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Recent research has highlighted the valuable role that coastal and marine ecosystems play in sequestering carbon dioxide (CO 2 ). The carbon (C) sequestered in vegetated coastal ecosystems, specifically mangrove forests, seagrass beds, and salt marshes, has been termed \"blue carbon\". Although their global area is one to two orders of magnitude smaller than that of terrestrial forests, the contribution of vegetated coastal habitats per unit area to long-term C sequestration is much greater, in part because of their efficiency in trapping suspended matter and associated organic C during tidal inundation. Despite the value of mangrove forests, seagrass beds, and salt marshes in sequestering C, and the other goods and services they provide, these systems are being lost at critical rates and action is urgently needed to prevent further degradation and loss. Recognition of the C sequestration value of vegetated coastal ecosystems provides a strong argument for their protection and restoration; however, it is necessary to improve scientific understanding of the underlying mechanisms that control C sequestration in these ecosystems. Here, we identify key areas of uncertainty and specific actions needed to address them.

The threats posed to the marine environment by increasing atmospheric carbon dioxide are historically unprecedented, and will probably require the use of unconventional, non-passive methods to conserve marine ecosystems. In this Perspective it is argued that soliciting such approaches and evaluating their cost, safety and effectiveness must be part of a robust ocean conservation and management strategy. The historically unprecedented threats to the marine environment posed by increasing atmospheric carbon dioxide will probably require the use of unconventional, non-passive methods to conserve marine ecosystems. Soliciting such approaches and evaluating their cost, safety and effectiveness must be part of a robust ocean conservation and management plan going forward.

The Paris agreement target of limiting global surface warming to 1.5-2°C compared to pre-industrial levels by 2100 will heavily impact the ocean. While ambitious mitigation and adaptation are both needed, the ocean provides major opportunities for action to reduce climate change globally and its impacts on vital ecosystems and ecosystem services. A comprehensive and systematic assessment of 13 global- and local-scale, ocean-based measures was performed to help steer the development and implementation of technologies and actions towards a sustainable outcome. We show that (1) all measures have tradeoffs and multiple criteria must be used for a comprehensive assessment of their potential, (2) greatest benefit is derived by combining global and local solutions, some of which could be implemented or scaled-up immediately, (3) some measures are too uncertain to be recommended yet, (4) political consistency must be achieved through effective cross-scale governance mechanisms, (5) scientific effort must focus on effectiveness, co-benefits, disbenefits, and costs of poorly tested as well as new and emerging measures.

The marine management community is missing critical opportunities to incorporate restoration into coastal planning as well as formal marine spatial planning (MSP) initiatives. Not committing to restoration as decisions are made on how to allocate ocean space and resources means that priority areas for restoration are being ignored, and the potential for using management to restore ecosystem services and improve human well-being may not be met. Large scale restoration, widely acknowledged as needed, is much more difficult in the absence of a systematic framework to remove pressures or practice active reconstruction in key ecologically linked habitats. To address this deficit, we highlight how restoration can be brought into MSP processes across eight waypoints: (1) determining if restoration can be added as a goal of existing MSP; (2) scoping the problems to craft the correct restoration solutions in the planning area; (3) committing to reconciling development with conservation; (4) utilizing MSP frameworks for restoration in a constellation of interlinked sites; (5) doing participatory master planning to set priorities for action; (6) planning with long time horizons and adaptation in mind; (7) building the foundation for long-term financing; and (8) coming to scale. We show how linking restoration planning with MSP has reciprocal benefits: restoration can be done more efficiently and at larger scales when interventions occur across linked habitats, and marine spatial plans can catalyze broader outcomes when degraded areas are restored to their full potential for ecosystem service delivery. Restoration aims to result in healthier ecosystems, greater delivery of ecosystem services, more ‘usable’ space for both humans and nature, and enhanced values—potentially diminishing conflicts and improving well-being in coastal communities.

Managing coral reefs for resilience to climate change is a popular concept but has been difficult to implement because the empirical scientific evidence has either not been evaluated or is sometimes unsupportive of theory, which leads to uncertainty when considering methods and identifying priority reefs. We asked experts and reviewed the scientific literature for guidance on the multiple physical and biological factors that affect the ability of coral reefs to resist and recover from climate disturbance. Eleven key factors to inform decisions based on scaling scientific evidence and the achievability of quantifying the factors were identified. Factors important to resistance and recovery, which are important components of resilience, were not strongly related, and should be assessed independently. The abundance of resistant (heat-tolerant) coral species and past temperature variability were perceived to provide the greatest resistance to climate change, while coral recruitment rates, and macroalgae abundance were most influential in the recovery process. Based on the 11 key factors, we tested an evidence-based framework for climate change resilience in an Indonesian marine protected area. The results suggest our evidence-weighted framework improved upon existing un-weighted methods in terms of characterizing resilience and distinguishing priority sites. The evaluation supports the concept that, despite high ecological complexity, relatively few strong variables can be important in influencing ecosystem dynamics. This is the first rigorous assessment of factors promoting coral reef resilience based on their perceived importance, empirical evidence, and feasibility of measurement. There were few differences between scientists' perceptions of factor importance and the scientific evidence found in journal publications but more before and after impact studies will be required to fully test the validity of all the factors. The methods here will increase the feasibility and defensibility of including key resilience metrics in evaluations of coral reefs, as well as reduce costs. Adaptation, marine protected areas, priority setting, resistance, recovery.

By necessity Pacific Islands have become hubs of innovation, where climate strategies are piloted and refined to inform adaptation efforts globally. Pacific Island communities face increasingly severe climate impacts including sea-level rise, changing temperature and rainfall patterns, changes in food and water security, and social, cultural, and political impacts including loss of identity, climate-induced migration and threats to sovereignty. In response, communities in the region are leading climate adaptation strategies, often combining traditional practices and cutting-edge science, to build the resilience of their communities and ecosystems in the face of increasing climate risk. For example, communities are implementing resilient networks of marine protected areas using the best available science and strengthening tribal governance to manage these networks, experimenting with salt and drought tolerant crops, revegetating coastlines with native salt-tolerant plants, revitalizing traditional wells, and implementing climate-smart development plans. Often these efforts contribute to local development priorities and create co-benefits for multiple sustainable development goals (SDGs). These community efforts are being scaled up through provincial and national policies that reinforce the critical role that ecosystems play in climate adaptation and provide a model for the rest of the world. While adaptation efforts are critical to help communities cope with climate impacts, in some cases, they will be insufficient to address the magnitude of climate impacts and local development needs. Thus, there are inherent trade-offs and limitations to climate adaptation with migration being the last resort for some island communities.

Background Ehlers–Danlos syndrome (EDS) type IV is a rare subtype of EDS, but has important surgical implications. Case presentation Here, we present a case of a spontaneous sigmoid perforation in a 14-year-old boy. He was initially treated with laparotomy, oversew of the sigmoid perforation and a diverting ileostomy. He developed a complete wound dehiscence and enteroatmospheric fistulae. These were managed with a combination of negative pressure wound therapy and Eakin (TG Eakin™) pouch changes. We discuss the clinical features and presentation of EDS type IV, the surgical implications of managing patients with the condition, and the challenges in management of enteroatmospheric fistulae in children. Conclusions Ehlers–Danlos syndrome type IV should be considered as a cause of any spontaneous colonic perforation in children.

The health of coastal human communities and marine ecosystems are at risk from a host of anthropogenic stressors, in particular, climate change. Because ecological health and human well-being are inextricably connected, effective and positive responses to current risks require multidisciplinary solutions. Yet, the complexity of coupled social-ecological systems has left many potential solutions unidentified or insufficiently explored. The urgent need to achieve positive social and ecological outcomes across local and global scales necessitates rapid and targeted multidisciplinary research to identify solutions that have the greatest chance of promoting benefits for both people and nature. To address these challenges, we conducted a forecasting exercise with a diverse, multidisciplinary team to identify priority research questions needed to promote sustainable and just marine social-ecological systems now and into the future, within the context of climate change and population growth. In contrast to the traditional reactive cycle of science and management, we aimed to generate questions that focus on what we need to know, before we need to know it. Participants were presented with the question, \"If we were managing oceans in 2050 and looking back, what research, primary or synthetic, would wish we had invested in today?\" We first identified major social and ecological events over the past 60 years that shaped current human relationships with coasts and oceans. We then used a modified Delphi approach to identify nine priority research areas and 46 questions focused on increasing sustainability and well-being in marine social-ecological systems. The research areas we identified include relationships between ecological and human health, access to resources, equity, governance, economics, resilience, and technology. Most questions require increased collaboration across traditionally distinct disciplines and sectors for successful study and implementation. By identifying these questions, we hope to facilitate the discourse, research, and policies needed to rapidly promote healthy marine ecosystems and the human communities that depend upon them.

Climate change is a public health emergency. Yet, incongruously, the healthcare sector is a significant source of global greenhouse gas emissions. Surgical systems are uniquely situated to address this public health crisis due to the high carbon footprint associated with surgical care delivery and the ability of strong surgical systems to foster broader climate resilience. There is an urgent need for climate change and health indicators (CCHIs) specific to surgical care to address the environmental impacts of surgery and reduce the impacts of climate change on the health of individuals, populations and surgical care delivery. In proposing a set of example CCHIs pertinent to surgical care, we call the surgical community to action to improve and refine existing indicators while simultaneously engaging in national and regional surgical system strengthening efforts. Moreover, aligning such efforts can help bridge existing climate and health funding gaps which, to date, have proved a critical barrier to ensuring effective healthcare mitigation and adaptation.

The World Health Assembly resolution 68.15 recognised emergency and essential surgery as a critical component of universal health coverage. The first session of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia–Pacific Region focused on the current status of surgical care and opportunities for improvement. During this session, Ministries of Health and World Health Organization (WHO) Regional Directors shared country- and regional-level progress in surgical system strengthening. The WHO Western Pacific Regional Office (WPRO) has developed an Action Framework for Safe and Affordable Surgery, whilst the WHO South-East Asia Regional Office (SEARO) highlighted their efforts in emergency obstetric care, workforce strengthening, and blood safety. Numerous countries have begun developing and implementing National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). Participants agreed surgical system strengthening is an integral component of universal health coverage, pandemic preparedness, and overall health system resilience. Participants discussed common challenges, such as the COVID-19 pandemic, climate change, workforce capacity building, and improving access for hard-to-reach populations. They generated and shared common solutions, including strengthening surgical care capacity in first-level hospitals, anaesthesia task-shifting, remote training, and integrating surgical care with public health, preventive care, and emergency preparedness. Moving forward, participants committed to developing and implementing NSOAPs and agreed on the need to raise political awareness, build a broad-based movement, and form intersectoral collaborations.