Public and stakeholder participation for managing and reducing the risks of shale gas development.

Emerging technologies pose particularly strong challenges for risk governance when they have multidimensional and inequitable impacts, when there is scientific uncertainty about the technology and its risks, when there are strong value conflicts over the perceived benefits and risks, when decisions must be made urgently, and when the decision making environment is rife with mistrust. Shale gas development is one such emerging technology. Drawing on previous U.S. National Research Council committee reports that examined risk decision making for complex issues like these, we point to the benefits and challenges of applying the analytic-deliberative process recommended in those reports for stakeholder and public engagement in risk decision making about shale gas development in the United States. We discuss the different phases of such a process and conclude by noting the dangers of allowing controversy to ossify and the benefits of sound dialogue and learning among publics, stakeholders, industry, and regulatory decision makers.

Natural History of Obesity Subphenotypes: Dynamic Changes Over Two Decades and Prognosis in the Framingham Heart Study.

Context: The natural histories of obesity subphenotypes are incompletely delineated. Objectives: To investigate dynamic changes in obesity subphenotypes and associations with outcomes. Design, Setting, Participants, and Measurements: Framingham Offspring Cohort participants (n = 4291) who attended the examination cycles 2 (1979 to 1983) to 7 (1998 to 2001), which included 26,508 participant observations. Obesity subphenotypes [metabolically healthy nonobese (MHNO), metabolically healthy obese (MHO), metabolically unhealthy nonobese (MUNO), and metabolically unhealthy obese (MUO)] were ascertained based on metabolic health (<2 Adult Treatment Panel III criteria). The outcomes were subclinical cardiovascular disease (CVD), incident diseases [diabetes, hypertension, chronic kidney disease (CKD), CVD], and all-cause mortality. Results: At baseline, 4% and 31% of participants exhibited the MHO and MUNO subphenotypes, respectively. Four-year probability of MHO participants becoming MUO was 43% in women and 46% in men. Compared with MHNO, MHO participants had 1.28-fold (95% CI, 0.85 to 1.93) and 1.92-fold (95% CI, 1.38 to 2.68) higher odds of subclinical CVD and coronary artery calcification, respectively; corresponding values for MUNO were 1.95 (1.54 to 2.47) and 1.92 (1.38 to 2.68). During follow-up (median of 14 years), 231 participants developed diabetes, 784 hypertension, 423 CKD, 639 CVD, and 1296 died. Compared with MHNO, MHO conferred higher risks of diabetes [hazard ratio (HR), 4.69; 95% CI, 2.21 to 9.96] and hypertension (HR, 2.21; 95% CI, 1.66 to 2.94). Compared with MUO, MHO conferred lower risks of diabetes (0.21; 0.12 to 0.39), CVD (0.64; 0.43 to 0.95), and CKD (0.44; 0.27 to 0.73), but similar hypertension, cardiovascular mortality, and overall mortality risks. Conclusion: Over time, most MHO participants developed metabolic abnormalities and clinical disease. The MHO subphenotype is a harbinger of future risk.

LDL-Cholesterol Is Not the Only Clinically Relevant Biomarker for Coronary Artery Disease or Acute Coronary Syndrome.

Coronary artery disease (CAD) is a progressive disorder and its risk is best determined using multiple biomarkers and risk factors. Many novel biomarkers have been shown to improve cardiovascular disease risk beyond that of the traditional risk factors, including polygenic risk scores, small very low-density lipoprotein (VLDL), ApoB, triglycerides (TG), non-HDL-c, lipoprotein (a) (Lp(a)), coronary calcium scores, C-reactive protein (CRP), B-type natriuretic peptide (BNP), troponins, and many other novel biomarkers that have been measured using high throughput assays.

Risk perception, risk communication, and stakeholder involvement for biosolids management and research.

An individual's perception of risk develops from his or her values, beliefs, and experiences. Social scientists have identified factors that affect perceptions of risk, such as whether the risk is knowable (uncertainty), voluntary (can the individual control exposure?), and equitable (how fairly is the risk distributed?). There are measurable differences in how technical experts and citizen stakeholders define and assess risk. Citizen knowledge and technical expertise are both relevant to assessing risk; thus, the 2002 National Research Council panel on biosolids recommended stakeholder involvement in biosolids risk assessments. A survey in 2002 identified some of the factors that influence an individual's perception of the risks involved in a neighbor's use of biosolids. Risk communication was developed to address the gap between experts and the public in knowledge of technical topics. Biosolids management and research may benefit from applications of current risk communication theory that emphasizes (i) two-way communications (dialogue); (ii) that the public has useful knowledge and concerns that need to be acknowledged; and (iii) that what may matter most is the credibility of the purveyor of information and the levels of trustworthiness, fairness, and respect that he or she (or the organization) demonstrates, which can require cultural change. Initial experiences in applying the dialogue and cultural change stages of risk communication theory--as well as consensus-building and joint fact-finding--to biosolids research suggest that future research outcomes can be made more useful to decision-makers and more credible to the broader public. Sharing control of the research process with diverse stakeholders can make research more focused, relevant, and widely understood.

A Meckel's diverticulum presenting as pyogenic liver abscesses.

Meckel's diverticula are the most common congenital malformation of the small intestine. The condition is rarely symptomatic and is usually an incidental finding during surgery. Bleeding in children and obstruction in adults are the most common symptomatic presentations. Our case involves a 50-year-old man with multiple pyogenic liver abscesses due to a Meckel's diverticulum. The abscesses were percutaneously drained and the diverticulum was eventually resected. Pyogenic liver abscess is a very rare presentation of a Meckel's diverticulum. The diverticulum in our case appeared to have a thickened wall on imaging but no signs of acute inflammation were present on the CT scan or noticed intraoperatively. It was presumed to be the possible source as all other possibilities were ruled out. Ultimately, the surgical pathology revealed acute inflammation and focal abscess. We propose that elective resection of a Meckel's diverticulum should be considered in the setting of pyogenic liver abscess with no other identifiable source.