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.
Cetacean watching is an increasingly popular economic activity in Ecuador for tourism operators. Despite government regulations, cetacean watching can have a negative impact on observed animal populations. To enhance good dolphin-watching practices, a course was carried out in Puerto El Morro, Ecuador about sensitisation activities promoting empathy towards and knowledge about bottlenose dolphins, local avifauna and mangrove ecosystems. The course provided tourism operator staff with theoretical and practical knowledge on dolphin physiology and ecology, with a focus on empathy towards the species and on regulations to be respected during the watching tours. The course included interactive workshops, didactic materials, advice, video screening and structured conversations. Two innovative questionnaires were implemented on the boat during 68 dolphin-watching tours to evaluate whether the training course had improved the regulation compliance and on-tour guiding quality of the tour guides and boat drivers. The results showed a statistically significant improvement in dolphin-watching practices in compliance with the “Regulations for the Whale and Dolphin Watching of Ecuador” (p = .0002) and in guidance quality (p = .0004) after the training course. Boat drivers were identified as influential actors in compliance with regulations and should also be included in the environmental awareness training courses. The study showed that empathy-based sensitisation and knowledge reinforcement positively affect policy compliance and can generate new sustainable approaches for future dolphin-watching activities.
Approximately 80% of neotropical forests are subject to unsustainable economic practices, such as logging. Spiders are a megadiverse taxonomic group with a particularly great diversity in forest ecosystems and could help indicate the sustainability of logging operations. At six sites at 400–700 m altitude in the piedmont forest of north-western Argentina, spiders collected using pitfall traps and forest structure and spider assemblage structure variables were quantified in order to examine the association between them and to identify indicator spider families. Logging changes forest structure and seems to generate an unsuitable habitat for spiders associated with mature forests. The family taxonomic level is a good surrogate for spider morphospecies. The Mysmenidae, Nemesiidae, Theridiidae, Pholcidae, Hahniidae and Tetragnathidae families were associated with upper canopy cover of 20% or more and with more than two dead fallen trees per 0.1 ha and >15 live trees per 0.1 ha, found in unlogged forests. Bearing in mind that the piedmont forest of north-western Argentina is being logged in the absence of sustainability criteria, we suggest including spiders in monitoring schemes to complement the information obtained from more readily used groups, such as charismatic vertebrates.
Transforming the way that public governance is produced and delivered is difficult given the combination of bureaucratic politics and institutional path-dependence. To imagine whether it is still possible, this chapter looks at how public leaders can transform public institutions through intentional reform and what kind of change they must bring about in order to advance and support co-creation. First, it discusses how different forms of strategic management can help to spur the transition to co-creation. Next, it presents four crucial conditions for enabling the future expansion of co-creation into a predominant mode of governance: 1) the creation of new institutional designs; 2) the cultivation of new forms of leadership and management; 3) the transformation of the role perceptions of key social and political actors; and 4) the development of new ways of measuring effects. The conclusion critically examines competing scenarios for the development of co-creation into a mode of governance and presents a five-step model for the transition to co-creation.
There is an important small-scale fishery using mechanized dredges and targeting clams (mainly wedge clam Donax trunculus and striped venus clam Chamelea gallina) along the Catalan coast (NW Mediterranean Sea). This study evaluated for the first time the discards and impact of mechanized clam dredging on the Catalan coast. To this end, three surveys were performed on board standard clam vessels (September and November 2016 and January 2017). Surveys were conducted in the three main clam fishing areas (Rosas Bay, South Barcelona and Ebro Delta). The composition of discards and the impact caused to discarded species was assessed using a three-level scale (undamaged; minor or partial damage; and lethal damage). Our study revealed that a large proportion of the catch (between 67–82% weight) is discarded. Even though about 63% of the discarded species were undamaged, 11% showed minor or partial damage and 26% lethal damage. Infaunal and epifaunal species with soft-body or fragile shells were the most impacted by the fishing activity (e.g. the sea urchin Echinocardium mediterraneum (~89%) and the bivalve Ensis minor (~74%)). Our results showed different levels of impact by target species and fishing area.
The value of strong, compassionate medical leadership in the delivery of high-quality care to patients within mental health services is clear. Leadership development, however, is far less well explored. This article is for psychiatric trainees, trainers and mental health organisations. It provides an introduction to the importance of leadership development within postgraduate medical training, the theory that should underpin its delivery, and the opportunities for both informal and formal leadership development within psychiatric training.
Palmer amaranth–a fast-growing, challenging-to-control noxious weed that significantly reduces crop yields—was first found in Minnesota in September 2016 in conservation plantings sown with Palmer amaranth contaminated seed mixes. Minnesota Department of Agriculture (MDA) designated Palmer amaranth as a Prohibited Noxious Weed in 2015 and listed it as a Noxious Weed Seed in 2016 by emergency order. A genetic test to identify Palmer amaranth was simultaneously developed by multiple laboratories, providing a tool to limit its spread as a contaminant in seed. Seed companies adopted genetic testing methods for labeling seed for sale, thus reducing introductions via the seed pathway. Additionally, MDA determined that manure spread on crop fields from contaminated screenings fed to livestock resulted in new infestations. Limiting spread via these and other potential pathways was critical to successfully reducing the impact of Palmer amaranth. MDA, University of Minnesota (UMN) Extension, Conservation Corps Minnesota and Iowa (CCMI), farmers, and other partners are working to eradicate these infestations before they can spread. In 2016, 35 sites were sown with Palmer amaranth–contaminated seed mixes. Palmer amaranth was found at eight (23%) of these sites. Management with intensive scouting, torching, prescribed burning, and herbicide application was implemented in 2016 and 2017. By 2018, no Palmer amaranth was found at any of these sites. Similar success to newer infestations in 2018, 2019, and 2020 was achieved using the same methods. MDA recorded management activities and documented a comprehensive timeline of Palmer amaranth in Minnesota. This timeline provides a story of success and challenges in combating and eradicating Palmer amaranth.
Parkinson's psychosis can be very challenging to manage, with limited treatment options available. There is a good evidence base to support the use of clozapine, but practical obstacles often prevent its use. There is a drive nationally to set up services so that people with Parkinson's psychosis can access treatment with clozapine in a timely manner and, where possible, with initiation in the community. The authors describe their experiences in setting up clozapine services specifically for this patient group in England and offer a practical approach to the assessment of Parkinson's psychosis. They also outline the evidence base in relation to treatment options and share their experiences of prescribing clozapine for Parkinson's psychosis.
Endometriosis is a chronic oestrogen-dependent condition that affects 10% of women from puberty to menopause. It is characterised by the presence and proliferation of endometrial-like cells outside the uterine cavity, generally within the pelvis. Endometriosis can present as superficial or deep peritoneal lesions, ovarian endometrioma or deep rectovaginal disease. The two hallmark symptoms of endometriosis are pelvic pain and infertility resulting in poor quality of life. There is no correlation between the extent of the disease and severity of symptoms. The true prevalence of the condition is not known, as it requires a laparoscopy to confirm the diagnosis. It is found in up to 30% of women with infertility and in 45% of those with pelvic pain. While there are several theories of pathogenesis, an interplay of genetic, hormonal, environmental and immunological factors is implicated in the development of endometriosis in susceptible women. Symptoms are managed with a combination of hormonal treatment and laparoscopic ablation or excision of lesions for pain and usually assisted reproduction for infertility. Endometriosis is prone to recurrence after treatment, requiring multiple contacts with healthcare and repeat surgery. Management of endometriosis requires an individualised approach based on the woman’s age, predominant symptoms and priorities, which are subject to change over time.
Strong competitive ability of introduced plant species has been frequently stated as a key factor promoting successful invasion. The dynamics of invasive species may depend on their abilities to compete for resources and exploit disturbances relative to native species. This study compares the growth performance of the invasive blackberry (Rubus niveus Thunb.) with four of the most common woody native species of the Scalesia forest in the Galapagos Islands. Using a series of greenhouse and field studies, the growth rate and biomass production of native species alone and in competition with R. niveus was compared under different water and light stress conditions. Rubus niveus showed a faster growth rate and biomass production than the native species as well as a broad tolerance to light and water stress conditions. Competitive ability was also assessed by looking at the seedbank and regeneration processes after herbicide control in the field. Although the number of R. niveus seedlings that germinated from the soil samples was considerably larger than that of native species, recruitment of the invasive on the experimental plots was limited. Overall, R. niveus showed superior competitive ability over native species with comparable growth forms, suggesting a possible mechanism that enables R. niveus to successfully invade a wide range of habitats in the Galapagos Islands. Implementing an integrated management strategy including biological control, seedbank reduction, and active revegetation, should improve the efficiency of R. niveus management, enabling the restoration of degraded vegetation in the Galapagos.
People with NCDs are particularly vulnerable to disasters. This research systematically reviewed reports describing studies on the status of patients with NCDs before, during and after disasters.
Relevant articles published from 1997 to 2019 were collected by searching the Scopus, PubMed, and Science Direct databases. We specifically examined reports describing NCDs and including the key words ‘Non-Communicable Disease and Disasters.’ NCDs include cardiovascular, respiratory, diabetes and cancer diseases.
The review identified 42 relevant articles. Most of the included studies were found to have described the conditions of patients with NCDs after disasters - 14 (13.3%), during disasters – 11 (26.2%), before disasters – 6 (14.3%), within all stages of disasters: before, during and after – 6 (14.3%), only during and after disasters – 4 (9.5%), and includes before and during disasters – 1 (2.4%).
NCDs pose major health issues in disasters. Development of strong counter measures against the interruption of treatment, as well as surveillance systems to ascertain medical needs for NCDs are necessary as preparation for future disasters.
Firm operators continually manage multiple sources of risk. In an application to cattle feedlot operations, our objective is to determine if producers view output price and animal health risks separately or jointly. We conduct a survey with a choice experiment placing operators in forward looking, decision-making scenarios, and capture information on past risk management approaches. Evidence regarding a relationship between animal health and output price risk mitigation is mixed and depends on the decision being made. Combined, these results provide new insight into how managers approach multiple risks when facing resource constraints.
Myasthenia gravis (MG) is an autoimmune disorder that frequently affects young women of reproductive age. The multidirectional interplay between MG, pregnancy, and fetal health poses a complex scenario for pregnant women with MG and the healthcare team. Here, we reviewed our local experience with MG, pregnancy, and outcomes.
We performed a retrospective chart review of patients with MG attending the Prosserman Family Neuromuscular Clinic from 2001 to 2019 and who were referred to a high-risk pregnancy clinic. MG status was defined as stable, better, or worse. Information was collected on the delivery route, pregnancy, and neonatal complications.
We identified 20 women with MG for a total of 28 pregnancies. Worsening was observed in 50% of pregnancies: 18% during pregnancy, 25% following delivery, and 7% during both. 66.7% of patients with MG duration of 2 years or less had worsening during pregnancy. Three patients who stopped immunosuppressive treatment during pregnancy worsened and one had a crisis. C-section was done in 29% of pregnancies. The rate of delivery complications was 7% and of neonatal MG was 7%.
A high proportion of MG patients worsened during pregnancy, particularly those with disease duration less than 2 years, and those who discontinued immunosuppression during pregnancy. However, pregnancy was largely unaffected, rate of neonatal MG was low, frequencies of C-section, delivery complications, and premature births were similar to the general population. While the study has limitations due to the retrospective nature, these insights provide some guidance when counseling young myasthenic women about family planning.
African lovegrass [Eragrostis curvula (Schrad.) Nees] is a highly invasive C4 perennial grass that threatens global biodiversity. Appropriate management of this species has been hampered by a lack of knowledge concerning its seed ecology, resulting in significant economic and environmental impacts within various environments. Consequently, this study explored the effects of a selection of environmental factors (photoperiod, alternating temperature, pH, and salinity) by analyzing several measures of germination on four geographically distinct populations of E. curvula to assist in its extirpation from infested sites. Seeds were collected in Australia from Maffra and Shepparton, VIC; Tenterfield, NSW; and Midvale, WA. Key results showed that seeds from Maffra (54% vs. 79%), Tenterfield (38% vs. 61%), and Shepparton (34% vs. 71%) had significantly reduced germination in complete darkness compared with an alternating 12-h light and 12-h dark photoperiod, whereas Midvale had consistent germination (91% vs. 99%). Temperatures between 17/7 C reduced germination for Maffra (42% vs. 73%), Tenterfield (34% vs. 55%), and Shepparton (33% vs. 59%) compared with the mean of all other temperature combinations, whereas Midvale had consistent germination. Furthermore, germination for all populations was consistent between pH 4 and 9. For salinity, germination was significantly reduced at ≥100 mM for Maffra (29% vs. 67%), ≥150 mM for Tenterfield (29% vs. 94%) and Shepparton (39.5% vs. 81.5%), and 250 mM for Midvale (39% vs. 82%) compared with the mean of all other concentrations. Although each trial was conducted independently, the data can be used to generate species-targeted management. Such strategies include maintaining high levels of quarantine and hygiene programs to avoid future spread; where practical, applying light-limiting strategies (mulching, tilling, or scraping) for the Maffra, Tenterfield, and Shepparton populations; and maintaining management efforts year-round, as the species can germinate under a wide range of conditions.
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
Systems thinking provides a comprehensive range of theories and methods that are useful for understanding and managing sustainability challenges. Biodiversity conservation is riddled with complex interactions between science, society and myriad interacting systems through temporal and spatial scales. This article presents a synthetic analysis of the history of systems thinking from a genealogical perspective, drawing from hard and soft systems thinking, and resilience and social-ecological systems. Using the anchor point of system leverage points and system characteristics (parameters, feedbacks, design and intent), we employ a diversity of examples to illustrate their relevance to multiple biodiversity related problems. We conclude by illustrating the opportunities for systems thinking to bridge epistemic divides with multiple biodiversity actors working towards conservation outcomes. Systems thinking can support more integrative biodiversity interventions, as they provide a pluralistic set of tools for bridging knowledges and disciplines, which can be useful to create new shared understandings of how to conserve biodiversity.
Wild-type transthyretin amyloidosis (wtATTR) is an important cause of heart failure (HF); however, the prevalence and clinical significance of neurologic complications remains uncertain.
This analysis reports findings from a single-centre experience of routine neuropathy screening at the time of wtATTR diagnosis by nerve conduction studies and neurologist assessment, compared with age-matched controls.
Forty-one wtATTR patients were included, 39 (95%) males, mean age 78.4 ± 7.7 years, 22 (54%) New York Heart Association (NYHA) class III–IV HF, along with 15 age-matched controls (mean age 77.1 ± 4.2 years, 80% male). Twenty-one (51%) wtATTR patients were diagnosed with polyneuropathy, 15 (37%) with spinal stenosis, 36 (88%) with carpal tunnel syndrome (CTS) and 14 (34%) with ulnar neuropathy. Comparison diagnoses among controls were 1 (7%), 0, 1 (7%) and 3 (20%), respectively. Among patients with NYHA class III–IV HF, 16 (73%) had polyneuropathy compared with 5 (26%) with class I–II (p < 0.01), odds ratio of 7.5 (95% confidence interval 1.9–29.9). After neuropathy screening, 19 (46%) patients were offered neurologic therapy and/or additional diagnostic evaluation. This included CTS release surgery (16, 39%), neuropathic pain medication (3, 7%), nerve block (1, 2%), wrist splinting (2, 5%) and foot care (1, 2%). Spine imaging was performed for 3 (7%) patients, and deltoid muscle and sural nerve biopsy for 1 (2%) patient.
Screening of wtATTR patients for neurologic complications resulted in a management change for nearly half. CTS, polyneuropathy and ulnar neuropathy were common. This approach warrants consideration as part of routine assessment for newly diagnosed wtATTR patients.
More than 20,000 patients have participated in clinical trials of more than 100 neuroprotective therapies, but no study has provided convincing evidence of benefit. Several improvements to the rigor of preclinical agent qualification have been identified to increase the likelihood of success in human clinical trials: stringent randomization and blinding techniques to mitigate observer bias; assessment in in time periods achievable in the clinical setting; testing in older animals with comorbidities; and robust and reproducible benefit magnitudes. Human clinical trials should start agents hyperacutely, in the first minutes and hours after onset, when treatment effect would be maximal; target enrolment of patients likely to have transient rather than permanent ischaemic exposure; and use factorial and platform trial designs that would permit efficient testing of combinations of agents able to block multiple ischaemic injury-mediating pathways concurrently, including both anti-necrotic and anti-apoptotic interventions. For agents that allow cells to endure ischaemic stress, human trial delivery approaches include: prehospital initiation; initiation immediately upon brain imaging in patients destined for endovascular intervention; and initiation at outside hospitals in patients undergoing transfer to a neurothrombectomy center. For agents that mitigate reperfusion injury, treatment start before or concurrent with reperfusion, including intra-arterial administration via catheter immediately after endovascular thrombectomy, should be pursued.
Aneurysmal SAH is a severe disease, and the post-haemorrhage period fraught with potential complications that must be recognized and treated early for favourable outcome. While diagnosis of SAH is often straightforward from clinical history and initial CT, some patients will require cerebrospinal fluid evaluation. The aneurysm must be secured urgently to reduce rerupture and clinical worsening. Endovascular coiling is preferable when feasible, but surgical clipping is sometimes needed based on patient or aneurysmal characteristics, or presence of intraparenchymal haemorrhage requiring evacuation. Treatment of symptomatic hydrocephalus with CSF diversion is also crucial. Patients with aneurysmal SAH should be managed by a team of nurses and physicians with neurocritical care, neuroendovascular, and neurosurgical expertise, preferably in a dedicated neurosciences intensive care unit. Early complications include aneurysmal rebleeding, hydrocephalus, and neurogenic cardiopulmonary injury. In the subacute phase, delayed cerebral ischaemia and hyponatremia are more commonly seen. With optimal multidisciplinary management, many patients can return to their previous level of function only weeks after the aneurysm rupture. Still, most treatments in SAH are based on insufficient evidence, and more collaborative research from the bench to the bedside is necessary to continue improving patient outcomes.
In broad, relatively unselected patients with acute ischaemic stroke, immediate high-dose anticoagulation therapy to avert early stroke progression or recurrence reduces recurrent ischaemic stroke compared with control during the treatment period but this benefit is offset by an increase in intracranial haemorrhage (ICH) and extracranial haemorrhage (ECH). Immediate antiplatelet therapy has similarly efficacy as anticoagulation in averting early stroke progress or recurrence, and is safer when used as an immediate agent (see Chapter 9). In acute ischaemic stroke patients with atrial fibrillation, after start of antiplatelet therapy on presentation, early switchover to anticoagulation therapy 2 -14 days after stroke onset is reasonable, but caution should be taken in certain subgroups of patients with high risk of bleeding. In broad, relatively unselected ischaemic stroke patients, low-dose, venous prophylaxis anticoagulation compared with control reduces the occurrence of asymptomatic deep venous thrombosis (DVT) and shows a tendency to reduce pulmonary embolism, but also shows off-setting tendencies to increase ICH and ECH, without conferring a clear net clinical benefit. Low-molecular-weight heparins (LMWH) or heparinoids, compared with unfractionated heparin, appear to further decrease the occurrence of DVT and PE but potentially further increase ICH, but there are too few data to provide reliable information.
In acute ischaemic stroke, cerebral blood flow autoregulatory mechanisms may be disrupted so that cerebral perfusion becomes reliant on systemic blood pressure. Too low blood pressure may lead to progression of the infarction and too high blood pressure may cause cerebral oedema or haemorrhagic transformation of the infarct. In patients with BP = 220/120 mm Hg who do not receive intravenous thrombolysis, it is reasonable to lower BP by 15% during the first 24 hours after stroke onset. Patients who have elevated blood pressure and are otherwise eligible for treatment with intravenous rt-PA should have their blood pressure lowered so that systolic blood pressure is < 185 mm Hg and their diastolic blood pressure is < 110 mm Hg before thrombolytic treatment is administered. Acute stroke patients should be assessed for dehydration and a fluid balance chart should be kept. Underlying causes of hypotension should be treated rapidly. There is no beneficial effect of hemodilution treatment for acute ischaemic stroke. Fibrinogen-depleting agents that reduce viscosity may marginally reduce risk of recurrent ischaemic stroke, but more greatly increases symptomatic intracranial haemorrhage. Methylxanthine derivatives such as pentoxyphylline and propenofylline that reduce viscosity and produce vasodilation have insufficient evidence to support their use.