Lars Hein

Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial.

Objective:For patients in intensive care units, sepsis is a common and potentially deadly complication and prompt initiation of appropriate antimicrobial therapy improves prognosis. The objective of this trial was to determine whether a strategy of antimicrobial spectrum escalation, guided by daily measurements of the biomarker procalcitonin, could reduce the time to appropriate therapy, thus improving survival. Design:Randomized controlled open-label trial. Setting:Nine multidisciplinary intensive care units across Denmark. Patients:A total of 1,200 critically ill patients were included after meeting the following eligibility requirements: expected intensive care unit stay of ≥24 hrs, nonpregnant, judged to not be harmed by blood sampling, bilirubin <40 mg/dL, and triglycerides <1000 mg/dL (not suspensive). Interventions:Patients were randomized either to the “standard-of-care-only arm,” receiving treatment according to the current international guidelines and blinded to procalcitonin levels, or to the “procalcitonin arm,” in which current guidelines were supplemented with a drug-escalation algorithm and intensified diagnostics based on daily procalcitonin measurements. Measurements and Main Results:The primary end point was death from any cause at day 28; this occurred for 31.5% (190 of 604) patients in the procalcitonin arm and for 32.0% (191 of 596) patients in the standard-of-care-only arm (absolute risk reduction, 0.6%; 95% confidence interval [CI] −4.7% to 5.9%). Length of stay in the intensive care unit was increased by one day (p = .004) in the procalcitonin arm, the rate of mechanical ventilation per day in the intensive care unit increased 4.9% (95% CI, 3.0–6.7%), and the relative risk of days with estimated glomerular filtration rate <60 mL/min/1.73 m2 was 1.21 (95% CI, 1.15–1.27). Conclusions:Procalcitonin-guided antimicrobial escalation in the intensive care unit did not improve survival and did lead to organ-related harm and prolonged admission to the intensive care unit. The procalcitonin strategy like the one used in this trial cannot be recommended.

A multi - scale modelling approach for analysing landscape service dynamics

Shifting societal needs drive and shape landscapes and the provision of their services. This paper presents a modelling approach to visualize the regional spatial and temporal dynamics in landscape service supply as a function of changing landscapes and societal demand. This changing demand can result from different policy targets. In this paper we conceptualise the system in which these dynamics take place by explicitly addressing (i) the multifunctional character of a landscape, (ii) the different spatial levels at which interactions between landscape service supply, demand, and land management occur, and (iii) trade-offs in service supply as a result of land management actions. Next, we translate the resulting conceptual framework into an operational model. As a demonstration, this model is applied to simulate changes in landscape service supply driven by regional policies in a rural region of the Netherlands. This application demonstrates potential trade-offs, which emerge in a spatially explicit way in the region over time. It illustrates the potential relevance of modelling landscape service dynamics for environmental management and decision making.

Market-based mechanisms for biodiversity conservation: a review of existing schemes and an outline for a global mechanism

Continuous decline of biodiversity over the past decades suggests that efforts to decrease biodiversity loss have been insufficient. One option to deal with this problem is the use of market-based mechanisms for biodiversity conservation. Several studies have analysed such mechanisms individually, but there is no comprehensive review with a comparative assessment of the performance of various mechanisms. This paper presents (i) an analysis of the economic conditions under which markets for biodiversity can be expected to function; (ii) an analysis of the efficiency of five selected biodiversity markets in the light of market and contract theory; and (iii) an assessment of the potential to scale up local or national payment mechanisms for biodiversity conservation. Our analysis shows the difficulties that market-based mechanisms face, among which are the need to ensure long-term conservation and the lack of a standardized unit of measurement for biodiversity. We provide a number of recommendations on how to overcome these difficulties. We argue that the set-up of a global registry embedded within the framework of the Convention on Biological Diversity would facilitate measurement, reporting and verification of biodiversity credits to support market-based mechanisms.

Economic Benefits Generated by Protected Areas: the Case of the Hoge Veluwe Forest, the Netherlands

Eliciting the economic benefits provided by protected areas is important in order to ensure that they are properly considered in policy and decision making. There are relatively few studies that provide a comprehensive overview of the economic benefits provided by European forest ecosystems, in spite of the large share of forests in the protected area system in most countries. An economic valuation of the ecosystem services supplied by the Hoge Veluwe forest in the Netherlands is presented. The Hoge Veluwe forest is one of the largest and most well-known protected areas in the country. The services included in the study are wood production, supply of game, groundwater recharge, carbon sequestration, air filtration, recreation, and nature conservation. A conservative estimate of the total economic benefits generated by the forest is around 2000 Euro/ha/year, which is more than three times higher than the per hectare-value generated by nearby agricultural land. The study provides an analysis of the economic value of eight ecosystem services, discusses the uncertainties of the value estimates, and examines the implications for financing protected area management.

To Value Functions or Services? An Analysis of Ecosystem Valuation Approaches

Monetary valuation of ecosystem services is a widely used approach to quantify the benefits supplied by the natural environment to society. An alternative approach is the monetary valuation of ecosystem functions, which is defined as the capacity of the ecosystem to supply services. Using two European case-study areas, this paper explores the relative advantages of the two valuation approaches. This is done using a conceptual analysis, a qualitative application, and an overall comparison of both approaches. It is concluded that both approaches can be defended on theoretical grounds, and - if properly applied - will provide the same value estimates. However, valuation of ecosystem services is preferred from a practical point of view. Because there is no one-to-one match between functions and services, researchers should be consistent in their valuation approach. To avoid overlooking or overlapping of values, valuation should either be solely based on functions, or solely based on services.

Mapping Ecosystem Services for Land Use Planning, the Case of Central Kalimantan

Abstract Indonesia is subject to rapid land use change. One of the main causes for the conversion of land is the rapid expansion of the oil palm sector. Land use change involves a progressive loss of forest cover, with major impacts on biodiversity and global CO2 emissions. Ecosystem services have been proposed as a concept that would facilitate the identification of sustainable land management options, however, the scale of land conversion and its spatial diversity pose particular challenges in Indonesia. The objective of this paper is to analyze how ecosystem services can be mapped at the provincial scale, focusing on Central Kalimantan, and to examine how ecosystem services maps can be used for a land use planning. Central Kalimantan is subject to rapid deforestation including the loss of peatland forests and the provincial still lacks a comprehensive land use plan. We examine how seven key ecosystem services can be mapped and modeled at the provincial scale, using a variety of models, and how large scale ecosystem services maps can support the identification of options for sustainable expansion of palm oil production.

The Impact of First-Generation Biofuels on the Depletion of the Global Phosphorus Reserve

The large majority of biofuels to date is “first-generation” biofuel made from agricultural commodities. All first-generation biofuel production systems require phosphorus (P) fertilization. P is an essential plant nutrient, yet global reserves are finite. We argue that committing scarce P to biofuel production involves a trade-off between climate change mitigation and future food production. We examine biofuel production from seven types of feedstock, and find that biofuels at present consume around 2% of the global inorganic P fertilizer production. For all examined biofuels, with the possible exception of sugarcane, the contribution to P depletion exceeds the contribution to mitigating climate change. The relative benefits of biofuels can be increased through enhanced recycling of P, but high increases in P efficiency are required to balance climate change mitigation and P depletion impacts. We conclude that, with the current production systems, the production of first-generation biofuels compromises food production in the future.

Profound endothelial damage predicts impending organ failure and death in sepsis.

Endothelial damage contributes to organ failure and mortality in sepsis, but the extent of the contribution remains poorly quantified. Here, we examine the association between biomarkers of superficial and profound endothelial damage (syndecan-1 and soluble thrombomodulin [sTM], respectively), organ failure, and death in sepsis. The data from a clinical trial, including critically ill patients predominantly suffering sepsis (Clinicaltrials.gov: NCT00271752) were studied. Syndecan-1 and sTM levels at the time of study enrollment were determined. The predictive ability of biomarker levels on death and organ failures during follow-up were assessed in Cox models adjusted for potential confounders including key organ dysfunction measures assessed at enrollment. Of the 1,103 included patients, 418 died. sTM levels at the time of enrollment independently predicted risk of death in adjusted models (hazard ratio [HR] [highest quartile > 14 ng/mL vs. lowest quartile < 7 ng/mL] 2.2 [95% confidence interval [CI]: 1.2-4.0], p = 0.02, respectively). Conversely, syndecan-1 levels failed to predict death (adjusted HR [> 240 vs. < 70 ng/mL] 1.0 [95% CI: 0.6-1.5], p = 0.67). sTM but not syndecan-1 levels at enrollment predicted risk of multiple organ failure during follow-up (HR [> 14 ng/mL vs. < 7 ng/mL] 3.5 [95% CI: 1.5-8.3], p = 0.005 and 2.0 [95% CI: 0.8-5.0], p = 0.1321, respectively). Profound damage to the endothelium independently predicts risk of multiple organ failure and death in septic patients. Our findings also suggest that the detrimental effect of profound endothelial damage on risk of death operates via mechanisms other than causing organ failures per se. Therefore, damage to the endothelium appears centrally involved in the pathogenesis of death in sepsis and could be a target for intervention.

Hydrological and economic effects of oil palm cultivation in Indonesian peatlands

Oil palm has increasingly been established on peatlands throughout Indonesia. One of the concerns is that the drainage required for cultivating oil palm in peatlands leads to soil subsidence, potentially increasing future flood risks. This study analyzes the hydrological and economic effects of oil palm production in a peat landscape in Central Kalimantan. We examine two land use scenarios, one involving conversion of the complete landscape including a large peat area to oil palm plantations, and another involving mixed land use including oil palm plantations, jelutung (jungle rubber; (Dyera spp.) plantations, and natural forest. The hydrological effect was analyzed through flood risk modeling using a high-resolution digital elevation model. For the economic analysis, we analyzed four ecosystem services: oil palm production, jelutung production, carbon sequestration, and orangutan habitat. This study shows that after 100 years, in the oil palm scenario, about 67% of peat in the study area will be subject to regular flooding. The flood-prone area will be unsuitable for oil palm and other crops requiring drained soils. The oil palm scenario is the most profitable only in the short term and when the externalities of oil palm production, i.e., the costs of CO2 emissions, are not considered. In the examined scenarios, the social costs of carbon emissions exceed the private benefits from oil palm plantations in peat. Depending upon the local hydrology, income from jelutung, which can sustainably be grown in undrained conditions and does not lead to soil subsidence, outweighs that from oil palm after several decades. These findings illustrate the trade-offs faced at present in Indonesian peatland management and point to economic advantages of an approach that involves expansion of oil palm on mineral lands while conserving natural peat forests and using degraded peat for crops that do not require drainage.

Defining ecosystem assets for natural capital accounting

In natural capital accounting, ecosystems are assets that provide ecosystem services to people. Assets can be measured using both physical and monetary units. In the international System of Environmental-Economic Accounting, ecosystem assets are generally valued on the basis of the net present value of the expected flow of ecosystem services. In this paper we argue that several additional conceptualisations of ecosystem assets are needed to understand ecosystems as assets, in support of ecosystem assessments, ecosystem accounting and ecosystem management. In particular, we define ecosystems’ capacity and capability to supply ecosystem services, as well as the potential supply of ecosystem services. Capacity relates to sustainable use levels of multiple ecosystem services, capability involves prioritising the use of one ecosystem service over a basket of services, and potential supply considers the ability of ecosystems to generate services regardless of demand for these services. We ground our definitions in the ecosystem services and accounting literature, and illustrate and compare the concepts of flow, capacity, capability, and potential supply with a range of conceptual and real-world examples drawn from case studies in Europe and North America. Our paper contributes to the development of measurement frameworks for natural capital to support environmental accounting and other assessment frameworks.