Early onset and high prevalence of chronic disease among Indigenous Australians call for action on prevention. However, there is deficiency of information on the extent to which preventive services are delivered in Indigenous communities. This study examined the variation in quality of preventive care for well adults attending Indigenous community health centres in Australia.During 2005-2009, clinical audits were conducted on a random sample (stratified by age and sex) of records of adults with no known chronic disease in 62 Indigenous community health centres in four Australian States/Territories (sample size 1839). Main outcome measures: i) adherence to delivery of guideline-scheduled services within the previous 24 months, including basic measurements, laboratory investigations, oral health checks, and brief intervention on lifestyle modification; and ii) follow-up of abnormal findings.Overall delivery of guideline-scheduled preventive services varied widely between health centres (range 5-74%). Documentation of abnormal blood pressure reading , proteinuria and abnormal blood glucose  was found to range between 0 and > 90% at the health centre level. A similarly wide range was found between health centres for documented follow up check/test or management plan for people documented to have an abnormal clinical finding. Health centre level characteristics explained 13-47% of variation in documented preventive care, and the remaining variation was explained by client level characteristics.There is substantial room to improve preventive care for well adults in Indigenous primary care settings. Understanding of health centre and client level factors affecting variation in the care should assist clinicians, managers and policy makers to develop strategies to improve quality of preventive care in Indigenous communities. As part of the response to high levels of chronic disease among Indigenous Australians, there hPrevious research provides limited information on delivery of preventive care in Indigenous primary care settings. Studies conducted in the Northern Territory (NT) have documented substantial deficiencies in delivery of preventive care to Indigenous adults in rural and remote communities: on average only 40-50% of preventive services were delivered in line with the best practice guidelines . StudiesThe Audit and Best-practice for Chronic Disease Extension (ABCDE) project is a national quality improvement initiative which aims to improve quality of care in a range of priority aspects of Indigenous primary health care, including chronic disease care, preventive care, and maternal and child health care . During Participation by health centres was from five regions where we had established project hub coordinators Figure . On a voBaseline audits of preventive care were completed during 2005-2009. Audits covered both paper-based and electronic clinical records. The records of health centre clients who met all of the following criteria were eligible for inclusion: 1) aged between 15 and 54 years; 2) resident in the community for at least 6 of the last 12 months; 3) not having a diagnosis of diabetes, hypertension, ischaemic heart disease, rheumatic heart disease, renal disease or other major chronic illness; and 4) not pregnant or post partum at the time of the audit. Eligibility was verified by checking an up-to-date population list of health centre clients with assistance from health centre staff who knew the community and health centre well. A sample of 30 records, stratified by sex and age groups , was selected randomly from records of eligible clients in each health centre. Thus, each random sample comprised 5 males and 5 females in each of the age groups. In communities where there were fewer than 5 people in a sex- and age-specific group, all eligible people in that group were included.The audit measured 16 selected service items  between regions using linear regression models Tables  and 4. CWhen treating individual clients as the unit of analysis, our data had inherent multilevel, dependency structure, as preventive care data collected at the individual client level (level 1) were clustered within health centres (level 2). Two-level random effects regression models (linear or logistic)  were use1) Adherence to delivery of services and follow up of abnormal findings were treated as dependent variables in the random effects models respectively. We constructed a two-level  random intercept model with no explanatory variables  . In the 2) Using two-level random effects regression models, we also tested associations of specific factors at health centre  and individual levels (age and sex) with the quality of preventive care.We obtained approval from formally constituted Human Research Ethics Committees  in each region in which the project operated, including the NT Department of Health & Community Services and Menzies School of Health Research HREC, the Central Australian HREC, the Western Australian Aboriginal Health Information and Ethics Committee, the Macquarie and Far West Area Health Services HREC, and the Townsville Health Service District HREC.Of 62 participating health centres, 47% were managed by a local or regional Aboriginal committee (board), with the remainder government funded/operated Table . Sixty nRecords of 1839 well adults were audited  was found in 15% of adults, proteinuria in 20%, and abnormal blood glucose (≥ 5.5 mmol/L) in 37% ; and between 62-87% for follow up of abnormal findings  Health centres were not randomly selected and their participation in the project was on a voluntary basis and enrolment was staggered over a period of some years. Therefore, these data are not representative for the regions involved and differences between health centres may be partly the result of introduction of new policies over time. A longitudinal analysis including services with more than three years of data through participating in this project will be reported separately. 2) We relied on clinical medical records to retrieve preventive care data, which may underestimate actual service delivery if delivered services are not recorded in clinical records. While failure to document services may mean that services are delivered at higher levels than reflected in our data, the failure to document delivered services is itself a significant barrier to continuity and coordination of care and in preventing duplication and over servicing - especially in areas of high workforce turnover. Failure to document delivered services is therefore in itself a deficiency in quality of care. 3) The unweighted age and sex stratified random samples are designed to facilitate analysis of quality of care between communities. Estimates based on this sampling approach may differ from sampling approaches designed to provide population estimates.The pattern of delivery of different services  to some extent reflects a gradient in strength of evidence for the preventive services specified in best practice guidelines ,15. PracThe comparability of these findings with similar studies ,18 is liHigh prevalence of health problems among "healthy adults" and low follow-up of identified problems are of significant concern. Similar to previous reports from Indigenous primary care settings ,8, aboutOur analysis of variation in preventive care indicates health centre level and individual client level factors have a similar level of influence on delivery of preventive care. The finding that accreditation of services is not clearly associated with quality of care is consistent with other research on this topic ,20, and The substantial proportion of variation in preventive care attributable to client level factors points to the importance of health centre systems to deliver care in a way that most effectively meets the varying needs of individual clients. Regarding client level factors, we only collected demographic information of participants . Male participants appeared less likely to access preventive services than females in our study. This may reflect the perceptions of many Indigenous men who consider health centres as "women's places" , as healBeyond addressing potential health centre and client level factors, a supportive health policy has been recognised as critical to the implementation of preventive care to populations . The intThere is great potential to improve delivery of preventive services to well adults in Indigenous primary care settings. Particular attention should be given to improving follow-up of abnormal clinical findings identified by preventive health assessments. The national collaborative approach that underpins the data presented in this paper provides a significant opportunity to advance understanding of variation in care and to develop and examine the effect of innovative strategies to enhance the quality of care for Indigenous Australians.The authors declare that they have no competing interests.RB played a lead role in conceptualisation of study design, development of measurement tools, project management, and revising of the manuscript. DS played a major role in reviewing the literature and conceptualisation, conducted data analysis, and drafted the manuscript. CC, AB, TW and ST and HB contributed to study design and facilitated engagement of health services. MD and LO contributed to study design and development of measurement tools. MD, LO, RK, CK, RC, HL, JH carried out field work and conducted data collection. All authors contributed to the interpretation of findings, read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/139/prepub


Meshfree methods are viewed as next generation computational techniques. With evident limitations of conventional grid based methods, like FEM, in dealing with problems of fracture mechanics, large deformation, and simulation of manufacturing processes, meshfree methods have gained much attention by researchers. A number of meshfree methods have been proposed till now for analyzing complex problems in various fields of engineering. Present work attempts to review recent developments and some earlier applications of well-known meshfree methods like EFG and MLPG to various types of structure mechanics and fracture mechanics applications like bending, buckling, free vibration analysis, sensitivity analysis and topology optimization, single and mixed mode crack problems, fatigue crack growth, and dynamic crack analysis and some typical applications like vibration of cracked structures, thermoelastic crack problems, and failure transition in impact problems. Due to complex nature of meshfree shape functions and evaluation of integrals in domain, meshless methods are computationally expensive as compared to conventional mesh based methods. Some improved versions of original meshfree methods and other techniques suggested by researchers to improve computational efficiency of meshfree methods are also reviewed here. Numerical simulation has proved to be a good alternative scientific investigation tool to expensive, time consuming, and sometimes dangerous experiments in complex engineering problems. Grid based numerical methods, like FEM, are widely used for analyzing various engineering problems. There are two fundamental approaches in grid based methods: Eulerian and Lagrangian grid. To strengthen the advantages of each approach and avoid their limitations, new combined approaches were also developed . But grithere is no mesh alignment sensitivity, and mesh used in background is for integration purpose;node connectivity is not predefined by mesh;no remeshing is required especially in case of large deformation and moving discontinuity problems;shape functions of any desired order continuity can be constructed;no postprocessing required for smooth derivatives of unknowns and their derivatives.By modifying the internal structure of gird based method, meshfree methods were developed which are expected to be more adaptive, versatile, and robust and can deal with problems where conventional methods are not suitable. The concept of the meshfree methods is to provide accurate and stable numerical solutions for integral equations or PDEs with all types of possible boundary conditions with a set of arbitrarily distributed nodes without defining mesh which connects these nodes . Many meProcedural steps involved in developing solution using meshfree method are shown in Some review papers have also been presented in the area of development and applications of meshfree methods, earlier. Like, Belytschko et al. presented review on meshless approximation based on MLS, reproducing kernels (RK) and partition of unity methods (PUM) in 1996. The review included the following aspects: salient features of these methods, techniques to handle material and geometric discontinuity, implementation issues, like EBCs, coupling with finite elements, computational efficiency, convergence rate, and so forth, review of applications of plate and shell problems . Nguyen The present paper attempts to review recent and some earlier applications of some of the well-known meshfree methods like EFG and MLPG, without giving mathematical description, to structure and fracture mechanics problems. The outline of paper is as follows. Meshfree methods are classified based on use of global or local weak form to derive system matrices. Accordingly, EFG method is based on global weak form, while MLPG method is based on local symmetric weak form (LSWF). In both these methods, approximation is based on moving least square (MLS) approximants. But in moving least square methods interpolants do not pass through data point as interpolation functions are not unity at nodes . Hence, The basic idea of MLS approximation is based on construction of set of nodes in the problem domain and hence the method is element free .uh(x) of the function u(x) defined over the domain Ω is given bypT(x) are monomial basis functions of order m and a(x) are vector coefficients which are functions of space coordinates x, which can be determined at any point x by minimizing weighted discrete L2 norm defined as follows,n is the number of nodes in neighborhood of x for which weigh function wi (x − xi) cannot be zero and ui is the nodal value of u at x = xi. On further solution for a(x), final expression for MLS approximants is given byi(x) is called the shape function of MLS approximation. Detailed shape function construction can be referred from references [The MLS approximant ferences , 13.x to xi increase. Selected weight functions must be positive and the function and its derivative should be continuous up to required degree [Weight function selection is also an important parameter while developing the meshfree solution. It should be constructed in such a way that their value should decrease as the distance from d degree . Some ofdi = |x − xi| is the distance from node xi to any point x, ci is the constant controlling shape of the weight function, and ri is the size of the support. There are several other types of weight functions used like conical weight function, cubic spline weight function, and so forth.Gaussian weight function:Because MLS shape functions used in EFG and MLPG do not satisfy Kronecker delta criterion, process of imposition of EBCs gets complicated than FEM. Number of techniques were developed for enforcing EBCs in the problem like Lagrange multiplier, penalty method, orthogonal transformation techniques, coupling with FEM, Nitsche's method, singular weighing functions, boundary collocation, and D'Alembert's Principle. Out of these techniques, penalty method can be easily implemented and do not increase much computational effort. Detailed description of these techniques can be referred from references , 14–19.L2 norm at a quadrature point [Several different techniques were suggested for numerical integration of Galerkin weak form. Gauss quadrature is most commonly employed technique to evaluate integrals in Galerkin weak form. Integration in meshfree method is based on background cells which are independent of nodes. Background cells serve important purpose of identifying nodes contributing to discrete re point . By minire point . But becre point , 22.Meshless methods developed, in their original form, are not entirely “meshless” and each method falls in one of the following categories: methods based on global weak form requiring background cells for integration like EFG, methods based on local weak form requiring background cells locally like MLPG, and particle methods which require predefinition of particles for their volume or mass like SPH . FollowiThe element-free Galerkin (EFG) method was developed by Belytschko et al. based on the diffuse elements method (DEM) originated by Nayroles et al. In original form of EFG, moving least square (MLS) approximants were used to approximate field variables but due to lack of Kronecker delta property in MLS shape functions, essential boundary conditions (EBCs) cannot be imposed in straight forward way as in FEM and some special techniques are required. Lagrange multiplier technique was used for enforcing EBCs. Because EFG method is based on global weak form, it requires a mesh of background cells for integration in computing the system matrices. Proposed EFG method had advantages like high rate of convergence, no post processing for unknowns or their derivatives, and suitability to fracture mechanics problems . SeveralAnother new meshfree computational method was developed and proposed by Atluri and Zhu, known as meshless Local Petrov Galerkin method (MLPG), based on local weak form and MLS approximants. EBCs are imposed by penalty method in MLPG. Selection of trial (shape) function and test function in MLPG is done from entirely different spaces and it is considered as a truly meshless method because all integrals can be easily evaluated over regular shaped domains and their boundaries. High convergence rate and accurate values of unknown variables and its derivatives were observed . Elastosh-Adaptive EFG method with MLS approximation was proposed by Le et al. for limit analysis of plates. Accuracy of limit analysis is often affected and decided by local singularities arising from localized plastic deformations and to capture it accurately automatic h-refinement is performed. Taylor expansion technique is used for error estimation in computed displacement field to identify the area needing refinement [Due to the flexibility in constructing approximation functions with desired smoothness and accuracy in meshfree methods, they have been successfully applied to Kirchhoff type of plates and shell problems. Applications to plates were first investigated by Hein  but due finement . In anotfinement . In a refinement . Spatialfinement . A meshffinement .Numerical simulation of contact between two different objects like sheet metal forming, vehicle crash worthiness, impact, penetration, and so forth, is a challenging task. While dealing with contact problems, mesh density must be maintained at a sufficiently high level around contact region to obtain reasonably accurate results. Li et al. proposed a contact detection algorithm based on moment matrix of meshfree approximation. The mathematical principle of contact detection algorithm is that the determinant of moment matrix can automatically determine Lagrangian movement of continuum and on the basis of that one can accurately detect contact or penetration without solving any complex equations. It was implemented to simulate Taylor bar impact problem which is a deformable solid bar impacting rigid target problem . Large sDesign sensitivity analysis and shape optimization is applied to observe and find the variation of response measure like displacement, stress due to variation of some design parameter that is, geometric parameter, and finding optimal layout of a structure within a specified region. Bobaru and Mukherjee demonstrated application of EFG to shape design sensitivity analysis and shape optimization for 2D elasticity problems wherein EFG was used first time with continuous formulation using material derivative approach. Penalty approach was used for imposing EBCs and a numerical example of shape optimization of fillet was used to demonstrate robustness and ability of EFG method. The presented approach can be extended to 3D and nonlinear problems. Another application of EFG to shape optimization in linear thermoelasticity problem was also demonstrated by the same authors , 67. ZhaBelytschko et al. developed EFG method for linear elastic fracture problems in 1994 where “Visibility criterion” was proposed firstly to model geometric discontinuity (crack) in which domain of influence for nodes near the crack are truncated whenever they intersect the crack surface and hence a node on one side of crack will not affect the point on other side of crack. But “visibility criterion” had difficulty in treating nodes near crack tip. Other improved techniques for handling discontinuity were also suggested: diffraction method, transparency method, and “see through” method or continuous line criterion. Two methods for enriching EFG approximations for linear elastic fracture problems were also proposed by Belytschko: extrinsic and intrinsic enrichment , 71. BelFunctionally graded materials (FGM) possesses continuously varying microstructure and material properties in a predetermined way and they are used in structures subjected to nonuniform service conditions. Rao and Rahman proposed EFG approach for calculating stress intensity factors (SIF) for stationary crack in twodimensional functionally graded materials of arbitrary geometry. In proposed method, the interaction integral method was extended for FGM and material properties were taken as smooth functions of spatial coordinates and two newly developed interaction integrals were introduced for analysis of basic modes and mixed mode fracture problems . While tOver a period of time in service, mechanical systems and structures accumulate cracks due to fatigue. Duflot and Nguyen-Dang proposed an enriched meshless method to analyze fatigue crack growth under cyclic loading. The crack propagation was modeled by successive linear extensions determined by SIFs obtained after each linear elastic analysis. A fixed set of three nodes with special weight function were added at each crack tip to accurately catch the stress singularities in proposed approach . Use of Meshfree shape functions are not interpolation functions and do not possess Kronecker delta properties. Hence imposition of EBCs consumes much computation time. Several techniques were presented for imposing EBCs, like Lagrange multiplier, penalty method, orthogonal transformation techniques, coupling with FEM, Nitsche's method, singular weighing functions, boundary collocation, and D'Alembert's Principle. An overview of existing techniques for enforcing EBCs was presented by Fernández-Méndez and Huerta. With focus on meshfree method coupled with finite elements and methods based on modification of Galerkin weak form . Chen anh and p adaptivity but in EFG method it is not possible because changing the density of nodes both changes the error eh and also changes the space of the shape functions and hence the error ep. Hence it is difficult to achieve error control and adaptivity in meshfree methods. In proposed approach the discretization error was split into contributions arising from an inadequate number of degrees of freedom eh and from an inadequate basis ep [Though meshfree methods look quite attractive for solving a special class of problems, there are issues like error estimate and control, integral evaluation, and accuracy. Errors in numerical modeling arise from number of sources like discretization, quality of mathematical model, rounding off operations in computations, and so forth. Chung and Belytschko, in 1998, proposed estimation of local and global error in EFG method where in error estimation was based on difference between the values of projected stress and stress given by EFG method. Effectiveness of proposed error estimator was validated by various one-dimensional and two-dimensional problems . Zhuang asis ep . Kim andasis ep .Objective of the present work is to provide exposure in terms of versatility of meshfree methods in handling different types of engineering problems without detailed mathematical description. Some of the worth notable recent developments include development of extended element free Galerkin (XEFG) method for thermo-mechanical crack propagation, CVEFG using CVMLS for elastoplasticity problems, ICVEFG using ICVMLS for large deformation problems, simulation of failure transition in impact problems by EFG, local buckling analysis of steel plates with irregular openings by EFG, and adaptive EFG and MLPG approaches.Though MMs have found application in almost all areas of structure and fracture mechanics, still there are challenges in developing computationally efficient algorithms with accurate nodal integration techniques with scalable implementation of EBCs. Improved versions of original MMs are also proposed by many researchers like XEFG, IEFG, CVEFG, ICVEFG, and so forth, while some of the other techniques for improving computational efficiency are reviewed in


Blood donors are considered one of the healthiest populations. This study describes the epidemiology of cancer in a cohort of blood donors up to 20 years after blood donation. Records from donors who participated in the Retroviral Epidemiology Donor Study  at Blood Centers of the Pacific (BCP), San Francisco, were linked to the California Cancer Registry . Standardized incidence ratios (SIR) were estimated using standard US 2000 population, and survival analysis used to compare all-cause mortality among donors and a random sample of nondonors with cancer from CCR. Of 55,158 eligible allogeneic blood donors followed-up for 863,902 person-years, 4,236 (7.7%) primary malignant cancers were diagnosed. SIR in donors was 1.59 . Donors had significantly lower mortality  compared with nondonor cancer patients, except for respiratory system cancers . Elevated cancer incidence among blood donors may reflect higher diagnosis rates due to health seeking behavior and cancer screening in donors. A “healthy donor effect” on mortality following cancer diagnosis was demonstrated. This population-based database and sample repository of blood donors with long-term monitoring of cancer incidence provides the opportunity for future analyses of genetic and other biomarkers of cancer. Blood donors are considered to be one of the healthiest populations due to donation eligibility requirements. Studies have suggested a lower incidence of cancer diagnosis and mortality in blood donors. Merk et al. and Edgren et al. estimated cancer incidence in Swedish donors and Swedish and Danish donors, respectively, and showed lower incidence of cancer—including hematological malignancies—in blood donors , 2. ThesWe are unaware of any similar large-scale longitudinal study of cancer occurrence in the US blood donor population. Moreover, the Swedish and Danish studies did not retain samples from donors, in contrast to the existence of cryopreserved plasma and cellular sample repositories from a large number of US blood donors who consented to long-term outcome research studies in the past several decades. Establishment of a population-based database for long-term monitoring of cancer incidence and outcome among these US blood donors therefore provides a necessary base on which future analyses of genetic or other biomarkers of cancer can be conducted.Here we describe characteristics of a sample of the California blood donor population who consented to collection and storage of repository samples of serum, plasma, or whole blood for future research. By linking identity of these donors with the California Cancer Registry (CCR) we identified donors who developed cancer after blood donation and were able to estimate incidence of cancer among donors for all cancers and by anatomic site. We also compared survival in blood donors with a primary cancer to a demographically matched sample of nondonor population with malignancies to investigate the so-called “healthy donor effect” on overall mortality.Beginning as early as 1974, as part of blood transfusion safety studies in the United States the National Heart Lung and Blood Institute (NHLBI) and others funded the creation and maintenance of a series of large-scale blood specimen repositories . DetailsWe obtained electronic record files from the data coordinating center for REDS  that included the repository specimen number, donor and donation identification numbers, and dates of donation(s) in the repositories for BCP blood donors who had consented to participate and donated specimens to any of the three REDS repositories between 1991 and 2002. The files were provided to BCP information technology (IT) staff who then submitted an electronic file containing personal identifiers of the REDS repository donors to CCR to be matched against their records between January 1991 and December 2010.The CCR is a population-based registry that maintains records of nearly all cancer cases diagnosed in California . StatewiThe linked database was also matched against the Social Security Administration (SSA) Death Master File (DMF) to verify vital status of blood donors and date of death for those who are no longer alive. The SSA has been collecting information for DMF since 1936. The SSA-DMF contains over 89 million records of deaths. An encrypted file including social security number, first and last name, date of birth, and date of last visit to blood center was sent to the SSA and compared to the DMF to identify matches. We verified information received from SSA with CCR and BCP records, using multiple time points and data elements, including date of last visit to the blood center, cancer diagnosis date, hospital admission date, and last date known alive/dead in CCR and BCP records. Where there was a discrepancy among multiple sources, we assumed BCP records to be the gold standard with respect to vital status, because donors must be physically present at BCP for each donation visit; followed by CCR, which annually updates vital status of cancer patients using multiple national and local sources; and then SSA-DMF.n = 66, 984) was divided into one of 26,400 categories. The categories were determined by a unique combination of “year of diagnosis/quintile of SES/race/sex/SEER tumor categories” . A uniform random number was assigned between zero and one to each of the non-donor birth certificates in CCR database. Then, the records were sorted in each of the 26,400 categories by this random number. Records in each category were selected for inclusion in the study dataset with the first record up to three times the number of matches in that category to achieve a 3 : 1 ratio of non-donor to donor records.To compare overall survival of donor and non-donor cancer patients, we also requested a comparison group of frequency matched non-donor cancer records from CCR in a ratio of 1 donor with cancer to 3 nondonors with cancer . The linIRB approvals to conduct this data linkage and analysis were obtained from the University of California, San Francisco Committee on Human Research (the IRB of record for BSRI/BCP), and from the California Public Health Service (the IRB of record for CCR).The resulting linked master database contains demographic and donation history data from BCP's database for 66,984 donors and CCR records for the subset of these donors who were diagnosed with cancer between 1991 and 2009.BCP Data. The BCP dataset consists of the demographic information required by the CCR in order to link donors to cancer registrants: first name, middle initial, last name, social security number, date of birth, sex, last known street address, city, and zip code. Donors' current address is actively updated only when donors visit the center seeking to donate. This dataset also contains the following demographic and donation history variables: birth state and/or country, race/ethnicity, marital status at time of last BCP visit, education, first or repeat status on repository specimen donation, donation type, date of repository specimen donation, first donation date, total number of presentations to attempt to donate, total number and types of successful donations, last donation date, and ABO/Rh blood groups [d groups . CCR Data. The CCR dataset includes additional variables in addition to demographics related to the following domains for donors and nondonors who had a cancer:socioeconomic: occupation, median household income, education index (average years of schooling in a given census tracts), college degree index, poverty index, socioeconomic status (SES) index, and urban/rural status;cancer diagnosis: date of diagnosis, date of admission, primary or secondary tumor, number of tumors, tumor size, and diagnosis location;cancer description: tumor primary site (SEER ICD-O-2 and ICD-O-3 definition), tumor stage at diagnosis, histologic type and grade/differentiation, and regional node extension;cancer biomarkers (available for some records): estrogen receptor for breast cancer, acid phosphatase for prostate cancer, alphafetoprotein for testicular cancer, carcinoembryonic antigen (CEA) for colorectal cancer, and carbohydrate antigen (CA-125) for ovarian cancer;treatment: type of chemotherapy, hormonal therapy, and immunotherapy;outcomes: vital status, date of last contact/death, place of death, and cause of death.n = 2, 870), donors who gave autologous donations , donors with unknown donation type or confirmatory testing blood sample (n = 529), and those who were diagnosed with a cancer before their first donation to REDS repositories or had invalid date records in the linked database (n = 236) .We excluded donors who donated before age of 18 (n = 236) . We furtn = 3, 663), nonprimary tumors , tumors with unknown sequence (n = 2), duplicate tumor IDs (n = 6), or a tumor diagnosed before age of 18 (n = 230)  we excluded records of donors with autologous/unknown donation type (n = 230) .Number of diagnosed cancer cases for all cancers and by anatomic site were estimated using SEER ICD-O-3 site codes . Donors'n = 55, 158); then we limited the eligible study population to donors who had more than one year of follow-up  and to those with two years or longer of follow-up time . Confidence intervals (CI) for the SIRs were calculated based on Poisson distribution as described in Rothman and Boice [The observed incidence rate of any cancer among BCP donors was compared with the rates expected based on SEER 9 registry data, including Atlanta, Connecticut, Detroit, Hawaii, Iowa, New Mexico, San Francisco-Oakland, Seattle-Puget Sound, and Utah. The number of expected cancer cases was calculated using multiplication of person-years of followup by the sex- and age-specific SEER incidence rates for the calendar years 1992 to 2009. We also estimated the expected cancer cases using only San Francisco-Oakland SEER data. Standardized incidence ratios (SIRs) were calculated by dividing the number of observed over expected cases for all cancers and by anatomic sites. Sensitivity analysis was conducted to estimate SIRs using different latency periods between first repository donation and primary cancer diagnosis and to exclude potential cancer patients that were not diagnosed at time of first donation . We estind Boice .Hazard ratios (HRs) and 95% CI for death following cancer diagnoses were calculated using Cox proportional hazard regression models for all primary cancers combined and by cancer site, adjusted for age at diagnosis, sex, race, SES, tumor stage, and grade at diagnosis to compare all-cause mortality among donors and nondonors diagnosed with primary cancer .All data analyses were performed using STATA 11.2 . All statistical tests were two sided with a 5% type I error.A total of 66,984 BCP donors who had consented to one or more of the REDS repository studies were searched for a link to 3,413,457 CCR records. The linkage resulted in 7,943 individual donors with cancer. Between 1991 and 2009, 4,236 primary malignant cancer records were identified among 55,158 blood donors eligible for this analysis .Demographic characteristics and donation history of eligible BCP blood donors with and without a primary cancer record are presented in n = 1, 000 and 754, resp.) followed by cancers of digestive system (n = 523). Compared with the general US population, BCP blood donors had a higher number of observed cases for most cancer sites than expected . Excluding donors with less than one year of followup, the number of observed primary cancers decreased to 4,092 cases during 808,855 person-years of followup . Restricexpected . Using “n = 4, 805) to a demographically matched sample of the California cancer population . In analyses adjusted for cancer site, we found that donors had a significantly higher overall survival following diagnoses of cancer compared with nondonors regardless of the cancer site . In stratified analyses by cancer site, we observed a significantly higher overall survival among donors with site-specific cancers .We compared BCP allogeneic blood donors with a primary cancer record  and an adjusted HR of 0.70  linked data on all registered blood donors and recipients in Sweden and Denmark with national population and health registries with complete followup up to 36 years . The invLikely explanations for increase in cancer incidence among BCP donors relative to the general US population are the differences in demographics and access to primary care in BCP blood donors and the general population. BCP blood donors are disproportionately young and white and are more educated than the general US population. The higher incidence rates of breast and male genital system cancers for which screening of healthy adults is available and recommended, for example, could be due to known differences in education level, race, SES, geographic location, or unmeasured differences in health-seeking behavior and access to health care for blood donors compared to the general US population. Our SIR estimates do not take into account the stage and grade of cancer at time of diagnosis (and hence entry into CCR database); a more educated donor with more frequent primary doctor visits and access to preventive care and screening is more likely to be diagnosed with a low grade cancer at earlier stages than the general population . InteresOur study documented lower overall mortality following diagnoses when comparing blood donors with cancer and non-donor cancer populations. Selection bias due to “healthy worker effect” has been indicated in relation to various diseases including cancer –20. HoweBetter survival among BCP blood donors with cancer after adjusting for multiple confounding factors suggests the possibility of differences in access to health care resulting in earlier diagnosis and better treatment of malignancies. One might again assume health seeking behavior of blood donors and lag time effect as an explanation, that is, more frequent doctor's office visits and screening during donor's lifetime; and therefore, cancers were diagnosed at earlier stages with a better prognosis . This isThe present data is limited by differential ascertainment of the vital status for donors with and without cancer. For donors with a cancer record in CCR the “vital status” variable is updated through various registries and data sources (source of last followup information is the CCR) , with a The SSA does not guarantee the accuracy of their SSA-DMF records. Thus, the absence of a particular person is not proof that this person is alive. Based on age-adjusted US mortality rates from 1997 to 2009 , we expeIn another set of sensitivity analyses we calculated a range of SIRs without updated vital status information. We estimated SIRs assuming two extreme ranges for person-years of followup: from first donation to cancer diagnosis or December 31, 2009  or from first donation to cancer diagnosis or last visit to the blood center . Our conservative estimate after vital status update and excluding donors with less than 12 months of followup time showed 64% greater incidence of primary malignant tumors among BCP REDS donors compared with the general US population (95% CI = 59–70%). While our data are observational with limited follow-up information for donors without a cancer record, sensitivity analyses assuming the best and worst case scenarios for donors without a cancer  indicate that cancer incidence among our blood donor cohort exceeds that of the general US population in each extreme assumption scenario.A second limitation of the current analysis is that we had access to limited demographic and medical history information for donors. Data on variables generally known as risk or prognostic factors for cancer, such as weight and height, smoking status, alcohol drinking, family history of cancer, and diabetes, are not captured in BCP or REDS donor data.Third, our results are limited to northern California blood donors who participated in REDS during 1991–2002. Blood donors have different demographic and behavioral risk factor profiles than the general population, and furthermore BCP blood donors may be a group of blood donors that are different from the general US blood donor population in many aspects related to cancer incidence and mortality. Lastly, while non-donor cancer population is not reflected in BCP REDS, there is a possibility of misclassification if they donated blood at other times or other blood centers. If this is true, the actual donor, non-donor differences in mortality would likely be even greater than the current report.This is the first report of cancer incidence among US blood donors in comparison with the general population. In the next phase of the study a larger dataset including additional REDS donor records from other participating blood centers will be matched against National Death Index to increase the precision and accuracy of the standardized cancer incidence and outcomes estimates among REDS blood donors. A noteworthy aspect of the existing linked donor-cancer database is the stored repository of whole blood and/or serum/plasma specimens which were collected years prior to cancer diagnosis. The current study establishes the capability of health outcomes linkage and presages utility of the stored specimens in a way that had not been considered during the design and creation of the REDS repositories. The establishment of the linked database for these repository donors is the first step towards further investigation of repository samples to investigate cancer biomarkers that may have been present in serum, plasma or whole blood samples during a time period when these individuals were healthy cancer-free blood donors. These investigations should help us to better understand biomarker development and changes that may be present in blood years before clinical cancer is diagnosed.


Rural Australians face a higher mental health and lifestyle disease burden  than their urban counterparts. Our ongoing research reveals that the Australian farming community has even poorer physical and mental health outcomes than rural averages. In particular, farm men and women have high rates of overweightness, obesity, abdominal adiposity, high blood pressure and psychological distress when compared against Australian averages. Within our farming cohort we observed a significant association between psychological distress and obesity, abdominal adiposity and body fat percentage in the farming population.This paper presents a hypothesis based on preliminary data obtained from an ongoing study that could potentially explain the complex correlation between obesity, psychological distress and physical activity among a farming population. We posit that spasmodic physical activity, changing farm practices and climate variability induce prolonged stress in farmers. This increases systemic cortisol that, in turn, promotes abdominal adiposity and weight gain.The hypothesis will be tested by anthropometric, biochemical and psychological analysis matched against systemic cortisol levels and the physical activity of the subjects.Previous studies indicate that farming populations have elevated rates of psychological distress and high rates of suicide. Australian farmers have recently experienced challenging climatic conditions including prolonged drought, floods and cyclones. Through our interactions and through the media it is not uncommon for farmers to describe the effect of this long-term stress with feelings of 'defeat'. By gaining a greater understanding of the role cortisol and physical activity have on mental and physical health we may positively impact the current rates of psychological distress in farmers.ACTRN12610000827033 The agrarian myth of an agricultural utopia supports the notion that living on a farm is coupled to the stereotypical view of stress-free, happy and healthy lifestyle. Unfortunately, this is not the case as rural Australians face an environment of high occupational hazards, poor access to services, higher mental health burden, vulnerability to adverse climatic conditions, socio-economic constraints, food insecurity, alcohol misuse and an increasing burden of chronic disease.In particular, Australian farmers are at higher risk of physical and mental illness when compared to rural and metropolitan populations. These differences are highlighted by the increased incidence of suicide in farming communities. SuicideIt is widely reported that there are multifarious interrelationships between lifestyle, anthropometric, psychological and activity variables . DepressThe Sustainable Farm Families™ (SFF) program focuses on the health, well-being and safety of farm men and women . This onA preliminary analysis of SFF data was conducted on a cohort of 1813 adult farmers, revealing that physical and mental health indicators are substandard within farming communities. This preliminary analysis also revealed that 64.3% of farm men and women were either obese or overweight which is significantly higher than current age standardised Australian national averages (p < 0.05) , high density lipoproteins (HDL), fasting blood glucose and cortisol will be measured in overweight and obese farm men and women.A complete health history will be obtained from participants registered in the Farming Fit study. Assessments will include anthropometric measures of height, weight, hip and waist circumference, body fat analysis and biochemical analysis of fasted total serum cholesterol, triglycerides, low density lipids (LDL), high density lipids (HDL), blood glucose and cortisol. Salivary cortisol at different time points across a 24-hour period will also be collected.Alcohol habits, activity levels, dietary habits and smoking will be recorded.A validated questionnaire, the depression, anxiety, stress score (DASS) will be used. The DASS 21 is made up of three seven item subscales covering depression, anxiety and stress as specified in Lovibonds and Lovibond .Ethics approval has been granted to the project by Deakin University Human Research Ethics Committee (HREC 2009/215 dated 03/02/2010) and the South West Multidisciplinary Ethics Committee. All participants in the study will be provided with a plain language statement to enable informed written consent prior to participation in this study. The collected data will be appropriately stored at the Western District Health Service in Hamilton, Victoria, Australia.Rural populations face poor outcomes in mental health and the associated co-morbidities of obesity, diabetes and cardiovascular disease. Farming populations are a subset of this group that face additional challenges due to the tyranny of distance, the distance decay effect and predicted on going climatic and environmental challenges. Farmers have a high mental health burden and higher rates of obesity and associated lifestyle disease.It is plausible that the anthropometric and psychological conditions we observed in our preliminary farming cohort are linked to this 'defeat' response . HoweverThe outcome results of this study will be used in further research into the physical and mental health of farmers as well as provide important insights in to the development of novel physical activity interventions, improved service delivery programs and future prevention opportunities.The presence of confounding factors such as dietary variation, physical activity dissimilarity and individual social interaction may affect the final outcome of this study but are difficult to control. The effects of climate variability in the short term may also affect the final outcomes of the Farming Fit hypothesis but are outside the scope of this project. Further extended research on these confounding factors is warranted.Australian farmers experience high rates of physical and psychological disease. As global demand for food rises, Australia as a large food exporter and food manufacturer will require a healthy farming workforce to enable it to make the most of this opportunity. With depleting agricultural communities, an ageing farmer workforce and predicted climatic adversity, it is important to understand the links between physical and mental health and agricultural productivity. Understanding how physical health is important for the well-being of farmers and their enterprise will help to break the 'defeat' cycle and assist the agricultural industry to be Farming Fit.SFF: Sustainable Farm Families™; K-10, Kessler 10; HPA: Hypothalamus Pituitary Adrenal; LDL: Low Density Lipoproteins; HDL: High Density Lipoproteins; DASS-21: Depression, Anxiety, Stress Score-21; WC: Waist circumference; BMI: Body Mass Index.The authors declare that they have no competing interests.SB, AC and SM originated the Farming Fit concept and drafted the initial manuscript. All authors contributed to the methods and design of the study. All authors have read and approved the final manuscript.


In Sub-Saharan Africa, 40% of children under five years in age are chronically undernourished. As new investments and attention galvanize action on African agriculture to reduce hunger, there is an urgent need for metrics that monitor agricultural progress beyond calories produced per capita and address nutritional diversity essential for human health. In this study we demonstrate how an ecological tool, functional diversity (FD), has potential to address this need and provide new insights on nutritional diversity of cropping systems in rural Africa.Data on edible plant species diversity, food security and diet diversity were collected for 170 farms in three rural settings in Sub-Saharan Africa. Nutritional FD metrics were calculated based on farm species composition and species nutritional composition. Iron and vitamin A deficiency were determined from blood samples of 90 adult women. Nutritional FD metrics summarized the diversity of nutrients provided by the farm and showed variability between farms and villages. Regression of nutritional FD against species richness and expected FD enabled identification of key species that add nutrient diversity to the system and assessed the degree of redundancy for nutrient traits. Nutritional FD analysis demonstrated that depending on the original composition of species on farm or village, adding or removing individual species can have radically different outcomes for nutritional diversity. While correlations between nutritional FD, food and nutrition indicators were not significant at household level, associations between these variables were observed at village level.This study provides novel metrics to address nutritional diversity in farming systems and examples of how these metrics can help guide agricultural interventions towards adequate nutrient diversity. New hypotheses on the link between agro-diversity, food security and human nutrition are generated and strategies for future research are suggested calling for integration of agriculture, ecology, nutrition, and socio-economics. While great strides in reducing hunger through increases in agricultural productivity have been made worldwide, more than 900 million people are undernourished In nutritional sciences, several methods have been developed that look beyond the single nutrient or food item to capture the broader picture of diet diversity Approaches to quantifying diet diversity in nutrition research have direct analogs to approaches to quantifying biological diversity in ecology. Counting total number of food items or food groups is analogous to counting species richness and functional group richness. In ecology, there is increasing interest in quantitative measures of functional diversity, which take advantage of the wealth of information available on species' traits, particularly for plants, to overcome some of the drawbacks or lack of sensitivity of the simpler measures of diversity Here we introduce a novel nutritional functional diversity metric . The nutritional FD metric is based on plant species composition on farm and the nutritional composition of these plants for 17 nutrients that are key in human diets and for which reliable plant composition data are available . We use The three sites examined here, Mwandama in Malawi, Sauri in Kenya, and Ruhiira in Uganda, are part of the Millennium Villages Project (MVP), where food insecurity and under-nutrition rates are high total describing diversity for all 17 nutrients of macronutrients for the four macronutrients, FDminerals for the seven minerals and FDvitamins for the six vitamins. Differences between farms and villages for species richness, nutritional FD, household food and health indicators were analyzed as well as relationships between these different indicators.In this study we explore how nutritional FD metrics can provide insights in nutrient diversity of farming systems and can have potential to guide agricultural management. Data on plant species diversity, food security and diet diversity were collected for plots and home gardens of 170 farms in Mwandama, Sauri and Ruhiira and iron and vitamin A deficiency was determined from blood samples for 30 adult women per village. Four nutritional FD metrics were calculated: FDThe Mwandama village cluster is located in southern Zomba district of Malawi and covers an approximate population of 35,000 people. The region once characterized by native Miombo woodlands is now intensively cultivated. Smallholders grow mainly maize, pigeon peas, cassava, and groundnuts, while commercial estates produce tobacco and maize. Livestock management is practiced on a small scale and is restricted to chicken and goats.The Sauri cluster is located in the Kenyan highlands in the western Nyanza Province and has a farm community of 63,500 people. The main occupations are subsistence farming, consisting primarily of maize, sorghum and cassava, and animal husbandry, including goats, chickens, and cattle.The Ruhiira cluster is situated in the Isingiro District in the hilly, dissected terrain of southwest Uganda and has a population of approximately 43,056 people. The agricultural system is predominantly a mixed system with livestock and cultivation of annual and perennial crops. The main crop is banana, which covers approximately 30% of the total cropland.Further site characteristics are outlined in A random sample of 50 to 60 farms per site was selected based on demographic and geographic MVP data for 300 previously randomly selected households per cluster. For Ruhiira and Mwandama data for 60 farms were collected during June–September of 2009. For Sauri data for 50 farms were collected during November of 2009. A full explanation of the study procedures, purpose, risks and benefits were explained to participants during the informed consent process. The study received ethical approval from the Institutional Review Board at Columbia University.For each of the 170 farms, all plots, including home gardens, cultivated by the household, were sampled to document all crop, plant and tree species, with different species and varieties according to local definitions. Plant species were confirmed with the help of local botany studies A database of plant nutritional composition data was developed based on existing studies and databases  project were used to develop questionnaires for the months of inadequate household food provisioning  to determine iron and vitamin A deficiency.3+ ions to Fe2+ ions, which then react with FerroZine reagent to form a colored complex. The color intensity is directly proportional to the iron concentration in the sample and is measured photometrically. Iron at the concentration of 46; 93 and 138 ug/dL has a day-to-day variability of 1.8%; 1.1% and 0.6%, respectively. Iron deficiency was defined as a level less than 15 ng/mL Iron was measured by a colorimetric assay using the Hitachi 917 analyzer . Under acidic conditions, iron is liberated from transferrin. Ascorbate reduces the FeThe levels of vitamin A were measured by high performance liquid chromatography . Vitamin A is de-proteinized from the serum/plasma sample using ethanol and extracted with hexane. The extract is dried, re-dissolved with ethanol and injected into the chromatograph. Retinyl acetate is used as the internal standard. This assay is standardized using calibrators from the National Institute of Standards and Technology. The minimum required volume for this assay is 150 microliters. Vitamin A deficiency was defined as a level <20 micrograms/dL www.r-project.org).All calculations, as well as general linear models and analysis of variance, were done in the statistical programming environment R , also when corrected for village. The five most commonly grown crops across all three sites are bananas (on 93% of the farms), maize (91%), beans (75%), cassava (75%), and mango (69%). Examples of unique species for one of the sites include several green leafy vegetables such as Corchorus olitorius (apoth) and Crotalaria brevidens (mito) for Sauri in Kenya; tamarillo or tree tomato (Solanum betaceum) and some spices e.g., ginger and cardamom, for Ruhiira in Uganda; certain fruits such as peaches, figs and pomegranates for Mwandama in Malawi  were calculated for each of the 170 farms (vitamins (p = 0.41). Similar to species richness, all FD metrics were found to be independent from farm landholding size (p>0.1).Four nutritional FD metrics  between FDtotal and species richness, independent of village. Thus, as the number of edible species increases, the diversity of nutrients that farm provides also increases. Second, at a level of around 25 species per farm, the relationship between FDtotal and species richness starts leveling off, meaning that additional species to a farm, with around 25 or more species, increases nutritional diversity very little. Third, although species richness and FDtotal are correlated, farms with the same number of species can have very different nutritional FD scores. For example, two farms in Mwandama . Trait analysis shows that pumpkin  adds diversity to the system by its relatively high nutritional content in vitamin A, Zn, and S-containing amino acids (methionine and cysteine) compared to other species; mulberry by its levels of vitamin B complexes  and groundnut by its nutritional content for fat, Mn, and S. The black jack, avocado and peaches found in the lower FD farm add less nutritional diversity to the system than pumpkin, mulberry, and groundnut since they do not contain the vitamin B or S complexes, and thus are less complementary to the other plants in the system for their nutritional content. This example shows how different crop species compositions can result in very disparate nutritional FD even with identical numbers of crops planted in a field.total  against macronutrients increases nearly linearly with increasing species richness, FDvitamins shows abrupt changes and is highly dependent on the presence of few species. For example, addition of mulberry or guava species strongly increases the FDvitamins value of the farm because of their unique high values for vitamin B complexes and vitamin C, respectively. This uniqueness attributed to a few key species results in a stepwise pattern of different FDvitamins levels instead of a gradual increase with number of species and indicates high species sensitivity . For FDminerals, the group of farms in Mwandama differs significantly from the Ruhiira and Sauri farms, by lower FDminerals values and a lower slope in the FDminerals - species richness relationship (p<0.001). This suggests that the species on the Mwandama farms are not contributing as much mineral diversity to the system than species in the Kenya or Uganda village .When considering the FD values based on the nutrient subgroups, i.e. macronutrients, minerals and vitamins, the pattern of the relationship between species richness and FD differs among subgroups . While FA crucial component of FD is functional redundancy total and FDmacronutrients no strong redundancy patterns are observed  which is particularly rich in Fe, Eleusine coracana (finger millet) with high Ca and Mn levels, Glycine max (soybean) rich in Fe, Mg and Mn, Helianthus anuus (sunflower) which seeds have high levels of Zn, Mg and S and Solanum nigrum (black nightshade) rich in Fe and Mn.observed . For FDmminerals, for FDvitamins a group of farms . As mentioned above, mulberry, especially the leaves, contain vitamins B complex and C, in higher levels than most other plants. Addition or loss of mulberry as one of the few species in the community providing vitamin B complex, can increase or reduce FDvitamins significantly.In contrast to the pattern of high redundancy for FDIn addition to agro-biodiversity data, data on household food indicators including a household food insecurity access scale (HFIAS), number of months of inadequate household food provisioning (MIHFP) and household diet diversity scores (HHDDS) were obtained for each of the 170 farms . SignifiAnalysis of correlations between these household food indicators and farm species richness and nutritional FD metrics indicate that for each of the food indicators, correlation coefficients are slightly higher for FD metrics than for species richness. But none of these correlations are significant and significance does not change when corrected for village and/or land size (data not shown).minerals and FDvitamins respectively: while Mwandama shows significantly higher rates of Fe deficiency than Ruhiira and Sauri, average FDminerals of Mwandama farms is significantly lower compared to FDminerals in Ruhiira and Sauri. No significant differences between sites are found for Vitamin A deficiency and similarly, FDvitamins is the only FD metric for which the three sites score equally.The patterns for iron and vitamin A deficiencies at the village level  are simiSub-Saharan Africa faces pressing challenges, with 40% of children chronically undernourished or stunted total, high species sensitivity for FDvitamins, high redundancy for FDminerals).The strengths of the study lie in the development of a systems approach that is able to consider the large variety of species available in the system together with their nutritional composition and in the step it takes towards integrating agriculture, nutrition and ecology studies While in the past, food-based interventions in developing countries have focused mostly on a single nutrient This study is, however, limited and offers room for improvement on several fronts. First, no data were collected on the quantities produced or on species evenness. Cropping area or yield data would further strengthen the study by allowing calculation of an abundance-weighted FD metric, several of which have been developed in community ecology Phaseolus vulgaris L. (common bean) are significantly higher in iron and zinc than other P. vulgaris varieties Second, the nutritional composition data and FD metric calculations were based on available species level data. It is known that a large diversity in nutritional composition exists among different varieties of species as well as among different environments in which plants are cultivated minerals and Fe deficiency, FDvitamins and vitamin A deficiency and FDtotal and diet diversity, food insecurity and number of months of insufficient food supply. These findings generate new hypotheses on the link between nutritional diversity of the farming system and nutrition outcomes at the village or in particular the foodshed level such as: Can the high rate of Fe deficiency among adult women in Mwandama be due partly to a lack of species that contribute more significantly to mineral diversity, particularly those high in Fe? Also, does the high crop species richness in Sauri and Ruhiira play a role in their relatively lower level of food insecurity?No significant correlations at the farm level were found between nutritional FD of crops grown and household food consumption indicators. This might be partly due to limitations of the proposed FD metrics or the relatively simple household food indicators used in this study, but also to the complex pathway between agricultural production and food consumption minerals in Mwandama remains relatively low. Several potential barriers for growing species that add more to FDminerals can be hypothesized and could be categorized under ecological , dispersal (large distance to origin of seeds) or anthropogenic determinants . In this context, it is interesting to note that soil fertility measures in the Mwandama village  Box S1List of main sources used to establish nutritional composition database used in this study.(DOC)Click here for additional data file.Figure S1total taking into account the 17 nutrients listed in Dendogram for nutritional FD. Species are abbreviated as first three letters of genus plus first three letters of species. Full species names are outlined in Table S3.(TIF)Click here for additional data file.Table S1List of edible, characterized plant species that were identified at the study sites.(XLS)Click here for additional data file.


The ratio of habitat generalists to specialists in birds has been suggested as a good indicator of ecosystem changes due to e.g. climate change and other anthropogenic perturbations. Most studies focusing on this functional component of biodiversity originate, however, from temperate regions. The Eurasian Arctic tundra is currently experiencing an unprecedented combination of climate change, change in grazing pressure by domestic reindeer and growing human activity.2). Willow shrub thickets were a hotspot for bird density, but not for species richness. The thickets hosted many specialized species whose main distribution area was south of the tundra.Here we monitored bird communities in a tundra landscape harbouring shrub and open habitats in order to analyse bird habitat relationships and quantify habitat specialization. We used ordination methods to analyse habitat associations and estimated the proportions of specialists in each of the main habitats. Correspondence Analysis identified three main bird communities, inhabiting upland, lowland and dense willow shrubs. We documented a stable structure of communities despite large multiannual variations of bird density (from 90 to 175 pairs/kmIf current arctic changes result in a shrubification of the landscape as many studies suggested, we would expect an increase in the overall bird abundance together with an increase of local specialists, since they are associated with willow thickets. The majority of these species have a southern origin and their increase in abundance would represent a strengthening of the boreal component in the southern tundra, perhaps at the expense of species typical of the subarctic zone, which appear to be generalists within this zone. Bird communities and populations are monitored in many parts of the world, as they often are the focus of considerable interest from the general public. Their abundance and distributions are considered effective indicators of changes in biodiversity, habitat quality and availability Rangifer tarandus) can, however, limit shrub expansion Most studies investigating the response of bird communities to environmental changes have been carried out in temperate regions, and little is known on how the identified trends – homogenization of biodiversity In this paper, we investigate habitat associations and the degree of habitat specialization of bird communities in the shrub tundra of the south-western Yamal peninsula, Russia. This region is experiencing both a rapid development of the oil and gas industry, and growth of reindeer herds Salix spp.) thickets for the bird communities, as their extent in the shrub tundra is likely to change under the influence of climate change, erosion and/or intense browsing. Willow thickets have been described as hotspots of productivity and biodiversity in general Here we present results of a systematic bird survey carried out over eight years (2002–2009) in five habitat types of the shrub tundra in southern Yamal, habitats that are typical for vast areas in the southern Eurasian Arctic The study was conducted in the frame of ecosystem monitoring carried out by the Ecological Research Station of the Institute of Plant & Animal Ecology, Ural Division Russian Academy of Sciences, and part of the approved science plan of this institution. Permissions for field work were obtained from the Department of Bioresource of the Government of Yamalo-Nenetsky Autonomous Okrug (the administrative region where the study was carried out). As this was a purely observational study, no specific permits were needed.Data were collected during a long-term study of birds at the Erkuta tundra monitoring site, situated close to Erkutayakha River in southwest Yamal (68°13′N 69°09′E), Russia . Mean teAlnus fruticosa) occur along streams and lakes.The study area is situated in a flat tundra landscape interspersed with hills (ca. 30 m) and river cliffs (up to 40 m high). A dense network of rivers, streams and lakes creates wide lowlands with large areas being flooded in spring. The area is at the border between two vegetation zones: erect dwarf-shrub and low-shrub tundra 2. After an initial survey of a larger area of about 100 km2 the study area was chosen because 1) it contained all major landscape elements typical for the region, elements which are also characteristic of the southern tundra in Russia in general , and 2) the size of the area was small enough to carry out the survey several times per season and by the same observer. The area was divided into four plots of about 0.8 km2 each, delimited mostly by landscape elements such as rivers or lakes, to assess the local variation in bird communities  and smaller shrubs , as well as moisture, we distinguished two upland habitats: upland open tundra (UOT) and upland shrub tundra  was calculated for each species following Julliard et al. A community specialization index (CSI) was estimated for the birds in each habitat on each plot (14 habitat x plot units). CSI was calculated as the average SSI of the individuals counted in that habitat/plot over the years of the survey Average species richness for each habitat was estimated applying the first order jackknife estimator to the bird counts on each habitat in each year, and using plots as replicates 2 over the years (average 108.7±10.4 (SE) pairs/km2). In total, 41 species were recorded as breeders. Several species occurred however at very low densities or were recorded only once. These were the following : Rough-legged Buzzard Buteo lagopus, Black-throated Diver Gavia arctica, Red-throated Diver Gavia stellata, Long-tailed Duck Clangula hyemalis, Bean Goose Anser fabalis, Greater White-fronted Goose Anser albifrons, Heuglin's Gull Larus heuglini, Pintail Anas acuta, Greater Scaup Aythya marila, Common Scoter Melanitta nigra, Arctic Skua Stercorarius parasiticus, Common Teal Anas crecca, and Wigeon Anas Penelope.The overall density of breeding birds in the study area fluctuated from 90 to 175 pairs per km2 (2 on average). Little Bunting, Redpoll, Willow Warbler, Bluethroat, Redwing, Citrine Wagtail, Meadow Pipit and Chiffchaff were common, but less abundant. Among waders, the most common species were Temminck's Stint, Wood Sandpiper as well as Common Snipe, with densities ranging from 4.5 to 5.4 pairs/km2 . These two first axes reflected the difference in bird composition among three types of habitats, the upland tundra (UOT and UST), the lowland flooded tundra (LST and LM), and willow thickets WT; . DespiteWe also investigated whether an interaction between year and habitat could explain some additional variation, but this was not the case . The species composition overlapped largely between the four plots and differences were largely confounded with the different habitats present on each plot. Generalist species, characterized by a large variance along the two first CA axes, were Wood Sandpiper, Temminck's Stint, Red-throated Pipit, and Lapland Bunting . These sThe gradient from generalists to specialists was well described by SSI . The RedAmong the five habitats, the density of breeding birds was clearly highest in willow thickets . EstimatAs far as we know, relatively few studies have been published on bird communities in the shrub tundra zone, and this is particularly true for passerines Compared to studies from the North American Arctic, the number of species registered in the present study was high, particularly so for small passerines. Eighteen small passerine species were breeding at Erkuta, compared to values ranging from eight to nine in a comparable biogeographic zone in eastern Canada Anthus rubescens) is a willow specialist Passerine communities at Erkuta differed from North American ones by the occurrence of pipits, wagtails, warblers, as well as one thrush species. Specifically the Red-throated Pipit was an abundant generalist at Erkuta, with two other pipit species being present, whereas the only study we could find from the Canadian Arctic with significant numbers of pipits was on Ungava peninsula where the American Pipit Click here for additional data file.Figure S1Summer pictures of the habitats monitored in our study, Erkuta, 2002–2009, Yamal, Russia.(TIF)Click here for additional data file.Figure S2Map of breeding pairs for two species breeding in open habitat (Lapland bunting) and closed habitats . Each star represents the centre of a territory.(TIF)Click here for additional data file.Figure S3Bird communities have been described at several sites on the Yamal Peninsula by different authors. A) Map of the sites where communities were described. B) Result of a correspondence analysis which shows that the community at Erkuta was similar to those observed at sites located in the same biogeographic area, such as Hanovey and Yuribey .(TIF)Click here for additional data file.


Women's ill-health and its consequences are poorly defined. Despite women living longer than men, their lives are not necessarily healthy, according to the 2009 Women and Health Report of the World Health Organization (WHO) . One conWith limited and patchy data, maternal deaths and disabilities are considered a leading contributor to the burden of disease among women. Maternal conditions were second only to HIV/AIDS in terms of women's deaths worldwide and third in terms of disability-adjusted life-years (DALYs) for women aged 15-44 years, based on the 2005 global burden of disease estimates. More specifically, maternal conditions contributed to 2.7% of deaths among women worldwide and 12% of deaths among women aged 15-44 years. In the South-East Asian region, maternal conditions are the leading cause of women's death and responsible for 14% of deaths among women aged 15-44 years  the inconsistent use of terminologies to describe maternal morbidities and disabilities, and their consequences and (b) the methods used for ascertaining these quantitatively.The inconsistent use of terminologies to describe various maternal morbidities and disabilities is a major source of confusion in interpreting the available literature. In this series, the obstetric complications that can kill are part of a wider group of morbidities suffered during the antenatal, natal or postpartum periods that we call acute maternal morbidities. Those that affect women and their families in the longer-term are called postpartum maternal morbidities and disabilities. The following section provides a general review of terms used in the literature on various conditions of maternal morbidity.Maternal morbidity is an overarching term that refers to any physical or mental illness or disability directly related to pregnancy and/or childbirth. These are not necessarily life-threatening but can have a significant impact on the quality of life.Acute maternal morbidities include various terms, such as ‘obstetric complications’, ‘maternal complications’, ‘absolute maternal indications’ (AMIs), ‘severe acute maternal morbidities’ (SAMMs), and ‘near-miss’ and typically refers to acute problems suffered during pregnancy through the standard postpartum period of 42 days.Obstetric or maternal complications are acute conditions that may directly cause maternal deaths. According to the United Nations Children's Fund/WHO/United Nations Population Fund (1997) ‘complicated cases’ include antepartum or postpartum haemorrhage, prolonged or obstructed labour, postpartum sepsis, complications of abortion, pre-eclampsia/eclampsia, ectopic pregnancy, and ruptured uterus  are life-threatening or severe obstetric complications requiring a specific major obstetric intervention which can be verified through records of health services. AMIs reflect conditions that, without intervention, have a high probability of causing maternal death during childbirth or sequelae including the following Shoulder or transverse lieSevere acute maternal morbidities (SAMMs) include complications that are ‘absolutely’ life-threatening using concepts of organ failure and lifesaving surgery—such that women who experience these problems are unlikely to survive if they do not receive care in a hospital  that is more limited than SAMMs, i.e. women presenting with features of organ dysfunction. They have also developed tools and outlined a process of gathering data to improve comparability across studies .This special issue of the Journal aims to respond to the major gaps in knowledge with studies on acute and postpartum maternal morbidities and disabilities from Matlab in Bangladesh and Rajasthan in India. A conceptual framework for this work is depicted in The level of severe and less-severe acute maternal morbidities during pregnancy, childbirth, and postpartum (42 days) in rural Bangladesh and Rajasthan in IndiaThe consequences of maternal morbidity , and death or developmental delays (for her newborn)The longer-term impact on women and families—mentally, socially, and economically (Bangladesh) and deaths of children or mothers up to one year postpartum (India).The hypotheses underlying the studies of maternal morbidities, disabilities, and consequences include the following:Women who suffer from severe acute maternal morbidities are at risk of suffering from long-term consequences  or death compared to those with vaginal deliveries with no complications.Women who suffer from moderate and severe acute maternal morbidities and those who die are at higher risk of suffering poor pregnancy outcomes  compared to those with vaginal deliveries with no complications.A child of a mother suffering from long-term consequences of severe acute maternal morbidities is at higher risk of death and poorer development than those of women without such consequences.Families of women who have suffered from severe acute maternal morbidities (and/or poor pregnancy outcomes) are at higher risk of dissolution, violence, and/or impoverishment.Driven by the above hypotheses, three types of studies were conducted, each with qualitative and quantitative components. The papers detailing the findings of each study type are listed below.Examination of the incidence of short- and long-term morbidities and physical disabilities of women with severe and less-severe acute maternal morbidities (obstetric complications) and those with normal vaginal deliveries in rural Bangladesh and India:et al.)Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur, Bangladesh Occurrence and determinants of maternal postpartum morbidities and disabilities among women in Matlab, Bangladesh et al.).Consequences of maternal complications on women's lives in the first postpartum year: a prospective cohort study  as related to maternal morbidity/mortality:et al.)Consequences of maternal complications on women's lives in the first postpartum year: a prospective cohort study Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur, Bangladesh .Association of postpartum maternal morbidities with children's mental, psychomotor and language development in rural Bangladesh  on women and other members living in the family unit:et al.)Obstetric complications and psychological well-being: Bangladeshi women's experiences with pregnancy and childbirth An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh Violence against women with chronic maternal disabilities in rural Bangladesh Costs of maternal health complications in Bangladesh .et al.In Bangladesh, the icddr,b's community data from the Matlab intervention area with its population of 110,000 plus facility data from Matlab and Chandpur district town provide a unique opportunity to capture the levels of maternal mortality, morbidities, and disabilities while tracing women and families who have suffered and linking them to changes in familial, social and economic status over time. This is done through secondary analysis of the existing data dating back 30 years plus prospective data collected over 24 months starting in 2007. In the prospective study, only those women who had a care provider's diagnosis of morbidity were included , a non-profit organization based in Udaipur, provides data on maternal morbidities and their consequences from a 36-month prospective study (starting in 2007) on a rural tribal population of 58,000 in southern Rajasthan. Given that few women in the area used facilities for deliveries, morbidity data on all women with a birth in the area were collected by midwives within 2-3 days of birth during home-visits, using a checklist developed to question women on pregnancy or intrapartum complications and their consequences; they also carried out a physical examination, including measurement of haemoglobin. Follow-up visits of these women continued for 12 months postpartum. Recently-delivering women were identified by the family members or community workers [accredited social health activists (ASHAs) and village health volunteers] who were paid by ARTH for providing information on births.Finally, we contemplated the recalculation of the burden of disease for maternal death and disabilities for Bangladesh, using the methodology of the Global Burden of Disease Study  with theCalculation of DALY for Maternal Conditions—What Is Missing?Global burden of disease morbidities for which there are DALYs include anaemia, cardiovascular conditions, obstructed labour, haemorrhage, hypertensive disorders, reproductive tract infections, and sepsis.Unaccounted disabilities in the global burden of disease calculation (as of 2008) include dyspareunia, genital prolapse, haemorrhoids, mastitis, stillbirths, perineal tears, postpartum depression, urinary tract infections, and vulvar disruption.Such an undervaluation is only secondary to the underestimation of the incidence of maternal morbidities and disabilities and to the undervaluation of women's health more generally.The authors are grateful to Evelyn Ford (Intern), Sushil Dasgupta , and Sandee Minovi (John Snow Inc.) for their assistance with this document. They also thank the United States Agency for International Development for funding this effort and for stimulating them to think beyond the conventional boundaries of the topic.