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The highly productive northern Bering and Chukchi marine shelf ecosystem has long been dominated by strong seasonality in sea-ice and water temperatures. Extremely warm conditions from 2017 into 2019—including loss of ice cover across portions of the region in all three winters—were a marked change even from other recent warm years. Biological indicators suggest that this change of state could alter ecosystem structure and function. Here, we report observations of key physical drivers, biological responses and consequences for humans, including subsistence hunting, commercial fishing and industrial shipping. We consider whether observed state changes are indicative of future norms, whether an ecosystem transformation is already underway and, if so, whether shifts are synchronously functional and system wide or reveal a slower cascade of changes from the physical environment through the food web to human society. Understanding of this observed process of ecosystem reorganization may shed light on transformations occurring elsewhere. Exceptionally warm years in 2017–2019 have caused changes in the physical and biological characteristics of the Pacific Arctic Ocean. What these changes mean for the ecosystem and societal consequences will depend on if they are evidence of a transformation or anomalies in the system.

Background Traditionally, clinical psychomotor skills are taught through videos and demonstration by faculty, which does not allow for the visualization of internal structures and anatomical landmarks that would enhance the learner skill performance. Method Sophomore and junior nursing students attending a large Midwestern institution (N = 69) participated in this mixed methods study. Students demonstrated their ability to place a nasogastric tube (NGT) after being randomly assigned to usual training (control group) or an iPad anatomy-augmented virtual simulation training module (augmented reality [AR] group). The ability of the participants to demonstrate competence in placing the NGT was assessed using a 17-item competency checklist. After the demonstration, students completed a survey to elicit information about students' level of training, prior experience with NGT placement, satisfaction with the AR technology, and perceptions of AR as a potential teaching tool for clinical skills training. Results The ability to correctly place the NGT through all the checklist items was statistically significant in the AR group compared with the control group (p = .011). Eighty-six percent of participants in the AR group rated AR as superior/far superior with other procedural training programs to which they had been exposed, whereas, only 5.9% of participants in the control group rated the control program as superior/far superior (p Conclusions Overall, the AR module was better received compared with the control group with regard to realism, identifying landmarks, visualization of internal organs, ease of use, usefulness, and promoting learning and understanding.

Background Application of annuloplasty rings during mitral valve (MV) repair has been shown to significantly change the mitral annular geometry. Until recently, a comprehensive two-dimensional echocardiographic evaluation of annular geometric changes was difficult owing to its nonplanar orientation. In this study, an analysis of the three-dimensional intraoperative transesophageal echocardiographic evaluation of the MV annulus is presented before and immediately after repair. Methods We performed three-dimensional geometric analysis on 75 patients undergoing MV repair during coronary artery bypass graft surgery for mitral regurgitation or myxomatous mitral valve disease. Geometric analysis of the MV was performed before and immediately after valve repair with full rings and annuloplasty bands. The acquired three-dimensional volumetric data were analyzed in the operating room. Specific measurements included annular diameter, leaflet lengths, the nonplanarity angle, and the circularity index. Before and after repair data were compared. Results Complete echocardiographic assessment of the MV was feasible in 69 of 75 patients (92%) within 2 to 3 minutes of acquisition. Placement of full rings resulted in an increase in the nonplanarity angle or a less saddle shape of the native mitral annulus (137 ± 14 versus 146 ± 14; p = 0.002. By contrast, the nonplanarity angle did not change significantly after placement of partial rings. Conclusions Mitral annular nonplanarity can be assessed in the operating room. Application of full annuloplasty rings resulted in the mitral annulus becoming more planar. Partial annuloplasty bands did not significantly change the nonplanarity angle. Neither of the two types of rings restored the native annular planarity.

Study objective: To compare the risk of infection for IV lines placed in the prehospital versus in the in-hospital setting in a midsized emergency medical service system. Design: A retrospective analysis was made of all IV line site infections among patients admitted to ward beds from a university hospital emergency department in 1992. Methods: The hospitals infection control team conducted daily ward rounds and a surveillance of all wound and blood cultures. Patients with signs and/or symptoms consistent with Centers for Disease Control and Prevention guidelines for skin and soft tissue infection were reported to the responsible medical team. Infections were documented based on consensus opinion between the infection control team and the physicians responsible for the care of the patient. IV lines placed in the prehospital phase of care were identified by electronic retrieval from the prehospital database. Results: Three thousand one hundred eighty-five patients who had a prehospital or an in-hospital IV line placed were admitted from the ED. Eight hundred fifty-nine IV lines were prehospital placed (27%), and 2,326 were in-hospital placed (73%). There was one infection in the prehospital group and four in the in-hospital group (infection rate: .0012 for prehospital patients and .0017 for in-hospital patients; P =.591 by Fishers exact test). Conclusion: Both cohorts had exceptionally low infection rates. No clinically or statistically significant increase in the risk of infection among prehospital- or in-hospitalinitiated IV lines was identified. [Levine R, Spaite DW, Valenzuela TD, Criss EA, Wright AL, Meislin HW: Comparison of clinically significant infection rates among prehospital- versus in-hospitalinitiated IV lines. Ann Emerg Med April 1995;25:502-506.]

Many scholars, and the public at large, stereotype Latin America as a Roman Catholic patriarchy, divided into a small Europeanized upper class of descendants from the Spanish landholding class and a large lower class comprised of mestizos, Indians and the descendants of African slaves. This stereotype has not been valid for at least a century. Recent scholarship on Jews in Latin America has widened our vision of society, culture and politics by emphasizing both the heterogeneity in religious observance and the region's increasing social diversity. Indeed many immigrant groups not only Jews but Arabs, Japanese, Chinese, Koreans, people from the Caribbean, arrivals from eastern Europe and many others have for decades played major roles in this demographic diversification. Studies of these groups offer invaluable insight not only into the history of the newcomers but into the dynamics of the host society as well. One group that has seen a small but expanding stream of research in recent decades is Brazilian Jewry. Just as in other cases of minority groups and immigrants, early historical writing about Jews and Jewish lives was largely celebratory. Genealogical sleuthing predominated, searching for clues that individual historical personages were Jews or were descended from conversos or were secret Jews. One group claimed, for example, that the Portuguese national hero, sea captain and discoverer Vasco da Gama, had been born Gaspar da Gama, a converso. Professional historical studies addressing broader questions followed only gradually, and, during the 1950s, more serious work began

Carolina Maria de Jesús was a fiercely proud black Brazilian woman who lived in a São Paulo favela with her three illegitimate children (each with a different father). She had learned to read and write by continuing to study on her own after only two years of primary school. In 1958 fragments of her diary came to the attention of an enterprising journalist, Audálio Dantas, who helped her get it published. For a brief period, Carolina Maria de Jesús became an international celebrity as the author of the best-selling book in Brazilian publishing history. For many reasons, however, Carolina fell from favor: the rise of a military dictatorship in 1964, which led to an accompanying reaction against social criticism, and especially the ways in which she handled her fame and related to the press and the literary elite. Within a few years, she was forced to move back into the favela and scavenge for a living. A brief flurry of publicity in 1969 about her fallen condition prompted a slight improvement in her circumstances, but she was soon forgotten again. Carolina died in 1977, on the verge of indigence. Her complete life story has never been told, and most Brazilians today are unaware that a black favelada in the 1960s became the symbol (to foreigners, at least) of the struggle to rise above poverty. Most Brazilians neither read her books nor consider them noteworthy. Evidently, the author of what The New York Times called a “rarely matched essay on the meaning and the feeling of hunger, degradation, and want” touched no nerve in the Brazilian sensibility.

Background Several studies suggest that standard verbal and written consent information for treatment is often poorly understood by patients and their families. The present study examines the effect of an interactive computer-based information program on patients' understanding of cardiac catheterization. Methods Adult patients scheduled to undergo diagnostic cardiac catheterization (n = 135) were randomized to receive details about the procedure using either standard institutional verbal and written information (SI) or interactive computerized information (ICI) preloaded on a laptop computer. Understanding was measured using semistructured interviews at baseline (ie, before information was given), immediately following cardiac catheterization (early understanding), and 2 weeks after the procedure (late understanding). The primary study outcome was the change from baseline to early understanding between groups. Results Subjects randomized to the ICI intervention had significantly greater improvement in understanding compared with those who received the SI (net change, 0.81; 95% confidence interval, 0.01-1.6). Significantly more subjects in the ICI group had complete understanding of the risks of cardiac catheterization (53.6% vs 23.1%) ( P = .001) and options for treatment (63.2% vs 46.2%) ( P = .048) compared with the SI group. Several predictors of improved understanding were identified, including baseline knowledge ( P P = .002), and use of the ICI ( P = .003). Conclusions Results suggest that an interactive computer-based information program for cardiac catheterization may be more effective in improving patient understanding than conventional written consent information. This technology, therefore, holds promise as a means of presenting understandable detailed information regarding a variety of medical treatments and procedures.

In 1893, the penitent known as Antônio Conselheiro convinced several thousand devout followers to join with him in creating a religious community at Canudos in the Bahian sertão. It grew precipitously, attracting pilgrims from every part of the region, some from places more than two hundred kilometers distant. Within two years it had become the second largest urban center (after the capital, Salvador) in Bahia, Brazil's second most populous state. As soon as the effect on the traditional labor system began to be felt by landowners, pressure was applied to state officials, who in 1896 agreed to take action to dismantle the settlement. This would prove arduous, but after four bloody military campaigns, Canudos was destroyed by the Brazilian army in 1897. The so-called “rebellion” left an indelible legacy on late nineteenth-century Brazil. Taken to be a symbol of the clash between urban rationality and rural “backwardness,” Canudos was celebrated as a pivotal national victory for “progress” and “civilization.”

Photographs probably expanded more horizons and redefined more ways of knowing the world than any other product of nineteenth-century technology. The first daguerreotypes appeared in the Western Hemisphere merely months after the triumphal announcement of Daguerre's process by the French Academy in 1839. In the next three decades, millions of photographic images were produced. Three distinct categories predominated: studio portraits, scenic views for collectors and, after the early 1850s, photographic images transferred to woodcuts and, later, lithographs for publication as line sketches in illustrated newspapers and magazines. Photographic “science” complemented neatly the elite's striving for ways to affirm the region's material progress. Photographers played a vital role in presenting to the world a vision rooted in the aspirations of the dominant members of society.

Just weeks after his arrival in Miami in 1960, Bernardo Benes hurled himself into community causes and bridge building with the Anglo and African American segments of Miami’s tripartite population. Nu-merous Miami Cubans considered him an outsider, and did not appreciate his efforts. But these slights proved trivial compared to the opprobrium he received after newspaper articles in late 1978 described his personal dialogues with Fidel Castro. Benes expected that the discussions with Castro would yield humanitarian benefits both for exiled Cubans and those under Castro; instead, they infuriated hardline Cuban Miamians and created such a poisonous atmosphere that even non-Cubans ostracized him.

Fidel Castro’s victory over Batista’s corrupt dictatorship not only dramatically affected relations between the United States and Cuba; in the words of a foreign policy analyst, “its principal effect was to dynamite the logjam in U.S. policy toward Latin America.”1 Almost overnight, Washington officials and journalists thrust Castro’s revolutionary government into the cauldron of the Cold War. The United States awoke to the threat posed by revolutionary Cuba to the entire region, especially in countries ruled by strongmen dictators in league with a tiny elite. This, experts theorized, would leave the rest of the immiserated population vulnerable to Castro-like movements, or, in the case of fragile democracies like Brazil, where rural peasant leagues threatened to topple the ruling landed oligarchy, it would create the pre-conditions for the spread of revolution within the hemisphere.

The 1980 Mariel boatlift brought tens of thousands of desperate Cubans to Florida and further hardened the anti-Castro policy of the United States. Mariel was not only difficult for its participants, but also for the Cuban families who stayed behind while family members left. In the mid-1980s, Cuba again shut its doors, refusing to honor its 1978 agreement of permitting exiles to visit. Some Cubans committed suicide in despair over the departure of their children or other close relatives, and Cubans who lined up to apply for visas at the height of Mariel were insulted by hecklers, splattered by eggs thrown at them, and in some cases were forced to wear signs reading, “I am a worm.” Many received beatings, and one or two were beaten to death.1 Many Mariel arrivals initially fared badly in the United States, too, although over time they adjusted.

Since 1959, when Hispanics comprised less than 5 percent of its population, the city and surrounding area has absorbed newcomers from Latin America to the point at which Miami now has a sizeable Hispanic majority. Because the United States census does not break down its Hispanic category by country of origin, the total number of Cubans in Miami remains unknown, but the figure ranges between 650,000 to 700,000 today. From 1959 to the present, Anglos have departed for Broward and Palm Beach counties as waves of immigrants and refugees poured in from Cuba and many parts of Latin America. Cubans, who made up 90 percent of the Dade’s Hispanic population in 1970, represented 60 percent in 1998. The first post-Castro-wave Cubans reoriented the local economy from seasonal tourism toward trade and banking, remaking Miami the de facto capital of Latin America. Yet the success story overlooked other issues. The 1980 Mariel boatlift and the flow of rafters who followed in their wake brought Cubans who were young, unprepared for the realities of life in the United States, and darker-complexioned than the elite Cubans of the first waves. These and other differences, caused a breach in the community; most earlier arrivals stood at arms’ length from the newcomers, who had to rely more on family and government assistance because enclave sources of aid did not cover their needs.

Arguably, the turning point for Cuban Miami was the Thanksgiving Day 1999 arrival of Elian Gonzalez. Two men fishing off the coast of Fort Lauderdale spotted an inner tube holding a small boy, still alive, reportedly surrounded by dolphins. The boy was taken to a hospital and found to be five years old; his mother and a dozen others on their overcrowded seventeen-foot powerboat had drowned when the craft capsized, but they managed to lash Elian to a tube so that he might be rescued.

Preface, Acknowledgments, and a Statement on Corroboration List of Photographs and sources Beginnings Cuban Miami Mission to Havana: The Carter Years Mission to Havana: The Reagan Years Revolutionary Justice Only in Miami Bibliographic Notes