Conceptualizing Trust and Distrust as Alternative Stable States: Lessons from the Flint Water Crisis.

Despite the universally recognized importance of fostering trust and avoiding distrust in governance relationships, there remains considerable debate on core questions like the relation between (dis)trust and the evaluations of the characteristics that make a governance agent appear (un)worthy of trust. In particular, it remains unclear whether levels of (dis)trust simply follow levels of (dis)trustworthiness-such that building trust is primarily a question of increasing evidence of trustworthiness and avoiding evidence of distrustworthiness, or if their dynamics are more complicated. The current paper adds novel theory for thinking about the management of trust and distrust in the governance context through the application of principles borrowed from resilience theory. Specifically, we argue that trust and distrust exist as distinct, self-reinforcing (i.e., stable) states separated by a threshold. We then theorize as to the nature of the self-reinforcing processes and use qualitative data collected from and inductively coded in collaboration with Flint residents as part of a participatory process to look for evidence of our argument in a well-documented governance failure. We conclude by explaining how this novel perspective allows for clearer insight into the experience of this and other communities and speculate as to how it may help to better position governance actors to respond to future crises.

Survival by genotype: patterns at Mc1r are not black and white at the White Sands ecotone.

Measuring links among genotype, phenotype and survival in the wild has long been a focus of studies of adaptation. We conducted a 4-year capture-recapture study to measure survival by genotype and phenotype in the Southwestern Fence Lizard (Sceloporus cowlesi) at the White Sands ecotone (transition area between white sands and dark soil habitats). We report several unanticipated findings. First, in contrast with previous work showing that cryptic blanched coloration in S. cowlesi from the heart of the dunes is associated with mutations in the melanocortin-1 receptor gene (Mc1r), ecotonal S. cowlesi showed minimal association between colour phenotype and Mc1r genotype. Second, the frequency of the derived Mc1r allele in ecotonal S. cowlesi appeared to decrease over time. Third, our capture-recapture data revealed a lower survival rate for S. cowlesi individuals with the derived Mc1r allele. Thus, our results suggest that selection at the ecotone may have favoured the wild-type allele in recent years. Even in a system where a genotype-phenotype association appeared to be black and white, our study suggests that additional factors - including phenotypic plasticity, epistasis, pleiotropy and gene flow - may play important roles at the White Sands ecotone. Our study highlights the importance of linking molecular, genomic and organismal approaches for understanding adaptation in the wild. Furthermore, our findings indicate that dynamics of natural selection can be particularly complex in transitional habitats like ecotones and emphasize the need for future research that examines the patterns of ongoing selection in other ecological 'grey' zones.

Examining the relationship between ovarian reserve, as measured by basal FSH levels, and the risk of poor obstetric outcome in singleton IVF gestations.

BACKGROUND: The higher prevalence of preterm birth (PTB) and low birthweight (LBW) following infertility treatment may relate to the treatment itself or indicate that subfertility predisposes to a higher risk. Our aim was to examine whether basal FSH levels are related to the risk for PTB and LBW among pregnancies resulting from IVF. METHODS: We studied a retrospective cohort in the 2008 National Society for Assisted Reproductive Technology Database, including all women who underwent a fresh non-donor IVF cycle resulting in a singleton live birth having a recorded basal serum FSH value (n = 14 262). The FSH value used was either the maximum basal or clomiphene-stimulated serum level. Log binomial models were created to assess the associations between FSH and PTB (<37 weeks), and between FSH and LBW (<2500 g), adjusting for maternal age, ethnicity, gravidity/parity, history of PTB, smoking, BMI and infant gender. RESULTS: Data for 14 086 patients were analyzed. FSH levels were inversely related to the risk of PTB and LBW. Women in the highest quartile of FSH levels (≥ 9 mIU/ml) had the longest adjusted mean gestational age (271.2 days), the lowest adjusted relative risk (RR) of PTB [0.87, 95% confidence interval (CI): 0.76-1.01], the highest adjusted mean birthweight (3249 g) and the lowest adjusted RR of LBW (0.89, 95% CI: 0.73-1.04). CONCLUSIONS: The inverse relationship between maximal basal FSH levels and the risk for PTB and LBW in singleton IVF gestations suggests that diminished ovarian reserve is not the primary mediator of the increased prevalence of PTB and LBW in IVF pregnancies.

Oncoplastic breast conserving surgery: a renaissance of anatomically-based surgical technique.

Using oncoplastic surgical techniques for breast preservation, breast surgeons can achieve widened surgical margins at the same time that the shape and appearance of the breast is preserved and sometimes rejuvenated. Oncoplastic surgical resection is designed to follow the cancer's contour, which generally follows the segmental anatomy of the breast, which has been well understood since the mid 19th century because of pioneering anatomic studies performed by Sir Astley Paston Cooper. The quadrantectomy, developed by Veronesi and colleagues in the 1970's, follows these same anatomic principles of wide segmental resection. The more surgically narrow lumpectomy as popularized in the U.S. uses a smaller, scoop-like non-anatomic resection of cancer. With negative surgical margins, the lumpectomy is equivalent to the quadrantectomy in achieving the goals of breast conservation as measured by local recurrence and survival. However, the lumpectomy is less versatile for resection of larger cancers, and can be more prone to creating suboptimal cosmetic defects. Cancers with large in situ components can be particularly problematic for resection with the standard lumpectomy, when they extend both centrally toward the nipple and peripherally to distal terminal ductulo-lobular units, which typically occur in a pie-shaped segmental distribution. Ductal segments, each of which ultimately drains to a single major lactiferous sinus at the nipple, vary in size and depth in the breast. Breast surgeons should carefully evaluate the cancer distribution and extent in the breast before operation. A combination of imaging methods (mammography with magnification views, ultrasonography, magnetic resonance imaging [MRI], or all) may yield the best estimates of overall tumor extent. Multiple bracketing wires afford the greater help to complete surgical excision. Those tumors with segmental spreading are best excised by oncoplastic resections according to their distribution.

Prevalence of hypersensitivity to specific fungal allergens as determined by intradermal dilutional testing.

OBJECTIVE: To determine fungal allergen reactivity prevalence by intradermal dilutional testing in patients with and without chronic rhinitis or rhinosinusitis symptoms. STUDY DESIGN: Prospective comparison of fungal allergen reactivity prevalence in symptomatic and asymptomatic patients. SETTING: University medical center. METHODS: Group I (chronic rhinitis and/or rhinosinusitis symptoms) and Group II (asymptomatic) patients underwent intradermal dilutional testing with usual and fungal allergens. RESULTS: Fungal reactivity occurred in 65% (13/20) of Group I, and 13% (4/30) of Group II (P < 0.0002 by chi(2) testing). Group I was more reactive to non-fungal allergens (85% vs. 33%, p < 0.0004), and to all allergens considered together (95% vs. 40%, p < 0.0001). CONCLUSIONS: Patients with chronic rhinitis and rhinosinusitis symptoms were more reactive to fungal and nonfungal allergens. Fungal allergens were as likely as nonfungal to elicit reactivity. SIGNIFICANCE: These findings suggest a role for fungal hypersensitivity in chronic rhinitis and chronic rhinosinusitis.

The impact of a skilled nursing facility on the cost of surgical treatment of major head and neck tumors.

BACKGROUND: The finite resources available for health care and the proliferation of managed care in the United States have forced the head and neck surgeon to critically evaluate the cost of tumor treatment. OBJECTIVE: To determine whether the cost of treating patients with head and neck tumors would be reduced if the patients were to spend a portion of what would otherwise be acute care hospital days in a hospital-based skilled nursing facility (HB/SNF). DESIGN: Retrospective cost-benefit analysis. SETTING: Tertiary referral center. PATIENTS: Twenty-four consecutive hospital admissions for definitive surgical treatment of head and neck tumors were retrospectively reviewed. The postoperative day on which the patient theoretically could have been transferred to the HB/SNF was determined. The charges and cost of each patient's actual hospital stay were compared with the theoretical counterparts had the patient been transferred to the HB/SNF on the determined day. MAIN OUTCOME MEASURE: Cost savings. RESULTS: The total hospital stay for the 24 patients was 524 days. One hundred eighty-two of those days could have been spent in the HB/SNF. The total charge and cost savings with the use of an HB/SNF were $201,045 and $84,238, respectively (15% of the total charge and cost). This represents an average charge and cost savings of $8377 and $3510, respectively, per patient. The difference was statistically significant (P<.005). CONCLUSION: An HB/SNF could reduce the cost of head and neck tumor treatment without compromising patient care.

Sexual revictimization prevention: an outcome evaluation.

This investigation tested a program to reduce women's risk for sexual revictimization. Participants were 66 women with histories of sexual victimization as adolescents or adults who were randomly assigned to a preventive intervention group or a no-treatment control group. They completed initial measures assessing history of sexual assault, self-efficacy, and psychological functioning, returning approximately 2 months later for follow-up assessment using the same measures. Results suggest that the prevention program may be effective in reducing the incidence of sexual assault revictimization in this population. In addition, participants in the intervention group displayed significant improvement in psychological adjustment and self-reported self-efficacy.

Homophobia and physical aggression toward homosexual and heterosexual individuals.

This study examined the relationship between homophobia (defined as self-reported negative affect, avoidance, and aggression toward homosexuals) and homosexual aggression. Self-identified heterosexual college men were assigned to homophobic (n = 26) and nonhomophobic (n = 26) groups on the basis of their scores on the Homophobia Scale (HS; L. W. Wright, H. E. Adams, & J. A. Bernat, 1999). Physical aggression was examined by having participants administer shocks to a fictitious opponent during a competitive reaction time (RT) task under the impression that the study was examining the relationship between sexually explicit material and RT. Participants were exposed to a male homosexual erotic videotape, their affective reactions were assessed, and they then competed in the RT task against either a heterosexual or a homosexual opponent. The homophobic group reported significantly more negative affect, anxiety, and anger-hostility after watching the homosexual erotic videotape than did the nonhomophobic group. Additionally, the homophobic group was significantly more aggressive toward the homosexual opponent, but the groups did not differ in aggression toward the heterosexual opponent.

Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women.

Symptoms of depression and posttraumatic stress disorder (PTSD) were examined for their association with health status in a sample of sexual assault victims. Hypotheses were that symptoms of each disorder would account for unique variance in health status among individuals exposed to traumatic stressors. Fifty-seven sexually assaulted college women were assessed for prior victimization history, assault characteristics, and depressive and PTSD symptoms. When prior history of sexual victimization, assault severity, and physical reactions during the assault were controlled, hierarchical multiple regression models indicated that symptoms of PTSD and depression were significantly associated with global health perceptions and severity of self-reported health symptoms. Only PTSD symptoms were significantly associated with reproductive health symptoms. The results suggest that both symptoms of PTSD and depression account for the relationship between exposure and health impairment among sexual assault victims.

Sexually aggressive and nonaggressive men: sexual arousal and judgments in response to acquaintance rape and consensual analogues.

Self-identified sexually aggressive (SA) and nonaggressive (NA) college men listened to audiotape analogues of consensual sexual intercourse and acquaintance rape. Phallometric and decision-latency methodology was used to examine sexual arousal and decisions to stop sexual advances in each scenario. Both groups showed increases in penile response to the consensual scenario. Consistent with the inhibition model of sexual aggression, the SA group showed greater sexual arousal and failed to inhibit responding when force was introduced in the rape, whereas the NA group exhibited less arousal and greater inhibition to force. The SA group allowed the rape to continue significantly longer than the NA group. These effects were greatly magnified in SA men who endorsed high calloused sexual beliefs, implying that a cognitive set that justifies sexual aggression and lacks victim empathy may disinhibit sexual arousal and potentiate coercive decision making.

Risk recognition and trauma-related symptoms among sexually revictimized women.

This study used experimental methodology to investigate the differential impact of various levels of sexual victimization on women's perceptions of risk and evaluative judgments of sexual assault within a dating interaction. Single- and multiple-incident victims were compared with nonvictims. Results supported the hypothesis that revictimized women would exhibit longer latencies than either single-incident victims or nonvictims in signaling that an audiotaped date rape should be halted. Revictimized women with greater posttraumatic stress disorder (PTSD) symptoms, arousal symptoms in particular, exhibited latencies similar to those of nonvictims, whereas revictimized women with lower levels of PTSD symptoms had significantly longer latencies. Dissociative symptoms were not related to latency. These findings suggest that PTSD-related arousal symptoms may serve a buffering effect, increasing sensitivity to threat cues that portend a sexually coercive interaction.

Nocturnal nasal congestion and nasal resistance.

OBJECTIVES: To compare total nasal resistance (TNR) in upright and supine positions in patients who did and did not complain of nocturnal (supine) nasal congestion symptoms without daytime (upright) congestion, and to determine what other conditions were associated with nocturnal nasal congestion (NNC) symptoms. STUDY DESIGN: A prospective study comparing objectively measured nasal airflow in different positions (upright and reclining) with subjective patient symptoms. METHODS: Subjects completed a questionnaire about nasal symptoms. Anterior rhinomanometry was performed with patients upright, reclined 45 degrees, and supine. TNR in subject subsets was compared using the Student t test. RESULTS: TNR did not differ between upright patients with (n = 27) and without (n = 20) NNC. Supine TNR (P < .04) and increase in TNR (P < .02) between upright and supine was greater in patients with NNC. Smokers (n = 15, 10 with NNC, 5 without) had greater TNR increases when supine versus nonsmokers (P < .02). Patients with rhinitis symptoms (n = 29, 18 with NNC, 11 without) had greater TNR increases when supine than patients without rhinitis (P < .01). Patients who both smoked and had rhinitis (n = 11, 7 with NNC, 4 without) had a greater supine TNR than patients who smoked or had rhinitis alone (P < .02). CONCLUSIONS: Some patients without daytime nasal congestion experience NNC. They have a significantly greater TNR increase when supine versus patients without NNC. Smokers and patients with rhinitis, with or without NNC, have a significantly greater TNR increase when supine versus nonsmokers or patients without rhinitis. Smoking cessation and treatment of rhinitis may improve the patients' NNC.

Traumatic stress in HIV-infected women.

This study assesses the prevalence of specific traumatic stressors that meet criterion A for the Diagnostic and Statistical Manual of Mental Disorders' (DSM-IV) diagnosis of posttraumatic stress disorder (PTSD) and symptoms of PTSD in a representative sample of HIV-infected women. The study also assesses the impact of these stressors and symptoms on the clinical progression of HIV infection. The Life Stressor Checklist and the Impact of Events Scale-Revised were administered via interview to 67 Africa-American women beyond the initial stages of HIV infection. The ratio of CD4 t-cells to CD8 t-cells were abstracted from medical records at dates that approximated psychological interviews and were examined at two points in time 12 to 14 months apart. The prevalence of traumatic stressors and PTSD symptoms were high among HIV-infected women. Traumatic stressors were significantly associated with a lower CD4 to CD8 ratio at the 1-year follow-up. Among women who reported a traumatic event, those who also met criteria for PTSD evidenced a lower CD4 to CD8 ratio at the follow-up assessment. The study concludes that prevention and treatment efforts targeted at HIV-infected women must take into account traumatic stressors and PTSD symptoms and their potential impact on the course of the disease.

Effect of diameter of microvascular interposition vein grafts on vessel patency and free flap survival in the rat model.

Interposition vein grafting is an important technique in microvascular free tissue transfer. Studies in rats have demonstrated that the patency rate of vessels is not affected by interposition grafting when the vein grafts and receipt vessels are of similar diameter. Size discrepancy between vein grafts and recipient vessels is frequently encountered in clinical practice and may potentially be an important factor in anastomotic patency. This study was, therefore, designed to assess the effect of vein graft diameter on the patency of arterial repair and survival of a groin free flap in the rat model. Forty-nine Sprague-Dawley rats were used. The inferior epigastric and femoral veins were used to reconstruct the femoral artery in situ (12 rats, 24 anastomoses) and in groin free flaps (30 rats). The vessel patency with inferior epigastric (1:1 size match) and femoral (2:1 size match) veins was 100% in the non free flap model. In the free flap model, flap survival was 30% in the femoral (2:1 size match) vein graft group. This was significantly less than both the free flap epigastric vein graft group (90% survival) and primary anastomoses group (100% survival). The results of this study suggest that size-matched interposition vein grafts can provide a high degree of reliability, but with size mismatch vein grafts are prone to thrombus formation and subsequent free flap failure.

Sexual coercion history, calloused sexual beliefs and judgments of sexual coercion in a date rape analogue.

This study compared men with and without a history of coercive sexual behavior on their judgments of how far a man should go in using coercion in an audiotaped date rape simulation. Calloused sexual beliefs (CSB) and a "token resistance" manipulation were expected to differentially interact with coercion history. Results showed no effect for "token resistance." Calloused sexual beliefs interacted with coercion group, such that sexually coercive men high in CSB took significantly longer to stop the date rape interaction than coercive men low in CSB, who did not differ from noncoercive men. These findings support a model of sexual coercion in which a cognitive set consisting of rape-supportive beliefs may serve as a disinhibitor of behavior.

Age-related changes in orofacial force generation in women.

OBJECTIVES: This study was designed to assess the effect of age on orofacial force generation. STUDY DESIGN: Forty women participated in a cross-sectional design, with 10 in each age group from 20 to 39, 40 to 59, 60 to 79, and 80 to 100 years of age. METHODS: Measures of force generation were obtained for the upper lip, lower lip, tongue, and jaw. RESULTS: There were no statistical differences among age groups, probably because of large individual variability within groups. Trends indicated a decline, particularly after age 80 years. CONCLUSION: Although trends in the data suggest some decline in the function of orofacial structures with age, it is unlikely that these changes would noticeably affect functional communication.

Role of screening chest computed tomography in patients with advanced head and neck cancer.

OBJECTIVE: The presence of pulmonary metastases significantly alters the treatment of patients with head and neck cancers. Currently, a chest radiograph (CXR) is used as a screening examination, although a chest CT (CCT) can detect smaller lesions. The aim of this study was to evaluate the benefit of CCT as a screening tool in patients with newly diagnosed advanced head and neck cancers. METHOD: New patients with stage III and IV head and neck squamous cell carcinomas were enrolled in this prospective study from August 1994 to December 1995. Twenty-five patients underwent CXR ($71) and CCT ($597) within 2 weeks of diagnosis of the index cancer. RESULTS: In 20 patients neither the CXR nor the CCT showed any evidence of pulmonary malignancy. Two patients had normal CXRs but possible metastases on CCT. Both the pulmonary lesions resolved on follow-up evaluation. Two patients had suspicious lesions on CXR, 1 of whom had a normal CCT. The second patient underwent CT-guided biopsy which was negative for malignancy. Both the CXR and CCT of the final patient, who had a bronchogenic carcinoma, were suspicious. CONCLUSION: In 2 patients CCT detected suspicious lesions missed on CXR, although neither revealed malignancy. Three patients with suspicious CXRs would have had CCTs anyway. Thus 22 of 25 CCTs done at the additional cost of $13,314 did not add to the sensitivity of the screening for pulmonary metastasis or second lung primary.

An integrated theory of the no-reflow phenomenon and the beneficial effect of vascular washout on no-reflow.

OBJECTIVES: No-reflow is failure of perfusion in free tissue transfer despite adequate arterial inflow. The objectives of this study were to construct a theory of interactive mechanisms of the no-reflow phenomenon and to determine whether preischemic vascular washout could increase flap ischemia tolerance. STUDY DESIGN: The evidence for the role of various mechanisms in the development of no-reflow is reviewed, and an integrated network proposed. A rat-groin free flap model is used to test preischemic vascular washout with normal saline, heparinized normal saline, lactated Ringer's solution, Tis-U-Sol, and Viaspan. METHODS: The mean ischemia tolerance of this flap without any therapeutic intervention was first determined, using 22 animals. An additional 50 animals were used to compare with the control group the ischemia tolerance of flaps washed out with the above fluids before their ischemic period. RESULTS: The critical ischemia time 50 (time after which half of the flaps are expected to survive and half, die) of the untreated flap is 23.4 hours in this model (P<.05). Flaps washed out with normal saline or lactated Ringer's solution have significantly worse ischemia tolerance (P<.0001). Flaps washed out with Tis-U-Sol or Viaspan behave similarly to the control group (P>.57). Flaps receiving preischemic washout with heparinized normal saline (4,000 units/L) had a significantly better outcome than the control group (P<.027). CONCLUSIONS: Preischemic washout with normal saline, lactated Ringer's solution, or heparinized Tis-U-Sol is detrimental for flap survival after ischemia, Tis-U-Sol- and Viaspan-treated flaps do have ischemia tolerance similar to the control group, and flaps washed out with heparinized normal saline have a survival advantage in this model.

Epistaxis.

Epistaxis is a common clinical problem. The widespread availability of endoscopic equipment is shifting management philosophy toward targeting the bleeding point. This shift may have a significant impact on decreasing length of stay and blood transfusion rates. Advances in interventional radiology have also reduced the risk of embolization. Patient education, especially teaching first-aid measures to patients at high risk for nosebleeds, also encourages more effective use of health care resources.