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Antheridiogen systems are a set of pheromonal mechanisms that control sex expression in fern gametophytes. However, antheridiogen has rarely been studied outside of the laboratory, and little is known about its function in natural settings. Combining predictions based on field and laboratory study, we tested whether the sexual structure of gametophytic colonies of a tree fern were attributable to antheridiogen.Gametophytic colonies of the antheridiogen-producing tree fern Cyathea multiflora were collected at La Selva Biological Station in Costa Rica in January 2019. The sex of each gametophyte was determined, mapped, and spatial statistic approaches were used to examine the distribution of sex in each colony.In all gametophytic colonies, males were most common, representing 62-68% of individuals. No hermaphroditic gametophytes were identified in any colony. A quadrat-based method showed female gametophytes were not clustered in each colony, while male gametophytes were clustered. In two of the colonies, the K(r) test statistic for males was greater than expected compared to random simulations of sex expression, indicating male sex expression was spatially associated with females.This study provides the first documentation of spatial sex expression in natural settings of gametophytes of an antheridiogen-producing tree fern species. The profound impact of antheridiogen on gametophytic sex expression in field settings suggests this system is intimately tied to mating system, fitness, and genetic diversity in Cyathea multiflora.

Vascular ring is a rare congenital anomaly in which the abnormal origin of the aorta or its branches and pulmonary arteries leads to encircling and compression of the trachea and esophagus. A right aortic arch (RAA) with an aberrant left subclavian artery is one of the most common forms of vascular ring. Here, we report a case of a prenatally diagnosed vascular ring resulting from an RAA with an aberrant left subclavian artery. When the infant was 7 months of age, the development of noisy breathing prompted further evaluation with cardiac magnetic resonance imaging that showed an atretic left subclavian artery associated with collateral retrograde flow from the left vertebral artery to the distal portion of the subclavian artery. Our findings indicate that an untreated RAA with an aberrant left subclavian artery may be associated with an increased risk of developing subclavian artery steal syndrome.

Double outlet left ventricle (DOLV) is a rare congenital heart defect where the aorta and the pulmonary trunk arise predominantly from the morphologic left ventricle. The clinical manifestations depend upon the location of the ventricular septal defect in relation to the great arteries, degree of pulmonary and aortic outflow tract obstruction, and other associated cardiac defects. We describe a neonate with DOLV, sub-aortic ventricular septal defect, and side-by-side great vessels who continued to require oxygen for desaturation to 60% in the neonatal period. His clinical symptoms were suggestive of persistent pulmonary hypertension, with 5-8% higher saturations in the leg compared to arm. He was started on oral sildenafil and his oxygen requirement decreased from 2 L/min to 0.1 L/min within 24 hours of initiating sildenafil.

OBJECTIVE: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. COMPOSITION OF THE COMMITTEE: A volunteer Writers’ Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. METHODS: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. REPORT: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. CONCLUSION: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program—Rural Surgical Obstetrical Networks—built on the principles and supporting evidence described in this consensus statement.

RESUME Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l’evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l’evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d’etude canadien sur les soins de sante preventifs (Tableau 1).

Background and Aims The ability of individuals to change sex during their lifetime is known as environmental sex determination (ESD). This represents a unique life history trait, allowing plants to allocate resources differentially to male and female functions across lifetimes, potentially maximizing fitness in response to changing environmental or internal cues. In this study, Acer pensylvanicum, a species with an unconfirmed sex determination system, was investigated to see what patterns in sex expression existed across multiple years, if there were sex-based differences in growth and mortality, and whether this species conformed to theoretical predictions that females are larger and in better condition. Methods Patterns of sex expression were documented over 4 years in a phenotypically subdioecious A. pensylvanicum population located in New Jersey, USA, and data on size, mortality, health and growth were collected. A machine-learning algorithm known as a boosted classification tree was used to develop a model to predict the sex of a tree based on its condition, size and previous sex. Results In this study, 54 % of the trees switched sex expression during a 4-year period, with 26 % of those trees switching sex at least twice. Consistently monoecious trees could change relative sex expression by as much as 95 %. Both size and condition were influential in predicting sex, with condition exerting three times more relative influence than size on expressed sex. Contrary to theoretical predictions, the model showed that full female sex expression did not increase with size. Healthy trees were more likely to be male; predicted female sex expression increased with deteriorating health. Growth rate negatively correlated with multiple years of female sex expression. Populations maintained similar male-skewed sex ratios across years and locations and may result from differential mortality: 75 % of dead trees flowered female immediately before death. Conclusions This study shows conclusively that A. pensylvanicum exhibits ESD and that femaleness correlates with decreased health, in contrast to prevailing theory. The mortality findings advance our understanding of puzzling non-equilibrium sex ratios and life history trade-offs resulting from male and female sex expression.

Background: Benefits of screening should outweigh its potential harms. We compared various metrics to assess the balance of benefits and harms of cervical cancer screening. Methods: We used a cervical cancer natural history Markov model calibrated to the Canadian context to simulate 100,000 unvaccinated women over a lifetime of screening with either cytology every 3 years or human papillomavirus (HPV) testing every 5 years. We estimated the balance of benefits and harms attributable to screening using various metrics, including colposcopies/life-year gained, and net lifetime quality-adjusted life-years (QALY) gained, a measure integrating women's health preferences. We present the average (minimum–maximum) model predictions. Results: Cytology-based screening led to 1,319,854 screening tests, 30,395 colposcopies, 13,504 life-years gained over a lifetime, 98 screening tests/life-year gained, 2.3 (1.6–3.3) colposcopies/life-year gained, and a net lifetime gain of 10,735 QALY (5,040–17,797). HPV-based screening with cytology triage in the same population would lead to 698,250 screening tests, 73,296 colposcopies, 15,066 life-years gained over a lifetime, 46 screening tests/life-year gained, 4.9 colposcopies/life-year gained (2.9–11.1), and a net lifetime gain of 11,690 QALY (4,409–18,742). HPV-based screening was predicted to prevent more cancers, but also incur more screening harms than cytology-based screening. Conclusions: Metrics using colposcopies as the main harm outcome favored cytology-based screening, whereas metrics based on screening tests and health preferences tended to favor HPV-based screening strategies. Impact: Whether HPV-based screening will improve the balance between benefits and harms of cervical cancer screening depends on how the balance between benefits and harms is assessed.

Premise Environmental sex determination (ESD) is a rare sex determination system in which individuals may switch sex expression throughout their lifetimes in response to environmental factors. In sexually stable species, individuals usually bear more female flowers if the plants are larger, have greater access to limiting resources, or are in better condition. Research regarding sexually plastic species with ESD and how resources correlate with sex expression is limited. Furthermore, most research investigates resources at the population level, failing to account for resources available to individuals for growth, maintenance, or reproduction. Methods Acer pensylvanicum is a species that is known to switch sex. Using twig samples collected during 2014-2016 in December and May, we analyzed resource status in the form of stored nonstructural carbohydrates (NSCs) and compared this with expressed sex. Results We found that females had higher sugar concentrations than males. Furthermore, males changing expression to female had higher sugar concentrations during the prior winter than did males remaining male. We found that size was not a key predictor: neither male nor female-flowering individuals increased NSC concentrations with size. Dying female trees had high concentrations of NSCs throughout the dying process and only manifested reduced NSCs once dead. Conclusions This is the first study showing significant correlations between NSCs and sex expression in a plant species with ESD. These findings support the hypothesis that sex switching could be a consequence of increased resource availability and that the high female mortality of A. pensylvanicum populations is likely not a direct result of carbon starvation.

Premise Plant sex is usually fixed, but in rare cases, sex expression is flexible and may be influenced by environmental factors. Theory links female sex expression to better health, but manipulative work involving the experimental change of health via injury is limited, particularly in sexually plastic species. A better understanding of mechanisms influencing shifts in sex is essential to our understanding of life history theory regarding trade-offs in sex allocation and differential mortality. Methods We investigated the relationship between physiological stress and sex expression in sexually plastic striped maple trees (Acer pensylvanicum) by inflicting damage of various intensities (crown pruning, defoliation, and hydraulic restriction). We then monitored the sex expression of injured and control individuals for 2 years to assess the extent to which injury may cue changes in sex expression. Results We found that severe damage such as full defoliation or severe pruning increased odds of changing sex to female and decreased odds of changing to male. In fact, no pruned male trees flowered male 2 years later, while all males in the control group flowered partially or fully male. After full defoliation, trees had 4.5 times higher odds of flowering female. Not all injury is equal; less-severe physical trauma did not affect the frequency of sex change to femaleness. Conclusions This work demonstrates that physical trauma in striped maple appears to exhibit a threshold effect in which only the most stressful of physiological cues instigate changes in sex expression, a phenomenon previously unknown, and that damage stress is strongly correlated with switching to femaleness. These findings have implications for population sex ratios and sustainability within an increasing stressful climate regime.

Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause.We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately.We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and5 (6%), to complications of management. There were 21 (25%) maternal deaths with indirect obstetric causes, and5 (6%) with undetermined causes. Of 120 late maternal deaths, 16 (13%) had direct obstetric causes, among them, 9 deaths by suicide (56%). One hundred late maternal deaths (83%) had indirect obstetric causes; and5 (4%) had undetermined causes.The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.

© 2015 The Authors. Exposure to toxic environmental chemicals during pregnancy and breastfeeding is ubiquitous and is a threat to healthy human reproduction. There are tens of thousands of chemicals in global commerce, and even small exposures to toxic chemicals during pregnancy can trigger adverse health consequences. Exposure to toxic environmental chemicals and related health outcomes are inequitably distributed within and between countries; universally, the consequences of exposure are disproportionately borne by people with low incomes. Discrimination, other social factors, economic factors, and occupation impact risk of exposure and harm. Documented links between prenatal exposure to environmental chemicals and adverse health outcomes span the life course and include impacts on fertility and pregnancy, neurodevelopment, and cancer. The global health and economic burden related to toxic environmental chemicals is in excess of millions of deaths and billions of dollars every year. On the basis of accumulating robust evidence of exposures and adverse health impacts related to toxic environmental chemicals, the International Federation of Gynecology and Obstetrics (FIGO) joins other leading reproductive health professional societies in calling for timely action to prevent harm. FIGO recommends that reproductive and other health professionals advocate for policies to prevent exposure to toxic environmental chemicals, work to ensure a healthy food system for all, make environmental health part of health care, and champion environmental justice.

Analysis of a mass burial of seven males at CA-ALA-554, a prehistoric site in the Amador Valley, CA, was undertaken to determine if the individuals were "locals" or "non-locals," and how they were genetically related to one another.The study includes osteological, genetic (mtDNA), and stable (C, N, O, S) and radiogenic (Sr) isotope analyses of bone and tooth (first and third molars) samples.Isotopes in first molars, third molars, and bone show they spent the majority of their lives living together. They are not locals to the Amador Valley, but were recently living to the east in the San Joaquin Valley, suggesting intergroup warfare as the cause of death. The men were not maternally related, but represent at least four different matrilines. The men also changed residence as a group between age 16 and adult years.Isotope data suggest intergroup warfare accounts for the mass burial. Genetic data suggest the raiding party included sets of unrelated men, perhaps from different households. Generalizing from this case and others like it, we hypothesize that competition over territory was a major factor behind ancient warfare in Central California. We present a testable model of demographic expansion, wherein villages in high-population-density areas frequently fissioned, with groups of individuals moving to lower-population-density areas to establish new villages. This model is consistent with previous models of linguistic expansion.

Maternal mortality and severe maternal morbidity are devastating for women, their families and care providers. International efforts have been made to develop and to implement data collection, management and surveillance systems that capture pregnancy-related information that can be assessed and used to improve health and system outcomes. At present, Canada does not have a national enquiry process to review maternal deaths, severe morbidity and near misses, and has not set targets for maternal mortality reduction. Maternal mortality rates are critical measures of maternal health and provide important information for analysis of trends and priorities among and within countries. Information about near misses as well as maternal morbidity is crucial to truly understand and to prevent maternal mortality. Canadian experts must work together with governments, provinces and territories to determine key indicators, measurement and meaningful data analysis strategies. These data and their comparisons will form the foundation of evidence to guide programs, policies, priorities and interventions that will ultimately improve the health of mothers and their children.

Resume Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l'evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library , en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality. Outcomes Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections. Values The quality of the evidence in this document was rated using the criteria described by the Report of the Canadian Task Force on Preventive Health Care (Table 1).

I read with interest Dr. Popadiuk’s commentary[1][1] on cervical cancer screening starting at 25 years of age. I am familiar with the powerful OncoSim tool, but I continue to have nagging concerns that, by doing right for the majority, we may inadvertently leave behind the most disadvantaged.

Objectives Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes. Design This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data. Setting and participants Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014. Primary outcomes Numerous adverse maternal and perinatal health outcomes. Results Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers. Conclusions Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences.

A 15-year-old previously healthy girl presented to the general paediatrics clinic for follow-up for inguinal lymphadenitis diagnosed the week before at a local emergency room. Approximately two weeks before the clinic visit, she developed continuous discomfort in her left inguinal area. A few days later, the discomfort progressed to significant pain, and she noticed swelling in the left inguinal area. The pain was so intense that she walked with a limp, favouring her left leg, and had difficulty climbing stairs. She denied any trauma to her pelvic or inguinal area. When seen in the emergency room, an inguinal ultrasound was completed, which revealed an enlarged lymph node, thought to be inflamed, without any evidence of a hernia. The patient was discharged home on a seven-day course of oral cephalexin and a preparation of hydrocodone and acetaminophen, as needed, for pain. Despite completing the course of antibiotics and taking analgesia, the patient did not have any relief of her pain or swelling. The patient denied fevers or other associated symptoms. On physical examination, the patient was found to have a 3 cm 7 cm ill-defined mass in the left inguinal region, without overlying erythema. The mass was tender to palpation, was not pulsatile and was easily reduced by external pressure. On musculoskeletal examination, she had pain with external rotation of the left hip, yet all other hip movements were full and without associated pain. When asked to walk, the patient had an antalgic gait. A further diagnostic test uncovered the source of the problem.

In order to support and facilitate continuous learning and a growth mindset, it is essential that students be exposed to learning opportunities that explicitly allow them to apply and practice what they have learned. (Dweck, 2007)This paper focuses on one such approach, taken in the My Learning Essentials skills support programme developed at the University of Manchester. This programme rests on a constructivist and collectivist approach that requires student engagement in the creation of learning opportunities and thus encourages students to apply what they have learned to a wide variety of opportunities and assessments, pushing the response to feedback or to an identified skills gap from specific assignments to skill progression and personal development. In addition, the facilitators of such sessions are also freed from the role of “expert” and instead act as knowledge builders with the rest of the group. This change removes the possibility of one “correct” answer and the assumption of eventual perfection and instead encourages the entire group to focus on understanding the process and progressing both within the session and beyond. Although there are still a number of questions to be answered, initial feedback and investigations support the assertions that students engagement in the creation of such opportunities leads to a clearer understanding of the efficacy of the skills involved and the power of the prior knowledge of the community.

Interactions between soil moisture and the atmosphere are driven by the partitioning of sensible and latent heating, through which, soil moisture has been connected to atmospheric modification that could potentially lead to initiation of convective precipitation. The majority of previous studies linking the land surface to subsequent precipitation have used atmospheric reanalysis or model datasets. In this study, we link in situ observations of soil moisture from more than 100 stations in Oklahoma to subsequent unorganized afternoon convective precipitation. We use hourly, high resolution NEXRAD radar-derived precipitation to identify convective events, and then compare the location of precipitation initiation to underlying soil moisture anomalies the morning prior. Overall we find a statistically significant preference for convective precipitation initiation over drier than normal soils, with over 70% of events initiating over soil moisture below the long-term median. The significant preference for precipitation initiation over drier than normal soils is in contrast with previous studies using satellite-based precipitation products to identify the region of maximum precipitation accumulation. We sub-sample 19 convective events occurring near Lamont, Oklahoma, where soundings of the atmospheric profile at 06:00 and 12:00 LST are also available. For these events, soil moisture is strongly, negatively correlated with the level of free convection, planetary boundary layer height, and surface temperature changes from 06:00 to 12:00 LST. We also find strong, positive correlations between morning soil moisture and morning-to-afternoon changes in convective available potential energy and convective inhibition. In general, the results of this study demonstrate that both positive and negative soil moisture feedbacks to the atmosphere are relevant in this region of the United States.

A notable deficiency in the use of tandem mass spectrometry (MS/MS) for newborn screening is the inability to screen for urea cycle defects. The most common of these, with an incidence of 1 in 14 000 births (1), is the inherited X-linked disorder ornithine transcarbamylase deficiency (OTCD). A majority (60%) of hemizygous males risk death from hyperammonemic coma during the first week of life. The remainder, including 10% of heterozygous females, exhibit lethargy, vomiting episodes, and behavioral problems during childhood. The severity of the disorder and the potential for correction of OTCD by liver transplantation and gene therapy (2) provide adequate justification for newborn screening. OTCD patients have low blood citrulline because of reduced conversion from carbamoyl phosphate. Citrulline is one of the amino acids routinely measured in MS/MS newborn-screening programs. Unfortunately, many protein-restricted newborns also have low blood citrulline (3). A more selective amino acid metabolite for OTCD is glutamine. The derivatization procedure used in many MS/MS screening programs (4), which uses butanol–hydrogen chloride, destroys glutamine. Approximately one-half of the glutamine is converted to glutamic acid dibutyl ester and is indistinguishable from that formed from endogenous glutamic acid in the blood. The surviving glutamine butyl ester is deaminated in acidic solution to a protonated form of pyroglutamic acid butyl ester in the electrospray source of the MS/MS. Again it is not possible to distinguish this pyroglutamic acid from what is already present in the blood. As a secondary consequence, the measurements of glutamic and pyroglutamic (and by analogy, aspartic) acids in blood spots after derivatization are grossly inaccurate. MS/MS newborn-screening programs that do not derivatize amino acids avoid solvolysis of glutamine and of pyroglutamic acid to glutamic acid. During electrospray ionization-MS/MS analysis, however, glutamine is again indistinguishable from pyroglutamic acid. Resolution is possible by separation with time-consuming liquid chromatography …

Resume Le rapport recent de l'etude Women's Health Initiative a evalue les bienfaits et les risques a long terme de l'hormonotherapie substitutive chez les femmes post-menopausees en sante. Le rapport a demontre que le profl des risques-bien-faits de l'hormonotherapie substitutive combinee et continue n'etait pas conforme a la prevention primaire de la cardiopathie ischemique. L'etude Women's Health Initiative de l'hormono-therapie substitutive combinee et continue est une etude marquante et les resultats fournissent des renseignements pertinents aux patientes et aux cliniciens. Par contre, les symptomes de la menopause, et non la prevention de la maladie constituent l'indication la plus commune de l'hormonotherapie substitutive, pour lesquels elle est efficace; de plus, la duree d'emploi la plus commune est de moins de trois ans. Toutefois meme l'emploi a court terme entraine des effets au niveau de certaines issues. Cette declaration discute de l'application des resultats de l'etude Women's Health Initiative dans le but de prendre des decisions cliniques appropriees.

Nursery-reared infants have several behavioral and physiologic differences from their mother-reared counterparts. We investigated whether a response-contingent surrogate mitigated some of those differences by decreasing fearfulness and partner-clinging and increasing environmental exploration in nursery-reared infants continuously paired with a peer. Six nursery-reared infant rhesus macaques (in pairs) were given a mechanical responsive surrogate (RS), and 6 (in pairs) were given an identical but nonresponsive surrogate (NRS). The 2 treatment groups were compared and then combined into a single group of all 12 of surrogate-exposed animals (CS) that was compared with a nonsurrogate control group (NS) of 10 nursery-reared infants. Results showed significant differences between CS and NS infants but no significant differences between the RS and NRS infants. As compared with NS infants, CS infants showed less partner-clinging, less affiliation directed toward only partner, and more foraging and tactile–oral exploration of the environment. These advantageous effects support additional research to develop improved surrogate and the implementation of surrogate programs for nursery-reared infants.

Objective To provide guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis. Outcomes Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response to management, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library on August 30 and September 18, 2012, respectively. The strategy included the use of appropriate controlled vocabulary (e.g., oteoporosis, bone density, menopause) and key words (e.g., bone health, bone loss, BMD). Results were restricted to systematic reviews, practice guidelines, randomized and controlled clinical trials, and observational studies published in English or French. The search was limited to the publication years 2009 and following, and updates were incorporated into the guideline to March 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). Sponsors The Society of Obstetricians and Gynaecologists of Canada.

To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality.Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline.Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections.

Care during pregnancy and childbirth is provided by midwives, family practitioners and obstetrician–gynecologists, either individually or in collaboration. These groups have unique but often overlapping areas of competence and expertise. Those who provide such care are declining in number in this

Objective To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor symptoms or with urogenital, mood, or memory concerns, and on considerations related to cardiovascular disease, breast cancer, and bone health, including the diagnosis and clinical management of postmenopausal osteoporosis. Outcomes Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Strategies for identifying and evaluating women at high risk of osteoporosis, along with options for the prevention and treatment of osteoporosis, are presented. Evidence MEDLINE was searched up to October 1, 2008, and the Cochrane databases up to issue 1 of 2008 with the use of a controlled vocabulary and appropriate key words. Research-design filters for systematic reviews, randomized and controlled clinical trials, and observational studies were applied to all PubMed searches. Results were limited to publication years 2002 to 2008; there were no language restrictions. Additional information was sought in BMJ Clinical Evidence, in guidelines collections, and from the Web sites of major obstetric and gynaecologic associations world wide. The authors critically reviewed the evidence and developed the recommendations according to the methodology and consensus development process of the Journal of Obstetrics and Gynaecology Canada. Values The quality of the evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table. Sponsor The Society of Obstetricians and Gynaecologists of Canada.

Objectives: to provide an overview of the literature on the subject of phytoestrogens, with particular emphasis on their role in menopause, and to a lesser extent, on women's health. Data Sources: a ten-year Medline search using phytoestrogens as both a subject and a textword. The author's personal files and the reference lists from selected articles were explored. The Internet was selectively explored. Study Selection: review articles and those dealing with women's health or menopausal issues were selected as were other studies if they shed light on the primary objective. Data Extraction: data were heterogeneous and not appropriate for formal analysis. Results: the phytoestrogens are non-steroidal, diphenolic compounds that occur naturally in plants. Soybeans and flaxseed both contain large amounts of isoflavones and lignans, which are metabolized in the gut to compounds which bind to the estrogen receptor and have weak estrogenic or anti-estrogenic activity. Epidemiological evidence of a lower incidence of menopausal symptoms, breast, endometrial and prostate cancer, and of a lower rate of cardiovascular disease in populations consuming large amounts of the phytoestrogens in their diet, has led to interest in their preventive benefits. Phytoestrogens appear to increase sex hormone binding globulin levels, compete for aromatase and inhibit tyrosine kinase. Individuals vary greatly in how they metabolize and absorb these substances. Clinically, such substances may reduce the severity of menopausal flushing. Conclusions: physicians seeing menopausal women should be aware of these compounds and of the type and amount of dietary supplements their patients may be taking.