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Abstract Background Besides the importance of estimating the global economic impact of care for persons with dementia, there is an emerging need to identify the key factors associated with this cost. The aim of this study was to analyze associations between the cost of care in community-dwelling persons with dementia and caregiver characteristics from both the healthcare third party payer perspective and the societal perspective. Methods Several characteristics based on the cross-sectional data of 355 dyads of informal caregivers and persons with dementia living in Belgium were identified to include in a log-gamma generalized linear model and were used in a multiple linear regression model with bootstrapping to test robustness. Results The mean monthly cost of care for a community-dwelling person with dementia was estimated at € 2339 (95% CI € 2133 – € 2545) per person from a societal perspective and at € 968 (95% CI € 825 – € 1111) per person from a third party payer viewpoint. Informal care accounted for the majority of the monthly costs from the societal perspective. Community based healthcare resource use represented the largest cost from the third party perspective. According to the regression analyses, a higher level of functional dependency of the person with dementia and a higher educational level of the caregiver were associated with a higher monthly cost from both a third party payer perspective and a societal perspective. In addition, being retired and a higher quality of life in the caregivers were associated with a lower monthly cost of care from the societal perspective. Conclusions Several characteristics of the caregiver and the person with dementia were associated with the monthly costs of care from a third party payer and a societal perspective. Despite the lack of clear causal relationships, the results of this study can assist policy makers in planning and financing future dementia care. Trial registration Clinicaltrials.gov NCT02630446, December 15, 2015.

Viking Age ring fortresses were some of the largest construction projects in Danish prehistory. In this article we reconstruct the amount of turf and timber used in the construction of the Borgring ring fortress and estimate the resource area needed to supply the building materials. Using REVEALS pollen data modelling, we quantify the regional oak land cover and estimate the resource area. The results show that even though Borgring was built in an open cultural landscape, sufficient supply of oak for the construction would have been accessible within a few kilometres from the fortress.

Abstract Invasion of non‐native species might alter food web structure and the strength of top‐down control within lake ecosystems. As top‐down control exerted by fish populations is often dominated by young of the year fish, the impact of new fish species might depend on the feeding rates of the juvenile fish. Here we provide comparative analyses of feeding rates of juvenile whitefish (Coregonus wartmanni) – a native and specialised planktivore and an invasive generalist (sticklebacks, Gasterosteus aculeatus). We studied feedings rates of whitefish and sticklebacks in aquaria experiments using 2 cm to 8 cm fish feeding on seven zooplankton species common to Lake Constance. As whitefish hatch several months earlier than sticklebacks, 0+ whitefish are larger than 0+ sticklebacks throughout the year and hence are predicted to have higher feeding rates on especially large zooplankton species. We show that sticklebacks as small as 2 cm were able to feed on the largest zooplankton species of Lake Constance. Further, stickleback feeding rates were similar to both the same size 0+ whitefish and the larger 0+ whitefish co‐occurring with smaller 0+ sticklebacks. Hence, 0+ sticklebacks will compete with 0+ whitefish for the same zooplankton species, therefore the invasion of sticklebacks is unlikely to change the relative feeding pressure by individual 0+ fish on zooplankton species.

Abstract Background Diabetic foot ulcers not only have a negative impact on patient mortality, morbidity and quality of life, but also require high resource utilization to achieve complete wound healing. The aim of this evaluation was to compare resource utilization of negative pressure wound therapy (NPWT) and standard moist wound care (SMWC) for diabetic foot wounds after amputation, surgical debridement or wound cleansing. Methods The multicenter clinical DiaFu study enrolled 368 adults with diabetic foot ulcers between December 23, 2011 and October 21, 2014. Patients were randomly assigned to NPWT and SMWC. Evaluation of direct resource use comprised inpatient and outpatient treatment time, and personnel and material for wound treatment within 16 weeks. This resource use analysis was primarily based on the per protocol population (NPWT 44; SMWC 110). Results Treatment duration was 16 days shorter with NPWT (mean (SD) 82.8 (31.6), SMWC 98.8 (24.6); U test, p = 0.001) with 14.9 days shorter outpatient treatment (mean (SD) NPWT 68.3 (31.1), SMWC 83.2 (29.7)). The number of dressing changes per study participant was lower with NPWT (mean (SD) 35.1 (18.6), SMWC (42.9 (21.4); U test, p = 0.067). Time per dressing change was significantly lower with SMWC (mean (SD) 19.7 (12.8), NPWT (16.5 (8.2) minutes; U test, p

(1) Background: In the mHeart trial, we showed that an eHealth intervention, mHeart, improved heart transplant (HTx) recipients’ adherence to immunosuppressive therapy compared with the standard of care. Herein, we present the analysis assessing whether mHeart reduces complication frequency and healthcare resource use, and whether this reduction depends on patients’ adherence. (2) Methods: The mHeart was a single-center randomized-controlled trial (IIBSP-MHE-2014-55) in 134 adult HTx recipients (n = 71 intervention; n = 63 controls). The endpoints were mortality, complications, and resource use during follow-up (mean 1.6 ± 0.6 years). (3) Results: A significantly lower proportion of HTx recipients in mHeart had echocardiographic alteration (2.8% vs. 13.8%; p = 0.02), cardiovascular events (0.35% vs. 2.4%; p = 0.006), infections (17.2% vs. 56%; p = 0.03), and uncontrolled Hba1c (40.8% vs. 59.6%; p = 0.03) than controls. In addition, a significantly lower proportion of patients in the intervention needed hospital (32.4% vs. 56.9%; p = 0.004) or urgent admissions (16.9% vs. 41.4%; p = 0.002) and emergency room visits (50.7% vs. 69.0%; p = 0.03). Adherence status (measured by the self-reported SMAQ) influenced only controls regarding hospitalizations and emergency room visits. Differences were not significant on deaths (intervention 4.2% vs. control 9.5%; p = 0.4) (4) Conclusions: the mHeart strategy significantly reduced the occurrence of the studied post-transplant complications and the need for medical attention in HTx recipients. Adherence status influenced controls in their need for medical care.

Abstract Background Investigator-led multicentre randomised trials are essential to generate evidence on the optimal use of medical interventions. These non-commercial trials are often hampered by underfunding, which may lead to difficulties in gathering a team with the necessary expertise, a delayed trial start, slow recruitment and even early trial discontinuation. As a new public funder of pragmatic clinical trials, the KCE Trials programme was committed to correctly pay all trial activities in order to assure timely delivery of high-quality trial results. As no appropriate trial budget tool was readily publicly available that took into account the costs for the sponsor as well as the costs for participating sites, we developed a tool to make the budgeting of a clinical trial efficient, transparent and fair across applicants. Methods All trial-related activities of the sponsor and sites were categorised, and cost drivers were identified. All elements were included in a spreadsheet tool allowing the sponsor team to calculate in detail the various activities of a clinical trial and to appreciate the budget impact of specific cost drivers, e.g. a delay in recruitment. Hourly fees by role were adapted from published data. Fixed amounts per activity were developed when appropriate. Results This publicly available tool has already been used for 17 trials funded since the start of the KCE Trials programme in 2016, and it continues to be used and improved. This budget tool is used together with additional risk-reducing measures such as a multistep selection process with advance payments, a recruitment feasibility check by sponsor and funder, a close monitoring of study progress and a milestone-based payment schedule with the last payment made when the manuscript is submitted. Conclusions The budget tool helps the KCE Trials programme to answer relevant research questions in a timely way, within budget and with high quality, a necessary condition to achieve impact of this programme for patients, clinical practice and healthcare payers.

Abstract Background Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in China. However, identifying patients has proved challenging, resulting in widespread under-diagnosis of the condition. We examined the prevalence of COPD diagnosis and COPD risk among adults in urban mainland China, the factors associated with having a COPD diagnosis or COPD risk, and the healthcare resource use and health outcomes of these groups compared with controls. Methods Respondents to the 2017 National Health and Wellness Survey in China (n = 19,994) were classified into three groups: ‘COPD Diagnosed’, ‘COPD Risk (undiagnosed)’, and Control (unaffected), based on their self-reported diagnosis and Lung Function Questionnaire (LFQ) score. The groups were characterised by sociodemographic, health-related quality of life (HRQoL), productivity impairment, and healthcare resource use. Pairwise comparisons (t tests and chi-squared tests) and multivariable regression analyses were used to investigate factors associated with being at risk of, or diagnosed with, COPD. Results 3320 (16.6%) respondents had a suspected risk of COPD but did not report receiving a diagnosis. This was projected to 105.3 million people, or 16.9% of adult urban Chinese. Of these respondents with an identified risk, only 554 (16.7%) were aware of COPD by name. Relative to those without COPD, those with a risk of COPD (undiagnosed) had significantly greater healthcare resource use, lower productivity and lower HRQoL not only compared to those without COPD, but also compared to people with a COPD diagnosis. Factors associated with increased odds of being at risk of COPD were older age, smoking, alcohol consumption, overweight BMI, occasional exercise, higher comorbidities, asthma diagnosis, being female, lower education, not being employed, and living in a high pollution province (p

Disparate resource use originating from phenology of biotic resources, abiotic conditions, and life cycles of exploiting organisms underscores the importance of research across time and space to guide management practices. Our goal was to evaluate resource use of northern bobwhite (Colinus virginianus; bobwhite) at two spatial scales and across three age classes, from hatching through a period of the postjuvenile molt. Our study was conducted at Tall Timbers Research Station, Tallahassee, FL, USA—situated in a landscape subjected to small scale (<20 ha) prescribed fires on a 2‐year fire rotation. We predicted prescribed fire, disking, and supplemental feeding would dictate resource use, but effects would depend on time since fire, brood age, and time of day. We predicted vegetation and temperature would govern roost use by broods, but these effects would also depend on age. We radio‐tracked 62 broods 21–35 times / week during May–October 2018 and 2019. Broods were less likely to use areas with large proportions of hardwood drains but favored sites with greater proportions of burned uplands, regardless of the time of day. Broods were less likely to use areas at greater distances from supplemental feed; this relationship had no interaction with age but was stronger later in the nesting season (>July 15). Broods were more likely to use areas with greater proportions of fallow fields during the day than for roosting. Broods used roosts with more woody cover and visual obscurity than at available sites. Roosts consisted of less grass and bare ground. However, these effects interacted with age; broods used sparser cover at older ages. Neonate broods were more likely to use cooler roosts with greater thermal stability, but this effect was reversed for juveniles. Broods may alter resource use with changes in vulnerabilities to threats such as thermal risks and predation. [ABSTRACT FROM AUTHOR]

Objectives: To estimate resource use and costs, including direct and indirect costs, in relation to levels of severity in individuals with Parkinson's disease (PD) in a Swedish setting. Materials and methods: Patients with idiopathic PD registered in the National Parkinson's Disease Patient Registry (PARKreg), with registrations of Hoehn and Yahr (H&Y) and "off time" in the Skåne Region, were included. Annual costs of healthcare contacts, drugs, formal and informal care, and productivity loss associated with PD were estimated using data from PARKreg linked with regional and national healthcare registers between 2013 and 2019. Results: In total, 960 patients and 1324 observations (patient‐years) were included. Total average cost per patient‐year was SEK 168,982 (EUR 15,958) and ranged from SEK 62,404 (EUR 5893) for H&Y stage I to SEK 1,056,324 (EUR 99,755) in H&Y stage V. The dominating part of total costs for early stages were indirect costs accounting for 50–60% while formal care made up for 55% and 81% of total costs in H&Y IV and V, respectively. Total mean costs for formal care, informal care, and productivity loss also increased with increasing off‐time. Conclusion: Advanced and late stages of PD are associated with significant societal costs as patients in those stages often require resource‐intensive and costly formal care. Thus, there are potential savings to be made, by optimizing the pharmacological and surgical symptomatic treatment of patients with advanced disease. [ABSTRACT FROM AUTHOR]

Aims: To evaluate the cost-effectiveness of adding prolonged-release (PR)-fampridine to best supportive care (BSC) versus BSC alone for the improvement of walking ability in patients with MS. Methods: A cost-utility analysis based on a Markov model was developed to model responders and timed 25-foot walk (T25FW) scores, accumulated costs, and quality-adjusted life-years (QALY) in adults with MS and Expanded Disability Status Scale (EDSS) scores between 4 and 7. The analysis was conducted from a Swedish societal perspective. Results: In the base-case analysis, PR-fampridine plus BSC led to a higher QALY gain than BSC alone. The largest direct cost was professional care provision followed by hospital inpatient stays while the indirect cost was the loss of earnings due to days off work. The incremental cost-effectiveness ratio (ICER) for PR-fampridine plus BSC compared with BSC alone was 57,109 Swedish Kronor (kr)/QALY (e5,607/QALY [1 kr = e0.0981762 on 8 April 2021] and $6,675/QALY [1 kr = $0.116890 on 8 April 2021]). All sensitivity analyses performed resulted in ICERs below 500,000 kr (e49,088 and $58,445). Limitations: Resource use data were not specific to the Swedish market. Conclusions: PR-fampridine represents a cost-effective treatment for MS-related walking impairment in Sweden, due to improvements in patients' quality of life and reduced healthcare resource utilization. [ABSTRACT FROM AUTHOR]

Background: The reasons for acute hospital admissions among people with Parkinson's disease are well documented. However, understanding of crises that are managed in the community is comparatively lacking. Most existing literature on the causes of crisis for people with Parkinson's disease (PwP) uses hospital data and excludes the individual's own perspective on the crisis trigger and the impact of the crisis on their care needs. Objective: To identify the causes and impact of crises in both community and hospital settings, from a patient and carer perspective. Methods: A total of 550 UK-based PwP and carers completed a survey on (a) their own personal experiences of crisis, and (b) their general awareness of potential crisis triggers for PwP. Results: In addition to well-recognised causes of crisis such as falls, events less widely associated with crisis were identified, including difficulties with activities of daily living and carer absence. The less-recognised crisis triggers tended to be managed more frequently in the community. Many of these community-based crises had a greater impact on care needs than the better-known causes of crisis that more frequently required hospital care. PwP and carer responses indicated a good general knowledge of potential crisis triggers. PwP were more aware of mental health issues and carers were more aware of cognitive impairment and issues with medications. Conclusion: These findings could improve care of Parkinson's by increasing understanding of crisis events from the patient and carer perspective, identifying under-recognised crisis triggers, and informing strategies for best recording symptoms from PwP and carers. [ABSTRACT FROM AUTHOR]

Consistent individual differences in behaviour, or personality, likely influence patterns of space use and resource use in wild animals. However, studies on personality-dependent space use in natural ecosystems remain rare due to the difficulty of obtaining paired data sets on spatial dynamics and repeated personality measures from marked animals. We used repeated standardized assays (open field, mirror image stimulation, flight initiation distance and behaviour in trap) to perform the first characterization of personality in a free-ranging population of golden-mantled ground squirrels, Callospermophilus lateralis. We then used multilevel modelling to determine whether personality influenced 95% home range size, 50% core area size, movement speed or use of a preferred resource ('perches', vision-enhancing prominences such as rocks, which enhance survival) in nature. Data collected over 3 years showed that individual squirrels consistently differed in activity, sociability, boldness and aggressiveness (adjusted repeatability 0.16–0.44) and that activity was correlated with sociability (posterior mean correlation [95% credible interval] = 0.65 [0.39, 0.87]). We did not find an effect of personality on home range size, but bolder individuals maintained larger core areas than shyer individuals. More active and bolder individuals moved faster under natural conditions compared to their less active and shyer conspecifics. Individuals that scored higher for all four personality traits had more perches in both their home ranges and core areas compared to individuals with lower personality scores. Our results are indicative of personality-dependent space use and resource use in this study system. We hope our study will inspire future research that links animal personality with spatial ecology to inform wildlife management in natural ecosystems. • Bolder individuals maintained larger core areas than shyer individuals. • More active and bolder individuals moved faster under natural conditions. • More proactive and sociable personality types had greater access to a preferred resource. • Among-individual variation in activity and sociability was positively correlated. • Our data support personality-dependent use of space and resources in nature. [ABSTRACT FROM AUTHOR]

We study the effect that neighboring parties have on the economic rents from owning the rights to a natural resource. Our application uses winning bid prices from state timber auctions in three western states. We model and show how differing nearby neighbors increase the costs and risks associated with purchasing certain rights. Consistent with our hypotheses, the winning bid price of state‐run timber auctions is inversely related to the length of the border that a third party shares with the harvesting area. The lower winning bid prices reflect an increase in the expected costs of protecting the rents due to the presence of potential third parties' challenges to property rights. We further test our model when there is third party demand for other uses to the timber such as a scenic view. The results consistently show that when third parties potentially threaten property rights, the winning bid decreases. [ABSTRACT FROM AUTHOR]

Featured Application: Integration of early palliative care improves quality of life and access to hospice. We found that eligibility to active oncological care affects how end of life care is provided. The current study describes health care resource use as a benchmark of lung cancer costs prior to immunotherapy. Future research should focus on patterns of costs related to immunotherapy and targeted therapies, and improvement of hospice care. We aimed to study differences in the use of health care resources in relation to time before death in patients with advanced lung cancer who either received systemic anti-cancer treatment (SACT) or were ineligible for SACT. A retrospective cohort of lung cancer patients (N = 778) diagnosed with advanced disease at North Estonia Medical Centre from 2015–2017 was linked to population-based health care data. We calculated a composite measure of cumulative resource use, comprised from the following: outpatient care, emergency department (ED) visit, inpatient care, admission to intensive care unit, nursing care and prescriptions. Costs were highest in patients who received SACT in the last month before death and decreased in parallel with the time elapsed from the last SACT. Only 20% of SACT patients received nursing care in the final month of life. The no-SACT patients had less time covered by health care services per month, and large differences were seen in the type of service received by the study groups. The largest contributor of health care costs at end of life was acute inpatient care, including approximately 10% of patients who died on the same day as or day following the emergency department visit. These results demonstrate the low nursing care and hospice utilization rates in Estonia. [ABSTRACT FROM AUTHOR]

Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained the reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness. Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life years (QALYs) was measured using the Euro Qol-5D-3L instrument at baseline and at 3 months and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US dollars and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties, and sensitivity analysis to examine the impact of hospitalization costs. A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 more QALYs (95% confidence interval [CI] 0.00–0.08) 6 months after enrolment. The mean cost per participant in the intervention arm was US $1001 (95% CI 968–1031), resulting in an incremental cost of the intervention of US $640 (95% CI 595–679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was US $16 254 (95% CI 7116–99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between US $20 000 and US $30 000. Cost-effectiveness results remained robust to sensitivity analyses. C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions. • A culturally adapted manual-assisted problem-solving training intervention reduced suicidal ideation, hopelessness, and depression in patients with a history of self-harm, but its cost-effectiveness is unknown. • This analysis demonstrated that a culturally adapted manual-assisted problem-solving training intervention in Pakistan could be potentially cost-effective in the short term from a health service's perspective. • Longer study follow-ups including a detailed assessment of patient healthcare use and patient-related costs, including loss of productivity—that is, broader societal costs—are needed to further strengthen the evidence on the cost-effectiveness of this self-harm intervention. [ABSTRACT FROM AUTHOR]

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Cuscuta campestris is one of the most widespread and most harmful parasitic plants in the world. It regularly infests economically important crops substantially reducing their yield. Its host preference has been frequently investigated in natural habitats, but studies have usually been performed at only one site. In this study, I tested the hypothesis that host-preference studies performed at a single site provide information only about local individuals of the host species and not about the species of hosts in general. The preferential status of host species was investigated in different geographical regions, in different species environments. Altogether 1847 relationships between parasite and plant species were examined and categorized at 171 places in Hungary. The used method took into account the frequency and intensity of infestations on the hosts, the proportion of resource use and availability, the resource distribution as well as the defence mechanisms of the hosts. The frequency and intensity of infestations greatly varied amongst the 174 detected host species. The results confirmed that frequently parasitized hosts of C. campestris are not necessarily preferred. Most host species have infestations of varying intensity in different species environments. Poaceae species were found to differ from each other in the extent to which they support the parasite's growth. The study revealed also that C. campestris does not always develop haustoria on individuals of those species, which are unable to contribute significantly to its growth. [ABSTRACT FROM AUTHOR]

© 2015 The Authors. Stable isotope analysis is a powerful method for estimating the impacts animals have on their environment (resource use), revealing their ecological niches. We demonstrated the use of a stable isotope mixing model for measuring the ecological niches of consumers. In particular, we used the model IsotopeR to estimate the resource use of two species with complex, omnivorous diets: invasive Norway rats from the Aleutian Islands, AK, and American black bears from Yosemite National Park, CA. Marginal posterior distributions for major food sources (for populations, groups and individuals) described the resource axes that partly define the realized niches of these omnivores. We used measures of these resource axes to inform resource management in the Aleutians and Yosemite. Results from our analyses confirm that coastal rats did not rely on marine birds on rat-infested islands in the Aleutians. Instead, rats foraged primarily on terrestrial plants and preferred amphipods when they were available. We also use stable isotopes to confirm that plants and acorns are the largest contributors to black bear nutrition in Yosemite and learned that female bears foraged for acorns and pine nuts more heavily than males. Although it is unclear if Norway rats can maintain viable populations in the Aleutians without access to marine-derived animal protein, results from our analyses suggest their dependence on such nutrients. In addition, sex-specific differences in foraging for high-fat acorns and pine nuts in Yosemite suggest black bear populations in the Sierra Nevada may be limited by the productivity and health of hard mast species. As demonstrated here, stable isotope analysis has wide applicability for investigating the resource use and ecological niches of animals. We anticipate and encourage its rapid development in this fundamental field of ecology.

Political ontology reveals the processes of domination at play in the enactment of realities in a(post-) colonial context. In this article, we illustrate the implications of the power asymmetries inherent in conservation and co-management of protected areas involving Indigenous populations. We do so by exploring the case of Pilón Lajas in the Bolivian Amazon region, an area with double legal status as an Indigenous Territory and Biosphere Reserve. Drawing from our ethnographic fieldwork, we describe how indigenous relational ontology and the modern ontology of 'cultural diversity' are enacted by different stakeholders, and analyse critically the problems that arise for protected area management owing to the domination of a single ontology in a context where different ontologies are enacted. We finish by presenting our argument that solving such problems requires a cognitive justice approach.

Background: To estimate the resource use and costs associated to the initial phase of treatment for colorectal cancer in Iran. Methods: A retrospective study was conducted using routinely collected data within Electronic Health Records System (SEPAS), a national database representing public hospitals in Iran between March 20, 2016 and March 19, 2017. Primary end points included healthcare resource use, direct medical and non-medical costs of care in the 12-month study period. Results: The study population included 657 patients with colorectal cancer who underwent surgery and the follow-up chemotherapy. We estimated a total direct cost of $21,407 per patient. The results indicated that direct medical costs were primarily driven by inpatient hospital care, followed by surgery, chemotherapy, and diagnostic services. Conclusion: The initial 12-month of treatment for colorectal cancer, including surgery and the follow-up chemotherapy, is resource intensive. The total direct costs associated to the disease are remarkable, with Inpatient hospital services being the main contributor followed by surgery and chemotherapy.

Habitat fragmentation and loss are two of the leading causes of species declines world-wide. To mitigate these effects, land managers have engaged two major pathways to conserve biodiversity: land-sparing (set aside for wildlife and conservation) or land-sharing (land is managed to provide benefits for multiple land uses). We examined the movement ecology of a wide-ranging snake in a fragmented landscape as a case study to examine the efficacy of small nature preserves to protect threatened biodiversity. We monitored the movement patterns and habitat use of 25 timber rattlesnakes (Crotalus horridus) over the course of four years in a small nature preserve and fragmented agricultural landscape in central Tennessee, USA. Rattlesnakes showed a positive association with rocky cedar barrens and glades, habitat edges, and sites with dense ground cover and relatively open canopy cover. In addition, 49% of all rattlesnake locations fell outside the nature preserve boundary. Most rattlesnakes travelled through the nature preserve and into patchy agricultural areas and rural housing properties while foraging for food and searching for mates. The conservation of species, especially those that have large movement patterns or migratory behaviors, are difficult to protect in a land-sparing or protected area scenario. We highlight that while the nature preserve does not adequately contain timber rattlesnakes throughout the year, it does support the conservation of key habitat for overwintering, which is essential for the survival of this species. A combination of land-sparing and land-sharing are required for the protection and management of this and many other species.

Wetlands provide a range of environmental, cultural and economic values, however, despite this they continue to be degraded and destroyed at an alarming rate. As a result, protection and conservation of the remaining wetlands is significant. An understanding on the attitudes of the people living in the peripheral of wetlands is crucial for conservation and management of wetlands. The aim of the study was to analyse communities’ attitudes towards wetlands and the implications for sustainability at Duthuni Village falling under the Vhembe District in Limpopo Province, South Africa. Door-to-door surveys were undertaken from 29 July to the end of October 2020 during which interview-administered questionnaires were used to collect data. Systematic random sampling was used to obtain a sample of 312 households from the target households of 1 655. Data obtained from questionnaires was analysed using descriptive statistics and this helped to generate frequencies up to 100% from the responses. The study showed that wetlands play a significant role in the lives of people as sources of water for domestic and irrigation purposes, important areas for fishing, harvesting of plant resources for roofing and handcraft production, crop production and valuable land for grazing purposes. The study revealed that the majority of respondents (98.1%; n = 306) in the study area had positive attitudes towards wetlands and wetlands conservation. Motivation for wetlands conservation tended to be ethical, with 67.6% (n = 211) of local communities willing to donate money for wetlands conservation, and 83% (n = 259) willing to vote for a councillor who promised to protect wetlands. It is concluded that the positive attitude of communities toward wetland conservation offers some hope for sustainable utilisation of wetlands.

The nutritional composition of food is often complex as resources contain a plethora of different chemical compounds, some of them more, some less meaningful to consumers. Plant pollen, a major food source for bees, is of particular importance as it comprises nearly all macro- and micronutrients required by bees for successful development and reproduction. However, perceiving and evaluating all nutrients may be tedious and impair quick foraging decisions. It is therefore likely that nutrient perception is restricted to specific nutrients or nutrient groups. To better understand the role of taste in pollen quality assessment by bees we investigated nutrient perception in the Western honey bee, Apis mellifera. We tested if the bees were able to perceive concentration differences in amino acids, fatty acids, and sterols, three highly important nutrient groups in pollen, via antennal reception. By means of proboscis extension response (PER) experiments with chemotactile stimulation, we could show that honey bees can distinguish between pollen differing in amino and fatty acid concentration, but not in sterol concentration. Bees were also not able to perceive sterols when presented alone. Our finding suggests that assessment of pollen protein and lipid content is prioritized over sterol content.

1. The trophic ecology of organisms is often mediated by habitat characteristics. Ants are key organisms of most food webs, and their diet can be plastic depending on the relative availability of different nutrients. 2. Using stable isotope analysis, we investigated whether there were differences in the trophic position (δ15N) and/or in the relative importance of different carbon sources (δ13C) between the arboreal and ground‐dwelling ant communities inhabiting two adjacent and contrasting habitats (savannas and semideciduous forests). 3. Arboreal species on average occupied lower trophic positions (lower δ15N) than did the ground‐dwelling species, as probably in the arboreal stratum there is a prevalence of genera whose species rely heavily on plant and insect exudates. However, regardless of the foraging/nesting strata, there was no difference in mean δ15N between the savanna and forest communities, indicating that differences between these two habitats in the relative availability of sources of protein and carbohydrates for ants are either small or non‐significant. 4. The savanna ant community presented a greater δ13C than did the forest community, as expected, given the high abundance of C4 grasses in savannas. However, the difference in δ13C between the two communities was relatively small, as few savanna species derived most of their carbon from C4‐based food webs. 5. Overall, our study provided important insights into the trophic ecology of ant communities inhabiting contrasting natural habitats, such as different vegetation strata and adjacent forests and savannas. [ABSTRACT FROM AUTHOR]

Background/Aim: Traumatic dental injuries are common and affect many children. The aim of this retrospective study was to investigate the prevalence and characteristics of dental trauma as well as the costs and resource use in a cohort of children aged 1-3 years in low socioeconomic areas (low income and educational level) of Stockholm. Materials and Methods: Data were extracted from a larger intervention trial and analyzed for the prevalence and other characteristics of dental trauma as well as patient characteristics of children (n = 1346) from six dental clinics in low-income, multicultural areas. Variables describing the trauma, socioeconomic status, direct and indirect costs, and time spent at the emergency visit for the dental trauma were retrieved from the dental records. The study also recorded which healthcare profession handled the first and follow-up visits. Results: The prevalence of dental trauma in the study cohort was 8.2%, and higher among boys (n = 71) than girls (n = 39). Boys exhibited a significantly higher risk for dental trauma (OR, 1.76; 95% CI = 1.17-2.65). Maxillary incisors were the teeth most often traumatized, and lateral luxation was the most common diagnosis. The mean time spent per child during the first year following the dental trauma was 36 min, and the mean costs per child were EUR 878. The total average per-child cost (direct and indirect costs) for dental trauma was EUR 2107. Dental visits due to traumatic injuries were significantly less common among children with an immigrant background and in families with an income =EUR 2000 per month. Conclusions: Toddlers in families who have a low socioeconomic status, a foreign background, and live in multicultural areas of Stockholm visit dental clinics for traumatic dental injuries less often than non-immigrant children living in families with a high socioeconomic status. [ABSTRACT FROM AUTHOR]

To determine the longitudinal societal costs and burden of community-dwelling patients with Alzheimer's disease (AD) and their caregivers in Japan. GERAS-J was an 18-month, prospective, longitudinal, observational study. Using the Mini-Mental State Examination (MMSE), patients routinely visiting memory clinics were stratified into groups based on AD severity at baseline (mild, moderate, and moderately severe/severe [MS/S]). Healthcare resource utilization and caregiver burden were assessed using the Resource Utilization in Dementia and Zarit "Caregiver" Burden Interview questionnaires, respectively. Total monthly societal costs were estimated using Japan-specific unit costs of services and products (patient direct healthcare use, patient social care use, and informal caregiving time). Overall, 553 patients (156 mild; 209 moderate; 188 MS/S) were enrolled. MMSE scores declined (1.73, 1.38, and 0.95 points for the mild, moderate, and MS/S AD groups, respectively) and caregiver burden and resource utilization increased over 18 months in each of the AD severity groups. Cumulative total societal costs per patient over 18 months were 3.1, 3.8, and 5.3 million Japanese yen (29,006, 35,662, and 49,725 USD) for mild, moderate, and MS/S AD, respectively. Both patient social care costs and caregiver informal care costs increased with baseline disease severity, with >50% of total costs due to caregiver informal care in each disease severity subgroup. Total treatment costs increased with AD severity over 18 months due to increases in both patient social care costs and caregiver informal care costs. Our data suggest current social care services in Japan are insufficient to alleviate the negative impact of AD on caregiver burden. [ABSTRACT FROM AUTHOR]

A survey of 101 shrimp farms in Ecuador revealed that the average annual shrimp yield based on production pond water surface area was 7.03 ± 0.93 (SE) t/ha/year. The range in annual yield among the five provinces with shrimp farms was 3.67 ± 0.71 to 11.95 ± 5.56 t/ha year, respectively. Averages for total land, water, and energy use were 0.54 ± 0.01 ha/t shrimp, 76,817 ± 6,330 m3/t shrimp, and 61.2 ± 4.2 GJ/t shrimp, respectively. Average wild fish use for fish meal and fish oil included in feed was 0.65 ± 0.02 t/t shrimp. One‐fourth of land use was land embodied in feed. Nearly 80% of total water use was incurred for exchanging water. Eighty‐seven of the farms practiced daily water exchange at an average rate of 8.5% pond volume per day (range 0.7–30%). Pumping water at all farms and mechanical aeration at 47 of the farms were the major direct energy uses. About half of the total energy use was embodied, and roughly half of the embodied energy was in feed. [ABSTRACT FROM AUTHOR]

Delayed autonomous selfing (DAS) provides reproductive assurance under conditions of pollinator and/or pollen-limitation. Few plant species have been investigated to determine if DAS is terminated when a flower is sufficiently pollinated by a pollen vector, thereby saving plant resources for other purposes. We examined this possibility in bumblebee-pollinated Salvia umbratica. We first showed that DAS resulting in high fruit set (100%) and seed set (>80%) per flower occurred in the absence of insect pollinators by means of style recurvature and was completed in 94% of flowers 72 h after they opened. In contrast, in flowers pollinated immediately after opening, DAS was prevented by corollas dropping away before styles recurve toward the upper thecae. We next showed that hand-pollination of flowers immediately after they opened resulted in high fruit set (100%) and seed set (>80%) when 5–10 pollen grains or more were deposited on their stigmas, whereas fruit set and seed set were reduced to 45.00 and 22.50%, respectively, when pollen loads were reduced to 1–3 pollen grains. Finally, we showed that on average single pollinator visits deposited 26 pollen grains on stigmas of flowers that had just opened, which is more than enough to ensure high fruit and seed set. Our results indicate that flower longevity is highly correlated with the pollinator environment and female fitness of S. umbratica , with extended flower longevity allowing DAS to occur being advantageous when pollinators are absent, while reduced floral longevity and prevention of DAS being favored when flowers are pollinated by pollinators. Thus, flower longevity in S. umbratica varies so as to optimize reproductive output and resource efforts, and is dependent on the availability and effectiveness of pollinators to pollinate flowers. [ABSTRACT FROM AUTHOR]

Introduction., The organization of the resource management system of an agricultural enterprise is subject to both requirements for ensuring the competitiveness of the adopted resource use regime in market conditions and requirements for ensuring the ecological balance of man-made load on agricultural land in today's economic conditions. That is why, it is necessary to ensure the interdisciplinary nature of the formation of the enterprise's management system. This approach makes it necessary to consider analytical support for management decisions in finding a compromise between the environmental and economic interests of sustainable development of the enterprise. Purpose. Development of a system for assessing the current state of the organization of resource potential management to ensure a scientifically based classification of management approaches of agricultural enterprises to resource use. Methods. Studies were conducted on the basis of the use of abstract and logical, statistical, economic and mathematical methods. The methodological basis in preparing the material made dialectical method of knowledge of social and economic phenomena. Results. In the course of scientific research, it was established that the classification functions of discriminant analysis are an effective basis for scientific substantiation of the system of assessment and differentiation of approaches to managing the resource potential of an agricultural enterprise. The main advantage of the discriminant analysis apparatus in this particular situation is the possibility of statistical and mathematical modelling of the principle of classification of the studied objects by an expert group. The obtained models can be used to identify the effectiveness of resource potential management by business entities to diagnose problems and identify sources of resource use efficiency. The quality of the obtained models depends on the correct choice of a set of indicators for evaluating and taking into account business conditions in the parameters. Discussion. The results of testing the proposed approach using statistical data of the Lugansk region allowed us to identify the main prerequisites for improving the efficiency of resource potential management, the main of which is to ensure a balance of the crop production system through regulating the intensity of resource use. Management of mainly market principles has unbalanced the mechanisms of self-recovery of land resources, which, accordingly, requires replacement agrotechnical measures. This requires appropriate investment resources, and resource potential management projects are treated as promising investments. [ABSTRACT FROM AUTHOR]

Wood-boring beetle larvae act as ecosystem engineers by creating stem cavities that are used secondarily as nests by many arboreal ant species. Understanding the heterogeneity and distribution of available cavities and their use by ants is therefore key to understanding arboreal ant community assembly and diversity. Our goals were to quantify the abundance and diversity of beetle-produced cavity resources in a tropical canopy, reveal how ants use these resources, and determine which characteristics of the cavity resource contribute to ant use. We dissected branches from six common tree species in the Brazilian Cerrado savanna, measuring cavity characteristics and identifying the occupants. We sampled 2310 individual cavities, 576 of which were used as nests by 25 arboreal ant species. We found significant differences among tree species in the proportion of stem length bored by beetles, the number of cavities per stem length, average entrance-hole size, and the distribution of cavity volumes. The likelihood that a cavity was occupied was greater for cavities with larger entrance-hole sizes and larger volumes. In particular, there was a strong positive correlation between mean head diameters of ant species and the mean entrance-hole diameter of the cavities occupied by those ant species. Wood-boring beetles contribute to the structuring of the Cerrado ant community by differentially attacking the available tree species. In so doing, the beetles provide a wide range of entrance-hole sizes which ant species partition based on their body size, and large volume cavities that ants appear to prefer. [ABSTRACT FROM AUTHOR]

Background: COVID‐19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low‐risk women in Australia gave birth at home or in birth centers. Methods: A whole‐of‐population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low‐risk Australian women gave birth at home or in birth centers. Results: If all low‐risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births. Conclusions: Significant health resource savings could occur by shifting low‐risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed. [ABSTRACT FROM AUTHOR]

To determine the all-cause health care resource utilization and costs among long-term nursing home (LTNH) residents with and without overactive bladder (OAB). Retrospective cohort study. Minimum Data Set (MDS)–linked Medicare Part A, B, and D claims data from 2013 to 2015 were analyzed. LTNH residents aged 65 years or older with a diagnosis of OAB (n = 216,731) were propensity score matched with LTNH residents without OAB (n = 300,327) (non-OAB cohort). We measured health care resource utilization and costs associated with OAB by setting (inpatient, outpatient, emergency department, or prescription) during the 6 months following nursing home admission. Descriptive and multivariate (negative binomial for health care resource utilization and 2-part model for costs) analyses were performed to examine the health care resource utilization and costs among LTNH residents with and without OAB. The annual cost attributed to OAB was calculated as the difference between total annual OAB costs and total annual non-OAB costs. A total of 214,505 patients were included in each matched cohort. Across all health care resource categories, LTNH residents with OAB had higher health care resource utilization and costs compared to the non-OAB cohort (all P <.001). The mean annual direct total cost was $57,984 in the OAB cohort compared with $54,285 in the non-OAB cohort. The annual cost of OAB in nursing homes was estimated at $793 million. Adjusted analyses revealed that the OAB cohort was 9% more likely to have hospitalization and emergency department visits, 15% more likely to have outpatient visits, 27% more likely to have physician visits, and 12% more likely to have prescription counts compared with the non-OAB cohort. The study findings suggest that LTNH residents with OAB have significantly more health care resource utilization compared with patients without OAB. These results provide health care decision makers with recent estimates of the burden of OAB in LTNH to assist them with resource planning. [ABSTRACT FROM AUTHOR]

Wild ungulates seek out food resources at the bottom of mountain valleys in winter and spring, where their high density can negatively impact the production of hay meadows. This study determines the factors that explain the meadow use of four sympatric species: red-, roe-, and fallow-deer, and wild boar. In 2017, we counted the individuals of each species in 94 meadows for eight nights, between March and June, and estimated the frequency of meadow use as the proportion of positive censuses over the total censuses per meadow. We also recorded the presence of domestic ungulates. We inventoried the floristic composition in June. Species tended to use different meadows but only fallow- and roe-deer significantly segregated, indicated by the negative C-score index. As the ungulate frequency was skewed to 0, we used a generalized additive model (GAMLSS) to simultaneously simulate the probability of animals being absent and the frequency of positive censuses. Landscape features contributed to explaining the absence probability, while plant richness and legume cover explained the frequency of meadow use. The presence of domestic ungulates did not affect wild ungulate behavior. All studied species, except roe-deer, avoided exposed spots, preferentially using large meadows close to the forest. At meadow level, each species seemed to have different forage requirements. The frequency of fallow deer increased with the meadow forage quality, indicating a more grasses-based diet than the other two deer, and probably displacing roe-deer to suboptimum meadows. Red-deer used less plant-rich meadows, suggesting flexibility in their dietary choices. [ABSTRACT FROM AUTHOR]

The sharing economy was initially beckoned as a facilitator of exchanges that would not compromise future needs and held great promise for those at the lower end of the socioeconomic pyramid. However, as the sharing economy expanded, questions about its sustainability emerged. This expansion manifested in two main forms: an influx of new users and providers into existing operations and the emergence of new platforms, resulting in a proliferation of sharing economy models. By categorizing these models based on their resource utilization, this paper establishes a connection between scalability and compromised sustainability, shedding light on the interplay between the two. The paper identifies seven distinct configurations in the sharing economy: co-use, re-use, repeated use, sustainable output, pooling of resources, and products and services created specifically for individual users. These configurations serve as a tool to uncover the tensions between scalability and coordination, as well as between sustainability and provision. The paper contributes to prior research by bringing attention to how the sharing economy is entangled in these tensions and by developing a typology. Understanding how these tensions can be resolved presents a highly significant practical contribution, allowing stakeholders in the sharing economy to navigate the challenges of scalability and sustainability effectively. • Discusses the tension between the sustainability and scalability of sharing economy models. • Categorizes sharing economy models based on different resource uses. • Identifies co-use, re-use, repeated use, sustainable output, pooling, and services or products created specifically for individual users. • Highlights the presence of tension between scalability and coordination, and between sustainability and provision. • Develops a typology for sharing economy models, describing uni-sided, share-washing, true sharing, and resource efficiency models. [ABSTRACT FROM AUTHOR]

Numerous experiments have demonstrated that diverse plant communities use nitrogen (N) more completely and efficiently, with implications for how species conservation efforts might influence N cycling and retention in terrestrial ecosystems. However, most such experiments have randomly manipulated species richness and minimized environmental heterogeneity, two design aspects that may reduce applicability to real ecosystems. Here we present results from an experiment directly comparing how realistic and randomized plant species losses affect plant N use across a gradient of soil depth in a native-dominated serpentine grassland in California. We found that the strength of the species richness effect on plant N use did not increase with soil depth in either the realistic or randomized species loss scenarios, indicating that the increased vertical heterogeneity conferred by deeper soils did not lead to greater complementarity among species in this ecosystem. Realistic species losses significantly reduced plant N uptake and altered N-use efficiency, while randomized species losses had no effect on plant N use. Increasing soil depth positively affected plant N uptake in both loss order scenarios but had a weaker effect on plant N use than did realistic species losses. Our results illustrate that realistic species losses can have functional consequences that differ distinctly from randomized losses, and that species diversity effects can be independent of and outweigh those of environmental heterogeneity on ecosystem functioning. Our findings also support the value of conservation efforts aimed at maintaining biodiversity to help buffer ecosystems against increasing anthropogenic N loading.

Background: A better understanding of resource use of new psychiatric admissions is important for healthcare providers and policymakers to improve psychiatric care. This study aims to describe the pattern of new psychiatric admissions and length of stay in Japan. Methods: A retrospective cohort study was conducted using data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). All patients newly admitted to psychiatric wards from April 2014 through March 2016 were included and followed up until discharge to the community. Results: Our sample included 605,982 admissions from 1,621 hospitals over 2 years. The average monthly number of admissions was 25,024 in fiscal year 2014 and 25,475 in fiscal year 2015. There was a seasonal trend in the number of admissions, with a peak in summer (in July). The discharge rates within 90 days and 360 days were 64.1% and 85.7%, respectively, and varied by type of hospital fee and by hospital. For example, the range of hospital-level discharge rate within 90 days in psychiatric emergency units was 46.0–75.3% in the 1st (lowest) quintile, while it was 83.6–96.0% in the 5th (highest) quintile. The prefecture-level indicators in the NDB and the 630 survey had correlations of >0.70. Conclusions: Our study provides fundamental information on resource use of new psychiatric admissions in Japan. Although using the NDB has substantial benefits in monitoring resource use, the results should be interpreted with some caution owing to methodological issues inherent in the database.

The essence and generalizations of the use of resources of marginal productivity and the influence of factors of production on the behavior of the commodity producer under the conditions of resource constraints are discovered. On the basis of the classification model, the essence of the influence of groups of factors on economic, socio-economic and nature-economic productivity is disclosed. The models of interaction of internal, external and nature-economic factors, their interdependence from demand and supply and laws of labor restoration, laws of nature, increase of consumption, institutional environment and classification, economic and normative systems, indicators of measuring productivity of agrarian production are offered. In the process of the research the theoretical and methodological principles of formation of cost factors of productivity on the basis of resource factors of influence on production and their interaction, in particular, in the projection of the theory of downward (marginal) productivity of agrarian enterprises are revealed. The main directions of the system approach to the formation of a costing mechanism on the basis of multifactorial influence and interaction of factors on the productivity of agrarian production have been formed. The theoretical and methodological positions of estimation, the role and place of performance indicators, as well as the influence of management activity on the efficiency of production systems of different levels are substantiated. Research results are aimed at introducing organizational and economic mechanisms for the formation of production costs on the basis of measuring the impact of internal, external and environmental and economic factors in order to form a system-wide (collective) productivity of agrarian enterprises.

Abstract Background Drug-resistant epilepsy negatively impacts the quality of life and is associated with increased morbidity and mortality and high costs to the healthcare system. Cannabis-based treatments may be effective in reducing seizures in this population, but whether they are cost-effective is unclear. In this systematic review, we will search for cost-effectiveness analyses involving the treatment of pediatric drug-resistant epilepsy with cannabis-based products to inform decision-making by public healthcare payers about reimbursement of such products. We will also search for cost-effectiveness analyses of other pharmacologic treatments for pediatric drug-resistant epilepsy, as well as estimates of healthcare resource use, costs, and utilities, for use in a subsequent cost-utility analysis to address this decision problem. Methods We will search the published and gray literature for economic evaluations of cannabis-based products and other pharmacologic treatments for pediatric drug-resistant epilepsy, as well as resource utilization and utility studies. Two independent reviewers will screen the title and abstract of each identified record and the full-text version of any study deemed potentially relevant. Study and population characteristics, the incremental cost-effectiveness ratio (ICER), as well as total costs and benefits, will be extracted, and quality will be assessed by use of the Drummond and CHEERS checklists; context-specific issues will also be considered. From model-based cost-utility and cost-effectiveness analyses, we will extract and summarize the model structure, including health states, time horizon, and cycle length. From resource utilization studies, we will extract data about the frequency of resource use (e.g., neurology visits, emergency department visits, admissions to hospital). From utility studies, we will extract the utility for each health state, the source of the preferences (e.g., child, parent, patient, general public), and the method of elicitation. Discussion Drug-resistant epilepsy in children is associated with important costs to the healthcare system, and decision-makers require high-quality evidence on which to base reimbursement decisions. The results of this review will be useful to both decision-makers considering the decision problem of whether to reimburse cannabis-based products through public formularies and to analysts conducting studies in this area. Systematic review registration PROSPERO no.: CRD42018099591.

Abstract Background The increasing prevalence and recognition of bronchiectasis in clinical practice necessitates a better understanding of the economic disease burden to improve the management and achieve better clinical and economic outcomes. This study aimed to assess the economic burden of bronchiectasis based on a review of published literature. Methods A systematic literature review was conducted using MEDLINE, Embase, EconLit and Cochrane databases to identify publications (1 January 2001 to 31 December 2016) on the economic burden of bronchiectasis in adults. Results A total of 26 publications were identified that reported resource use and costs associated with management of bronchiectasis. Two US studies reported annual incremental costs of bronchiectasis versus matched controls of US$5681 and US$2319 per patient. Twenty-four studies reported on hospitalization rates or duration of hospitalization for patients with bronchiectasis. Mean annual hospitalization rates per patient, reported in six studies, ranged from 0.3–1.3, while mean annual age-adjusted hospitalization rates, reported in four studies, ranged from 1.8–25.7 per 100,000 population. The average duration of hospitalization, reported in 12 studies, ranged from 2 to 17 days. Eight publications reported management costs of bronchiectasis. Total annual management costs of €3515 and €4672 per patient were reported in two Spanish studies. Two US studies reported total costs of approximately US$26,000 in patients without exacerbations, increasing to US$36,00–37,000 in patients with exacerbations. Similarly, a Spanish study reported higher total annual costs for patients with > 2 exacerbations per year (€7520) compared with those without exacerbations (€3892). P. aeruginosa infection increased management costs by US$31,551 to US$56,499, as reported in two US studies, with hospitalization being the main cost driver. Conclusions The current literature suggests that the economic burden of bronchiectasis in society is significant. Hospitalization costs are the major driver behind these costs, especially in patients with frequent exacerbations. However, the true economic burden of bronchiectasis is likely to be underestimated because most studies were retrospective, used ICD-9-CM coding to identify patients, and often ignored outpatient burden and cost. We present a conceptual framework to facilitate a more comprehensive assessment of the true burden of bronchiectasis for individuals, healthcare systems and society.

The product material footprint (PMF) represents a central instrument to assess the potential environmental impacts of products and services based on their life-cycle-wide material use. Within the life cycle impact assessment framework, the indicators raw material input (RMI) and total material requirement (TMR) have been used for its calculation, but so far, only abiotic materials have been considered. This research analyses the requirements and indicators for the assessment of the biotic part of the PMF. The central question is whether the indicators RMI biotic and TMR biotic are suitable for this purpose or if they need to be adapted. For comparison, the indicator cumulative raw material demand (CRD) is applied. The indicator concepts of RMI, TMR, and CRD are compared by defining the system boundaries for determining the biotic parts of the footprint. To test the applicability, the production of wheat bread is assessed as a case study. The characterization factors of wheat grains are determined and each of the three indicators is implemented in the software openLCA for use with the ecoinvent database. The results show that RMI biotic and TMR biotic are suitable indicators for the quantification and assessment of the biotic part of the PMF. While CRD abiotic provides the same information as RMI abiotic, both indicators differ regarding the biotic part. The CRD per definition does not consider biotic inputs from agriculture and forestry and thus conveys insufficient information on the used and unused biomass extraction for the product LCA. The ratio of RMI biotic to the net annual increment and TMR biotic to the net primary production could be used for absolute sustainability assessment.