PA Management Research Articles

Using microwave thermal ablation to develop a subtotal, cortical-sparing approach to the management of primary aldosteronism

Objective: To investigate the feasibility and efficacy of localized, subtotal, cortical-sparing microwave thermal ablation (MTA) as a potential curative management for primary aldosteronism. The study investigated with equal importance the selected ablation of small volumes of adrenal cortex while sparing adjacent cortex.Method: An in-vivo study was carried out in swine (n = 8) where MTA was applied under direct visualization, to the adrenal glands at 45 W or 70 W for 60 s, using a lateral, side-firing probe and a non-penetrative approach. Animals were survived for 48 h post-procedurally. Animals were investigated for markers of histological, immunohistochemical and biochemical evidence of adrenal function and adrenal damage by assessing samples drawn intra-operatively and at the time of euthanasia.Results: Selected MTA (70 W for 60 s) successfully ablated small adrenocortical volumes (∼0.8 cm3) characterized by coagulative necrosis and abnormal expression of functional markers (CYP11B1 and CYP17). Non-ablated, adjacent cortex was not affected and preserved normal expression of functional markers, without increased expression of markers of heat damage (HSP-70 and HMGB-1). Limited adrenal medullary damage was demonstrated histologically, clinically and biochemically.Conclusion: MTA offers potential as an efficient methodology for delivering targeted subtotal cortical-sparing adrenal ablation. Image-guided targeted MTA may also represent a safe future modality for curative management of PA, in the setting of both unilateral and bilateral disease.

The extirpation of species outside protected areas

AbstractProtected areas (PAs) are fundamental to conservation efforts but they are only part of a successful conservation strategy. We examine biodiversity outside PAs in Sundaland, one of the world's most biologically degraded regions. Using the avian order Galliformes as a case study, we identify species that have not been sighted outside PAs within the last 20 years on each individual landmass (i.e., Malay Peninsula, Borneo, Sumatra, Java, and Bali). We estimate these species’ extirpation dates outside PAs using optimal linear estimation and species’ sighting records.We conclude there have been up to 13 extirpations of Galliformes from outside PAs in Sundaland. Three Sundaic endemics now occur only inside PAs. Sumatra has suffered the highest proportion of extirpations (50% of its galliform species). Effective management of Sundaland's PAs is thus critical to species’ persistence and the conservation strategy for species outside PAs must be improved.

Effectiveness of protected areas in preventing rubber expansion and deforestation in Xishuangbanna, Southwest China

AbstractProtected areas (PAs) are supposedly key refuges for the world's remaining biodiversity. Our study site, Xishuangbanna, harbors a high proportion of China's biodiversity but is threatened by rapid deforestation and expansion of monoculture rubber. We quantified the success of Xishuangbanna's PAs in preventing deforestation. Most previous analyses of PA effectiveness have insufficiently accounted for biases arising from PA location and establishment, because they overlooked the importance of site‐matching in accounting for landscape change. We used matching methods to minimize such biases in comparing land use conversion rates inside and outside‐PAs. By 2010, Xishuangbanna had 3,455.5 km2 (~18%) designated as PAs. However, rubber occupied 22% of its land area and was expanding at a rate of 153.4 km2/year. Between 1988 and 2010, conventional analysis showed a deforestation rate of 9.3 km2/year. However, matching analysis showed a significantly higher rate of deforestation, 10.7 km2/year, which resulted in the deforestation of ~11% of PA's land. We argue that PAs were less effective than had previously been thought. The situation worsened from 2002 to 2010, when the deforestation rate within PAs was actually higher than that of outside PAs, although this difference was not significant. The designated higher levels of protection in ‘core’ zones were also unsuccessful in preventing deforestation. At current rates, within the next 50 years, a further 16% of PAs would be deforested in Xishuangbanna. This could even be an underestimate, as without intervention, drivers of deforestation tend to accelerate. Therefore, reviewing and strengthening current PA management policies is essential.

Commentaries on health services research

Commentaries on health services research

Informing Translation: The Accuracy of Information on Websites for Lifestyle Management of Polycystic Ovary Syndrome.

Lifestyle (diet, physical activity [PA], and/or behavioral) interventions are recommended for all women with polycystic ovary syndrome (PCOS) in international guidelines. The internet is a widely used health information resource. However, the accuracy of lifestyle information on PCOS websites is unknown and is reviewed here to inform translation of the international guideline on PCOS. An internet search was conducted with three search engines across different web browsers and countries. Accuracy was assessed through a checklist of 29 questions based on international guidelines for diet, PA, or weight management for the general population and for PCOS with higher scores indicating greater accuracy. Fifteen websites were eligible out of 72 (20%). The total accuracy score was 56 ± 13 (mean ± standard deviation; potential range: -29 to 87) comprising 23 ± 6 for diet (-11 to 33), 15 ± 5 for PA (-9 to 27), and 14 ± 3 for weight management (-8 to 24). A moderate proportion of websites provided general information on appropriate diet (40-80%) or weight management strategies (47-60%), but only 10 to 40% of websites provided information on core foods, discretionary foods, exercise quantity/intensity, energy deficits, or behavioral strategies. Limited websites on PCOS contain information on lifestyle management. The majority provided information on general diet, PA, and weight recommendations but less information on practical implementation of lifestyle change as an identified translation gap for the international guideline on PCOS.

Commentaries on health services research

Commentaries on health services research

Local people and conservation officials’ perceptions on relationships and conflicts in South African protected areas

ABSTRACTProtected areas (PAs) are often conflict-ridden, but conflict resolution mechanisms are often constrained by little appreciation of the perceptions of the principal agents (PA managers and local communities) about such conflicts. Getting local people’s support in PA management efforts is considered important for achieving conservation and livelihood goals. Using data from 13 nature reserves in South Africa, this study explores the perceptions of reserve managers and local communities about their relationships and the existence and underlying causes of conflicts. The findings showed sharp contrasts in perceptions between reserve managers and local communities. Reserve managers generally perceived that there were no conflicts with local communities and that their relationship with them was positive while local communities thought otherwise, claiming conflicts were centred around restricted access to PAs, lack of benefits from PAs and communication problems. These findings have profound implications for conservation, especially considering the importance of getting local people’s support in PA management.EDITED BY Isabelle Durance

Israeli survey of anesthesia practice related to placenta previa and accreta.

Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.

Estimating the effect of plantations on pine invasions in protected areas: a case study from South Africa

Summary Protected areas (PAs) are a key intervention for conserving biodiversity and ecosystem services. A major challenge for PAs is the control of invasive non‐native plants that spread into PAs from surrounding sources such as forestry plantations. The links between invasions and different source populations are poorly understood, making it difficult to apportion responsibilities for control costs. We estimated the effect of plantations of invasive pines (Pinus species) on the spread of these trees into PAs in South Africa's Cape Floristic Region (CFR). We assessed the effect of (i) distance from plantation, (ii) plantation and PA orientation in relation to the prevailing wind and (iii) the proportionate size of the surrounding plantation on the abundance of invasions in PAs. We also estimated the historic and potential future costs of controlling invasions in the PAs. PA management units within 3 km of a plantation had over double the pine cover of control units >6 km from plantations (6·12% vs. 2·39%). We attributed 51% of the pine invasions in PAs to plantations. Neither the proportional size of the plantations nor their orientation relative to prevailing winds had a detectable effect on the cover of invasive pines. Costs of controlling invasive pines in the study area totalled 98 million Rand (10 Rand = c. 1 US$ in 2013) between 2001 and 2012. It could cost between 273 and 916 million Rand (all future costs expressed in 2013 Rand), and take between 34 and 113 years, to clear the remaining invasive pines in the study area, depending on rates of spread and the cost–effectiveness of control. Policy implications. Estimating the contribution of an invasion source, in this case forestry plantations, requires estimating an unobservable counterfactual outcome: the invasions that would have occurred in the absence of the plantations. We have made a first step towards doing this by using empirical approaches that vary in the strictness of their assumptions, along with robustness tests to that assess the plausibility of these assumptions. Our study provides the starting point for estimating the contribution of plantation forestry to protected area invasions in the Cape Floristic Region of South Africa.

The relevant scales of ecosystem services demand

Exploring win-win approaches to ecological conservation and community development goals is a central issue in the management of PAs. Achieving sustainable management of ESs in PAs is more of a social governance issue, requiring the SES managers to understand the diverse tradeoffs among ESs and well-beings and design management plans with supportive governance processes and institutions. To solve this issue, ESs importance was chosen as the entry point, which is good at “understanding” but weak in “designing” in most cases. We proposed a “KESs-based PAs management plans formulating framework,” which is born out of the ESs importance analysis and knowledge for win-win management in PAs. Through the six steps and two tools (“Identification Methodology for PAs KESs” and the “Standard Strategies for PAs KESs Management”) embedded in the framework, the win-win management plan for dual goals could be formulated. By applying the framework in the Shennongjia National Park in China, we obtained three directions for adjusting strategies and eight directions for adjusting measures for the National Park Services to formulate management plans. The framework promotes the sustainable management of ESs in PAs by making up for the gap in applying ESs importance in designing feasible, specific, and systematic management plans with policies and institutions.

FRI0585-HPR A Survey of Irish Physiotherapists' Current Practice in Promoting Physical Activity in Rheumatoid Arthritis

BackgroundPhysical activity (PA) and exercise are important for people with rheumatoid arthritis (RA) (Van den Ende et al 2000; Kennedy et al 2007). Establishing current practice among Irish Physiotherapists regarding...

Usefulness of 11C-Methionine Positron Emission Tomography in Differential Diagnosis between Recurrent Tumours and Radiation Necro-sis in Patients with Glioma: An Overview

Differential diagnosis between radiation necrosis and tumour recurrence is important in the clinical manage- ment of patients with glioma. We performed an overview of the literature in order to summarize the role of 11 C- methionine positron emission tomography (MET-PET) in this setting. This functional imaging method appears to have a high sensitivity, specificity, and accuracy in differentiating between glioma recurrence and radiation necrosis. Neverthe- less, possible false negative and false positive results of MET-PET should be well kept in mind in the management of pa- tients with glioma.

Gastroparesis among Type 1 and Type 2 Diabetic Patients in the United Arab Emirates

Aims: Delayed gastric emptying (GE) may have a major effect on the management of diabetic pa- tients by causing upper gastrointestinal symptoms, impaired oral drug absorption and contri- buting to poor blood sugar control. Although the United Arab Emirates (UAE) has one of the high- est prevalence of diabetes in the world, studies focusing on the prevalence of diabetes gastropare- sis among these diabetics have never been reported previously. The aim of this study was to in- vestigate gastroparesis among randomly selected Emirati type 1 and type 2 diabetic patients re- ferred to a national diabetes center in the UAE. Methods: The study was designed as a controlled, single-blinded study. Using a standardized ultrasound technique, GE was studied in thirty-one randomly recruited type 1 and type 2 diabetic patients and ten normal healthy volunteers. The gastric emptying rate (GER) was estimated and expressed as the percentage reduction in antral cross-sectional area from 15 to 90 min after the ingestion of a semisolid breakfast meal. Results: In comparison to healthy volunteers, diabetic patients showed overall significantly wider mean values of the fasting as well as the postprandial antral areas. The mean value of GER in these Emirati diabetic patients was estimated at 17%, which was less than half of that in the healthy volunteers (50%). Statistically the difference was highly significant (p 32%. Consequently, 71% (22 of 31) of the diabetic patients in this study had more or less pronounced delays in GER (gastroparesis). Conclusions: The results from the present study indicate a higher prevalence of gastroparesis among randomly selected Emirati type 1 and type 2 diabetic patients, than in any other study previously published around the world. This is in line with previous reports about the high prevalence of diabetes complica- tions among UAE diabetics. A larger study is needed to confirm these results. * Corresponding author.

Variables Influencing Subjective Well-Being in Patients with Schizophrenia

Objectives : The purpose of this study was to analyze the relationship between subjective well-being and other clinical parameters such as sociodemographic and clinical variables, which include positive and negative symptoms, depressive symptoms, insight, and side effects. Methods : Fifty-one outpatients diagnosed with schizophrenia were recruited in this study. Subjective well-being was assessed using a self-rating scale, the Subjective Well-being under Neuroleptics-Short form (SWN-K). Sociodemographic variables were also evaluated and other evaluations were conducted using the Positive and Negative Syndrome Scale (PANSS), Calgary Depres- sion Scale for Schizophrenia (CDSS), Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS), Korean Version of the Revised Insight Scale for Psychosis (KISP), and Multidimensional Scale of Perceived Social Support (MSPSS). The relation- ship between subjective well-being and these clinical variables was assessed. Results : Education years and social support scores were positively correlated with the total SWN-K scores, but severity of illness, severity of depression, severity of side effect, and the scores on insight were negatively correlated. The stepwise multiple regression analyses indicated that the total SWN-K score of the patients with schizophrenia was associated with negative symptoms and in- sight. Conclusion : Better insight and more severe negative symptoms in patients with schizophrenia may be associated with worse subjective well-being. Results indicate that careful evaluation of subjective well-being is essential for proper management of pa- tients with schizophrenia. (Korean J Schizophr Res 2014;17:93-99)

UNIDADES DE CONSERVAÇÃO DA NATUREZA: DIAGNÓSTICO DO PROGRAMA ESTADUAL DE UNIDADES DE CONSERVAÇÃO-PEUC NO RIO GRANDE DO NORTE-BRASIL

The deployment of Conservation of Nature in Rio Grande do Norte / Brazil, under state responsibility, competence is the Institute of Sustainable Development and Environment-IDEMA. This research develops a preliminary study to evaluate management in these protected areas. The method used was RAPPAM (Rapid Assessment and Prioritization of Protected Areas Management) pela.WWF developed and used in several states in Brazil. Data collection presented two biases: adirect form of questionnaires to managers and employees of two conservation units. The analysiswas indirect documentary of laws with definitions and standards applied in different UCs. The aimwas to relate the implementation of the State Program of Conservation - PEUC andrecommendations of the National System of Conservation Units-SNUC and other documents onPAs defining a preliminary diagnosis of the current status of Conservation Units established by thestate government. As a result relates to the UCs established with the objectives for which theywere created and the improvements that showed the region where they are located. Thisassessment by analyzing the theoretical guidelines and management of PAs, noted the currentstatus of state UCs. It is addressed aspects politico-institutional, administrative and land andrelations with the local population. As preliminary answers can be observed that the managementof these territories legally protected, is being implemented satisfactorily. Already anthropicpressure and lack of priority for biodiversity conservation of natural resources, both thegovernment and the population, prevents management aligning conservationism andsustainability. A number already quite worrying starts by the number of UC state created.

Intravenous Treprostinil Delivered by the Implantable Pump Lenus Pro®: A Innovative “Surgical” Approach to Management of PAH

Purpose Continuous application of parenteral prostanoids with external pump systems is associated with frequent side effects such as infusion site pain with subcutaneous (s.c.) and rare but possibly life-threatening catheter related infections with intravenous (i.v.) administration. Lenus Pro ® implantable infusion pump was developed to overcome the drawbacks of s.c. administration. Methods and Materials Between September 2010 and October 2012 20 patients underwent implantation at our center. All patients had experienced significant clinical benefits with s.c. Treprostinil but reported serious site pain. All implantations were performed under general anesthesia. Preoperatively single-shot antibiotic prophylaxis was given. After a catheter was placed in the subclavian or cephalic vein, the pump pocket was prepared in the abdominal wall. Lenus Pro® pump was filled intraoperatively, placed in the pump pocket and fixed to the fascia. A catheter was tunneled under the breast tissue and connected with the central venous access by means of a titan connector. No intraoperative complications occurred; postoperatively three patients developed mild seroma. During follow-up, no other complications were observed. More than 300 refill procedures have been performed without any complications. Control of the reflow volume at every refill procedure revealed accurate and constant flow rate of Lenus Pro ® in all patients. Results Parenteral prostanoids are a cornerstone in the treatment of PAH. I.v. Treprostinil administered by Lenus Pro® was safe and effective in our study population, during more than 330 patient-months of treatment there were no pump or catheter related complications, especially no infections. No refill complications were observed. The absence of infusion related side effects is associated with an increase in quality of life, filling intervals of 28 days ensure optimal patient management and compliance. Conclusions We consider this new treatment option a milestone achievement in prostanoid therapy and management of PA.

Survey of the management of borderline ovarian tumors in the United Kingdom

Borderline ovarian tumors (BOTs) represent approximately 10% of ovarian neoplasms and are a heterogeneous group of tumors with variable biological behaviour. The majority present with disease confined to the ovary and have an excellent prognosis after surgical removal. A small proportion subsequently has recurrent disease or progression to invasive cancer. Tumor recurrence can occur up to 20 years after surgical resection. There are no robust clinical, histological or molecular markers that distinguish high risk cases and no satisfactory treatment for patients with progressive disease. This results in great variability in management in different centres. We conducted a national survey on the management of borderline ovarian tumors in cancer centres representing different regions in the United Kingdom. In this article we review the literature for the current concepts in diagnosis, treatment and follow up of BOTs and we report the results of the survey of current practice in the United Kingdom. On that basis we provide recommendations for the management of pa-

High and Far: Biases in the Location of Protected Areas

BackgroundAbout an eighth of the earth's land surface is in protected areas (hereafter “PAs”), most created during the 20th century. Natural landscapes are critical for species persistence and PAs can play a major role in conservation and in climate policy. Such contributions may be harder than expected to implement if new PAs are constrained to the same kinds of locations that PAs currently occupy.Methodology/Principal FindingsQuantitatively extending the perception that PAs occupy “rock and ice”, we show that across 147 nations PA networks are biased towards places that are unlikely to face land conversion pressures even in the absence of protection. We test each country's PA network for bias in elevation, slope, distances to roads and cities, and suitability for agriculture. Further, within each country's set of PAs, we also ask if the level of protection is biased in these ways. We find that the significant majority of national PA networks are biased to higher elevations, steeper slopes and greater distances to roads and cities. Also, within a country, PAs with higher protection status are more biased than are the PAs with lower protection statuses.Conclusions/SignificanceIn sum, PAs are biased towards where they can least prevent land conversion (even if they offer perfect protection). These globally comprehensive results extend findings from nation-level analyses. They imply that siting rules such as the Convention on Biological Diversity's 2010 Target [to protect 10% of all ecoregions] might raise PA impacts if applied at the country level. In light of the potential for global carbon-based payments for avoided deforestation or REDD, these results suggest that attention to threat could improve outcomes from the creation and management of PAs.

Spatial modeling of extraction and enforcement in developing country protected areas

Budget constraints prohibit protected area managers (PAMs) in developing countries from completely deterring extraction and the resulting resource degradation. Because benefits from extraction are a function of distance, PAMs have an opportunity to patrol in a spatial pattern that minimizes degradation for a given budget level. This paper develops a spatial model of a game between a PAM and neighboring villagers to determine the optimal patterns of extraction and enforcement under various constraints. It demonstrates the importance of spatial aspects of PA management, reveals the inefficiency of many PA policies, and supports explicitly spatial management schemes such as extraction zones. The framework underpins a discussion of incomplete enforcement, rural welfare, budgetary tradeoffs between PA size and enforcement costs, and PA shape decisions with human-induced edge effects.

Indigenous ecological knowledge as social capital: How citizen science can help us replenish the bank

Abstract *Background/Question/Methods* In our increasingly urban world, indigenous knowledge of local ecology is declining rapidly, because survival in industrialized urban environments does not depend on knowing the details of local flora, fauna, or phenologies. While traditional ecological knowledge has been documented since 1980s, this is has been largely descriptive, e.g., ethnobotany of sacred groves, cultivation practices, or use of medicinal plants. Until recently, conservation biologists and managers of protected areas have followed western models of conservation that exclude local people and often abandon local ecological knowledge. However, many scientific studies of local ecosystems would not have been possible without the knowledge-base of indigenous people helping researchers. Yet, careful scientific analysis of such knowledge systems is scarce, except in some commercial applications such as forestry or fisheries. Further, even in rare instances when park managers have recruited knowledgeable locals as partners in PA management, the bureaucracy ended up dissipating ecological knowledge rather than sustaining it. The challenge therefore is to understand the epistemology of ecological knowledge, especially the costs and benefits to local people, to help create novel management regimes which provide new incentives for sustaining such knowledge even as traditional dependencies on natural resources are transformed for long-term sustainability of biodiversity. *Results/Conclusions* This paper reviews the literature on indigenous ecological knowledge in South Asia, to establish a baseline for systematic epistemological analyses. Examples include the Bihari bird-trappers assisting the Bombay Natural History Society's bird-ringing projects, Irulas helping snake research at Madras Crocodile Bank, Kanis supporting a variety of research projects, including our own, in Kalakad-Mundanthurai Tiger Reserve over the past two decades, and the modern day settlers in Andaman Islands who have turned from over-harvesting and poaching to sustainable cultivation of Edible-nest Swiftlets. We argue that indigenous knowledge is useful not only for monitoring ecosystems or determining use of natural resources, but more importantly for generating fundamental scientific insights, and adding to the knowledge part of our collective social capital. Even as indigenous knowledge is being lost, volunteer-based Citizen Science projects are recruiting amateur naturalists, especially in urban areas, to monitor and study local biodiversity. Such approaches need to be extended into genuinely participatory research programs where indigenous people are engaged in generating and sustaining ecological knowledge, from traditional and modern scientific perspectives, to become well-informed stewards of the socio-ecological systems we inhabit from local to global scales. This is a crucial step towards slowing the loss of biodiversity by reversing our collective loss of knowledge of biodiversity.