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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.

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.

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

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.

An integrated dataset was developed that combined stakeholder perceptions of environmental change (precipitation, air temperature, water temperature, fish abundance, fish size, residential development) and comparable instrumented measures of environmental changes based on sensor records. All data were transformed to a common 3-point categorical scale to support statistical comparison of social and biophysical change for the same change variables. The integrated dataset is available on Mendeley ( http://dx.doi.org/10.17632/cjfxg84bmx.1 ).

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)

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

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.

Supraventricular tachycardia (SVT) is the most common arrhythmia in the pediatric population. Despite its commonality, presentation of SVT can be nonspecific and varies based upon age with infants demonstrating fussiness or irritability and older children reporting vague perceptions of tachycardia or palpitations. Furthermore, SVT may manifest as self-limited paroxysms or with prolonged runs of SVT with subsequent development of cardiac dysfunction, heart failure, and multiorgan shock. Clinicians must maintain high levels of suspicion for SVT given the potentially dire consequences of untreated SVT. When diagnosed, there are effective acute and chronic treatments for SVT, with potential for spontaneous resolution in many infants. [ Pediatr Ann . 2014;43(11):456–460.]

In this study we investigated whether the addition of peak oxygen consumption (VO(2)) improves the predictive accuracy of the Seattle Heart Failure Model (SHFM). The SHFM is a validated multivariate risk model that uses NYHA classification to assess functional capacity rather than peak oxygen consumption (VO(2)).Outpatients (n = 1,240) evaluated for transplant at three centers had their SHFM score calculated and peak VO(2) measured. The outcomes assessed were death/LVAD/urgent transplant with censoring at the time of elective transplant.Over the course of 4.0 (mean) years of observation, there were 571 events. Both the SHFM score (χ(2) = 227) and peak VO(2) (χ(2) = 88, both p0.0001) were highly predictive of outcomes. The SHFM and peak VO(2) were modestly correlated (r = 0.39, p0.0001). In a multivariate Cox model, peak VO(2) added to the SHFM with a hazard ratio of 0.949 (p0.0001) for each 1-ml/kg/min increase. Peak VO(2) improved both the net reclassification improvement and integrated discrimination index (both p ≤ 0.0002). Peak VO(2) provided additive prognostic information within each SHFM score (p0.05). The 1-year areas under the receiver-operating characteristic curve were obtained for peak VO(2) (0.645, 95% CI 0.606 to 0.684), SHFM (0.758, 95% CI 0.721 to 0.795) and SHFM with peak VO(2) (0.766, 95% CI 0.731 to 0.802). The SHFM-predicted vs actual survival free of LVAD/UNOS Status 1 transplant at 1 year (86% vs 83%) and 4 years (63% vs 63%) were similar.The multivariate SHFM is a powerful predictor of death/LVAD/urgent transplant. Peak VO(2) adds prognostic information across the spectrum of the SHFM, but changes in decision regarding transplant listing occur mainly in moderate-risk patients.

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.

The Heart Failure Survival Score (HFSS) risk-stratifies patients with chronic heart failure (CHF) referred for heart transplantation using 7 parameters, including peak VO₂. The Seattle Heart Failure Model (SHFM) is a 20-variable model that combines clinical, laboratory and therapeutic data. Although both models have excellent accuracy, only the HFSS was derived and validated in patients referred for transplantation, and the HFSS and SHFM have not been directly compared.We tested the accuracy of the SHFM and compared the HFSS and SHFM in 715 patients referred for heart transplantation.Over a follow-up of 962 ± 912 days, 354 patients died or received an urgent heart transplantation or a ventricular assist device. One-year event-free survival was 89%, 72% and 60%, respectively, for the low-, medium- and high-risk HFSS strata, and 93%, 76%, and 58%, respectively, for the low-, medium- and high-risk SHFM strata. The HFSS and SHFM were modestly correlated (R = -0.48, p0.001). In receiver operating characteristic curve analysis, areas under the curves (AUCs) for the HFSS and SHFM were comparable (1 year: 0.72 vs 0.73; 2-year: 0.70 vs 0.74, respectively) and incremental to New York Heart Association class. The 1- and 2-year combined HFSS+SHFM AUCs were 0.77 and 0.76, respectively, significantly better than the HFSS or SHFM alone.The HFSS and SHFM provide accurate and comparable risk stratification in CHF patients referred for transplantation. Combining the HFSS and SHFM improves predictive ability.

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)

Technology is often touted as a collective solution to environmental problems. However, what if technology results in trade-offs in long-term resilience that ultimately pose a critical vulnerability for society? In this study, we examine the change in values of freshwater from traditional to convenience-oriented values in remote, resource-dependent communities that are in the process of modernization. Individuals living in remote resource-dependent communities in Alaska were interviewed and asked a series of questions concerning their values toward freshwater and the importance of those values. As age of the individual decreased, traditional-subsistence values of water diminished, and both convenience and recreational values of water increased. Individuals from communities without municipal water systems expressed greater traditional-subsistence values and less convenience-oriented values than individuals from communities with municipal water systems. The data presented suggest that as communities increas...

Peak oxygen consumption (Vo(2)) is a powerful prognostic predictor of survival in patients with chronic heart failure (CHF) because it provides an indirect assessment of a patient's ability to increase cardiac output (CO). However, many patients with CHF who undergo cardiopulmonary exercise testing are unable to perform maximal exercise. New metabolic carts coupled with the inert gas rebreathing technique provide a noninvasive measurement of CO. Whether the noninvasive measurement of CO at a fixed submaximal workload can predict outcome is unknown. This study's population comprised 259 patients (mean age 54 +/- 14 years, mean left ventricular ejection fraction 27 +/- 14%) with CHF who underwent symptom-limited incremental cardiopulmonary exercise testing. Vo(2) and CO were measured at rest, at 25 W, and at peak exercise. Submaximal exercise was defined as80% peak Vo(2). Among 259 patients, 145 had Vo(2) at 25 W80% of peak. Vo(2) at 25 W averaged 9.3 +/- 1.8 ml/kg/min. This Vo(2) represented 62 +/- 11% of peak Vo(2), which averaged 15.4 +/- 4.4 ml/kg/min. Prospective follow-up averaged 521 +/- 337 days. In this cohort, there were 15 outcome events (death, urgent heart transplantation, or implantation of a left ventricular assist device as a bridge to transplantation). On univariate Cox hazard analysis, CO at 25 W (hazard ratio 0.64, 95% confidence interval 0.48 to 0.84, p = 0.002) was found to be significant predictor of events of outcome. In conclusion, CO at 25 W measured noninvasively during submaximal exercise may have potential value as a predictor of outcomes in patients with CHF.

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.

This paper provides empirical evidence to suggest that modernization, and its resulting infrastructure, creates a filter which distances people from the resources they use. The data presented suggest that installation of a municipal water supply, piped water to residences, affects a community's ability to perceive change in surrounding water sources. Since individual perceptions and values are instrumental in determining whether or not change merits response, failing to perceive change threatens a community's ability to note and respond to variations in critical natural resources. A conceptual model for the effect of distancing from a resource is proposed.

Atrial flutter (AFL) is the second most common type of tachyarrhythmia in the fetus and neonate. An atrial rate of 240 to 360 beats per minute, 2:1 atrioventricular conduction, and a “saw tooth” appearance on electrocardiogram (ECG) are characteristic. On echocardiogram, bilateral atrial dilatation is the most common finding. Treatment is dependent on the severity of symptoms; delivery is usually indicated in the case of fetal heart failure or hydrops fetalis, whereas postnatal AFL is most commonly treated with direct current cardioversion (DCC). This article presents an illustrative case in which the patient presented antenatally via abnormal nonstress testing and subsequent fetal echocardiogram that was concerning for AFL. Postnatal ECG confirmed this diagnosis and the patient received DCC on the day of birth, followed by digoxin and propranolol as maintenance therapy. [ Pediatr Ann . 2015;44(10):e247–e250.]

Critical congenital heart disease (CCHD) is defined as a ductal-dependent congenital heart defect requiring surgical or percutaneous intervention via cardiac catheterization before 1 year of age. Most cases of CCHD can be diagnosed with prenatal ultrasound or fetal echocardiogram. If not prenatally diagnosed, CCHD can be stable in the newborn nursery due to persistent ductal patency, and the patient may only be diagnosed after ductal closure and development of cardiac symptoms at home. In this case, a 6-day-old female presented to the emergency department (ED) floppy with agonal respirations, poor capillary refill, and absent femoral pulses. On the day of presentation, the patient became increasingly fussy, refused feeding, and began to gasp. The patient was transported to the ED for evaluation, where a bedside echocardiogram revealed interrupted aortic arch (IAA), ventricular septal defect, minimal flow through a thread-like ductus arteriosus, and severely depressed cardiac function. IAA is very rare, with an incidence of three cases per 1 million live births. Patients require neonatal supportive care, continuous prostaglandin E1 infusion, and urgent referral for neonatal surgical repair in the first days to weeks of life. To reduce the volume of undiagnosed CCHD in the immediate newborn period, the U.S. Department of Health and Human Services Secretary’s Advisory Committee on Heritable Diseases in Newborns and Children (SACHDNC) recommended that CCHD screening via pulse oximetry be added to the recommended uniform screening panel. A positive screen results in an immediate referral for an echocardiogram. Fetal diagnosis, newborn screening, and/or careful clinical examination may have resulted in detection of IAA in our patient prior to ductal closure.

It has been well documented that high-intensity strength training using weight machines and other laboratory controlled equipment and procedures improves strength in older adults. However, few studies have investigated the effects of low-cost, less intense strength conditioning programs suitable for use in a community setting. The purpose of this study was to test the effects of a 16-week, self-regulated resistance training program on strength and endurance of the ankle dorsi- and plantar flexors, and of the knee extensors and flexors. Forty-six older women (M = 67 yrs) were randomly assigned to either control or exercise groups. After initial testing, exercisers began a training regimen of seven exercises that stressed muscle groups of the lower extremities. Control subjects maintained their normal activity patterns. Significant (p < .05) or borderline significant (p < .07) exercise effects were found on 10 of the 16 dependent measures. Results of this study indicate that a field-based strength conditioning program of moderate, self-regulated intensity can improve some aspects of lower limb muscle function of older women.

Background Hemodynamic responses to exercise were assessed in patients with varying degrees of chronic heart failure (CHF) to determine the feasibility of using bioreactance during exercise testing in multicenter studies of CHF. Methods and Results A total of 210 symptomatic CHF patients and 22 subjects without heart failure were subjected to symptom-limited exercise testing on a bicycle (105) or treadmill (127) while measuring gas exchange for VO 2 , cardiac output (CO) noninvasively by a bioreactance technique, heart rate, and blood pressure. Peak CO (pCO) and VO 2 (pVO 2 ) during exercise were lower in patients with higher New York Heart Association (NYHA) class, in females and in older patients. Multiple linear regression analysis showed that pCO (L/min)=19.6+4·M –2.1·NYHA+1.9·G –0.09·Age, where M=1 for treadmill and 0 for bicycle and G=1 for males and 0 for females. Similarly, pVO 2 (mL/kg/min)=24+2.1·M –2.9·NYHA+1.26·G –0.08·Age. VO 2 and CO were also highly correlated to each other: pCO (mL/kg/min)=0.059+0.007·pVO 2 +0.036·M –0.025·G. Similar correlations were determined for other parameters of exercise, including left ventricular power, and the ratio of peak/resting VO 2 (cardiovascular reserve), the ratio of peak/resting CO (cardiac reserve), and total peripheral vascular resistance. Conclusion Bioreactance-based noninvasive measurements of CO at rest and during exertion identified abnormalities of cardiovascular function consistent with those identified by pVO 2 and in prior studies using invasive CO measurements. This technique might therefore be useful for indexing disease severity, prognostication, and for tracking responses to treatment in clinical practice and in clinical trials.

This research investigates recent developments in assessment methods of green buildings and compares the differences in rating systems among the United Kingdom, USA, and Germany. There are indications that the rating systems are moving from green buildings to sustainable buildings. In order to understand the recent research in academic areas, we survey the recent Ph.D. dissertations and literature related to green building assessment. Discussion is provided on the major research areas of green buildings, which cover accountability of life cycle cost, methodology for balancing the three pillars, and government vision and public policy.

Hybrid coronary revascularization (HCR), an emerging treatment paradigm, combines minimally invasive internal mammary artery (IMA) to left anterior descending artery (LAD) revascularization with percutaneous coronary intervention (PCI) to treat multi–vessel coronary artery disease (CAD) that