The pluralism that characterized the development of psychiatric services around the world created a variety of policies, care models and building types, and fostered experimental approaches. Increased complexities of care, institutional remnants, stigma, and the limited diagnostic and interventional accuracy of psychiatric treatments resulted in institutional behaviors surviving, even in newly built facilities. This was raised by research on awarded psychiatric buildings. The locus of the research comprised two acute psychiatric wards in London. Each was evaluated using the SCP model, a tool specifically developed for the evaluation of mental health facilities, identifying the relation between policy, care regime, and patient-focused environment. Data were derived from plans, visits, and staff and patient interviews. Findings were juxtaposed to those of an earlier study using the same methodology. Also, a syntactic analysis was conducted, to identify the social logic of ward layouts. There were potential connections between regimes, spatial configuration, and the social fabric. Methodologies of architectural morphologies indicated areas that would attract people because of the layout rather than function. However, insights into medical architecture outlined institutional undercurrents and provided alternative interpretation to spatial analysis. Comprehending the social fabric of psychiatric facilities could challenge the current surveillance-led model, as psychosocial rehabilitation uses could be encouraged at points of higher integration. Mental health provision has historically been determined by perceived risks as those have been defined by each social context, rather than patients' needs . It all The variety of provision translated to variety of facility types, collaborating to each other and collectively responding to the spectrum of patients' needs. These networks were unique. Each responded to different financial, social, and organizational priorities operating locally and had rarely being copied elsewhere or at least not without adaptations.This localized planning was encouraged by the principle of sectorisation , 9. EstaDefining the aims of healthcare architecture, Scher  urged thThe detailed guidance of Sivadon or Amiel was not expanded or materialized in the newly established community mental health facilities. Those were set up in diverse settings such as storefronts, office buildings, former private homes, or even self-contained luxurious clinics, providing in-patient and outpatient care, partial hospitalisation, emergencies, or consultation , 20. In As community care progressed, the role of facilities had not been clearly defined especially on the transitory versus permanent characters . There wHere, we need to mention that the efforts of defining psychiatric space between the two poles of hospital and home constituted a discussion mostly among psychiatrists and healthcare professionals. The models of medical architecture could offer little help to address the following issues: this was because a) they focused on the increasing clinical and technological complexity of the general hospital, where most psychiatric wards sat, b) the sift of mental health provision towards the community constituted the hospital ward typologies irrelevant.To bridge the gap, “normalisation theory” was introduced to mental healthcare. Normalisation was derived from the field of learning disability, where it was and remains an established theory . In shorTowards the last quarters of the last century, three options of care coexisted: (a) ordinary housing for all, (b) care in the community but in cooperation with a hospital, and (c) modernised hospital care with its own community network . So, wheThis diversity and limited interdisciplinary relations between architectural practice and health sciences created an experimental, intuitive as opposed to evidence-based, approach regarding the design of psychiatric facilities. This has been rapidly changing in the last decade , the casThe increased complexities of psychiatric care, including limited diagnostic and interventional accuracy of mental health conditions .Institutional residues in community mental health facilities. Bricks and mortar alone could not fully address social reintegration , 38.The stigma . Mental Additionally, one should consider the following:This combination resulted in an array of institutional behaviors and practices still surviving in purpose-built facilities or new, community-based buildings. Lack of knowledge of how space operates might lead to build environments that generate social problems . The morThe gap of knowledge on psychiatric space was accentuated when interdisciplinary research combining methodologies deriving from medical sociology and architecture found that even awarded psychiatric facilities might present strong institutional characteristics regarding building features and in terms of users' perspective . The resTo explore the spatial dynamics of psychiatric institutions and how those influence (a) the personal and (b) the social milieu of psychiatric spaceTo identify environmental requirements of mentally ill people according to needs, therapeutic regimes, and principles deriving from deinstitutionalizationThese generated the question on the relation of the building layout to psychosocial performance, together with requirements related to pathology and potential therapeutic aspects. Translated to research aims, this research set the following objectives:x, y, and z)  , where s, and z) . The modAdditionally, the model incorporated the key issues behind mental illness expressed by the dominant models of care as they evolved over the years. These three main concepts, the jurisdictional, the medical, and the psychosocial rehabilitation model, were described in the introduction of this paper, and each corresponds to one of the parameters .Even though the shift has changed over the years from the custodial to the psychosocial rehabilitation models, elements of each still exist in each psychiatric structure. The relationship of each facility or each care program to each of the three defines where each facility sits between the three: for example, a forensic facility might appear closer to the jurisdictional model, and a service-user operated café is closer to the concept of psychosocial rehabilitation. Yet, each displays elements that belong to the other two. For example, a forensic facility might have an occupational or music therapy room, or the rehabilitation café might be supervised by a clinician.Harm and self-harm prevention  and corresponds to safety and securityMedical and nursing provision, to restore competence compromised by mental illnessSocial reintegration, promoting the personalization and choice that are lost in institutional environments and correspond to well-beingFrom the above, it is clear that all topics on mental health environments could be classified according to these parameters. These derived from the basic needs related to mental health priorities as they relate to the main objectives of care:The SCP model could help define enabling environments which staff consider as best practice and patients perceive as suitable for their environments of care. So far, the SCP model has been already applied in facilities in the UK and in France . Data usTherefore, it has limitations regarding the sociospatial dynamics inside the wards.To address these sociospatial dynamics, a second method would be needed. One of the most widespread architectural theories associated with sociospatial dynamics is the theory of space syntax , 52. ThiSpace Syntax is a sociospatial theory with a strong algorithmic toolset, involving all scales of planning and design and all typologies looking at their spatial structure. According to the theoretical framework of Space Syntax, the relation of space and society is interconnected. Hillier  suggestsThe emphasis on layout irrespectively to other qualities of placemaking that the SCP model addresses is an important reason of including Space Syntax in this project: data occurring from spatial analysis would be ‘unpolluted' from preconceptions of medical architecture.Space Syntax being a generic sociospatial theory has been mostly employed in urban studies. Nevertheless, it starts to be applied in healthcare –60. HoweBy combining these two methodologies, the research set to investigate both patients' relation to the therapeutic regime and social relations to the spatial configuration. The SCP model constituted the basis of the evaluation, being more high-level in the aspects covered even though it is less generic when it comes to population and the building types, since it has been specifically designed for mental health. Space Syntax, on the contrary, has broader applicability in the build environment but is more focused on layout issues and does not cover issues such as fixtures and fittings, technologies, availability, and types of human resources or aesthetics. Thus, it provided tools on observability, wayfinding, and social solidarity. The findings from that methodology enriched areas that come under the SCP parameters. The morphological analysis is used for the first time in psychiatric wards, yet a meta-analysis of earlier research using the SCP model is possible. This could extend the sample and provide a clear understanding to the methodology, especially if performed to the awarded case studies of the previous UK sample of the SCP model research. However, this is an area for further research and remains beyond the scope of this paper. Findings of agreement between the two frameworks enable the formulation of an integrated model for mental health design, and findings of nonagreement allow these theories to evolve by addressing the limitations that the research pointed out.Regarding the objective on the built environment in relation to psychiatric space, the research sets to establish a valid framework of designing for mental health. To achieve that, this user-inclusive research involves academics and architects, health authorities, staff, and patients. The locus involved two secure acute facilities chosen according to preset criteria and permission granting, in line with the growing policy of community care. For the secure, acute parameter, the more severe the symptomatology is and the closer to the acute episode id, the more important the therapeutic environment is, and the more persistent the institutional regime might be.For the SCP model: a staff questionnaire, a patient questionnaire, a building trait checklistFor the spatial analysis: Depthmap and JASS tools on blueprintsThe main tools used for the research comprised the following:For evaluating patients' needs and the compliance to care regime, patients and staff were interviewed by the researcher using semistructured interview questionnaires of 30 and 23 main sets of questions, respectively. These questionnaires were designed, piloted, and used by the same researcher for the previous research on the UK and France community mental health facilities, in the early 2000s. It comprised three subsets of questions, each referring to one of the three parameters . The topics were derived from literature on psychiatric rehabilitation and policies related to psychiatric inpatient environments and were then translated to spatial implications that were then checked with patients and staff.Architectural auditing: data on the physical environment and sense of place of the wards derived from a systematic architecture account for spatial organization, therapeutic regime, salutogenic qualities, i.e., the building qualities that enhance health –65 such Checklist: third, a detailed architectural checklist, part of the SCP methodology, was used to identify the “normal” as opposed to the institutional traits of the buildings. The checklist dissecting each building to 212 traits identified institutional physical characteristics in a comparative scale to the local norm as defined by the neighboring or local residential buildings in parameters related to the exterior, the layout, and the design of the interior. It was the same checklist that was developed for the UK-France study and had been adapted by a similar checklist of Robinson et al.  researchFinally, regarding architectural morphology, each facility has been examined using Space Syntax, a theory focused on the research and analysis of buildings as patterns of space inhabited by individuals, communities, and organizations . Space SThe selection of the case studies was done by the two participating Trusts. The inclusion criteria comprised each facility serving the most acute spectrum of care, being for inpatients and not being part of the forensic mental health system. As the research had a limited time span of two years including ethics approvals, timing was crucial.For interviews, the ward manager approached staff and patients and distributed information about the project, after prior discussion with the ward psychiatrist on which patients were well enough to participate. The researcher then interviewed each staff and patient willing to participate. Each participant was given the ethics material to read, and the interviews took place after the consent form was signed by each participant. Interviews took place in a room that could offer auditory, but in the case of patients having visual permeability, in the corridor. For patients, it was the quiet room for Ward A and either the dining room or a consultation room for Ward B, depending on availability. For staff, there were some additional locations: the staff meeting room in Ward A and the nursing stations in both wards. Each interview lasts approximately from half to one hour, depending on participants' willingness to talk. The interviews were conducted by the PI of the project. The transcripts of the interviews were done by the PI.To avoid the researchers' bias in the ward selection process and the influence of building aesthetics, sites were chosen by the two participating Trusts.The researcher kept a detailed photographic record of the physical environment of the wards and was escorted by a member of staff in all common ward and staff areas and a selective number of bedrooms, mostly those not occupied at the time.Ward A accommodated 22 patients and Ward B 15. For patients involved, staff suggested a potential pool of patients who were well enough to participate. Then, it was up to these patients to decide if they wanted to take part. Staff recruitment was related to staff availability. In the total of 11 patients, 4 from Ward A and 7 from Ward B were well enough for staff to allow them to take part and at the same time people willing to participate were 10 members of staff, five from each ward. Due to the facts that the potential sample was rather small, the results to protect participants' identity and the ethics approval individual characteristics, such as name, age, gender, and exact pathology, were not asked. All patients belonged to the acute spectrum of psychiatric illness requiring hospitalization, and Ward A was for a single gender. The stage of the illness—closer to the acute episode vs closer to independent life—was the main factor that could affect preferences compared to age or gender in the previous study . Th. Th46]. The strong emphasis on suicide prevention through design is one of the clear differences between the original research conducted using the SCP method in the UK in early 2000s, together with a clearer gender segregation. The move towards increased antiligature and gender segregation agrees with the National Service Framework (NSF) for Mental Health . In factThe qualitative characteristics are mostly depicted by the analysis according to the three parameters of the SCP model , the architectural morphology analysis, and in particular, the analysis of user hierarchies  and policies such as gender segregation, smoking policy, or access to the existing outdoor areas.Higher percentages of private areas did not prevent that, on the contrary . More grFrom those differences, it is worth looking at the smoking policy. This is a delicate point as smoking is harmful for patients' health. Yet, being forced to stop at a time one had to deal with a crisis and involuntary admission could be adding to stress. This resulted in long queues for escorted leave to smoke, unrest, and incidents of violence outside the nursing station and had been the reason behind the fire according to the ward manager. The participants, staff, and patients were in favor of patients smoking in the courtyard as opposed to leaving the premises. Smoking policy might be related to cultural and local trends, although a survey among staff in New York indicated that staff tend to change the position regarding smoking areas lately, towards smoke-free environments .One less institutional facility (Ward B) in terms of building features might demonstrate a strong institutional behavior, such as institutional queuing outside the nursing station like former asylum practice of “cigarette distribution” by a specific policy.Social unrest can be created by policies (such as the nonsmoking policy in Ward B) even if buildings have provided solutions (such as an enclosed courtyard).Policy and buildings in mental health facilities are interrelated. Yet, policies might change at any time during the building life circle.Policy might affect the spatial use of mental health facilities considerably.Therefore,The integration of the nursing station could generate food for thought regarding the application of Space Syntax in institutions. What Hiller and Hanson  would deThe above becomes more complex when we consider the visibility from the nursing stations. One of the key aims of a nursing station is surveillance . HoweverDangerousness and perception of risk for harm or self-harm still dominate the design of mental health facilities in the UK. This is the case despite the optimism that surrounded psychiatric rehabilitation movements. The paper presented findings highlighting potential connections between policies, care-regimes, spatial configuration, and the social fabric in psychiatric institutions. The research combined the SCP model, a tool specifically developed for the evaluation of mental health facilities to Space Syntax, a generic methodology that identifies the potential for socialization that spaces generate. These methodologies of architectural morphologies indicated areas that would attract people because of the layout rather than the function . HoweverThis indicates that generic methodologies such as Space Syntax used without involving tools deriving either from medical humanities such as medical architecture and medical sociology or from a more clinical or healthcare management perspective could not provide results that could be used with confidence, as the healthcare context is a much more controlled and multiparametric environment than normative urban or architectural planning. In the case of the psychiatric facilities, this research demonstrated that Space Syntax produced inverse results of what was actually happening by indicating as areas of the social value the areas where antisocial behaviors used to take place. This could be interpreted as inadequacy of Space Syntax to cover complex multiparametric settings—especially as Space Syntax takes a minimal number of parameters into account—but also could mean that psychiatric facilities are still what Goffman named “total institutions” . At the The insights into medical architecture and healthcare facilities planning can outline institutional undercurrents and help make better sense of the spatial analysis, which on its own can been misleading. This is in agreement with the growing trend of employing comparative methodologies to conduct research in healthcare buildings .The most important finding is better understanding on the dynamics of the psychiatric institutions in general, even when care in the community policy suggests that institutions have been abolished by downsizing. This project indicates that this has not been achieved yet. As a result, it challenges the way psychiatric buildings are planned and designed from the current surveillance-led model to integrated design for patient well-being. From a clinical perspective, this would mean that psychosocial rehabilitation uses could be encouraged at points of higher integration. This would be beneficial for all user groups and mostly the actual recipients of care.Regarding limitations, the interconnection between design and social logic results in difficulty to establish cause and effect. Future research involving more case studies that vary considerably in spatial configurations, institutional levels, and regimes could gradually provide better understanding on the key determinants. To move to the next level, we need a larger sample of wards with significantly different layouts, and spatial configuration could indicate more accurately a relation between the most integrated areas and higher chances of patient copresence. If such a relationship could be established, then spatial planning should consider placing activity or the social areas in zones of potential high spatial integration. It would also be important to investigate a potential association between behaviors and institutional features. These could provide new insights into psychosocially supportive ways of designing.Due to the complexity of this methodology, especially the significant involvement of very vulnerable patients, adopting a larger scale approach might be challenging. UK wards also tend to be variant and small with a limited number of patients and an even smaller number that would be well enough and willing to participate and limited staff. The fact that they differ in policies increase the complexity further. However, a larger scale study using this methodology would provide a considerable amount of data that could give a very comprehensive understanding of several aspects of the planning and the design of psychiatric facilities and especially those of the most acute spectrum.The experience of people living or working in psychiatric facilities and their interpersonal relations, health, and well-being are influenced by their environment. The research provides the ground for an integrated design framework for evidence-based mental health architecture to serve as a design and evaluation tool, immediately accessible to architects, planners, and stakeholders. It contributes to the growing sector of evidence base design, informing body of knowledge that aims at improving healthcare conditions for patients and the efficiency of facilities through design. Incorporating the full spectrum of patients' needs  and recognizing spaces as cells that allow mechanisms to operate and influence behavior towards social integration, unlike institutions , could i


The goal of this study is to examine how cultural values are preserved and transmitted by grandparents rearing grandchildren in one community in the southeast region of the Yukon-Koyukuk Census Area in Alaska. The eight participants  lived in a community in the Kusilvak Census Area, with ages ranging from 47 to 73 years old. Participants’ took part in a semi-structured interview, which were then transcribed and coded into larger themes of 1) loss of traditional values, 2) continuing traditional values, 3) practicing traditional values, and 4) transmitting traditional values. The participants provided examples of how the cultural values that were strong at one point in their lives, were no longer exemplified in their community, and, in fact, behaviors that went against accepted values were seen. Participants spoke most often of how community members were cared for, how the community was valued over the individual, and the connections within families. The GRGs practiced those traditional values by caring, supporting, and loving the people in their families and communities, and by practicing humor and sharing with others. While this community has been influenced by modern ways of living currently found in the United States and Canada, it still remains relatively isolated from the technological and social influences that dominate what is considered “typical, modern” family life. The findings from this study illustrate the important roles that GRGs play in the persistence of cultural values, and the importance of incorporating these values in programs to assist this community.


Supernumerary teeth in the premolar region, unlike other supernumeraries, occur more often in the mandible where they are generally of the supplemental type. Occasionally, they are conical or smaller than normal, particularly in the upper premolar regions. They might occur singly or in multiples, be erupted or impacted, but the majority have been found to be unerupted and asymptomatic. The prevalence of supernumerary teeth in the premolar region has been demonstrated to be between 0.01 and 1 percent depending on the population studied. Interestingly, populations from the East or Africa are known to be the most affected. Various theories have been suggested to explain the etiology of supernumerary teeth in general including both genetic and environmental factors. Furthermore, it has been suggested that supernumerary premolar teeth belong to a third (postpermanent) series, developing from extensions of the dental lamina. Several consequences can result from the presence of supernumerary premolars, especially in the mandible, such as cyst formation, transposition, and other clinical scenarios. There have been multiple review studies reporting on several aspects of supernumerary teeth –4 with tA literature search was undertaken with PubMed and Ovid Medline databases using the keywords premolar and supernumerary. Relevant publications addressing the prevalence and management of supernumerary premolars were then selected and included in the review. It is relatively common for the occurrence of supernumerary teeth in the premolar region. About 8-9% of all supernumerary teeth occur in the premolar region , 4, 5.  Supernumerary teeth in the premolar region, unlike other supernumeraries, occur more frequently in the mandible , 2, wher1Supernumerary teeth in the premolar region might occur singly Figures  and 5 or2Seventy-five percent of supernumerary premolars were determined to be unerupted, and the majority of them appeared asymptomatic –18. ThusFrom the literature, it is evident that most of the supernumerary teeth reported in the premolar region have been found in patients from the East or from Africa. Still  stated tPoyton et al.  reportedSix patients 0.15%) were found to have supernumerary mandibular premolars in a sample population of 4,000 patient records . Four ca5% were fVarious theories have been suggested to explain the etiology of supernumerary teeth including both genetic and environmental factors , 28. FurMoreover, Price and Hoggins  establisRanta and Ylipaavalniemi  reportedBowden  reportedMandibular supernumerary premolars have a marked tendency towards the formation of cysts and pathological changes , 41, 42.Late-developing supernumerary teeth in the premolar region are often detected at the end of orthodontic treatment at approximately 13 years of age and may interfere with space closure and implant placement . FurtherEarly diagnosis of supernumerary teeth in the premolar region is important in their management. This should involve taking a thorough medical and dental history and carrying out a radiological assessment following a clinical examination. Most supernumerary teeth in the premolar region are unerupted, with no clinical signs or symptoms and often observed as incidental findings on radiographs , 16, 34.A decision needs to be made whether to extract or leave supernumerary premolar teeth in situ once they are diagnosed , 51. If Ultimately, it is the clinician's responsibility to fully explain all appropriate and feasible treatment options to the patient and/or guardian including the risks and benefits of each option as part of the consent process. The patient and/or guardian's wishes should be respected as to which treatment option should be chosen in each case. The patient and/or guardian may choose to leave any unerupted supernumerary premolar tooth in situ, especially if it has not caused any iatrogenic effects or is unlikely to interfere with orthodontic treatment. In such a case, it is important to highlight to the patient and/or guardian the potential risks that may occur in the future and the need for periodic radiographic monitoring of the unerupted supernumerary premolar tooth/teeth to detect any iatrogenic damage at an early stage which may occur .Supernumerary teeth in the premolar region, unlike other supernumeraries, occur more often in the mandible, where the supernumerary teeth are generally of the supplemental type.They might occur singly or in multiples, be erupted or impacted, but the majority is found to be unerupted and asymptomatic.The prevalence of supernumerary teeth in the premolar region is between 0.01 and 1 percent depending on the population studied, with populations from the East or Africa the most affected.It has been suggested that supernumerary premolar teeth belong to a third (postpermanent) series, developing from extensions of the dental lamina.Several consequences can result from the presence of supernumerary premolars, especially in the mandible, such as cyst formation, transposition, and malocclusion.


This original research confronted challenges to environmental management and sustainability posed by veld fires in the Bulilima and Mangwe Districts of Matabeleland in the South Province in southern Zimbabwe. Veld fires have affected the fauna and flora, polluted air and water, and destroyed livelihoods. The study aimed at establishing challenges to environmental sustainability posed by veld fires, identifying the type of environment upon which veld fires have impacted, analysing legal issues and other interventions surrounding the control of veld fires and suggesting new control measures for veld fires. A qualitative research design and quota sampling were used. The study involved 30 participants. Data was collected through a questionnaire, an interview guide and participant observation. Challenges to environmental management and sustainability posed by veld fires include property damage, reduced soil fertility, destruction of vegetation, air and water pollution and destruction of wildlife. Most veld fires are a result of human actions that emanate from the disposal of cigarettes, the burning of vegetation when preparing fields, the use of fire by hunters, smoking out bees and the making of fires by motorists along highways. The government should consider reviewing the current environmental statues. Fireguards should be wide enough to lessen veld-fire impact. Lastly, veld-fire campaigns and rehearsals should be run on a regular basis. It is hoped that this work would make a significant contribution through improving the current thinking about environmental management and sustainability, thereby benefiting policy makers, practitioners and stakeholders. Veld fires pose great challenges for environmental management and sustainability in context of the development of rural communities in Zimbabwe. As such, many communities experienced massive and widespread environmental losses through veld fires. The recent increase in incidences of veld fires has been attributed to newly resettled smallholder farmers . The government and stakeholders have found it difficult to manage veld fires in many parts of the country, which brought environmental sustainability into a precarious position. The protection and preservation of the environment in our societies are also emphasised in the Millennium Development Goals (MDGs), with MDG 7 meaning to ‘ensure environmental sustainability’ Loewe . Such enestablish the challenges posed to environmental sustainability by veld firesidentify the type of environment upon which veld fires have an impactanalyse legal issues and other interventions surrounding the control of veld firessuggest improved control measures for veld fires to ensure environmental sustainability.It is important, therefore, that the government and stakeholders adopt a new approach towards the control of veld fires so that the management and sustainability of the environment can be improved.Veld fires, also known as bushfires, are posing major challenges to environmental management and sustainability in the Bulilima and Mangwe Districts of the Matabeleland South Province in southern Zimbabwe. The veld fires have been taking their toll on the environment in communal areas, destroying any damageable material. Trees, species of wildlife, farming land, livestock, human lives and livelihoods suffer under the severe threat posed by veld fires. If not controlled, veld fires would result in an unclean environment, severe environmental degradation and diminished livelihoods. As such, there is need to come up with sound interventions meant to protect, preserve and sustain the environment. The Bulilima and Mangwe districts share a common boundary in Matabeleland South Province. According to the Zimbabwe National Statistical Agency Zimstat , the estIn recent years, the concept of environmental management and sustainability has gained widespread recognition the world over. Efforts have been made by nations to demonstrate the serious attention that environmental management and sustainability deserve. The United Nations Conference on Environment and Development, through the Earth Summit in Rio, are testimony of governments’ commitment towards a sustainable environment. Environmental management principles set out at the first Earth Summit in Rio have been acknowledged by scientists and practitioners as well as the participating governments Murphree .South African National Environmental Management Act (NEMA), Act 107 of 1998, regards the environment as the surroundings within which humans exist and that are made up of:Different views have been advanced by scholars regarding the concepts of environmental management and sustainability. According to Rabie , there ii the land, water and atmosphere of the earthii micro-organisms, plant and animal lifeiii any part or combination of (i) and (ii) and the interrelationships amongst and between themiv the physical, chemical, aesthetic and cultural properties and conditions of the foregoing that influence human health and well-being. (n.p.)Environmental management came about as a need to protect and preserve the environment which is under threat. This research focuses on the environment in the context of improving environmental sustainability. In theory and practice, environmental management is concerned with the protection of what is considered to be the natural and human environment Murphree . Howevera concept of care applied to individual premises, corporate enterprises, localities, regions, catchments, natural resources, areas of high conservation values, lifetime cycles, waste handling and disposal, cleaner processing and recycling systems with the purpose of protecting the environment in the broadest sense, which involves the -Identification of objectivesThe adoption of appropriate mitigation measuresThe protection of ecosystemsThe enhancement of quality of life for those affected, andThe minimisation of environmental costs. (p.170)It involves the identification of objectives, the adoption of appropriate mitigation measures, the protection of ecosystems, the enhancement of the quality of life for those affected and the minimisation of environmental costs Gilpin .From the conceptualisation of environmental management above, it can be observed that effective environmental management ushers in environmental sustainability. The sustainability of the environment would mean that benefits that communities derive from the environment are lasting rather than passing. Nel and Kotzé :9 posit Many factors have been identified as causes of veld fires in societies. These causes have resulted in veld fires of varied magnitude and effect on the natural and human environment. The natural environment has seen the destruction of the fauna and flora whilst the loss of property, pollution and at times injury have been the order of the day in the human environment. Statistics show that most of the veld fires emanated from human activities. Mkhwananzi  observesThe dangers that veld fires pose to the environment include the destruction of ecosystems, fauna, flora and farming land. In the context of the environment, an ecosystem is viewed as a social-ecological unit that is stable and sustainable, maintaining its characteristic composition, organisation and function over time while remaining economically viable and sustaining human communities  to give information on the effects of veld fires on the environment. These are the people directly affecting and being affected by environmental degradation through veld fires. The same sampling method was applied to choose officials with a duty to protect the environment. This quota consisted of 10 participants chosen from departments that deal with veld fires. Such departments included EMA, the Zimbabwe Republic Police (ZRP) and the Fire and Ambulance Services. Officials from EMA and officers from ZRP were chosen for their expertise and experience in enforcing environmental legislation whilst staff from the Fire and Ambulance Services were chosen for their expertise in managing veld fires.A qualitative research design uses mainly questionnaires, interviews and observations to explore and understand the attitudes, opinions, feelings and behaviour of individuals or groups Du Plooy . In thisAn interview is a two-person conversation initiated by the interviewer for the purpose of obtaining research data focused on content specified by the research objectives, namely systematic description, prediction or explanation  felt that veld fires have led to property damage, 2 (10%) indicated that soil fertility has been affected, 5 (25%) said that the fires destroy vegetation, 2 (10%) indicated that they cause air pollution, 2 (10%) said that they pollute water sources, and 5 (25%) said that veld fires destroy wildlife . These fHaving indicated the major impact of veld fires, respondents went on to reveal what they thought were the major causes of veld fires in their communities. Most veld fires in the Bulilima and Mangwe districts are a result of actions by human beings .As can be observed , most veRespondents who work in organisations or departments with a mandate to deal with veld fires were given self-administered questionnaires with open-ended questions. From the questionnaires given, respondents showed that there are two types of environment upon which veld fires have the biggest impact – the natural and human environments.Six (60%) of ten respondents indicated that veld fires have the biggest impact on the natural environment whilst four (40%) indicated that it is the human environment that suffers the biggest impact. The natural environment includes all types of vegetation, all animal species and their surroundings. The human environment consists of places where people live and where they are likely to be found, their property and everything that they have built. However, respondents were of the opinion that both types of environment are heavily affected even though respondents had disparate views on the intensity of the impact on each.In the two types of environment, various livelihoods are seen to be affected by veld fires. These include crops, vegetable gardens, livestock, firewood and wild fruit. Data on the nature of livelihoods most affected by veld fires were obtained from the members of the community as shown .As can be seen in Environmental Management Act, Chapter 20:27; the Rural District Councils Act, Chapter 29:13; the Parks and Wildlife Act, Chapter 20:14; and the Forestry Act, Chapter 19:09. Part IX of the Environmental Management Act deals with standards of environmental quality  preferred fireguards, two respondents (20%) preferred campaigns, two respondents (20%) preferred law enforcement, one respondent (10%) preferred public education, and one respondent (10%) preferred rehearsals . FireguaResearch ethics were observed in carrying out the study. This had the aim of improving participation by the respondents. A university clearance, permitting the researcher to conduct the study, was obtained and made available to all respondents.The potential benefits from the study are available for the government and its stakeholders. They would benefit from the new approach towards environmental management and sustainability. This study entailed no risks or harm that could have affected the participants. All participants were assured that no physical or psychological harm would emanate from the study. They were also assured that no hazards were associated with data collected from them.The recruitment procedure for the study was based on voluntarism with none of the participants forced to provide information. The participants were advised that they were entitled to withdraw their consent at any stage of the study if they so wished to do so.Full consent was obtained from participants before the study was conducted. Their consent was checked and verified before they participated to make sure that it was real. This was to make sure that participants had no reservations and that their consent was not unduly influenced.Data obtained from the respondents in both Bulilima and Mangwe were treated with the utmost confidentiality. Data were carefully handled so that there was no unauthorised access, and such data were used solely for the purposes of the study.To ensure the trustworthiness of the data collected, the study first obtained information from members of the community since they are the ones affected by veld fires. These provided first-hand information from their lived experiences, namely being affected by the phenomenon. Officials from EMA and police officers being the law enforcers also provided data from their experiences in enforcing legislation related to environment conservation. These are experts in the field of law enforcement. The trustworthiness of the data was further enhanced by visiting places affected by veld fires in order to make on-site observations.This study provides news ways of dealing with veld fires, thereby helping governments and stakeholders in improving environmental sustainability. The suggested interventions include the review of the current statues for veld fires, the creation of fireguards conforming to the widths laid down in the statutes and regular campaigns. These interventions have the potential to inform policy and practice.Limitations to this study included resistance from some respondents, who seemed unwilling to release information, as well as the large size of the study area to be covered. To ensure that the reliability of the results was not affected, the purpose of the research was first explained to the participants in order to increase their response. A high degree of confidentiality was also assured for the participants. For easy coverage of the study area, the researcher stayed within the communities.Having analysed and considered the findings, a new approach towards veld-fire management and environmental sustainability should not be taken for granted. The study, therefore, recommends that the government should consider a review of the current statues for veld fires so that the statutes become stricter, thus deterring more would-be offenders. Fireguards should be intensified, and these should also conform to the widths laid down in the statutes of the country. More campaigns and rehearsals should be undertaken in order to educate the communities about the dangers of veld fires and equip stakeholders with the necessary expertise to deal with veld fires. This view sits well with the thinking of Forsyth, Kruger, and Le Maitre , namely Environmental Management Act, Chapter 20:27; the Rural District Councils Act, Chapter 29:13; and the Forestry Act, Chapter 19:09. According to government officials responsible for law enforcement who participated in the study, these measures have not been effective and are not able to deter enough people. Respondents revealed other veld-fire control measures that have been used, which include fireguards, campaigns, public education and rehearsals. Respondents felt that these too have not been effective. A new approach towards veld-fire management and environmental sustainability is recommended. The government should consider a review of the current legislation so that is becomes more deterrent to would-be offenders. Fireguards should be properly used, and fireguards that conform to the width gazetted in the statutes should be adopted. Regular campaigns should be run in the communities. Lastly, rehearsals also need to be run to equip stakeholders with the necessary skills.Veld fires are posing serious challenges to the environment and sustainability in the communal areas of the Bulilima and Mangwe districts of Matabeleland South in Zimbabwe. It was the respondents’ feelings that veld fires destroy crops, soil fertility, vegetation and animal species. According to the participants to the study, most of the veld fires in the said communal areas emanate from careless human activities. Respondents’ opinions were that such activities include the burning of vegetation in field preparation, the use of fire by hunters, smoking out bees, improper disposal of cigarette stubs and the making of fires by motorists along highways. From their experiences, the burning of vegetation in field preparation and the improper disposal of cigarette stubs are the major causes of veld fires in the Bulilima and Mangwe communal areas. Members of the community were of the view that veld fires impact negatively on both the natural and human environments. However, some respondents thought that their impact on the natural environment is more severe. The livelihoods of communities such as crops, vegetable gardens, livestock, firewood and wild fruit are destroyed by ravaging veld fires as perceived by the study participants. The government of Zimbabwe put in place supporting legislation to regulate conduct that could cause veld fires. Such legislation includes the


Involuntary hospitalization is a frequently discussed intervention physicians must sometimes execute. Because this intervention has serious implications for the citizens' civil liberties it is regulated by law. Every country's health system approaches this issue differently with regard to the relevant laws and the logistical processes by which involuntary hospitalization generally is enacted. This paper aims at analyzing the regulation and process of involuntary hospitalization in New York (United States) and Zurich (Switzerland). Comparing the respective historical, political, and economic backgrounds shows how notions of risk and liberty are culture-bound and consequently shape legislation and local practices. It is highly relevant to reconsider which criteria are required for involuntary hospitalization as this might shape the view of society on psychiatric patients and psychiatry itself. Furthermore, this article discusses the impact that training and experience of the person authorized to conduct and maintain an involuntary hospitalization has on the outcome. The use of coercion—whilst deeply controversial and ethically problematic—is a global phenomenon in psychiatry. It comes in many different forms, the most common ones being involuntary hospitalization, forced administration of medication, confinement in seclusion, physical or mechanical restraint, and compulsory treatment in outpatient settings. As all coercive measures severely compromise a person's autonomy and right to freedom, most nations have strict codes regulating their application –41. AlmoSharing concerns about the recent rise in the use of coercion in psychiatry worldwide , and hopAfter a short account of the respective histories of coercion and of the current organization of mental health care provision in the U.S. and Switzerland, we then compare the legal regulations surrounding coercion: specifically, involuntary hospitalization and involuntary outpatient treatment in New York and Zurich. As far as the available data allow, we also compare the actual clinical practice of involuntary hospitalization and involuntary outpatient treatment. We end with a discussion of the differences and similarities found, trying to better understand how the above-mentioned factors, especially notions of risk and liberty, are interrelated and converge in shaping the ‘culture of coercion’ and related research in the two regions.Both the United States of America (U.S.) and Switzerland significantly value civil liberties. This sentiment is also reflected in the respective constitutions. The preamble to the U.S. Constitution from 1787, specifies that its aim is to “secure the Blessings of Liberty to ourselves and our Posterity” . The anaIn the U.S., psychiatrists in the early Twentieth century administered several interventions that were harmful to psychiatric patients, and were largely carried out without permission and informed consent. Examples of such practices were pyrotherapy , insulin shock therapy , and the prefrontal lobotomy . ElectroSwitzerland, in turn, has its own history of abusive psychiatric practices. Eugenics was discussed in psychiatric circles and sterilization and castration were performed in psychiatric hospitals . In 1928Eugenics lost favor among Swiss psychiatrists and the population in general in the late 1930's and early 1940's, when reports of forced sterilization in Germany reached other parts of Europe . AlthougOverall, the use of coercive measures in psychiatry results from the negotiation of three values: safety of the community, need for treatment, and protection of the patient's liberties . FollowiWhile sharing some key features, Switzerland and the U.S. are significantly different countries with some profound distinctions in regards to the health care delivery systems , 31 and In the U.S., the 2010 Affordable Care Act (ACA) changed the health care laws. This enacted a system whereby the majority of US citizens is required to purchase private insurance, whereas the indigent population is covered by the joint federal/state program Medicaid, and the elderly (over 65) are covered by Medicare. Since enactment of the law in 2010 the uninsured rate has declined from 16.0 to 9.1% in 2015 . In 2017In Switzerland, as stipulated by the 1996 Health Insurance Law, all residents are required to purchase private insurance. Government assistance is available in cases where residents are unable to afford an insurance package so that every resident has health insurance .On the organizational level the number of beds in mental health hospitals decreased dramatically in the US during the last decades to a mean of 12 beds per 100.000 inhabitants  , compareBoth countries are a collection of states (cantons) with respective governing bodies. Each state's government is responsible for drafting laws not specified by the federal government. Neither Bern , nor Washington, D.C. have specifically dictated the exact processes by which psychiatric patients are admitted involuntary to institutions, so each state and canton has distinct regulations.It would go beyond the scope of this paper to compare the laws of each country. The aim was to examine two representative region's respective laws concerning compulsory hospitalization.New York State and the canton of Zurich are especially populous regions in their countries, the United States of America and Switzerland. Both regions are anchored by the biggest cities in the two countries, namely New York City and Zurich, which are important cultural and economic centers in both countries and often considered the capitals of the respective countries, and neither is the seat of the federal government.In New York State, the Office of Mental Health (OMH), under the ultimate jurisdiction of the Governor of New York State, dictates the laws regarding involuntary observation and hospitalization. These laws are called the Mental Hygiene Laws (MHL) and subsumed in Article 9 of the New York State Laws. There are essentially four laws  that govThe corresponding laws in Switzerland have experienced recent changes. On January 1st, 2013 a new legislation on child and adult protection was implemented, stipulating the process of “care-centered placement” (“Fuersorgerische Unterbringung”) which is similar to the concept of involuntary hospitalization . The canIn the light of the differences regarding legislation between both regions, the question arises if it results in differences in the organizational level of mental health care and/or in different rates of involuntary hospitalization.In Switzerland, the rates of involuntary hospitalization differ widely, ranging from 8% in the city of Basel (the second largest city in Switzerland) to 25–33% in Zurich (the canton with the biggest city in Switzerland) , 48. ForIn New York, the law regarding outpatient commitment was revised in 1999 after the public became aware of dramatic incidents caused by people with untreated and decompensated mental illness. Concrete changes to the NYS Mental Health Law were implemented after a young woman  was pushed in front of a subway and died. Due to this tragedy the law was named after this woman and is known today as Kendra‘s Law, characterized in Section 9.60 of the NYS Mental Health LawIn Switzerland, Art. 437 of the new child and adult protective law stipulates that the cantons are responsible for regulating the implementation of involuntary outpatient treatment . In ZuriThe U.S. and Switzerland are both high income countries that invest significant resources in their mental health systems. Whilst their approaches to mental health care share many similarities, there are also important cultural differences. These characteristics concern the relevant legislation, organizational structures of mental health care, the health insurance system and expert views. Also, views of the public and socioeconomic aspects may have a substantial effect on these divergences. Those different aspects in turn influence the legislation and will be discussed in the following section.The legislation, which stipulates involuntary hospitalization in the two regions, share many similarities. The essence of what constitutes grounds for involuntary hospitalization remains a mental disorder. Besides this, there are several interesting distinctions. In the State of New York, the danger to self and others is a major criterion for involuntary hospitalization and its prolongation. In Zurich, this danger criterion is not required and only listed as an additional criterion after the primary criteria, i.e., weakness and need for protection. In general, the Swiss Laws have a broader range in the criteria for conduction of an involuntary hospitalization, especially as there is a specific provision directed at the issue of whether the patient would be a burden on the family or other caretakers in the community when deciding whether involuntary hospitalization in necessary. With these broader formulated criteria, Swiss laws have a more farsighted view of the challenges facing the treatment of mental illness, accepting that the risk of meeting the criteria for initiation of an involuntary hospitalization is higher in many patients. One argument in favor of this criterion is that if care is burdensome to others, there will likely be a worse prognosis for the patient and his/her family. Nevertheless the question arises how a physician can define when the point is reached that the burden for others justifies the restriction of an individual's freedom (in this case the patient). A Norwegian study showed that many referring physicians felt pressured by the patient's environment to order an involuntary hospitalization . In ZuriIn New York, the law limits the length of an involuntary hospitalization at several time points, and a prolongation must be actively appealed for by the physicians in charge or additional physicians. This is contrasted by the Zurich legislation where an involuntary hospitalization can remain for as long as 42 days. This regulation spares resources on one hand, whereas on the other hand the consequent lack of regular revisions at court may increase the risk for longer involuntary hospitalizations The only other limitation provided for is if the patient him/herself appeals for an earlier discharge in court. This may account for the longer duration of involuntary hospitalizations in Zurich (20 days)  relativeThe low number of psychiatric beds in New York may actually be a reflection of the low median length of stay among psychiatric inpatients. A reduction of psychiatric beds has also been discussed in connection with an increase of psychiatric patients in the prison system , 56. HowThe fear of untreated psychiatric patients and their potential actions seems to be higher in New York or the U.S. in general compared to Zurich or Switzerland. The easy accessibility of weapons in the U.S. has been discussed as a contributing factor to this fear . It may Because of the controversy of AOT, research about its effects and possible adverse effects has become an important field in epidemiological research. One of the major criticisms is the lack of uniformity in the law . Each stIn Zurich, the legislation is more restrictive according to involuntary outpatient treatment and as a result involuntary outpatient treatment does not play a role in mental health care. Therefore, research aimed at involuntary treatment only focuses on involuntary hospitalization in institutional settings.New York and Zurich are both high-income regions in the Western world. They share basic democratic and liberal values, respect for human rights, personal freedom, and autonomy. This broad cultural similarity entails similar approaches to mental health care, and yet as we have shown, there are important differences with regards to the specifics of clinical practice, esp. involuntary hospitalization and assertive outpatient treatment. These differences become understandable when local culture, with its specific historical, economic and social background, is taken into consideration. Psychiatry's characteristic dual role—its duty to provide care for mentally ill persons on the one hand and the role as society's “safe-keeper” on the other—implies that there is a constant tension among the treatment needs of the individual, the safety needs of society, and the individual's liberties . This neThe focus on the danger criterion in New York might aggravate the stigmatization of psychiatric patients and the field of psychiatry itself. This is relevant as it was shown that besides self-stigmatization of patients also the stigma of psychiatry itself can be problematic. Some patients avoid psychiatric help because they do not want their family, friends, or employer to find out about their mental health problem . ChangesIn Zurich, the less specific criteria for involuntary hospitalization might lessen such stigmatization. However, they might lead to higher rates of involuntary hospitalization. With a broader margin of legal interpretation, the influence of the health care provider increases. In Zurich, the quality of the commitment process and the course of treatment after involuntary hospitalization differs according to the referring physicians and their experience dealing with psychiatric emergencies , 70. ThuGiven the gravity of coercion, knowledge of the laws that govern the process of coercive treatment locally and awareness of local alternatives to this most intrusive intervention appear to be crucial. Also, research examining ways to minimize the use of coercive interventions is fundamental. However, such research needs to be implemented in a specific cultural context. While certain “best practices” might be highly beneficial for one community, they might not be suitable for another. It is therefore essential to develop a sensitivity to cultural and local influences on psychiatric practice. A cross-cultural comparison can help develop such sensibility. It can also open one's eyes to alternative ways of meeting common challenges and thereby offer inspiration for change.This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.FH, JK, AM, and AS: Conception and design; data collection, analysis, and interpretation; FH, JK, AM, MJ and AS: Drafting the article and revising it critically for important intellectual content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer CM declared a past co-authorship with one of the authors MJ to the handling Editor.


According toestimates by the World Health Organization (WHO), approximately 17.9 million individualsdie per year due to this clinical condition.3Considering the strong association of CVD with morbidity and mortality, as well as theimpairment of functional capacity and quality of life shown by these patients,strategies aimed at minimizing these impairments and that can be shown to becost-effective should be implemented. In this scenario, cardiovascular rehabilitation(CVR) is crucial and should be part of the overall treatment of CVD.4 According to theSouth-American Guideline for Cardiovascular Prevention and Rehabilitation,3 for this process to be feasible and forthe objectives to be attained, the integrated performance of a multidisciplinary team isrequired. Physical training, associated with drug treatment, is the central component ofCVR. However, the professionals' performance is not restricted to creating the plan andapplying the exercises. Special attention should also be given to the patients' fulleducation regarding their health condition and appropriate management of risk factors,aiming at having a healthy lifestyle.3Specific characteristics of each patient, such as socioeconomic and educational levels,may influence the prior knowledge and understanding of information provided byprofessionals. In this sense, tools that evaluate the patients' knowledge regardingtheir health condition are useful and can help the professionals to create and applyeffective strategies.The WHO defines CVR as "the sum of activities required to ensure people with CVD have thebest possible physical, mental and social conditions, so that the patients may, by theirown efforts, preserve or resume when lost as normal a place as possible in thesociety."5 This questionnaireassesses the knowledge of CVD patients regarding their health condition, including theclinical aspects, risk factors, exercise, diet and psychosocial risk. Concerning thepreviously validated questionnaires (CADE-Q and CADE-Q II),7 the new proposalmaintains the assessment of central components of CVR, with differences being related tothe fact that it is a more concise tool that can be applied in ten minutes, as reportedby the researchers. The short time required, and the objective profile of the responseoptions may favor the applicability of this tool in research and clinical practice,providing relevant information for better targeting of interventions in secondaryprevention in Brazil.Recently, the validation of the Portuguese version of the Coronary Artery DiseaseEducation Questionnaire - Short Version (CADE-Q SV) was published in thisjournal.8It has been previously shown that the context in which the subject is placed caninfluence their knowledge about health. In a previous study, using the pioneer CADE-Qversion, the researchers found that CVR participants in Brazil had lower levels ofknowledge about their condition when compared to Canadian patients.6In the most recent CADE-Q SV validation study, outpatients who did not necessarilyparticipate in a formal CVR program were included. The area identified with greaterknowledge was that related to risk factors and the one with the lowest score was thatrelated to psychosocial risk. Overall, the patients showed a low level of knowledge, andthose with lower educational level, as well as those with family income, showedsignificantly higher needs. On the other hand, characteristics such as age younger than65 years and previous infarction or arrhythmia were associated with significantly higherlevel of knowledge.CADE-Q SV is a short, valid and reliable tool to evaluate the knowledge of CVD patientsin Brazil. It can be useful in the characterization of groups of patients and especiallyin the identification of each individual's specific needs, allowing the implementationof targeted educational strategies. Therefore, it is a potential tool to be used insecondary prevention and should be tested and administered in different health programsand regions of our country. After applying the questionnaire, it is recommended that theprofessionals clarify doubts about the answers to the patients, in order to help in theprocess of learning and health care.


The management of lymphatic malformations (LMs) is challenging, particularly for large and complex lesions involving anatomical structures in the adjacent tissue. While lymphovenous anastomosis (LVA) has been reported as an effective treatment for lymphedema, it has hardly been described as a treatment for LM. Virtual reality has the ability to visualize human structures in three dimensions and can be used for the preoperative planning of complex cases. Here, we describe the first case of the management of an LM by LVA preoperatively planned with virtual reality. A young woman presented with an LM previously treated by gross excision. Following persistent complaints of swelling, a minimally invasive microsurgical intervention was planned. The results of the single photon emission tomography with computed tomography (SPECT-CT) and lymphoscintigraphy were analyzed using a virtual reality program, and a 3D patient-specific model was constructed. Based on the combined findings of this 3D model and lymphography with a fluorescent marker, a precise skin incision could be determined and one lymph vessel was anastomosed to a nearby vein. The swelling of the thigh reduced and the discomfort disappeared. Although more reports are needed to confirm its efficacy, LVA planned with virtual reality constructed images appears to be a valuable treatment option for complex lesions, including LMs. Lymphatic malformations, also known as lymphangiomas, are a complex group of congenital vascular anomalies that do not undergo involution and can cause pain, swelling, and functional impairment ,2. GivenVirtual reality is an emerging field with the ability to visualize and interact with complex human structures in three dimensions. Particularly in the field of medicine, virtual reality applications are increasingly used for the teaching and training of students  and surgHere, we describe the first case of microsurgical treatment of a lymphatic malformation preoperatively planned with virtual reality.A 27-year-old female patient with a simple vascular malformation—described as ‘lymphangioma’ —at the lConservative treatment by means of manual lymph drainage and compression garments was initiated; however, results were unsatisfactory. Given the refractory swelling and continued complaints of a feeling of pressure at the level of the groin, and given the applied gross excision in the past, a minimally invasive surgical intervention was planned. Lymphatic mapping was performed by means of lymphography , with the fluorescent marker indocyanine green (ICG). Patent lymphatics at the medial side of the thigh, visualized by near-infrared technology, were marked on the skin . A lymphoscintigraphy image of the lower extremities showed a pronounced uptake of radioactive tracer on the medial side of the thigh a. The coFinally, the images from the SPECT-CT and lymphoscintigraphy were analyzed with a virtual reality program   that allBased on the 3D model and the mapping by ICG lymphography, the incision site was determined a, and anThe postoperative course was uneventful. Immediately after surgery, the feeling of tension disappeared and the volume of the right thigh decreased b. Four mThe conventional images of the SPECT-CT and lymphoscintigraphy, stored as DICOM data, were processed by dedicated software . The DICThe treatment was conducted in accordance with the Declaration of Helsinki and under the institutional ethical review board of the hospital. Written informed consent was obtained. The patient provided written informed consent for the publication and the use of the images.This report describes the first case of lymphovenous anastomosis planned using virtual reality and successfully applied to a patient with a lymphatic malformation.Lymphovenous anastomosis as a treatment for lymphatic malformations has rarely been described in literature. Kato et al.  successfWhile virtual and augmented reality-based navigation surgery is commonly applied in neurosurgery and maxilla-facial surgery , its appThe strategy of the intervention was to identify the lymphatics leaking into the malformation and to interrupt the inflow towards the lesion by redirecting the lymph towards the venous system. To do so, it was mandatory to find the exact localization of the afferent lymphatic vessels. Lymphoscintigraphy is the gold standard imaging modality of lymphatic disorders, but it provides only static information . SPECT-CThe advantages of virtual reality in this setting are obvious. Firstly, the visualization of complex human structures in 3D with a head-mounted display provides a realistic representation of the human body, which is a three-dimensional object. Looking at it in its original dimensions in an immersive virtual reality environment, rather than on an artificial two-dimensional image on a screen, enables the viewer to gain insight into the actual anatomy of the patient. As such, patients with a complex lymphocele are ideal candidates for treatment with virtual reality guided LVA. Secondly, the patient-specific model visualized in a 3D virtual space can be simultaneously viewed by others. Moreover, one can collaborate on the medical DICOM data using a dedicated platform provided by the software . Although we did not use this platform in our case, it could be useful for discussing the approach of complicated cases with other surgeons around the world. Furthermore, since several care providers can collaborate and communicate in real time thanks to this Cloud, difficulties can be discovered before the actual surgical intervention is carried out. However, virtual reality devices and associated hardware and software remain relatively expensive and their use is time-consuming and difficult to integrate into standard practice. In our case, whilst only 15 min were required to study the anatomy of the lymphatic malformation in order to plan the subsequent intervention, one must account for at least 1 hour of preparation for the data to be processed by the dedicated software. On the other hand, as a result of the rapid progress in this field of technology, costs associated with hard- and software are expected to decrease. As it is highly likely that virtual and augmented reality will become more popular in all fields of medicine in the near future, medical staff will easily gain experience in handling the medical DICOM data of the patient.In conclusion, we successfully treated a lymphatic malformation after preoperative planning using the visualization of standard imaging in virtual reality. Although further development is needed, our initial experience suggests the utility of virtual reality for the planning of surgical interventions on complex lymphatic lesions.


With over 6000 rivers and 5358 lakes, surface water is one of the most important resources in Nepal. However, the quantity and quality of Nepal’s rivers and lakes are decreasing due to human activities and climate change. Despite the advancement of remote sensing technology and the availability of open access data and tools, the monitoring and surface water extraction works has not been carried out in Nepal. Single or multiple water index methods have been applied in the extraction of surface water with satisfactory results. Extending our previous study, the authors evaluated six different machine learning algorithms: Naive Bayes (NB), recursive partitioning and regression trees (RPART), neural networks (NNET), support vector machines (SVM), random forest (RF), and gradient boosted machines (GBM) to extract surface water in Nepal. With three secondary bands, slope, NDVI and NDWI, the algorithms were evaluated for performance with the addition of extra information. As a result, all the applied machine learning algorithms, except NB and RPART, showed good performance. RF showed overall accuracy (OA) and kappa coefficient (Kappa) of 1 for the all the multiband data with the reference dataset, followed by GBM, NNET, and SVM in metrics. The performances were better in the hilly regions and flat lands, but not well in the Himalayas with ice, snow and shadows, and the addition of slope and NDWI showed improvement in the results. Adding single secondary bands is better than adding multiple in most algorithms except NNET. From current and previous studies, it is recommended to separate any study area with and without snow or low and high elevation, then apply machine learning algorithms in original Landsat data or with the addition of slopes or NDWI for better performance. Nepal is a geographically diverse country with flats in the south and increasing hills, to the mighty Himalayas in the north. In Nepal, approximately 70% to 90% of the total annual rainfall occurs during the monsoon period resulting in high runoff and sediment discharge causing surface water area change . Thus, iIn such cases, remote sensing technology plays a very important role on detecting, extracting, and monitoring surface water ,9. Open With recent developments in computing technology, the machines are cheaper, and the algorithms are efficient. Therefore, the abundance of these machines and machine learning algorithms have been widely applicable in almost every aspect of human life. Moreover, their optimization has outperformed the classical ones. Numerous machine learning algorithms have been applied for remotely sensed imageries ,17,18,19Hence, the motivation of this work is to introduce the application of the most common algorithms used by the remote sensing community in Nepal and evaluate their performance for surface water extraction. The six most common algorithms, naive Bayes (NB), recursive partitioning and regression trees (RPART), neural networks (NNET), support vector machine (SVM), random forest (RF), and gradient boosted machines (GBM) were evaluated in a Landsat 8 operational land imager (OLI) bands. Also, the slope, normalized difference vegetation index (NDWI) and normalized difference water index (NDWI) were combined one at a time and all three at once with OLI bands to evaluate whether the combination can overcome the limitations of the original bands in water extraction. In the future, such evaluation will assist in selection of proper methods to develop an effective time series database at national scale in Nepal.As the study is the extension of our previous study , the autTo better evaluate and compare the results, our previous study had six classes in the scene . HoweverUsing the digital elevation model (DEM) and pre-possessed OLI bands (LS8), three secondary bands were created: Slope, NDVI and NDWI. A total of 800 reference datasets were used in the whole scene. To minimize the overfitting or selection bias in the predictive ability of machine learning algorithms, the authors used ten folds cross-validation to train the model. In the process, the data is divided into ten sets, nine sets are first used to train the model and the remaining one is used for validation purposes. The process is repeated ten times with each of the ten subsamples being used for both training and validation. Thus, each observation is used exactly once for training and validation.After forming the dataset, six machine learning methods, NB, RPART, NNET, SVM, RF, and GBM, were implemented in the CARET package of R, and were used for training and preparing the models. The advantage of the CARET package is that it provides complete machine learning processes from data preparation, training, modelling and prediction to validation. Moreover, the train function in the caret sets up a grid of tuning parameters as required for the algorithm which fits each model and calculates a resampling based performance measure. As details on these models can be widely found in the literature, the authors will be briefly describing these algorithms.NB is a probabilistic classifier based on Bayes’ theorem with the independent assumptions between predictors. It is easy to build, with no complicated iterative parameter estimation and suited particularly when the dimensionality of the inputs is high. With few tuneable parameters and fast, they end up being very useful as a quick-and-dirty baseline for a classification problem. RPART is a type of binary tree used for classification or regression tasks. It performs a search over all possible splits by maximizing an information measure of node impurity, selecting the covariate showing the best split.NNET in R, is a feed-forward neural network with a single hidden layer flowing left to right. Feed-forward neural networks were the first type of artificial neural network invented, and are simpler than their counterparts, recurrent neural networks. They are called feed-forward networks because information only travels forward in the network (no loops), first through the input nodes, then through the hidden nodes (if present), and finally through the output nodes. These are primarily used for supervised learning in cases where the data to be learned are neither sequential nor time dependent.SVM is a data classification method that separates data using a hyperplane. In other words, for the given labelled training data (supervised learning), the algorithm outputs an optimal hyperplane which separates only one type of data. The SVM technique is generally useful for data that is non-regularity, which means data whose distribution is unknown.RF is a meta estimator that fits several decision tree classifiers on various sub-samples of the dataset and uses averaging to improve the predictive accuracy and control over-fitting.GBM is a class of ensemble learning techniques to create a collection of shallow and weak successive trees with each tree learning and improving on the previous based on a cost function .All these six models for five different datasets were applied to the full scene to classify the image into binary water and non-water maps. After the classification, the full reference dataset was evaluated for overall accuracy (OA) and kappa coefficient (Kappa) .In this section, first, the results of the cross-validated models were assessed, and then they were applied to the whole scene for the surface water extraction. Next, the complete reference dataset was tested against the predicted results. In the end, a detailed comparison and discussion of the different machine learning algorithms were done to evaluate the performance case by case.In the CARET package, the train function produces the model with tuning parameters. Therefore, the produced models can be easier to apply in the prediction. For the quantitative evaluation, the confusion matrix-based OA and Kappa were produced for the full reference class and predicted class. In Except RF and NNET, similar patterns of performance were seen. NDWI followed by the slope, increases the performance of the machine learning algorithms. In contrast, NDVI or adding all bands reduced the performance. It shows that adding specific secondary bands with the original LS8 band is useful for enhancement of surface water. Similarly, the slope that ensures flat surface of water bodies is also useful if added. In NDVI, water are negative values at the same time that many other non-vegetative bodes can also have the same value, which has led to a decrease in performance. NNET and SVM are very well-known state-of-art algorithms in classification. They perform well in many cases and their performance in the original Landsat 8 scene of Nepal is satisfactory. However, the interesting result is that while NNET increased the performance with that addition of data gradually, SVM went the other side. This also shows that the addition of secondary data does not necessarily improve performance and are rather dependent on algorithms. Thus, comparative studies are necessary to check these performances and select the best one for the area under study.In As both RF and GBM are ensemble methods, their performance on the cases are quite similar in In comparison to the previous study , except (a)All the applied machine learning algorithms showed OA above 90% but in case of Kappa except NB and RPART, it was above 90%.(b)RF showed OA and Kappa both 1 for the all the multiband data with the reference dataset.(c)GBM and NNET also showed good performance followed by the SVM.(d)Machine learning algorithms were able to perform better in the hilly regions and flat lands but not well in the Himalayas with ice, snow and shadows.(e)The addition of the slope and NDWI showed improvement in the results compared to the NDVI except NNET. Others do not improve with the addition of all three secondary bands compared with the individual addition.In this study, we extended the previous study and applied six machine learning algorithms: NB, RPART, NNET, SVM, RF and GBM to evaluate the surface water extraction using a Landsat 8 OLI images in Nepal. Using the previous reference dataset and Landsat scene, six different models were developed using the CARET package in R software. Cross-validation was completed to minimize the overfitting then train the model to predict the surface water and validate the full reference dataset. With three secondary bands: Slope, NDVI and NDWI, the algorithms were evaluated for performance with the addition of extra information. The results were compared, case by case, and the following conclusions were drawn from the test scene and applied machine learning algorithms:It seems that machine learning methods could be very useful for the accurate automated binary classification of surface water in Nepal. The use of RF with original LS8 data or with the addition of the slope or NDWI with another algorithm can be undertaken. Based on this and previous work , it is rFor further investigation, this study aimed to evaluate the application of convolutional neural networks or deep learning for better accuracy. In addition, individual original bands and secondary bands with the RF and GBM can be evaluated so that high accuracy can be achieved with minimum bands.