Interventions to help coral reefs under global change – a complex decision challenge

Climate change is impacting coral reefs now. Recent pan-tropical bleaching events driven by unprecedented global heat waves have shifted the playing field for coral reef management and policy. While best-practice conventional management remains essential, it may no longer be enough to sustain coral reefs under continued climate change. Nor will climate change mitigation be sufficient on its own. Committed warming and projected reef decline means solutions must involve a portfolio of mitigation, best practice conventional management and coordinated restoration and adaptation measures involving new and perhaps radical interventions. We propose that proactive research and development to expand the reef management toolbox fast but safely, combined with expedient trialling of promising interventions is now urgently needed, whatever emissions trajectory the world follows. We discuss the challenges and opportunities of embracing new interventions in a race against time, including their risks and uncertainties. Ultimately, solutions to the climate challenge for coral reefs will require consideration of what society wants, what can be achieved technically and economically, and what opportunities we have for action in a rapidly closing window. Finding solutions that work for coral reefs and people will require exceptional levels of coordination of science, management and policy, and open engagement with society. It will also require compromise, because reefs will change under climate change despiteour best interventions. We argue that being clear about society’s priorities, and understanding both the opportunities and risks that come with an expanded toolset, can help us make the most of a challenging situation

Circulating Serum Exosomal miRNAs As Potential Biomarkers for Esophageal Adenocarcinoma

Author version made available in accordance with publisher policy.Abstract Background The poor prognosis and rising incidence of esophageal adenocarcinoma highlight the need for improved detection methods. The potential for circulating microRNAs (miRNAs) as biomarkers in other cancers has been shown, but circulating miRNAs have not been well characterized in esophageal adenocarcinoma. We investigated whether circulating exosomal miRNAs have potential to discriminate individuals with esophageal adenocarcinoma from healthy controls and non-dysplastic Barrett’s esophagus. Methods Seven hundred fifty-eight miRNAs were profiled in serum circulating exosomes from a cohort of 19 healthy controls, 10 individuals with Barrett’s esophagus, and 18 individuals with locally advanced esophageal adenocarcinoma. MiRNA expression was assessed using all possible permutations of miRNA ratios per individual. Four hundred eight miRNA ratios were differentially expressed in individuals with cancer compared to controls and Barrett’s esophagus (Mann-Whitney U test, P<0.05). The 179/408 ratios discriminated esophageal adenocarcinoma from healthy controls and Barrett’s esophagus (linear regression, P0.7, P<0.05). A multi-biomarker panel (RNU6-1/miR- 16-5p, miR-25-3p/miR-320a, let-7e-5p/miR-15b-5p, miR- 30a-5p/miR-324-5p, miR-17-5p/miR-194-5p) demonstrated enhanced specificity and sensitivity (area under ROC=0.99, 95 % CI 0.96–1.0) over single miRNA ratios to distinguish esophageal adenocarcinoma from controls and Barrett’s esophagus. Conclusions This study highlights the potential for serum exosomal miRNAs as biomarkers for the detection of esophageal adenocarcinoma

Effects on musculoskeletal pain, work ability and sickness absence in a 1-year randomised controlled trial among cleaners

<p>Abstract</p> <p>Background</p> <p>Only a few workplace initiatives among cleaners have been reported, even though they constitute a job group in great need of health promotion. The purpose of this trial was to evaluate the effect of either physical coordination training or cognitive behavioural training on musculoskeletal pain, work ability and sickness absence among cleaners.</p> <p>Methods</p> <p>A cluster-randomised controlled trial was conducted among 294 female cleaners allocated to either physical coordination training (PCT), cognitive behavioural training (CBTr) or a reference group (REF). Questionnaires about musculoskeletal pain and work ability were completed at baseline and after one year's intervention. Sickness absence data were obtained from the managers' records. Analyses were performed according to the intention-to-treat-principle (ITT).</p> <p>Results</p> <p>No overall reduction in musculoskeletal pain, work ability or sickness absence from either PCT or CBTr compared with REF was found in conservative ITT analyses. However, explorative analyses revealed a treatment effect for musculoskeletal pain of the PCT. People with chronic neck/shoulder pain at baseline were more frequently non-chronic at follow-up after PCT compared with REF (p = 0.05).</p> <p>Conclusions</p> <p>The PCT intervention appeared effective for reducing chronic neck/shoulder pain among the female cleaners. It is recommended that future interventions among similar high-risk job groups focus on the implementation aspects of the interventions to maximise outcomes more distal from the intervention such as work ability and sickness absence.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN96241850">ISRCTN96241850</a></p

Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition)

<p>Abstract</p> <p>Background</p> <p>Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.</p> <p>Methods/design</p> <p>In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention. <it>Participants</it>: 1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. <it>Intervention</it>: Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations. <it>Evaluation</it>: We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the “intention-to-treat” principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.</p> <p>Discussion</p> <p>This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.</p> <p>Trial registration</p> <p>The Netherlands National Trial Register NTR2160.</p

Activity-Based Funding of Hospitals and Its Impact on Mortality, Readmission, Discharge Destination, Severity of Illness, and Volume of Care: A Systematic Review and Meta-Analysis

Background: Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care. &nbsp; &nbsp; Methods: We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication. &nbsp; &nbsp; Results: Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences. &nbsp; &nbsp; Conclusions: Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes

A critical analysis of the European Union as an international environmental leader: opportunities, limitations and the quest for legitimacy

© 2007 Dr. Karen E. HusseyThe ability of states to tackle global environmental problems, and to manage the natural resources within their territories sustainably, is severely hampered by the imperative of international competitiveness and the perceived trade-off between that and environmental protection. To alleviate that trade-off the international community of states has turned to ‘collective action’ as the most appropriate means available. Despite a myriad of promising domestic and multilateral initiatives, tangible outcomes to date have been very limited. It is under these circumstances that the role of an international environmental leader becomes essential. Following fifty years of intense political and economic integration the European Union (EU) has emerged as an actor in international affairs in its own right, and as an international environmental leader. In the wake of the United States' withdrawal from environmental multilateralism, the EU's leadership in international environmental politics is all the more important. The focus of this study has been to critically assess the EU's environmental leadership, both in terms of how it has emerged as a leader, and what limitations might prevent it from enjoying greater leadership in the future. The study examines the political, economic, legal and institutional dynamics within the EU that have enabled the EU's leadership, as well as developments internationally that have encouraged the leadership of a supranational entity in international politics. Drawing on a conceptual framework which identifies three types of leadership, with varying degrees of sustainability, the study analyses the EU's engagement in international fora and its chosen methods of leadership. The study focuses particularly on the limitations on the EU to demonstrate ‘leadership through exemplary action’. The hypothesis of this research is that the EU's distinctive governance arrangements and unique position as a supranational entity have encouraged the development of progressive environmental policy domestically, which has consequently led to its leadership in international environmental politics. However, the use of unsustainable modes of leadership (particularly ‘leadership through material inducements’) to gain compliance from other actors is not sustainable in the long term, and its significant implementation deficit undermines its credibility as a leader

Mainstreaming deliberative principles in Environmental Impact Assessment: current practice and future prospects in the Great Barrier Reef, Australia

The Great Barrier Reef (GBR) is a highly complex social-ecological system that is under pressure from a variety of human activities, including coastal development for industrial purposes. A 2012 World Heritage Committee review found that the speed and scale of large industrial developments along the GBR coast exceeded the capacity of governments to manage their impacts. Ameliorating the impacts of large developments in the GBR is likely to require changes to the Environmental Impact Assessment (EIA) processes that form the centrepiece of Australian environmental legislation. As part of this, environmental managers must find ways to ensure that EIA decisions reflect both best-available science and community concerns. It has been suggested that innovative forms of structured decision making, such as public deliberation, could democratise impact assessment decisions, and could be accommodated within existing EIA processes, but the literature on this question is predominantly theoretical. In this paper, we explore the extent to which participatory and deliberative approaches have been integrated into existing EIA processes, using data from a survey of local residents in an area of the Great Barrier Reef coast undergoing rapid industrial development. We find that current processes provide few formalised opportunities for deliberative engagement, but that the principles of deliberative democracy could provide a foundation for more robust decision making, provided that such processes are part of an adaptive strategy of review over the life of a project, combined with genuine openness on the part of proponents and regulators to accept and respond to community knowledge. We elaborate on this through discussing a series of principles to support the integration of deliberative practices into EIA decision making

What’s critical about critical infrastructure?

Critical infrastructure (CI) has received much attention in research, policy and political discussions in recent years, following concern over exposure of infrastructure to terrorist attack, disruption through disasters, rising awareness of the interdependent nature of infrastructure in modern urban systems, and changes in the ownership of and responsibility for infrastructure assets. In this paper, we explore the implications of different framings of both “critical” and “infrastructure”, through two questions: critical how and for whom; critical when and at what scale? Framings of CI, and their increasingly important manifestations in policy and law, have deep but too-often unexposed implications: the lines drawn between what is defined as critical and that which is not concerns not only the physical or informational assets, but the inclusion/exclusion of communities and their places and values as important aspects of modern urban governance. We argue that a better understanding of what is critical about urban infrastructure is not just recognition of their vulnerability and interconnectedness, but also of the key linkages between critical infrastructure and human and environmental system integrity and equity within the context of capitalist urbanisation