Trace elements and heavy metals in black vultures (Coragyps atratus) and turkey vultures (Cathartes aura) in the southeastern United States.

Many vulture species worldwide are declining at alarming rates due to a variety of anthropogenic causes, including exposure to pollutants and pharmaceuticals through consumption of contaminated carrion. However, little is known about the extent to which vultures are exposed to various contaminants as well as toxicity thresholds for trace elements and heavy metals. Our objective was to quantify levels of trace elements and heavy metals within black vulture (Coragyps atratus) and turkey vulture (Cathartes aura) tissues to determine the extent to which populations in the Southeastern United States are exposed to carrion that contains high levels of contaminants. We collected 34 black vulture liver samples and examined differences in trace element and heavy metal concentrations between sexes and age classes (adult and juvenile). Further, we collected 81 blood and 42 feather samples from additional black and turkey vultures and compared differences between species and age classes. We found similar element concentrations between juvenile and adult black vultures with the exception of Cu, where levels were higher in juveniles compared to adults. However, we did observe substantial differences in element concentrations between species for both blood and feather samples, with black vultures generally having higher concentrations of most elements. Our data revealed higher element levels in both species compared to toxicity thresholds found in other bird of prey species, such as blood and liver toxicity threshold suggestions for Pb poisoning in Falconiformes. Further, while average contaminant levels were generally low, extreme outliers were observed for some elements, including Pb, suggesting some individuals were exposed to high levels of potentially toxic elements. More research is needed to better understand contaminant exposure in black and turkey vultures across a broader geographic region, as well as elucidate toxicity thresholds and non-lethal impacts of contaminant exposure in these species.

The genome sequence of the White-barred Gold, Micropterix aruncella (Scopoli, 1763).

We present a genome assembly from an individual female Micropterix aruncella (the White-barred Gold; Arthropoda, Insecta, Lepidoptera; Micropterigidae). The genome sequence is 1,079 megabases in span. Most of the assembly is scaffolded into 31 chromosomal pseudomolecules, including the assembled Z sex chromosome. The mitochondrial genome has also been assembled and is 15.0 kilobases in length.

Web-Based Yoga-Pilates: A Prospective Cohort Study.

IMPORTANCE: There are limited data to determine the change in severity, efficacy, and mechanism of action of yoga-Pilates in the treatment of stress urinary incontinence (SUI). OBJECTIVES: The primary objective was to evaluate the effect of an 8-week web-based home yoga-Pilates exercise program on SUI severity and to evaluate the potential mechanism of action through ultrasound examination of the urethral rhabdosphincter cross-sectional area. STUDY DESIGN: This was a prospective cohort study of women with SUI. Participants underwent visits pre- and post-intervention, completed quality of life/severity surveys, and underwent pelvic examination and 3-dimensional transperineal ultrasonography to determine the urethral cross-sectional area. Pre- and post-intervention 24-hour voiding diaries were also collected. The intervention was an 8-week online yoga-Pilates video that tracked and prompted participation. RESULTS: Sixty women completed the study; they were predominantly premenopausal (67%) and vaginally parous (65%) and had done yoga (76%) and/or Pilates (44%). Seventy-three percent performed the exercises ≥3 times per week. For the primary outcome, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score improved from 9.5 (95% confidence interval [CI], 8.7-10.4) to 7.1 (95% CI, 6.3-7.9) (P < 0.001). The median (interquartile range) number of incontinence episodes per 24 hours decreased from 1 (1-3) to 1 (0-1) (P < 0.001). The Brink pelvic floor strength score improved from 7.1 (95% CI, 6.6-7.7) to 7.7 (95% CI, 7.2-8.2) (P = 0.01). Eighty-three percent reported that they were "better" on Patient Global impression of Improvement. There were no significant changes in urethral measurements. CONCLUSIONS: Although it did not meet the minimal clinically important difference, this 8-week web-based yoga-Pilates exercise program improved SUI symptoms and decreased the number of incontinence episodes in women with SUI.

Integrating data types to estimate spatial patterns of avian migration across the Western Hemisphere.

For many avian species, spatial migration patterns remain largely undescribed, especially across hemispheric extents. Recent advancements in tracking technologies and high-resolution species distribution models (i.e., eBird Status and Trends products) provide new insights into migratory bird movements and offer a promising opportunity for integrating independent data sources to describe avian migration. Here, we present a three-stage modeling framework for estimating spatial patterns of avian migration. First, we integrate tracking and band re-encounter data to quantify migratory connectivity, defined as the relative proportions of individuals migrating between breeding and nonbreeding regions. Next, we use estimated connectivity proportions along with eBird occurrence probabilities to produce probabilistic least-cost path (LCP) indices. In a final step, we use generalized additive mixed models (GAMMs) both to evaluate the ability of LCP indices to accurately predict (i.e., as a covariate) observed locations derived from tracking and band re-encounter data sets versus pseudo-absence locations during migratory periods and to create a fully integrated (i.e., eBird occurrence, LCP, and tracking/band re-encounter data) spatial prediction index for mapping species-specific seasonal migrations. To illustrate this approach, we apply this framework to describe seasonal migrations of 12 bird species across the Western Hemisphere during pre- and postbreeding migratory periods (i.e., spring and fall, respectively). We found that including LCP indices with eBird occurrence in GAMMs generally improved the ability to accurately predict observed migratory locations compared to models with eBird occurrence alone. Using three performance metrics, the eBird + LCP model demonstrated equivalent or superior fit relative to the eBird-only model for 22 of 24 species-season GAMMs. In particular, the integrated index filled in spatial gaps for species with over-water movements and those that migrated over land where there were few eBird sightings and, thus, low predictive ability of eBird occurrence probabilities (e.g., Amazonian rainforest in South America). This methodology of combining individual-based seasonal movement data with temporally dynamic species distribution models provides a comprehensive approach to integrating multiple data types to describe broad-scale spatial patterns of animal movement. Further development and customization of this approach will continue to advance knowledge about the full annual cycle and conservation of migratory birds.

Levator-Urethra Gap: Normative Data in a Nonpregnant Nulliparous Population.

OBJECTIVE: This study aimed to establish a normative range of the levator-urethra gap (LUG) measurement in nonpregnant, nulliparous women to be used as a standard against which assessments of injury or avulsion of the levator ani could be made. METHODS: Nulliparous women in the Pacific Northwest who were planning pregnancy within the ensuing 12 months underwent high-resolution magnetic resonance imaging (MRI) and 3-dimensional transperineal ultrasonography. In the plane of minimal hiatal dimensions, the LUG was measured on both the right and left sides for 3 contiguous image slices. RESULTS: One hundred thirty-five participants underwent examinations, of which 134 had evaluable MRIs and 70 had evaluable ultrasounds. Mean (SD) age was 30.8 (4.0) years, and mean (SD) body mass index was 25.9 (6.4). The majority of the participants self-identified as White (80%) and non-Hispanic (89%). The 99th percentile was no greater than 2.39 cm on any slice for either MRI or US-based measurements. In the MRI set, the lowest LUG values at which all 3 measurements on a side were found to have exceeded a putative threshold value (for injury) were 2.1 cm for the right side and 2.05 cm for the left side. The corresponding LUG values in the ultrasound set were 2.2 cm on the right and 2.25 cm on the left. CONCLUSIONS: The LUG threshold in 3 successive slices in the minimal hiatal dimension suggestive of levator ani injury could be as low as 2.1 cm when using MRI and 2.25 cm when using ultrasound in a similar population.

Forming Consensus To Advance Urobiome Research.

Urobiome research has the potential to advance the understanding of a wide range of diseases, including lower urinary tract symptoms and kidney disease. Many scientific areas have benefited from early research method consensus to facilitate the greater, common good. This consensus document, developed by a group of expert investigators currently engaged in urobiome research (UROBIOME 2020 conference participants), aims to promote standardization and advances in this field by the adoption of common core research practices. We propose a standardized nomenclature as well as considerations for specimen collection, preservation, storage, and processing. Best practices for urobiome study design include our proposal for standard metadata elements as part of core metadata collection. Although it is impractical to follow fixed analytical procedures when analyzing urobiome data, we propose guidelines to document and report data originating from urobiome studies. We offer this first consensus document with every expectation of subsequent revision as our field progresses.

Changes in Morphology of the Urethral Rhabdosphincter Postpartum.

OBJECTIVE: The aim of the study was to determine the effect of pregnancy on urethral rhabdosphincter cross-sectional area (CSA) and any association of CSA to urinary symptoms. METHODS: Nulliparous women planning pregnancy (N = 135) underwent standardized evaluations (symptom and quality of life [QOL] questionnaires, magnetic resonance imaging, ultrasonography, and neurophysiologic testing) between January 2008 and December 2013 (V1). The participants who became pregnant and gave birth underwent the same evaluations at 6 weeks (V2) and 6 months postpartum (V3). Participants who had magnetic resonance imaging data from both V1 and V3 were selected. We measured urethral rhabdosphincter CSA from high-resolution axial MRIs in a masked fashion. The mean CSA for each participant was calculated. The change from V1 to V3 was assessed. RESULTS: Sixty-eight women were evaluated. There was a significant decrease of 0.05 cm2 (interquartile range, -0.03 to 0.16 cm2; P = 0.002) in the median sphincter CSA between V1 and V3. There was a significant increase in the median Urinary Distress Inventory (UDI) subscore of the Pelvic Floor Distress Inventory (PFDI) from V1 to V3 (median increase of 0 [IQR, 0 to 8.3]; P = 0.033), but this was not significantly correlated with the change in the urethral CSA (Spearman correlation, 0.199; P = 0.107). Increasing fetal weight was correlated with a decrease in CSA postpartum after vaginal birth (Spearman correlation, -0.340; P = 0.017). CONCLUSIONS: There is a decrease in urethral rhabdosphincter CSA with worsening Urinary Distress Inventory scores from prepregnancy to postpartum, but these two do not correlate in this cohort with low symptom levels. Among women who give birth vaginally, decrease in rhabdosphincter CSA is correlated with increasing fetal weight, perhaps with ramifications to be seen later in life.

Evidence of niche differentiation for two sympatric vulture species in the Southeastern United States.

BACKGROUND: As obligate scavengers utilizing similar habitats, interspecific competition undoubtedly occurs between resident black (Coragyps atratus) and turkey (Cathartes aura) vultures. In the interest of exploring how sympatric species coexist through habitat segregation, we examined resource selection of resident black and turkey vultures in the southeastern United States (US) for evidence of niche differentiation. METHODS: Using fine-scale movement data, we assessed interspecific seasonal differences in monthly roost reuse frequency and roost site fidelity, as well as monthly flight, roost, and diurnal rest site resource selection based on > 2.8 million locations of 9 black vultures and 9 turkey vultures tracked from September 2013 to August 2015 using Groupe Spécial Mobile/Global Positioning System (GSM/GPS) transmitters. RESULTS: Black vultures generally exhibited greater roost fidelity as well as a greater maximum number of nights spent at a single roost than turkey vultures. Patterns of flight, roost, and resting habitat selection within the home range varied monthly as well as between species, providing evidence for habitat segregation and niche differentiation by sympatric vultures. In particular, our results indicate the importance of wooded wetlands for resting and roosting locations for both species, and revealed clear differences in the use of forested habitats between species during flight, resting, and roosting behavioral states. CONCLUSIONS: By examining differences in resource selection and spatial ecology of black and turkey vultures across a range of behaviors, this study demonstrates mechanisms of niche differentiation in these ecologically similar species, and enhances potential for conservation and informed management of this important group of birds.

What helps children learn difficult tasks: A teacher's presence may be worth more than a screen.

AIMS: What helps children learn: is it a presence of a live teacher or an interaction with the learning materials? Addressing this question, we manipulated a teacher's presence (on-screen vs. present) and activity (observing vs. doing) while teaching children about the properties of geometric shapes. METHOD: Five-year-olds (n = 215) completed two shape-sorting tasks in which they distinguished between typical, atypical and non-valid shapes. In between these tasks, they took part in one of four training sessions: doing teacher-present, observing teacher-present, doing teacher-on-screen and observing teacher-on-screen. RESULTS: Although children's shape knowledge improved across all training conditions, learning showed an interaction between teacher presence and task difficulty. In a teacher's presence, children learned more about the most difficult (atypical) shapes, irrespective of activity. It may be the social interaction, associated with a teacher's presence, that enhances learning. Conversely, physically taking part in interactive touchscreen training did not result in more learning than passive screen viewing.

Nrf2 regulates CD4+ T cell-induced acute graft-versus-host disease in mice.

Nuclear factor erythroid-derived 2-like 2 (Nrf2) is a ubiquitously expressed transcription factor that is well known for its role in regulating the cellular redox pathway. Although there is mounting evidence suggesting a critical role for Nrf2 in hematopoietic stem cells and innate leukocytes, little is known about its involvement in T-cell biology. In this study, we identified a novel role for Nrf2 in regulating alloreactive T-cell function during allogeneic hematopoietic cell transplantation (allo-HCT). We observed increased expression and nuclear translocation of Nrf2 upon T-cell activation in vitro, especially in CD4+ donor T cells after allo-HCT. Allo-HCT recipients of Nrf2 -/- donor T cells had significantly less acute graft-versus-host disease (GVHD)-induced mortality, morbidity, and pathology. This reduction in GVHD was associated with the persistence of Helios+ donor regulatory T cells in the allograft, as well as defective upregulation of the gut-homing receptor LPAM-1 on alloreactive CD8+ T cells. Additionally, Nrf2 -/- donor CD8+ T cells demonstrated intact cytotoxicity against allogeneic target cells. Tumor-bearing allo-HCT recipients of Nrf2 -/- donor T cells had overall improved survival as a result of preserved graft-versus-tumor activity and reduced GVHD activity. Our findings characterized a previously unrecognized role for Nrf2 in T-cell function, as well as revealed a novel therapeutic target to improve the outcomes of allo-HCT.

Preschoolers fast map and retain artifact functions as efficiently as artifact names, but artifact actions are the most easily learned.

To become skilled artifact users, children must learn the actions and functions associated with artifacts. We investigated preschoolers' ability to fast map an action, function and name associated with a novel artifact, and retain the new mapping long term following brief incidental exposure to the artifact being used. In Experiment 1, 3- and 5-year-olds (N = 144) were tested 1 week after two exposures to a novel action, function, and name. Participants performed well on comprehension tests of all three kinds of information. In Experiment 2, 3-year-olds (N = 100) were exposed to these three kinds of information only once. Retention of the action-artifact link was above chance levels, whereas retention of function and the name was not. Finally, in Experiment 3, 4-year-olds (N = 128) performed well on an action production task 1 week after brief exposure. In contrast, their performance on a name production task immediately after exposure was poor. Our data suggest that preschoolers can retain function information about a novel artifact from minimal exposure, similar to their ability to learn an artifact name. Crucially, their ability to remember action-artifact mappings is markedly better than their ability to remember functions and names.

Parasitaemia data and molecular characterization of Haemoproteus catharti from New World vultures (Cathartidae) reveals a novel clade of Haemosporida.

BACKGROUND: New World vultures (Cathartiformes: Cathartidae) are obligate scavengers comprised of seven species in five genera throughout the Americas. Of these, turkey vultures (Cathartes aura) and black vultures (Coragyps atratus) are the most widespread and, although ecologically similar, have evolved differences in morphology, physiology, and behaviour. Three species of haemosporidians have been reported in New World vultures to date: Haemoproteus catharti, Leucocytozoon toddi and Plasmodium elongatum, although few studies have investigated haemosporidian parasites in this important group of species. In this study, morphological and molecular methods were used to investigate the epidemiology and molecular biology of haemosporidian parasites of New World vultures in North America. METHODS: Blood and/or tissue samples were obtained from 162 turkey vultures and 95 black vultures in six states of the USA. Parasites were identified based on their morphology in blood smears, and sequences of the mitochondrial cytochrome b and nuclear adenylosuccinate lyase genes were obtained for molecular characterization. RESULTS: No parasites were detected in black vultures, whereas 24% of turkey vultures across all sampling locations were positive for H. catharti by blood smear analysis and/or PCR testing. The phylogenetic analysis of cytochrome b gene sequences revealed that H. catharti is closely related to MYCAMH1, a yet unidentified haemosporidian from wood storks (Mycteria americana) in southeastern USA and northern Brazil. Haemoproteus catharti and MYCAMH1 represent a clade that is unmistakably separate from all other Haemoproteus spp., being most closely related to Haemocystidium spp. from reptiles and to Plasmodium spp. from birds and reptiles. CONCLUSIONS: Haemoproteus catharti is a widely-distributed parasite of turkey vultures in North America that is evolutionarily distinct from other haemosporidian parasites. These results reveal that the genetic diversity and evolutionary relationships of avian haemosporidians are still being uncovered, and future studies combining a comprehensive evaluation of morphological and life cycle characteristics with the analysis of multiple nuclear and mitochondrial genes will be useful to redefine the genus boundaries of these parasites and to re-evaluate the relationships amongst haemosporidians of birds, reptiles and mammals.

Comparing 3-Dimensional Ultrasound to 3-Dimensional Magnetic Resonance Imaging in the Detection of Levator Ani Defects.

OBJECTIVE: The aim of this study was to compare the detection of levator ani defects (LAD) between 3-dimensional (3D) ultrasound (US) and 3D magnetic resonance imaging (MRI). METHODS: This is a secondary analysis of the Pelvic Floor Nerve Injury Following Childbirth Study. Nulliparous women underwent a standardized protocol of pelvic floor evaluations between January 2008 and December 2013, prior to pregnancy (V1) and at 2 points postpartum: 6 weeks (V2) and 6 months (V3). Those women who underwent a high-resolution 3D MRI pelvic floor sequence were selected. Comparisons were made to concomitantly acquired 3D perineal US. Eight tomographic slices were examined in the axial plane, each side independently scored with 0 (no defect) or 1 (defect). A similar tomographic approach was applied to the MRI. For both MRI and US, the right and left sides were each scored. A total score of 0 to 8 was given to each side. A dichotomous variable "complete LAD" was defined. Cohen κ was used as a measurement of agreement of complete LAD between MRI and US. Kendall τ b was used to correlate total scores. RESULTS: On the right side, 80 (90%) of 89 pairs were in agreement (concordant in the diagnosis or not of a "defect"). On the left side, 72 (81%) of 89 pairs were in agreement. Correlations (Cohen κ) of complete LAD were 0.65 (P < 0.001) on the right and 0.37 (P < 0.001) on the left. Correlations of total scores were 0.47 (P < 0.001) on the right and 0.41 (P < 0.001) on the left. CONCLUSIONS: Moderate agreement was found between 3D US and 3D MRI LAD detection. More LADs and discordance were seen on the left.

Fine-scale assessment of home ranges and activity patterns for resident black vultures (Coragyps atratus) and turkey vultures (Cathartes aura).

Knowledge of black vulture (Coragyps atratus) and turkey vulture (Cathartes aura) spatial ecology is surprisingly limited despite their vital ecological roles. Fine-scale assessments of space use patterns and resource selection are particularly lacking, although development of tracking technologies has allowed data collection at finer temporal and spatial resolution. Objectives of this study were to conduct the first assessment of monthly home range and core area sizes of resident black and turkey vultures with consideration to sex, as well as elucidate differences in monthly, seasonal, and annual activity patterns based on fine-scale movement data analyses. We collected 2.8-million locations for 9 black and 9 turkey vultures from June 2013 -August 2015 using solar-powered GSM/GPS transmitters. We quantified home ranges and core areas using the dynamic Brownian bridge movement model and evaluated differences as a function of species, sex, and month. Mean monthly home ranges for turkey vultures were ~50% larger than those of black vultures, although mean core area sizes did not differ between species. Turkey vulture home ranges varied little across months, with exception to a notable reduction in space-use in May, which corresponds with timing of chick-rearing activities. Black vulture home ranges and core areas as well as turkey vulture core areas were larger in breeding season months (January-April). Comparison of space use between male and female vultures was only possible for black vultures, and space use was only slightly larger for females during breeding months (February-May). Analysis of activity patterns revealed turkey vultures spend more time in flight and switch motion states (between flight and stationary) more frequently than black vultures across temporal scales. This study reveals substantive variability in space use and activity rates between sympatric black and turkey vultures, providing insights into potential behavioral mechanisms contributing to niche differentiation between these species.

A type 2 cytokine axis for thymus emigration.

In the thymus, stromal microenvironments support a developmental program that generates mature T cells ready for thymic exit. The cellular and molecular specialization within thymic stromal cells that enables their regulation of specific stages of thymocyte development is poorly understood. Here, we show the thymic microenvironment expresses the type 2 IL-4R complex and is functionally responsive to its known ligands, IL-4 and IL-13. Absence of IL-4Rα limits thymocyte emigration, leading to an intrathymic accumulation of mature thymocytes within medullary perivascular spaces and reduced numbers of recent thymic emigrants. Thymus transplantation shows this requirement maps to IL-4Rα expression by stromal cells, and we provide evidence that it regulates thymic exit via a process distinct from S1P-mediated migration. Finally, we reveal a cellular mechanism by which IL-4+IL-13+ invariant NKT cells are necessary for IL-4Rα signaling that regulates thymic exit. Collectively, we define a new axis for thymic emigration involving stimulation of the thymic microenvironment via type 2 cytokines from innate T cells.

Iron pyrrole-based PNP pincer ligand complexes as catalyst precursors.

The structure of a pincer ligand consists of a backbone and two `arms' which typically contain a P or N atom. They are tridentate ligands that coordinate to a metal center in a meridional configuration. A series of three iron complexes containing the pyrrole-based PNP pincer ligand 2,5-bis[(diisopropylphosphanyl)methyl]pyrrolide (PNpyrP) has been synthesized. These complexes are possible precursors to new iron catalysts. {2,5-Bis[(diisopropylphosphanyl)methyl]pyrrolido-κ3P,N,P'}carbonylchlorido(trimethylphosphane-κP)iron(II), [Fe(C18H34NP2)Cl(C3H9P)(CO)] or [Fe(PNpyrP)Cl(PMe3)(CO)], (I), has a slightly distorted octahedral geometry, with the Cl and CO ligands occupying the apical positions. {2,5-Bis[(diisopropylphosphanyl)methyl]pyrrolido-κ3P,N,P'}chlorido(pyridine-κN)iron(II), [Fe(C18H34NP2)Cl(C5H5N)] or [Fe(PNpyrP)Cl(py)] (py is pyridine), (II), is a five-coordinate square-pyramidal complex, with the pyridine ligand in the apical position. {2,5-Bis[(diisopropylphosphanyl)methyl]pyrrolido-κ3P,N,P'}dicarbonylchloridoiron(II), [Fe(C18H34NP2)Cl(CO)2] or [Fe(PNpyrP)Cl(CO)2], (III), is structurally similar to (I), but with the PMe3 ligand replaced by a second carbonyl ligand from the reaction of (II) with CO. The two carbonyl ligands are in a cis configuration, and there is positional disorder of the chloride and trans carbonyl ligands.

Get Your Facts Right: Preschoolers Systematically Extend Both Object Names and Category-Relevant Facts.

There is an ongoing debate over the extent to which language development shares common processing mechanisms with other domains of learning. It is well-established that toddlers will systematically extend object labels to similarly shaped category exemplars (e.g., Markman and Hutchinson, 1984; Landau et al., 1988). However, previous research is inconclusive as to whether young children will similarly extend factual information about an object to other category members. We explicitly contrast facts varying in category relevance, and test for extension using two different tasks. Three- to four-year-olds (N = 61) were provided with one of three types of information about a single novel object: a category-relevant fact ('it's from a place called Modi'), a category-irrelevant fact ('my uncle gave it to me'), or an object label ('it's called a Modi'). At test, children provided with the object name or category-relevant fact were significantly more likely to display systematic category extension than children who learnt the category-irrelevant fact. Our findings contribute to a growing body of evidence that the mechanisms responsible for word learning may be domain-general in nature.

Flying Start health visitors' views of implementing the Newborn Behavioural Observation: barriers and facilitating factors.

Investment in early intervention by health visitors to support positive parent-infant relationships is a Welsh Government target. An initiative called 'Flying Start' (FS) employs health visitors to undertake intensive home visiting with families who have a new baby to promote positive family interactions. As part of this role FS health visitors utilise the Newborn Behavioural Observation (NBO) system to observe, assess, support and enhance relationships between parent(s) and child. A project was undertaken to evaluate implementation and make recommendations for future service improvement. This paper describes stage one of the project which set out to evaluate FS health visitors' views of NBO implementation by means of a questionnaire and identifies barriers and facilitating factors to its use. Stage 2 of the project was to identify how NBO use could be improved in health visiting practice, discussed in a further paper. Results revealed a majority of practitioners felt NBO implementation benefited parents and enhanced the parent-infant relationship. It was viewed as an important part of the FS health visitors' role. Barriers included lack of time coupled with chaotic home environments. Variations in practice were identified, contrary to local guidelines. Recommendations are made to enhance NBO implementation that include the development of an NBO champion to support practitioners and provide further training.