Emerging Solutions to Return Nature to the Urban Ocean.

Urban and periurban ocean developments impact 1.5% of the global exclusive economic zones, and the demand for ocean space and resources is increasing. As we strive for a more sustainable future, it is imperative that we better design, manage, and conserve urban ocean spaces for both humans and nature. We identify three key objectives for more sustainable urban oceans: reduction of urban pressures, protection and restoration of ocean ecosystems, and support of critical ecosystem services. We describe an array of emerging evidence-based approaches, including greening grayinfrastructure, restoring habitats, and developing biotechnologies. We then explore new economic instruments and incentives for supporting these new approaches and evaluate their feasibility in delivering these objectives. Several of these tools have the potential to help bring nature back to the urban ocean while also addressing some of the critical needs of urban societies, such as climate adaptation, seafood production, clean water, and recreation, providing both human and environmental benefits in some of our most impacted ocean spaces.

Individual Calculation of Effective Dose and Risk of Malignancy Based on Monte Carlo Simulations after Whole Body Computed Tomography.

Detailed knowledge about radiation exposure is crucial for radiology professionals. The conventional calculation of effective dose (ED) for computed tomography (CT) is based on dose length product (DLP) and population-based conversion factors (k). This is often imprecise and unable to consider individual patient characteristics. We sought to provide more precise and individual radiation exposure calculation using image based Monte Carlo simulations (MC) in a heterogeneous patient collective and to compare it to phantom based MC provided from the National Cancer Institute (NCI) as academic reference. Dose distributions were simulated for 22 patients after whole-body CT during Positron Emission Tomography-CT. Based on MC we calculated individual Lifetime Attributable Risk (LAR) and Excess Relative Risk (ERR) of cancer mortality. EDMC was compared to EDDLP and EDNCI. EDDLP (13.2 ± 4.5 mSv) was higher compared to EDNCI (9.8 ± 2.1 mSv) and EDMC (11.6 ± 1.5 mSv). Relative individual differences were up to -48% for EDMC and -44% for EDNCI compared to EDDLP. Matching pair analysis illustrates that young age and gender are affecting LAR and ERR significantly. Because of these uncertainties in radiation dose assessment automated individual dose and risk estimation would be desirable for dose monitoring in the future.

The Global Flood Protection Benefits of Mangroves.

Coastal flood risks are rising rapidly. We provide high resolution estimates of the economic value of mangroves forests for flood risk reduction every 20 km worldwide. We develop a probabilistic, process-based valuation of the effects of mangroves on averting damages to people and property. We couple spatially-explicit 2-D hydrodynamic analyses with economic models, and find that mangroves provide flood protection benefits exceeding $US 65 billion per year. If mangroves were lost, 15 million more people would be flooded annually across the world. Some of the nations that receive the greatest economic benefits include the USA, China, India and Mexico. Vietnam, India and Bangladesh receive the greatest benefits in terms of people protected. Many (>45) 20-km coastal stretches particularly those near cities receive more than $US 250 million annually in flood protection benefits from mangroves. These results demonstrate the value of mangroves as natural coastal defenses at global, national and local scales, which can inform incentives for mangrove conservation and restoration in development, climate adaptation, disaster risk reduction and insurance.

Pediatric Tetanus in Central Pennsylvania.

Approximately 20% of the nationally reported tetanus infections in children aged 0 to 14 years that occurred in the United States between 2005 and 2015 were treated at Penn State Children's Hospital. With an electronic medical record search, we identified 5 cases of pediatric tetanus; 100% of these cases occurred in unimmunized children. Their median length of stay was 10 days, and the costs were significant.

Assessment of Treatment Response by 99mTc-MIP-1404 SPECT/CT: A Pilot Study in Patients With Metastatic Prostate Cancer.

BACKGROUND: We investigated the role of Tc-MIP-1404 (Progenics Pharmaceuticals, Inc, New York, NY) SPECT/CT of PSMA expression in the assessment of treatment response in patients with metastatic prostate cancer. METHODS: We retrospectively analyzed Tc-MIP-1404 SPECT/CT scans from 28 patients with metastatic prostate cancer examined before initiation and after completion of therapy. Eight of these patients had been treated with androgen deprivation therapy, 10 with docetaxel, and another 10 with external beam radiotherapy. On the CT images from SPECT/CT, treatment response was assessed according to RECIST 1.1 criteria; independently from that analysis, maximal standardized uptake values (SUVmax) were quantified in representative tumor lesions and treatment response assumed at differences in SUVmax greater than 30%. Radiographic response assessment was correlated to biochemical response (BR) based on prostate-specific antigen serum levels. RESULTS: The concordance rate between SPECT and BR was 75% (95% confidence interval [CI], 0.55-0.89) (Cohen κ = 0.57; 95% CI, 0.29-0.85; P ≤ 0.01), higher than for that between SPECT and CT with 57% (95% CI, 0.37-0.76) (κ = 0.40; 95% CI, 0.14-0.65; P ≤ 0.01), as well as that between CT and BR with 50% (95% CI, 0.31-0.69) (κ = 0.31; 95% CI, 0.06-0.57, P ≤ 0.05). Discordant findings between SPECT and CT were most likely due to limitations of CT in assessing metastases in lymph nodes, as well as bone involvement, which was sometimes not detectable on CT scans. CONCLUSIONS: The high agreement between treatment response, as assessed by Tc-MIP-1404 SPECT/CT and BR, suggests a possible role of that imaging tool for monitoring treatment in metastatic prostate cancer. Larger, ideally prospective trials are needed to help to reveal the full potential of SPECT imaging of PSMA expression in that regard.

The global flood protection savings provided by coral reefs.

Coral reefs can provide significant coastal protection benefits to people and property. Here we show that the annual expected damages from flooding would double, and costs from frequent storms would triple without reefs. For 100-year storm events, flood damages would increase by 91% to $US 272 billion without reefs. The countries with the most to gain from reef management are Indonesia, Philippines, Malaysia, Mexico, and Cuba; annual expected flood savings exceed $400 M for each of these nations. Sea-level rise will increase flood risk, but substantial impacts could happen from reef loss alone without better near-term management. We provide a global, process-based valuation of an ecosystem service across an entire marine biome at (sub)national levels. These spatially explicit benefits inform critical risk and environmental management decisions, and the expected benefits can be directly considered by governments (e.g., national accounts, recovery plans) and businesses (e.g., insurance).

Comparing the cost effectiveness of nature-based and coastal adaptation: A case study from the Gulf Coast of the United States.

Coastal risks are increasing from both development and climate change. Interest is growing in the protective role that coastal nature-based measures (or green infrastructure), such as reefs and wetlands, can play in adapting to these risks. However, a lack of quantitative information on their relative costs and benefits is one principal factor limiting their use more broadly. Here, we apply a quantitative risk assessment framework to assess coastal flood risk (from climate change and economic exposure growth) across the United States Gulf of Mexico coast to compare the cost effectiveness of different adaptation measures. These include nature-based (e.g. oyster reef restoration), structural or grey (e.g., seawalls) and policy measures (e.g. home elevation). We first find that coastal development will be a critical driver of risk, particularly for major disasters, but climate change will cause more recurrent losses through changes in storms and relative sea level rise. By 2030, flooding will cost $134-176.6 billion (for different economic growth scenarios), but as the effects of climate change, land subsidence and concentration of assets in the coastal zone increase, annualized risk will more than double by 2050 with respect to 2030. However, from the portfolio we studied, the set of cost-effective adaptation measures (with benefit to cost ratios above 1) could prevent up to $57-101 billion in losses, which represents 42.8-57.2% of the total risk. Nature-based adaptation options could avert more than $50 billion of these costs, and do so cost effectively with average benefit to cost ratios above 3.5. Wetland and oyster reef restoration are found to be particularly cost-effective. This study demonstrates that the cost effectiveness of nature-based, grey and policy measures can be compared quantitatively with one another, and that the cost effectiveness of adaptation becomes more attractive as climate change and coastal development intensifies in the future. It also shows that investments in nature-based adaptation could meet multiple objectives for environmental restoration, adaptation and flood risk reduction.

[Lysosomal Storage Diseases: Challenges in Multiprofessional Patient Care with Enzyme Replacement Therapy]. / Lysosomale Speichererkrankungen: Herausforderungen bei der sektorübergreifenden, multiprofessionellen Patientenversorgung mit Enzymersatztherapie.

Background Due to their rarity studies in (ultra-) rare diseases are difficult. Only for a minority of these diseases causal therapies are available. Development and production of enzyme replacement therapies (ERT) for example are challenging and expensive. The number of patients is low, costs per patient are high. We will focus on the challenges of providing long-term ERT to patients with lysosomal storage diseases (LSD) in an out- and inpatient setting based on a literature search in Pubmed and own experience. Many ERTs for LSDs have a positive cost-benefit ratio. Possible side-effects are severe allergic reactions. ERT is covered by the insurance companies when prescribed by a physician, however they are liable to recourse by the insurance company as the expenses for drugs of the prescribing physician will be above average. In most cases the recourse can be averted if diagnoses of individual patients are disclosed. Intravenous infusion of ERT is not well-regulated in Germany/Austria. Infusion on a ward is safe however often not covered by the insurance companies as patients do not stay overnight. Another option is infusion in a day-care setting, however the lump sum paid for infusion does not cover costs for ERT. On an individual basis, reimbursement for medication (ERT) has to be negotiated with the insurance companies before infusion takes place. Home infusions are feasible, however careful evaluations of the infusion-team and the risk for side-effects have to be performed on an individual basis, legal issues have to be considered. In- and outpatient ERT of patients with LSDs is challenging but feasible after individual evaluation of patient and infusion team.

The Effectiveness, Costs and Coastal Protection Benefits of Natural and Nature-Based Defences.

There is great interest in the restoration and conservation of coastal habitats for protection from flooding and erosion. This is evidenced by the growing number of analyses and reviews of the effectiveness of habitats as natural defences and increasing funding world-wide for nature-based defences-i.e. restoration projects aimed at coastal protection; yet, there is no synthetic information on what kinds of projects are effective and cost effective for this purpose. This paper addresses two issues critical for designing restoration projects for coastal protection: (i) a synthesis of the costs and benefits of projects designed for coastal protection (nature-based defences) and (ii) analyses of the effectiveness of coastal habitats (natural defences) in reducing wave heights and the biophysical parameters that influence this effectiveness. We (i) analyse data from sixty-nine field measurements in coastal habitats globally and examine measures of effectiveness of mangroves, salt-marshes, coral reefs and seagrass/kelp beds for wave height reduction; (ii) synthesise the costs and coastal protection benefits of fifty-two nature-based defence projects and; (iii) estimate the benefits of each restoration project by combining information on restoration costs with data from nearby field measurements. The analyses of field measurements show that coastal habitats have significant potential for reducing wave heights that varies by habitat and site. In general, coral reefs and salt-marshes have the highest overall potential. Habitat effectiveness is influenced by: a) the ratios of wave height-to-water depth and habitat width-to-wavelength in coral reefs; and b) the ratio of vegetation height-to-water depth in salt-marshes. The comparison of costs of nature-based defence projects and engineering structures show that salt-marshes and mangroves can be two to five times cheaper than a submerged breakwater for wave heights up to half a metre and, within their limits, become more cost effective at greater depths. Nature-based defence projects also report benefits ranging from reductions in storm damage to reductions in coastal structure costs.

Aligning Natural Resource Conservation and Flood Hazard Mitigation in California.

UNLABELLED: Flooding is the most common and damaging of all natural disasters in the United States, and was a factor in almost all declared disasters in U.S. HISTORY: Direct flood losses in the U.S. in 2011 totaled $8.41 billion and flood damage has also been on the rise globally over the past century. The National Flood Insurance Program paid out more than $38 billion in claims since its inception in 1968, more than a third of which has gone to the one percent of policies that experienced multiple losses and are classified as "repetitive loss." During the same period, the loss of coastal wetlands and other natural habitat has continued, and funds for conservation and restoration of these habitats are very limited. This study demonstrates that flood losses could be mitigated through action that meets both flood risk reduction and conservation objectives. We found that there are at least 11,243km2 of land in coastal California, which is both flood-prone and has natural resource conservation value, and where a property/structure buyout and habitat restoration project could meet multiple objectives. For example, our results show that in Sonoma County, the extent of land that meets these criteria is 564km2. Further, we explore flood mitigation grant programs that can be a significant source of funds to such projects. We demonstrate that government funded buyouts followed by restoration of targeted lands can support social, environmental, and economic objectives: reduction of flood exposure, restoration of natural resources, and efficient use of limited governmental funds.

Catching the right wave: evaluating wave energy resources and potential compatibility with existing marine and coastal uses.

Many hope that ocean waves will be a source for clean, safe, reliable and affordable energy, yet wave energy conversion facilities may affect marine ecosystems through a variety of mechanisms, including competition with other human uses. We developed a decision-support tool to assist siting wave energy facilities, which allows the user to balance the need for profitability of the facilities with the need to minimize conflicts with other ocean uses. Our wave energy model quantifies harvestable wave energy and evaluates the net present value (NPV) of a wave energy facility based on a capital investment analysis. The model has a flexible framework and can be easily applied to wave energy projects at local, regional, and global scales. We applied the model and compatibility analysis on the west coast of Vancouver Island, British Columbia, Canada to provide information for ongoing marine spatial planning, including potential wave energy projects. In particular, we conducted a spatial overlap analysis with a variety of existing uses and ecological characteristics, and a quantitative compatibility analysis with commercial fisheries data. We found that wave power and harvestable wave energy gradually increase offshore as wave conditions intensify. However, areas with high economic potential for wave energy facilities were closer to cable landing points because of the cost of bringing energy ashore and thus in nearshore areas that support a number of different human uses. We show that the maximum combined economic benefit from wave energy and other uses is likely to be realized if wave energy facilities are sited in areas that maximize wave energy NPV and minimize conflict with existing ocean uses. Our tools will help decision-makers explore alternative locations for wave energy facilities by mapping expected wave energy NPV and helping to identify sites that provide maximal returns yet avoid spatial competition with existing ocean uses.

The effect of a provider-enhanced clinical decision support tool for guiding venous thromboembolism pharmacoprophylaxis in low-risk patients.

BACKGROUND: Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in high-risk hospitalized patients. However, VTE risk may be underestimated using computer-based tools alone. We tested the effect of a provider-enhanced clinical decision support (CDS) tool on VTE pharmacoprophylaxis and VTE incidence in patients who would have been deemed "low risk" using a computer-based risk-assessment tool alone. METHODS: The study sample was adult patients hospitalized during a 13-month period who were determined to be at low risk for VTE with a computer-based risk-assessment tool. The provider-enhanced CDS tool was implemented 4 months into the study period and required providers to stratify patients as being at high, moderate, or low risk for VTE. We compared rates of VTE pharmacoprophylaxis and VTE incidence before and after implementation of the provider-enhanced CDS tool. RESULTS: There were 1322 patients in the 4-month pre-implementation period and 3347 patients in the 9-month post-implementation period who were determined to be at low risk for VTE based on a computer-based risk-assessment tool. Using the provider-enhanced CDS tool, providers stratified 31% of these computer-assigned low-risk patients as being at moderate risk for VTE and 7% as being at high risk for VTE. The rate of VTE pharmacoprophylaxis increased from 27% to 34% (P < 0.01). The venous thromboprophylaxis rate decreased from 0.98% to 0.42% after implementation of the provider-enhanced CDS tool (P < 0.02). CONCLUSION: Patients identified as being at low risk for VTE solely by computer-based algorithms may include patients whom providers determine to be at risk for VTE. Provider-enhanced CDS tools may outperform computer-based VTE risk-stratification algorithms.

Reliability of a point-based VTE risk assessment tool in the hands of medical residents.

BACKGROUND: Venous thromboembolic events (VTE) are a significant cause of mortality in hospitalized medical and surgical patients. Despite recommendations and guidelines, current evidence demonstrates that VTE prophylaxis remains underutilized in at-risk patients. The process of providing VTE prophylaxis begins with assessing each patient's VTE risk. Using an individualized, point-based protocol in the assessment process is a complex task, and might contribute to variability in VTE prescribing behavior. There are no published data on how reliably residents can perform risk assessment and prophylaxis using a point-based VTE risk assessment tool. OBJECTIVE: Our aim was to determine inter-rater reliability of a point-based risk assessment tool by residents early in the academic year. DESIGN: The design was a cross-sectional-cohort observational study. SETTING: The site was an academic medical center. PATIENTS: Case-based clinical vignettes were used. INTERVENTIONS: Verbal instructions were given to medical residents about how to apply our hospital's point-based VTE risk assessment tool. MEASUREMENTS: Interobserver agreement was measured of: 1) risk score, 2) risk-stratification, 3) identification of contraindications, 4) VTE prophylaxis plan, and 5) resident adherence to the protocol. RESULTS: The intra-class correlation (ICC) for the total risk score was 0.66 and the kappa coefficient for risk stratification was 0.51. The kappa scores for absolute and relative contraindications were 0.29 and 0.23, respectively. The kappa score for the VTE plan was 0.28. CONCLUSIONS: We determined that, following brief instructions early in the academic year, a point-based VTE risk assessment tool has only fair to moderate inter-rater reliability, with suboptimal adherence to the protocol. Both might lead to underutilization of VTE prevention strategies.

Critical assessment of chitotriosidase analysis in the rational laboratory diagnosis of children with Gaucher disease and Niemann-Pick disease type A/B and C.

Laboratory diagnosis of lysosomal storage disorders, especially sphingomyelinase deficiency (Niemann-Pick disease type A/B) and Niemann-Pick disease type C (NPC) can be challenging. We therefore aimed to analyse the feasibility of first-step screening with specific chitotriosidase cut-off values in children

Alcoholism: low standing with the public? Attitudes towards spending financial resources on medical care and research on alcoholism.

AIMS: To assess the extent to which the German public supports the allocation of financial resources to the care of people with alcoholism and to research on alcoholism as compared with other conditions. METHODS: 5025 interviews were conducted in the scope of a representative survey in Germany during May and June of 2001, using a personal, fully structured interview. RESULTS: Respondents most frequently selected alcoholism as the disease for which medical care expenditures could be spared and cut down and on which research funds should neither be spent in the first place nor should be spent at all. CONCLUSION: Our study shows that despite the spread of the concept 'alcoholism is an illness', this disease is still treated 'unfavourably' compared to other conditions. Health campaigns that increase the public's awareness that alcoholism is not a personal failure but an illness with severe medical and social consequences may help reduce the public acceptance of structural discrimination.