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Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.
Introduction: Emergency Department (ED) utilization during pregnancy may be common, but data specific to universal healthcare systems like Canada are lacking, where pregnancy care is supposed to be standardized. The objective of this study was to quantify and characterize ED utilization among all Ontarian women who had a recognized pregnancy, including by trimester and within 42 days after pregnancy, and further stratified by pregnancy outcome. Methods: Utilizing provincial administrative health databases, this retrospective population-based cohort study included all recognized pregnancies in Ontario conceived between April 1, 2002 and March 31, 2017. Peri-pregnancy ED utilization was defined as any ED visit from 0-42 weeks’ gestation, or within 42 days after the end of pregnancy. Modified Poisson regression was used to generate relative risks (RR) and 95% confidence intervals (CI) for the outcome of any peri-pregnancy ED utilization in association with maternal characteristics. Results: Peri-pregnancy ED utilization occurred among 1,075,991 of 2,728,236 recognized pregnancies (39.4%), including among 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages, and 84.8% of threatened abortions. There were 22,802 (0.84%) ectopic pregnancies among all pregnancies in the cohort. ED utilization peaked in the first trimester and in the first week postpartum. A dose-response effect was seen in the number of peri-pregnancy ED visits in relation to certain maternal characteristics. Women residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39 to 3.49) for ≥ 3 ED visits, compared to those in urban areas. Women with 3-5 (OR 1.99 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49 to 3.61), or ≥ 7 (OR 7.59, 95% CI 7.39 to 7.78) pre-pregnancy comorbidities were more likely to have ≥ 3 peri-pregnancy ED visits than those with 0-2 comorbidities. Of all recognized pregnancies in the cohort, only 106,989 (3.9%) had an injury-related ED visit. Conclusion: Peri-pregnancy ED utilization occurs in nearly 40% of pregnancies, notably in the first trimester and immediately postpartum. Efforts are needed to streamline rapid access to ambulatory obstetrical care during these peak periods, when women are vulnerable to either a miscarriage, or a complication after a livebirth.
Social contact is one of the most effective strategies for improving inter-group relations and is supported by decades of positive evidence. Several studies specifically support social contact interventions as a way of reducing stigma against people with mental health problems. Despite the effectiveness of this approach, some social groups have few opportunities for social contact in the real world.
Using the England Time to Change anti-stigma campaign as an example, we investigate the feasibility and effectiveness of delivering social contact interventions at the mass population level to reduce stigma and discrimination against people with mental health problems.
To investigate: (i) the feasibility of scaling up social contact interventions to reduce stigma and discrimination against people with mental health problems and (ii) the effectiveness of mass population social contact interventions to: improve intended stigmatising behaviour, increase willingness to disclose mental health problems and to promote engagement in antistigma activities.
Two types of mass participation social contact programmes within England's Time to Change campaign were evaluated via self-report questionnaire. Participants at social contact events were asked about the occurrence and quality of contact, attitudes, readiness to discuss mental health, and intended behaviour towards people with mental health problems.
Findings on feasibility and effectiveness of social contact programmes will be presented.
This study suggests that social contact interventions can be used by anti-stigma campaigns to reduce stigma and discrimination against people with mental health problems. Further investigation is needed regarding the maintenance of these changes
This article examines an environmental experiment in northern Kenya that went badly amiss. Focusing on the introduction of an invasive plant, prosopis juliflora, it explores wider issues of scientific hegemony, political identity, and land conflicts. Two legal cases pitting a small pastoralist community against the Kenyan state are discussed, which reveal a new but generally unsuccessful strategy by indigenous groups of utilizing courts to address injustices. The research draws on ethnographic, archival, and visual materials collected over a thirty-five-year period to demonstrate the violence and impoverishment that can be associated with technical interventions aimed at “greening” the environment.
An improved understanding of diagnostic and treatment practices for patients with rare primary mitochondrial disorders can support benchmarking against guidelines and establish priorities for evaluative research. We aimed to describe physician care for patients with mitochondrial diseases in Canada, including variation in care.
We conducted a cross-sectional survey of Canadian physicians involved in the diagnosis and/or ongoing care of patients with mitochondrial diseases. We used snowball sampling to identify potentially eligible participants, who were contacted by mail up to five times and invited to complete a questionnaire by mail or internet. The questionnaire addressed: personal experience in providing care for mitochondrial disorders; diagnostic and treatment practices; challenges in accessing tests or treatments; and views regarding research priorities.
We received 58 survey responses (52% response rate). Most respondents (83%) reported spending 20% or less of their clinical practice time caring for patients with mitochondrial disorders. We identified important variation in diagnostic care, although assessments frequently reported as diagnostically helpful (e.g., brain magnetic resonance imaging, MRI/MR spectroscopy) were also recommended in published guidelines. Approximately half (49%) of participants would recommend “mitochondrial cocktails” for all or most patients, but we identified variation in responses regarding specific vitamins and cofactors. A majority of physicians recommended studies on the development of effective therapies as the top research priority.
While Canadian physicians’ views about diagnostic care and disease management are aligned with published recommendations, important variations in care reflect persistent areas of uncertainty and a need for empirical evidence to support and update standard protocols.
Significant inter-centre variability in the intensity of endomyocardial biopsy surveillance for rejection following paediatric cardiac transplantation has been reported. Our aim was to determine if low-intensity biopsy surveillance with two scheduled biopsies in the first year would produce outcomes similar to published registry outcomes.
A retrospective study of paediatric recipients transplanted between 2008 and 2014 using a low-intensity biopsy protocol consisting of two surveillance biopsies at 3 and 12–13 months in the first post-transplant year, then annually thereafter. Additional biopsies were performed based on echocardiographic and clinical surveillance. Excluded were recipients that were re-transplanted or multi-organ transplanted or were followed at another institution.
A total of 81 recipients in the first 13 months after transplant underwent an average of 2 (SD ± 1.3) biopsies, 24 ± 6.8 echocardiograms, and 17 ± 4.4 clinic visits per recipient. During the 13-month period, 19 recipients had 24 treated rejection episodes, with the first at an average of 2.8 months post-transplant. The 3-, 12-, 36-, and 60-month conditional on discharge graft survival were 100%, 98.8%, 98.8%, and 90.4%, respectively, comparable to reported figures in major paediatric registries. At a mean follow-up of 4.7 ± 2.1 years, four patients (4.9%) developed cardiac allograft vasculopathy, three (3.7%) developed a malignancy, and seven (8.6%) suffered graft loss.
Rejection surveillance with a low-intensity biopsy protocol demonstrated similar intermediate-term outcomes and safety measures as international registries up to 5 years post-transplant.
Concentrate inclusion levels in dairy cow diets are often adjusted so that the milk yield responses remain economic. While changes in concentrate level on performance is well known, their impact on other biological parameters, including immune function, is less well understood. The objective of this study was to evaluate the effect of concentrate inclusion level in a grass silage-based mixed ration on immune function. Following calving 63 (45 multiparous and 18 primiparous) Holstein Friesian dairy cows were allocated to one of three isonitrogenous diets for the first 70 days of lactation. Diets comprised of a mixture of concentrates and grass silage, with concentrates comprising either a low (30%, LC), medium (50%, MC) or high (70%, HC) proportion of the diet on a dry matter (DM) basis. Daily DM intakes, milk yields and BW were recorded, along with weekly body condition score, milk composition and vaginal mucus scores. Blood biochemistry was measured using a chemistry analyzer, neutrophil phagocytic and oxidative burst assessed using commercial kits and flow cytometry, and interferon-γ production evaluated by ELISA after whole blood stimulation. Over the study period cows on HC had a higher total DM intake, milk yield, fat yield, protein yield, fat+protein yield, protein content, mean BW and mean daily energy balance, and a lower BW loss than cows on MC, whose respective values were higher than cows on LC. Cows on HC and MC had a lower serum non-esterified fatty acid concentration than cows on LC (0.37, 0.37 and 0.50 mmol/l, respectively, P=0.005, SED=0.032), while cows on HC had a lower serum β-hydroxybutyrate concentration than cows on MC and LC (0.42, 0.55 and 0.55 mmol/l, respectively, P=0.002, SED=0.03). Concentrate inclusion level had no effect on vaginal mucus scores. At week 3 postpartum, cows on HC tended to have a higher percentage of oxidative burst positive neutrophils than cows on LC (43.2% and 35.3%, respectively, P=0.078, SED=3.11), although at all other times concentrate inclusion level in the total mixed ration had no effect on neutrophil phagocytic or oxidative burst characteristics, or on interferon-γ production by pokeweed mitogen stimulated whole blood culture. This study demonstrates that for high yielding Holstein Friesian cows managed on a grass silage-based diet, concentrate inclusion levels in early lactation affects performance but has no effect on neutrophil or lymphocyte immune parameters.
The present study evaluated the behaviour of the AusBeef model for beef production as part of a 2 × 2 study simulating performance on forage-based and concentrate-based diets from Oceania and North America for four methane (CH4)-relevant outputs of interest. Three sensitivity analysis methods, one local and two global, were conducted. Different patterns of sensitivity were observed between forage-based and concentrate-based diets, but patterns were consistent within diet types. For the local analysis, 36, 196, 47 and 8 out of 305 model parameters had normalized sensitivities of 0, >0, >0·01 and >0·1 across all diets and outputs, respectively. No parameters had a normalized local sensitivity >1 across all diets and outputs. However, daily CH4 production had the greatest number of parameters with normalized local sensitivities >1 for each individual diet. Parameters that were highly sensitive for global and local analyses across the range of diets and outputs examined included terms involved in microbial growth, volatile fatty acid (VFA) yields, maximum absorption rates and their inhibition due to pH effects and particle exit rates. Global sensitivity analysis I showed the high sensitivity of forage-based diets to lipid entering the rumen, which may be a result of the use of a feedlot-optimized model to represent high-forage diets and warrants further investigation. Global sensitivity analysis II showed that when all parameter values were simultaneously varied within ±10% of initial value, >96% of output values were within ±20% of the baseline, which decreased to >50% when parameter value boundaries were expanded to ±25% of their original values, giving a range for robustness of model outputs with regards to potential different ‘true’ parameter values. There were output-specific differences in sensitivity, where outputs that had greater maximum local sensitivities displayed greater degrees of non-linear interaction in global sensitivity analysis I and less variance in output values for global sensitivity analysis II. For outputs with less interaction, such as the acetate : propionate ratio and microbial protein production, the single most sensitive term in global sensitivity analysis I contributed more to the overall total-order sensitivity than for outputs with more interaction, with an average of 49, 33, 15 and 14% of total-order sensitivity for microbial protein production, acetate : propionate ratio, CH4 production and energy from absorbed VFAs, respectively. Future studies should include data collection for highly sensitive parameters reported in the present study to improve overall model accuracy.
As demand for animal products, such as meat and milk, increases, and concern over environmental impact grows, mechanistic models can be useful tools to better represent and understand ruminant systems and evaluate mitigation options to reduce greenhouse gas emissions without compromising productivity. The objectives of the present study were to describe the representation of processes for growth and enteric methane (CH4) production in AusBeef, a whole-animal, dynamic, mechanistic model for beef production; evaluate AusBeef for its ability to predict daily methane production (DMP, g/day), gross energy intake (GEI, MJ/day) and methane yield (MJ CH4/MJ GEI) using an independent data set; and to compare AusBeef estimates to those from the empirical equations featured in the current National Academies of Sciences, Engineering and Medicine (NASEM, 2016) beef cattle requirements for growth and the Ruminant Nutrition System (RNS), a dynamic, mechanistic model of Tedeschi & Fox, 2016. AusBeef incorporates a unique fermentation stoichiometry that represents four microbial groups: protozoa, amylolytic bacteria, cellulolytic bacteria and lactate-utilizing bacteria. AusBeef also accounts for the effects of ruminal pH on microbial degradation of feed particles. Methane emissions are calculated from net ruminal hydrogen balance, which is defined as the difference between inputs from fermentation and outputs due to microbial use and biohydrogenation. AusBeef performed similarly to the NASEM empirical model in terms of prediction accuracy and error decomposition, and with less root mean square predicted error (RMSPE) than the RNS mechanistic model when expressed as a percentage of the observed mean (RMSPE, %), and the majority of error was non-systematic. For DMP, RMSPE for AusBeef, NASEM and RNS were 24·0, 19·8 and 50·0 g/day for the full data set (n = 35); 25·6, 18·2 and 56·2 g/day for forage diets (n = 19); and 21·8, 21·5 and 41·5 g/day for mixed diets (n = 16), respectively. Concordance correlation coefficients (CCC) were highest for GEI, with all models having CCC > 0·66, and higher CCC for forage diets than mixed, while CCC were lowest for MY, particularly forage diets. Systematic error increased for all models on forage diets, largely due to an increase in error due to mean bias, and while all models performed well for mixed diets, further refinements are required to improve the prediction of CH4 on forage diets.
This study examined six- and 12-month levels of adherence to physical activity, functional changes, and psychosocial determinants of physical activity in 176 older adults who participated in the “Get Fit for Active Living (GFAL)” pilot program. Functional and psychosocial measures were conducted in person at six months; psychosocial measures and physical activity participation were assessed by telephone interview at 12 months. Ninety-five per cent were retained in the study at the six-month follow-up, and 88 per cent at 12 months. The self-reported adherence rate to exercise at 12 months was 66 per cent. The main reason for continued exercise participation was to maintain health (45%). Reasons for nonadherence were illness (38%) and lack of motivation (32%). Results identify factors associated with positive behaviour change that health promoters can utilize when targeting the older adult population. The GFAL project results can serve as a model for sustainable, community-based older-adult exercise programs.
The methodological and epistemological challenges that research on ethnopolitical violence faces are examined. This research area is fundamentally important for political reasons and for understanding, as well as subsequent interventions to ameliorate, youths’ responses to ethnopolitical violence. Advances in methods are reviewed that can overcome the obstacles placed by the various challenges. These issues are discussed in the context of the articles that comprise this Special Section.
A few studies have examined the association between vitamin D and telomere length, and fewer still have examined the relationship in black or male populations. We investigated the cross-sectional association between the vitamin D metabolite 25-hydroxyvitamin D (25(OH)D) concentration in plasma and relative leucocyte telomere length (LTL) in 1154 US radiologic technologists who were 48–93 years old (373 white females, 278 white males, 338 black females, 165 black males). Plasma 25(OH)D concentration was measured by the chemiluminescence immunoassay, and relative LTL was measured by quantitative PCR. Logistic regression was used to obtain OR and 95 % CI for long v. short (based on median) LTL in relation to continuous 25(OH)D, quartiles of 25(OH)D and 25(OH)D deficiency. We found no significant association between continuous 25(OH)D and long LTL in all participants (Ptrend=0·440), nor in white females (Ptrend=0·845), white males (Ptrend=0·636), black females (Ptrend=0·967) or black males (Ptrend=0·484). Vitamin D deficiency (defined as 25(OH)D<30 nmol/l), however, was significantly associated with short LTL in whites (P=0·024), but not in other groups. In this population, we found little evidence to support associations between 25(OH)D and long LTL over the entire range of 25(OH)D in the overall study population or by sex and race.
The Cycadales are a group of significant global conservation concern and have the highest extinction risk of all seed plants. Understanding the synchronisation of reproductive phenology of Cycadales may be useful for conservation by enabling the targeting of pollen and seed collection from wild populations and identifying the window of fertilisation to aid in the cultivation of Cycadales. Phenological data for 11 species of Zamia were gathered from herbarium specimens. Four phenological characters were coded with monthly character states. DNA was isolated and sequenced for 26S, CAB, NEEDLY, matK and rbcL, and a simultaneous phylogenetic analysis of phenology and DNA sequence data was carried out. Three major clades were recovered: a Caribbean clade, a Central American clade and a South American clade. Eight species showed statistically significant synchronisation in microsporangiate and ovulate phenological phases, indicating the time of fertilisation. Close reproductive synchronisation was consistently observed throughout the Caribbean clade (statistically significant in four of five species) but was less consistent in the Central American clade (statistically significant in one of two species) and South American clade (statistically significant in three of four species). Ultimately, phenology is shown to be a potential driver of speciation in some clades of Zamia and in others to be a potential barrier to hybridisation.
The status and potential of aquaculture is considered as part of a broader food landscape of wild aquatic and terrestrial food sources. The rationale and resource base required for the development of aquaculture are considered in the context of broader societal development, cultural preferences and human needs. Attention is drawn to the uneven development and current importance of aquaculture globally as well as its considerable heterogeneity of form and function compared with established terrestrial livestock production. The recent drivers of growth in demand and production are examined and the persistent linkages between exploitation of wild stocks, full life cycle culture and the various intermediate forms explored. An emergent trend for sourcing aquaculture feeds from alternatives to marine ingredients is described and the implications for the sector with rapidly growing feed needs discussed. The rise of non-conventional and innovative feed ingredients, often shared with terrestrial livestock, are considered, including aquaculture itself becoming a major source of marine ingredients. The implications for the continued expected growth of aquaculture are set in the context of sustainable intensification, with the challenges that conventional intensification and emergent integration within, and between, value chains explored. The review concludes with a consideration of the implications for dependent livelihoods and projections for various futures based on limited resources but growing demand.
The number and size of free-range laying hen (Gallus gallus domesticus) production systems are increasing within Australia in response to consumer demand for perceived improvement in hen welfare. However, variation in outdoor stocking density has generated consumer dissatisfaction leading to the development of a national information standard on free-range egg labelling by the Australian Consumer Affairs Ministers. The current Australian Model Code of Practice for Domestic Poultry states a guideline of 1500 hens/ha, but no maximum density is set. Radio-frequency identification (RFID) tracking technology was used to measure daily range usage by individual ISA Brown hens housed in six small flocks (150 hens/flock – 50% of hens tagged), each with access to one of three outdoor stocking density treatments (two replicates per treatment: 2000, 10 000, 20 000 hens/ha), from 22 to 26, 27 to 31 and 32 to 36 weeks of age. There was some variation in range usage across the sampling periods and by weeks 32 to 36 individual hens from the lowest stocking density on average used the range for longer each day (P<0.001), with fewer visits and longer maximum durations per visit (P<0.001). Individual hens within all stocking densities varied in the percentage of days they accessed the range with 2% of tagged hens in each treatment never venturing outdoors and a large proportion that accessed the range daily (2000 hens/ha: 80.5%; 10 000 hens/ha: 66.5%; 20 000 hens/ha: 71.4%). On average, 38% to 48% of hens were seen on the range simultaneously and used all available areas of all ranges. These results of experimental-sized flocks have implications for determining optimal outdoor stocking densities for commercial free-range laying hens but further research would be needed to determine the effects of increased range usage on hen welfare.
The under-rock guild of nemerteans from Lough Hyne, south-west Ireland was recorded during a long-term benthic survey of the marine reserve. From 2004 to 2014, common nemerteans were recorded annually in late summer for ten historical monitoring sites (each 10 m of shoreline); more comprehensive surveys were completed in 2012 (4126 low-intertidal to shallow-subtidal rocks were turned) and 2014 (1289 rocks turned) with supplementary information in 2015. The bootlace worm, Lineus longissimus, was the most abundant nemertean species. It was significantly more abundant at the extremely shallow East Castle site than the other nine sites; peak populations (across all ten sites) occurred in 2012. The Lusitanian nemertean Paradrepanophorus crassus was abundant after 2007. To date, 13 nemertean species were recorded with numerous new records for the lough, including Tubulanus annulatus, Micrura purpurea, Ramphogordius sanguineus, Micrella rufa and Emplectonema gracile. Three additional nemertean species were previously recorded, indicating that at least 16 species occur in the lough. Given the low densities and paucity of comprehensive earlier records, we are not able to ascertain definitely whether these species are new incursions or if sparsely distributed residents have increased.
Marine worms in the genus Osedax, have specialized ‘root’ tissues used to bore into the bones of decomposing vertebrate skeletons and obtain nutrition. We investigated the borings of nine Osedax species, using micro computed tomography to quantitatively describe the morphology of the borings and provide three-dimensional reconstructions of the space occupied by Osedax root tissues inside the bone. Each Osedax species displayed a consistent boring morphology in any given bone, but these differed between bones. In bones where multiple species coexisted there was limited evidence for spatial niche partitioning by Osedax root tissues inside the bones investigated here. The new morphological data may be applied to Osedax traces in fossil bones, showing that borings can be used to indicate minimum species richness in these bones.