Promoting palliative care in the community: production of the primary palliative care toolkit by the European Association of Palliative Care Taskforce in primary palliative care

BACKGROUND A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. AIM To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. DESIGN (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. RESULTS Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. CONCLUSION Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

High-Frequency in Situ Optical Measurements During a Storm Event: Assessing Relationships Between Dissolved Organic Matter, Sediment Concentrations, and Hydrologic Processes

Dissolved organic matter (DOM) dynamics during storm events has received considerable attention in forested watersheds, but the extent to which storms impart rapid changes in DOM concentration and composition in highly disturbed agricultural watersheds remains poorly understood. In this study, we used identical in situ optical sensors for DOM fluorescence (FDOM) with and without filtration to continuously evaluate surface water DOM dynamics in a 415 km(2) agricultural watershed over a 4 week period containing a short-duration rainfall event. Peak turbidity preceded peak discharge by 4 h and increased by over 2 orders of magnitude, while the peak filtered FDOM lagged behind peak turbidity by 15 h. FDOM values reported using the filtered in situ fluorometer increased nearly fourfold and were highly correlated with dissolved organic carbon (DOC) concentrations (r(2) = 0.97), providing a highly resolved proxy for DOC throughout the study period. Discrete optical properties including specific UV absorbance (SUVA(254)), spectral slope (S(290-350)), and fluorescence index (FI) were also strongly correlated with in situ FDOM and indicate a shift toward aromatic, high molecular weight DOM from terrestrially derived sources during the storm. The lag of the peak in FDOM behind peak discharge presumably reflects the draining of watershed soils from natural and agricultural landscapes. Field and experimental evidence showed that unfiltered FDOM measurements underestimated filtered FDOM concentrations by up to similar to 60% at particle concentrations typical of many riverine systems during hydrologic events. Together, laboratory and in situ data provide insights into the timing and magnitude of changes in DOM quantity and quality during storm events in an agricultural watershed, and indicate the need for sample filtration in systems with moderate to high suspended sediment loads.

Balancing groundwater conservation and rural livelihoods under water and climate uncertainties: An integrated hydro-economic modeling framework

In arid countries worldwide, social conflicts between irrigation-based human development and the conservation of aquatic ecosystems are widespread and attract many public debates. This research focuses on the analysis of water and agricultural policies aimed at conserving groundwater resources and maintaining rurallivelihoods in a basin in Spain's central arid region. Intensive groundwater mining for irrigation has caused overexploitation of the basin's large aquifer, the degradation of reputed wetlands and has given rise to notable social conflicts over the years. With the aim of tackling the multifaceted socio-ecological interactions of complex water systems, the methodology used in this study consists in a novel integration into a common platform of an economic optimization model and a hydrology model WEAP (Water Evaluation And Planning system). This robust tool is used to analyze the spatial and temporal effects of different water and agricultural policies under different climate scenarios. It permits the prediction of different climate and policy outcomes across farm types (water stress impacts and adaptation), at basin's level (aquifer recovery), and along the policies’ implementation horizon (short and long run). Results show that the region's current quota-based water policies may contribute to reduce water consumption in the farms but will not be able to recover the aquifer and will inflict income losses to the rural communities. This situation would worsen in case of drought. Economies of scale and technology are evidenced as larger farms with cropping diversification and those equipped with modern irrigation will better adapt to water stress conditions. However, the long-term sustainability of the aquifer and the maintenance of rurallivelihoods will be attained only if additional policy measures are put in place such as the control of illegal abstractions and the establishing of a water bank. Within the policy domain, the research contributes to the new sustainable development strategy of the EU by concluding that, in water-scarce regions, effective integration of water and agricultural policies is essential for achieving the water protection objectives of the EU policies. Therefore, the design and enforcement of well-balanced region-specific polices is a major task faced by policy makers for achieving successful water management that will ensure nature protection and human development at tolerable social costs. From a methodological perspective, this research initiative contributes to better address hydrological questions as well as economic and social issues in complex water and human systems. Its integrated vision provides a valuable illustration to inform water policy and management decisions within contexts of water-related conflicts worldwide.

Water scarcity and climate change impact and vulnerability in irrigated agriculture in Mediterranean river basins

Actualmente, la escasez de agua constituye un importante problema en muchos lugares del mundo. El crecimiento de la población, la creciente necesidad de alimentos, el desarrollo socio-económico y el cambio climático ejercen una importante y cada vez mayor presión sobre los recursos hídricos, a la que muchos países van a tener que enfrentarse en los próximos anos. La región Mediterránea es una de las regiones del mundo de mayor escasez de recursos hídricos, y es además una de las zonas más vulnerables al cambio climático. La mayoría de estudios sobre cambio climático prevén mayores temperaturas y una disminución de las precipitaciones, y una creciente escasez de agua debida a la disminución de recursos disponibles y al aumento de las demandas de riego. En el contexto actual de desarrollo de políticas se demanda cada vez más una mayor consideración del cambio climático en el marco de las políticas sectoriales. Sin embargo, los estudios enfocados a un solo sector no reflejan las múltiples dimensiones del los efectos del cambio climático. Numerosos estudios científicos han demostrado que el cambio climático es un fenómeno de naturaleza multi-dimensional y cuyos efectos se transmiten a múltiples escalas. Por tanto, es necesaria la producción de estudios y herramientas de análisis capaces de reflejar todas estas dimensiones y que contribuyan a la elaboración de políticas robustas en un contexto de cambio climático. Esta investigación pretende aportar una visión global de la problemática de la escasez de agua y los impactos, la vulnerabilidad y la adaptación al cambio climático en el contexto de la región mediterránea. La investigación presenta un marco integrado de modelización que se va ampliando progresivamente en un proceso secuencial y multi-escalar en el que en cada etapa se incorpora una nueva dimensión. La investigación consta de cuatro etapas que se abordan a lo largo de cuatro capítulos. En primer lugar, se estudia la vulnerabilidad económica de las explotaciones de regadío del Medio Guadiana, en España. Para ello, se utiliza un modelo de programación matemática en combinación con un modelo econométrico. A continuación, en la segunda etapa, se utiliza un modelo hidro-económico que incluye un modelo de cultivo para analizar los procesos que tienen lugar a escala de cultivo, explotación y cuenca teniendo en cuenta distintas escalas geográficas y de toma de decisiones. Esta herramienta permite el análisis de escenarios de cambio climático y la evaluación de posibles medidas de adaptación. La tercera fase consiste en el análisis de las barreras que dificultan la aplicación de procesos de adaptación para lo cual se analizan las redes socio-institucionales en la cuenca. Finalmente, la cuarta etapa aporta una visión sobre la escasez de agua y el cambio climático a escala nacional y regional mediante el estudio de distintos escenarios de futuro plausibles y los posibles efectos de las políticas en la escasez de agua. Para este análisis se utiliza un modelo econométrico de datos de panel para la región mediterránea y un modelo hidro-económico que se aplica a los casos de estudio de España y Jordania. Los resultados del estudio ponen de relieve la importancia de considerar múltiples escalas y múltiples dimensiones en el estudio de la gestión de los recursos hídricos y la adaptación al cambio climático en los contextos mediterráneos de escasez de agua estudiados. Los resultados muestran que los impactos del cambio climático en la cuenca del Guadiana y en el conjunto de España pueden comprometer la sostenibilidad del regadío y de los ecosistemas. El análisis a escala de cuenca hidrográfica resalta la importancia de las interacciones entre los distintos usuarios del agua y en concreto entre distintas comunidades de regantes, así como la necesidad de fortalecer el papel de las instituciones y de fomentar la creación de una visión común en la cuenca para facilitar la aplicación de los procesos de adaptación. Asimismo, los resultados de este trabajo evidencian también la capacidad y el papel fundamental de las políticas para lograr un desarrollo sostenible y la adaptación al cambio climático es regiones de escasez de agua tales como la región mediterránea. Especialmente, este trabajo pone de manifiesto el potencial de la Directiva Marco del Agua de la Unión Europea para lograr una efectiva adaptación al cambio climático. Sin embargo, en Jordania, además de la adaptación al cambio climático, es preciso diseñar estrategias de desarrollo sostenible más ambiciosas que contribuyan a reducir el riesgo futuro de escasez de agua. ABSTRACT Water scarcity is becoming a major concern in many parts of the world. Population growth, increasing needs for food production, socio-economic development and climate change represent pressures on water resources that many countries around the world will have to deal in the coming years. The Mediterranean region is one of the most water scarce regions of the world and is considered a climate change hotspot. Most projections of climate change envisage an increase in temperatures and a decrease in precipitation and a resulting reduction in water resources availability as a consequence of both reduced water availability and increased irrigation demands. Current policy development processes require the integration of climate change concerns into sectoral policies. However, sector-oriented studies often fail to address all the dimensions of climate change implications. Climate change research in the last years has evidenced the need for more integrated studies and methodologies that are capable of addressing the multi-scale and multi-dimensional nature of climate change. This research attempts to provide a comprehensive view of water scarcity and climate change impacts, vulnerability and adaptation in Mediterranean contexts. It presents an integrated modelling framework that is progressively enlarged in a sequential multi-scale process in which a new dimension of climate change and water resources is addressed at every stage. It is comprised of four stages, each one explained in a different chapter. The first stage explores farm-level economic vulnerability in the Spanish Guadiana basin using a mathematical programming model in combination with an econometric model. Then, in a second stage, the use of a hydro-economic modelling framework that includes a crop growth model allows for the analysis of crop, farm and basin level processes taking into account different geographical and decision-making scales. This integrated tool is used for the analysis of climate change scenarios and for the assessment of potential adaptation options. The third stage includes the analysis of barriers to the effective implementation of adaptation processes based on socioinstitutional network analysis. Finally, a regional and country level perspective of water scarcity and climate change is provided focusing on different possible socio-economic development pathways and the effect of policies on future water scarcity. For this analysis, a panel-data econometric model and a hydro-economic model are applied for the analysis of the Mediterranean region and country level case studies in Spain and Jordan. The overall results of the study demonstrate the value of considering multiple scales and multiple dimensions in water management and climate change adaptation in the Mediterranean water scarce contexts analysed. Results show that climate change impacts in the Guadiana basin and in Spain may compromise the sustainability of irrigation systems and ecosystems. The analysis at the basin level highlights the prominent role of interactions between different water users and irrigation districts and the need to strengthen institutional capacity and common understanding in the basin to enhance the implementation of adaptation processes. The results of this research also illustrate the relevance of water policies in achieving sustainable development and climate change adaptation in water scarce areas such as the Mediterranean region. Specifically, the EU Water Framework Directive emerges as a powerful trigger for climate change adaptation. However, in Jordan, outreaching sustainable development strategies are required in addition to climate change adaptation to reduce future risk of water scarcity.

Analyzing climate change adaptation in the agriculture and water sectors: screening risks and opportunities.

As part of the Mediterranean area, the Guadiana basin in Spain is particularly exposed to increasing water stress due to climate change. Future warmer and drier climate will have negative implications for the sustainability of water resources and irrigation agriculture, the main socio- economic sector in the region. This paper illustrates a systematic analysis of climate change impacts and adaptation in the Guadiana basin based on a two-stage modeling approach. First, an integrated hydro-economic modeling framework was used to simulate the potential effects of regional climate change scenarios for the period 2000-2069. Second, a participatory multi-criteria technique, namely the Analytic Hierarchy Process (AHP), was applied to rank potential adaptation measures based on agreed criteria. Results show that, in the middle-long run and under severe climate change, reduced water availability, lower crop yields and increased irrigation demands might lead to water shortages, crop failure, and up to ten percent of income losses to irrigators. AHP results show how private farming adaptation measures, including improving irrigation efficiency and adjusting crop varieties, are preferred to public adaptation measures, such as building new dams. The integrated quantitative and qualitative methodology used in this research can be considered a socially-based valuable tool to support adaptation decision-making.

Analyzing adaptation to climate change in the water and the agricultural sectors in the Spanish Guadiana basin.

1. Introduction: setting and problem definition 2. The Adaptation Pathway –2.1 Stage 1: appraising risks and opportunities •Step 1: Impact analysis •Step 2: Policy analysis •Step 3: Socio-institutional analysis –2.2 Stage 2: appraising and choosing adaptation opt ions •Step 4: identifying and prioritizing adaptation o ptions 3. Conclusions

How can irrigated agriculture adapt to climate change? Insights from the Guadiana Basin in Spain

Climate change is already affecting many natural systems and human environments worldwide, like the semiarid Guadiana Basin in Spain. This paper illustrates a systematic analysis of climate change adaptation in the Guadiana irrigation farming region. The study applies a solution-oriented diagnostic framework structured along a series of sequential analytical steps. An initial stage integrates economic and hydrologic modeling to evaluate the effects of climate change on the agriculture and water sectors. Next, adaptation measures are identified and prioritized through a stakeholder-based multi-criteria analysis. Finally, a social network analysis identifies key actors and their relationships in climate change adaptation. The study shows that under a severe climate change scenario, water availability could be substantially decreased and drought occurrence will augment. In consequence, farmers will adapt their crops to a lesser amount of water and income gains will diminish, particularly for smallholder farms. Among the various adaptation measures considered, those related to private farming (new crop varieties and modern irrigation technologies) are ranked highest, whereas public-funded hard measures (reservoirs) are lowest and public soft measures (insurance) are ranked middle. In addition, stakeholders highlighted that the most relevant criteria for selecting adaptation plans are environmental protection, financial feasibility and employment creation. Nonetheless, the social network analysis evidenced the need to strengthen the links among the different stakeholder groups to facilitate the implementation of adaptation processes. In sum, the diagnostic framework applied in this research can be considered a valuable tool for guiding and supporting decision making in climate change adaptation and communicating scientific results.

AS MARCAS E O CONSUMIDOR: Um estudo dos discursos da publicidade na perspectiva da modificação dos estereótipos na representação da família.The

Os papeis de homens e mulheres na sociedade contemporânea têm sido reestruturados, assim como a própria noção das estruturas familiares se renova. Algumas marcas estão atentas a essas mudanças e, no contexto mercadológico, fica evidente que os consumidores são diversos, com novas demandas e expectativas pelo reconhecimento dessa diversidade. Esta dissertação discute a mudança de abordagem na representação da família, demonstrando suas mutações de papeis na publicidade, esta vista como um produto sociocultural. Para tanto foi desenvolvida uma pesquisa qualitativa subsidiada pela análise de discurso de linha francesa. Primeiramente, o estudo qualitativo se desenvolve a partir de uma abordagem bibliográfica e documental e uma parte empírica de análise de discurso de campanhas publicitárias dos últimos anos, selecionadas a partir de seu foco nas representações familiares contemporâneas, de marcas que as tratem com naturalidade e demonstrem aceitar essas transições, buscando-as através da análise de casos múltiplos de amostras intencionais os avanços quando se trata dos modelos familiares, elementos que se desviam de representação conservadora da família. Demonstrou-se que há uma tendência de algumas marcas reforçarem qual é o público que desejam atingir através de suas construções discursivas que apontam para o reconhecimento das famílias reconstituídas, para a adoção e para a homo e monoparentalidade, ou seja, para a confirmação da existência dos variados tipos de família.

Inhibition of the visual cycle in vivo by 13-cis retinoic acid protects from light damage and provides a mechanism for night blindness in isotretinoin therapy

Isotretinoin (13-cis retinoic acid) is frequently prescribed for severe acne [Peck, G. L., Olsen, T. G., Yoder, F. W., Strauss, J. S., Downing, D. T., Pandya, M., Butkus, D. & Arnaud-Battandier, J. (1979) N. Engl. J. Med. 300, 329–333] but can impair night vision [Fraunfelder, F. T., LaBraico, J. M. & Meyer, S. M. (1985) Am. J. Ophthalmol. 100, 534–537] shortly after the beginning of therapy [Shulman, S. R. (1989) Am. J. Public Health 79, 1565–1568]. As rod photoreceptors are responsible for night vision, we administered isotretinoin to rats to learn whether night blindness resulted from rod cell death or from rod functional impairment. High-dose isotretinoin was given daily for 2 months and produced systemic toxicity, but this caused no histological loss of rod photoreceptors, and rod-driven electroretinogram amplitudes were normal after prolonged dark adaptation. Additional studies showed, however, that even a single dose of isotretinoin slowed the recovery of rod signaling after exposure to an intense bleaching light, and that rhodopsin regeneration was markedly slowed. When only a single dose was given, rod function recovered to normal within several days. Rods and cones both showed slow recovery from bleach after isotretinoin in rats and in mice. HPLC analysis of ocular retinoids after isotretinoin and an intense bleach showed decreased levels of rhodopsin chromophore, 11-cis retinal, and the accumulation of the biosynthetic intermediates, 11-cis and all-trans retinyl esters. Isotretinoin was also found to protect rat photoreceptors from light-induced damage, suggesting that strategies of altering retinoid cycling may have therapeutic implications for some forms of retinal and macular degeneration.

The binding conformation of Taxol in β-tubulin: A model based on electron crystallographic density

The chemotherapeutic drug Taxol is known to interact within a specific site on β-tubulin. Although the general location of the site has been defined by photoaffinity labeling and electron crystallography, the original data were insufficient to make an absolute determination of the bound conformation. We have now correlated the crystallographic density with analysis of Taxol conformations and have found the unique solution to be a T-shaped Taxol structure. This T-shaped or butterfly structure is optimized within the β-tubulin site and exhibits functional similarity to a portion of the B9-B10 loop in the α-tubulin subunit. The model provides structural rationalization for a sizeable body of Taxol structure–activity relationship data, including binding affinity, photoaffinity labeling, and acquired mutation in human cancer cells.

Surfactant protein a promotes attachment of Mycobacterium tuberculosis to alveolar macrophages during infection with human immunodeficiency virus.

The incidence of tuberculosis is increasing on a global scale, in part due to its strong association with human immunodeficiency virus (HIV) infection. Attachment of Mycobacterium tuberculosis to its host cell, the alveolar macrophage (AM), is an important early step in the pathogenesis of infection. Bronchoalveolar lavage of HIV-infected individuals demonstrated the presence of a factor which significantly enhances the attachment of tubercle bacilli to AMs 3-fold relative to a normal control population. This factor is surfactant protein A (SP-A). SP-A levels are increased in the lungs of HIV-infected individuals. SP-A levels and attachment of M. tuberculosis to AMs inversely correlate with peripheral blood CD4 lymphocyte counts. Elevated concentrations of SP-A during the progression of HIV infection may represent an important nonimmune risk factor for acquiring tuberculosis, even before significant depletion of CD4 lymphocytes in the peripheral blood occurs.

A constant radius of curvature model for the organization of DNA in toroidal condensates.

Toroidal DNA condensates have received considerable attention for their possible relationship to the packaging of DNA in viruses and in general as a model of ordered DNA condensation. A spool-like model has primarily been supported for DNA organization within toroids. However, our observations suggest that the actual organization may be considerably different. We present an alternate model in which DNA for a given toroid is organized within a series of equally sized contiguous loops that precess about the toroid axis. A related model for the toroid formation process is also presented. This kinetic model predicts a distribution of toroid sizes for DNA condensed from solution that is in good agreement with experimental data.

Europe, wake up! CEPS Commentary, 21 July 2014

Following the wanton downing of a civilian aircraft by Russian-backed separatists in Ukraine and Israel’s ground offensive in Gaza, Karel Lannoo takes the EU to task for reverting to its usual ostrich-like behaviour in the face of threats to the security and stability of the entire continent. With the entry into force of the Treaty of Lisbon, he argues that the European Union, as representative of its 28 member states, should be capable of acting far more forcefully in both of these conflicts than its individual member states, but regrettably the EU has so far remained on the sidelines.

Ukraine, Russia and the need for more flexibility in EU foreign policy-making. CEPS Policy Brief No. 320, 25 July 2014

After the illegal annexation of Crimea and Russia’s indirect responsibility for the downing of Malaysia Airlines flight MH17 in eastern Ukraine, Steven Blockmans asks what it will take before the EU is able to confront a conflict on its borders and prove to both its own citizens and third countries that it has a meaningful role to play in foreign policy. With numerous competing national interests and some member states unwilling to pay different prices for collective action, any sector-wide EU sanctions are likely to lack serious bite. In an effort to paper over the cracks, the author makes a number of recommendations for policy-makers.