LIFE Viva Grass recommendations on ecosystem-based planning and grassland management

Grasslands are among the most biologically diverse ecosystems in the world, providing a wide range of the ecosystem services essential for human welfare, e.g. biomass production for grazing animals, carbon storage, flood reduction, erosion prevention, water infiltration and purification, habitats for pollinators and protected species, etc. At the same time, semi-natural grasslands are among the most threatened habitat types in Europe – a substantial decrease in area and connectivity has been observed since the mid-20th century and the quality of the grassland habitats continues to deteriorate. This is also the case in the Baltic States, where the unfavourable conservation status of the semi-natural habitats has been confirmed by the last report of the Member States to the European Commission under the Article 17 requirements of the Habitats Directive. The policy analysis, carried out within the LIFE Viva Grass project, confirms that the EU Common Agricultural Policy (CAP) is the strongest driver for the change in land use in the Baltic States, as well as the most influential policy instrument determining the grassland management practices and thus impacting the status of grassland ecosystems and services they provide. The financial contribution of CAP for the measures to support biodiversity maintenance is considerably higher compared to other financial mechanisms financing nature conservation. CAP and the national Rural Development Programmes (RDP) in the Baltic States support measures for maintaining grasslands and have thus minimised the trend of grassland abandonment. However, the assessment of the status of semi-natural grasslands indicates that the implementation of the RDP measures has not been efficient in halting the decline of grassland quality and thus also many of the ecosystem services provided by grasslands. The drawbacks of the rural support policy are related to rather superficial conditions for implementation of the agri-environmental measures as well as a non-motivating support policy, which is targeted more towards agriculture production, disregarding the public benefits resulting from ecosystem services provided by grasslands (e.g. healthy environment, amenities, opportunities for recreation, security etc.). A nature conservation policy and related financing instruments (including national and EU, e.g. LIFE + programme) provides support for the restoration of semi-natural grasslands, guidance on suitable management practices, as well as data collection and administration on distribution and quality of semi-natural grasslands. However, the nature conservation measures and financial resources are not sufficient for long-term maintenance of grassland biodiversity, and therefore the CAP support is acknowledged as the main financial instrument for achieving biodiversity conservation targets. This, however, requires close co-operation and coordination between the two sectors - agriculture and nature conservation - which so far has not been achieved in the Baltic States. The ecosystem service approach offers a holistic view on interactions between nature and humans, thus providing a suitable framework for policy and decision-makers to address conflicts and synergies between environmental and socio-economic goals and to balance different interests. Application of the ecosystem service approach in rural support policy would facilitate integration of ecological principles into agricultural practice and better targeting of interventions to areas with suitable agro-ecological conditions, thus increasing the efficiency and multi-functionality of the measures applied, as well as stimulating synergies between agricultural production and other ecosystem services. The ecosystem service approach can also be operationalised through spatial planning practices by defining the land use priorities based on the ecosystem service supply potential, as well as assessing trade-offs of different development alternatives. The Viva Grass integrated planning tool is designed to support application of the ecosystem service approach in land use planning and sustainable grassland management. Following the objectives of the LIFE Viva Grass project, as well as the concerns and opportunities described above, we have developed recommendations on how to: support maintenance of grassland biodiversity and ecosystem services provided by grasslands; foster ecosystem-based planning and land management; promote application of the integrated planning tool into daily processes of public administration at national, regional and municipality level

A multitiered approach for grassland ecosystem services mapping and assessment: The Viva Grass tool

Throughout the second half of the 20th Century, the area of semi-natural grasslands in the Baltic States decreased substantially, due to agricultural abandonment in some areas and intensification in more productive soil types. In order to halt the loss of biodiversity and ecosystem services provided by grasslands, the LIFE+ programme funded project, LIFE Viva Grass, aims at developing an integrated planning tool that will support ecosystem-based planning and sustainable grassland management. LIFE Viva Grass integrated planning tool is spatially explicit and allows the user to assess the provision and trade-offs of grassland ecosystem services within eight project case study areas in Estonia, Latvia and Lithuania. In order to ensure methodological adaptability, the structure of the LIFE Viva Grass integrated planning tool follows the framework of the tiered approach. In a multi-tier system, each consecutive tier entails an increase in data requirements, methodological complexity or both. The present paper outlines the adaptation of the tiered approach for mapping and assessing ecosystem services provided by grasslands in the Baltic States. The first tier corresponds to a deliberative decision process: The matrix approach is used to assess the potential supply of grassland ecosystem services based on expert estimations. Expert values are subsequently transferred to grassland units and therefore made spatially explicit. The data collected in the first tier was further enhanced through a Principal Components Analysis (PCA) in order to explore ES bundles in tier 2. In the third tier, Multi-Criteria Decision Analysis is used to target specific policy questions

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

HAMLET cytotoxicity in colorectal cancer cell models with different mutation status in Vitro

HAMLET (Human Alpha-lactalbumin Made LEthal to Tumor cells) is a proteolipid complex of partially unfolded α-lactalbumin and several oleate residues. Its efficacy as a selective killer of tumor cells has been documented in vitro and in vivo in several animal models [1]. HAMLET interacts with multiple tumor cell compartments, affecting cell morphology, metabolism, proteasome function, chromatin structure and cell viability [2]. Colorectal cancer is one of the most frequent malignancies worldwide, being second in males and third in females for its frequency and ranking fourth and third for cancer-related deaths among males and females, respectively [3]. KRAS and BRAF are major oncogenic drivers of colorectal cancer (CRC) [4]. The aim of this study was to evaluate antitumoral activity of the HAMLET complex on three different CRC cell lines (LoVo, WiDr, Caco-2) with different mutation status (KRAS/BRAF, wild type). HAMLET complex was prepared using controlled temperature (partial protein unfold) combined with mixing/shaking with olein acid additive (acid incorporation in protein structure) [5]. Cytotoxicity of complex (metabolic activity and viability of the cells) was evaluated using 6 h exposition and different concentration in compliance with MTT and clonogenic assay protocols. The results suggest that HAMLET affects cell metabolism, this effect is severe and at the same time irreparable for cells, leading to cell death. The complex exhibits cytotoxicity in dose-response manner against all cell lines. However, BRAF mutant cells seems to be more resistant to HAMLET in comparison to KRAS mutants and wild type cells. HAMLET has anticancer potency for CRC in in vitro modelGamtos mokslų fakultetasLietuvos sveikatos mokslų universitetas. Medicinos akademijaVytauto Didžiojo universiteta

Integrating ecosystem services into decision support for management of agroecosystems: Viva Grass tool

The area covered by low-input agroecosystems (e.g. semi-natural and permanent grasslands) in Europe has considerably decreased throughout the last century. To support more sustainable management practices, and to promote biodiversity and ecosystem service values of such agroecosystems a decision support tool was developed. The tool aims to enhance the operationalization of ecosystem services and address the challenge of their integration into spatial planning. The Viva Grass tool aims to enhance the maintenance of ecosystem services delivered by low-input agroecosystems. It does so by providing spatially explicit decision support for land-use planning and sustainable management of agroecosystems. The Viva Grass tool is a multi-criteria decision analysis tool for integrated planning. It is designed for farmers, spatial planners and policy makers to support decisions of management of agroecosystems. The tool has been tested to assess spatial planning in eight case studies across the Baltic States

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially