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Purpose: To compare the predictive accuracy of Barrett total keratometry (Barrett TK) toric calculator with the measured posterior corneal astigmatism (PCA) by using Pentacam in toric intraocular lens (IOL) power calculation. Methods: A prospective analysis was done on 118 eyes requiring toric IOL power implantation. The absolute prediction error of the Barrett TK toric calculator and the measured PCA in the online toric calculator were assessed and compared to the standard Alcon toric calculator (with Barrett toric calculator incorporated). Results: The mean absolute prediction error of the online toric calculator (0.32 D) (with Barrett toric calculator incorporated), Barrett TK Toric (0.34 D), and measured PCA of Pentacam in Barrett toric calculator (0.33 D) were found to be similar with no statistically significant difference. Subanalysis in eyes with with-the-rule astigmatism, against-the-rule astigmatism, and oblique astigmatism showed similar results. Alpins analysis showed that all three methods overcorrected corneal astigmatism. Conclusion: The Barrett TK toric calculator and the measured PCA of Pentacam in the Barrett toric calculator have similar predictive accuracy to the online toric calculator (with Barrett toric calculator incorporated).

Abstract Sonodynamic therapy (SDT) is currently on critical path for glioblastoma therapeutics. SDT is a non-invasive approach utilising focused ultrasound to activate photosensitisers like 5-ALA to impede tumour growth. Unfortunately, the molecular mechanisms underlying the therapeutic functions of SDT remain enigmatic. This is primarily due to the lack of intricately optimised instrumentation capable of modulating SDT delivery to glioma cells in vitro. Consequently, very little information is available on the effects of SDT on glioma stem cells which are key drivers of gliomagenesis and recurrence. To address this, the current study has developed and validated an automated in vitro SDT system to allow the application and mapping of focused ultrasound fields under varied exposure conditions and setup configurations. The study optimizes ultrasound frequency, intensity, plate base material, thermal effect, and the integration of live cells. Indeed, in the presence of 5-ALA, focused ultrasound induces apoptotic cell death in primary patient-derived glioma cells with concurrent upregulation of intracellular reactive oxygen species. Intriguingly, primary glioma stem neurospheres also exhibit remarkably reduced 3D growth upon SDT exposure. Taken together, the study reports an in vitro system for SDT applications on tissue culture-based disease models to potentially benchmark the novel approach to the current standard-of-care.

Background: The mitotic kinesin, KIF18A, is required for proliferation of cancer cells that exhibit chromosome instability (CIN), implicating it as a promising target for treatment of a subset of aggressive tumor types. Determining regions of the KIF18A protein to target for inhibition will be important for the design and optimization of effective small molecule inhibitors.Methods: In this study, we used cultured cell models to investigate the effects of mutating S284 within the alpha-4 helix of KIF18A, which was previously identified as a phosphorylated residue.Results: Mutations in S284 cause relocalization of KIF18A from the plus-ends of spindle microtubules to the spindle poles. Furthermore, KIF18A S284 mutants display loss of KIF18A function and fail to support proliferation in CIN tumor cells. Interestingly, similar effects on KIF18A localization and function were seen after treatment of CIN cells with KIF18A inhibitory compounds that are predicted to interact with residues within the alpha-4 helix.Conclusion: These data implicate the KIF18A alpha-4 helix as an effective target for inhibition and demonstrate that small molecules targeting KIF18A selectively limit CIN tumor cell proliferation and result in phenotypically similar effects on mitosis at the single cell level compared to genetic perturbations.

The most common measures of childhood undernutrition are based on anthropometric measures such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). It is well recognised that the determinants of undernutrition are multiple, including food intake, dietary diversity, health, sanitation and women’s status. Currently, most countries across the world including India use the globally accepted WHO-Multicentre Growth Reference Study (MGRS) growth standards (2006) for the purposes of measurement as well as for evaluating progress on these metrics. However, there is some discussion on the universal relevance of these standards, and in the Indian context, whether these standards overestimate the prevalence of stunting, considering differences in genetic potential for growth. This is especially relevant in the context of increasing burden of obesity and non-communicable diseases in India. Based on a detailed review of literature, policy documents and expert inputs, this review paper discusses the relevance of the WHO growth standards for height/stunting, in the context of India. Issues discussed related to the MGRS methodology include pooling of data and intersite and intrasite variability, opting for standards as opposed to references, and external validity. Other issues related to plasticity of stunting and the influence of maternal heights are also discussed, in the context of analysing the appropriateness of using universal growth standards. Based on the review, it is recommended that the current standards may continue to be used until a newer global standard is established through a similar study.

PurposeHeating of gradient coils and passive shim components is a common cause of instability in the B0 field, especially when gradient intensive sequences are used. The aim of the study was to set a benchmark for typical drift encountered during MR spectroscopy (MRS) to assess the need for real-time field-frequency locking on MRI scanners by comparing field drift data from a large number of sites.MethodA standardized protocol was developed for 80 participating sites using 99 3T MR scanners from 3 major vendors. Phantom water signals were acquired before and after an EPI sequence. The protocol consisted of: minimal preparatory imaging; a short pre-fMRI PRESS; a ten-minute fMRI acquisition; and a long post-fMRI PRESS acquisition. Both pre- and post-fMRI PRESS were non-water suppressed. Real-time frequency stabilization/adjustment was switched off when appropriate. Sixty scanners repeated the protocol for a second dataset. In addition, a three-hour post-fMRI MRS acquisition was performed at one site to observe change of gradient temperature and drift rate. Spectral analysis was performed using MATLAB. Frequency drift in pre-fMRI PRESS data were compared with the first 5:20 minutes and the full 30:00 minutes of data after fMRI. Median (interquartile range) drifts were measured and showed in violin plot. Paired t-tests were performed to compare frequency drift pre- and post-fMRI. A simulated in vivo spectrum was generated using FID-A to visualize the effect of the observed frequency drifts. The simulated spectrum was convolved with the frequency trace for the most extreme cases. Impacts of frequency drifts on NAA and GABA were also simulated as a function of linear drift. Data from the repeated protocol were compared with the corresponding first dataset using Pearson's and intraclass correlation coefficients (ICC).ResultsOf the data collected from 99 scanners, 4 were excluded due to various reasons. Thus, data from 95 scanners were ultimately analyzed. For the first 5:20 min (64 transients), median (interquartile range) drift was 0.44 (1.29) Hz before fMRI and 0.83 (1.29) Hz after. This increased to 3.15 (4.02) Hz for the full 30 min (360 transients) run. Average drift rates were 0.29 Hz/min before fMRI and 0.43 Hz/min after. Paired t-tests indicated that drift increased after fMRI, as expected (p < 0.05). Simulated spectra convolved with the frequency drift showed that the intensity of the NAA singlet was reduced by up to 26%, 44 % and 18% for GE, Philips and Siemens scanners after fMRI, respectively. ICCs indicated good agreement between datasets acquired on separate days. The single site long acquisition showed drift rate was reduced to 0.03 Hz/min approximately three hours after fMRI.DiscussionThis study analyzed frequency drift data from 95 3T MRI scanners. Median levels of drift were relatively low (5-min average under 1 Hz), but the most extreme cases suffered from higher levels of drift. The extent of drift varied across scanners which both linear and nonlinear drifts were observed.

Photoacoustic imaging (PAI), also referred to as optoacoustic imaging, has shown promise in early-stage clinical trials in a range of applications from inflammatory diseases to cancer. While the first PAI systems have recently received regulatory approvals, successful adoption of PAI technology into healthcare systems for clinical decision making must still overcome a range of barriers, from education and training to data acquisition and interpretation. The International Photoacoustic Standardisation Consortium (IPASC) undertook an community exercise in 2022 to identify and understand these barriers, then develop a roadmap of strategic plans to address them. Here, we outline the nature and scope of the barriers that were identified, along with short-, medium- and long-term community efforts required to overcome them, both within and beyond the IPASC group.

Capacity for generativity and unlimited association is the defining characteristic of sentience, and this capacity somehow arises from neuronal self-organization in the cortex. We have previously argued that, consistent with the free energy principle, cortical development is driven by synaptic and cellular selection maximizing synchrony, with effects manifesting in a wide range of features of mesoscopic cortical anatomy. Here, we further argue that in the postnatal stage, as more structured inputs reach the cortex, the same principles of self-organization continue to operate at multitudes of local cortical sites. The unitary ultra-small world structures that emerged antenatally can represent sequences of spatiotemporal images. Local shifts of presynapses from excitatory to inhibitory cells result in the local coupling of spatial eigenmodes and the development of Markov blankets, minimizing prediction errors in each unit's interactions with surrounding neurons. In response to the superposition of inputs exchanged between cortical areas, more complicated, potentially cognitive structures are competitively selected by the merging of units and the elimination of redundant connections that result from the minimization of variational free energy and the elimination of redundant degrees of freedom. The trajectory along which free energy is minimized is shaped by interaction with sensorimotor, limbic, and brainstem mechanisms, providing a basis for creative and unlimited associative learning.

Abstract Objective Accurate measurement of physicians’ time spent during patient care stands to inform emergency department (ED) improvement efforts. Direct observation is time consuming and cost prohibitive, so we sought to determine if physician self‐estimation of time spent during patient care was accurate. Methods We performed a prospective, convenience‐sample study in which research assistants measured time spent by ED physicians in patient care. At the conclusion of each observed encounter, physicians estimated their time spent. Using Mann–Whitney U tests and Spearman's rho, we compared physician estimates to actual time spent and assessed for associations of encounter characteristics and physician estimation. Results Among 214 encounters across 10 physicians, we observed a medium‐sized correlation between actual and estimated time (Spearman's rho = 0.63, p

The purpose of this research is to investigate experiences of K-12 classroom teachers of deaf students with additional disabilities. Today, more deaf and hard of hearing students are identified as having additional disabilities (Bruce, DiNatale & Ford, 2008; Ewing, 2011; Gallaudet Research Institute, 2011; Jones, Jones & Ewing, 2006; Mitchell & Karchmer, 2004); there is a need to explore ways of providing educational services to these students. Utilizing a phenomenological design, data were collected using survey questionnaires, focus groups and individual interviews. Several themes emerged, such as the typical school day, previous training, and continuous professional development. Understanding the experiences of the K-12 teachers can provide valuable information for deaf education teacher preparation programs.

Developmental selection of neurons and synapses so as to maximize pulse synchrony has recently been used to explain antenatal cortical development. Consequences of the same selection process—an application of the Free Energy Principle—are here followed into the postnatal phase in V1, and the implications for cognitive function are considered. Structured inputs transformed via lag relay in superficial patch connections lead to the generation of circumferential synaptic connectivity superimposed upon the antenatal, radial, “like-to-like” connectivity surrounding each singularity. The spatiotemporal energy and dimension reduction models of cortical feature preferences are accounted for and unified within the expanded model, and relationships of orientation preference (OP), space frequency preference (SFP), and temporal frequency preference (TFP) are resolved. The emergent anatomy provides a basis for “active inference” that includes interpolative modification of synapses so as to anticipate future inputs, as well as learn directly from present stimuli. Neurodynamic properties are those of heteroclinic networks with coupled spatial eigenmodes.

Abstract Background Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians’ estimates of their own behavior, few interventions have included assessment of clinicians’ estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians’ baseline estimates of their own behavior compared to peers. Methods Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group’s baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. Results Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. Conclusions Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After “audit,” it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.

Abstract Background/Objectives Medical nutrition therapy along with pharmacological interventions as a multidisciplinary approach is required to treat type 2 diabetes mellitus (T2DM). This study evaluated the efficacy of Jackfruit365™ green jackfruit flour as an integral part of daily meal in patients with T2DM. Subjects/Methods This was a randomized, double-blind, placebo-controlled study conducted between May 2019 and February 2020. Patients of either sex aged ≥18 to ≤60 years with a diagnosis of T2DM for >1 year receiving oral antihyperglycemic agents were randomized (1:1) to receive either jackfruit flour 30 g/day (Group A) or placebo flour (Group B) (breakfast and dinner) daily for 12 weeks replacing an equal volume of rice or wheat flour. The primary endpoint was a mean change in glycosylated hemoglobin (HbA1c). Other endpoints were mean changes in fasting plasma glucose (FPG), postprandial plasma glucose (PPG), lipid profile, and body weight. The independent t-test was used to compare changes between the groups. Results A total of 40 patients were enrolled (n = 20 each). A significantly higher reduction in HbA1c was observed in Group A compared to Group B from baseline to week 12 [−2.73 mmol/mol (−0.25%) vs. 0.22 mmol/mol (0.02%), p = 0.006]. The mean change in FPG and PPG was significantly higher in Group A than that of Group B (p = 0.043 and p = 0.001). The continuous glucose monitoring showed decreasing mean blood glucose in 7 days of administration of jackfruit flour meal. Conclusion Patients from Group A had a significantly higher reduction in HbA1c, FPG, and PPG than Group B demonstrating the efficacy of jackfruit flour in glycemic control as medical nutrition therapy replacing an equal volume of rice or wheat flour in daily meal. Clinical trial registry CTRI/2019/05/019417.

Abstract Background Ductal carcinoma in situ (DCIS) is a non-invasive form of early breast cancer, with a poorly understood natural history of invasive transformation. Necrosis is a well-recognized adverse prognostic feature of DCIS, and non-invasive detection of its presence and spatial extent could provide information not obtainable by biopsy. We describe here imaging of the distribution and extent of comedo-type necrosis in a model of human DCIS using C2Am, an imaging agent that binds to the phosphatidylserine exposed by necrotic cells. Methods We used an established xenograft model of human DCIS that mimics the histopathological features of the disease. Planar near-infrared and optoacoustic imaging, using fluorescently labeled C2Am, were used to image non-invasively the presence and extent of lesion necrosis. Results C2Am showed specific and sensitive binding to necrotic areas in DCIS tissue, detectable both in vivo and ex vivo. The imaging signal generated in vivo using near-infrared (NIR) fluorescence imaging was up to 6-fold higher in DCIS lesions than in surrounding fat pad or skin tissue. There was a correlation between the C2Am NIR fluorescence (Pearson R = 0.783, P = 0.0125) and optoacoustic signals (R > 0.875, P

The benefits of physical activity (PA) for health have been extensively studied; however, people with disabilities (PWDs) are more likely to be inactive compared to the general population. The topic of barriers and facilitators to PA for PWDs has been studied, but most reviews have focused on specific impairments, institution-based exercise programs, and/or persons who reside in high-income countries. A comprehensive review describing the barriers and facilitators to PA for community-dwelling PWDs (including developmental, intellectual, sensory, physical, and mental disabilities) from a global perspective has not been published. The aim of this paper is to describe the protocol used to conduct a systematic review concerning the socioenvironmental factors that encourage and discourage PA in PWDs around the world, by investigating the current knowledge, identifying gaps in the literature, and providing guidance for future research and guidelines. MEDLINE All, PsycINFO, and Web of Science Core Collection were searched. Gray literature sources included were extracted from the three main databases used for the literature search. A total of 6434 records were identified for the initial title/abstract screen. The following data were extracted from the final full-text articles: author, title, publication information (journal, year), study design, methodology, data collection instruments employed, language, country or countries where the study was conducted, subject characteristics, disabilities reported, disability characteristics, subjects' mobility level, a relation of stakeholder(s) to PWDs (self, family), PA mode, barriers, and facilitators.

Abstract Background Lower limb venous disease can cause significant pain, loss of mobility, and can be detrimental to an individual's quality of life. Manifestations of venous disease often pose a substantially negative impact on patients and place a high demand on finite healthcare resources. Whilst this problem is internationally recognised, most research and discourse has predominantly focussed on treatment of leg ulceration and prevention of recurrence. Prevention of lower limb venous disease progression to the first ulceration has received far less attention. Overall, the care of this condition appears to rest in the domain of medicine and nursing yet podiatry, a profession with responsibility for the lower limb and foot, is conspicuous by its absence from the literature. Methods An ethnographic approach was used to gather data from 26 participants through observation, semi‐structured interviews, and a focus group interview. Qualitative analysis was conducted using the framework approach. Results The findings revealed an identity crisis within the podiatry profession. Evidence emerged of ritual and routine practices that did not include lower limb venous disease. External control over practice limited the professional autonomy of podiatrists determining their own activities. Inter‐professional relationships with nursing, and perceptions of boundaries that venous disease was a nursing role were also found to be limiting factors. Conclusions This research revealed that podiatry does not occupy a substantive role in contributing to the early identification and prevention of lower limb venous disease. Policy, education, research and practice changes are all required to enhance the contribution of podiatry to reduce the burden of this disease.

Purpose: Heating of gradient coils and passive shim components is a common cause of instability in the B0 field, especially when gradient intensive sequences are used. The aim of the study was to set a benchmark for typical drift encountered during MR spectroscopy (MRS) to assess the need for real-time field-frequency locking on MRI scanners by comparing field drift data from a large number of sites. Method: A standardized protocol was developed for 80 participating sites using 99 3T MR scanners from 3 major vendors. Phantom water signals were acquired before and after an EPI sequence. The protocol consisted of: minimal preparatory imaging; a short pre-fMRI PRESS; a ten-minute fMRI acquisition; and a long post-fMRI PRESS acquisition. Both pre- and post-fMRI PRESS were non-water suppressed. Real-time frequency stabilization/adjustment was switched off when appropriate. Sixty scanners repeated the protocol for a second dataset. In addition, a three-hour post-fMRI MRS acquisition was performed at one site to observe change of gradient temperature and drift rate. Spectral analysis was performed using MATLAB. Frequency drift in pre-fMRI PRESS data were compared with the first 5:20 minutes and the full 30:00 minutes of data after fMRI. Median (interquartile range) drifts were measured and showed in violin plot. Paired t-tests were performed to compare frequency drift pre- and post-fMRI. A simulated in vivo spectrum was generated using FID-A to visualize the effect of the observed frequency drifts. The simulated spectrum was convolved with the frequency trace for the most extreme cases. Impacts of frequency drifts on NAA and GABA were also simulated as a function of linear drift. Data from the repeated protocol were compared with the corresponding first dataset using Pearson's and intraclass correlation coefficients (ICC). Results: Of the data collected from 99 scanners, 4 were excluded due to various reasons. Thus, data from 95 scanners were ultimately analyzed. For the first 5:20 min (64 transients), median (interquartile range) drift was 0.44 (1.29) Hz before fMRI and 0.83 (1.29) Hz after. This increased to 3.15 (4.02) Hz for the full 30 min (360 transients) run. Average drift rates were 0.29 Hz/min before fMRI and 0.43 Hz/min after. Paired t-tests indicated that drift increased after fMRI, as expected (p < 0.05). Simulated spectra convolved with the frequency drift showed that the intensity of the NAA singlet was reduced by up to 26%, 44 % and 18% for GE, Philips and Siemens scanners after fMRI, respectively. ICCs indicated good agreement between datasets acquired on separate days. The single site long acquisition showed drift rate was reduced to 0.03 Hz/min approximately three hours after fMRI. Discussion: This study analyzed frequency drift data from 95 3T MRI scanners. Median levels of drift were relatively low (5-min average under 1 Hz), but the most extreme cases suffered from higher levels of drift. The extent of drift varied across scanners which both linear and nonlinear drifts were observed.

For this qualitative case study (Patton, 2003), we used narrative inquiry (Erlandson, Harris, Skipper, & Allen, 1993) and sought to analyze extended interviews and field notes based on interactions with three rural superintendents working in high-needs, public PK-12 school districts in Texas. We collected data with regard to these superintendents' perceptions of themselves as social justice/equity oriented change agents based on the Equity Oriented Change Agent or EOCA framework developed by Skrla, McKenzie, and Scheurich (2009). Our goal with this study was to glean greater insight into the work of these rural school leaders as potential equity oriented change agents. Additionally, we sought to ascertain any additional EOCA characteristics through analysis of the participants' perceptions. The data revealed themes that aligned with the Skrla et al., (2009) framework as well as some emergent data beyond those EOCA characteristics. These themes afforded us a better understanding of the work of these three rural superintendents as equity oriented change agents and how they perceive their work. (Contains 3 figures and 2 footnotes.)

Recent advances in high power, pulsed, light emitting diodes (LEDs) have shown potential as fast, robust and relatively inexpensive excitation sources for photoacoustic imaging (PAI), yet systematic characterization of performance for biomedical imaging is still lacking. We report here technical and biological validation studies of a commercial dual-wavelength LED-based PAI and ultrasound system. Phantoms and small animals were used to assess temporal precision. In phantom studies, we found high temporal stability of the LED-based PAI system, with no significant drift in performance observed during 6 h of operation or over 30 days of repeated measurements. In vivo dual-wavelength imaging was able to map the dynamics of changes in blood oxygenation during oxygen-enhanced imaging and reveal the kinetics of indocyanine green contrast agent inflow after intravenous administration (Tmax∼6 min). Taken together, these studies indicate that LED-based excitation could be promising for future application in functional and molecular PAI.

Hyperspectral imaging (HSI) enables recording both morphological and biochemical information, but image acquisition time and geometric distortions limit its clinical applicability. Here the authors overcome these challenges with an endoscope combining HSI and white light to correct for image distortion during freehand operation.

Front kicks are often used in combat activities that involve the use of kicks and punches, including close combat military training. To mimic real-life combative environments where soldiers execute forceful front kicks while wearing military boots, it is logical to wear these boots during close combat training. However, the effect of military footwear on front kick forces remain unknown. Therefore, the aim of this study was to compare the effects of military boots on front kick dynamics. Six male soldiers (23.3 ± 1.7 yr, 74.3 ± 6.2 kg, 175.5 ± 4.5 cm) performed eight individual front kicks with no military boots, in bare feet (NB) and with military boots (MB). Peak force (N), impulse (N.s) and time to reach peak force (ms), were measured during each kick. Data were analyzed using paired sample t-tests or nonparametric Wilcoxon pair test and Cohen’s d. Results. Neither peak force (3180 ± 647 N) nor impulse (367 ± 40 N.s) of MB were different than NB (3157 ± 291 N and 360 ± 48 N.s, respectively) (p = 0.85; d = 0.04 and p = 0.36; d = 0.12, respectively). Peak force was reached in a significantly shorter time during MB (39 ± 16 ms) compared to NB (56 ± 8 ms; d = −0.88). Conclusion. Peak force was reached in a shorter time using MB compared to barefoot (NB) front kicks. The use of military boots changes the time course of peak force during the front kick.

Differential fertility preferences for men and women may provide insights into human sexual conflict. We explore whether pairbonded couples have different preferences for future offspring, which socioecological factors are associated with these preferences, and who achieves their desired fertility over time. We utilise the Indonesia Family Life Survey (IFLS), a longitudinal survey which collected data from 1993 to 2015, to compare desired future fertility for 9655 couples and follow couples who had divergent preferences. The majority of couples (64.8%) want the same number of future offspring. In 20.7% of couples, husbands want more future offspring than their wives, while the reverse occurs in 14.5% of couples. Living in villages with the husband's or the wife's parent(s) is associated with having divergent preferences for future offspring, where there is a higher likelihood that women prefer more offspring than their husbands. When examining fertility outcomes, women, particularly those who marry at older ages, are more likely to achieve their desired preference. Contrary to previous research, we do not find that living near one's natal kin or having increased autonomy increases an individual's likelihood of achieving desired fertility outcomes.