Feasibility of Closed-Loop Insulin Delivery with a Pregnancy-Specific Zone Model Predictive Control Algorithm.

Objective: Evaluating the feasibility of closed-loop insulin delivery with a zone model predictive control (zone-MPC) algorithm designed for pregnancy complicated by type 1 diabetes (T1D). Research Design and Methods: Pregnant women with T1D from 14 to 32 weeks gestation already using continuous glucose monitor (CGM) augmented pump therapy were enrolled in a 2-day multicenter supervised outpatient study evaluating pregnancy-specific zone-MPC based closed-loop control (CLC) with the interoperable artificial pancreas system (iAPS) running on an unlocked smartphone. Meals and activities were unrestricted. The primary outcome was the CGM percentage of time between 63 and 140 mg/dL compared with participants' 1-week run-in period. Early (2-h) postprandial glucose control was also evaluated. Results: Eleven participants completed the study (age: 30.6 ± 4.1 years; gestational age: 20.7 ± 3.5 weeks; weight: 76.5 ± 15.3 kg; hemoglobin A1c: 5.6% ± 0.5% at enrollment). No serious adverse events occurred. Compared with the 1-week run-in, there was an increased percentage of time in 63-140 mg/dL during supervised CLC (CLC: 81.5%, run-in: 64%, P = 0.007) with less time >140 mg/dL (CLC: 16.5%, run-in: 30.8%, P = 0.029) and time <63 mg/dL (CLC: 2.0%, run-in:5.2%, P = 0.039). There was also less time <54 mg/dL (CLC: 0.7%, run-in:1.6%, P = 0.030) and >180 mg/dL (CLC: 4.9%, run-in: 13.1%, P = 0.032). Overnight glucose control was comparable, except for less time >250 mg/dL (CLC: 0%, run-in:3.9%, P = 0.030) and lower glucose standard deviation (CLC: 23.8 mg/dL, run-in:42.8 mg/dL, P = 0.007) during CLC. Conclusion: In this pilot study, use of the pregnancy-specific zone-MPC was feasible in pregnant women with T1D. Although the duration of our study was short and the number of participants was small, our findings add to the limited data available on the use of CLC systems during pregnancy (NCT04492566).

Traveling Across Time Zones With Type 1 Diabetes: A Pilot Study Comparing Insulin Degludec With Insulin Glargine U100.

OBJECTIVE: For people with type 1 diabetes, there are limited evidence-based resources to support self-management when traveling across multiple time zones. Here, we compared glycemic control on insulin degludec versus glargine U100 as the basal insulin for adults using multiple daily injections (MDI) while traveling across multiple time zones. RESEARCH DESIGN AND METHODS: This randomized crossover pilot study compared insulin degludec versus glargine U100 for adults with type 1 diabetes using MDI insulin during long-haul travel to and from Hawaii to New York. Insulin degludec was administered daily at the same time regardless of time zone, and glargine was administered per travel algorithm. Primary end point was the percentage of time in range (TIR) between 70 and 140 mg/dL during the initial 24 h after each direction of travel. Secondary end points included standard continuous glucose monitoring metrics, jet lag, fatigue, and sleep. RESULTS: The study enrolled 25 participants (56% women, mean ± SD age of 35 ± 14.5 years, HbA1c of 7.4 ± 1.2% [57 ± 13.1 mmol/mol], and diabetes duration of 20.6 ± 15 years). There was no significant difference in glycemic outcomes between the two arms of the study, including TIR, hypoglycemia, or hyperglycemia. Neither group achieved >70% TIR 70-180 mg/dL during travel. Jet lag was greater on glargine U100 in eastward travel but not westward. Fatigue was greater after westward travel on glargine. Sleep was not significantly different between basal insulins. CONCLUSIONS: In adults with type 1 diabetes using MDI of insulin and traveling across multiple time zones, glycemic outcomes were similar comparing insulin degludec and glargine U100.

Residential yard management and landscape cover affect urban bird community diversity across the continental USA.

Urbanization has a homogenizing effect on biodiversity and leads to communities with fewer native species and lower conservation value. However, few studies have explored whether or how land management by urban residents can ameliorate the deleterious effects of this homogenization on species composition. We tested the effects of local (land management) and neighborhood-scale (impervious surface and tree canopy cover) features on breeding bird diversity in six US metropolitan areas that differ in regional species pools and climate. We used a Bayesian multiregion community model to assess differences in species richness, functional guild richness, community turnover, population vulnerability, and public interest in each bird community in six land management types: two natural area park types (separate and adjacent to residential areas), two yard types with conservation features (wildlife-certified and water conservation) and two lawn-dominated yard types (high- and low-fertilizer application), and surrounding neighborhood-scale features. Species richness was higher in yards compared with parks; however, parks supported communities with high conservation scores while yards supported species of high public interest. Bird communities in all land management types were composed of primarily native species. Within yard types, species richness was strongly and positively associated with neighborhood-scale tree canopy cover and negatively associated with impervious surface. At a continental scale, community turnover between cities was lowest in yards and highest in parks. Within cities, however, turnover was lowest in high-fertilizer yards and highest in wildlife-certified yards and parks. Our results demonstrate that, across regions, preserving natural areas, minimizing impervious surfaces and increasing tree canopy are essential strategies to conserve regionally important species. However, yards, especially those managed for wildlife support diverse, heterogeneous bird communities with high public interest and potential to support species of conservation concern. Management approaches that include the preservation of protected parks, encourage wildlife-friendly yards and acknowledge how public interest in local birds can advance successful conservation in American residential landscapes.

Testing an invasion mechanism for Eucalyptus globulus: Is there evidence of allelopathy?

PREMISE: Sparse understory communities, in association with non-native tree species, are often attributed to allelopathy, the chemical inhibition of a plant by another. However, allelopathy is a difficult ecological phenomenon to demonstrate as many studies show conflicting results. Eucalyptus globulus, a tree native to Australia, is one of the most widely planted trees around the world. Sparse understories are common beneath E. globulus plantations and are often attributed to allelopathy, but the ecological impacts of E. globulus on native plant communities outside Austrialia are poorly understood. METHODS: To assess allelopathy as a mechanism of understory inhibition, we tested volatile- and water-soluble leaf extracts from E. globulus, Salvia apiana, and Quercus agrifolia on seed germination of California native plants. We also quantified germination rates and early seedling growth of California native plants grown in soil from E. globulus plantations versus soil from an adjacent native plant community. RESULTS: Volatile compounds from E. globulus did not significantly reduce germination for any species. Inhibition from water-soluble E. globulus compounds was comparable to that of a native tree, Quercus agrifolia (10%). Eucalyptus globulus soil supported germination and early seedling growth of native species equal to or better than coastal scrub soil, although species responses were variable. CONCLUSIONS: In contrast to previous studies, our results fail to support the hypothesis that E. globulus chemically inhibits germination of native species. California native plants germinate and grow well in soils from E. globulus plantations, which may have significant implications for management and restoration of land historically occupied by E. globulus plantations.

Municipal regulation of residential landscapes across US cities: Patterns and implications for landscape sustainability.

Local regulations on residential landscapes (yards and gardens) can facilitate or constrain ecosystem services and disservices in cities. To our knowledge, no studies have undertaken a comprehensive look at how municipalities regulate residential landscapes to achieve particular goals and to control management practices. Across six U.S. cities, we analyzed 156 municipal ordinances to examine regional patterns in local landscape regulations and their implications for sustainability. Specifically, we conducted content analysis to capture regulations aimed at: 1) goals pertaining to conservation and environmental management, aesthetics and nuisance avoidance, and health and wellbeing, and 2) management actions including vegetation maintenance, water and waste management, food production, and chemical inputs. Our results reveal significant variation in local and regional regulations. While regulatory goals stress stormwater management and nuisance avoidance, relatively few municipalities explicitly regulate residential yards to maintain property values, mitigate heat, or avoid allergens. Meanwhile, biological conservation and water quality protection are common goals, yet regulations on yard management practices (e.g., non-native plants or chemical inputs) sometimes contradict these purposes. In addition, regulations emphasizing aesthetics and the maintenance of vegetation, mowing of grass and weeds, as well as the removal of dead wood, may inhibit wildlife-friendly yards. As a whole, landscaping ordinances largely ignore tradeoffs between interacting goals and outcomes, thereby limiting their potential to support landscape sustainability. Recommendations therefore include coordinated, multiobjective planning through partnerships among planners, developers, researchers, and non-government entities at multiple scales.

Performance of the Dexcom G6 Continuous Glucose Monitoring System in Pregnant Women with Diabetes.

Background: The aim of this study was to determine the performance of the Dexcom G6 continuous glucose monitoring (CGM) system across three sensor wear sites in pregnant women with diabetes in the second or third trimesters. Methods: Participants with type 1 (T1D), type 2 (T2D), or gestational (GDM) diabetes mellitus were enrolled at three sites. Each wore two G6 sensors on the abdomen, upper buttock, and/or posterior upper arm for 10 days and underwent a 6-h clinic session between days 3 and 7 of sensor wear, during which YSI reference blood glucose values were obtained every 30 min. No intentional glucose manipulations were performed. Accuracy metrics included the proportion of CGM values that were within ±20% of paired reference values >100 mg/dL or ±20 mg/dL of YSI values ≤100 mg/dL (hereafter referred to as %20/20), as well as the analogous %15/15, %30/30, and %40/40. The mean absolute relative difference (MARD) between CGM-YSI pairs was also calculated. Results: Thirty-two participants with T1D (n = 20), T2D (n = 3), or GDM (n = 9) were enrolled: 19 were in the second trimester and 13 were in the third trimester of pregnancy. Compared with the reference, 92.5% of CGM values were within ±20%/20 mg/dL. The overall MARD and that of sensors worn on the abdomen, upper buttock, and posterior upper arm was 10.3%, 11.5%, 11.2%, and 8.7%, respectively. There were no device-related adverse events. Skin reactions at the insertion sites were absent or minor. Conclusions: The Dexcom G6 CGM system is accurate and safe in pregnant women with diabetes.

Horticultural availability and homeowner preferences drive plant diversity and composition in urban yards.

Understanding the factors that influence biodiversity in urban areas is important for informing management efforts aimed at enhancing the ecosystem services in urban settings and curbing the spread of invasive introduced species. We determined the ecological and socioeconomic factors that influence patterns of plant richness, phylogenetic diversity, and composition in 133 private household yards in the Minneapolis-Saint Paul Metropolitan area, Minnesota, USA. We compared the composition of spontaneously occurring plant species and those planted by homeowners with composition in natural areas (at the Cedar Creek Ecosystem Science Reserve) and in the horticulture pool of species available from commercial growers. Yard area and fertilizer frequency influenced species richness of the spontaneous species but expressed homeowner values did not. In contrast, the criteria that homeowners articulated as important in their management decisions, including aesthetics, wildlife, neatness and food provision, significantly predicted cultivated species richness. Strikingly, the composition of plant species that people cultivated in their yards resembled the taxonomic and phylogenetic composition of species available commercially. In contrast, the taxonomic and phylogenetic composition of spontaneous species showed high similarity to natural areas. The large fraction of introduced species that homeowners planted was a likely consequence of what was available for them to purchase. The study links the composition and diversity of yard flora to their natural and anthropogenic sources and sheds light on the human factors and values that influence the plant diversity in residential areas of a major urban system. Enhanced understanding of the influences of the sources of plants, both native and introduced, that enter urban systems and the human factors and values that influence their diversity is critical to identifying the levers to manage urban biodiversity and ecosystem services.

Effects From Continuous Infusions of Dexmedetomidine and Propofol on Hemodynamic Stability in Critically Ill Adult Patients With Septic Shock.

PURPOSE: To compare the development of clinically significant hemodynamic event (ie, hypotension or bradycardia) in adults with septic shock receiving either propofol or dexmedetomidine. MATERIALS AND METHODS: A retrospective cohort study of adults with septic shock admitted to an intensive care unit (ICU) at an academic medical center between July 2013 and July 2017. RESULTS: Patients in the propofol (n = 35) and dexmedetomidine (n = 37) groups developed a clinically significant hemodynamic event at similar frequencies (31.4 vs 29.7%, P = .99). All patients with an event experienced hypotension, whereas 2 (5.4%) patients in the dexmedetomidine group also experienced bradycardia. Most patients in both groups (70% vs 90%) received an escalating sedative dose, and almost half (42.9%) in the dexmedetomidine group had the sedative dosage increased more frequently than every 30 minutes. Patients in both groups had similar ICU (24.1 vs 24.3 days, P = .98) and hospital (37.9 vs 29.7 days, P = .29) lengths of stay. There was no difference in median time to hemodynamic event between the groups (propofol 1 hour [interquartile range, IQR: 0.5-9.9] vs dexmedetomidine 2 hours [IQR: 1.5-11.1 hours], P = .85). CONCLUSION: Patients with septic shock receiving propofol or dexmedetomidine experienced similar rates of clinically significant hemodynamic events. Most patients did not experience an event and those who did most frequently did so in the first couple of hours of therapy.

Residential household yard care practices along urban-exurban gradients in six climatically-diverse U.S. metropolitan areas.

Residential land is expanding in the United States, and lawn now covers more area than the country's leading irrigated crop by area. Given that lawns are widespread across diverse climatic regions and there is rising concern about the environmental impacts associated with their management, there is a clear need to understand the geographic variation, drivers, and outcomes of common yard care practices. We hypothesized that 1) income, age, and the number of neighbors known by name will be positively associated with the odds of having irrigated, fertilized, or applied pesticides in the last year, 2) irrigation, fertilization, and pesticide application will vary quadratically with population density, with the highest odds in suburban areas, and 3) the odds of irrigating will vary by climate, but fertilization and pesticide application will not. We used multi-level models to systematically address nested spatial scales within and across six U.S. metropolitan areas-Boston, Baltimore, Miami, Minneapolis-St. Paul, Phoenix, and Los Angeles. We found significant variation in yard care practices at the household (the relationship with income was positive), urban-exurban gradient (the relationship with population density was an inverted U), and regional scales (city-to-city variation). A multi-level modeling framework was useful for discerning these scale-dependent outcomes because this approach controls for autocorrelation at multiple spatial scales. Our findings may guide policies or programs seeking to mitigate the potentially deleterious outcomes associated with water use and chemical application, by identifying the subpopulations most likely to irrigate, fertilize, and/or apply pesticides.

Climate and lawn management interact to control C4 plant distribution in residential lawns across seven U.S. cities.

In natural grasslands, C4 plant dominance increases with growing season temperatures and reflects distinct differences in plant growth rates and water use efficiencies of C3 vs. C4 photosynthetic pathways. However, in lawns, management decisions influence interactions between planted turfgrass and weed species, leading to some uncertainty about the degree of human vs. climatic controls on lawn species distributions. We measured herbaceous plant carbon isotope ratios (δ13 C, index of C3 /C4 relative abundance) and C4 cover in residential lawns across seven U.S. cities to determine how climate, lawn plant management, or interactions between climate and plant management influenced C4 lawn cover. We also calculated theoretical C4 carbon gain predicted by a plant physiological model as an index of expected C4 cover due to growing season climatic conditions in each city. Contrary to theoretical predictions, plant δ13 C and C4 cover in urban lawns were more strongly related to mean annual temperature than to growing season temperature. Wintertime temperatures influenced the distribution of C4 lawn turf plants, contrary to natural ecosystems where growing season temperatures primarily drive C4 distributions. C4 cover in lawns was greatest in the three warmest cities, due to an interaction between climate and homeowner plant management (e.g., planting C4 turf species) in these cities. The proportion of C4 lawn species was similar to the proportion of C4 species in the regional grass flora. However, the majority of C4 species were nonnative turf grasses, and not of regional origin. While temperature was a strong control on lawn species composition across the United States, cities differed as to whether these patterns were driven by cultivated lawn grasses vs. weedy species. In some cities, biotic interactions with weedy plants appeared to dominate, while in other cities, C4 plants were predominantly imported and cultivated. Elevated CO2 and temperature in cities can influence C3 /C4 competitive outcomes; however, this study provides evidence that climate and plant management dynamics influence biogeography and ecology of C3 /C4 plants in lawns. Their differing water and nutrient use efficiency may have substantial impacts on carbon, water, energy, and nutrient budgets across cities.

Beekeeper stewardship, colony loss, and Varroa destructor management.

Varroa (Varroa destructor) is a leading cause of honey bee mortality worldwide. In a U.S. national survey of beekeepers, 3519 respondents noted what they believe are the advantages and disadvantages of managing for Varroa, what good stewardship means in beekeeping, and whether they treated for Varroa. Dominant attitudes were keeping bees healthy, minimizing disturbance, and monitoring hives. We found a bifurcation in Varroa management beliefs. Decision tree analyses show group distinctions. Treatment Skeptics tend to say that stewardship means bees should not be disturbed or subjected to chemicals, and should be given forage to do their 'normal business.' This group was less likely to treat for Varroa. Treatment Adherents identify themselves as bee stewards and say stewardship means active hive management and keeping bees healthy and alive. Illuminating beekeeper stewardship is essential for a socioecological understanding of how to address challenging Varroa management and complex human-environmental production systems that have landscape-level effects.

Modeling the effect of social networks on adoption of multifunctional agriculture.

Rotational grazing (RG) has attracted much attention as a cornerstone of multifunctional agriculture (MFA) in animal systems, potentially capable of producing a range of goods and services of value to diverse stakeholders in agricultural landscapes and rural communities, as well as broader societal benefits. Despite these benefits, global adoption of MFA has been uneven, with some places seeing active participation, while others have seen limited growth. Recent conceptual models of MFA emphasize the potential for bottom-up processes and linkages among social and environmental systems to promote multifunctionality. Social networks are critical to these explanations but how and why these networks matter is unclear. We investigated fifty-three farms in three states in the United States (New York, Wisconsin, Pennsylvania) and developed a stylized model of social networks and systemic change in the dairy farming system. We found that social networks are important to RG adoption but their impact is contingent on social and spatial factors. Effects of networks on farmer decision making differ according to whether they comprise weak-tie relationships, which bridge across disparate people and organizations, or strong-tie relationships, which are shared by groups in which members are well known to one another. RG adoption is also dependent on features of the social landscape including the number of dairy households, the probability of neighboring farmers sharing strong ties, and the role of space in how networks are formed. The model replicates features of real-world adoption of RG practices in the Eastern US and illustrates pathways toward greater multifunctionality in the dairy landscape. Such models are likely to be of heuristic value in network-focused strategies for agricultural development.

Exploring homeowner diffusion of yard care knowledge as one step toward improving urban ecosystems.

Urban ecosystems are increasingly influenced by residential yard care decisions. This had led researchers to focus on homeowner education programs when it comes to yard care. Typically, the success of programs designed to influence yard care is based on whether the target subject changes his or her behavior in a more environmentally conscious manner. This threshold, however, fails to consider if individuals share this information with their friends and neighbors, thus having a possible spillover effect. In this paper, we focus on the transmission of new lawn management information among neighbors and consider (1) if individuals discuss information they learned in a short-term educational program, (2) what factors are associated with diffusion, (3) what information individuals share, and (4) what barriers to transmission exist. In the Minneapolis-St. Paul metropolitan area, we used data from a mailed survey, group discussions, and mailed information exchanges. Results indicate that best management practices for yards can diffuse through the neighborhood (approximately 34 % shared information with their neighbors in a one-month period). In addition, factors such as (1) attending a group discussion, 2) individual social connectedness, (3) length of home ownership, and (4) the presence of children in the household were found to be positively related to increased sharing of information. Also, for lawns, the content of information shared tended to be about increasing grass height and reducing fertilizer applications. Finally, we find barriers to sharing ideas based on spatial, temporal, or perception factors but overcoming some of these barriers is possible.

Does multifunctionality matter to US farmers? Farmer motivations and conceptions of multifunctionality in dairy systems.

The concept of multifunctionality describes and promotes the multiple non-production benefits that emerge from agricultural systems. The notion of multifunctional agriculture was conceived in a European context and largely has been used in European policy arenas to promote and protect the non-production goods emerging from European agriculture. Thus scholars and policy-makers disagree about the relevance of multifunctionality for United States agricultural policy and US farmers. In this study, we explore lived expressions of multifunctional agriculture at the farm-level to examine the salience of the multifunctionality concept in the US. In particular, we investigate rotational grazing and confinement dairy farms in the eastern United States as case studies of multifunctional and productivist agriculture. We also analyze farmer motivations for transitioning from confinement dairy to rotational grazing systems. Through interviews with a range of dairy producers in Wisconsin, Pennsylvania, and New York, we found that farmers were motivated by multiple factors--including improved cow health and profitability--to transition to rotational grazing systems to achieve greater farm-level multifunctionality. Additionally, rotational grazing farmers attributed a broader range of production and non-production benefits to their farm practice than confinement dairy farmers. Further, rotational grazing dairy farmers described a system-level notion of multifunctionality based on the interdependence of multiple benefits across scales--from the farm to the national level--emerging from grazing operations. We find that the concept of multifunctionality could be expanded in the US to address the interdependence of benefits emerging from farming practices, as well as private benefits to farmers. We contend that understanding agricultural benefits as experienced by the farmer is an important contribution to enriching the multifunctionality concept in the US context, informing agri-environmental policy and programs, and ultimately expanding multifunctional agricultural practice in the US.

Assessing the homogenization of urban land management with an application to US residential lawn care.

Changes in land use, land cover, and land management present some of the greatest potential global environmental challenges of the 21st century. Urbanization, one of the principal drivers of these transformations, is commonly thought to be generating land changes that are increasingly similar. An implication of this multiscale homogenization hypothesis is that the ecosystem structure and function and human behaviors associated with urbanization should be more similar in certain kinds of urbanized locations across biogeophysical gradients than across urbanization gradients in places with similar biogeophysical characteristics. This paper introduces an analytical framework for testing this hypothesis, and applies the framework to the case of residential lawn care. This set of land management behaviors are often assumed--not demonstrated--to exhibit homogeneity. Multivariate analyses are conducted on telephone survey responses from a geographically stratified random sample of homeowners (n = 9,480), equally distributed across six US metropolitan areas. Two behaviors are examined: lawn fertilizing and irrigating. Limited support for strong homogenization is found at two scales (i.e., multi- and single-city; 2 of 36 cases), but significant support is found for homogenization at only one scale (22 cases) or at neither scale (12 cases). These results suggest that US lawn care behaviors are more differentiated in practice than in theory. Thus, even if the biophysical outcomes of urbanization are homogenizing, managing the associated sustainability implications may require a multiscale, differentiated approach because the underlying social practices appear relatively varied. The analytical approach introduced here should also be productive for other facets of urban-ecological homogenization.

Outcomes of heart transplantation in small children bridged with ventricular assist devices.

BACKGROUND: Ventricular assist devices (VADs) have been used with increasing frequency to bridge small children to heart transplantation (HTx), but outcomes in large cohorts are not well established. METHODS: Small children (≤ 10 kg) bridged to HTx with VADs between 2004 and 2010 were identified in the United Network for Organ Sharing database. Survival was modeled using the Kaplan-Meier method, and 2:1 propensity matching was used to compare outcomes with a well-matched control cohort of nonbridged HTx recipients. RESULTS: Of the 803 small children who underwent HTx during the study period, 59 (7%) were bridged with a VAD. The proportion of recipients that were bridged with a VAD increased from 3% in 2004 to 9% in 2010 (p = 0.03). Kaplan-Meier 30-day, 6-month, and 1-year survival was comparable between those bridged with a VAD and 118 well-matched nonbridged children. Rates of postoperative renal failure, reoperation, infection, and rejection were also comparable. Those bridged with a VAD had a significantly higher rate of postoperative stroke (8.5% vs 0.9%; p = 0.008). CONCLUSIONS: Small children bridged to HTx with a VAD have early survival rates that are comparable to nonbridged children; however, this is achieved at the expense of a higher rate of stroke. Identifying the risk factors for early death and stroke in small children bridged to HTx with VADs is prudent as more experience with this patient population accumulates.

Characteristics of medication use during pediatric medical emergency team events and the role of a pharmacist-provided medication supply.

OBJECTIVES: To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized "pharmacist PMET supply," and the pharmacist's role in implementation and ongoing improvement of a PMET. METHODS: This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. RESULTS: The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the "pharmacist PMET supply." CONCLUSIONS: A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.

Diagnostic reframing of intractable environmental problems: case of a contested multiparty public land-use conflict.

Intractable conflicts are omnipresent in environmental management. These conflicts do not necessarily resist resolution but need to be fundamentally transformed in order to reach agreement. Reframing, a process that allows disputants to create new alternative understandings of the problem, is one way of transforming these conflicts. Cognitive and interactional reframing are the two major approaches to conflict transformation. These approaches have some drawbacks. Cognitive reframing does not guarantee commensurate consideration of all disputants' views about the problem. Interactional reframing is prone to inter-disputant influences that interfere with presenting the problems as accurately as they exist in disputants' minds. Inadequate consideration of other disputants' views and inter-disputant influences often lead to inaccurate problem identification and definition. This in turn leads to solving the wrong problem, enabling intractability to persist. Proper problem identification and definition requires commensurate consideration of all sides of the conflict while minimizing inter-disputant influences. From a problem diagnosis perspective, we show how Q methodology is used to reframe environmental problems, rendering them more tractable to analysis while minimizing the influence of who disputants are talking with, and without ignoring the perspectives of other disputants. Using a case of contentious All-Terrain Vehicle (ATV) use in a state-administered public land, conflicting parties reframed the problem by prioritizing issues, outlining areas and levels of consensus and disagreement, and revealing inherent unrecognized and/or unspoken agendas. The reframing process surprisingly revealed several areas of common ground in disputants' diagnosis of the problem, including lack of emphasis on environmental protection and uncoordinated management factions. Emergent frames were misaligned on some issues, such as the behaviors of ATV riders and the role of management, including political and economic influences on decision making. We discuss how the reframing process enhances tractability of multiparty environmental problems. We point to some limitations of Q methodology as a tool for the diagnostic reframing of such problems.