Evidence from high‐income countries suggests that group antenatal care, an alternative service delivery model, may be an effective strategy for improving both the provision and experience of care. Until recently, published research about group antenatal care did not represent findings from low‐ and middle‐income countries, which have health priorities, system challenges, and opportunities that are different than those in high‐income countries. Because high‐quality evidence is limited, the World Health Organization recommends group antenatal care be implemented only in the context of rigorous research. In 2016 the Global Group Antenatal Care Collaborative was formed as a platform for group antenatal care researchers working in low‐ and middle‐income countries to share experiences and shape future research to accelerate development of a robust global evidence base reflecting implementation and outcomes specific to low‐ and middle‐income countries. This article presents a brief history of the Collaborative's work to date, proposes a common definition and key principles for group antenatal care, and recommends an evaluation and reporting framework for group antenatal care research. In October 2015, at the Global Maternal and Newborn Health Conference in Mexico City, Jhpiego organized a panel of group antenatal care researchers working in low‐ and middle‐income countries. The individuals on the panel represented group antenatal care initiatives in low‐income countries that were conducted by the University of Michigan (Ghana),In March 2016, the Global Group Antenatal Care Collaborative was formally created as a platform for researchers working in low‐ and middle‐income countries to (1) share experiences, learning, and data collection tools (2) build consensus around defining and evaluating group antenatal care, and (3) advocate for more group antenatal care research in low‐ and middle‐income countries. Prior to the Collaborative's formation little was known about group antenatal care implementation, sustainability, or performance in low‐ and middle‐income country contexts. The founding members saw an opportunity to accelerate learning and innovation around group antenatal care in low‐ and middle‐income countries by working together to codify its essential elements, research tools, and priorities.The Global Group Antenatal Care Collaborative believes that group antenatal care has transformational potential. However, that potential will only be realized if coordinated research can clarify the relationships between model and implementation characteristics, context, and outcomes. Since its inception the Collaborative has worked toward mitigating the challenges outlined in Table The Global Group Antenatal Care Collaborative recognizes that group antenatal care models in low‐ and middle‐income countries need to be customized to local contexts and local priorities to ensure ownership, sustainability, and scalability. Furthermore, research has not yet established ideal parameters for some aspects of implementation , which may also vary by context and program priorities. However, the Collaborative believes a common definition of group antenatal care in low‐ and middle‐income countries is needed to create a credible and useful body of evidence. A definition that includes a minimum set of defining characteristics and key principles based on Collaborative members’ expertise in group antenatal care, other successful group interventions, and theories of social and behavioral change is proposed and described in Table Because group antenatal care is unlikely to look the same across settings, a unified evaluation and reporting framework for group antenatal care can help ensure that research priorities align with the data needed by policy and funding decision makers and that adequate information is reported to consider the relative impact of context, implementation strength, and specific model characteristics on outcomes. The Collaborative urges use of the framework, presented in Table Group antenatal care models and frameworks will vary by setting both by necessity and because of innovation. The Collaborative urges researchers to explicitly describe key components of each model such as the number, timing, and structure of meetings and group composition. In addition, researchers should comment on how each key principle of group antenatal care Table  has or hThe Collaborative has not, as yet, endorsed specific indicators for client‐focused outcomes. Instead, 6 priority subdomains of outcomes listed in Table When a health system considers widespread adoption of research findings into practice, potential changes in outcomes must be balanced with potential changes in the health system itself. Human resources allocation is of particular interest in low‐ and middle‐income country contexts in which health care staff shortages are common. If group antenatal care is associated with improved outcomes, decision makers will need additional information on necessary health system inputs and impacts to develop appropriate policies and guidelines and dedicate sufficient resources. This is particularly important as many low‐ and middle‐income countries have decentralized health systems, and subnational health officials ultimately will need guidance from their respective ministries of health to implement group antenatal care where feasible, plan activities in annual workplans, and budget adequate resources. Gathering and reporting this information for all group antenatal care projects will accelerate understanding of these important issues and subsequently speed or prevent scale‐up as appropriate.Current Global Group Antenatal Care Collaborative members are committed to using the evaluation framework outlined in this article to advance our shared research agenda. Members of the Collaborative actively share theoretical frameworks, experiences, materials, evaluation frameworks, and data collection tools, aligning data collection where possible to strengthen the external validity of findings. Collaborative members have contributed significantly to the global evidence base for group antenatal care in low‐ and middle‐income countries since formation of the Collaborative, confirming the feasibility and acceptability of group antenatal care in multiple low‐ and middle‐income countries and finding associations with increased quality of care, facility‐based delivery, antenatal care attendance, uptake of postpartum family planning, health literacy, and pregnancy‐related empowerment.ganccollaborative.com). The Collaborative hopes that ultimately its work results in an increase in high‐quality evidence regarding the effectiveness of group antenatal care across the globe that ultimately contributes to greater antenatal care access, quality, and coverage for all pregnant women.In low‐ and middle‐income countries, group antenatal care has the potential to transform the dominant antenatal care service delivery model and provide a better care experience for women and antenatal care providers. The Global Group Antenatal Care Collaborative has a definition, key principles, and research framework for implementors and investigators presented in this article. All groups and individuals engaged in group antenatal care research in low‐ and middle‐income countries are invited to join this collaboration to expedite the development of a robust evidence base on group antenatal care research in low‐ and middle‐income countries. More information about the Global Group Antenatal Care Collaborative is available at its website (The authors have no conflicts of interest to disclose.


Fluoropyrimidines (FP) are among the most common class of prescribed anti‐neoplastic drugs. This class has severe to moderate toxicity in around 10%–40% of those who take 5‐fluorouracil (5‐FU) or capecitabine for the treatment of cancer. In practice many patients with severe toxicities from FP use had dihydropyrimidine dehydrogenase (DPD) enzyme deficiency. Several studies have proposed DPD screening before treatment with 5‐fluorouracil (5‐FU) and capecitabine or other drugs belonging to the FP group. This study aims to assess the level of awareness and attitudes of oncology specialists in Saudi Arabia toward genetic screening for DPD prior to giving FP. This highlights the importance of health guidelines required for implementation in our health care system, as a framework to adopt testing as a regular practice in clinical care. Based on the findings in this study, guidelines have been suggested for the Middle East North Africa region.A cross‐sectional survey study was conducted during 2021 targeting oncologists and clinical pharmacists working in the oncology departments across Saudi Arabia.A total of 130 oncologists and pharmacists completed the questionnaire representing a response rate of 87%. Most of the respondents indicated that they prescribe FP in clinical practice, but 41% of respondents reported that they have never ordered a specific molecular test during their practice. Only 20% of respondents reported that they often screen for DPD deficiency prior to prescribing FP. Significantly higher rates of awareness of potential dihydropyrimidine dehydrogenase gene (DPYD) mutation were observed among respondents in governmental hospitals , and among those with more years of practice (80.6% if 5 or more years of practice vs. 59.3% if less than 5 years of practice). Also, higher rates of observing the impact of DPD testing were present among respondents with a PharmD (35% vs. 11% for oncologists and 18% for other professions) and among those with 5 or more years of practice (24.6% vs. 7.7% among those with less than 5 years).While in some institutions there is a high level of awareness among oncology specialists in Saudi Arabia regarding the effect of the potentially serious DPD enzyme deficiency as a result of gene mutations, screening for these mutations prior to prescribing FP is not a routine practice in hospitals across the country. The findings of this study should promote personalized medicine with recognition of interpatient variability via DPD testing to manage the risks of FP prescribing more effectively in the Kingdom of Saudi Arabia. They include 5‐fluorouracil (5‐FU) and its prodrugs (capecitabine and tegafur).Eighty percent of the administered FP is metabolized by the DPD liver enzyme.DPD deficiency is an inherited condition characterized by a wide range of symptoms; some patients experience neurological problems from infancy while no signs or symptoms are evident in others.About 2%–8% of the general population may be vulnerable to toxic reactions to FP drugs caused by asymptomatic DPD deficiency.The national guidelines for colorectal cancer in the Netherlands recommend DPD testing prior to therapy.2This was a cross‐sectional study where a survey was designed and distributed to oncologists and clinical pharmacists in different hospitals in Saudi Arabia. The questionnaire was adapted and modified from previous studies.Inclusion Criteria: All oncologist and clinical pharmacist in all cancer centers in Saudi Arabia.Exclusion Criteria: Retail pharmacists, outpatient pharmacists and non‐oncology doctors.The questionnaire was distributed to selected HCPs who worked in oncology centers and hospitals with support from the Saudi Commission for health specialties to target active registered practitioners in oncology.2.1Previous studies have estimated the prevalence of health care professionals (HCPs) awareness toward pharmacogenomics testing to be between 31% and 62%.2.2p < .05. All statistical analyses were performed using IBM SPSS 21.0 .Descriptive statistics were performed on data collected from the study sample. For continuous variables, data were expressed as means ± SDs, medians, and ranges. Proportions were used to describe categorical variables. The awareness was evaluated and compared by demographic characteristics including age, hospital department, duration of work experience and current designation using the chi‐square test. Statistical significance is defined as 3To account for an anticipated response rate of 75%, the questionnaire was administered to 150 oncology specialists, out of whom 130 completed it, indicating a higher than expected response rate of 87%. Descriptive statistics of the study sample are provided in Table Fifty‐nine percent of respondents reported that they have never ordered a specific molecular test during their practice Table . The majEighty four percent and 76% of respondents reported awareness of a mutation that causes DPD deficiency, and drug‐gene implications (toxicity) that is caused by this mutation, respectively. Only 38.5% of respondents indicated the existence of guidelines for prescribing FB in their hospital, while 66.2% said that they have seen patients with severe toxicity related to the use of FP. Only 16.2% of respondents reported that they have seen the impact of DPD testing in their clinical practice. The vast majority of respondents (61.5%) did not know of any available guidelines or protocols in their own institute or by the ministry of health. Also, they noted that there is lack also of promotion of the practice of DPD deficiency testing before FP group of medications.p < .05]). Significantly higher rates of awareness of the drug‐gene interaction causing mutation were observed among respondents working in governmental hospitals compared to private hospitals 81.1% versus 47.4% respectively (p = .003), and among those with more years of practice . In addition, significantly higher rates of observing the impact of DPD testing were observed among respondents with PharmD compared to those with MD and other degrees , as well as among those with more years of practice .Table 4FPs are a commonly used group of chemotherapeutic drugs in the management of several types of cancer.Only 20% of the respondents in the study reported that they screen for the DPD variant prior to administering FP. Regardless, about 80% of the professionals are aware of DPD and the potential interaction with anti‐cancer drugs, while most of the respondents were aware of the presence of different DPD variants that might affect the level of FP toxicity.Many countries worldwide have specific guidelines for FP therapy.The authors of this report aspire to help in establishing a national clinical guideline addressing DPYD screening and genetic counseling prior to FP‐based chemotherapy. EMA and MHRA recommend testing all patients for DPD deficiency prior to systemic treatment with FP drugs. Patients with a known complete DPD deficiency must not be given FP. As for patients with a partial DPD deficiency, a reduced starting dose should be considered.An interesting study reported that HCPs have limited awareness about personalized medicine in general, but have positive attitudes toward it and are keen and eager to learn more about personalized medicine for future practice.In a further recommendation, additional training and awareness programs are required to raise health care providers' understanding of personalized medicine and to assist its implementation in Saudi Arabia. More emphasis on this topic should be put into the curricula of health colleges.The major strength of this study is its uniqueness in terms of assessing awareness of healthcare professionals about genetic screening prior to administering FP drugs in Saudi Arabia. We used an instrument that was carefully developed to examine physicians' current practice and attitudes toward such screening. We also explored the association between the demographic characteristics and awareness and attitudes of oncologists toward DPD testing in Saudi Arabia.A limitation of this study is its reliance on participants' capacity to recall prior experiences, which might have resulted in bias. We limited recollection time to 1 year to reduce the possibility of such bias. Based on our findings, we recommend that immediate measures should be taken to increase awareness among oncology staff about genetic testing, and written guidelines related to FP should be established and implemented.5Our survey clarified the status of awareness of healthcare providers about performing genetic testing prior to FP. Genetic testing was not prevalent among most patients in Saudi Arabia. A lack of awareness regarding the existing rules and policies related to testing before FP was observed. The results of the study indicate an urgent need for actions to improve clinical practice by screening to find genetic variants for DPD deficiency prior to prescribing FP. A simple, inexpensive and cost effective test would substantially reduce the risk of serious and life threatening, drug related toxicity. Adoption of this practice will promote personalized medicine with safer medication use for FP in the Kingdom of Saudi Arabia.Hatouf Husni Sukkarieh: Conceptualization (lead); data curation (lead); formal analysis (lead); investigation (lead); methodology (lead); project administration (lead); resources ; software ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing . Turki Alsagoor: Conceptualization ; data curation ; formal analysis ; investigation ; methodology ; project administration ; resources ; software ; validation ; visualization ; writing – original draft ; writing – review and editing . Mohammed Alnuhait: Conceptualization ; data curation ; formal analysis ; investigation ; methodology ; resources ; software ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing . Rami Bustami: Conceptualization ; data curation ; formal analysis ; investigation ; methodology ; resources ; supervision ; validation ; visualization ; writing – review and editing . Scott Bryson: Conceptualization ; writing – original draft ; writing – review and editing . Fatima Adem: Investigation ; methodology ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing . Hana Abdalla: Conceptualization ; investigation ; methodology ; writing – original draft ; writing – review and editing . Gulsan Karbani: Conceptualization ; investigation ; methodology ; visualization ; writing – review and editing .The authors have stated explicitly that there are no conflicts of interest in connection with this article.Ethical approval was obtained from the Institutional Review Board (IRB) of Saudi Food and Drug Authority (SFDA), Research Center, Riyadh, Saudi Arabia. The IRB approval number is 04_2021. All participants signed a consent form prior to participation. The completed questionnaires were collected and securely stored in the principal investigator's office.


Shared decision‐making (SDM) is intended to increase patient‐centredness of medical decision‐making for patients with acute and chronic conditions. Concurrently, patient decision aids (PtDAs) can supplement SDM by providing information to guide communication between patients and healthcare providers. Because of the prevalence of chronic conditions, where decisions may be extended or recurring, we sought to explore how effectively these tools have been leveraged in this context.We conducted a narrative review of the literature on both SDM and PtDAs, searching PubMed and Boston University's library database search tool for English‐language articles published from January 2005 until March 2021. Additional search terms focused on temporality. Drawing from our findings, we developed a combined framework to highlight areas for future research using the discussion of end‐of‐life decisions as an exemplar to illustrate its relevance to chronic care contexts.After screening 57 articles, we identified 25 articles that fulfilled the inclusion criteria on SDM, PtDA use and temporality for chronic care. The literature on SDM highlighted time outside of the medical visit and opportunity to include outside decision partners as important elements of the process. PtDAs were commonly evaluated for process‐related and proximal outcomes, but less often for distal outcomes. Early evidence points to the value of comparative outcome evaluation based on the timing of PtDA distribution.Our review of the literature on SDM and PtDAs reveals less attention to the timing of PtDAs relative to that of SDM. We highlight the need for further study of timing in PtDA use to improve longitudinal SDM for chronic care. The model that we propose in our discussion provides a starting point for future research on PtDA efficacy.Five patient consultants provided input and feedback on the development and utility of our model. Key features of SDM that may be particularly salient for chronic care include recognition of decision partners, time for patient reflection and occurrence of decision‐supporting activities external to the provider visit.Patient decision aids (PtDAs) are valuable, prevalent tools to facilitate SDMTherefore, this paper aims to describe SDM and PtDAs in the context of care for chronic conditions. We begin by reviewing the literature on SDM and PtDAs, with particular focus on the temporal elements of each . Following this, we discuss our proposed intersection between the two concepts, illustrating how PtDAs might be timed for current models of SDM and later evaluated through this lens to determine optimal use. Finally, to demonstrate conceptual utility, we apply our framework to SDM about care towards the end of life, one of many contexts of SDM that unfolds over time.2Following guidance promulgated by the Scale for the Quality Assessment of Narrative Review Articles,3In contrast to acute care, decisions for chronic conditions are typically less time‐sensitive, involve subsequent opportunities to readdress and engage patients' social networks in decision‐making.3.1Many SDM models emphasize the role of ‘decision partners’, such as spouses, family, friends, other HCPs and acquaintances, in a patient's medical decisions.3.2Closely tied to the role of outside influences, new SDM frameworks focus on the role of time before, between and after healthcare visits in the patient's trajectory of decision‐making. Notably, two models clearly emphasize this element of SDM. Clayman et al.longitudinal shared decision‐making (L‐SDM).In another model, Bomhof‐Roordink et al.4While the utility of decision aids for single‐timepoint‐based SDM is well supported,4.1PtDAs promote SDM in many ways. Patients equipped with information are more likely to engage in their healthcare decisions,4.2To date, there has been little comparative evaluation of PtDA outcomes based on variability in the timing of distribution . Instead, many systematic reviews and meta‐analyses have attempted to assess patient‐associated outcomes and, less often, provider‐associated outcomes. Commonly measured patient‐associated outcomes are both process‐related  and proximal .4.3As a tool to facilitate SDM in general, PtDA placement in the decision‐making cycle can impact both patient and provider outcomes. Most studies evaluating PtDA effectiveness have not tested the optimal timing of distribution, and yet, a few studies did yield promising evidence. Although a systematic review comparing studies that used previsit versus in‐visit distribution found no differences in the mean patient knowledge or risk‐perception scores,5Individuals noted value in receiving decision aids before, during or after a visit, suggesting variability in preferences despite potential benefits from all options. However, one noted that receiving information before a visit could be anxiety‐inducing if the proper supports were not provided. Another panel member said, ‘If this is going to be a [patient]‐centric solution, you gotta provide some flexibility so that the [patient] gets to choose the path they want to follow in gathering that information’. In other words, decisions about distribution points should incorporate patient preferences in addition to those of providers. It was suggested that opportunities for the patient and provider to correspond about the materials before or after their visit might enhance their value by allowing patients to ask questions of providers and giving providers the opportunity to prepare materials based on patient input. However, panel members also noted that patients may not read materials outside of a visit unless it was a very serious condition.6There is growing understanding of the extended timeline and involvement of decision partners in medical decision‐making for chronic conditions. Despite explicit inclusion of timing into SDM , data on optimal timing of PtDA distribution remain relatively sparse. Early findings , excluding ‘feedback, continuation and resolution’, because it does not have a parallel PtDA distribution point Figure . We viewTiming refers to whether PtDAs are distributed in the preparation (previsit), encounter (in‐visit) or processing (postvisit) stages  timing, 2) single‐visit frequency and 3) cross‐visit frequency as they relate to improvement of L‐SDM.  single‐v cross‐vi6.1We examine the application of PtDAs to L‐SDM for end‐of‐life decisions to demonstrate how understanding the integration of these two concepts can impact healthcare delivery. After providing background information on advance care planning (ACP), we discuss the current state of SDM in ACP and explore the potential for PtDAs in L‐SDM to improve outcomes.End‐of‐life care can involve difficult decisions between aggressive life‐sustaining treatments or less invasive care with a primary focus on quality of life.While 65%–87% of patients express a desire to participate in end‐of‐life treatment decisions, providers used SDM in fewer than half of palliative care visits.While decision partners may be present for any medical decision, their inclusion is especially relevant in the context of ACP. They may be participants and discussants, or they may serve as proxies for underage or incapacitated patients.For patients with advanced illness, PtDAs have been shown to increase their sense of empowerment and control by affirming their choices, encouraging future proactivity and strengthening motivation.7PtDAs are an important element of SDM, but to date, there has been limited evidence for optimal frequency and timing of their use in L‐SDM. We propose a model for both testing and implementing L‐SDM that (a) highlights three timepoints of PtDA distribution, and (b) shows how these timepoints may be leveraged across visits to improve L‐SDM.This model has multiple implications for future research. The design of PtDAs distributed outside of the visit may need to differ in content from in‐visit PtDAs to encourage engagement and reduce harm . Providers and healthcare systems may need to incentivize and reinforce review of PtDAs outside of the visit , give patients options to choose the timing and frequency of receiving PtDAs and facilitate discussion of PtDAs external to clinical visits .timing and frequency for PtDAs in L‐SDM are far‐reaching. By introducing, understanding and leveraging how these two factors impact the process of decision‐making—and the resulting choice—we may improve patient and provider outcomes.Ultimately, the implications of evaluating optimal The authors declare no conflict of interest.


Parental care is extremely diverse but, despite much research, why parental care evolves is poorly understood. Here we address this outstanding question using egg attendance, the simplest and most common care form in many taxa. We demonstrate that, in amphibians, terrestrial egg deposition, laying eggs in hidden locations and direct development promote the evolution of female egg attendance. Male egg attendance follows the evolution of hidden eggs and is associated with terrestrial egg deposition but not with direct development. We conclude that egg attendance, particularly by females, evolves following changes in reproductive ecology that are likely to increase egg survival, select for small clutches of large eggs and/or expose eggs to new environmental challenges. While our results resolve a long‐standing question on whether reproductive ecology traits are drivers, consequences or alternative solutions to caring, they also unravel important, yet previously unappreciated, differences between the sexes. Parental care is extremely diverse but, despite much research, why parental care evolves is poorly understood. Here we address this outstanding question using egg attendance, the simplest and most common care form in many taxa. Our results suggest that amphibian egg attendance, particularly by females, evolves following changes in reproductive ecology that are likely to increase egg survival, select for small clutches of large eggs, and/or expose eggs to new environmental challenges. While parents in many species do not provide care for their offspring after fertilisation, parental care has evolved numerous times and diversified into many forms across the animal kingdom . For all analyses, we examined the trace plots of the posterior distributions to confirm that the chains converged and exhibited adequate mixing with acceptable low levels of autocorrelation. All analyses were run in triplicate and converged on qualitatively similar solutions; here we report the results for the first chain.8) for the fixed effects and a chi‐squared prior, which approximates a cumulative uniform distribution, for the phylogeny treated as a random effect. We fixed the residual variance to 1 because this cannot be estimated in models with binary response variables  crossed zero (Px)  to quantify the importance of species' shared evolutionary history. Heritability can be interpreted in the same way as Pagel's lambda ranging from 0 (no phylogenetic effects) to 1 (strongest phylogenetic effects)  as a function of all binary predictors entered together in a phylogenetic linear mixed model  is present, while significant negative associations indicate the two traits are mutually exclusive as predicted by hypotheses that they are alternative adaptations to increase egg survival Figure , Table 1We used Discrete Dependent models to reveal the order of evolutionary events for those predictors that were identified as significantly associated with egg attendance in probit models, after confirming that they were also evolutionarily associated when tested in Discrete framework (Supplementary Methods). We then examined the posterior distributions of the eight transition rates between the four possible combinations of character states in Discrete models to identify evolutionary pathways consistent with the proposed hypotheses Figure , Table 1In all discrete analyses, we scaled the branch lengths of the phylogeny by a constant (mean of 0.1), as scaling enables the algorithm to better explore parameter space when transition rates are small, hard to estimate or to search for. MCMC chains were run for 400 million iterations with a burnin of 500,000 and sampling every 200,000. We used an exponential prior with mean seeded from a uniform hyperprior ranging from 0 to 20, and Reversible Jump (RJ) in all analyses. RJ can propose models with transition rates equal to zero or to one another, helping to reduce model complexity and avoid over‐parametrisation, and are thus particularly useful for analyses where the sample size for some combination of character states is small  but is gained when terrestrial eggs are present (q34 > q12)  , and of egg attendance when eggs are aquatic or terrestrial , overlap substantially, indicating they are of similar magnitude  but, contrary to females, attendance of terrestrial eggs is unlikely to favour a reversal to attendance of aquatic eggs  and at a slower rate than hidden eggs from the absence of both traits (q13 > q12)  , egg attendance is gained nearly an order of magnitude faster with direct‐developing eggs than with eggs hatching as tadpoles (q34 > q12). In contrast, the posterior distribution of q13 and q24 overlap substantially indicating that direct development evolves at similar rates with and without female egg attendance (Figures Finally, while direct development and female egg attendance evolve at a similar rate from a condition where both are absent (q Figures . Once ev Figures . These rWhether reproductive ecology promotes the evolution of parental care is an open question. Here we tested hypotheses suggesting that reproductive ecology facilitates the origin of amphibian egg attendance, and counter‐hypotheses proposing either the opposite direction of causation, or that care and reproductive ecology represent alternative adaptations to increase egg survival. Our study reveals that terrestrial egg laying facilitates the origin of female egg attendance but could not identify whether male egg attendance follows or precedes the transition to terrestrial egg development. Hidden eggs promote the evolution of both male and female egg attendance, while direct development facilitates only the acquisition of female egg attendance. Thus, we find limited evidence for hypotheses proposing reversed causation and no evidence that changes in reproductive ecology are alternative adaptations to providing care in amphibians.While we find strong evidence that both male and female egg attendance are evolutionarily associated with terrestrial egg deposition, our analysis identified a clear evolutionary pathway for females only. Specifically, female egg attendance follows the shift to terrestrial egg development as predicted by the hypothesis that terrestrial reproduction drives the evolution of parental care Crump, . AlthougAlthough our analysis shows that male egg attendance and terrestrial eggs have evolved together and are not alternative adaptations, the pathway through which they become evolutionarily associated remains unclear. Other ecological and social conditions may need to be considered to identify the evolutionary pathway in males. For example, eggs may suffer different levels of predation risk or oxygen limitation across different types of aquatic or terrestrial habitats, and male egg attendance may evolve in more specific habitats. Social factors, such as male territoriality, may also facilitate the origin of male care in amphibians and other taxa (Gross & Sargent, Consistent with the hypothesis that hiding eggs may reduce predation risk to eggs and parents and drive the evolution of parental care Crump, , we findWe proposed that direct‐developing eggs could facilitate the origin of egg attendance particularly in females. These eggs are large, laid in small clutches (Furness et al., Research has revealed the costs and benefits of parental care in many species but understanding why care has evolved in some taxa but not others have remained elusive (Royle et al., Drivers for the origin of parental care do not necessarily select for its persistence over evolutionary time (Royle et al., In conclusion, egg attendance is the most common form of care in the animal kingdom (Balshine, IC and AIF designed the study, AIF assembled the data set and conducted analyses with guidance from IC, and IC and AIF wrote the manuscript.https://publons.com/publon/10.1111/ele.14109.The peer review history for this article is available at Table S1Table S2Table S3Table S4Table S5Table S6Table S7Click here for additional data file.


The vulnerability of marine biodiversity to accelerated rates of climatic change is poorly understood. By developing a new method for identifying extreme oceanic warming events during Earth's most recent deglaciation, and comparing these to 21st century projections, we show that future rates of ocean warming will disproportionately affect the most speciose marine communities, potentially threatening biodiversity in more than 70% of current‐day global hotspots of marine species richness. The persistence of these richest areas of marine biodiversity will require many species to move well beyond the biogeographic realm where they are endemic, at rates of redistribution not previously seen. Our approach for quantifying exposure of biodiversity to past and future rates of oceanic warming provides new context and scalable information for deriving and strengthening conservation actions to safeguard marine biodiversity under climate change. Using a new approach for quantifying exposure of biodiversity to oceanic warming, we show that future climate change will disproportionately affect Earth's most speciose marine communities, potentially threatening biodiversity in more than 70% of current‐day global hotspots of marine species richness. Near‐term persistence of these richest areas of marine biodiversity will require many species to move well beyond the biogeographic realm where they are endemic, at rates of redistribution not previously seen. The approach, which builds off methodological advances in modelling the exposure of terrestrial biodiversity to climate change . See Brown, Wigley, Otto‐Bliesner, and Fordham et al.  and variability  to quantify the exposure of marine biodiversity to projected rates of oceanic warming following industrialisation. We did this by subtracting past SNR values from post‐industrial to 2100 C.E. values . Differences between past and future SNR within realms were assessed using a Kolmogorov–Smirnov test, with p‐values adjusted for multiple comparisons following Benjamini and Yekutieli . This approach is conservative compared with competing methods for calculating climate exposure  were generated for cells containing species richness ≥95th percentile of global values (see above). Upper grid cell temperatures during the Holocene thermal maximum (HTM)—a variable period between 9000 and 5000 B.P., where tropical ocean temperatures were up to 1°C warmer than pre‐industrial temperatures , based on a comparison of rates of extreme warming using SNR over the last 21,000 years and for the 21st century. Specifically, our modelling indicates that 6 out of 17 tropical and mid‐latitude biogeographic realms will be highly exposed to novel  rates of future oceanic warming  by 2100 C.E. under RCP 4.5  of the richest areas of global marine biodiversity to future climate‐driven species redistributions. This variation in the spatial pattern of rates of change in SST, acting alone, or in synergy with other human impacts on the marine realm  that exceed those observed for most marine taxa  when oceanic temperatures in many regions were as warm or warmer than pre‐industrial temperatures  biogeographic realms in the Northern Hemisphere, biodiversity has persisted through climatic perturbations during the last deglaciation that approximate those predicted for the future Figure . While tHere we developed and applied a new climate change metric to more than 21,000 years of continuous global climate data to quantify exposure of marine biodiversity to human‐induced oceanic warming, avoiding well‐established limitations in statistical projections of species' range shifts (Yates et al., Marine life in tropical regions is ill‐equipped to respond to large relative shifts in rates of future warming and changes in absolute temperatures. Within tropical regions, locations of exceptionally high marine biodiversity will be highly exposed to oceanic warming, making them particularly vulnerable to 21st century climatic change. This new approach and understanding of exposure of marine biodiversity to past and future rates of oceanic warming provides important context and scalable information for deriving and strengthening conservation actions to safeguard marine biodiversity under climate change.Stuart C. Brown and Damien A. Fordham conceived and led the project. Jorge García Molinos produced the marine species richness maps. Stuart C. Brown did the analysis and produced all outputs. Stuart C. Brown drafted the manuscript and all authors reviewed and edited the manuscript.Authors declare that they have no competing interests.Figure S1.Click here for additional data file.Table S1.Click here for additional data file.


Health professionals in paediatric medical imaging are routinely required to communicate radiation risks to carers and patients. Effective dose alone cannot be used to specify and communicate the radiation risk for an individual as risks are dependent on many factors including age and patient sex. In this study, we estimated typical effective doses for 20 commonly performed paediatric general radiography examinations using the weight‐based imaging protocols employed at a major Australian specialist paediatric hospital. Effective doses were used to estimate and categorise associated age‐based stochastic risks with commonly used risk terminology to facilitate communication of risk.Paediatric protocols for common general radiography examinations and World Health Organization 50th percentile weight‐for‐age data for females and males aged up to 18 years were used to estimate typical effective doses using Monte Carlo software and lifetime risk of cancer incidence using published data. Results were used to determine standardised levels of risk using the Calman risk model.Effective doses, corresponding lifetime risk of cancer incidence and level of risk category from 20 general radiography examinations for paediatric patients were calculated and presented for ease of communication. Doses ranged from <0.001 mSv (negligible risk) to 1.6 mSv (low risk).Typical effective doses from common paediatric general radiography examinations, the associated lifetime risk of cancer incidence and level of risk have been established for our institution. This can be used to convey risks to health professionals, patients and carers in ways that are easy to understand and compare with other everyday risks. The typical effective doses for 20 of the most commonly performed paediatric general radiography examinations were estimated using the weight‐based imaging protocols employed at our institution. The effective doses were used to estimate and categorise associated age‐based stochastic risks with commonly used risk terminology to facilitate the communication of risk to patients and carers in ways that are easy to understand and compare with other everyday risks. Diagnostic general radiography examinations are performed routinely in children, providing important information for the diagnosis, staging, treatment and follow‐up of a range of conditions and diseases. The Royal Children's Hospital, Melbourne, Australia (RCH) has five fixed general radiography rooms using indirect digital detector technology (Shimadzu RADSpeed Pro UD 150B‐10 with Canon CXDI‐70C CsI(CsI:Tl) wireless digital detector) installed in 2011. The Medical Imaging department provides a 24‐hour service. In the period January 2021 to December 2021, the Medical Imaging department imaged over 28,000 patients and acquired over 33,000 radiographs. The most commonly performed general radiography service was extremity imaging (44%) followed by chest imaging (38%). Whilst the effective doses from general radiography examinations are typically lower than those received from computed tomography (CT), fluoroscopic and nuclear medicine procedures, the radiation exposure must still be justified.Whilst there is published data regarding effective doses for paediatric general radiography examinations,At our institution, a weight‐based exposure chart is employed to ensure a certain level of image quality is achieved given the large variation in patient weight and height for any given age. Stochastic risk is based on a patient's age so an age–weight relationship needs to be used to be able to estimate and communicate risk meaningfully.As previously discussed by the authors,for effective radiation risk communication we need to personalise communication like we personalise medical diagnosis and treatment.The majority of patients, carers and some health professionals are not radiation‐literate. Using too many technical terms and complicating the narrative may increase confusion and concern in the audience.The primary aim of this study is to estimate the radiation dose and associated risk for the most commonly performed paediatric radiographic examinations at our institution. The secondary aim is to provide clear and accurate information to assist medical imaging professionals and other clinical staff, in the communication of radiation dose and associated risk in the paediatric setting using common risk classifications and terminologies. The standardised information can then be personalised by health professionals as required .Age‐dependent effective doses for the 20 of the most commonly performed general radiography examinations with one or more views at RCH Table  for chilThe views listed in Table The 50th percentile weight‐for‐age and body mass index (BMI) values published by the World Health Organization (WHO) in 2007 for female and male children from 0 to 18 years old were used to represent the average weight for each age.Calculations and statistical analyses were performed using Microsoft Excel (Microsoft 365). The effective doses were calculated for the weight ranges 3–7, 8–15, 16–25, 26–40, 41–60 kg and 60+ kg using the corresponding anthropomorphic PCXMC phantom . The PCXMC phantom for a 15‐year‐old (168.1 m and 56.3 kg) was suitable for use to model an 18‐year‐old female using the median WHO data (163.1 m and 56.7 kg). The adult phantom (178.6 m and 73.2 kg) was too large to model the median 18‐year‐old male and such as the decision was made to modify the 15‐year‐old phantom for the dosimetry. The RCH general radiography exposure chart provides the recommended kVp and mAs based on these weight ranges  by comparing the level of risk with the published classifications Table .13The BERT was calculated using the typical effective dose for each examination and the Australian natural background radiation dose of 1.5 mSv per annum.The equivalent in international flight time was calculated using the typical effective dose for each examination, the quoted effective dose for a return flight between Melbourne and London of 0.11 mSv, and a typical return flight time of 46 hours.The statistical analysis consisted of determining the maximum effective dose and associated BEIR VII risk and Calman risk category of the female and male estimates for the previously stated weight ranges. The maximum value in each weight range was used to conservatively represent that weight range.Table The typical effective doses for 20 of the most commonly performed paediatric general radiography examinations were estimated using the weight‐based imaging protocols employed at our institution. The effective doses were used to estimate and categorise associated age‐based stochastic risks with commonly used risk terminology to facilitate the communication of risk to patients and carers. This mirrored the approach used by the authors in their earlier publication for estimating age‐dependent organ and effective doses and the associated lifetime risk of cancer incidence and level of risk for the six most commonly performed nuclear medicine and PET procedures at RCH for children aged 0–18 years using published organ and effective dose coefficients and commonly used risk terminology.As noted in ICRP Publication 128, effective dose can be a useful tool for comparing doses related to stochastic effects from other radiological procedures, similar or otherwise, performed at other institutions provided that the populations involved are of similar age and patient sex.Whilst Table There are significant limitations involved in using the currently available data and information such as those provided in PCXMC, ICRP and BEIR VII documents for estimating an individual's dose and associated risk. Individuals who differ considerably from the body size and shape assumed in the calculations will have significantly different effective doses and risk estimates than those presented in Table The accuracy of the PCXMC program has been well validated and its limitations well documented.Another limitation is modelling and estimating the dosimetry for upper extremities. As noted earlier, our dose estimates for humerus, forearm and hand were obtained by normalising published data for the exposure parameters (i.e. correcting for differences in kVp and mAs to account for a different beam quantity). It was not possible to account for other differences such as total beam filtration, source to skin and source to detector differences as this information was not provided in the published literature.The estimated effective doses and associated risks can be used as a guide, with caution, for patients whose weight is significantly below or above the median weight for their age. The information is presented in large weight ranges therefore, for these patient cohorts, healthcare professionals can use the estimates to provide an approximate magnitude of dose and risk.It should be noted that the information presented is for a single occurrence of the relevant examination. Some patients may require multiple radiographic examinations over time and the risk of stochastic effects is cumulative (additive) over a person's lifetime.It is important that every imaging examination or procedure is appropriately justified by a radiation medical practitioner which includes comparing the clinical benefit of performing the examination with the radiation related risks.As a result of this study, Figure Typical effective doses from common paediatric general radiography examinations and the associated lifetime risk of cancer incidence and level of risk have been established for our institution. This work can be used to standardise the approach for communicating radiation dose and associated risk information in a paediatric setting. The information presented in this paper, namely Figure


To explore adult Emergency Department patient experiences to inform the development of a new Emergency Department patient‐reported experience measure.Descriptive, exploratory qualitative study using semi‐structured individual interviews with adult Emergency Department patients.Participants were recruited across two Emergency Departments in Southeast Queensland, Australia during September and October 2020. Purposive sampling based on maximum variation was used. Participants were recruited during their Emergency Department presentation and interviewed in 2‐weeks via telephone. Inductive thematic analysis followed the approach proposed by Braun and Clarke (2012).Caring relationships between patients and Emergency Department care providers; Being in the Emergency Department environment; Variations in waiting for care; and Having a companion in the Emergency Department. Caring relationships between patients and Emergency Department care providers included being treated like a person and being cared for, being informed about and included in care, and feeling confident in care providers. Being in the Emergency Department environment included being around other patients, feeling comfortable and having privacy. Variations in waiting for care included expecting a longer wait, waiting throughout the Emergency Department journey and receiving timely care. Having a companion in the Emergency Department included not feeling alone, and observing care providers engage with companions.Thirty participants were interviewed, and four themes were inductively identified: Patient experiences in the Emergency Department are multifaceted, and themes are not mutually exclusive. These findings demonstrate consistency with the core experiential themes identified in the international literature.Strategies to improve patient engagement in shared decision‐making, and communication between patients and care providers about wait times will be critical to optimizing Emergency Department patient experiences, and person‐centred practice. These findings holistically conceptualize patient experiences in the Emergency Department which is the first step to developing a new Emergency Department patient‐reported experience measure. All participants provided written consent to participate in the study.3.6Preliminary data analysis occurred simultaneous to data collection, enabling constant comparison and the identification of data saturation  undertook all interviews. She has an honours degree and this study forms part of her PhD candidature. All authors are experienced in qualitative research.This study was guided by Koch's  criteriaFindings are reported using themes and sub‐themes. Direct extracts from interview transcripts are included to support the findings and strengthen dependability. Participant labels are based on participant number: gender: age to maintain participant anonymity.44.1Thirty participants were interviewed; their characteristics are presented in Table 4.2Four themes were inductively identified from the qualitative data: (i) Caring relationships between patients and Emergency Department care providers; (ii) Being in the Emergency Department environment; (iii) Variations in waiting for care; and (iv) Having a companion in the Emergency Department. Themes and sub‐themes Table  overlapp4.2.1Caring relationships occurring between patients and Emergency Department care providers involved both physical and emotional aspects of care. This met participants' health and well‐being needs (i.e. the need to be looked after) and their need for companionship and comradery with care providers. These relationships contributed to patients feeling valued, cared for and welcome in the Emergency Department. Three sub‐themes underpin this theme: (i) Being treated like a person and being cared for; (ii) Feeling confident in Emergency Department care providers; and (iii) Feeling included in and informed about care.‘empathy’, ‘concern’, ‘compassion’ and ‘reassurance’ were crucial to making participants feel humanized and cared for, and had an enduring impact on their overall Emergency Department experience .Participants described being treated like a person when receiving medical care. This care was respectful and considerate of them as an individual, not a medical condition. Interactions with care providers who demonstrated ‘…the fact I was offered pain medication and it wasn't delivered on three or four occasions; that is the purpose of my visit and that wasn't fulfilled’. (P5:55:M) While some participants viewed instances of being dismissed as ‘frustrating’ and ‘comical’, others highlighted how it made them feel like a burden and as though they did not have a legitimate reason for presenting to the Emergency Department.Being treated like a person was exemplified when participants were taken seriously by care providers and not dismissed about their expertise and knowledge of their own health and body. This contributed to egalitarian relationships where participants felt free to express their thoughts and opinions Table : Quote 4‘appreciating the little things’, such as being offered blankets, drinks and food  and discharge education. For some, being informed alleviated the anxiety, fear, confusion and isolation they felt on first entering the Emergency Department. It also meant that, despite a sense of unfamiliarity, what was happening next in the care journey did not come as a surprise Table : Quote 7‘It's your body and they're making all these decisions for you… It's going to happen whether you like it or not’. (P23:74:F) Others highlighted that receiving limited information about their injury/condition left them with a sense of not knowing  and provided thorough and comprehensive care. This promoted relationships founded on trust, leading participants to feel safe and relaxed in the hands of their Emergency Department care providers (Table Participants described feeling confident when care providers 4.2.2This theme describes how the Emergency Department environment––particularly the tangible features and atmosphere of the environment––influenced participant experiences. Three sub‐themes underpin this theme: (i) Being around other patients; (ii) Feeling comfortable; and (iii) Having privacy.‘probably the worst part of being in the Emergency Department’. (P15:60:M).Participants actively observed the health conditions, behaviours and demeanour of other patients in the Emergency Department. When observing the health condition of other patients, some participants reflected with compassion and empathy, acknowledging that their own condition and circumstances were better than that of others , despite his injuries.Feeling comfortable included how tangible features of the Emergency Department and the general atmosphere of the environment shaped participant experiences. Tangible features of the Emergency Department environment that contributed to participant comfort included clean waiting and treatment areas, suitable temperature control and useful facilities in the waiting room  (Table ‘Some of the seats were quite cracked and in bad condition…’ (P1:48:F), and the televisions were not switched on, which left patients ‘just looking at each other, waiting…’ (P6:36:M) Others highlighted that the level of noise and cold temperatures in the Emergency Department made them physically uncomfortable.Yet not all participants described the Emergency Department environment as comfortable. In particular, the waiting room was consistently highlighted as uncomfortable because it was overcrowded  care progressed. Participants described perceived delays in the initiation of their Emergency Department care (waiting in the waiting room), and in the progression of their Emergency Department care (waiting throughout their Emergency Department journey). Conversely, they also described aspects of their care that occurred quicker than they anticipated, highlighting that participant expectations influenced their experiences of waiting in the Emergency Department. Three sub‐themes underpin this theme: (i) Expecting a longer wait; (ii) Waiting throughout the Emergency Department journey; and (iii) Receiving timely care.‘prepared with some books and things… knowing that generally emergency departments have quite a wait’, described that ‘based on how busy it was, it didn't feel like I had to wait a long time… they [Emergency Department care providers] seemed like they were quite proficient’. (P12:33:F) Thus, when participants' expectations about long waits in the Emergency Department waiting room were disproved, their overall experience improved.A long Emergency Department wait time was expected by many participants, influenced by past experiences of waiting and how busy the Emergency Department appeared to be. Many participants reflected that their current experience of waiting was better than their past experiences, noting how surprised they were  Not feeling alone; and (ii) Observing staff engage with companions.Not feeling alone describes how having a companion in the Emergency Department provided participants with support and company. Companions played a critical role in some participant experiences as they helped pass the time and provided someone with whom participants could communicate  and noted how this impacted their Emergency Department experience. Namely, that there was no one else to hear discharge advice, and no one to ask questions that the participant had not thought to ask  Participants appreciated this engagement as they believed that it made their companion more comfortable and respected as someone of importance in the experience, despite not being there to receive care. When care providers did not acknowledge or engage with companions, some participants were neutral, believing that there was no added value in consulting with their companion when they themselves could communicate with care providers adequately  with them in the Emergency Department described the value this added to their Emergency Department experience by reducing loneliness and helping the time pass. Yet some patients noted instances where Emergency Department care providers did not acknowledge their companions, which was viewed as rude and dismissive. Demonstrating person‐ and family‐centred care is a key competency for emergency nurses and physicians globally . Additionally, the period between presentation and follow‐up enabled participants to recover/ get well before being contacted. Second, selection bias may have impacted recruitment as Emergency Department care providers were critical to consenting participants. The use of a maximum variation sample frame aimed to negate this. Third, all interviews were conducted over the phone due to COVID‐19 restrictions and ethical requirements. Thus, the researcher was unable to utilize participants' visual cues such as non‐verbal body language to prompt for further questioning Sweet, . However6The findings of this study indicate that there are four critical aspects to patient experiences in the Emergency Department. These are patient‐care provider relationships; the Emergency Department environment itself; wait times and waiting in the Emergency Department environment; and the inclusion of family and friends in the care experience. Our findings posit that patient‐care provider relationships are the most important aspect of patient Emergency Department experiences. Greater efforts to engage in shared decision‐making with Emergency Department patients will be critical to promoting person‐centredness in Emergency Department services, as will investigating strategies to enhance patient‐care provider communication about wait times. These findings contribute to the holistic conceptualization of patient experiences in the Emergency Department which is the first step in the development of a new Emergency Department patient‐reported experience measure.This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.No conflict of interest has been declared by the author(s).


Associational resistance to herbivore and pathogen attack is a well documented ecological phenomenon and, if applied to agriculture, may reduce impact of pests and diseases on crop yields without recourse to pesticides.The value of associational resistance through intercropping, planting multiple crops alongside each other, as a sustainable control method remains unclear, due to variable outcomes reported in the published literature. We performed a meta‐analysis to provide a quantitative assessment of benefits of intercropping for target plant resistance to plant‐parasitic nematodes and soil‐borne diseases.We found that intercropping reduced damage to focal crops from nematodes by 40% and disease incidence by 55%. Intercropping efficacy varied with biological variables, such as field fertilisation status and intercrop family, and methodology, including whether study samples were potted or in fields.Nematode control using intercropping was sufficient to offset reductions in focal crop yield from intercrop presence, making intercropping a viable agricultural tool. We identify key drivers for underpinning the success of intercropping and indicate areas for future research to improve efficacy. This study also highlights the potential benefits of harnessing ecological knowledge on plant–enemy interactions for improving agricultural and landscape sustainability. Full search query strings are provided in supplementary information, under Supporting Information Notes We performed literature searches in the Web of Science  with randomly assigned treatments.To be included, experiments were required to compare (1) damage caused by plant‐parasitic nematodes or disease incidence on a primary  crop species grown alone as a monocrop (control) with (2) damage or incidence on the same focal crop when grown intercropped with one other plant species (treatment). Experiments had to be replicated , defined as the mean value for the damage/disease found within the treatment (intercrop) group divided by the mean value for the control  group, as the effect size. L, defined as the natural logarithm of R, was used in the meta‐analysis calculations along with a nonparametric variance estimate that allowed more experiments to be included, giving greater statistical power  group and x¯C is the mean value for the control  group  could not be calculated for experiments in which the monocropping treatment had a damage or disease value of zero. To avoid introducing bias against experiments in which the focal monocrop control had no observed damage or disease but the intercrop treatment did, we used the highest value of L in the final dataset in place of the infinitely large effect size that would have been calculated otherwise in these cases. Similarly, for experiments in which the intercropping treatment had a disease or damage value of zero , we used the lowest value of L to avoid bias against experiments in which intercrop treatment reduced damage or disease below detectable levels.The response ratio  to check plant species, and multiple sources to check nematode and pathogen species set of each meta‐regression that yielded interesting results (and were therefore reported and discussed), to give the number of experiments (‘fail‐safe number’) with an average effect size of zero that would have to be added to the dataset to render the estimated mean true effect nonsignificant  plus 188 contained (potted) nematode experiments and 89 uncontained plus 28 contained soil‐borne disease experiments. These published findings included 45 focal crops (limited due to the priority focus on soil pests and pathogens), 21 intercropping families, seven nematode genera inclusive of 16 nematode species, and 10 pathogen genera, including bacterial, fungal and oomycete varieties Table . Beyond Both disease incidence and pest damage were significantly reduced through intercropping. Soil‐borne disease damage to the focal crop within in‐field studies was reduced by 55% due to intercropping  of 67 to 38%) and 44% (95% CI of 57 to 28%) in contained experiments Table . NematodNineteen studies that reported nematode damage data also contained yield information, for 76 experiments in total  and M. incognita and M. javanica as the least affected species of those commonly studied  and contained (NC1) nematode datasets were quite close, 0.60 and 0.55, respectively Table , suggestPublication bias towards positive outcomes does not appear to have had a significant effect on our results: the fail‐safe numbers for the NU1, NC2, and DU1 datasets were 2250, 9773, and 3513, respectively, and no bias in the datasets was detected in the funnel plots Figs –S3.We found strong quantitative evidence in support of intercropping as an effective method of control for both plant‐parasitic nematodes and soil‐borne diseases.Nematode impacts were reduced by 40% in‐field experiments, and 45% in pot studies Table . The metet al., et al., et al., et al., Variability in the effectiveness of intercropping as a control strategy is driven by substantially different factors for nematodes compared with disease. Both nematode and pathogenic microbial survival are determined by soil texture, moisture, temperature and pH Menzies, . On specet al., et al., et al., et al., Intercrop family explained a significant fraction of the efficacy of intercropping against nematodes in uncontained field studies. For example, interplanting with Asteraceae, Pedaliaceae or Solanaceae species was associated with better nematode control, whereas Poaceae, Brassicaceae and Fabaceae intercrops were associated with less effective control. Intercrop root exudates can lead to associational resistance to nematodes through several mechanisms: (1) acting as biocidal compounds, so killing pests, or reducing their fitness; (2) acting as an attractant, so trapping pests away from the focal crop; (3) acting as a repellent, reducing pest population near the focal crop; or (4) modifying hatching rates, creating phenological mismatch between crops and early‐stage feeding  and greater evapotranspiration (reducing soil moisture), producing less favourable conditions for infection and disease development  and more salicylic acid (inducing resistance against pathogens)  final model specifications, and moderator omnibus test results for each meta‐regression performed using the nematode and disease data.New Phytologist Central Office.Please note: Wiley Blackwell are not responsible for the content or functionality of any Supporting Information supplied by the authors. Any queries  should be directed to the Click here for additional data file.


The concept that all the tumors need the formation of new vessels to grow inspired the hypothesis that inhibition of angiogenesis would have led to “cure” cancer. The expectancy that this type of therapy would have avoided the insurgence of resistance was based on the concept that targeting normal vessels, instead of the cancer cells which easily develop new mutations, would have allowed evasion of drug caused selection is, however, more complex as it was made apparent by the discovery of nonangiogenic tumors. At the same time an increasing number of trials with antiangiogenic drugs were coming out as not as successful as expected, mostly because of the appearance of unexpected resistance.Among the several different mechanisms of resistance to antiangiogenic treatment by now described, we review the evidences that vascular co‐option and vasculogenic mimicry by nonangiogenic tumors are effectively two of such mechanisms. We focused on reviewing exclusively the study, both clinical and preclinical, that offer a demonstration that vascular co‐option and vasculogenic mimicry are effectively two mechanisms of both intrinsic and acquired resistance.The discovery that vascular co‐opting and vasculogenic mimicry are two ways of escaping antiangiogenic treatment, prompts the need for a better understanding of this phenomenon in order to improve cancer treatment. Following a first period in which data from all over the world seemed to support this hypothesis, “inducing angiogenesis” has been considered to be a hallmark of cancer.The idea that angiogenesis is necessary to cancer growth is the brainchild of Judah Folkman who went as far as to propose that, by inhibiting angiogenesis with appropriate drugs, it would be possible to treat any type of tumors or, at least, maintaining or inducing dormancy and preventing the formation of metastatic lesions.Resistance to antiangiogenic treatments had been first predicted in 1997Vascular mimicry also occurs in tumors not inducing the formation of new nonneoplastic blood vessels, that is, nonangiogenic. However, these nonangiogenic cancer cells instead of co‐opting preexisting vessels, form themselves channels that provide blood flow to the neoplastic mass.This patterns of tumor vascularization are commonly ignored but can mediate cancer progression and establishment of metastasis.2As said above, for many years the data seemed to support Folkman's hypothesis. A first group of studies supporting it reported an association between the microvascular density (MVD) present in tumors and their aggressiveness,Contrary to expectations the clinical trials results have been disheartening. Representative is what has been observed in high‐grade glioma: overall survival failed to improve with antiangiogenic drugs.3It becomes evident that resistance to antiangiogenic treatment is widespread. It can be intrinsic, when it is observed at the beginning of the treatment, or acquired, that is, that it affects the relapsing disease after an initial response to therapy.4Nonangiogenic tumors grow in the absence of angiogenesis by two main mechanisms. One way is by cancer cells infiltrating and occupying the normal tissues to exploit preexisting vessels, which is known as vascular co‐option or vessel co‐option. The second is one, less frequent, in which no new vessels are formed but the cancer cells themselves forms channels able to provide blood flow, the so called vasculogenic mimicry.Nonangiogenic tumors can be very aggressive and induce metastatic spreading but as they lack new vessels, it was immediately evident that antiangiogenic treatment could not have worked in these patients as the target of the treatment itself is not present.In 1999, Holash et al reported that tumor cells migrate to host organ blood vessels in sites of metastases, or in organs with an extensive vascularization likes the brain, and initiate nonangiogenic tumor growth instead of classic angiogenesis. These vessels then regress owing to apoptosis of the constituent endothelial cell, apparently mediated by angiopoietin‐ 2 (Ang‐2). Lastly, at the periphery of the growing tumor mass angiogenesis occurs by cooperative interaction of VEGF and Ang‐2. Tumor cells often have immediate access to blood vessels, such as when they metastasize to or are implanted within a vascularized tissue, co‐opt and often grow as cuffs around adjacent existing vessels.The ability of cancer cells to co‐opt the vessels initiates the process through few of them will intravasate, starting the metastatic process.Maniotis et al5Only a limited number of retrospective clinical studies looking at the correlation between the presence of nonangiogenic tumors and the effect of antiangiogenic drugs has been so far published Table .Frentzas et alLazaris et alThe lymph node is also involved in nonangiogenic growth by vascular co‐option.Antiangiogenic treatment of primary central nervous systems tumors has been used for several years but, again, the results have not lived up the expectations.Breast cancer patients treated with Bevacizumab showed, by dynamic contrast‐enhanced magnetic resonance (DCE‐MRI) imaging, three response patterns. In the first one, a decrease in K‐trans values over the extent of the tumor was demonstrated, that is, decreased vascular permeability and/or vascular surface area, while the second was characterized by extensive necrosis. These two patterns indicate a response to antiangiogenic treatment. In the third one, instead, no changes were seen and the authors conclude that, in these lesions, the vessels were independent of VEGF. Whether they were preexisting normal vessels or not, it has not been investigated in this studyHelfrich et al investigated the vascularization of metastases from stage III melanoma patients enrolled in the United Kingdom adjuvant bevacizumab trial. All the metastatic lesions presenting in subjects treated with bevacizumab, had a mature vessel morphology and phenotype in contrast with the newly formed vessels present in the relapsing disease from the trial patients not receiving the antiangiogenic drug. The authors do not discuss whether these are preexisting vessels or by now matured “normalized” newly formed vascularization,In a case report study of a renal cell carcinoma (RCC), Kats‐Urgurlu et al showed that lung metastases occurred 3 years after the primary tumor resection. Treatment with the antiangiogenic drug cedinarib and gefitinib, an epidermal growth factor receptor (EGFR) inhibitor was started and partial response was achieved. The metastatic lesions were resected but ultimately new lung metastases appeared. The authors reported that antiangiogenic treatment caused an adaptation of the phenotype in the lung with a “signature” infiltration of cancer cells along and even in the pulmonary vasculature, resembling pulmonary lymphangitis carcinomatosis, reflected by a cloudy pattern on CT, alongside nonangiogenic intra alveolar growth. These reports suggest that lung metastases of RCC can escape antiangiogenic treatments by switching phenotype and progress in an angiogenesis‐independent fashion exploiting preexisting vessels.Nonangiogenic growth and spread in the lung has also been linked to resistance to surgical treatment.6A first group of models employs antiangiogenic drugs of the tyrosine kinases inhibitor (TKI) group.Bridgeman et al investigated the effect of sunitinib on xenografts from three different cell lines from breast, colorectal renal cancer respectively. Sunitinib inhibited the growth of all the subcutaneous tumors and reduced the vascular density, whereas, the same treatment did not inhibit the growth of 4T1 breast cancer and C26 colorectal cancer lung metastases and had no effects on vessel density. A response, but only partial, was instead observed on RENCA generated lung metastases. Histological examination revealed that both the 4T1 and C26 lines are growing in the lung in a nonangiogenic fashion, contrary to their angiogenic growth in the subcutaneous tissue. Otherwise, the lung metastases of the RENCA renal carcinoma are prevalently angiogenic; however, the residual secondaries after sunitinib treatment, presented a switch toward the nonangiogenic growth pattern.Comparable results have been obtained in another model where response of the subcutaneous tumor, in this case orthotopic implantation in the mammary pad of the human breast carcinoma variant MDA‐MB‐231/LM2.4 line and their visceral metastases where challenged with sunitinib, Pazopanib or the anti‐VEGFA antibody DC101. All the three drugs where effective in treating established orthotopic primary tumors either as monotherapy or in association with Paclitaxel. They instead failed to show an effect, either as monotherapy or combination chemotherapy when used, after the resection of the mammary pad xenograft, to treat visceral metastases. No data are presented in this study as far as the vascularization of the resistant metastases is concern but the hypothesis that vascular co‐option could be involved it is discussed.A third study show that sunitinib accelerated metastatic tumor growth and decreased overall survival in mice receiving short‐term therapy in various metastasis assays. A faster metastatic process was identified in mice treated with sunitinib in advance of intravenous implantation of tumor cells, raising the possibility of a “metastatic conditioning” in multiple organs. As in the two studies discussed above, these observations of metastatic acceleration were in contrast to the demonstrable antitumor benefits obtained when the tumor cell lines were grown orthotopically as primary tumors and subjected to Sunitinib treatment. The authors, however, do not investigate where vascular co‐option is occurring,In an orthotopic hepatocellular carcinoma mouse model the implant is initially sensitive to sorafenib, another TKI blocking the VEGF pathway signaling, only to develop resistance after 1 month when an invasive phenotype develops and cancer cells switch to co‐option of sinusoidal and portal‐tract vessels in association with upregulation of epithelial mesenchymal transition (EMT)‐associated genes.Alongside their observations on patients with metastatic melanoma previously cited, Helfrich et al evaluated also the activity of another TKI, PTK/ZK , in a MT/ret transgenic mice, which spontaneously develop melanoma with metastatic disease.glucose transporter (GLUT), a characteristic marker of the blood‐brain barrier, is present in the vessels of the treated but not of the placebo mice; c) ZD6474 intratumor vessels are not leaky, contrary to the placebo‐ receiving ones; d) the endothelial cells in the tumors receiving antiangiogenic treatment are not proliferating, as assessed by stain for Ki67 proliferating marker.A model of melanoma metastatic to the brain was set up injecting Mel157 cell line in the carotid artery of Balb/c mice. This model was chosen as the authors had already described that it grows in a nonangiogenic way by co‐opting the brain vessels.Treatment with cabozantinib, a c‐MET‐ and VEGFR2 tyrosine kinase inhibitor, of BALB/c nu/nu mice with orthotopic E98 glioblastoma xenografts lead to an improvement in overall survival. Cabozantinib blocked angiogenesis with a consequent increase of hypoxia in the angiogenesis‐dependent cancer regions with following vessel normalization.However, tumors eventually became more infiltrative and escaped treatment via vessel co‐option.7Using animal models Frentzas et alA more recent study demonstrated that patient‐derived colorectal cancer organoids, grafted into the livers of mice, adopted a replacement growth pattern and that these tumors responded poorly to the antiangiogenic drug regorafenibFranco et al using a genetically engineered mouse model of pancreatic neuroendocrine tumors, found that tumors refractory to long‐term treatment with the anti VEGFR2 blocking antibody DC101, contained mature blood vessels covered by pericytes. Markers used to identify pericytes were alpha smooth actin (αSMA), NG2 proteoglycan and platelet‐derived growth factor receptor (PDGFR)‐beta. As in control animals, mature vessels covered by pericytes where at the edge between tumor and normal tissue and in the surrounding normal tissue, the authors concluded that the increased abundance of this particular subtype of blood vessels inside the resistant neoplasms, most likely occurred by co‐option of vessels from the surrounding exocrine pancreas.Murine and rat models are very well established models to study nonangiogenic growth and vascular co‐option.That orthotopically implanted glioma cells invaded and proliferated within brain perivascular space was once more demonstrated using fractal dimension analysis on fluorescence scanning confocal micrographs of the orthotopic grafts.Perivascular invading brain tumors are irrorated by normal brain microvessels as individual glioma cells use perivascular space to invade. Both antibodies, bevacizumab and DC101, failed to reduce neoplastic growth or to improve overall survival of mice bearing wither orthotopic grafts or endogenous gliomas. Furthermore, the neoplastic cells become more invasive in treated animals. These results provide further experimental evidences that vascular co‐option by nonangiogenic tumors is a way to escape antiangiogenic treatment.Others orthotopic murine model once again showed that in animals treated with either DC101, bevacizumab or VEGF‐Trap (a decoy molecule trapping VEGFA) confirmed that presence of nonangiogenic cancer cells can lead to tumor progression. Despite the observation of a marked reduction of the primary lesions, there was a striking increase in the number small perivascular lesions developing away from the primary mass. Such a satellite lesions were also recognizable distant from the primary due to an increased migratory ability of these nonangiogenic cells. Infiltration of the leptomeninges has been also observed. The authors concluded that blockage of the VEGFR2 can stop neovascularization and reduce the primary tumor but can, at the same time, lead to increased co‐option of preexistent cerebral blood vessels, disease spreading and therefore defeat the original object of achieve treatment.8A few studies have started to explore the role of vasculogenic mimicry in inducing resistance to anti angiogenic treatment.In an in vitro study van der Schaft et alXu et alN‐hydroxy‐N′‐(4‐butyl‐2 methylphenyl) formamidine (HET0016), a highly selective inhibitor of 20‐hydroxy eicosatetraenoic acid (20‐HETE) synthesis, by regulating the enzymes of the cytochrome P450 families. This compound has been reported to be an effective angiogenesis inhibitor in preclinical models.As vascular co‐option, also vascular mimicry plays a role in the resistance to anti angiogenic drugs in orthotopic glioblastoma models.9So far antiangiogenic trials have been conducted mostly on the principle that all the tumors depend on neoangiogenesis and therefore any neoplastic patient has been automatically deemed eligible,A first step in solving these issues would be to run clinical trials where patients are selected for antiangiogenic drugs according to predictive biomarkers.An obvious one would be the vascular pattern of the tumors, however this at present require surgical resection to allow histological examination, but in most of the cases extensive surgery is not needed. Radiological imaging will hopefully provide with methodology alternative to the histopathological characterization. An example is the work of Cheng et alAnother emerging approach is to combine antiangiogenic compounds with blockage of vascular co‐option. This is likely to be the most successful because tumors can actually change their vascular status during progression in both waysThe combined approach is now being explored at preclinical level. The use of bevacizumab with the antibody OS2966 against beta1integrin, one of the keys molecules in co‐option, has demonstrated that the two have a synergic effect.The potential value of this “double therapy” approach is further supported by a very thorough study by Voutouri et alThis model further indicates that vascular co‐option is a mechanism of escape and suggest that “double therapy,” antiangiogenic and anti‐co‐option, is predicted to give the best results.10As always, things in biology are frequently more complicated that initially tough. Deemed as one of the six original Hallmark of Cancer,Another potentially very important issue in cancer treatment, is the plasticity cancer cells can have: one example is how some neoplastic cell lines produce an angiogenic tumor if injected subcutaneous but a nonangiogenic one if eventually lodging into the lung after inoculation in the tail vein.The authors declare that they have no conflicts of interest.Not applicable.Francesco Pezzella: Conceptualization; writing‐original draft; writing‐review and editing. Domenico Ribatti: Conceptualization; writing‐original draft; writing‐review and editing.


Evidence that exposure to environmental pollutants can alter the gut microbiota composition of wildlife includes studies of rodents exposed to radionuclides.Myodes glareolus, Apodemus agrarius, A. flavicollis and A. sylvaticus) inhabiting the Chernobyl Exclusion Zone (CEZ) to examine possible changes in gut bacteria (microbiota) and gut fungi (mycobiota) associated with exposure to radionuclides and whether the sample type (from caecum or faeces) affected the analysis.Antwis et al. (2021) used amplicon sequencing to characterise the gut microbiota of four species of rodent  and gut mycobiota (e.g. microfungi and yeasts), which mask the patterns of inter‐ and intraspecific variation in the authentic gut mycobiota.Implying that ‘faecal samples are not an accurate indicator of gut composition’ creates an unnecessary controversy about faecal sampling because the comparison of samples from the caecum and faeces confounds many other possible drivers  of variation in gut microbiota.Apodemus mice had experienced a medium or high total absorbed dose rate and (2) they did not collect samples of bank voles (M. glareolus) from replicate contaminated and uncontaminated locations.It is relevant also that Antwis et al.'s (2021) data lack statistical power to detect an effect of exposure to radionuclides on the gut microbiota because (1) all of their samples of Discussion of Antwis et al.'s (2021) analysis, especially the claims presented in the Abstract, is important to prevent controversy about the outcome of research on the biological impacts of wildlife inhabiting the CEZ. The authors' work highlights: (1) the need to consider host and fungal ecology when analysing the apparent assemblages of fungi from animal gastrointestinal tracts, and (2) that differences in sampling and laboratory protocols need to be fully considered when making a contrast between separate studies of wildlife gut microbiota. Photo credit: Pinja Rautio.  The CEZ was established to limit human exposure to radionuclides, but the wildlife inhabiting the CEZ provide the best‐studied models of the biological impacts of exposure to environmental radionuclides ‘We provide novel evidence that host species determines fungal community composition’,(1b)‘… fungi (Steccherinaceae and Strophariaceae) in the guts of bank voles that may serve as biomarkers of radiation exposure’,(2)‘…considerable variation between results for faecal and gut samples of bank voles, suggesting faecal samples are not an accurate indicator of gut composition’ and(3)‘associations between radiation exposure and microbiome composition of gut samples were not robust against geographical variation’.These points have clear implications for our understanding of the effects of environmental radionuclides on wild animal gut microbiota, and for studies of exposure to pollutants on wildlife microbiota generally. However, statements  need clarification as the fungal amplicon sequence data represent a mixture of ingested fungal material and authentic gut mycobiota. Conclusion (2) creates an unnecessary controversy as it neglects to account for confounding effects of multiple drivers of variation in the gut microbiota in the comparison of samples from the caecum and faeces. We discuss statement (3) to highlight the need for greater clarity about the power of Antwis et al.'s  inhabiting the CEZ, Ukraine. Samples were collected by live trapping from two areas: (1) a contaminated site in the Red Forest and adjacent area, and (2) an uncontaminated site about 10 km south‐west of the Red Forest  to remove primer/adaptor sequences and DADA2 . We further classified fungal SVs according to guild or growth form based on assignments made by FUNGUILD v.1.2  interspecific differences in the amount of dispersion were detected in the analyses based on the entire dataset and the suspected non‐resident fungi, but not in the subset of possible resident gut fungi  limited , and yet the authors included it in analyses as categorical predictor of three levels . The analysis by Antwis et al.  species of Apodemus are apparent in samples collected from the CEZ and the Fukushima accident sites (Lavrinienko, Hämäläinen, et al., Antwis et al.  note thas et al.  potentia5The literature about biological impacts of inhabiting the area surrounding the former nuclear power plant at Chernobyl is littered with arguments and counterarguments (Beresford et al., Demonstrating that the inclusion of non‐resident fungal SV data impacts amplicon sequencing‐based analyses of ‘gut mycobiota’ has important implications for studies of wildlife gut mycobiota (Lavrinienko, Scholier, et al., Understanding whether laboratory protocols and sample type impact study conclusions is an important topic in microbiota research (Ingala et al., Apodemus mice but not the impacts of radiation exposure on gut microbiota. By contrast, with a sample of animals from contaminated and uncontaminated areas, Antwis et al.'s (With reference to studies on wildlife inhabiting the CEZ, Beresford, Scott, et al.  stressedet al.'s  caecum sIt is relevant also that the studies by Lavrinienko, Mappes, et al. , LavriniA comprehensive discussion of the statements presented by Antwis et al.  in theirThe authors declare no conflict of interest.All authors conceived the ideas; P.C.W. analysed the data; A.L. and P.C.W. led the writing of the manuscript, with all authors making critical contributions to the drafts and giving their final approval for publication.


Abundance estimation methods that combine several types of data are becoming increasingly common because they yield more accurate and precise parameter estimates and predictions than are possible from a single data source. These beneficial effects result from increasing sample size (through data pooling) and complementarity between different data types. Here, we test whether integrating mark–recapture data with passive acoustic detections into a joint likelihood improves estimates of population size in a multi‐guild community. We compared the integrated model to a mark–recapture‐only model using simulated data first and then using a data set of mist‐net captures and acoustic recordings from an Afrotropical agroforest bird community. The integrated model with simulated data improved accuracy and precision of estimated population size and detection parameters. When applied to field data, the integrated model was able to produce, for each bird guild, ecologically plausible estimates of population size and detection parameters, with more precision compared with the mark–recapture model. Overall, our results show that adding acoustic data to mark–recapture analyses improves estimates of population size. With the increasing availability of acoustic recording devices, this data collection technique could readily be added to routine field protocols, leading to a cost‐efficient improvement of traditional mark–recapture population estimation. Evaluating trends in species abundance is central to questions of single species and whole ecosystem conservation. Hence, estimating the size of populations remains as critical as it is challenging. At the heart of the issue is that ecological sampling of organisms is rarely exhaustive, and therefore to estimate population size we need to also estimate probabilities of detection Dorazio, . DetectaThe concept of data integration (combining data types) relies heavily on complementarities between data sources. In general, different methods of data collection will suffer from different detection biases; for instance, it may be more likely that a species is detected by citizen science programs in areas with high human population density , and can generate a wealth of data . Our focus was on exploring the trade‐offs and complementarities of the joint analysis of these two common data types, and we wished to isolate these issues from the wider problems of population change and emigration. Therefore, we assumed throughout that population size remained constant during each sampling period.Our model integrates mark–recapture and acoustic data into a joint likelihood, to estimate population size  was the same or smaller than the mist‐net sampling radius, so that the number of individuals detectable by acoustic recorders was proportional  to the number of individuals detectable by mist nets. We assumed that the population size (Nij) of guild i at site j was Poisson distributed (but our method is easily adapted to other distributions) with expected number of animals per site DijDij was modeled as a log‐linear functionQf covariates, Xjq, affecting population size, and their respective regression coefficients νiq, where q refers to the qth covariate (the intercept (νi0) was included by setting Xj0=1).Throughout these analyses, we considered animal communities made up of several subgroups. We use the term “guilds” to describe taxonomic groups, which may be species but could also be functional groups, families, etc. We considered site as the discrete area covered by the sampling radius of our mist nets, and therefore the population size at site rij captures per unit time  follows an exponential distribution with mean 1/rijckij>Tj, the animal was not detected. The probability of detection is then Pckij<Tj=1−exp−rijTj. Therefore, the total number of first captures nij for the ith guild at the jth site wasykij) in the remaining time  was a Poisson variate given byrij, was modeled as a log‐linear functionQh covariates, Wjq, and their respective regression coefficients ρiq, with q referring to the qth covariate and where ρi0 is the intercept. This mark–recapture model assumes that capture rate did not vary between individuals of same guild, did not decline with consecutive captures, and marks were not lost. Additionally, we assumed instantaneous sampling .Instead of dividing each survey event into arbitrary discrete time periods as is commonly done in mark–recapture studies , and to have been visited twice. This represents a minimally realistic design for a mark–recapture study, given the number of guilds and parameters involved. We included several environmental covariates: the first was a site‐specific covariate that affected both population size and capture rate  each lasting 0.03 hours . For both models we examined accuracy and precision by recording the mean and 95% Bayesian credible intervals  from each posterior. Additionally, we performed model validation to assess the effects of a range of data‐generating parameters on model performance, and an exploration of trade‐offs between acoustic and mark–recapture effort  and two covariates (Qf=2): a guild‐specific effect of canopy cover  on population size (νi1Xj1) and a seasonal categorical covariate shared between guilds . For these two coefficients, the integrated model was more than two times more precise than the mark–recapture model , this assumption is reasonable, but a natural extension of our model would be to consider longer sampling periods over which demographic processes occur. Additional extensions to this model could consider longitudinal effects such as capture shyness, which can be a common phenomenon in active trapping methods such as mist‐netting (Marques et al., In conclusion, the combination of acoustic and mark–recapture data offers an opportunity for more accurate and precise estimates of population size. This method can be applied to any taxa for which these data types are available, including birds, bats, cetaceans, and amphibians. To achieve accurate estimates of population size, we should move towards a modeling approach that accounts for possible biases and makes the most of available data.The authors declare no conflict of interest.Appendix S1Click here for additional data file.