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Targeted threatened species management is a central component of efforts to prevent species extinction. Despite the development of a range of management frameworks to improve conservation outcomes over the past decade, threatened species management is still commonly characterised as ad hoc. Although there are notable successes, many management programs are ineffective, with relatively few species experiencing improvements in their conservation status. We identify underlying factors that commonly lead to ineffective and inefficient management. Drawing attention to some of the key challenges, and suggesting ways forward, may lead to improved management effectiveness and better conservation outcomes. We highlight six key areas where improvements are needed: 1) stakeholder engagement and communication; 2) fostering strong leadership and the development of achievable long-term goals; 3) knowledge of target species' biology and threats, particularly focusing on filling knowledge gaps that impede management, while noting that in many cases there will be a need for conservation management to proceed initially despite knowledge gaps; 4) setting objectives with measurable outcomes; 5) strategic monitoring to evaluate management effectiveness; and 6) greater accountability for species declines and failure to recover species to ensure timely action and guard against complacency. We demonstrate the importance of these six key areas by providing examples of innovative approaches leading to successful species management. We also discuss overarching factors outside the realm of management influence that can help or impede conservation success. Clear recognition of factors that make species' management more straightforward - or more challenging - is important for setting realistic management objectives, outlining strategic action, and prioritising resources. We also highlight the need to more clearly demonstrate the benefit of current investment, and communicate that the risk of under-investment is species extinctions. Together, improvements in conservation practice, along with increased resource allocation and re-evaluation of the prioritisation of competing interests that threaten species, will help enhance conservation outcomes for threatened species.

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Visualisation of periacetabular osteolysis by standard anteroposterior (AP) radiographs underestimates the extent of bone loss around a metal-backed acetabular component. We have assessed the effectiveness of standard radiological views in depicting periacetabular osteolysis, and recommend additional projections which make these lesions more visible. This was accomplished using a computerised simulation of radiological views and a radiological analysis of simulated defects placed at regular intervals around the perimeter of a cadaver acetabulum. The AP view alone showed only 38% of the defects over all of the surface of the cup and failed to depict a 3 mm lesion over 83% of the cup. When combined with the AP view, additional 45 degree obturator-oblique and iliac-oblique projections increased the depiction, showing 81% of the defects. The addition of the 60 degree obturator-oblique view further improved the visualisation of posterior defects, increasing the rate of detection to 94%. Based on this analysis, we recommend using at least three radiographic views when assessing the presence and extent of acetabular osteolysis.

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OBJECTIVE: To compare a clinical nurse specialist/neonatal practitioner (CNS/NP) team with a pediatric resident team in the delivery of neonatal intensive care. DESIGN: Randomized, controlled trial. SETTING: A 33-bed tertiary-level neonatal intensive care unit. PATIENTS: Of 821 infants admitted to the neonatal intensive care unit between September 1991 and September 1992, 414 were randomized to care by the CNS/NP team, and 407 were randomized to care by the pediatric resident team. INTERVENTION: Infants assigned to the CNS/NPs team were cared for by CNS/NPs during the day and by pediatric residents during the night. Infants assigned to the pediatric resident team were cared for by pediatric residents around the clock. Neonatologists supervised both teams. MEASURES: Outcome measures included mortality; number of neonatal complications; length of stay; quality of care, as assessed by a quantitative indicator condition approach; parent satisfaction with care, measured using the Neonatal Index of Parent Satisfaction; long-term outcomes, measured using the Minnesota Infant Development Inventory; and costs. RESULTS: There were 19 (4.6%) deaths in the CNS/NP group and 24 (5.9%) in the resident group (relative risk [RR], 0.78; confidence interval [CI], 0.43 to 1.40). In the CNS/NP group, 230 (55.6%) neonates had complications, in comparison with 220 (54.1%) in the resident group (RR, 1.03; CI 0.91 to 1.16). Mean lengths of stay were 12.5 days in the CNS/NP group and 11.7 days in the resident group (difference in means, 0.8 days; CI, -1.1 to 2.7). The performance on the indicator conditions was comparable in the two groups except for two instances, jaundice and charting, both of which favored the CNS/NP group. Mean scores on the Neonatal Index of Parent Satisfaction were 140 in the CNS/NP group and 139 in the resident group (difference in means, 1.0; CI, -3.6 to 5.6). In the CNS/NP group, 6 (2.6%) infants performed 30% or more below their age level in the Minnesota Infant Development Inventory, in comparison with 2 (0.9%) in the resident group (RR, 2.87; CI, 0.59 to 14.06) The cost per infant in the CNS/NP group was $14,245 and in the resident group $13,267 (difference in means, $978; CI, -1303.18 to 3259.05). CONCLUSIONS: CNS/NP and resident teams are similar with respect to all tested measures of performance. These results support the use of CNS/NPs as an alternative to pediatric residents in delivering care to critically ill neonates.

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In an age of cost containment, agency partnerships have become an essential element for future planning and program implementation. This paper describes a trisectoral collaboration of a hospital, health department, university and school of nursing to compare the efficacy and efficiency of referral decisions of hospital staff nurses to those of the public health liaison nurses (LNs). A process to identify decision criteria was undertaken and an educational programme was designed to assist the staff nurses with the referral process and to assure consistency of decision making. The two groups were then compared. The results of the study found staff nurses, using the decision criteria, identified more patients who required public health nursing visits than did the liaison nurses, refusal rate of the patients to participate was no different, staff nurses cost less than LNs and job satisfaction was not significantly altered for either group. In addition to providing information to guide administrative and clinical decision making, the project also provided a learning experience for the staff of three agencies in conducting research and in using evidence-based practice to change traditional practice.

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The objective of this study was to develop a valid and reliable discriminative index that measures parent satisfaction with the medical care of their infant in the NICU. We developed an initial questionnaire (Item Reduction Questionnaire) by reviewing the literature, surveying 63 NICU clinicians, and interviewing 125 parents of infants in 2 tertiary level NICUs regarding what they liked and disliked about the medical care of their infants. We administered the Item Reduction Questionnaire, which included 154 items, to 60 parents, who rated the frequency and importance of these items. We included the items identified most frequently as sources of dissatisfaction and rated most important in a second, briefer instrument, the Neonatal Index of Parent Satisfaction (NIPS). To measure reliability we administered the NIPS to 47 parents twice, separated by a 1-week interval. We assessed validity by comparing actual to predicted correlations between NIPS scores and other measures: parent's global rating of satisfaction, medical caregiver ratings of mother's satisfaction, medical caregiver ratings of father's satisfaction, and parents' perception of their infant's health status. We also compared mean NIPS scores for parents who did and who did not report incidents when errors occurred in the medical care of the infant. Of 154 items generated, we included 27 in the NIPS. The intraclass correlation between two administrations of the NIPS to the same 47 parents was 0.71. As predicted, there was a high correlation (0.61) between the NIPS score and parent global rating of satisfaction, and much lower correlations with other variables. Mean NIPS scores for parents who did and who did not report errors differed significantly (difference, 14.6; 95% CI around difference, 5.8-23.5; p < 0.001). The NIPS is likely to be a useful measure for discriminating between parents who differ in terms of their satisfaction with the medical care of their infant in the NICU.

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OBJECTIVE: Our purpose was to examine the reproducibility of intertwin membrane thickness measurements used to predict chorionicity in twin pregnancies. STUDY DESIGN: Twenty-seven twin pregnancies were scanned with high-resolution ultrasonography on 52 occasions during the second and third trimesters. Two observers, blind to other criteria of chorionicity, measured the dividing membrane twice in five different sites (total measurements 1040). The data were log-transformed and the coefficient of repeatability calculated as a measure of intraobserver variability. Interobserver variability was estimated by the Bland and Altman 95% limits of agreement. Random variation was assessed with the restricted maximum likelihood procedure in Genstat. RESULTS: The overall estimate of the coefficient of repeatability was 2.14, indicating that 95% of repeated measurements would be expected to be within 114% of each other. Measurements taken close to the placenta (up to 3 cm) were the most repeatable and displayed no bias when repeated. Coefficients of repeatability at this site ranged from 1.42 to 1.91, with no evidence of consistent differences between monochorionic and dichorionic twins. Gestational age was not significantly associated with membrane thickness for any of the models. The pregnancy type x subject x observer and pregnancy type x subject x site interactions were statistically significant (p < 0.001 and p < 0.005, respectively), implying that interobserver variability depends on the subject being measured, the site of sampling, and chorionicity. CONCLUSION: Ultrasonographic measurement of membrane thickness has high intraobserver and interobserver variability in the second and third trimesters. Our findings provide an explanation for the suboptimal accuracy reported with this method in determining chorionicity in the second and third trimesters.

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Clinical decision making and diagnostic testing procedures are frequently evaluated using indices such as sensitivity and specificity. These indices require an assumption that the underlying disease state or the diagnostic test result is binary, which may be an unreasonable assumption in many clinical situations. They also fail to recognise the potential for different degrees of diagnostic confidence. In this paper, we report some data from a clinical study of postpartum mothers in which, in addition to the diagnostic result, an expression of certainty or strength of belief was ascertained. We illustrate how the certainty of opinion data can be combined with the diagnostic opinion in order to enhance the interpretation of the study, and the implications for improving the accuracy of clinical decision making in general.

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OBJECTIVE: Our purpose was to study the effect of operator transducer pressure on amniotic fluid index and single deepest pool measurements and their intraobserver and interobserver variability. STUDY DESIGN: Forty subjects in the third trimester with intact membranes were studied by two observers at three predetermined operator pressures. Pressure was measured by interfacing a flexible water-filled reservoir connected to a manometer between the maternal abdomen and the ultrasonography transducer. The amniotic fluid index and single deepest pool were measured on screen by another operator, and data were analyzed by calculating components of variance. RESULTS: Compared with medium pressure, low pressure resulted in a 13% increase in amniotic fluid index (p < 0.001), and high pressure resulted in a 21% fall in amniotic fluid index (p < 0.001). The single deepest pool was less sensitive to pressure, with a 11% increase at low pressure (p < 0.001) and a 16% fall at high pressure (p < 0.001). Intraobserver error was 17% for amniotic fluid index and 18% for single deepest pool when operator pressure was controlled at medium pressure; this increased to 28% and 24%, respectively, when pressure was not controlled (p < 0.01). Interobserver error was consistently very low. CONCLUSION: Both techniques are highly sensitive to the pressure applied to the maternal abdomen during scanning. The reproducibility of amniotic fluid index and single deepest pool is comparable. The use of the same observer for serial measurements of amniotic fluid index would appear to be less important than careful attention to transducer pressure.

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The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.

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We surveyed 655 health professionals affiliated with tertiary level neonatal intensive care units in Canada and the United States to define an expanded role for nurses in neonatology and to determine the educational requirements for the role. The role, comprising advanced clinical practice, educational, research, and administrative responsibilities, is a blend of nurse practitioner and clinical nurse specialist activities. Based on survey findings, a neonatal stream within the existing Master of Health Sciences program at McMaster University was developed. To date, 15 clinical nurse specialists/neonatal practitioners (CNS/NPs) are employed in five neonatal intensive care units in Ontario and other related institutions. A randomized trial to evaluate these individuals is in progress.

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To compare the knowledge and problem-solving, communication, and clinical skills of graduating neonatal nurse practitioners (NNPs) and pediatric residents, a cohort study was conducted in a 33-bed tertiary-level neonatal intensive care unit in a 400-bed teaching hospital affiliated with a faculty of health sciences. Participants were all (n = 10) NNP graduates from the first 3 years of the educational program and 13 (87%) of 15 second-year pediatric residents. One hundred multiple-choice questions and 20 radiographic slides were used to test knowledge; a semistructured oral examination tested problem-solving skills; three simulated interactions with parents tested communication skills; and seven simulated procedures tested clinical skills. Graduating NNPs scored similarly to the pediatric residents on the multiple-choice questions (difference -3.4%; 95% confidence interval [CI] around difference -9.7, 2.9), radiographs (difference -1.4%; 95% CI -11.5, 8.7), oral examination (difference 2.8%; 95% CI -11.1, 16.7), communication skills (simulated parents assessment: difference 0.8%; 95% CI -4.2, 5.7; expert observer assessment: difference 5.8%; 95% CI -2.8, 14.3), and clinical skills (difference 7.4%; 95% CI -5.5, 20.2). The NNPs about to graduate from their educational program showed knowledge and problem-solving, communication, and clinical skills equivalent to those of second-year pediatric residents and are thus likely to deliver comparable care in the clinical setting. The results support the adoption of the NNP role.

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Advances in technology have improved the survival rates of infants of low birth weight. Increasing service commitments together with cutbacks in Canadian training positions have caused concerns about medical staffing in neonatal intensive care units (NICUs) in Ontario. To determine whether an imbalance exists between the supply of medical personnel and the demand for health care services, in July 1985 we surveyed the medical directors, head nurses and staff physicians of nine tertiary level NICUs and the directors of five postgraduate pediatric residency programs. On the basis of current guidelines recommending an ideal neonatologist:patient ratio of 1:6 (assuming an adequate number of support personnel) most of the NICUs were understaffed. Concern about the heavy work pattern and resulting lifestyle implications has made Canadian graduates reluctant to enter this subspecialty. We propose strategies to correct staffing shortages in the context of rapidly increasing workloads resulting from a continuing cutback of pediatric residency positions and restrictions on immigration of foreign trainees.

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To assess the effect of grading of tenderness on the interrater reliability of the Ritchie articular index (RAI), 3 physicians recorded independent joint scores on each of 18 patients, examined in random order. Our results indicate that close agreement (Intraclass Correlation Coefficient = 0.85) can be achieved on global RAI scores, and that raters can achieve reasonable agreement (kappa = 0.40-0.59) on the absolute presence or absence of tenderness of individual joints. By contrast, interrater agreement hardly exceeds the chance level (kappa = 0.008-0.148) when degree of tenderness is independently assessed. The grading system of the RAI may thus be implicated as an important source of the instrument's interrater error.

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The occluded vasoconstrictor assay was used to assess the effect of penetration enhancers on the topical bioavailability of a representative steroid, betamethasone 17-benzoate, with dimethylisosorbide (DMI) as a reference solvent. In the initial test, only N-methyl-2-pyrrolidone (NMP) increased the steroid bioavailability; acetone, dimethylformamide (DMF), 2-pyrrolidone (2-P), and 1-ethyl-2-pyrrolidone (EP) were equal to DMI, while propylene glycol (PG) and N,N-diethyl-m-toluamide (DEET) were poorer. Reocclusion showed that NMP and acetone established superior stratum corneum reservoirs; DMF, 2-P, EP, and PG were as effective as DMI but DEET was less effective. It was concluded that occlusive hydration and lack of thermodynamic control may have obscured the enhancing abilities of the solvents, 2-P, NMP, EP, DMF, and DEET induced erythema in some volunteers, although this was usually short-lived.

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Penetration-enhancing solvents may modify diffusional routes through the stratum corneum and the partitioning of drugs into these pathways. To investigate the mechanisms of action of enhancers, steady-state fluxes were measured in vitro for polar methanol, nonpolar octanol, and an intermediate compound, caffeine, selected as model penetrants; human stratum corneum conditioned on both sides with water or accelerants (2-pyrrolidone or dimethylformamide solutions) was used. We determined partition, permeability, and apparent diffusion coefficients, and derived the standard free energy of transfer of the methylene group from water to stratum corneum (-423 cal mol-1); less negative values were obtained for transfer from 2-pyrrolidone solutions. We conclude that for these model compounds, and taking a fully hydrated membrane as a standard: (a) 2-pyrrolidone enhances permeation through the polar route of the skin by increasing the diffusivity, and reduces passage through the nonpolar route by decreasing diffusivity and partitioning, (b) dimethylformamide promotes polar route absorption by raising diffusivity and partitioning and reduces nonpolar absorption by decreasing both parameters, and (c) for caffeine, the markedly increased absorption (15-fold) caused by dimethylformamide is associated with damage to the membrane.

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