Knowledge coproduction to improve assessments of nature's contributions to people.

Sustainability science needs new approaches to produce, share, and use knowledge because there are major barriers to translating research into policy and practice. Multiple actors hold relevant knowledge for sustainability including indigenous and local people who have developed over generations knowledge, methods, and practices that biodiversity and ecosystem assessments need to capture. Despite efforts to mainstream knowledge coproduction, less than 3% of the literature on nature's contributions to people (NCP) integrates indigenous and local knowledge (ILK). Approaches and tools to better integrate scientific and ILK knowledge systems in NCP assessments are urgently needed. To fill this gap, we conducted interviews with ILK experts from Abancay and Tamburco, Peru, and convened focus groups and workshops during which participatory mapping, a serious game, a Bayesian belief network based on ILK were introduced. We inventoried 60 medicinal plants used to treat different illnesses, and analyzed the spatial distribution of the 7 plants that contribute the most to a good quality of life, and delineated their nonmedicinal uses. Based on the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services conceptual framework, we defined dimensions of a good quality of life according to indigenous and local worldviews. Medicinal plants contributed strongly to health and household security, among other contributions. Climate change and overexploitation were the main perceived threats to medicinal plants, despite the existence of formal and customary institutions to regulate trade. Our approach was flexible enough to integrate diverse forms of knowledge, as well as qualitative and quantitative information from, for example, the Bayesian belief network.

Coproducción de conocimiento para mejorar la evaluación de las contribuciones de la naturaleza para las personas Resumen La ciencia de la sostenibilidad necesita nuevos enfoques para producir, compartir y utilizar los conocimientos, ya que existen grandes obstáculos para trasladar la investigación a la política y la práctica. Varios actores poseen conocimientos relevantes para la sostenibilidad, incluidos los pueblos originarios y locales que han desarrollado conocimientos, métodos y prácticas a lo largo de generaciones, que deben reflejarse en las evaluaciones de la biodiversidad y los ecosistemas. A pesar de los esfuerzos por integrar la coproducción de conocimientos, <3% de la bibliografía sobre las contribuciones de la naturaleza a las personas (CNP) integra los conocimientos autóctonos y locales (CAL). Se necesitan urgentemente enfoques y herramientas para integrar mejor los sistemas de conocimiento científico y los conocimientos autóctonos y locales en las evaluaciones de los CNP. Para llenar este vacío, realizamos entrevistas con expertos en CAL de Abancay y Tamburco, Perú, y convocamos grupos focales y talleres durante los cuales se introdujeron el mapeo participativo, un juego serio y una red de creencia bayesiana basada en CAL. Inventariamos 60 plantas medicinales utilizadas para tratar diferentes enfermedades y analizamos la distribución espacial de las siete especies de plantas que más contribuyen a una buena calidad de vida y delineamos sus usos no medicinales. A partir del marco conceptual de la Plataforma Intergubernamental Científico-Normativa sobre Diversidad Biológica y Servicios de los Ecosistemas, definimos las dimensiones de una buena calidad de vida según las cosmovisiones autóctonas y locales. Las plantas medicinales contribuían en gran medida a la salud y a la seguridad de los hogares, entre otras aportaciones. El cambio climático y la sobreexplotación fueron las principales amenazas percibidas para las plantas medicinales a pesar de la existencia de instituciones tradicionales que regulan el mercado. Nuestra estrategia fue lo suficientemente flexible para integrar el conocimiento diverso, así como la información cualitativa y cuantitativa, como por ejemplo la red de creencia bayesiana.

An environmental justice perspective on ecosystem services.

Mainstreaming of ecosystem service approaches has been proposed as one path toward sustainable development. Meanwhile, critics of ecosystem services question if the approach can account for the multiple values of ecosystems to diverse groups of people, or for aspects of inter- and intra-generational justice. In particular, an ecosystem service approach often overlooks power dimensions and capabilities that are core to environmental justice. This article addresses the need for greater guidance on incorporating justice into ecosystem services research and practice. We point to the importance of deep engagement with stakeholders and rights holders to disentangle contextual factors that moderate justice outcomes on ecosystem service attribution and appropriation in socio-political interventions. Such a holistic perspective enables the integration of values and knowledge plurality for enhancing justice in ecosystem services research. This broadened perspective paves a way for transformative ecosystem service assessments, management, and research, which can help inform and design governance structures that nourish human agency to sustainably identify, manage, and enjoy ecosystem services for human wellbeing.

Trees as brokers in social networks: Cascades of rights and benefits from a Cultural Keystone Species.

Indigenous trees play key roles in West African landscapes, such as the néré tree (Parkia biglobosa (Jacq.) R.Br. ex G.Don). We applied social-ecological network analysis to understand the social-ecological interactions around néré. We documented the benefits néré provides and the multiple social interactions it creates amongst a large range of actors. The flows of rights over the trees and benefits from them formed two hierarchical networks, or cascades, with different actors at the top. The two forms of power revealed by the two cascades of rights and benefits suggest possible powers and counter-powers across gender, ethnicity, and age. We documented how the tree catalyses social interactions across diverse groups to sustain vital social connections, and co-constitute places, culture, and relationships. We argue that a paradigm shift is urgently needed to leverage the remarkable untapped potential of indigenous trees and Cultural Keystone Species in current global restoration and climate change agendas.

Slowing deforestation in Indonesia follows declining oil palm expansion and lower oil prices.

Much concern about tropical deforestation focuses on oil palm plantations, but their impacts remain poorly quantified. Using nation-wide interpretation of satellite imagery, and sample-based error calibration, we estimated the impact of large-scale (industrial) and smallholder oil palm plantations on natural old-growth ("primary") forests from 2001 to 2019 in Indonesia, the world's largest palm oil producer. Over nineteen years, the area mapped under oil palm doubled, reaching 16.24 Mha in 2019 (64% industrial; 36% smallholder), more than the official estimates of 14.72 Mha. The forest area declined by 11% (9.79 Mha), including 32% (3.09 Mha) ultimately converted into oil palm, and 29% (2.85 Mha) cleared and converted in the same year. Industrial plantations replaced more forest than detected smallholder plantings (2.13 Mha vs 0.72 Mha). New plantations peaked in 2009 and 2012 and declined thereafter. Expansion of industrial plantations and forest loss were correlated with palm oil prices. A price decline of 1% was associated with a 1.08% decrease in new industrial plantations and with a 0.68% decrease of forest loss. Deforestation fell below pre-2004 levels in 2017-2019 providing an opportunity to focus on sustainable management. As the price of palm oil has doubled since the start of the COVID-19 pandemic, effective regulation is key to minimising future forest conversion.

Co-producing ecosystem services for adapting to climate change.

Ecosystems can sustain social adaptation to environmental change by protecting people from climate change effects and providing options for sustaining material and non-material benefits as ecological structure and functions transform. Along adaptation pathways, people navigate the trade-offs between different ecosystem contributions to adaptation, or adaptation services (AS), and can enhance their synergies and co-benefits as environmental change unfolds. Understanding trade-offs and co-benefits of AS is therefore essential to support social adaptation and requires analysing how people co-produce AS. We analysed co-production along the three steps of the ecosystem cascade: (i) ecosystem management; (ii) mobilization; and (iii) appropriation, social access and appreciation. Using five exemplary case studies across socio-ecosystems and continents, we show how five broad mechanisms already active for current ecosystem services can enhance co-benefits and minimize trade-offs between AS: (1) traditional and multi-functional land/sea management targeting ecological resilience; (2) pro-active management for ecosystem transformation; (3) co-production of novel services in landscapes without compromising other services; (4) collective governance of all co-production steps; and (5) feedbacks from appropriation, appreciation of and social access to main AS. We conclude that knowledge and recognition of co-production mechanisms will enable pro-active management and governance for collective adaptation to ecosystem transformation. This article is part of the theme issue 'Climate change and ecosystems: threats, opportunities and solutions'.

Pediatric anesthesia practice in Italy: a multicenter national prospective observational study derived from the APRICOT Trial.

BACKGROUND: Pediatric anesthesia nowadays requires specific knowledge and expertise. The Anesthesia PRactice In Children Observational Trial (APRICOT) was a European multicenter study designed for the identification of perioperative severe critical events and management. We aimed at analyzing the Italian database in an attempt to determine the practice of anesthesia and the incidence of severe critical events in Italy. METHODS: Secondary analyses of the database consisted in extracting the raw data from the 25 Italian centers that participated to APRICOT. Descriptive statistics and comparison with the reference data were made for all the variables collected. RESULTS: The study analyzed 2087 children. The Italian cohort represents 6.7% of the overall study population. Most of the children were ASA 1-2 (90.6%) and underwent a surgical procedure (62.8%). In more than 84% of the cases, anesthesia management was performed by an expert with main or frequent activity in pediatric anesthesia with on an average 15 years of experience. The overall incidence of severe critical events was 3% (95% CI: 2.2-3.8). The most frequently reported severe critical incidents were of respiratory (2%; CI: 1.4-2.6) and cardiovascular origin (0.7%; CI. 0.3-1), while drug error, anaphylaxis and bronchial aspiration were very rare. There were no reports of perioperative cardiac arrest or patients with neurological damage. CONCLUSIONS: This secondary analysis demonstrates that the incidence of severe critical incidence was lower in Italy in comparison to that reported for Europe. This low rate of critical events may be related to the high expertise and experience of the anesthesiologists in charge of the children in the Italian centres that participated to APRICOT.

Nature's contributions to people in mountains: A review.

Mountains play a key role in the provision of nature's contributions to people (NCP) worldwide that support societies' quality of life. Simultaneously, mountains are threatened by multiple drivers of change. Due to the complex interlinkages between biodiversity, quality of life and drivers of change, research on NCP in mountains requires interdisciplinary approaches. In this study, we used the conceptual framework of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) and the notion of NCP to determine to what extent previous research on ecosystem services in mountains has explored the different components of the IPBES conceptual framework. We conducted a systematic review of articles on ecosystem services in mountains published up to 2016 using the Web of Science and Scopus databases. Descriptive statistical and network analyses were conducted to explore the level of research on the components of the IPBES framework and their interactions. Our results show that research has gradually become more interdisciplinary by studying higher number of NCP, dimensions of quality of life, and indirect drivers of change. Yet, research focusing on biodiversity, regulating NCP and direct drivers has decreased over time. Furthermore, despite the fact that research on NCP in mountains becoming more policy-oriented over time, mainly in relation to payments for ecosystem services, institutional responses remained underexplored in the reviewed studies. Finally, we discuss the relevant knowledge gaps that should be addressed in future research in order to contribute to IPBES.

A novel telecoupling framework to assess social relations across spatial scales for ecosystem services research.

Access to ecosystem services and influence on their management are structured by social relations among actors, which often occur across spatial scales. Such cross-scale social relations can be analysed through a telecoupling framework as decisions taken at local scales are often shaped by actors at larger scales. Analyzing these cross-scale relations is critical to create effective and equitable strategies to manage ecosystem services. Here, we develop an analytical framework -i.e. the 'cross-scale influence-dependence framework'- to facilitate the analysis of power asymmetries and the distribution of ecosystem services among the beneficiaries. We illustrate the suitability of this framework through its retrospective application across four case studies, in which we characterize the level of dependence of multiple actors on a particular set of ecosystem services, and their influence on decision-making regarding these services across three spatial scales. The 'cross-scale influence-dependence framework' can improve our understanding of distributional and procedural equity and thus support the development of policies for sustainable management of ecosystem services.

Reducing risks by transforming landscapes: Cross-scale effects of land-use changes on ecosystem services.

Globally, anthropogenic environmental change is exacerbating the already vulnerable conditions of many people and ecosystems. In order to obtain food, water, raw materials and shelter, rural people modify forests and other ecosystems, affecting the supply of ecosystem services that contribute to livelihoods and well-being. Despite widespread awareness of the nature and extent of multiple impacts of land-use changes, there remains limited understanding of how these impacts affect trade-offs among ecosystem services and their beneficiaries across spatial scales. We assessed how rural communities in two forested landscapes in Indonesia have changed land uses over the last 20 years to adapt their livelihoods that were at risk from multiple hazards. We estimated the impact of these adaptation strategies on the supply of ecosystem services by comparing different benefits provided to people from these land uses (products, water, carbon, and biodiversity), using forest inventories, remote sensing, and interviews. Local people converted forests to rubber plantations, reforested less productive croplands, protected forests on hillsides, and planted trees in gardens. Our results show that land-use decisions were propagated at the landscape scale due to reinforcing loops, whereby local actors perceived that such decisions contributed positively to livelihoods by reducing risks and generating co-benefits. When land-use changes become sufficiently widespread, they affect the supply of multiple ecosystem services, with impacts beyond the local scale. Thus, adaptation implemented at the local-scale may not address development and climate adaptation challenges at regional or national scale (e.g. as part of UN Sustainable Development Goals or actions taken under the UNFCCC Paris Agreement). A better understanding of the context and impacts of local ecosystem-based adaptation is fundamental to the scaling up of land management policies and practices designed to reduce risks and improve well-being for people at different scales.

Persistent pain following common outpatient surgeries in children: A multicenter study in Italy.

INTRODUCTION: The prevalence of persistent postsurgical pain in children is over 20% after major surgeries; however, data are scarce on the prevalence, character, and risk factors among children undergoing common ambulatory surgeries. The primary aim of this study was to evaluate the prevalence of persistent pain following pediatric ambulatory surgery at 1, 3, and 6 months. Secondary aims were to identify risk factors and characterize the pain and consequences of persistent postsurgical pain. METHODS: ASA I-II, ages 1 month to 16 years old, undergoing elective hypospadias repair, herniorraphy, orchiopexy, and orthopedic surgery were enrolled in a prospective, longitudinal, observational study at 3 pediatric centers in Italy. All patients received general plus regional anesthesia. Postoperative pain was evaluated using age appropriate pain scales at 1 and 3 hours. At 1, 3, and 6 months, pain scores were obtained and Parent's Postoperative Pain Measures (<8 yo) and Child Activity Limitations Interview (>8 yo) surveys were administered. RESULTS: About 350 patients completed the study. The prevalence of pain at 1, 3, and 6 months was 24% (84/350), 6.0% (21/350), and 4.0% (14/350), respectively. Inguinal herniorraphy patients experienced significantly higher pain at all 3-time points; 35.6%, 14.9%, and 9.2%. There was no significant association between mean pain scores >4 in PACU and persistent pain. Pain persisting at 6 months had neuropathic characteristics and frequently interfered with daily activities and sleep. CONCLUSION: Our data support the presence of persistent pain in pediatric patients after common surgeries. Most patients who developed persistent pain at 6 months had pain at 1 month. We recommend questioning at follow-up visit about persistent pain and functional impairment with follow-up until resolution.

Coupling of pollination services and coffee suitability under climate change.

Climate change will cause geographic range shifts for pollinators and major crops, with global implications for food security and rural livelihoods. However, little is known about the potential for coupled impacts of climate change on pollinators and crops. Coffee production exemplifies this issue, because large losses in areas suitable for coffee production have been projected due to climate change and because coffee production is dependent on bee pollination. We modeled the potential distributions of coffee and coffee pollinators under current and future climates in Latin America to understand whether future coffee-suitable areas will also be suitable for pollinators. Our results suggest that coffee-suitable areas will be reduced 73-88% by 2050 across warming scenarios, a decline 46-76% greater than estimated by global assessments. Mean bee richness will decline 8-18% within future coffee-suitable areas, but all are predicted to contain at least 5 bee species, and 46-59% of future coffee-suitable areas will contain 10 or more species. In our models, coffee suitability and bee richness each increase (i.e., positive coupling) in 10-22% of future coffee-suitable areas. Diminished coffee suitability and bee richness (i.e., negative coupling), however, occur in 34-51% of other areas. Finally, in 31-33% of the future coffee distribution areas, bee richness decreases and coffee suitability increases. Assessing coupled effects of climate change on crop suitability and pollination can help target appropriate management practices, including forest conservation, shade adjustment, crop rotation, or status quo, in different regions.

Beyond dichotomies: Gender and intersecting inequalities in climate change studies.

Climate change and related adaptation strategies have gender-differentiated impacts. This paper reviews how gender is framed in 41 papers on climate change adaptation through an intersectionality lens. The main findings show that while intersectional analysis has demonstrated many advantages for a comprehensive study of gender, it has not yet entered the field of climate change and gender. In climate change studies, gender is mostly handled in a men-versus-women dichotomy and little or no attention has been paid to power and social and political relations. These gaps which are echoed in other domains of development and gender research depict a 'feminization of vulnerability' and reinforce a 'victimization' discourse within climate change studies. We argue that a critical intersectional assessment would contribute to unveil agency and emancipatory pathways in the adaptation process by providing a better understanding of how the differential impacts of climate change shape, and are shaped by, the complex power dynamics of existing social and political relations.

Dynamics of Ecosystem Services during Forest Transitions in Reventazón, Costa Rica.

The forest transition framework describes the temporal changes of forest areas with economic development. A first phase of forest contraction is followed by a second phase of expansion once a turning point is reached. This framework does not differentiate forest types or ecosystem services, and describes forests regardless of their contribution to human well-being. For several decades, deforestation in many tropical regions has degraded ecosystem services, such as watershed regulation, while increasing provisioning services from agriculture, for example, food. Forest transitions and expansion have been observed in some countries, but their consequences for ecosystem services are often unclear. We analyzed the implications of forest cover change on ecosystem services in Costa Rica, where a forest transition has been suggested. A review of literature and secondary data on forest and ecosystem services in Costa Rica indicated that forest transition might have led to an ecosystem services transition. We modeled and mapped the changes of selected ecosystem services in the upper part of the Reventazón watershed and analyzed how supply changed over time in order to identify possible transitions in ecosystem services. The modeled changes of ecosystem services is similar to the second phase of a forest transition but no turning point was identified, probably because of the limited temporal scope of the analysis. Trends of provisioning and regulating services and their tradeoffs were opposite in different spatial subunits of our study area, which highlights the importance of scale in the analysis of ecosystem services and forest transitions. The ecosystem services transition framework proposed in this study is useful for analyzing the temporal changes of ecosystem services and linking socio-economic drivers to ecosystem services demand at different scales.

Addressing Climate Change Mitigation and Adaptation Together: A Global Assessment of Agriculture and Forestry Projects.

Adaptation and mitigation share the ultimate purpose of reducing climate change impacts. However, they tend to be considered separately in projects and policies because of their different objectives and scales. Agriculture and forestry are related to both adaptation and mitigation: they contribute to greenhouse gas emissions and removals, are vulnerable to climate variations, and form part of adaptive strategies for rural livelihoods. We assessed how climate change project design documents (PDDs) considered a joint contribution to adaptation and mitigation in forestry and agriculture in the tropics, by analyzing 201 PDDs from adaptation funds, mitigation instruments, and project standards [e.g., climate community and biodiversity (CCB)]. We analyzed whether PDDs established for one goal reported an explicit contribution to the other (i.e., whether mitigation PDDs contributed to adaptation and vice versa). We also examined whether the proposed activities or expected outcomes allowed for potential contributions to the two goals. Despite the separation between the two goals in international and national institutions, 37% of the PDDs explicitly mentioned a contribution to the other objective, although only half of those substantiated it. In addition, most adaptation (90%) and all mitigation PDDs could potentially report a contribution to at least partially to the other goal. Some adaptation project developers were interested in mitigation for the prospect of carbon funding, whereas mitigation project developers integrated adaptation to achieve greater long-term sustainability or to attain CCB certification. International and national institutions can provide incentives for projects to harness synergies and avoid trade-offs between adaptation and mitigation.

Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial.

BACKGROUND: Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial. METHODS: In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600. FINDINGS: Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98.6 (14.2) in the awake-regional group and 98.2 (14.7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0.169, 95% CI -2.30 to 2.64). The median duration of anaesthesia in the general anaesthesia group was 54 min. INTERPRETATION: For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia. FUNDING: Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).

Ecosystem Services and Biodiversity in a Rapidly Transforming Landscape in Northern Borneo.

Because industrial agriculture keeps expanding in Southeast Asia at the expense of natural forests and traditional swidden systems, comparing biodiversity and ecosystem services in the traditional forest-swidden agriculture system vs. monocultures is needed to guide decision making on land-use planning. Focusing on tree diversity, soil erosion control, and climate change mitigation through carbon storage, we surveyed vegetation and monitored soil loss in various land-use areas in a northern Bornean agricultural landscape shaped by swidden agriculture, rubber tapping, and logging, where various levels and types of disturbance have created a fine mosaic of vegetation from food crop fields to natural forest. Tree species diversity and ecosystem service production were highest in natural forests. Logged-over forests produced services similar to those of natural forests. Land uses related to the swidden agriculture system largely outperformed oil palm or rubber monocultures in terms of tree species diversity and service production. Natural and logged-over forests should be maintained or managed as integral parts of the swidden system, and landscape multifunctionality should be sustained. Because natural forests host a unique diversity of trees and produce high levels of ecosystem services, targeting carbon stock protection, e.g. through financial mechanisms such as Reducing Emissions from Deforestation and Forest Degradation (REDD+), will synergistically provide benefits for biodiversity and a wide range of other services. However, the way such mechanisms could benefit communities must be carefully evaluated to counter the high opportunity cost of conversion to monocultures that might generate greater income, but would be detrimental to the production of multiple ecosystem services.

Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study--Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial.

BACKGROUND: Postoperative apnea is a complication in young infants. Awake regional anesthesia (RA) may reduce the risk; however, the evidence is weak. The General Anesthesia compared to Spinal anesthesia study is a randomized, controlled trial designed to assess the influence of general anesthesia (GA) on neurodevelopment. A secondary aim is to compare rates of apnea after anesthesia. METHODS: Infants aged 60 weeks or younger, postmenstrual age scheduled for inguinal herniorrhaphy, were randomized to RA or GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born less than 26 weeks gestation. The primary outcome of this analysis was any observed apnea up to 12 h postoperatively. Apnea assessment was unblinded. RESULTS: Three hundred sixty-three patients were assigned to RA and 359 to GA. Overall, the incidence of apnea (0 to 12 h) was similar between arms (3% in RA and 4% in GA arms; odds ratio [OR], 0.63; 95% CI, 0.31 to 1.30, P = 0.2133); however, the incidence of early apnea (0 to 30 min) was lower in the RA arm (1 vs. 3%; OR, 0.20; 95% CI, 0.05 to 0.91; P = 0.0367). The incidence of late apnea (30 min to 12 h) was 2% in both RA and GA arms (OR, 1.17; 95% CI, 0.41 to 3.33; P = 0.7688). The strongest predictor of apnea was prematurity (OR, 21.87; 95% CI, 4.38 to 109.24), and 96% of infants with apnea were premature. CONCLUSIONS: RA in infants undergoing inguinal herniorrhaphy reduces apnea in the early postoperative period. Cardiorespiratory monitoring should be used for all ex-premature infants.

Low-dose RATG with or without basiliximab in renal transplantation: a matched-cohort observational study.

BACKGROUND/AIMS: In renal transplantation, peri-operative low-dose rabbit-antithymocyte-globulin (RATG) plus basiliximab induction prevented acute allograft rejection more effectively than post-operative RATG plus basiliximab induction. We investigated the specific antirejection contribution of basiliximab in this context. METHODS: This single-center, observational, matched-cohort study evaluated allograft rejections (primary outcome), steroid exposure and side effects, GFR (iohexol plasma clearance) and treatment costs in 16 deceased-donor renal transplant recipients induced with RATG (0.5 mg/kg/day) and 32 age-, gender- and treatment-matched reference-patients given RATG plus basiliximab (20 mg on days 0 and 4). RESULTS: Induction was well tolerated. At 18 months, 8 patients (50%) vs. 3 reference-patients (9.4%) rejected the graft [HR (95% CI): 6.53 (1.73-24.70), p = 0.006]. Difference was significant (p < 0.01) even after adjusting for recipient/donor age and gender, cold ischemia time and HLA mismatches. There were 1 antibody-mediated rejection and 2 moderate cellular rejections in patients vs. none in reference-patients (p = 0.032). The median (interquartile range) prednisone cumulative dose was remarkably higher in patients than reference-patients [4.78 (1.12-6.10) vs. 0.19 (0.18-3.81) grams, p = 0.002]. Three patients vs. 24 reference-patients were off-steroid at study end (p < 0.001). Three patients vs. no reference-patient developed new-onset diabetes (p = 0.003). Both inductions similarly depleted B-cells. Outcomes of AZA- vs. MMF-treated participants were similar. GFR was similar in all groups. Compared to MMF, AZA therapy saved ≈ EUR 2,500/year and by month 14.3 post-transplant compensated basiliximab costs. CONCLUSION: In renal transplantation, basiliximab plus peri-operative low-dose RATG more efficiently prevented allograft rejection than RATG monotherapy, and minimized steroid exposure and toxicity. AZA- vs MMF-based maintenance immunosuppression largely compensated the extra costs of basiliximab.

Major atmospheric emissions from peat fires in Southeast Asia during non-drought years: evidence from the 2013 Sumatran fires.

Trans-boundary haze events in Southeast Asia are associated with large forest and peatland fires in Indonesia. These episodes of extreme air pollution usually occur during drought years induced by climate anomalies from the Pacific (El Niño Southern Oscillation) and Indian Oceans (Indian Ocean Dipole). However, in June 2013--a non-drought year--Singapore's 24-hr Pollutants Standards Index reached an all-time record 246 (rated "very unhealthy"). Here, we show using remote sensing, rainfall records and other data, that the Indonesian fires behind the 2013 haze followed a two-month dry spell in a wetter-than-average year. These fires were short-lived (one week) and limited to a localized area in Central Sumatra (1.6% of Indonesia): burning an estimated 163,336 ha, including 137,044 ha (84%) on peat. Most burning was confined to deforested lands (82%; 133,216 ha). The greenhouse gas (GHG) emissions during this brief, localized event were considerable: 172 ± 59 Tg CO2-eq (or 31 ± 12 Tg C), representing 5-10% of Indonesia's mean annual GHG emissions for 2000-2005. Our observations show that extreme air pollution episodes in Southeast Asia are no longer restricted to drought years. We expect major haze events to be increasingly frequent because of ongoing deforestation of Indonesian peatlands.

A novel balanced isotonic sodium solution vs normal saline during major surgery in children up to 36 months: a multicenter RCT.

BACKGROUND: The use of isotonic electrolytic solutions for the intraoperative fluid management in children is largely recognized, but the exact composition still needs to be defined. OBJECTIVES: The primary objective of this randomized controlled open trial was to compare the changes in chloride plasma concentration using two intraoperative isotonic fluid regimens (Sterofundin vs. normal saline, both added with 1% of glucose) in children undergoing major surgery. Secondary objectives were to compare changes in other electrolytes, renal function, and the occurrence of hypoglycemia. METHODS: Children aged between 1 and 36 months, scheduled for major surgery, were randomized to receive Sterofundin or saline during the intraoperative time. Children with preoperative electrolyte abnormalities, hemodynamic instability, and severe renal or hepatic dysfunction were excluded. The primary outcome was the Δ of Cl(-) (Δ = change in plasma concentration between post- and pre-infusion), and secondary outcomes included Δ of other electrolytes and intraoperative hypoglycemia. RESULTS: A total of 240 patients were included in the two study sites and randomized to receive Sterofundin plus 1% glucose or normal saline plus 1% glucose, in a open fashion (229 were finally analyzed). Δ of Cl- and Mg++ was statistically less relevant in patients who received intraoperative Sterofundin, and Δ of the other electrolytes was comparable between the two study groups. Relative risk of hyperchloremia was significantly higher when large volumes were infused (over than 46.7 ml·kg(-1) ), regardless of type of crystalloid infused. Hypoglycemia occurred in two of 229 patients. CONCLUSIONS: Sterofundin is safer than normal saline in protecting young children undergoing major surgery against the risk of increasing plasma chlorides and the subsequent metabolic acidosis.