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1.
The use of reproductive technology to service a preference for male offspring has created an artificial gender imbalance, notably in Asian countries. The social effects of this large surplus of young men are not yet clear, but concerted action might be necessary to address the problemOne of the problems of sexual reproduction, especially in predominantly monogamous species that pair ‘for life'', is to ensure a balance between the birth rate of males and females. In humans, this balance has been remarkably even, but the past few decades have seen a substantial shift towards men, notably in some Asian countries. The reason, however, is not biological; there has simply been a cultural preference for sons in the affected societies, which together with recent availability of prenatal sex-selection technologies has led to widespread female feticide. The result has been a huge excess of males in several countries. Whilst it is not yet fully clear how a surplus of millions of men will affect these societies—perhaps even leading to civil unrest—some countries have already taken steps to alleviate the problem by addressing the underlying cultural factors. However, the problem is about to come to a crisis point, as a large surplus of men reach reproductive age. It will take many decades to reach a balanced representation of both sexes again.The sex ratio at birth (SRB) is defined as the number of boys born to every 100 girls. It is remarkably consistent in human populations, with around 103–107 male babies for every 100 female ones. John Graunt first documented this slight excess of male births in 1710 for the population of London, and many studies have since confirmed his finding [1]. Higher mortality from disease, compounded by the male tendency towards risky behaviours and violence, means that the initial surplus of boys decreases to roughly equal number of males and females during the all-important reproductive years in most populations.Researchers have studied a large number of demographic and environmental factors that could affect the SRB, including family size, parental age and occupation, birth order, race, coital rate, hormonal treatments, environmental toxins, several diseases and, perhaps most intriguingly, war [2,3,4]. It is well documented that wars are associated with a small increase in the sex ratio. This phenomenon occurs both during the war and for a short period afterwards. The best examples of this were reported for the First and Second World Wars in both the USA and Europe, and for the Korean and Vietnam Wars in the USA [5,6]. However, these findings were not reproduced in the more recent Balkan Wars and the Iran–Iraq war [7]. There have been several biological explanations for these increases. It has been proposed, for example, that the stress of war adversely affects the viability of XY-bearing sperm. Alternatively, a higher frequency of intercourse after prolonged separation during times of war is thought to lead to conception earlier in the menstrual cycle, which has been shown to result in more males [4,8]. There have been evolutionary explanations, such as the loss of large numbers of men in war leading to an adaptive correction of the sex ratio [4,9]. Nonetheless, the real causes of the altered SRB during war remain elusive: all of the discussed biological and social factors have been shown to cause only marginal deviations from the normal sex ratio.Whilst war has only slightly shifted SRB towards more male babies and only for a limited time period, cultural factors, namely a strong preference for sons, has been causing large distortions of gender balance during the past decades. Son preference is most prevalent in a band of countries from East Asia through to South Asia and the Middle East to North Africa [9]. For centuries, sons have been regarded as more valuable, because males can earn higher wages especially in agrarian economies, they generally continue the family line, are recipients of inheritance and are responsible for their parents in illness and old age. By contrast, daughters often become members of the husband''s family after marriage, no longer having responsibility for their biological parents [10]. There are also location-specific reasons for son preference: in India, the expense of the dowry, and in South Korea and China, deep-rooted Confucian values and patriarchal family systems [11].… cultural factors, namely a strong preference for sons, has been causing large distortions of gender balance during the past decadesUntil recently, son preference was manifest post-natally through female infanticide, abandonment of newborn girls, poorer nutrition and neglect of health care, all causing higher female mortality [12]. Studies have shown that unequal access to health care is the most important factor in differential gender mortality [13,14], especially in countries where health care costs are borne by the family [15]. As early as 1990, the Indian economist Amaryta Sen estimated that differential female mortality had resulted in around 100 million missing females across the developing world with the overwhelming majority of these in China, India, Pakistan and Bangladesh [16].
Open in a separate windowAdapted from Zhu et al 2009 [18].South Koreans are inclined to use sex selection, even in their first pregnancy, as there is a traditional preference for the first-born to be a son. This tendency towards sex selection rises for third and fourth births as parents try to ensure they produce a son. In the peak years of the early 1990s, when the overall SRB was 114, the sex ratio for fourth births was 229 [17].… it is clear that large parts of China and India will have a 15–20% excess of young men during the next 20 yearsSince prenatal sex determination only became accessible during the mid-1980s, and even later still in rural areas, the large cohorts of surplus young men have only now started to reach reproductive age. The consequences of this male surplus in the all-important reproductive age group are therefore still speculative and the existing literature about the consequences of distorted sex ratios is predominantly theoretical with few hypothesis-testing investigations [24,25]. In addition, most research focuses on countries in which sex ratios differ only marginally from biological norms [26]; few researchers have systematically examined the massive sex ratio distortion in China and India. However, it is clear that large parts of China and India will have a 15–20% excess of young men during the next 20 years. These men will be unable to get married, in societies in which marriage is regarded as virtually universal, and where social status depends, in large part, on being married and having children. An additional problem is the fact that most of these men will come from the lowest echelons of society: a shortage of women in the marriage market enables women to ‘marry-up'', inevitably leaving the least desirable men with no marriage prospects [27]. As a result, most of these unmarriageable men are poor, uneducated peasants.One hypothesis assumes that not being able to meet the traditional expectations of marriage and childbearing will cause low self-esteem and increased susceptibility to psychological difficulties, including suicidal tendencies [28]. A recent study using in-depth interviews with older unmarried men in Guizhou province, in south west China, found that most of these men have low self-esteem, with many describing themselves as depressed, unhappy and hopeless [29].The combination of psychological vulnerability and sexual frustration might lead to aggression and violence. There is empirical support for this prediction: gender is a well-established individual-level correlate of crime, especially violent crime [30,31]. A consistent finding across cultures is that most crime is perpetrated by young, single males, of low socioeconomic status [32]. A particularly intriguing study carried out in India in the early 1980s showed that the sex ratio at the state level correlated strongly with homicide rates, and the relationship persisted after controlling for confounders such as urbanization and poverty [33]. The authors had expected to find that the high sex ratio would lead to increased violence against women, but their conclusion was that high sex ratios are a cause of violence of all types in society.However, no other study has found similar results. The study mentioned above from rural Guizhou, for example, could find no evidence that unmarried men were especially prone to violence and aggression. Rather, the men were characterized as shy and withdrawn, rather than aggressive [29]. In addition, reports of crime and disorder are not higher in areas with a known excess of young, single men. This might be because there is not yet a large enough crucial mass of unmarriageable men to have an impact, or assumptions about male aggression do not apply in this context.A consistent finding across cultures is that most crime is perpetrated by young, single males, of low socioeconomic statusIn China and parts of India, the sheer numbers of single men have raised other concerns. Because these men might lack a stake in the existing social order, it is feared that they will bind together in an outcast culture, turning to antisocial behaviour and organized crime [34], thereby threatening societal stability and security [35]. Some theorize that it could lead to intergroup conflict and civil war could erupt [32]; other authors go further, predicting that such men will be attracted to military-type organizations, potentially triggering large-scale domestic and international conflicts [36]. However, there is no evidence yet to support these scenarios. Crime rates are relatively low in India and China compared with other countries [37]. Such outcomes are probably multifactorial in their causes, and therefore the role of sex imbalance is difficult to determine.An excess of men, however, should be beneficial for women, especially in those Asian societies in which women have traditionally low social status. In fact, much of the literature on sex ratios has focused on women''s status and role in society, and on mating strategies; but again the literature has come from scenarios in which the sex ratio is only marginally distorted [38,39]. It is intuitive to see that women are a valuable commodity when sex ratios are high [40,41]. Because women generally prefer long-term monogamous relationships [42], it is predicted that monogamy will be more prevalent in high sex ratio societies, with less premarital and extramarital sex [43], lower divorce rates [38,24] and less illegitimacy [31]. In India and China, tradition militates against some of these eventualities; for example, divorce and illegitimacy are rare in both countries, owing to the traditional values of these societies. But other effects can be explored. If women are more highly valued, it is predicted that they will have higher self-esteem, resulting in lower rates of depression and suicide [24]. In China, where suicide rates in rural women have been among the highest in the world [28], women now show improved self-esteem and self-efficacy: 47% of university graduates are female and women account for 48% of the labour force [19].However, this increase in the value of women could also have paradoxically adverse effects on women, especially in rural societies. Benefits might accrue to men, such as fathers, husbands, traffickers and pimps, who control many female lives [35]. Increases in prostitution, kidnapping and trafficking of women in China have already been attributed to high sex ratios [44]. Hudson and Den Boer [36] cite the increase in kidnapping and trafficking of women, which has been reported from many parts of Asia, and the recent large increases in dowry prices in parts of India.Despite the negative and potentially damaging culturally driven use of prenatal sex selection, there might be some positive aspects of easy access to this technology. First, access to prenatal sex determination probably increases the proportion of wanted births, leading to less discrimination against girls and lower postnatal female mortality. India, South Korea and China have all reported reductions in differential mortality [45]. Second, it has been argued that an imbalance in the sex ratio could be a means to reduce population growth [46]. Third, the improved status of women should result in reduced son preference with fewer sex-selective abortions and an ultimate rebalancing of the sex ratio [4].Other consequences of an excess of men have been described, but the evidence for causation is limited. Much has been made of the impact on the sex industry. It is assumed that the sexual needs of large numbers of single men will lead to an expansion of the sex industry, including the more unacceptable practices of coercion and trafficking. During the past 20 years the sex industry has in fact expanded in both India and China [47,48], but the role that the high sex ratio has played is impossible to isolate. The marked rise in the number of sex workers in China, albeit from a low baseline, has been attributed more to a relaxation in sexual attitudes, increased inequality, and much greater mobility in the country, than an increase in the sex ratio. For example, the sex ratio is close to normal in border areas of Yunnan Province, where there is known to be the highest number of sex workers [49].Similarly, it is impossible to say whether gender imbalance is a contributory factor to the reported, largely anecdotal, increases in trafficking for the sex industry and for marriage. Most unmarried men in China and India are in the poorest echelons of society, and thus unable to buy a bride. In addition, trafficking is probably far more common in parts of Eastern Europe and Africa where the sex ratio is normal [50]. Several commentators have suggested that an excess of men might encourage an increase in homosexual behaviour [17]. This is clearly highly contentious, and begs questions about the aetiology of sexual orientation. However, if this leads to increased tolerance towards homosexuality in societies where homophobia is still highly prevalent, it is perhaps a positive consequence of the high sex ratio.There is clear concern at the governmental level about high sex ratios in the affected countries. In 2004, clearly risible with hindsight, China set a target to lower the SRB to normal levels by 2010 [51]. The Chinese government expressed concerns recently about the potential consequences of excess men for societal stability and security [52]. In the short term, little can be done to address the problem. There have been some extreme suggestions, for example recruiting men into the armed forces and posting them to remote areas [35], but such suggestions are clearly not feasible or realistic.However, much can be done to reduce sex selection, which would have clear benefits for the next generation. There are two obvious policy approaches: to outlaw sex selection, and to address the underlying problem of son preference. In China and India, laws forbidding infanticide and sex selection exist. It is therefore perplexing that sex-selective abortion is carried out, often quite openly, by medical personnel in clinics and hospitals that are often state-run and not in back-street establishments [20]. Enforcement of the law should therefore be straightforward—as the lessons from South Korea demonstrate. In the late 1980s, alarming rises in the SRB, because of easy access to sex-selective abortion, caused the government to act decisively. Eight physicians in Seoul, who had performed sex determination, had their licenses suspended in 1991 leading to a fall in the SRB from 117 to 113 in the following year. Following this success, laws forbidding sex selection were enforced across the country. This was combined with a widespread and influential public awareness campaign, warning of the dangers of distorted sex ratios, focusing especially on the shortage of brides. The results led to a gradual decline in the SRB from 116 in 1998 to 110 in 2009 [11].An excess of men […] should be beneficial for women, especially in those Asian societies in which women have traditionally low social statusThe lessons are clear. The fact that in China and India sex-selective abortion is still carried out with impunity—by licensed medical personnel and not even in backstreet establishments—makes the failure of the government to enforce the law all the more obvious. One of the problems is that although sex-selective abortion is illegal, abortion itself is readily available, especially in China, and it is often difficult to prove that an abortion has been carried out to select the sex of the child, as opposed to family planning reasons.To successfully address the underlying issue of son preference is, of course, hugely challenging, and requires a multi-faceted approach. Evidence from areas outside Asia strongly supports the idea that a higher status for women leads to less traditional gender attitudes and lower levels of son preference [52]. Laws in China and India have made important moves towards gender equality in terms of social and economic rights. These measures, together with socio-economic improvements and modernization, have improved the status of women and are gradually influencing traditional gender attitudes [44].The recognition that intense intervention would be necessary to change centuries-long traditions in China led to the Care for Girls campaign, instigated by the Chinese Population and Family Planning Commission in 2003. It is a comprehensive programme of measures, initially conducted in 24 counties in 24 provinces, which aims to improve perceptions of the value of girls and emphasizes the problems that young men face in finding brides. In addition, there has been provision of a pension for parents of daughters in rural areas. The results have been encouraging: in 2007, a survey showed that the campaign had improved women''s own perceived status, and that stated son preference had declined. In one of the participating counties in Shanxi Province, the SRB dropped from 135 in 2003 to 118 in 2006 [53].Surveys of sex preference are encouraging. In 2001, a Chinese national survey found that 37% of the female respondents—predominantly younger, urban women—claimed to have no gender preference for their offspring, 45% said the ideal family consisted of one boy and one girl, and the number expressing a preference for a girl was almost equal to those who wanted a boy [54]. A study conducted ten years later in three Chinese provinces showed that around two-thirds of adults of reproductive age classify themselves as gender indifferent; of the remainder, 20% said they would prefer to have a girl, with just 12% admitting to wanting a boy [52].Other policy measures that can influence social attitudes include equal social and economic rights for males and females—for example, in relation to rights of inheritance—and free basic health care to remove the financial burden of seeking health care for daughters. Neither of these has yet been implemented. However, another suggestion that special benefits be given to families with no sons to ensure protection in old age has been introduced in some Chinese provinces.Despite the grim outlook for the generation of males entering their reproductive years over the next two decades, the future is less bleak. The global SRB has probably already peaked. In South Korea, the sex ratio has already declined markedly and China and India are both reporting incipient declines: in China the SRB for 2010 was reported as 118 down from the peak of 121 in 2005, and, importantly,14 provinces with high sex ratios are beginning to show a downward trend [19]. India is now reported to have an SRB of around 109, down from a peak of around 111 in 2005 [21]. Whilst the combination of these incipient declines in SRB, and the changing attitudes towards the imperative to have sons, are encouraging, they will not start to filter through to the reproductive age group for another two decades. In China and India the highest sex ratio cohorts have yet to reach reproductive age, so the situation will get worse before it gets better. Normal sex ratios will not be seen for several decades.?
Open in a separate windowTherese HeskethOpen in a separate windowJiang Min Min 相似文献
Science & Society Series on Sex and Science
Sex is the greatest invention of all time: not only has sexual reproduction facilitated the evolution of higher life forms, it has had a profound influence on human history, culture and society. This series explores our attempts to understand the influence of sex in the natural world, and the biological, medical and cultural aspects of sexual reproduction, gender and sexual pleasure.To make matters worse, during the 1980s, diagnostic ultrasound technology became available in many Asian countries, and the opportunity to use the new technology for prenatal sex selection was soon exploited. Indeed, the highest SRBs are seen in countries with a combination of son preference, easy access to sex-selection technologies and abortion, and a small family culture. The latter is important because where larger families are the norm, couples will continue to have children until they have a boy. If the couple plan, or are legally restricted, as in China, to only one or two children, they will use sex selection to ensure the birth of a son [17]. This combination has resulted in serious and unprecedented sex ratio imbalances that are now affecting the reproductive age groups in several countries, most notably China, South Korea and parts of India.South Korea was the first country to report a very high SRB, because the widespread uptake of sex-selection technology preceded other Asian countries. The sex ratios started to rise in the mid-1980s in cities; ultrasound was already widely available even in rural areas by 1990 [17]. By 1992, the SRB was reported to be as high as 125 in some cities.South Korea was the first country to report a very high SRB, because the widespread uptake of sex-selection technology preceded other Asian countriesChina soon followed. Here, the situation was further complicated by the one-child policy introduced in 1979. This has undoubtedly contributed to the steady increase in the reported SRB from 106 in 1979 to 111 in 1990, 117 in 2001, 121 in 2005 and as high as 130 in some rural counties [18]. The latest figures for 2010 report an SRB of 118 [19] (National Bureau of Statistics of China 2011), the first drop in three decades, suggesting an incipient downturn. However, the number of excess males in the reproductive age group will continue to increase for at least another two decades. Because of China''s huge population, these ratios translate into massive numbers: in 2005, an estimated 1.1 million excess males were born across the country and the number of males under the age of 20 might exceed females by around 30 million [18].These overall figures conceal wide variations across the country (Fig 1): the SRB is higher than 130 in a strip of heavily populated provinces from Henan in the north to Hainan in the south, but close to normal in the large sparsely populated provinces of Xinjiang, Inner Mongolia and Tibet. Some are sceptical about these high SRB figures or have suggested that, under the constraints of the one-child policy, parents might fail to register a newborn girl, so that they might go on to have a boy [20]. However, recent evidence shows that such under-registration explains only a small proportion of missing females and that sex-selective abortion undoubtedly accounts for the overwhelming majority [18].Open in a separate windowFigure 1Sex ratio at birth for China''s provinces in 2005.There are marked regional differences in SRB in India. Because incomplete birth registrations make the SRB difficult to calculate accurately, the closely related ratio of boys to girls under the age of six is used, showing distinct regional differences across the country with much higher levels in the north and west. According to the most recent census in 2010, the SRB for the whole country was 109, a marginal increase on the previous census in 2001, which showed an SRB of 108. These national figures, however, hide wide differences from a low SRB of 98 in the state of Kerala to 119 in Haryana State. The highest SRBs at district level for the whole of India are in two districts of Haryana state, where the SRBs are both 129 [21]. The Indian figures contrast with the Chinese in two ways: nowhere in China is the sex ratio low, and in India the sex ratio is higher in rural than urban areas, whereas the reverse is true for China [22].A consistent pattern in all three countries is a clear trend across birth order, that is first, second and subsequent children, and the sex of the preceding child. This is driven by the persistence of the ‘at least one boy'' imperative in these cultures. Where high fertility is the norm, couples will continue to reproduce until they have a boy. Where couples aim to restrict their family size, they might be content if the first child is a girl, but will often use sex selection to ensure a boy in the second pregnancy. This was shown in a large Indian study: the SRB was 132 for second births with a preceding girl, and 139 for third births with two previous girls. By contrast, the sex ratios were normal when the first born was a boy [23].The sex ratio by birth order is particularly interesting in China (18].Table 1
Sex ratio at birth for China''s provinces in 2005.| Total | First order | Second order | Third order | |
|---|---|---|---|---|
| Total | 120 | 108 | 143 | 157 |
| Urban | 115 | 110 | 138 | 146 |
| Rural | 123 | 107 | 146 | 157 |
2.
Background:Very little research has described risk of suicidal ideation and suicide attempt among transgender youth using high-quality, nationally representative data. We aimed to assess risk of suicidality among transgender and sexual minority adolescents in Canada.Methods:We analyzed a subsample of adolescents aged 15–17 years from the 2019 Canadian Health Survey on Children and Youth, a nationally representative, cross-sectional survey. We defined participants’ transgender identity (self-reported gender different from sex assigned at birth) and sexual minority status (self-reported attraction to people of the same gender) as exposures, and their self-reported previous-year suicidal ideation and lifetime suicide attempt as outcomes.Results:We included 6800 adolescents aged 15–17 years, including 1130 (16.5%) who indicated some degree of same-gender attraction, 265 (4.3%) who were unsure of their attraction and 50 (0.6%) who reported a transgender identity. Compared with cisgender, heterosexual adolescents, transgender adolescents showed 5 times the risk of suicidal ideation (95% confidence interval [CI] 3.63 to 6.75; 58% v. 10%) and 7.6 times the risk of suicide attempt (95% CI 4.76 to 12.10; 40% v. 5%). Among cisgender adolescents, girls attracted to girls had 3.6 times the risk of previous-year suicidal ideation (95% CI 2.59 to 5.08) and 3.3 times the risk of having ever attempted suicide (95% CI 1.81 to 6.06), compared with their heterosexual peers. Adolescents attracted to multiple genders had 2.5 times the risk of suicidal ideation (95% CI 2.12 to 2.98) and 2.8 times the risk of suicide attempt (95% CI 2.18 to 3.68). Youth questioning their sexual orientation had twice the risk of having attempted suicide in their lifetime (95% CI 1.23 to 3.36).Interpretation:We observed that transgender and sexual minority adolescents were at increased risk of suicidal ideation and attempt compared with their cisgender and heterosexual peers. These findings highlight the need for inclusive prevention approaches to address suicidality among Canada’s diverse youth population.Suicide is the second leading cause of death among adolescents and young adults aged 15–24 years in Canada.1,2 Suicidal ideation and suicide attempt are common among adolescents3 and are risk factors for death by suicide.4 Sexual minority youth (i.e., youth who are attracted to the same gender or multiple genders, or who identify as lesbian, gay, bisexual or queer)5 are known to be at increased risk of poor mental health,6–8 including suicidal ideation and attempt.5–10 Over the previous 2 decades, stigma around identifying as a sexual minority has reduced;7 however, the risk of poor mental health and of suicidality remains high among sexual minority youth.7,11 This population is still more likely to experience bullying and peer victimization,9,12,13 which is associated with suicidality among sexual minority adolescents.5Transgender youth are those whose gender identity does not match their sex assigned at birth.14 Among other terms, gender-nonconforming, nonbinary, genderqueer and genderfluid are used to describe the gender identity of a subset of young people who identify outside the gender binary (i.e., as neither male nor female) or who experience fluidity between genders.9 Suicidality among transgender and gender-nonconforming adolescents is not as well studied. In a Canadian survey of transgender and gender-nonconforming youth aged 14–25 years, 64% of participants reported that they had seriously considered suicide in the previous 12 months.15 Transgender and gender-nonconforming youth seem to have a higher probability of many risk factors for suicidality, including peer victimization,8,16 family dysfunction7,17 and barriers to accessing mental health care.18 However, the epidemiology of suicidality among transgender and gender-nonconforming youth remains understudied in population-based samples; most research on the mental health of transgender youth comes from small community samples of help-seeking youth or targeted surveys of transgender adolescents.5,19,20 Two population-based studies from California21 and New Zealand22 suggested that transgender youth are at increased risk of suicidal ideation and suicide attempt. However, only the New Zealand study22 used the gold-standard measure of gender identity, contrasting adolescents’ sex assigned at birth with their self-identified gender.23Further epidemiological research employing large, representative samples and adequate measures of gender identity is needed to understand the burden of suicidality among lesbian, gay, bisexual, transgender and queer youth. We sought to build on existing evidence to assess risk of suicidal ideation and attempt among transgender and sexual minority adolescents in Canada, as compared with their cisgender and heterosexual peers, as well as to explore the relation between suicidality and experience of bullying. 相似文献
3.
Geoffrey Miller 《EMBO reports》2012,13(10):880-884
Runaway consumerism imposes social and ecological costs on humans in much the same way that runaway sexual ornamentation imposes survival costs and extinction risks on other animals.Sex and marketing have been coupled for a very long time. At the cultural level, their relationship has been appreciated since the 1960s ‘Mad Men'' era, when the sexual revolution coincided with the golden age of advertising, and marketers realized that ‘sex sells''. At the biological level, their interplay goes much further back to the Cambrian explosion around 530 million years ago. During this period of rapid evolutionary expansion, multicellular organisms began to evolve elaborate sexual ornaments to advertise their genetic quality to the most important consumers of all in the great mating market of life: the opposite sex.Maintaining the genetic quality of one''s offspring had already been a problem for billions of years. Ever since life originated around 3.7 billion years ago, RNA and DNA have been under selection to copy themselves as accurately as possible [1]. Yet perfect self-replication is biochemically impossible, and almost all replication errors are harmful rather than helpful [2]. Thus, mutations have been eroding the genomic stability of single-celled organisms for trillions of generations, and countless lineages of asexual organisms have suffered extinction through mutational meltdown—the runaway accumulation of copying errors [3]. Only through wildly profligate self-cloning could such organisms have any hope of leaving at least a few offspring with no new harmful mutations, so they could best survive and reproduce.Around 1.5 billion years ago, bacteria evolved the most basic form of sex to minimize mutation load: bacterial conjugation [4]. By swapping bits of DNA across the pilus (a tiny intercellular bridge) a bacterium can replace DNA sequences compromised by copying errors with intact sequences from its peers. Bacteria finally had some defence against mutational meltdown, and they thrived and diversified.Then, with the evolution of genuine sexual reproduction through meiosis, perhaps around 1.2 billion years ago, eukaryotes made a great advance in their ability to purge mutations. By combining their genes with a mate''s genes, they could produce progeny with huge genetic variety—and crucially with a wider range of mutation loads [5]. The unlucky offspring who happened to inherit an above-average number of harmful mutations from both parents would die young without reproducing, taking many mutations into oblivion with them. The lucky offspring who happened to inherit a below-average number of mutations from both parents would live long, prosper and produce offspring of higher genetic quality. Sexual recombination also made it easier to spread and combine the rare mutations that happened to be useful, opening the way for much faster evolutionary advances [6]. Sex became the foundation of almost all complex life because it was so good at both short-term damage limitation (purging bad mutations) and long-term innovation (spreading good mutations).Sex became the foundation of almost all complex life because it was so good at both short-term damage limitation […] and long-term innovation…Yet, single-celled organisms always had a problem with sex: they were not very good at choosing sexual partners with the best genes, that is, the lowest mutation loads. Given bacterial capabilities for chemical communication such as quorum-sensing [7], perhaps some prokaryotes and eukaryotes paid attention to short-range chemical cues of genetic quality before swapping genes. However, mating was mainly random before the evolution of longer-range senses and nervous systems.All of this changed profoundly with the Cambrian explosion, which saw organisms undergoing a genetic revolution that increased the complexity of gene regulatory networks, and a morphological revolution that increased the diversity of multicellular body plans. It was also a neurological and psychological revolution. As organisms became increasingly mobile, they evolved senses such as vision [8] and more complex nervous systems [9] to find food and evade predators. However, these new senses also empowered a sexual revolution, as they gave animals new tools for choosing sexual partners. Rather than hooking up randomly with the nearest mate, animals could now select mates based on visible cues of genetic quality such as body size, energy level, bright coloration and behavioural competence. By choosing the highest quality mates, they could produce higher quality offspring with lower mutation loads [10]. Such mate choice imposed selection on all of those quality cues to become larger, brighter and more conspicuous, amplifying them into true sexual ornaments: biological luxury goods such as the guppy''s tail and the peacock''s train that function mainly to impress and attract females [11]. These sexual ornaments evolved to have a complex genetic architecture, to capture a larger share of the genetic variation across individuals and to reveal mutation load more accurately [12].Ever since the Cambrian, the mating market for sexually reproducing animal species has been transformed to some degree into a consumerist fantasy world of conspicuous quality, status, fashion, beauty and romance. Individuals advertise their genetic quality and phenotypic condition through reliable, hard-to-fake signals or ‘fitness indicators'' such as pheromones, songs, ornaments and foreplay. Mates are chosen on the basis of who displays the largest, costliest, most precise, most popular and most salient fitness indicators. Mate choice for fitness indicators is not restricted to females choosing males, but often occurs in both sexes [13], especially in socially monogamous species with mutual mate choice such as humans [14].Thus, for 500 million years, animals have had to straddle two worlds in perpetual tension: natural selection and sexual selection. Each type of selection works through different evolutionary principles and dynamics, and each yields different types of adaptation and biodiversity. Neither fully dominates the other, because sexual attractiveness without survival is a short-lived vanity, whereas ecological competence without reproduction is a long-lived sterility. Natural selection shapes species to fit their geographical habitats and ecological niches, and favours efficiency in growth, foraging, parasite resistance, predator evasion and social competition. Sexual selection shapes each sex to fit the needs, desires and whims of the other sex, and favours conspicuous extravagance in all sorts of fitness indicators. Animal life walks a fine line between efficiency and opulence. More than 130,000 plant species also play the sexual ornamentation game, having evolved flowers to attract pollinators [15].The sexual selection world challenges the popular misconception that evolution is blind and dumb. In fact, as Darwin emphasized, sexual selection is often perceptive and clever, because animal senses and brains mediate mate choice. This makes sexual selection closer in spirit to artificial selection, which is governed by the senses and brains of human breeders. In so far as sexual selection shaped human bodies, minds and morals, we were also shaped by intelligent designers—who just happened to be romantic hominids rather than fictional gods [16].Thus, mate choice for genetic quality is analogous in many ways to consumer choice for brand quality [17]. Mate choice and consumer choice are both semi-conscious—partly instinctive, partly learned through trial and error and partly influenced by observing the choices made by others. Both are partly focused on the objective qualities and useful features of the available options, and partly focused on their arbitrary, aesthetic and fashionable aspects. Both create the demand that suppliers try to understand and fulfil, with each sex striving to learn the mating preferences of the other, and marketers striving to understand consumer preferences through surveys, focus groups and social media data mining.…single-celled organisms always had a problem with sex: they were not very good at choosing the sexual partners with the best genes…Mate choice and consumer choice can both yield absurdly wasteful outcomes: a huge diversity of useless, superficial variations in the biodiversity of species and the economic diversity of brands, products and packaging. Most biodiversity seems to be driven by sexual selection favouring whimsical differences across populations in the arbitrary details of fitness indicators, not just by naturally selected adaptation to different ecological niches [18]. The result is that within each genus, a species can be most easily identified by its distinct mating calls, sexual ornaments, courtship behaviours and genital morphologies [19], not by different foraging tactics or anti-predator defences. Similarly, much of the diversity in consumer products—such as shirts, cars, colleges or mutual funds—is at the level of arbitrary design details, branding, packaging and advertising, not at the level of objective product features and functionality.These analogies between sex and marketing run deep, because both depend on reliable signals of quality. Until recently, two traditions of signalling theory developed independently in the biological and social sciences. The first landmark in biological signalling theory was Charles Darwin''s analysis of mate choice for sexual ornaments as cues of good fitness and fertility in his book, The Descent of Man, and Selection in Relation to Sex (1871). Ronald Fisher analysed the evolution of mate preferences for fitness indicators in 1915 [20]. Amotz Zahavi proposed the ‘handicap principle'', arguing that only costly signals could be reliable, hard-to-fake indicators of genetic quality or phenotypic condition in 1975 [21]. Richard Dawkins and John Krebs applied game theory to analyse the reliability of animal signals, and the co-evolution of signallers and receivers in 1978 [22]. In 1990, Alan Grafen eventually proposed a formal model of the ‘handicap principle'' [23], and Richard Michod and Oren Hasson analysed ‘reliable indicators of fitness'' [24]. Since then, biological signalling theory has flourished and has informed research on sexual selection, animal communication and social behaviour.…new senses also empowered a sexual revolution […] Rather than hooking up randomly with the nearest mate, animals could now select mates based on visible cues of genetic quality…The parallel tradition of signalling theory in the social sciences and philosophy goes back to Aristotle, who argued that ethical and rational acts are reliable signals of underlying moral and cognitive virtues (ca 350–322 BC). Friedrich Nietzsche analysed beauty, creativity, morality and even cognition as expressions of biological vigour by using signalling logic (1872–1888). Thorstein Veblen proposed that conspicuous luxuries, quality workmanship and educational credentials act as reliable signals of wealth, effort and taste in The Theory of the Leisure Class (1899), The Instinct of Workmanship (1914) and The Higher Learning in America (1922). Vance Packard used signalling logic to analyse social class, runaway consumerism and corporate careerism in The Status Seekers (1959), The Waste Makers (1960) and The Pyramid Climbers (1962), and Ernst Gombrich analysed beauty in art as a reliable signal of the artist''s skill and effort in Art and Illusion (1977) and A Sense of Order (1979). Michael Spence developed formal models of educational credentials as reliable signals of capability and conscientiousness in Market Signalling (1974). Robert Frank used signalling logic to analyse job titles, emotions, career ambitions and consumer luxuries in Choosing the Right Pond (1985), Passions within Reason (1988), The Winner-Take-All-Society (1995) and Luxury Fever (2000).Evolutionary psychology and evolutionary anthropology have been integrating these two traditions to better understand many puzzles in human evolution that defy explanation in terms of natural selection for survival. For example, signalling theory has illuminated the origins and functions of facial beauty, female breasts and buttocks, body ornamentation, clothing, big game hunting, hand-axes, art, music, humour, poetry, story-telling, courtship gifts, charity, moral virtues, leadership, status-seeking, risk-taking, sports, religion, political ideologies, personality traits, adaptive self-deception and consumer behaviour [16,17,25,26,27,28,29].Building on signalling theory and sexual selection theory, the new science of evolutionary consumer psychology [30] has been making big advances in understanding consumer goods as reliable signals—not just signals of monetary wealth and elite taste, but signals of deeper traits such as intelligence, moral virtues, mating strategies and the ‘Big Five'' personality traits: openness, conscientiousness, agreeableness, extraversion and emotional stability [17]. These individual traits are deeper than wealth and taste in several ways: they are found in the other great apes, are heritable across generations, are stable across life, are important in all cultures and are naturally salient when interacting with mates, friends and kin [17,27,31]. For example, consumers seek elite university degrees as signals of intelligence; they buy organic fair-trade foods as signals of agreeableness; and they value foreign travel and avant-garde culture as signals of openness [17]. New molecular genetics research suggests that mutation load accounts for much of the heritable variation in human intelligence [32] and personality [33], so consumerist signals of these traits might be revealing genetic quality indirectly. If so, conspicuous consumption can be seen as just another ‘good-genes indicator'' favoured by mate choice.…sexual attractiveness without survival is a short-lived vanity, whereas ecological competence without reproduction is a long-lived sterilityIndeed, studies suggest that much conspicuous consumption, especially by young single people, functions as some form of mating effort. After men and women think about potential dates with attractive mates, men say they would spend more money on conspicuous luxury goods such as prestige watches, whereas women say they would spend more time doing conspicuous charity activities such as volunteering at a children''s hospital [34]. Conspicuous consumption by males reveals that they are pursuing a short-term mating strategy [35], and this activity is most attractive to women at peak fertility near ovulation [36]. Men give much higher tips to lap dancers who are ovulating [37]. Ovulating women choose sexier and more revealing clothes, shoes and fashion accessories [38]. Men living in towns with a scarcity of women compete harder to acquire luxuries and accumulate more consumer debt [39]. Romantic gift-giving is an important tactic in human courtship and mate retention, especially for men who might be signalling commitment [40]. Green consumerism—preferring eco-friendly products—is an effective form of conspicuous conservation, signalling both status and altruism [41].Findings such as these challenge traditional assumptions in economics. For example, ever since the Marginal Revolution—the development of economic theory during the 1870s—mainstream economics has made the ‘Rational Man'' assumption that consumers maximize their expected utility from their product choices, without reference to what other consumers are doing or desiring. This assumption was convenient both analytically—as it allowed easier mathematical modelling of markets and price equilibria—and ideologically in legitimizing free markets and luxury goods. However, new research from evolutionary consumer psychology and behavioural economics shows that consumers often desire ‘positional goods'' such as prestige-branded luxuries that signal social position and status through their relative cost, exclusivity and rarity. Positional goods create ‘positional externalities''—the harmful social side-effects of runaway status-seeking and consumption arms races [42].…biodiversity seems driven by sexual selection favouring whimsical differences […] Similarly […] diversity in consumer products […] is at the level of arbitrary design…These positional externalities are important because they undermine the most important theoretical justification for free markets—the first fundamental theorem of welfare economics, a formalization of Adam Smith''s ‘invisible hand'' argument, which says that competitive markets always lead to efficient distributions of resources. In the 1930s, the British Marxist biologists Julian Huxley and J.B.S. Haldane were already wary of such rationales for capitalism, and understood that runaway consumerism imposes social and ecological costs on humans in much the same way that runaway sexual ornamentation imposes survival costs and extinction risks on other animals [16]. Evidence shows that consumerist status-seeking leads to economic inefficiencies and costs to human welfare [42]. Runaway consumerism might be one predictable result of a human nature shaped by sexual selection, but we can display desirable traits in many other ways, such as green consumerism, conspicuous charity, ethical investment and through social media such as Facebook [17,43].Future work in evolutionary consumer psychology should give further insights into the links between sex, mutations, evolution and marketing. These links have been important for at least 500 million years and probably sparked the evolution of human intelligence, language, creativity, beauty, morality and ideology. A better understanding of these links could help us nudge global consumerist capitalism into a more sustainable form that imposes lower costs on the biosphere and yields higher benefits for future generations.?
Open in a separate windowGeoffrey Miller 相似文献
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Elucidating the temporal order of silencing 总被引：1，自引：0，他引：1
Izaurralde E 《EMBO reports》2012,13(8):662-663
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The temptation to silence dissenters whose non-mainstream views negatively affect public policies is powerful. However, silencing dissent, no matter how scientifically unsound it might be, can cause the public to mistrust science in general.Dissent is crucial for the advancement of science. Disagreement is at the heart of peer review and is important for uncovering unjustified assumptions, flawed methodologies and problematic reasoning. Enabling and encouraging dissent also helps to generate alternative hypotheses, models and explanations. Yet, despite the importance of dissent in science, there is growing concern that dissenting voices have a negative effect on the public perception of science, on policy-making and public health. In some cases, dissenting views are deliberately used to derail certain policies. For example, dissenting positions on climate change, environmental toxins or the hazards of tobacco smoke [1,2] seem to laypeople as equally valid conflicting opinions and thereby create or increase uncertainty. Critics often use legitimate scientific disagreements about narrow claims to reinforce the impression of uncertainty about general and widely accepted truths; for instance, that a given substance is harmful [3,4]. This impression of uncertainty about the evidence is then used to question particular policies [1,2,5,6].The negative effects of dissent on establishing public polices are present in cases in which the disagreements are scientifically well-grounded, but the significance of the dissent is misunderstood or blown out of proportion. A study showing that many factors affect the size of reef islands, to the effect that they will not necessarily be reduced in size as sea levels rise [7], was simplistically interpreted by the media as evidence that climate change will not have a negative impact on reef islands [8].In other instances, dissenting voices affect the public perception of and motivation to follow public-health policies or recommendations. For example, the publication of a now debunked link between the measles, mumps and rubella vaccine and autism [9], as well as the claim that the mercury preservative thimerosal, which was used in childhood vaccines, was a possible risk factor for autism [10,11], created public doubts about the safety of vaccinating children. Although later studies showed no evidence for these claims, doubts led many parents to reject vaccinations for their children, risking the herd immunity for diseases that had been largely eradicated from the industrialized world [12,13,14,15]. Many scientists have therefore come to regard dissent as problematic if it has the potential to affect public behaviour and policy-making. However, we argue that such concerns about dissent as an obstacle to public policy are both dangerous and misguided.Whether dissent is based on genuine scientific evidence or is unfounded, interested parties can use it to sow doubt, thwart public policies, promote problematic alternatives and lead the public to ignore sound advice. In response, scientists have adopted several strategies to limit these negative effects of dissent—masking dissent, silencing dissent and discrediting dissenters. The first strategy aims to present a united front to the public. Scientists mask existing disagreements among themselves by presenting only those claims or pieces of evidence about which they agree [16]. Although there is nearly universal agreement among scientists that average global temperatures are increasing, there are also legitimate disagreements about how much warming will occur, how quickly it will occur and the impact it might have [7,17,18,19]. As presenting these disagreements to the public probably creates more doubt and uncertainty than is warranted, scientists react by presenting only general claims [20].A second strategy is to silence dissenting views that might have negative consequences. This can take the form of self-censorship when scientists are reluctant to publish or publicly discuss research that might—incorrectly—be used to question existing scientific knowledge. For example, there are genuine disagreements about how best to model cloud formation, water vapour feedback and aerosols in general circulation paradigms, all of which have significant effects on the magnitude of global climate change predictions [17,19]. Yet, some scientists are hesitant to make these disagreements public, for fear that they will be accused of being denialists, faulted for confusing the public and policy-makers, censured for abating climate-change deniers, or criticized for undermining public policy [21,22,23,24].…there is growing concern that dissenting voices can have a negative effect on the public perception of science, on policy-making and public healthAnother strategy is to discredit dissenters, especially in cases in which the dissent seems to be ideologically motivated. This could involve publicizing the financial or political ties of the dissenters [2,6,25], which would call attention to their probable bias. In other cases, scientists might discredit the expertise of the dissenter. One such example concerns a 2007 study published in the Proceedings of the National Academy of Sciences USA, which claimed that cadis fly larvae consuming Bt maize pollen die at twice the rate of flies feeding on non-Bt maize pollen [26]. Immediately after publication, both the authors and the study itself became the target of relentless and sometimes scathing attacks from a group of scientists who were concerned that anti-GMO (genetically modified organism) interest groups would seize on the study to advance their agenda [27]. The article was criticized for its methodology and its conclusions, the Proceedings of the National Academy of Sciences USA was criticized for publishing the article and the US National Science Foundation was criticized for funding the study in the first place.Public policies, health advice and regulatory decisions should be based on the best available evidence and knowledge. As the public often lack the expertise to assess the quality of dissenting views, disagreements have the potential to cast doubt over the reliability of scientific knowledge and lead the public to question relevant policies. Strategies to block dissent therefore seem reasonable as a means to protect much needed or effective health policies, advice and regulations. However, even if the public were unable to evaluate the science appropriately, targeting dissent is not the most appropriate strategy to prevent negative side effects for several reasons. Chiefly, it contributes to the problems that the critics of dissent seek to address, namely increasing the cacophony of dissenting voices that only aim to create doubt. Focusing on dissent as a problematic activity sends the message to policy-makers and the public that any dissent undermines scientific knowledge. Reinforcing this false assumption further incentivizes those who seek merely to create doubt to thwart particular policies. Not surprisingly, think-tanks, industry and other organizations are willing to manufacture dissent simply to derail policies that they find economically or ideologically undesirable.Another danger of targeting dissent is that it probably stifles legitimate crucial voices that are needed for both advancing science and informing sound policy decisions. Attacking dissent makes scientists reluctant to voice genuine doubts, especially if they believe that doing so might harm their reputations, damage their careers and undermine prevailing theories or policies needed. For instance, a panel of scientists for the US National Academy of Sciences, when presenting a risk assessment of radiation in 1956, omitted wildly different predictions about the potential genetic harm of radiation [16]. They did not include this wide range of predictions in their final report precisely because they thought the differences would undermine confidence in their recommendations. Yet, this information could have been relevant to policy-makers. As such, targeting dissent as an obstacle to public policy might simply reinforce self-censorship and stifle legitimate and scientifically informed debate. If this happens, scientific progress is hindered.Second, even if the public has mistaken beliefs about science or the state of the knowledge of the science in question, focusing on dissent is not an effective way to protect public policy from false claims. It fails to address the presumed cause of the problem—the apparent lack of understanding of the science by the public. A better alternative would be to promote the public''s scientific literacy. If the public were educated to better assess the quality of the dissent and thus disregard instances of ideological, unsupported or unsound dissent, dissenting voices would not have such a negative effect. Of course, one might argue that educating the public would be costly and difficult, and that therefore, the public should simply listen to scientists about which dissent to ignore and which to consider. This is, however, a paternalistic attitude that requires the public to remain ignorant ‘for their own good''; a position that seems unjustified on many levels as there are better alternatives for addressing the problem.Moreover, silencing dissent, rather than promoting scientific literacy, risks undermining public trust in science even if the dissent is invalid. This was exemplified by the 2009 case of hacked e-mails from a computer server at the University of East Anglia''s Climate Research Unit (CRU). After the selective leaking of the e-mails, climate scientists at the CRU came under fire because some of the quotes, which were taken out of context, seemed to suggest that they were fudging data or suppressing dissenting views [28,29,30,31]. The stolen e-mails gave further ammunition to those opposing policies to reduce greenhouse emissions as they could use accusations of data ‘cover up'' as proof that climate scientists were not being honest with the public [29,30,31]. It also allowed critics to present climate scientists as conspirators who were trying to push a political agenda [32]. As a result, although there was nothing scientifically inappropriate revealed in the ‘climategate'' e-mails, it had the consequence of undermining the public''s trust in climate science [33,34,35,36].A significant amount of evidence shows that the ‘deficit model'' of public understanding of science, as described above, is too simplistic to account correctly for the public''s reluctance to accept particular policy decisions [37,38,39,40]. It ignores other important factors such as people''s attitudes towards science and technology, their social, political and ethical values, their past experiences and the public''s trust in governmental institutions [41,42,43,44]. The development of sound public policy depends not only on good science, but also on value judgements. One can agree with the scientific evidence for the safety of GMOs, for instance, but still disagree with the widespread use of GMOs because of social justice concerns about the developing world''s dependence on the interests of the global market. Similarly, one need not reject the scientific evidence about the harmful health effects of sugar to reject regulations on sugary drinks. One could rationally challenge such regulations on the grounds that informed citizens ought to be able to make free decisions about what they consume. Whether or not these value judgements are justified is an open question, but the focus on dissent hinders our ability to have that debate.Focusing on dissent as a problematic activity sends the message to policy-makers and the public that any dissent undermines scientific knowledgeAs such, targeting dissent completely fails to address the real issues. The focus on dissent, and the threat that it seems to pose to public policy, misdiagnoses the problem as one of the public misunderstanding science, its quality and its authority. It assumes that scientific or technological knowledge is the only relevant factor in the development of policy and it ignores the role of other factors, such as value judgements about social benefits and harms, and institutional trust and reliability [45,46]. The emphasis on dissent, and thus on scientific knowledge, as the only or main factor in public policy decisions does not give due attention to these legitimate considerations.Furthermore, by misdiagnosing the problem, targeting dissent also impedes more effective solutions and prevents an informed debate about the values that should guide public policy. By framing policy debates solely as debates over scientific facts, the normative aspects of public policy are hidden and neglected. Relevant ethical, social and political values fail to be publicly acknowledged and openly discussed.Controversies over GMOs and climate policies have called attention to the negative effects of dissent in the scientific community. Based on the assumption that the public''s reluctance to support particular policies is the result of their inability to properly understand scientific evidence, scientists have tried to limit dissenting views that create doubt. However, as outlined above, targeting dissent as an obstacle to public policy probably does more harm than good. It fails to focus on the real problem at stake—that science is not the only relevant factor in sound policy-making. Of course, we do not deny that scientific evidence is important to the develop.ment of public policy and behavioural decisions. Rather, our claim is that this role is misunderstood and often oversimplified in ways that actually contribute to problems in developing sound science-based policies.?
Open in a separate windowInmaculada de Melo-MartínOpen in a separate windowKristen Intemann 相似文献
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Ian Williamson Jane Vennik Anthony Harnden Merryn Voysey Rafael Perera Sadie Kelly Guiqing Yao James Raftery David Mant Paul Little 《CMAJ》2015,187(13):961-969
Background:Otitis media with effusion is a common problem that lacks an evidence-based nonsurgical treatment option. We assessed the clinical effectiveness of treatment with a nasal balloon device in a primary care setting.Methods:We conducted an open, pragmatic randomized controlled trial set in 43 family practices in the United Kingdom. Children aged 4–11 years with a recent history of ear symptoms and otitis media with effusion in 1 or both ears, confirmed by tympanometry, were allocated to receive either autoinflation 3 times daily for 1–3 months plus usual care or usual care alone. Clearance of middle-ear fluid at 1 and 3 months was assessed by experts masked to allocation.Results:Of 320 children enrolled, those receiving autoinflation were more likely than controls to have normal tympanograms at 1 month (47.3% [62/131] v. 35.6% [47/132]; adjusted relative risk [RR] 1.36, 95% confidence interval [CI] 0.99 to 1.88) and at 3 months (49.6% [62/125] v. 38.3% [46/120]; adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). Autoinflation produced greater improvements in ear-related quality of life (adjusted between-group difference in change from baseline in OMQ-14 [an ear-related measure of quality of life] score −0.42, 95% CI −0.63 to −0.22). Compliance was 89% at 1 month and 80% at 3 months. Adverse events were mild, infrequent and comparable between groups.Interpretation:Autoinflation in children aged 4–11 years with otitis media with effusion is feasible in primary care and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life. Trial registration: ISRCTN, No. 55208702.Otitis media with effusion, also known as glue ear, is an accumulation of fluid in the middle ear, without symptoms or signs of an acute ear infection. It is often associated with viral infection.1–3 The prevalence rises to 46% in children aged 4–5 years,4 when hearing difficulty, other ear-related symptoms and broader developmental concerns often bring the condition to medical attention.3,5,6 Middle-ear fluid is associated with conductive hearing losses of about 15–45 dB HL.7 Resolution is clinically unpredictable,8–10 with about a third of cases showing recurrence.11 In the United Kingdom, about 200 000 children with the condition are seen annually in primary care.12,13 Research suggests some children seen in primary care are as badly affected as those seen in hospital.7,9,14,15 In the United States, there were 2.2 million diagnosed episodes in 2004, costing an estimated $4.0 billion.16 Rates of ventilation tube surgery show variability between countries,17–19 with a declining trend in the UK.20Initial clinical management consists of reasonable temporizing or delay before considering surgery.13 Unfortunately, all available medical treatments for otitis media with effusion such as antibiotics, antihistamines, decongestants and intranasal steroids are ineffective and have unwanted effects, and therefore cannot be recommended.21–23 Not only are antibiotics ineffective, but resistance to them poses a major threat to public health.24,25 Although surgery is effective for a carefully selected minority,13,26,27 a simple low-cost, nonsurgical treatment option could benefit a much larger group of symptomatic children, with the purpose of addressing legitimate clinical concerns without incurring excessive delays.Autoinflation using a nasal balloon device is a low-cost intervention with the potential to be used more widely in primary care, but current evidence of its effectiveness is limited to several small hospital-based trials28 that found a higher rate of tympanometric resolution of ear fluid at 1 month.29–31 Evidence of feasibility and effectiveness of autoinflation to inform wider clinical use is lacking.13,28 Thus we report here the findings of a large pragmatic trial of the clinical effectiveness of nasal balloon autoinflation in a spectrum of children with clinically confirmed otitis media with effusion identified from primary care. 相似文献
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Gilaad G. Kaplan Elijah Dixon Remo Panaccione Andrew Fong Li Chen Mieczyslaw Szyszkowicz Amanda Wheeler Anthony MacLean W. Donald Buie Terry Leung Steven J. Heitman Paul J. Villeneuve 《CMAJ》2009,181(9):591-597
Background
The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis.Methods
We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 μ and less than 2.5 μ in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season.Results
An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03–1.25). In summer (July–August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10–1.57), sulfur dioxide (OR 1.30, 95% CI 1.03–1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20–2.58), carbon monoxide (OR 1.35, 95% CI 1.01–1.80) and particulate matter less than 10 μ in diameter (OR 1.20, 95% CI 1.05–1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21–3.47, among men and 1.48, 95% CI 0.85–2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01–1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97–2.24).Interpretation
Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis.Appendicitis was introduced into the medical vernacular in 1886.1 Since then, the prevailing theory of its pathogenesis implicated an obstruction of the appendiceal orifice by a fecalith or lymphoid hyperplasia.2 However, this notion does not completely account for variations in incidence observed by age,3,4 sex,3,4 ethnic background,3,4 family history,5 temporal–spatial clustering6 and seasonality,3,4 nor does it completely explain the trends in incidence of appendicitis in developed and developing nations.3,7,8The incidence of appendicitis increased dramatically in industrialized nations in the 19th century and in the early part of the 20th century.1 Without explanation, it decreased in the middle and latter part of the 20th century.3 The decrease coincided with legislation to improve air quality. For example, after the United States Clean Air Act was passed in 1970,9 the incidence of appendicitis decreased by 14.6% from 1970 to 1984.3 Likewise, a 36% drop in incidence was reported in the United Kingdom between 1975 and 199410 after legislation was passed in 1956 and 1968 to improve air quality and in the 1970s to control industrial sources of air pollution. Furthermore, appendicitis is less common in developing nations; however, as these countries become more industrialized, the incidence of appendicitis has been increasing.7Air pollution is known to be a risk factor for multiple conditions, to exacerbate disease states and to increase all-cause mortality.11 It has a direct effect on pulmonary diseases such as asthma11 and on nonpulmonary diseases including myocardial infarction, stroke and cancer.11–13 Inflammation induced by exposure to air pollution contributes to some adverse health effects.14–17 Similar to the effects of air pollution, a proinflammatory response has been associated with appendicitis.18–20We conducted a case–crossover study involving a population-based cohort of patients admitted to hospital with appendicitis to determine whether short-term increases in concentrations of selected air pollutants were associated with hospital admission because of appendicitis. 相似文献10.
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Meredith Vanstone Shipra Taneja Anuoluwa Popoola Janelle Panday Devon Greyson Robin Lennox Sarah D. McDonald 《CMAJ》2021,193(50):E1906
Background:Cannabis use among pregnant and lactating people is increasing, despite clinical evidence showing that cannabis use may be associated with low birth weight and childhood developmental deficits. Our objective was to understand why pregnant and lactating people use cannabis and how these motivations change across perinatal stages.Methods:Using qualitative, constructivist grounded theory methodology, we conducted telephone and virtual interviews with 52 individuals from across Canada. We selected participants using maximum variation and theoretical sampling. They were eligible if they had been pregnant or lactating within the past year and had decided to continue, cease or decrease their cannabis use during the perinatal period.Results:We identified 3 categories of reasons that people use cannabis during pregnancy and lactation: sensation-seeking for fun and enjoyment; symptom management of chronic conditions and conditions related to pregnancy; and coping with the unpleasant, but nonpathologized, experiences of life. Before pregnancy, participants endorsed reasons for using cannabis in these 3 categories in similar proportions, with many offering multiple reasons for use. During pregnancy, reasons for use shifted primarily to symptom management. During lactation, reasons returned to resemble those expressed before pregnancy.Interpretation:In this study, we showed that pregnant and lactating people use cannabis for many reasons, particularly for symptom management. Reasons for cannabis use changed across reproductive stages. The dynamic nature of the reasons for use across stages speaks to participant perception of benefits and risks, and perhaps a desire to cast cannabis use during pregnancy as therapeutic because of perceived stigma.Cannabis use by pregnant and lactating people is increasing, though it is difficult to establish the prevalence of cannabis use in pregnancy. Reported prevalence varies from 2% to 36%, depending on the methodology used to detect use, the population studied and the definition of use.1–12 Pregnant people have reported using cannabis to manage pregnancy-related conditions (e.g., nausea, weight gain, sleep difficulty)13–19 and pre-existing conditions (e.g., mental health, insomnia, chronic pain),13,14,18 as well as to improve mood, mental, physical and spiritual well-being,16,18 provide pleasure and manage stress.13–16 Recent systematic reviews have not found empirical data on reasons for cannabis use during lactation.20,21Evidence is still emerging about clinical outcomes related to cannabis use during pregnancy and lactation, and well-controlled studies are lacking.22–24 The available evidence is limited by reliance on self-reported data about dose, composition and timing of exposure, the changing nature of tetrahydrocannabinol levels in cannabis over time, and a lack of studies that control for known confounders such as polysubstance and tobacco use.25–31 The available evidence does suggest that cannabis use during pregnancy may be associated with complications such as low birth weight, childhood neurodevelopmental outcomes and preterm birth.22–24,32,33 Very few studies have analyzed the outcomes associated with cannabis exposure through breastmilk, with 1 study suggesting decreased infant motor development and another showing no effects on developmental outcomes.34–36 Given the potential harms identified, and in the absence of high-quality evidence available to guide practice, most clinical guidelines recommend abstinence from cannabis during pregnancy and lactation.37–39People who perceive benefits from cannabis may wish to or may be motivated to continue using it through pregnancy and lactation, however. Counselling that explores the reasons patients are considering cannabis use and suggests related alternatives or harm reduction strategies has been identified as a helpful strategy to minimize potential harm.13,40,41,42 Such an approach requires that clinicians understand the motivations to use cannabis before pregnancy, during pregnancy and during lactation. We sought to explore why people use cannabis during pregnancy and lactation. 相似文献
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Cari L. Miller Margo E. Pearce Akm Moniruzzaman Vicky Thomas Chief Wayne Christian Martin T. Schechter Patricia M. Spittal 《CMAJ》2011,183(10):1147-1154
Background:
Studies suggest that Aboriginal people in Canada are over-represented among people using injection drugs. The factors associated with transitioning to the use of injection drugs among young Aboriginal people in Canada are not well understood.Methods:
The Cedar Project is a prospective cohort study (2003–2007) involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. Participants’ venous blood samples were tested for antibodies to HIV and the hepatitis C virus, and drug use was confirmed using saliva screens. The primary outcomes were use of injection drugs at baseline and tranisition to injection drug use in the six months before each follow-up interview.Results:
Of 605 participants, 335 (55.4%) reported using injection drugs at baseline. Young people who used injection drugs tended to be older than those who did not, female and in a relationship. Participants who injected drugs were also more likely than those who did not to have been denied shelter because of their drug use, to have been incarcerated, to have a mental illness and to have been involved in sex work. Transition to injection drug use occurred among 39 (14.4%) participants, yielding a crude incidence rate of 19.8% and an incidence density of 11.5 participants per 100 person-years. In unadjusted analysis, transition to injection drug use was associated with being female (odds ratio [OR] 1.98, 95% confidence interval (CI) 1.06–3.72), involved in sex work (OR 3.35, 95% CI 1.75–6.40), having a history of sexually transmitted infection (OR 2.01, 95% CI 1.07–3.78) and using drugs with sex-work clients (OR 2.51, 95% CI 1.19–5.32). In adjusted analysis, transition to injection drug use remained associated with involvement in sex work (adjusted OR 3.94, 95% CI 1.45–10.71).Interpretation:
The initiation rate for injection drug use of 11.5 participants per 100 person-years among participants in the Cedar Project is distressing. Young Aboriginal women in our study were twice as likely to inject drugs as men, and participants who injected drugs at baseline were more than twice as likely as those who did not to be involved in sex work.Aboriginal leadership in Canada is deeply concerned about substance use, more specifically injection drug use and its association with the spread of HIV and the hepatitis C virus among Aboriginal young people.1,2 Recent studies in Canada suggest that Aboriginal people are over-represented among people who use injection drugs.3,4 For Aboriginal young people in Canada under the age of 24 years, injection drug use accounts for the majority of infections with the hepatitis C virus (70%–80%)5,6 and over half (59%) of HIV infections.7Indigenous scholars have stated that research on substance use within Aboriginal communities must consider the context of colonization, including the intergenerational impacts of the residential school and child welfare systems.8–11 It is now well documented that Aboriginal children experienced extensive psychological, sexual, physical and emotional abuses within those systems.12,13 As former students of residential schools raise children and grandchildren, the intergenerational effects of abuse and familial fragmentation are evident in communities where interpersonal violence and drug dependence are pervasive.14–16A priority for preventing infections with HIV and hepatitis C among young Aboriginal people is the development of programs and rights-based,18,19 youth-informed17 policies aimed at preventing the use of injection drugs. However, research to date has not provided sufficient evidence to inform such development.2,19 Concerns over this paucity of information led to the launch of a two-city cohort study in 2003 to address HIV-related vulnerabilities among young Aboriginal people in British Columbia — a unique study centred on at-risk youth and supported by and partnered with Aboriginal investigators and collaborators.We report here baseline and longitudinal data on the factors associated with injection drug use and the transition to injection drug use to inform the development of prevention programs and policies. 相似文献13.
Adam T. Hancock Christian D. Mallen Sara Muller John Belcher Edward Roddy Toby Helliwell Samantha L. Hider 《CMAJ》2014,186(13):E495-E501
Background:
Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events.Methods:
We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica.Results:
A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis.Interpretation:
Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.Inflammatory rheumatologic disorders such as rheumatoid arthritis,1,2 systemic lupus erythematosus,2,3 gout,4 psoriatic arthritis2,5 and ankylosing spondylitis2,6 are associated with an increased risk of vascular disease, especially cardiovascular disease, leading to substantial morbidity and premature death.2–6 Recognition of this excess vascular risk has led to management guidelines advocating screening for and management of vascular risk factors.7–9Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults,10 with a lifetime risk of 2.4% for women and 1.7% for men.11 To date, evidence regarding the risk of vascular disease in patients with polymyalgia rheumatica is unclear. There are a number of biologically plausible mechanisms between polymyalgia rheumatica and vascular disease. These include the inflammatory burden of the disease,12,13 the association of the disease with giant cell arteritis (causing an inflammatory vasculopathy, which may lead to subclinical arteritis, stenosis or aneurysms),14 and the adverse effects of long-term corticosteroid treatment (e.g., diabetes, hypertension and dyslipidemia).15,16 Paradoxically, however, use of corticosteroids in patients with polymyalgia rheumatica may actually decrease vascular risk by controlling inflammation.17 A recent systematic review concluded that although some evidence exists to support an association between vascular disease and polymyalgia rheumatica,18 the existing literature presents conflicting results, with some studies reporting an excess risk of vascular disease19,20 and vascular death,21,22 and others reporting no association.23–26 Most current studies are limited by poor methodologic quality and small samples, and are based on secondary care cohorts, who may have more severe disease, yet most patients with polymyalgia rheumatica receive treatment exclusively in primary care.27The General Practice Research Database (GPRD), based in the United Kingdom, is a large electronic system for primary care records. It has been used as a data source for previous studies,28 including studies on the association of inflammatory conditions with vascular disease29 and on the epidemiology of polymyalgia rheumatica in the UK.30 The aim of the current study was to examine the association between polymyalgia rheumatica and vascular disease in a primary care population. 相似文献14.
Fabian Sanchis-Gomar Carme Perez-Quilis Giuseppe Lippi 《Molecular medicine (Cambridge, Mass.)》2013,19(1):62-64
The erythropoietin receptor (EpoR) was discovered and described in red blood cells (RBCs), stimulating its proliferation and survival. The target in humans for EpoR agonists drugs appears clear—to treat anemia. However, there is evidence of the pleitropic actions of erythropoietin (Epo). For that reason, rhEpo therapy was suggested as a reliable approach for treating a broad range of pathologies, including heart and cardiovascular diseases, neurodegenerative disorders (Parkinson’s and Alzheimer’s disease), spinal cord injury, stroke, diabetic retinopathy and rare diseases (Friedreich ataxia). Unfortunately, the side effects of rhEpo are also evident. A new generation of nonhematopoietic EpoR agonists drugs (asialoEpo, Cepo and ARA 290) have been investigated and further developed. These EpoR agonists, without the erythropoietic activity of Epo, while preserving its tissue-protective properties, will provide better outcomes in ongoing clinical trials. Nonhematopoietic EpoR agonists represent safer and more effective surrogates for the treatment of several diseases such as brain and peripheral nerve injury, diabetic complications, renal ischemia, rare diseases, myocardial infarction, chronic heart disease and others.In principle, the erythropoietin receptor (EpoR) was discovered and described in red blood cell (RBC) progenitors, stimulating its proliferation and survival. Erythropoietin (Epo) is mainly synthesized in fetal liver and adult kidneys (1–3). Therefore, it was hypothesized that Epo act exclusively on erythroid progenitor cells. Accordingly, the target in humans for EpoR agonists drugs (such as recombinant erythropoietin [rhEpo], in general, called erythropoiesis-simulating agents) appears clear (that is, to treat anemia). However, evidence of a kaleidoscope of pleitropic actions of Epo has been provided (4,5). The Epo/EpoR axis research involved an initial journey from laboratory basic research to clinical therapeutics. However, as a consequence of clinical observations, basic research on Epo/EpoR comes back to expand its clinical therapeutic applicability.Although kidney and liver have long been considered the major sources of synthesis, Epo mRNA expression has also been detected in the brain (neurons and glial cells), lung, heart, bone marrow, spleen, hair follicles, reproductive tract and osteoblasts (6–17). Accordingly, EpoR was detected in other cells, such as neurons, astrocytes, microglia, immune cells, cancer cell lines, endothelial cells, bone marrow stromal cells and cells of heart, reproductive system, gastrointestinal tract, kidney, pancreas and skeletal muscle (18–27). Conversely, Sinclair et al.(28) reported data questioning the presence or function of EpoR on nonhematopoietic cells (endothelial, neuronal and cardiac cells), suggesting that further studies are needed to confirm the diversity of EpoR. Elliott et al.(29) also showed that EpoR is virtually undetectable in human renal cells and other tissues with no detectable EpoR on cell surfaces. These results have raised doubts about the preclinical basis for studies exploring pleiotropic actions of rhEpo (30).For the above-mentioned data, a return to basic research studies has become necessary, and many studies in animal models have been initiated or have already been performed. The effect of rhEpo administration on angiogenesis, myogenesis, shift in muscle fiber types and oxidative enzyme activities in skeletal muscle (4,31), cardiac muscle mitochondrial biogenesis (32), cognitive effects (31), antiapoptotic and antiinflammatory actions (33–37) and plasma glucose concentrations (38) has been extensively studied. Neuro- and cardioprotection properties have been mainly described. Accordingly, rhEpo therapy was suggested as a reliable approach for treating a broad range of pathologies, including heart and cardiovascular diseases, neurodegenerative disorders (Parkinson’s and Alzheimer’s disease), spinal cord injury, stroke, diabetic retinopathy and rare diseases (Friedreich ataxia).Unfortunately, the side effects of rhEpo are also evident. Epo is involved in regulating tumor angiogenesis (39) and probably in the survival and growth of tumor cells (25,40,41). rhEpo administration also induces serious side effects such as hypertension, polycythemia, myocardial infarction, stroke and seizures, platelet activation and increased thromboembolic risk, and immunogenicity (42–46), with the most common being hypertension (47,48). A new generation of nonhematopoietic EpoR agonists drugs have hence been investigated and further developed in animals models. These compounds, namely asialoerythropoietin (asialoEpo) and carbamylated Epo (Cepo), were developed for preserving tissue-protective properties but reducing the erythropoietic activity of native Epo (49,50). These drugs will provide better outcome in ongoing clinical trials. The advantage of using nonhematopoietic Epo analogs is to avoid the stimulation of hematopoiesis and thereby the prevention of an increased hematocrit with a subsequent procoagulant status or increased blood pressure. In this regard, a new study by van Rijt et al. has shed new light on this topic (51). A new nonhematopoietic EpoR agonist analog named ARA 290 has been developed, promising cytoprotective capacities to prevent renal ischemia/reperfusion injury (51). ARA 290 is a short peptide that has shown no safety concerns in preclinical and human studies. In addition, ARA 290 has proven efficacious in cardiac disorders (52,53), neuropathic pain (54) and sarcoidosis-induced chronic neuropathic pain (55). Thus, ARA 290 is a novel nonhematopoietic EpoR agonist with promising therapeutic options in treating a wide range of pathologies and without increased risks of cardiovascular events.Overall, this new generation of EpoR agonists without the erythropoietic activity of Epo while preserving tissue-protective properties of Epo will provide better outcomes in ongoing clinical trials (49,50). Nonhematopoietic EpoR agonists represent safer and more effective surrogates for the treatment of several diseases, such as brain and peripheral nerve injury, diabetic complications, renal ischemia, rare diseases, myocardial infarction, chronic heart disease and others. 相似文献
15.
16.
Clare L. Atzema Peter C. Austin Thao Huynh Ansar Hassan Maria Chiu Julie T. Wang Jack V. Tu 《CMAJ》2011,183(13):1482-1491
Background:
Coronary artery disease is the most common cause of death in the Western world, and being married decreases the risk of death from cardiovascular causes. We aimed to determine whether marital status was a predictor of the duration of chest pain endured by patients with acute myocardial infarction before they sought care and whether the patient’s sex modified the effect.Methods:
We conducted a retrospective, population-based cohort analysis of patients with acute myocardial infarction admitted to 96 acute care hospitals in Ontario, Canada, from April 2004 to March 2005. We excluded patients who did not experience chest pain. Using multivariable regression analyses, we assessed marital status in relation to delayed presentation to hospital (more than six hours from onset of pain), both overall and stratified by sex. In patients who reported the exact duration of chest pain, we assessed the effect of marital status on the delay in seeking care.Results:
Among 4403 eligible patients with acute myocardial infarction, the mean age was 67.3 (standard deviation 13.6) years, and 1486 (33.7%) were women. Almost half (2037 or 46.3%) presented to a hospital within two hours, and 3240 (73.6%) presented within six hours. Overall, 75.3% (2317/3079) of married patients, 67.9% (188/277) of single patients, 68.5% (189/276) of divorced patients and 70.8% (546/771) of widowed patients presented within six hours of the onset of chest pain. Being married was associated with lower odds of delayed presentation (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.30–0.71, p < 0.001) relative to being single. Among men, the OR was 0.35 (95% CI 0.21–0.59, p < 0.001), whereas among women the effect of marital status was not significant (OR 1.36, 95% CI 0.49–3.73, p = 0.55).Interpretation:
Among men experiencing acute myocardial infarction with chest pain, being married was associated with significantly earlier presentation for care, a benefit that was not observed for married women. Earlier presentation for medical care appears to be one reason for the observed lower risk of cardiovascular death among married men, relative to their single counterparts.Marriage has long been known to offer health benefits1,2 and is associated with a lower risk of death3,4 relative to people who are not married. The effect is more pronounced among men than among women.5,6 However, the specific mechanisms responsible for the lower rate of cardiovascular deaths in married persons7 are not known.Effective, time-sensitive therapy for acute myocardial infarction is available,8,9 and delays in the emergency department and for in-hospital components of care have been substantially reduced over the past few decades.10,11 In contrast, patients’ delay in seeking care for acute myocardial infarction has shown little improvement over time,12,13 despite intensive campaigns to raise public awareness.14,15 Patients’ delay remains by far the largest component of the overall delay between onset of symptoms and receipt of therapy.16 No study has examined the effect of marital status on patients’ delay, and only a few small studies have examined predictors of this component of delay by sex.17,18We examined the effect of marital status, a social factor, on the time from onset of chest pain to arrival in an emergency department or hospital, in a population-based cohort of patients with acute myocardial infarction. We hypothesized that being married or in a common-law relationship would be associated with less delay, because we surmised that a spouse would encourage earlier pursuit of medical care, either directly or indirectly (i.e., even if the spouse was not physically present during the symptoms, his or her existence might spur the patient to seek care earlier). We hypothesized that wives would be more likely than husbands to assume the caregiver role and that the beneficial effect of marriage would therefore be stronger among men than among women. 相似文献17.
Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months 总被引：1，自引：0，他引：1
Meghan B. Azad Theodore Konya Heather Maughan David S. Guttman Catherine J. Field Radha S. Chari Malcolm R. Sears Allan B. Becker James A. Scott Anita L. Kozyrskyj 《CMAJ》2013,185(5):385-394
Background:
The gut microbiota is essential to human health throughout life, yet the acquisition and development of this microbial community during infancy remains poorly understood. Meanwhile, there is increasing concern over rising rates of cesarean delivery and insufficient exclusive breastfeeding of infants in developed countries. In this article, we characterize the gut microbiota of healthy Canadian infants and describe the influence of cesarean delivery and formula feeding.Methods:
We included a subset of 24 term infants from the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort. Mode of delivery was obtained from medical records, and mothers were asked to report on infant diet and medication use. Fecal samples were collected at 4 months of age, and we characterized the microbiota composition using high-throughput DNA sequencing.Results:
We observed high variability in the profiles of fecal microbiota among the infants. The profiles were generally dominated by Actinobacteria (mainly the genus Bifidobacterium) and Firmicutes (with diverse representation from numerous genera). Compared with breastfed infants, formula-fed infants had increased richness of species, with overrepresentation of Clostridium difficile. Escherichia–Shigella and Bacteroides species were underrepresented in infants born by cesarean delivery. Infants born by elective cesarean delivery had particularly low bacterial richness and diversity.Interpretation:
These findings advance our understanding of the gut microbiota in healthy infants. They also provide new evidence for the effects of delivery mode and infant diet as determinants of this essential microbial community in early life.The human body harbours trillions of microbes, known collectively as the “human microbiome.” By far the highest density of commensal bacteria is found in the digestive tract, where resident microbes outnumber host cells by at least 10 to 1. Gut bacteria play a fundamental role in human health by promoting intestinal homeostasis, stimulating development of the immune system, providing protection against pathogens, and contributing to the processing of nutrients and harvesting of energy.1,2 The disruption of the gut microbiota has been linked to an increasing number of diseases, including inflammatory bowel disease, necrotizing enterocolitis, diabetes, obesity, cancer, allergies and asthma.1 Despite this evidence and a growing appreciation for the integral role of the gut microbiota in lifelong health, relatively little is known about the acquisition and development of this complex microbial community during infancy.3Two of the best-studied determinants of the gut microbiota during infancy are mode of delivery and exposure to breast milk.4,5 Cesarean delivery perturbs normal colonization of the infant gut by preventing exposure to maternal microbes, whereas breastfeeding promotes a “healthy” gut microbiota by providing selective metabolic substrates for beneficial bacteria.3,5 Despite recommendations from the World Health Organization,6 the rate of cesarean delivery has continued to rise in developed countries and rates of breastfeeding decrease substantially within the first few months of life.7,8 In Canada, more than 1 in 4 newborns are born by cesarean delivery, and less than 15% of infants are exclusively breastfed for the recommended duration of 6 months.9,10 In some parts of the world, elective cesarean deliveries are performed by maternal request, often because of apprehension about pain during childbirth, and sometimes for patient–physician convenience.11The potential long-term consequences of decisions regarding mode of delivery and infant diet are not to be underestimated. Infants born by cesarean delivery are at increased risk of asthma, obesity and type 1 diabetes,12 whereas breastfeeding is variably protective against these and other disorders.13 These long-term health consequences may be partially attributable to disruption of the gut microbiota.12,14Historically, the gut microbiota has been studied with the use of culture-based methodologies to examine individual organisms. However, up to 80% of intestinal microbes cannot be grown in culture.3,15 New technology using culture-independent DNA sequencing enables comprehensive detection of intestinal microbes and permits simultaneous characterization of entire microbial communities. Multinational consortia have been established to characterize the “normal” adult microbiome using these exciting new methods;16 however, these methods have been underused in infant studies. Because early colonization may have long-lasting effects on health, infant studies are vital.3,4 Among the few studies of infant gut microbiota using DNA sequencing, most were conducted in restricted populations, such as infants delivered vaginally,17 infants born by cesarean delivery who were formula-fed18 or preterm infants with necrotizing enterocolitis.19Thus, the gut microbiota is essential to human health, yet the acquisition and development of this microbial community during infancy remains poorly understood.3 In the current study, we address this gap in knowledge using new sequencing technology and detailed exposure assessments20 of healthy Canadian infants selected from a national birth cohort to provide representative, comprehensive profiles of gut microbiota according to mode of delivery and infant diet. 相似文献18.
Hazel J. Jenkins Mark J. Hancock Simon D. French Chris G. Maher Roger M. Engel John S. Magnussen 《CMAJ》2015,187(6):401-408
Background:Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes. We conducted a systematic review to investigate the effectiveness of interventions aimed at reducing the use of imaging for low-back pain.Methods:We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from the earliest records to June 23, 2014. We included randomized controlled trials, controlled clinical trials and interrupted time series studies that assessed interventions designed to reduce the use of imaging in any clinical setting, including primary, emergency and specialist care. Two independent reviewers extracted data and assessed risk of bias. We used raw data on imaging rates to calculate summary statistics. Study heterogeneity prevented meta-analysis.Results:A total of 8500 records were identified through the literature search. Of the 54 potentially eligible studies reviewed in full, 7 were included in our review. Clinical decision support involving a modified referral form in a hospital setting reduced imaging by 36.8% (95% confidence interval [CI] 33.2% to 40.5%). Targeted reminders to primary care physicians of appropriate indications for imaging reduced referrals for imaging by 22.5% (95% CI 8.4% to 36.8%). Interventions that used practitioner audits and feedback, practitioner education or guideline dissemination did not significantly reduce imaging rates. Lack of power within some of the included studies resulted in lack of statistical significance despite potentially clinically important effects.Interpretation:Clinical decision support in a hospital setting and targeted reminders to primary care doctors were effective interventions in reducing the use of imaging for low-back pain. These are potentially low-cost interventions that would substantially decrease medical expenditures associated with the management of low-back pain.Current evidence-based clinical practice guidelines recommend against the routine use of imaging in patients presenting with low-back pain.1–3 Despite this, imaging rates remain high,4,5 which indicates poor concordance with these guidelines.6,7Unnecessary imaging for low-back pain has been associated with poorer patient outcomes, increased radiation exposure and higher health care costs.8 No short- or long-term clinical benefits have been shown with routine imaging of the low back, and the diagnostic value of incidental imaging findings remains uncertain.9–12 A 2008 systematic review found that imaging accounted for 7% of direct costs associated with low-back pain, which in 1998 translated to more than US$6 billion in the United States and £114 million in the United Kingdom.13 Current costs are likely to be substantially higher, with an estimated 65% increase in spine-related expenditures between 1997 and 2005.14Various interventions have been tried for reducing imaging rates among people with low-back pain. These include strategies targeted at the practitioner such as guideline dissemination,15–17 education workshops,18,19 audit and feedback of imaging use,7,20,21 ongoing reminders7 and clinical decision support.22–24 It is unclear which, if any, of these strategies are effective.25 We conducted a systematic review to investigate the effectiveness of interventions designed to reduce imaging rates for the management of low-back pain. 相似文献
19.
Background:
Suboptimal human papillomavirus (HPV) vaccine coverage in some jurisdictions is partly attributed to fears that vaccination may increase risky sexual behaviour. We assessed the effect of HPV vaccination on clinical indicators of sexual behaviour among adolescent girls in Ontario.Methods:
Using Ontario’s administrative health databases, we identified a population-based cohort of girls in grade 8 in the 2 years before (2005/06 and 2006/07) and after (2007/08 and 2008/09) implementation of Ontario’s grade 8 HPV vaccination program. For each girl, we then obtained data on vaccine receipt in grades 8 and 9 and data on indicators of sexual behaviour (pregnancy and non–HPV-related sexually transmitted infections) in grades 10–12. Using a quasi-experimental method known as regression discontinuity, we estimated, for each outcome, the risk difference (RD) and relative risk (RR) attributable to vaccination and to program eligibility.Results:
The cohort comprised 260 493 girls, of whom 131 781 were ineligible for the program and 128 712 were eligible. We identified 15 441 (5.9%) cases of pregnancy and sexually transmitted infection and found no evidence that vaccination increased the risk of this composite outcome: RD per 1000 girls −0.61 (95% confidence interval [CI] −10.71 to 9.49) and RR 0.96 (95% CI 0.81 to 1.14). Similarly, we found no discernible effect of program eligibility: RD per 1000 girls −0.25 (95% CI −4.35 to 3.85) and RR 0.99 (95% CI 0.93 to 1.06). The findings were similar when outcomes were assessed separately.Interpretation:
We present strong evidence that HPV vaccination does not have any significant effect on clinical indicators of sexual behaviour among adolescent girls. These results suggest that concerns over increased promiscuity following HPV vaccination are unwarranted and should not deter from vaccinating at a young age.Infection with the human papillomavirus (HPV) is the most commonly diagnosed sexually transmitted infection in Canada and around the world.1 Although most of these infections are transient and self-resolving, others persist and can cause important health outcomes, including cervical cancer and anogenital warts.In 2006, Canada was among 49 countries to license Gardasil (Merck, Whitehouse Station, New Jersey), a quadrivalent HPV vaccine designed to protect against 4 types of HPV (6, 11, 16, 18) that cause 70% of cases of cervical cancer and most cases of anogenital warts.2–4 As one of the first cancer-preventing vaccines, this vaccine received expedited approval in several countries and was the subject of intensive marketing, lobbying and public health campaigns around the world.5 By 2012, it had been approved in almost 100 countries, many of which also implemented nationwide HPV vaccination programs aimed primarily at immunizing young girls before the onset of sexual activity.6Despite the popularity of large-scale immunization programs, HPV vaccination has faced a great deal of controversy regarding unanswered questions about the real-world effects of this vaccine.7,8 A major topic of public debate has been the possibility that HPV vaccination might lead to sexual disinhibition,9 that is, that receipt of the vaccine might give women and girls a false sense of protection against all sexually transmitted infections and that this false sense of protection might lead them to engage in more risky sexual behaviours than they would otherwise (e.g., be more promiscuous or neglect to use condoms). Increases in these risky behaviours could have important clinical consequences, including increased risk of pregnancy and sexually transmitted infections. Although there is little empirical support for the notion that sexual health interventions promote risky sexual behaviours,10,11 this possible unintended effect of the HPV vaccine would undermine its value for reducing the burden of sexual health–related diseases. Moreover, parental fears of increased promiscuity following HPV vaccination have been reported as a major determinant of vaccine refusal,12 which may help to explain suboptimal HPV vaccine coverage in some jurisdictions.6,13 Evidently, both actual and perceived sexual disinhibition can have a negative effect on the potential health benefits of HPV vaccination. Therefore, we conducted a population-based, retrospective cohort study to assess the effect of HPV vaccination on clinical indicators of sexual behaviour among adolescent girls in Ontario. 相似文献20.
Anjali Sergeant Sudipta Saha Anushka Lalwani Anand Sergeant Avery McNair Elias Larrazabal Kelsey Yang Orly Bogler Arti Dhoot Dan Werb Nazlee Maghsoudi Lisa Richardson Gillian Hawker Arjumand Siddiqi Amol Verma Fahad Razak 《CMAJ》2022,194(10):E371
Background:Diverse health care leadership teams may improve health care experiences and outcomes for patients. We sought to explore the race and gender of hospital and health ministry executives in Canada and compare their diversity with that of the populations they serve.Methods:This cross-sectional study included leaders of Canada’s largest hospitals and all provincial and territorial health ministries. We included individuals listed on institutional websites as part of the leadership team if a name and photo were available. Six reviewers coded and analyzed the perceived race and gender of leaders, in duplicate. We compared the proportion of racialized health care leaders with the race demographics of the general population from the 2016 Canadian Census.Results:We included 3056 leaders from 135 institutions, with reviewer concordance on gender for 3022 leaders and on race for 2946 leaders. Reviewers perceived 37 (47.4%) of 78 health ministry leaders as women, and fewer than 5 (< 7%) of 80 as racialized. In Alberta, Saskatchewan, Prince Edward Island and Nova Scotia, provinces with a centralized hospital executive team, reviewers coded 36 (50.0%) of 72 leaders as women and 5 (7.1%) of 70 as racialized. In British Columbia, New Brunswick and Newfoundland and Labrador, provinces with hospital leadership by region, reviewers perceived 120 (56.1%) of 214 leaders as women and 24 (11.5%) of 209 as racialized. In Manitoba, Ontario and Quebec, where leadership teams exist at each hospital, reviewers perceived 1326 (49.9%) of 2658 leaders as women and 243 (9.2%) of 2633 as racialized. We calculated the representation gap between racialized executives and the racialized population as 14.5% for British Columbia, 27.5% for Manitoba, 20.7% for Ontario, 12.4% for Quebec, 7.6% for New Brunswick, 7.3% for Prince Edward Island and 11.6% for Newfoundland and Labrador.Interpretation:In a study of more than 3000 health care leaders in Canada, gender parity was present, but racialized executives were substantially under-represented. This work should prompt health care institutions to increase racial diversity in leadership.Race and gender-based disparities in health care leadership1–4 may negatively affect the health of marginalized patients.5,6 Diverse leadership is an integral step in establishing equitable health care institutions that serve the needs of all community members.7 Many barriers prevent racialized people, women and gender nonbinary individuals from attaining leadership positions, including reduced access to networking opportunities, 8–10 discrimination from patients and colleagues2,11–13 and an institutional culture that views white, male leaders as most effective. 14,15 The intersectional effects of discrimination may intensify these barriers for racialized women and nonbinary people.16,17 Fundamentally, diversity and inclusion in our institutions is important on the basis of basic human rights for all people.18Health care leadership in Europe and the United States is thought to lack gender and racial diversity.19–22 The degree to which these imbalances exist across Canadian health care institutions is not clear. Despite past evidence that men hold a disproportionate number of health care leadership positions in Canada,23,24 a recent study noted gender parity among leaders of provincial and territorial ministries of health.25 Among university faculty26,27 and administration, 28 racialized individuals appear to be under-represented, suggesting that a similar trend may exist in health care leadership.Race and gender can be studied in many ways.29 Perceived race is a measure of “the race that others believe you to be,” and these assessments “influence how people are treated and form the basis of racial discrimination including nondeliberate actions that nonetheless lead to socioeconomic inequities.”29 Similarly, perceived gender refers to an observer’s assumptions about a person’s gender, which can lead to differential and unfair treatment. 30 Assessing perceived race and gender provides crucial insights into the ways in which social inequalities are informed and produced.29 In this study, we sought to identify the perceived race and gender of hospital executive leaders in Canada and of nonelected leaders of the provincial and territorial health ministries. Furthermore, we wanted to analyze how the perceived racial composition of health care leadership compares with the racial composition of the population in the geographic areas that these leaders serve. 相似文献