Scaling up area-based conservation to implement the Global Biodiversity Framework's 30x30 target: The role of Nature's Strongholds.

The Global Biodiversity Framework (GBF), signed in 2022 by Parties to the Convention on Biological Diversity, recognized the importance of area-based conservation, and its goals and targets specify the characteristics of protected and conserved areas (PCAs) that disproportionately contribute to biodiversity conservation. To achieve the GBF's target of conserving a global area of 30% by 2030, this Essay argues for recognizing these characteristics and scaling them up through the conservation of areas that are: extensive (typically larger than 5,000 km2); have interconnected PCAs (either physically or as part of a jurisdictional network, and frequently embedded in larger conservation landscapes); have high ecological integrity; and are effectively managed and equitably governed. These areas are presented as "Nature's Strongholds," illustrated by examples from the Congo and Amazon basins. Conserving Nature's Strongholds offers an approach to scale up initiatives to address global threats to biodiversity.

Antibiotics Prophylaxis Practice in Arthroplasty Surgeries.

Background Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability, and increased mortality. One of the cornerstones of the prevention of infections is antibiotic prophylaxis. This study assessed the practice of antibiotic prophylaxis in arthroplasty surgeries in our local hospital. Methods One hundred and seventy-one elective joint replacement patients were retrospectively analyzed for documentation of antibiotic plan in postoperative instruction, choice of antibiotic, dose, and dosage. Compliance with the dosage (duration and frequency) of antibiotic prophylaxis was compared among patients who underwent different operations, among patients whose operation notes had antibiotics plans, and among those patients whose operation notes lacked this information. Results Ninety-six females and 75 males with a mean age of 71.4±9.8 years who underwent hip replacement, knee replacement, or shoulder replacement were included in this study. Preoperative and postoperative antibiotics were received by 100% and 94.7% of patients, respectively. In 19.3%, there was no instruction about postoperative antibiotics while 4% missed at least one postoperative dose. The dosage of postoperative prophylactic antibiotics was variable as 26.3% of the patients experienced delayed administration of doses. Not having intravenous access, failure to prescribe antibiotics, and prescribing antibiotics in the "once only" rather than "regular medication" section of the medication chart were the reasons for improper timing of antibiotic doses. Observing surgical safety checklist was effective in ensuring preoperative antibiotic administration, whereas failing to document antibiotic plan in operation note was associated with poor compliance with postoperative dosage. Interprofessional participation is crucial to compliance with antibiotic prophylaxis practice. Conclusion This study identified key areas for improvement in our antibiotics prophylaxis practice. It resulted in implementing strategies to improve staff's awareness about the importance of timely administration of prophylactic antibiotics and proper documentation by all team members.

Audit on the Adequacy of Consenting Practices for Neck of Femur Fracture Surgeries.

INTRODUCTION: Doctors are bound to obtain informed written consent prior to any form of surgical procedure on a patient. The General Medical Council (GMC) and the Royal College of Surgeons of England (RCS) provide guidance on what constitutes valid consent. Failure to obtain valid and adequate consent can have legal ramifications. All relevant material risks associated with the surgery must be discussed with the patient during the consenting process. MATERIALS AND METHODS: This was a retrospective cross-sectional study of the consenting practices for neck of femur fracture surgeries, covering a period of three months, from the 15th of April to the 15th of July 2023. We evaluated the consent forms of 100 patients, of which 63 were consent form-1 and were included in the study. The British Orthopaedics Association (BOA)-endorsed consent forms, together with the RCS and GMC guidance on consent, which were used as the standard for the audit. RESULTS: The majority of the consents were obtained by senior house officers (SHO) and core surgical trainees who did not have prior formal orthopaedic training (52.4%). The risks that were most frequently documented were infection, blood clots (deep vein thrombosis and pulmonary embolism), and bleeding, with documentation rates of over 90%. Prosthetic joint dislocation following hemiarthroplasty or total hip replacement was not mentioned in 22.2% of the forms. Neurovascular injury was not documented in 20.6% of the consent forms. Less than 75% documentation rates were observed for postoperative pain (74.6%), anesthetic complications (73%), failure (malunion/non-union/loosening of prosthesis) (68.3%), leg length discrepancy (60.3%), bone damage/fracture (50.8%), death (49.2%), wound-related complications/scars (42.9%), and hip stiffness (14.3%). None of the patients had been advised about the probable need for catheterization following surgery. We also noted that 22.2% (n=14) of the consent forms did not contain the diagnosis or the indication for surgery, 12.7% (n=8) did not mention the intended benefits, and 28.6% (n=18) of the consent forms had no mention of the responsible consultant. We also noted that in 25.4% (n=16) of the cases, the possible requirement of a blood transfusion had not been mentioned. CONCLUSION: The audit revealed several deficiencies in the consenting of patients for neck and femur fracture surgeries. There were poor documentation rates for risks associated with surgery, especially the less common and rare ones. We also identified several deficiencies in the remaining aspects of the consent forms that were not in keeping with the GMC and RCS guidance on consent. The lack of orthopaedic training and knowledge among the senior house officers and core trainees may be a contributing factor.

Novel use of a bronchoscope and bariatric needle holder for retrieval of retained intramedullary metalwork during total knee arthroplasty.

Retained metalwork during total joint arthroplasties usually occur from accidental misplacement of jig locking pins into the medullary canal via the aperture created for intramedullary referencing. They are associated with significant clinical and financial consequences for the patient, surgeon and health care provider. Hence the imperative to device methods to not only prevent their occurrence but reliably retrieve any trapped foreign body. We describe an easy, reliable, reproducible, fluoroscopy-free and time efficient way to retrieve metalworks trapped in the medullary canal, with the aid of a bronchoscope and a bariatric needle holder.•The described method utilises two instruments which are readily available in theatres - single use flexible bronchoscope and bariatric needle holder.•Prior experience in bronchoscopy or laparoscopic surgery is not required to adapt the instruments for this purpose.•This technique minimises both the stress on the patient and the surgical team.

What's on the horizon for community-based conservation? Emerging threats and opportunities.

Community-based conservation can support livelihoods and biodiversity, while reinforcing local and Indigenous values, cultures, and institutions. Its delivery can help address cross-cutting global challenges, such as climate change, conservation, poverty, and food security. Therefore, understanding trends in community-based conservation is pertinent to setting and implementing global goals. We undertook a horizon scan to prioritize 15 emerging threats and opportunities expected to impact the future effectiveness of community-based conservation. Topics relate to global biodiversity policy; human rights; shifting human geography; inclusion, diversity, equity, and access; conservation finance and income; and economic reforms. Our findings offer guidance on strengthening community-based conservation to achieve global environmental and development goals.

Drivers of deforestation and degradation for 28 tropical conservation landscapes.

Analysing the drivers of deforestation and forest degradation in conservation landscapes can provide crucial information for conservation management. While rates of forest loss can be measured through remote sensing, on the ground information is needed to confirm the commodities and actors behind deforestation. We administered a questionnaire to Wildlife Conservation Society's landscape managers to assess the deforestation drivers in 28 tropical conservation landscapes. Commercial and subsistence agriculture were the main drivers of deforestation, followed by settlement expansion and infrastructure development. Rice, rubber, cassava and maize were the crops most frequently cited as drivers of deforestation in these emblematic conservation landscapes. Landscape managers expected deforestation trends to continue at similar or greater magnitude in the future, calling for urgent measures to mitigate these trends.

Virtual Interviews at Graduate Medical Education Training Programs: Determining Evidence-Based Best Practices.

The COVID-19 pandemic has had a profound impact on the nation's health care system, including on graduate medical education (GME) training programs. Traditionally, residency and fellowship training program applications involve in-person interviews conducted on-site, with only a minority of programs offering interviews remotely via a virtual platform. However, in light of the COVID-19 pandemic, it is anticipated that most interviews will be conducted virtually for the 2021 application cycle and possibly beyond. Therefore, GME training programs need to prepare for the transition to virtual interviews using evidence-based practices. At the University of California, San Francisco, a multidisciplinary task force was convened to review existing literature about virtual interviews and determine best practices. This article summarizes these findings, first discussing the advantages and disadvantages of the virtual interview format and then providing evidence-based best practices for GME training programs. Specifically, the authors make the following recommendations: develop a detailed plan for the interview process, consider using standardized interview questions, recognize and respond to potential biases that may be amplified with the virtual interview format, prepare your own trainees for virtual interviews, develop electronic materials and virtual social events to approximate the interview day, and collect data about virtual interviews at your own institution. With adequate preparation, the virtual interview experience can be high yield, positive, and equitable for both applicants and GME training programs.

Management of periprosthetic distal femur fractures using distal femoral arthroplasty and fixation - Comparative study of outcomes and costs.

PURPOSE: Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing) in the management of distal femur peri-prosthetic fractures. METHODS: We reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005 and 2013 (n = 61). The patients were stratified into 2 groups based on management method. The Distal Femoral Arthroplasty group (Group A) had 21 patients and the Fixation group (Group B) had 40 patients. Outcome & cost were compared. Minimum follow-up was 3 years. RESULTS: The mean length of stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 3 in group A, compared to a mean of 11 weeks in group B. Mean OKS was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. In group A, there were 2 deaths, 1 superficial infection, and 1 DVT. In group B, there were 6 deaths, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £9600 and the fixation group costs were on average of £9800. CONCLUSION: Distal femoral arthroplasty appears to provide good clinical results, with comparable overall costs to fixation.

Presenting for Duty: Lessons From A Specialty Surgery Division at the Pandemic Epicenter.

MINI-ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic has had catastrophic repercussions across the world and here in the United States. The healthcare system in New York City, the epicenter, has faced significant disruptions due to the sheer volume of cases and critical care needs of severely ill patients. For surgical specialty services, the postponement of all elective surgeries, redeployment of faculty and staff, and cancellation of outpatient clinics became a rapid reality. These circumstances required a nimble restructuring of services and communications to facilitate continued support of academic and clinical missions. Throughout the course of the pandemic, significant adjustments were made in regards to duties, patient services, and communication. The frameworks and techniques utilized are described along with the relevant outcomes. Immediate restructuring of tumor boards, a focused multidisciplinary approach to management that incorporated the barriers presented by the pandemic, optimization of telehealth services, inclusive communication, and a service-oriented approach to redeployment were critical to sustaining the Division of Breast, Melanoma, and Soft Tissue surgery.

Preoperative laboratory testing - Comparison of National Institute of Clinical Excellence guidelines with current practice - An observational study.

BACKGROUND AND AIMS: Preoperative laboratory testing is done to detect abnormalities in the body not detected by clinical examination. Often a battery of tests is advocated as a routine for patients scheduled for low or intermediate risk surgery. This prospective observational study was aimed to assess agreement of the current practice of preoperative laboratory investigations with the National Institute of Clinical Excellence (NICE) guidelines, and the impact of investigations on patient care and costs. MATERIAL AND METHODS: The study was conducted at a tertiary referral center on 385 patients aged 18-70 years of either gender, posted for elective general surgical, gynaecological or otolaryngological surgery. Sixteen investigations were examined: hemogram, blood urea, serum creatinine, serum electrolytes, coagulation profile, urinalysis, thyroid function tests, electrocardiogram, echocardiogram, chest x-ray, pulmonary function tests, blood sugar, glycosylated hemoglobin, liver function tests, treadmill test and coronary angiogram. The history and physical examination were reviewed to examine for indication for these laboratory investigations. These were compared with NICE guidelines. Impact of these investigations on anesthetic decision-making was noted. RESULTS: There was almost no agreement of the current practice with the NICE guidelines. The total cost of all tests obtained was Rs 5,48,755. Total additional cost of unindicated tests was Rs 5,10,730 (93%). Average amount spent on additional investigations per patient was Rs 1326.57. CONCLUSION: Most investigations are overprescribed and have minimal agreement with NICE guidelines. None of the tests had any impact on clinical care. Nearly a million rupees is incurred per year in one referral hospital alone, when NICE guidelines are not followed.

Influences on safety consciousness in a utility company: A sequential mediation model.

INTRODUCTION: The purpose of this research was to determine whether the influence of supervisory support for safety on safety consciousness is direct or indirect. Based in part on predictions from the Theory of Reasoned Action (TRA) and Social Cognitive Theory (SCT), we examined the extent to which belief (safety self-efficacy) and attitude (cavalier safety attitude) mediate the impact of supervisory support for safety on employee safety consciousness. METHOD: A survey of 995 employees was distributed across 24 work groups in an electric utility company, and sequential mediation modeling was used to determine indirect effects on safety consciousness. RESULTS: We found that the effect of supervisory support on safety consciousness was indirect, fully mediated through both efficacy and attitude in a sequential mediation model. Practical applications: Supervisors should be aware of and emphasize supportive behaviors and create welcoming conditions for employees to raise safety concerns. Furthermore, organizational programs pertaining to safety improvement need to consider how to develop positive beliefs regarding safety activity and attitudes and reduce negative ones.

Effect of air, anesthetic gas mixture, saline, or 2% lignocaine used for tracheal tube cuff inflation on coughing and laryngotracheal morbidity after tracheal extubation.

BACKGROUND AND AIMS: Coughing and sore throat postoperatively are common clinical problems during general anesthesia which can be avoided by various methods including topicalization of airway with local anesthetics, endotracheal tube cuff (ETT) inflation with local anesthetics, use of intravenous drugs such as dexamethasone, maintaining ETT cuff pressure, intubation by an experienced anethesiologist, etc. The aims of the study were to compare postextubation coughing response, mean number of cuff deflations required intraoperatively, and postoperative airway morbidity in terms of sore throat (2 h and 18-24 h), hoarseness of voice, and dysphagia following inflation of ETT cuff with air, anesthetic gas mixture, saline, and 2% lignocaine during general anesthesia. MATERIAL AND METHODS: One hundred and four patients were randomized into 1 of 4 groups depending on whether air, anesthetic gas mixture, saline, or 2% lignocaine was used to inflate the cuff of ETT using computer-generated randomization table. RESULTS: There was no significant difference in the postextubation cough response among the four groups. The mean number of times the ETT cuff was deflated was significantly in favor of liquid media comapred to gaseous media (P < 0.001). The incidence of sore throat at 2 h and at 18-24 h, hoarseness of voice, and dysphagia were comparable in all groups. CONCLUSION: ETT cuff inflation with air, anesthetic gas mixture, 2% lignocaine, and saline are comparable in terms of incidence of postextubation cough and postoperative airway morbidity symptoms such as sore throat, hoarseness of voice, and dysphagia.

Dramatic cropland expansion in Myanmar following political reforms threatens biodiversity.

Effective conservation planning needs to consider the threats of cropland expansion to biodiversity. We used Myanmar as a case study to devise a modeling framework to identify which Key Biodiversity Areas (KBAs) are most vulnerable to cropland expansion in a context of increasingly resolved armed conflict. We studied 13 major crops with the potential to expand into KBAs. We used mixed-effects models and an agricultural versus forest rent framework to model current land use and conversion of forests to cropland for each crop. We found that the current cropland distribution is explained by higher agricultural value, lower transportation costs and lower elevation. We also found that protected areas and socio-political instability are effective in slowing down deforestation with conflicts in Myanmar damaging farmland and displacing farmers elsewhere. Under plausible economic development and socio-political stability scenarios, the models forecast 48.5% of land to be converted. We identified export crops such as maize, and pigeon pea as key deforestation drivers. This cropland expansion would pose a major threat to Myanmar's freshwater KBAs. We highlight the importance of considering rapid land-use transitions in the tropics to devise robust conservation plans.

Comparison of laryngeal mask airway CTrach™ and Airtraq® videolaryngoscopes as conduits for endotracheal intubation in patients with simulated limitation of cervical spine movements by manual in-line stabilization.

BACKGROUND AND AIMS: Laryngeal mask airway (LMA) CTrach™ and Airtraq® videolaryngoscopes are useful for endotracheal intubation in patients with limited cervical spine movements and other predicted difficult airways. We aimed to compare LMA CTrach™ and Airtraq® videolaryngoscopes as conduits for endotracheal intubation in patients with simulated limitation of cervical spine movements by manual in-line stabilization (MILS). MATERIAL AND METHODS: This was a prospective, randomized study including 50 patients undergoing elective surgeries under general anesthesia. Patients were assigned to undergo intubation using Airtraq® (n = 25) or LMA CTrach™ (n = 25) by an experienced anesthesiologist, while MILS was provided. Laryngoscopy and intubation were compared in terms of time taken to obtain optimal laryngeal view, successful intubation, total time, percentage of glottis opening (POGO) score, maneuvers required for optimal laryngeal view and alignment of endotracheal tube, and number of attempts and complications. An integrated score was calculated to classify the attempt as good, restricted, or poor. RESULTS: Time taken to obtain optimal laryngeal view, successful intubation, and total time in both groups were comparable. POGO score >50% was seen in 25 and 21 patients in Groups A and C. Seventy-six percent and ninety-six percent in Groups A and C, respectively, had a good integrated score; 6% and 1% had restricted score; none had a poor score; and the difference between them was statistically significant (P = 0.042). CONCLUSIONS: LMA CTrach™ and Airtraq® are similar with respect to time taken for obtaining optimal laryngeal view, successful intubation, and total time when used for intubation in patients with simulated limitation of cervical spine movements.

Merkel-cell carcinoma of the upper limb.

Merkel-cell carcinoma is a rare form of aggressive cutaneous cancer that is associated with a poor prognosis. Despite significant advances, its pathogenesis is still poorly understood, and treatment remains controversial. Timely diagnosis and early management is essential in improving survival rate. We present a case of a 63-year-old patient with a rapidly growing upper limb Merkel-cell carcinoma. It was treated with wide-local excision and adjuvant radiotherapy.

Sleep and hypothalamic pituitary adrenal axis responses to metyrapone in posttraumatic stress disorder.

Disturbed sleep is a core feature of posttraumatic stress disorder (PTSD), characterized in part by decreased delta power sleep that may result from stress-related alterations in corticotropin releasing factor (CRF), hypothalamic pituitary adrenal axis (HPA) regulation and glucocorticoid signaling. Overnight HPA axis response mediating sleep disturbances in men and women with PTSD was examined using a metyrapone challenge. Metyrapone blocks cortisol synthesis, removing negative feedback, and increases the release of hypothalamic CRF and pituitary adrenocorticotropic hormone (ACTH). Laboratory-based polysomnography was used to monitor the sleep of 66 medically healthy, medication-free men and pre-menopausal follicular phase women including 33 with chronic PTSD (16 women and 17 men) and 33 age- and sex-matched controls (14 women and 19 men) over 3 consecutive nights. Participants completed an overnight metyrapone challenge after an adaptation and baseline night of sleep and ACTH was obtained by repeated blood sampling. Metyrapone resulted in a greater increase in ACTH and greater decreases in cortisol and delta spectral power sleep in PTSD subjects compared to controls, and a greater increase in ACTH in women compared to men. There was no sex difference in metyrapone effects on delta power sleep, and no significant metyrapone by PTSD by sex interactions with either ACTH or delta power sleep. Regression analyses indicated that a greater increase in ACTH response was associated with a greater decrease in delta power sleep response in PTSD subjects, but no such relationship was found in controls. The PTSD group difference was similar in men and women. These results suggest that stress-related alterations of the HPA axis in PTSD may contribute to sleep difficulties. Therapeutics that target the HPA axis may offer promise as a potential future treatment for PTSD and related sleep difficulties.

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.