Integrated Collaborative Governance Approaches towards Urban Transformation: Experiences from the CLEVER Cities Project

Within the framework of CLEVER Cities Horizon 2020, London, Milan, and Hamburg are putting in place nine Urban Living Labs in order to implement Nature-based Solutions that address urban challenges in socially disadvantaged neighborhoods. In this article, the means by which co-creation processes and pathways may lead to innovation in governance structures are considered. Through a comparative case study analysis, this research aims to identify integrated, collaborative governance frameworks that are complex and adaptive, as well as reflect the actual changes in governance in cities. Herein, ULLs are intended not just as a vehicle for place-based urban regeneration but also as a starting point for collaborative governance. In this article, it is considered how co-creation pathways may lead to innovation in current local governance structures and achieve transformational change. This paper analyzes the collaborative governance dynamic models at three points in time in the three cities. It is also considered how co-creation pathways may lead to innovation in current local governance structures and achieve transformational change

Greening Cities Shaping Cities: Pinpointing Nature-Based Solutions in Cities between Shared Governance and Citizen Participation

The topic of pinpointing Nature-Based Solutions (NBS) in the urban context has been cultivating interests lately from different scholars, urban planning practitioners and policymakers. This Special Issue originates from the Greening Cities Shaping Cities Symposium held at the Politecnico di Milano (12–13 October 2020), aiming at bridging the gap between the science and practice of implementing NBS in the built environment, as well as highlighting the importance of citizen participation in shared governance and policy making. The Special Issue was also made open to other contributions from outside the symposium in order to allow for contributions from a major scientific and practical audience wherever possible. Indeed, we have gathered contributions from Italy, Germany, the Netherlands, Turkey, Brazil, Portugal, Denmark, France, Bulgaria, Sweden, Hungary, Spain, the UAE, the UK, and the USA

Setting the Social Monitoring Framework for Nature-Based Solutions Impact: Methodological Approach and Pre-Greening Measurements in the Case Study from CLEVER Cities Milan

: Nature-based solutions (NBS) are currently being deployed in many European Commission Horizon 2020 projects in reaction to the increasing number of environmental threats, such as climate change, unsustainable urbanization, degradation and loss of natural capital and ecosystem services. In this research, we consider the application of NBS as a catalyst for social inclusivity in urban regeneration strategies, enabled through civic participation in the co-creation of green interventions with respect to social cohesion and wellbeing. This article is focused on a social monitoring framework elaborated within the H2020 CLEVER Cities project, with the city of Milan as a case study. Firstly, we overviewed the major regeneration challenges and expected co-benefits of the project, which are mainly human health and wellbeing, social cohesion and environmental justice, as well as citizen perception about safety and security related to the NBS implementation process. Secondly, we examined the relevance of using NBS in addressing social co-benefits by analyzing data from questionnaires against a set of five major indicators, submitted to citizens and participants of activities during pre-greening interventions: (1) Place, use of space and relationship with nature, (2) Perceived ownership and sense of belonging, (3) Psychosocial issues, social interactions and social cohesion, (4) Citizen perception about safety and security, and lastly, we analyzed (5) knowledge about CLEVER interventions and NBS benefits in relation to socio-demographics of the questionnaires’ respondents. Thirdly, we cross-referenced a wind-rose multi-model of co-benefits analysis for NBS across the regeneration challenges of the project. Because of the COVID-19 emergency, in this research we mainly focused on site observations and online questionnaires, as well as on monitoring pre-greening scenarios in three Urban Living Labs (ULLs) in Milan, namely CLEVER Action Labs. Lastly, this study emphasizes the expected social added values of NBS impact over long-term urban regeneration projects. Insights from the pre-greening surveys results accentuate the importance of the NBS interventions in citizens’ perceptions about their wellbeing, general health and strong sense of neighborhood belonging. A wider interest towards civic participation in co-management and getting informed about NBS interventions in the Milanese context is also noted.This document has been prepared in the framework of the European project CLEVER Cities. This project has received funding from the European Union’s Horizon 2020 innovation action program under grant agreement no. 776604. The sole responsibility for the content of this publication lies with the authors. It does not necessarily represent the opinion of the European Union. Neither the EASME nor the European Commission are responsible for any use that may be made of the information contained herein

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

From ‘Highway into Greenway’: How Public Spaces Change Zoning Regulations

The case study presented in this paper is a manifestation for an urban regeneration project that transformed a Highway into a Greenway. The first part aims to understand the contextual background of the highway regeneration Project, and it analyses the key factors of the long-debated land use and how the public authorities mandated the development of open public places as a policy. The second part, entails the rebirth of the Public Space as part of the Rose Kennedy Greenway where the role goes beyond the semantics from just a park towards being considered the front porch of the city oldest Neighborhood, the Northend. The last part analyses in depth the cultural programming of the Public Place and its character as a livable destination in the heart of the Downtown district. The methodological approach uses a public Life Matrix of evaluation to identify users’ behavioral patterns through intercept surveys, frequency of social activities through intensive three months long physical observation analysis, and lastly in-depth interviews with local Stakeholders, related Governmental bodies and Boston development and planning authorities. The findings highlighted a tendency that community involvement in the planning and placemaking process helped inform the Public Policy about the needs of surrounding neighborhood residents; as well as, emphasize the Public Private Partnerships in successful urban regeneration projects such as the case of the Northend Park

Greening Cities, Shaping Cities: Pinpointing Nature-Based Solutions in Cities between Shared Governance and Citizen Participation

The topic of pinpointing Nature-Based Solutions (NBS) in the urban context has been cultivating interests lately from different scholars, urban planning practitioners and policymakers. This Special Issue originates from the Greening Cities Shaping Cities Symposium held at the Politecnico di Milano (12–13 October 2020), aiming at bridging the gap between the science and practice of implementing NBS in the built environment [1], as well as highlighting the importance of citizen participation in shared governance and policy making. The Special Issue was also made open to other contributions from outside the symposium in order to allow for contributions from a major scientific and practical audience wherever possible. Indeed, we have gathered contributions from Italy, Germany, the Netherlands, Turkey, Brazil, Portugal, Denmark, France, Bulgaria, Sweden, Hungary, Spain, the UAE, the UK, and the USA