Introduction

The heterogeneous nature of the Mediterranean environment, combined with a wide diversity of socio-economic and cultural identities, make this region particularly amenable to integrated research on climate change impacts, vulnerabilities, and adaptive response. Eleven case-study locations have been strategically selected to represent three generic Mediterranean environments (urban, rural and coastal). While each case study location comprises a unique and complex set of climate-related issues, the range and scope of the case studies allows identification of common lessons and messages for the wider Mediterranean region. The aim is to perform an integrated assessment of climate impacts, vulnerability and adaptation at a regional to local scale. A risk-based \u2018bottom up\u2019 approach (based on regional stakeholder dialogue) is combined with a \u2018top down\u2019 case-study indicator assessment focused on a common conceptual and methodological framework

Design and Rationale of the National Tunisian Registry of Heart Failure (NATURE-HF): Protocol for a Multicenter Registry Study

BackgroundThe frequency of heart failure (HF) in Tunisia is on the rise and has now become a public health concern. This is mainly due to an aging Tunisian population (Tunisia has one of the oldest populations in Africa as well as the highest life expectancy in the continent) and an increase in coronary artery disease and hypertension. However, no extensive data are available on demographic characteristics, prognosis, and quality of care of patients with HF in Tunisia (nor in North Africa). ObjectiveThe aim of this study was to analyze, follow, and evaluate patients with HF in a large nation-wide multicenter trial. MethodsA total of 1700 patients with HF diagnosed by the investigator will be included in the National Tunisian Registry of Heart Failure study (NATURE-HF). Patients must visit the cardiology clinic 1, 3, and 12 months after study inclusion. This follow-up is provided by the investigator. All data are collected via the DACIMA Clinical Suite web interface. ResultsAt the end of the study, we will note the occurrence of cardiovascular death (sudden death, coronary artery disease, refractory HF, stroke), death from any cause (cardiovascular and noncardiovascular), and the occurrence of a rehospitalization episode for an HF relapse during the follow-up period. Based on these data, we will evaluate the demographic characteristics of the study patients, the characteristics of pathological antecedents, and symptomatic and clinical features of HF. In addition, we will report the paraclinical examination findings such as the laboratory standard parameters and brain natriuretic peptides, electrocardiogram or 24-hour Holter monitoring, echocardiography, and coronarography. We will also provide a description of the therapeutic environment and therapeutic changes that occur during the 1-year follow-up of patients, adverse events following medical treatment and intervention during the 3- and 12-month follow-up, the evaluation of left ventricular ejection fraction during the 3- and 12-month follow-up, the overall rate of rehospitalization over the 1-year follow-up for an HF relapse, and the rate of rehospitalization during the first 3 months after inclusion into the study. ConclusionsThe NATURE-HF study will fill a significant gap in the dynamic landscape of HF care and research. It will provide unique and necessary data on the management and outcomes of patients with HF. This study will yield the largest contemporary longitudinal cohort of patients with HF in Tunisia. Trial RegistrationClinicalTrials.gov NCT03262675; https://clinicaltrials.gov/ct2/show/NCT03262675 International Registered Report Identifier (IRRID)DERR1-10.2196/1226

Integration of the Climate Impact Assessments with Future Projections ,in (A.Navarra and L.Tubiana eds), Regional Assessment of Climate Change in the Mediterran

Climate projections are essential in order to extend the case-study impacts and vulnerability assessments to encompass future climate change. Thus climatemodel based indicators for the future (to 2050 and for the A1B emissions scenario) are presented for the climate and atmosphere theme (including indices of temperature and precipitation extreme events), together with biogeophysical and socioeconomic indicators encompassing the other case-study themes. For the latter, the speci fi c examples presented here include peri-urban fi res, air pollution, human health risks, energy demand, alien marine species and tourism (attractiveness and socio-economic consequences). The primary source of information about future climate is the set of global and regional model simulations performed as part of CIRCE. These have the main novel characteristic of incorporating a realistic representation of the Mediterranean Sea including coupling between sea and atmosphere. These projections are inevitably subject to uncertainties relating to unpredictability, model structural uncertainty and value uncertainty. These uncertainties are addressed by taking a multi-model approach, but problems remain, for example, due to a systematic cold bias in the CIRCE models. In the context of the case-study integrated assessments, there are also uncertainties \u2018downstream\u2019 of climate modeling and the construction of climate change projections \u2013 largely relating to the modeling of impacts. In addition, there are uncertainties associated with all socio-economic projections used in the case studies \u2013 such as population projections. Thus there are uncertainties inherent to all stages of the integrated assessments and it is important to consider all these aspects in the context of adaptation decision making

Climate Impact Assessments

This chapter highlights key climate impacts, hazards and vulnerabilities and associated indicators that have been used to assess current (recent) climate impacts at each of the case-study sites. The aim is to illustrate some of the wide range of information available from individual case studies and highlight common themes that are evident across multiple case-study locations. This is used to demonstrate linkages and sensitivities between the speci fi c climate impacts of relevance for each case-study type (urban, rural and coastal) and the key climate hazards and biogeophysical and social vulnerabilities representing the underlying drivers and site conditions. For some impacts, there are clear, direct links with climate events, such as heat stress and fl ooding, while for others, such as energy supply and demand, the causal relationships are more indirect, via a cascade of climate, social and economic in fl uences. Water availability and extreme temperatures are common drivers of current climate impacts across all case studies, including, for example, freshwater supply and heat stress for urban populations; irrigation capacity and growing season length for agricultural regions; and saltwater intrusion of aquifers and tourist visitor numbers at coastal locations. At some individual case-study locations, speci fi c impacts, hazards and/ or vulnerabilities are observed, such as peri-urban fires in Greater Athens, infrastructure vulnerability to coastal fl ooding in Alexandria, groundwater levels in Tel Hadya and vector-borne diseases in the Gulf of Oran. Throughout this chapter, evidence of current climate impacts, hazards and vulnerabilities from each of the case studies is detailed and assessed relative to other case studies. This provides a foundation for considering the wider perspective of the Mediterranean region as a whole, and for providing a context from which to assess consequences of future climate projections and consider suitable adaptation options

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research