Sustainable urban systems: Co-design and framing for transformation.

Rapid urbanisation generates risks and opportunities for sustainable development. Urban policy and decision makers are challenged by the complexity of cities as social-ecological-technical systems. Consequently there is an increasing need for collaborative knowledge development that supports a whole-of-system view, and transformational change at multiple scales. Such holistic urban approaches are rare in practice. A co-design process involving researchers, practitioners and other stakeholders, has progressed such an approach in the Australian context, aiming to also contribute to international knowledge development and sharing. This process has generated three outputs: (1) a shared framework to support more systematic knowledge development and use, (2) identification of barriers that create a gap between stated urban goals and actual practice, and (3) identification of strategic focal areas to address this gap. Developing integrated strategies at broader urban scales is seen as the most pressing need. The knowledge framework adopts a systems perspective that incorporates the many urban trade-offs and synergies revealed by a systems view. Broader implications are drawn for policy and decision makers, for researchers and for a shared forward agenda.

Incorporating ecological and evolutionary processes into continental-scale conservation planning.

Systematic conservation planning research has focused on designing systems of conservation areas that efficiently protect a comprehensive and representative set of species and habitats. Recently, there has been an emphasis on improving the adequacy of conservation area design to promote the persistence and future generation of biodiversity. Few studies have explored incorporating ecological and evolutionary processes into conservation planning assessments. Biodiversity in Australia is maintained and generated by numerous ecological and evolutionary processes at various spatial and temporal scales. We accommodated ecological and evolutionary processes in four ways: (1) using sub-catchments as planning units to facilitate the protection of the integrity and function of ecosystem processes occurring on a sub-catchment scale; (2) targeting one type of ecological refugia, drought refugia, which are critical for the persistence of many species during widespread drought; (3) targeting one type of evolutionary refugia which are important for maintaining and generating unique biota during long-term climatic changes; and (4) preferentially grouping priority areas along vegetated waterways to account for the importance of connected waterways and associated riparian areas in maintaining processes. We identified drought refugia, areas of relatively high and regular herbage production in arid and semiarid Australia, from estimates of gross primary productivity derived from satellite data. In this paper, we combined the novel incorporation of these processes with a more traditional framework of efficiently representing a comprehensive sample of biodiversity to identify spatial priorities across Australia. We explored the trade-offs between economic costs, representation targets, and connectivity. Priority areas that considered ecological and evolutionary processes were more connected along vegetated waterways and were identified for a small increase in economic cost. Priority areas for conservation investment are more likely to have long-term benefits to biodiversity if ecological and evolutionary processes are considered in their identification.

Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker.

OBJECTIVE: The purpose of this study was to compare the use of a double-lumen endotracheal tube to a single-lumen tube combined with a bronchial blocker for lung isolation during Port-Access cardiac surgery. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary care university hospital. PARTICIPANTS: Thirty-two patients undergoing Port-Access cardiac surgery via a right minithoracotomy. INTERVENTIONS: Patients were randomized to intubation with either a left-sided double-lumen tube (double-lumen group) or a single-lumen tube with concomitant use of a bronchial blocker (blocker group). Comparisons between groups included (1) intubation time, (2) number of laryngoscopy attempts, (3) time required for tube exchange at the end of the operation, and (4) surgical satisfaction with the lung deflation (1-5 scale: 5 = excellent). MEASUREMENTS AND MAIN RESULTS: The initial intubation time was similar between groups (118 +/- 82 seconds, double-lumen v 144 +/- 32 seconds, blocker; p = 0.2781). An additional 105 +/- 37 seconds was needed to exchange the double-lumen tube at the end of the operation. The double-lumen group also required more laryngoscopy attempts compared with the blocker group (2.3 +/- 0.6, double-lumen v 1.1 +/- 0.4, blocker; p = 0.0001). The lung deflation was better in the double-lumen group (5 [4-5], double-lumen v 4 [3-5], blocker, p = 0.0414). CONCLUSIONS: Compared with a single-lumen tube/bronchial blocker combination the double-lumen endotracheal tube required more laryngoscopy attempts and additional time to replace the tube at the end of the case but resulted in slightly better overall lung deflation.

Chronic kidney disease, mortality, and treatment strategies among patients with clinically significant coronary artery disease.

Cardiovascular disease is an important cause of mortality among patients with chronic kidney disease (CKD). This study describes associations between CKD, cardiac revascularization strategies, and mortality among patients with CKD and cardiovascular disease. All patients undergoing cardiac catheterization at Duke University Medical Center (1995 to 2000) with documented stenosis > or =75% of at least one coronary artery and available creatinine data were included. CKD was staged using creatinine clearance (CrCl) derived from the Cockcroft-Gault formula (normal, > or = 90 ml/min; mild, 60 to 89 ml/min; moderate, 30 to 59 ml/min; severe, 15 to 29 ml/min). Cox proportional-hazard regression estimated the relationship between clinical variables, including CrCl and percutaneous coronary artery intervention (PCI), coronary artery bypass grafting (CABG), medical management, and patient survival. There were 4584 patients included, and 24% had CrCl <60 ml/min. Each 10-ml/min decrement in CrCl was associated with an increase in mortality (hazard ratio, 1.14; P < 0.0001). CABG was associated with a survival benefit among patients with both normal renal function and patients with CKD compared with medical management. In patients with normal renal function, CABG was not associated with survival benefit over PCI. However, in patients with CKD, CABG was associated with improved survival. PCI was associated with a survival benefit compared with medical management among patients with normal, mildly, and moderately impaired renal function. Among patients with severe CKD, PCI was not associated with improved survival. CABG is associated with greater mortality reduction than PCI in severe CKD.

Risk of anaphylaxis from aprotinin re-exposure during LVAD removal and heart transplantation.

Aprotinin has been shown to reduce transfusion requirements in re-operative cardiac surgery and in implantation of long-term left ventricular assist devices (LVAD). However, it is an antigenic polypeptide and re-exposure is associated with a small incidence of anaphylaxis. This report describes 2 cases of anaphylactic response to aprotinin when the agent was employed for both the LVAD implant and for the subsequent explant and cardiac transplant. Early re-exposure to just the test dose was associated with a significant incidence of anaphylaxis.