War came to the Iowa community

On April 6, 1917, the United States of America declared war. Throughout the country communities marshalled forces to meet the situation. Today the United States is engaged in another war, which is creating problems of social and economic war planning on dimensions greater than those of the war in 1917-18. As the defense effort expands each community will face a notable increase in organized group activities, in new integrating organizations, heightened enthusiasm expressed in rallies and campaigns, new regulations of private lives. Everyone today recognizes that war involves readjustments in our society. Economic and political adjustments are obviously serious. Equally drastic are the necessary modifications in family life, in churches, in recreation, in education, in the innumerable activities which in peacetime follow so normal a routine that we accept them as a matter of course. These problems are no less vital to the welfare of our people than the effects of war upon land values and prices of farm products. The preservation of a democratic way of life depends upon the actions and attitude of all members of the nation in their local communities. The successful adjustment of individuals to these changes, and the organization of our energies for effective prosecution of the war require an understanding of the problems which will be involved

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial

Context Goal-directed resuscitation for severe sepsis and septic shock has been reported to reduce mortality when applied in the emergency department. Objective To test the hypothesis of noninferiority between lactate clearance and central venous oxygen saturation (ScvO2) as goals of early sepsis resuscitation. Design, Setting, and Patients Multicenter randomized, noninferiority trial involving patients with severe sepsis and evidence of hypoperfusion or septic shock who were admitted to the emergency department from January 2007 to January 2009 at 1 of 3 participating US urban hospitals. Interventions We randomly assigned patients to 1 of 2 resuscitation protocols. The ScvO2 group was resuscitated to normalize central venous pressure, mean arterial pressure, and ScvO2 of at least 70%; and the lactate clearance group was resuscitated to normalize central venous pressure, mean arterial pressure, and lactate clearance of at least 10%. The study protocol was continued until all goals were achieved or for up to 6 hours. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. Main Outcome Measure The primary outcome was absolute in-hospital mortality rate; the noninferiority threshold was set at Δ equal to −10%. Results Of the 300 patients enrolled, 150 were assigned to each group and patients were well matched by demographic, comorbidities, and physiological features. There were no differences in treatments administered during the initial 72 hours of hospitalization. Thirty-four patients (23%) in the ScvO2 group died while in the hospital (95% confidence interval [CI], 17%-30%) compared with 25 (17%; 95% CI, 11%-24%) in the lactate clearance group. This observed difference between mortality rates did not reach the predefined −10% threshold (intent-to-treat analysis: 95% CI for the 6% difference, −3% to 15%). There were no differences in treatment-related adverse events between the groups. Conclusion Among patients with septic shock who were treated to normalize central venous and mean arterial pressure, additional management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality

Maximum likelihood estimation of influenza vaccine effectiveness against transmission from the household and from the community

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142449/1/sim7558_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142449/2/sim7558.pd

Prognostic Value and Agreement of Achieving Lactate Clearance or Central Venous Oxygen Saturation Goals During Early Sepsis Resuscitation

Objectives:  Lactate clearance (LC) and central venous oxygen saturation (ScvO2) have been proposed as goals of early sepsis resuscitation. The authors sought to determine the agreement and prognostic value of achieving ScvO2 or LC goals in septic shock patients undergoing emergency department (ED)-based early resuscitation. Methods:  This was a preplanned analysis of a multicenter ED randomized controlled trial of early sepsis resuscitation targeting three variables: central venous pressure, mean arterial pressure, and either ScvO2 or LC. Inclusion criteria included suspected infection, two or more systemic inflammation criteria, and either systolic blood pressure of 4 mmol/L. Both ScvO2 and LC were measured simultaneously. The ScvO2 goal was defined as ≥70%. Lactate was measured at enrollment and every 2 hours until the goal was reached or up to 6 hours. LC goal was defined as a decrease of ≥10% from initial measurement. The primary outcome was in-hospital mortality. Results:  A total of 203 subjects were included, with an overall mortality of 19.7%. Achievement of the ScvO2 goal only was associated with a mortality rate of 41% (9/22), while achievement of the LC goal only was associated with a mortality rate of 8% (2/25; proportion difference = 33%; 95% confidence interval [CI] = 9% to 55%). No agreement was found between goal achievement (κ = –0.02), and exact test for matched pairs demonstrated no significant difference between discordant pairs (p = 0.78). Conclusions:  No agreement was found between LC and ScvO2 goal achievement in early sepsis resuscitation. Achievement of a ScvO2≥ 70% without LC ≥ 10% was more strongly associated with mortality than achievement of LC ≥ 10% with failure to achieve ScvO2≥ 70%

Association Between Timing of Antibiotic Administration and Mortality from Septic Shock in Patients Treated with a Quantitative Resuscitation Protocol

Objective We sought to determine the association between time to initial antibiotics and mortality of septic shock patients treated with an emergency department (ED) based early resuscitation protocol. Design Pre-planned analysis of a multicenter randomized controlled trial of early sepsis resuscitation. Setting 3 urban US EDs. Patients Adult septic shock patients. Interventions A quantitative resuscitation protocol in the ED targeting 3 physiological variables: central venous pressure, mean arterial pressure and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all endpoints were achieved or a maximum of 6 hours. Measurements Data on patients who received an initial dose of antibiotics after presentation to the ED were categorized based on both time from triage and time from shock recognition to initiation of antibiotics. The primary outcome was in-hospital mortality. Main Results Of 291 included patients, mortality did not change with hourly delays in antibiotic administration up to 6 hours after triage: 1 hour (OR 1.2, 0.6–2.5), 2 hours (OR 0.71, 0.4–1.3), 3 hours (OR 0.59, 0.3–1.3). Mortality was significantly increased patients who received initial antibiotics after shock recognition (N=172, 59%) compared with before shock recognition (OR 2.4, 1.1–4.5); however, among patients who received antibiotics after shock recognition, mortality did not change with hourly delays in antibiotic administration. Conclusion In this large, prospective study of ED patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality

Chaotic Friedmann-Robertson-Walker Cosmology

We show that the dynamics of a spatially closed Friedmann - Robertson - Walker Universe conformally coupled to a real, free, massive scalar field, is chaotic, for large enough field amplitudes. We do so by proving that this system is integrable under the adiabatic approximation, but that the corresponding KAM tori break up when non adiabatic terms are considered. This finding is confirmed by numerical evaluation of the Lyapunov exponents associated with the system, among other criteria. Chaos sets strong limitations to our ability to predict the value of the field at the Big Crunch, from its given value at the Big Bang. (Figures available on request)Comment: 28 pages, 11 figure

Quantization of Nonstandard Hamiltonian Systems

The quantization of classical theories that admit more than one Hamiltonian description is considered. This is done from a geometrical viewpoint, both at the quantization level (geometric quantization) and at the level of the dynamics of the quantum theory. A spin-1/2 system is taken as an example in which all the steps can be completed. It is shown that the geometry of the quantum theory imposes restrictions on the physically allowed nonstandard quantum theories.Comment: Revtex file, 23 pages, no figure

Negotiating daughterhood and strangerhood: retrospective accounts of serial migration

Most considerations of daughtering and mothering take for granted that the subjectivities of mothers and daughters are negotiated in contexts of physical proximity throughout daughters’ childhoods. Yet many mothers and daughters spend periods separated from each other, sometimes across national borders. Globally, an increasing number of children experience life in transnational families. This paper examines the retrospective narratives of four women who were serial migrants as children (whose parents migrated before they did) . It focuses on their accounts of the reunion with their mothers and how these fit with the ways in which they construct their mother-daughter relationships. We take a psychosocial approach by using a psychoanalytically-informed reading of these narratives to acknowledge the complexities of the attachments produced in the context of migration and to attend to the multi-layered psychodynamics of the resulting relationships. The paper argues that serial migration positioned many of the daughters in a conflictual emotional landscape from which they had to negotiate ‘strangerhood’ in the context of sadness at leaving people to whom they were attached in order to join their mothers (or parents). As a result, many were resistant to being positioned as daughters, doing daughtering and being mothered in their new homes

A Uniqueness Theorem for Constraint Quantization

This work addresses certain ambiguities in the Dirac approach to constrained systems. Specifically, we investigate the space of so-called ``rigging maps'' associated with Refined Algebraic Quantization, a particular realization of the Dirac scheme. Our main result is to provide a condition under which the rigging map is unique, in which case we also show that it is given by group averaging techniques. Our results comprise all cases where the gauge group is a finite-dimensional Lie group.Comment: 23 pages, RevTeX, further comments and references added (May 26. '99

Regime shifts and panarchies in regional scale social-ecological water systems

In this article we summarize histories of nonlinear, complex interactions among societal, legal, and ecosystem dynamics in six North American water basins, as they respond to changing climate. These case studies were chosen to explore the conditions for emergence of adaptive governance in heavily regulated and developed social-ecological systems nested within a hierarchical governmental system. We summarize resilience assessments conducted in each system to provide a synthesis and reference by the other articles in this special feature. We also present a general framework used to evaluate the interactions between society and ecosystem regimes and the governance regimes chosen to mediate those interactions. The case studies show different ways that adaptive governance may be triggered, facilitated, or constrained by ecological and/or legal processes. The resilience assessments indicate that complex interactions among the governance and ecosystem components of these systems can produce different trajectories, which include patterns of (a) development and stabilization, (b) cycles of crisis and recovery, which includes lurches in adaptation and learning, and (3) periods of innovation, novelty, and transformation. Exploration of cross scale (Panarchy) interactions among levels and sectors of government and society illustrate that they may constrain development trajectories, but may also provide stability during crisis or innovation at smaller scales; create crises, but may also facilitate recovery; and constrain system transformation, but may also provide windows of opportunity in which transformation, and the resources to accomplish it, may occur. The framework is the starting point for our exploration of how law might play a role in enhancing the capacity of social-ecological systems to adapt to climate change