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This dissertation examines the relationship between commercial beekeepers and the California almond industry to better understand the drivers behind honey bee declines and honey bee (Apis mellifera) vulnerability. Much of the current scholarship on honey bee declines addresses ecological drivers such as pesticides, parasites, and disease. Drawing on critical social theory and the tools of political ecology, this work contextualizes these drivers, and demonstrates that federal and state policies, beekeeper and almond industry management practices, and land use change have played important roles in shaping bee health. Nearly all almond varieties are reliant on honey bee pollination and require approximately two colonies per acre each February. Since the mid-1980s, the almond industry has tripled its acreage from 400,000 acres to 1.2 million acres, and almonds have become one of the top agricultural exports in California. At the same time, beekeepers have struggled with annual colony losses each year as bees have become increasingly vulnerable to parasitic Varroa mites, pesticides, and land use changes that reduce floral resources. How have beekeepers been able to pollinate this ever-increasing acreage with a decreasing number of colonies nationwide? And how has honey bee health suffered as a consequence? These are the primary puzzles motivating this research. I argue that beekeepers were able to pollinate for the almond industry with a diminishing number of colonies for two reasons. First, an increasing percentage of the nation’s beekeepers migrated to pollinate almond bloom, and second, beekeepers industrialized bee production to provide larger colonies for almond pollination. In addition, I argue that producing bees industrially for the almond industry, rather than for honey production, has reconfigured the production of honey bees and contributed to honey bee vulnerability. Bitter Honey is thus a double entendre, with both meanings applicable to the stories told in this dissertation. Materially, it refers to the acrid honey that bees produce during almond bloom, a varietal that beekeepers typically cannot sell. Symbolically, it alludes to the tenuous and at times fraught alliance between the two industries; one where beekeepers struggle to produce an ever-increasing number of bees in the middle of winter, growers increasingly grumble about the high cost of pollination fees, and bees suffer the consequences of industrialized production for commercial agriculture. But it is not only the industrial production of bees for almond pollination that contributes to honey bee vulnerability. Bees can also be exposed to acutely and sublethally toxic agrochemicals while in almond orchards. This is in part because EPA pesticide labeling requirements produce ignorance about bee-toxic agrochemicals. I introduce the terms ‘regulatory disengagement’ and ‘ignorance loops’ to describe how beekeepers disengage from regulatory processes that document bee kills.I also build on theories of access and exclusion, to explain how honey bee vulnerability is perpetuated through lost access to forage, in part due to the neonicotinoid insecticides used on corn and soy in the Midwest. I use the term “toxic exclusion” to describe how pesticide use, in particular, excludes bees and beekeepers from the forage they need to produce honey. Despite the challenges of pollinating for the almond industry, many beekeepers feel an economic imperative to do so as forage for honey production diminishes across the U.S. and cheap honey imports keep the price of honey low. By making honey production increasingly unviable, these trends incentivize beekeepers to shift their operations towards almond pollination, further cementing the U.S. beekeeping industry's dependence on the almond industry.

PURPOSE Perioperative ostomy education is essential for patients to develop skills and comfort with self-care at home with a new ostomy, but shortened hospital length of stay (LOS) reduces time for postoperative education for patients. This study explored the initial experiences and care needs of patients who have undergone creation of a new ostomy during their transition from hospital to home. DESIGN Qualitative interpretive description using latent content analysis. SUBJECTS AND SETTING Thirteen patients who had undergone an elective colorectal surgery involving creation of an ostomy were interviewed. Participants were 33 to 78 years of age, 54% were female, and 62% were undergoing ostomy creation for colorectal cancer operations. Eleven participants underwent temporary ileostomy creation, and 2 patients had permanent end colostomies created. METHODS Interviews were conducted in person and audiotaped by study investigators within 4 to 6 weeks postoperatively. Audiotapes were transcribed verbatim by trained transcriptionists, and each transcript was reviewed in duplicate by study investigators. A latent content analysis method was used to determine the implied meaning in participants' experiences of having a new ostomy. RESULTS The transition from hospital to home with a new ostomy was illustrated by 5 major themes: (1) Having an ostomy is a life-changing and bizarre experience; (2) Adjustment and adaptation occur through acceptance and self-reliance; (3) It's a hands-on thing: with the role of WOC nurse providing support in achieving independence; (4) Improved home care infrastructure is needed; and (5) Practical advice shared from experiential learning. CONCLUSION Patients with new ostomies are motivated and able to cope with the ostomy and regain independence over a short period after surgery. Shorter LOS does not impede ostomy education so long as adequate home care and support group programs are available. Knowledge gained through this study will assist WOC nurses in managing patients' expectations and the planning and delivery of education to patients with newly created ostomies.

Optimal management of bile leaks (BLs) after severe liver injury is unknown. Study objectives were to define current practices in diagnosis and management of BL to determine which patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP).American Association for the Surgery of Trauma grade ≥III liver injuries from 10 North American trauma centers were included in this retrospective study (February 2011 to January 2021). Groups were defined as patients who developed BL versus those who did not. Subgroup analysis of BL patients was performed by management strategy. Bivariate analysis compared demographics, clinical/injury data, and outcomes. Receiver operating characteristic curves were performed to investigate the relationship between bilious drain output and ERCP.A total of 2,225 patients with severe liver injury met the study criteria, with 108 BLs (5%). Bile leak patients had higher American Association for the Surgery of Trauma grade of liver injury ( p0.001) and were more likely to have been managed operatively from the outset (69% vs. 25%, p0.001). Bile leak was typically diagnosed on hospital day 6 [4-10] via surgical drain output (n = 37 [39%]) and computed tomography scan (n = 34 [36%]). On the BL diagnosis day, drain output was 270 [125-555] mL. Endoscopic retrograde cholangiopancreatography was the most frequent management strategy (n = 59 [55%]), although 32 patients (30%) were managed with external drains alone. Bile leak patients who underwent ERCP, surgery, or percutaneous transhepatic biliary drain had higher drain output than BL patients who were managed with external drains alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Receiver operating characteristic curve analysis of BL demonstrated moderate accuracy (area under the receiver operating characteristic curve, 0.636) for ERCP at a cutoff point of 390 mL of bilious output on the day of diagnosis.Patients with BL300 to 400 mL were most likely to undergo ERCP, percutaneous transhepatic biliary drain, or surgical management. Once external drainage of BL has been established, we recommend ERCP be reserved for patients with BL300 mL of daily output. Prospective multicenter examination will be required to validate these retrospective data.Therapeutic and Care Management; Level IV.

BACKGROUND The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN This was a population-based, retrospective administrative analysis. SETTINGS This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p =

HIV/AIDS continues to be a major public health problem throughout the world. In 2011, 23.5 million people were living with HIV/AIDS worldwide, with the greatest burden of disease in Africa, representing 2/3 of the total HIV/AIDS population. Specifically, sub-Saharan Africa bears the highest burden of the disease, with 22.9 million people living with HIV/AIDS (PLWHA), 60% of the total infections worldwide. Furthermore, within this region, women are disproportionately affected, accounting for 58% of people living with HIV/AIDS.1 With the continued high prevalence and incidence of HIV among women, despite an increase in prevention interventions, including pre-exposure prophylaxis (PrEP), suggests behavior change still plays a key role in transmission. This dissertation aims to seek to understand high-risk sexual behaviors and other factors associated with an increased risk of secondary transmission among women in order to inform the implementation of new HIV prevention strategies and reduce the burden of HV. Chapter 1 is a brief introduction into HIV and the high-risk sexual behaviors that affect its transmission. Chapter 2 is based on data from a cohort study of recently sero-converted women from the Microbicide Trials Network (MTN) and demonstrated that depression plays a significant role in the acquisition of STIs. Chapter 3 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that there are several factors that influence disclosure and timing of disclosure of HIV status. Chapter 4 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that high-risk sexual behaviors are still frequent among HIV-infected women, and that ART may modify the risk of high-risk sexual behaviors. Finally, Chapter 5 is a brief discussion of results as well as their implications for future research.

The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes.This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications.One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect.In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.Les Tokyo Guidelines, publiées en 2007, puis mises à jour en 2013 et en 2018, contiennent des recommandations sur le diagnostic et la prise en charge de la cholécystite aiguë. Nous avons évalué le respect de ces lignes directrices dans notre centre universitaire et son incidence sur les issues pour les patients.Ce document est une revue rétrospective de dossiers des patients atteints de cholécystite aiguë calculeuse qui ont subi une cholécystectomie dans notre établissement entre novembre 2013 et mars 2015. La gravité de la cholécystite a été établie de manière rétrospective si elle n’avait pas été documentée avant l’opération. Le respect des recommandations des Tokyo Guidelines concernant le recours à des antibiotiques et la durée de l’opération a été étudié. Nous avons comparé statistiquement les groupes de gravité de la cholécystite, et avons utilisé une régression logistique pour déterminer les prédicteurs de complications.Au total, 150 patients ont été inclus dans l’étude. Parmi eux, 104 avaient une cholécystite légère, 45, une cholécystite modérée et 1, une cholécystite grave. La gravité de la maladie n’avait été documentée avant l’opération pour aucun patient. Le respect des recommandations sur les antibiotiques était faible (18,0 %) et ne variait pas selon la gravité de la cholécystite (p = 0,90). Le respect des recommandations sur la durée de l’opération était de 86,0 %, sans différence entre les groupes (p = 0,63); il était toutefois plus élevé lorsqu’une équipe de soins chirurgicaux aigus participait aux soins (91,0 % c. 76,0 %, p = 0,025). L’analyse multivariée a permis de déterminer que les comorbidités (rapport des cotes [RC] 1,47, intervalle de confiance [IC] de 95 % 1,19–1,85, p0,001) et la conversion en laparotomie (RC 13,45, IC de 95 % 2,16–125,49, p = 0,01) étaient des prédicteurs de complications postopératoires, alors que la gravité de la cholécystite et le respect des recommandations sur les antibiotiques et la durée de l’opération n’avaient pas d’effet.Dans cette étude, le respect des Tokyo Guidelines était acceptable seulement pour la durée de l’opération. Bien qu’un faible respect des recommandations quant à la documentation de la gravité et à l’utilisation d’antibiotiques n’ait pas eu d’effets négatifs sur les issues pour les patients, ces recommandations sont importantes parce qu’elles favorisent l’utilisation appropriée des antibiotiques et une bonne stratification du risque pour le patient.

Background and purpose Adults ages ≥65 years are at increased risk for infectious diseases. Ensuring these individuals are fully vaccinated is imperative. The purpose of this study was to assess the immunization rates of adults ages ≥65 years managed by nurse practitioners (NPs) and compare the results with national immunization rates and Healthy People 2020 goals. Methods A convenience sample of adults ages ≥65 years was obtained from two NP-managed clinics. The vaccine records of each subject were reviewed for documentation of having received five vaccines (tetanus, diphtheria, and pertussis; influenza; pneumococcal polysaccharide vaccine 23; pneumococcal conjugate vaccine 13; and herpes zoster vaccine). Conclusions One hundred and fifty females (70.8%) and 62 males (29.2%) met inclusion criteria. NP-managed patients had higher immunization rates than the national averages across all five major vaccines. The herpes zoster vaccination rates exceeded the recommendations from Healthy People 2020 whereas pneumococcal and influenza rates were below. Implications for practice The stocking of vaccines within the NP-managed clinics, direct billing to Medicare for Part D vaccines, and previsit care planning likely contributed to the high vaccination rates. These high immunization rates in patients managed by NPs provide support for the important role that NPs play in the care of older adults.

Korean children's evaluations of parental restrictions of children's activities based on gender stereotypic expectations were investigated. Third and sixth grade Korean (N = 128) children evaluated scenarios in which a boy or girl desired to play ballet or soccer. Participants used stereotypes to support children's desires to play gender-consistent activities and adhered to parental authority for choice of gender-consistent social activities. Yet, they also rejected parental decisions to treat sons and daughters differently based on the view that it would be unfair. Stereotypic expectations decreased with age and were used more by boys than by girls when evaluating exclusion. The results are discussed in terms of exclusion, development, and culture.

Research Findings: An empirical investigation was conducted to test young Palestinian, Jordanian, Israeli-Palestinian, and Israeli-Jewish children's (N = 433; M = 5.7 years of age) cultural stereotypes and their evaluations of peer intergroup exclusion based upon a number of different factors, including being from a different country and speaking a different language. Children in this study lived in a geographical region that has a history of cultural and religious tension, violence, and extreme intergroup conflict. Our findings reveal that the negative consequences of living with intergroup tension are related to the use of stereotypes. At the same time, the results for moral judgments and evaluations about excluding peers provide positive results about the young children's inclusive views regarding peer interactions. Practice: These findings indicate that practitioners working with young children should focus on inclusion in peer contexts. Curricula, media, and social intervention programs must begin in...

To address the questions and challenges commonly faced by primary care physicians when ordering serologic tests for celiac disease (CD) and provide practical clinical tips to help in the interpretation of test results.MEDLINE was searched from 2000 to 2015 for English-language guidelines on the diagnosis and management of CD published by professional gastroenterological organizations.To screen patients for CD, measurement of the immunoglobulin A (IgA) tissue transglutaminase antibody is the preferred test. Total serum IgA level should be measured to exclude selective IgA deficiency and to avoid false-negative test results. Patients with positive serologic test results should be referred to a gastroenterologist for endoscopic small intestinal biopsies to confirm the diagnosis. Testing for human leukocyte antigens DQ2 and DQ8 can help exclude the diagnosis. A gluten-free diet should not be started before confirming the diagnosis of CD.Serologic testing is very useful for screening patients with suspected CD. Early diagnosis is essential to prevent complications of CD.

Recent discoveries of disease-causing genes in Parkinson's disease (PD) have generated considerable interest regarding genetic testing in PD. The attitudes toward genetic testing are largely influenced by knowledge and preconceived notions.We investigated the relationship between knowledge of and attitude towards predictive genetic testing of PD in two independent centers in America and Asia involving PD patients and caregivers.In a prospective study involving 515 subjects comprising of PD patients and their caregivers in two independent centers in America and Asia, the level of knowledge about genetic testing and patients' attitudes towards such testing were evaluated using a standardized questionnaire.American PD patients had a higher level of knowledge of PD genetics than Asian PD (31.1% vs. 12.3%, p=0.0002). A greater number of American PD patients and caregivers reported a positive attitude towards the potential medical benefits of genetic testing compared to their Asian counterparts (85.4% vs. 42.2%, 92.2% vs. 32.1%, p0.00005), but a more negative attitude towards potential compromise in getting health and life insurance (43.7% vs. 25.8%, p=0.0002). However, in the Asian cohort, multivariate analysis revealed that a high level of genetics knowledge was associated with a positive attitude response regarding the potential medical benefits of testing (p0.0005), but a negative attitude towards compromises in healthcare and life insurance, getting a job and starting a family (p0.0005). These associations were not observed amongst American subjects.The relationship between level of genetic knowledge and attitude towards potential risks and benefits of predictive genetic testing in PD was distinctly different in two independent, racially and culturally different PD populations and caregivers. These observations have clinical implications in the development of PD genetic counseling programs.

An empirical investigation was conducted of young Palestinian, Jordanian, Israeli-Palestinian, and Israeli-Jewish children’s (N = 433; M = 5.7 years of age) cultural stereotypes and their evaluations of peer intergroup exclusion based upon a number of different factors, including being from a different country and speaking a different language. Children in this study live in a geographical region that has a history of cultural and religious tension, violence, and extreme intergroup conflict. Our findings revealed that the negative consequences of living with intergroup tension are related to the use of stereotypes. At the same time, the results for moral judgments and evaluations about excluding peers provided positive results about the young children’s inclusive views regarding peer interactions.

Objective. To determine how parents evaluate decisions about children's autonomy, Korean mothers and fathers as well as nonparental female and male adults, all living in the United States, were interviewed about parental decisions regarding children's engagement in gender consistent and gender inconsistent extracurricular activities. Design. A homogeneous sample of parents and nonparental adults (N = 80) participated to control for social experience beyond parental status. Participants were interviewed about whether it was acceptable for parents to allow their sons and daughters to engage in gender consistent (boy plays baseball, girl takes ballet), gender inconsistent (boy takes ballet, girl plays baseball), and gender neutral (boy goes to a sleepover, girl goes to a sleepover) peer activities, along with questions about autonomy, gender preferences, parental jurisdiction, cultural change, and stereotype knowledge. Results. Whereas all participants promoted autonomy, parents were more likely to sacrifice...

Seventy-two children (35 4 1/2-year-olds and 37 5 1/2-year-olds), nearly evenly divided by gender, from European American (71%), Asian American (17%), and African American (12%) middle-class backgrounds, were individually interviewed about straightforward exclusion and inclusion for two gender-stereotypic peer-group contexts: activities (doll and truck play) and role-play (teacher and firefighter). All children evaluated straightforward exclusion based on gender (e.g., girls excluding a boy from doll play) as wrong and used moral reasons. Preliminary inclusion decisions in the activity contexts (choosing a boy or a girl to join the group) were based on stereotypic expectations, particularly for younger children. Given the opportunity to weigh alternative considerations, however, all children gave priority to fairness over stereotypic expectations in both multifaceted inclusion peer-group contexts.

This research sought to explain the emergence of the Wyoming Core Area Strategy (WCAS), a state-based Greater Sage Grouse conservation plan. It presents a theoretical framework that is based on and adds nuance to the Advocacy Coalition Framework (ACF). The hypothesis this study explored was: if a subsystem's jurisdiction is threatened by a hierarchically superior subsystem's policy outputs and this jurisdiction is necessary to meet the threatened subsystem's goals, then policy change may occur as a result of a strategy by the agents in the threatened subsystem. The data used to examine the hypothesis included expert interviews, historical documents, and interviews from media sources (secondary source interviews). The hypothesis was supported; the WCAS emerged because the Endangered Species Act listing outputs within the Species Conservation Policy Subsystem threatened the Wyoming Land Use Policy (WLUP) Subsystem's jurisdiction, which was necessary to meet the WLUP Subsystem's economic and lifestyle goals; the Governor of Wyoming drove the development and enactment of the WCAS as a strategy to retain jurisdiction. The research demonstrated that in order to fully account for the WCAS's emergence, a less mechanistic view of the framework, one that accounts for the ability of agents in a subsystem to act strategically, was needed. The research also demonstrated that the Greater Sage Grouse conservation benefited from the ESA listing process despite its warranted but precluded listing status. The time frame the research explored was 2002 through March 2012. Master of Arts

Children's and adolescents' social reasoning about exclusion was assessed in three different social contexts. Participants (N = 294) at three ages, 10 years (4th grade), 13.7 years (7th grade), and 16.2 years (10th grade), fairly evenly divided by gender, from four ethnic groups, European-American (n = 109), African-American (n = 96), and a combined sample of Asian-American and Latin-American participants (n = 89) were interviewed regarding their social reasoning about exclusion based on group membership, gender, and race. The contexts for exclusion were friendship, peer, and school. Significant patterns of reasoning about exclusion were found for the context, the target (gender or race) of exclusion, and the degree to which social influence, authority expectations, and cultural norms explained children's judgments. There were also significant differences depending on the gender, age, and ethnicity of the participants. The findings support our theoretical proposal that exclusion is a multifaceted phenomenon and that different forms of reasoning are brought to bear on the issue. This model was drawn from social-cognitive domain theory, social psychological theories of stereotype knowledge and intergroup relationships, and developmental studies on peer relationships. The results contribute to an understanding of the factors involved in the developmental emergence of judgments about exclusion based on group membership as well as to the phenomena of prejudice, discrimination, and the fair treatment of others.

Introduction Although the esophagus constitutes the beginning of the gastrointestinal tract, its study has been more neglected than that of any other component part. This neglect has resulted primarily from the difficulty in investigating symptoms referable to this organ. Recent advances in diagnostic equipment and procedures, however, have made possible a better understanding of the pathophysiology of the esophagus. Flexible esophagoscopes, cinefluorography, the use of transistors in recording esophageal pressures, biopsy, and cytology have made exact study of this structure possible. Decision to utilize any of these procedures must be based upon an awareness of the characteristic symptoms of esophageal disease. Attention is directed to the esophagus by such symptoms as dysphagia, substernal pain during deglutition, heartburn (pyrosis), regurgitation, and hematemesis. Esophageal symptoms usually originate at the site of a lesion; however, pain may extend into the neck, the back, and, if a lesion is near the diaphragmatic portion of

Since the introduction of the flexible gastroscope in this country 23 years ago, gastroscopy has been widely employed, usually in conjunction with roentgenography, in the diagnosis of gastric ulcers and tumors. Two recent reports offer excellent background material on this subject. 2,3 The present study, describing recent experiences with gastroscopy at the University of California Medical Center, was undertaken to define the usefulness of this procedure. In correlating the information obtained, special attention was given to situations where gastroscopy was of value in the detection, exclusion, or appraisal of gastric lesions and to others where it was misleading or noncontributory. Methods The records of 303 consecutive clinic patients who were examined by gastroscopy at the University of California Medical Center between January, 1952, and September, 1954, were reviewed. Of the 303 cases, 70 were considered unacceptable and were excluded from the series—25 because of insufficient follow-up information and 45 because