The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes

Objective To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. Setting 14 nursing homes in Sydney and Brisbane, Australia. Participants 92 residents with a mean age of 85 years. Measurements Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. Results The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. Conclusion When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

Comparison of Body Composition Assessment Methods in Breast Cancer Survivors

Purpose/Objectives: To examine and compare the reliability of four body composition methods commonly used in assessing breast cancer survivors. Design: Cross-sectional. Setting: A rehabilitation facility at a university-based comprehensive cancer center in the southeastern United States. Sample: 14 breast cancer survivors aged 40-71 years. Methods: Body fat (BF) percentage was estimated via bioelectric impedance analysis (BIA), air displacement plethysmography (ADP), and skinfold thickness (SKF) using both three- and seven-site algorithms, where reliability of the methods was evaluated by conducting two tests for each method (test 1 and test 2), one immediately after the other. An analysis of variance was used to compare the results of BF percentage among the four methods. Intraclass correlation coefficient (ICC) was used to test the reliability of each method. Main Research Variable: BF percentage. Findings: Significant differences in BF percentage were observed between BIA and all other methods (three-site SKF, p < 0.001; seven-site SKF, p < 0.001; ADP, p = 0.002). No significant differences (p > 0.05) in BF percentage between three-site SKF, seven-site SKF, and ADP were observed. ICCs between test 1 and test 2 for each method were BIA = 1, ADP = 0.98, three-site SKF = 0.99, and seven-site SKF = 0.94. Conclusions: ADP and both SKF methods produce similar estimates of BF percentage in all participants, whereas BIA overestimated BF percentage relative to the other measures. Caution is recommended when using BIA as the body composition method for breast cancer survivors who have completed treatment but are still undergoing adjuvant hormonal therapy. Implications for Nursing: Measurements of body composition can be implemented very easily as part of usual care and should serve as an objective outcome measure for interventions designed to promote healthy behaviors among breast cancer survivors. - See more at: https://onf.ons.org/onf/38/4/comparison-body-composition-assessment-methods-breast-cancer-survivors#sthash.5djfTS1Q.dpuf

Multiple perspectives on quality of life for residents with dementia in long term care facilities: Protocol for a comprehensive Australian study

Background Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL. Methods The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also taking part in qualitative interviews and observations. Conclusions This national study will provide a broad understanding of factors underlying QoL for residents with dementia in long term care. The present study uses a similar methodology to the US-based Collaborative Studies of Long Term Care (CS-LTC) Dementia Care Study, applying it to the Australian setting.

Quantitative assessment and characterisation of airborne engineered nanoparticles

This research has brought new scientific insight into the characteristics of airborne engineered nanoparticles, which is essential when considering their effects on human health. The key findings of the work were a harmonised and traceable protocol for the size characterisation of engineered nanoparticles, and quantification of their emissions and dynamics in workplaces. The novelty of this project is in coupling a comprehensive experimental measurement approach with innovative and effective data interpretation. Also, for the first time, the existence of a general trend in the emission of nanoparticles from a nanotechnology process was investigated.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes

Background Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting. Methods Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves. Results Among residents without dementia, both the self-rated (AUC = 0.75–0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively. Conclusions The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

Automated fit assessment of intramedullary nail designs during insertion

Modern intramedullary nails, which are utilised for the treatment of bone fractures, need to be designed to fit the anatomy of the patient population. Traditional and recent semi-automated approaches for quantifying the anatomical fit between bones and nail designs suffer from various drawbacks. This thesis proposed an automated comprehensive nail design validation method. The developed software tool was utilised to quantify the anatomical fit of four commercial nail designs. Furthermore, the thesis demonstrated the existence of a bone-nail specific nail entry point. The developed method is of great benefit for the implant manufacturing industry as a nail design validation tool.

Damage assessment of basaltic rock mass due to repeated blasting in a railway tunnelling project - A case study

The demand for tunnelling and underground space creation is rapidly growing due to the requirement of civil infrastructure projects and urbanisation. Blasting remains the most inexpensive method of underground excavations in hard rock. Unfortunately, there are no specific safety guidelines available for the blasted tunnels with regards to the threshold limits of vibrations caused by repeated blasting activity in the close proximity. This paper presents the results of a comprehensive study conducted to find out the effect of repeated blast loading on the damage experienced by jointed basaltic rock mass during tunnelling works. Conducting of multiple rounds of blasts for various civil excavations in a railway tunnel imparted repeated loading on rock mass of sidewall and roof of the tunnel. The blast induced damage was assessed by using vibration attenuation equations of charge weight scaling law and measured by borehole extensometers and borehole camera. Ground vibrations of each blasting round were also monitored by triaxial geophones installed near the borehole extensometers. The peak particle velocity (V-max) observations and plastic deformations from borehole extensometers were used to develop a site specific damage model. The study reveals that repeated dynamic loading imparted on the exposed tunnel from subsequent blasts, in the vicinity, resulted in rock mass damage at lesser vibration levels than the critical peak particle velocity (V-cr). It was found that, the repeated blast loading resulted in the near-field damage due to high frequency waves and far-field damage due to low frequency waves. The far field damage, after 45-50 occurrences of blast loading, was up to 55% of the near-field damage in basaltic rock mass. The findings of the study clearly indicate that the phenomena of repeated blasting with respect to number of cycles of loading should be taken into consideration for proper assessment of blast induced damage in underground excavations.

A new data source for fisheries resource assessment: genetic estimates of the effective number of spawners. Final Report to the Fisheries Research and Development Corporation.

The development of innovative methods of stock assessment is a priority for State and Commonwealth fisheries agencies. It is driven by the need to facilitate sustainable exploitation of naturally occurring fisheries resources for the current and future economic, social and environmental well being of Australia. This project was initiated in this context and took advantage of considerable recent achievements in genomics that are shaping our comprehension of the DNA of humans and animals. The basic idea behind this project was that genetic estimates of effective population size, which can be made from empirical measurements of genetic drift, were equivalent to estimates of the successful number of spawners that is an important parameter in process of fisheries stock assessment. The broad objectives of this study were to 1. Critically evaluate a variety of mathematical methods of calculating effective spawner numbers (Ne) by a. conducting comprehensive computer simulations, and by b. analysis of empirical data collected from the Moreton Bay population of tiger prawns (P. esculentus). 2. Lay the groundwork for the application of the technology in the northern prawn fishery (NPF). 3. Produce software for the calculation of Ne, and to make it widely available. The project pulled together a range of mathematical models for estimating current effective population size from diverse sources. Some of them had been recently implemented with the latest statistical methods (eg. Bayesian framework Berthier, Beaumont et al. 2002), while others had lower profiles (eg. Pudovkin, Zaykin et al. 1996; Rousset and Raymond 1995). Computer code and later software with a user-friendly interface (NeEstimator) was produced to implement the methods. This was used as a basis for simulation experiments to evaluate the performance of the methods with an individual-based model of a prawn population. Following the guidelines suggested by computer simulations, the tiger prawn population in Moreton Bay (south-east Queensland) was sampled for genetic analysis with eight microsatellite loci in three successive spring spawning seasons in 2001, 2002 and 2003. As predicted by the simulations, the estimates had non-infinite upper confidence limits, which is a major achievement for the application of the method to a naturally-occurring, short generation, highly fecund invertebrate species. The genetic estimate of the number of successful spawners was around 1000 individuals in two consecutive years. This contrasts with about 500,000 prawns participating in spawning. It is not possible to distinguish successful from non-successful spawners so we suggest a high level of protection for the entire spawning population. We interpret the difference in numbers between successful and non-successful spawners as a large variation in the number of offspring per family that survive – a large number of families have no surviving offspring, while a few have a large number. We explored various ways in which Ne can be useful in fisheries management. It can be a surrogate for spawning population size, assuming the ratio between Ne and spawning population size has been previously calculated for that species. Alternatively, it can be a surrogate for recruitment, again assuming that the ratio between Ne and recruitment has been previously determined. The number of species that can be analysed in this way, however, is likely to be small because of species-specific life history requirements that need to be satisfied for accuracy. The most universal approach would be to integrate Ne with spawning stock-recruitment models, so that these models are more accurate when applied to fisheries populations. A pathway to achieve this was established in this project, which we predict will significantly improve fisheries sustainability in the future. Regardless of the success of integrating Ne into spawning stock-recruitment models, Ne could be used as a fisheries monitoring tool. Declines in spawning stock size or increases in natural or harvest mortality would be reflected by a decline in Ne. This would be good for data-poor fisheries and provides fishery independent information, however, we suggest a species-by-species approach. Some species may be too numerous or experiencing too much migration for the method to work. During the project two important theoretical studies of the simultaneous estimation of effective population size and migration were published (Vitalis and Couvet 2001b; Wang and Whitlock 2003). These methods, combined with collection of preliminary genetic data from the tiger prawn population in southern Gulf of Carpentaria population and a computer simulation study that evaluated the effect of differing reproductive strategies on genetic estimates, suggest that this technology could make an important contribution to the stock assessment process in the northern prawn fishery (NPF). Advances in the genomics world are rapid and already a cheaper, more reliable substitute for microsatellite loci in this technology is available. Digital data from single nucleotide polymorphisms (SNPs) are likely to super cede ‘analogue’ microsatellite data, making it cheaper and easier to apply the method to species with large population sizes.

Risk assessment of wandering behavior in mild dementia

Objective This prospective longitudinal study aims to determine the risk factors of wandering-related adverse consequences in community-dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior. Methods We recruited 143 dyads of persons with mild dementia and their caregivers from a veteran's hospital and memory clinic in Florida. Wandering-related adverse consequences were measured using the Revised Algase Wandering Scale – Community Version. Variables such as personality (Big Five Inventory), behavioral response to stress, gait, and balance (Tinetti Gait and Balance), wayfinding ability (Wayfinding Effectiveness Scale), and neurocognitive abilities (attention, cognition, memory, language/verbal skills, and executive functioning) were also measured. Bivariate and logistic regression analyses were performed to assess the predictors of these wandering-related adverse consequences. Results A total of 49% of the study participants had falls, fractures, and injuries due to wandering behavior, and 43.7% demonstrated eloping behaviors. Persistent walking (OR = 2.6) and poor gait (OR = 0.9) were significant predictors of negative outcomes of wandering, while persistent walking (OR = 13.2) and passivity (OR = 2.55) predicted eloping behavior. However, there were no correlations between wandering-related adverse consequences and participants' characteristics (age, gender, race, ethnicity, and education), health status (Charlson comorbidity index), or neurocognitive abilities. Conclusion Our results highlight the importance of identifying at-risk individuals so that effective interventions can be developed to reduce or prevent the adverse consequences of wandering.

Depression and its assessment among stroke patients and their caregivers

Approximately one-third of stroke patients experience depression. Stroke also has a profound effect on the lives of caregivers of stroke survivors. However, depression in this latter population has received little attention. In this study the objectives were to determine which factors are associated with and can be used to predict depression at different points in time after stroke; to compare different depression assessment methods among stroke patients; and to determine the prevalence, course and associated factors of depression among the caregivers of stroke patients. A total of 100 consecutive hospital-admitted patients no older than 70 years of age were followed for 18 months after having their first ischaemic stroke. Depression was assessed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), Beck Depression Inventory (BDI), Hamilton Rating Scale (HRSD), Visual Analogue Mood Scale (VAMS), Clinical Global Impression (CGI) and caregiver ratings. Neurological assessments and a comprehensive neuropsychological test battery were performed. Depression in caregivers was assessed by BDI. Depressive symptoms had early onsets in most cases. Mild depressive symptoms were often persistent with little change during the 18-month follow-up, although there was an increase in major depression over the same time interval. Stroke severity was associated with depression especially from 6 to 12 months post-stroke. At the acute phase, older patients were at higher risk of depression, and a higher proportion of men were depressed at 18 months post-stroke. Of the various depression assessment methods, none stood clearly apart from the others. The feasibility of each did not differ greatly, but prevalence rates differed widely according to the different criteria. When compared against DSM-III-R criteria, sensitivity and specificity were acceptable for the CGI, BDI, and HRSD. The CGI and BDI had better sensitivity than the more specific HRSD. The VAMS seemed not to be a reliable method for assessing depression among stroke patients. The caregivers often rated patients depression as more severe than did the patients themselves. Moreover, their ratings seemed to be influenced by their own depression. Of the caregivers, 30-33% were depressed. At the acute phase, caregiver depression was associated with the severity of the stroke and the older age of the patient. The best predictor of caregiver depression at later follow-up was caregiver depression at the acute phase. The results suggest that depression should be assessed during the early post-stroke period and that the follow-up of those at risk of poor emotional outcome should be extended beyond the first year post-stroke. Further, the assessment of well-being of the caregivers of stroke patients should be included as a part of a rehabilitation plan for stroke patients.

High resolution satellite imagery and GPS collars can help assist in the assessment of patch selection by grazing cattle in semi-arid savannas.

The selection of different patch types for grazing by cattle in tropical savannas is well documented. Advances in high resolution satellite imagery and computing power now allow us to identify patch types over an entire paddock, combined with GPS collars as a non instrusive method of capturing positional data, an accurate and comprehensive picture of landscape use by cattle can be quantified.

Variability in exposure to ambient ultrafine particles in urban schools: Comparative assessment between Australia and Spain

Ambient ultrafine particle number concentrations (PNC) have inhomogeneous spatio-temporal distributions and depend on a number of different urban factors, including background conditions and distant sources. This paper quantitatively compares exposure to ambient ultrafine particles at urban schools in two cities in developed countries, with high insolation climatic conditions, namely Brisbane (Australia) and Barcelona (Spain). The analysis used comprehensive indoor and outdoor air quality measurements at 25 schools in Brisbane and 39 schools in Barcelona. PNC modes were analysed with respect to ambient temperature, land use and urban characteristics, combined with the measured elemental carbon concentrations, NOx (Brisbane) and NO2 (Barcelona). The trends and modes of the quantified weekday average daily cycles of ambient PNC exhibited significant differences between the two cities. PNC increases were observed during traffic rush hours in both cases. However, the mid-day peak was dominant in Brisbane schools and had the highest contribution to total PNC for both indoors and outdoors. In Barcelona, the contribution from traffic was highest for ambient PNC, while the mid-day peak had a slightly higher contribution for indoor concentrations. Analysis of the relationships between PNC and land use characteristics in Barcelona schools showed a moderate correlation with the percentage of road network area and an anti-correlation with the percentage of green area. No statistically significant correlations were found for Brisbane. Overall, despite many similarities between the two cities, school-based exposure patterns were different. The main source of ambient PNC at schools was shown to be traffic in Barcelona and mid-day new particle formation in Brisbane. The mid-day PNC peak in Brisbane could have been driven by the combined effect of background and meteorological conditions, as well as other local/distant sources. The results have implications for urban development, especially in terms of air quality mitigation and management at schools.

A systematic review of instruments for assessment of capacity in activities of daily living in children with developmental co-ordination disorder

Children with developmental co-ordination disorder (DCD) face evident motor difficulties in activities of daily living (ADL). Assessment of their capacity in ADL is essential for diagnosis and intervention, in order to limit the daily consequences of the disorder. The aim of this study is to systematically review potential instruments for standardized and objective assessment of children's capacity in ADL, suited for children with DCD. As a first step, databases of MEDLINE, EMBASE, CINAHL and PsycINFO were searched to identify studies that described instruments with potential for assessment of capacity in ADL. Second, instruments were included for review when two independent reviewers agreed that the instruments: (1) are standardized and objective; (2) assess at activity level and comprise items that reflect ADL, and; (3) are applicable to school-aged children that can move independently. Out of 1507 publications, 66 publications were selected, describing 39 instruments. Seven of these instruments were found to fulfil the criteria and were included for review: the Bruininks-Oseretsky Test of Motor Performance-2 (BOT2); the Do-Eat (Do-Eat); the Movement Assessment Battery for Children-2 (MABC2); the school-Assessment of Motor and Process Skills (schoolAMPS); the Tuffts Assessment of Motor Performance (TAMP); the Test of Gross Motor Development (TGMD); and the Functional Independence Measure for Children (WeeFIM). As a third step, for the included instruments, suitability for children with DCD was discussed based on the ADL comprised, ecological validity and other psychometric properties. We concluded that current instruments do not provide comprehensive and ecologically valid assessment of capacity in ADL as required for children with DCD.

Iäkkäiden lääkehoitoihin liittyvien riskien kartoittaminen – Arviointityökalun kehittäminen Delfoi-menetelmällä

Tutkimuksen taustalla on väestön ikääntyminen ja iäkkäiden lisääntynyt lääkkeiden käyttö. Ikääntyminen aiheuttaa elimistössä useita muutoksia, jotka voivat muuttaa lääkevastetta ja altistaa potilaan haittavaikutuksille. Iäkkäillä riski joutua sairaalaan lääkkeen haittavaikutuksen vuoksi on arvioitu olevan neljä kertaa suurempi kuin nuoremmilla. Monet lääkkeiden yhteis- ja haittavaikutukset olisivat ehkäistävissä välttämällä iäkkäillä tiettyjä lääkeaineita. Iäkkäiden lääkehoitojen seurantaa ja arviointia varten on kehitetty erilaisia suosituksia sekä Suomessa että kansainvälisesti. Tutkimuksen tavoitteena oli luoda Suomen oloihin soveltuva, hoitajien koulutettuina käytettävissä oleva, avohoidon yli 65-vuotiaiden iäkkäiden lääkitykseen liittyviä riskejä arvioiva työkalu. Työkalun avulla voitaisiin löytää ne potilaat, joiden lääkitykseen liittyy paljon riskejä. Tutkimuksen aineistona olivat laaja kansainvälinen kirjallisuuskatsaus iäkkäiden lääkehoitoihin liittyvistä tekijöistä sekä asiantuntijakommentoinnit, joiden perusteella luotiin alustava arviointityökalu. Alustava arviointityökalu validoitiin kolmikierroksisella Delfoi-menetelmällä. Delfoi-menetelmä on laadullinen konsensusmenetelmä, joka perustuu asiantuntijoiden arvioihin tutkittavasta asiasta. Kaksi ensimmäistä Delfoi-kierrosta mittasivat alustavan arviointityökalun kohtien soveltuvuutta ja kolmas kierros kohtien tärkeyttä arvioitaessa iäkkään lääkityksiin liittyviä riskejä. Tutkimuksen Delfoi-kierroksien vastaajiksi pyydettiin 33 geriatrian asiantuntijaa, joista vastaajiksi lupautui 11 lääkäriä, 3 proviisoria ja 4 sairaanhoitajaa. Delfoi-kierrosten tuloksia analysoitiin sekä kvantitatiivisesti että kvalitatiivisesti. Tutkimuksen tuloksena saatu arviointityökalu käsittää 19 iäkkäiden lääkehoitoa arvioivaa kohtaa. Asiantuntijapaneelin mukaan kaikki arviointityökalun lääkitykseen liittyviä riskejä mittaavat kohdat ovat tärkeitä tai jokseenkin tärkeitä, joten työkalun voidaan olettaa olevan validi mitattaessa lääkitykseen liittyviä riskejä. Jatkotutkimuksissa työkalun käytettävyyttä sekä riskien mittaamiskykyä tulee testata sekä arviointityökalun käyttäjien että potilaiden keskuudessa. Kehitettyä työkalua voidaan jatkossa hyödyntää esimerkiksi koulutustarkoituksissa sen varsinaisen käyttötarkoituksen lisäksi. Työkalun avulla iäkkäiden lääkehoitoa voidaan tulevaisuudessa toteuttaa entistä turvallisemmin ja tarkoituksenmukaisemmin.

Local systems, global impacts : Using life cycle assessment to analyse the potential and constraints of industrial symbioses

Human activities extract and displace different substances and materials from the earth s crust, thus causing various environmental problems, such as climate change, acidification and eutrophication. As problems have become more complicated, more holistic measures that consider the origins and sources of pollutants have been called for. Industrial ecology is a field of science that forms a comprehensive framework for studying the interactions between the modern technological society and the environment. Industrial ecology considers humans and their technologies to be part of the natural environment, not separate from it. Industrial operations form natural systems that must also function as such within the constraints set by the biosphere. Industrial symbiosis (IS) is a central concept of industrial ecology. Industrial symbiosis studies look at the physical flows of materials and energy in local industrial systems. In an ideal IS, waste material and energy are exchanged by the actors of the system, thereby reducing the consumption of virgin material and energy inputs and the generation of waste and emissions. Companies are seen as part of the chains of suppliers and consumers that resemble those of natural ecosystems. The aim of this study was to analyse the environmental performance of an industrial symbiosis based on pulp and paper production, taking into account life cycle impacts as well. Life Cycle Assessment (LCA) is a tool for quantitatively and systematically evaluating the environmental aspects of a product, technology or service throughout its whole life cycle. Moreover, the Natural Step Sustainability Principles formed a conceptual framework for assessing the environmental performance of the case study symbiosis (Paper I). The environmental performance of the case study symbiosis was compared to four counterfactual reference scenarios in which the actors of the symbiosis operated on their own. The research methods used were process-based life cycle assessment (LCA) (Papers II and III) and hybrid LCA, which combines both process and input-output LCA (Paper IV). The results showed that the environmental impacts caused by the extraction and processing of the materials and the energy used by the symbiosis were considerable. If only the direct emissions and resource use of the symbiosis had been considered, less than half of the total environmental impacts of the system would have been taken into account. When the results were compared with the counterfactual reference scenarios, the net environmental impacts of the symbiosis were smaller than those of the reference scenarios. The reduction in environmental impacts was mainly due to changes in the way energy was produced. However, the results are sensitive to the way the reference scenarios are defined. LCA is a useful tool for assessing the overall environmental performance of industrial symbioses. It is recommended that in addition to the direct effects, the upstream impacts should be taken into account as well when assessing the environmental performance of industrial symbioses. Industrial symbiosis should be seen as part of the process of improving the environmental performance of a system. In some cases, it may be more efficient, from an environmental point of view, to focus on supply chain management instead.