Self-Reported Effects of the Covid-19 Pandemic on Stewardship Organizations and Their Activities in Southeast New England, USA.

In many communities, regions, or landscapes, there are numerous environmental groups working across different sectors and creating stewardship networks that shape the environment and the benefits people derive from it. The make-up of these networks can vary, but generally include organizations of different sizes and capacities. As the Covid-19 pandemic (2020 to the present) shuts down businesses and nonprofits, catalyzes new initiatives, and generally alters the day-to-day professional and personal lives, it is logical to assume that these stewardship networks and their environmental work are impacted; exactly how, is unknown. In this study, we analyze the self-reported effects of the Covid-19 pandemic on stewardship groups working in southeast New England, USA. Stewardship organizations were surveyed from November 2020 to April 2021 and asked, among other questions, "How is Covid-19 affecting your organization?" We analyzed responses using several qualitative coding approaches. Our analysis revealed group-level impacts including changes in group capacity, challenges in managing access to public green spaces, and altered forms of volunteer engagement. These results provide insights into the varied effects of the Covid-19 pandemic and government responses such as stay-at-home orders and social distancing policies on stewardship that can inform the development of programs to reduce negative outcomes and enhance emerging capacities and innovations.

Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models.

OBJECTIVES: To develop and internally validate risk prediction models identifying women at risk for cardiovascular severe maternal morbidity (CSMM). DESIGN: A retrospective cohort study. SETTING: An obstetric teaching hospital between 2007 and 2017. POPULATION: A total of 89 681 delivery hospitalisations. METHODS: We created and evaluated two models, one predicting CSMM at delivery (delivery model) and the other predicting CSMM postpartum following discharge from delivery hospitalisation (postpartum CSMM). We assessed model discrimination and calibration and used bootstrapping for internal validation. MAIN OUTCOME MEASURES: Cardiovascular severe maternal morbidity comprised the following confirmed conditions: pulmonary oedema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm and difficult-to-control severe hypertension. RESULTS: The delivery model contained 11 variables and 3 interaction terms. The strongest predictors were gestational hypertension, chronic hypertension, multiple gestation, cardiac lesions or valvular heart disease, maternal age ≥40 years and history of poor pregnancy outcome. The postpartum model comprised eight variables. The strongest predictors were severe pre-eclampsia, non-Hispanic Black race/ethnicity, chronic hypertension, gestational hypertension, non-severe pre-eclampsia and maternal age ≥40 years at delivery. The delivery and postpartum models had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.89) and 0.85 (95% CI 0.80-0.90), respectively. Both models were adequately calibrated and performed well on internal validation. CONCLUSIONS: These tools may help providers to identify women at highest risk of CSMM and enable future prevention measures. TWEETABLE ABSTRACT: Risk assessment tools for cardiovascular severe maternal morbidity were developed and internally validated.

Depth specialization in mesophotic corals (Leptoseris spp.) and associated algal symbionts in Hawai'i.

Corals at the lower limits of mesophotic habitats are likely to have unique photosynthetic adaptations that allow them to persist and dominate in these extreme low light ecosystems. We examined the host-symbiont relationships from the dominant coral genus Leptoseris in mesophotic environments from Hawai'i collected by submersibles across a depth gradient of 65-125 m. Coral and Symbiodinium genotypes were compared with three distinct molecular markers including coral (COX1-1-rRNA intron) and Symbiodinium (COI) mitochondrial markers and nuclear ITS2. The phylogenetic reconstruction clearly resolved five Leptoseris species, including one species (Leptoseris hawaiiensis) exclusively found in deeper habitats (115-125 m). The Symbiodinium mitochondrial marker resolved three unambiguous haplotypes in clade C, which were found at significantly different frequencies between host species and depths, with one haplotype exclusively found at the lower mesophotic extremes (95-125 m). These patterns of host-symbiont depth specialization indicate that there are limits to connectivity between upper and lower mesophotic zones, suggesting that niche specialization plays a critical role in host-symbiont evolution at mesophotic extremes.

Nitric oxide inhalation increases alveolar gas exchange by decreasing deadspace volume.

OBJECTIVE: To test the hypothesis that nitric oxide inhalation facilitates CO2 elimination by decreasing alveolar deadspace in an ovine model of acute lung injury. DESIGN: Prospective, placebo-controlled, randomized, crossover model. SETTING: University research laboratory. SUBJECTS: Eleven mixed-breed adult sheep. INTERVENTIONS: To induce acute lung injury, hydrochloric acid was instilled into the tracheas of paralyzed sheep receiving controlled mechanical ventilation. Each sheep breathed 0 ppm, 5 ppm, and 20 ppm nitric oxide in random order. MEASUREMENTS AND MAIN RESULTS: Estimates of alveolar deadspace volumes and arterial-to-end tidal CO2 partial pressure differences were used as indicators of CO2 elimination efficiency. At a constant minute ventilation, nitric oxide inhalation caused dose-independent decreases in Paco2 (p <.05), alveolar deadspace (p <.01), and arterial-to-end tidal CO2 partial pressure differences (p <.01). We found that estimates of arterial-to-end tidal CO2 partial pressure differences may be used to predict alveolar deadspace volume (r2 =.86, p <.05). CONCLUSIONS: Estimates of arterial-to-end tidal CO2 partial pressure differences are reliable indicators of alveolar deadspace. Both values decreased during nitric oxide inhalation in our model of acutely injured lungs. This finding supports the idea that nitric oxide inhalation facilitates CO2 elimination in acutely injured lungs. Future studies are needed to determine whether nitric oxide therapy can be used to reduce the work of breathing in selected patients with cardiopulmonary disorders.

Bedside placement of transpyloric feeding tubes in the pediatric intensive care unit using gastric insufflation.

OBJECTIVE: To test the effectiveness of gastric insufflation as an adjunct to placement of feeding tubes in the small bowel. DESIGN: Prospective, randomized, controlled study. SETTING: Pediatric intensive care unit in a tertiary children's hospital. PATIENTS: A total of 50 children requiring enteral nutrition via a nasoenteral feeding tube in the small bowel. INTERVENTIONS: An unweighted nasoenteral feeding tube attached to a three-way stopcock and a 60 mL syringe was inserted through the nares into the stomach. After 10 mL/kg of air was injected, the tube was advanced a distance estimated to position the tip of the tube proximal to the pylorus. An additional 10 mL/kg of air was then injected, and the tube was advanced a distance needed to place the tube in the fourth part of the duodenum. In the control group, feeding tubes were inserted through the nares and into the stomach. The tube was then advanced a distance estimated to place the tube in the fourth part of the duodenum. No air was injected in the control group. MEASUREMENTS AND MAIN RESULTS: When gastric insufflation was used, 23 of 25 feeding tubes were successfully placed in the small bowel on the first attempt compared with 11 of 25 in the control group (p = .001). All feeding tubes were successfully placed after two attempts in the gastric insufflation group compared with 18 of 25 in the control group (p < .001). The time between the first attempt at placement of a transpyloric feeding tube and the initiation of feeding was significantly shorter in the study group than in the control group. There were no complications in either group. CONCLUSION: Gastric insufflation allows rapid placement of feeding tubes into the small bowel with fewer attempts compared with a standard insertion technique in children.

Transvaginal salpingosonography for assessing tubal patency in women previously treated for pelvic inflammatory disease and benign ovarian tumors.

OBJECTIVE: The aim of this study was to evaluate the role of transvaginal salpingosonography in the assessment of tubal patency among women previously treated conservatively for pelvic inflammatory disease and surgically for a benign ovarian tumor. DESIGN: Twenty-two women were recruited for this study at the University Hospital of Oulu. Transvaginal salpingosonography was scheduled to be performed twice within a 3-month interval. X-ray hysterosalpingography was chosen as a reference method and was performed within 2 days of the second salpingosonography examination during the same menstrual cycle. Altogether, 31 Fallopian tubes were assessed with the second salpingosonography examination and X-ray hysterosalpingography. RESULTS: Twenty-nine Fallopian tubes were observed by both methods to be patent (i.e. 29 tubes by each method, but not necessarily the same tubes). An occlusion was diagnosed by each method in two tubes only, of which one appeared occluded by both methods, while one tube from each method appearing to be occluded was demonstrated to be patent using the other method. The agreement of transvaginal salpingosonography compared with X-ray hysterosalpingography was 94%, the sensitivity 50%, the specificity 97%, the positive predictive value 50% and the negative predictive value 97%. Two successive transvaginal salpingosonography examinations were performed in 18 patients with 27 Fallopian tubes. Disagreement was observed for only one tube. The agreement between these two examinations was 96%, the sensitivity 100%, the specificity 96%, the positive predictive value 67% and the negative predictive value 100%. The kappa coefficient was 0.78 (95% confidence interval 0.75-0.81). CONCLUSIONS: In conclusion, transvaginal salpingosonography can be used in patients with previous pelvic inflammatory disease and adnexal surgery due to its ease of use, reliability and low costs on an out-patient basis. Among these patients, tubal patency was a common finding.

Assessing tubal patency with transvaginal salpingosonography after the reversal of tubal ligation for female sterilization.

The objective of this study was to assess tubal patency using transvaginal salpingosonography (TSSG) among women treated by tubal ligation after sterilization and to compare these results with those obtained using X-ray hysterosalpingography (HSG). Twenty-one healthy women were recruited. Air was used as a contrast medium in TSSG and Omnipaque as a water-soluble contrast medium in the HSG examination. All women underwent at least one TSSG. If the woman did not become pregnant during the follow-up or had a miscarriage or tubal pregnancy, she was re-examined with a second TSSG and the results were compared with those of HSG undertaken during the same menstrual cycle. Because of the high pregnancy rate the final number of patients was reduced to 10. The observed agreement between the two TSSGs was 70%, which was low compared with our earlier results. The kappa coefficient was only 0.41. The sensitivity of TSSG for the detection of tubal occlusion was 54%. This can be explained by the fact that the mean time interval between the two TSSGs was long (5.5 months) and results were not therefore comparable or repeatable. We can conclude that the women with patent tubes became pregnant after the first TSSG while the women taking part in the second TSSG had impaired tubal function. There were more occluded tubes observed in the second TSSG than in the first. An analysis comparing the second TSSG with HSG produced better results. The observed agreement was 84%, kappa coefficient 0.67, demonstrating a good reproducibility of TSSG; the sensitivity of TSSG for the detection of tubal occlusion was 83%, specificity 85%, positive predictive value 91% and negative predictive value 75%. Thus, TSSG should be regarded as a reliable, rapid, safe and inexpensive method for testing tubal patency after reversal of tubal ligation for sterilization. It also allows simultaneous scanning of the uterine corpus, endometrium and ovaries and may have a clearing action on occluded tubes. TSSG can thus replace X-ray HSG in the primary evaluation of tubal status, even in this special group of patients.

Agreement between two successive transvaginal salpingosonography assessments of tubal patency.

OBJECTIVE: To evaluate the agreement between repeat transvaginal sonographic assessments of tubal patency using a combination of air and saline. MATERIAL AND METHODS: Twenty-nine patients were examined twice by the same investigator (H.S.). There was a three-month interval between the observations, and the investigator was blinded to the results of the first examination. Each patient was evaluated using three categories classified as: 1) bilateral patency, 2) unilateral patency and 3) bilateral occlusion. In addition, the pooled data from individual tubes was examined with respect to the detection of patency or occlusion. Data from the right and left tubes were analyzed separately as well. Agreement between the two examinations was subsequently determined using Cohen's kappa coefficient (kappa). When there were more than two categories, a weighted kappa coefficient was used. RESULTS: There was good (kappa = 0.61) agreement between the two examinations when each patient was evaluated individually. For the pooled data of all tubes (n = 46), the kappa coefficient was 0.53, but increased to 0.66 after correction for prevalence. There was no systematic bias between the successive examinations of tubes. There was more consistency between repeated observations in the right (kappa = 0.70) than in the left (kappa = 0.37) tubes. The prevalence of occlusion was higher in the left tubes. CONCLUSION: Transvaginal salpingosonography was shown to be a reliable method for the assessment of tubal patency.

Assessment of tubal patency with transvaginal salpingosonography after treatment for tubal pregnancy.

Tubal patency was studied in 32 patients who had previously undergone a laparoscopic or laparotomy procedure (salpingostomy, salpingectomy or tubal resection), or who had received a local injection of hypertonic glucose because of tubal pregnancy. Transvaginal salpingosonography (TSSG) was subsequently performed in the follicular phase of the menstrual cycle, and laparoscopic chromopertubation was carried out as a comparative method after TSSG. Of 32 patients (47 Fallopian tubes examined), the affected tube was observed to be patent by TSSG in 68%. The contralateral tube was patent in 93%. Nine patients became pregnant and were thus not subsequently assessed with laparoscopy. Two of these pregnancies ended in a miscarriage and one in a recurrent tubal pregnancy. A concordance of 86% for Fallopian tubes was achieved between the TSSG and laparoscopic chromopertubation methods. When checking the Fallopian tubes separately, the concordance for the results in the affected tubes was 67%, and 100% for the contralateral tube. Therefore TSSG appears to be a practical method for the primary examination of tubal patency in patients treated previously for tubal pregnancy. Guidelines for the treatment of infertility after tubal pregnancy can also be set out according to TSSG findings.

A randomized study comparing air to Echovist as a contrast medium in the assessment of tubal patency in infertile women using transvaginal salpingosonography.

This study was undertaken to compare two different contrast media (air and Echovist) in the assessment of tubal patency using transvaginal salpingosonography (TSSG) in 32 infertile women referred to an infertility outpatient clinic. Altogether, 59 Fallopian tubes were examined with TSSG. Laparoscopic chromopertubation was used as a reference method. In group A (air), concordance was 90%, Cohen's kappa coefficient 0.71 [95% confidence interval (CI): 0.64-0.77], sensitivity 63%, specificity 100%, negative predictive value 88% and positive predictive value 100%. In group B (Echovist), the corresponding parameters were as follows: 93%, 0.71 (CI: 0.67-0.76), 60, 100, 93 and 100% respectively. No statistically significant differences were found between these two contrast media. Either one can reliably be used for assessing tubal patency with TSSG in infertile women as a primary phase examination modality.

Effects of the adjuvant DEAE-dextran and Staphylococcus aureus on the lymph pathways and filtering capacity of popliteal lymph nodes in sheep.

The effects of subcutaneous injections of the adjuvant DEAE-dextran and, or killed Staphylococcus aureus on the structure of the lymph pathways of popliteal lymph nodes in sheep were examined using light and electron microscopy and Microfil casts. Dextran with or without killed S aureus caused significant changes in the lymph pathways both within the node and outside it. However, killed S aureus alone did not. The changes included anastomoses among afferent lymph vessels and between afferent and efferent lymph vessels; proliferation of vessels around the node; joining of parts of the capsule and trabeculae to adjacent parenchyma with loss of parts of the subcapsular and trabecular sinuses; enlargement of medullary sinuses; and reduction of the number of reticular processes in sinuses throughout the node. These changes were accompanied by a reduced ability of the node to filter chicken red blood cells labelled with chromium-51 which were injected into an afferent lymph vessel.

Fine structure of lymph pathways in nodes from the superficial inguinal lymph centre in the pig.

In the pig lymph node most lymph passes from afferent lymphatics to trabecular sinuses in centrally located dense nodular tissue. The lining of these sinuses is continuous adjacent to the trabecula but it is interrupted by numerous gaps adjacent to the parenchyma. Where the trabeculae end, their associated sinuses are continuous with the many interstitial spaces, up to 10 microns across, in the diffuse tissue. Lymph percolates through these spaces and is directly exposed to large numbers of macrophages with elaborate cytoplasmic veils and to reticular fibres which could be involved in antigen retention. Parts of the diffuse tissue are arranged into sinuses and cords in a manner similar to the medullary tissue in other species and a subcapsular sinus is also present over the diffuse tissue. There are gaps in the lining of these sinuses through which they communicate with the interstices of the parenchyma. Lymph flows from the sinuses in the diffuse tissue into efferent lymph vessels; these are usually in the capsule or along the plane of fusion of adjacent node anlagen.

Blood vessels within lymph nodes: a comparison between pigs and sheep.

In sheep, most blood vessels enter the lymph nodes at a discrete hilus, which is where the capsule overlies medullary tissue. In pigs, vessels within the node arise from an extensive network of arteries on the surface, and most vessels penetrate the capsule where it overlies diffuse tissue--the counterpart of the sheep medulla. In both species the blood vessels divide extensively as they approach and supply the dense lymphoid tissue which contains lymph nodules. The blood vessels within sheep lymph nodules are surrounded by a thick layer of amorphous material. The dense lymphoid tissue has an abundant network of venules which have smooth muscle cells in their walls. These venules are involved in lymphocyte migration and in pigs they are lined by high endothelium which is similar to that in most other species, while in sheep the endothelium is much lower. Fenestrated capillaries occur in both pig and sheep lymph nodes.

Pathways of lymph flow to and from the medulla of lymph nodes in sheep.

Medullary sinuses are continuous with penetrating afferent lymphatics, and with the trabecular and tubular sinuses which penetrate through the cortex. Tubular sinuses are often associated with blood vessels, especially in the deep cortex, and they appear to be important in the transport of lymphocytes. The subcapsular sinus is continuous over the cortex and the medulla, although trabeculae and reticular processes appear to restrict the flow of afferent lymph to the subcapsular sinus over the medulla. Lymph leaves the medulla through up to 100 or more initial efferent lymphatics, some only 60 micron across. Almost all of these arise from sinuses adjacent to the capsule lining the hilus. Some efferents remain associated with the capsule for a short distance whereas others, especially in nodes with a deep hilar depression, leave immediately at an angle of 30-90 degrees.

Arterial supply to the pig intestine: an unusual pattern in the mesentery.

The arrangement of arteries in the mesentery in pigs was studied with latex casts and light microscopy. Arterial arcades, which are characteristic of the mesentery in man and other species, are absent. Instead, a narrow band of numerous, anastomosing arteries gives rise to up to about 500 bundles of arteries and accompanying veins, which radiate out in the mesentery. Each bundle contains up to 30 arteries, but these recombine as they approach the jejunum, and form 1-4 arteriae rectae. The significance of the very large number of small arteries in the mesentery is not known, but they may play a role in the control of blood pressure in the intestinal wall, or as sites of countercurrent exchange.

Pathways of lymph flow through superficial inguinal lymph nodes in the pig.

The pig lymph node has an unusual structure in that tissue containing lymph nodules generally occupies a central position. Our aim was to describe the lymphatic pathways through this node. We studied the structure of these pathways with light and electron microscopy, made casts of lymphatic vessels and sinuses with Microfil, and studied the distribution within the node of subcutaneously injected carbon particles. Most afferent lymphatics penetrate deeply within the node, where they give off several branches to peritrabecular sinuses that ramify through centrally located nodular tissue. However, where an afferent lymphatic enters the node there is a subcapsular sinus over an area of nodular tissue that occupies a conventional superficial position. Some lymph reaches this sinus from the central peritrabecular sinuses, but there can also be direct communications between this sinus and the afferent lymphatic. After flowing through sinuses in nodular tissue, lymph enters tissue that is analogous to medullary tissue in other species. This tissue is of two types, one consisting mainly of a diffuse network of reticular cells around spaces up to 10-12 microns across, and one that more closely resembles conventional medullary tissue. Lymph then flows to collecting ducts, which lack valves, and then to efferent lymphatics. Our findings do not support suggestions that a purely physical obstruction of lymphocytes in the lymph node accounts for the dearth of lymphocytes in efferent lymph of pigs.

Afferent pathways of lymph flow within the popliteal node in sheep.

Lymph enters the popliteal node in sheep either at the subcapsular sinus, or through terminal afferent lymphatics which pass within trabeculae to medullary sinuses. Lymph from the subcapsular sinus traverses trabecular sinuses and/or a network of tubular sinuses in the cortex before entering the medullary sinuses, which are very extensive. Carbon particles, injected either into an afferent lymphatic or subcutaneously into the leg, were initially found mainly in a circumscribed area of the subcapsular sinus. Within a few hours they were present within macrophages in and around medullary sinuses in a band which extended around virtually the whole medulla. It was concluded that the pathways taken by lymph constituents in the sheep node may differ from those described for mice, rats and rabbits.

Blood vessels of lymph nodes in the pig.

Pig lymph nodes have an unusual arrangement of cortical and medullary tissue, and lack a hilus. The aim of the present study was to describe the pathways by which blood reaches these lymph nodes. Natural or synthetic latex casts were made of blood vessels of superficial inguinal, popliteal and jejunal lymph nodes. Major nodal arteries approach these lymph nodes and give rise to about five branches, most of which remain on the node surface. These branches often wrap around part or all of the node in a claw-like manner and they divide to form a network on its surface. Arteries from this network penetrate the capsule directly to supply the lymphoid parenchyma. Anastomoses are common at all levels between the arteries supplying the nodes and arteriovenous anastomoses occur within the nodes. These may help to maintain and regulate blood flow within the lymph node under different conditions of stimulation.