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Integrated cross-sectoral impact assessments facilitate a comprehensive understanding of interdependencies and potential synergies, conflicts, and trade-offs between sectors under changing conditions. This paper presents a sensitivity analysis of a European integrated assessment model, the CLIMSAVE integrated assessment platform (IAP). The IAP incorporates important cross-sectoral linkages between six key European land- and water-based sectors: agriculture, biodiversity, flooding, forests, urban, and water. Using the IAP, we investigate the direct and indirect implications of a wide range of climatic and socio-economic drivers to identify: (1) those sectors and regions most sensitive to future changes, (2) the mechanisms and directions of sensitivity (direct/indirect and positive/negative), (3) the form and magnitudes of sensitivity (linear/non-linear and strong/weak/insignificant), and (4) the relative importance of the key drivers across sectors and regions. The results are complex. Most sectors are either directly or indirectly sensitive to a large number of drivers (more than 18 out of 24 drivers considered). Over twelve of these drivers have indirect impacts on biodiversity, forests, land use diversity, and water, while only four drivers have indirect effects on flooding. In contrast, for the urban sector all the drivers are direct. Moreover, most of the driver-indicator relationships are non-linear, and hence there is the potential for 'surprises'. This highlights the importance of considering cross-sectoral interactions in future impact assessments. Such systematic analysis provides improved information for decision-makers to formulate appropriate adaptation policies to maximise benefits and minimise unintended consequences. [ABSTRACT FROM AUTHOR]

Background: Postoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems., Objective: To identify independent variables associated with the occurrence of postoperative pneumonia., Design: A prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database)., Setting: Sixty-three hospitals in Europe., Patients: Patients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period., Main Outcome Measure: The primary outcome was postoperative pneumonia., Definition: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 μl., Results: Postoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P < 0.001). We identified five variables independently associated with postoperative pneumonia: functional status [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.58 to 3.12], pre-operative SpO2 values while breathing room air (OR 0.83, 95% CI 0.78 to 0.84), intra-operative colloid administration (OR 2.97, 95% CI 1.94 to 3.99), intra-operative blood transfusion (OR 2.19, 95% CI 1.41 to 4.71) and surgical site (open upper abdominal surgery OR 3.98, 95% CI 2.19 to 7.59). The model had good discrimination (c-statistic 0.89) and calibration (Hosmer-Lemeshow P = 0.572)., Conclusion: We identified five variables independently associated with postoperative pneumonia. The model performed well and after external validation may be used for risk stratification and management of patients at risk of postoperative pneumonia., Trial Registration: NCT 01346709 (ClinicalTrials.gov).

Background: Postoperative respiratory failure (PRF) is the most frequent respiratory complication following surgery., Objective: The objective of this study was to build a clinically useful predictive model for the development of PRF., Design: A prospective observational study of a multicentre cohort., Setting: Sixty-three hospitals across Europe., Patients: Patients undergoing any surgical procedure under general or regional anaesthesia during 7-day recruitment periods., Main Outcome Measures: Development of PRF within 5 days of surgery. PRF was defined by a partial pressure of oxygen in arterial blood (PaO2) less than 8 kPa or new onset oxyhaemoglobin saturation measured by pulse oximetry (SpO2) less than 90% whilst breathing room air that required conventional oxygen therapy, noninvasive or invasive mechanical ventilation., Results: PRF developed in 224 patients (4.2% of the 5384 patients studied). In-hospital mortality [95% confidence interval (95% CI)] was higher in patients who developed PRF [10.3% (6.3 to 14.3) vs. 0.4% (0.2 to 0.6)]. Regression modelling identified a predictive PRF score that includes seven independent risk factors: low preoperative SpO2; at least one preoperative respiratory symptom; preoperative chronic liver disease; history of congestive heart failure; open intrathoracic or upper abdominal surgery; surgical procedure lasting at least 2 h; and emergency surgery. The area under the receiver operating characteristic curve (c-statistic) was 0.82 (95% CI 0.79 to 0.85) and the Hosmer-Lemeshow goodness-of-fit statistic was 7.08 (P = 0.253)., Conclusion: A risk score based on seven objective, easily assessed factors was able to predict which patients would develop PRF. The score could potentially facilitate preoperative risk assessment and management and provide a basis for testing interventions to improve outcomes.The study was registered at ClinicalTrials.gov (identifier NCT01346709).

Global change will alter the supply of ecosystem services that are vital for human well-being. To investigate ecosystem service supply during the 21st century, we used a range of ecosystem models and scenarios of climate and land-use change to conduct a Europe-wide assessment. Large changes in climate and land use typically resulted in large changes in ecosystem service supply. Some of these trends may be positive (for example, increases in forest area and productivity) or offer opportunities (for example, "surplus land" for agricultural extensification and bioenergy production). However, many changes increase vulnerability as a result of a decreasing supply of ecosystem services (for example, declining soil fertility, declining water availability, increasing risk of forest fires), especially in the Mediterranean and mountain regions.