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.

Eemian and Holocene sea-surface conditions in the southern Black Sea: organic-walled dinoflagellate cyst record from core 22-GC3

In order to compare the sea-surface conditions in the Black Sea during the Holocene and Eemian, sapropelic parts of marine core 22-GC3 (42°13.53′N/36°29.55′E, 838 m water depth) were studied for organic-walled dinoflagellate cyst content. The record shows a change from freshwater/brackish assemblages (Pyxidinopsis psilata, Spiniferites cruciformis, and Caspidinium rugosum) to more marine assemblages (Lingulodinium machaerophorum and Spiniferites ramosus complex) during each interglacial, due to the inflow of saline Mediterranean water. The lacustrine–marine transitions in 22-GC3 occurred at ~ 8.3 cal kyr BP during the early Holocene and ~ 128 kyr BP during the early Eemian, slightly later compared to the onset of interglacial conditions on the adjacent land. Dinoflagellate cyst assemblages reveal higher sea-surface salinity (~ 28–30) (e.g. Spiniferites pachydermus, Bitectatodinium tepikiense, and Spiniferites mirabilis) around ~ 126.5–121 kyr BP in comparison to the Holocene (~ 15–20) as well as relatively high sea-surface temperature (e.g. Tuberculodinium vancampoae, S. pachydermus, and S. mirabilis) especially at ~ 127.6–125.3 kyr BP. Establishment of high sea-surface salinity during the Eemian correlates very well with reconstructed relatively high global sea-level and is explained as a combined effect of increased Mediterranean supply and high temperatures at the beginning of the last interglacial. The observed changes in the dinocyst record highlight the importance of nutrients for the composition of the Eemian and Holocene dinocyst assemblages.

Chronostratigraphy of the 600,000 year old continental record of Lake Van

Lake Van sediment cores from the Ahlat Ridge and Northern Basin drill sites of the ICDP project PALEOVAN contain a wealth of information about past environmental processes. The sedimentary sequence was dated using climatostratigraphic alignment, varve chronology, tephrostratigraphy, argon-argon single-crystal dating, radiocarbon dating, magnetostratigraphy, and cosmogenic nuclides. Based on the lithostratigraphic framework, the different age constraints are compiled and a robust and precise chronology of the 600,000 year-old Lake Van record is constructed. Proxy records of total organic carbon content and sediment color, together with the calcium/potassium-ratios and arboreal pollen percentages of the 174-meter-long Ahlat Ridge record, mimic the Greenland isotope stratotype (NGRIP). Therefore, the proxy records are systematically aligned to the onsets of interstadials reflected in the NGRIP or synthesized Greenland ice-core stratigraphy. The chronology is constructed using 27 age control points derived from visual synchronization with the GICC05 timescale, an absolutely-dated speleothem record (e.g., Hulu, Sanbao, Linzhu cave) and the Epica Dome C timescale. In addition, the uppermost part of the sequence is complemented with four ages from Holocene varve chronology and two calibrated radiocarbon ages. Furthermore, nine argon-argon ages and a comparison of the relative paleointensity record of the magnetic field with reference curve PISO-1500 confirm the accuracy of the age model. Also the identification of the Laschamp event via measurements of 10Be in the sediment confirms the presented age model. The chronology of the Ahlat Ridge record is transferred to the 79-meter-long event-corrected composite record from the Northern Basin and supplemented by additional radiocarbon dating on organic marco-remains. The basal age of the Northern Basin record is estimated at ~90 ka. The variations of the time series of total organic carbon content, the Ca/K ratio, and the arboreal pollen percentages illustrate that the presented chronology and paleoclimate data are suited for reconstructions and modeling of the Quaternary and Pleistocene climate evolution in the Near East at millennial timescales. Furthermore, the chronology of the last 250 kyr can be used to test other dating techniques.

A 2600-year record of past polycyclic aromatic hydrocarbons (PAHs) deposition at Holzmaar (Eifel, Germany)

Polycyclic aromatic hydrocarbons (PAHs) are a proxy for climate- and human-related historical fire activity which has rarely been used beyond 1800 AD. We explored the concentration and composition patterns of PAHs together with other proxies (charcoal, C, N, S, δ13C, δ15N, and δ34S) in a sediment core of Holzmaar as indicators of variations in climate and anthropogenic activity over the past 2600 years. The concentrations of pyrogenic PAHs remained low (< 500 ng g− 1) from the pre-Roman Iron Age (600 BC) until the first significant increases to ca. 1000–1800 ng g− 1 between 1700 and 1750 AD related to regional iron production. The highest increases in pyrogenic PAH concentrations occurred with industrialization peaking in the 1960s. PAH concentrations in most recent sediments decreased to pre-industrial levels because of emission control measures and the switch from coal to oil and gas as major fuel sources. Fluxes of PAHs (mg km− 2 yr− 1) increased in the order Migration Period and Early Middle Ages < pre-Roman Iron Ages < Roman era < High Middle Ages and Renaissance < pre-industrial modern period < industrial modern period. The changes of PAHs fluxes in pre-industrial times parallel known changes in local, regional and continental anthropogenic activity and climatic variations or their interactions across these historical periods. Perylene, a mainly biologically produced compound, was the dominant PAH in pre-industrial times. The Migration Period and the Early Middle Ages witnessed the most profound and simultaneous changes to the sedimentary organic matter properties in the past 2600 years including the lowest PAH fluxes because of reduced human activity and more negative δ13C and δ15N values probably in response to colder and wetter conditions.

A 12,000 Year Record of Explosive Volcanism in the Siple Dome Ice Core, West Antarctica

Air mass trajectories in the Southern Hemisphere provide a mechanism for transport to and deposition of volcanic products on the Antarctic ice sheet from local volcanoes and from tropical and subtropical volcanic centers. This study extends the detailed record of Antarctic, South American, and equatorial volcanism over the last 12,000 years using continuous glaciochemical series developed from the Siple Dome A (SDMA) ice core, West Antarctica. The largest volcanic sulfate spike ( 280 mu g/L) occurs at 5881 B. C. E. Other large signals with unknown sources are observed around 325 B. C. E. ( 270 mu g/L) and 2818 B. C. E. ( 191 mu g/L). Ages of several large equatorial or Southern Hemisphere volcanic eruptions are synchronous with many sulfate peaks detected in the SDMA volcanic ice chemistry record. The microprobe "fingerprinting'' of glass shards in the SDMA core points to the following Antarctic volcanic centers as sources of tephra found in the SDMA core: Balenny Island, Pleiades, Mount Berlin, Mount Takahe, and Mount Melbourne as well as Mount Hudson and possibly Mount Burney volcanoes of South America. Identified volcanic sources provide an insight into the poorly resolved transport history of volcanic products from source volcanoes to the West Antarctic ice sheet.

A 200 Year Sulfate Record from Sixteen Antarctic Ice Cores and Associations With Southern Ocean Sea-Ice Extent

Chemistry data from 16, 50-115 m deep, sub-annually dated ice cores are used to investigate spatial and temporal concentration variability of sea-salt (ss) SO42- and excess (xs) SO42- over West Antarctica and the South Pole for the last 200 years. Low-elevation ice-core sites in western West Antarctica contain higher concentrations Of SO42- as a result of cyclogenesis over the Ross Ice Shelf and proximity to the Ross Sea Polynya. Linear correlation analysis of 15 West Antarctic ice-core SO42- time series demonstrates that at several sites concentrations Of ssSO(4)(2-) are higher when sea-ice (SIE) extent is greater, and the inverse for XSS04. Concentrations Of XSS04 from the South Pole site (East Antarctica) are associated with SIE from the Weddell region, and West Antarctic XSSO42- concentrations are associated with SIE from the Bellingshausen-Amundsen-Ross region. The only notable rise of the last 200 years in xsSO(4)(2-), around 1940, is not related to SIE fluctuations and is most likely a result of increased xsSO(4)(2-) production in the mid-low latitudes and/or an increase in transport efficiency from the mid-low latitudes to central West Antarctica. These high-resolution records show that the source types and source areas Of ssSO(4)(2-) and xsSO(4)(2-) delivered to eastern and western West Antarctica and the South Pole differ from site to site but can best be resolved using records from spatial ice-core arrays such as the International Trans-Antarctic Scientific Expedition (ITASE).

Recent Increases in Atmospheric Concentrations of Bi, U, Cs, S and Ca from a 350-Year Mount Everest Ice Core Record

High-resolution major and trace elements (Sr, Cs, Ba, La, Ce, Pr, Nd, Sm, Eu, Tb, Dy, Ho, Er, Tm, Yb, Lu, Bi, U, Tl, Al, S, Ca, Ti, V, Cr, Mn, Fe, and Co) quantified in a Mount Everest ice core ( 6518 m above sea level) spanning the period 1650-2002 AD provides the first Asian record of trace element concentrations from the pre-industrial era, and the first continuous high-resolution Asian record from which natural baseline concentrations and subsequent changes due to anthropogenic activities can be examined. Modern concentrations of most elements remain within the pre-industrial range; however, Bi, U, and Cs concentrations and their enrichment factors (EF) have increased since the similar to 1950s, and S and Ca concentrations and their EFs have increased since the late 1980s. A comparison of the Bi, U, Cs, S, and Ca data with other ice core records and production data indicates that the increase in atmospheric concentrations of trace elements is widespread, but that enrichment varies regionally. Likely sources for the recent enrichment of these elements include mining, metal smelting, oil and coal combustion, and end uses for Bi, and mining and refinement for U and Cs. The source of the synchronous enrichment of Ca and S is less certain, but may be related to land use and environmental change.

High-resolution late-glacial chronology for the Gerzensee lake record (Switzerland): δ18O correlation between a Gerzensee-stack and NGRIP

Oxygen-isotope variations were analyzed on bulk samples of shallow-water lake marl from Gerzensee, Switzerland, in order to evaluate major and minor climatic oscillations during the late-glacial. To highlight the overall signature of the Gerzensee δ18O record, δ18O records of four parallel sediment cores were first correlated by synchronizing major isotope shifts and pollen abundances. Then the records were stacked with a weighting depending on the differing sampling resolution. To develop a precise chronology, the δ18O-stack was then correlated with the NGRIP δ18O record applying a Monte Carlo simulation, relying on the assumption that the shifts in δ18O were climate-driven and synchronous in both archives. The established chronology on the GICC05 time scale is the basis for (1) comparing the δ18O changes recorded in Gerzensee with observed climatic and environmental fluctuations over the whole North Atlantic region, and (2) comparing sedimentological and biological changes during the rapid warming with smaller climatic variations during the Bølling/Allerød period. The δ18O record of Gerzensee is characterized by two major isotope shifts at the onset and at the termination of the Bølling/Allerød warm period, as well as four intervening negative shifts labeled GI-1e2, d, c2, and b, which show a shift of one third to one fourth of the major δ18O shifts at the beginning and end of the Bølling/Allerød. Despite some inconsistency in terminology, these oscillations can be observed in various climatic proxies over wide regions in the North Atlantic region, especially in reconstructed colder temperatures, and they seem to be caused by hemispheric climatic variations.

Ice Core Record of Rising Lead Pollution in the North Pacific Atmosphere

A high-resolution, 8000 year-long ice core record from the Mt. Logan summit plateau (5300 m asl) reveals the initiation of trans-Pacific lead (Pb) pollution by ca. 1730, and a > 10-fold increase in Pb concentration (1981-1998 mean = 68.9 ng/l) above natural background (5.6 ng/l) attributed to rising anthropogenic Pb emissions from Asia. The largest rise in North Pacific Pb pollution from 1970-1998 (end of record) is contemporaneous with a decrease in Eurasian and North American Pb pollution as documented in ice core records from Greenland, Devon Island, and the European Alps. The distinct Pb pollution history in the North Pacific is interpreted to result from the later industrialization and less stringent abatement measures in Asia compared to North America and Eurasia. The Mt. Logan record shows evidence for both a rising Pb emissions signal from Asia and a trans-Pacific transport efficiency signal related to the strength of the Aleutian Low.

A High-Resolution Record of Atmospheric Dust Composition and Variability Since Ad 1650 from a Mount Everest Ice Core

A Mount Everest ice core analyzed at high resolution for major and trace elements (Sr, Cs, Ba, La, Ce, Pr, Nd, Sm, Eu, Tb, Dy, Ho, Er, Tm, Yb, Lu, Bi, U, Tl, Al, S, Ca, Ti, V, Cr, Mn, Fe, Co) and spanning the period A. D. 1650- 2002 is used to investigate the sources of and variations in atmospheric dust through time. The chemical composition of dust varies seasonally, and peak dust concentrations occur during the winter-spring months. Significant correlations between the Everest dust record and dust observations at stations suggest that the Everest record is representative of regional variations in atmospheric dust loading. Back-trajectory analysis in addition to a significant correlation of Everest dust concentrations and the Total Ozone Mapping Spectrometer (TOMS) aerosol index indicates that the dominant winter sources of dust are the Arabian Peninsula, Thar Desert, and northern Sahara. Factors that contribute to dust generation at the surface include soil moisture and temperature, and the long-range transport of dust aerosols appears to be sensitive to the strength of 500-mb zonal winds. There are periods of high dust concentration throughout the 350-yr Mount Everest dust record; however, there is an increase in these periods since the early 1800s. The record was examined for recent increases in dust emissions associated with anthropogenic activities, but no recent dust variations can be conclusively attributed to anthropogenic inputs of dust.

Multi-Decadal Record of Ice Dynamics on Daugaard Jensen Gletscher, East Greenland, from Satellite Imagery and Terrestrial Measurements

The history of ice velocity and calving front position of Daugaard Jensen Gletscher, a large outlet glacier in East Greenland, is reconstructed from field measurements, aerial photography and satellite imagery for the period 1950-2001. The calving terminus of the glacier has remained in approximately the same position over the past similar to 50 years. There is no evidence of a change in ice motion between 1968 and 2001, based on a comparison of velocities derived from terrestrial surveying and feature tracking using sequential satellite images. Estimates of flux near the entrance to the fjord vs snow accumulation in the interior catchment show that Daugaard Jensen Gletscher has a small negative mass balance. This result is consistent with other mass-balance estimates for the inland region of the glacier.

A 200 Year Sub-Annual Record of Sulfate in West Antarctica, from Sixteen Ice Cores

Sixteen high-resolution ice-core records from West Antarctica and South Pole are used to examine the spatial and temporal distribution of sulfate for the last 200 years. The preservation of seasonal layers throughout the length of each record results in a dating accuracy of better than 1 year based on known global-scale volcanic events. A dual transport source for West Antarctic sea-salt (ss) SO42- and excess (xs) SO42- is observed: lower-tropospheric for areas below 1000m elevation and mid-/upper-tropospheric/stratospheric for areas located above 1000m. Our XsSO(4)(2-) records with volcanic peaks removed do not display any evidence of an anthropogenic impact on West Antarctic SO42- concentrations but do reveal that a major climate transition takes place over West Antarctica at similar to 1940. Global-scale volcanic eruptions appear as significant peaks in the robust-spline residual xsSO(4)(2-) records from sites located above 1000 m elevation but do not appear in the residual records from sites located below 1000 m.

Frost-Free Record Reconstruction for Eastern Massachusetts, 1733-1980

A reconstruction methodology utilizing such varied documents as diaries, agricultural journals, U.S. Weather Bureau killing frost records and instrumental records is discussed. A resultant 248-year frost record for eastern Massachusetts exhibits marked variations in the length of the growing season, that occur on a time scale of approximately 70 years. There is an apparent systematic long-term relationship between the timing of spring and fall killing frosts and the last 100 years of record reveals a decline in year-to-year variability.

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.

A Record of Atmospheric Co2 During the Last 40,000 Years from the Siple Dome, Antarctica Ice Core

We have measured the CO2 concentration of air occluded during the last 40,000 years in the deep Siple Dome A ( hereafter Siple Dome) ice core, Antarctica. The general trend of CO2 concentration from Siple Dome ice follows the temperature inferred from the isotopic composition of the ice and is mostly in agreement with other Antarctic ice core CO2 records. CO2 rose initially at similar to 17.5 kyr B. P. ( thousand years before 1950), decreased slowly during the Antarctic Cold Reversal, rose during the Younger Dryas, fell to a local minimum at around 8 kyr B. P., and rose continuously since then. The CO2 concentration never reached steady state during the Holocene, as also found in the Taylor Dome and EPICA Dome C ( hereafter Dome C) records. During the last glacial termination, a lag of CO2 versus Siple Dome isotopic temperature is probable. The Siple Dome CO2 concentrations during the last glacial termination and in the Holocene are at certain times greater than in other Antarctic ice cores by up to 20 ppm (mumol CO2/mol air). While in situ production of CO2 is one possible cause of the sporadic elevated levels, the mechanism leading to the enrichment is not yet clear.