Modification of turbulent dissipation rates by a deep Southern Ocean eddy

This is the final version. Available from AGU via the DOI in this recordAll data used in this study are available by communication with the author and will be archived at British Oceanographic Data CentreThe impact of a mesoscale eddy on the magnitude and spatial distribution of diapycnal ocean mixing is investigated using a set of hydrographic and microstructure measurements collected in the Southern Ocean. These data sampled a baroclinic, middepth eddy formed during the disintegration of a deep boundary current. Turbulent dissipation is suppressed within the eddy but is elevated by up to an order of magnitude along the upper and lower eddy boundaries. A ray tracing approximation is employed as a heuristic device to elucidate how the internal wave field evolves in the ambient velocity and stratification conditions accompanying the eddy. These calculations are consistent with the observations, suggesting reflection of internal wave energy from the eddy center and enhanced breaking through critical layer processes along the eddy boundaries. These results have important implications for understanding where and how internal wave energy is dissipated in the presence of energetic deep geostrophic flows.DIMES is supported by the Natural Environment Research Council (NERC) grants NE/E007058/1 and NE/E005667/1 and U.S. National Science Foundation grants OCE‐1231803, OCE‐0927583, and OCE‐1030309. K.L.S. and J.A.B. are supported by NERC

Integrating the promotion of physical activity within a smoking cessation programme: Findings from collaborative action research in UK Stop Smoking Services

Background: Within the framework of collaborative action research, the aim was to explore the feasibility of developing and embedding physical activity promotion as a smoking cessation aid within UK 6/7-week National Health Service (NHS) Stop Smoking Services. Methods: In Phase 1 three initial cycles of collaborative action research (observation, reflection, planning, implementation and re-evaluation), in an urban Stop Smoking Service, led to the development of an integrated intervention in which physical activity was promoted as a cessation aid, with the support of a theoretically based self-help guide, and self monitoring using pedometers. In Phase 2 advisors underwent training and offered the intervention, and changes in physical activity promoting behaviour and beliefs were monitored. Also, changes in clients’ stage of readiness to use physical activity as a cessation aid, physical activity beliefs and behaviour and physical activity levels were assessed, among those who attended the clinic at 4-week post-quit. Qualitative data were collected, in the form of clinic observation, informal interviews with advisors and field notes. Results: The integrated intervention emerged through cycles of collaboration as something quite different to previous practice. Based on field notes, there were many positive elements associated with the integrated intervention in Phase 2. Self-reported advisors’ physical activity promoting behaviour increased as a result of training and adapting to the intervention. There was a significant advancement in clients’ stage of readiness to use physical activity as a smoking cessation aid. Conclusions: Collaboration with advisors was key in ensuring that a feasible intervention was developed as an aid to smoking cessation. There is scope to further develop tailored support to increasing physical activity and smoking cessation, mediated through changes in perceptions about the benefits of, and confidence to do physical activity

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

BRIEF REPORT: Hospitalized Patients' Attitudes About and Participation in Error Prevention

BACKGROUND AND OBJECTIVE: Although many patient safety organizations and hospital leaders wish to involve patients in error prevention, it is unknown whether patients will take the recommended actions or whether error prevention involvement affects hospitalization satisfaction. DESIGN AND PARTICIPANTS: Telephone interviews with 2,078 patients discharged from 11 Midwest hospitals. RESULTS: Ninety-one percent agreed that patients could help prevent errors. Patients were very comfortable asking a medication's purpose (91%), general medical questions (89%), and confirming their identity (84%), but were uncomfortable asking medical providers whether they had washed their hands (46% very comfortable). While hospitalized, many asked questions about their care (85%) and a medication's purpose (75%), but fewer confirmed they were the correct patient (38%), helped mark their incision site (17%), or asked about handwashing (5%). Multivariate logistic regression revealed that patients who felt very comfortable with error prevention were significantly more likely to take 6 of the 7 error-prevention actions compared with uncomfortable patients. CONCLUSIONS: While patients were generally comfortable with error prevention, their participation varied by specific action. Since patients who were very comfortable were most likely to take action, educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged

Eddy-induced variability in Southern Ocean abyssal mixing on climatic timescales

PublishedJournal ArticleThis is the author accepted manuscript. The final version is available from Nature Publishing Group via the DOI in this record.The Southern Ocean plays a pivotal role in the global ocean circulation and climate. There, the deep water masses of the world ocean upwell to the surface and subsequently sink to intermediate and abyssal depths, forming two overturning cells that exchange substantial quantities of heat and carbon with the atmosphere. The sensitivity of the upper cell to climatic changes in forcing is relatively well established. However, little is known about how the lower cell responds, and in particular whether small-scale mixing in the abyssal Southern Ocean, an important controlling process of the lower cell, is influenced by atmospheric forcing. Here, we present observational evidence that relates changes in abyssal mixing to oceanic eddy variability on timescales of months to decades. Observational estimates of mixing rates, obtained along a repeat hydrographic transect across Drake Passage, are shown to be dependent on local oceanic eddy energy, derived from moored current meter and altimetric measurements. As the intensity of the regional eddy field is regulated by the Southern Hemisphere westerly winds, our findings suggest that Southern Ocean abyssal mixing and overturning are sensitive to climatic perturbations in wind forcing. © 2014 Macmillan Publishers Limited.The DIMES experiment is supported by the Natural Environment Research Council (NERC) of the UK and the US National Science Foundation. K.L.S. is supported by NERC. We are grateful to J. Ledwell, A. Bogdanoff, P. Courtois, K. Decoteau, D. Evans and X. Liang for their help in data collection and acknowledge the valuable assistance and hard work of the crew and technicians on the RRS James Cook, the RRS James Clark Ross and the RV Thomas G. Thompson. We also thank A. Thompson who provided many helpful comments, and E. Murowinski, R. Lueck and F. Wolk from Rockland Scientific for their support in microstructure data analysis

How the Dutch plan to stay dry over the next Century

Over two-thirds of the Netherlands’ economy and half its population is below sea level. The Dutch government recently set out far-reaching recommendations on how to keep the country flood-proof over the next century given the likelihood of rising sea levels and river flows. This paper explains the recommendations, which are based on a gradual upgrading of safety standards in the light of economic growth and group casualty risk, together with triggers provided by debates and data on climate change. It concludes that protection is feasible both technically and economically, costing up to \u803 billion a year, and that the approach could be useful for other low-lying areas.Hydraulic EngineeringCivil Engineering and Geoscience

Accuracy of Capsule Colonoscopy in Detecting Colorectal Polyps in a Screening Population

BACKGROUND & AIMS: Capsule colonoscopy is a minimally invasive imaging method. We measured the accuracy of this technology in detecting polyps 6 mm or larger in an average-risk screening population. METHODS: In a prospective study, asymptomatic subjects (n = 884) underwent capsule colonoscopy followed by conventional colonoscopy (the reference) several weeks later, with an endoscopist blinded to capsule results, at 10 centers in the United States and 6 centers in Israel from June 2011 through April 2012. An unblinded colonoscopy was performed on subjects found to have lesions 6 mm or larger by capsule but not conventional colonoscopy. RESULTS: Among the 884 subjects enrolled, 695 (79%) were included in the analysis of capsule performance for all polyps. There were 77 exclusions (9%) for inadequate cleansing and whole-colon capsule transit time fewer than 40 minutes, 45 exclusions (5%) before capsule ingestion, 15 exclusions (2%) after ingestion and before colonoscopy, and 15 exclusions (2%) for site termination. Capsule colonoscopy identified subjects with 1 or more polyps 6 mm or larger with 81% sensitivity (95% confidence interval [CI], 77%-84%) and 93% specificity (95% CI, 91%-95%), and polyps 10 mm or larger with 80% sensitivity (95% CI, 74%-86%) and 97% specificity (95% CI, 96%-98%). Capsule colonoscopy identified subjects with 1 or more conventional adenomas 6 mm or larger with 88% sensitivity (95% CI, 82%-93) and 82% specificity (95% CI, 80%-83%), and 10 mm or larger with 92% sensitivity (95% CI, 82%-97%) and 95% specificity (95% CI, 94%-95%). Sessile serrated polyps and hyperplastic polyps accounted for 26% and 37%, respectively, of false-negative findings from capsule analyses. CONCLUSIONS: In an average-risk screening population, technically adequate capsule colonoscopy identified individuals with 1 or more conventional adenomas 6 mm or larger with 88% sensitivity and 82% specificity. Capsule performance seems adequate for patients who cannot undergo colonoscopy or who had incomplete colonoscopies. Additional studies are needed to improve capsule detection of serrated lesions. Clinicaltrials.gov number: NCT01372878