Emergency versus Elective Cervical Cerclage: An Audit of Our First Two Years of Service.

One of the biggest obstetric challenges is the diagnosis and management of a short cervix as cervical length has an inverse relationship with risk of preterm birth. A cervical cerclage is a surgical procedure to reduce the risk of preterm birth and can be placed in an elective or emergency setting. This is a retrospective review of cervical cerclages inserted at an outer metropolitan hospital from February 2014 to May 2017. Since the introduction of the service, a total of 43 patients were identified as requiring a cervical cerclage. Four of these patients were transferred to tertiary hospitals. Of the 39 cerclages inserted, 26 were elective and 13 were emergency, placed at a mean gestation of 15.6 and 19.6 weeks. In total, there were 35 live births, 2 stillbirths, and 2 neonatal deaths. The maternal demographics (age, gravidity, parity, and preterm risk factors) were not statistically significant between the two groups. The mean pregnancy prolongation and birthweight was greater in the elective than the emergency group (21.4 versus 14.1 weeks; 3148.2 versus 2447.2 grams). There was no obvious pattern with which patients received antibiotics pre-, intra-, or postoperatively or received a vaginal swab. This audit identified the need for improvements to guidelines to standardise the use of antibiotics and progesterone in women with a cervical cerclage.

Impact on short-lived climate forcers increases projected warming due to deforestation.

The climate impact of deforestation depends on the relative strength of several biogeochemical and biogeophysical effects. In addition to affecting the exchange of carbon dioxide (CO2) and moisture with the atmosphere and surface albedo, vegetation emits biogenic volatile organic compounds (BVOCs) that alter the formation of short-lived climate forcers (SLCFs), which include aerosol, ozone and methane. Here we show that a scenario of complete global deforestation results in a net positive radiative forcing (RF; 0.12 W m-2) from SLCFs, with the negative RF from decreases in ozone and methane concentrations partially offsetting the positive aerosol RF. Combining RFs due to CO2, surface albedo and SLCFs suggests that global deforestation could cause 0.8 K warming after 100 years, with SLCFs contributing 8% of the effect. However, deforestation as projected by the RCP8.5 scenario leads to zero net RF from SLCF, primarily due to nonlinearities in the aerosol indirect effect.

Impact on short-lived climate forcers (SLCFs) from a realistic land-use change scenario via changes in biogenic emissions.

More than one quarter of natural forests have been cleared by humans to make way for other land-uses, with changes to forest cover projected to continue. The climate impact of land-use change (LUC) is dependent upon the relative strength of several biogeophysical and biogeochemical effects. In addition to affecting the surface albedo and exchanging carbon dioxide (CO2) and moisture with the atmosphere, vegetation emits biogenic volatile organic compounds (BVOCs), altering the formation of short-lived climate forcers (SLCFs) including aerosol, ozone (O3) and methane (CH4). Once emitted, BVOCs are rapidly oxidised by O3, and the hydroxyl (OH) and nitrate (NO3) radicals. These oxidation reactions yield secondary organic products which are implicated in the formation and growth of aerosol particles and are estimated to have a negative radiative effect on the climate (i.e. a cooling). These reactions also deplete OH, increasing the atmospheric lifetime of CH4, and directly affect concentrations of O3; the latter two being greenhouse gases which impose a positive radiative effect (i.e. a warming) on the climate. Our previous work assessing idealised deforestation scenarios found a positive radiative effect due to changes in SLCFs; however, since the radiative effects associated with changes to SLCFs result from a combination of non-linear processes it may not be appropriate to scale radiative effects from complete deforestation scenarios according to the deforestation extent. Here we combine a land-surface model, a chemical transport model, a global aerosol model, and a radiative transfer model to assess the net radiative effect of changes in SLCFs due to historical LUC between the years 1850 and 2000.

Small global effect on terrestrial net primary production due to increased fossil fuel aerosol emissions from East Asia since the turn of the century.

The global terrestrial carbon sink has increased since the start of this century at a time of growing carbon emissions from fossil fuel burning. Here we test the hypothesis that increases in atmospheric aerosols from fossil fuel burning enhanced the diffuse light fraction and the efficiency of plant carbon uptake. Using a combination of models, we estimate that at global scale changes in light regimes from fossil fuel aerosol emissions had only a small negative effect on the increase in terrestrial net primary production over the period 1998-2010. Hereby, the substantial increases in fossil fuel aerosol emissions and plant carbon uptake over East Asia were effectively canceled by opposing trends across Europe and North America. This suggests that if the recent increase in the land carbon sink would be causally linked to fossil fuel emissions, it is unlikely via the effect of aerosols but due to other factors such as nitrogen deposition or nitrogen-carbon interactions.

Large contribution of natural aerosols to uncertainty in indirect forcing.

The effect of anthropogenic aerosols on cloud droplet concentrations and radiative properties is the source of one of the largest uncertainties in the radiative forcing of climate over the industrial period. This uncertainty affects our ability to estimate how sensitive the climate is to greenhouse gas emissions. Here we perform a sensitivity analysis on a global model to quantify the uncertainty in cloud radiative forcing over the industrial period caused by uncertainties in aerosol emissions and processes. Our results show that 45 per cent of the variance of aerosol forcing since about 1750 arises from uncertainties in natural emissions of volcanic sulphur dioxide, marine dimethylsulphide, biogenic volatile organic carbon, biomass burning and sea spray. Only 34 per cent of the variance is associated with anthropogenic emissions. The results point to the importance of understanding pristine pre-industrial-like environments, with natural aerosols only, and suggest that improved measurements and evaluation of simulated aerosols in polluted present-day conditions will not necessarily result in commensurate reductions in the uncertainty of forcing estimates.

Adherence to medication regimens among children with human immunodeficiency virus infection.

BACKGROUND: Rigorous adherence to antiretroviral medication regimens is necessary to achieve and maintain undetectable viral levels. This study describes adherence in a population of children with HIV infection. METHODS: Caregivers of HIV-infected children were interviewed about their experiences with administration of medications for treatment of HIV, opinions regarding medication-related issues and the potential usefulness of interventions to improve adherence. RESULTS: In the 90 caregiver interviews completed, 78% of the children were taking 3 or more medications, 17% missed a dose in the previous 24 h and 43% missed at least 1 dose in the previous week. Children whose caregivers reported no missed doses in the previous week (adherent) were more likely to have an HIV viral load <400 copies/ml (50% vs. 24%, P = 0.04). Nonadherent caregivers (who reported 1 or more missed doses in the previous week) were more likely than adherent caregivers to agree with a statement that full adherence is impossible (44% vs. 12%, P = 0.001) and express the need for more help with medication administration (26% vs. 6%, P = 0.02). They were less likely to have informed the school or day-care site about the child's HIV infection (42% vs. 67%, P = 0.05) and more concerned about the child's teachers and friends finding out (54% vs. 31%, P = 0.05). Of 10 potential interventions 6 were rated by a majority of respondents as "very helpful": better tasting medications (81%); longer dosing intervals (72%); medications that did not require refrigeration (63%); access to 24-h telephone advice (62%); a follow-up call from a health care provider (57%); and a pill organizer (56%). CONCLUSIONS: Caregivers' perceptions that adherence is too difficult or concerns about loss of privacy may affect their ability to adhere to complicated medication regimens. Caregivers felt that the most helpful interventions would be modifications to improve the convenience and palatability of medications and increased access to medical advice.

School-related issues among HIV-infected children.

OBJECTIVE: Many children with human immunodeficiency virus (HIV) infection are surviving long enough to reach school age. This study describes issues related to school attendance and disclosure of HIV infection in a population of HIV-infected children. METHODS: A statewide pediatric HIV surveillance system was used to collect data on school-age (>/=5 years old) HIV-infected children. In addition, HIV clinic nurses familiar with the child's history participated in a cross-sectional survey that collected information on school-related issues during the 1993-1994 school year. RESULTS: Of the 92 school-age children, only 3 were too ill to attend school. Another 5 children were home-schooled. Of the 84 who attended school outside the home, 25% had severe symptoms of HIV infection (Centers for Disease Control and Prevention [CDC] clinical category C). Absence from school ranged from less than 2 weeks during the year for half of the children (51%) to more than 8 weeks for 9 children (12%). Twenty-nine percent of the children received medication in school, usually administered by the school nurse. Over two thirds of the 50 children ages 5 to 10 years had not been told that they had HIV infection. Only 1 of the 20 children more than 10 years of age was not aware of her HIV infection. For 53% of the children attending school, no school personnel had been informed of the child's HIV infection. Administration of HIV medications at school, age of child, and treatment at one particular HIV clinic were associated with the parents' decision to inform school personnel. In the 47% of cases where the school had been informed, school nurses were most frequently notified, followed by principals and teachers. CONCLUSION: Only 3% of school-age children were too ill to attend school, and almost all were enrolled in public schools. The number of HIV-infected children reaching school age will continue to grow, and public schools will bear the responsibility for educating these children. Health care providers will increasingly be called upon for guidance by both educators and families to assure that HIV-infected children receive the best education possible.

Invasive pneumococcal infections in human immunodeficiency virus-infected children.

Invasive pneumococcal infection (IPI) is the most common serious bacterial infection in human immunodeficiency virus (HIV)-infected children. Data from a population-based pediatric HIV surveillance project were used to determine the incidence of IPI in HIV-infected children and to conduct a case-control study assessing potential risk factors for IPI in HIV-infected children. There were 50 episodes of IPI and a cumulative incidence of 6.1 cases/100 patient-years through age 7 years. Children with IPI were more likely to have a prior AIDS diagnosis (odds ratio, 4.2; 95% confidence interval, 1.2-15.1) and higher levels of IgG and IgM (P=.01) than were controls. In a separate case-control study, the manifestations of IPI in HIV-infected children were compared with those in HIV-negative controls. Focal complication rates in the 2 groups did not differ; however, HIV-infected children were less likely than controls to have leukocytosis (P<.001) and more likely to have isolates with penicillin resistance (P=.03).