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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.

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).

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.

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.

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.

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.

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

Sustainable design-centered manufacturing (SDM) will create competitive advantages for future new product development. However, selecting and balancing the indicators for economic, environmental, and social sustainability is difficult. In this research, we define the major indicators of social sustainability for development of SDM and propose a Balanced Scorecard method to evaluate the weighting factors among the three pillars and the indicators used to assess each pillar. The algorithm for the analysis is based on Structural Equation Modeling (SEM). A case, using the manufacturing data for Polylactic Acid (PLA), is developed. The results can be adapted to evaluate the performance of outcomes for new product development utilizing SDM.

OBJECTIVE: To analyze patient risk factors and processes of care associated with secondary surgical site infection (SSI) after coronary artery bypass grafting (CABG). METHODS: Data were collected prospectively between February and October 2010 for consenting adult patients undergoing CABG with saphenous vein graft (SVG) conduits. Patients who developed a deep or superficial SSI of the leg or groin within 65 days of CABG were compared to those who did not develop a secondary SSI. RESULTS: Among 2,174 patients identified, 65 (3.0%) developed a secondary SSI. Median time to diagnosis was 16 days (interquartile range [IQR]: 11 - 29) with the majority (86%) diagnosed after discharge. Gram-positive bacteria were most common. Readmission was more common in patients with a secondary SSI (34% vs 17%, p < 0.01). After adjustment, an open SVG harvest approach was associated with an increased risk of secondary SSI (adjusted hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.28, 3.48). Increased body mass index (BMI) (adjusted HR: 1.08, 95% CI: 1.04, 1.12) and packed red blood cell (PRBC) transfusions (adjusted HR: 1.13, 95% CI: 1.05, 1.22) were associated with a higher risk of secondary SSI. Antibiotic type, antibiotic duration, and post-operative hyperglycemia were not associated with risk of secondary SSI. CONCLUSIONS: Secondary SSI following CABG continues to be an important source of morbidity. This serious complication often occurs after discharge and is associated with open SVG harvesting, larger BMI, and blood transfusions. Patients with a secondary SSI have longer lengths of stay and are readmitted more frequently.

Summary Background Understanding of adolescent-onset asthma remains limited. We sought to characterise this state and identify associated factors within a longitudinal birth cohort study. Methods The Isle of Wight Whole Population Birth Cohort was recruited in 1989 ( N =1456) and characterised at 1, 2, 4, 10 and 18-years. "Adolescent-onset asthma" was defined as asthma at age 18 without prior history of asthma, "persistent-adolescent asthma" as asthma at both 10 and 18 and "never-asthma" as those without asthma at any assessment. Results Adolescent-onset asthma accounted for 28.3% of asthma at 18-years and was of similar severity to persistent-adolescent asthma. Adolescent-onset asthmatics showed elevated bronchial hyper-responsiveness (BHR) and atopy at 10 and 18 years. BHR in this group at 10 was intermediate to that of never-asthmatics and persistent-adolescent asthma. By 18 their BHR, bronchodilator reversibility and sputum eosinophilia was greater than never-asthmatics and comparable to persistent-adolescent asthma. At 10, males who later developed adolescent-onset asthma had reduced FEV 1 and FEF 25–75 , while females had normal lung function but then developed impaired FEV 1 and FEF 25–75 in parallel with adolescent asthma. Factors independently associated with adolescent-onset asthma included atopy at 10 (OR=2.35; 95% CI=1.08–5.09), BHR at 10 (3.42; 1.55–7.59), rhinitis at 10 (2.35; 1.11–5.01) and paracetamol use at 18-years (1.10; 1.01–1.19). Conclusions Adolescent-onset asthma is associated with significant morbidity. Predisposing factors are atopy, rhinitis and BHR at age 10 while adolescent paracetamol use is also associated with this state. Awareness of potentially modifiable influences may offer avenues for mitigating this disease state.

Objective To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P Results Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P Conclusions Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.

Peak oxygen consumption (VO(2) ) during cardiopulmonary exercise testing (CPET) is a powerful predictor of survival, providing an indirect assessment of cardiac output (CO). Noninvasive indices of CO derived from bioreactance methodology would add significantly to peak VO(2) as a means of risk-stratifying patients with heart failure. In this study, 127 patients (53 ± 14 years of age, 66% male) with heart failure and an average ejection fraction of 31% ± 15% underwent symptom-limited CPET using a bicycle ergometer while measuring CO noninvasively by a bioreactance technique. Peak cardiac power was derived from the product of the peak mean arterial blood pressure and CO divided by 451. Follow-up averaged 404 ± 179 days (median, 366 days) to assess endpoints including death (n=3), heart transplant (n=10), or left ventricular assisted device implantation (n=2). Peak VO(2) and peak power had similar areas under the curve (0.77 and 0.76), which increased to 0.83 when combined. Kaplan-Meier cumulative survival curves demonstrated different outcomes in the subgroup with a VO(2)

This paper provides empirical evidence to support existing anecdotal studies regarding the mechanisms by which human communities become vulnerable to rapid changes in freshwater resources on the Seward Peninsula, Alaska. We interviewed adults, stratified by age, sex, and extended family, in Inupiat communities on the Seward Peninsula. Using categorical indices as part of a semi-structured interview we elicited a respondent's perception of the availability and quality of freshwater resources in their community as well as their perception of change in the availability and quality of freshwater during the period of their lifetime in that community. Significant relationships were observed between age groups for the perception of change in the availability of the local water source and the perception of change in its quality—older generations perceiving more change than younger age groups. These perceptions of change were examined with respect to recent historic changes in precipitation and temperature on the Seward Peninsula. These findings suggest that individual perceptions are instrumental in determining whether or not change merits response. The findings also provide evidence that oral traditional knowledge systems have shifted from continuous to discontinuous transmission, distancing the users from traditional resources. We discuss the role of collective knowledge, through the transmission of knowledge from elders to subsequent generations, in aiding the development of a community's ability to note and respond to changes in critical natural resources.

Changes in epithelial cell shape can lead to cell death and detachment. Actin filaments are cleaved during apoptosis, but whether disruption in the actin cytoskeletal network, as one manifestation of cell shape change, can itself induce apoptosis is not known. We tested this hypothesis in the airway epithelial cell line 1HAEo(-) and in primary airway epithelial cells by preventing actin filament elongation with cytochalasin D or by aggregating actin filaments with jasplakinolide. Disruption of actin filament integrity promptly induced apoptosis in adherent epithelial cells within 5 h. Jasplakinolide-induced apoptosis did not disrupt focal adhesions, whereas cytochalasin D-induced apoptosis decreased focal adhesion protein expression and occurred despite ligation of the fibronectin receptor. Death induction was abrogated by the caspase inhibitors z-VAD-fmk and Ac-DEVD-cho but not by blocking the Fas (CD95) receptor. Whereas cytochalasin D--induced apoptosis was associated with cleavage of pro-caspase-8, jasplakinolide-induced apoptosis was not. Both agents induced formation of a death-inducing signaling complex. These data demonstrate that disruption of actin filament integrity with either cytochalasin D or jasplakinolide induces apoptosis in airway epithelial cells but by different mechanisms, and suggest that actin may be an early modulator of apoptotic commitment.