The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms.

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320

Overlooked ocean strategies to address climate change

The U.N. Framework Convention on Climate Change’s (UNFCCC’s) Paris Agreement—which aims to limit climate change and increase global resilience to its effects—was a breakthrough in climate diplomacy, committing its Parties to develop and update national climate plans. Yet the Parties to the Agreement have largely overlooked the effect of climate change on ocean-based communities, economies, and ecosystems—as well as the role that the ocean can play in mitigating and adapting to climate change. Because the ocean is an integral part of the climate system, stronger inclusion of ocean issues is critical to achieving the Agreement’s goals. Here we discuss four ocean-climate linkages that suggest specific responses by Parties to the Agreement connected to 1) accelerating climate ambition, including via sustainable ocean-based mitigation strategies; 2) focusing on CO2 emissions to address ocean acidification; 3) better understanding ocean-based mitigation; and 4) pursuing ocean-based adaptation. These linkages offer a more complete perspective on the reasons strong climate action is necessary and inform a systematic approach for addressing ocean issues under the Agreement to strengthen climate mitigation and adaptation

"Things Have Changed"-Laparoscopic Cytoreduction for Advanced and Recurrent Ovarian Cancer: The Experience of a Referral Center on 108 Patients

Objective: To report the feasibility of laparoscopic cytoreduction surgery for primary and recurrent ovarian cancer in a select group of patients. Methods: A retrospective analysis was conducted on a cohort of patients with FIGO stage IIIA-IV advanced ovarian cancer who underwent laparoscopic primary debulking surgery (PDS), interval debulking surgery (IDS), or secondary debulking surgery (SDS) between June 2008 and January 2020. The primary endpoint was achieving optimal cytoreduction, defined as residual tumor less than 1 cm. Secondary endpoints included evaluating surgical complications and long-term survival, assessed at three-month intervals during the initial two years and then every six months. Results: This study included a total of 108 patients, among whom, 40 underwent PDS, 44 underwent IDS, and 24 underwent SDS. Optimal cytoreduction rates were found to be 95.0%, 97.7%, and 95.8% for the PDS, ISD, and SDS groups, respectively. Early postoperative complications (<30 days from surgery) occurred in 19.2% of cases, with 7.4% of these cases requiring reintervention. One patient died following postoperative respiratory failure. Late postoperative complications (<30 days from surgery) occurred in 9.3% of cases, and they required surgical reintervention only in one case. After laparoscopic optimal cytoreduction with a median follow-up time of 25 months, the overall recurrence rates were 45.7%, 38.5%, and 39.3% for PDS, ISD, and SDS, respectively. The three-year overall survival rates were 84%, 66%, and 63%, respectively, while the three-year disease-free survival rates were 48%, 51%, and 71%, respectively. Conclusions: Laparoscopic cytoreduction surgery is feasible for advanced ovarian cancer in carefully selected patients, resulting in high rates of optimal cytoreduction, satisfactory peri-operative morbidity, and encouraging survival outcomes. Future studies should focus on establishing standardized selection criteria and conducting well-designed investigations to further refine patient selection and evaluate long-term outcomes

A comprehensive review of climate adaptation in the United States: more than before, but less than needed

We reviewed existing and planned adaptation activities of federal, tribal, state, and local governments and the private sector in the United States (U.S.) to understand what types of adaptation activities are underway across different sectors and scales throughout the country. Primary sources of review included material officially submitted for consideration in the upcoming 2013 U.S. National Climate Assessment and supplemental peer-reviewed and grey literature. Although substantial adaptation planning is occurring in various sectors, levels of government, and the private sector, few measures have been implemented and even fewer have been evaluated. Most adaptation actions to date appear to be incremental changes, not the transformational changes that may be needed in certain cases to adapt to significant changes in climate. While there appear to be no one-size-fits-all adaptations, there are similarities in approaches across scales and sectors, including mainstreaming climate considerations into existing policies and plans, and pursuing no- and low-regrets strategies. Despite the positive momentum in recent years, barriers to implementation still impede action in all sectors and across scales. The most significant barriers include lack of funding, policy and institutional constraints, and difficulty in anticipating climate change given the current state of information on change. However, the practice of adaptation can advance through learning by doing, stakeholder engagements (including “listening sessions”), and sharing of best practices. Efforts to advance adaptation across the U.S. and globally will necessitate the reduction or elimination of barriers, the enhancement of information and best practice sharing mechanisms, and the creation of comprehensive adaptation evaluation metrics

Global COVID-19 lockdown highlights humans as both threats and custodians of the environment

The global lockdown to mitigate COVID-19 pandemic health risks has altered human interactions with nature. Here, we report immediate impacts of changes in human activities on wildlife and environmental threats during the early lockdown months of 2020, based on 877 qualitative reports and 332 quantitative assessments from 89 different studies. Hundreds of reports of unusual species observations from around the world suggest that animals quickly responded to the reductions in human presence. However, negative effects of lockdown on conservation also emerged, as confinement resulted in some park officials being unable to perform conservation, restoration and enforcement tasks, resulting in local increases in illegal activities such as hunting. Overall, there is a complex mixture of positive and negative effects of the pandemic lockdown on nature, all of which have the potential to lead to cascading responses which in turn impact wildlife and nature conservation. While the net effect of the lockdown will need to be assessed over years as data becomes available and persistent effects emerge, immediate responses were detected across the world. Thus initial qualitative and quantitative data arising from this serendipitous global quasi-experimental perturbation highlights the dual role that humans play in threatening and protecting species and ecosystems. Pathways to favorably tilt this delicate balance include reducing impacts and increasing conservation effectiveness