Operationalising coastal resilience to flood and erosion hazard: A demonstration for England

Resilience is widely seen as an important attribute of coastal systems and, as a concept, is increasingly prominent in policy documents. However, there are conflicting ideas on what constitutes resilience and its operationalisation as an overarching principle of coastal management remains limited. In this paper, we show how resilience to coastal flood and erosion hazard could be measured and applied within policy processes, using England as a case study. We define resilience pragmatically, integrating what is presently a disparate set of policy objectives for coastal areas. Our definition uses the concepts of resistance, recovery and adaptation, to consider how the economic, social and environmental dimensions of coastal systems respond to change. We develop a set of composite indicators for each dimension, grounded empirically with reference to national geospatial datasets. A prototype Coastal Resilience Model (CRM) has been developed, which combines the dimensions and generates a quantitative resilience index. We apply it to England's coastal hazard zone, capturing a range of different stakeholder perspectives using relative indicator weightings. The illustrative results demonstrate the practicality of formalising and quantifying resilience. To re-focus national policy around the stated desire of enhancing resilience to coastal flooding and erosion would require firm commitment from government to monitor progress towards resilience, requiring extension of the present risk-based approach, and a consensus methodology in which multiple (and sometimes conflicting) stakeholder values are explicitly considered. Such a transition may also challenge existing governance arrangements at national and local levels, requiring incentives for coastal managers to engage with and apply this new approach, more departmental integration and inter-agency cooperation. The proposed Coastal Resilience Model, with the tools to support planning and measure progress, has the potential to help enable this transition.

Early antiretroviral treatment reduces risk of bacille Calmette-Guérin immune reconstitution adenitis

SETTING

Two centres in Soweto and Cape Town, South Africa.

OBJECTIVE

To assess the effects of timing of initiation of antiretroviral treatment (ART) and other factors on the risk of bacille Calmette-Guérin (BCG) related regional adenitis due to immune reconstitution inflammatory syndrome (BCG-IRIS) in human immunodeficiency virus (HIV) infected infants.

DESIGN

HIV-infected infants aged 6-12 weeks with CD4 count ≥25% enrolled in the Children with HIV Early Antiretroviral Therapy (CHER) Trial received early (before 12 weeks) or deferred (after immunological or clinical progression) ART; infants with CD4 count <25% all received early ART. All received BCG vaccination after birth. Reactogenicity to BCG was assessed prospectively during routine study follow-up.

RESULTS

Of 369 infants, 32 (8.7%) developed BCG-IRIS within 6 months of starting ART, 28 (88%) within 2 months after ART initiation. Of the 32 cases, 30 (93.8%) had HIV-1 RNA > 750 000 copies/ml at initiation. Incidence of BCG-IRIS was 10.9 and 54.3 per 100 person-years (py) among infants with CD4 count ≥25% at enrolment receiving early (at median age 7.4 weeks) vs. deferred (23.2 weeks) ART, respectively (HR 0.24, 95%CI 0.11-0.53, P < 0.001). Infants with CD4 count <25% receiving early ART had intermediate incidence (41.7/100 py). Low CD4 counts and high HIV-1 RNA at initiation were the strongest independent risk factors for BCG-IRIS.

CONCLUSIONS

Early ART initiation before immunological and/or clinical progression substantially reduces the risk of BCG-IRIS regional adenitis.

Sonographic appearance of early complete molar pregnancies

Since our anecdotal experience indicates that the classically described "snowstorm" appearance on ultrasonography of early molar pregnancies is often not present and that theca-lutein cysts are also rare, we examined the ultrasonographic appearance of early complete molar pregnancies. We reviewed the ultrasonographic reports and clinical data of 21 cases of histologically diagnosed complete molar pregnancies with a mean gestational age at sonography of 10.5 weeks (range, 4 to 18 weeks). The diagnosis of molar pregnancy was made on ultrasonography in 12 (57%) cases, was second in the differential diagnosis of one (4.8%) case, and was not considered in eight (38%) cases. No theca-lutein cysts were identified. Five of five (100%) molar pregnancies of 13 weeks or over were diagnosed prospectively, while only eight of 16 (50%) earlier pregnancies were correctly diagnosed prospectively. In a retrospective review of the available images of 16 patients, only nine of 16 (56%) images demonstrated the classic appearance, and no theca-lutein cysts were seen. We conclude that the classic appearance of complete moles on ultrasonography is seen in less than two thirds of cases and even less commonly in the first trimester. The prevalence of theca-lutein cysts is very low.

Axillary lymphadenopathy due to Swanson implants

We describe a case of unilateral axillary lymphadenopathy in an elderly woman with a long history of rheumatoid arthritis, 7 years status post placement of Swanson silastic elastomer implants in her right hand with good surgical outcome and with no outward reason for adenopathy. Though there was concern for malignancy, pathologic evaluation of the lymph node revealed foreign body giant cells reacting to silastic from her hand implants and no evidence of malignancy. This is only the 10th such case reported, despite the number of implants placed.

The revolution that wasn't: health care's role in the 1992 elections

Ever since Harris Wofford won a U.S. Senate seat in Pennsylvania in November 1991 largely by calling for national health insurance, health reform has been considered a "top-tier" issue. But post-1992 election polls reveal that while Americans have remained disenchanted with the current system, they have not refined their views on reform much further. Because the issue is so complex and because specific proposals involve so many trade-offs, the best course of action for candidates in the 1992 races was to echo voter dissatisfaction and signal a desire for reform without stating specifics.

Natural history of disseminated Mycobacterium avium complex infection in AIDS

This study sought to better characterize the natural history of AIDS-associated disseminated Mycobacterium avium complex (MAC) infection. Towards that end two retrospective studies were done: a case-control survival study and a MAC respiratory colonization study. Among 137 consecutive patients who had a sterile body site cultured for mycobacteria within 3 months of their first AIDS-defining episode of Pneumocystis carinii pneumonia, median survival was significantly shorter in those with disseminated MAC infection (107 days; 95% confidence interval [CI] 55-179) than those with negative cultures (275 days; 95% CI 230-318; P less than .01), even after controlling for age, absolute lymphocyte count, and hemoglobin concentration. Among 34 patients with AIDS and respiratory MAC colonization, 22 later developed disseminated infection (65% predictive value for subsequent MAC dissemination). Disseminated MAC infection was associated with significantly shorter survival for patients with AIDS, and the presence of MAC in respiratory specimens has substantial predictive value for subsequent disseminated infection.