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Stroke is the leading cause of death with over 5 million deaths worldwide each year. About 80% of strokes are ischemic strokes caused by blood clots. Tissue plasminogen activator (tPa) is the only FDA-approved drug to treat ischemic stroke with a wholesale price over $6000. tPa is now off patent although no biosimilar has been developed. The production of tPa is complicated by the 17 disulfide bonds that exist in correctly folded tPA. Here, we present an Escherichia coli-based cell-free protein synthesis platform for tPa expression and report conditions which resulted in the production of active tPa. While the activity is below that of commercially available tPa, this work demonstrates the potential of cell-free expression systems toward the production of future biosimilars. The E. coli-based cell-free system is increasingly becoming an attractive platform for low-cost biosimilar production due to recent developments which enable production from shelf-stable lyophilized reagents, the removal of endotoxins from the reagents to prevent the risk of endotoxic shock, and rapid on-demand production in hours.

This paper reports on the research of factors that impact the accuracy and efficiency of an unmanned aerial vehicle (UAV) based radio frequency (RF) and microwave data collection system. The swarming UAVs (agents) can be utilized to create micro-UAV swarm-based (MUSB) aperiodic antenna arrays that reduce angle ambiguity and improve convergence in sub-space direction-of-arrival (DOA) techniques. A mathematical data model is addressed in this paper to demonstrate fundamental properties of MUSB antenna arrays and study the performance of the data collection system framework. The Cramer−Rao bound (CRB) associated with two-dimensional (2D) DOAs of sources in the presence of sensor gain and phase coefficient is derived. The single-source case is studied in detail. The vector-space of emitters is exploited and the iterative-MUSIC (multiple signal classification) algorithm is created to estimate 2D DOAs of emitters. Numerical examples and practical measurements are provided to demonstrate the feasibility of the proposed MUSB data collection system framework using iterative-MUSIC algorithm and benchmark theoretical expectations.

This study aimed to develop a scale to assess counselors' ability to provide counseling to address the mental health impacts of climate change. Over three studies, we provide reliability and validity evidence for a Climate Change Counseling Scale (3CS) in a large representative sample of counselors across the US. In study one and two, an overinclusive item pool was developed using a theoretical framework and were subjected to exploratory factor analysis. In study three, confirmatory factor analytic models and corollary analysis were utilized to establish construct validity and convergent validity, respectively. Two factors with seven items each were supported across studies. The first factor represented Climate Change Knowledge. The second factor represented skills and abilities consistent with Climate Informed Counseling. Reliability and validity were acceptable by standard convention in all three studies. The 3CS represents the first measure to assess counseling skills to mitigate mental health impacts of climate change.

Digital forensic examiners are tasked with retrieving data from digital storage devices, and frequently these examiners are expected to explain the circumstances that led to the data being in its current state. Through written reports or verbal, expert testimony delivered in court, digital forensic examiners are expected to describe whether data have been altered, and if so, then to what extent have data been altered. Addressing these expectations results from opinions digital forensic examiners reach concerning their understanding of electronic storage and retrieval methods. The credibility of these opinions evolves from the scientific basis from which they are drawn using forensic methodology. Â Digital forensic methodology, being a scientific process, is derived from observations and repeatable findings in controlled environments. Furthermore, scientific research methods have established that causal conclusions can be drawn only when observed in controlled experiments. With this in mind, it seems beneficial that digital forensic examiners have a library of experiments from which they can perform, observe results, and derive conclusions. After having conducted an experiment on a specific topic, a digital forensic examiner will be in a better position to express with confidence the state of the current data and perhaps the conditions that led to its current state. Â This study provides a simple experiment using the contemporary versions of the most widely used software applications running on the most commonly installed operation system. Here, using the Microsoft Office 2010 applications, a simple Word document, an Excel spreadsheet, a PowerPoint presentation, and an Access database are created and then modified. A forensic analysis is performed to determine the extent in which the changes to the data are identified. The value in this study is not that it yields new forensic analysis techniques, but rather that it illustrates a methodology that other digital forensic examiners can apply to develop experiments representing their specific data challenges.

The stressors of global environmental change make it impossible over the long term for natural systems to maintain their historical composition. Conservation's new objective must be to maintain the building blocks of future systems (e.g., species, genes, soil types, and landforms) as they continuously rearrange. Because of the certainty of change, some biologists and managers question continued use of retrospective conservation strategies (e.g., reserves and restoration) informed by the historical range of variability. Prospective strategies that manage toward anticipated conditions have joined the conservation toolbox alongside retrospective conservation. We argue that high uncertainty around the rates and trajectories of climate and ecological change dictate the need to spread ecological risk using prospective and retrospective strategies across conservation networks in a systematic and adaptively managed approach. We term this a portfolio approach drawing comparisons to financial portfolio risk management as a means to maximize conservation benefit and learning. As with a financial portfolio, the portfolio approach requires that management allocations receive minimum temporal commitments to realize longer‐term benefits. Our approach requires segregation of the strategies into three landscape zones to avoid counterproductive interactions. The zones will be managed to (1) observe change, (2) resist change, and (3) facilitate change. We offer guidelines for zone allocation based on ecological integrity. All zones should follow principles of conservation design traditionally applied to reserves. Comparable to financial portfolios, zone performance is monitored to facilitate learning and potential reallocation for long‐term net minimization of risk to the building blocks of future ecosystems.

One area of particular concern for computer forensics examiners involves situations in which someone utilized software applications to destroy evidence. There are products available in the marketplace that are relatively inexpensive and advertised as being able to destroy targeted portions of data stored within a computer system. This study was undertaken to identify these tools and analyze them to determine the extent to which each of the evaluated data wiping applications perform their tasks and to identify trace evidence, if any, left behind on disk media after executing these applications. We evaluated five Windows 7 compatible software products whose advertised features include the ability for users to wipe targeted files, folders, or evidence of selected activities. We conducted a series of experiments that involved executing each application on systems with identical data, and we then analyzed the results and compared the before and after images for each application. We identified information for each application that is beneficial to forensics examiners when faced with similar situations. This paper describes our application selection process, our application evaluation methodology, and our findings. Following this, we describe limitations of this study and suggest areas of additional research that will benefit the study of digital forensics.

As the proliferation of digital computational systems continue to expand, increasingly complex technologies emerge, including those regarding large, enterprise-wide, information storage and retrieval systems. Within this study, we examine four contemporary enterprise storage technologies. Our examination of these technologies is presented with an overview of the technological features of each offering and then followed with a discussion of the impact of these technologies on digital forensics methods, particularly regarding forensic data acquisition. We offer a general opinion concerning a recommended data acquisition method when faced with the task of obtaining a forensic image of data contained within these technologies, we discuss limitations of our study, and lastly, we suggest areas in which additional research would benefit the field of digital forensics.

The usage of digital evidence from electronic devices has been rapidly expanding within litigation, and along with this increased usage, the reliance upon forensic computer examiners to acquire, analyze, and report upon this evidence is also rapidly growing. This growing demand for forensic computer examiners raises questions concerning the selection of individuals qualified to perform this work. While courts have mechanisms for qualifying witnesses that provide testimony based on scientific data, such as digital data, the qualifying criteria covers a wide variety of characteristics including, education, experience, training, professional certifications, or other special skills. In this study, we compare task performance responses from forensic computer examiners with an expert review panel and measure the relationship with the characteristics of the examiners to their quality responses. The results of this analysis provide insight into identifying forensic computer examiners that provide high-quality responses.

Introduction Despite the prevalence of corticosteroid injections in athletes, little is known about their efficacy in triathletes. We aim to assess attitudes, use, subjective effectiveness, and time to return to sport with corticosteroid injections compared to alternative methods in triathletes with knee pain. Methods This is an observational study during the COVID-19 pandemic. Triathletes answered a 13-question survey posted to three triathlon-specific websites. Results Sixty-one triathletes responded, 97% of whom experienced knee pain at some point in their triathlete career; 63% with knee pain received a corticosteroid injection as treatment (average age 51 years old). The most popular attitude (44.3%) regarding corticosteroid injections was "tried them, with good improvement". Most found the cortisone injection helpful for two to three months (28.6%), or more than one year (28.6%); of individuals who found the injections useful for more than one year, four-eight (50%) had received multiple injections during that same period. After injection, 80.6% returned to sport within one month. The average age of people using alternative treatment methods was 39 years old; most returned to sport within one month (73.7%). Compared to alternative methods, there was an ~80% higher odds of returning to sport within one month using corticosteroid injections; however, this relationship was not significant (OR=1.786, p=0.480, 95% CI:0.448-7.09). Conclusion This is the first study to examine corticosteroid use in triathletes. Corticosteroid use is more common in older triathletes and results in subjective pain improvement. A strong association does not exist for a quicker return to sport using corticosteroid injections compared to alternative methods. Triathletes should be counseled on the timing of injections, duration of side effects, and be aware of potential risks.

The two most common computer forensics applications perform exclusively on Microsoft Windows Operating Systems, yet contemporary computer forensics examinations frequently encounter one or more of the three most common operating system environments, namely Windows, OS-X, or some form of UNIX or Linux. Additionally, government and private computer forensics laboratories frequently encounter budget constraints that limit their access to computer hardware. Currently, Macintosh computer systems are marketed with the ability to accommodate these three common operating system environments, including Windows XP in native and virtual environments. We performed a series of experiments to measure the functionality and performance of the two most commonly used Windows-based computer forensics applications on a Macintosh running Windows XP in native mode and in two virtual environments relative to a similarly configured Dell personal computer. The research results are directly beneficial to practitioners, and the process illustrates affective pedagogy whereby students were engaged in applied research.

As a relatively new field of study, little empirical research has been conducted pertaining to computer forensics. This lack of empirical research contributes to problems for practitioners and academics alike.For the community of practitioners, problems arise from the dilemma of applying scientific methods to legal matters based on anecdotal training methods, and the academic community is hampered by a lack of theory in this evolving field. A research study utilizing a multi-method approach to identify and measure tasks practitioners perform during forensic data acquisitions and lay a foundation for academic theory development was conducted in 2006 in conjunction with a doctoral dissertation.An overview of the study’s findings is presented within this article.

Autism spectrum disorders (ASD) are a common neurodevelopmental disorder of unknown etiology. Studies suggest a link between autism and neonatal jaundice. A 1:3 matched case–control study was conducted with children enrolled in the Military Health System born between October 2002 and September 2009. Diagnostic and procedure codes were used for identifying ASD and hyperbilirubinemia. Two definitions for hyperbilirubinemia were evaluated: an inpatient admission with a diagnosis of jaundice and treatment with phototherapy. A total of 2917 children with ASD and 8751 matched controls were included in the study. After adjustment, there remained an association between ASD in children and an admission with a diagnosis of jaundice (odds ratio = 1.18; 95% confidence interval = 1.06-1.31; P = .001) and phototherapy treatment (odds ratio = 1.33; 95% confidence interval = 1.04-1.69; P = .008). Children who develop ASD are more likely to have an admission with a diagnosis of jaundice in the neonatal period and more likely to require treatment for this jaundice.

Terrestrial open water evaporation is difficult to measure both in situ and remotely yet is critical for understanding changes in reservoirs, lakes, and inland seas from human management and climatically altered hydrological cycling. Multiple satellite missions and data systems (e.g., ECOSTRESS, OpenET) now operationally produce evapotranspiration (ET), but the open water evaporation data produced over millions of water bodies are algorithmically produced differently than the main ET data and are often overlooked in evaluation. Here, we evaluated the open water evaporation algorithm, AquaSEBS, used by ECOSTRESS and OpenET against 19 in situ open water evaporation sites from around the world using MODIS and Landsat data, making this one of the largest open water evaporation validations to date. Overall, our remotely sensed open water evaporation retrieval captured some variability and magnitude in the in situ data when controlling for high wind events (instantaneous: r2 = 0.71; bias = 13% of mean; RMSE = 38% of mean). Much of the instantaneous uncertainty was due to high wind events (u > mean daily 7.5 m·s-1) when the open water evaporation process shifts from radiatively-controlled to atmospherically-controlled; not accounting for high wind events decreases instantaneous accuracy significantly (r2 = 0.47; bias = 36% of mean; RMSE = 62% of mean). However, this sensitivity minimizes with temporal integration (e.g., daily RMSE = 1.2-1.5 mm·day-1). To benchmark AquaSEBS, we ran a suite of 11 machine learning models, but found that they did not significantly improve on the process-based formulation of AquaSEBS suggesting that the remaining error is from a combination of the in situ evaporation measurements, forcing data, and/or scaling mismatch; the machine learning models were able to predict error well in and of itself (r2 = 0.74). Our results provide confidence in the remotely sensed open water evaporation data, though not without uncertainty, and a foundation by which current and future missions may build such operational data.

Upper extremity amputations represent a prime opportunity to restore function through replantation. There are a variety of options that treating surgeons use to protect neurovascular repairs and restore function including Kirschner wire fixation, external fixation, wrist arthrodesis, and proximal row carpectomy. Additionally, the dorsal spanning plate may be a valuable tool for protecting neurovascular repairs. Compared to temporary immobilization with Kirschner wire fixation, which has previously been described in conjunction with upper extremity replantation, dorsal spanning plates can be left in place for longer durations with a lower risk of loosening and loss of fixation and for preventing postoperative sabotage or repeat amputation of the replant by the patient. In this article, we describe a unique case of a patient with acute psychiatric illness that presented with a self-inflicted amputation through the radiocarpal joint and was initially treated with emergent replantation and application of a dorsal spanning plate to protect the neurovascular repair from patient sabotage and allow for early rehabilitation. We found the dorsal spanning plate to be an effective option in this complex clinical scenario. This case illustrates the utility of the dorsal spanning plate in protecting complex neurovascular repairs in the setting of severe skeletal and psychiatric instability.

Un método sencillo de laboratorio reveló diferencias en el éxito de alimentación de Lutzomyia evansi, el vector de Leishmania chagasi en el norte de Colombia, cuando se alimentó sobre cinco especies de pequeños mamíferos de un foco endémico de leishmaniasis visceral, en los que éstos podrían actuar como reservorios. En cada ensayo, a 50 flebótomos hembra se les permitió alimentarse durante 30 minutos sobre un área similar de piel depilada de la pata posterior en 44 mamíferos. El número de flebótomos alimentados se comparó entre especies a través de un análisis de varianza y de la prueba de Tukey de comparaciones múltiples. Los flebótomos escasamente se alimentaron sobre Sciurus granatensis, una ardilla común en el área endémica que no se ha encontrado infectada con Leishmania chagasi. En otros dos mamíferos que hasta el presente han sido negativos para L. chagasi (Heteromys anomalus y Zygodontomys brevicauda), los flebótomos se alimentaron en bajos números. En cambio, los flebótomos se alimentaron en altas proporciones sobre Didelphis marsupialis y Proechimys canicollis, los dos mamíferos más abundantes en el área endémica y que se hallan infectados con L. chagasi. Los resultados aportaron evidencia adicional que estas dos especies de mamíferos silvestres serían una fuente de sangre común para los flebótomos y que, por lo tanto, pueden tener gran impacto sobre la transmisión de L. chagasi en el norte de Colombia.

High-fat diets (HFD) increase lipopolysaccharide (LPS) activity in the blood and may contribute to systemic inflammation with obesity. We hypothesized that dietary milk sphingomyelin (SM), which reduces lipid absorption and colitis in mice, would reduce inflammation and be mediated through effects on gut health and LPS activity. C57BL/6J mice were fed high-fat, high-cholesterol diets (HFD, n = 14) or the same diets with milk SM (HFD-MSM, 0.1% by weight, n = 14) for 10 weeks. HFD-MSM significantly reduced serum inflammatory markers and tended to lower serum LPS (p = 0.08) compared to HFD. Gene expression related to gut barrier function and macrophage inflammation were largely unchanged in colon and mesenteric adipose tissues. Cecal gut microbiota composition showed greater abundance of Acetatifactor genus in mice fed milk SM, but minimal changes in other taxa. Milk SM significantly attenuated the effect of LPS on pro-inflammatory gene expression in RAW264.7 macrophages. Milk SM lost its effects when hydrolysis was blocked, while long-chain ceramides and sphingosine, but not dihydroceramides, were anti-inflammatory. Our data suggest that dietary milk SM may be effective in reducing systemic inflammation through inhibition of LPS activity and that hydrolytic products of milk SM are important for these effects.

Skeletal muscle (SKM) atrophy is a potentially debilitating condition induced by muscle disuse, denervation, many disease states, and aging. The ubiquitin proteasome pathway (UPP) contributes greatly to the protein loss suffered in muscle atrophy. The MERG1a K+ channel is known to induce UPP activity and atrophy in SKM. It has been further demonstrated that the mouse ether-a-gogo-related gene (Merg)1a channel modulates expression of MURF1, an E3 ligase component of the UPP, while it does not affect expression of the UPP E3 ligase Mafbx/ATROGIN1. Because the UBR2 E3 ligase is known to participate in SKM atrophy, we have investigated the effect of Merg1a expression and hind limb suspension on Ubr2 expression. Here, we report that hind limb suspension results in a significant 25.6% decrease in mouse gastrocnemius muscle fiber cross sectional area (CSA) and that electro-transfer of Merg1a alone into gastrocnemius muscles yields a 15.3% decrease in CSA after 7 days. More interestingly, we discovered that hind limb suspension caused a significant 8-fold increase in Merg1a expression and a significant 4.7-fold increase in Ubr2 transcript after 4 days, while electro-transfer of Merg1a into gastrocnemius muscles resulted in a significant 6.2-fold increase in Merg1a transcript after 4 days but had no effect on Ubr2 expression. In summary, the MERG1a K+ channel, known to induce atrophy and MURF1 E3 ligase expression, does not affect UBR2 E3 ligase transcript levels. Therefore, to date, the MERG1a channel’s contribution to UPP activity appears mainly to be through up-regulation of Murf1 gene expression.

The last decade has witnessed enormous growth in the spectrum of highly efficient asymmetric synthetic transformations. One prominent example of this progress is the application of dirhodium (II) carbenes generated from diazo- precursors. Innovative construction of ‘designer’ catalysts has played a integral role in extending the breadth of the synthetic cascade of non-racemic products now available through the range of cyclopropanation, C-X insertion, aromatic cycloaddition-rearrangement, and ylide-based reaction types. This review deals briefly with an overview of the important catalytic systems and maintains as its primary focus the cascade of diverse optically enriched products that flow from their applications.

The first reported acyl and sulfonylisocyanates were developed and tested in reactions with chiral alcohols to afford diastereomeric carbamates. NMR analysis of these investigates the chemical shift discrimination that would allow these activated isocyanates to be used as diagnostic probes of enantiomeric purity.

Conserving bird populations is a key goal for management of the Sacramento–San Joaquin Delta ecosystem and is likely to have effects well beyond its boundaries. To inform bird- conservation strategies, we identified Priority Bird Conservation Areas for riparian landbirds and waterbirds in the Delta, defined as the most valuable 5% of the landscape for each group. We synthesized data from 2,547 surveys for riparian landbirds and 7,820 surveys for waterbirds to develop predictive distribution models, which then informed spatial prioritization analyses. We identified a total of 26,019 ha that are a high priority for conserving riparian landbirds, waterbirds, or both, representing the most important places in the Delta to protect and manage, as well as strategic areas where adjacent restoration could expand valuable habitat. These Priority Bird Conservation Areas include the Yolo Bypass Wildlife Area, Cosumnes River Preserve, Stone Lakes National Wildlife Refuge, and bufferlands that surround the Sacramento County Regional Sanitation District. However, we also found that over 60% of the Priority Bird Conservation Areas are not currently protected, indicating a vulnerability to changes in land cover or land use. We recommend advancing strategies for bird conservation in the Delta by developing more specific objectives and priorities, extending these analyses to include other bird species, and planning to mitigate the loss of Priority Bird Conservation Areas where they are most vulnerable to land cover change. The predictive models and analysis framework we developed represent the current state of the science on areas important to bird conservation, while also providing a foundation for an evolving bird-conservation strategy that reflects the Delta’s continuously evolving knowledge base and landscape.

Large-scale ecosystem restoration projects seldom undergo comprehensive evaluation to determine project effectiveness. Consequently, there are missed opportunities for learning and strategy refinement. Before our study, monitoring information from California’s middle Sacramento River had not been synthesized, despite restoration having been ongoing since 1989. Our assessment was based on the development and application of 36 quantitative ecological indicators. These indicators were used to characterize the status of terrestrial and floodplain resources (e.g., flora and fauna), channel dynamics (e.g., planform, geomorphology), and the flow regime. Indicators were also associated with specific goal statements of the CALFED Ecosystem Restoration Program. A collective weight of evidence approach was used to assess restoration success. Our synthesis demonstrates good progress in the restoration of riparian habitats, birds and other wildlife, but not in restoration of streamflows and geomorphic processes. For example, from 1999 to 2007, there was a > 600% increase in forest patch core size, and a 43% increase in the area of the river bordered by natural habitat > 500 m wide. Species richness of landbirds and beetles increased at restoration sites, as did detections of bats. However, degraded post-Shasta Dam streamflow conditions continued. Relative to pre-dam conditions, the average number of years that pass between flows that are sufficient to mobilize the bed, and those that are of sufficient magnitude to inundate the floodplain, increased by over 100%. Trends in geomorphic processes were strongly negative, with increases in the amount of bank hardened with riprap, and decreases in the area of floodplain reworked. Overall the channel simplified, becoming less sinuous with reduced overall channel length. Our progress assessment presents a compelling case for what needs to be done to further advance the ecological restoration of the river. The most important actions to be taken relate to promoting river meander and floodplain connectivity, and restoring components of the natural flow regime.

Diabetic nephropathy is the leading cause of end-stage kidney disease worldwide but current treatments remain suboptimal. This review examines the evidence for inflammation in the development and progression of diabetic nephropathy in both experimental and human diabetes, and provides an update on recent novel experimental approaches targeting inflammation and the lessons we have learned from these approaches. We highlight the important role of inflammatory cells in the kidney, particularly infiltrating macrophages, T-lymphocytes and the subpopulation of regulatory T cells. The possible link between immune deposition and diabetic nephropathy is explored, along with the recently described immune complexes of anti-oxidized low-density lipoproteins. We also briefly discuss some of the major inflammatory cytokines involved in the pathogenesis of diabetic nephropathy, including the role of adipokines. Lastly, we present the latest data on the pathogenic role of the stress-activated protein kinases in diabetic nephropathy, from studies on the p38 mitogen activated protein kinase and the c-Jun amino terminal kinase cell signalling pathways. The genetic and pharmacological approaches which reduce inflammation in diabetic nephropathy have not only enhanced our understanding of the pathophysiology of the disease but shown promise as potential therapeutic strategies.

IntroductionThe American Association of Psychiatric Pharmacists (AAPP) used multiple modalities to develop and refine 28 attribute statements to describe a best practice model for outpatient psychiatric pharmacists. Before addressing implementation, assessment, and field testing, it was necessary to finalize and confirm the statements and their supporting narratives among stakeholders. The objective of this project was to confirm the attribute statements and supporting justifications for a best practice model for outpatient psychiatric pharmacists providing direct patient care.MethodsThe 4 phases that resulted in the 28 attribute statements and supporting narratives have been described and published elsewhere. As part of phase 5, the confirmation survey was distributed to pharmacists and resident members of AAPP in November 2021 for 3 weeks.ResultsThe survey respondents (n = 74; 6.1%) were licensed pharmacists for an average of 15.6 years (SD = 12.0) and had been practicing as psychiatric pharmacists for an average of 11.3 years (SD = 10.4). Slightly more than half (54.2%) of the respondents reported practicing in the outpatient setting and three-fourths (74.3%) were Board Certified Psychiatric Pharmacists. For each of the 28 statements, more than 90% of respondents either agreed or agreed with minimal reservations.DiscussionGiven the high degree of agreement on the proposed practice model statements, they will be used as the basis for the outpatient psychiatric pharmacist best practice model. Next steps in developing this model include establishing implementation guidance, determining appropriate metrics for evaluation of these statements in practice, and establishing appropriate field-testing methods.

IntroductionA 2019 survey identified significant variability of practice characteristics among outpatient psychiatric pharmacists (OPPs). No published model establishes which attributes constitute best practice for OPPs. By developing a consensus for best practice model attributes, OPPs can work toward consistent, effective patient care. This project aimed to develop attribute statements for a best practice model for OPPs providing direct patient care.MethodsBoard Certified Psychiatric Pharmacists and American Association of Psychiatric Pharmacists (AAPP) members were questioned using a 5-phase (P1-P5) survey and summit approach. The phases were: P1, broad ideation survey; P2, 10-person summit to develop draft statements; P3, survey of the draft statements for acceptance; P4, summit to resolve review feedback; and P5, survey of AAPP membership to confirm the finalized statements.ResultsP1 survey results generated a list of 143 possible attributes that informed the P2 summit, which were refined to 28 statements. P3 survey results confirmed at least 70% agreement with each statement. The P4 summit evaluated all P3 survey results and made significant modifications to 4 statements. Informal feedback was sought with other stakeholders, and supporting narratives and references were developed to provide clarity regarding the intent of each statement. Finalized statements and supporting narratives were confirmed in the P5 survey.DiscussionThe 28 attribute statements were developed over 18 months by gathering input and consensus through multiple modalities, including 3 surveys, 2 summit meetings, and numerous informal feedback requests. The agreement on the attribute statements was consistently high across all phases. The final attribute statements are presented elsewhere in this issue.