Climate change adaptation with limited resources: adaptive capacity and action in small- and medium-sized municipalities

Administrations in small- and medium-sized municipalities (SMM) are confronted with the impacts of climate change while having inadequate resources to adapt. In order to establish the current state of research on climate change adaptation in SMM, a systematic literature review was conducted. Using reported SMM adaptation in the peer-reviewed literature as our data base, we documented 115 adaptation initiatives between 2015 and 2021 matching our criteria, with substantial geographical and thematic differences. The qualitative analysis of highly relevant articles has shown that the specific understanding about the challenges and barriers of climate change adaptation in SMM remains limited. We highlight recent key trends and challenges and conclude by offering a refined research agenda for addressing identified knowledge gaps as well as key barriers in relation to SMM adaptation.

[Intractable cancer pain as a reason for referral : Analysis of pain etiology and previous drug treatment.]

Many studies have demonstrated that cancer pain can be relieved in most cases by suitable analgesic medication. Patients with a diagnosis of "intractable cancer pain", however, are referred to our pain clinic nearly every day. A retrospective study of 1140 patients was therefore performed to evaluate the pain mechanisms and whether analgesic pretreatment had been adequate. Half of the patients (53%) were suffering from pain at more than one site. The most frequent locations were the back (36% of the patients), abdomen (30%), and the thoracic (22%) region. The main pain etiologies were compression or infiltration of pain-sensitive structures by the tumor (84% of the patients), and less frequently oncological treatment (18%), debilitating disease (10%), or causes unrelated to tumor or therapy (9%). Pain could be classified with almost equal frequency as neuropathic, visceral, soft tissue-related, or bone-related. Upon admission to our pain clinic, most patients (86%) indicated pain of severe intensity. The principal causes for the inadequacy of the analgesic pretreatment were: failure to prescribe analgesics (10% of the patients), irregular intake schedule or prolonged intervals between applications (66%), underdosage of nonopioid analgesics (27%) or opioids (42%), and withholding of nonopioid analgesics (30%), strong opioids (14%), or co-analgesic drugs (17%), although their prescription was indicated. The severe pain was thus caused in many patients by simple mistakes in the prescription of analgesics. Terms like "intractable" should be used with caution when referring to cancer pain because they are often unreflected and can make patients and physicians feel helpless or insecure.

Lactated Ringer's solution versus hydroxyethyl starch for volume replacement in autologous blood donors with cardiovascular disease: a controlled, randomized trial

BACKGROUND AND OBJECTIVES

The study was designed to evaluate whether volume replacement following blood donation can prevent arterial hypotension in autologous blood donors with cardiovascular disease.

MATERIALS AND METHODS

One hundred nineteen autologous blood donors with known cardiovascular disease were randomly allocated to receive, following withdrawal of 500 ml of blood, either no infusion (control group) or a 25 ml/min intravenous infusion of either 1,500 ml of lactated Ringer's solution (LRS) or 500 ml of 6% hydroxyethyl starch (HES). Starting before phlebotomy, arterial blood pressure was measured oscillometrically every 5 min until 90 min after donation.

RESULTS

Group means showed little difference between the groups in blood pressure throughout the monitoring period. The proportion of patients who at least once had a > or = 20% decrease from baseline in systolic blood pressure was 3-5 times greater in the control group than in the LRS and the HES group (50 vs. 10 and 15%, respectively; p < 0.001 on chi 2 analysis for a 2 x 3 table). Systolic hypertensive episodes (> or = 20% increase over baseline) were observed more frequently in the LRS group than in the control and the HES group (41 vs. 10 and 18%, respectively; p = 0.003).

CONCLUSION

Both LRS and HES, administered at a volume ratio to blood loss of 3:1 and 1:1, respectively, significantly reduced the incidence of systolic hypotensive episodes in autologous blood donors with cardiovascular disease. LRS at a 3:1 volume ratio to blood loss was associated with a high rate of systolic hypertension.

[The importance of autologous blood transfusion in the Federal Republic of Germany. Results of a survey carried out in 1989]

The study was designed to evaluate the role of autologous blood transfusion in current clinical practice. METHODS. Standardized questionnaires were distributed to the anesthesia departments of 421 randomly selected hospitals in the 'old' Federal Republic of Germany and West Berlin in August 1989. The questionnaires contained 26 questions relating to (1) the particular hospital, (2) preoperative autologous blood donation (PABD), (3) preoperative plasmapheresis, (4) isovolemic hemodilution, (5) intra- and postoperative autotransfusion, (6) general practice followed in blood transfusion, and (7) blood salvage in children. RESULTS. In all, 207 completed questionnaires (49%) were returned, 12% of which came from university hospitals, 25% from hospitals with more than 500 beds, 58% from hospitals with fewer than 500 beds and 5% from smaller specialized hospitals. Over half (52%) of the responding hospitals were running their own transfusion services or were located in the vicinity of a regional blood bank. The overall proportion of surgical procedures requiring perioperative blood transfusions was 10%. PABD was performed "not at all" in 24% of the hospitals, "rarely" in 28%, "occasionally" in 24%, "frequently" in 10%, and "routinely" in 13%. PABD was standard in 75% of the departments of orthopedic surgery, in 68% of the departments of cardiac surgery, and in 33% of the departments of vascular surgery. In two-thirds of the hospitals reporting the use of PABD, the anesthesia departments were in charge of the autologous blood service. For 64% of the hospitals, liquid storage of whole blood was reported as the standard technique. Patients normally not eligible for homologous blood donation according to established donor criteria were accepted for autologous blood donation at most "occasionally" in 60% of the hospitals, but "frequently" or "mostly" in 36%. Preoperative autologous plasmapheresis was performed when major intraoperative blood loss was anticipated in 12% of the hospitals. Isovolemic hemodilution was performed "not at all" in 30% of the hospitals, "rarely" in 17%, "occasionally" in 25%, "frequently" in 14%, and "mostly" in 12%. The reasons most frequently given for not performing hemodilution were "too time-consuming" (41%) and "too little blood-saving effect" (32%). Autotransfusion devices were available in 40% of the hospitals. Others deemed such devices "badly needed" (5%) or "desirable" (43%), while 45% found them "not necessary." The principal use of intraoperative autotransfusion was in cardiac surgery (79% of the departments), orthopedics (47% of the departments) and vascular surgery (45% of the departments). In 29% of the responding hospitals autotransfusion devices were also used for postoperative autotransfusion ("seldom" in 7%, "occasionally" in 10%, "frequently" in 6%, "mostly" in 6%). In the absence of cardiopulmonary disease, hemoglobin concentrations below 8-10 g/dl were considered an indication for blood transfusion. In patients with compromised cardiopulmonary function the lowest acceptable level was 10-12 g/dl. Blood salvage techniques are obviously rarely used in children. Experiences with PABD in children were reported by 14.5% of the hospitals, experience with isovolemic hemodilution by 22% and with intra- and postoperative autotransfusion in 18% and 12.5% of the hospitals, respectively. Preoperative plasmapheresis was performed in children in 3.5% of the hospitals. CONCLUSIONS. Although the present sample is not representative on a national level, our findings allow the conclusion that the simple techniques of both preoperative autologous blood donation and isovolemic hemodilution are unduly neglected in surgical and anesthetic practice, whereas even smaller hospitals are fairly well equipped with sophisticated autotransfusion devices.

[Preoperative autologous blood donation and intraoperative autotransfusion in first implantation of hip endoprostheses--a retrospective study]

The records of a total of 102 patients who underwent primary total hip replacement during 1987-88 were evaluated retrospectively. 36 patients had donated 1-3 units of whole blood preoperatively. Surgery was performed with the use of a device for intraoperative autotransfusion (IAT). Another 25 patients without preoperative autologous blood donation were operated with the use of IAT. None of these techniques was available for the remaining 41 patients. The mean perioperative blood loss and the mean volume of transfused blood were 1400 ml and 1000 ml respectively. Equal quantities of blood were lost intra- and postoperatively, whereas only one fifth of transfused blood was given intraoperatively. Homologous blood transfusion was not required in 32% of the patients for whom autologous blood was not available. However after preoperative autologous blood donation, 95% of the 2-unit donors and 100% of the 3-unit donors could be operated without homologous blood transfusion. Autologous blood donation did not increase the need for homologous blood transfusions. With the use of IAT it was only 20% of the patients that at least 500 ml of blood were salvaged for retransfusion. On the basis of these findings, elective primary total hip replacement would seem to be the ideal operation to be performed after preoperative autologous blood donation and, whenever possible with the use of IAT. The desirable ratio of 1,5:1 for the units of blood to be crossmatched preoperatively vs. units transfused perioperatively can be achieved solely by preoperative donation of 3 units of autologous blood.

[Blood loss and the need for homologous blood transfusion in elective general surgery as a basis for indications for preoperative autologous blood donation]

The records of 279 surgical patients of 1986 were retrospectively evaluated for blood loss and blood-transfusion in order to provide a basis for an autologous blood donation program. 90% of the large bowel resections, gastrectomy and peripheral artery interventions with a blood loss between 0.5 and 1.51 could have been performed with the sole use of autologous blood. 50% of the operations of the abdominal aorta and all operations of the oesophagus would have required the additional use of other autotransfusion techniques or homologous blood transfusions.