The cost-effectiveness of procalcitonin for guiding antibiotic prescribing in individuals hospitalized with COVID-19: part of the PEACH study.

BACKGROUND: Many hospitals introduced procalcitonin (PCT) testing to help diagnose bacterial coinfection in individuals with COVID-19, and guide antibiotic decision-making during the COVID-19 pandemic in the UK. OBJECTIVES: Evaluating cost-effectiveness of using PCT to guide antibiotic decisions in individuals hospitalized with COVID-19, as part of a wider research programme. METHODS: Retrospective individual-level data on patients hospitalized with COVID-19 were collected from 11 NHS acute hospital Trusts and Health Boards from England and Wales, which varied in their use of baseline PCT testing during the first COVID-19 pandemic wave. A matched analysis (part of a wider analysis reported elsewhere) created groups of patients whose PCT was/was not tested at baseline. A model was created with combined decision tree/Markov phases, parameterized with quality-of-life/unit cost estimates from the literature, and used to estimate costs and quality-adjusted life years (QALYs). Cost-effectiveness was judged at a £20 000/QALY threshold. Uncertainty was characterized using bootstrapping. RESULTS: People who had baseline PCT testing had shorter general ward/ICU stays and spent less time on antibiotics, though with overlap between the groups' 95% CIs. Those with baseline PCT testing accrued more QALYs (8.76 versus 8.62) and lower costs (£9830 versus £10 700). The point estimate was baseline PCT testing being dominant over no baseline testing, though with uncertainty: the probability of cost-effectiveness was 0.579 with a 1 year horizon and 0.872 with a lifetime horizon. CONCLUSIONS: Using PCT to guide antibiotic therapy in individuals hospitalized with COVID-19 is more likely to be cost-effective than not, albeit with uncertainty.

Damage to tropical forests caused by cyclones is driven by wind speed but mediated by topographical exposure and tree characteristics.

Each year, an average of 45 tropical cyclones affect coastal areas and potentially impact forests. The proportion of the most intense cyclones has increased over the past four decades and is predicted to continue to do so. Yet, it remains uncertain how topographical exposure and tree characteristics can mediate the damage caused by increasing wind speed. Here, we compiled empirical data on the damage caused by 11 cyclones occurring over the past 40 years, from 74 forest plots representing tropical regions worldwide, encompassing field data for 22,176 trees and 815 species. We reconstructed the wind structure of those tropical cyclones to estimate the maximum sustained wind speed (MSW) and wind direction at the studied plots. Then, we used a causal inference framework combined with Bayesian generalised linear mixed models to understand and quantify the causal effects of MSW, topographical exposure to wind (EXP), tree size (DBH) and species wood density (ρ) on the proportion of damaged trees at the community level, and on the probability of snapping or uprooting at the tree level. The probability of snapping or uprooting at the tree level and, hence, the proportion of damaged trees at the community level, increased with increasing MSW, and with increasing EXP accentuating the damaging effects of cyclones, in particular at higher wind speeds. Higher ρ decreased the probability of snapping and to a lesser extent of uprooting. Larger trees tended to have lower probabilities of snapping but increased probabilities of uprooting. Importantly, the effect of ρ decreasing the probabilities of snapping was more marked for smaller than larger trees and was further accentuated at higher MSW. Our work emphasises how local topography, tree size and species wood density together mediate cyclone damage to tropical forests, facilitating better predictions of the impacts of such disturbances in an increasingly windier world.

Ability of new protected areas to counteract losses from downgrading, downsizing, and degazettement.

Protected area downgrading, downsizing, and degazettement (PADDD) is a common occurrence. Although PADDD is expected to weaken biodiversity protection, PADDD offsets and new unrelated protected areas (PAs) could help restore representation of biodiversity features to the reserve network affected by PADDD. Globally, we analyzed 16 territories with terrestrial PADDD and 4 territories with marine PADDD from 2011 to 2020. Our objective was to evaluate whether PADDD offsets and new PAs could restore the PAs, key biodiversity areas (KBAs), ecoregions, and threatened amphibian, mammal, bird, and reptile species ranges where PADDD had occurred. In our studied territories, offsets of PADDD were rare (enacted in 3 [19%] terrestrial territories and one [25%] marine territory). One territory had PADDD losses that were compensated fully by PADDD offsets in terms of area coverage and ecoregions represented. All other territories failed to achieve compensation goals. In territories affected by PADDD, PADDD offsets and new PAs partially restored area representation (63%) and KBA coverage (57%). However, only 38% of ecoregion representation and 20%, 33%, 31%, and 21% of threatened amphibian, mammal, bird, and reptile representation, respectively, were restored. Overall, we found a large shortfall in PADDD offsets, even when unrelated PAs were included in the calculus. There is an urgent need to expand PADDD offsets and PAs to advance biodiversity conservation and achieve the Global Biodiversity Framework's 30×30 target. Future planning of newly enacted conservation areas needs to prioritize biodiversity conservation and consider the purpose of restoring reserve networks affected by PADDD, rather than solely focusing on areal targets.

Capacidad de las áreas protegidas nuevas para contrarrestar las pérdidas por el cambio de categoría, la reducción de tamaño y la desclasificación Resumen La degradación, reducción y desclasificación de áreas protegidas (DRDAP) es un fenómeno común. Aunque se espera que la DRDAP debilite la protección de la biodiversidad, las compensaciones de la DRDAP y las nuevas áreas protegidas (AP) sin relación podrían ayudar a restaurar la representación de las características de la biodiversidad en la red de reservas afectadas por la DRDAP. Analizamos 16 territorios a nivel mundial con DRDAP terrestre y cuatro territorios con DRDAP marina entre 2011 y 2020. Nuestro objetivo era evaluar si las compensaciones de la DRDAP y las nuevas AP podrían restaurar las AP, las áreas clave para la biodiversidad (ACB), las ecorregiones y las áreas de distribución de especies amenazadas de anfibios, mamíferos, aves y reptiles donde se había producido la DRDAP. En nuestros territorios estudiados, las compensaciones de DRDAP fueron escasas (promulgadas en tres [19%] territorios terrestres y un [25%] territorio marino). Un territorio tuvo pérdidas de DRDAP que fueron compensadas totalmente por compensaciones de DRDAP en términos de cobertura de área y ecorregiones representadas. En los demás territorios no se alcanzaron los objetivos de compensación. En los territorios afectados por la DRDAP, las compensaciones de la DRDAP y las nuevas AP restauraron parcialmente la representación de la superficie (63%) y la cobertura de las ACB (57%). Sin embargo, sólo se restauró el 38% de la representación de la ecorregión y el 20%, 33%, 31% y 21% de la representación de anfibios, mamíferos, aves y reptiles amenazados, respectivamente. En general, encontramos un gran déficit en las compensaciones DRDAP, incluso cuando se incluyeron APs no relacionadas en el cálculo. Existe una necesidad urgente de ampliar las compensaciones DRDAP y las AP para avanzar en la conservación de la biodiversidad y alcanzar el objetivo 30x30 del Marco Global de Biodiversidad. La planificación futura de las áreas de conservación de nueva creación debe dar prioridad a la conservación de la biodiversidad y tener en cuenta el propósito de restaurar las redes de reservas afectadas por la DRDAP, en lugar de centrarse únicamente en objetivos de área.

Something for everybody? Assessing the suitability of AAC systems for children using stated preference methods.

Little is known about what features of AAC systems are regarded by AAC professionals as more suitable for children with different characteristics. A survey was conducted in which participants rated the suitability of hypothetical AAC systems on a Likert scale from 1 (very unsuitable) to 7 (very suitable) alongside a discrete choice experiment. The survey was administered online to 155 AAC professionals in the United Kingdom of Great Britain and Northern Ireland. Statistical modeling was used to estimate how suitable 274 hypothetical AAC systems were for each of 36 child vignettes. The proportion of AAC systems rated at least 5 out of 7 for suitability varied from 51.1% to 98.5% for different child vignettes. Only 12 out of 36 child vignettes had any AAC systems rated at least 6 out of 7 for suitability. The features of the most suitable AAC system depended on the characteristics of the child vignette. The results show that, while every child vignette had several systems that had a good suitability rating, there were variations, that could potentially lead to inequalities in provision.

Rarity patterns of woody plant species are associated with life form and diversification rates in Pacific islands forests.

PREMISE: Rarity is a complex and central concept in ecology and conservation biology. Yet, it is still poorly understood why some species are rare and others common. Here, we aimed to understand the drivers of species rarity patterns in woody plant communities. METHODS: We analyzed the local abundance and landscape frequency of 121 woody plant species across 238 plots on American Samoa and Hawaiian islands. We first assessed whether taxonomy, life form (shrub, small tree, large tree), and dispersal syndrome (dispersed by animals or by other means) are associated with the rarity of species. We then analyzed phylogenetic patterns in plant rarity and tested whether rarity patterns are associated with species evolutionary distinctiveness and the number of species within genera and families. RESULTS: Large trees were less abundant but more frequent than shrub species. Animal-dispersed species tended to be less abundant than species dispersed by other means, while species frequency was not associated with dispersal syndromes. Relative frequency in Hawai'i exhibited a more robust phylogenetic signal than did abundance. Both evolutionary distinctiveness and taxa species richness were significantly associated with the frequency of shrub species in Hawai'i. CONCLUSIONS: Life form appears consistently associated with the rarity of species. High diversification rate is probably a key factor explaining landscape-scale rarity of native species on isolated archipelagos like Hawai'i. At the landscape scale, rarity appears to be inversely associated with evolutionary distinctiveness, but at the local scale, species abundance may be not associated with evolutionary distinctiveness.

Attribute Selection for a Discrete Choice Experiment Incorporating a Best-Worst Scaling Survey.

OBJECTIVES: Although literature exists on using qualitative methods to generate potential attributes for a discrete choice experiment (DCE), there is little on selecting which attributes to include. We present a case study in which a best-worst scaling case 1 (BWS-1) survey was used to guide attribute selection for a DCE. The case study's context was the decision making of professionals around the choice of augmentative and alternative communication (AAC) systems for children with limited natural speech. METHODS: BWS-1 survey attributes were generated from literature reviews and focus groups. DCE attributes were selected from BWS-1 attributes. The selection criteria were: include mostly important attributes; create coherent descriptions of children and AAC systems; address the project's research aims; have an appropriate respondent burden. Attributes' importance was judged using BWS-1 relative importance scores. RESULTS: The BWS-1 survey included 19 child and 18 AAC device/system attributes and was administered to N = 93 AAC professionals. Four child and five device/system attributes were selected for the DCE, administered to N = 155 AAC professionals. CONCLUSIONS: In this case study BWS-1 results were useful in DCE attribute selection. Four recommendations are made for future studies: define selection criteria for DCE attributes a priori; consider the impact participant's perspective will have on BWS-1 and DCE results; clearly define key terminology at the start of the study and refine it as the study progresses to reflect interim findings; BWS will be useful when there is little existing stated preference work on a topic and/or qualitative work is difficult.

Does a health crisis change how we value health?

General population health state values are used in healthcare resource allocation, including health technology assessment. We examine whether UK general population health valuations changed during the COVID-19 pandemic. Ratings of EQ-5D-5L health states 11111 (no problems), 55555 (extreme problems), and dead were collected in a UK general population survey during the pandemic (April-May 2020) using the 0 = worst imaginable health, 100 = best imaginable health visual analog scale (EQ-VAS). Ratings for 55555 were transformed to a full health = 1, dead = 0 scale. Responses were compared to similar data collected pre-pandemic (2018). After propensity score matching to minimize sample differences, EQ-VAS responses were analyzed using Tobit regressions. On the 0-100 scale, 11111 was rated on average 8.67 points lower, 55555 rated 9.56 points higher, and dead rated 7.45 points lower post-pandemic onset compared to pre-pandemic. On the full health = 1, dead = 0 scale, 55555 values were 0.09 higher post-pandemic onset. There was evidence of differential impacts of COVID-19 by gender, age, and ethnicity, although only age impacted values on the 1-0 scale. COVID-19 may have affected how people value health. It is unknown whether the effect is large enough to have policy relevance, but caution should be taken in assuming pre-COVID-19 values are unchanged.

Changing the eligibility criteria for welfare payments at the end of life - a budget impact analysis for England and Wales.

BACKGROUND: Terminal illness can cause a financial burden for many households. In England and Wales, fast-track access to welfare payments is available through special rules for the terminally ill (SRTI). Individuals are eligible for SRTI if they are judged to have 6 months or less to live. This criterion has been criticised as lacking a clinical basis, and being unfair for people with conditions where life-expectancy is difficult to accurately assess. AIM: To conduct a budget impact analysis on the possible increase in expenditure of personal independence payments (PIP) following a change in England and Wales to SRTI so that everyone with a terminal illness is eligible. METHODS: The fraction of individuals with a given long-term condition was estimated by combining data from the Health Survey for England, the Office for National Statistics (ONS) and the Department for Work and Pensions. Logistic growth modelling and ONS population projections were used to project PIP expenditure from 2020 to 2025. The increased expenditure was calculated for hypothetical scenarios which may occur following an SRTI regime change, specifically an increase of 1, 2 and 3 percentage points in the fraction of individuals claiming PIP under SRTI. Data from the literature on the projected prevalence of mild, moderate and severe dementia was used to calculate the cost if everyone with a given severity of dementia claimed PIP under SRTI. RESULTS: Under the current SRTI regime, PIP expenditure under SRTI was projected to increase from £0.231bn in 2020 to £0.260bn in 2025, compared to equivalent figures of £11.1bn and £12.7bn under non-SRTI. Expenditure in 2025 following an increase in the fraction claiming of 1, 2 and 3 percentage points was projected to be £1.1bn, £1.9bn and £2.7bn respectively. In 2025, PIP expenditure was estimated to be £7.4bn if everyone with dementia claimed under SRTI, compared to £6.4bn if only individuals with moderate and severe dementia claimed, and £4.7bn if only individuals with severe dementia claimed. CONCLUSION: Changes in SRTI are projected to lead to increases in PIP expenditure. However, the increased cost is small compared to expenditure under non-SRTI, especially as the highest costs were associated with extreme scenarios.

Making Public Involvement in Research More Inclusive of People With Complex Speech and Motor Disorders: The I-ASC Project.

In this study, we aimed to identify processes that enabled the involvement of a person with complex speech and motor disorders and the parent of a young person with these disorders as co-researchers in a U.K. research project. Semi-structured individual and focus group interviews explored participants' experiences and perceptions of public involvement (PI). Sixteen participants were recruited, with representation from (a) the interdisciplinary project team; (b) academics engaged in discrete project activities; (c) individuals providing organizational and operational project support; and (d) the project's two advisory groups. Data were analyzed using Framework Analysis. Five themes were generated: (a) the challenge of defining the co-researcher role; (b) power relations in PI; (c) resources used to enable PI; (d) perceived benefits of PI; and (e) facilitators of successful PI. Our findings provide new evidence about how inclusive research teams can support people with complex speech and motor disorders to contribute meaningfully to co-produced research.

Coordinated intensification to reconcile the 'zero hunger' and 'life on land' Sustainable Development Goals.

The Sustainable Development Goals (SDGs) encourage nations to substantially increase food production to achieve zero hunger (SDG 2) while preserving life on land (SDG 15). A key question is how to reconcile these potentially competing goals spatially. We use integer linear programming to develop an 'integrated land use planning framework' that identifies the optimal allocation of 17 crops under different hypothetical conservation targets while meeting agricultural demands by 2030. Intensifying existing cropland to maximum yield before allocating new cropland would reduce land requirement by 43% versus cropland expansion without intensification. Even with yield gap closure, tropical and sub-tropical crops still require expansion, primarily allocated to Venezuela, eastern Brazil, Congo Basin, Myanmar and Indonesia. Enforcement of protected areas, via avoiding conversion in 75% of Key Biodiversity Areas and 65% of intact areas, is vital to attain biodiversity targets but bears large opportunity costs, with agricultural rents dropping from $4.1 to $2.8 trillion. Although nationally constrained forest conservation efforts would earn 9% less agricultural rents compared to globally coordinated conservation solutions, they were also able to reduce intact habitat and forest loss (43% and 35% reduction). Our results demonstrate that careful choice of the allocation of future cropland expansion, could dramatically reduce-but not eliminate-the tradeoffs between the SDGs for food production and land biodiversity conservation.

Global economic trade-offs between wild nature and tropical agriculture.

Global demands for agricultural and forestry products provide economic incentives for deforestation across the tropics. Much of this deforestation occurs with a lack of information on the spatial distribution of benefits and costs of deforestation. To inform global sustainable land-use policies, we combine geographic information systems (GIS) with a meta-analysis of ecosystem services (ES) studies to perform a spatially explicit analysis of the trade-offs between agricultural benefits, carbon emissions, and losses of multiple ecosystem services because of tropical deforestation from 2000 to 2012. Even though the value of ecosystem services presents large inherent uncertainties, we find a pattern supporting the argument that the externalities of destroying tropical forests are greater than the current direct economic benefits derived from agriculture in all cases bar one: when yield and rent potentials of high-value crops could be realized in the future. Our analysis identifies the Atlantic Forest, areas around the Gulf of Guinea, and Thailand as areas where agricultural conversion appears economically efficient, indicating a major impediment to the long-term financial sustainability of Reducing Emissions from Deforestation and forest Degradation (REDD+) schemes in those countries. By contrast, Latin America, insular Southeast Asia, and Madagascar present areas with low agricultural rents (ARs) and high values in carbon stocks and ES, suggesting that they are economically viable conservation targets. Our study helps identify optimal areas for conservation and agriculture together with their associated uncertainties, which could enhance the efficiency and sustainability of pantropical land-use policies and help direct future research efforts.

UK General Population Utility Values for the SIDECAR-D Instrument Measuring the Impact of Caring for People With Dementia.

OBJECTIVES: Dementia affects many people, with numbers expected to grow as populations age. Many people with dementia receive informal/family/unpaid care, for example, from a spouse or child, which may affect carer quality of life. Measuring the effectiveness of health/social care interventions for carers requires a value measure of the quality-of-life impact of caring. This motivated development of the Scales Measuring the Impact of Dementia on Carers-D (SIDECAR-D) instrument. This study aimed to obtain general population values for SIDECAR-D to aid incorporating the impact of caring in economic evaluation. METHODS: Members of the UK general public completed a best-worst scaling object case survey, which included the 18 SIDECAR-D items and EQ-5D-3L descriptions. Responses were analyzed using scale-adjusted finite mixture models. Relative importance scores (RISs) for the 18 SIDECAR-D items formed the SIDECAR-D relative scale measuring the relative impact of caring. The SIDECAR-D tariff, on the full health = 1, dead = 0 scale, was derived by rescaling EQ-5D-3L and SIDECAR-D RISs so the EQ-5D-3L RISs equaled anchored valuations of the EQ-5D-3L pits state from a visual analog scale task. RESULTS: Five hundred ten respondents completed the survey. The model had 2 parameter and 3 scale classes. Additive utility decrements of SIDECAR-D items ranged from -0.05 to -0.162. Utility scores range from 0.95 for someone affirming 1 item to -0.297 for someone affirming all 18. CONCLUSION: SIDECAR-D is a needs-based scale of the impact on quality of life of caring for someone with dementia, with a valuation tariff to support its use in economic evaluation.

Measuring commissioners' willingness-to-pay for community based childhood obesity prevention programmes using a discrete choice experiment.

BACKGROUND: In the UK, rates of childhood obesity remain high. Community based programmes for child obesity prevention are available to be commissioned by local authorities. However, there is a lack of evidence regarding how programmes are commissioned and which attributes of programmes are valued most by commissioners. The aim of this study was to determine the factors that decision-makers prioritise when commissioning programmes that target childhood obesity prevention. METHODS: An online discrete choice experiment (DCE) was used to survey commissioners and decision makers in the UK to assess their willingness-to-pay for childhood obesity programmes. RESULTS: A total of 64 commissioners and other decision makers completed the DCE. The impact of programmes on behavioural outcomes was prioritised, with participants willing to pay an extra £16,600/year if average daily fruit and vegetable intake increased for each child by one additional portion. Participants also prioritised programmes that had greater number of parents fully completing them, and were willing to pay an extra £4810/year for every additional parent completing a programme. The number of parents enrolling in a programme (holding the number completing fixed) and hours of staff time required did not significantly influence choices. CONCLUSIONS: Emphasis on high programme completion rates and success increasing children's fruit and vegetable intake has potential to increase commissioning of community based obesity prevention programmes.

Reliability of pelvimetry is affected by observer experience but not by breed and sex: A cross-sectional study in beef cattle.

Pelvis size plays an important role to prevent dystocia in cattle caused by the foeto-maternal disproportion in commonly primiparous females. The reproducibility and repeatability are two important aspects for the reliability of the measurements to use in the selection of cattle for culling. Pelvic measures were taken with a Rice pelvimeter from 224 young cattle (180 females and 44 males) of four beef breeds in South Africa. One experienced and two inexperienced observers each measured pelvic height and width twice. The proportion measurements with a maximum difference of 0.5 cm within animal compared with the first measurement by the experienced observer are around 80% and by the inexperienced observers around 50% for pelvic height and around 60% for pelvic width. Breed and sex do not affect the reliability of pelvimetry by an experienced observer. Under- and overestimation of pelvis size were observed in inexperienced observers, which seems to be unrelated to breed and sex.

Germination niches and seed persistence of tropical epiphytic orchids in an urban landscape.

Urbanisation has contributed to significant biodiversity loss, yet, urban areas can facilitate biodiversity conservation. For instance, there is evidence of urban trees supporting natural establishments of orchids, the most species-rich plant family on Earth. However, the germination niches-which include both suitable biophysical conditions and orchid mycorrhizal fungus/fungi (OMF)-are not sufficiently known for most species, especially tropical epiphytic orchids. The fate of their dispersed seeds is poorly understood as well. We conducted fungal baiting and seed sowing experiments, next-generation sequencing, generalised linear models, and seed viability tests to detect and identify potential OMF, investigate biophysical factors that influenced OMF availability and orchid germination, and assess seed longevity. Ceratobasidiaceae- and Serendipitaceae-associated OMF were successfully detected in three of four orchid species. In general, orchid species and humus presence had significant effects on OMF availability. Orchid species and temperature were predictive of germination. Post-experiment viability tests revealed that one orchid species, Grammatophyllum speciosum Blume, may produce long-lived seeds. The results suggest that urban trees can support OMF and orchid germination, but both processes are limited by biophysical factors. This study also indicates the possibility of seed persistence among epiphytic species. As orchid germination niches are complex and tend to be unique to individual species, we do not encourage generalisations. In contrast, species-specific information can help formulate useful recommendations towards conservation.

What's important in AAC decision making for children? Evidence from a best-worst scaling survey.

The choice of which AAC device to provide for a child can have long lasting consequences, but little is known about the decision-making of AAC professionals who make recommendations in this context. A survey was conducted with AAC professionals using best-worst scaling methodology examining what characteristics of children and attributes of AAC devices are considered most important in decision-making. A total of 19 child characteristics and 18 device attributes were selected by the authors from lists generated from literature reviews and from focus groups with AAC professionals, people who use AAC, and other stakeholders. The characteristics and attributes were used to develop two best-worst scaling surveys that were administered to 93 AAC professionals based in the UK. The relative importance of characteristics/attributes was estimated using statistical modelling. Child characteristics related to language and communication, cognitive and learning abilities, and personality traits were generally found to be more important than physical features. Communication, language, and interface-related AAC device attributes were generally more important than hardware and physical attributes. Respondent demographics (e.g., experience, professional background) did not seem to influence the importance assigned to device characteristics or attributes. Findings may inform both future quantitative research into decision-making and efforts to improve decision-making in practice.

Very small relict populations suggest high extinction debt of gingers in primary forest fragments of a tropical city.

PREMISE OF THE STUDY: Tropical plant communities in fragmented forests are likely to experience an extinction debt, i.e., the habitat cannot support as many species as are present due to reduced habitat size and connectivity. There are few estimates of the number of species that represent extinction debt, and the number of extinctions over time has rarely been recorded. We recorded population sizes to assess threats and extinctions in gingers (sensu Zingiberales) in fragmented rainforest in Singapore, ca. 200 yr after fragmentation began. METHODS: We surveyed extant diversity and population sizes of gingers and used the results to estimate species survival. We critically assessed historic specimens to estimate initial extinctions and extinctions realized in present habitats. KEY RESULTS: We recorded 23 species, including five species previously presumed nationally extinct and four species omitted from the national checklist. The revised extinction rate is much lower than previously reported (12 vs. 37%). Most gingers have very small populations or miniscule ranges, implying that extinction debt has not been paid off. CONCLUSIONS: Ginger diversity remains high, but the number of species at immediate risk of extinction outnumber recorded extinctions. Although tropical forest fragments remain arks of plant diversity for a long time, extinction debt may be prevalent in all plant groups in Singapore. Slow relaxation of extinction debt should be explicitly identified as a conservation challenge and opportunity. For conserving plant diversity in tropical fragments, relaxation must be reversed through restoration of degraded landscapes and, where feasible, targeted ex situ conservation and planting.

Untangling the proximate causes and underlying drivers of deforestation and forest degradation in Myanmar.

Political transitions often trigger substantial environmental changes. In particular, deforestation can result from the complex interplay among the components of a system-actors, institutions, and existing policies-adapting to new opportunities. A dynamic conceptual map of system components is particularly useful for systems in which multiple actors, each with different worldviews and motivations, may be simultaneously trying to alter different facets of the system, unaware of the impacts on other components. In Myanmar, a global biodiversity hotspot with the largest forest area in mainland Southeast Asia, ongoing political and economic reforms are likely to change the dynamics of deforestation drivers. A fundamental conceptual map of these dynamics is therefore a prerequisite for interventions to reduce deforestation. We used a system-dynamics approach and causal-network analysis to determine the proximate causes and underlying drivers of forest loss and degradation in Myanmar from 1995 to 2016 and to articulate the linkages among them. Proximate causes included infrastructure development, timber extraction, and agricultural expansion. These were stimulated primarily by formal agricultural, logging, mining, and hydropower concessions and economic investment and social issues relating to civil war and land tenure. Reform of land laws, the link between natural resource extraction and civil war, and the allocation of agricultural concessions will influence the extent of future forest loss and degradation in Myanmar. The causal-network analysis identified priority areas for policy interventions, for example, creating a public registry of land-concession holders to deter corruption in concession allocation. We recommend application of this analytical approach to other countries, particularly those undergoing political transition, to inform policy interventions to reduce forest loss and degradation.

Political transition and emergent forest-conservation issues in Myanmar.

Political and economic transitions have had substantial impacts on forest conservation. Where transitions are underway or anticipated, historical precedent and methods for systematically assessing future trends should be used to anticipate likely threats to forest conservation and design appropriate and prescient policy measures to counteract them. Myanmar is transitioning from an authoritarian, centralized state with a highly regulated economy to a more decentralized and economically liberal democracy and is working to end a long-running civil war. With these transitions in mind, we used a horizon-scanning approach to assess the 40 emerging issues most affecting Myanmar's forests, including internal conflict, land-tenure insecurity, large-scale agricultural development, demise of state timber enterprises, shortfalls in government revenue and capacity, and opening of new deforestation frontiers with new roads, mines, and hydroelectric dams. Averting these threats will require, for example, overhauling governance models, building capacity, improving infrastructure- and energy-project planning, and reforming land-tenure and environmental-protection laws. Although challenges to conservation in Myanmar are daunting, the political transition offers an opportunity for conservationists and researchers to help shape a future that enhances Myanmar's social, economic, and environmental potential while learning and applying lessons from other countries. Our approach and results are relevant to other countries undergoing similar transitions.

Agricultural intensification escalates future conservation costs.

The supposition that agricultural intensification results in land sparing for conservation has become central to policy formulations across the tropics. However, underlying assumptions remain uncertain and have been little explored in the context of conservation incentive schemes such as policies for Reducing Emissions from Deforestation and forest Degradation, conservation, sustainable management, and enhancement of carbon stocks (REDD+). Incipient REDD+ forest carbon policies in a number of countries propose agricultural intensification measures to replace extensive "slash-and-burn" farming systems. These may result in conservation in some contexts, but will also increase future agricultural land rents as productivity increases, creating new incentives for agricultural expansion and deforestation. While robust governance can help to ensure land sparing, we propose that conservation incentives will also have to increase over time, tracking future agricultural land rents, which might lead to runaway conservation costs. We present a conceptual framework that depicts these relationships, supported by an illustrative model of the intensification of key crops in the Democratic Republic of Congo, a leading REDD+ country. A von Thünen land rent model is combined with geographic information systems mapping to demonstrate how agricultural intensification could influence future conservation costs. Once postintensification agricultural land rents are considered, the cost of reducing forest sector emissions could significantly exceed current and projected carbon credit prices. Our analysis highlights the importance of considering escalating conservation costs from agricultural intensification when designing conservation initiatives.