The United States spends more than most other countries per capita on maternal and child health (MCH), and yet lags behind other countries in MCH outcomes. Local health departments (LHDs) are responsible for administering various maternal and child health programs and interventions, especially to vulnerable populations. The goal of this study was to identify local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers – positive deviants (PDs) - in Washington, Florida and New York in order to support the identification of strategies that can improve community health outcomes.n = 67), and WA (n = 35), and most LHDs in NY (n = 48) for 2009–2010 from the Public Health Activities and Services Tracking (PHAST) database. We conducted our analysis in 2014–2015. Data were linked with variables depicting local context and LHD structure. We used a cross-sectional study design to identify communities with better than expected MCH outcomes and multiple regression analysis to control for factors outside of and within LHD control.We used MCH expenditure data for all LHDs in FL (We identified 50 positive deviant LHD jurisdictions across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Overall, internal factor variables improved model fit for identifying PD LHD jurisdictions, but individual variables were not significant.We empirically identified LHD jurisdictions with better MCH outcomes compared to their peers. Research is needed to assess what factors contributed to these exceptional MCH outcomes and over which LHDs have control. The positive deviance method we used to identify high performing local health jurisdictions in the area of maternal and child health outcomes can assist in better understanding what practices work to improve health outcomes. We found that funding may not be the only predictor of exceptional outcomes, but rather, there may be activities that positive deviant LHDs are conducting that lead to improved outcomes, even during difficult financial circumstances. This method can be applied to other outcomes, communities, and/or services. The U.S. spends more on maternal and child health (MCH) services than most of the world;  however,Mays, et al. noted that the ability of LHDs to meet community needs varies with spending levels, identifying funding as a major contributor to LHD performance . This evLHD leaders, nonetheless, use a variety of strategies to minimize negative financial impacts,  with somSince the articulation of the ten essential public health services, researchers have used a variety of strategies to assess public health system performance including grant reporting requirements, program evaluations, and community health assessments . These aPositive deviance is a framework that identifies and learns from units that perform beyond expectations. In public health, positive deviance originated from the concept that interventions could be designed around uncommon beneficial health behaviors that some community members already practiced,  and morewhy.According to Pawson  a primarcontext in which they find themselves [Numerous factors influence population health outcomes, over which LHD administrators have varying levels of immediate control. Factors over which LHD leaders have limited or no control - the emselves  - may inemselves , 20. LHDmechanisms [Factors over which LHD leaders have some control include the activities they choose to undertake - chanisms  used to Outcomes result from a combination of context and mechanisms (context + mechanism = outcome) [outcome) . We idenWe defined positive deviants as LHD jurisdictions with better MCH outcomes compared to peers within their state. We used data compiled within the Public Health Activities and Services Tracking (PHAST) database. The Robert Wood Johnson Foundation (RWJF)-funded PHAST study team (PI. B. Bekemeier) has compiled externally validated measures of public health service production in key public health priority areas including MCH .PHAST is a multidisciplinary, practice-based research collaborative developed in relation to RWJF’s national system of Public Health Practice-Based Research Networks (PBRNs) . The PHAn = 67) and WA (n = 35) and most jurisdictions in NY (n = 48) in our study. We conducted our analysis in 2014–2015 using the most recent data available. Additionally the PHAST database only had complete data available for 2009–2010 and for the three states we included in the analysis. A PHAST dataset similar to ours was used in a study of associations between LHD MCH expenditures and health outcomes [We conducted a cross sectional study, and we included complete and fully linked annual data from 2009 to 2010 for all LHD jurisdictions in FL  survey [Profile capture an LHD’s general approach to service delivery as in a range of overall service delivery: limited to comprehensive [We included the following contextual variables in our analysis : total L) survey . The latehensive . For outehensive .Step 1: We regressed Y = α + β1(Z) + e to identify potential positive deviants in each outcome taking into account local contextual factors.Step 2: We added in X variables Y = α + β1(Z) + β2(X) + e to assess how well the models fit when including LHD-controlled variables.Step 3: We conducted a likelihood ratio test (LRT) to evaluate whether the inclusion of the additional variables based on theoretical considerations improved model fit. If the coefficients for the X variables β2 ≠ 0, we examined residuals (e) from the regression in step 2, therefore taking advantage of the variance explained by measurable factors in refining our identification of outliers. β2 ≠ 0 for all of our models except two outcomes in NY where the LRT indicated that β2 did not add anything  to ensure we were obtaining the same positive deviants with and without them. The analysis was robust to the removal of leverage points except for two LHDs each in 2009 and 2010 which were removed from the Florida models for low birth weight, infant mortality rate and late or no prenatal care. The positive deviant observations we identified were largely robust to sensitivity analyses with and without these influential leverage points. The few that were not robustExamining each outcome where lower was better; we identified potential positive deviants as those with studentized residuals less than −1, as they performed better in the outcome than the model predicted (better than their peers). Using a cutoff of −2 was too restrictive and did not allow for variation in LHD context. We identified influential leverage points , across 3 states: WA = 10 (29 %); FL = 24 (36 %); NY = 16 (33 %). Forty-six of 50 LHDs (92 %) performed better than expected in at least one MCH outcome over 2 years, and 32 LHDs (64 %) had 2 or more exceptional outcomes in a single study year. Positive deviant LHD jurisdictions varied by community-type similarly to the pool of LHDs we included in our study: 28 % of positive deviant LHD jurisdictions were from rural communities, 20 % micropolitan, and 52 % metropolitan compared to 25, 23, and 52 % of all LHD jurisdictions respectively. An advisory council reviewed our findings to ensure face validity of the results.context variables were significantly associated with the outcomes of interest  that had exceptional maternal and child health outcomes compared to their in-state peers – positive deviants (PDs) - in Washington, Florida and New York. Additionally, we hoped to identify the combination of ocations . The finutcomes, , 21 is smechanisms used by exceptional LHD jurisdictions improved model fit for identifying positive deviants; however, none of the individual mechanism variables were significant. This suggests that in-depth study of the specific mechanisms used by LHDs in these exceptional communities could point to underlying best practices that we did not measure and that may not currently be well understood among researchers and practice leaders.We also found that the LHDs in positive deviant communities may have strong partnerships with local providers and community-based organizations that have led to exceptional outcomes. There is some evidence that partnerships may be associated with better health outcomes and LHD performance;  however,American Journal of Preventive Medicine focused entirely on public health workforce issues and highlighted the need for a better-trained workforce capable of effectively addressing community health needs in a highly volatile public health environment [A recent issue of the ironment . Many LHironment  requirinironment . PositivSome LHDs in positive deviant jurisdictions may also be using robust systems of data collection and reporting to identify MCH priorities specific to their communities. Nationally, most LHDs conduct community health assessments,  but the context and mechanisms that has led to exceptional outcomes in the jurisdictions we identified is essential for identifying these modifiable factors and best practices in MCH. An in-depth analyses of these positive deviant jurisdictions would generate evidence regarding why some communities have better outcomes, even in resource-constrained environments, and provide critical guidance to LHD leaders and community partners in other jurisdictions. This finding led us to conduct in-depth interviews with LHD staff to learn more about activities that may influence MCH outcomes but were not captured in the quantitative analysis [Additional research about the combination of analysis .Limitations of our study include regression models that may have been underpowered given our small sample size. Our approach helped mitigate this by including all LHDs with complete data for each study state. Our quantitative analysis may also have led to inclusion of some LHDs that met our cut off of exceptional by chance. We erred on the side of inclusion in order to have sufficient examples of positive deviants by community type as small, rural LHDs are often excluded from analyses of LHD activities. The cross sectional nature of our study limited the ability to consider high performers over time; however comparing within states allowed for some parity in the comparisons. To obtain as robust a sample as possible, we included only LHDs that were positive deviants for multiple outcomes and/or years. We intend to update the analysis with additional years of data and additional states in the future.mechanisms that lead to exceptional outcomes.In this project, we identified local health department jurisdictions (LHDs) that had exceptional maternal and child health outcomes compared to their in-state peers – positive deviants (PDs) - in order to support the identification of strategies that can improve community health outcomes. Our research demonstrated a means to empirically identify communities with exceptional MCH outcomes while taking local context into consideration. Such identification lays the groundwork for conducting in-depth analyses with positive deviant LHDs in order to understand what local MCH practices lead to exceptional outcomes. The empirical positive deviance method presented here offers an initial and necessary step in discovering the kinds of practices high performing LHDs and their communities have in place that lead to better MCH outcomes than their peers. Further study is needed to identify and measure the LHD, Local Health Department; MCH, maternal and child health; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)


IWM). Although cultivars with high competitive potential have been identified amongst cereal crops, competitiveness has not traditionally been considered a priority for breeding or farmer cultivar choice. The challenge of managing herbicide‐resistant weed populations has, however, renewed interest in cultural weed control options, including competitive cultivars. We evaluated the current understanding of the traits that explain variability in competitive ability between cultivars, the relationship between suppression of weed neighbours and tolerance of their presence and the existence of trade‐offs between competitive ability and yield in weed‐free scenarios. A large number of relationships between competitive ability and plant traits have been reported in the literature, including plant height, speed of development, canopy architecture and partitioning of resources. There is uncertainty over the relationship between suppressive ability and tolerance, although tolerance is a less stable trait over seasons and locations. To realise the potential of competitive crop cultivars as a tool in IWM, a quick and simple‐to‐use protocol for assessing the competitive potential of new cultivars is required; it is likely that this will not be based on a single trait, but will need to capture the combined effect of multiple traits. A way needs to be found to make this information accessible to farmers, so that competitive cultivars can be better integrated into their weed control programmes.Competitive crop cultivars offer a potentially cheap option to include in integrated weed management strategies ( In this study, control of weeds ranged from 59% to 96% when compared to plots where the crop had been removed by cultivation prior to May.Variability between cereal cultivars in their ability to resist yield losses from weed competition was demonstrated in the 1970s. Four winter wheat cultivars were compared for their ability to withstand competitive pressure, with a range of 28–39% reduction in yield when es Moss, . Wicks e, et al.  demonstrTriticum aestivum L.), barley (Hordeum vulgare L.) and oats (Avena sativa L.). Allelopathy has more recently started to attract interest in cereals and has been demonstrated to be of importance in both wheat and barley in determining competitive outcomes   cultivars of wheat. Whilst lower yielding in weed‐free situations, taller cultivars were typically better tolerators of weed pressure and suppressors of weed growth  across all years of study. Bread wheat and durum wheat (Triticum durum) cultivars that were more competitive against L. rigidum also had high vigour, acquiring higher biomass at the seedling stage , and their competitive strength was partially attributed to corresponding root growth and the increased water uptake early in the season. Other studies have also found that wheat cultivars with late spike emergence were less tolerant of weed competition and suffered greater yield loss when grown with weeds . Rate of tiller production and final tiller number are morphologically plastic and density dependent; tiller numbers reduced with increased inter‐ and intraspecific competition. This has been demonstrated in wheat, barley and oats and can vary between cultivars  are more likely to suffer mineral deficiencies, and there could be more potential in developing cultivars that are more competitive for belowground resources. In an experiment comparing the relative importance of aboveground and belowground traits of et al., et al., et al., et al., et al., The majority of traits discussed above are not independent of one another and have implications for other plant functions in addition to weed competition, including yield potential and tolerance of stress. The higher potential yields of semidwarf modern cultivars have been achieved through changes in partitioning of carbon and nitrogen between stem and grain and more erect canopies with improved light use efficiency . Predicting the relative benefit of contrasting combinations of cultivar, sowing date and seed rate will require the application of mechanistic models of crop/weed competition (Kropff & Spitters, et al., et al., et al., The idea of developing a ranking system for competitiveness of cultivars has been around for the past two decades. A screening protocol that predicts the competitive ability of cultivars would ideally be based on simple and rapid assessment of a selection of suitable traits (Cousens & Fletcher, et al. (Hansen et al.  were sucet al., et al., et al., et al. (Competitive traits vary in their impact between years (Christensen, , et al.  found th, et al. .Many studies have illustrated the variation in competitive ability between cultivars. Traits that contribute to increased suppressive ability have been established, although the importance of these traits can vary between years. Further work would assist in clarifying the nature of the relationships between traits and competitive ability across sites and seasons. A rigorous screening protocol that ranks cultivars in a system similar to ranking for disease resistance would be most beneficial to farmers. Advice on how to best utilise competitive cultivars as part of an integrated weed management strategy would give growers more confidence in applying this approach.


CTNNB1 (gene encoding β‐catenin). Mouse studies have shown that only pituitary embryonic precursors or adult stem cells are able to generate tumors when targeted with oncogenic β‐catenin, suggesting that the cell context is critical for mutant β‐catenin to exert its oncogenic effect. Surprisingly, the bulk of the tumor cells are not derived from the mutant progenitor/stem cells, suggesting that tumors are induced in a paracrine manner. Therefore, the cell sustaining the mutation in β‐catenin and the cell‐of‐origin of the tumors are different. In this review, we will discuss the in vitro and in vivo evidence demonstrating the presence of stem cells in the adult pituitary and analyze the evidence showing a potential role of these stem cells in pituitary tumors. Stem Cells2016;34:268–276The existence of tissue‐specific progenitor/stem cells in the adult pituitary gland of the mouse has been demonstrated recently using genetic tracing experiments. These cells have the capacity to differentiate into all of the different cell lineages of the anterior pituitary and self‐propagate in vitro and can therefore contribute to normal homeostasis of the gland. In addition, they play a critical role in tumor formation, specifically in the etiology of human adamantinomatous craniopharyngioma, a clinically relevant tumor that is associated with mutations in  In this concise review, we aim to discuss the accumulated evidence suggesting the presence of PSCs within the adult pituitary gland and the potential role of these cells in normal organ homeostasis. Additionally, we will elaborate on the data supporting the existence of CSCs in human and mouse tumours with particular emphasis to the role of pituitary PSCs in the aetiology of human craniopharyngioma.In recent years, solid evidence has emerged for the existence of a tissue‐specific population of undifferentiated progenitors or stem cells within the hormone‐secreting anterior pituitary gland . These long‐lived, undifferentiated cells have the capacity to directly commit or generate daughter cells of three main progenitor lineages, characterized by respective expression of three transcription factors, PIT1 (POU1F1), TPIT (TBX19), and SF1 (NR5A1). Expression of these factors is a necessary step toward differentiation into a hormone‐secreting cell in the pituitary, where: PIT1‐positive cells give rise to GH‐expressing somatotrophs, PRL‐expressing lactotrophs, and TSH‐expressing thyrotrophs (PIT1‐cell lineage); TPIT‐positive cells give rise to ACTH‐expressing adrenocorticotrophs and melanotrophs; and finally, SF1‐positive cells give rise to LH‐ and FSH‐expressing gonadotrophs. The precise regulation of these populations ensures effective homeostasis and is dynamic throughout life, largely dependent on physiological demand. This can also be influenced by damage to pituitary tissue or to any of its target endocrine organs, and can be affected during disease states.Similar to organ‐specific stem cells, analyses of many tumors and cancers have revealed the presence of multipotent cells, often thought to drive tumor formation. Conceptually, cancer stem cells (CSCs) are characterized by two features: (a) self‐renewal and (b) capability to generate the mass of the tumor/cancer cells in a cell‐autonomous manner . This definition does not relate to their potential origin, whether these are normal tissue‐specific somatic stem cells, progenitors or differentiated cells. Experimentally, CSCs are determined by the identification of specific cells able to propagate a tumor/cancer and replicate its cellular composition in a relevant experimental setting, ideally in situ, either by lineage tracing or orthotopic transplantation. These have been isolated from leukemia and solid tumors Many of the properties of CSCs are shared by normal tissue‐specific stem cells; slow cycling status, self‐renewal, and differentiation capacity and even resistance to cytotoxic drugs. For some tumors, it has been shown that normal stem cells are transformed into CSCs when targeted to express oncogenic proteins. For instance, stem cells of the intestinal crypt become CSCs when the WNT/β‐catenin pathway is over‐activated In this concise review, we aim to discuss the accumulated evidence suggesting the presence of PSCs within the adult pituitary gland and the potential role of these cells in normal organ homeostasis. Additionally, we will elaborate on the data supporting the existence of CSCs in human and mouse tumors with particular emphasis to the role of pituitary PSCs in the etiology of human craniopharyngioma. For more detailed discussion, we refer the reader to other recent reviews Sca1, Oct4, and NanogTwo initial studies revealed postnatal mouse pituitary populations with in vitro self‐renewal capabilities; one population was shown capable of forming adherent colonies, and was characterized by the uptake of the fluorescent dipeptide β‐Ala‐Lys‐N ε AMCA (AMCA is 7‐amino‐4‐methylcourmarin‐3‐acetic acid) and included cells expressing S100 calcium‐binding protein B (S100β) Although SOX2‐positive cells do not express any hormone and SOX2 expression does not overlap with expression of the committed progenitor markers, the population has a heterogeneous nature in terms of properties, where only a low proportion (2.5%–5%) are shown to be capable of in vitro self‐renewal. This suggests that perhaps not all SOX2‐positive cells in the pituitary have stem cell capacity, or that our current assay methodologies select a subpopulation, perhaps at a particular primed state or phase of the cell cycle, and maybe the remainder of the SOX2‐positive cells would flourish under alternative conditions. Both cases highlight the need for better marker characterization, whose overlapping combination would possibly define the true pituitary stem cell, poised for activation. Purifying pituitary cells based on S100β expression using S100β‐GFP transgenic animals enriches in vitro colony formation, a property lying exclusively within the SOX2‐positive component + cells on either side. Additionally, SOX2+ cells are found in the parenchyma of the anterior pituitary, often in groups distributed among hormone‐secreting cells , that facilitates formation of homophilic tight junctions +/S100β+/CAR+ cells, both in the marginal epithelium and throughout the parenchyma The location of cells expressing SOX2/S100β has also been proposed to enable stem cell function. The marginal zone, lining the remnants of Rathke's pouch lumen, retains an epithelium of SOX2Sox2, but will not be active until the administration of tamoxifen, allowing temporal control of recombinase action. Although the expression construct of these two strains is not identical, the expression of CreERT2 faithfully reproduces that of Sox2 in both. We used one of these mouse strains to lineage trace cells expressing Sox2 beginning at different stages, both during gestation and postnatally Sox2‐expressing cells from embryonic stages Sox2‐expressing cells gave rise to all committed progenitor cell types , and thus all hormone‐secreting cells types of the anterior lobe . One limitation of this assay is that it does not distinguish between a multipotent population of Sox2‐expressing cells and the possibility that several oligopotent or unipotent populations of Sox2‐expressing cells exist, collectively giving rise to all differentiated lineages. To demonstrate that the population of SOX2+ cells is not depleted, as would be expected by transit‐amplifying progenitor cells, we activated CreERT2 in SOX2+ cells by postnatal tamoxifen administration, enabling expression of R26R‐EYFP and cells were traced for 6 months. At the end of this period, descendants of SOX2+ cells were flow sorted for EYFP expression and cultured to assess clonogenic potential, a property contained only among SOX2+ cells. Most of the cells with clonogenic potential were residing in the EYFP positive fraction, suggesting that SOX2 cells are either long‐lived hence persisting after their initial labeling, or maintained as a self‐renewing pool of stem cells derived from the originally labeled SOX2+ cells. If SOX2+ cells were a population of transit amplifying cells with short‐term uncommitted proliferative potential, we would expect that this population would become depleted and lose properties associated with the stem cell state, such as clonogenic capacity, following their commitment/differentiation. Complementing this, following postnatal tamoxifen inductions we found a significant population of uncommitted SOX2+ and SOX9+ cells up to a year following tamoxifen administration. The above experiments demonstrate the presence of a long‐lived population that retains pituitary stem cell properties throughout normal life.Despite a plethora of identified markers, until recently, there was no evidence to support that pituitary stem cells function as such in vivo. This changed with the generation of two similar genetic tools, inducible mouse strains expressing CreERT2 under the regulation of the SOX2 promoter generated by the Hochedlinger and Martinez‐Barbera/Pevny labs Several groups have reported the presence of putative CSCs in pituitary adenomas isolated from mice and humans A summary of the experimental approach used is as follows Fig. : tumors Overall, these reports have provided evidence supporting the existence of CSCs with tumor‐propagating capacity. However, several questions remain unanswered, among them: (a) Do CSCs arise from PSCs? PSCs and CSCs share similar properties, for instance in vitro self‐propagation and differentiation potential, and it is likely that PSCs are also chemoresistant, since a side population that is enriched for PSCs can be purified from normal mouse pituitaries using the vital dye Hoechst efflux assay In our opinion, questions (b) and (c) are very relevant because they will assess the effects of the culture conditions and cellular microenvironment on the tumorigenic capacity of normal PSCs and of CSCs. Although generally speaking normal stem cells do not form tumors, the potential of tumor development is considered as one of the risks of the use of stem cells in regenerative medicine Similarly, the expansion of clonogenic pituitary CSCs before transplantation that has been carried out in all published reports could select for specific cell populations present in the tumor or even induce genetic or epigenetic changes that could account for the tumorigenic effect described. Fresh cell suspensions from pituitary tumors that have not been cultured in vitro should also be tested in transplantation experiments. In this regard, a recent report has shown how critical the influence of the in vitro manipulations may be on the final outcome of the transplantations. Human glioma tumor cells cultured in stem cell‐promoting medium generate tumors of human origin in orthotopic xenotransplantations, whilst fresh cell suspensions induce tumors of mouse origin, suggesting a paracrine influence on the host tissue Recent studies of a type of pituitary tumor called adamantinomatous craniopharyngioma (ACP) have revealed a critical role for mutated PSCs in promoting tumorigenesis through paracrine activities.CTNNB1, the gene encoding β‐catenin, have been identified in the majority of ACP samples ACPs are aggressive tumors of the sellar region due to their tendency to infiltrate the brain, optic pathways and nearby vascular structures Cre/+; Ctnnb1lox(ex3)/+Hesx1 mouse model) is sufficient to form tumors that are very similar to human ACP It has been shown that the expression of a degradation‐resistant form of β‐catenin in Rathke's pouch (RP) precursors in the mouse /+Sox2 mouse model) also results in tumors that are similar to human ACP + PSCs, a technique referred to as “genetic tracing” + cell are targeted to express simultaneously oncogenic β‐catenin and yellow fluorescent protein (YFP), the former is the oncogenic stimulus and the latter allows identification of all the daughter cells derived from the mutated SOX2+ PSCs. These experiments have revealed that the typical cell clusters derive from SOX2+ cells, but intriguingly, the bulk of the tumor mass does not. In other words, mutated SOX2+ cells are not transformed into CSCs by oncogenic β‐catenin; mutated SOX2+ PSCs generate cell clusters that have the capacity to induce tumors in a paracrine fashion so that the tumor cells are not derived from SOX2+ cells Further studies in mice, aiming to understand the role of PSCs in generation of ACP tumors have been performed. Expression of oncogenic β‐catenin specifically in SOX2nnb1loxex/+ mouse CSCs carry mutations in oncogenes and tumor supressors, which are mostly responsible for their tumorigenic behavior. The identification of these mutations in human neoplasms is of much clinical relevance, as this is the first step toward the development of specific therapies to kill these cells that drive neoplasia. The better understanding of the early steps that lead to the generation of CSCs is also relevant, as this may lead to development of early diagnostic tools that would allow the treatment of human neoplasms at incipient stages, possibly where they are more vulnerable to anti‐cancer therapies. The pertinent question is what drives the oncogenic transformation and generation of CSCs?An excess of growth factors/mitogenic signals may lead to cell transformation. For instance, by over‐activating the same pathways affected by oncogenic mutations  resulting in increased cell proliferation, DNA replicative stress, DNA damage, and eventually genetic mutations conferring tumorigenic capacity in transformed cells. Compatible with this notion, the synthesis and secretion of human TGF‐alpha by rat fibroblasts results in the loss of anchorage‐dependent growth in vitro and tumor formation in nude mice Notch1 in mouse skin epidermis Notch1). Additionally, the expression of a constitutively active form of MEK1, activating the Erk mitogen‐activated protein kinase (MAPK) pathway, in mouse epidermis results in skin polyps which are mostly formed by wild‐type cells for MEK1 Genetic evidence in mouse has also shown that tumors/cancers can develop in a noncell autonomous manner, whereby the bulk of the tumor mass consists of cells that do not carry the oncogenic mutations. For instance, conditional deletion of Two recent manuscripts have shown that cell transformation can occur in a paracrine manner in vivo. In a hepatocellular carcinoma mouse model, it was demonstrated that deletion of the tumor suppressor gene p53 specifically in hepatic stellate cells induces epithelial tumors that are mostly wild type for p53 We think that the studies cited above provide support to the potential tumor‐inducing properties of the β‐catenin‐accumulating cluster cells in mouse and human ACP. These cluster cells express members of the TGF, FGF, and PDGF families of growth factors among many others. In addition, the extracellular matrix (ECM) is also altered around the clusters Murine and human studies have provided support to the idea that CSCs play a role in pituitary tumorigenesis. Moreover, analyses of a mouse model for human craniopharyngioma have revealed that paracrine signaling may be critical in tumour initiation. It may be argued that paracrinicity is only of relevance to the understanding of benign tumours. However, once tumours progress into malignancy, cancer cells may be self‐sufficient and able to generate the trophic factors needed for survival and growth, independent of the initial signals that cause cell transformation. Even if this latter scenario is real, elucidating these initial stages of tumorigenesis will provide with a better grasp of the pathways that initiate these malignancies. Such knowledge could translate to the discovery of early diagnostic biomarkers, which could detect the cancer at incipient stages of development, when tumour cells are more susceptible to anti‐cancer treatments. Efforts to better characterise and understand the potential of normal stem cells of the pituitary gland can only enhance our ability to comprehend their possible role in pituitary tumour formation and propagation, which can lead to more effective prognosis and treatments.J.P.M.B. and C.L.A. wrote the manuscript and approved the final version for publication.The authors indicate no potential conflicts of interest.


Protection from care–related catastrophic expenditures through equitable access to affordable health services is the hallmark of a pro–poor health policy . Over thAll–inclusive, community–led primary health care is the bedrock of the health services in Ethiopia. Notwithstanding its low–income status, the country has gradually but radically expanded access to a spectrum of health services and essential medicines. More than 38 000 all–female Health Extension Workers (HEWs) have been deployed to more than 16 500 community health posts across the country to lead a novel primary health care– Health Extension Program (HEP). Launched in 2003, the HEP has brought simple, cost–effective and locally–desired health interventions  close toEyeing Universal Health Coverage (UHC), Ethiopia has intensified its implementation of pro–poor initiatives. It is currently rolling out the second generation HEP to meet the growing needs of the community. The second generation program adds more interventions targeted on emerging infectious diseases, common non–communicable diseases and, mental health. It also includes deepening the partnership with the community even beyond primary care level. The government has put a mechanism to stimulate innovations improving access to and utilization of health services by the poor .Whereas the HEP remains country’s priority, considerable efforts have been made to improve the higher levels of health care. For example the number of health centers and hospitals in the country has sharply increased by 350% and 150%, respectively between 2004 and 2015. Correspondingly, an enormous development has been made in human resources for health through increasing the number of medical universities. Tuition fees and lodging expenses have been covered by the government in all public medical universities and colleges; and a pay–by–service strategy has been implemented whereby health professionals eventually return the cost by rendering health services at public health facilities. As a consequence, the number of medical doctors graduated annually in the country greatly increased, from about 150 in 2004 to 3000 in 2016. Similarly, unprecedented increase has been seen in the number of other critical cadres including mid–wives and specialized nurses. To achieve the right balance between public health and clinical interventions, the country trained innovative cadres like public health officers and integrated emergency surgical officers. Integrated emergency surgical officers perform major surgeries for emergency obstetric and surgical conditions, close to where the rural poor live .In 2006, Ethiopia established Pharmaceutical Fund and Supply Agency (PFSA) with the primary mission of expanding access to medicines, vaccines and laboratory services. Following its launch, PFSA has steered a comprehensive health supply chain management in the country. The agency has used pooled procurement strategy as a vantage to gain economies of scale. It has procured refrigerated trucks, constructed 17 cold room–installed hubs, at least one within 180 km radius of each health facility across the country to maximize the efficiency gains in pharmaceuticals distribution. These gains in efficiency have led to a huge decline in retail prices of medicines with consequential drop in the out–of–pocket expenditure [A complete set of care for priority maternal and child health interventions , infectious diseases  and diseases of poverty  are provided free of charge at all public service delivery points. Community needs, the ability to pay and potential population level impacts were factored in defining program services and medicines. The strategic removal of financial barrier to care for maternal and child conditions and major infectious diseases has significantly contributed to Ethiopia’s recent achievements including meeting all health MDG targets.Improved access to affordable health care embraces the budding non–communicable diseases including diabetes mellitus and cardio–vascular diseases. For instance, mark–up has been removed from insulin and medicines used for common malignant conditions. To address the growing demand and expectations of the public and the limited outlets for medicines and supplies for non–prioritised interventions, Ethiopia is currently rolling out community pharmacies in cities and big towns across the country. Similar to health facility–embedded pharmacies, community pharmacies provide medicines at substantially reduced prices.Ethiopia has established a stringent regulatory system to guard the poor against low standard and counterfeit medicines. Evidence shows that the comprehensive supply management and robust regulation has effectively blocked entry of counterfeit medicines into the market and significantly reduced stock–outs and wastage of medicines . FurtherAlthough access to health care has been expanded, significant geographic disparities persist in regards to health care utilization and health outcomes. The inequity in health care is largely attributed to the lifestyles of communities. Pastoralist communities in Ethiopia are generally lagging behind in major health indicators. Further, differences in service uptake exist within communities, denting Ethiopia’s pro–poor, pro–equity route towards UHC.The health sector is currently providing differentiated support to communities and regions left behind. More broadly, to ensure the universality of health coverage and prevent financial impoverishment, it is scaling up the successful Community–Based Health Insurance pilot for citizens in informal sector, where the poor predominate. Also, the country is introducing Social Health Insurance targeted at employees of formal sector for full coverage. Both schemes offer a package of clinical services without cost ceiling upon services provided at any domestic health facility. The two schemes are expected to cover 80% of the population within the next 5 years and will be consolidated as a single payer system within the next 10 years.In conclusion, Ethiopia advances locally–tailored, multi–faceted pro–poor approaches to ensure UHC building on its successful transformation of the health sector in the last two decades and the achievement of key health MDG targets. Broader plan for inclusive economic development, effective implementation of primary health care, expansion of access to medicines and introduction of health insurance is the pathway towards UHC for all citizens. Concurrently, quality improvement initiatives and pushing non–communicable diseases to the forefront of the agenda are under way. More importantly, levelled partnership of the government with the community across the spectrum of health care ensures sustainability and community ownership of the system. We believe that these approaches to health care could propel Ethiopia to expedite its efforts to achieve the sustainable development goals including UHC within a short time.


Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies.We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007–2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013.The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births  189 to 249) in the period 1991–1995 to 119 deaths (95% CI 105 to 132) in the period 2006–2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide–treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses.Malawi provides a strong example for countries in sub–Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community–based delivery platform, can lead to significant reductions in child mortality. Since 2010, Malawi has been on track to reach Millennium Development Goal (MDG) 4 and is one of the first countries in sub–Saharan Africa to have reached the target .Malawi showed commitment to accelerating child survival and development through the establishment of the Accelerated Child Survival and Development policy in 2006 which was implemented through the Integrated Management of Childhood Illness (IMCI) five year strategic plan (2006–2011) and the Strategic Plan for Child Survival in 2007. The strategy aimed to reduce childhood morbidity and mortality by two–thirds between 2000 and 2015, and it focused on the scaling up of high impact interventions including integrated community case management of childhood illnesses and newborn care (iCCM) .From 2008 iCCM was scaled up nationally under the coordination of the Ministry of Health with the support of partners in different districts including UNICEF, WHO, Save the Children, and others. UNICEF worked as an implementing partner in ten of twenty–eight districts throughout the country through the Catalytic Initiative (CI) Integrated Health Systems Strengthening (IHSS) programme  in late 2007 with the main aim of assisting low and middle–income countries in Central, West and Southern Africa with high maternal and child mortality rates, including Malawi, to scale up services to children and pregnant women . The CI HSAs have played a central role in the delivery of health services in Malawi since the 1960s, delivering an increasingly broad array of services at the community level . InitialThe analyses undertaken were part of a multi–country retrospective evaluation of the CI programme. The selection of the 10 CI districts for UNICEF support was undertaken jointly by UNICEF and the Ministry of Health  platform (particularly related to integrated community case management (iCCM) of malaria, pneumonia and diarrhoea):• Communication and social mobilisation on iCCM (through job aids)• Recruitment, selection and training of HSAs• Basic supplies for HSAs • Supervision (quarterly mentorship and review meetings on iCCM)• M&E (support to M&E officer at IMCI unit)Renovation of three training centers:• Review of health surveillance curriculae to include new competencies • Purchased sachets of oral rehydration salts (ORS) and zinc tablets, cotrimoxazole, sulfadoxine–pyrimethamine and artemisinin–combination therapies (ACTs) for village clinicsIntegrated Management of Childhood Illnesses (IMCI):• Training of nurses and clinicians in IMCIMalaria prevention:• Supply and distribution of ITNs for pregnant women and children under five yearsHealth promotionInfant and young child feeding:• Promotion of early initiation and exclusive breastfeeding for six months• Screening for severe and acute malnutritionWASH:• Education on safe water, sanitation and hygieneWe used birth and death history data collected from women aged 15 to 49 years in nationally representative surveys: namely the 2000 Demographic and Health Survey (DHS), 2004 DHS, 2006 Multiple Indicator Cluster Survey (MICS), and the 2010 DHS to calculate under–5 mortality. The surveys covered 14 213, 13 664, 30 553, and 24 825 households respectively.Online Supplementary Document(Online Supplementary Document)). All surveys provided cross–sectional data on intervention coverage in their respective years. Full survey data sets with district sampling weights were used for the analysis. For further details on the surveys included in the analysis see Table s1 in Online Supplementary Document(Online Supplementary Document). Adjustments were made to align indicator definitions across the DHS, MICS and LQAS surveys (Section B in Online Supplementary Document(Online Supplementary Document)).For analysis of intervention coverage we used standard indicator definitions  for 11 i). For further details on the contextual analysis see Panel s1 in Online Supplementary Document(Online Supplementary Document).Contextual information about child health policies, CI implementation and other relevant child health programmes was obtained through a desk review of documents and databases obtained during a 10–day country visit (August 2013). The information gathered from these sources was used to compile a policy and programme timeline (Online Supplementary Document(Online Supplementary Document)) [Online Supplementary Document(Online Supplementary Document)).We used a direct method for estimating under–5 mortality based on the synthetic cohort approach ,19. Undecument)) . A serieFor analysis of intervention coverage, the 10 CI districts were treated as one stratum. We re–calculated all relevant coverage indicators from each survey data set in order to obtain the confidence intervals around the estimates. We then assessed whether there was a significant difference in the AAC in coverage for 11 indicators between the pre–CI period (2000–2006) and the CI implementation period (2006–2013) for the 10 CI districts. The 95% confidence intervals (95% CI) around the AAC on the log scale were based on standard deviations calculated using the delta method for the log function of a proportion.The 95% confidence intervals were used to assess whether the changes were significantly different between pre–CI and CI periods. In order to check the hypothesis that the simultaneous national scale up of iCCM would result in similar coverage change between CI and non–CI districts (supported by other partners), we calculated AAC in intervention coverage in CI and non–CI districts between 2000 and 2010 (data for the non–CI districts was not collected in the 2013 LQAS).To assess the contribution of iCCM by HSAs, data relating to care and treatment sought for fever, suspected pneumonia and diarrhoea by place of treatment were extracted from the available household surveys. The 2006 MICS only collected data on place of treatment for suspected pneumonia but not for diarrhoea or fever [The sampling design of the household surveys such as regional and rural/urban stratification, clustering at enumeration areas and sampling weights  were taken into account. We used Stata (version 12) for these analyses .Online Supplementary Document(Online Supplementary Document)).An attempt to quantify the association between change in contextual factors and intervention coverage with change in under–5 mortality in a multivariate analysis did not yield meaningful results due to the limited number of data points for macroeconomic contextual variables (Section D in Online Supplementary Document(Online Supplementary Document)) and interpolated changes in coverage from the MICS 2006, DHS 2010 and LQAS 2013. We present the estimates of lives saved in 2013, relative to 2008 when CI implementation began, and used the LiST model to investigate the extent to which the declines in child mortality could be attributed to changes in intervention coverage. We also considered the proportion of deaths averted between 2000 and 2008 using our measured baseline mortality and coverage data from the DHS 2000, MICS 2006 and DHS 2010 to compare results between pre–CI and CI periods. The LiST modelling methods have been widely published, including discussion of the limitations which are particularly related to the lack of population–based coverage data for certain key interventions [We used the Lives Saved Tool (LiST)  to forecventions –24.Online Supplementary Document(Online Supplementary Document). The analysis was done with the computer programme Spectrum/ Lives Saved Tool, version 5.04. The study received ethical approval from the ethics committee of the South African Medical Research Council (EC021–9/2012).Specific input values used in this LiST application are available in Table s6 in The mortality rate in children younger than 5 years decreased rapidly in the 10 CI districts from 219 child deaths per 1000 live births (95% CI 189–249) in the period 1991–1995 to 119 child deaths per 1000 live births in the period 2006–2010 (105–132) with an average annual change of –4.1%. The mortality decline was similar nationally and in the non–CI districts ), meaning that although coverage levels differed by intervention and by district, the AAC was consistent across the country for each intervention examined.The AAC in coverage for the examined high impact child health interventions in the CI districts compared to the non CI districts between 2000 and 2010 showed no statistically significant difference for any of the indicators  as a denominator  . These eOur results show that Malawi, one of the least developed countries in the world, ranking 170 out of 187 on the Human Development Index in 2012 , has manThe coverage of many priority child health interventions increased significantly since 2000, particularly preventive interventions including IPTp, immunisations and use of ITNs, as well as health behaviours such as early and exclusive breastfeeding and care–seeking for suspected pneumonia. The health interventions that account for the majority of the deaths averted are delivered at village clinic level through both outreach and stimulating increased demand . A number of high impact interventions increased in coverage at a higher rate than prior to the CI implementation. A similar AAC in coverage between 2000 and 2010 was seen in all districts across the country, evidence of the Ministry’s approach of scaling up high impact interventions across the entire country.The contextual analysis provides insight into the lack of difference in mortality and coverage change between the CI and non–CI districts. The implementation of the Strategic Plan for Child Survival and subsequent scale up of iCCM occurred simultaneously across the whole country supported by a collective of partners and donors allocated to each of the 28 districts with a partnership agreement to guide implementation. Although the 10 CI districts were the focus of DFATD support, other donors implemented the same packages of support in the remaining 18 districts.Our findings suggest that several factors worked synergistically to achieve the decreases in child mortality in Malawi. First, these improvements have taken place within a context of strong child health policies and clear leadership of the Ministry of Health, which, although donor dependent, channelled support in a co–ordinated manner to effectively implement national child survival policies ,29,30. TWhile HSAs play a very important role in the health system, the contribution that community level care (through HSAs) has made to child survival should not be overstated. While the 7 percentage point increase in care–seeking at the community level is substantial in a context where care–seeking at this level was 2% at the start of iCCM scale–up and almost non–existent prior to this, it does point to a need for greater efforts to generate demand for community care–seeking. However, it should be noted that there is a theoretical ceiling for treatment of childhood illness at community level since HSAs delivering iCCM services are situated in hard–to–reach areas and therefore not all communities sampled in household surveys will have been exposed to iCCM–trained HSAs. With just over a third of HSAs trained in iCCM, the Government of Malawi and its partners have yet to fully leverage the potential of this service delivery platform. However, this task–shifting needs to be aligned with investments to enable effective supervision and mentorship of this front–line cadre ,34.A strength of this evaluation is that the 10 CI districts are geographically–dispersed across all three regions of the country, thus limiting regional biases. Population–based household survey data on mortality and coverage from all 10 CI districts were available for analysis from the time of implementation of the CI (2006), during the CI period (sampling in 2010), and at the end of the programme (2013). These data were triangulated with an in–country document review to gain a more in depth understanding of the reasons for the quantitative changes in coverage and mortality.Online Supplementary Document(Online Supplementary Document)). Second, due to the mix of methods used to collect contextual data, we are unable to quantitatively estimate the relative contributions of wider changes in the health system and beyond to the reduction of child mortality. However we have followed the approach used in two previous country case studies [There were weaknesses to this evaluation. First, the lack of oversampling to provide district level coverage estimates for all districts in the 2000 DHS. Although the data were aggregated across the two strata (CI and non–CI districts), there could be regional biases from the pre–CI estimates. A sensitivity analysis revealed no significant changes to the AAC comparisons  to run the LiST model.Malawi has achieved remarkable progress in reducing child mortality and a recently released household survey reports a further decline which will almost certainly enable the country to achieve MDG4 . However


Venom immunotherapy (VIT) is the only effective treatment for prevention of further anaphylactic reactions to bee and wasp stings in allergic individuals. A previous national survey carried out in 2006/2007 revealed significant heterogeneity in UK practice This repeat survey was carried out to assess whether publication of BSACI guidelines helped improve the diagnosis and management of HV allergy in the UK National Health Service (NHS).via a web link (www.surveymonkey.com) to all consultant physicians who were members of the BSACI in March 2014. A total of 247 practitioners from 80 UK NHS hospitals were contacted. Respondents were requested to identify their speciality interest as well as whether they were adult or paediatric physicians.The survey questionnaire  responses were received. One hundred and seven (95%) respondents worked in 75 centres across the United Kingdom. Two respondents were from the republic of Ireland and three UK respondents did not divulge their centre of work. One responder was not practising in the United Kingdom at the time of the survey and was therefore excluded from analysis.n = 67/113; 59.3%) carried out VIT. Of these, 64 responses received from 35 UK centres were deemed eligible for analysis.Over half of the respondents of this resurvey (n = 10) were respiratory physicians with an interest in allergy, whilst three were paediatricians with an interest in allergy.Amongst the 64 respondents undertaking VIT, 28 (44%) were adult or paediatric allergists, 21 (33%) were immunologists and 15 (23%) identified themselves as ‘other’ clinicians. A majority of the latter group  respondents managed only adults with allergy, 12 (19%) only treated children, whilst 15 respondents (23%) managed both adults and children at their clinic.Six centres had no patients undergoing VIT, whilst seven had more than 30 patients undergoing VIT at the time of the survey see Fig. . Just ovThe table provided summarizes the clinical practice relating to the diagnosis of HV allergy. About two‐thirds of the respondents use skin prick tests (SPTs) as the first‐line investigation for diagnosis and a majority carried out intradermal tests  and/or component‐resolved diagnostic (CRD) tests (85%) when skin prick and serum‐specific IgE tests do not provide a clear diagnosis. Baseline serum tryptase (bT) measurement is also requested by most respondents (88%) in all patients presenting with a systemic reaction to HV, irrespective of severity.Almost all respondents check the patients' identity at each visit and ensure that changes to medication are regularly documented. Only about 65% of respondents check pulse and blood pressure before every injection. 90% check peak expiratory flow rate (PEFR) prior to VIT injections. Most (88%) monitor patients for a minimum of an hour post‐VIT injection.Most physicians (92%) consider individuals with severe, uncontrolled or brittle asthma unsuitable for VIT. Ongoing beta‐blocker and ACE inhibitor therapy is considered as a contraindication by most , whereas most physicians (88%) are happy to initiate VIT in patients with an elevated bT.The data pertaining to administration of VIT are summarized in the table. The majority prefer conventional up‐dosing protocol (76%) aiming for a maintenance dose of 100 mcg (98%) and administer maintenance injections at a 4‐ to 8‐weekly interval (94%).Conventional protocol  is favoured by most (76%), although rush (4–7 days) and ultra‐rush (1–2 days) up‐dosing are preferred by 22%. Forty percent of respondents routinely use pre‐medication with antihistamines in all patients undergoing VIT, whereas the others only used antihistamines in patients experiencing allergic reactions to VIT.Ninety percent offer VIT for 3 years, whereas the others routinely continue treatment for 5 years.A third and none of the respondents check serum‐specific IgE and serum‐specific IgG4 antibodies to HV, respectively, at the end of the VIT programme. Five percent of the respondents extended VIT on the basis of a positive serum‐specific IgE test to insect venom at the end of 3 years.In the survey carried out in 2006/2007, 53 responses were received in response to 86 online questionnaires (61.6% response rate). Serum‐specific IgE was more frequently used as a first‐line investigation (55%) compared to SPTs (45%). Only half the respondents carried out intradermal tests when initial tests were negative. Fifty‐three percent checked bT in individuals with systemic reactions to insect venom. Ninety‐two percent preferred conventional up‐dosing protocols for VIT and 56% carried out VIT for 3 years.P = 0.05, chi‐square test, 1 df), in the use of intradermal tests when skin and specific IgE tests are not conclusive  and in testing baseline tryptase levels when an individual presents with a systemic reaction to insect venom .Since the last survey, there has been a statistically significant improvement in the use of skin tests as first line of diagnosis , although the absolute number of responses was lower (53 responses). Of the respondents, 48 (85%) carried out VIT at their centre Although the results of the current survey are not directly comparable with the results from the 2006/2007 study Box 1There has been a significant increase in the number of practitioners who carried out SPTs (66% vs. 45% in 2006/2007), IDTs (80% vs. 50% in 2006/2007) and check bT (88% vs. 47% in 2006/2007) in keeping with the BSACI guidelines.A majority of practitioners offer VIT to patients with an elevated bT.Component‐resolved diagnosis has become an invaluable tool enhancing the accuracy of diagnosis, particularly in patients with dual sensitization to bee and wasp venoms Our data have also highlighted significant deviations from recommendations made in the BSACI guideline regarding diagnosis of HV allergy see Box .Box 2One‐third do not use SPTs as the primary diagnostic tool, and about 20% do not carry out IDT at their centre when SPT and serum‐specific IgE are negative.62% of the respondents use concentrations up to 300 mcg/mL for SPTs and 15% use up to 10 mcg/mL for IDTs, which are higher than those recommended in the BSACI guideline12% of respondents do not check bT in all patients with a systemic reaction to HV.12% do not monitor patients for an hour after administration of VIT injection.35% do not measure pulse and blood pressure prior to the VIT injection.60% of the respondents do not offer VIT to individuals on ACE inhibitor therapy.5% may continue VIT beyond 3 years based on a positive serum‐specific IgE result.Concomitant use of beta‐blockers can potentially interfere with the therapeutic efficacy of adrenaline and cause refractory or protracted anaphylaxis. The BSACI guideline therefore recommends that these drugs are substituted or temporarily withdrawn following a risk–benefit analysis in the individual patient Although some aspects of VIT have improved in the United Kingdom, others remain unchanged since our last survey; a few of these  could potentially compromise patient safety.Several factors may affect uptake of a guideline. These include quality of evidence underlying the guidance, extent of promotion and awareness of the guidance and commitment of individual trusts to guideline implementation This is the first report assessing the impact of a national guideline on allergy services in the published literature. The British Society for Allergy and Clinical Immunology is the largest professional body for allergists and clinical immunologists in the United Kingdom. Venom immunotherapy in the United Kingdom is administered only in secondary care under specialist supervision. The initial survey was carried out prior to publication of the BSACI guidelines in 2011. However, there have since been two other significant publications that could have affected UK VIT practice. These include the NIHR HTA guidance for the use of Pharmalgen in VIT The response rate for the current survey was lower (46%) although the number of respondents was greater than in the previous survey. Only 59% of those who responded  practised VIT during the recent survey. It is worth stating that this is comparable to the response rate of the previous survey (56%) and that of other national UK allergy surveys In addition, there was no classification of practitioners into the allergy, immunology or other specialist groups. The results are presented based on the self‐identification of respondents into these categories in the recent survey questionnaire.The previous survey was sent only to 81 UK practitioners identified as practising VIT from the BSACI website. The membership has since grown and database updated and therefore the current cohort (247 members) is not directly comparable to those surveyed in 2006/2007. Respondents chose not to answer some questions in the survey. Where data were missing, this was ignored. This approach may have potentially introduced some bias into the interpretation of the data.As with any survey, these data are subject to response bias (i.e. the tendency of respondents to provide responses considered ‘acceptable’ rather than those that reflect their true practice). However, it is hoped that this was minimal given that in our survey, the respondents were made aware of the confidential nature of the responses upfront.The survey may also be subject to a selection bias, as only those individuals with some familiarity with the guidelines may have responded to the survey.The data from this survey have been used to assess the uptake of VIT guidelines in the United Kingdom. Respondents may be directly asked for their opinion regarding existing guidelines in future surveys. This would help improve the quality and uptake of future guidelines.To understand the effect of centre size on practice, future surveys could be made centre‐focussed rather than focussing on individual practice where appropriate. Also, it may be useful to have generic sections in the questionnaire as well as separate sections aimed at adult and paediatric practices since practice of allergy in children can be different from that of adults in some areas .To assess patient selection criteria in accordance with the NIHR HTA recommendations Despite above‐stated limitations, the current survey suggests better adherence to best practice parameters in several domains of diagnosis and management of HV allergy. However, the data also highlighted the following areas where further improvement is needed: use of SPTs as the first‐line investigation, use of optimal allergen concentrations for skin tests, checking bT in all patients with systemic reactions to HV, and monitoring patients for an optimal duration following VIT injections. Updating guidelines regularly and having a plan for dissemination may improve adherence.


Benchmarking the quality of river discharge data and understanding its information content for hydrological analyses is an important task for hydrologic science. There is a wide variety of techniques to assess discharge uncertainty. However, few studies have developed generalized approaches to quantify discharge uncertainty. This study presents a generalized framework for estimating discharge uncertainty at many gauging stations with different errors in the stage‐discharge relationship. The methodology utilizes a nonparametric LOWESS regression within a novel framework that accounts for uncertainty in the stage‐discharge measurements, scatter in the stage‐discharge data and multisection rating curves. The framework was applied to 500 gauging stations in England and Wales and we evaluated the magnitude of discharge uncertainty at low, mean and high flow points on the rating curve. The framework was shown to be robust, versatile and able to capture place‐specific uncertainties for a number of different examples. Our study revealed a wide range of discharge uncertainties , but the majority of the gauging stations (over 80%) had mean and high flow uncertainty intervals of less than 40%. We identified some regional differences in the stage‐discharge relationships, however the results show that local conditions dominated in determining the magnitude of discharge uncertainty at a gauging station. This highlights the importance of estimating discharge uncertainty for each gauging station prior to using those data in hydrological analyses. A generalized framework for discharge uncertainty estimation is presentedAllows estimation of place‐specific discharge uncertainties for many catchmentsLocal conditions dominate in determining discharge uncertainty magnitudes These data not only underpin our knowledge of the hydrologic system but they are also utilized for flood and drought analysis, hydrological modeling, and water resources monitoring, from which important management decisions are made. Therefore, it is essential that the quality of discharge data is assessed and benchmarked [McMillan et al., Beven et al., Venetis, Clarke, Clarke et al., Petersen‐Øverleir and Reitan, Moyeed and Clarke, Petersen‐Øverleir and Reitan, Reitan and Petersen‐Øverleir, Le Coz et al, 2014; Juston et al., Le Coz et al., Krueger et al., Guerrero et al., Jalbert et al., Westerberg et al., McMillan et al., McMillan et al., Westerberg et al., Shrestha et al., Jalbert et al., McMillan and Westerberg [Di Baldassarre and Claps, Di Baldassarre and Montanari, Franchini et al., Petersen‐Øverleir et al. [Techniques for quantifying the uncertainty in discharge data are becoming an increasingly important area of scientific research within hydrology [sterberg  developer et al.  who utilThis paper aimed to develop a novel generalized framework to quantify, characterize and benchmark discharge uncertainty for hundreds of gauging stations. The framework was demonstrated on rating curves and stage‐discharge measurements from 500 gauging stations across England and Wales, which represent a range of errors and different types of stage‐discharge relationships. The framework is primarily based on a nonparametric regression and includes methods for determining gauging measurement uncertainty, for using information from the temporal changes in the rating curves to pool groups of stage‐discharge measurements, and for modeling multisection rating curves. Results from the study were used to: (1) examine whether such a general methodology can estimate place‐specific uncertainties, and (2) benchmark discharge uncertainties  at a national scale.22.1We chose 500 gauging stations to evaluate the framework for discharge uncertainty estimation from a large data set of 910 gauging stations located throughout England and Wales . The metadata included information on the type and history of the gauging station, information about problems associated with weed growth or siltation, and bankfull stage. Data on the field methods used to collect the stage‐discharge measurements were not available for every gauging station and neither was detailed information on the hydraulic characteristics of each site .Metadata was taken from the UK Hydrometric Register [2.2Q represents the discharge, a is a coefficient, b is an exponent, h is the stage and 0h is the stage of zero flow. The rating curve equation is either based on theoretical weir equations where the parameters a and b are related to the shape of the weir or these parameters are calibrated from a set of stage‐discharge measurements. The use of this rating curve implies the assumption of a unique stage‐discharge relationship at the river cross section where the geometry of the section is assumed to be stable over time and where the relationship can be expressed by a single or by multiple power‐law equation(s). These assumptions are not always fulfilled and the discharge estimates can be subject to uncertainty from four main sources of error; (1) gauging data, (2) natural conditions, (3) rating‐curve approximation, and (4) human alterations. Figure The majority of river discharge time series in England and Wales are derived from a multisection rating curve equation describing the relationship between stage and discharge. In almost all cases, each section of the rating curve is an empirical equation which takes the form of:ng data,  natural McMillan et al. [Jalbert et al., Guerrero et al., Errors in the stage‐discharge gauging data are affected by both random and non‐random errors including errors in the point velocity measurements, insufficient sampling of velocity in the cross‐section, data processing errors, and level observation errors . Nonran2.3Given the wide range of place‐specific uncertainties and the limited data available on site‐specific conditions in the data set, a generalized and flexible framework was needed for the estimation of discharge uncertainty. We focused on the most prevalent uncertainties found in the data set of gauging stations from England and Wales; including errors in the stage‐discharge measurements, changes in the rating curves over time, outliers in the data and the definition of multisection rating curves. An overview of the methodology is given in Figure 2.3.1The first step was a quality assessment of the stage‐discharge data and the removal of any assumed erroneous data Figure , step 1.Discharge uncertainty estimates could be calculated for all of the England and Wales gauging stations that had stage‐discharge measurements. However, to keep the scale of the task feasible and to ensure robust discharge uncertainty estimates, we selected 500 gauging stations from the 910 gauging stations in the database. These gauging stations were selected to have more than 20 stage‐discharge measurements and an applicable rating curve (this discounted ∼32% (295) gauging stations from the total data set). A threshold of twenty stage‐discharge measurements was chosen as the nonparametric framework relies on data and fewer than 20 stage‐discharge measurements often resulted in unrealistic uncertainty bounds and/or poor LOWESS fits (see supporting information). We selected 500 gauging stations from the remaining 615 gauging stations for which there was sufficient information available about gauging data quality and the stage‐discharge relationship to ensure that the discharge uncertainty was reliably estimated. We also ensured that the selected gauging stations covered a wide range of gauging station types, locations and errors in the stage‐discharge relationship, thus providing a representative picture of the gauging network in England and Wales.2.3.2An important consideration for this study was how to account for time variability in the gauging data and thus temporal changes in the discharge uncertainty. The EA accounts for changes in the stage‐discharge relationship  by changing the rating curve, which means that the discharge uncertainty calculated for each individual EA rating curve is different. To reflect these changes, we separated the stage‐discharge measurements into groups based on the date range for which each official EA rating curve was valid. However, this resulted in a number of groups with very low numbers of stage‐discharge measurements or a lack of stage‐discharge measurements for a particular flow range (often high flows). To allow for discharge uncertainty to be calculated for as many rating curves and flow ranges as possible, an automated method was required to pool the stage‐discharge measurements based on the similarity of the rating curves. This was seen as the most pragmatic approach given the other uncertainties. Here, we took the approach of quantifying the maximum standardized deviation between the EA rating curves for each gauge. We generated 1000 stage values between the minimum and maximum stage from all the EA rating curves, then calculated the discharge from each of the EA rating curves from this stage range and normalized the discharge values by the maximum flow. We then compared the normalized discharge values for each rating curve and if the maximum deviation between these normalized discharge values was less than 0.01 across the whole flow range we treated them as being effectively the same. In this case we then pooled the populations of individual stage‐discharge measurements together into groups of stage‐discharge measurements which would either be associated with one or multiple rating curves. This was repeated sequentially in time for all historical rating curves for each gauge.2.3.3x axis log scale), which is expected given higher relative uncertainties in low‐flow discharge measurement as a result of greater inaccuracies of hydro‐acoustic and current meter measurements in shallow and low‐velocity flow situations [Petersen‐Øverleir et al., McMillan et al. [Pelletier [To define the error associated with each discharge gauging measurement we utilized the residuals from 26 gauging stations with stable stage‐discharge relationships to estimate the measurement error as a function of normalized discharge . These gauging stations were selected according to the following criteria; 1) no changes to the rating curve over time had occurred, 2) no outliers, and 3) marked as a good quality gauging station in the metadata from the EA. The stations covered all the hydrometric regions of the data set and measurements taken from 1962 to 2012. The majority of the stations  had flow measurement structures with theoretically developed ratings for which the gauging measurements are used to check the theoretical rating. The other stations consisted of eight rated sections and two ultrasonic stations, and there was no significant difference to the estimated uncertainties if only the structures were used. The relative rating‐curve residuals  from the 26 gauging stations were plotted against normalized measured discharge Figure a. The reelletier , and areMcMillan et al., McMillan et al., Stage is measured directly and measurement errors are generally reported to be less uncertain than those for discharge measurement [2.3.4Cleveland, Given the wide range of stage‐discharge relationships, the large number of gauging stations, and the metadata we had for each gauging station, we needed a methodology that was (1) computationally fast, (2) ran automatically for each gauging station with minimal user input, and 3) relied only on the information from the stage‐discharge measurements. As a result of these requirements, we decided not to fit power‐law equations and instead use a nonparametric local weighted regression (LOWESS) approach [ relied oi are dependent upon the differences in stage and given by the tri‐cube weight function:i are the other stage‐discharge measurements in the set of 2k+1 data points defined by the span. The weight function gives the most weight to data closest to the central stage‐discharge measurement and the least weight to the data furthest away. To account for outliers in the stage‐discharge relationship, the original data were used for a first LOWESS fit and the residuals r were then calculated from this initial fit. A bi‐square weight function was then used to weight each stage‐discharge measurement depending on how far the point is from the fitted line.i is the residual of the ith residual data point and MAD is the median absolute deviation of the residuals. This function down‐weighted any data points that had large residual values.The LOWESS procedure takes in turn each stage‐discharge measurement as the central point x in a set of 2k+1 data points. The remaining 2k data points consist of the k preceding and k following points when the data set is sorted by stage. The estimate of the discharge for the data point and its variance is generated by fitting a weighted linear regression to the selected data. This process was then repeated for all of the data points to provide a single LOWESS fit. Weights wThe span defined by k is an important consideration as large spans will result in excessively smooth curves and small spans will result in overfitting the data. Fixing the span to a set number or percentage of stage‐discharge measurements for all the gauging stations gave inconsistent results, thus the span for each set of stage‐discharge measurements was estimated. A range of spans was evaluated (0.025–25% of the number of stage‐discharge measurement points in 0.005% increments) and the span which maximized the log‐likelihood of the data for predictions generated from a leave‐one‐out cross‐validation was chosen.2.3.5We repeated the LOWESS fit 500 times, and for each fit all the stage‐discharge measurements were resampled using the measurement error distributions described in section 2.4Petersen‐Øverleir et al. [HF) and low (HLF) flow values as the stage corresponding to the means of the annual maxima and minima discharges obtained from the daily discharge time series. For mean flow, we used the stage corresponding to the mean of the discharge time series (over the period of record for each gauge). The 2.5th and 97.5th percentile discharge uncertainty bounds  were then used to define the upper (Q^U95) and lower (Q^L95) discharge uncertainty bounds for the low, mean and high discharge evaluation points. If there were multiple rating curves then an average of the stage values from the multiple curves were used. Note that Petersen‐Øverleir et al. instead used the mean daily stage time series for calculating the low, high and mean points on the rating curves, but we did not have stage time series data for all stations. Finally, relative uncertainties were quantified by calculating the width of the interval between the uncertainty bounds as a percentage of the discharge values from the official rating curve (QRC). The equation for high flows is shown as an example:We quantified discharge uncertainty at low, mean and high flow to compare results for each gauging station, and to compare to r et al. , who est33.1To demonstrate the flexibility of the methodology, we present results from eight gauging stations Figures  and 6 reThe framework also provided a measure of how the discharge uncertainty changes over time. Figure 3.23/s meaning that the absolute discharge uncertainty is small (0.06m3/s) despite the high percentage. For low flows, 37% of the groups of stage‐discharge measurements fell within the 40–80% discharge uncertainty band, with 24% of the groups having a low‐flow uncertainty less than 40%. In contrast, 70% (53%) of the groups (83% (96%) discounting the groups where we were unable to calculate discharge uncertainty) had a mean (high) flow uncertainty interval of less than 40%. The high proportion of missing values for high flows (403 or 44% of the groups) occurred because the methodology was unable to extrapolate beyond the limits of the stage‐discharge measurements, and therefore reflects the lack of stage‐discharge measurements at high flows.Figures Figure 44.1Guerrero et al., Le Coz et al., Reitan and Petersen‐Øverleir, Westerberg et al., Gupta et al., McMillan et al., This study has developed a generalized framework for estimating discharge uncertainty and evaluated it nationally for gauging stations in England and Wales. Many studies have developed methods for estimating discharge uncertainty for different gauging stations and types of stage‐discharge relationships [4.2Petersen‐Øverleir et al., Petersen‐Øverleir et al., Tomkins, Westerberg et al., Petersen‐Øverleir et al., Our results allow the quality of discharge data to be assessed nationally. We found that mean (high) flow relative discharge uncertainty was less than 40% for 83% (96%) of the gauging stations for the most recent group of stage‐discharge measurements. Similar to results from Norway [Lloyd et al., Coxon et al., Renard et al., Thyer et al., Westerberg and Birkel, Coron et al., Kollat et al., Perrin et al., Pushpalatha et al., Van Esse et al., Merz and Blöschl, Oudin et al., Parajka et al., Sefton and Howarth, Yadav et al., Young, Despite regional differences in the type of gauging station, the number of historical rating curves and stage‐discharge measurements Figure , dischar4.3There are still some challenging cases where the resulting uncertainty bounds may not be appropriate and where the framework could be further developed. First, although the window size was chosen by a cross‐validation procedure, it did not always provide the best option for all sets of stage‐discharge measurements and the resultant uncertainty bounds could in some cases become uneven and unrealistic particularly when there was large scatter in the stage‐discharge data Figure g. These Di Baldassarre and Claps, Second, the LOWESS procedure is a data‐driven approach that depends on fitting the data locally within windows and it is therefore highly dependent on the available stage‐discharge data. This leads to two limitations in our approach. First, we set 20 stage‐discharge measurements as a minimum number to provide an estimate of discharge uncertainty (fewer than 20 measurements often led to poor LOWESS fits) and this meant that 152 gauging stations were discounted from this study. The framework is therefore currently not applicable in regions where the established practise is to make few gaugings. Second, the methodology is unable to extrapolate beyond the limits of the data and we were unable to calculate uncertainties at low (high) flows for 31% (44%) of the groups of stage‐discharge measurements. Care must be taken when extrapolating the stage‐discharge relationship as the estimated uncertainties may not be valid in some cases. This would in particular be the case where bankfull stage values are reached but no data exist to characterize the step change in the stage‐discharge relationship. Figure Third, the estimate of the discharge measurement errors using the logistic distributions likely provides a better estimate than using (constant) literature values transferred from other studies, however, there are some limitations with this approach. Although the stage‐discharge measurements included in estimating the measurement uncertainties were taken over a long period (1962–2012) using different gauging techniques, we did not include information about measurement methods or how these have changed over time. The estimates may also not be equally representative across the flow range as we did not have any measurements for out‐of‐bank flows where a site‐specific step change in variance is expected, and there is potentially more error equifinality at low flows . There was only a small effect to the final LOWESS estimates at low flows of using a constant logistic measurement error equal to the high flow estimate across the whole flow range (results not shown). For the stage data a constant value of ±5 mm was assumed since we did not have further information about these errors. However, this estimate could be expected to vary significantly both spatially and temporally with larger uncertainties, for example, occurring during flow peaks if stage changes rapidly during the time of the gauging.robust outer estimates for the discharge uncertainty. These results highlight the uncertainty about uncertainty intervals (or 2uncertainty) in the presence of non‐negligible epistemic uncertainty sources, discussed and illustrated by Juston et al. [Finally, when using the framework to obtain the uncertainty bounds, the aim was to represent the uncertainty of the scatter in the stage‐discharge data since there are often important non‐random error sources affecting the data and information about these in the scatter. This means that the uncertainty bounds may be too wide if the scatter at a particular gauging station is instead dominated by random error sources in the observations of stage and discharge. However, the analyses of the 500 gauging stations in this study showed that non‐random error sources of varying origin were frequently present in the data section . Withoutn et al.  in the c5This paper presents a versatile framework for assessing the discharge uncertainty at many gauging stations with a variety of different errors in the stage‐discharge relationship. The framework relies on information from the rating curves and stage‐discharge measurements and is based around three key components; (1) a robust nonparametric approach for fitting multiple rating curves, (2) a methodology for quantifying discharge measurement error, and (3) techniques to account for outliers in the data and scatter in the stage‐discharge data. It also uses information from the official EA rating curves to assess how discharge uncertainties change over time. To demonstrate its flexibility and applicability to many gauging stations we tested the framework on 500 gauging stations in England and Wales. Results show that the framework is robust for a number of different gauge types where the uncertainty bounds reflect the scatter in the stage‐discharge measurements well. An important outcome of this study is how local conditions at a gauging station determine the magnitude of discharge uncertainty and how the discharge uncertainty changes over the flow range and over time. These local conditions not only include natural changes such as weed growth but also the management of the gauging station such as how often the rating curve is updated. The analysis undertaken in this study could be extended by utilizing the framework to identify more/less reliable gauging stations and indicate priorities for hydrometry teams. Future research will aim to extend the framework to enable uncertainty estimates for extrapolated segments and assess discharge uncertainty at gauging stations with few stage‐discharge measurements.Supporting Information:Supporting Information S1Click here for additional data file.


Development of an accurate and affordable test for the non‐invasive prenatal diagnosis of Duchenne and Becker muscular dystrophies (DMD/BMD) to implement in clinical practice.Cell‐free DNA was extracted from maternal blood and prepared for massively parallel sequencing on an Illumina MiSeq by targeted capture enrichment of single nucleotide polymorphisms (SNPs) across the dystrophin gene on chromosome X. Sequencing data were analysed by relative haplotype dosage.Seven healthy pregnant donors and two pregnant DMD carriers all bearing a male fetus were recruited through the non‐invasive prenatal diagnosis for single gene disorders study. Non‐invasive prenatal diagnosis testing was conducted by relative haplotype dosage analysis for X‐linked disorders where the genomic DNA from the chorionic villus sampling  or from the proband (for pregnant DMD carriers) was used to identify the reference haplotype. Results for all patients showed a test accuracy of 100%, when the calculated fetal fraction was >4% and correlated with known outcomes. A recombination event was also detected in a DMD patient.Prenatal Diagnosis published by John Wiley & Sons, Ltd.Our new test for NIPD of DMD/BMD has been shown to be accurate and reliable during initial stages of validation. It is also feasible for implementation into clinical service. © 2016 The Authors.  What's Already Known About This Topic?Recent research has shown that non‐invasive prenatal diagnosis for some single gene disorders is possible, and there is some implementation into clinical practice for the detection or exclusion of the paternal allele. However, this is not yet available for definitive diagnosis of X‐linked conditions.What Does This Study Add?We have developed an accurate and feasible test for the non‐invasive prenatal diagnosis of Duchenne and Becker muscular dystrophies. Early validation data have proven that the method could potentially be implemented into clinical practice. After carefully considering various methods described in previous studies,Duchenne and Becker muscular dystrophies are X‐linked neuromuscular recessive disorders associated with mutations of the dystrophin gene.Patients were recruited into two separate groups through the NIPSIGEN study . Group 1 included pregnant women at risk for fetal aneuploidy who were offered invasive prenatal testing (CVS) at West Midlands Regional Genetics Laboratory. Blood samples from women with male pregnancies in this group were initially used to validate the efficiency, accuracy and multiplexing capacity of our method. RHDO analysis can be performed on these patients by using the genomic DNA from CVS to determine the reference haplotype needed to measure the allelic imbalance within the plasma cfDNA . Six to nine samples  were multiplexed per sequencing run using 2 × 80 cycles paired‐end settings. More details can be found in Relative haplotype dosage analysis measures the allelic imbalance between two haplotypes in plasma cfDNA to determine which haplotype has been inherited by the fetus.Routine invasive prenatal diagnosis of DMD/BMD patients was conducted using multiplex ligation‐dependent probe amplification (MLPA) analysis of the dystrophin gene (MRC‐Holland kits P034‐A2 and P035‐A2) to detect exon deletions/duplications. Linkage analysis was performed using a multiplexed set of fluorescent linkage markers .DNA library preparation for MPS was obtained by capture‐based targeted enrichment. This method has been successfully used for similar copy number variation tests in combination with RHDO analysis.Initial testing for the validation of our method was conducted on patients recruited to group 1. Eight patients were tested overall, and details on outcomes and testing parameters for seven of these patients are summarised in Table In family H, the patient was a carrier of a deletion of exon 45 in the dystrophin gene, which is associated with DMD. She had had a previous affected child and was 8 weeks and 4 days pregnant at blood draw .Non‐invasive prenatal testing is rapidly being implemented in many clinical genetics laboratories across the world. Fetal sexing and RhD typing using cffDNA are now in routine clinical service,In order to address some of the issues listed earlier, we plan to further improve our method by designing a new probe library. Coverage of a number of SNPs across various autosomes will be included for the accurate measurement of fetal fraction. Additional SNPs will be targeted at the 3′ and 5′ untranslated regions of the dystrophin gene to take into account the possibility of fewer informative SNPs being identified due to a pregnancy between consanguineous parents or to the presence of a large deletion. Taken together, these advances will significantly improve the test accuracy and applicability.At present the main drawback to the implementation of NIPD for SGDs in public health services has been the elevated cost incurred.The successful development of an NIPD test for patients at risk of carrying a fetus affected with DMD/BMD suggests that the same method can potentially by applied to many other SGDs. Indeed, the different types and locations of mutations associated with SGDs do not affect RHDO analysis. On this premise, we are adapting our method to include other disorders such as spinal muscular atrophy, CAH and cystic fibrosis. This will increase our NIPD testing repertoire and the number of patients we can offer this service to, which will prove beneficial in ensuring a quick turn‐around‐time and maintaining testing costs at the lowest possible level (by grouping together at least three patients a week per sequencing run).To conclude, RHDO analysis has been successfully used to determine the genome‐wide genetic and mutational profile of the fetusSupporting info itemClick here for additional data file.