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OBJECTIVE: To evaluate the impact of the reorganization of oral AC treatment management in a primary healthcare setting in terms of quality of care and cost of care. The evaluated reorganization involved the adoption of an AC nurse service model supported by the use of information and communication technology for storing and handling follow-up data. DESIGN: Statistical analysis of AC follow-up data, personnel task distribution and resource use analysis, and survey of personnel experiences. SETTING: The Paloheinä health station in Helsinki, Finland. SUBJECTS: All 122 Paloheinä patients on oral AC treatment and the related Paloheinä personnel. Also, follow-ups from two comparison health stations from Helsinki were used. MAIN OUTCOME MEASURES: Laboratory P-INR and follow-up density distributions before and after follow-up reorganization for Paloheinä and comparison station patients, task distribution, and personnel resource use in treatment guideline assignment before and after reorganization and gathered personnel experiences. RESULTS: No statistically significant changes (Pearson's chi-square test, p < 0.05) were observed in P-INR distributions, considering also the comparison stations. Adoption of the AC nurse model resulted in a 66%/34% task distribution between nurses and physicians in guideline assignment. Personnel resource use analysis showed a cost decrease of 1.61 euros per follow-up in guideline assignment. Users who responded to the survey were generally satisfied with the reorganization and its subjective impacts. CONCLUSION: Reorganization resulted in a potential reduction in cost of care per follow-up without a change in the observed quality of care in the Paloheinä setting. Personnel generally accepted the reorganization. [ABSTRACT FROM AUTHOR]

Global environmental changes have accelerated at an unprecedented rate in recent decades due to human activities. As a consequence, the incidence of novel abiotic conditions and biotic communities, which have been continuously emerging in the Earth system, has rapidly risen. Despite growing attention to the incidence and challenges posed by novelty in terrestrial ecosystems, novelty has not yet been quantified in marine ecosystems. Here, we measured for the rate of novelty (RoN) in abiotic conditions and community structure for three trophic levels, i.e., phytoplankton, zooplankton, and fish, in a large marine system - the Baltic Sea. We measured RoN as the degree of dissimilarity relative to a specific spatial and temporal baseline, and contrasted this with the rate of change as a measure of within-basin change over time. We found that over the past 35 years abiotic and biotic RoN showed complex dynamics varying in time and space, depending on the baseline conditions. RoN in abiotic conditions was smaller in the open Central Baltic Sea than in the Kattegat and the more enclosed Gulf of Bothnia, Gulf of Riga, and Gulf of Finland in the north. We found a similar spatial pattern for biotic assemblages, which resulted from changes in composition and stock size. We identified sea-surface temperature and salinity as key drivers of RoN in biotic communities. Hence, future environmental changes that are expected to affect the biogeochemistry of the Baltic Sea, may favor the rise of biotic novelty. Our results highlighted the need for a deeper understanding of novelty development in marine ecosystems, including interactions between species and trophic levels, ecosystem functioning under novel abiotic conditions, and considering novelty in future management interventions., (© 2021 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Ocean temperatures are rising; species are shifting poleward, and pH is falling (ocean acidification, OA). We summarise current understanding of OA in the brackish Baltic-Skagerrak System, focussing on the direct, indirect and interactive effects of OA with other anthropogenic drivers on marine biogeochemistry, organisms and ecosystems. Substantial recent advances reveal a pattern of stronger responses (positive or negative) of species than ecosystems, more positive responses at lower trophic levels and strong indirect interactions in food-webs. Common emergent themes were as follows: OA drives planktonic systems toward the microbial loop, reducing energy transfer to zooplankton and fish; and nutrient/food availability ameliorates negative impacts of OA. We identify several key areas for further research, notably the need for OA-relevant biogeochemical and ecosystem models, and understanding the ecological and evolutionary capacity of Baltic-Skagerrak ecosystems to respond to OA and other anthropogenic drivers.

Alternatives in ecosystem-based management often differ with respect to trade-offs between ecosystem values. Ecosystem or food-web models and demographic models are typically employed to evaluate alternatives, but the approaches are rarely integrated to uncover conflicts between values. We applied multistate models to a capture-recapture dataset on common guillemots Uria aalge breeding in the Baltic Sea to identify factors influencing survival. The estimated relationships were employed together with Ecopath-with-Ecosim food-web model simulations to project guillemot survival under six future scenarios incorporating climate change. The scenarios were based on management alternatives for eutrophication and cod fisheries, issues considered top priority for regional management, but without known direct effects on the guillemot population. Our demographic models identified prey quantity (abundance and biomass of sprat Sprattus sprattus ) as the main factor influencing guillemot survival. Most scenarios resulted in projections of increased survival, in the near (2016-2040) and distant (2060-2085) future. However, in the scenario of reduced nutrient input and precautionary cod fishing, guillemot survival was projected to be lower in both future periods due to lower sprat stocks. Matrix population models suggested a substantial decline of the guillemot population in the near future, 24% per 10 years, and a smaller reduction, 1.1% per 10 years, in the distant future. To date, many stakeholders and Baltic Sea governments have supported reduced nutrient input and precautionary cod fishing and implementation is underway. Negative effects on nonfocal species have previously not been uncovered, but our results show that the scenario is likely to negatively impact the guillemot population. Linking model results allowed identifying trade-offs associated with management alternatives. This information is critical to thorough evaluation by decision-makers, but not easily obtained by food-web models or demographic models in isolation. Appropriate datasets are often available, making it feasible to apply a linked approach for better-informed decisions in ecosystem-based management., Competing Interests: None declared.

While the physical dimensions of climate change are now routinely assessed through multimodel intercomparisons, projected impacts on the global ocean ecosystem generally rely on individual models with a specific set of assumptions. To address these single-model limitations, we present standardized ensemble projections from six global marine ecosystem models forced with two Earth system models and four emission scenarios with and without fishing. We derive average biomass trends and associated uncertainties across the marine food web. Without fishing, mean global animal biomass decreased by 5% (±4% SD) under low emissions and 17% (±11% SD) under high emissions by 2100, with an average 5% decline for every 1 °C of warming. Projected biomass declines were primarily driven by increasing temperature and decreasing primary production, and were more pronounced at higher trophic levels, a process known as trophic amplification. Fishing did not substantially alter the effects of climate change. Considerable regional variation featured strong biomass increases at high latitudes and decreases at middle to low latitudes, with good model agreement on the direction of change but variable magnitude. Uncertainties due to variations in marine ecosystem and Earth system models were similar. Ensemble projections performed well compared with empirical data, emphasizing the benefits of multimodel inference to project future outcomes. Our results indicate that global ocean animal biomass consistently declines with climate change, and that these impacts are amplified at higher trophic levels. Next steps for model development include dynamic scenarios of fishing, cumulative human impacts, and the effects of management measures on future ocean biomass trends., Competing Interests: The authors declare no conflict of interest., (Copyright © 2019 the Author(s). Published by PNAS.)

Benthic-pelagic coupling is manifested as the exchange of energy, mass, or nutrients between benthic and pelagic habitats. It plays a prominent role in aquatic ecosystems, and it is crucial to functions from nutrient cycling to energy transfer in food webs. Coastal and estuarine ecosystem structure and function are strongly affected by anthropogenic pressures; however, there are large gaps in our understanding of the responses of inorganic nutrient and organic matter fluxes between benthic habitats and the water column. We illustrate the varied nature of physical and biological benthic-pelagic coupling processes and their potential sensitivity to three anthropogenic pressures - climate change, nutrient loading, and fishing - using the Baltic Sea as a case study and summarize current knowledge on the exchange of inorganic nutrients and organic material between habitats. Traditionally measured benthic-pelagic coupling processes (e.g., nutrient exchange and sedimentation of organic material) are to some extent quantifiable, but the magnitude and variability of biological processes are rarely assessed, preventing quantitative comparisons. Changing oxygen conditions will continue to have widespread effects on the processes that govern inorganic and organic matter exchange among habitats while climate change and nutrient load reductions may have large effects on organic matter sedimentation. Many biological processes (predation, bioturbation) are expected to be sensitive to anthropogenic drivers, but the outcomes for ecosystem function are largely unknown. We emphasize how improved empirical and experimental understanding of benthic-pelagic coupling processes and their variability are necessary to inform models that can quantify the feedbacks among processes and ecosystem responses to a changing world., (© 2017 The Authors. Global Change Biology Published by John Wiley & Sons Ltd.)

Regime shifts triggered by human activities and environmental changes have led to significant ecological and socioeconomic consequences in marine and terrestrial ecosystems worldwide. Ecological processes and feedbacks associated with regime shifts have received considerable attention, but human individual and collective behavior is rarely treated as an integrated component of such shifts. Here, we used generalized modeling to develop a coupled social-ecological model that integrated rich social and ecological data to investigate the role of social dynamics in the 1980s Baltic Sea cod boom and collapse. We showed that psychological, economic, and regulatory aspects of fisher decision making, in addition to ecological interactions, contributed both to the temporary persistence of the cod boom and to its subsequent collapse. These features of the social-ecological system also would have limited the effectiveness of stronger fishery regulations. Our results provide quantitative, empirical evidence that incorporating social dynamics into models of natural resources is critical for understanding how resources can be managed sustainably. We also show that generalized modeling, which is well-suited to collaborative model development and does not require detailed specification of causal relationships between system variables, can help tackle the complexities involved in creating and analyzing social-ecological models.

We give a new explanation for why some biological systems can stay quantum coherent for a long time at room temperature, one of the fundamental puzzles of quantum biology. We show that systems with the right level of complexity between chaos and regularity can increase their coherence time by orders of magnitude. Systems near Critical Quantum Chaos or Metal-Insulator Transition (MIT) can have long coherence times and coherent transport at the same time. The new theory tested in a realistic light harvesting system model can reproduce the scaling of critical fluctuations reported in recent experiments. Scaling of return probability in the FMO light harvesting complex shows the signs of universal return probability decay observed at critical MIT. The results may open up new possibilities to design low loss energy and information transport systems in this Poised Realm hovering reversibly between quantum coherence and classicality.

We present a multi-model ensemble study for the Baltic Sea, and investigate the combined impact of changing climate, external nutrient supply, and fisheries on the marine ecosystem. The applied regional climate system model contains state-of-the-art component models for the atmosphere, sea ice, ocean, land surface, terrestrial and marine biogeochemistry, and marine food-web. Time-dependent scenario simulations for the period 1960-2100 are performed and uncertainties of future projections are estimated. In addition, reconstructions since 1850 are carried out to evaluate the models sensitivity to external stressors on long time scales. Information from scenario simulations are used to support decision-makers and stakeholders and to raise awareness of climate change, environmental problems, and possible abatement strategies among the general public using geovisualization. It is concluded that the study results are relevant for the Baltic Sea Action Plan of the Helsinki Commission.

Changes in climate, in combination with intensive exploitation of marine resources, have caused large-scale reorganizations in many of the world's marine ecosystems during the past decades. The Baltic Sea in Northern Europe is one of the systems most affected. In addition to being exposed to persistent eutrophication, intensive fishing, and one of the world's fastest rates of warming in the last two decades of the 20th century, accelerated climate change including atmospheric warming and changes in precipitation is projected for this region during the 21st century. Here, we used a new multimodel approach to project how the interaction of climate, nutrient loads, and cod fishing may affect the future of the open Central Baltic Sea food web. Regionally downscaled global climate scenarios were, in combination with three nutrient load scenarios, used to drive an ensemble of three regional biogeochemical models (BGMs). An Ecopath with Ecosim food web model was then forced with the BGM results from different nutrient-climate scenarios in combination with two different cod fishing scenarios. The results showed that regional management is likely to play a major role in determining the future of the Baltic Sea ecosystem. By the end of the 21st century, for example, the combination of intensive cod fishing and high nutrient loads projected a strongly eutrophicated and sprat-dominated ecosystem, whereas low cod fishing in combination with low nutrient loads resulted in a cod-dominated ecosystem with eutrophication levels close to present. Also, nonlinearities were observed in the sensitivity of different trophic groups to nutrient loads or fishing depending on the combination of the two. Finally, many climate variables and species biomasses were projected to levels unseen in the past. Hence, the risk for ecological surprises needs to be addressed, particularly when the results are discussed in the ecosystem-based management context., (© 2013 John Wiley & Sons Ltd.)

Several marine ecosystems under anthropogenic pressure have experienced shifts from one ecological state to another. In the central Baltic Sea, the regime shift of the 1980s has been associated with food-web reorganization and redirection of energy flow pathways. These long-term dynamics from 1974 to 2006 have been simulated here using a food-web model forced by climate and fishing. Ecological network analysis was performed to calculate indices of ecosystem change. The model replicated the regime shift. The analyses of indicators suggested that the system's resilience was higher prior to 1988 and lower thereafter. The ecosystem topology also changed from a web-like structure to a linearized food-web.

Natural resource management requires approaches to understand and handle sources of uncertainty in future responses of complex systems to human activities. Here we present one such approach, the "biological ensemble modeling approach," using the Eastern Baltic cod (Gadus morhua callarias) as an example. The core of the approach is to expose an ensemble of models with different ecological assumptions to climate forcing, using multiple realizations of each climate scenario. We simulated the long-term response of cod to future fishing and climate change in seven ecological models ranging from single-species to food web models. These models were analyzed using the "biological ensemble modeling approach" by which we (1) identified a key ecological mechanism explaining the differences in simulated cod responses between models, (2) disentangled the uncertainty caused by differences in ecological model assumptions from the statistical uncertainty of future climate, and (3) identified results common for the whole model ensemble. Species interactions greatly influenced the simulated response of cod to fishing and climate, as well as the degree to which the statistical uncertainty of climate trajectories carried through to uncertainty of cod responses. Models ignoring the feedback from prey on cod showed large interannual fluctuations in cod dynamics and were more sensitive to the underlying uncertainty of climate forcing than models accounting for such stabilizing predator-prey feedbacks. Yet in all models, intense fishing prevented recovery, and climate change further decreased the cod population. Our study demonstrates how the biological ensemble modeling approach makes it possible to evaluate the relative importance of different sources of uncertainty in future species responses, as well as to seek scientific conclusions and sustainable management solutions robust to uncertainty of food web processes in the face of climate change.

Understanding how climate change, exploitation and eutrophication will affect populations and ecosystems of the Baltic Sea can be facilitated with models which realistically combine these forcings into common frameworks. Here, we evaluate sensitivity of fish recruitment and population dynamics to past and future environmental forcings provided by three ocean-biogeochemical models of the Baltic Sea. Modeled temperature explained nearly as much variability in reproductive success of sprat (Sprattus sprattus; Clupeidae) as measured temperatures during 1973-2005, and both the spawner biomass and the temperature have influenced recruitment for at least 50 years. The three Baltic Sea models estimate relatively similar developments (increases) in biomass and fishery yield during twenty-first century climate change (ca. 28 % range among models). However, this uncertainty is exceeded by the one associated with the fish population model, and by the source of global climate data used by regional models. Knowledge of processes and biases could reduce these uncertainties.

Models that can project ecosystem dynamics under changing environmental conditions are in high demand. The application of such models, however, requires model validation together with analyses of model uncertainties, which are both often overlooked. We carried out a simplified model uncertainty and sensitivity analysis on an Ecopath with Ecosim food-web model of the Baltic Proper (BaltProWeb) and found the model sensitive to both variations in the input data of pre-identified key groups and environmental forcing. Model uncertainties grew particularly high in future climate change scenarios. For example, cod fishery recommendations that resulted in viable stocks in the original model failed after data uncertainties were introduced. In addition, addressing the trophic control dynamics produced by the food-web model proved as a useful tool for both model validation, and for studying the food-web function. These results indicate that presenting model uncertainties is necessary to alleviate ecological surprises in marine ecosystem management.

Does the post-WWII burial at sea of chemical weapons still pose a human and environmental risk?

The goal of this study is to present the experiences gathered from the migration of an existing and deployed joint replacement surgery information system from a classical 2-tier architecture to a 4-tier architecture. These include discussion on the motivation for the migration and on the technical benefits of the chosen technical migration path and an evaluation of user experiences. The results from the analysis of clinical end-user and administrator experiences show an increase in the perceived performance and maintainability of the system and a high level of acceptance for the new system version.

Objective: In this study we sought to develop a comparative cost evaluation between conventional and new media, e.g. web, mobile communication technology and digital television, and near patient testing supported anticoagulant (ac) treatment follow-up in a primary health care setting., Method: The comparison was done for two patient groups, self-care and home-care patients, on oral ac treatment in the primary health care centre of the rural and sparsely populated municipality of Ikaalinen. In practise case analysis was used to develop cost functions from collected economic data, which were analysed to determine the break-even point in total cost between conventional and new media supported follow-up for the two patient groups., Results: In the home-care setting the break-even point is 14 patients; in the self-care setting new media supported follow-up is always more cost-effective., Conclusion: The results illustrate that the use of new media and near patient testing in ac treatment follow-up brings about an economic benefit even with a small number of patients in the Ikaalinen setting. However, the sensitivity of break-even to perturbations in the individual costs of the used economic models remains high. Still, when the economic benefits are considered together with the clinical and practical benefits shown to result from self-testing, self-management and use of new media technologies the new service models can be said to provide noticeable benefits both in terms of quality of care and economics in our specific setting.

The purpose of our study was to develop a generic reference model for home telecare in a digital television environment and to suggest how it might be deployed at a test village. We describe here an architecture based on digital video broadcast standards, its components, services, and required additional technical solutions to provide a unified home telecare solution. We also suggest different user groups within the village context and possible service scenarios for them. We conclude that, in general, digital television provides a potentially flexible and promising platform for home telecare services.

Objective: To determine the feasibility of a more personal anticoagulant treatment follow-up routine involving the use of a personal measurement device along with the new media (e.g. the Internet)., Design: A telephone interview., Setting: The municipality of Ikaalinen with a total population of 7795., Subjects: Forty patients on anticoagulant treatment who have personal responsibility for their treatment follow-up., Main Outcome Measures: Demographic data, data and opinions on anticoagulant treatment and data and opinions on personal health care and the new media., Results: More than two-thirds of the interviewed were generally pleased with the current AC treatment routine in the Ikaalinen area. Sixty-eight percent of the patients feel that they are able to determine the anticoagulant dosage from the follow-up test results and almost a third have independently changed their dosage. Approximately half of the interviewed were willing to take various health-related measurements at home, but approximately only 20% of the interviewed were ready to use health-related services; for example, related to the follow-up of anticoagulant treatment, through the new media., Conclusion: Part of the population receiving anticoagulant treatment is ready to move to a more personal treatment routine involving home measurements in follow-up tests. However, most interviewed patients were not interested in using the new media as part of the new routine.

The primary objective of this study is to evaluate a sample of health-related services available on the internet. In addition, types of new services and service qualities that may be required in the future were estimated. A registered nurse using a questionnaire containing items about usability, quality, and other characteristics related to the subject carried out an evaluation of 100 health-related internet sites, and the results were processed to determine average qualities and graphical presentations for the studied parameters. The services studied differed greatly from each other both in terms of content and quality. A general observation was that sites of larger organizations were, typically, both in terms of presentation and content, more sophisticated than sites of smaller producers. A typical characteristic was the superficiality of the information presented. In conclusion, the internet is an emerging medium for health-related information, and standards for the production and presentation of health content for the internet are still in development. However, even at this early stage, the internet represents a valuable source of information for those in need of health-related information for both health care professionals and consumers.