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Australia currently produces more than 18,600 petajoules of energy annually. Only 2% of this energy is produced via renewable means of energy production with the remaining 98% produced by non-renewable means such as fossil fuels and natural gas. With the 2020 October budget announcement by the Australian Government that the Australian Renewable Energy Agency (ARENA) will continue to be funded for a further 10 years, there is financial incentive and capacity to continue the development of marine renewable energy technologies in Australian coastal waters. The ecological impacts of these technologies, however, are not well understood. Marine Renewable Energy Converters (MRECs) are typically situated in volatile, dynamic environments which creates challenges for conducting robust ecological research to determine impact. Furthermore, these ecosystems usually contain many species with conservation and/or commercial value. Given studies into the impact of MRECs are very limited, developing a more robust framework to determine impact is timely. This research investigated the potential impacts of the introduction of MRECs on coastal marine ecosystems. Specifically, it assessed the current state of MREC technologies, the sources of impact of MRECs and the component within a marine ecosystem susceptible to those impacts and undertook robust quantitative and qualitative studies for assessing these impacts. There are four fundamental types of MRECs – wave, tide, current and ocean thermal. With over 350 MREC designs and developers worldwide, many of these designs have reached the environmental approval stage in their respective regions with little identification of the environmental impacts of these devices. Chapter 2 highlighted that the main sources of impact were those that occur during installation and assembly of the MREC, caused by the presence of the MREC structure itself, and the resultant artificial light and noise associated with the functioning of MRECs. Marine mammals, seabirds and migratory shorebirds, fishes, large invertebrates such as crustaceans and benthic communities are all likely to be impacted by these sources. Impacts recorded can be both positive, for example providing haul-out sites for pinnipeds and negative, for example through the potential for seabirds to collide with turbines. In Chapter 3 I identify and describe a rigorous identification framework for assessing the impacts of an MREC on components of a coastal system. The framework involves the use of both quantitative and qualitative research designs. Two examples of these research designs provided are a modified Before-After-Control-Impact (BACI) design for quantitative analysis of ecosystem response and Loop Analysis, a technique of qualitative modelling of socio-economic and functional group response to a perturbation in a model system. In Chapter 4 I used a modified BACI design and characterised fish and crustacean assemblages at control sites and the proposed site of a wave-energy converter (i.e., impact site) utilising baited underwater video. Sampling was undertaken twice before the installation and revealed the impact site had a higher relative abundance of species but there was no statistical difference in number of individuals, number of species and species diversity among the control/impact sites. Unfortunately, due to a shipping accident the MREC was not installed at the site and no ‘after’ sampling was possible. Nonetheless, the sampling before installation highlighted the natural ecological variation likely at many sites of proposed MRECs and the importance of a rigorous approach to determining impact. In Chapter 5 I used qualitative modelling (Loop Analysis) to make predictions of the impact of the introduction of an MREC into the Western Bass Strait Shelf Transition, southern Australia, a region of high potential for marine renewable energy production but also a region with a large commercial fishery and high marine conservation value. Models included socio-economic and biological components and focussed on the effects of an MREC on five components of the model ecosystem: macroalgae, carnivorous and herbivorous fish species, large commercially harvested crustaceans, migratory shorebirds and seabirds. Both positive and negative effects of the MREC on the different components of the ecosystem were revealed by the models. However, the models showed that impact will be dependent on that component first impacted and an overall model of the whole system indicated that while the majority of components have the potential to be positively impacted, there is a high level of uncertainty in the level of confidence in this result. This research provides a framework for assessing the impact of MRECs on coastal marine environments. An increasing number of MRECs are being developed, with the potential for broad impacts on marine ecosystems. The research required to fully understand these impacts will take significant time and resources and is likely to vary depending on the ecosystem itself, the type of MREC being installed and the regulatory requirements of the country.

Background: In adult surgical patients rapid recovery pathways after surgery have shown improvement in postoperative complications and length of hospital stay . Enhanced recovery after surgery is a concept which includes patient management protocols beginning from the preoperative period, continues in the intraoperative period and the postoperative period. This concept aims to improve postoperative outcome. In pediatric patients rapid recovery pathways are beginning to develop. This study is undertaken to analyse whether enhanced recovery after surgery improves postoperative outcome in children. Methods: systematic review and meta-analysis of randomized and randomized trials starting in April 2019 until July 2019. Statistic analysis will be realised with RevMan 5.3 software. Results are expected by July 2019. Conclusion: This protocol was realised to describe the systematic review and meta-analysis which will be undertaken to clarify the impact on postoperative outcome of rapid recovery pathways after surgery in children.

Objective: To compare the outcome of superovulation using clomiphene citrate (CC) versus hMG in conjunction with IUI. Design: Sequentially assigned, observational study. Couples initially were assigned to receive either CC or hMG for three cycles. Setting: The Clinical Outpatient Department of the Dartmouth-Hitchcock Medical Center. Patient(s): Eighty-three infertile couples. Intervention(s): IUI with hMG use. Main Outcome Measure(s): Conception rate, term pregnancy rate (PR), and pregnancy complications, such as spontaneous miscarriage and multiple gestation. Result(s): Of 83 couples who underwent at least one treatment cycle, 29 (35%) conceived during the study period. The relative rate of conception for hMG versus CC was 2.08 (95% confidence interval [CI], 0.93 to 4.68). The relative term PR was 2.10 (95% CI, 0.77 to 5.73) for hMG versus CC. There was no difference in the miscarriage rate for hMG versus CC. Conclusion(s): Both the conception rate and the term PR were higher using hMG, compared with CC, in combination with IUI, and showed a trend toward statistical significance.

Objectives. To better understand the outcomes and management of patients when there is a failure to visualize kidneys on prenatal ultrasound. Methods. Nine thousand five hundred twelve prenatal ultrasound studies performed on 4900 patients were reviewed retrospectively for the findings of a failure to visualize kidneys. The prenatal ultrasounds, pregnancy outcomes, and postmortem studies were reviewed for each of the 10 patients identified. Results. Nine of 10 patients experienced fetal death in the index pregnancy: 7 had therapeutic abortions, 1 had an intrauterine fetal demise, and 1 gave birth to a stillborn infant. One patient gave birth to a live infant with Bartter’s syndrome and grossly normal kidneys, as diagnosed by ultrasound. Developmental renal anomalies were identified in only 4 of 10 cases, and only 2 patients had true bilateral renal agenesis. There was 1 case each of bilateral renal medullary cystic dysplasia and bilateral renal hypoplasia. Three cases had no renal anomalies and included 1 case each of Turner’s syndrome, chronic abruption, and a cord accident. In 2 cases, postmortem examinations were not performed because of family wishes. Conclusions. Prenatal failure to visualize kidneys represents a spectrum of clinical problems not all of which are fatal. Close consultation with an experienced ultrasonographer is essential to provide informed counseling to expectant parents. Pathologic examination should be recommended when there is fetal demise and a suspicion of genitourinary anomalies. Screening of family members of the index patient and genetic counseling may be indicated.

Rationale and Objectives. We devised a prediction rule for estimating pleural effusion volume on the basis of posteroanterior and lateral chest radiographs. Methods. A prediction rule was devised for estimating pleural effusion volume on the basis of the presence or absence of a meniscus on chest radiographs. The rule was tested and validated using separate data sets obtained from a retrospective review of patients having both a chest radiograph and computed tomography (CT) scan (the gold standard) within 24 hr of each other. The accuracy of the prediction rule and the degree of interobserver agreement between the two independent readers were determined. Results. For the test and validation sets, the weighted accuracies of the prediction rule were 86% and 85%, respectively. The respective weighted interobserver agreements were 97% and 88%. Pleural effusions became visible as a meniscus on the lateral chest radiograph at a volume of approximately 50 ml; at a volume of 200 ml, the meniscus could be identified on the posteroanterior radiograph. At a volume of about 500 ml, the meniscus obscured the hemidiaphragm. Conclusion. The volume of a pleural effusion can be estimated from the chest radiograph appearance with a reasonable degree of accuracy.