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Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures.
Design:
A before-after, quasi-experimental trial with a baseline (July 2020–June 2022), an implementation (July 2022), and an intervention period (August 2022–July 2023).
Setting:
Three participating medical centers.
Intervention:
We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing.
Results:
1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02–0.45). There was no significant increase in post-procedural unplanned visits at any of the sites.
Conclusions:
Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.
This trial was registered on clinicaltrials.gov, NCT04196777.
Wild sheep and many primitive domesticated breeds have two coats: coarse hairs covering shorter, finer fibres. Both are shed annually. Exploitation of wool for apparel in the Bronze Age encouraged breeding for denser fleeces and continuously growing white fibres. The Merino is regarded as the culmination of this process. Archaeological discoveries, ancient images and parchment records portray this as an evolutionary progression, spanning millennia. However, examination of the fleeces from feral, two-coated and woolled sheep has revealed a ready facility of the follicle population to change from shedding to continuous growth and to revert from domesticated to primitive states. Modifications to coat structure, colour and composition have occurred in timeframes and to sheep population sizes that exclude the likelihood of variations arising from mutations and natural selection. The features are characteristic of the domestication phenotype: an assemblage of developmental, physiological, skeletal and hormonal modifications common to a wide variety of species under human control. The phenotypic similarities appeared to result from an accumulation of cryptic genetic changes early during vertebrate evolution. Because they did not affect fitness in the wild, the mutations were protected from adverse selection, becoming apparent only after exposure to a domestic environment. The neural crest, a transient embryonic cell population unique to vertebrates, has been implicated in the manifestations of the domesticated phenotype. This hypothesis is discussed with reference to the development of the wool follicle population and the particular roles of Notch pathway genes, culminating in the specific cell interactions that typify follicle initiation.
Drawing has always been an integral part of the FRCS examination, be it as a method to understand a complex process during revision or as a tool for explanation in the viva itself. In order to use drawings in the viva exam the candidate must be able to draw, explain and answer questions simultaneously. Thus, practice and understanding are essential.
In this chapter, we have selected the drawings that we think are most useful, having recently been through the examination or taught on this subject for many years.
On August 24, 2016, the Colombian government of President Juan Manuel Santos and leaders of the FARC rebel movement (Revolutionary Armed Forces of Colombia) signed a peace agreement designed to bring to an end the FARC insurgency that had lasted since 1964. One provision of the agreement was that it would be put to a vote in a plebiscite for Colombian citizens to ratify or reject. On October 2, 2016, the plebiscite was held and, surprisingly, 50.2 percent of voters rejected the agreement. Shortly thereafter, the Colombian government and FARC negotiated and signed a revised agreement and sent it directly to the Colombian legislature for ratification, bypassing a second referendum. Both houses of the Congress ratified the agreement, marking a formal end to the war between FARC and the government of Colombia.
Benzobicyclon will be the first 4-hydroxyphenylpyruvate dioxygenase (HPPD)–inhibiting herbicide available in US rice production pending registration completion. An observation of benzobicyclon controlling weedy rice in two field trials prompted a greenhouse and field evaluation to determine if benzobicyclon would control weedy rice accessions from Arkansas, Mississippi, and southeastern Missouri. A total of 100 accessions were screened in the greenhouse and field. Percentage mortality was determined in the greenhouse, and percentage control was recorded in the field. Benzobicyclon at 371 g ai ha–1 caused at least 80% mortality of 22 accessions in the greenhouse and at least 80% control of 30 accessions in the field. For most accessions, individual plants within the accession varied in response to benzobicyclon. Based on these results, the sensitivity of weedy rice to benzobicyclon varies across accessions collected in the midsouthern United States, and it may provide an additional control option for weedy rice in some fields.
A progradational regime of falling sea level and/or high sediment input has produced extensive beach ridge plains in northwest Alaska during the last 4000 yr. Eleven Chukchi Sea beach ridge complexes, oriented at various angles to wind fetch, provide a cumulative history of longshore transport and erosion. Archaeological and geological upper limiting radiocarbon ages (n = 59) allow correlations between depositional units on seven beach ridge complexes. Progradation started 4000 yr B.P. at nearly all complexes, as eustatic sea level stabilized. Two disconformities or truncations are found on most of the complexes, providing time-parallel storm horizons, dated at 3300-1700 and 1200-900 14C yr B.P. Between 1700 and 1200 14C yr B.P. most of the complexes prograded, indicating the predominance of less-stormy conditions. Modern synoptic patterns that produce Chukchi beach ridge erosion are linked to northerly shifts in North Pacific storm tracks. The regionwide beach ridge erosional truncations correlate with records of glacier expansion, heightened precipitation evident in tree-rings, stream flooding, and shelf deposits reworked by storm surges.
An exceptional stratigraphic and pedologic record of Pleistocene environmental conditions occurs at the Kieler Site in the Driftless Area of southwestern Wisconsin. Peoria, Roxana, Loveland, and pre-Loveland loesses overlie weathered bedrock residuum. The pre-Loveland unit previously has been included as part of the residuum at other Driftless Area sites. Early and middle Pleistocene loesses in the Mississippi Valley are normally absent at most localities. Rather than nondeposition, we suggest the apparent absence of pre-Illinoian loess units is due in part to erosion, but also to weathering that renders loesses unrecognizable so they are classified as “residuum.”
The Palisades Site is an extensive silt-loam bluff complex on the central Yukon River preserving a nearly continuous record of the last 2 myr. Volcanic ash deposits present include the Old Crow (OCt; 140,000 yr), Sheep Creek (SCt; 190,000 yr), PA (2.02 myr), EC (ca. 2 myr), and Mining Camp (ca. 2 myr) tephras. Two new tephras, PAL and PAU, are geochemically similar to the PA and EC tephras and appear to be comagmatic. The PA tephra occurs in ice-wedge casts and solifluction deposits, marking the oldest occurrence of permafrost in central Alaska. Three buried forest horizons are present in association with dated tephras. The uppermost forest bed occurs immediately above the OCt; the middle forest horizon occurs below the SCt. The lowest forest bed occurs between the EC and the PA tephras, and correlates with the Dawson Cut Forest Bed. Plant taxa in all three peats are common elements of moist taiga forest found in lowlands of central Alaska today. Large mammal fossils are all from common late Pleistocene taxa. Those recovered in situ came from a single horizon radiocarbon dated to ca. 27,000 14C yr B.P. The incongruous small mammal assemblage in that horizon reflects a diverse landscape with both wet and mesic environments.
New solar soft X-ray (SXR) and extreme ultraviolet (EUV) irradiance observations from NASA Solar Dynamics Observatory (SDO) EUV Variability Experiment (EVE) provide full coverage from 0.1 to 106 nm and continuously at a cadence of 10 seconds for spectra at 0.1 nm resolution. These observations during flares can usually be decomposed into four distinct characteristics: impulsive phase, gradual phase, coronal dimming, and EUV late phase. Over 6000 flares have been observed during the SDO mission; some flares show all four phases, and some only show the gradual phase. The focus is on the newer results about the EUV late phase and coronal dimming and its relationship to coronal mass ejections (CMEs). These EVE flare measurements are based on observing the sun-as-a-star, so these results could exemplify stellar flares. Of particular interest is that new coronal dimming measurements of stars could be used to estimate mass and velocity of stellar CMEs.
Evidence-based practice has become an integral part of routine trauma and orthopaedic practice. You apply evidence of many kinds in your daily practice and this has been reflected in the FRCS (Tr & Orth) exam. In the MCQ part, candidates are given a paper to appraise and answer related questions. Although evidence-based practice may be applied in each exam station, you may be specifically asked about different points of evidence-based practice and be probed to assess the depth of your understanding of these aspects, their strengths or limitations. In the structured oral exam, quoting evidence to support your views is perceived highly and can raise your performance and pass grade. This chapter will cover, in a series of questions, the common scenarios you may face. It has been based on real exam questions that have appeared in the FRCS (Tr & Orth), the EBOT and SICOT exams. The answers are deliberately expanded for comprehension and to help address potential follow-up questions.
Station 1: Level of evidence and grades of recommendations
Q 1: Look at Table 17.1 and fill in the blanks.
Systematic review (SR) of randomized controlled trials (RCT) with homogeneous findings.
Individual RCT with narrow confidence interval (CI).
All-or-none studies.
Absolute SpPins and SnNouts.
Expert opinion.
Analysis based on clinically sensible costs of alternatives; systematic review(s) of the evidence; and including multi-way sensitivity analyses.
Q 2: What is a systematic review and meta-analysis? What is meant by homogeneity or heterogeneity?
For many surgical procedures, there have been a number of clinical studies and it would seem natural to want to combine them to get the most comprehensive overview of the effect of treatment. A review locates and summarizes the findings of studies. A systematic review is a rigorous and pre-structured approach to conducting a review. The researchers decide beforehand on their inclusion and exclusion criteria, how they will search the literature, extract data, synthesize and analyse them. The meta-analysis attempts to combine data from different studies statistically with a view to get a combined and more precise estimate of the intervention effectiveness. This is not always possible due to data limitations.
Case studies contribute more focused analyses which, in the context of human loss and damage, demonstrate the effectiveness of response strategies and prevention measures and identify lessons about success in disaster risk reduction and climate change adaptation. The case studies were chosen to complement and be consistent with the information in the preceding chapters, and to demonstrate aspects of the key messages in the Summary for Policymakers and the Hyogo Framework for Action Priorities.
The case studies were grouped to examine types of extreme events, vulnerable regions, and methodological approaches. For the extreme event examples, the first two case studies pertain to events of extreme temperature with moisture deficiencies in Europe and Australia and their impacts including on health. These are followed by case studies on drought in Syria and dzud, cold-dry conditions in Mongolia. Tropical cyclones in Bangladesh, Myanmar, and Mesoamerica, and then floods in Mozambique are discussed in the context of community actions. The last of the extreme events case studies is about disastrous epidemic disease, using the case of cholera in Zimbabwe, as the example.
The case studies chosen to reflect vulnerable regions demonstrate how a changing climate provides significant concerns for people, societies, and their infrastructure. These are: Mumbai as an example of a coastal megacity; the Republic of the Marshall Islands, as an example of small island developing states with special challenges for adaptation; and Canada's northern regions as an example of cold climate vulnerabilities focusing on infrastructures.
This chapter addresses changes in weather and climate events relevant to extreme impacts and disasters. An extreme (weather or climate) event is generally defined as the occurrence of a value of a weather or climate variable above (or below) a threshold value near the upper (or lower) ends (‘tails’) of the range of observed values of the variable. Some climate extremes (e.g., droughts, floods) may be the result of an accumulation of weather or climate events that are, individually, not extreme themselves (though their accumulation is extreme). As well, weather or climate events, even if not extreme in a statistical sense, can still lead to extreme conditions or impacts, either by crossing a critical threshold in a social, ecological, or physical system, or by occurring simultaneously with other events. A weather system such as a tropical cyclone can have an extreme impact, depending on where and when it approaches landfall, even if the specific cyclone is not extreme relative to other tropical cyclones. Conversely, not all extremes necessarily lead to serious impacts. [3.1]
Many weather and climate extremes are the result of natural climate variability (including phenomena such as El Niño), and natural decadal or multi-decadal variations in the climate provide the backdrop for anthropogenic climate changes. Even if there were no anthropogenic changes in climate, a wide variety of natural weather and climate extremes would still occur. [3.1]
A changing climate leads to changes in the frequency, intensity, spatial extent, duration, and timing of weather and climate extremes, and can result in unprecedented extremes. Changes in extremes can also be directly related to changes in mean climate, because mean future conditions in some variables are projected to lie within the tails of present-day conditions. Nevertheless, changes in extremes of a climate or weather variable are not always related in a simple way to changes in the mean of the same variable, and in some cases can be of opposite sign to a change in the mean of the variable. Changes in phenomena such as the El Nino-Southern Oscillation or monsoons could affect the frequency and intensity of extremes in several regions simultaneously. [3.1]
We review the use and value of seasonal climate forecasting for agriculture in sub-Saharan Africa (SSA), with a view to understanding and exploiting opportunities to realize more of its potential benefits. Interaction between the atmosphere and underlying oceans provides the basis for probabilistic forecasts of climate conditions at a seasonal lead-time, including during cropping seasons in parts of SSA. Regional climate outlook forums (RCOF) and national meteorological services (NMS) have been at the forefront of efforts to provide forecast information for agriculture. A survey showed that African NMS often go well beyond the RCOF process to improve seasonal forecast information and disseminate it to the agricultural sector. Evidence from a combination of understanding of how climatic uncertainty impacts agriculture, model-based ex-ante analyses, subjective expressions of demand or value, and the few well-documented evaluations of actual use and resulting benefit suggests that seasonal forecasts may have considerable potential to improve agricultural management and rural livelihoods. However, constraints related to legitimacy, salience, access, understanding, capacity to respond and data scarcity have so far limited the widespread use and benefit from seasonal prediction among smallholder farmers. Those constraints that reflect inadequate information products, policies or institutional process can potentially be overcome. Additional opportunities to benefit rural communities come from expanding the use of seasonal forecast information for coordinating input and credit supply, food crisis management, trade and agricultural insurance. The surge of activity surrounding seasonal forecasting in SSA following the 1997/98 El Niño has waned in recent years, but emerging initiatives, such as the Global Framework for Climate Services and ClimDev-Africa, are poised to reinvigorate support for seasonal forecast information services for agriculture. We conclude with a discussion of institutional and policy changes that we believe will greatly enhance the benefits of seasonal forecasting to agriculture in SSA.
Multilayered films comprising alternating layers of polycarbonate (PC) and poly(vinylidene fluoride-hexafluoropropylene) (P[VDF-HFP]) show an enhanced dielectric strength (EB> 750 kV/mm) and an increased energy storage density (Ud ~ 13.5 J/cm3) compared to monolithic PC and P[VDF-HFP] films. Here the role of electromechanical effects in the breakdown of multilayer films is explored both by imaging the changes in the layer structure caused by electrical fields below the breakdown field and by a direct measurement of the strain in multilayer PC/ P[VDF-HFP] films subjected to similar fields. Focused Ion Beam (FIB)/ Scanning Electron Microscopy (SEM) images of the layer structure in films subjected to repeated cycles at near-breakdown fields showed local changes in the thickness of individual layers, suggesting that mechanical forces arising from field-induced compression may play a role in the steps preceding the breakdown. The directly measured field induced strain showed evidence for both an elastic and a flow component to the strain. The mechanical responses of films with ≤ 50 vol% P[VDF-HFP] were modeled as simply the sum of an elastic and viscous flow. The observed electromechanical properties vary with the layer structure. This suggests that multilayering polymers may provide a means to mitigate deleterious electromechanical effects in low modulus, high dielectric materials.