Navigating Institutional Challenges: Design to Enable Community Participation in Social Learning for Freshwater Planning.

Social learning is a process suited to developing understanding and concerted action to tackle complex resource dilemmas, such as freshwater management. Research has begun to recognise that in practice social learning encounters a variety of institutional challenges from the shared habits and routines of stakeholders (organised by rules, norms and strategies) that are embedded in organisational structures and norms of professional behaviour. These institutional habits and routines influence the degree of willingness to engage with stakeholders, and expectations of behaviours in social learning processes. Considering this, there has been a call to understand how institutions influence social learning and emergent outcomes. We addresses this by presenting a heuristic for implementing social learning cognisant of institutional context to answer three questions: (i) How institutional influences impact implementation of social learning design; (ii) how implementation of social learning design modifies institutions influencing social learning; and (iii) how these changes in design and institutions together shape social learning outcomes? To answer these questions a freshwater planning exercise was designed, implemented and evaluated as a social learning process with community groups in two New Zealand catchments. Incorporating participatory reflection enabled the project team to modify social learning design to manage institutional influences hindering progress toward outcomes. Findings emphasise that social learning is underpinned by participants' changing assumptions about what constitutes the institution of learning itself-from instruction to a dynamic, collective and emergent process. Reflecting on these assumptions also challenged participants' expectations about their own and others' behaviours and roles in freshwater planning.

Severe Hypertriglyceridemia Possibly Masked Acute Pancreatitis and Led to a Difficult Diagnosis in an Obese Patient with Ketoacidosis-onset Type 2 Diabetes.

A young obese man with ketoacidosis-onset type 2 diabetes mellitus, associated with severe hypertriglyceridemia, was admitted to a local hospital complaining of abdominal pain. Although the abdominal pain worsened, his serum amylase level remained normal with persistent severe hypertriglyceridemia until the second day of hospitalization. The next day, computed tomography showed severe acute pancreatitis (AP) with serum amylase elevation, while the patient's triglyceride level decreased to 558 mg/dL. He was transferred to our hospital and recovered after intensive care. AP accompanied by diabetic ketoacidosis is not rare but an early diagnosis can be difficult to make due to normal amylase levels in the presence of severe hypertriglyceridemia.