Search

Scientific study of issues at the nexus of food–energy–water systems (FEWS) requires grappling with multifaceted, “wicked” problems. FEWS involve interactions occurring directly and indirectly across complex and overlapping spatial and temporal scales; they are also imbued with diverse and sometimes conflicting meanings for the human and more-than-human beings that live within them. In this paper, we consider the role of language in the dynamics of boundary work, recognizing that the language often used in stakeholder and community engagement intended to address FEWS science and decision-making constructs boundaries and limits diverse and inclusive participation. In contrast, some language systems provide opportunities to build bridges rather than boundaries in engagement. Based on our experiences with engagement in FEWS science and with Indigenous knowledges and languages, we consider examples of the role of language in reflecting worldviews, values, practices, and interactions in FEWS science and engagement. We particularly focus on Indigenous knowledges from Anishinaabe and the language of Anishinaabemowin, contrasting languages of boundaries and bridges through concrete examples. These examples are used to unpack the argument of this work, which is that scientific research aiming to engage FEWS issues in working landscapes requires grappling with embedded, practical understandings. This perspective demonstrates the importance of grappling with the role of language in creating boundaries or bridges, while recognizing that training in engagement may not critically reflect on the role of language in limiting diversity and inclusivity in engagement efforts. Leaving this reflexive consideration of language unexamined may unknowingly perpetuate boundaries rather than building bridges, thus limiting the effectiveness of engagement that is intended to address wicked problems in working landscapes.

Cardiosphere-derived cells (CDCs) ameliorate skeletal and cardiac muscle deterioration in experimental models of Duchenne muscular dystrophy. The HOPE-2 trial examined the safety and efficacy of sequential intravenous infusions of human allogeneic CDCs in late-stage Duchenne muscular dystrophy.In this multicentre, randomised, double-blind, placebo-controlled, phase 2 trial, patients with Duchenne muscular dystrophy, aged 10 years or older with moderate upper limb impairment, were enrolled at seven centres in the USA. Patients were randomly assigned (1:1) using stratified permuted blocks to receive CAP-1002 (1·5 × 10Between March 1, 2018, and March 31, 2020, 26 male patients with Duchenne muscular dystrophy were enrolled, of whom eight were randomly assigned to the CAP-1002 group and 12 to the placebo group (six were not randomised due to screening failure). In patients who had a post-treatment PUL 1.2 assessment (eight in the CAP-1002 group and 11 in the placebo group), the mean 12-month change from baseline in mid-level elbow PUL1.2 favoured CAP-1002 over placebo (percentile difference 36·2, 95% CI 12·7-59·7; difference of 2·6 points; p=0·014). Infusion-related hypersensitivity reactions without long-term sequelae were observed in three patients, with one patient discontinuing therapy due to a severe allergic reaction. No other major adverse reactions were noted, and no deaths occurred.CAP-1002 cell therapy appears to be safe and effective in reducing deterioration of upper limb function in patients with late-stage Duchenne muscular dystrophy. Various measures of cardiac function and structure were also improved in the CAP-1002 group compared with the placebo group. Longer-term extension studies are needed to confirm the therapeutic durability and safety of CAP-1002 beyond 12 months for the treatment of skeletal myopathy and cardiomyopathy in Duchenne muscular dystrophy.Capricor Therapeutics.

Introduction Bedtime procrastination, a behavior associated with poor sleep health and wellbeing, refers to voluntary delays of bedtime. Although bedtime procrastination is often defined as a needless or mindless delay, bedtime procrastinators often report delaying their bedtime strategically to regulate sleep-interfering processes. One such process is pre-sleep arousal, an important vulnerability for and perpetuating factor in insomnia. Preliminary evidence supports this association, as some bedtime procrastinators report delaying bedtime to avoid anxiety-producing bedtime routines. However, this association has not been directly examined. To further investigate strategic delay in bedtime procrastination, the current study examined the association between pre-sleep arousal and bedtime procrastination using a daily diary design. Methods 390 young adult participants (Mage = 24.4, SD = 6.5) completed 14-days of experience sampling procedures, including completing self-report measures of nightly pre-sleep arousal and morning ratings of prior-night bedtime procrastination. Associations between pre-sleep arousal and bedtime procrastination were estimated with multilevel models using centering procedures which disaggregated between- and within-person covariance. Gender and age were entered into each model as covariates. Results Pre-sleep arousal was associated with increased bedtime procrastination both within- (B = 0.01, p < 0.001) and between-persons (B = 0.02, p < 0.001). Additionally, cognitive pre-sleep arousal was more strongly associated with bedtime procrastination (Bwithin = 0.014, p < 0.001; Bbetween = 0.032, p < 0.001) than somatic arousal (Bwithin = 0.007, p = 0.165; Bbetween = 0.038, p < 0.001). Conclusion The results suggest that pre-sleep arousal is a putative mechanism for bedtime procrastination. Cognitive arousal, including worry and rumination, may be particularly relevant for the development of this behavior. This finding supports the notion that bedtime procrastination may occur as a (maladaptive) strategy to regulate pre-sleep arousal. Alternatively, findings may suggest that bedtime procrastinators engage in arousing pre-sleep activities. Regardless, the association between bedtime procrastination and pre-sleep arousal suggests that bedtime procrastination is relevant in the development and/or maintenance of sleep-related disorders. Treatment of bedtime procrastination may be enhanced by considering the role this behavior has in regulating pre-sleep arousal. Support (if any)

This exploratory investigation examined the transformation of a traditional summer reading intervention (SRI) to synchronous virtual format in response to school closures due to COVID-19. Goals wer...

Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

New applied approaches are needed to address urgent, global environmental issues. Practitioners, scholars, and policy makers alike call for increased integration of natural and social sciences to develop new frameworks for better addressing the range of contemporary environmental issues. From a theoretical perspective, social–ecological systems (SES) offers a novel approach for enhancing sustainability science and for improving the practice of environmental management. To translate SES theory into action, education and training programs are needed that focus on the application of SES approaches across the education and professional spectrum, from K-12 to graduate training to agency management. We developed a training framework that serves sustainability practitioners by building their capacity to apply SES approaches to real world problems and decision-making. The framework uses a SES-based environmental management approach based on a systemic worldview, transdisciplinary thinking, co-development of knowledge, stakeholder engagement, and adaptive governance. The social–ecological systems training and education program (SESTEP or “see-step”) framework was designed to provide SES training opportunities as a response to the need expressed by senior directors of US federal land management agencies. The core of the framework is a 12-step SES heuristic that provides a diagnostic tool for practitioners as they work through a SES case-study issue or problem. The curriculum provides adaptable and tailored professional development training for sustainability professionals to enhance sustainability science in practice. The evaluation of the inaugural course indicates achievement of positive course learning outcomes consistent with advancing sustainability science in practice.

Environmental changes caused by climate change in Alaska pose a serious threat to the food, energy and water systems that support the culturally diverse communities statewide. The fishing industry, watershed managers and other stakeholders struggle with understanding and predicting the rates, magnitude and location of changes occurring in their regions primarily because of the significant range of uncertainty inherent in these changes. With the guidance of stakeholders, we demonstrate a scenario analysis methodology to elucidate the interactions among various components and uncertainties within the food, energy and water systems of the Kenai River Watershed. Alternative scenario analysis provided stakeholders with a venue and process to consider plausible futures in which rates of change in critical uncertainties were modeled to elucidate potential responses. Critical uncertainties ranged from climatic impacts on freshwater systems, to new energy development proposals, to changes in sport and personal use fisheries. Working together, stakeholders developed narratives that reflected different combinations of future uncertainty to guide potential management actions now and in the future. Five scenarios were developed by stakeholders that capture the complex interactions in the Kenai River Watershed as a social–ecological system. This process provides a way for managers and stakeholders to plan for the future in a richer way than extrapolating trends for obvious drivers of change. We present this framework as a platform for integrating climate, landscape and cultural change data into actionable decisions, crafted by stakeholders, to improve future food, energy and water resource management at the watershed scale.

As pressure on the dairy industry to reduce its environmental impact increases, efficient recycling of manure nutrients through local cropping systems becomes crucial. The aim of this study was to calculate annual nitrogen (N) and phosphorus (P) budgets in six counties located in the Magic Valley, Idaho and estimate what distance manure would need to be transported to be in balance with crop nutrient demand given current dairy cattle populations and cropping systems. Our analysis suggests that crop N needs will not be met solely by manure, and synthetic fertilizer will need to be applied. However, to balance P with crop production, manure would need to be transported a minimum of 12.9 km from dairies and would have to replace synthetic fertilizer P on 91% of regional cropland. Education of producers and technical specialists would be necessary to improve the management of manure use in regional cropping systems. Technical solutions such as alternative diets for cattle and nutrient capture from manure streams will also likely be necessary to bring regional P into balance to protect environmental quality and improve the sustainability of the regional dairy industry.

Community and stakeholder engagement is increasingly recognized as essential to science at the nexus of food, energy, and water systems (FEWS) to address complex issues surrounding food and energy production and water provision for society. Yet no comprehensive framework exists for supporting best practices in community and stakeholder engagement for FEWS. A review and meta-synthesis were undertaken of a broad range of existing models, frameworks, and toolkits for community and stakeholder engagement. A framework is proposed that comprises situational awareness of the FEWS place or problem, creation of a suitable culture for engagement, focus on power-sharing in the engagement process, co-ownership, co-generation of knowledge and outcomes, the technical process of integration, the monitoring processes of reflective and reflexive experiences, and formative evaluation. The framework is discussed as a scaffolding for supporting the development and application of best practices in community and stakeholder engagement in ways that are arguably essential for sound FEWS science and sustainable management.

Introduction Pre-sleep arousal contributes to over 50% of pregnant people experiencing poor sleep quality and clinical insomnia. Given that poor sleep during pregnancy is associated with depression and suicide ideation, there is a critical need to identify intervention targets, such as difficulties with emotion regulation. However, emotion dysregulation is multifaceted and warrants further investigation in sleep research, particularly during pregnancy. Thus, the present study examined associations among pre-sleep arousal, various dimensions of emotion dysregulation, and sleep outcomes during pregnancy. Methods Participants (N = 62; Mage = 29.89, SD = 4.19 years) were recruited during pregnancy and enrolled to represent a range of scores on the Difficulties in Emotion Regulation Scale. For 7 days during the 3rd trimester, they wore CamNtech MotionWatch-8 wrist actigraphs and completed the Pre-Sleep Arousal Scale and Consensus Sleep Diary. Results Hierarchical linear regression analyses indicated that high pre-sleep arousal predicted low sleep efficiency (measured via actigraphy) above and beyond facets of emotion dysregulation (B = -.316, p = .026). High pre-sleep arousal also predicted poor sleep quality (measured via diary) above and beyond total emotion dysregulation (B = -.038, p = .010). However, an interaction emerged between pre-sleep arousal and one particular facet of emotion dysregulation: access to emotion regulation strategies (B = -.005, p = .023). Specifically, high pre-sleep arousal was associated with poor sleep quality only among those who reported limited abilities to use emotion regulation strategies. Among participants who reported that they could access effective emotion regulation strategies, pre-sleep arousal did not predict sleep quality. Conclusion This study indicates that high pre-sleep arousal may not always be associated with poor sleep quality during pregnancy. Equipping pregnant people with emotion regulation strategies may buffer this association and promote long-term health. It is recommended that perinatal sleep scientists continue investigating relations between facets of emotion dysregulation and sleep. Support (If Any) This project was supported by the National Institute of Mental Health under Awards R01MH119070 (MPIs Crowell & Conradt) and F31MH124275 (PI Kaliush). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH.

Revised breakpoints for cefazolin (CFZ) against Enterobacterales may be difficult to implement with current automated susceptibility testing platforms and could falsely report organisms as susceptible, leading to inappropriate treatment for bloodstream infections (BSI). This was a retrospective cohort of adult patients with Enterobacterales BSI reported CFZ susceptible per Vitek®2. The primary outcome was the percentage susceptible by minimum inhibitory concentration (MIC) Gradient Test Strips and disk diffusion. Secondary outcomes included clinical outcomes between CFZ and non–CFZ-treated patients. Among 195 isolates reported CFZ-susceptible per Vitek®2, 84 (43.1%) were CFZ susceptible by MIC Gradient Test Strips vs 119 (61%) by disk diffusion. No difference was noted in 30-day all-cause mortality, secondary complications, or 30-day readmissions. Treatment failure was less likely to occur with source control (adjusted OR 0.06) and infectious disease consult (adjusted OR 0.37). There was a large degree of discrepancy between automated testing and manual methods; the clinical impact of this discrepancy warrants further investigation.

Adaptation to environmental change has become a necessity and a norm for many Arctic communities. We examine whether the adaptive capacity varies in different communities in Alaska with contrasting ecologies and socio-economic systems using the Arctic Water Resources Vulnerability Index (AWRVI). We applied the index to six communities in three distinct regions of Alaska with respect to water resources: Nuiqsut in Northern Alaska, Cooper Landing, Sterling, Soldotna and Kenai in the Kenai River watershed of Southcentral Alaska and Juneau in Southeast Alaska. We modified the AWRVI tool to accommodate the breadth of physical and social conditions in these communities. Using the AWRVI, we measured the adaptive capacity of the communities, which reflect greater vulnerability in Nuiqsut in Northern Alaska due to limitations in water supply and greater surrounding development that could pollute water in their food-shed. The overall adaptive capacities of the two communities that are more mountainous, Cooper Landing and Juneau are similar, as are Sterling, Soldotna and Kenai’s, which are in flatter terrain along the Kenai River. However, the physical and social sub-indices of the communities in the Kenai River watershed and Juneau differ. We discuss actions each community could take to improve their respective capacity to respond to anticipated change. Keywords: Adaptive capacity, Resilience, Vulnerability, Water resource index

Careful allotment of water resources for irrigation is critical for ensuring the resiliency of agriculture in semiarid regions, and modernizing irrigation technology to minimize inefficient water losses is an important tool for farmers and agricultural economies. While modernizing irrigation technology can achieve reductions in the nonbeneficial use of water, such as bare soil evaporation and nonconsumptive losses, water returned to the landscape is also reduced, often eliminating flow paths that other users rely on. In basins using a combination of surface and groundwater, replenishing aquifer storage by the managed aquifer recharge (MAR) of seasonally available water can mitigate the aquifer drawdown that results from reduced recharge when irrigation efficiency is improved. We examine the effects of MAR on the system-scale efficiency of modernizing irrigation technology and the resulting changes in the reuse of nonconsumptive losses, using a macroscale hydrologic model applied to the semiarid upper Snake River basin (USRB) of western Wyoming and southern Idaho, USA. Irrigation technologies were represented explicitly in the model, and available data informed baseline parameterizations of the irrigation technology. A suite of parameterizations were simulated that updated the existing technologies to be more efficient, both with and without sufficient MAR to cause a stabilization of the aquifer at the present-day head. As expected, simulated changes in irrigation technology resulted in greater downstream export of pristine water and a higher rate of aquifer drawdown when MAR was not simulated. Under current water use and cropping patterns, we were not able to simulate aquifer stabilization and maintain discharge downstream at any level of irrigation efficiency. We found support for the hypothesis that, as efficiency improves, less MAR is required to maintain a stable aquifer than when return flows are reduced due to increased efficiency. To evaluate the hypothesis, we defined the management benefit as a metric that compared the difference between the change in irrigation's net recharge and the change in MAR required as irrigation technology became more efficient. The metric generally indicated that less MAR was needed than net recharge was lost, but only for the most efficient case did the management benefit exceed the MAR needed at the baseline to stabilize the aquifer. Increasing efficiency of irrigation technology reduced the reuse of the gross irrigation derived from prior nonconsumptive losses, but simulating MAR increased reuse for a given parameterization, leading to higher effective irrigation efficiency. We find that local groundwater storage that users depend on is generally more sensitive to management decisions than downstream flows, and the drawdown of the aquifer without MAR always exceeded any decrease in discharge induced by MAR. Improving resource sufficiency in semiarid systems like the USRB will require an array of solutions that will need to balance benefits to local and downstream users.

Scenarios of landscape change have the capacity to address spatial and temporal issues, current and future trends, and solutions that increase capacity and/or resilience in social-ecological systems and their networks. In this study, we present a resilience framework for food–energy–water systems and demonstrate it with a case study in Magic Valley, Idaho. We formulated scenarios of change based on stakeholder input (qualitative data), researcher-developed models (quantitative data), and validation of plausibility through impact and indicator evaluation. The stakeholder engagement process identified key issues, critical uncertainties, and plausible and viable solutions to future challenges. Specifically, we analyzed cross-scenario futures and their solutions to address water quality issues in the face of climate change, land-use change conflicts, and population shifts in the region. The process activates stakeholder and research-based models to create geospatial alternative futures and their associated timesteps, with embedded solutions, which broadens and improves conventional scenario-based research. The process intends to provide policy-makers, researchers, and scenario facilitators with a strategic framework to activate solutions temporally with a stakeholder-defined suite of scenarios.

People in the Arctic and sub-Arctic continue to face uncertainty in their livelihoods as they contend with environmental variability and change operating at multiple scales. The arctic water resources vulnerability index (AWRVI) was proposed as a tool that arctic communities could use to assess their susceptibility to both changing biophysical conditions affecting their water resources and socioeconomic conditions measuring their ability to respond to such changes. The application of AWRVI in six communities in Northwest Alaska and one in Southcentral Alaska is explored with a view to enhancing the tool as an adaptive capacity index, and a set of AWRVI indicators and parameters was refined by modifying the suite of biophysical measures and societal capacities to enhance the ability of the tool to gauge community adaptive capacity, and incorporate the use of more diverse datasets. A critical update was the development of an indicator for change in timing of precipitation in response to advice from Alaskan practitioners and scientists. Index scores based on the updated AWRVI are compared with the original AWRVI for the seven communities and show small to modest changes in the adaptive capacity scores. The role of the updated AWRVI is discussed as a tool to assist communities as they attempt to understand, negotiate, and reconcile adaptation measures for environmental change at local scales, potentially providing a guide for communities to target adaptive responses.

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Many papers have addressed the differing approaches to observation by scientists collecting instrumented data and by community or local knowledge-based observations. Integrating these ways of knowing is difficult because they operate at different scales and have different goals. It would benefit both scientists and communities to integrate community-based observations and instrumented data, despite obstacles, because it would expand scales of observation and because gauged data in the Arctic are sparse. This requires development of a protocol to integrate these knowledge systems to maximize reliability and validity. We used survey data from a community-based observing network in the Bering Sea and examined the correspondence of community-based observations with instrument-derived data for air temperature, sea ice break-up and freeze-up, and vegetation changes. Results highlight that there is a high correspondence between community-based observations for sea ice and vegetation change and instrumented data, but there is an inherent conflict in scales of observation for air temperature data. This helps to elucidate the benefits of community-based observing as a process for understanding and responding to change in the Arctic.

Objective The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Integrative research is increasingly a priority within the scientific community and is a central goal for the evolving field of sustainability science. While it is conceptually attractive, its successful implementation has been challenging and recent work suggests that the move towards interdisciplinarity and transdisciplinarity in sustainability science is being only partially realized. To address this from the perspective of social-ecological systems (SES) research, we examine the process of conducting a science of integration within the Southcentral Alaska Test Case (SCTC) of Alaska-EPSCoR as a test-bed for this approach. The SCTC is part of a large, 5 year, interdisciplinary study investigating changing environments and adaptations to those changes in Alaska. In this paper, we review progress toward a science of integration and present our efforts to confront the practical issues of applying proposed integration frameworks. We: (1) define our integration framework; (2) describe the collaborative processes, including the co-development of science through stakeholder engagement and partnerships; and (3) illustrate potential products of integrative, social-ecological systems research. The approaches we use can also be applied outside of this particular framework. We highlight challenges and propose improvements for integration in sustainability science by addressing the need for common frameworks and improved contextual understanding. These insights may be useful for capacity-building for interdisciplinary projects that address complex real-world social and environmental problems.

Background The Clinical and Laboratory Standards Institute (CLSI) revised breakpoints for cefazolin (CFZ) may be difficult to implement with current automated susceptibility testing (AST) platforms and Enterobacterales may be falsely reported as susceptible to CFZ. The possibility remains that CFZ may then be inappropriately used as definitive therapy. Methods This was a retrospective observational cohort of adult patients with Enterobacterales bloodstream infections (BSI) reported CFZ susceptible per Vitek®2 (bioMerieux, Durham NC). The primary outcome was the percentage of CFZ susceptible Enterobacterales isolates using three different susceptibility testing methods: Vitek®2 automated testing, ETEST® (bioMerieux, Durham NC), and disk diffusion. Secondary outcomes included treatment failure defined as a composite outcome of 30-day all-cause inpatient mortality, 30-day recurrent BSI, 60-day recurrent infection, or infectious complications. Results In 195 isolates reported CFZ susceptible per Vitek®2, 84 (43.1%) were CFZ susceptible using E-test vs.119 (61%) using disk diffusion (Figure 1). Rates of treatment failure were similar in both CFZ and non-CFZ groups (33.3% vs. 38.5% respectively; p=0.57). Both groups had high rates of ID consult involvement (>60%) and source control (>80%) with urinary tract being the most reported source. No difference was noted in 30-day all-cause mortality, secondary infectious complications, 30-day readmissions, or 60-day recurrent infections. A subgroup analysis of patients receiving CFZ vs. ceftriaxone suggests treatment failure was significantly less likely to occur in the setting of source control (adjusted OR 0.06; 95% CI, 0.13–0.32) and ID consult Figure 1: CFZ Susceptibilities by Testing Method Conclusion There was a large discrepancy among testing methods; additional confirmatory CFZ susceptibility testing beyond AST platforms should be considered prior to definitive use of CFZ for systemic Enterobacterales infections. Disclosures All Authors: No reported disclosures

Background The incidence of permanent pacemaker (PPM) implantation is higher following mitral valve surgery (MVS) with ablation for atrial fibrillation (AF) compared with MVS alone. Objectives This study identified risk factors and outcomes associated with PPM implantation in a randomized trial that evaluated ablation for AF in patients who underwent MVS. Methods A total of 243 patients with AF and without previous PPM placement were randomly assigned to MVS alone (n = 117) or MVS + ablation (n = 126). Patients in the ablation group were further randomized to pulmonary vein isolation (PVI) (n = 62) or the biatrial maze procedure (n = 64). Using competing risk models, this study examined the association among PPM and baseline and operative risk factors, and the effect of PPM on time to discharge, readmissions, and 1-year mortality. Results Thirty-five patients received a PPM within the first year (14.4%), 29 (83%) underwent implantation during the index hospitalization. The frequency of PPM implantation was 7.7% in patients randomized to MVS alone, 16.1% in MVS + PVI, and 25% in MVS + biatrial maze. The indications for PPM were similar among patients who underwent MVS with and without ablation. Ablation, multivalve surgery, and New York Heart Association functional (NYHA) functional class III/IV were independent risk factors for PPM implantation. Length of stay post-surgery was longer in patients who received PPMs, but it was not significant when adjusted for randomization assignment (MVS vs. ablation) and age (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.61 to 1.08; p = 0.14). PPM implantation did not increase 30-day readmission rate (HR: 1.43; 95% CI: 0.50 to 4.05; p = 0.50). The need for PPM was associated with a higher risk of 1-year mortality (HR: 3.21; 95% CI: 1.01 to 10.17; p = 0.05) after adjustment for randomization assignment, age, and NYHA functional class. Conclusions AF ablation, multivalve surgery, and NYHA functional class III/IV were associated with an increased risk for permanent pacing. PPM implantation following MVS was associated with a significant increase in 1-year mortality. (Surgical Ablation Versus No Surgical Ablation for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgery; NCT00903370)

Environmental non-governmental organizations can work in partnership with fishing communities to secure vibrant fishing communities and thriving marine ecosystems. Abundant, biodiverse oceans and increased food and prosperity for small-scale fisheries are within our reach. There is an incredible groundswell of people and organizations working to realize the vision set forth in the FAO Voluntary Guidelines for Securing Sustainable Small-Scale Fisheries (SSF Guidelines), with small-scale fishing communities taking the lead in designing and implementing solutions. Environmental NGOs, including the Environmental Defense Fund (EDF) and the World Wide Fund for Nature (WWF), share the vision of thriving, healthy oceans and small-scale fisheries that provide sustainable and stable livelihoods for coastal communities, essential nutrients and a secure source of food for millions. Much has already been accomplished, yet it is clear that in order to achieve widespread impact, more could be done to amplify the efforts already underway by fishing communities.

Congenital Morgagni hernia (CMH) is a rare congenital anomaly is typically diagnosed in childhood and on occasions in adults during work up of unexplained respiratory infections or gastrointestinal symptoms. The average age of laparoscopic repair of CMH was 3.3 years. We describe a newborn with fetal aberrant ductus venosus with progressive right ventricular dilation prompting early delivery. Post-natally, the baby had frequent episodes of cyanosis. Echocardiogram during distress showed compression of the inferior vena cava and of the right heart, with significant right to left shunt through patent foramen ovale. Infant underwent successful laparoscopic diaphragmatic hernia repair with resolution in her episodes of cyanosis. Keywords: Morgagni diaphragmatic hernia, Neonate, Cyanosis, Tamponade

Almost every formal organization has a multilayered hierarchy. The role of the leader has been discussed in the literature for decades. Less well understood, and certainly less well documented, is the role of the follower. Followers make up the majority of any organization but have been overlooked as a worthy component of the team. The first step in breaking this mold is identifying the types of followership that are present within the nursing profession. A population of nurses with 4 or fewer years of experience in a designated hospital setting in Southwest Texas. A descriptive study, using a 20-question, 7-point (0-6) Likert-type, validated questionnaire, was changed to an electronic format in Qualtrics and used to survey the identified nursing population. Data collected within Qualtrics XM were exported into Excel and then into SPSS 20 IBM version that was then used to create a scatterplot. The 2 axes represented the independent thinking and the active engagement of the participants. Correlations between demographics and followership styles were also conducted, using a chi-square automatic interaction detector (CHAID) analysis. Using Robert E. Kelley's scatterplot to analyze the data, 3 different types of followers were identified within the respondents. The 3 types were exemplary followers, conformist followers, and pragmatist followers. Of the qualified participants who completed the questionnaire, the majority fell into the exemplary follower category. The results identified that an issue with active engagement exists among all of the participants.

Objective Fetal tachyarrhythmias complicate 0.5% of pregnancies, with high morbidity and mortality. We hypothesized that maternal factors may predispose to fetal supraventricular tachycardia (SVT). Study Design We reviewed medical records of all 124 mothers who presented to the Vanderbilt Fetal Cardiology Clinic from 2004 to 2010 for fetal arrhythmias, excluding heart block. Maternal factors were compared between 28 fetuses with SVT and a control group of 112 fetuses screened for noncardiac conditions. The proportions were analyzed using chi-square or Fisher exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Results Of maternal factors, thyroid disease was statistically significant compared with controls. Among mothers whose fetuses had SVT, 21% had thyroid disease (83% hypothyroidism) compared with 3% of controls ( p Conclusion In this cohort, the maternal thyroid disease was more common in fetuses with SVT compared with controls (odds ratio = 9.8, 95% confidence interval 2.3–42.3), suggesting closer screening for fetal arrhythmias and SVT in mothers with thyroid disease. Also, routine screening of thyroid functions and thyroid autoantibodies may be warranted in mothers of fetuses with SVT.

More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P