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Transfer centers play a vital role in the efficient triage of hospital admission requests that generate outside the emergency department (ED) of the given facility. This cohort study includes all the calls processed through the transfer center requesting an admission to Mayo Clinic, Rochester, from January 2016 to December 2018. More than 116,000 transfer request calls were processed. Of these, about 65% (75,000) were accepted for ED evaluation or direct admission. Of the 75,000 patients, >50% were accepted as direct admits. Among patients accepted for direct admission, a trend toward reduced utilization of ED reevaluation at the receiving facility was noted from 2016 to 2018. A temporal trend of overall reduced ED utilization reflects the adeptness of the transfer center. An effective transfer center promotes value-based care, optimizes the workflow in a hospital, and augments hospital administrative decisions to allocate resources.

Objective Growing a strong Aboriginal and Torres Strait Islander health workforce is key to closing the gap in health outcomes between Indigenous and non-Indigenous Australians. This study sought to explore barriers and enablers to career development for Aboriginal health staff and potential strategies to enhance career pathways. Design Qualitative study, with data collected primarily through focus group discussions (yarning circles) at different health workplaces. Setting Western New South Wales. Participants Aboriginal health staff (n = 54) from Aboriginal Community Controlled Health Services, a Local Health District and a Primary Health Network, and their managers (Aboriginal and non-Aboriginal; n = 28). Main outcome measures Identified barriers and enablers and regional strategies for improving career pathways. Results Aboriginal people interested in pursuing a career in health face barriers in: pre-employment, recruitment, the workplace and further education and training. Being given practical and emotional support, as well as opportunities, makes a difference at every stage. Family and community are very influential in career decisions. Within the workplace, culturally appropriate human resource systems and management structures are vital. The ability to obtain employment and access education and training locally is important to rural and remote communities. Conclusion To enhance health career pathways for Aboriginal people, strategies are needed at all levels: community, organisation, system and society. Aboriginal leadership and self-determination are crucial, as are partnerships within the health sector and between the health and the education and training sectors. Cultural safety is essential to expansion of the Aboriginal workforce, and to health care experiences and outcomes for Aboriginal community members.

Using mark-recapture, we estimated the age at first return and survival of juveniles of the Sooty Shearwater (Puffinus griseus), a medium-sized burrow-breeding procellariiform, at two New Zealand breeding colonies, Taiaroa Head and The Snares. Sooty Shearwaters were first observed at the colony between 2 and 10 years after being banded as chicks, with a mean of 5.7 years at Taiaroa Head and 5.4 years at The Snares. After accounting for imperfect detectability with a mark-recapture model, we estimate the mean age at first return as 4.8 years. Extrapolation from observed delays between arrival and breeding of the Short-tailed Shearwater (P. tenuirostris) suggests that the mean age at first breeding was 7.7 years. Annualized estimates of survival from 0 to 2 years were 0.54 at Taiaroa Head and 0.41 at The Snares. Overall estimates of the generation time and maximum rate of population growth were 13.1 years and 7.7%, respectively. Many published estimates of age at first return and age at first bree...

Rakiura Māori seek robust population monitoring to guide sustainable management of the annual take of muttonbird (tītī, Puffinus griseus), in southern New Zealand. Analyses of eight muttonbirder harvest records spanning 67 years and consisting of 6744 hunts show systematic commonalities in seasonal patterns of hunt tallies. General linear models (GLMs) explained between 26% and 75% of variation in the number of chicks caught per hunt within each manu (family harvested area), and strong effects of increased catch rates in the rama harvest phase during wet and windy conditions. The absolute differences in the diary mean hunt tallies show that catches vary considerably among whānau (extended family groups) and cannot be reliably used to compare chick abundance between manu. However, tracking trends in hunt success on the same ground by the same whānau offer a cost-effective means of monitoring population abundance. Recording the duration of hunts and detailed measurements of the number of catchers a...

Postgraduate medical conferences are a prominent feature of continuing medical education across all health-related disciplines. These gatherings aim to disseminate new medical innovations, technologies, and approaches to treatment as well as review core topics and procedural skills. Sessions are often led by subspecialty experts, but rarely do these experts collaborate to address clinical problems in the same patient context. We restructured our postgraduate medical conference by following a single patient longitudinally through their complex hospitalization. As the case evolves, subspecialists provided recommendations addressing specific medical dilemmas while working within the confines of the patient scenario. We present expert speaker perspectives, discuss challenges to this method of medical conference organization, and survey the audience on our presentation.

Cultural evidence suggests that sooty shearwater (Puffinus griseus) chicks have been harvested by Rakiura Māori on islands in southern New Zealand since prehistoric times. Concerns exist that modern harvests may be impacting sooty shearwater abundance. We modeled human-related and ecological determinants of harvest (total no. of individuals harvested) of sooty shearwater chicks on 11 islands and examined the relationship between shearwater abundance and harvesting rates (chicks/hr) and harvester behavior throughout the harvesting season. Models best explaining variation in harvest between harvesting areas (manu), for both the early and late parts of the harvesting season, included harvester-days (included in all models with change in deviance information criteria [ΔDIC], ΔDIC < 8.36 and ΔDIC < 11.5, for the early and late periods, respectively). Other harvest determinants included shearwater density, size of the manu, and number of people helping harvesters (all included in the top 5 models withi...

OBJECTIVES: Evaluate the spectrum of neurodevelopmental outcome in a contemporary cohort of extremely preterm infants. We hypothesize that the rate of severe neurodevelopmental impairment (NDI) decreases over time. METHODS: Retrospective analysis of neurodevelopmental outcome of preterm infants ≤27 weeks’ gestational age (GA) from a Neonatal Research Network center that completed neurodevelopmental follow-up assessments between April 1, 2011, and January 1, 2015. The Bayley Scales of Infant Development-III (BSID III) and a standardized neurosensory examination were performed between 18 and 26 months’ adjusted age. Outcome measures were neurologic examination diagnoses, BSID III cognitive and motor scores, sensory impairment, and the composite outcome of NDI, based on the BSID III cognitive score (analyzed by using a cutoff of

Introduction: Western NSW is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes. A strategy to transform current services into a patient centred, coherent system of care is well into its 4th year. A range of locality-based initiatives are being implemented to better connect health and social care providers to improve health outcomes for the region. Methods: The Western NSW Integrated Care Strategy (Strategy) is being implemented using a collaborative partnership approach between the LHD, the Western Primary Health Network, and Bila Muuji Aboriginal Health Service. The vision for the Strategy: To transform existing services into an integrated Western NSW system of care that is tailored to the needs of our rural and remote communities, and improves access to care and health outcomes, with particular focus on closing the Aboriginal health gap. A key element of the Strategy was the establishment of local demonstrator sites to test new integrated models of care at a locality level. Features of the models include: Primary care led team based care Risk stratification Comprehensive assessment Shared care planning Health and social care coordination Multi-disciplinary case conferencing in primary care Results: Over 4 years the Strategy has: Enrolled 1500 people across 12 local demonstrator sites focusing on chronic disease management, the first 2000 days of life and Aboriginal Health. Strengthened the connection between care providers to provide team based care Appointed local Health and Social Care Coordinators Introduced primary care based multidisciplinary case conferencing Established a change team to enable rapid transfer of integrated models across the region Evaluation of the Strategy is indicating an improved health journey, improved health outcomes and a reduction in acute care utilisation. Discussion: We consider the learnings from our experience transferable to other environments, with suitable local tailoring.

Between 2001 and 2006, we systematically sampled the entire coast of Whenua Hou, a rugged offshore island in southern New Zealand, to estimate the population densities of sooty shearwaters (Puffinus griseus) and mottled petrels (Pterodroma inexpectata) by counting the entrances of breeding burrows. A two‐step regression modelling process using binomial errors was used to predict the presence of a colony, and a normal general linear model was used to predict the density of entrances within colonies. Aerial photography, GIS and a Digital Elevation Model were used to extract relevant habitat and location variables, and a combination of both regression models was used to predict the density of breeding burrows within each 5.32 m2 pixel on the island. This complex GIS and habitat prediction modelling approach gave population estimates very similar to a more traditional simple area extrapolation method and gave no improvement in precision. However, correction for the slope of the land increased our sim...

Recent comprehensive survey data from multiple New Zealand offshore islands were combined with demographic population models to produce the first formal estimate of the total population of sooty shearwaters within New Zealand territory. We estimated the total population over 1994–2005 to be 21.3 (19.0–23.6) million individual birds in the New Zealand region. This population consisted of 12.8 (12.0–13.6) million adults, 2.8 (2.5–3.1) million chicks, and 4.4 (4.2–4.7) million breeding pairs. Breeding sooty shearwaters were concentrated primarily around the southern islands of New Zealand, with 53% breeding in the Titi Islands surrounding Rakiura (Stewart Island). Rakiura Maori muttonbirders were estimated to harvest 360 000 (320 000–400 000) sooty shearwaters per year, equivalent to 18% of the chicks produced in the harvested areas and 13% of chicks in the New Zealand region. Overall, 11% of the chicks within the Titi Islands live on unharvested ground. Systematic and widespread surveys of breeding...

Adaptive co‐management and Participatory Action Research (PAR) promotes social ecological resilience by simultaneously protecting wildlife and its habitat and promoting capacity and motivation for sustainable harvest management by communities. We report here on a case study of learning through a partnership (1994–2009) between science and Traditional Ecological Knowledge (TEK) to determine the sustainability of titi (sooty shearwater, Puffinus griseus) harvests by Rakiura Maori in southern New Zealand. Testimony of Maori elders and titi harvesters (birders), members of the Rakiura Titi Islands Administering Body, researchers and participants in workshops and meetings were recorded throughout the 14‐year research project to identify critical determinants of success of the partnership. A large majority of participants supported the research, mainly because it expanded their knowledge by investigating the reasons for declining bird numbers and the means of ensuring the continuation of their muttonbi...

We estimated the change in abundance of sooty shearwater (titi, Puffinus griseus) at six Rakiura Titi Islands, New Zealand, by comparing historical and recent surveys of the density of entrances to breeding burrows. We found evidence that entrance density between 1994 and 2006 was lower than it was between 1961 and 1976. Our overall estimate of the annual rate of change in burrow entrance density is ‐1.0% (95% CI ‐2.3 to ‐ 0.1%). Declines have been slower on four islands where Rakiura Maori maintain a traditional harvest of sooty shearwater chicks ("muttonbirding") compared with three unharvested islands. Density‐dependent population processes may explain this difference: rates of decline have been faster in areas of relatively high initial entrance density, and historically the harvested islands have had lower initial density. There was a strong, apparently linear, relationship between entrance density and chick density on breeding colonies, so changes in entrance density probably do indicate a ...

Sooty shearwater (Puffinus griesus, titi) abundance, harvest levels and chick mass were monitored repeatedly on Putauhinu Island, south‐west of Rakiura (Stewart Island) between 1997 and 2005. Putauhinu is the second largest of the Titi Islands and has a relatively high density of chicks distributed over most of the island, so it supports what is likely the second‐largest population of sooty shearwaters in the Rakiura region (after Taukihepa, Big South Cape Island). Rakiura Maori harvested chicks from five “manu” (family birding areas) that covered 56% of the 128.4 ha of breeding colony of the island. Chick density was lower on the unharvested area in the interior of the island than on harvested areas. Burrow entrance density was higher where there was more ground cover (mainly fern) vegetation, but these areas had lower burrow occupancy, so overall chick density was similar at different levels of ground cover. Twenty‐six harvesters present on Putauhinu in 2005 took 31 280 chicks in total, equival...

MicroRNAs (miRNAs) are crucial for normal embryonic stem (ES) cell self-renewal and cellular differentiation, but how miRNA gene expression is controlled by the key transcriptional regulators of ES cells has not been established. We describe here a new map of the transcriptional regulatory circuitry of ES cells that incorporates both protein-coding and miRNA genes, and which is based on high-resolution ChIP-seq data, systematic identification of miRNA promoters, and quantitative sequencing of short transcripts in multiple cell types. We find that the key ES cell transcription factors are associated with promoters for most miRNAs that are preferentially expressed in ES cells and with promoters for a set of silent miRNA genes. This silent set of miRNA genes is co-occupied by Polycomb Group proteins in ES cells and expressed in a tissue-specific fashion in differentiated cells. These data reveal how key ES cell transcription factors promote the miRNA expression program that contributes to normal self-renewal and cellular differentiation, and integrate miRNAs and their targets into an expanded model of the regulatory circuitry controlling ES cell identity.

We estimated the total number of burrow entrances, chicks and total population size of the Sooty Shearwater, Puffinusgriseus, colony on Taukihepa (Big South Cape), the largest of the 36 Titi Islands where Titi (Sooty Shcarwater chicks) are harvested. Between 1999 and 2005 we surveyed six manu (family birded areas) as well as a colony in the interior forested region on the island, measuring entrance density and burrow occupancy and habitat variables, as well as recording birders' harvest intensity. We found little support for any relationship between habitat variables and entrance density on the surveyed manu. Therefore we used a detailed aerial image to map areas and extrapolate these estimates to island totals and a simple population model, incorporating known demographic parameters to calculate the total population size. We estimated that the island contains 1.67 million (95% CI: 1.47-1.88) burrow entrances and 1.12 million (0.959-1.28) breeding pairs, equating to a total of 5.31 million (95% CI: 3.98-6.77) juveniles, pre-breeders and adults associated with the island. Assuming the harvest intensity on the surveyed manu 0.18% (0.16-0.21) was similar elsewhere on the unsurveyed but harvested region of the island, we estimated that ofthe 807000 (712000-901 000) fledging chicks on the island, 137000 (105000-173000) are harvested each year. These findings highlight the importance of the island both in terms of total Sooty Shearwater population in New Zealand and to the Rakiura Maori who harvest the Titi.

We investigated the precision and accuracy of an infrared burrowscope for detecting sooty shearwater (Puffinus griseus) chicks at 13 plots from 3 islands in southern New Zealand in 2003. We partially excavated burrows systems to reveal the entire burrow contents after 2 teams of observers had prospected all burrow entrances. Accuracy was similar between islands and observer teams at approximately 85%. The majority of the inaccuracy stemmed from failure to detect some chicks. Logistic regression modeling identified 4 burrow characteristics occurring between the entrance and the nest-site that influenced detection of burrow occupants. Detection was lower at nest-sites further from burrow entrances, in burrows with a high rate of burrow division, and in burrows with a high level of curvature. There was a positive relationship between the interaction of rate of division and curvature and detection of chicks. Distance from the burrow entrance was the only parameter that could be reliably used as a pre...

Muttonbirding for sooty shearwaters (Puffinus griseus) on islands around Rakiura is an ongoing traditional activity of local Maori. There is little archaeological evidence to pinpoint the onset of large‐scale birding, so some researchers have suggested that widespread systematic muttonbirding only began in protohistoric times. We present AMS radiocarbon data from an archaeological fire found 65 cm subsurface on Poutama, an island off Rakiura. Duplicate analyses of charcoal and a single analysis of underlying peat were used to date the fire, constrained by C accumulation calculations and chemical and isotopic analysis. By comparing C:N ratios and C accumulation calculations with literature values, the peat result (176 ± 55 BP) was shown to be invalid because of contamination viabioturbation. The combined charcoal radiocarbon data were consistent with being estimates of a single value (326 ± 42 BP). After calibration, the fire was dated at AD 1470–1660 (95% confidence interval). Carbon‐13 analysis ...

Introduction : Western NSW is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes. A strategy to transform current services into a patient centred, coherent system of care is well into its third year with Western NSW Local Health District (LHD) leading the way as a NSW Health Integrated Care Demonstrator Site. A range of district-wide and locality-based integrated care initiatives are being implemented to better connect health and social providers to improve health outcomes for the region in a large and sparsely populated area. Methods : The Western NSW Integrated Care Strategy (Strategy) is being implemented using a collaborative partnership approach between the LHD, the Western Primary Health Network, and Bila Muuji Aboriginal Health Services. The vision of the Strategy is: _To transform existing services into an integrated Western NSW system of care that is tailored to the needs of our rural and remote communities, and improves access to care and health outcomes, with particular focus on closing the Aboriginal health gap._ A key element of the Strategy was the establishment of five ‘first wave’ local demonstrator sites to test new models of care at a locality level. Local Leaderships Groups were established at each site and tasked with developing and implementing locally led integrated models of care tailored to their identified local health needs. Features of the demonstrator site models of care include: - Defining target population groups with a focus on chronic disease management - GP-led multi-disciplinary team based care - Standardised risk stratification process using agreed clinical markers - Standardised enrolment process, including patient consent to share information across providers - Comprehensive patient assessment to address medical and social care needs - Shared care planning utilising an electronic shared care platform - Care Navigation, including social care coordination - Multi-disciplinary case conferencing Results : Over two and a half years the Strategy has: - Established a Health Intelligence Unit providing a one-stop-shop for health care data, analysis, advice and support - Established five first wave local demonstrator sites with over 600 patients enrolled - Five additional communities were selected to become second wave demonstrator sites in January 2016 to test the transferability of the first wave chronic disease models of care and allow the introduction of new models of care targeting antenatal care and the first 2000 days of life. - Strengthened the connection between all care providers in a locality. - Appointed local Care Navigators and Social Care Coordinators based in primary care - Development of risk stratification criteria - Implemented an electronic shared care planning tool - Introduced primary care based multidisciplinary case conferencing Early analysis of the enrolled cohort is indicating an improved health journey, improved health reported outcomes and a reduction in acute care utilisation Discussion :A key objective the Strategy was to develop sustainable models of care that are easily and rapidly transferable to other sites and localities. We consider the learnings from our experience in transforming our local health system transferable to other contexts, with suitable tailoring to local funding, delivery and accountability environments. Declaration of any conflict of interest : Nil

Prey remains from sooty shearwater (Puffinus griseus Gmelin, 1792) regurgitates, stomachs, and gizzards, were collected from four breeding colonies in southern New Zealand. We found a wide range of prey species (minimum 39 species of 35 genera), the most important of which were crustaceans (particularly euphausiid krill and hyperiid amphipods), cephalopods (notably arrow squid), fishes, and salps. Malacostracans (krill, amphipods, and decapods) were the predominant taxa of prey in both diversity and frequency of occurrence. Regurgitates were easily obtained from harvested chicks and provided the greatest range of prey remains (36 of the 39 species identified). However, these regurgitates comprised only 29% of the total number of samples collected. Fish, malacostracan, and salp prey ranged from 4 to 170 mm in size, whereas total lengths of squid ranged from 50 to 535 mm. Based on size and mass, the largest squid were undoubtedly scavenged, possibly in association with commercial fishers. The geogr...

Diet samples from sooty shearwaters (Puffinus griseus) were collected during the breeding season at Poutama (Evening) Island (1994 & 1995) and Putauhinu (Hidden) Island (1996–1998), southern New Zealand. Regurgitate samples and whole guts were obtained from chicks harvested by Rakiura Māori muttonbirders. The relative proportions of six major prey categories (decapod, fish, squid, euphausiid, salp and amphipod) varied markedly between years and/or islands. Many more decapods were eaten in 1994 than 1995 (regurgitates). More euphausiids, amphipods and squid were eaten in 1997 than in 1998 (stomachs). The number of regurgitates with identifiable prey remains was significantly higher in 1998 than 1997. Many of the differences in diet between Poutama and Putauhinu probably reflected interannual diet variation rather than site‐specific differences, because the two nearby islands were sampled in different years. Interannual variation in diet may correlate with fluctuations in adult survival and breedin...

We live in an age defined by global access to information. This has rapidly increased the scale of our ecological and social awareness (e.g., fair trade movement) and helped us to identify ecological problems and conservation solutions beyond the typical scale of traditional knowledge (i.e., the foraging range of a human group) or political jurisdictions (i.e., state or national boundaries). For the first time, we can comprehend and accumulate biological knowledge for species on the scale of ocean basins (Prince et al. 1992; Burger & Shaffer 2008). Coincident with this knowledge has been the awareness of the global human footprint and some of its consequences, such as, resource over-exploitation, habitat degradation, and species extinctions. Presently, however, we have a mis-match between the scales at which management frameworks operate (local, regional, national) and the scales at which ecosystems or their components exist (Crowder et al. 2006). Significant conservation actions must be made at appropriate scales (ocean basin, continental) for migratory species, particularly when these resources (e.g., blue fin tuna) are subject to extraction by entities with a variety of national and international allegiances (Block et al. 1995). Geopolitical boundaries arbitrarily delineate sub-populations and hinder effective management and understanding of these species. This is particularly true for far-ranging or migratory species, where foraging, moulting, or nesting ranges can be widely dispersed. Knowledge about habitat connectivity among neotropical migratory songbirds and butterflies that breed in nearctic (North America) and winter in the neotropics (Central and South America) has led to the recognition of flyways or migratory corridors and the development of international conservation consortiums. In 1990, the “Partners in Flight/Companeros en Vuelo/Partenaires d’Envo”, an international conservation programme, was formed in response to growing knowledge of wintering area habitat loss and concerns about population declines. Such international programmes can address conservation issues at the appropriate (and in some cases, global) ecological scale and can be used as models for species not covered by such conservation initiatives. The Kia Mau te Tītī mo Ake Tōnu Atu (Keep the Tītī Forever) project exemplifies a crosscultural collaboration of scientists and Māori community members to inform co-management of an important seabird resource (Moller et al. 2009a,b). Building upon this established partnership, we initiated the Rakiura Tītī Islands Restoration Project, an international collaboration between a United States non-profit conservation organisation, University of Otago scientists, and Rakiura Māori, with support from New Zealand conservation managers. Our shared resource, taonga tītī (the treasured sooty shearwater, Puffinus griseus), brought us together and

This study aimed to document the types, management and follow up of health issues identified by all Aboriginal Health Assessments (AHA) performed at Orange Aboriginal Medical Service from 1 January 2011 to 31 December 2012. This was done with a retrospective audit of clinical records. In total, 1169 AHAs were performed: 41% child, 53% adult and 6% older person AHAs. Newly identified health issues were documented in 85% (984). Being overweight (41%; 476) and smoking (26%; 301) were the common risk factors identified. As a result of the AHA, most children who were not up-to-date with their vaccinations received catch-up immunisations; 11% (36) of adult women (n=314) received a Pap smear, although Pap smear status was unknown or not up-to-date for 61% (192); 27% (311) of cases were prescribed new medication; and 1239 referrals were made but only 40% were attended. At 6 months following the AHA, 26% (240) of cases with newly identified health issues were completely managed and followed up, whereas 25% (226) received no follow up. The AHAs are useful for identifying new health issues; however, follow up of the identified health issues should be improved. If AHAs are to improve health outcomes, appropriate management and follow up of the identified health issues are essential.

Monitoring of breeding success in burrow-nesting seabirds is problematic, owing to the difficulties of detecting occupants in complex burrow systems. We summarise 6 years of monitoring the breeding success of sooty shearwater (tītī, muttonbird, Puffinus griseus) on two southern New Zealand islands, The Snares and Whenua Hou, with a portable infrared camera system. Breeding attempts were monitored three times during the breeding season, i.e. egg laying, hatching and fledging. Overall breeding success was calculated in two stages. First, we estimated breeding success for each island–site–year combination with a model that allowed for imperfect detection of an egg or chick and accounted for the proportion of the breeding season that was covered by monitoring. The resulting estimates for each island were then analysed with a linear model, to provide a single estimate for that island. Breeding success was found to be highly variable and non-synchronous between islands, with the average proportion of eggs successfully fledging on The Snares (0.35, 0.20–0.52; mean and 95% creditable interval) being considerably lower and more variable than that on Whenua Hou (0.76, 0.70–0.82). Probability of detecting a breeding attempt was higher on The Snares whereas correcting for the proportion of the season monitored had a variable effect, reducing The Snares and Whenua Hou estimates by 27% and 7% respectively. The implications of these findings with respect to the demographic modelling of burrow-nesting species are discussed.

Recent declines of many seabird populations have placed increased emphasis on determining the status of potentially threatened species. However, the burrow-nesting habits and inter-annual fluctuation in breeding numbers of some species make trend detection difficult, and so knowledge of their population dynamics often remains coarse. Here we report observed fluctuations, and assess the efficacy of monitoring of sooty shearwaters (Puffinus griseus), on three islands in southern New Zealand between the breeding seasons of 1996–97 and 2004–05. Apart from a steady increase in burrow-occupant density at one island, few significant trends in abundance measures were detected. Considerable variation among individual sites within islands led to high uncertainty in island-wide trend estimates. Simulations showed that the measurements of occupant density have a limited ability of detecting all but very pronounced trends, whereas changes in burrow-entrance density are more likely to be detected. Annual fluctuations in the proportion of occupied burrows at individual sampling sites were highly synchronous within islands and reasonably synchronous between two of the islands, suggesting that breeding numbers are at least partly determined by broad-scale factors. The large declines in the abundance of sooty shearwaters reported from the late 1980s to mid-1990s appear not to have continued through our monitoring period. Lack of adequate within- and among-island replication, and short time series of data may severely reduce our ability reliably to detect population trends in many studies of burrowing Procellariiformes.

Super-enhancers are large clusters of transcriptional enhancers that drive expression of genes that define cell identity. Improved understanding of the roles that super-enhancers play in biology would be afforded by knowing the constellation of factors that constitute these domains and by identifying super-enhancers across the spectrum of human cell types. We describe here the population of transcription factors, cofactors, chromatin regulators, and transcription apparatus occupying super-enhancers in embryonic stem cells and evidence that super-enhancers are highly transcribed. We produce a catalog of super-enhancers in a broad range of human cell types and find that super-enhancers associate with genes that control and define the biology of these cells. Interestingly, disease-associated variation is especially enriched in the super-enhancers of disease-relevant cell types. Furthermore, we find that cancer cells generate super-enhancers at oncogenes and other genes important in tumor pathogenesis. Thus, super-enhancers play key roles in human cell identity in health and in disease., National Institutes of Health (U.S.) (NIH grant HG002668), National Institutes of Health (U.S.) (NIH grant CA109901), National Institutes of Health (U.S.) (NIH grant CA146445), National Institutes of Health (U.S.) (NIH Roadmap Epigenome Projects and the Rush Alzheimer’s Disease Center at Rush University Medical Center, Chicago (P30AG10161), National Institutes of Health (U.S.) (NIH Roadmap Epigenome Projects and the Rush Alzheimer’s Disease Center at Rush University Medical Center, Chicago (R01AG36042), National Institutes of Health (U.S.) (NIH Roadmap Epigenome Projects and the Rush Alzheimer’s Disease Center at Rush University Medical Center, Chicago (RC2AG36547)