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In the Sacramento–San Joaquin Delta (Delta), widespread drainage of historical wetlands has led to extensive subsidence and peat carbon losses, as well as high ongoing greenhouse gas (GHG) emissions. Large-scale wetland restoration and conversion to rice fields has the potential to mitigate these effects while conferring flood protection and creating habitat for wetland species. To explore the scale of these potential benefits, this study evaluated the effects of seven Delta-wide land-use scenarios on carbon stocks, land-surface elevation, GHG emissions, and habitat. Peat mapping and data from peat cores indicate that soil carbon stocks have decreased between the early 1800s and 2010s from 288 ± 15 to 145 ± 14 million metric tons (Mt) of carbon (C). If existing land uses continue, the Delta could lose an additional 8.3 Mt C during the coming 40 years, equal to average GHG emissions of 1.2 Mt CO2 equivalents (CO2e) yr-1. Future restoration and rice-farming scenarios indicate that wetland restoration could theoretically halt GHG emissions, converting the Delta from a large GHG source to a weak net source or sink. Across three future scenarios based on existing restoration targets, wetland creation and conversion to rice fields reduced GHG emissions by 0.39 to 0.67 Mt CO2e yr-1, with per-area benefits of 16 to 28 t CO2e per hectare (ha) yr-1. Differences among scenarios in extents of wetland types influenced their relative benefits for different management goals. Tidal restoration and conversion to rice fields enhanced habitat benefits and offered a source of agricultural income, but with reduced GHG mitigation compared with conversion to peat-building wetlands. This highlights the importance of clear objectives when developing land-use plans. A strategic land-management portfolio that includes rice fields and both impounded and tidal wetlands could be designed to provide GHG and subsidence mitigation while offering a diverse suite of benefits for ecosystems and people.

More than 80% of adult manual wheelchair users with spinal cord injuries will experience shoulder pain. Females and those with decreased shoulder dynamics variability are more likely to experience pain in adulthood. Sex-related differences in shoulder dynamics variability during pediatric manual wheelchair propulsion may influence the lifetime risk of pain. We evaluated the influence of sex on 3-dimensional shoulder complex joint dynamics variability in 25 (12 females and 13 males) pediatric manual wheelchair users with spinal cord injury. Within-subject variability was quantified using the coefficient of variation. Permutation tests evaluated sex-related differences in variability using an adjusted critical alpha of P =.001. No sex-related differences in sternoclavicular or acromioclavicular joint kinematics or glenohumeral joint dynamics variability were observed (all P ≥.042). Variability in motion, forces, and moments are considered important components of healthy joint function, as reduced variability may increase the likelihood of repetitive strain injury and pain. While further work is needed to generalize our results to other manual wheelchair user populations across the life span, our findings suggest that sex does not influence joint dynamics variability in pediatric manual wheelchair users with spinal cord injury. [ABSTRACT FROM AUTHOR]

BackgroundThe appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy.MethodsUsing an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis.ResultsA total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]).ConclusionsIn this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Higher education scholars often investigate the policy mechanisms of external accountability, but rarely explore institutional mechanisms of internal accountability. This chapter, which reports select findings from an in-depth case study of institutional budgeting at an American public research university, examines an underexplored mechanism of internal accountability -- annual budget reviews. The findings illustrate that the university's budget review often constitutes a fantasy practice that affirms the institution's commitment to fiscal prudence as much as scrutinizes budgetary decisions in academic units. The findings reveal opportunities to strengthen budget reviews at institutions that have adopted decentralized budget models such as Responsibility Center Budgeting.

Transition from pediatric to adult health care systems presents unique challenges for adolescents with autism spectrum disorder who often have complex medical and mental health needs. Without a coordinated transition plan, pediatric providers often continue to provide care to young adults with autism spectrum disorder beyond the scope of their medical training. Adult providers may be unwilling and untrained to accept care for young adults with autism spectrum disorder. This quality improvement study identified baseline transition-related practices within a pediatric medical home practice and developed a model to promote transition to adult heath care for patients with autism spectrum disorder. Participants were 251 patients with autism spectrum disorder aged 12-21 years. Baseline data revealed limited and inconsistent communication directed to patients and families regarding transition. An evidence-based and replicable transition checklist, templated documentation, and resources geared to patients aged 12-21 years were developed. While improvement was noted in number of visits addressing transition, medical providers skipped or deferred transition discussion in approximately half of well visits for targeted patients. Challenges in implementing the transition process included finding time to discuss transition-related issues with patients/families, preference of medical providers to defer to social work to address transition, and difficulty identifying adult providers with whom to collaborate regarding care needs.

Background: This study aimed to identify the potential roles for Community Health Navigators (CHNs) in addressing problems faced by patients on discharge from hospital to the community, and attitudes and factors which may influence their adoption. Methods: Twenty-six qualitative interviews and an online codesign workshop were conducted with patients, nurses, general practice staff, health service managers, community health workers, general practitioners, medical specialists, and pharmacists in the Sydney Local Health District. Qualitative themes from the interviews and workshop transcripts were analysed inductively and subsequently grouped according to a socio-ecological model. Results: CHNs could assist patients to navigate non-clinical problems experienced by patients on discharge through assessing needs, establishing trust, providing social and emotional support that is culturally and linguistically appropriate, engaging family and carers, supporting medication adherence, and helping to arrange and attend follow up health and other appointments. Important factors for the success of the CHNs in the performance and sustainability of their roles were the need to establish effective communication and trust with other healthcare team members, be accepted by patients, have access to information about referral and support services, receive formal recognition of their training and experience, and be supported by appropriate supervision. Conclusions: This study was unique in exploring the potential role of CHNs in addressing problems faced by patients on discharge from Australian hospitals and the factors influencing their adoption. It informed training and supervision needs and further research to evaluate CHNs' effectiveness and the acceptance of their role within the healthcare team. Community health workers have been demonstrated in overseas research to play a key role in supporting patients to prevent hospital readmission. This role is now emerging in Australia especially for vulnerable and disadvantaged groups. This study identifies the key potential roles in the Australian context and the training and supervision required. [ABSTRACT FROM AUTHOR]

Background Primary care clinicians have key responsibilities in obesity prevention and weight management. Aims We aimed to identify risk factors for developing obesity among people aged ≥45 years. Methods We conducted a record linkage longitudinal study of residents of metropolitan Sydney, Australia using data from the: (1) 45 and Up Study at baseline (2005–2009) and first follow-up (2012–2015); (2) Medicare claims; (3) Pharmaceutical Benefits Scheme; and (4) deaths registry. We examined risk factors for developing obesity (body mass index [BMI]: 30–40) at follow-up, separately for people within the: (1) healthy weight range (BMI 18.5–<25) and (2) overweight range (BMI 25–<30) at baseline. Covariates included demographics, modifiable behaviours, health status, allied health use, and medication use. Crude and adjusted relative risks were estimated using Poisson regression modelling. Results At follow-up, 1.1% (180/16,205) of those in the healthy weight range group, and 12.7% (1,939/15,266) of those in the overweight range group developed obesity. In both groups, the following were associated with developing obesity: current smoking at baseline, physical functioning limitations, and allied health service use through team care planning, while any alcohol consumption and adequate physical activity were found to be associated with a lower risk of developing obesity. In the healthy weight group, high psychological distress and the use of antiepileptics were associated with developing obesity. In the overweight group, female sex and full-time work were associated with developing obesity, while older age was found to be associated with a lower risk of developing obesity. Conclusions These findings may inform the targeting of preventive interventions for obesity in clinical practice and broader public health programs. [ABSTRACT FROM AUTHOR]

This chapter examines an underexplored way in which deans enact their authority in Responsibility Center Budgeting (RCB)--mobilizing the expertise of administrators in their colleges to establish academic and budgetary priorities. The findings underscore the benefits of deans harnessing the expertise of their senior administrative teams to make sense of complex issues and problems.

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.