The Acute Care Undergraduate TEaching (ACUTE) initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom

Background: The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation. Design: Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale. Results: A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation. Conclusions: We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Introduction: perspectives for economically important wild species and neglected crops in the Mediterranean

The Mediterranean region is one of the major centres of origin and diversification of cultivated plants and many crop wild relatives are found there. In addition, many native species are still widely harvested from the wild for food, medicine and other uses and some of these have potential for development as alternative crop especially in marginal zones. While there have been several recent initiatives that address the cataloguing and conservation of these species, such as the Network on Identification, Conservation and Use of Wild Plants in the Mediterranean Region (MEDUSA and the Bioversity International (IPGRI) studies on Underutilized Mediterranean Species (VMS), no comprehensive assessment has yet been made and little work undertaken on their agricultural potential. It has been confidently predicted that consequences of global change in the Mediterranean region - population movements and migrations, changes in disturbance regimes, and climate change - will be serious. One the one hand, this will affect the survival prospects of many of these underutilized species and on the other hand it will enhance their importance as the source of potential new crop germplasm. The conservation and availability of genetic diversity of both crops and underutilized species is essential if we are to be able to meet the increasing demand for food and other crops that will be adapted to the new ecoclimatic envelopes that will develop in the region as a consequence of global change. The rapid rate of climatic and other change that is expected adds urgency to the task of assessing, conserving and sustainably using this rich diversity of wild species of economic value in the region but new strategies will be need to be developed to achieve this. The Mediterranean region has the potential of becoming a major source of new crop development in the coming decades.

An integrated assessment of carbon dioxide capture and storage in the UK

Geological carbon dioxide storage (CCS) has the potential to make a significant contribution to the decarbonisation of the UK. Amid concerns over maintaining security, and hence diversity, of supply, CCS could allow the continued use of coal, oil and gas whilst avoiding the CO2 emissions currently associated with fossil fuel use. This project has explored some of the geological, environmental, technical, economic and social implications of this technology. The UK is well placed to exploit CCS with a large offshore storage capacity, both in disused oil and gas fields and saline aquifers. This capacity should be sufficient to store CO2 from the power sector (at current levels) for a least one century, using well understood and therefore likely to be lower-risk, depleted hydrocarbon fields and contained parts of aquifers. It is very difficult to produce reliable estimates of the (potentially much larger) storage capacity of the less well understood geological reservoirs such as non-confined parts of aquifers. With the majority of its large coal fired power stations due to be retired during the next 15 to 20 years, the UK is at a natural decision point with respect to the future of power generation from coal; the existence of both national reserves and the infrastructure for receiving imported coal makes clean coal technology a realistic option. The notion of CCS as a ‘bridging’ or ‘stop-gap’ technology (i.e. whilst we develop ‘genuinely’ sustainable renewable energy technologies) needs to be examined somewhat critically, especially given the scale of global coal reserves. If CCS plant is built, then it is likely that technological innovation will bring down the costs of CO2 capture, such that it could become increasingly attractive. As with any capitalintensive option, there is a danger of becoming ‘locked-in’ to a CCS system. The costs of CCS in our model for UK power stations in the East Midlands and Yorkshire to reservoirs in the North Sea are between £25 and £60 per tonne of CO2 captured, transported and stored. This is between about 2 and 4 times the current traded price of a tonne of CO2 in the EU Emissions Trading Scheme. In addition to the technical and economic requirements of the CCS technology, it should also be socially and environmentally acceptable. Our research has shown that, given an acceptance of the severity and urgency of addressing climate change, CCS is viewed favourably by members of the public, provided it is adopted within a portfolio of other measures. The most commonly voiced concern from the public is that of leakage and this remains perhaps the greatest uncertainty with CCS. It is not possible to make general statements concerning storage security; assessments must be site specific. The impacts of any potential leakage are also somewhat uncertain but should be balanced against the deleterious effects of increased acidification in the oceans due to uptake of elevated atmospheric CO2 that have already been observed. Provided adequate long term monitoring can be ensured, any leakage of CO2 from a storage site is likely to have minimal localised impacts as long as leaks are rapidly repaired. A regulatory framework for CCS will need to include risk assessment of potential environmental and health and safety impacts, accounting and monitoring and liability for the long term. In summary, although there remain uncertainties to be resolved through research and demonstration projects, our assessment demonstrates that CCS holds great potential for significant cuts in CO2 emissions as we develop long term alternatives to fossil fuel use. CCS can contribute to reducing emissions of CO2 into the atmosphere in the near term (i.e. peak-shaving the future atmospheric concentration of CO2), with the potential to continue to deliver significant CO2 reductions over the long term.

SORMA - business cases for an open grid market: concept and implementation

Economic mechanisms enhance technological solutions by setting the right incentives to reveal information about demand and supply accurately. Market or pricing mechanisms are ones that foster information exchange and can therefore attain efficient allocation. By assigning a value (also called utility) to their service requests, users can reveal their relative urgency or costs to the service. The implementation of theoretical sound models induce further complex challenges. The EU-funded project SORMA analyzes these challenges and provides a prototype as a proof-of-concept. In this paper the approach within the SORMA-project is described on both conceptual and technical level.

A review of climate risk information for adaptation and development planning

Although the use of climate scenarios for impact assessment has grown steadily since the 1990s, uptake of such information for adaptation is lagging by nearly a decade in terms of scientific output. Nonetheless, integration of climate risk information in development planning is now a priority for donor agencies because of the need to prepare for climate change impacts across different sectors and countries. This urgency stems from concerns that progress made against Millennium Development Goals (MDGs) could be threatened by anthropogenic climate change beyond 2015. Up to this time the human signal, though detectable and growing, will be a relatively small component of climate variability and change. This implies the need for a twin-track approach: on the one hand, vulnerability assessments of social and economic strategies for coping with present climate extremes and variability, and, on the other hand, development of climate forecast tools and scenarios to evaluate sector-specific, incremental changes in risk over the next few decades. This review starts by describing the climate outlook for the next couple of decades and the implications for adaptation assessments. We then review ways in which climate risk information is already being used in adaptation assessments and evaluate the strengths and weaknesses of three groups of techniques. Next we identify knowledge gaps and opportunities for improving the production and uptake of climate risk information for the 2020s. We assert that climate change scenarios can meet some, but not all, of the needs of adaptation planning. Even then, the choice of scenario technique must be matched to the intended application, taking into account local constraints of time, resources, human capacity and supporting infrastructure. We also show that much greater attention should be given to improving and critiquing models used for climate impact assessment, as standard practice. Finally, we highlight the over-arching need for the scientific community to provide more information and guidance on adapting to the risks of climate variability and change over nearer time horizons (i.e. the 2020s). Although the focus of the review is on information provision and uptake in developing regions, it is clear that many developed countries are facing the same challenges. Copyright © 2009 Royal Meteorological Society

Climate change and the emergence of new organizational landscapes

There is general agreement across the world that human-made climate change is a serious global problem,although there are still some sceptics who challenge this view. Research in organization studies on the topic is relatively new. Much of this research, however, is instrumental and managerialist in its focus on ‘win-win’ opportunities for business or its treatment of climate change as just another corporate social responsibility (CSR) exercise. In this paper, we suggest that climate change is not just an environmental problem requiring technical and managerial solutions; it is a political issue where a variety of organizations – state agencies, firms, industry associations, NGOs and multilateral organizations – engage in contestation as well as collaboration over the issue. We discuss the strategic, institutional and political economy dimensions of climate change and develop a socioeconomic regimes approach as a synthesis of these different theoretical perspectives. Given the urgency of the problem and the need for a rapid transition to a low-carbon economy, there is a pressing need for organization scholars to develop a better understanding of apathy and inertia in the face of the current crisis and to identify paths toward transformative change. The seven papers in this special issue address these areas of research and examine strategies, discourses, identities and practices in relation to climate change at multiple levels.

Whole life carbon – a building case study

There is potential to reduce both operational and embodied greenhouse gas emission from buildings. To date the focus has been on reducing the operational element, although given the urgency of carbon reductions, it may be more beneficial to consider upfront embodied carbon reductions. This paper describes a case study on the whole life carbon cycle of a warehouse building in Swindon, UK. It examines the relationship between embodied carbon (Ec) and operational carbon (Oc), the proportions of Ec from the structural and non-structural elements, carbon benchmarking of the structure, the value of ‘cradle to site’ or ‘cradle to grave’ assessments and the significance of the timing of emissions during the life of the building. The case study indicates that Ec was dominant for the building and that the structure was responsible for more than half of the Ec. Weighting of future emissions appears to be an important factor to consider. The PAS 2050 reduction factors had only a modest effect but weighting to allow for future decarbonisation of the national grid energy supply had a large effect. This suggests that future operational carbon emissions are being overestimated compared to embodied.

The persistent challenge of encouraging public participation in the low-carbon transition

In order to address the growing urgency of issues around environmental and resource limits, there is a clear need to develop policies that promote changes in behavior and the ways in which society both views and consumes goods and services. However, there is an argument to suggest that, in order to develop effective policies in this area, we need to move beyond a narrow understanding of ‘how individuals behave’ in order to cultivate a more nuanced approach that encompasses behavioral influences in different societies, contexts and settings. In this opinion article we therefore draw on a range of our own recent comparative research studies in order to provide fresh insights into the continued problem of how to engage people individually and collectively in establishing more sustainable, low-carbon societies.

Time valued life cycle greenhouse gas emissions from buildings

The UK has adopted legally binding carbon reduction targets of 34% by 2020 and 80% by 2050 (measured against the 1990 baseline). Buildings are estimated to be responsible for more than 50% of greenhouse gas (GHG) emissions in the UK. These consist of both operational, produced during use, and embodied, produced during manufacture of materials and components, and during construction, refurbishments and demolition. A brief assessment suggests that it is unlikely that UK emission reduction targets can be met without substantial reductions in both Oc and Ec. Oc occurs over the lifetime of a building whereas the bulk of Ec occurs at the start of a building’s life. A time value for emissions could influence the decision making process when it comes to comparing mitigation measures which have benefits that occur at different times. An example might be the choice between building construction using low Ec construction materials versus building construction using high Ec construction materials but with lower Oc, although the use of high Ec materials does not necessarily imply a lower Oc. Particular time related issues examined here are: the urgency of the need to achieve large emissions reductions during the next 10 to 20 years; the earlier effective action is taken, the less costly it will be; future reduction in carbon intensity of energy supply; the carbon cycle and relationship between the release of GHG’s and their subsequent concentrations in the atmosphere. An equation is proposed, which weights emissions according to when they occur during the building life cycle, and which effectively increases Ec as a proportion of the total, suggesting that reducing Ec is likely to be more beneficial, in terms of climate change, for most new buildings. Thus, giving higher priority to Ec reductions is likely to result in a bigger positive impact on climate change and mitigation costs.

High density lipoproteins (HDLs) and atherosclerosis; the unanswered questions

The concentration of high density lipoprotein-cholesterol (HDL-C) has been found consistently to be a powerful negative predictor of premature coronary heart disease (CHD) in human prospective population studies. There is also circumstantial evidence from human intervention studies and direct evidence from animal intervention studies that HDLs protect against the development of atherosclerosis. HDLs have several documented functions, although the precise mechanism by which they prevent atherosclerosis remains uncertain. Nor is it known whether the cardioprotective properties of HDL are specific to one or more of the many HDL subpopulations that comprise the HDL fraction in human plasma. Several lifestyle and pharmacological interventions have the capacity to raise the level of HDL-C, although it is not known whether all are equally protective. Indeed, despite the large body of information identifying HDLs as potential therapeutic targets for the prevention of atherosclerosis, there remain many unanswered questions that must be addressed as a matter of urgency before embarking wholesale on HDL-C-raising therapies as strategies to prevent CHD. This review summarises what is known and highlights what we still need to know.

Challenging climate change and migration discourse: different understandings of time-scale and temporality in the Maldives

This article draws on ongoing research in the Maldives to explore differences between elite and non-elite perceptions of climate change and migration. It argues that, in addition to variations in perceptions based on diverse knowledge, priorities and agendas, there exists a more fundamental divergence based upon different understandings of the time-scale of climate change and related ideas of urgency and crisis. Specifically, elites tend to focus on a distant future which is generally abstracted from people’s everyday lived realities, as well as utilise the language of a climate change-induced migration ‘crisis’ in their discussions about impacts in a manner not envisaged by non-elites. The article concludes that, rather than unproblematically mapping global, external facing narratives wholesale onto ordinary people’s lives and experiences, there needs to be more dialogue between elites and non-elites on climate change and migration issues. These perspectives should be integrated more effectively in the development of policy interventions designed to help people adapt to the impacts of global environmental change.