Medication regimen complexity vs patient acuity for predicting critical care pharmacist interventions.

PURPOSE: Quantifying and predicting critical care pharmacist (CCP) workload has significant ramifications for expanding CCP services that improve patient outcomes. Medication regimen complexity has been proposed as an objective, pharmacist-oriented metric that demonstrates relationships to patient outcomes and pharmacist interventions. The purpose of this evaluation was to compare the relationship of medication regimen complexity versus a traditional patient acuity metric for evaluating pharmacist interventions. SUMMARY: This was a post hoc analysis of a previously completed prospective, observational study. Pharmacist interventions were prospectively collected and tabulated at 24 hours, 48 hours, and intensive care unit (ICU) discharge, and the electronic medical record was reviewed to collect patient demographics, medication data, and outcomes. The primary outcome was the relationship between medication regimen complexity-intensive care unit (MRC-ICU) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and pharmacist interventions at 24 hours, 48 hours, and ICU discharge. These relationships were determined by Spearman rank-order correlation (rS) and confirmed by calculating the beta coefficient (ß) via multiple linear regression adjusting for patient age, gender, and admission type. Data on 100 patients admitted to a mixed medical/surgical ICU were retrospectively evaluated. Both MRC-ICU and APACHE II scores were correlated with ICU interventions at all 3 time points (at 24 hours, rS = 0.370 [P < 0.001] for MRC-ICU score and rS = 0.283 [P = 0.004] for APACHE II score); however, this relationship was not sustained for APACHE II in the adjusted analysis (at 24 hours, ß = 0.099 [P = 0.001] for MRC-ICU and ß = 0.031 [P = 0.085] for APACHE II score). CONCLUSION: A pharmacist-oriented score had a stronger relationship with pharmacist interventions as compared to patient acuity. As pharmacists have demonstrated value across the continuum of patient care, these findings support that pharmacist-oriented workload predictions require tailored metrics, beyond that of patient acuity.

Changing atmospheric acidity as a modulator of nutrient deposition and ocean biogeochemistry.

Anthropogenic emissions to the atmosphere have increased the flux of nutrients, especially nitrogen, to the ocean, but they have also altered the acidity of aerosol, cloud water, and precipitation over much of the marine atmosphere. For nitrogen, acidity-driven changes in chemical speciation result in altered partitioning between the gas and particulate phases that subsequently affect long-range transport. Other important nutrients, notably iron and phosphorus, are affected, because their soluble fractions increase upon exposure to acidic environments during atmospheric transport. These changes affect the magnitude, distribution, and deposition mode of individual nutrients supplied to the ocean, the extent to which nutrient deposition interacts with the sea surface microlayer during its passage into bulk seawater, and the relative abundances of soluble nutrients in atmospheric deposition. Atmospheric acidity change therefore affects ecosystem composition, in addition to overall marine productivity, and these effects will continue to evolve with changing anthropogenic emissions in the future.

Tracing and constraining anthropogenic aerosol iron fluxes to the North Atlantic Ocean using iron isotopes.

Atmospheric dust is an important source of the micronutrient Fe to the oceans. Although relatively insoluble mineral Fe is assumed to be the most important component of dust, a relatively small yet highly soluble anthropogenic component may also be significant. However, quantifying the importance of anthropogenic Fe to the global oceans requires a tracer which can be used to identify and constrain anthropogenic aerosols in situ. Here, we present Fe isotope (δ56Fe) data from North Atlantic aerosol samples from the GEOTRACES GA03 section. While soluble aerosol samples collected near the Sahara have near-crustal δ56Fe, soluble aerosols from near North America and Europe instead have remarkably fractionated δ56Fe values (as light as -1.6‰). Here, we use these observations to fingerprint anthropogenic combustion sources, and to refine aerosol deposition modeling. We show that soluble anthropogenic aerosol Fe flux to the global surface oceans is highly likely to be underestimated, even in the dusty North Atlantic.

Pyrogenic iron: The missing link to high iron solubility in aerosols.

Atmospheric deposition is a source of potentially bioavailable iron (Fe) and thus can partially control biological productivity in large parts of the ocean. However, the explanation of observed high aerosol Fe solubility compared to that in soil particles is still controversial, as several hypotheses have been proposed to explain this observation. Here, a statistical analysis of aerosol Fe solubility estimated from four models and observations compiled from multiple field campaigns suggests that pyrogenic aerosols are the main sources of aerosols with high Fe solubility at low concentration. Additionally, we find that field data over the Southern Ocean display a much wider range in aerosol Fe solubility compared to the models, which indicate an underestimation of labile Fe concentrations by a factor of 15. These findings suggest that pyrogenic Fe-containing aerosols are important sources of atmospheric bioavailable Fe to the open ocean and crucial for predicting anthropogenic perturbations to marine productivity.

Influence of Atmospheric Processes on the Solubility and Composition of Iron in Saharan Dust.

Aerosol iron was examined in Saharan dust plumes using a combination of iron near-edge X-ray absorption spectroscopy and wet-chemical techniques. Aerosol samples were collected at three sites located in the Mediterranean, the Atlantic, and Bermuda to characterize iron at different atmospheric transport lengths and time scales. Iron(III) oxides were a component of aerosols at all sampling sites and dominated the aerosol iron in Mediterranean samples. In Atlantic samples, iron(II and III) sulfate, iron(III) phosphate, and iron(II) silicates were also contributors to aerosol composition. With increased atmospheric transport time, iron(II) sulfates are found to become more abundant, aerosol iron oxidation state became more reduced, and aerosol acidity increased. Atmospheric processing including acidic reactions and photoreduction likely influence the form of iron minerals and oxidation state in Saharan dust aerosols and contribute to increases in aerosol-iron solubility.

Nitrogen fixation and nitrogenase (nifH) expression in tropical waters of the eastern North Atlantic.

Expression of nifH in 28 surface water samples collected during fall 2007 from six stations in the vicinity of the Cape Verde Islands (north-east Atlantic) was examined using reverse transcription-polymerase chain reaction (RT-PCR)-based clone libraries and quantitative RT-PCR (RT-qPCR) analysis of seven diazotrophic phylotypes. Biological nitrogen fixation (BNF) rates and nutrient concentrations were determined for these stations, which were selected based on a range in surface chlorophyll concentrations to target a gradient of primary productivity. BNF rates greater than 6 nmolN l(-1) h(-1) were measured at two of the near-shore stations where high concentrations of Fe and PO(4)(3-) were also measured. Six hundred and five nifH transcripts were amplified by RT-PCR, of which 76% are described by six operational taxonomic units, including Trichodesmium and the uncultivated UCYN-A, and four non-cyanobacterial diazotrophs that clustered with uncultivated Proteobacteria. Although all five cyanobacterial phylotypes quantified in RT-qPCR assays were detected at different stations in this study, UCYN-A contributed most significantly to the pool of nifH transcripts in both coastal and oligotrophic waters. A comparison of results from RT-PCR clone libraries and RT-qPCR indicated that a γ-proteobacterial phylotype was preferentially amplified in clone libraries, which underscores the need to use caution interpreting clone-library-based nifH studies, especially when considering the importance of uncultivated proteobacterial diazotrophs.