The impact of cross-jurisdictional patient flows on ascertainment of hospitalisations and cardiac procedures for ST-segment-elevation myocardial infarction in an Australian population

Introduction

The patient journey for residents of New South Wales (NSW) Australia with ST-elevation myocardial infarction (STEMI) often involves transfer between hospitals and these can include stays in hospitals in other jurisdictions.

Objective

To estimate the change in enumeration of STEMI hospitalisations and time to subsequent cardiac procedures for NSW residents using cross-jurisdictional linkage of administrative health data.

Methods

Records for NSW residents aged 20 years and over admitted to hospitals in NSW and four adjacent jurisdictions (Australian Capital Territory, Queensland, South Australia, and Victoria) between 1 July 2013 and 30 June 2018 with a principal diagnosis of STEMI were linked with records of the Australian Government Medicare Benefits Schedule (MBS). The number of STEMI hospitalisations, and rates of angiography, percutaneous coronary intervention and coronary artery bypass graft were compared for residents of different local health districts within NSW with and without inclusion of cross-jurisdictional data.

Results

Inclusion of cross-jurisdictional hospital and MBS data increased the enumeration of STEMI hospitalisations for NSW residents by 8% (from 15,420 to 16,659) and procedure rates from 85.6% to 88.2%. For NSW residents who lived adjacent to a jurisdictional border, hospitalisation counts increased by up to 210% and procedure rates by up to 70 percentage points.

Conclusions

Cross-jurisdictional linked hospital data is essential to understand patient journeys of NSW residents who live in border areas and to evaluate adherence to treatment guidelines for STEMI. MBS data are useful where hospital data are not available and for procedures that may be conducted in out-patient settings.

1394Better Cardiac Care Data Linkage Project: utilising cross-jurisdictional data to improve patient-flow capture

Background

For patients experiencing acute myocardial infarction (AMI), particularly ST-elevation myocardial infarction (STEMI), timely revascularisation is important to optimise prognosis. The AMI patient journey often involves presentation to the closest appropriate facility and transfers between hospitals, including across jurisdictions. The Better Cardiac Care (BCC) dataset consists of cross-jurisdictional linked ambulance, emergency, hospital, outpatient, deaths, Medicare and Pharmaceutical Benefits Scheme records for residents of New South Wales (NSW), Australia. This dataset will be updated annually.

Methods

The BCC dataset comprises 332 million records, from 18 datasets, across 6 jurisdictions. For NSW residents hospitalised for STEMI between 2013 to 2018, we compared the number of STEMI hospitalisations, the proportion of patients receiving revascularisation procedures, and the time to procedures using only NSW records versus records from all jurisdictions and Medicare Benefits Scheme.

Results

Compared with NSW hospital data, including data from other jurisdictions increased the ascertainment of STEMI hospitalisations by 8.0% and procedures by 11.2% for NSW residents. This increase was greatest for residents living near state borders, increasing the number of STEMI hospitalisations by up to 210% and the percentage receiving procedures by up to 70%.

Conclusions

Cross-jurisdictional data is essential to understand patient journeys of residents who live in border areas and to evaluate patient care for STEMI and AMI more broadly.

Key messages

The BCC dataset is a vital asset that enables a more comprehensive view of care for AMI than has been possible to date.

The microstructure of white feathers predicts their visible and near-infrared reflectance properties

Research on the optical properties of animal integuments, including fur, feather, skin and cuticle, has focussed almost exclusively on animal-visible wavelengths within the narrow range of 300-700 nm. By contrast, the near-infrared (NIR) portion of direct sunlight, spanning 700-2600 nm, has been largely ignored despite its potentially important thermal consequences. We quantified variation in visible and NIR reflectance and transmission for white body contour feathers of 50 bird species, and examined how well they are predicted by feather macro- and micro-structural morphology. Both visible and NIR reflectance of the feathers varied substantially across species. Larger, thicker, and sparser feathers that are characteristic of larger species, and feathers with rounder barbs and more closely spaced barbules, had high average reflectance, particularly within avian-visible wavelengths (300-700 nm). Feathers with rounder barbs and more closely situated barbules also had high average reflectance, particularly for NIR wavelengths. Barb roundness and barbule density were the only predictors of NIR reflectance after accounting for variation in visible reflectance and body size. Our results highlight the potential for adaptive variation in NIR reflectance mediated by feather structure, which may inform the design of functional materials to control light and heat.

Which egg features predict egg rejection responses in American robins? Replicating Rothstein's (1982) study

Rothstein (Behavioral Ecology and Sociobiology, 11, 1982, 229) was one of the first comprehensive studies to examine how different egg features influence egg rejection behaviors of avian brood parasite-hosts. The methods and conclusions of Rothstein (1982) laid the foundation for subsequent experimental brood parasitism studies over the past thirty years, but its results have never been evaluated with replication. Here, we partially replicated Rothstein's (1982) experiments using parallel artificial model egg treatments to simulate cowbird (Molothrus ater) parasitism in American robin (Turdus migratorius) nests. We compared our data with those of Rothstein (1982) and confirmed most of its original findings: (1) robins reject model eggs that differ from the appearance of a natural robin egg toward that of a natural cowbird egg in background color, size, and maculation; (2) rejection responses were best predicted by model egg background color; and (3) model eggs differing by two or more features from natural robin eggs were more likely to be rejected than model eggs differing by one feature alone. In contrast with Rothstein's (1982) conclusion that American robin egg recognition is not specifically tuned toward rejection of brown-headed cowbird eggs, we argue that our results and those of other recent studies of robin egg rejection suggest a discrimination bias toward rejection of cowbird eggs. Future work on egg recognition will benefit from utilizing a range of model eggs varying continuously in background color, maculation patterning, and size in combination with avian visual modeling, rather than using model eggs which vary only discretely.

Egg discrimination along a gradient of natural variation in eggshell coloration

Accurate recognition of salient cues is critical for adaptive responses, but the underlying sensory and cognitive processes are often poorly understood. For example, hosts of avian brood parasites have long been assumed to reject foreign eggs from their nests based on the total degree of dissimilarity in colour to their own eggs, regardless of the foreign eggs' colours. We tested hosts' responses to gradients of natural (blue-green to brown) and artificial (green to purple) egg colours, and demonstrate that hosts base rejection decisions on both the direction and degree of colour dissimilarity along the natural, but not artificial, gradient of egg colours. Hosts rejected brown eggs and accepted blue-green eggs along the natural egg colour gradient, irrespective of the total perceived dissimilarity from their own egg's colour. By contrast, their responses did not vary along the artificial colour gradient. Our results demonstrate that egg recognition is specifically tuned to the natural gradient of avian eggshell colour and suggest a novel decision rule. These results highlight the importance of considering sensory reception and decision rules when studying perception, and illustrate that our understanding of recognition processes benefits from examining natural variation in phenotypes.

Beyond colour: consistent variation in near infrared and solar reflectivity in sunbirds (Nectariniidae)

The visible spectrum represents a fraction of the sun's radiation, a large portion of which is within the near infrared (NIR). However, wavelengths outside of the visible spectrum that are reflected by coloured tissues have rarely been considered, despite their potential significance to thermal effects. Here, we report the reflectivity from 300 to 2100 nm of differently coloured feathers. We measured reflectivity across the UV-Vis-NIR spectra of different (a) body parts, (b) colour-producing mechanisms and (c) sexes for 252 individuals of 68 sunbird (family: Nectariniidae) species. Breast plumage was the most reflective and cap plumage the least. Female plumage had greater reflectivity than males. Carotenoid-based colours had the greatest reflectivity, followed by non-iridescent and iridescent melanin-based colours. As ordered arrays of melanin-filled organelles (melanosomes) produce iridescent colours, this suggests that nanostructuring may affect reflectance across the spectrum. Our results indicate that differently coloured feathers consistently vary in their thermal, as well as obvious visual, properties.

Manakins can produce iridescent and bright feather colours without melanosomes

Males of many species often use colourful and conspicuous ornaments to attract females. Among these, male manakins (family: Pipridae) provide classic examples of sexual selection favouring the evolution of bright and colourful plumage coloration. The highly iridescent feather colours of birds are most commonly produced by the periodic arrangement of melanin-containing organelles (melanosomes) within barbules. Melanin increases the saturation of iridescent colours seen from optimal viewing angles by absorbing back-scattered light; however, this may reduce the wide-angle brightness of these signals, contributing to a dark background appearance. We examined the nanostructure of four manakin species (Lepidothrix isidorei, L. iris, L. nattereri and L. coeruleocapilla) to identify how they produce their bright plumage colours. Feather barbs of all four species were characterized by dense and fibrous internal spongy matrices that likely increase scattering of light within the barb. The iridescent, yet pale or whitish colours of L. iris and L. nattereri feathers were produced not by periodically arranged melanosomes within barbules, but by periodic matrices of air and β-keratin within barbs. Lepidothrix iris crown feathers were able to produce a dazzling display of colours with small shifts in viewing geometry, likely because of a periodic nanostructure, a flattened barb morphology and disorder at a microstructural level. We hypothesize that iridescent plumage ornaments of male L. iris and L. nattereri are under selection to increase brightness or luminance across wide viewing angles, which may potentially increase their detectability by females during dynamic and fast-paced courtship displays in dim light environments.

Crying wolf to a predator: deceptive vocal mimicry by a bird protecting young

Animals often mimic dangerous or toxic species to deter predators; however, mimicry of such species may not always be possible and mimicry of benign species seems unlikely to confer anti-predator benefits. We reveal a system in which a bird mimics the alarm calls of harmless species to fool a predator 40 times its size and protect its offspring against attack. Our experiments revealed that brown thornbills (Acanthiza pusilla) mimic a chorus of other species' aerial alarm calls, a cue of an Accipiter hawk in flight, when predators attack their nest. The absence of any flying predators in this context implies that these alarms convey deceptive information about the type of danger present. Experiments on the primary nest predators of thornbills, pied currawongs (Strepera graculina), revealed that the predators treat these alarms as if they themselves are threatened by flying hawks, either by scanning the sky for danger or fleeing, confirming a deceptive function. In turn, these distractions delay attack and provide thornbill nestlings with an opportunity to escape. This sophisticated defence strategy exploits the complex web of interactions among multiple species across several trophic levels, and in particular exploits a predator's ability to eavesdrop on and respond appropriately to heterospecific alarm calls. Our findings demonstrate that prey can fool predators by deceptively mimicking alarm calls of harmless species, suggesting that defensive mimicry could be more widespread because of indirect effects on predators within a web of eavesdropping.

A nanostructural basis for gloss of avian eggshells

The role of pigments in generating the colour and maculation of birds' eggs is well characterized, whereas the effects of the eggshell's nanostructure on the visual appearance of eggs are little studied. Here, we examined the nanostructural basis of glossiness of tinamou eggs. Tinamou eggs are well known for their glossy appearance, but the underlying mechanism responsible for this optical effect is unclear. Using experimental manipulations in conjunction with angle-resolved spectrophotometry, scanning electron microscopy, atomic force microscopy and chemical analyses, we show that the glossy appearance of tinamou eggshells is produced by an extremely smooth cuticle, composed of calcium carbonate, calcium phosphate and, potentially, organic compounds such as proteins and pigments. Optical calculations corroborate surface smoothness as the main factor producing gloss. Furthermore, we reveal the presence of weak iridescence on eggs of the great tinamou (Tinamus major), an optical effect never previously documented for bird eggs. These data highlight the need for further exploration into the nanostructural mechanisms for the production of colour and other optical effects of avian eggshells.

Wild birds learn to eavesdrop on heterospecific alarm calls

Many vertebrates gain critical information about danger by eavesdropping on other species' alarm calls [1], providing an excellent context in which to study information flow among species in animal communities [2-4]. A fundamental but unresolved question is how individuals recognize other species' alarm calls. Although individuals respond to heterospecific calls that are acoustically similar to their own, alarms vary greatly among species, and eavesdropping probably also requires learning [1]. Surprisingly, however, we lack studies demonstrating such learning. Here, we show experimentally that individual wild superb fairy-wrens, Malurus cyaneus, can learn to recognize previously unfamiliar alarm calls. We trained individuals by broadcasting unfamiliar sounds while simultaneously presenting gliding predatory birds. Fairy-wrens in the experiment originally ignored these sounds, but most fled in response to the sounds after two days' training. The learned response was not due to increased responsiveness in general or to sensitization following repeated exposure and was independent of sound structure. Learning can therefore help explain the taxonomic diversity of eavesdropping and the refining of behavior to suit the local community. In combination with previous work on unfamiliar predator recognition (e.g., [5]), our results imply rapid spread of anti-predator behavior within wild populations and suggest methods for training captive-bred animals before release into the wild [6]. A remaining challenge is to assess the importance and consequences of direct association of unfamiliar sounds with predators, compared with social learning-such as associating unfamiliar sounds with conspecific alarms.

Experimental shifts in egg-nest contrasts do not alter egg rejection responses in an avian host-brood parasite system

Obligate brood parasitic birds exploit their hosts to provide care for unrelated young in the nest. Potential hosts can reduce the cost of parasitism by rejecting foreign eggs from the nest. Observational, comparative, and experimental studies have concluded that most hosts use the coloration and patterning of eggshells to discriminate between own and foreign eggs in the nest. However, an alternative hypothesis is that birds use the colour contrasts between eggshells and the nest lining to identify parasitic eggs (egg-nest contrast hypothesis). In support of this hypothesis, we found that the avian perceivable chromatic contrasts between dyed eggs and unmanipulated nest linings significantly and negatively covaried with the rejection rates of different dyed eggs of the great reed warbler Acrocephalus arundinaceus, a frequently parasitized host of the common cuckoo Cuculus canorus. To experimentally test whether egg-nest contrasts influence rejection, we reciprocally dyed both eggs and the nest lining of this host species with one of two colours: orange and green. Contrary to the egg-nest contrast hypothesis, host rejection patterns in response to dyed eggs were not altered by dyeing nests, relative to unmanipulated control eggs and nests. In turn, experimental egg colour was the only significant predictor of egg rejection rate. Our results demonstrate that egg-nest contrast is a collateral, not a causal factor in egg rejection, and confirm the conclusions of previous studies that hosts can rely on the parasitic egg's appearance itself to recognize the foreign egg in the nest.

Using 3D printed eggs to examine the egg-rejection behaviour of wild birds

The coevolutionary relationships between brood parasites and their hosts are often studied by examining the egg rejection behaviour of host species using artificial eggs. However, the traditional methods for producing artificial eggs out of plasticine, plastic, wood, or plaster-of-Paris are laborious, imprecise, and prone to human error. As an alternative, 3D printing may reduce human error, enable more precise manipulation of egg size and shape, and provide a more accurate and replicable protocol for generating artificial stimuli than traditional methods. However, the usefulness of 3D printing technology for egg rejection research remains to be tested. Here, we applied 3D printing technology to the extensively studied egg rejection behaviour of American robins, Turdus migratorius. Eggs of the robin’s brood parasites, brown-headed cowbirds, Molothrus ater, vary greatly in size and shape, but it is unknown whether host egg rejection decisions differ across this gradient of natural variation. We printed artificial eggs that encompass the natural range of shapes and sizes of cowbird eggs, painted them to resemble either robin or cowbird egg colour, and used them to artificially parasitize nests of breeding wild robins. In line with previous studies, we show that robins accept mimetically coloured and reject non-mimetically coloured artificial eggs. Although we found no evidence that subtle differences in parasitic egg size or shape affect robins’ rejection decisions, 3D printing will provide an opportunity for more extensive experimentation on the potential biological or evolutionary significance of size and shape variation of foreign eggs in rejection decisions. We provide a detailed protocol for generating 3D printed eggs using either personal 3D printers or commercial printing services, and highlight additional potential future applications for this technology in the study of egg rejection.

The cuticle modulates ultraviolet reflectance of avian eggshells

Avian eggshells are variedly coloured, yet only two pigments, biliverdin and protoporphyrin IX, are known to contribute to the dramatic diversity of their colours. By contrast, the contributions of structural or other chemical components of the eggshell are poorly understood. For example, unpigmented eggshells, which appear white to the human eye, vary in their ultraviolet (UV) reflectance, which may be detectable by birds. We investigated the proximate mechanisms for the variation in UV-reflectance of unpigmented bird eggshells using spectrophotometry, electron microscopy, chemical analyses, and experimental manipulations. We specifically tested how UV-reflectance is affected by the eggshell cuticle, the outermost layer of most avian eggshells. The chemical dissolution of the outer eggshell layers, including the cuticle, increased UV-reflectance for only eggshells that contained a cuticle. Our findings demonstrate that the outer eggshell layers, including the cuticle, absorb UV-light, probably because they contain higher levels of organic components and other chemicals, such as calcium phosphates, compared to the predominantly calcite-based eggshell matrix. These data highlight the need to examine factors other than the known pigments in studies of avian eggshell colour.

Avian vocal mimicry: a unified conceptual framework

Mimicry is a classical example of adaptive signal design. Here, we review the current state of research into vocal mimicry in birds. Avian vocal mimicry is a conspicuous and often spectacular form of animal communication, occurring in many distantly related species. However, the proximate and ultimate causes of vocal mimicry are poorly understood. In the first part of this review, we argue that progress has been impeded by conceptual confusion over what constitutes vocal mimicry. We propose a modified version of Vane-Wright's (1980) widely used definition of mimicry. According to our definition, a vocalisation is mimetic if the behaviour of the receiver changes after perceiving the acoustic resemblance between the mimic and the model, and the behavioural change confers a selective advantage on the mimic. Mimicry is therefore specifically a functional concept where the resemblance between heterospecific sounds is a target of selection. It is distinct from other forms of vocal resemblance including those that are the result of chance or common ancestry, and those that have emerged as a by-product of other processes such as ecological convergence and selection for large song-type repertoires. Thus, our definition provides a general and functionally coherent framework for determining what constitutes vocal mimicry, and takes account of the diversity of vocalisations that incorporate heterospecific sounds. In the second part we assess and revise hypotheses for the evolution of avian vocal mimicry in the light of our new definition. Most of the current evidence is anecdotal, but the diverse contexts and acoustic structures of putative vocal mimicry suggest that mimicry has multiple functions across and within species. There is strong experimental evidence that vocal mimicry can be deceptive, and can facilitate parasitic interactions. There is also increasing support for the use of vocal mimicry in predator defence, although the mechanisms are unclear. Less progress has been made in explaining why many birds incorporate heterospecific sounds into their sexual displays, and in determining whether these vocalisations are functionally mimetic or by-products of sexual selection for other traits such as repertoire size. Overall, this discussion reveals a more central role for vocal mimicry in the behavioural ecology of birds than has previously been appreciated. The final part of this review identifies important areas for future research. Detailed empirical data are needed on individual species, including on the structure of mimetic signals, the contexts in which mimicry is produced, how mimicry is acquired, and the ecological relationships between mimic, model and receiver. At present, there is little information and no consensus about the various costs of vocal mimicry for the protagonists in the mimicry complex. The diversity and complexity of vocal mimicry in birds raises important questions for the study of animal communication and challenges our view of the nature of mimicry itself. Therefore, a better understanding of avian vocal mimicry is essential if we are to account fully for the diversity of animal signals.

A shared chemical basis of avian host-parasite egg colour mimicry

Avian brood parasites lay their eggs in other birds' nests and impose considerable fitness costs on their hosts. Historically and scientifically, the best studied example of circumventing host defences is the mimicry of host eggshell colour by the common cuckoo (Cuculus canorus). Yet the chemical basis of eggshell colour similarity, which impacts hosts' tolerance towards parasitic eggs, remains unknown. We tested the alternative scenarios that (i) cuckoos replicate host egg pigment chemistry, or (ii) cuckoos use alternative mechanisms to produce a similar perceptual effect to mimic host egg appearance. In parallel with patterns of similarity in avian-perceived colour mimicry, the concentrations of the two key eggshell pigments, biliverdin and protoporphyrin, were most similar between the cuckoo host-races and their respective hosts. Thus, the chemical basis of avian host-parasite egg colour mimicry is evolutionarily conserved, but also intraspecifically flexible. These analyses of pigment composition reveal a novel proximate dimension of coevolutionary interactions between avian brood parasites and hosts, and imply that alternative phenotypes may arise by the modifications of already existing biochemical and physiological mechanisms and pathways.

Alternative mechanisms of increased eggshell hardness of avian brood parasites relative to host species

Obligate brood parasitic birds lay their eggs in nests of other species and parasite eggs typically have evolved greater structural strength relative to host eggs. Increased mechanical strength of the parasite eggshell is an adaptation that can interfere with puncture ejection behaviours of discriminating hosts. We investigated whether hardness of eggshells is related to differences between physical and chemical traits from three different races of the parasitic common cuckoo Cuculus canorus, and their respective hosts. Using tools developed for materials science, we discovered a novel correlate of increased strength of parasite eggs: the common cuckoo's egg exhibits a greater microhardness, especially in the inner region of the shell matrix, relative to its host and sympatric non-host species. We then tested predictions of four potential mechanisms of shell strength: (i) increased relative thickness overall, (ii) greater proportion of the structurally harder shell layers, (iii) higher concentration of inorganic components in the shell matrix, and (iv) elevated deposition of a high density compound, MgCO(3), in the shell matrix. We confirmed support only for hypothesis (i). Eggshell characteristics did not differ between parasite eggs sampled from different host nests in distant geographical sites, suggesting an evolutionarily shared microstructural mechanism of stronger parasite eggshells across diverse host-races of brood parasitic cuckoos.

Size dimorphism and avian-perceived sexual dichromatism in a New Zealand endemic bird, the whitehead Mohoua albicilla

Sex differences in behavior, morphology, and physiology are common in animals. In many bird species, differences in the feather colors of the sexes are apparent when judged by human observers and using physical measures of plumage reflectance, cryptic (to human) plumage dichromatism has also been detected in several additional avian lineages. However, it remains to be confirmed in almost all species whether sexual dichromatism is perceivable by individuals of the studied species. This latter step is essential because it allows the evaluation of alternative hypotheses regarding the signaling and communication functions of plumage variation. We applied perceptual modeling of the avian visual system for the first time to an endemic New Zealand bird to provide evidence of subtle but consistent sexual dichromatism in the whitehead, Mohoua albicilla. Molecular sexing techniques were also used in this species to confirm the extent of the sexual size dimorphism in plumage and body mass. Despite the small sample sizes, we now validate previous reports based on human perception that in male whiteheads head and chest feathers are physically brighter than in females. We further suggest that the extent of sexual plumage dichromatism is pronounced and can be perceived by these birds. In contrast, although sexual dimorphism was also detectable in the mass among the DNA-sexed individuals, it was found to be less extensive than previously thought. Sexual size dimorphism and intraspecifically perceivable plumage dichromatism represent reliable traits that differ between female and male whiteheads. These traits, in turn, may contribute to honest communication displays within the complex social recognition systems of communally breeding whitehead and other group-breeding taxa.

Studies of self-incompatibility in wild tomatoes: I. S-allele diversity in Solanum chilense (Dun.) Reiche [corrected] (Solanaceae)

We characterized the molecular allelic variation of RNases at the self-incompatibility (SI) locus of Solanum chilense Dun. We recovered 30 S-RNase allele sequences from 34 plants representing a broad geographic sample. This yielded a species-wide estimate of 35 (95% likelihood interval 31-40) S-alleles. We performed crosses to confirm the association with SI function of 10 of the putative S-RNase allele sequences. Results in all cases were consistent with the expectation that these sequences represent functional alleles under single-locus gametophytic SI. We used the allele sequences to conduct an analysis of selection, as measured by the excess of nonsynonymous changes per site, and found evidence for adaptive changes both within the traditionally defined hypervariable regions and downstream, near the 3'-end of the molecule.

Evolutionary relationships among self-incompatibility RNases

T2-type RNases are responsible for self-pollen recognition and rejection in three distantly related families of flowering plants-the Solanaceae, Scrophulariaceae, and Rosaceae. We used phylogenetic analyses of 67 T2-type RNases together with information on intron number and position to determine whether the use of RNases for self-incompatibility in these families is homologous or convergent. All methods of phylogenetic reconstruction as well as patterns of variation in intron structure find that all self-incompatibility RNases along with non-S genes from only two taxa form a monophyletic clade. Several lines of evidence suggest that the best interpretation of this pattern is homology of self-incompatibility RNases from the Scrophulariaceae, Solanaceae, and Rosaceae. Because the most recent common ancestor of these three families is the ancestor of approximately 75% of dicot families, our results indicate that RNase-based self-incompatibility was the ancestral state in the majority of dicots.