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ObjectiveData suggest that redo mitral valve surgery is being performed in increasing numbers, possibly with superior results according to single-centre studies. The purpose of this study is to describe outcomes of redo mitral valve surgery and identify risk-adjusted predictors of poor outcomes.MethodsAll (11 973) open mitral valve cases were evaluated (2002–2016) from a regional Society of Thoracic Surgery (STS) database. Patients were stratified by primary versus redo mitral valve surgery. Mixed effects logistic regression models including hospital as a random effect were used to identify risk factors for patients undergoing redo mitral valve surgery.ResultsOf all mitral valve cases, 1096 (9.7%) had a previous mitral operation. Redo patients had higher rates of valve replacement and preoperative comorbidities resulting in more complications, operative mortalities (11.1%vs6.5%, p<0.0001) and higher resource utilisation. Several factors independently increased risk for composite STS major morbidity and 30-day mortality, including cardiogenic shock (OR 10.3, p=0.0001), severe tricuspid insufficiency (OR 2.3, p=0.001), urgent/emergent status (OR 1.8, p=0.001) and concurrent coronary artery bypass grafting (OR 2.4, p=0.002). The volume of redo mitral valve surgery increased 10% per year and the observed-to-expected ratios (O/E) for operative mortality in redo mitral surgery improved from 1.44 early in the study period to 0.72 in the most recent era.ConclusionsRedo mitral valve surgery accounts for approximately 10% of mitral valve operations and is associated with increased risk and resource utilisation. However, as the volume of redo mitral surgery increases, outcomes have dramatically improved and are now better than predicted.

The enormous increase in mid-IR sensitivity and spatial and spectral resolution provided by the JWST spectrographs enables, for the first time, detailed extragalactic studies of molecular vibrational bands. This opens an entirely new window for the study of the molecular interstellar medium in luminous infrared galaxies (LIRGs). We present a detailed analysis of rovibrational bands of gas-phase CO, H2O, C2H2, and HCN toward the heavily obscured eastern nucleus of the LIRG VV 114, as observed by NIRSpec and the medium resolution spectrograph on the Mid-InfraRed Instrument (MIRI MRS). Spectra extracted from apertures of 130 pc in radius show a clear dichotomy between the obscured active galactic nucleus (AGN) and two intense starburst regions. We detect the 2.3 μm CO bandheads, characteristic of cool stellar atmospheres, in the star-forming regions, but not toward the AGN. Surprisingly, at 4.7 μm, we find highly excited CO (T ex ≈ 700–800 K out to at least rotational level J = 27) toward the star-forming regions, but only cooler gas (T ex ≈ 200 K) toward the AGN. We conclude that only mid-infrared pumping through the rovibrational lines can account for the equilibrium conditions found for CO and H2O in the deeply embedded starbursts. Here, the CO bands probe regions with an intense local radiation field inside dusty young massive star clusters or near the most massive young stars. The lack of high-excitation molecular gas toward the AGN is attributed to geometric dilution of the intense radiation from the bright point source. An overview of the relevant excitation and radiative transfer physics is provided in an appendix.

Sustainable thinking provides an opportunity to create new value to the mission of health care, rather than settling for less. Success stories and case studies exist, which if replicated can have an enormous positive effect. The future holds promise. Many health care organizations are signing up with efforts such as the Healthier Hospitals initiative, a program of the Practice Greenhealth membership organization for sustainable health care, to set new standards and learn more about methods to reduce the environmental footprint and negative health effects from the delivery of care to their communities. Providing safe and affordable care to patients and their families must remain paramount in the decisions that are made, but good environmental stewardship can be achieved. Setting organizational goals holds the key to finding the optimal balance.

This paper describes a pilot study into the spectral energy distribution (SED) fitting and the derivation of physical parameters for 19 galaxies observed as part of the Great Observatories All-sky LIRG Survey (GOALS) survey as observed with the Spitzer Space Telescope . For this we have used the pan-spectral fitting tools developed in a series of papers by Dopita and his co-workers. We show that the standard Lee and Draine ‘astronomical silicate’ model cannot provide a good fit to the silicate absorption features as observed in the heavily dust-extinguished ( A V ∼50 mag.) starbursts. We have derived an empirical fit to the ‘starburst silicate’ absorption in these objects. This absorption curve is consistent with the silicate grains being systematically larger in starburst environments than in the local Galactic interstellar medium. We demonstrate the sensitivity of the SED fitting to each of the fitted parameters, and derive these parameters for those galaxies which do not have an embedded AGN. This technique is simple and provides reasonably robust and uniform parameters for the starburst, especially as far as the star formation rate, population of old stars, compactness of the starburst region and total foreground extinction are concerned. However, the chemical abundances and the optical extinction cannot be reliably determined by this analysis, and optical SEDs will also be required to provide a complete characterization of the starburst region and of the surrounding galaxy.

The Snapshot: Climate issue of Southern Cultures includes photography and reflections on climate impacts across the southern states by Jenny Adler, Austin Anthony, Kate Auger, Arden Barnes, Monica Patrice Barra, Robin Boggs, Jared Bramblett, Lily Brooks, Hannah Brown, Becca Burton, Matthew Busch, Gordon Campbell, Natalie Chanin, Vanessa Charlot, Walter Coker, Justin Cook, Cameron Davidson, Marquetta Dickens, Brandon Dill, Benjamin Dimmitt, Rory Doyle, Ryan Emanuel, Cameron Evans, J Henry Fair, Megan Faust, Annie Flanagan, Kathleen Flynn, Jerod Foster, John Gaulden, Hermina Glass-Hill, Allison Grant, Jerry Dickson Greer, Joshua Dudley Greer, Anna Hamilton, Virginia Hanusik, John Lusk Hathaway, Chuck Hemard, Tom Kimmerer, Virginie Kippelen, Jeremy M. Lange, Nate Larson, Mark Long, Jordan Lovejoy, Megan May, Roger May, Lisette Morales McCabe, Rob McDonald, Andrew Moore, Stephen B. Morton, Anna Gage Norton, Jocelyn Painter, Elena Peterman, Daniel Pullen, Tom Rankin, Robert Rausch, Jeff Rich, Beth Roach, Derek Slagle, Michael O. Snyder, Michael K. Steinberg, Bryan Thomas, Jacqui Thurlow-Lippisch, Simon Tye, Turcois Vazquez, Jordan Vonderhaar, Jason Matthew Walker, Will Warasila, Carlton Ward Jr., Brooke White, William Widmer, and Devin Wright.

In an interview, Gundersen Health System executive director Jeff Rich talked about Gundersen's \"Envision\" environmental program. On how the Envision program started, he said that when he came to Gundersen, he focused on using his experience in Lean Six Sigma process improvement to reduce costs and increase efficiency. One of the first things they noticed was their big utility bill -- in 2008, their utilities expenses totaled $5.3 million. In the first six months of implementing their first energy conservation measures, they experienced a 10% improvement in energy efficiency, and by the end of the second year of the initiative, they had recorded a 20% improvement. They're now sustaining a 25% to 30% improvement in energy efficiency compared with energy use before they implemented the initiative. Gundersen has always been environmentally conscious and has had a good recycling program. But the Envision program is heavily involved in reducing pharmaceutical, surgical, and medical waste; packaging; and parts and equipment.

Bars play an important role in mixing material in the inner regions of galaxies and stimulating radial migration. Previous observations have found evidence for the impact of a bar on metallicity gradients but the effect is still inconclusive. We use the TYPHOON/PrISM survey to investigate the metallicity gradients along and beyond the bar region across the entire star-forming disk of five nearby galaxies. Using emission line diagrams to identify star-forming spaxels, we recover the global metallicity gradients ranging from -0.0162 to -0.073 dex/kpc with evidence that the galactic bars act as an agent in affecting in-situ star formation as well as the motions of gas and stars. We observe cases with a `shallow-steep' metallicity radial profile, with evidence of the bar flattening the metallicity gradients inside the bar region (NGC~5068 and NGC~1566) and also note instances where the bar appears to drive a steeper metallicity gradient producing `steep-shallow' metallicity profiles (NGC~1365 and NGC~1744). For NGC~2835, a `steep-shallow' metallicity gradient break occurs at a distance \\(\\) 4 times the bar radius, which is more likely driven by gas accretion to the outskirt of the galaxy instead of the bar. The variation of metallicity gradients around the bar region traces the fluctuations of star formation rate surface density in NGC~1365, NGC~1566 and NGC~1744. A larger sample combined with hydrodynamical simulations is required to further explore the diversity and the relative importance of different ISM mixing mechanisms on the gas-phase metallicity gradients in local galaxies.