Voluntary sustainability standards could significantly reduce detrimental impacts of global agriculture.

Voluntary sustainability standards (VSS) are stakeholder-derived principles with measurable and enforceable criteria to promote sustainable production outcomes. While institutional commitments to use VSS to meet sustainable procurement policies have grown rapidly over the past decade, we still have relatively little understanding of the (i) direct environmental benefits of large-scale VSS adoption; (ii) potential perverse indirect impacts of adoption; and (iii) implementation pathways. Here, we illustrate and address these knowledge gaps using an ecosystem service modeling and scenario analysis of Bonsucro, the leading VSS for sugarcane. We find that global compliance with the Bonsucro environmental standards would reduce current sugarcane production area (-24%), net tonnage (-11%), irrigation water use (-65%), nutrient loading (-34%), and greenhouse gas emissions from cultivation (-51%). Under a scenario of doubled global sugarcane production, Bonsucro adoption would further limit water use and greenhouse gas emissions by preventing sugarcane expansion into water-stressed and high-carbon stock ecosystems. This outcome was achieved via expansion largely on existing agricultural lands. However, displacement of other crops could drive detrimental impacts from indirect land use. We find that over half of the potential direct environmental benefits of Bonsucro standards under the doubling scenario could be achieved by targeting adoption in just 10% of global sugarcane production areas. However, designing policy that generates the most environmentally beneficial Bonsucro adoption pathway requires a better understanding of the economic and social costs of VSS adoption. Finally, we suggest research directions to advance sustainable consumption and production.

Functional analysis of normalized difference vegetation index curves reveals overwinter mule deer survival is driven by both spring and autumn phenology.

Large herbivore populations respond strongly to remotely sensed measures of primary productivity. Whereas most studies in seasonal environments have focused on the effects of spring plant phenology on juvenile survival, recent studies demonstrated that autumn nutrition also plays a crucial role. We tested for both direct and indirect (through body mass) effects of spring and autumn phenology on winter survival of 2315 mule deer fawns across a wide range of environmental conditions in Idaho, USA. We first performed a functional analysis that identified spring and autumn as the key periods for structuring the among-population and among-year variation of primary production (approximated from 1 km Advanced Very High Resolution Radiometer Normalized Difference Vegetation Index (NDVI)) along the growing season. A path analysis showed that early winter precipitation and direct and indirect effects of spring and autumn NDVI functional components accounted for 45% of observed variation in overwinter survival. The effect size of autumn phenology on body mass was about twice that of spring phenology, while direct effects of phenology on survival were similar between spring and autumn. We demonstrate that the effects of plant phenology vary across ecosystems, and that in semi-arid systems, autumn may be more important than spring for overwinter survival.

The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies.

INTRODUCTION: Postoperative hypocalaemia commonly occurs after extensive thyroid surgery and may require calcium and/or vitamin D supplements to alleviate or prevent the symptoms. In this study, we determined the risk factors for developing hypocalcaemia and whether early serum calcium levels can predict the development of or differentiate between temporary or permanent hypocalcaemia. PATIENTS AND METHODS: A total of 162 patients who either had a completion or total thyroidectomy formed the basis of this prospective study. Serial serum calcium measurements were recorded as well as details of the operation, pathology, indications for surgery, number of parathyroids identified at operation and any complications. RESULTS: Eighty-four (52%) patients did not develop hypocalcaemia but 69 (43%) were found to have temporary hypocalcaemia and 9 (5%) had permanent hypocalcaemia. Hypocalcaemia was more common after total than completion thyroidectomies and the identification of parathyroids at operation appears to have a significant adverse effect on outcome. The calcium levels measured on day 1 postoperatively and the slope (serum calcium levels of day 1 postoperative minus day of operation) were statistically significant in predicting the development of hypocalcaemia and possibly to differentiate between temporary or permanent hypocalcaemia. DISCUSSION: Although almost half the patients having extensive thyroid surgery developed hypocalcaemia (as defined by any postoperative corrected serum calcium level of < 2.12 mmol/l) only 24% had a serum calcium of < 2.12 mmol/l associated with clinical symptoms of hypocalcaemia or a calcium level of < 2.0 mmol/l. Only 5% had persistent hypocalcaemia defined as requiring exogenous supplements at 6 months' postoperatively. Patients having a completion thyroidectomy appear to be less likely to develop hypocalcaemia perhaps as a result of any iatrogenic effects on the parathyroids at the first operation being reversed before the second operation. Identification and, therefore, exposure of parathyroids at operation may have an adverse effect on the blood supply to the glands affecting their function. CONCLUSIONS: Serum calcium levels measured 6 hours' post-surgery and on day 1 postoperatively can be useful in predicting if the patient will develop hypocalcaemia and the slope may indicate whether the hypocalcaemia will be temporary or permanent. Patients with toxic goitres and those having a one-stage total thyroidectomy are most at risk of developing hypocalcaemia.

Posterior nasal septal abscess in a healthy adult patient.

OBJECTIVE: We report an extremely rare case of bilateral posterior nasal septal abscess in an otherwise healthy adult patient. METHOD: Case report and a review of the world literature concerning atraumatic nasal septal abscess and its management. RESULTS: The development of an atraumatic nasal septal abscess is rare, but it has been reported in association with acute sinusitis, in patients with poor immunity and in children. The presentation, clinical course and treatment are discussed in the presented patient. CONCLUSION: To our knowledge, this is the first report in the world literature of a bilateral posterior septal abscess associated with acute sinusitis in an otherwise healthy adult.

Intratympanic gentamicin treatment in Meniere's disease: patients' experiences and outcomes.

OBJECTIVE: The aim of this study was to assess the experiences and outcomes of patients receiving intratympanic gentamicin treatment for Ménière's disease in Norfolk, UK. DESIGN: This study was based on a retrospective questionnaire survey and a review of patients' medical records. SETTING: Two district hospitals. PARTICIPANTS: All 29 patients treated between 1999 and 2001, with a minimum follow up of two years post-treatment, were included in the study. Twenty-three patients completed the questionnaires (79 per cent response rate). MAIN OUTCOME MEASURES: Glasgow benefit inventory (GBI) and vertigo symptom scale (VSS) scores, plus change in hearing thresholds. RESULTS: The mean GBI total score was +36, indicating substantial improvement in patients' overall quality of life following gentamicin treatment. The VSS scores demonstrated low levels of vertigo or unsteadiness in treated patients. Three patients suffered deterioration in their hearing thresholds following a single injection of gentamicin. However, 96 per cent of responders stated that they would be willing to have such treatment again, if necessary. CONCLUSION: Intratympanic gentamicin treatment ought to be offered to Ménière's patients suffering from disabling vertigo, with the proviso that they be made aware of the possibility of hearing deterioration.

A national survey amongst UK otolaryngologists regarding the treatment of Ménière's disease.

Since Dr Prosper Ménière described the vertiginous syndrome that now bears his name, a large variety of medical and surgical treatments have been introduced. To determine the way in which this condition is currently managed in the United Kingdom, a postal survey amongst consultant otolaryngologists was carried out. It revealed that 52 per cent were actively involved in the treatment of patients with Ménières disease using a wide range of medical and surgical therapies that have little or no evidence base. The survey found that 94 per cent of surgeons prescribe betahistine, 63 per cent diuretics and 71 per cent advise salt restriction to their patients, while 52 per cent of surgeons continue to recommend saccus decompression and 50 per cent are still inserting a grommet. However, two thirds of respondents now advocate the use of gentamicin therapy despite it only being introduced to this country just over 10 years ago. The results of this study and their relevance to the recommended present day management of Meniere's disease are discussed.

CIR sand casting system for trans-tibial socket.

The authors have developed a trans-tibial socket fabrication system based on the "dilatancy" principle, a process that has been commonly used in forming wheelchair Seating. The CIR Sand Casting System replaces plaster of Paris with sand for forming both a negative sand mould and a positive sand model, which can be modified for either thermoplastic socket formation or resin lamination. Initial clinical trials suggest that fabrication times are approximately 90 minutes from patient evaluation and casting to dynamic alignment. Compatibility with all existing prosthetic components is retained. It is believed the CIR socket fabrication system may be a competitive alternative for prosthetic service providers in developing countries.

The use of the KTP laser in the management of hypertrophic tracheal mucosa and granulation tissue around Provox valve protheses.

The development of hypertrophic mucosa and granulation tissue around a tracheo-oesophageal fistula voice prosthesis is a commonly encountered problem occurring in 15-20 per cent of patients. Upsizing of the voice prosthesis as well as cautery (silver nitrate and electocautery) are used to counteract this problem to a varying degree of success. The use of the CO2 laser has been mentioned by some authors but details of the method and results have not been published. We report the successful use of the KTP laser for removing such granulations whilst retaining the valve and discuss the reasons why this method should be considered.

Osteoradionecrosis of the hyoid presenting as a cause of intractable neck pain following radiotherapy and the role of magnetic resonance image scanning to aid diagnosis.

Osteoradionecrosis of the hyoid has been reported rarely in the worldwide literature. We present the case of a 56-year-old gentleman who presented with intractable neck pain, following surgery and radiotherapy for a T(2)N(2c)M(0) tongue base carcinoma, to highlight the need to consider osteoradionecrosis of the hyoid rather than recurrence of the carcinoma as the cause of such symptoms. The previously unreported appearance of osteoradionecrosis of the hyoid on a magnetic resonance image (MRI) scan and the use of this investigation to aid diagnosis is discussed.

The development of thermal resistance of the feather coat in broilers with different feathering genotypes and feeding regimes.

1. This study compared the development of thermal resistance of the feather coat in broilers, with early or late feathering genes, and with or without the naked neck gene, allowed ad libitum or restricted feeding. 2. Male and female broilers of one of the 4 genotypes were reared to 6 weeks of age and allocated to one of the two feeding regimes. The thermal resistance of the back and crop region was measured at weekly intervals. A sample of birds were killed at the same ages and total feather weight, primary and secondary flight feather weight, liver weight and abdominal fat weight were measured. 3. All three main factors, sex, feeding and genotype, had significant effects on feather weight over time. The primary and secondary flight feathers were less affected by feed restriction than the feather coat as a whole. Birds with the naked neck gene showed a greater depression in growth rate than birds with a normal neck under conditions of restricted feeding. 4. The thermal resistance of the feathers on the back was greater in females, increased by early feather growth and decreased by restricted feeding. 5. Relative to metabolic body size, birds on restricted feeding had a greater feather weight and a smaller liver. There was a marked reduction in fat deposition, to almost negligible levels by 6 weeks of age. 6. Broilers given restricted feeding, in preparation for breeding, would benefit by a warmer environment, particularly those with feathering genotypes which confer a lower thermal resistance.

Laryngoscopy findings in outpatient notes: the accuracy of the recording of the side of the lesion.

An analysis of 100 patient notes was performed in the South-west Thames Region to determine the accuracy of recording the side of the abnormality in outpatient clinic notes when compared to the findings at direct laryngoscopy. Direct laryngoscopy was felt to be the most accurate method of viewing the larynx. The results were analysed to determine if the specific method of outpatient laryngoscopy or grade of examiner influenced the error rates. Inconsistencies occurred in 29% of the clinic notes when a diagram of the larynx was present. Specialist Registrars made 59% of the errors. Flexible nasendoscopy accounts for more errors than indirect laryngoscopy.

Floral movements in response to thunderstorms improve reproductive effort in the alpine species Gentiana algida (Gentianaceae).

Studies of floral movements in response to environmental change are rare in the literature, and information about possible adaptive benefits appears nonexistent. The closure of the upright, tubular flowers of alpine gentian (Gentiana algida) were observed during the frequent afternoon thunderstorms characteristic of the central and southern Rocky Mountains (USA). Flowers closed within minutes of an approaching thunderstorm and reopened after direct sunlight returned. Corolla opening widths decreased ∼10%/min prior to rainfall, in close correspondence to declines in air and corolla temperatures. Identical floral behavior was also induced experimentally in the field and laboratory by artificial changes in corolla temperature. Corolla closure did not occur during experiments that simulated natural changes in solar irradiance, wind, or absolute humidity during a thunderstorm. Furthermore, individual G. algida plants forced experimentally to remain open during rain had substantial losses of pollen after single rain events (up to 34%) and if forced to remain open for the entire flowering period (59%). Subsequent seasonal reductions in female fitness (up to 73%) also occurred, including seed size and mass, number of ovules produced, number of viable seeds produced per ovule, and seed germination. Thus, corolla closing and opening in G. algida associated with frequent summer thunderstorms may be a behavioral adaptation that improves both paternal and maternal reproductive effort.

Resection of a plantar calcaneal spur using the holmium:yttrium-aluminum-garnet (Ho:YAG) laser.

Many procedures have been described for the resection of plantar calcaneal spurs as treatment of heel spur syndrome and chronic plantar fasciitis. Most of these techniques involve a medial incision of between 2 and 6 cm for adequate exposure of the calcaneal spur. This article describes a new technique for resecting a calcaneal spur with a smaller medial incision using the holmium:yttrium-aluminum-garnet (Ho:YAG) laser. This laser permits adequate resection of a plantar calcaneal spur as well as coagulation of the bone and surrounding tissues. This minimally invasive procedure has been used with good results over the past year by the senior author (W.K.S.) for the resection of calcaneal spurs.

Estimating near-infrared leaf reflectance from leaf structural characteristics.

The relationship between near-infrared reflectance at 800 nm (NIRR) from leaves and characteristics of leaf structure known to affect photosynthesis was investigated in 48 species of alpine angiosperms. This wavelength was selected to discriminate the effects of leaf structure vs. chemical or water content on leaf reflectance. A quantitative model was first constructed correlating NIRR with leaf structural characteristics for six species, and then validated using all 48 species. Among the structural characteristics tested in the reflectance model were leaf trichome density, the presence or absence of both leaf bicoloration and a thick leaf cuticle (>1 µm), leaf thickness, the ratio of palisade mesophyll to spongy mesophyll thickness (PM/SM), the proportion of the mesophyll occupied by intercellular air spaces (%IAS), and the ratio of mesophyll cell surface area exposed to IAS (A(mes)) per unit leaf surface area (A), or A(mes)/A. Multiple regression analysis showed that measured NIRR was highly correlated with A(mes)/A, leaf bicoloration, and the presence of a thick leaf cuticle (r = 0.93). In contrast, correlations between NIRR and leaf trichome density, leaf thickness, the PM/SM ratio, or %IAS were relatively weak (r < 0.25). A model incorporating A(mes)/A, leaf bicoloration, and cuticle thickness predicted NIRR accurately for 48 species (r = 0.43; P < 0.01) and may be useful for linking remotely sensed data to plant structure and function.

Leptin and maternal growth during adolescent pregnancy.

BACKGROUND: Maternal growth on the basis of knee height occurs in nearly 50% of pregnant teenagers and is associated with greater gestational weight gain and accrual of subcutaneous fat in the mother but lower fetal growth compared with nongrowing teenagers and mature pregnant women. OBJECTIVE: The objective of this study was to determine whether leptin is a biomarker for continued maternal growth. DESIGN: Leptin concentrations were measured in 162 growing and nongrowing teenage gravidas (aged 5-fold, fetal growth restriction increased >6-fold, and infant birth weight decreased by approximately 200 g. Gravidas who developed pregnancy-induced hypertension showed a different pattern-higher leptin concentrations at entry and week 28, no difference in the leptin surge, and no postpartum difference in leptin concentration. CONCLUSION: A leptin surge by week 28 appears to mark reduced mobilization of maternal fat stores that is associated with maternal growth on the basis of knee height during adolescent pregnancy.

Assessment of hearing in persons with learning disabilities: the Phoenix NHS Trust, January 1997 to September 1998.

People with learning disabilities are at increased risk of impaired hearing. The aims of this study were to assess the prevalence of hearing impairment and ear disease in people attending the specialist Otolaryngology/Hearing Therapy clinic at the Phoenix NHS Trust, Bristol. The present and future process of such a service was explored. Data were obtained from the referral form and notes made by the consultant otolaryngologist. In 20 months, there were 226 consultations, 188 of which were new referrals. The majority of patients had verbal communication to some extent. Suspected infection/inflammation and unobtainable/abnormal tympanograms, each accounted for 43 per cent of reasons for referral. Twenty per cent of patients were normal otologically. Eighteen per cent were provided with hearing aids and nine per cent required surgery. Ten patients underwent brainstem evoked response testing, half of whom had aidable hearing. Our results are comparable to published data of similar units. It is recommended that combined otolaryngology/specialist hearing therapy services are continued and further developed.

Lymphoedema and hand surgery.

We report the case of a woman with a previous history of breast carcinoma, treated with a left radical mastectomy and axillary clearance, who developed lymphoedema in the left arm following a carpal tunnel decompression complicated by a superficial wound infection.

Interrelationships among light, photosynthesis and nitrogen in the crown of mature Pinus contorta ssp. latifolia.

Scaling leaf-level measurements to estimate carbon gain of entire leaf crowns or canopies requires an understanding of the distribution of photosynthetic capacity and corresponding light microenvironments within a crown. We have compared changes in the photosynthetic light response and nitrogen (N) content (per unit leaf area) of Pinus contorta Dougl. ssp. latifolia Engelm. (lodgepole pine) leaves in relation to their age and light microenvironment. The vertical gradient in integrated daily photosynthetic photon flux density (PPFD) from the upper to the lower crown of lodgepole pine was similar in magnitude to the horizontal gradient in daily PPFD along shoots from young to old leaves. The relationship between light-saturated net photosynthesis (A(max)) and daily PPFD was significant for both young and old leaves. However, old leaves had a lower A(max) than young leaves in a similar daily irradiance regime. For leaves of all ages from throughout the crown, A(max) was linearly related to the estimated daily net carbon gain that leaves could achieve in their natural PPFD environment (estimated A(day)) (r(2) = 0.84, P < 0.001, n = 39), indicating that estimated A(day) may be dominated by carbon fixed when leaves are light-saturated and operating at A(max). Comparison of the PPFD required to achieve A(max) and the PPFD available to the leaves showed that all of the measured leaves (n = 39), regardless of their position in the crown or age, were in light environments that could light-saturate photosynthesis for a similar proportion of the day. For all data pooled, foliar N was weakly correlated with daily PPFD. Analyzing each leaf age class separately showed that foliar N was significantly related to daily PPFD, A(max), and estimated A(day) for the youngest leaves but not for middle-aged or old leaves. Therefore, the general theory that foliar N is allocated within a crown according to total daily light availability was supported only for young (1-4 years old) leaves in this study.

Ontogenetic differences in mesophyll structure and chlorophyll distribution in Eucalyptus globulus ssp. globulus.

Mesophyll structure has been associated with the photosynthetic performance of leaves via the regulation of internal light and CO(2) profiles. Differences in mesophyll structure and chlorophyll distribution within three ontogenetically different leaf types of Eucalyptus globulus ssp. globulus were investigated. Juvenile leaves are blue-grey in color, dorsiventral (adaxial palisade layer only), hypostomatous, and approximately horizontal in orientation. In contrast, adult leaves are dark green in color, isobilateral (adaxial and abaxial palisade), amphistomatous, and nearly vertical in orientation. The transitional leaf type has structural features that appear intermediate between the juvenile and adult leaves. The ratio of mesophyll cell surface area per unit leaf surface area (A(mes)/A) of juvenile leaves was maximum at the base of a single, adaxial palisade layer and declined through the spongy mesophyll. Chlorophyll a + b content showed a coincident pattern, while the chlorophyll a:b ratio declined linearly from the adaxial to abaxial epidermis. In comparison, the mesophyll of adult leaves had a bimodal distribution of A(mes)/A, with maxima occurring beneath both the adaxial and abaxial surfaces within the first layer of multiple palisade layers. The distribution of chlorophyll a + b content had a similar pattern, although the maximum ratio of chlorophyll a:b occurred immediately beneath the adaxial and abaxial epidermis. The matching distributions of A(mes)/A and chlorophyll provide further evidence that mesophyll structure may act to influence photosynthetic performance. These changes in internal leaf structure at different life stages of E. globulus may be an adaptation for increased xeromorphy under increasing light exposure experienced from the seedling to adult tree, similar to the characteristics reported for different species according to sunlight exposure and water availability within their native habitats.