present the first continuous records from 0 to 5 Ma (in 0.333 m.y. integrated time steps) of paired boron/calcium (B/Ca) ratios and boron isotopes (d11B) in the planktonic foraminifera Globogerinoides sacculifer (without sacc) from a site in the western equatorial Pacific Ocean (Ocean Drilling Program Site 806). These measurements, the first made in conjunction with calcification temperature (magnesium/calcium ratios) and average shell mass measurements, indicate that pH is not the sole environmental variable controlling B in planktonic foraminiferal calcite. Our data are consistent with calcification temperature exerting a primary control on B concentration and isotopic composition in planktonic foraminifera. If so, calcification temperature must be taken into account if pH for past oceans and atmospheric pCO2 are to be estimated from B isotope measurements in foraminiferal calcite. Doing so will substantially increase the uncertainty of pH estimates. Although this work was designed as a temporal study, its results define new aspects of calibrating the d11B paleo-pH tracer.

Pollen record with radiocarbon datings from Faddeyevskiy Island, Laptev Sea

Pollen, plant macrofossil, loss-on-ignition and radiocarbon analyses of a 1.4-m section in thermokarst topography from Faddeyevskiy Island (75°20'N, 143°50'E, 30 m elevation) provides new information on Late Pleistocene interstadial environmental history of this high Arctic region. Conventional radiocarbon dates (25,700 ± 1000, 32,780 ± 500, 35,200 ± 650 yr BP) and two AMS dates (29,950 ± 660 and 42,990 ± 1280 yr BP) indicate that the deposits accumulated during the Kargian (Boutellier) interval. Numerous mammoth (Mammuthus primigenius) remains that have been collected in vicinity of the site in this study were radio-carbon dated to 36,700-18,500 yr BP. Rare bison (Bison priscus) bones were dated to 32,200 ± 600 and 33,100 ± 320 yr BP. Poaceae, Cyperaceae, and Artemisia pollen dominate the spectra with some Ranunculaceae, Caryophyllaceae, Rosaceae, and Asteraceae. The pollen spectra reflect steppe-like (tundra-steppe) vegetation, which was dominant on the exposed shelf of the Arctic Ocean. Numerous Carex macrofossils suggest that the summer climate was at least 2°C warmer than today. The productivity of the local vegetation during the Kargian interstadial was high enough to feed the population of grazing mammals.

Stable carbon and oxygen isotope record of foraminifera of IODP Site 303-1307

A major tipping point of Earth's history occurred during the mid-Pliocene: the onset of major Northern-Hemisphere Glaciation (NHG) and of pronounced, Quaternary-style cycles of glacial-to-interglacial climates, that contrast with more uniform climates over most of the preceding Cenozoic and continue until today (Zachos et al., 2001, doi:10.1126/science.1059412). The severe deterioration of climate occurred in three steps between 3.2 Ma (warm MIS K3) and 2.7 Ma (glacial MIS G6/4) (Lisiecki and Raymo, 2005, doi:10.1029/2004PA001071). Various models (sensu Driscoll and Haug, 1998, doi:10.1126/science.282.5388.436) and paleoceanographic records (intercalibrated using orbital age control) suggest clear linkages between the onset of NHG and the three steps in the final closure of the Central American Seaways (CAS), deduced from rising salinity differences between Caribbean and the East Pacific. Each closing event led to an enhanced North Atlantic meridional overturning circulation and this strengthened the poleward transport of salt and heat (warmings of +2-3°C) (Bartoli et al., 2005, doi:10.1016/j.epsl.2005.06.020). Also, the closing resulted in a slight rise in the poleward atmospheric moisture transport to northwestern Eurasia (Lunt et al., 2007, doi:10.1007/s00382-007-0265-6), which probably led to an enhanced precipitation and fluvial run-off, lower sea surface salinity (SSS), and an increased sea-ice cover in the Arctic Ocean, hence promoting albedo and the build-up of continental ice sheets. Most important, new evidence shows that the closing of the CAS led to greater steric height of the North Pacific and thus doubled the low-saline Arctic Throughflow from the Bering Strait to the East Greenland Current (EGC). Accordingly, Labrador Sea IODP Site 1307 displays an abrupt but irreversible EGC cooling of 6°C and freshening by ~2 psu from 3.25/3.16-3.00 Ma, right after the first but still reversible attempt of closing the CAS.