Bringing order to Petra's tourism economy

The popularity of Petra, Jordan, as a tourist destination has surged among international visitors since the 1980s. This has led to the tourism sector's emergence as a major source of income for indigenous communities living adjacent to the ancient city's ruins. Rapidly expanding visitor numbers and business activity-both licensed and unlicensed-exposed the need for government to play an active role in organizing Petra's tourism industry. Drawing upon a thematic analysis of interviews I conducted in three tourism-reliant, tribal communities in Petra's vicinity in 2022, this case study examines relations between the Petra Development and Tourism Region Authority (PDTRA) and indigenous stakeholders in the local economy. Focusing on the period extending from 2019-just before the COVID-19 pandemic's onset-to 2022, I explore local perspectives towards PDTRA policies impacting indigenous work in the tourism sector. I find that legality, size, and internal organization of stakeholder groups affect their capacity to influence political decisions that impact their lives and livelihoods.

Dramatically increased accessibility and decreased cost-per-person impacts are needed for scaling IPM in Africa.

While traditional scaling for integrated pest management (IPM) in Africa requires the movement of expert trainers from village to village, these efforts are often costly, time-inefficient, hampered by distance, and became impossible under COVID-19's movement restrictions (despite tremendously increased public need for IPM-scaling knowledge). One solution to this dilemma is IPM-scaling, usable by a diversity of development actors expending limited or few resources, to deliver critical information to large numbers of people with systems-approach information and communication technologies. This paper describes one such systems-approach scaling platform, Scientific Animations Without Borders, which effectively elicited end-user solution-adoption and decreased unit costs over increasing scales in three African countries during COVID-19. How to scale game-changing IPM insights 'off the shelf' and 'into people's hands in the field' is also discussed.

Demonstrating New-onset orWorsened Sudomotor Function post COVID-19

Objective: Identify if SARS-CoV-2 virus is triggering and/or worsening dysautonomia by reviewing the function of autonomic patients pre-COVID-19 and post-COVID-19 infection, as well as new onset autonomic patients post-COVID-19 infection. Background: Autonomic dysfunction may be part of acute and long COVID-19 infection. Design/Methods: Six participants were enrolled and divided into two groups. The first group of 4 volunteers reported worsened autonomic symptoms post-COVID-19 infection. These individuals had first autonomic test prior to COVID-19 pandemic outbreak (July 2019- December 2019). Autonomic function testing was repeated in these participants, 6 months to 1- year post-COVID-19 infection (June, 2021). The second group of 2 volunteers reported newonset autonomic symptoms post-COVID-19 infection and were tested March-May, 2021. All participants were screened for known causes of autonomic dysfunction and had normal neurophysiological studies (EMG/NCS), no hypertension/hyperlipidemia or thyroid dysfunction, no diabetes/prediabetes, no vitamin deficiencies, no history of HIV, hepatitis, or syphilis, no prior radiation or chemical exposure and no evidence of monoclonal gammopathy, or autoimmune condition. Participants were diagnosed with COVID-19 via PCR testing, and tested again via SARS-CoV-2 capsid-antibody test. Results: All volunteers were female (age: 21-37y) and endorsed orthostatic intolerance. Gastrointestinal symptoms (5/6), new-onset paresthesias, drier skin (3/6), and sexual dysfunction (2/6) were reported. Dysgeusia reported in 50%, but was not demonstrated on neurological examination. Parasympathetic autonomic function remained stable 6-months to 1- year post-COVID-19 infection and not demonstrated in participants with new-onset symptoms. Sympathetic-adrenergic dysfunction as new-onset orthostatic hypotension and abnormalities on blood-pressure response to Valsalva was found in 50% of participants. Sympathetic cholinergic (sudomotor) dysfunction was demonstrated in ALL participants. Worsened, or new-onset, sudomotor dysfunction was demonstrated in those with mild or normal sudomotor function on pre-COVID-19 autonomic testing Conclusions: Sudomotor dysfunction was demonstrated as worsened or new-sequelae to COVID-19 infection. COVID-19 may be responsible for new-onset or worsened small-fiber neuropathy in this sample.

The use of Faecal Immunochemical Testing (FIT) and Minimal Preparation Computed Tomography (MPCT) during COVID-19 for Urgent Suspected Cancer (USC) referrals in patients with lower gastro-intestinal symptoms

Introduction: Revised patient pathways incorporating combinations of FIT and MPCT were introduced to triage USC referrals during the COVID-19 pandemic to replace straight-to- test colonoscopy. This study aims to evaluate the effectiveness of a secondary care diagnostic pathway improvement initiative for colorectal cancer referrals. Method: All consecutive patients referred from primary care on the USC pathway between 15th March -15th June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations, timelines and patient outcomes up to 90 days following initial referral. Results: 816 patients across 8 sites in Wales were included in this initial analysis. 52.7% of patients were female with median age 69 (21 -97) years. Of the 50.7% who had first-line clinical review, 70.5% were virtual consultations. 49.3% had primary investigations, with FIT in 31% of patients and MPCT in 18.3%. This was compliant with locally agreed pathways for 77.3% of referrals. COVID-response pathways achieved a 28.5% reduction in use of colonoscopy as first-line investigation and 84.3% of patients avoided face-to- face consultations during this first wave of the pandemic. Referred patients required a median of 1 secondary care investigation (0 -6). Overall, 5.6% of USC referrals were diagnosed with CRC, similar to pre-pandemic rates. Median timescale from diagnosis to treatment for CRC was 82 (4 -175) days. The NPV for FIT in this cohort was 99.5%. MPCT as the first modality had a NPV of 99%. Conclusion: A modified investigation pathway maintained cancer diagnosis during the pandemic with improved resource utilisation to that used previously.

COVID-19 and the emergency presentation of colorectal cancer

Introduction: The COVID-19 pandemic led to widespread disruption of colorectal cancer services during 2020. Cancer referral pathways were modified in response to reduced diagnostic availability. Our aim was to assess the impact of COVID-19 on colorectal cancer referral, presentation and stage. Methods: This single centre, retrospective cohort study was performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January to December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging. Results: 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender, and tumour location (P = >0.05). There was a significant decrease in Urgent Suspected Cancer (USC) referrals, diagnostic colonoscopy and radiological imaging performed between March to June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018/19 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018/19 (P = 0.03). Conclusion: This study demonstrates that a relatively short-term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is critical that efforts are made to make this pathway more robust to minimise the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment.

Where have all the appendicectomies gone?

INTRODUCTION: The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS: A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS: A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS: The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.