Europe

This chapter reviews the scientific evidence published since the IPCC Fourth Assessment Report (AR4) on observed and projected impacts of anthropogenic climate change in Europe and adaptation responses. The geographical scope of this chapter is the same as in AR4 with the inclusion of Turkey. Thus, the European region includes all countries from Iceland in the west to the Russian Federation (west of the Urals) and the Caspian Sea in the east, and from the northern shores of the Mediterranean and Black Seas and the Caucasus in the south to the Arctic Ocean in the north. Impacts above the Arctic Circle are addressed in Chapter 28 and impacts in the Baltic and Mediterranean Seas in Chapter 30. Impacts in Malta, Cyprus, and other island states in Europe are discussed in Chapter 29. The European region has been divided into five sub-regions: Atlantic, Alpine, Southern, Northern, and Continental. The sub-regions are derived by aggregating the climate zones developed by Metzger et al. (2005) and therefore represent geographical and ecological zones rather than political boundaries. The scientific evidence has been evaluated to compare impacts across (rather than within) sub-regions, although this was not always possible depending on the scientific information available

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

BackgroundRheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.ObjectivesTo (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.DesignObservational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.SettingObservational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).ParticipantsPatients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.InterventionsIntensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.Main outcome measuresDisease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR ResultsEvaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p LimitationsThe main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.ConclusionThe benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.Future workFurther research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.Trial registrationCurrent Controlled Trials ISRCTN70160382.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.NIH

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Landscapes of cellular phenotypic diversity in breast cancer xenografts and their impact on drug response

Funder: Cancer Research UK (CRUK); doi: https://doi.org/10.13039/501100000289Funder: AstraZeneca; doi: https://doi.org/10.13039/100004325Abstract: The heterogeneity of breast cancer plays a major role in drug response and resistance and has been extensively characterized at the genomic level. Here, a single-cell breast cancer mass cytometry (BCMC) panel is optimized to identify cell phenotypes and their oncogenic signalling states in a biobank of patient-derived tumour xenograft (PDTX) models representing the diversity of human breast cancer. The BCMC panel identifies 13 cellular phenotypes (11 human and 2 murine), associated with both breast cancer subtypes and specific genomic features. Pre-treatment cellular phenotypic composition is a determinant of response to anticancer therapies. Single-cell profiling also reveals drug-induced cellular phenotypic dynamics, unravelling previously unnoticed intra-tumour response diversity. The comprehensive view of the landscapes of cellular phenotypic heterogeneity in PDTXs uncovered by the BCMC panel, which is mirrored in primary human tumours, has profound implications for understanding and predicting therapy response and resistance

Weather Preferences for Urban Tourism: An Empirical Study in the Greek Capital of Athens, Greece

Several climate indices have been developed to analyze the relationship between climatic variables and tourist comfort at different destinations, although, none of the indices applied so far in cities have been informed by empirical data collected exclusively at urban tourist destinations. The present paper aims to cover this gap by developing an “Urban Climate Comfort Index” (UCCI) that integrates critical climate variables for urban tourism and is informed by empirical data from an in-situ survey conducted in southern Europe, namely, in close proximity to the Acropolis Museum in Athens, Greece. The survey provided input on the ideal and unacceptable climatic conditions as perceived by urban tourists and on the relevant weight of the selected climatic parameters. Tourist preferences were then translated into a numerical scale by assigning utility scores of 0% and 100% to the “unacceptable” and “ideal” values while using a linear change for the intermediate values. Hence, a best-fitting utility function for each climatic variable was created, and all utility functions were then aggregated through their relative weights to form the UCCI index. The new index can be applied to other similar urban tourist destinations and assist impact assessment studies and tourism management measures, including climate change adaptation

Weather Preferences for Ski Tourism: An Empirical Study on the Largest Ski Resort in Greece

Numerous studies have demonstrated the tourism industry to be especially sensitive to weather and climate variability. Snow-related tourism, being largely dependent on climatic resources, is particularly affected by climate change. Our study provides a new index to reflect the climatic suitability of a given destination for snow-related tourism activities, focusing on resorts with usually limited snowfall. The proposed Skiing Utility Index (SUI) is based purely on the weather preferences of skiers, extracted by questionnaires distributed at the Parnassos ski center (Greece). The index incorporates four different weather variables considered to be the most influential for this type of tourism. The ideal temperature for skiing was found to be close to 0 °C, the ideal wind speed between 0–3.3 m/s, the ideal cloud cover between 0–25% and the snowfall duration between 1–2 h, with the latter found to be the most important variable for skiing. For each climatic variable, a mean utility score profile was developed from all respondents. Following, a utility function was fitted via linear regression to the above-mentioned utility score. All four utility functions were aggregated into one total SUI score. When combined with climate projections, the SUI can support the assessment of climate change risks for snow-related tourism destinations

Weather Preferences for Ski Tourism: An Empirical Study on the Largest Ski Resort in Greece

Numerous studies have demonstrated the tourism industry to be especially sensitive to weather and climate variability. Snow-related tourism, being largely dependent on climatic resources, is particularly affected by climate change. Our study provides a new index to reflect the climatic suitability of a given destination for snow-related tourism activities, focusing on resorts with usually limited snowfall. The proposed Skiing Utility Index (SUI) is based purely on the weather preferences of skiers, extracted by questionnaires distributed at the Parnassos ski center (Greece). The index incorporates four different weather variables considered to be the most influential for this type of tourism. The ideal temperature for skiing was found to be close to 0 °C, the ideal wind speed between 0–3.3 m/s, the ideal cloud cover between 0–25% and the snowfall duration between 1–2 h, with the latter found to be the most important variable for skiing. For each climatic variable, a mean utility score profile was developed from all respondents. Following, a utility function was fitted via linear regression to the above-mentioned utility score. All four utility functions were aggregated into one total SUI score. When combined with climate projections, the SUI can support the assessment of climate change risks for snow-related tourism destinations