A coupled human–natural system analysis of freshwater security under climate and population change

Limited water availability, population growth, and climate change have resulted in freshwater crises in many countries. Jordan's situation is emblematic, compounded by conflict-induced population shocks. Integrating knowledge across hydrology, climatology, agriculture, political science, geography, and economics, we present the Jordan Water Model, a nationwide coupled human-natural-engineered systems model that is used to evaluate Jordan's freshwater security under climate and socioeconomic changes. The complex systems model simulates the trajectory of Jordan's water system, representing dynamic interactions between a hierarchy of actors and the natural and engineered water environment. A multiagent modeling approach enables the quantification of impacts at the level of thousands of representative agents across sectors, allowing for the evaluation of both systemwide and distributional outcomes translated into a suite of water-security metrics (vulnerability, equity, shortage duration, and economic well-being). Model results indicate severe, potentially destabilizing, declines in freshwater security. Per capita water availability decreases by approximately 50% by the end of the century. Without intervening measures, >90% of the low-income household population experiences critical insecurity by the end of the century, receiving <40 L per capita per day. Widening disparity in freshwater use, lengthening shortage durations, and declining economic welfare are prevalent across narratives. To gain a foothold on its freshwater future, Jordan must enact a sweeping portfolio of ambitious interventions that include large-scale desalinization and comprehensive water sector reform, with model results revealing exponential improvements in water security through the coordination of supply- and demand-side measures

1998 Proceedings. Ohio Grape-Wine Short Course

The dollars and sense of starting a small winery / Chris Stamp -- You have the key, now where is the lock? You have the answer, now what was the question? / David Whiting -- Winery design and equipment / Domenic Carisetti -- Use of oak chips in winemaking / Bill Butler -- Matching wine style with your market / Edward Boas -- Open house--riesling reception / Roland Riesen -- 1997 vineyard survey / The Ohio Grape Team -- Economics of Midwestern grape production / Bruce Bordelon -- The economics of grape growing in Ohio / Gene Sigel -- The importance of reserves for rapid initial development of grapevines, shoots and berry set / Steven McArtney and Dave Ferree -- Influence of gibberellin sprays and leaf removal on vignoles / Dave Ferree, Steven McArtney and Mike Ellis -- Controlling color deterioration in blush wines / Jim Gallander, Roland Riesen and Todd Steiner -- Understanding and controlling powdery mildew and phomopsis cane and leaf spot of grape / Mike Ellis -- Managing late harvest and ice wines in the vineyard and winery / Ron Giesbrecht -- Ice wine production at Valley Vineyards / Greg Pollman -- The production of affordable ice wine / Chris Stamp -- A simple guide to sparkling wine production / Claudio Salvador -- Vineyard establishment in Wayne County Ohio / Andy Troutman -- New ideas in vineyard drainage / Gene Sigel -- Trellis and training systems for Midwest cultivars / Bruce Bordelon -- Soil and plant analyses / Maurus Brown -- Monitoring and control of grape pests in Ohio vineyards with insect attractants / Roger Williams, Dan Fickle, Chris Gertz -- Developing focus for vegetation management extension and research in vineyards / Douglas Doohan -- Grape cultivar selections for Ohio / Dave Ferree and Roland Riesen -- Ferrante Winery's need for grapes / Nick Ferrante -- Principles of wine stabilization / J. F. Gallander -- Working with a distributor / Jane Butler -- Vintners quality alliance; Ontario's success story / Angelo Pava

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used