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IMPORTANCE: The temporal association between the occurrence of neurological diseases, many autoimmune diseases, and vaccination against SARS-CoV-2 has been topically interesting and remains hotly debated both in the medical literature and the clinic. Given the very low incidences of these events both naturally occurring and in relation to vaccination, it is challenging to determine with certainty whether there is any causative association and most certainly what the pathophysiology of that causation could be. OBSERVATIONS: Data from international cohorts including millions of vaccinated individuals suggest that there is a probable association between the adenovirus-vectored vaccines and Guillain-Barré syndrome (GBS). Further associations between other SARS-CoV-2 vaccines and GBS or Bell palsy have not been clearly demonstrated in large cohort studies, but the possible rare occurrence of Bell palsy following messenger RNA vaccination is a topic of interest. It is also yet to be clearly demonstrated that any other neurological diseases, such as central nervous system demyelinating disease or myasthenia gravis, have any causative association with vaccination against SARS-CoV-2 using any vaccine type, although it is possible that vaccination may rarely trigger a relapse or worsen symptoms or first presentation in already-diagnosed or susceptible individuals. CONCLUSIONS AND RELEVANCE: The associated risk between SARS-CoV-2 vaccination and GBS, and possibly Bell palsy, is slight, and this should not change the recommendation for individuals to be vaccinated. The same advice should be given to those with preexisting neurological autoimmune disease.

CONTENTS INTRODUCTION PART I: DIVERSITY IN LEGAL EDUCATION AND PRACTICE--BENEFITS, BARRIERS, AND THE LAW A. Benefits of Diversity in Law Schools B. Barriers to Diversity in Law Schools C. Law [...]

Emissions of biogenic reactive carbon significantly influence atmospheric chemistry, contributing to the formation and destruction of secondary pollutants, such as secondary organic aerosol and ozone. While isoprene and monoterpenes are a major fraction of emissions and have been extensively studied, substantially less is known about the atmospheric impacts of higher-molecular-weight terpenes such as sesquiterpenes. In particular, sesquiterpenes have been proposed to play a significant role in ozone chemical loss due to the very high ozone reaction rates of certain isomers. However, relatively little data are available on the isomer-resolved composition of this compound class or its role in ozone chemistry. This study examines the chemical diversity of sesquiterpenes and availability of ozone reaction rate constants to evaluate the current understanding of their ozone reactivity. Sesquiterpenes are found to be highly diverse, with 72 different isomers reported and relatively few isomers that contribute a large mass fraction across all studies. For the small number of isomers with known ozone reaction rates, estimated rates may be 25 times higher or lower than measurements, indicating that estimated reaction rates are highly uncertain. Isomers with known ozone reaction rates make up approximately half of the mass of sesquiterpenes in concentration and emission measurements. Consequently, the current state of the knowledge suggests that the total ozone reactivity of sesquiterpenes cannot be quantified without very high uncertainty, even if isomer-resolved composition is known. These results are in contrast to monoterpenes, which are less diverse and for which ozone reaction rates are well-known, and in contrast to hydroxyl reactivity of monoterpenes and sesquiterpenes, for which reaction rates can be reasonably well estimated. Improved measurements of a relatively small number of sesquiterpene isomers would reduce uncertainties and improve our understanding of their role in regional and global ozone chemistry.

Context: Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness. Methods: Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007–2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories. Findings: Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period. Conclusions: While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

Women, ethnic minority, and less affluent groups are widely underrepresented in chemistry, a problem that is observed at all levels but begins before college matriculation takes place. The importance of representation and humanization of scientists is crucial. Despite limited progress over recent decades, poor visibility of role models from underrepresented groups remains problematic, emphasizing the importance of initiatives to positively introduce them in classroom settings. Through profiles of underrepresented “success stories” from academia and industry, the ChemDiverse project was developed to encourage underrepresented groups to pursue the chemical sciences at higher education levels by providing teachers with an easy and structured way of encouraging Scottish high school students into science, technology, engineering, and mathematics (STEM). Based on survey feedback from teachers at participating schools, it is a well-formulated project that is easy to implement within the context of the Scottish Curriculum for Excellence.

The article discusses the author's circumnavigation journey from New Zealand to the Whitsunday Islands in Australia, highlighting the challenges of biosecurity clearance and the eerie state of abandoned resorts in the region. Topics include the impact of the pandemic on travel plans, the isolation experienced in the Whitsundays, and a call to clean up the abandoned resorts for a renewed appreciation of the national treasure.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.im.2008.12.007 Byline: Mikko Siponen (a), Robert Willison (b) Keywords: Information systems security; Information security management standards; Information security management; Information security management guidelines; Information security certification Abstract: International information security management guidelines play a key role in managing and certifying organizational IS. We analyzed BS7799, BS ISO/IEC17799: 2000, GASPP/GAISP, and the SSE-CMM to determine and compare how these guidelines are validated, and how widely they can be applied. First, we found that BS7799, BS ISO/IEC17799: 2000, GASPP/GAISP and the SSE-CMM were generic or universal in scope; consequently they do not pay enough attention to the differences between organizations and the fact that their security requirements are different. Second, we noted that these guidelines were validated by appeal to common practice and authority and that this was not a sound basis for important international information security guidelines. To address these shortcomings, we believe that information security management guidelines should be seen as a library of material on information security management for practitioners. Author Affiliation: (a) University of Oulu, IS Security Research Center and Department of Information Processing Science, Linnanmaa, P.O. Box 3000, FIN-90014, Finland (b) Copenhagen Business School, Howitzvej 60, DK-2000 Frederiksberg, Denmark Article History: Received 28 July 2003; Revised 10 April 2007; Accepted 7 December 2008

My reflections in this article are not meant to criticize or pass judgment on any insurance company or health maintenance organization (HMO). They merely offer my perspective on the current [...]

Introduction: Variation across research ethics boards (REBs) in conditions placed on access to medical records for research purposes raises concerns around negative impacts on research quality and on human subject protection, including privacy. Aim: To study variation in REB consent requirements for retrospective chart review and who may have access to the medical record for data abstraction on. Methods: Thirty 90-min face-to-face interviews were conducted with REB chairs and administrators affiliated with faculties of medicine in Canadian universities, using structured questions around a case study with open-ended responses. Interviews were recorded, transcribed and coded manually. Results: Fourteen sites (47%) required individual patient consent for the study to proceed as proposed. Three (10%) indicated that their response would depend on how potentially identifying variables would be managed. Eleven sites (38%) did not require consent. Two (7%) suggested a notification and opt-out process. Most stated that consent would be required if identifiable information was being abstracted from the record. Among those not requiring consent, there was substantial variation in recognising that the abstracted information could potentially indirectly re-identify individuals. Concern over access to medical records by an outside individual was also associated with requirement for consent. Eighteen sites (60%) required full committee review. Sixteen (53%) allowed an external research assistant to information from the health record. Conclusions: Large variation was found across sites in the requirement for consent for research involving access to medical records. REBs need training in best practices for protecting privacy and confidentiality in health research. A forum for REB chairs to confidentially share concerns and decisions about specific studies could also reduce variation in decisions.

Abstract Objectives To assess patients' preferred method of consent for use of information from electronic medical records for research. Design Interviews and a structured survey of patients in practices with [...]

Xlinked retinitis pigmentosa (XLRP) is a heterogeneous disease causing a severe form of retinal degeneration. Patients typically present with night blindness and constricted visual fields within the first two decades [...]

A study of patients hospitalized for heart attack treatment indicates that the very elderly with severe comorbidty are more likely to receive delayed thrombolytic treatment after hospital presentation.These patients have the highest death rate from acute myocardial infarction and thus likely to derive the most benefit from speedy treatment.

Valuation assignments and investment studies rely heavily on discounted cash flow (DCF) analysis. Cash flow models are used in developing market value estimates, performing investment and acquisition analyses, loan underwriting, [...]

Study Design Survey.Introduction AO Spine Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (AO Spine RECODE-DCM) is an international initiative that aims to accelerate knowledge discovery and improve outcomes by developing a consensus framework for research. This includes defining the top research priorities, an index term and a minimum data set (core outcome set and core data elements set – core outcome set (COS)/core data elements (CDE)).Objective To describe how perspectives were gathered and report the detailed sampling characteristics.Methods A two-stage, electronic survey was used to gather and seek initial consensus. Perspectives were sought from spinal surgeons, other healthcare professionals and people with degenerative cervical myelopathy (DCM). Participants were allocated to one of two parallel streams: (1) priority setting or (2) minimum dataset. An email campaign was developed to advertise the survey to relevant global stakeholder individuals and organisations. People with DCM were recruited using the international DCM charity Myelopathy.organd its social media channels. A network of global partners was recruited to act as project ambassadors. Data from Google Analytics, MailChimp and Calibrum helped optimise survey dissemination.Results Survey engagement was high amongst the three stakeholder groups: 208 people with DCM, 389 spinal surgeons and 157 other healthcare professionals. Individuals from 76 different countries participated; the United States, United Kingdom and Canada were the most common countries of participants.Conclusion AO Spine RECODE-DCM recruited a diverse and sufficient number of participants for an international PSP and COS/CDE process. Whilst PSP and COS/CDE have been undertaken in other fields, to our knowledge, this is the first time they have been combined in one process.

Background: Trans-vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a recently popularised minimally invasive surgical procedure, aimed at minimising abdominal wall scars and improving pain and patient recovery times. Although vNOTES has been studied in the context of post-operative pain and cosmesis, women’s acceptance of the technique has only been cursorily examined. In this survey-based observational study, we assessed the acceptability of this technique among a cohort of Middle Eastern women. Materials and methods: A cohort of 175 Middle Eastern women were surveyed using a 13-item questionnaire at a single gynaecology centre. The survey used was a translated version of a questionnaire from a previous study (1) and comprised open-response, five-point Likert Scale and agree-disagree items. Results: Among 175 Middle Eastern women participated in this study most of them holding neutral view on abdominal and gynaecological procedures via vagina. 47% of participants were unsure regarding the effect of surgery via vagina on their sexual function. Although 61% of the participants showed no preference towards vNOTES over laparoscopic cholecystectomy, more than half of them indicated preference if vNOTES shown to be as effective and safe as laparoscopic cholecystectomy. The gender of the surgeon was shown to have no influence on the perspectives of the majority of participants to undergo vNOTES. Conclusions: vNOTES may hold value for women who have conservative upbringing and/or value cosmesis. This study provides information regarding Middle Eastern women’s perspectives on vNOTES, which may be of considerable clinical use as the popularity of this surgical technique continues to increase.

Background: The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care. Objective: To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI). Methods: We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, [Beta]-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone. Results: Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and [Beta]-blockers in these patients compared with those with a generalist attending physician only (P [is less than] .05 for [Beta]-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for [Beta]-blockers, respectively. Conclusions: For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions. Arch Intern Med. 1998;158:1778-1783

Background: In patients who have had acute myocardial infarction, the delay between the onset of symptoms and hospital presentation is a critical factor in determining the initial management strategy and outcomes of treatment. Objective: To examine the determinants of delayed hospital presentation in patients who have had acute myocardial infarction. Design: Retrospective chart review. Setting: 37 hospitals in Minnesota. Patients: 2409 persons hospitalized with acute myocardial infarction between October 1992 and July 1993. Main Outcome Measure: Hospital presentation delayed more than 6 hours after the onset of symptoms of acute myocardial infarction. Results: Information on length of delay was available for 2404 patients. Of these patients, 969 (40%) delayed presentation to the hospital for more than 6 hours after the onset of symptoms. Factors associated with prolonged delay included advanced age and female sex. The presence of chest discomfort and a history of mechanical revascularization significantly reduced the risk for prolonged delay. Risk for delay was greatest during the evening and early morning hours (6:00 p.m. to 6:00 a.m.) Patients with a history of hypertension were more likely to delay presentation. Only 42% of all patients hospitalized with acute myocardial infarction had used emergency medical transport services. Conclusions: Patients who have had acute myocardial infarction often delay hospital presentation. Educational interventions that encourage the prompt use of emergency medical transport services and target specific patient populations, such as elderly persons, women, and persons with cardiac risk factors, may be most successful in reducing the length of delay and improving the outcomes of patients with acute myocardial infarction., Many persons having a heart attack delay seeking hospital care. Delay means that they may miss the window for treatment with clot-dissolving medications. Of 2,400 patients hospitalized for a heart attack, 40% delayed arrival at the hospital for more than six hours after symptom onset. Older patients and women were more likely to delay seeking care as were patients whose symptoms began in the evening and early morning hours. Chest pain and history of angioplasty or bypass surgery reduced the odds of delay. Only 40% arrived via ambulance.

Background: Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings. Methods: Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patient who received thrombolytic, [beta]-blocker, aspirin, and lidocaine hydrochloride therapy. The effects of patient age, gender, and hospital teaching status on the use of these treatments were estimated using logistic regression models. Results: Eligibility for treatment ranged from 68% (n=1627) for aspirin therapy, 38% (n=906) for lidocaine therapy, and 30% (n=734) for thrombolytic therapy to 19% (n=447) for [beta]-blocker therapy. Seventy-two percent of patients eligible to receive a thrombolytic agent received this therapy; 53% received [beta]-blockers; 81% received aspirin; and 88% received lidocaine. Among patients ineligible for lidocaine therapy (n=1503), 20% received this agent. Use of study drugs was lower among eligible elderly patients, especially those older than 74 years (thrombolytic agent: odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; aspirin: odds ratio, 0.4, 95% confidence interval, 0.3 to 0.6; [beta]-blocker: odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Female gender was associated with lower levels of aspirin use among eligible patients (odds ratio, 0.7; 95% confidence interval, 0.6 to 0.9); and there was a trend toward lower levels of [beta]-blocker and thrombolytic use among eligible women. Conclusions: Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients. Lidocaine is still used inappropriately in a substantial proportion of patients with AMI. Increased adherence to AMI treatment guidelines is required for elderly patients and women.

Introduction:This study investigated formaldehyde decontamination efficacy against dried Bacillusspores on porous and non-porous test surfaces, under various environmental conditions. This knowledge will help responders determine effective formaldehyde exposure parameters to decontaminate affected spaces following a biological agent release.Methods:Prescribed masses of paraformaldehyde or formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor within a bench-scale test chamber. Adsorbent cartridges were used to measure formaldehyde vapor concentrations in the chamber at pre-determined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. Spores of Bacillus globigii, Bacillus thuringiensis,and Bacillus anthraciswere inoculated and dried onto porous bare pine wood and non-porous painted concrete material coupons. A series of tests was conducted where temperature, relative humidity, and formaldehyde concentration were varied, to determine treatment efficacy outside of conditions where this decontaminant is well-characterized (laboratory temperature and humidity and 12?mg/L theoretical formaldehyde vapor concentration) to predict decontamination efficacy in applications that may arise following a biological incident.Results:Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations collected in the ambient temperature trials (approximately 22°C). Generally, decontamination efficacy on wood was lower for all three spore types compared with painted concrete. Also, higher recoveries resulted from painted concrete compared to wood, consistent with historical data on these materials. The highest decontamination efficacies were observed on the spores subjected to the longest exposures (48 hours) on both materials, with efficacies that gradually decreased with shorter exposures. Adsorption or absorption of the formaldehyde vapor may have been a factor, especially during the low temperature trials, resulting in less available formaldehyde in the air when measured.Conclusion:Environmental conditions affect formaldehyde concentrations in the air and thereby affect decontamination efficacy. Efficacy is also impacted by the material with which the contaminants are in contact.

Since 2012, the Mashantucket Pequot Museum and Research Center in Mashantucket, Connecticut, in collaboration with the University of Connecticut, has carried out a research program to survey and document the battlefields of the Pequot War (1636–1637). The unique nature of the project has required the refinement of the long-standing field methods of battlefield archaeology. In this article, we argue that these techniques, while originally developed to explore sites of conflict, can be operationalized to locate 17th-century indigenous domestic sites. We describe this modified method and provide a site-specific case study to present its efficacy.

In the βTC3 insulin-secreting β-cell line, glucose rapidly induces the tyrosine phosphorylation of the 97-kDa insulin receptor β-subunit. Phosphorylation is transient, with fourfold stimulation by 2 min and subsequent dephosphorylation [...]

Thrift institutions, commercial banks, and insurance companies have been left with the legacy of real estate lending in the 1980s: value deterioration, increased delinquency and default rates, increased property vacancy [...]

Frequency-synthesis techniques provide stabilized RF and microwave signals to a wide range of defense-electronics systems, including electronic-warfare (EW) systems, signal-intelligence (SIGINT) receivers, and tactical radios. While a variety of analog [...]

ABSTRACTThis article analyzes an educational initiative between Kew Gardens, Royal Holloway, University of London, and two London primary schools. The schools, located in areas of high ethnic diversity, worked with the members of the Mobile Museum project team – including the Learning Department at Kew and researchers at both institutions – to create their own school museums. The idea was inspired by historical research conducted by the project team that demonstrated Kew’s historic involvement in the promotion of object-based learning in schools. The project team worked with teachers and pupils to develop a participatory approach to learning about plants and their uses through the creation of school museums. A whole-school framework was adopted, extending the potential reach of the project to pupils’ parents and communities. Inspired by the collections at Kew, schools used plants and plant-associated artifacts to learn more about the rich diversity of pupils' cultural backgrounds and the importance of plants to their heritage and their everyday lives.

This article explores the lessons that US governmental organizations can learn from the private sector in managing research and development (R&D) projects. It emphasizes the importance of understanding user needs, adapting requirements, evaluating success at the portfolio level, accepting failure as part of the process, and constructing a balanced R&D portfolio. By applying these lessons, the US government can foster innovation and become a global leader in R&D. The article draws insights from leading R&D organizations in the pharmaceutical, aerospace, and venture capital sectors. [Extracted from the article]

•Denmark, the US, and Canada are representative high-income liberal democracies.•Where vaccination uptake was higher deaths were lower despite low booster uptake.•A continuously updated strategy plan for future pandemics is important.

Published at www.cmaj.ca on Sept. 13, 2005. Emergency contraception (1) is just the latest example in a long list of medications that are being shifted from prescription only to over-the-counter [...]

Introduction:This effort investigated formaldehyde vapor characteristics under various environmental conditions by the analyses of air samples collected over a time-course. This knowledge will help responders achieve desired formaldehyde exposure parameters for decontamination of affected spaces after a biological contamination incident.Methods:Prescribed masses of paraformaldehyde and formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor. Adsorbent cartridges were used to collect air samples from the test chamber at predetermined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. In addition, material demand for the formaldehyde was evaluated by inclusion of arrays of Plexiglas panels in the test chamber to determine the impact of varied surface areas within the test chamber. Temperature was controlled with a circulating water bath connected to a radiator and fan inside the chamber. Relative humidity was controlled with humidity fixed-point salt solutions and water vapor generated from evaporated water.Results:Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations in the ambient temperature trials (approximately 22°C). The addition of clear Plexiglas panels to increase the surface area of the test chamber interior resulted in appreciable decreases of formaldehyde air concentration when compared to an empty test chamber.Conclusion:This work has shown that environmental variables and surface-to-volume ratios in the decontaminated space may affect the availability of formaldehyde in the air and, therefore, may affect decontamination effectiveness.

Drainage water recycling (DWR) involves capture, storage, and reuse of surface and subsurface drainage water as irrigation to enhance crop production during critical times of the growing season. Our objectives were to synthesize 53 site‐years of data from 1996 to 2017 in the midwestern United States to determine the effect of DWR using primarily subirrigation on corn (Zea maysL.) grain yield and yield variability and to identify precipitation factors at key stages of corn development (V1–V8, V9–VT, R1–R2, R3–R4, and R5–R6) that correlated to an increase in yield with DWR. A generalized additive model was used to quantify and characterize the relationship between precipitation and corn grain yield during corn development stages and to determine if that relationship differed between DWR and free drainage (FD). Corn yield response to precipitation was generally similar between DWR and FD, except during the critical period of V9–R2, in which DWR was more resilient to precipitation extremes than FD. Drainage water recycling was generally more responsive than FD in years with low and normal precipitation (<181 mm). When precipitation was low (27–85 mm) from V9 to R2, DWR had higher yields (77% of the site‐years evaluated), with an average yield increase of 3.6 Mg ha−1(1.2–7.5 Mg ha−1). Overall, FD had 28% greater yield variability than DWR. Additional research is needed on DWR impacts on different soils and locations throughout this region to improve the stability of corn yields and to develop automated DWR systems for enhancing efficiency of water management with increasing climate variability.