Shifting Sands and Shifting Strategies: Advocacy Coalitions, Bonner Bridge, and the Future of NC 12 on North Carolina's Outer Banks

Coastal management decisions are complicated. They involve an array of competing concerns, including environmental, social, economic, recreational, and property interests, and are inherently political. These decisions become even more difficult when interested groups use their political and economic leverage to influence the policy debate. The Bonner Bridge replacement project on North Carolina's Outer Banks is an example of how this blend of politics, science, and competing interests can result in extraordinary complexity. This research project uses a qualitative case study of the Bonner Bridge replacement to explore how a bridge project became more about priorities and values than science and technical feasibility and how interested parties, acting through informal coalitions, strategically worked to shape the policy debate. In the process, we see how the replacement of a single aging bridge required 25 years of planning, four environmental impact statements, an environmental assessment, federal and state lawsuits, and a negotiated settlement before a single piling was put into place. Drawing on the policy process literature, this project applies aspects of the Advocacy Coalition and Narrative Policy Frameworks to a qualitative content analysis of the bridge project over a 25 year period (1990-2015). The analysis tracks the emergence and evolution of two distinct coalitions and compares their use of general and narrative strategies to influence the bridge debate. The project addresses an under-explored area in the Advocacy Coalition Framework literature by focusing on how coalitions act strategically to exploit an internal shock within the policy subsystem and contributes to the literature by exploring the intersection of the two frameworks. The research design addresses three different questions: (1) did the bridge project function as an internal shock; (2) how did the coalitions use narratives and strategies to exploit this shock; and (3) what roles did science and politics play in these narratives and strategies? The context for the case study, including the science of barrier island and inlet migration, the history, economy, and demographics of Hatteras Island, NC, and regulatory and legal considerations, is explored through a detailed case background and chronology. This chronology is used to designate five policy periods within the case study. The source materials are publicly available narratives and comments produced by coalition members and compiled from newspaper accounts, websites, guest newspaper commentaries, letters to the editors, and comments submitted on the various environmental impact statements. These comments were coded, both by hand and using NVivo software, to identify and track the coalitions' key issues and both general and narrative strategies. These strategies and issues are compared between coalitions and tracked over time using the policy phases and case chronology. The analysis shows that the bridge project upset the status quo in the policy subsystem and triggered the emergence of two coalitions. These coalitions took distinctly different views on which issues were most important in the bridge decision and used different general strategies in the debate. Both sides altered their strategies and issues in response to each other and changing circumstances. The coalitions' narrative strategies indicated that they both perceived themselves as "losing" the debate. Finally, the analysis showed that the coalitions focused more on politics than scientific issues in their narratives. These results suggest directions for future research, including refinement of the idea of policy internal shocks (and related concepts), seconding calls for a hierarchy of coalition resources, and the need to develop a more fluid and dynamic understanding of "winning" and "losing" coalitions. While lessons from a single case study are not directly generalizable to other contexts, this project helps to refine aspects of two policy process frameworks. The case also offers insights into the interplay of science and politics and serves as a lesson in how individuals, both within and outside of government, influenced decisions in a high-stakes, high-visibility coastal infrastructure project

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Shifting Sands and Shifting Strategies: Advocacy Coalitions , Bonner Bridge , and the Future of NC 12 on North Carolina's Outer Banks

"Coastal management decisions are complicated. They involve an array of competing concerns , including environmental , social , economic , recreational , and property interests , and are inherently political. These decisions become even more difficult when interested groups use their political and economic leverage to influence the policy debate. The Bonner Bridge replacement project on North Carolina's Outer Banks is an example of how this blend of politics , science , and competing interests can result in extraordinary complexity. This research project uses a qualitative case study of the Bonner Bridge replacement to explore how a bridge project became more about priorities and values than science and technical feasibility and how interested parties , acting through informal coalitions , strategically worked to shape the policy debate. In the process , we see how the replacement of a single aging bridge required 25 years of planning , four environmental impact statements , an environmental assessment , federal and state lawsuits , and a negotiated settlement before a single piling was put into place. Drawing on the policy process literature , this project applies aspects of the Advocacy Coalition and Narrative Policy Frameworks to a qualitative content analysis of the bridge project over a 25 year period (1990-2015). The analysis tracks the emergence and evolution of two distinct coalitions and compares their use of general and narrative strategies to influence the bridge debate. The project addresses an under-explored area in the Advocacy Coalition Framework literature by focusing on how coalitions act strategically to exploit an internal shock within the policy subsystem and contributes to the literature by exploring the intersection of the two frameworks. The research design addresses three different questions: (1) did the bridge project function as an internal shock; (2) how did the coalitions use narratives and strategies to exploit this shock; and (3) what roles did science and politics play in these narratives and strategies? The context for the case study , including the science of barrier island and inlet migration , the history , economy , and demographics of Hatteras Island , NC , and regulatory and legal considerations , is explored through a detailed case background and chronology. This chronology is used to designate five policy periods within the case study. The source materials are publicly available narratives and comments produced by coalition members and compiled from newspaper accounts , websites , guest newspaper commentaries , letters to the editors , and comments submitted on the various environmental impact statements. These comments were coded , both by hand and using NVivo software , to identify and track the coalitions' key issues and both general and narrative strategies. These strategies and issues are compared between coalitions and tracked over time using the policy phases and case chronology. The analysis shows that the bridge project upset the status quo in the policy subsystem and triggered the emergence of two coalitions. These coalitions took distinctly different views on which issues were most important in the bridge decision and used different general strategies in the debate. Both sides altered their strategies and issues in response to each other and changing circumstances. The coalitions' narrative strategies indicated that they both perceived themselves as ""losing"" the debate. Finally , the analysis showed that the coalitions focused more on politics than scientific issues in their narratives. These results suggest directions for future research , including refinement of the idea of policy internal shocks (and related concepts) , seconding calls for a hierarchy of coalition resources , and the need to develop a more fluid and dynamic understanding of ""winning"" and ""losing"" coalitions. While lessons from a single case study are not directly generalizable to other contexts , this project helps to refine aspects of two policy process frameworks. The case also offers insights into the interplay of science and politics and serves as a lesson in how individuals , both within and outside of government , influenced decisions in a high-stakes , high-visibility coastal infrastructure project.

Shifting Sands and Shifting Strategies: Advocacy Coalitions, Bonner Bridge, and the Future of NC 12 on North Carolina's Outer Banks

Coastal management decisions are complicated. They involve an array of competing concerns, including environmental, social, economic, recreational, and property interests, and are inherently political. These decisions become even more difficult when interested groups use their political and economic leverage to influence the policy debate. The Bonner Bridge replacement project on North Carolina's Outer Banks is an example of how this blend of politics, science, and competing interests can result in extraordinary complexity. This research project uses a qualitative case study of the Bonner Bridge replacement to explore how a bridge project became more about priorities and values than science and technical feasibility and how interested parties, acting through informal coalitions, strategically worked to shape the policy debate. In the process, we see how the replacement of a single aging bridge required 25 years of planning, four environmental impact statements, an environmental assessment, federal and state lawsuits, and a negotiated settlement before a single piling was put into place. Drawing on the policy process literature, this project applies aspects of the Advocacy Coalition and Narrative Policy Frameworks to a qualitative content analysis of the bridge project over a 25 year period (1990-2015). The analysis tracks the emergence and evolution of two distinct coalitions and compares their use of general and narrative strategies to influence the bridge debate. The project addresses an under-explored area in the Advocacy Coalition Framework literature by focusing on how coalitions act strategically to exploit an internal shock within the policy subsystem and contributes to the literature by exploring the intersection of the two frameworks. The research design addresses three different questions: (1) did the bridge project function as an internal shock\; (2) how did the coalitions use narratives and strategies to exploit this shock\; and (3) what roles did science and politics play in these narratives and strategies? The context for the case study, including the science of barrier island and inlet migration, the history, economy, and demographics of Hatteras Island, NC, and regulatory and legal considerations, is explored through a detailed case background and chronology. This chronology is used to designate five policy periods within the case study. The source materials are publicly available narratives and comments produced by coalition members and compiled from newspaper accounts, websites, guest newspaper commentaries, letters to the editors, and comments submitted on the various environmental impact statements. These comments were coded, both by hand and using NVivo software, to identify and track the coalitions' key issues and both general and narrative strategies. These strategies and issues are compared between coalitions and tracked over time using the policy phases and case chronology. The analysis shows that the bridge project upset the status quo in the policy subsystem and triggered the emergence of two coalitions. These coalitions took distinctly different views on which issues were most important in the bridge decision and used different general strategies in the debate. Both sides altered their strategies and issues in response to each other and changing circumstances. The coalitions' narrative strategies indicated that they both perceived themselves as "losing" the debate. Finally, the analysis showed that the coalitions focused more on politics than scientific issues in their narratives. These results suggest directions for future research, including refinement of the idea of policy internal shocks (and related concepts), seconding calls for a hierarchy of coalition resources, and the need to develop a more fluid and dynamic understanding of "winning" and "losing" coalitions. While lessons from a single case study are not directly generalizable to other contexts, this project helps to refine aspects of two policy process frameworks. The case also offers insights into the interplay of science and politics and serves as a lesson in how individuals, both within and outside of government, influenced decisions in a high-stakes, high-visibility coastal infrastructure project

A Pilot Study of the Effects of Mindfulness-Based Cognitive Therapy on Positive Affect and Social Anxiety Symptoms

Randomized controlled trials have demonstrated that mindfulness-based cognitive therapy (MBCT) is efficacious in reducing residual depressive symptoms and preventing future depressive episodes (Kuyken et al., 2016). One potential treatment effect of MBCT may be improvement of positive affect (PA), due to improved awareness of daily positive events (Geschwind et al., 2011). Considering social anxiety disorder (SAD) is characterized by diminished PA (Brown et al., 1998; Kashdan, 2007), we sought to determine whether MBCT would reduce social anxiety symptoms, and whether this reduction would be associated with improvement of PA deficits. Adults (N = 22) who met criteria for varied anxiety disorders participated in a small, open-label trial of an 8-week manualized MBCT intervention. Most participants presented with either a diagnosis (primary, secondary, or tertiary) of generalized anxiety disorder (GAD) (N = 15) and/or SAD (N = 14) prior to treatment, with eight individuals meeting diagnostic criteria for both GAD and SAD. We hypothesized participants would demonstrate improvements in social anxiety symptoms, which would be predicted by improvements in PA, not reductions in negative affect (NA). Results of several hierarchical linear regression analyses (completed in both full and disorder-specific samples) indicated that improvements in PA but not reductions in NA predicted social anxiety improvement. This effect was not observed for symptoms of worry, which were instead predicted by decreased NA for individuals diagnosed with GAD and both decreased NA and increased PA in the entire sample. Results suggest that MBCT may be efficacious in mitigating social anxiety symptoms, and this therapeutic effect may be linked to improvements in PA. However, further work is necessary considering the small, heterogeneous sample, uncontrolled study design, and exploratory nature of the study

Comparing oxytocin and cortisol regulation in a double-blind, placebo-controlled, hydrocortisone challenge pilot study in children with autism and typical development.

BackgroundChildren with autism spectrum disorder (ASD) show marked impairment in social functioning and poor adaptation to new and changing contexts, which may be influenced by underlying regulatory processes. Oxytocin (OT) and cortisol are key neuromodulators of biological and behavioral responses, show a synergistic effect, and have been implicated in the neuropathological profile in ASD. However, they are rarely investigated together. The purpose of the pilot study was to evaluate the relationship between cortisol and OT in children with ASD under baseline and physiological stress (hydrocortisone challenge) conditions. Arginine vasopressin (AVP), structurally similar to OT, was also examined.MethodsA double-blind, placebo-controlled, randomly assigned, crossover design was employed in 25 children 8-to-12 years with ASD (N = 14) or typical development (TD, N = 11). A low dose of hydrocortisone and placebo were administered via liquid suspension. Analysis of variance (ANOVA) was used to examine the within-subject factor "Condition" (hydrocortisone/placebo) and "Time" (pre and post) and the between-subject factor "Group" (ASD vs. TD). Pearson correlations examined the relationship between hormone levels and clinical profile.ResultsThere was a significant Time × Condition × Group interaction F (1.23) = 4.18, p = 0.05 showing a rise in OT during the experimental condition (hydrocortisone) and a drop during the placebo condition for the TD group but not the ASD group. There were no group differences for AVP. Hormone levels were associated with social profiles.ConclusionsFor the TD group, an inverse relationship was observed. OT increased during physiological challenge suggesting that OT played a stress-buffering role during cortisol administration. In contrast for the ASD group, OT remained unchanged or decreased during both the physiological challenge and the placebo condition, suggesting that OT failed to serve as a stress buffer under conditions of physiological stress. While OT has been tied to the social ability of children with ASD, the diminished moderating effect of OT on cortisol may also play a contributory role in the heightened stress often observed in children with ASD. These results contribute to our understanding of the growing complexity of the effects of OT on social behavior as well as the functional interplay and differential regulation OT may have on stress modulation

Comparing oxytocin and cortisol regulation in a double-blind, placebo-controlled, hydrocortisone challenge pilot study in children with autism and typical development.

BackgroundChildren with autism spectrum disorder (ASD) show marked impairment in social functioning and poor adaptation to new and changing contexts, which may be influenced by underlying regulatory processes. Oxytocin (OT) and cortisol are key neuromodulators of biological and behavioral responses, show a synergistic effect, and have been implicated in the neuropathological profile in ASD. However, they are rarely investigated together. The purpose of the pilot study was to evaluate the relationship between cortisol and OT in children with ASD under baseline and physiological stress (hydrocortisone challenge) conditions. Arginine vasopressin (AVP), structurally similar to OT, was also examined.MethodsA double-blind, placebo-controlled, randomly assigned, crossover design was employed in 25 children 8-to-12 years with ASD (N = 14) or typical development (TD, N = 11). A low dose of hydrocortisone and placebo were administered via liquid suspension. Analysis of variance (ANOVA) was used to examine the within-subject factor "Condition" (hydrocortisone/placebo) and "Time" (pre and post) and the between-subject factor "Group" (ASD vs. TD). Pearson correlations examined the relationship between hormone levels and clinical profile.ResultsThere was a significant Time × Condition × Group interaction F (1.23) = 4.18, p = 0.05 showing a rise in OT during the experimental condition (hydrocortisone) and a drop during the placebo condition for the TD group but not the ASD group. There were no group differences for AVP. Hormone levels were associated with social profiles.ConclusionsFor the TD group, an inverse relationship was observed. OT increased during physiological challenge suggesting that OT played a stress-buffering role during cortisol administration. In contrast for the ASD group, OT remained unchanged or decreased during both the physiological challenge and the placebo condition, suggesting that OT failed to serve as a stress buffer under conditions of physiological stress. While OT has been tied to the social ability of children with ASD, the diminished moderating effect of OT on cortisol may also play a contributory role in the heightened stress often observed in children with ASD. These results contribute to our understanding of the growing complexity of the effects of OT on social behavior as well as the functional interplay and differential regulation OT may have on stress modulation