A Critical Evaluation of International Agreements Towards a Revised Categorization for Transfrontier Conservation Areas (TFCAs).

Transfrontier Conservation Areas (TFCAs) are widely promoted as an international instrument to achieve certain conservation, cooperation and developmental goals, especially within the Southern African Development Community (SADC). In the SADC context, the status of TFCAs is categorized based on the extent to which international agreements have been signed. These agreements take different forms such as treaties, memorandums of understanding (MoUs), protocols and bilateral agreements. However, the efficacy of agreement-based approaches towards the categorization of TFCAs has been questioned because it does not acknowledge the implementation complexities of TFCAs and lacks a sound conceptual basis. This research evaluates the international TFCA agreements in SADC with a view to recommending a revised categorization. This is achieved by applying Theory of Change (ToC) to a sample of ten signed TFCAs agreements. The results show a lack of enforcement mechanisms, weak provision for implementation and poorly defined objectives. These weaknesses of agreement-based approaches can best be addressed by expanding the categorization of TFCAs to also include the extent of legislative and operational alignment. The revised categorization supports a more complete understanding of TFCA implementation.

Clinical characteristics associated with mortality of COVID-19 patients admitted to an intensive care unit of a tertiary hospital in South Africa.

BACKGROUND: Over 130 million people have been diagnosed with Coronavirus disease 2019 (COVID-19), and more than one million fatalities have been reported worldwide. South Africa is unique in having a quadruple disease burden of type 2 diabetes, hypertension, human immunodeficiency virus (HIV) and tuberculosis, making COVID-19-related mortality of particular interest in the country. The aim of this study was to investigate the clinical characteristics and associated mortality of COVID-19 patients admitted to an intensive care unit (ICU) in a South African setting. METHODS AND FINDINGS: We performed a prospective observational study of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to the ICU of a South African tertiary hospital in Cape Town. The mortality and discharge rates were the primary outcomes. Demographic, clinical and laboratory data were analysed, and multivariable robust Poisson regression model was used to identify risk factors for mortality. Furthermore, Cox proportional hazards regression model was performed to assess the association between time to death and the predictor variables. Factors associated with death (time to death) at p-value < 0.05 were considered statistically significant. Of the 402 patients admitted to the ICU, 250 (62%) died, and another 12 (3%) died in the hospital after being discharged from the ICU. The median age of the study population was 54.1 years (IQR: 46.0-61.6). The mortality rate among those who were intubated was significantly higher at 201/221 (91%). After adjusting for confounding, multivariable robust Poisson regression analysis revealed that age more than 48 years, requiring invasive mechanical ventilation, HIV status, procalcitonin (PCT), Troponin T, Aspartate Aminotransferase (AST), and a low pH on admission all significantly predicted mortality. Three main risk factors predictive of mortality were identified in the analysis using Cox regression Cox proportional hazards regression model. HIV positive status, myalgia, and intubated in the ICU were identified as independent prognostic factors. CONCLUSIONS: In this study, the mortality rate in COVID-19 patients admitted to the ICU was high. Older age, the need for invasive mechanical ventilation, HIV status, and metabolic acidosis were found to be significant predictors of mortality in patients admitted to the ICU.

Identifying key risks to the performance of privately protected areas (PPAs) through theory of change (ToC).

Privately protected areas (PPAs) are internationally considered to be important policy implementation instruments to augment and strengthen protected area networks. However, there has been limited reflection on the performance of PPAs over time. This paper aims to identify key risks to the performance of PPAs as policy implementation instruments through the application of Theory of Change (ToC). Identifying and understanding these risks are important to allow for the evaluation and monitoring of PPA performance. The ToC method was applied to a specific PPA policy instrument namely, private nature reserves (PNRs) in the South African context. The research results produced 29 key assumptions translated into 29 key risks. These risk are critically discussed against existing South African and international literature. To test and refine the risks further it is recommended that they be applied to PPA case studies in different contexts.

The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis.

Bronchoscopy is useful as a diagnostic and therapeutic procedure in children with Tuberculosis (TB) disease complicated by airway obstruction. It is needed in children when surgical intervention may be required for airway compression, when drug resistance is suspected, and to rule out an alternative diagnosis for airway obstruction. Bronchoscopy with bronchoalveolar lavage (BAL) should be performed when other, less invasive samples cannot be collected, or when they fail to provide useful diagnostic information. BAL specimens collected at bronchoscopy can be tested using molecular TB assays and mycobacterial culture. The aim of this review is to evaluate the role of bronchoscopy in the diagnosis and management of pulmonary TB in children, and, specifically, to review the role of interventional bronchoscopy. A search of electronic databases was undertaken using the online databases PubMed, Ovid MEDLINE, EMBASE, Google Advanced Scholar, and Web of Science to identify relevant literature. The search was limited to pediatrics, pulmonology, bronchoscopy, and pediatric pulmonary tuberculosis for all articles published in English on pediatric bronchoscopy between 2010 and 2020. Recent advances in pediatric bronchoscopy was included, as well as recent research on improving the diagnosis with the use of interventional bronchoscopy. The role of bronchoscopy in pediatric pulmonary tuberculosis has changed during the last decade, from a simple method of collecting samples for bacteriological conformation to an more sophisticate procedure. New methods are available for collecting samples, which includes the use of Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and also better methods of bacteriological conformation. Interventions are now possible; not only to improve the diagnostic abilities of bronchoscopy but also to diagnose, manage, and follow-up upon airway-related complications. Bronchoscopy services remain limited in resource-limited countries due to the high cost of equipment.

Endobronchial actinomycosis in a child.

Actinomycosis is a rare, indolent and invasive infection caused by Actinomyces species. Pulmonary actinomycosis is very rarely seen in the paediatric population. The classic radiological presentation of thoracic involvement of actinomycosis includes lower lobe consolidation, empyema and periostitis of the ribs. We report a case of endobronchial actinomycosis in a child diagnosed on endobronchial biopsy and bronchoalveolar lavage (BAL). Bronchoscopy can be dangerous when performed on these cases, as there is a risk of severe bleeding and large airway obstruction, as was the case with this patient.

When is an Offset Not an Offset? A Framework of Necessary Conditions for Biodiversity Offsets.

Biodiversity offsets have become a widely accepted means of attempting to compensate for biodiversity loss from development, and are applied in planning and decision-making processes at many levels. Yet their use is contentious, and numerous problems with both the concept and the practice have been identified in the literature. Our starting point is the understanding that offsets are a kind of biodiversity compensation measure through which the goal of no net loss (or net gain) of biodiversity can be at least theoretically achieved. Based on a typology of compensation measures distinguishing between habitat protection, improvement (including restoration, habitat creation and improved management practices) and other compensation, we review the literature to develop a framework of conditions that must be met if habitat protection and improvement initiatives can be truly considered offsets and not merely a lesser form of compensation. It is important that such conceptual clarity is reflected in offset policy and guidance, if offsets are to be appropriately applied and to have any chance of fully compensating for biodiversity loss. Our framework can be used to support the review and ongoing development of biodiversity offset policy and guidance, with the aim of improving clarity, rigour and therefore the chances that good biodiversity outcomes can be achieved.

Bronchoscopy in children with COVID-19: A case series.

INTRODUCTION: The coronavirus disease-2019 (COVID-19) era is a challenging time for respiratory teams to protect their patients and staff. COVID-19 is predominantly transmitted by respiratory droplets; in the clinical setting, aerosol generating procedures pose the greatest risk for COVID-19 transmission. Bronchoscopy is associated with increased risk of patient-to-health care worker transmission, owing to aerosolized viral particles which may be inhaled and also result in environmental contamination of surfaces. METHODS: We describe our experience with the use of modified full-face snorkeling masks for pediatric bronchoscopy procedures in four COVID-19 infected children when filtering facepieces/respirators were in limited supply. RESULTS: Bronchoscopy was urgently required in four children, and could not be delayed until COVID-19 test results were available. During the pandemic peak, when respirators were in short supply, modified full-face snorkel masks (SEAC Libera, SEAC, Italy) were worn by the bronchoscopy team. Each mask was fitted with an O-ring, adapter, and heat and moisture exchanger filter. To date, there have been no COVID-19 infections among the bronchoscopy team staff, whereas the overall Hospital staff COVID-19 prevalence rate has exceeded 13.5% (667/4949). CONCLUSION: Emergency bronchoscopy procedures on COVID-19 infected patients or patients with unknown infection status can be safely performed using modified full-face snorkel masks.

Managing uncertainty, ambiguity and ignorance in impact assessment by embedding evolutionary resilience, participatory modelling and adaptive management.

In the context of continuing uncertainty, ambiguity and ignorance in impact assessment (IA) prediction, the case is made that existing IA processes are based on false 'normal' assumptions that science can solve problems and transfer knowledge into policy. Instead, a 'post-normal science' approach is needed that acknowledges the limits of current levels of scientific understanding. We argue that this can be achieved through embedding evolutionary resilience into IA; using participatory workshops; and emphasising adaptive management. The goal is an IA process capable of informing policy choices in the face of uncertain influences acting on socio-ecological systems. We propose a specific set of process steps to operationalise this post-normal science approach which draws on work undertaken by the Resilience Alliance. This process differs significantly from current models of IA, as it has a far greater focus on avoidance of, or adaptation to (through incorporating adaptive management subsequent to decisions), unwanted future scenarios rather than a focus on the identification of the implications of a single preferred vision. Implementing such a process would represent a culture change in IA practice as a lack of knowledge is assumed and explicit, and forms the basis of future planning activity, rather than being ignored.

Breast cancer in antiquity.

Cancer of the breast, seen by Galen as the commonest cancer of his time, was probably first mentioned by Hippocrates in the 5th century BC. A single case history was described but no specific treatment mentioned. For centuries no further cases were described, until Cato, 2nd century BC, advocated cabbage poultices for all tumours and breast cancer in particular. Aëtius of Amida probably first described Paget's cancer of the nipple. By the 2nd century AD treatment comprised a variety of local applications, systemic medicaments, venesection and surgery. Surgical resection first described by Celsus and subsequently by Leonidas (usually combined with cautery) proved curative when applied early in the disease.

Akhenaten, a unique pharaoh.

Akhenaten was a unique pharaoh in more ways than one. He initiated a major socio-religious revolution that had vast consequences for his country, and possessed a strikingly abnormal physiognomy that was of note in his time and has interested historians up to the present era. In this study, we attempt to identify the developmental disorder responsible for his eunuchoid appearance.

Illnesses of Herod the Great.

Herod the Great, Idumean by birth, was king of the Jews from 40 to 4 BC. An able statesman, builder and warrior, he ruthlessly stamped out all perceived opposition to his rule. His last decade was characterised by vicious strife within his family and progressive ill health. We review the nature of his illnesses and suggest that he had meningoencephalitis in 59 BC, and that he died primarily of uraemia and hypertensive heart failure, but accept diabetes mellitus as a possible underlying aetiological factor. The possibility that Josephus' classical descriptions of Herod's disease could be biased by 'topos' biography (popular at the time), is discussed. The latter consideration is particularly relevant in determining the significance of the king's reputed worm infestation.