SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study

Background

Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives).

Methods

An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs.

Discussion

This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child.

Trial registration

http://www.clinicaltrials.gov: NCT01261676     

How close are we to a predictive science of the biosphere?

In just 20 years, the field of biosphere-atmosphere interactions has gone from a nascent discipline to a central area of modern climate change research. The development of terrestrial biosphere models that predict the responses of ecosystems to climate and increasing CO2 levels has highlighted several mechanisms by which changes in ecosystem composition and function might alter regional and global climate. However, results from empirical studies suggest that ecosystem responses can differ markedly from the predictions of terrestrial biosphere models. As I discuss here, the challenge now is to connect terrestrial biosphere models to empirical ecosystem measurements. Only by systematically evaluating the predictions of terrestrial biosphere models against suites of ecosystem observations and experiments measurements will a true predictive science of the biosphere be achieved.     

Simulating boreal forest dynamics from perspectives of ecophysiology,resource availability,and climate change

Boreal forests are under strong influences from climate change, and alterations in forest dynamics will have significant impacts on global climate-biosphere feedback as well as local to regional conservation and resource management. To understand the mechanisms of forest dynamics and to assess the fate of boreal forests, simulation studies should be based on plant ecophysiological responses onto environmental conditions. In central Canadian boreal forests, local geomorphology created by past glacial activities often generates a mosaic of very distinctive forest types. On sandy hilltop of a glacial till, due to limitations in moisture availability and short fire return intervals, drought-tolerant and fire-adapted jack pine usually becomes the dominant species. On mesic and nutrient-rich slopes, fast-growing and resource-demanding trembling aspen forms mixed forests with coniferous species. In bottomland, black spruce, slowly growing but tolerant species, is often the only species that can survive to the adult stage. These three very distinctive forest types often occur within a scale of 10 m. Simulation models of boreal forests should be able to reproduce this heterogeneity in forest structure and composition as an emergent property of plant ecophysiological responses to varying environmental properties. In this study, a process-based forest dynamics model, ecosystem demography model version 1.0, is used to mechanically reproduce the landscape heterogeneity due to edaphic variations. First, boreal tree species of northern Manitoba, Canada, are parameterized according to field observations, and, to explicitly capture interactions among tree saplings, allometric equations based on diameter at height of 0.15 m, instead of the conventional breast height of 1.37 m, is parameterized. Then, soil moisture regime and nutrient concentrations are statistically incorporated from a dataset. The resultant simulation successfully reproduces the distinctive forest dynamics influenced by the edaphic heterogeneity. The sequences of succession and the trajectories of forest development are generally consistent with the field observations. The differences in resource availability are the essential control on equilibrium values of total forest leaf area index. Next, to show the effect of anthropogenic atmospheric changes, changes in temperature and CO₂ concentrations are studied by a set of factorial experiments. The magnitude of CO₂ fertilization is largely affected by soil fertility. The temperature rise will increase the length of growing season, but can have a negative impact on forest growth by increasing aridity and autotrophic respiration. Overall, the boreal forest responses to climate change are complex due to the inherent edaphic variations and ecophysiological responses.     

Localization of acetylcholine receptors and synaptic ultrastructure at nerve-muscle contacts in culture: dependence on nerve type

In cultures of xenopus myotomal muscle cells and spinal cord (SC) some of the nerve-muscle contacts exhibit a high density of acetylcholine receptors (AchRs [Anderson et al., 1977, J. Physiol. (Lond.). 268:731- 756,757-773]) and synaptic ultrastructure (Weldon and Cohen, 1979, J. Neurocytol. 8:239-259). We have examined whether similarly specialized contacts are established when the muscle cells are cultured with explants of xenopus dorsal root ganglia (DRG) or sympathetic ganglia (SG). The outgrowth from the ganglionic explants contained neuronal and non- neuronal cell processes. Although both types of processes approached within 100 A of muscle cells, synaptic ultrastructure was rarely observed at these contacts. Because patches of postsynaptic ultrastructure also develop on noncontacted muscle cells, the very few examples of contacts with such specializations probably occurred by chance. AChRs were stained with fluroscent α-bungarotoxin. More than 70 percent of the SC-contacted muscle cells exhibited a high receptor density along the path of contact. The corresponding values for DRG- and SG- contacted muscle cells were 10 and 6 percent. Similar values were obtained when the ganlionic and SC explants were cultured together in the same chamber. The few examples of high receptor density at ganglionic-muscle contacts resembled the characteristic receptor patches of noncontacted muscle cells rather than the narrow bands of high receptor density seen at SC-muscle contacts. In addition, more than 90 percent of these ganglionic- contacted muscle cells had receptor patches elsewhere, compared to less than 40 percent for the SC-contacted muscle cells. These findings indicate that the SC neurites possess a specific property which is important for the establishment of synaptically specialized contacts with muscle and that this property is lacking in the DRG and SG neurites.     

Molecular evolution in the gnd locus of Salmonella enterica

The gnd gene, the structural gene for 6-phosphogluconate dehydrogenase, was sequenced and analyzed in 34 isolates from different serovars of the seven subspecies of Salmonella enterica to provide comparative information on the evolution in this gene, which has been studied extensively in Escherichia coli. The gene tree obtained by the neighbor- joining method in general gave separate branches for each subspecies, with the few exceptions readily explained by recombination. There is evidence of recombination involving transfer of long (more than 400 bp) and short (30-150 bp) segments of DNA. Four of the six long-segment transfers detected are at the 5' end of the gene, and in all four cases a variant of the chi sequence is located close to the recombination junction and appears to have mediated the recombination events. We suggest that in these four cases and in a fifth case with intersubspecies transfer of the whole gnd gene, the adjacent rfb (O antigen) locus may have been transferred in the same event. The estimates of the number of synonymous substitutions per synonymous site, KS, and the number of nonsynonymous substitutions per nonsynonymous site, KA, within the E. coli and S. enterica gnd genes, and also between the two species show an interesting distribution, with KS being lower toward the ends of the gene and KA in particular being lower in the first than in the second domain. In S. enterica, synonymous sites also seem to be subjected to negative selection. The ratio of KA to KS was higher within S. enterica and E. coli than between them, which may indicate that intraspecies variation is essentially between clones and that mildly deleterious mutations can be fixed within clones, which would thus raise KA within species.      

Biofilter efficiency of <i>Eichhornia crassipes</i> in wastewater treatment of fish farming in Amazonia

Fish is a very important part of the human diet in Amazonia. Near the growing cities, fish populations and individual size have decreased over the past decades. Alternatives to traditional and industrial fishing arise, including fish farming. Strategies to minimize the impact of fish farms on the environment are needed to have a regular and healthy fish supply. This is to avoid a reduction of biodiversity, a depletion of natural resources, and/or the induction of significant changes in the structure and functioning of adjacent ecosystems. Very little research has been performed on management of effluents as to maintain the quality of water resources. The present study aimed at testing the efficiency of the Amazonian aquatic macrophyte Eichhornia crassipes as a biofilter for the treatment of effluents from fish farming. In three filtering treatments (50%, 75% and 100% plant cover) and a control (0%), physical and chemical properties of the water were measured and analyzed in a nursery with fish after passing the biofilter system, with a hydraulic retention time of 24 hours. The analyzed variables showed no significant differences (p>0.05) among the treatments with 50-100% cover, indicating that 50% cover would be enough for a good efficiency of the biofilter. All parameters were reduced after passage of the biofilter under the presence of E. crassipes: 73.7% for electrical conductivity, 15% for pH, 84.5% for turbidity, 86.8% for nitrite, 69% for total phosphorus, and 77.8% for orthophosphate. The concentrations of total nitrogen, nitrate and ammonium ions were not significantly changed (p>0.05). We conclude that E. crassipes is effective in improving the quality of effluents from fish farming, with less efficiency for nitrogen compounds. Our treatment system can be adopted by small and medium-sized farmers, aiming at a sustainable employment of the activity.     

ESS analysis of mechanistic models for territoriality: the value of scent marks in spatial resource partitioning

In this paper elements of game theory are used to analyse a spatially explicit home range model for interacting wolf packs. The model consists of a system of nonlinear partial differential equations whose parameters reflect the movement behavior of individuals within each pack and whose solutions describe the patterns of space-use by each pack. By modifying the behavioral parameters, packs adjust their patterns of movement so as to maximize their reproductive output. This involves a tradeoff between maximizing prey intake and minimizing conflict with neighbors. Evolutionarily stable choices of the behavioral parameters yields territories that are immune to invasion by groups with alternate behaviors.     

Recent advances in ecosystem-atmosphere interactions: an ecological perspective

The atmosphere and terrestrial ecosystems are fundamentally coupled on a variety of time-scales. On short time-scales, this bi-directional interaction is dominated by the rapid exchange of CO(2), water and energy between the atmosphere and the land surface; on long time-scales, the interaction involves changes in ecosystem structure and composition in response to changes in climate that feed back through biophysical and biogeochemical mechanisms to influence climate over decades and centuries. After briefly describing some early pioneering work, I focus this review on recent advances in understanding long-term ecosystem-atmosphere interactions through a discussion of three case studies. I then examine how efforts to assess the stability and resilience of ecosystem-atmosphere interactions over these long time-scales using Dynamic Global Vegetation Models are hampered by the presence of important functional diversity and heterogeneity within plant communities. Recent work illustrates how this issue can be addressed through the use of Structured Ecosystem Models that more accurately scale between the short-term physiological responses of individual plants and the long-term, large-scale dynamics of heterogeneous, functionally diverse ecosystems.     

Identification of structural DNA variations in human cell cultures after long-term passage

Random amplified polymorphic DNA (RAPD) analysis was adapted for genomic identification of cell cultures and evaluation of DNA stability in cells of different origin at different culture passages. DNA stability was observed in cultures after no more than 5 passages. Adipose-derived stromal cells demonstrated increased DNA instability. RAPD fragments from different cell lines after different number of passages were cloned and sequenced. The chromosomal localization of these fragments was identified and single-nucleotide variations in RAPD fragments isolated from cell lines after 8–12 passages were revealed. Some of them had permanent localization, while most variations demonstrated random distribution and can be considered as de novo mutations.     

Differential use of autophagy by primary dendritic cells specialized in cross-presentation

Antigen-presenting cells survey their environment and present captured antigens bound to major histocompatibility complex (MHC) molecules. Formation of MHC-antigen complexes occurs in specialized compartments where multiple protein trafficking routes, still incompletely understood, converge. Autophagy is a route that enables the presentation of cytosolic antigen by MHC class II molecules. Some reports also implicate autophagy in the presentation of extracellular, endocytosed antigen by MHC class I molecules, a pathway termed “cross-presentation.” The role of autophagy in cross-presentation is controversial. This may be due to studies using different types of antigen presenting cells for which the use of autophagy is not well defined. Here we report that active use of autophagy is evident only in DC subtypes specialized in cross-presentation. However, the contribution of autophagy to cross-presentation varied depending on the form of antigen: it was negligible in the case of cell-associated antigen or antigen delivered via receptor-mediated endocytosis, but more prominent when the antigen was a soluble protein. These findings highlight the differential use of autophagy and its machinery by primary cells equipped with specific immune function, and prompt careful reassessment of the participation of this endocytic pathway in antigen cross-presentation.