"It was hard to come to mutual understanding..." - Multidimensionality of social learning processes in natural resource use in India, Africa and Latin America

Sustainable natural resource use requires that multiple actors reassess their situation in a systemic perspective. This can be conceptualised as a social learning process between actors from rural communities and the experts from outside organisations. A specifically designed workshop oriented towards a systemic view of natural resource use and the enhancement of mutual learning between local and external actors, provided the background for evaluating the potentials and constraints of intensified social learning processes. Case studies in rural communities in India, Bolivia, Peru and Mali showed that changes in the narratives of the participants of the workshop followed a similar temporal sequence relatively independently from their specific contexts. Social learning processes were found to be more likely to be successful if they 1) opened new space for communicative action, allowing for an intersubjective re-definition of the present situation, 2) contributed to rebalance the relationships between social capital and social, emotional and cognitive competencies within and between local and external actors.

Impact of Helicobacter pylori eradication on dyspepsia, health resource use, and quality of life in the Bristol helicobacter project: randomised controlled trial

OBJECTIVE: To determine the impact of a community based Helicobacter pylori screening and eradication programme on the incidence of dyspepsia, resource use, and quality of life, including a cost consequences analysis. DESIGN: H pylori screening programme followed by randomised placebo controlled trial of eradication. SETTING: Seven general practices in southwest England. PARTICIPANTS: 10,537 unselected people aged 20-59 years were screened for H pylori infection (13C urea breath test); 1558 of the 1636 participants who tested positive were randomised to H pylori eradication treatment or placebo, and 1539 (99%) were followed up for two years. INTERVENTION: Ranitidine bismuth citrate 400 mg and clarithromycin 500 mg twice daily for two weeks or placebo. MAIN OUTCOME MEASURES: Primary care consultation rates for dyspepsia (defined as epigastric pain) two years after randomisation, with secondary outcomes of dyspepsia symptoms, resource use, NHS costs, and quality of life. RESULTS: In the eradication group, 35% fewer participants consulted for dyspepsia over two years compared with the placebo group (55/787 v 78/771; odds ratio 0.65, 95% confidence interval 0.46 to 0.94; P = 0.021; number needed to treat 30) and 29% fewer participants had regular symptoms (odds ratio 0.71, 0.56 to 0.90; P = 0.05). NHS costs were 84.70 pounds sterling (74.90 pounds sterling to 93.91 pounds sterling) greater per participant in the eradication group over two years, of which 83.40 pounds sterling (146 dollars; 121 euro) was the cost of eradication treatment. No difference in quality of life existed between the two groups. CONCLUSIONS: Community screening and eradication of H pylori is feasible in the general population and led to significant reductions in the number of people who consulted for dyspepsia and had symptoms two years after treatment. These benefits have to be balanced against the costs of eradication treatment, so a targeted eradication strategy in dyspeptic patients may be preferable.

Partner notification of chlamydia infection in primary care: randomised controlled trial and analysis of resource use

OBJECTIVE: To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection. DESIGN: Randomised controlled trial. SETTING: 27 general practices in the Bristol and Birmingham areas. PARTICIPANTS: 140 men and women with chlamydia (index cases) diagnosed by screening of a home collected urine sample or vulval swab specimen. INTERVENTIONS: Partner notification at the general practice immediately after diagnosis by trained practice nurses, with telephone follow up by a health adviser; or referral to a specialist health adviser at a genitourinary medicine clinic. MAIN OUTCOME MEASURES: Primary outcome was the proportion of index cases with at least one treated sexual partner. Specified secondary outcomes included the number of sexual contacts elicited during a sexual history, positive test result for chlamydia six weeks after treatment, and the cost of each strategy in 2003 sterling prices. RESULTS: 65.3% (47/72) of participants receiving practice nurse led partner notification had at least one partner treated compared with 52.9% (39/68) of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% confidence interval -1.8% to 26.5%). Of 68 participants referred to the clinic, 21 (31%) did not attend. The costs per index case were 32.55 pounds sterling for the practice nurse led strategy and 32.62 pounds sterling for the specialist referral strategy. CONCLUSION: Practice based partner notification by trained nurses with telephone follow up by health advisers is at least as effective as referral to a specialist health adviser at a genitourinary medicine clinic, and costs the same. Trial registration Clinical trials: NCT00112255.

Variability in outcome and resource use in intensive care units

OBJECTIVE: To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use. DESIGN AND SETTING: Cohort study, based on the SAPS 3 database in 275 ICUs worldwide. PATIENTS: 16,560 adults. MEASUREMENTS AND RESULTS: Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant. CONCLUSIONS: Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.

Resource use and outcome in critically ill patients with hematological malignancy: a retrospective cohort study

INTRODUCTION: The paucity of data on resource use in critically ill patients with hematological malignancy and on these patients' perceived poor outcome can lead to uncertainty over the extent to which intensive care treatment is appropriate. The aim of the present study was to assess the amount of intensive care resources needed for, and the effect of treatment of, hemato-oncological patients in the intensive care unit (ICU) in comparison with a nononcological patient population with a similar degree of organ dysfunction. METHODS: A retrospective cohort study of 101 ICU admissions of 84 consecutive hemato-oncological patients and 3,808 ICU admissions of 3,478 nononcological patients over a period of 4 years was performed. RESULTS: As assessed by Therapeutic Intervention Scoring System points, resource use was higher in hemato-oncological patients than in nononcological patients (median (interquartile range), 214 (102 to 642) versus 95 (54 to 224), P < 0.0001). Severity of disease at ICU admission was a less important predictor of ICU resource use than necessity for specific treatment modalities. Hemato-oncological patients and nononcological patients with similar admission Simplified Acute Physiology Score scores had the same ICU mortality. In hemato-oncological patients, improvement of organ function within the first 48 hours of the ICU stay was the best predictor of 28-day survival. CONCLUSION: The presence of a hemato-oncological disease per se is associated with higher ICU resource use, but not with increased mortality. If withdrawal of treatment is considered, this decision should not be based on admission parameters but rather on the evolutional changes in organ dysfunctions.

Water-use efficiency and transpiration across European forests during the Anthropocene

The Earth’s carbon and hydrologic cycles are intimately coupled by gas exchange through plant stomata1, 2, 3. However, uncertainties in the magnitude4, 5, 6 and consequences7, 8 of the physiological responses9, 10 of plants to elevated CO2 in natural environments hinders modelling of terrestrial water cycling and carbon storage11. Here we use annually resolved long-term δ13C tree-ring measurements across a European forest network to reconstruct the physiologically driven response of intercellular CO2 (Ci) caused by atmospheric CO2 (Ca) trends. When removing meteorological signals from the δ13C measurements, we find that trees across Europe regulated gas exchange so that for one ppmv atmospheric CO2 increase, Ci increased by ~0.76 ppmv, most consistent with moderate control towards a constant Ci/Ca ratio. This response corresponds to twentieth-century intrinsic water-use efficiency (iWUE) increases of 14 ± 10 and 22 ± 6% at broadleaf and coniferous sites, respectively. An ensemble of process-based global vegetation models shows similar CO2 effects on iWUE trends. Yet, when operating these models with climate drivers reintroduced, despite decreased stomatal opening, 5% increases in European forest transpiration are calculated over the twentieth century. This counterintuitive result arises from lengthened growing seasons, enhanced evaporative demand in a warming climate, and increased leaf area, which together oppose effects of CO2-induced stomatal closure. Our study questions changes to the hydrological cycle, such as reductions in transpiration and air humidity, hypothesized to result from plant responses to anthropogenic emissions.

Watershed classification in the Lower Mekong Basin: Rapid economic growth - a source of increasing potential for conflict over resource use

In the Lower Mekon Basin the extraordinary pace of economic development and growth contradicts with environmental protection. On base of the Watershed Classification Project (WSCP) and the inclusion of a DTM for the entire LMB the potential degradation risk was derived for each land unit. The risks were grouped into five classes, where classes one and two are considered critical with regard to soil erosion when the land is cleared of natural resources. For practical use the database has an enormous potential for further spatial analysis in combination with other datasets, as for example the NCCR North-South uses the WSCP within two research projects.

Contrasting growth and water use efficiency after thinning in mixed Abies pinsapo–Pinus pinaster–Pinus sylvestris forests

Foresters frequently lack sufficient information about thinning intensity effects to optimize semi-natural forest management and their effects and interaction with climate are still poorly understood. In an Abies pinsapo–Pinus pinaster–Pinus sylvestris forest with three thinning intensities, a dendrochronologial approach was used to evaluate the short-term responses of basal area increment (BAI), carbon isotope (δ13C) and water use efficiency (iWUE) to thinning intensity and climate. Thinning generally increased BAI in all species, except for the heavy thinning in P. sylvestris. Across all the plots, thinning increased 13C-derived water-use efficiency on average by 14.49% for A. pinsapo, 9.78% for P. sylvestris and 6.68% for P. pinaster, but through different ecophysiological mechanisms. Our findings provide a robust mean of predicting water use efficiency responses from three coniferous species exposed to different thinning strategies which have been modulated by climatic conditions over time.

Resilient Adaptation to Climate Change in African Agriculture

Africa’s agriculture faces varying climate change impacts which mainly worsen production conditions and adversely affect its economies. Adaptations thus need to build the resilience of farming systems. Using “resilient adaptation” as a concept, this study analyses how adaptations at farm and policy/institutional-levels contribute to the resilience of Sub-Saharan African agriculture. The developed tool, “the Resilience Check”, provides socio-economic data which complements existing adaptation tools. The underlying development gaps such as insecure property rights, poverty, low self-organisation, inadequate climate data and infrastructure limit resilient adaptations. If farmers could implement recommended practices, existing measures and improved crops can address most impacts expected in the medium-term. However, resource use efficiency remains critical for all farm management types. Development-oriented adaptation measures are needed to provide the robust foundations for building resilience. Reaching the very poor remains a challenge and the externally driven nature of many interventions raises concern about their sustainability. The study recommends practical measures such as decentralising various services and integrating the action plans of the multilateral environmental agreements into one national action plan.

Response of temperate grasslands at different altitudes to simulated summer drought differed but scaled with annual precipitation

Water is an important resource for plant life. Since climate scenarios for Switzerland predict an average reduction of 20% in summer precipitation until 2070, understanding ecosystem responses to water shortage, e.g. in terms of plant productivity, is of major concern. Thus, we tested the effects of simulated summer drought on three managed grasslands along an altitudinal gradient in Switzerland from 2005 to 2007, representing typical management intensities at the respective altitude. We assessed the effects of experimental drought on above- and below-ground productivity, stand structure (LAI and vegetation height) and resource use (carbon and water). Responses of community above-ground productivity to reduced precipitation input differed among the three sites but scaled positively with total annual precipitation at the sites (R2=0.85). Annual community above-ground biomass productivity was significantly reduced by summer drought at the alpine site receiving the least amount of annual precipitation, while no significant decrease (rather an increase) was observed at the pre-alpine site receiving highest precipitation amounts in all three years. At the lowland site (intermediate precipitation sums), biomass productivity significantly decreased in response to drought only in the third year, after showing increased abundance of a drought tolerant weed species in the second year. No significant change in below-ground biomass productivity was observed at any of the sites in response to simulated summer drought. However, vegetation carbon isotope ratios increased under drought conditions, indicating an increase in water use efficiency. We conclude that there is no general drought response of Swiss grasslands, but that sites with lower annual precipitation seem to be more vulnerable to summer drought than sites with higher annual precipitation, and thus site-specific adaptation of management strategies will be needed, especially in regions with low annual precipitation.