Perceptions of trekking tourism and social and environmental change in Nepal's Himalayas

The Himalayas are among the world’s youngest mountain ranges. In addition to the geologic processes of mountain building and erosion, they are also highly vulnerable to human influenced change, occurring at local, national, regional, and international scales. A photo-elicitation methodology is employed to show how residents perceive those changes from historical perspectives, as well as their current conditions and impacts on their daily lives. Nepal’s Khumbu region has undergone major social and environmental transformations since the 1960s when international trekking first began to influence the area's economy. The current perceptions of Khumbu residents of these changes is assessed through photo-elicitation interviews. Their responses are placed in the historical context of: (i) institutional and political changes, much of which have been driven by national government policies; (ii) social and economic changes, for which the tourism economy has been central; and (iii) environmental changes, reflecting the impacts of resource management and climate change. The mostly positive perceptions of Khumbu residents toward how their region has changed reflects general improvements in the physical and cultural landscapes of the Khumbu over time, as well as its continuing geographic isolation, which has helped to slow the rate of globalization, while also keeping the region a dynamic and popular tourist destination

Quality indicators for patients with traumatic brain injury in European intensive care units

Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measur

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe

Purpose: To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. Methods: This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. Results: A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13–15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatme

Machine learning algorithms performed no better than regression models for prognostication in traumatic brain injury

Objective: We aimed to explore the added value of common machine learning (ML) algorithms for prediction of outcome for moderate and severe traumatic brain injury. Study Design and Setting: We performed logistic regression (LR), lasso regression, and ridge regression with key baseline predictors in the IMPACT-II database (15 studies, n = 11,022). ML algorithms included support vector machines, random forests, gradient boosting machines, and artificial neural networks and were trained using the same predictors. To assess generalizability of predictions, we performed internal, internal-external, and external validation on the recent CENTER-TBI study (patients with Glasgow Coma Scale <13, n = 1,554). Both calibration (calibration slope/intercept) and discrimination (area under the curve) was quantified. Results: In the IMPACT-II database, 3,332/11,022 (30%) died and 5,233(48%) had unfavorable outcome (Glasgow Outcome Scale less than 4). In the CENTER-TBI study, 348/1,554(29%) died and 651(54%) had unfavorable outcome. Discrimination and calibration varied widely between the studies and less so between the studied algorithms. The mean area under the curve was 0.82 for mortality and 0.77 for unfavorable outcomes in the CENTER-TBI study. Conclusion: ML algorithms may not outperform traditional regression approaches in a low-dimensional setting for outcome prediction after moderate or severe traumatic brain injury. Similar to regression-based prediction models, ML algorithms should be rigorously validated to ensure applicability to new populations

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Frequency of fatigue and its changes in the first 6 months after traumatic brain injury: results from the CENTER-TBI study

Background: Fatigue is one of the most commonly reported subjective symptoms following traumatic brain injury (TBI). The aims were to assess frequency of fatigue over the first 6 months after TBI, and examine whether fatigue changes could be predicted by demographic characteristics, injury severity and comorbidities. Methods: Patients with acute TBI admitted to 65 trauma centers were enrolled in the study Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI). Subj

Tracheal intubation in traumatic brain injury

Background: We aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. Methods: Data from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. Results: In the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. Conclusion: The benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registration: NCT02210221

Informed consent procedures in patients with an acute inability to provide informed consent

Purpose: Enrolling traumatic brain injury (TBI) patients with an inability to provide informed consent in research is challenging. Alternatives to patient consent are not sufficiently embedded in European and national legislation, which allows procedural variation and bias. We aimed to quantify variations in informed consent policy and practice. Methods: Variation was explored in the CENTER-TBI study. Policies were reported by using a questionnaire and national legislation. Data on used informed consent procedures were available for 4498 patients from 57 centres across 17 European countries. Results: Variation in the use of informed consent procedur

Towards local bioeconomy: A stepwise framework for high-resolution spatial quantification of forestry residues

In the ambition of a transition from fossil carbon use, forestry residues are attracting considerable attention as a feedstock for the future bioeconomy. However, there is a limited spatially-explicit understanding of their availability. In the present study, this gap has been bridged by developing a generic framework "CamBEE", for a transparent estimation of aboveground primary forestry residues. CamBEE further includes guidelines, based on standard uncertainty propagation techniques, to quantify the uncertainty of the generated estimates. CamBEE is a four-step procedure relying on open-access spatial data. The framework further provides insights on the appropriate spatial resolution to select. In this study, the proposed framework has been detailed and exemplified through a case study for France. In the case study, primary forestry residues have been spatially quantified at a resolution of 10 m, using spatial and statistical data on forest parameters (net annual increment, factor of basic wood density, biomass expansion factors, etc.). The results for the case study indicate a total theoretical potential of 8.4 Million Mg(dry matter )year(-1) (4.4-13.9 Million Mg-dry matter year(-1)) available in France, the equivalent of 161 PJ year(-1). The case study validates that the CamBEE framework can be used for high-resolution spatial quantification of PFRs towards integration in local bioeconomy

An approach to designing smart future electronics using nature-driven biopiezoelectric/triboelectric nanogenerators

With the advancement of the modern ultrasmart world, our surroundings have become a dumping ground for electronic wastes, which not only is a threat to human lives, but has become dangerous for any living creature as well as for ecosystems. To keep our ecosystems healthy, the need has arisen to take immediate action against electronic waste. To overcome these issues, the design of smart devices with nontoxic, biodegradable or biocompatible materials is urgently desired, which will lead to devices that are easily recyclable, processable, and safe for the environment/living creatures. In recent times, piezoelectric/triboelectric nanogenerators (PNGs/TNGs) have attracted more and more attention among other renewable green energy-harvesting sources because of their easy accessibility, abundant sources, and conversion of mechanical energy into green electricity. Due to the toxic nature and incompatibility of inorganic/some organic-based PNGs/TNGs the designing of effective nature-driven bionanogenerator (PNG/TNG) devices with biocompatible/biodegradable materials would be a smart approach toward a future green electronics world. Here, we discuss the effectiveness of biowaste biodegradable materials in green energy harvesting technologies and their possible applications in a future smart/portable electronics world. Furthermore, using biowaste materials in energy-harvesting technology will help to clean biowastes from the environment as well as society. © 2021 Elsevier Inc. All rights reserved.11Nscopu