Rates of tree cover loss in Key Biodiversity Areas on Indigenous Peoples' lands.

Indigenous Peoples' lands (IPL) cover at least 38 million km2 (28.1%) of Earth's terrestrial surface. These lands can be important for biodiversity conservation. Around 20.7% of IPL intersect areas protected by government (PAs). Many sites of importance for biodiversity within IPL could make a substantial but hitherto unquantified contribution to global site-based conservation targets. Key Biodiversity Areas (KBAs) represent the largest global network of systematically identified sites of high importance for biodiversity. We assessed the effectiveness of IPL in slowing biodiversity loss inside and outside PAs by quantifying tree cover loss from 2000 to 2019 in KBAs at international and national levels and comparing it with losses at equivalent sites outside mapped IPL. Based on a matched sample of 1-km2 cells in KBAs inside and outside mapped IPL, tree cover loss in KBAs outside PAs was lower inside IPL than outside IPL. By contrast, tree cover loss in KBAs inside PAs was lower outside IPL than inside IPL (although the difference was far smaller). National rates of tree cover loss in KBAs varied greatly in relation to their IPL and PA status. In one half of the 44 countries we examined individually, there was no significant difference in the rate of tree cover loss in KBAs inside and outside mapped IPL. The reasons for this intercountry variation could illuminate the importance of IPL in meeting the Convention on Biological Diversity's ambition of conserving 30% of land by 2030. Critical to this will be coordinated action by governments to strengthen and enforce Indigenous Peoples' rights, secure their collective systems of tenure and governance, and recognize their aspirations for their lands and futures.

Tasas de pérdida de la cobertura arbórea en áreas clave de biodiversidad en suelo indígena Resumen Las tierras de los pueblos indígenas (TPI) cubren al menos 38 millones de km2 (28.1%) de la superficie del planeta. Estas tierras pueden ser importantes para la conservación de la biodiversidad. Un 20.7% de las TPI se intersecan con áreas protegidas (AP) por el gobierno. Muchos sitos con importancia para la biodiversidad dentro de las TPI podrían contribuir de forma sustancial, pero todavía sin cuantificar, a los objetivos globales de conservación in situ. Las áreas clave para la biodiversidad (ACB) representan la mayor red mundial de sitios con identificación sistemática de gran valor para la biodiversidad. Evaluamos la efectividad de las TPI en la reducción de la pérdida de la biodiversidad dentro y fuera de las AP mediante la cuantificación de la pérdida de la cobertura arbórea entre el 2000 y 2019 en las ACB a niveles nacional e internacional. También comparamos esta efectividad con las pérdidas en sitios equivalentes fuera de las TPI mapeadas. Con base en una muestra emparejada de celdas de 1-km2 en ACB dentro y fuera de las TPI mapeadas, la pérdida de la cobertura arbórea en las ACB ubicadas fuera de las AP fue menor dentro de las TPI que fuera de ellas. Al contrario, la pérdida en las ACB ubicadas dentro de las AP fue menor afuera de las TPI que adentro de ellas (aunque la diferencia fue por mucho menor). Las tasas nacionales de pérdida de la cobertura arbórea en las ACB variaron sobremanera en relación con su estado en las TPI y en las AP. En la mitad de los 44 países que analizamos individualmente no hubo una diferencia significativa en la tasa de pérdida de la cobertura arbórea en las ACB dentro y fuera de las TPI mapeadas. Las razones detrás de esta variación entre los países podrían aclarar la importancia que tienen las TPI para cumplir con la meta del Convenio sobre Diversidad Biológica de conservar el 30% del suelo para el 2030. La acción coordenada de los gobiernos será crítica para fortalecer y hacer cumplir los derechos de los pueblos indígenas, asegurar su sistema colectivo de tenencia y gobierno, y reconocer sus objetivos para sus tierras y el futuro.

Standardised Competency-Based Training of Medical Doctors and Associate Clinicians in Inguinal Repair with Mesh in Sierra Leone.

INTRODUCTION: In low-income settings, there is a high unmet need for hernia surgery, and most procedures are performed with tissue repair techniques. In preparation for a randomized clinical trial, medical doctors and associate clinicians received a short-course competency-based training on inguinal hernia repair with mesh under local anaesthesia. The aim of this study was to evaluate feasibility, safety and effectiveness of the training. METHODS: All trainees received a one-day theoretical module on mesh hernia repair under local anaesthesia followed by hands-on training. Performance was assessed using the American College of Surgeon's Groin Hernia Operative Performance Rating System. Patients were followed up two weeks and one year after surgery. Outcomes of the patients operated on during the training trial were compared to the 229 trial patients operated on after the training. RESULTS: During three surgical camps, seven medical doctors and six associate clinicians were trained. In total, 129 patients were operated on as part of the training. Of the 13 trainees, 11 reached proficiency. Patients in the training group had more wound infections after two weeks (8.5% versus 3.1%; p = 0.041). There was no difference in recurrence and mortality after one year, and none of the deaths were attributed to the surgery. DISCUSSION AND CONCLUSION: Mesh repair is the international standard for inguinal hernia repair worldwide. Nevertheless, this is not widely accessible in low-income settings. This study has demonstrated that short-course intensive hands-on training of MDs and ACs in mesh hernia repair is effective and safe. TRIAL REGISTRATION: International Clinical Trial Registry ISRCTN63478884.

Prevalence, incidence, repair rate, and morbidity of groin hernias in Sierra Leone: cross-sectional household study.

BACKGROUND: Knowledge about the prevalence of groin hernias in sub-Saharan Africa is limited. Previous studies have demonstrated a higher incidence of the condition than the annual repair rate. This study aimed to investigate prevalence, incidence, annual repair rate, morbidity, and health-seeking behaviour of persons with groin hernias in Sierra Leone. METHODS: This population-based, cross-sectional household survey on groin hernias in Sierra Leone was part of the Prevalence Study on Surgical Conditions 2020 (PRESSCO 2020). Those who indicated possible groin hernia were asked problem-specific questions and underwent physical examination to confirm or exclude the diagnosis. RESULTS: 3626 study participants were interviewed. The prevalence of untreated groin hernia was 1.1 per cent (95 per cent c.i. 0.8 to 1.5 per cent), whereas the prevalence of untreated and treated groin hernia was 2.5 per cent (95 per cent c.i. 2.0 to 3.0 per cent). The proportion of recurrence was 13.1 per cent. An incidence of 389 (95 per cent c.i. 213 to 652) groin hernia cases per 100 000 people per year was identified, while a population-based annual hernia repair rate estimation was 470 (95 per cent c.i. 350 to 620) per 100 000 people. Out of 39 participants with groin hernia, non-ignorable pain was reported by eight and 27 reported financial shortcomings as a reason for not seeking healthcare. CONCLUSIONS: Groin hernias are common in Sierra Leone and although the repair rate might match the incidence, the existing backlog of untreated hernias is likely to remain. It may be possible to reduce the number of recurrences through improved management. Measures to reduce financial barriers to treatment seem crucial to improve the health of people with groin hernias in Sierra Leone.

Inguinal hernia surgery learning curves by associate clinicians.

BACKGROUND: Open inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries. METHODS: Logbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated. RESULTS: Seventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3-84.0) to 48.6 (95% CI 44.3-52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7-20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1-10.8 vs. 5.4 days, 95% 3.1-7.6). Operating times flattened after 31-35 cases which corresponded with 1.5 years of training. CONCLUSIONS: The learning curve of inguinal hernia surgery for associate clinicians flattens after 31-35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BACKGROUND: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

Nanoscale Interfacial Smoothing and Dissolution during Unconventional Reservoir Stimulation: Implications for Hydrocarbon Mobilization and Transport.

Hydraulic fracturing of low-permeability rocks significantly enhances hydrocarbon production from unconventional reservoirs. However, fluid transport through low-permeability rocks and the influence of geochemical transformations on pore networks are poorly constrained. Mineral reactivity during interactions with injected water may alter the physical nature of the rock, which may affect hydrocarbon mobility. To assess alterations to the rock, we have previously conducted a hydrothermal experiment that reacted cubed rock samples (1 cm3) with synthetic hydraulic fracturing fluid (HFF) to simulate physicochemical reactivity during hydraulic fracturing. Here, we analyze unreacted and reacted rocks by small-angle neutron scattering and high-pressure mercury intrusion to determine how the pore networks of unconventional reservoir rocks are influenced by the reaction with hydraulic fracturing injectates. Our results suggest that fluid-rock interactions exhibit a two-fold influence on hydrocarbon recovery, promoting both hydrocarbon mobilization and transport. Pore-matrix interfaces smooth via the removal of clay mineral surface asperities, reducing the available surface area for hydrocarbon adsorption by 12-75%. Additionally, HFF-induced dissolution creates new pores with diameters ranging from 800-1400 nm, increasing the permeability of the rocks by a factor of 5-10. These two consequences of mineral dissolution likely act in concert to release hydrocarbons from the host rock and facilitate transport through the rock during unconventional reservoir production.

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial.

Importance: Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. Objective: To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. Design, Setting, and Participants: This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. Interventions: All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. Main Outcomes and Measures: The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. Results: A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001). Conclusions and Relevance: These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries. Trial Registration: isrctn.org Identifier: ISRCTN63478884.

Accuracy of vital status ascertainment using the Social Security Death Master File in a deceased population.

Both insurance and clinical studies depend on the Social Security Death Master File (SSDMF) to provide vital status on subjects that are unavailable for direct ascertainment. Using the Gen Re individual life claims data, we analyzed the accuracy of vital status determination in a population known to be deceased. Overall, only 75% of claims appeared in the SSDMF. The detection rate is highly skewed by age of the decedent. This systematically reduced ascertainment of mortality at younger ages could cause misleading conclusions in studies that measure absolute mortality rates, especially when they include a wide age span.

Mortality experience in the elderly in the Impairment Study Capture System.

Using the dataset of the Impairment Study Capture System, we analyzed mortality experience and underwriting on policies issued at ages 70 and up. Policy issue dates were from 1990-1998 and observation ran from 5-12 years. There were 1430 deaths in a total exposure of over 102,000 policy-years. Nearly two thirds of the total exposure was for females. Despite the use of expected mortality differentiated by smoking status, the mortality ratio for smokers was much higher than for nonsmokers. Both the type of underwriting (paramedical and medical compared to nonmedical and simplified) and the underwriting risk class confirmed the intended effects of underwriting. Variation of mortality ratio by duration after issue did not contradict the select period slope of the 2001 VBT.

Mortality and Morbidity Liaison Committee--ISCS body mass index study.

OBJECTIVE: This study used the Impairment Study Capture System (ISCS) to examine the relationship between mortality and body mass index (BMI) in an insured population, particularly BMI in isolation from other risk factors. BACKGROUND: Large-scale studies of build in an insured population have traditionally been done on policies issued at standard premium rates. Insured mortality experience on elevated BMI is scarce or outdated. Increasingly competitive underwriting of build throughout the years has influenced what has been issued standard, and therefore, the relative experience of substandard to standard business. METHODS: We studied 241,966 policies submitted through the ISCS between 1989 and 2003 with actual height and weight and a code signifying abnormal build. Actual BMI were derived for these insureds. The average BMI was 35.0. Standardized mortality ratios (SMR) were computed using the 2001 Valuation Basic Table (VBT) as the expected basis. The average duration of exposure was 2.5 years. Results were stratified by underwriting factors of interest. RESULTS: Standardized mortality ratios rose quite modestly as BMI increased up until reaching severe obesity. Ratios for nonsmoker policies where elevated build was the only impairment saw SMR of 265% at BMI < 18.5, 130% at BMI 30.0-34.9, 160% at BMI 35.0-39.9 and 239% at BMI > or = 40.0. Ratios where other impairments were present tended to be higher in moderately obese ranges and lower at extremely obese ranges. No underwriting factor of significance impacted the pattern of ratios as BMI increased. CONCLUSIONS: While an average of 3 years may not be long enough to see the true manifestations of obesity, excess mortality is exhibited at low and high BMI ranges, especially when seen in isolation. The study is not a direct comparison of obese to non-obese subjects, but it is a point of reference for how obese insureds have fared vs standard issued policies. The relatively favorable experience may have more to do with the construction of the (standard) VBT table than any mitigating effect of modest obesity.

Using predictive value, sensitivity and specificity to interpret laboratory tests: PSA for the diagnosis of prostate cancer.

The Prostate Cancer Prevention Trial yields a means to evaluate PSA screening for prostate cancer detection. The receiver operating characteristic curve shows that PSA above 2.5 provides optimum sensitivity and specificity for prostate cancer diagnosis by needle biopsy. However, the maximum positive predictive value of 48% occurs at PSA above 4.0 and does not increase at higher PSA cutpoints. Consideration of test sensitivity and specificity alone is not sufficient for optimal interpretation of test results.

Recurrent PSA after prostatectomy for prostate cancer: implications of PSA doubling time.

After radical prostatectomy for prostate cancer, men frequently develop detectable levels of prostate specific antigen (PSA). A slow rate of increase, as characterized by the PSA doubling time (PSADT) is the principal marker for a favorable prognosis. Data and results presented in 2 recent clinical articles studying cohorts of men with clinical stage T1/T2 prostate cancer are reviewed and used to develop mortality analyses. Life-table analysis shows a mortality ratio of 257% at 5 years for Gleason score < 8, PSA recurrence > 2 years after surgery for clinical stage T1/T2 disease, and PSA doubling time (PSADT) > 10 months. Markov modeling using transition probabilities derived from the clinical articles to develop a life table analysis yields a mortality ratio of 145% at 10 years for similar patients.

Coronary angiography report.

Reports of coronary angiography frequently determine underwriting decisions. This report exemplifies the ideal format and content for effective clinical or insurance risk assessment.