From COVID-19 to Green Recovery with natural capital accounting.

The COVID-19 pandemic and related social and economic emergencies induced massive public spending and increased global debt. Economic recovery is now an opportunity to rebuild natural capital alongside financial, physical, social and human capital, for long-term societal benefit. Yet, current decision-making is dominated by economic imperatives and information systems that do not consider society's dependence on natural capital and the ecosystem services it provides. New international standards for natural capital accounting (NCA) are now available to integrate environmental information into government decision-making. By revealing the effects of policies that influence natural capital, NCA supports identification, implementation and monitoring of Green Recovery pathways, including where environment and economy are most positively interlinked.

Reconciling climate action with the need for biodiversity protection, restoration and rehabilitation.

Globally, we are faced with a climate crisis that requires urgent transition to a low-carbon economy. Simultaneously, the biodiversity crisis demands equally urgent action to prevent further species loss and promote restoration and rehabilitation of ecosystems. Climate action itself must prevent further pressures on biodiversity and options for synergistic gains for both climate and biodiversity change mitigation and adaptation need to be explored and implemented. Here, we review the key potential impacts of climate mitigation measures in energy and land-use on biodiversity, including the development of renewable energy such as offshore and onshore wind, solar, and bioenergy. We also assess the potential impacts of climate action driven afforestation and native habitat rehabilitation and restoration. We apply our findings to Ireland as a unique case-study as the government develops a coordinated response to climate and biodiversity change through declaration of a joint climate and biodiversity emergency and inclusion of biodiversity in key climate change legislation and the national Climate Action Plan. However, acknowledgement of these intertwined crises is only a first step; implementation of synergistic solutions requires careful planning. We demonstrate how synergy between climate and biodiversity action can be gained through explicit consideration of the effects of climate change mitigation strategies, such as energy infrastructure development and land-use change, on biodiversity. We identify several potential "win-win" strategies for both climate mitigation and biodiversity conservation. For Ireland, these include increasing offshore wind capacity, rehabilitating natural areas surrounding onshore wind turbines, and limiting the development of solar photovoltaics to the built environment. Ultimately, climate mitigation should be implemented in a "Right Action, Right Place" framework to maximise positive biodiversity benefits. This review provides one of the first examples of how national climate actions can be implemented in a biodiversity-conscious way to initiate discussion about synergistic solutions for both climate and biodiversity.

Le diagnostic et la prise en charge du sepsis grave chez le patient pédiatrique.

Le sepsis est une réponse inflammatoire systémique à une infection présumée ou démontrée. Puisque c'est une cause importante de morbidité et de mortalité, plusieurs sociétés professionnelles ont lancé des initiatives ces dernières années, lesquelles ont débouché sur la rédaction de directives pour déceler le sepsis et le traiter rapidement. Les principaux aspects des directives les plus récentes sont résumés dans le présent point de pratique. Ils incluent la détection de changements à l'état clinique et aux signes vitaux qui doivent évoquer la possibilité de sepsis, tels que la fièvre, la tachycardie et des modifications de la perfusion périphérique, de même que la stabilisation initiale des voies respiratoires, de la respiration et de la circulation. Ils englobent également l'administration opportune d'une thérapie antimicrobienne, l'utilisation de bolus liquidiens et de médicaments vasoactifs et des considérations particulières chez les patients atteints de troubles médicaux sous-jacents, comme l'emploi de corticoïdes pour traiter une possible insuffisance surrénalienne découlant d'une suppression de l'axe hypothalamo-surrénalien. Deux modifications sont apportées aux directives précédentes, soit une réévaluation clinique après chaque bolus liquidien en raison de la crainte d'une surcharge hydrique et le remplacement de la dopamine comme agent vasoactif initial chez les patients pédiatriques hypotendus par de l'adrénaline ou de la noradrénaline en fonction du contexte clinique. Le présent point de pratique porte principalement sur la prise en charge du sepsis chez les nourrissons plus âgés, les enfants et les adolescents.

Diagnosis and management of severe sepsis in the paediatric patient.

Sepsis is a systemic inflammatory response to suspected or proven infection. Given its importance in terms of morbidity and mortality, a number of initiatives by several professional societies in recent years have led to the development of guidelines for the recognition and timely management of sepsis. The principal elements of the most recent guidelines are summarized in this practice point. These elements include recognition of changes in clinical condition and vital signs, such as fever, tachycardia, and changes in peripheral perfusion, which should raise concern for sepsis; initial stabilization of airway, breathing, and circulation; timely administration of empiric antimicrobial therapy; use of fluid boluses and vasoactive medications; and specific considerations in patients with underlying medical conditions, such as the use of corticosteroids for possible adrenal insufficiency due to hypothalamic-adrenal suppression. Two changes from previous guidelines are the concern for fluid overload, implying the need for clinical re-assessment after administration of each fluid bolus, and the removal of dopamine as the initial vasoactive agent for use in hypotensive paediatric patients, with recommendations for the use of epinephrine or norepinephrine as dictated by the clinical context. This practice point focuses primarily on sepsis management in older infants, children, and youth.

Multiyear greenhouse gas balances at a rewetted temperate peatland.

Drained peat soils are a significant source of greenhouse gas (GHG) emissions to the atmosphere. Rewetting these soils is considered an important climate change mitigation tool to reduce emissions and create suitable conditions for carbon sequestration. Long-term monitoring is essential to capture interannual variations in GHG emissions and associated environmental variables and to reduce the uncertainty linked with GHG emission factor calculations. In this study, we present GHG balances: carbon dioxide (CO2 ), methane (CH4 ) and nitrous oxide (N2 O) calculated for a 5-year period at a rewetted industrial cutaway peatland in Ireland (rewetted 7 years prior to the start of the study); and compare the results with an adjacent drained area (2-year data set), and with ten long-term data sets from intact (i.e. undrained) peatlands in temperate and boreal regions. In the rewetted site, CO2 exchange (or net ecosystem exchange (NEE)) was strongly influenced by ecosystem respiration (Reco ) rather than gross primary production (GPP). CH4 emissions were related to soil temperature and either water table level or plant biomass. N2 O emissions were not detected in either drained or rewetted sites. Rewetting reduced CO2 emissions in unvegetated areas by approximately 50%. When upscaled to the ecosystem level, the emission factors (calculated as 5-year mean of annual balances) for the rewetted site were (±SD) -104 ± 80 g CO2 -C m-2  yr-1 (i.e. CO2 sink) and 9 ± 2 g CH4 -C m-2  yr-1 (i.e. CH4 source). Nearly a decade after rewetting, the GHG balance (100-year global warming potential) had reduced noticeably (i.e. less warming) in comparison with the drained site but was still higher than comparative intact sites. Our results indicate that rewetted sites may be more sensitive to interannual changes in weather conditions than their more resilient intact counterparts and may switch from an annual CO2 sink to a source if triggered by slightly drier conditions.

Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children.

INTRODUCTION: The timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals. METHODS: We performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients. RESULTS: A total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001). CONCLUSIONS: The Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

Cardiac arrhythmias associated with severe traumatic brain injury and hypothermia therapy.

OBJECTIVE: Severe head trauma and/or severe hypothermia (< or =32 degrees C) can cause cardiac arrhythmias. Effect of moderate hypothermia (32-33 degrees C) on cardiac arrhythmias in children after severe traumatic brain injury is not well characterized. The objective is to determine the effect of moderate and short-term (24 hrs) hypothermia therapy on the incidence and severity of cardiac arrhythmias in children with severe traumatic brain injury compared with normothermic control subject using a 24-hr Holter recording. DESIGN: Prospective ancillary study of a multicenter randomized, controlled clinical trial. SETTING: A Canadian university-affiliated pediatric intensive care unit in a level III trauma center. PATIENTS Patients <18 yrs with severe traumatic brain injury. INTERVENTIONS: Holter recording during moderate hypothermia (HYPO group; esophageal temperature 32-33 degrees C) or normothermia (NORMO group; 36.5-37.5 degrees C) induced for 24 hrs started within 8 hrs after a severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Sixteen patients who had a median age of 12.7 yrs (range, 7.2-17.0 yrs) were enrolled. The time from the injury to the start of the cooling process was 7.3 hrs (range, 6.6-7.8 hrs). The temperature when Holter recording began was 32.9 degrees C (range, 31.6-34.4 degrees C) in the HYPO group. Overall, 44% of all patients (seven of 16 patients) had arrhythmias (two of nine in the NORMO group and five of seven in the HYPO group, p = .13). The most frequent arrhythmias were isolated premature atrial contractions. Hypothermic patients had lower heart rates than normothermic patients (p = .01), but none had a severe bradycardia. In the NORMO group, one patient had accelerated junctional rhythm associated with hypotension. In the HYPO group, one patient had nonsustained monomorphic ventricular tachycardia. CONCLUSIONS: Arrhythmias are frequent in severe pediatric traumatic brain injury. Further studies are needed to characterize the epidemiology and clinical impact of arrhythmias associated with severe pediatric head trauma and moderate hypothermia.