To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Prenatal diethylstilbestrol (DES) exposure is associated with increased risk of hormonally mediated cancers and other medical conditions. We evaluated the association between DES and risk of pancreatic cancer and pancreatic disorders, type 2 diabetes, and gallbladder disease, which may be involved with this malignancy. Our analyses used follow-up data from the US National Cancer Institute DES Combined Cohort Study. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for age, sex, cohort, body mass index, smoking, and alcohol for the association between prenatal DES exposure and type 2 diabetes, gallbladder disease (mainly cholelithiasis), pancreatic disorders (mainly pancreatitis), and pancreatic cancer among 5667 exposed and 3315 unexposed individuals followed from 1990 to 2017. Standardized incidence rate (SIR) ratios for pancreatic cancer were based on age-, race-, and calendar year-specific general population cancer incidence rates. In women and men combined, the hazards for total pancreatic disorders and pancreatitis were greater in the prenatally DES exposed than the unexposed (HR = 11, 95% CI 2.6–51 and HR = 7.0, 95% CI 1.5–33, respectively). DES was not associated overall with gallbladder disease (HR = 1.2, 95% CI 0.88–1.5) or diabetes (HR = 1.1, 95% CI 0.9–1.2). In women, but not in men, DES exposure was associated with increased risk of pancreatic cancer compared with the unexposed (HR: 4.1, 95% CI 0.84–20) or general population (SIR: 1.9, 95% CI 1.0–3.2). Prenatal DES exposure may increase the risk of pancreatic disorders, including pancreatitis in women and men. The data suggested elevated pancreatic cancer risk in DES-exposed women, but not in exposed men.
Background: Well-designed infection prevention programs include basic elements aimed at reducing the risk of transmission of infectious agents in healthcare settings. Although most acute-care facilities have robust infection prevention programs, data are sporadic and often lacking in other healthcare settings. Infection control assessment tools were developed by the CDC to assist health departments in assessing infection prevention preparedness across a wide spectrum of health care including acute care, long-term care, outpatient care, and hemodialysis. Methods: The North Carolina Division of Public Health collaborated with the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) to conduct a targeted number of on-site assessments for each healthcare setting. Three experienced infection preventionists recruited facilities, conducted on-site assessments, provided detailed assessment findings, and developed educational resources. Results: The goal of 250 assessments was exceeded, with 277 on-site assessments completed across 75% of North Carolina counties (Table 1). Compliance with key observations varied by domain and type of care setting (Table 2). Conclusions: Comprehensive on-site assessments of infection prevention programs are an effective way to identify gaps or breaches in infection prevention practices. Gaps identified in acute care primarily related to competency validation: however, gaps presenting a threat to patient safety (ie, reuse of single dose vials, noncompliance with sterilization and/or high-level disinfection processes) were identified in other care settings. Infection control assessment and response findings underscore the need for ongoing assessment, education, and collaboration among all healthcare settings.
The objects of town and country planning … are to secure a proper balance between the competing demands for land, so that all the land of the country is used in the best interests of the people…. The people whose surroundings are being planned must be given every chance to take an active part in the planning process … and when they have had it, the provisional plan may need a good deal of alteration…. In the past, plans have been too much the plans of officials…. (Lewis Silkin MP, Minister for Town and Country Planning, in the House of Commons Debate on the Second Reading of the Town and Country Planning Bill, Hansard, 29 January 1947, quoted in Silkin, 1947)
Lewis Silkin was a minister in the postwar Labour government, which introduced the Town and Country Planning Act in 1947, and this Act figures in every history of UK planning as the landmark mid-century coming of age of a new practice of spatial governance that promised to make cities civilized. It is a useful reminder that the 1945 Labour government did contain radicals like Silkin, whose ambition was to change (not consolidate) urban planning practice, where his notions of participation went well beyond representative democracy and trade union balloting. Silkin argued from democratic first principles that urban planning in ‘the interests of the people’ exists to articulate a collective purpose, and that only becomes possible if plan making is participative and involves active citizens who can challenge priorities and change official plans.
This radical theme – planning reshaped by active citizens – runs like a motif throughout the subsequent academic literature. The Oxford Handbook of Urban Planning includes a chapter on planning and citizenship by Miraftab (2012), who writes from the point of view that citizenship is not a political status with formal rights but an active process of making and doing. So the question is not about what citizenship is as given by the state, but what citizenship can do when grounded in civil society. In a scholarly and broad-ranging book, Mazza (2017) distinguishes between spatial planning and governance; planning is the technical knowledge and professional know-how that properly supports broad political choices, better described as spatial governance.
Vitamin D deficiency has been commonly reported in elite athletes, but the vitamin D status of UK university athletes in different training environments remains unknown. The present study aimed to determine any seasonal changes in vitamin D status among indoor and outdoor athletes, and whether there was any relationship between vitamin D status and indices of physical performance and bone health. A group of forty-seven university athletes (indoor n 22, outdoor n 25) were tested during autumn and spring for serum vitamin D status, bone health and physical performance parameters. Blood samples were analysed for serum 25-hydroxyvitamin D (s-25(OH)D) status. Peak isometric knee extensor torque using an isokinetic dynamometer and jump height was assessed using an Optojump. Aerobic capacity was estimated using the Yo-Yo intermittent recovery test. Peripheral quantitative computed tomography scans measured radial bone mineral density. Statistical analyses were performed using appropriate parametric/non-parametric testing depending on the normality of the data. s-25(OH)D significantly fell between autumn (52·8 (sd 22·0) nmol/l) and spring (31·0 (sd 16·5) nmol/l; P < 0·001). In spring, 34 % of participants were considered to be vitamin D deficient (<25 nmol/l) according to the revised 2016 UK guidelines. These data suggest that UK university athletes are at risk of vitamin D deficiency. Thus, further research is warranted to investigate the concomitant effects of low vitamin D status on health and performance outcomes in university athletes residing at northern latitudes.
Scientific quality and feasibility are part of ethics review by Institutional Review Boards (IRBs). Scientific Review Committees (SRCs) were proposed to facilitate this assessment by the Clinical and Translational Science Award (CTSA) SRC Consensus Group. This study assessed SRC feasibility and impact at CTSA-affiliated academic health centers (AHCs).
SRC implementation at 10 AHCs was assessed pre/post-intervention using quantitative and qualitative methods. Pre-intervention, four AHCs had no SRC, and six had at least one SRC needing modifications to better align with Consensus Group recommendations.
Facilitators of successful SRC implementation included broad-based communication, an external motivator, senior-level support, and committed SRC reviewers. Barriers included limited resources and staffing, variable local mandates, limited SRC authority, lack of anticipated benefit, and operational challenges. Research protocol quality did not differ significantly between study periods, but respondents suggested positive effects. During intervention, median total review duration did not lengthen for the 40% of protocols approved within 3 weeks. For the 60% under review after 3 weeks, review was lengthened primarily due to longer IRB review for SRC-reviewed protocols. Site interviews recommended designing locally effective SRC processes, building buy-in by communication or by mandate, allowing time for planning and sharing best practices, and connecting SRC and IRB procedures.
The CTSA SRC Consensus Group recommendations appear feasible. Although not conclusive in this relatively short initial implementation, sites perceived positive impact by SRCs on study quality. Optimal benefit will require local or federal mandate for implementation, adapting processes to local contexts, and employing SRC stipulations.
Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013.
A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends.
The derived cohort comprised 562,546 cases (April 2012–March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886–0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808–0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001).
Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.
The purpose of the article is to describe the progress of the Clinical and Translational Science Award (CTSA) Program to address the evaluation-related recommendations made by the 2013 Institute of Medicine’s review of the CTSA Program and guidelines published in CTS Journal the same year (Trochim et al., Clinical and Translational Science 2013; 6(4): 303–309). We utilize data from a 2018 national survey of evaluators administered to all 64 CTSA hubs and a content analysis of the role of evaluation in the CTSA Program Funding Opportunity Announcements to document progress. We present four new opportunities for further strengthening CTSA evaluation efforts: (1) continue to build the collaborative evaluation infrastructure at local and national levels; (2) make better use of existing data; (3) strengthen and augment the common metrics initiative; and (4) pursue internal and external opportunities to evaluate the CTSA program at the national level. This article will be of significant interest to the funders of the CTSA Program and the multiple stakeholders in the larger consortium and will promote dialog from the broad range of CTSA stakeholders about further strengthening the CTSA Program’s evaluation.
There are significant challenges to retaining indigenous biodiversity and ecological infrastructure in African cities. These include a lack of formal protection and status for remnant ecologically functional patches rendering them open to ad hoc human settlement, which is in part linked to weak governance and management emerging from complex histories, and competing crisis-ridden demands. Persistent gaps in knowledge and practice mean that the social, economic, development and well-being benefits of ecological infrastructure are not understood or demonstrated. Addressing these challenges requires the adoption of multiple top-down government interventions and bottom-up community and neighbourhood actions. The development of detailed case studies that engage with knowledge generation and sharing at multiple scales through co-learning practices will also help create a much-needed deeper understanding of development options within this context.
The aim of this integrative review is to determine the effectiveness of integrated heart failure (HF) care in terms of patient-, service- and resource-related outcomes, and to determine what model or characteristics of integrated care work best, for whom and in what contexts.
Integration of health and social care services is a significant driver in the development of better and more cost-effective health and social care systems in Europe and developed countries. As high users of health and social care services, considerable attention has been paid to the care of people with long-term conditions. HF is a progressive, prevalent and disabling condition, requiring complex management involving multiple health and social care agencies.
An integrative review was conducted according to a framework by Whittemore and Knafl (2005). A literature search was undertaken using the databases: Medline, CINAHL, Embase, PsychINFO and the Cochrane Library, using key words of ‘heart failure’ OR ‘cardiac failure’ AND ‘integrated’ OR ‘multidisciplinary’ OR ‘interdisciplinary’ OR ‘multiprofessional’ OR ‘interprofessional’ OR ‘collaborative care’. Application of the inclusion and exclusion criteria resulted in 17 articles being included in the review. Articles were screened and coded for methodological quality according to a two-point criteria. Data were extracted using a template and analysed thematically.
Integrated HF care results in enhanced quality of life (QoL), and improved symptom control and self-management. Reduced admission rates, reduced length of hospital stay, improved prescribing practices and better care co-ordination are also reported. There is more limited evidence for improved efficiency although overall costs may be reduced. Although findings are highly context dependent, key features of integrated HF models are: liaison between primary and secondary care services to facilitate planned discharge, early and medium term follow-up, multidisciplinary patient education and team working including shared professional education, and the development and implementation of comprehensive care pathways.
OBJECTIVES/SPECIFIC AIMS: To build a multisite de-identified database of female adolescents, aged 12–21 years (January 2011–December 2012), and their subsequent offspring through 24 months of age from electronic health records (EHRs) provided by participating Community Health. METHODS/STUDY POPULATION: We created a community-academic partnership that included New York City Community Health Centers (n=4) and Hospitals (n=4), The Rockefeller University, The Sackler Institute for Nutrition Science and Clinical Directors Network (CDN). We used the Community-Engaged Research Navigation model to establish a multisite de-identified database extracted from EHRs of female adolescents aged 12–21 years (January 2011–December 2012) and their offspring through 24 months of age. These patients received their primary care between 2011 and 2015. Clinical data were used to explore possible associations among specific measures. We focused on the preconception, prenatal, postnatal periods, including pediatric visits up to 24 months of age. RESULTS/ANTICIPATED RESULTS: The analysis included all female adolescents (n=122,556) and a subset of pregnant adolescents with offspring data available (n=2917). Patients were mostly from the Bronx; 43% of all adolescent females were overweight (22%) or obese (21%) and showed higher systolic and diastolic blood pressure, blood glucose levels, hemoglobin A1c, total cholesterol, and triglycerides levels compared with normal-weight adolescent females (p<0.05). This analysis was also performed looking at the nonpregnant females and the pregnant females separately. Overall, the pregnant females were older (mean age=18.3) compared with the nonpregnant females (mean age=16.5), there was a higher percentage of Hispanics among the pregnant females (58%) compared with the nonpregnant females (43.9%). There was a statistically significant association between the BMI status of mothers and infants’ birth weight, with underweight/normal-weight mothers having more low birth weight (LBW) babies and overweight/obese mothers having more large babies. The odds of having a LBW baby was 0.61 (95% CI: 0.41, 0.89) lower in obese compared with normal-weight adolescent mothers. The risk of having a preterm birth before 37 weeks was found to be neutral in obese compared with normal-weight adolescent mothers (OR=0.81, 95% CI: 0.53, 1.25). Preliminary associations are similar to those reported in the published literature. DISCUSSION/SIGNIFICANCE OF IMPACT: This EHR database uses available measures from routine clinical care as a “rapid assay” to explore potential associations, and may be more useful to detect the presence and direction of associations than the magnitude of effects. This partnership has engaged community clinicians, laboratory, and clinical investigators, and funders in study design and analysis, as demonstrated by the collaborative development and testing of hypotheses relevant to service delivery. Furthermore, this research and learning collaborative is examining strategies to enhance clinical workflow and data quality as well as underlying biological mechanisms. The feasibility of scaling-up these methods facilitates studying similar populations in different Health Systems, advancing point-of-care studies of natural history and comparative effectiveness research to identify service gaps, evaluate effective interventions, and enhance clinical and data quality improvement.
Endometriosis is the etiology in almost one-third of all gynecological admissions in the United States. It takes close to 12 years from first symptoms to confirmatory diagnosis. Early surgical intervention will promote earlier diagnosis. This chapter describes surgical management. The reader is referred to other sources for in-depth discussion of medical management.
Scope of the Problem
The problem of endometriosis is large. It is estimated that one in three gynecological admissions in the United States are related to this condition.  Diagnosis may be elusive, and many of the symptoms are vague and can represent a variety of gynecologic conditions. Almost 1 in 10 women of reproductive age suffers from the burden of this condition, and over 69 billion dollars was spent in 2009 on treating this condition. [2,3] As many as 40 percent of infertile couples and 9 percent of women with chronic pelvic pain demonstrate the presence of endometriosis.  Endometriosis is a disease with a genetic component, and as many as 5–7 percent of all women with the disease have a first-degree relative afflicted. The mode of inheritance is most likely polygenetic/multifactorial method of inheritance, as opposed to Mendelian. 
Endometriosis occurs when endometrial glands and stroma implant on extra-uterine surfaces. Classically, these lesions may be present on the pelvic and parietal peritoneum, the ovaries, the cul-de-sac, and uterosacral ligaments or bowel. The most common theory was developed by Dr. Sampson in the early part of twentieth century. He proposed retrograde menstruation allows the migration and implantation of ectopic glands. Support of this theory includes the preponderance of lesions in the cul-de-sac due to gravity, as well as the left hemi pelvis due to the recto sigmoid location. Other common theories for the etiology of endometriosis include coelemic metaplasia, hematogenous spread, lymphatic spread, and stem cell transplants spread via the bone marrow.
Whichever mechanism is ultimately proven to be the dominant one, changes at the molecular level also need to occur to influence the induction of the disease. There are four molecular characteristics that are associated with endometriosis. These include a genetic predilection, estrogen dependence, progesterone resistance, and local inflammation. Combination of these factors all contribute to the expression of this disease. 
Calling in staff and preparing the operating room for an urgent surgical procedure is a significant draw on hospital resources and disrupts care of other patients. It has been common practice to treat open fractures on an urgent basis. HTA methods can be applied to examine this prioritization of care, just like they can be applied to the acquisition of drugs and devices.
Our center completed a rapid systematic review of guidelines, systematic reviews, and primary clinical evidence, on urgent surgical debridement and stabilization of open fractures of long bones (“urgent” being defined as within six hours of the injury) compared to surgical debridement and reduction performed at a later time point. Meta-analyses were performed for infection and non-union outcomes and the GRADE system was used to assess the strength of evidence for each conclusion.
We found no published clinical guidelines for the urgency of treating open fractures. A good systematic review on the topic was published in 2012. We found six cohort studies published since completion of the earlier review. The summary odds ratio for any infection in patients with later treatment was 0.97 (95% confidence interval (CI) 0.78–1.22, sixteen studies, 3,615 patients) and for deep or “major” infections was 1.00 (95% CI 0.74–1.34, nine studies, 2,013 patients). The summary odds ratio of non-union with later treatment was 0.95 (95% CI 0.65–1.41, six studies, 1,308 patients). There was no significant heterogeneity in any of the results (I-squared = 0 percent) and no apparent trends in the results as a function of study size or publication date. We graded the strength of each of the conclusions as very low because they were based on cohort studies where the treating physician could elect immediate treatment for patients with severe soft-tissue injuries or patients at risk of complications. This raises the risk of spectrum bias.
Default urgent scheduling of patients with open fractures for surgical debridement and stabilization does not appear to reduce the risk of infection or fracture non-union. Based on this information, our surgery department managers no longer schedule patients with open fractures for immediate surgery unless there are specific circumstances necessitating it.