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Objective: The effect of Alberta's health reform on length of stay for maternity cases and on subsequent mothers' rehospitalization was examined in the present study. Methods: The data set included all Alberta acute care hospital separation records from 1991/92 to 1996/97 inclusive. A logistic regression was applied to the data in order to examine the effects of prepartum condition, type of delivery, length of stay, maternal age, and year on the likelihood of readmission. Results: Health reform proved to be associated with a dramatic decrease in length of stay for maternity cases; from 3.8 to 2.4 days on average. This was accompanied by very little variation in the 90-day readmission rate for mothers over the same time period (notably, a slight decrease). Higher readmission rates were associated with the existence of difficulties during the pregnancy and other prenatal conditions, maternal age, and with the type of delivery. There were no dramatic changes in the rates for prepartum diagnoses, nor for the type of delivery. Discussion: The data suggest that the reduction in the length of maternity stay has had no discernible negative health effects on new mothers, perhaps because of the home visiting programs that were put in place. Furthermore, there may still be room to improve outcomes by focussing on those with prepartum conditions and cases involving complicated births. Objectif : Cette étude porte sur l'effet de la réforme de la santé en Alberta sur la durée du séjour à l'hôpital après l'accouchement et sur les réhospitalisations subséquentes des mères. Méthode : Nous avons étudié les données de tous les registres de sortie des hôpitaux albertains de soins actifs, de 1991-1992 à 1996-1997, inclusivement. Nous les avons analysées par régression logistique pour déterminer les effets de diverses variables (état de santé avant l'accouchement, mode d'accouchement, durée du séjour, âge maternel et année) sur la vraisemblance d'une réadmission. Résultats : La réforme de la santé était associée à une réduction considérable de la durée du séjour à la maternité, qui est passé de 3,8 à 2,4 jours en moyenne. Elle s'est accompagnée d'un très faible écart (en fait, une légère baisse) dans le taux de réadmission des mères dans un délai de 90 jours pendant la même période. Les taux de réadmission élevés étaient associés aux grossesses difficiles et autres troubles prénatals, à l'âge maternel et au mode d'accouchement. Il n'y a pas eu de changements considérables dans les taux associés au diagnostic avant l'accouchement ou au mode d'accouchement. Discussion : Ces données portent à croire que la réduction de la durée du séjour à la maternité n'a eu aucun effet néfaste évident sur la santé des nouvelles mères, peut-être en raison de la mise en place de programmes de visites à domicile. En outre, il serait encore possible d'améliorer ces résultats en mettant l'accent sur les mères dont la grossesse a été difficile et les naissances avec complications.

As survival has improved in patients with metastatic breast cancer, quality of life issues have become more important in clinical and research assessment of treatment. We examined psychological aspects of sexuality, body image and health-related quality of life (HRQOL) in 19 patients who had completed high dose chemotherapy and peripheral stem cell transfusion (HDC/PBSCT), and in 19 who had undergone conventional chemotherapy (CC). There were no differences in mean age, time since treatment or demographic variables except education level. We found no significant differences in HRQOL (Functional Living Index-Cancer) nor on the Body Image Scale. On a measure of sexual fears, 74% of the HDC/PBSCT patients and 63% of the CC patients thought that cancer would make them unattractive to their mates. As well, 68% of the HDC/PBSCT patients and 37% of the CC women were fearful of sex being painful as a result of their cancer (p<0.01). Sixty eight percent of HDC/PBSCT women and 47% of CCs had change in level of sexual desire since treatment following their diagnosis of metastatic disease. Eighty five per cent of HDC/PBSCT and all CC women experienced this as decreased desire. We found few significant differences between the groups, but there were noteworthy effects on body image and psychological aspects of sexuality with both treatments. Key words: Breast cancer, Sexuality, Body image, Health-related quality of life INTRODUCTION Breast cancer is the most common malignancy in women, responsible for 27% of malignant tumours and 20% of cancer deaths. Once metastatic disease is documented, it has been considered incurable, with a median survival time of less than 2 years (Henderson, 1991). Poor survival has lead to aggressive high dose chemotherapy regimes with autologous peripheral blood stem cell transplant support (HDC/PBSCT). Recently, it has been shown that at least 50% of women undergo remission with high dose chemotherapy, compared with 5-15% treated with multi-dose conventional chemotherapy (Booser & Hortobagyi, 1992). As length of survival following a cancer diagnosis has increased, there has been a shift in focus from dying of cancer to living with the disease. Interest has been directed, in general, toward the evaluation of the effects of breast cancer and related medical therapies on health-related quality of life (HRQOL) (Baum, Ebbs, Fallowfield, & Fraser, 1990; Boyd, Selby, Sutherland, & Hogg, 1988: Coates, Gebski, Stat, Bishop, Jeal, Woods, Snyder, Tatersall, Byrne, Harvey, & Gill. 1987; Hallgren, Paterson, & Arcand, 1984; Levine, Guyatt, Gent, De Pauw, Goodyear, Hryniuk, Arnold, Findlay, Skillings, Bramwell, Levin, Bush, Abu-Zahra, & Kotalik, 1988). The area of quality of life assessment is not without controversy, particularly in the definition of the construct. The present literature consensus defines \"health-related quality of life\" as encompassing three major domains: physical well-being, psychological state and social functioning. Other areas are also currently being included such as personal financial impacts, and sexuality and body image. There is an emerging literature on HRQOL in breast cancer patients during treatment in HDC/PBSCT programs (Ahles, Tope, Furstenburg, Hann & Mills, 1996; Larsen, Gardulf, & Nordstrom, 1996; Litwins, Rodrique, & Weiner, 1994; Weiner, 1994). McQuellon and colleagues (1976) have recently reported that long-term quality of life in breast cancer patients is unchanged following HDC/PBSCT. These authors also reported that in structured interviews, concerns about physical appearance and about personal and physical relations emerged. The substantial physical illness immediately after high-dose chemotherapy is reflected in poor HRQOL, but this rebounds to normal levels within one month following discharge (Cumming, Nabholtz, Wentzel, Handman, Clinch, Sansregret, & Cumming, 1996). There are no published comparisons of quality of life following conventional and high-dose chemotherapy in a population of breast cancer patients. Further, physicians dealing with clinical and research problems do not generally ask about side effects of treatment in which there is substantial subjective patient input. In particular, until recently researchers have placed little emphasis on sexuality and body image during and after either high-dose or conventional forms of treatment (Love, Levanthal, Easterling, Nerenz, 1989). Women believe themselves to be uninformed about the sexual side effects of cancer treatment (Kaplan, 1994) and about body image (Mathieson, 1994). They view these areas to be of major concern (Hopwood, 1993). The goal of the present study, therefore, was to examine health-related quality of life, sexuality, and body image in women with metastatic breast cancer who had undergone either conventional or high-dose chemotherapy. SUBJECTS AND METHODS SUBJECTS The subjects in the study were 38 women, age 30 to 63 years, from urban and rural areas of Western Canada.

Protected areas (PAs) remain central to the conservation of biodiversity. Classical PAs were conceived as areas that would be set aside to maintain a natural state with minimal human influence. However, global environmental change and growing cross-scale anthropogenic influences mean that PAs can no longer be thought of as ecological islands that function independently of the broader social-ecological system in which they are located. For PAs to be resilient (and to contribute to broader social-ecological resilience), they must be able to adapt to changing social and ecological conditions over time in a way that supports the long-term persistence of populations, communities, and ecosystems of conservation concern. We extend Ostrom's social-ecological systems framework to consider the long-term persistence of PAs, as a form of land use embedded in social-ecological systems, with important cross-scale feedbacks. Most notably, we highlight the cross-scale influences and feedbacks on PAs that exist from the local to the global scale, contextualizing PAs within multi-scale social-ecological functional landscapes. Such functional landscapes are integral to understand and manage individual PAs for long-term sustainability. We illustrate our conceptual contribution with three case studies that highlight cross-scale feedbacks and social-ecological interactions in the functioning of PAs and in relation to regional resilience. Our analysis suggests that while ecological, economic, and social processes are often directly relevant to PAs at finer scales, at broader scales, the dominant processes that shape and alter PA resilience are primarily social and economic.

Scale is a concept that transcends disciplinary boundaries. In ecology and geography, scale is usually defined in terms of spatial and temporal dimensions. Sociological scale also incorporates space and time, but adds ideas about representation and organization. Although spatial and temporal location determine the context for social and ecological dynamics, social-ecological interactions can create dynamic feedback loops in which humans both influence and are influenced by ecosystem processes. We hypothesize that many of the problems encountered by societies in managing natural resources arise because of a mismatch between the scale of management and the scale(s) of the ecological processes being managed. We use examples from southern Africa and the southern United States to address four main questions: (1) What is a “scale mismatch?” (2) How are scale mismatches generated? (3) What are the consequences of scale mismatches? (4) How can scale mismatches be resolved? Scale mismatches occur when the scale of environmental variation and the scale of social organization in which the responsibility for management resides are aligned in such a way that one or more functions of the social-ecological system are disrupted, inefficiencies occur, and/or important components of the system are lost. They are generated by a wide range of social, ecological, and linked social-ecological processes. Mismatches between the scales of ecological processes and the institutions that are responsible for managing them can contribute to a decrease in social-ecological resilience, including the mismanagement of natural resources and a decrease in human well-being. Solutions to scale mismatches usually require institutional changes at more than one hierarchical level. Long-term solutions to scale mismatch problems will depend on social learning and the development of flexible institutions that can adjust and reorganize in response to changes in ecosystems. Further research is needed to improve our ability to diagnose, understand, and resolve scale mismatches in linked social-ecological systems.

Coral reefs support immense biodiversity and provide important ecosystem services to many millions of people. Yet reefs are degrading rapidly in response to numerous anthropogenic drivers. In the coming centuries, reefs will run the gauntlet of climate change, and rising temperatures will transform them into new configurations, unlike anything observed previously by humans. Returning reefs to past configurations is no longer an option. Instead, the global challenge is to steer reefs through the Anthropocene era in a way that maintains their biological functions. Successful navigation of this transition will require radical changes in the science, management and governance of coral reefs.