California State University, Sacramento

Importance Despite literature on migrant skin health globally, there remains a critical gap in understanding the dermatologic care and skin health of migrants in the US, where immigrants represent 13.9% of the population. Objective To understand the spectrum of dermatologic conditions reported among US migrant populations, identify considerations for dermatologic care delivery, and synthesize the current literature on skin health. Evidence Review PubMed, Embase, and ClasePeriodica were searched for articles published from January 2000 to December 2022 using search terms related to dermatologic conditions and migrants. Original research articles, review articles, case reports, and case series that reported on dermatologic conditions affecting migrant populations within the US and US territories were included. Findings Of 87 articles included, cross-sectional studies accounted for 37 (42.5%), followed by case reports and case series (36 [41.4%]), qualitative studies (3 [3.4%]), and a mixed-methods study (1 [1.1%]). Articles discussed a range of dermatologic conditions: infections (45 [51.7%]), inflammatory conditions (33 [37.9%]), traumatic wounds (16 [18.4%]), neoplasms (10 [11.5%]), pigmentary disorders (10 [11.5%]), signs of torture/violence (4 [4.6%]), cosmetic (3 [3.4%]), hair/nail disorders (1 [1.1%]), and genodermatoses (1 [1.1%]). Of 65 articles (74.6%) reporting migrants’ country of origin, Mexico was most frequently reported (28 [43.0%]), followed by Guatemala (14 [21.5%]), Vietnam (8 [12.3%]), and 38 other countries. Four themes were developed: (1) exposures before and during migration were risk factors for dermatologic conditions that presented at destination; (2) occupational and environmental exposures were risk factors for dermatologic conditions that developed at destination; (3) structural factors limited migrants’ access to quality health care; and (4) educational interventions targeting different learner groups were opportunities to improve skin health of migrants. Conclusions and Relevance This scoping review found that exposures before, during, and after migration and health care access are associated with the skin health of US migrant populations. Research opportunities include focusing on a broad spectrum of dermatologic diseases, countries of birth, occupations, and vulnerable populations, such as women and children, as well as implementing and evaluating policy that addresses structural barriers migrants face in accessing quality health care.

Desert kangaroo rats ( Dipodomys deserti ) construct burrows that can create micro-niches favorable to increased microbial activity. The aim of this study was to characterize the bacterial communities found in kangaroo rat burrows, in proximal desert surface sand, and in samples from kangaroo rats. We collected samples from burrow ceilings of actively inhabited burrows, from burrows that were no longer in use, and from the proximal surface sand in the Sonoran Desert, Yuma, AZ. Following DNA extraction from samples, 16S rRNA gene sequencing was performed, and functional predictions were made and assessed for each characterized bacterial community. Active burrow samples exhibited greater alpha diversity but similar beta diversity when compared to surface sand ( P < 0.05), with no significant differences observed between abandoned and active burrows. Bacterial genera and genes related to nitrogen fixation, nitrification, and urea hydrolysis were found in significantly higher abundance in active burrows compared to the surface sand ( P < 0.05). The core microbiome of active burrow samples was different from surface sand, including higher abundances of Acidimicrobiales and Acidobacteria subdivision Gp7. Active burrow samples included 30 unique genera. Kangaroo rat anal swabs shared 12, cheek pouches shared 6 unique genera with burrows. These findings suggest that kangaroo rats can shape the microbial composition of their burrow environment through the introduction of food material and waste, facilitating increased species richness and bacterial diversity. IMPORTANCE Animals can alter soil parameters, including microbial composition through burrowing activities, excretion, and dietary composition. Desert kangaroo rats ( Dipodomys deserti ) construct burrows within loose desert sand that have microclimatic conditions different from the surrounding desert climate. In this study, we explored the effect of disturbance from kangaroo rat activities on the bacterial composition of sand. We compared the bacterial community compositions of kangaroo rat ( D. deserti ) samples, their burrows, and the proximal surface sand. The results showed that burrow sand shows higher richness and diversity of bacterial community with higher abundances of bacterial genera and genes associated with nitrogen fixation, nitrification, and urea hydrolysis compared to the surface sand. These findings suggest that kangaroo rats affect the microbial composition of their burrow environment through the introduction of food material and waste.

Purpose Telehealth expansion offers physical therapists new opportunities; however, conducting virtual assessments raises concerns about validity, reliability, and safety. This study aimed to establish the concurrent validity, reliability, and correlations of the 2-minute step test (TMST) delivered virtually in community-dwelling older adults. Methods A cross-sectional design was used. A sample of community-dwelling older adults underwent single-session testing of the TMST. Scoring was conducted simultaneously by an in-person rater and a synchronous telehealth rater. Video recordings were scored by an asynchronous rater on day 1 and day 30 to assess interrater and intrarater reliability. Concurrent validity was calculated using the 95% level of agreement, intracorrelation coefficient (ICC), and Pearson correlation coefficient between the in-person and remote TMST score. Interrater and intrarater reliability were obtained for virtual raters by calculating the ICC 2-way mixed model. Pearson correlation coefficient was used to identify the correlation between the virtual TMST and fall risk outcome measures. Results Thirty older adults participated. Two-minute step test showed high levels of agreement between in-person and remote formats (ICC = 0.95–0.99, Pearson r = 0.96), good interrater reliability (ICC = 0.79), excellent interrater (ICC = 0.99), significant positive moderate relationship with the 30-second chair stand test, fair correlation with the activities-specific balance confidence scale, and a negative fair relationship with the Timed Up and Go test. Conclusions Two-minute step test is a valid, reliable, and safe tool for virtual aerobic testing in older adults. Assessing the TMST virtually requires considerations of fall risk, physiological exercise responses, influences of the environment, camera positioning, and internet connectivity.

Importance Direct immunofluorescence (DIF) testing has been an important ancillary tool for the diagnosis of various inflammatory mucocutaneous conditions for more than 50 years. Current DIF test panels are based on historical clinical descriptions; few studies have rigorously addressed preanalytical, analytical, and/or postanalytical aspects, and even fewer have been replicated or validated. Recent unresolved key issues include whether DIF testing and test panels should be triaged or truncated based on clinical indication or histopathologic findings. Objective To assess levels of consensus regarding practical aspects of DIF testing among immunodermatology testing specialists in the US. Design, Setting, and Participants Using modified Delphi methods with a priori characterized criteria, a survey containing 54 statements pertaining to DIF testing was created and distributed to assess consensus. Statements not initially reaching consensus were discussed in 2 live virtual sessions, which were supplemented by relevant literature review and free-text survey comments. These statements were then reassessed in a second survey. Immunodermatology testing specialists in US academic institution–based and independent laboratories were invited based on serving as immunodermatology laboratory medical directors, authoring pertinent literature, or delivering relevant talks at major conferences or by referral. The first survey was conducted from January to February 2024, and the second survey was conducted from March to April 2024. Main Outcomes and Measures The primary measured outcome was degree of consensus for various DIF testing practice, including DIF testing triage by histopathology/dermatopathology findings and DIF testing panel tailored truncations by clinical indication. Results A total of 23 respondents to the survey invitation had a mean (SD) of 18.5 (11.1) years and median (range) of 20.0 (1.5-46.0) years in immunodermatology laboratory practice. Consensus was achieved for 46 of 54 statements (85.2%) in the initial survey and for an additional 4 statements in the second survey (50 of 54 [92.6%]). Strong consensus was found against tailored truncation of DIF panel based on the clinical indication in the first survey round. The general acceptability of triaging specimens for DIF testing based on histopathology findings remained without consensus after both surveys. Conclusions and Relevance Overall, participating US specialists in immunodermatology laboratory testing agreed on many practical aspects of DIF testing, including matters not queried previously. The findings also revealed areas of continued controversy and identified issues for prioritized future study.

Background As the incidence of primary hip arthroscopic surgery has increased, the incidence of revision hip arthroscopic surgery has also increased. Although many factors have been reported that predict clinical failure of hip arthroscopic surgery, the outcomes of primary versus revision hip arthroscopic surgery are unknown. Purpose To perform a systematic review and meta-analysis comparing the outcomes of primary versus revision hip arthroscopic surgery. Study Design Systematic review and meta-analysis; Level of evidence, 3. Methods A search following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in the PubMed, Embase, and Cochrane Library databases. Studies were included if they compared the outcomes of primary versus revision hip arthroscopic surgery and had a minimum follow-up of 12 months. Data regarding study characteristics, patient characteristics, radiographic parameters, patient-reported outcomes, and adverse events were recorded. A meta-analysis was conducted using a random-effects model. Results There were 11 studies included, with 6437 patients (56.1% female; mean age, 37.1 years) and 1151 patients (65.3% female; mean age, 35.2 years) undergoing primary and revision hip arthroscopic surgery, respectively. Preoperative and postoperative radiographic parameters were not clinically different between the primary and revision groups. Postoperative scores for the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports-Specific Subscale, modified Harris Hip Score, International Hip Outcome Tool–12, and Non-Arthritic Hip Score were significantly lower (all P < .001), and the visual analog scale for pain ( P < .001) score was significantly higher, after revision hip arthroscopic surgery. For the primary versus revision group, the rate of achieving the minimal clinically important difference ranged from 66.7% to 92% versus 47.4% to 90%, respectively, and the rate of achieving the Patient Acceptable Symptom State ranged from 52.6% to 79.4% versus 20% to 64%, respectively. The risk of complications ( P = .04) and conversion to total hip arthroplasty ( P < .001) was significantly higher after revision hip arthroscopic surgery. Conclusion Patients undergoing revision hip arthroscopic surgery were less likely to achieve clinically significant improvements in postoperative patient-reported outcomes and exhibited a higher risk of complications and conversion to total hip arthroplasty compared with patients undergoing primary hip arthroscopic surgery. These findings suggest that outcomes are optimized in the primary setting, and surgeons should appropriately counsel patients regarding expectations after revision hip arthroscopic surgery.

Basic sciences form the foundation of medical knowledge and practice in medical schools. Since the 1910 Flexner Report, which led to the establishment of multiple basic science departments, faculty in these departments have been responsible for preclinical courses in the first 2 years of medical education. The basic science disciplines and their associated faculty have been crucial to medical education, fostering critical thinking and preparing physicians for rapid advancements in medicine. Importantly, they have grown as engines of innovation and influence to comprise hubs for fundamental and translational research. More recently, a convergence of influences, including the adoption of integrated curricula and other changes in the traditional medical education structure, as well as financial pressures and ongoing changes in research funding, has prompted many institutions to re‐evaluate the organization of basic sciences, leading to a wave of departmental consolidations. While this may seem administratively and financially attractive, it could have the unintended consequence of consolidating scientific thought, with an attendant stifling of innovation. To sustain the institutional capacity for making the paradigm‐shifting discoveries essential for transforming medicine in a shifting research landscape, we propose a new rationale for maintaining or even expanding the multi‐departmental structure. Our model builds on recent research suggesting that thematic diversity and inter‐ and trans‐disciplinary teams are fundamental features crucial for innovation. We propose a novel approach that involves the establishment of an institution‐wide strategic theme, layered over a multi‐departmental structure in which individual department chairs are recruited based on the extent to which their research agenda aligns with the strategic theme. This broad institutional strategy preserves the unique contributions of individual disciplines while fostering interdisciplinary collaboration, thereby maximizing thematic breadth and synergy. By balancing administrative efficiency with the imperative for innovative research, medical schools can establish a unique identity with an associated future vision. Importantly, the existing strengths that foster this vision provide the basis for explosive growth, with the capacity to shape the future of medical education while creating an environment conducive to groundbreaking discoveries and advancements in medical science.

Ableism is a bias or discrimination against individuals with a known or perceived disability in favor of those who do not have a known or perceived disability. One outcome of the COVID-19 pandemic was the realization that the nursing workforce lacked diversity and representation, including those who are disabled. This article discusses strategies to mitigate ableism in nursing and promote a more inclusive and diverse workforce.

We report results from a survey of members of the Society of Critical Care Medicine to assess ICU clinicians’ perceptions of artificial airway safety practices and unplanned extubation (UE) prevention. The survey was distributed between January and February 2024 and received 518 responses (68.5% response rate), with 87.5% from adult ICUs and 12.5% from Pediatric ICUs. Only 48% of adult ICU respondents tracked UE, compared with 73% tracking pressure injuries. Most respondents did not consider UE a “never event,” with over half viewing it as unavoidable. In adult ICUs, delirium was ranked as the highest UE risk factor, and commercial securement devices were the primary endotracheal tube securement method (75.2%). Significant variations were observed in artificial airway management practices and responsibility assignments across ICU settings. The results highlight substantial disparities in airway safety management beliefs and practices, underscoring the need for standardized, evidence-based guidelines.

Purpose The purpose of this study was to assess baseline knowledge and self-care practices about diabetes mellitus (DM) among patients with type 2 diabetes mellitus (T2DM) in Uvira, Kiliba, Sange, and Luvungi (U-KI-SA-LU), South Kivu Province of the Democratic Republic of Congo (DRC). Methods A community-based cross-sectional study was conducted among 328 T2DM patients (179 men and 149 women) in U-KI-SA-LU, South Kivu Province of DRC from February 1 to April 30, 2024. Data were collected using pretested questionnaires and were analyzed using descriptive statistics and F statistic for the analysis of variance test with value of P < .05 as the level of statistical significance. Results Of the 328 participants, 188 (57.4%) had good general knowledge about DM; only 149 (45.4%) had good self-care practices about DM. Being married, having higher education, and being on insulin injection were associated with good knowledge; only being married was associated with good self-care practices toward DM. Surprisingly, 167 (50.9%) of the participants never had an eye examination, only 51 (15.5%) ate fruits for 3 or more days over the past 7 days, and 77 (23.5%) had access to a personal glucometer. Conclusions Structured educational programs are needed to improve DM knowledge and self-care practices in order to slow down the progression of DM and prevent complications. These results also suggest raising awareness about health care professionals’ role in DM management through not only continuing education programs but also traditional media, including print advertising, television, radio, and newspapers.

Drawing on collaborative research with MILPA on their liberatory curriculum, Telpochcalli, this essay offers “ encuentros ” as a regenerative ethico‐methodology in community‐led and kinship‐grounded anthropological research into Chicano Indigenous educational spaces. Encuentros , encounters with others for relationship‐building and mutual learning, renew and expand existing relational knowledge. If an anthropology of education is concerned with epistemology and decolonization, we should approach how we study Indigenized educational projects with care and creativity.

Disparities exist in autism identification and service access in public schools. Over- or under-identification of autism may limit access to appropriate services. This study examined racial and ethnic differences in autism identification, general education inclusion, and service access in the California education system and examined trends in autism identification by race and ethnicity in special education from 2008 to 2018. Hispanic/Latino and Pacific Islander students were less likely to be identified with autism than other groups. Black autistic students were less likely to be included in general education settings. A narrowing gap in autism identification over the past decade between White and Hispanic/Latino students suggests some improvement in equitable identification practices, although continued disparities exist.

Background/Objectives: Regenerative therapies have gained interest in orthopedic applications for their potential to enhance tissue regeneration, functional recovery, and pain modification. This review evaluates the clinical efficacy of platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), peptide-based treatments, and biomimetic materials in orthopedic care, with a focus on pain reduction and functional outcomes. Methods: A structured literature search in PubMed (January 2009–January 2025) identified 160 studies. After applying inclusion criteria prioritizing randomized controlled trials (RCTs) and clinical trials, 59 studies were included: 20 on PRP, 20 on MSCs, 10 on peptide therapies, and 7 on biomimetics. Data extraction focused on pain reduction and functional recovery, with risk of bias assessed using the Cochrane Risk of Bias (RoB) tool and ROBINS-I tool. A random-effects meta-regression analysis was conducted to evaluate the impact of therapy type, sample size, and risk of bias on reported pain reduction outcomes. Results: Meta-regression analysis identified MSC therapy as the most effective intervention for pain reduction (β = 8.45, p < 0.05), with PRP and peptide-based therapies showing moderate improvements, and biomimetic therapies demonstrating the lowest effect. PRP provided short-term pain relief, particularly in acute injuries and tendon repair, though inconsistencies in preparation methods limited success in chronic conditions. MSC therapies demonstrated cartilage regeneration and early osteoarthritis improvement, but high costs and ethical concerns remain barriers to widespread adoption. Peptide-based therapies and biomimetic materials, including engineered scaffolds and autologous protein solutions, showed promise for infection control and wound healing, though further research is needed to optimize dosing, delivery methods, and long-term safety. Conclusions: Regenerative therapies offer significant potential in orthopedic care, with MSC therapies demonstrating the most reliable regenerative effects, PRP providing short-term symptomatic relief, and peptide-based and biomimetic treatments emerging as promising adjuncts. However, standardized protocols and large-scale clinical trials are needed to establish long-term efficacy and improve clinical translation for broader adoption.

Background: Herein, we review the Cotton Top Tamarin (CTT), Saguinus oedipus, a unique spontaneous model for colorectal cancer (CRC). Despite its predisposition to inflammatory bowel disease (IBD) and frequent development of CRC, the CTT is adept at avoiding colorectal metastasis in the liver. In contrast, the common marmoset (CM), Callithrix jacchus, is a natural negative control, in that it also contracts IBD, but usually not CRC. We review our findings in these New World monkeys in terms of the expression of CEACAM adhesion models and their related molecules to contrast them with human disease. Methods: Specimens were collected from aforementioned monkey colorectal and other tissues, colonic washings, serum for analysis of tissue extraction, and colonic washings via ELISA, using a battery of antibodies. Fixed tissues were analyzed using immunohistochemistry and CEACAMs were extracted via Western blotting. Serum CEA levels were analyzed using ELISA, and DNA was extracted via a Bigblast genomics sequencing kit. Results: Serum CEA was significantly elevated in CTTs, and one-third of them die from CRC. Unlike others, we were unable to stain for CEA in tissues. The sialylated carbohydrate antigen recognized by monoclonal antibody (MAb) SPAN-1 does stain in 16.7% of CTT tissues, but the anti-aminoproteoglycan MAb, CaCo.3/61, stained 93.3% (OR70·00[CI6.5–754.5] p < 0.0001). The common CEA kits from Abbott and Roche were non-conclusive for CEA. We later adopted a CEA AIA-PACK from Tosoh Medics, which identified a 50 Kda band via Western blotting in humans and CTTs. The CEA levels were higher using the CEA AIA-PACK than the Pharmatrope kit (932 ± 690 versus 432 ± 407 ng/mL (p < 0.05)) in human patient colonic effluent, not statistically significant (NSS) for CTT extracts or effluent (733 ± 325 and 739 ± 401 ng/mL, respectively). It was suggested that the smaller CTT CEA moiety might lack components that facilitate the spread of liver metastasis. Later, using more specific CEA assays and increased numbers of specimens, we were able to show higher CEA serum expression in CTTs than in CMs (632.1 ± 306.1 vs. 81.6 ± 183.6, p < 0.005), with similar differences in the serum samples. Western blotting with the anti-CEA T84.66 MAb showed bands above 100 KDa in CTTs. The profiles in CTTs were similar to human patients with inflammatory bowel disease. We established that the CEA anchorage to the cell was a GPI-linkage, advantageous for the inhibition of differentiation and anoikis. With further CEA DNA analysis, we were able to determine at least five different mechanisms that may inhibit liver metastasis, mostly related to CEA, but later expanded this to seven, and increased the relationships to CEACAM1 and other related molecules. Recently, we obtained CTT liver mRNA transcriptomes that implicated several pathways of interest. Conclusions: With efforts spanning over three decades, we were able to characterize CEA and other changes that allow us to better understand the CTT phenomenon of liver metastasis inhibition. We are in the process of characterizing the CTT liver mRNA transcriptome to compare it with that of the common marmoset. Currently, liver CTT gene expression patterns suggest that ribosomes, lipoproteins, and antioxidant defense are related to differences between CTTs and CMs.

Background Randomized controlled trials (RCTs) significantly influence clinical decision-making, necessitating comprehensive reporting of trial outcomes. However, previous studies have demonstrated that reporting of harms among RCTs is often inadequate. Purpose/Hypothesis The purpose of this study was to evaluate reporting of harms among RCTs cited within the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) for anterior cruciate ligament (ACL) injuries, with an emphasis on study characteristics associated with adherence. We hypothesized that >50% of these trials would have incomplete adherence to the checklist items outlined in the Consolidated Standards of Reporting Trials (CONSORT) extension for harms and that a larger sample size would be associated with greater compliance. Study Design Cross-sectional study. Methods We identified RCTs cited in the AAOS CPGs for the management of ACL injuries and assessed compliance with the 18-item CONSORT extension for harms checklist. Descriptive statistics were used to summarize overall adherence to the checklist items, and linear regression analysis evaluated adherence over time. Results Our analysis included 116 RCTs, the majority of which were single-center studies (81.0%). Most trials had sample sizes of 50-100 patients (45.7%) or 101-500 patients (37.9%). On average, trials adhered to 9.25 of 18 CONSORT items (51.4%), with the most compliant study meeting 15 of 18 items (83.3%) and the least compliant meeting 3 of 18 items (16.7%). Overall, 18 RCTs (15.5%) reported ≤33% of items, and 22 RCTs (19.0%) reported ≥67% of items. Studies with >500 patients had significantly higher adherence compared with studies with <50 patients ( P = .046). There was no significant difference in adherence based on the disclosure of funding sources ( P = .85) or the implementation of blinding ( P = .37). Interrupted time series regression analysis demonstrated no significant change in reporting both before ( R ² = 0.017; P = .62) and after ( R ² = 0.21; P = .16) the release of the checklist in 2004. Conclusion On average, RCTs cited within the AAOS CPGs for the management of ACL injuries adhered to 51.4% of CONSORT checklist requirements, with considerable variability across studies. Improvements in reporting practices are warranted to support evidence-based treatment decisions.

Recent public health events have brought to the forefront the challenges of incorporating collective action behaviors and information seeking and processing behaviors to motivate personal protections to an environmental risk. The economic and social costs of large-scale spread of disease when there is no cure for the disease, only preventative measures implemented in coordination and cooperation with others, will be effective at addressing the problem. To better understand these challenges in an agricultural context, we create an agent-based model (ABM) coupling ecological, epidemiological, and economic factors to simulate Huanglongbing (HLB) spread in California. The ABM is used to evaluate how participation in collective action through coordinated area-wide insecticide spraying is influenced by perception of other growers' participation and confidence in scientific information about the disease. We find a grower's participation in coordinated spraying has little influence on when the infection reaches them but depends primarily on the other growers' action. We discover that over time more growers cooperate in area-wide coordinated spraying, but after the disease has sufficiently spread, some growers stop cooperating. Moreover, as beliefs in other growers' participation becomes stronger, some growers cooperate less, leading to greater HLB spread. We observe that increased confidence in scientific information lowers HLB spread, as more growers are motivated to cooperate through increased expected cumulative profits. As such, a successful strategy to combat an incurable infectious disease, like

Background Syphilis is re-emerging, with recent increases in congenital infections. While cerebrospinal fluid (CSF) evaluation can inform management, specimen collection requires technical skill and the interpretation of indices is nuanced. We sought to understand the practical value of CSF indices as an evaluation tool among neonates exposed to syphilis in utero. Methods We performed chart reviews of infants <30 days old born to birthing parents with syphilis infection, delivered between January 2000 and October 2020. Syphilis evaluation and treatment information for birthing parents and infants were abstracted. Infants were categorized per the Centers for Disease Control and Prevention congenital syphilis (CS) scenarios. CSF indices and other evaluation test results were described by scenario. Results One hundred nine infants met the inclusion criteria. The overall lumbar puncture success rate was 59.7%. Among scenario 2 infants, 45.2% received 10 days of intravenous therapy due to an unsuccessful, uninterpretable or incomplete CSF evaluation. All infants with proven or highly probable CS (scenario 1) had ≥1 CSF abnormality compared with 35.1% of infants with possible CS (scenario 2; P = 0.0009; the Fisher exact test). All abnormal CSF results, inclusive of scenario 1 and 2 infants, had an elevated protein (≥119 mg/dL). Among those with elevated protein, 72.2% had either an abnormal Venereal Disease Research Laboratory, white blood cell counts (≥20 white blood cell counts/mm ³ ) or both. Among scenario 2 infants, 16.6% were indicated for intravenous therapy according to a non-CSF test result. Conclusions Several practice changes can be considered: a stepwise evaluation starting with less invasive procedures, prioritizing protein when CSF volume is low and implementing strategies to optimize successful CSF collection.

This study examines how coastal residents in the path of a hurricane manage the tension to evacuate or stay. In interviews with 17 coastal residents, we found evidence of tension management through account giving. Stayers justified their choices as keeping close to loved ones and animals, reducing difficulties in returning, and benchmarking prior storms to guide their actions over other sources of information. Evacuees framed the tension as either the only choice or the better of two poor choices. Our analysis also revealed contradictions in evacuating: a case of haves (have resources to evacuate but do not) and have nots (want to evacuate, but do not have the resources) and the perception that shelters were not a viable option. Lastly, stayers extracted lessons learned that reinforced their action and would likely guide future behaviours through benchmarking. Implications of these findings are offered for emergency managers, including speaking to residents' tension management, addressing contradictions, and acknowledging lesson learned, are discussed.