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Increased concentrations of atmospheric greenhouse gases have led to a global mean surface temperature 1.0°C higher than during the pre-industrial period. We expand on the recent IPCC Special Report on global warming of 1.5°C and review the additional risks associated with higher levels of warming, each having major implications for multiple geographies, climates, and ecosystems. Limiting warming to 1.5°C rather than 2.0°C would be required to maintain substantial proportions of ecosystems and would have clear benefits for human health and economies. These conclusions are relevant for people everywhere, particularly in low- and middle-income countries, where the escalation of climate-related risks may prevent the achievement of the United Nations Sustainable Development Goals. Fil: Hoegh Guldberg, O.. University of Queensland; Australia Fil: Jacob, D.. Helmholtz-Zentrum Geesthacht; Alemania Fil: Taylor, M.. University Of The West Indies; Jamaica Fil: Guillén Bolaños, T.. Helmholtz-Zentrum Geesthacht; Alemania Fil: Bindi, M.. Università degli Studi di Firenze; Italia Fil: Brown, S.. University of Southampton; Reino Unido Fil: Camilloni, Ines Angela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Centro de Investigaciones del Mar y la Atmósfera. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Centro de Investigaciones del Mar y la Atmósfera; Argentina. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Centro de Investigaciones del Mar y la Atmósfera; Argentina Fil: Diedhiou, A.. Universite Grenoble Alpes; Francia. Centre National de la Recherche Scientifique; Francia Fil: Djalante, R.. United Nations University; Japón. Universitas Halu Oleo; Indonesia Fil: Ebi, K.. University of Washington; Estados Unidos Fil: Engelbrecht, F.. University of the Witwatersrand; Sudáfrica Fil: Guiot, J.. Aix Marseille Université; Francia Fil: Hijioka, Y.. National Institute for Environmental Studies; Japón Fil: Mehrotra, S.. No especifíca; Fil: Hope, C.W.. University of Cambridge; Estados Unidos Fil: Payne, A.J.. University Of Bristol; Reino Unido Fil: Pörtner, H.O.. Helmholtz Centre for Polar and Marine Research, Bremerhaven; Alemania Fil: Seneviratne, S.I.. Institute for Atmospheric and Climate Science; Suiza Fil: Thomas, A.. University Of The Bahamas; Bahamas Fil: Warren, R.. University of East Anglia; Reino Unido Fil: Zhou, G.. Chinese Academy Of Meteorological Sciences; China

Human SCGB1A1 protein has been shown to be significantly reduced in BAL, sputum, and serum from humans with asthma as compared with healthy individuals. However, the mechanism of this reduction and its functional impact have not been entirely elucidated. By mining online datasets, we found that the mRNA of SCGB1A1 was significantly repressed in brushed human airway epithelial cells from individuals with asthma, and this repression appeared to be associated with reduced expression of FOXA2. Consistently, both Scgb1A1 and FoxA2 were downregulated in an ovalbumin-induced mouse model of asthma. Furthermore, compared with wild-type mice, Scgb1a1 knockout mice had increased airway hyperreactivity and inflammation when they were exposed to ovalbumin, confirming the antiinflammatory role of Scgb1a1 in protection against asthma phenotypes. To search for potential asthma-related stimuli of SCGB1A1 repression, we tested T-helper cell type 2 cytokines. Both IL-4 and IL-13 repressed epithelial expression of SCGB1A1 and FOXA2. Importantly, infection of epithelial cells with human rhinovirus similarly reduced expression of these two genes, which suggests that FOXA2 may be the common regulator of SCGB1A1. To establish the causal role of reduced FOXA2 in SCGB1A1 repression, we demonstrated that FOXA2 was required for SCGB1A1 expression at baseline. FOXA2 overexpression was sufficient to drive promoter activity and expression of SCGB1A1 and was also able to restore the repressed SCGB1A1 expression in IL-13–treated or rhinovirus-infected cells. Taken together, these findings suggest that low levels of epithelial SCGB1A1 in asthma are caused by reduced FOXA2 expression.

We use the flexible model coupling technology known as the bespoke framework generator to link established existing modules representing dynamics in the global economy (GEMINI-E3), the energy system (TIAM-WORLD), the global and regional climate system (MAGICC6, PLASIM-ENTS and ClimGEN), the agricultural system, the hydrological system and ecosystems (LPJmL), together in a single integrated assessment modelling (IAM) framework, building on the pre-existing framework of the Community Integrated Assessment System. Next, we demonstrate the application of the framework to produce policy-relevant scientific information. We use it to show that when using carbon price mechanisms to induce a transition from a high-carbon to a low-carbon economy, prices can be minimised if policy action is taken early, if burden sharing regimes are used, and if agriculture is intensified. The approach has created long-lasting coupled models available for use in research for the future at a secure and user-friendly web portal.

ObjectiveTo compare the efficacy, effectiveness, and safety of the herpes zoster live attenuated vaccine with the herpes zoster adjuvant recombinant subunit vaccine or placebo for adults aged 50 and older.DesignSystematic review with bayesian meta-analysis and network meta-analysis.Data sourcesMedline, Embase, and Cochrane Library (inception to January 2017), grey literature, and reference lists of included studies.Eligibility criteria for study selectionExperimental, quasi-experimental, and observational studies that compared the live attenuated vaccine with the adjuvant recombinant subunit vaccine, placebo, or no vaccine in adults aged 50 and older. Relevant outcomes were incidence of herpes zoster (primary outcome), herpes zoster ophthalmicus, post-herpetic neuralgia, quality of life, adverse events, and death.Results27 studies (22 randomised controlled trials) including 2 044 504 patients, along with 18 companion reports, were included after screening 2037 titles and abstracts, followed by 175 full text articles. Network meta-analysis of five randomised controlled trials found no statistically significant differences between the live attenuated vaccine and placebo for incidence of laboratory confirmed herpes zoster. The adjuvant recombinant subunit vaccine, however, was statistically superior to both the live attenuated vaccine (vaccine efficacy 85%, 95% credible interval 31% to 98%) and placebo (94%, 79% to 98%). Network meta-analysis of 11 randomised controlled trials showed the adjuvant recombinant subunit vaccine to be associated with statistically more adverse events at injection sites than the live attenuated vaccine (relative risk 1.79, 95% credible interval 1.05 to 2.34; risk difference 30%, 95% credible interval 2% to 51%) and placebo (5.63, 3.57 to 7.29 and 53%, 30% to 73%, respectively). Network meta-analysis of nine randomised controlled trials showed the adjuvant recombinant subunit vaccine to be associated with statistically more systemic adverse events than placebo (2.28, 1.45 to 3.65 and 20%, 6% to 40%, respectively).ConclusionsUsing the adjuvant recombinant subunit vaccine might prevent more cases of herpes zoster than using the live attenuated vaccine, but the adjuvant recombinant subunit vaccine also carries a greater risk of adverse events at injection sites.Protocol registrationProspero CRD42017056389.

Advances in computing power and infrastructure, increases in the number and size of ecological and environmental datasets, and the number and type of data collection methods, are revolutionizing the field of Ecology. To integrate these advances, virtual laboratories offer a unique tool to facilitate, expedite, and accelerate research into the impacts of climate change on biodiversity. We introduce the uniquely cloud-based Biodiversity and Climate Change Virtual Laboratory (BCCVL), which provides access to numerous species distribution modelling tools; a large and growing collection of biological, climate, and other environmental datasets; and a variety of experiment types to conduct research into the impact of climate change on biodiversity.Users can upload and share datasets, potentially increasing collaboration, cross-fertilisation of ideas, and innovation among the user community. Feedback confirms that the BCCVL's goals of lowering the technical requirements for species distribution modelling, and reducing time spent on such research, are being met. BCCVL facilitates and expedites modelling of climate change's impact on biodiversity.BCCVL integrates numerous species distribution modelling tools and myriad datasets.BCCVL negates the need for advanced programming and modelling expertise.BCCVL allows for increases in productivity and complexity of experimental design.BCCVL facilitates the sharing of data promoting transparency in the research process.

West African rainfed agriculture is highly vulnerable to climate variability and change. Global warming is projected to result in higher regional warming and have a strong impact on agriculture. This study specifically examines the impact of global warming levels (GWLs) of 1.5°, 2° and 3 °C relative to 1971–2000 on crop suitability over West Africa. We used 10 Coupled Model Intercomparison Project Phase5 Global Climate Models (CMIP5 GCMs) downscaled by Coordinated Regional Downscaling Experiment (CORDEX) Rossby Centre’s regional Atmospheric model version 4, RCA4, to drive Ecocrop, a crop suitability model, for pearl millet, cassava, groundnut, cowpea, maize and plantain. The results show Ecocrop simulated crop suitability spatial representation with higher suitability, observed to the south of latitude 14°N and lower suitability to its north for 1971–2000 for all crops except for plantain (12°N). The model also simulates the best three planting months within the growing season from September-August over the past climate. Projected changes in crop suitability under the three GWLs 1.5–3.0 °C suggest a spatial suitability expansion for legume and cereal crops, notably in the central southern Sahel zone; root and tuber and plantain in the central Guinea-Savanna zone. In contrast, projected decreases in the crop suitability index value are predicted to the south of 14°N for cereals, root and tuber crops; nevertheless, the areas remain suitable for the crops. A delay of between 1-3 months is projected over the region during the planting month under the three GWLs for legumes, pearl millet and plantain. A two month delay in planting is projected in the south, notably over the Guinea and central Savanna zone with earlier planting of about three months in the Savanna-Sahel zones. The effect of GWL2.0 and GWL3.0 warming in comparison to GWL1.5 °C are more dramatic on cereals and root and tuber crops, especially cassava. All the projected changes in simulated crop suitability in response to climatic variables are statistically significant at 99% confidence level. There is also an increasing trend in the projected crop suitability change across the three warming except for cowpea. This study has implications for improving the resilience of crop production to climate changes, and more broadly, to food security in West Africa.

The United Nations' Paris Agreement includes the aim of pursuing efforts to limit global warming to only 1.5 °C above pre-industrial levels. However, it is not clear what the resulting climate would look like across the globe and over time. Here we show that trajectories towards a '1.5 °C warmer world' may result in vastly different outcomes at regional scales, owing to variations in the pace and location of climate change and their interactions with society's mitigation, adaptation and vulnerabilities to climate change. Pursuing policies that are considered to be consistent with the 1.5 °C aim will not completely remove the risk of global temperatures being much higher or of some regional extremes reaching dangerous levels for ecosystems and societies over the coming decades.

We applied a recently developed tool to examine the reduction in climate risk to biodiversity in moving from a 2°C to a 1.5°C target. We then reviewed the recent literature examining the impact of (a) land-based mitigation options and (b) land-based greenhouse gas removal options on biodiversity. We show that holding warming to 1.5°C versus 2°C can significantly reduce the number of species facing a potential loss of 50% of their climatic range. Further, there would be an increase of 5.5–14% of the globe that could potentially act as climatic refugia for plants and animals, an area equivalent to the current global protected area network. Efforts to meet the 1.5°C target through mitigation could largely be consistent with biodiversity protection/enhancement. For impacts of land-based greenhouse gas removal technologies on biodiversity, some (e.g. soil carbon sequestration) could be neutral or positive, others (e.g. bioenergy with carbon capture and storage) are likely to lead to conflicts, while still others (e.g. afforestation/reforestation) are context-specific, when applied at scales necessary for meaningful greenhouse gas removal. Additional effort to meet the 1.5°C target presents some risks, particularly if inappropriately managed, but it also presents opportunities. This article is part of the theme issue ‘The Paris Agreement: understanding the physical and social challenges for a warming world of 1.5°C above pre-industrial levels'.

A wide range of climate vulnerability and risk assessments have been implemented using different approaches at different scales, some with a broad multi-sectoral scope and others focused on single risks or sectors. This paper describes the novel approach to vulnerability and risk assessment which was designed and put into practice in the United Kingdom's Second Climate Change Risk Assessment (CCRA2) so as to build upon its earlier assessment (CCRA1). First, we summarize and critique the CCRA1 approach, and second describe the steps taken in the CCRA2 approach in detail, providing examples of how each was applied in practice. Novel elements of the approach include assessment of both present day and future vulnerability, a focus on the urgency of adaptation action, and a structure focused around systems of receptors rather than conventional sectors. Both stakeholders and reviewers generally regarded the approach as successful in providing advice on current risks and future opportunities to the UK from climate change, and the fulfilment of statutory duty. The need for a well-supported and open suite of impact indicators going forward is highlighted. This article is part of the theme issue ‘Advances in risk assessment for climate change adaptation policy'.

Tuberculosis has historically thrived in some of the most impoverished and marginalized populations; however, research into why lower socio-economic populations are at a higher risk of contracting diseases remains to be a topic lacking exploration. This is becoming a more prevalent issue as multi-drug resistant Tuberculosis (MDR-TB) and extensively-drug resistant Tuberculosis (XDR-TB) are on the rise in individuals living in poverty. The main research question that will be addressed in this paper is: How do socio-economic inequalities play a role in rising incidence rates of Tuberculosis in South Africa, and what are the future challenges in dealing with MDR-TB and XDR-TB? South Africa is a particularly important country of focus because of the racial inequity that has resulted in economic disparity, and a large percentage of the population living below the poverty line. Reviews of existing literature on Tuberculosis and correlations to poverty will be critically analyzed and applied, as well as the use of government documents, including Statistics South Africa, and the World Health Organization. A cross-cultural comparison of Canada and South Africa will be included to highlight the long-term effects of marginalization societal stratification. The health care policies dealing with treatment will also be discussed, with a specific focus on social epidemiology. This paper will argue that long-term racial inequalities in South Africa has result in economic disparity, through which Black Africans and people of Colour are more susceptible to contracting TB, MDR-TB, and insufficient health resources to support them.

One and a half degrees on biodiversity Insects are the most diverse group of animals on Earth and are ubiquitous in terrestrial food webs. We have little information about their fate in a changing climate; data are scant for insects compared with other groups of organisms. Warren et al. performed a global-scale analysis of the effects of climate change on insect distribution (see the Perspective by Midgley). For vertebrates and plants, the number of species losing more than half their geographic range by 2100 is halved when warming is limited to 1.5°C, compared with projected losses at 2°C. But for insects, the number is reduced by two-thirds. Science , this issue p. 791 ; see also p. 714

Background A scoping review to characterize the literature on the use of conversations in social media as a potential source of data for detecting adverse events (AEs) related to health products. Methods Our specific research questions were (1) What social media listening platforms exist to detect adverse events related to health products, and what are their capabilities and characteristics? (2) What is the validity and reliability of data from social media for detecting these adverse events? MEDLINE, EMBASE, Cochrane Library, and relevant websites were searched from inception to May 2016. Any type of document (e.g., manuscripts, reports) that described the use of social media data for detecting health product AEs was included. Two reviewers independently screened citations and full-texts, and one reviewer and one verifier performed data abstraction. Descriptive synthesis was conducted. Results After screening 3631 citations and 321 full-texts, 70 unique documents with 7 companion reports available from 2001 to 2016 were included. Forty-six documents (66%) described an automated or semi-automated information extraction system to detect health product AEs from social media conversations (in the developmental phase). Seven pre-existing information extraction systems to mine social media data were identified in eight documents. Nineteen documents compared AEs reported in social media data with validated data and found consistent AE discovery in all except two documents. None of the documents reported the validity and reliability of the overall system, but some reported on the performance of individual steps in processing the data. The validity and reliability results were found for the following steps in the data processing pipeline: data de-identification (n = 1), concept identification (n = 3), concept normalization (n = 2), and relation extraction (n = 8). The methods varied widely, and some approaches yielded better results than others. Conclusions Our results suggest that the use of social media conversations for pharmacovigilance is in its infancy. Although social media data has the potential to supplement data from regulatory agency databases; is able to capture less frequently reported AEs; and can identify AEs earlier than official alerts or regulatory changes, the utility and validity of the data source remains under-studied. Trial registration Open Science Framework (https://osf.io/kv9hu/). Electronic supplementary material The online version of this article (10.1186/s12911-018-0621-y) contains supplementary material, which is available to authorized users.

Research findings are often inaccessible to those who need them and knowledge sharing between researchers, practitioners and community groups can be impeded by organizational, role and priority differences. This paper presents a university-community project designed to make research knowledge available to diverse users, facilitate their input, and build connections between diverse communities impacted by child disability. A team of Canadian researchers, social workers and community partners held workshops to discuss findings of a study on parenting adopted children with special needs and share research knowledge on advocacy for children with disabilities. Parents, service providers, professionals and organizations from disability and adoption communities met together in small mixed role groups to discuss the issues raised and identify priorities. Workshop material was captured to produce practical audio-visual and print documents, which were made available at no cost to all those who could use them. Formative and summative workshop evaluation concluded that project goals were achieved primarily because of ongoing community involvement and a respectful, open climate which encouraged sharing of expertise across roles and disciplines. Reflections of team members and community partners add data on the usefulness and challenges of this type of collaborative project.

Aim The evidence for self-management programmes in older adults varies in methodological approaches, and disease criteria. Using predetermined methodological criteria, we evaluated the effect of diabetes-specific self-management programme interventions in older adults. Methods The EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials databases were searched from January 1980 to November 2013, as were reference lists from systematic reviews, meta-analyses and clinical practice guidelines. A total of 13 trials met the selection criteria, which included 4517 older adult participants; 2361 participants randomized to a diabetes self-management programme and 2156 to usual care. Results The pooled effect on HbA1c was a reduction of –2 mmol/mol (–0.2%; 95% CI –0.3 to –0.1); tailored interventions [–3 mmol/mol (–0.2%; 95% CI –0.4 to –0.1)] or programmes with a psychological emphasis [–3 mmol/mol (–0.2; 95% CI –0.4 to –0.1)] were most effective. A pooled treatment effect on total cholesterol was a 5.81 mg/dl reduction (95% CI –10.33 to –1.29) and non-significant reductions in systolic and diastolic blood pressure. Conclusions Diabetes self-management programmes for older adults demonstrate a small reduction in HbA1c, lipids and blood pressure. These findings may be of greater clinical relevance when offered in conjunction with other therapies.

Background: Childhood obesity is a public health concern. One-third of North American children and youth are overweight or obese. We reviewed the evidence of behavioural and pharmacological weight-management interventions on body mass index (BMI), BMI z-score and the prevalence of overweight and obesity in children and youth. Methods: We updated the search of a previous review. We searched 4 databases up to August 2013. We included randomized trials of primary care–relevant behavioural (diet, exercise, lifestyle) and pharmacological (orlistat) interventions for treating overweight and obesity in children and youth aged 2–18 years if 6-month post-baseline data were provided for BMI, BMI z-score or prevalence of overweight and obesity. In addition, we examined secondary health outcomes such as lipid and glucose levels, blood pressure, quality of life and physical fitness. We included any study reporting harms. We performed meta-analyses when possible, and we examined the features of interventions that showed benefits. Results: Thirty-one studies (29 behavioural, 2 pharmacological and behavioural) were included. Both intervention types showed a significant effect on BMI or BMI z-score in favour of treatment (behavioural: standardized mean difference [SMD] –0.54, 95% confidence interval [CI] –0.73 to –0.36; orlistat plus behavioural: SMD –0.43, 95% CI –0.60 to –0.25). Studies reported no significant difference between groups in the likelihood of reduced prevalence of overweight or overweight and obesity. Pooled estimates for blood pressure and quality of life showed significant benefits in favour of treatment (systolic blood pressure mean difference [MD] –3.42, 95% CI –6.65 to –0.29; diastolic blood pressure MD –3.39, 95% CI –5.17 to –1.60; quality of life MD 2.10, 95% CI 0.60 to 3.60). Gastrointestinal difficulties were more common in youth taking orlistat than in the control group (risk ratio 3.77, 95% CI 2.56 to 5.55). We saw much variability across efficacious interventions. Interpretation: Low- to moderate-quality evidence suggests behavioural treatments are associated with a medium effect in terms of reduced BMI or BMI z-score compared with a small effect shown by combined pharmacological–behavioural interventions. Future research should evaluate active weight maintenance interventions in adolescents with longer follow-up and examine the effectiveness of combined pharmacological and behavioural interventions. Registration: PROSPERO no. CRD42012002754

The AVOID2 programme provided evidence for UK Government on what might constitute dangerous climate change and the feasibility of avoiding it. The programme quantified some of the benefits of moving from a world that warms by around 4?5?C to one limiting global warming to below or well below 2?C. Whilst there is evidence that this transition is feasible, it will require early action to reduce emissions and to develop the potential for large-scale deployment of a range of low carbon technologies.

The reasons for concern framework communicates scientific understanding about risks in relation to varying levels of climate change. The framework, now a cornerstone of the IPCC assessments, aggregates global risks into five categories as a function of global mean temperature change. We review the framework's conceptual basis and the risk judgments made in the most recent IPCC report, confirming those judgments in most cases in the light of more recent literature and identifying their limitations. We point to extensions of the framework that offer complementary climate change metrics to global mean temperature change and better account for possible changes in social and ecological system vulnerability. Further research should systematically evaluate risks under alternative scenarios of future climatic and societal conditions.

Over-exploitation and economic underperformance are widespread in the world's fisheries. Global climate change is further affecting the distribution of marine species, raising concern for the persistence of biodiversity and presenting additional challenges to fisheries management. However, few studies have attempted to extend bioclimatic projections to assess the socio-economic impacts of climate-induced range shifts. This study investigates the potential implications of changes in relative environmental suitability and fisheries catch potential on UK fisheries by linking species distribution modelling with cost-benefit analyses. We develop scenarios and apply a multimodel approach to explore the economic sensitivity of UK fisheries and key sources of uncertainty in the modelling procedure. We projected changes in maximum potential catch of key species and the resulting responses in terms of net present value (NPV) over a 45-year period under scenarios of change in fuel price, discount rate and government subsidies. Results suggest that total maximum potential catch will decrease within the UK EEZ by 2050, resulting in a median decrease in NPV of 10%. This value decreases further when trends of fuel price change are extrapolated into the future, becoming negative when capacity-enhancing subsidies are removed. Despite the variation in predictions from alternative models and data input, the direction of change in NPV is robust. This study highlights key factors influencing future profitability of UK fisheries and the importance of enhancing adaptive capacity in UK fisheries.

The study presents a methodology to characterise short- or long-term drought events, designed to aid understanding of how climate change may affect future risk. An indicator of drought magnitude, combining parameters of duration, spatial extent and intensity, is presented based on the Standardised Precipitation Index (SPI). The SPI is applied to observed (1955–2003) and projected (2003–2050) precipitation data from the Community Integrated Assessment System (CIAS). Potential consequences of climate change on drought regimes in Australia, Brazil, China, Ethiopia, India, Spain, Portugal and the USA are quantified. Uncertainty is assessed by emulating a range of global circulation models to project climate change. Further uncertainty is addressed through the use of a high-emission scenario and a low stabilisation scenario representing a stringent mitigation policy. Climate change was shown to have a larger effect on the duration and magnitude of long-term droughts, and Australia, Brazil, Spain, Portugal and the USA were highlighted as being particularly vulnerable to multi-year drought events, with the potential for drought magnitude to exceed historical experience. The study highlights the characteristics of drought which may be more sensitive under climate change. For example, on average, short-term droughts in the USA do not become more intense but are projected to increase in duration. Importantly, the stringent mitigation scenario had limited effect on drought regimes in the first half of the twenty-first century, showing that adaptation to drought risk will be vital in these regions.

Background The clinical specialty of obstetrics is under particular scrutiny with increasing litigation costs and unnecessary tests and procedures done in attempts to prevent litigation. We aimed to identify reports evaluating or comparing the effectiveness of medical liability reforms and quality improvement strategies in improving litigation-related outcomes in obstetrics. Methods We conducted a rapid scoping review with a 6-week timeline. MEDLINE, EMBASE, LexisNexis Academic, the Legal Scholarship Network, Justis, LegalTrac, QuickLaw, and HeinOnline were searched for publications in English from 2004 until June 2015. The selection criteria for screening were established a priori and pilot-tested. We included reports comparing or evaluating the impact of obstetrics-related medical liability reforms and quality improvement strategies on cost containment and litigation settlement across all countries. All levels of screening were done by two reviewers independently, and discrepancies were resolved by a third reviewer. In addition, two reviewers independently extracted relevant data using a pre-tested form, and discrepancies were resolved by a third reviewer. The results were summarized descriptively. Results The search resulted in 2729 citations, of which 14 reports met our eligibility criteria. Several initiatives for improving the medical malpractice litigation system were found, including no-fault approaches, patient safety policy initiatives, communication and resolution, caps on compensation and attorney fees, alternative payment system and liabilities, and limitations on litigation. Conclusions Only a few litigation policies in obstetrics were evaluated or compared. Included documents showed that initiatives to reduce medical malpractice litigation could be associated with a decrease in adverse and malpractice events. However, due to heterogeneous settings (e.g., economic structure, healthcare system) and variation in the outcomes reported, the advantages and disadvantages of initiatives may vary. Electronic supplementary material The online version of this article (10.1186/s13643-017-0569-5) contains supplementary material, which is available to authorized users.

Climate mitigation policies are rarely assessed in terms of the proportion of climate impacts they can avoid both regionally and globally. Research shows that policies with a 50% chance of remaining below a 2 °C rise in temperature may reduce the impacts of climate change by 20–65% by 2100, relative to pathways with a temperature rise of 4 °C.

This article considers social work engagement with the arts. We are interested in claims made in the social work literature about why art matters (or should matter) to social work, and about what art achieves for people and communities and ideas. We focus in particular on the images and metaphors at play in descriptions of arts-informed social work projects. Our intent is to offer a framework for understanding what social work communities think (and hope, and imagine) happens when we take up the arts in education, practice and research.

BACKGROUND Existing guidelines on screening children less than 5 years of age for developmental delay vary. In this systematic review, we synthesized the literature on the effectiveness and harms of screening for developmental delay in asymptomatic children aged 1-4 years. METHODS We searched MEDLINE, Embase and PsychINFO for relevant articles published to June 16, 2015. We identified studies that included children aged 1-4 years who were not at high risk of developmental delay, screened in a primary care setting. Randomized trials and controlled cohort studies were considered for benefits (cognitive, academic and functional outcomes); no restrictions on study design were imposed for the review of harms. RESULTS Two studies were included. One used the Ages and Stages Questionnaire II for screening and reported significantly more referrals to early intervention in the intervention groups than in the control group (relative risk [RR] 1.95, 95% confidence interval [CI] 1.49-2.54, in the intervention group with office support and RR 1.71, 95% CI 1.30-2.25, in the intervention group without office support). The time to referral was 70% shorter in the intervention group with office support (rate ratio 0.30, 95% CI 0.19-0.48) and 64% shorter in the intervention group without office support (rate ratio 0.36, 95% CI 0.23-0.59), compared with the control group. The other study used the VroegTijdige Onderkenning Ontwikkelingsstoornissen Language Screening instrument to screen children aged 15 months at enrolment for language delay. It reported no differences between groups in academic performance outcomes at age 8 years. INTERPRETATION The evidence on screening for developmental delay in asymptomatic children aged 1-4 years is inconclusive. Further research with longer-term outcomes is needed to inform decisions about screening and screening intervals.

Summary There is growing recognition as to the importance of extreme climatic events (ECEs) in determining changes in species populations. In fact, it is often the extent of climate variability that determines a population's ability to persist at a given site. This study examined the impact of ECEs on the resident UK butterfly species (n = 41) over a 37-year period. The study investigated the sensitivity of butterflies to four extremes (drought, extreme precipitation, extreme heat and extreme cold), identified at the site level, across each species' life stages. Variations in the vulnerability of butterflies at the site level were also compared based on three life-history traits (voltinism, habitat requirement and range). This is the first study to examine the effects of ECEs at the site level across all life stages of a butterfly, identifying sensitive life stages and unravelling the role life-history traits play in species sensitivity to ECEs. Butterfly population changes were found to be primarily driven by temperature extremes. Extreme heat was detrimental during overwintering periods and beneficial during adult periods and extreme cold had opposite impacts on both of these life stages. Previously undocumented detrimental effects were identified for extreme precipitation during the pupal life stage for univoltine species. Generalists were found to have significantly more negative associations with ECEs than specialists. With future projections of warmer, wetter winters and more severe weather events, UK butterflies could come under severe pressure given the findings of this study.

International audience; Climate change has significant implications for biodiversity and ecosystems. With slow progress towards reducing greenhouse gas emissions, climate engineering (or ‘geoengineering’) is receiving increasing attention for its potential to limit anthropogenic climate change and its damaging effects. Proposed techniques, such as ocean fertilization for carbon dioxide removal or stratospheric sulfate injections to reduce incoming solar radiation, would significantly alter atmospheric, terrestrial and marine environments, yet potential side-effects of their implementation for ecosystems and biodiversity have received little attention. A literature review was carried out to identify details of the potential ecological effects of climate engineering techniques. A group of biodiversity and environmental change researchers then employed a modified Delphi expert consultation technique to evaluate this evidence and prioritize the effects based on the relative importance of, and scientific understanding about, their biodiversity and ecosystem consequences. The key issues and knowledge gaps are used to shape a discussion of the biodiversity and ecosystem implications of climate engineering, including novel climatic conditions, alterations to marine systems and substantial terrestrial habitat change. This review highlights several current research priorities in which the climate engineering context is crucial to consider, as well as identifying some novel topics for ecological investigation.

Species distribution models are important tools to explore the effects of future global change on biodiversity. Specifically, AquaMaps, Maxent and the Sea Around Us Project algorithm are three approaches that have been applied to predict distributions of marine fishes and invertebrates. They were designed to cope with issues of data quality and quantity common in species distribution modelling, and especially pertinent to the marine environment. However, the characteristics of model projections for marine species from these different approaches have rarely been compared. Such comparisons provide information about the robustness and uncertainty of the projections, and are thus important for spatial planning and developing management and conservation strategies. Here we apply the three commonly used species distribution modelling methods for commercial fish in the North Sea and North Atlantic, with the aim of drawing comparisons between the approaches. The effect of different assumptions within each approach on the predicted current relative habitat suitability was assessed. Predicted current distributions were tested following data partitioning and selection of pseudoabsences from within a specified distance of occurrence data. As indicated by the test statistics, each modelling method produced plausible predictions of relative habitat suitability for each species, with subsequent incorporation of expert knowledge generally improving predictions. However, because of the differences between modelling algorithms, methodologies and patterns of relative suitability, comparing models using test statistics and selecting a ‘best’ model are not recommended. We propose that a multi-model approach should be preferred and a suite of possible predictions considered if biases due to uncertainty in data and model formulation are to be minimised.

The effectiveness of treatments for mild cognitive impairment is uncertain. The aim of this review was to evaluate the effectiveness and harms of treatment for mild cognitive impairment in adults 65 years of age and older.We searched MEDLINE, Embase and Cochrane Central (December 2012-December 2014); citations from 2 systematic reviews were considered for inclusion. We included randomized controlled trials involving community-dwelling adults aged 65 years and older with a diagnosis of mild cognitive impairment. Studies reporting on cognition, function, behaviour, global status, mortality and adverse events for treatment with pharmacologic and nonpharmacologic interventions were included.Seventeen studies were included. Cholinesterase inhibitor studies evaluating cognition (Alzheimer's Disease Assessment Scale, cognition subscale) showed no difference between intervention and control groups (mean difference [MD] -0.33, 95% CI -0.73 to 0.06]; one behavioural study showed no significant effect on cognition (Alzheimer's Disease Assessment Scale, cognition subscale) for the intervention group when compared to controls (MD -0.60, (95% CI -1.44 to 0.24), and one study on vitamin E showed no difference between intervention and control groups (MD 0.85, 95% CI -0.32 to 2.02). With the Mini-Mental State Examination, cholinesterase inhibitors showed no difference between intervention and control groups (MD 0.17, 95% CI -0.13 to 0.47); behavioural studies showed a significant difference favouring intervention (MD 1.01, 95% CI 0.25 to 1.77), and studies of dietary supplements and/or vitamins showed no difference between intervention and control groups (MD 0.20, 95% CI -0.04 to 0.43). Pharmacologic studies showed no difference in serious adverse events (risk ratio 0.98, 95% CI 0.86 to 1.10). No serious adverse events were reported for nonpharmacologic interventions.Treatment of mild cognitive impairment with cholinesterase inhibitors showed no benefit when compared with a control group. A small cognitive benefit was observed using behavioural therapies when compared with the control group. However, the clinical significance of this small benefit remains uncertain. The current evidence does not support the use of cholinesterase inhibitors for treating mild cognitive impairment, and future high-quality research using a standardized approach is needed to affirm the finding of a small benefit on cognition that was observed for behavioural interventions.PROSPERO no. CRD42014015431.

The UK’s eight proposed new nuclear power stations are all to be sited on the coast. With a total cradle-to-grave life cycle of at least 160 years, and heightened awareness of inundation risk following the failure of the Fukushima I nuclear plant in Japan this year, Britain’s nuclear developers have to show how they plan to cope with the possibility of rising sea levels, higher sea temperatures and more extreme weather events over the next two centuries. This paper describes the adaptation options for new nuclear and other major long-lived coastal developments. Despite uncertainty about climate scenarios for the 2200s, it explains how flexibility of design and safety margins can be incorporated from the outset and, when combined with routine environmental monitoring, how sites can be adaptively managed throughout their life cycles.

This article reviews some of the major lines of recent scientific progress relevant to the choice of global climate policy targets, focusing on changes in understanding since publication of the Intergovernmental Panel on Climate Change Fourth Assessment Report (IPCC AR4). Developments are highlighted in the following major climate system components: ice sheets; sea ice; the Atlantic Meridional Overturning Circulation; tropical forests; and accelerated carbon release from permafrost and ocean hydrates. The most significant developments in each component are identified by synthesizing input from multiple experts from each field. Overall, while large uncertainties remain in all fields, some substantial progress in understanding is revealed.

e18678Background: The use of neoadjuvant chemotherapy (NAC) has allowed pathologic complete response (pCR) to become a predictive measure for breast cancer recurrence-free survival and overall surv...

This paper describes the development and first results of the ''Community Integrated Assessment System'' (CIAS), a unique multi-institutional modular and flexible integrated assessment system for modelling climate change. Key to this development is the supporting software infrastructure, SoftIAM. Through it, CIAS is distributed between the communities of institutions which has each contributed modules to the CIAS system. At the heart of SoftIAM is the Bespoke Framework Generator (BFG) which enables flexibility in the assembly and composition of individual modules from a pool to form coupled models within CIAS, and flexibility in their deployment onto the available software and hardware resources. Such flexibility greatly enhances modellers' ability to re-configure the CIAS coupled models to answer different questions, thus tracking evolving policy needs. It also allows rigorous testing of the robustness of IA modelling results to the use of different component modules representing the same processes (for example, the economy). Such processes are often modelled in very different ways, using different paradigms, at the participating institutions. An illustrative application to the study of the relationship between the economy and the earth's climate system is provided.

This paper has three main objectives: firstly, to provide quantitative information on the potential greenhouse gas and air pollutant emissions reductions resulting from a number of future road transport scenarios; secondly, to illustrate the emission reduction measures available to local transport planners; and thirdly, to highlight the potential for these measures to be integrated into strategies that deliver other transport priorities. The results are drawn from a case study of Norfolk in the UK. We conclude that while technology can play a large part in reducing emissions of air pollutants, demand management is crucial to the delivery of long term greenhouse gas emission reduction and ultimately of air pollutant emissions too.

Drought events and their impacts pose a considerable problem for governments, businesses and individuals. Superimposed on this is the risk of anthropogenic climate change. Climate models are increasingly being used to understand how climate change may affect future drought regimes. However, methodologies to quantify economic costs which could occur under these future scenarios are virtually non-existent. In this study, historic drought events were identified in regional precipitation data using the Standardized Precipitation Index, and their magnitude quantified and linked to reported economic costs. Drought damage functions were created for Australia, Brazil, China, India, Spain/Portugal and the USA. Projections of drought magnitude for 2003–2050 were modeled using the Community Integrated Assessment System, for a range of climate and emission scenarios, and future economic costs estimated. Severe and extreme drought events were projected to cause estimated additional losses ranging between 0.04 and 9 percent of national GDP in Australia, the USA and Spain/Portugal under future scenarios of climate change. The combined effect on global GDP from projected long-term drought events in the countries analyzed resulted in additional annual losses of 0.01 to 0.25 percent. This is considered conservative as the analysis is representative of seven countries only; does not incorporate the possibility of successive drought events, or compounding effects on vulnerability from interactions with other extreme events. Furthermore, it excludes indirect economic effects; social and environmental losses; the possibility of increasing vulnerability due to changing socio-economic conditions; and the possibility of irreversible or systemic collapse of economies as the study highlighted that under future climate change drought magnitude may exceed current experience potentially passing thresholds of social and economic resilience. Stringent mitigation had little effect on the increasing impacts of drought in the first half of the 21st century, so in the short-term adaptation in drought "hot spots" will be crucial.

Integrated assessment modelling aims to bring together information on emissions, atmospheric transport between sources and exposed areas or populations, criteria for environmental protection, and potential emission control measures and their costs, in order to explore effective abatement strategies. We describe the development of a new UK scale Integrated Assessment Model which can be used to investigate strategies for the attainment of national emission ceilings. The model optimises abatement strategies in relation to acidification, eutrophication, and/or human-exposure to particulate PM10, with reference to the deposition of sulphur and nitrogen (oxidised and reduced), and concentrations of primary and secondary particles. The model combines sector specific emissions, atmospheric transport and deposition, ecosystem specific critical load exceedances, and pollution abatement costs to determine optimised abatement strategies using benefit and, where applicable, recovery functions.

Understanding what constitutes dangerous climate change is of critical importance for future concerted action (Schneider, 2001, 2002). To date separate scientific and policy discourses have proceeded with competing and somewhat arbitrary definitions of danger based on a variety of assumptions and assessments generally undertaken by 'experts'. We argue that it is not possible to make progress on defining dangerous climate change, or in developing sustainable responses to this global problem, without recognising the central role played by social or individual perceptions of danger. There are therefore at least two contrasting perspectives on dangerous climate change, what we term 'external' and 'internal' definitions of risk. External definitions are usually based on scientific risk analysis, performed by experts, of system characteristics of the physical or social world. Internal definitions of danger recognise that to be real, danger has to be either experienced or perceived - it is the individual or collective experience or perception of insecurity or lack of safety that constitutes the danger. A robust policy response must appreciate both external and internal definitions of danger.

Model development and testing tend to concentrate on how well models represent “reality” or reproduce measurements. However, there are many sources of uncertainty in modelling atmospheric pollution, and those responsible for decisions on abatement strategies need to use modelled scenarios without fear that inaccuracies and assumptions in the modelling may mislead them. This paper explores how techniques from risk assessment may be used to examine a modelling study systematically. Those assumptions and uncertainties which could have significant consequences, whether arising from data used, the modelling itself, or factors omitted and incompleteness, may be identified using hazard and operability studies. This helps to target supporting studies—possibly using more complex models, or Monte Carlo uncertainty analysis; and to indicate potential implications to the decision makers. As a case study we have used work undertaken on uncertainties with the Abatement Strategies Assessment Model for the task force on integrated assessment modelling under the convention on long-range transboundary air pollution of the UN Economic Commission for Europe.

Planning effective strategies to combat air pollution in amajor city such as London requires integration ofinformation on atmospheric concentrations and where theyexceed prescribed air quality standards, detailed data onemissions and potential measures to reduce them includingcosts, and a good understanding of the relativecontributions of different emission sources to pollutantconcentrations plus the remaining background. The UrbanScale Integrated Assessment Model (USIAM) is designed as atool to integrate such information, and to explore andassess a variety of potential strategies for improving airquality. It is based on the same principles as theAbatement Strategies Assessment Model (ASAM) that has beenused in the UN Economic Commission for Europe. To startwith the USIAM model is being developed with respect to theparticulate PM10 only, and in particular the primaryparticulate contribution. The secondary particulate istreated as part of the background superimposed on theprimary particulate concentrations; this may need to betreated more specifically at a later stage, particularlywith respect to nitrate formation over the city. The USIAMmodel therefore sets out to examine a selection of severeepisode conditions as well as long-term annual averageconcentrations, and aims to find strategies that aresuccessful in eliminating exceedance of the prescribedtarget concentrations. By ranking different options forabatement of emissions, for example in terms of cost orease of implementation, the USIAM model can also select andprioritise different potential strategies.

Background Low fruit and vegetable (FV) consumption is one of the top 10 global risk factors for mortality, and is related to increased risk for cancer, cardiovascular disease and diabetes. Many environmental, sociodemographic and personal factors affect FV consumption. The purpose of this review is to examine the effects of interventions delivered in the home, school and other nutritional environments designed to increase FV availability for five to 18-year olds. Methods The search included: 19 electronic bibliographic databases; grey literature databases; reference lists of key articles; targeted Internet searching of key organization websites; hand searching of key journals and conference proceedings; and consultation with experts for additional references. Articles were included if: in English, French and Spanish; from high-, middle-, and low-income countries; delivered to anyone who could bring about change in FV environment for 5 to 18 year olds; with randomized and non-randomized study designs that provided before-after comparisons, with or without a control group. Primary outcomes of interest were measures of FV availability. Results The search strategy retrieved nearly 23,000 citations and resulted in 23 unique studies. Interventions were primarily policy interventions at the regional or state level, a number of curriculum type interventions in schools and community groups and a garden intervention. The majority of studies were done in high-income countries. The diversity of interventions, populations, outcomes and outcome measurements precluded meta-analysis. The most promising strategies for improving the FV environment for children are through local school food service policies. Access to FV was successfully improved in four of the six studies that evaluated school-based policies, with the other two studies finding no effect. Broader state or federally mandated policies or educational programs for food service providers and decision makers had mixed or small impact. Similarly family interventions had no or small impact on home accessibility, with smaller impact on consumption. Conclusions The studies have high risk of bias but more rigorous studies are difficult to impossible to conduct in naturalistic settings and in policy implementation and evaluation. However, there are promising strategies to improve the FV environment, particularly through school food service policies.

The International Surface Temperature Initiative (ISTI) is striving towards substantively improving our ability to robustly understand historical land surface air temperature change at all scales. A key recently completed first step has been collating all available records into a comprehensive open access, traceable and version-controlled databank. The crucial next step is to maximise the value of the collated data through a robust international framework of benchmarking and assessment for product intercomparison and uncertainty estimation. We focus on uncertainties arising from the presence of inhomogeneities in monthly surface temperature data and the varied methodological choices made by various groups in building homogeneous temperature products. The central facet of the benchmarking process is the creation of global scale synthetic analogs to the real-world database where both the "true" series and inhomogeneities are known (a luxury the real world data do not afford us). Hence algorithmic strengths and weaknesses can be meaningfully quantified and conditional inferences made about the real-world climate system. Here we discuss the necessary framework for developing an international homogenisation benchmarking system on the global scale for monthly mean temperatures. The value of this framework is critically dependent upon the number of groups taking part and so we strongly advocate involvement in the benchmarking exercise from as many data analyst groups as possible to make the best use of this substantial effort.

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

The International Surface Temperature Initiative (ISTI) is striving towards substantively improving our ability to robustly understand historical land surface air temperature change at all scales. A key recently completed first step has been collating all available records into a comprehensive open access, traceable and version-controlled databank. The crucial next step is to maximise the value of the collated data through a robust international framework of benchmarking and assessment for product intercomparison and uncertainty estimation. We focus on uncertainties arising from the presence of inhomogeneities in monthly mean land surface temperature data and the varied methodological choices made by various groups in building homogeneous temperature products. The central facet of the benchmarking process is the creation of global-scale synthetic analogues to the real-world database where both the "true" series and inhomogeneities are known (a luxury the real-world data do not afford us). Hence, algorithmic strengths and weaknesses can be meaningfully quantified and conditional inferences made about the real-world climate system. Here we discuss the necessary framework for developing an international homogenisation benchmarking system on the global scale for monthly mean temperatures. The value of this framework is critically dependent upon the number of groups taking part and so we strongly advocate involvement in the benchmarking exercise from as many data analyst groups as possible to make the best use of this substantial effort.

Transport first became a significant source of air pollution after the problems of sooty smog from coal combustion had largely been solved in western European and North American cities. Since then, emissions from road, air, rail and water transport have been partly responsible for acid deposition, stratospheric ozone depletion and climate change. Most recently, road traffic exhaust emissions have been the cause of much concern about the effects of urban air quality on human health and tropospheric ozone production. This article considers the variety of transport impacts on the atmospheric environment by reviewing three examples: urban road traffic and human health, aircraft emissions and global atmospheric change, and the contribution of sulphur emissions from ships to acid deposition. Each example has associated with it a different level of uncertainty, such that a variety of policy responses to the problems are appropriate, from adaptation through precautionary emissions abatement to cost-benefit analysis and optimised abatement. There is some evidence that the current concern for road transport contribution to urban air pollution is justified, but aircraft emissions should also give cause for concern given that air traffic is projected to continue to increase. Emissions from road traffic are being reduced substantially by the introduction of technology especially three-way catalysts and also, most recently, by local traffic reduction measures especially in western European cities. In developing countries and Eastern Europe, however, there remains the possibility of great increase in car ownership and use, and it remains to be seen whether these countries will adopt measures now to prevent transport-related air pollution problems becoming severe later in the 21st Century. (C) 2001 Elsevier Science Ltd. All rights reserved.

Exposure to fine particles in the ambient air is recognized as a significant threat to human health. Two pathways contribute to the particle burden in the atmosphere: Fine particles originate from primary emissions, and secondary organic and inorganic particles are formed from the gas phase from the emissions of 'conventional' pollutants such as SO2, NOx, VOC and NH3. Both types of particulate matter can be transported over long distances in the atmosphere. An integrated assessment model for particulate matter developed at IIASA addresses the relative importance of the different types of particulates, distinguishing primary and secondary particles and two size fractions. The model projects these emissions into the future and seeks cost-effective strategies for reducing health risks to population. The model integrates the control of primary emissions of fine particles with strategies to reduce the precursor emissions for the secondary aerosols. Preliminary results addressing the PM2.5 fraction of both primary and secondary particulate matter indicate that in Europe the exposure to particulates will be significantly reduced as a side effect of the emission controls for conventional air pollutants (SO2, NOx, NH3).

The integrated assessment model, Abatement Strategies Assessment Model (ASAM) is described and applied to the reduction of sulphur dioxide emissions in order to ameliorate European acidification in a cost-effective manner. The use of critical loads to map the spatial variation of environmental sensitivity is a key factor underpinning this approach. Since these critical loads are not in practice attainable, intermediate target loads are required. ASAM is used in this paper to show that the use of the ‘gap-closure’ approach, to define target loads, and in particular the 60% gap-closure target used as a basis for the Oslo protocol, is particularly appropriate. The unique feature of ASAM it its step-wise approach to optimisation which allows examination of an abatement strategy aiming at a particular environmental target at any required overall European expenditure level, even if the target is not attained at this point. This is key to ASAM’s ability to compare the cost-effectiveness of strategies based upon different target-loads. Similarly, ASAM has been used to demonstrate the influence of the use of current reduction plans as a starting point for optimisation in countries which plan substantial emissions reductions. ASAM is also used to show that abatement strategies are robust to large uncertainties in abatement cost estimates in individual countries. Finally, the role played by individual countries in a typical model strategy is investigated by comparing the ecosystem areas brought under protection by expenditure in each country. This work was undertaken in the context of the United Nations Economic Commission for Europe’s (UNECE) preparations for a second sulphur protocol.

The Abatement Strategies AssessmentModel, ASAM, has been used to investigateEuropean emission abatement policies for ammoniaand oxides of sulphur and nitrogen. Thesepolicies are designed to reduce the depositionof acidifying substances towards critical loadsdefining the deposition which ecosystems cansustain. Since critical loads are not allattainable the model has been set up to reachvarious intermediate target loads. This paperuses the model to illustrate the sensitivity ofthe derived abatement strategies to the choiceof target load. Particular attention is paidto the various methods of `gap closure',designed to calculate target loads. Thesemethods have been discussed within the frameworkof the UN ECE Task Force on IntegratedAssessment Modelling in its preparations for thenew UN ECE `multi-pollutant multi-effectprotocol' and involve the reduction of the gapbetween the situation in 1990 and the criticalloads. The `gap' can be measured using variousmethods, `area', `ratio' and `accumulatedexceedance'. It is shown that the methods ofdefining target loads have an important bearingon the nature of abatement strategies forpollutants, in terms of the distribution acrosscountries of both costs and benefits. The`accumulated exceedance' approach reflects boththe differing sizes of ecosystem areas indifferent parts of Europe and the differentamounts by which their critical loads areexceeded. It probably reflects much morerealistically the relationship betweendeposition levels and damage to ecosystems.