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Sample records for changing surgical strategy

  1. Can SPECT change the surgical strategy in patients with primary hyperparathyroidism?

    Iervolino, Leticia; Scalisse, Nilza Maria; Maeda, Sergio Setsuo, E-mail: leiervolino@hotmail.com [Discipline of Endocrinology, Department of Medicine, Faculdade de Medicina da Santa Casa de Sao Paulo (FMSCSP), Sao Paulo, SP (Brazil)

    2012-06-15

    Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcaemia in outpatients. It is more common in females, after menopause, and the prevalence is 1 to 4:1000 in the general population. Patients with PHPT have abnormal regulation of PTH secretion, resulting in elevated serum calcium and inappropriately high or normal PTH in relation to the calcium value. Sporadic PTH-secreting adenoma alone accounts for 90% of cases of PHPT, while multiglandular hyperplasia is more common in familial hyperparathyroidism syndromes (5%) and parathyroid carcinomas represent less than 1% of cases. Only after making sure there is functional autonomy of one or more parathyroid glands, localization imaging tests should be performed to guide a possible surgical procedure. It is important to highlight that these tests have limitations and can yield false-positive and false-negative results. There are cases in which the parathyroid gland is difficult to be located, requiring a combination of imaging methods for pre-operative localization, such as {sup 99m}Tc-pertechnetate, SPECT, SPECT/CT, and US. We describe the case of a 50-year-old female patient diagnosed with PHPT, who underwent a surgical procedure without success, with maintenance of hypercalcaemia and hyperparathyroidism. In this case, the hyper functioning parathyroid was located in the retrotracheal region only after scintigraphy combined with SPECT/CT were used. (author)

  2. Can SPECT change the surgical strategy in patients with primary hyperparathyroidism?

    Iervolino, Leticia; Scalisse, Nilza Maria; Maeda, Sergio Setsuo

    2012-01-01

    Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcaemia in outpatients. It is more common in females, after menopause, and the prevalence is 1 to 4:1000 in the general population. Patients with PHPT have abnormal regulation of PTH secretion, resulting in elevated serum calcium and inappropriately high or normal PTH in relation to the calcium value. Sporadic PTH-secreting adenoma alone accounts for 90% of cases of PHPT, while multiglandular hyperplasia is more common in familial hyperparathyroidism syndromes (5%) and parathyroid carcinomas represent less than 1% of cases. Only after making sure there is functional autonomy of one or more parathyroid glands, localization imaging tests should be performed to guide a possible surgical procedure. It is important to highlight that these tests have limitations and can yield false-positive and false-negative results. There are cases in which the parathyroid gland is difficult to be located, requiring a combination of imaging methods for pre-operative localization, such as 99m Tc-pertechnetate, SPECT, SPECT/CT, and US. We describe the case of a 50-year-old female patient diagnosed with PHPT, who underwent a surgical procedure without success, with maintenance of hypercalcaemia and hyperparathyroidism. In this case, the hyper functioning parathyroid was located in the retrotracheal region only after scintigraphy combined with SPECT/CT were used. (author)

  3. Surgical strategies in childhood craniopharyngioma

    Jörg eFlitsch

    2011-12-01

    Full Text Available Craniopharyngiomas are biologically benign lesions (WHO Grade 1 of the sellar and suprasellar region, associated with a serious morbidity. About 50% of these tumors become clinically apparent during childhood. Clinical symptoms include headaches, chiasm syndrome, hydrocephalus, pituitary insufficiencies, and obesity. Growth arrest is a typical symptom in children. The treatment of craniopharyngiomas includes surgery as well as radiotherapy. The goal of surgery varies according to the tumor location and extension and may range from complete resection to biopsy. Surgical complications are well known and cause constant evaluation of surgical strategies. Diencephalic obesity is related to surgical manipulation of hypothalamic tissue. Therefore, a classification system for craniopharyngiomas based on preoperative MRI is suggested by the authors, which may help assess the surgical risk. Recurrences are frequent in craniopharyngiomas, even after complete or gross-total resection. Radiotherapy is therefore recommended to patients with incomplete resections. However, the ideal time for radiotherapy after surgery is under discussion.The treatment of craniopharyngiomas requires an interdisciplinary and multimodal approach. Each patient should receive an individually tailored treatment. Surgically, different approaches as well as different degrees of resection can be considered, depending on tumor location and tumor extension.

  4. [Changing surgical therapy because of clinical studies?].

    Schwenk, W; Haase, O; Müller, J M

    2002-04-01

    The randomised controlled clinical trial (RCT) is a powerful instrument to evaluate different therapeutic regimens. In a survey among 115 physicians visiting the 25th annual meeting of the Surgical Society of Berlin and Brandenburg, the RCT was judged to be very important when changes of therapeutic strategies are discussed. 90 % of all participants claimed to use data from RCTs in the clinical routine and 89 % would participate in such a trial. In official (e. g. discussions during coffee breaks at scientific meetings) or non-medical (e. g. non-scientific press or media) sources of information were assessed as irrelevant for decisions regarding therapeutic strategies. However, in contrast to this view laparoscopic cholecystectomy was introduced into clinical practice rapidly because patients informed by external (non-medical) sources preferred to be operated on with the "modern" technique. Clinical trials with a high level of evidence had no relevant influence on the rapid distribution of laparoscopic cholecystectomy. Controversial discussions concerning the extent of lymphadenectomy with gastric resection for carcinoma demonstrate that the value of excellent clinical RCTs is low if their results challenge a stable paradigma of the surgical scientific society. To allow a rational judgement, new surgical technologies should undergo a scientific gradual evaluation in agreement with the principles of evidence based medicine.

  5. Multimodal strategies to improve surgical outcome

    Kehlet, Henrik; Wilmore, Douglas W

    2002-01-01

    OBJECTIVE: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. BACKGROUND: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use...... anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. RESULTS: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day...... surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. CONCLUSIONS: Understanding perioperative...

  6. Mechanical ventilation strategies for the surgical patient

    Schultz, Marcus J.; Abreu, Marcelo Gama de; Pelosi, Paolo

    2015-01-01

    Purpose of review To summarize clinical evidence for intraoperative ventilation settings, which could protect against postoperative pulmonary complications (PPCs) in surgical patients with uninjured lungs. Recent findings There is convincing evidence for protection against PPCs by low tidal volumes:

  7. Surgical center: challenges and strategies for nurses in managerial activities.

    Martins, Fabiana Zerbieri; Dall'Agnoll, Clarice Maria

    2017-02-23

    Analyze the challenges and strategies of nurses performing managerial activities in a surgical center. Exploratory, descriptive study with a qualitative approach, involving six nurses by means of the Focus Group Technique, between April and August 2013. Data were submitted to thematic content analysis. The main challenges noted were deficiency of material resources, communication noise, adequacy of personnel downsizing, and relationships with the multidisciplinary team. Key strategies include construction of co-management spaces to promote integration among professionals, conflict resolution and exchange of knowledge. Managerial activities involve the promotion of dialogic moments to coordinate the different processes in the surgical center to provide inputs to expand safety and quality of services provided.

  8. Market strategies for climate change

    Kolk, A.; Pinkse, J.M.

    2004-01-01

    The issue of climate change has attracted increasing business attention in the past decade. Whereas companies initially aimed primarily at influencing the policy debate, corporate strategies increasingly include economic responses. Existing classifications for climate change strategies however still

  9. Vocal Fold Vibratory Changes Following Surgical Intervention.

    Chen, Wenli; Woo, Peak; Murry, Thomas

    2016-03-01

    High-speed videoendoscopy (HSV) captures direct cycle-to-cycle visualization of vocal fold movement in real time. This ultrafast recording rate is capable of visualizing the vibratory motion of the vocal folds in severely disordered phonation and provides a direct method for examining vibratory changes after vocal fold surgery. The purpose of this study was to examine the vibratory motion before and after surgical intervention. HSV was captured from two subjects with identifiable midvocal fold benign lesions and six subjects with highly aperiodic vocal fold vibration before and after phonosurgery. Digital kymography (DKG) was used to extract high-speed kymographic vocal fold images sampled at the midmembranous, anterior 1/3, and posterior 1/3 region. Spectral analysis was subsequently applied to the DKG to quantify the cycle-to-cycle movements of the left and the right vocal fold, expressed as a spectrum. Before intervention, the vibratory spectrum consisted of decreased and flat-like spectral peaks with robust power asymmetry. After intervention, increases in spectral power and decreases in power symmetry were noted. Spectral power increases were most remarkable in the midmembranous region of the vocal fold. Surgical modification resulted in improved lateral excursion of the vocal folds, vibratory function, and perceptual measures of Voice Handicap Index-10. These changes in vibratory behavior trended toward normal vocal fold vibration. Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

  10. A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy.

    Klatte, Tobias; Ficarra, Vincenzo; Gratzke, Christian; Kaouk, Jihad; Kutikov, Alexander; Macchi, Veronica; Mottrie, Alexandre; Porpiglia, Francesco; Porter, James; Rogers, Craig G; Russo, Paul; Thompson, R Houston; Uzzo, Robert G; Wood, Christopher G; Gill, Inderbir S

    2015-12-01

    A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). A literature review was conducted. Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the

  11. Navigating towards improved surgical safety using aviation-based strategies.

    Kao, Lillian S; Thomas, Eric J

    2008-04-01

    Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.

  12. Strategies for Change: Part II.

    Atkinson, Hugh C.

    1984-01-01

    Discusses present and future changes in library organization and management resulting from increasingly smaller library units, use of electronics to support decentralized services, new management style, and interlibrary cooperatives. Three strategies for change--to accept change, to change change, to recognize that some things cannot be…

  13. Surgical Management of Rib Fractures: Strategies and Literature Review.

    de Jong, M B; Kokke, M C; Hietbrink, F; Leenen, L P H

    2014-06-01

    Rib fractures can cause significant problems in trauma patients, often resulting in pain and difficulty with respiration. To prevent pulmonary complications and decrease the morbidity and mortality rates of patients with rib fractures, currently there is a trend to provide surgical management of patients with flail chest. However, the indications for rib fracture fixation require further specification. Past and current strategies are described according to a review of the medical literature. A systematic review was performed including current indications for rib fracture fixation. MEDLINE (2000-2013) was searched, as well as Embase (2000-2013) and Cochrane Databases, using the keywords rib, fracture, fixation, plate, repair, and surgery. Three retrospective studies were found that described different techniques for rib fracture fixation. The results demonstrated a reduced number of ventilation days, decreased long-term morbidity and pain, and satisfactory rehabilitation after surgical treatment. In addition to flail chest, age, Injury Severity Score, and the number of rib fractures were important predictive factors for morbidity and mortality. Surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed. Prospective randomized trials are needed for further confirmation. © The Finnish Surgical Society 2014.

  14. Combined Orbital Fractures: Surgical Strategy of Sequential Repair

    Su Won Hur

    2015-07-01

    Full Text Available BackgroundReconstruction of combined orbital floor and medial wall fractures with a comminuted inferomedial strut (IMS is challenging and requires careful practice. We present our surgical strategy and postoperative outcomes.MethodsWe divided 74 patients who underwent the reconstruction of the orbital floor and medial wall concomitantly into a comminuted IMS group (41 patients and non-comminuted IMS group (33 patients. In the comminuted IMS group, we first reconstructed the floor stably and then the medial wall by using separate implant pieces. In the non-comminuted IMS group, we reconstructed the floor and the medial wall with a single large implant.ResultsIn the follow-up of 6 to 65 months, most patients with diplopia improved in the first-week except one, who eventually improved at 1 year. All patients with an EOM limitation improved during the first month of follow-up. Enophthalmos (displacement, 2 mm was observed in two patients. The orbit volume measured on the CT scans was statistically significantly restored in both groups. No complications related to the surgery were observed.ConclusionsWe recommend the reconstruction of orbit walls in the comminuted IMS group by using the following surgical strategy: usage of multiple pieces of rigid implants instead of one large implant, sequential repair first of the floor and then of the medial wall, and a focus on the reconstruction of key areas. Our strategy of step-by-step reconstruction has the benefits of easy repair, less surgical trauma, and minimal stress to the surgeon.

  15. Effective strategies for behavior change.

    Coleman, Mary Thoesen; Pasternak, Ryan H

    2012-06-01

    Strategies that are most effective in both prevention and management of chronic disease consider factors such as age, ethnicity, community, and technology. Most behavioral change strategies derive their components from application of the health belief model, the theory of reasoned action/theory of planned behavior, transtheoretical model, and social cognitive theory. Many tools such as the readiness ruler and personalized action plan form are available to assist health care teams to facilitate healthy behavior change. Primary care providers can support behavior changes by providing venues for peer interventions and family meetings and by making new partnerships with community organizations. Copyright © 2012 Elsevier Inc. All rights reserved.

  16. Changes in thyroid hormones in surgical trauma.

    Arunabh

    1992-07-01

    Full Text Available A prospective study of 20 patients who underwent elective surgery, is presented reporting the effect of surgical trauma on circulating thyroid hormone levels. Although no increase in the serum T4 levels was observed following surgery, serum T3 values were found to decrease and serum rT3 values were found to increase in the post-operative period, representing activation of an alternate pathway in the peripheral conversion of T4 to T3. Since trauma induces a hypermetabolic state due to hypersecretion of cortisol, alterations in thyroid hormone levels were concluded to represent an appropriate response in trauma to counter the effects of trauma-induced cortisol hypersecretion.

  17. Strategy Implementation and Organizational Change

    Lynch, Susan E.; Mors, Louise

    2018-01-01

    . This paper considers how formal structural change affects senior managers’ ability to maintain their intraorganizational networks. The hypotheses are tested on sample of 884 work-related relationships of 96 partners in a global professional services firm. This firm had recently implemented a new strategy...

  18. The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies

    Groenewegen Peter P

    2011-05-01

    Full Text Available Abstract Background We need to know the scale and underlying causes of surgical adverse events (AEs in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units. Methods A structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail. Results Surgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training. Conclusions Surgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations

  19. Market Strategies for Climate Change

    Kolk, A.; Pinkse, J. [Business School, University of Amsterdam, Amsterdam (Netherlands)

    2004-06-01

    The issue of climate change has attracted increasing business attention in the past decade. Whereas companies initially aimed primarily at influencing the policy debate, corporate strategies increasingly include economic responses. Existing classifications for climate change strategies however still reflect the political, non-market components. Using empirical information from the largest multinational companies worldwide, this article examines current market responses, focusing on the drivers (threats and opportunities) and the actions being taken by companies to address climate change. It also develops a typology of climate strategies that addresses the market dimensions, covering both the aim (strategic intent) and the degree of cooperation (form of organisation). The aim turns out to be either innovation or compensation, while the organisational arrangements to reach this objective can be oriented at the company level (internal), at companies' own supply chain (vertical) or at cooperation with other companies (competitors or companies in other sectors - horizontal). The typology can assist managers in deciding about the strategic option(s) they want to choose regarding climate change, also based on the insights offered by the paper about the current state of activities of other companies worldwide.

  20. [The clinical features and surgical treatment strategies of cervical kyphosis].

    Fang, Jia-hu; Jia, Lian-shun; Zhou, Xu-hui; Song, Li-jun; Cai, Wei-hua; Li, Xiang

    2010-10-15

    To analyze the clinical characteristics and the surgical treatment strategy of cervical kyphosis. From March 2006 to October 2009, 31 cases of cervical kyphosis were treated. According to the clinical features and imaging findings, different treatment methods were used. There were 9 patients in operation group, including 4 male and 5 female patients, aged from 17 to 72 years (average age of 35 years). Among them, 5 cases were idiopathic kyphosis and 4 cases were caused by laminectomy or other reasons. There were 22 patients in conservative treatment group, including 11 male and 11 female patients, aged from 14 to 40 years (average age of 29 years), who were all idiopathic cervical kyphosis. Before and 1 week after operation, clinical assessment were taken for the patients in operation group using Spinal Cord Injuries Classification Standard of American Spinal Injury Association (AISA). During the periodic review, the anteroposterior, normal sagittal films of cervical spine were taken. At 1 week and every 6 months after operation, MRI films were also taken. These films were studied to evaluate the effects of the operations. In the conservative group, assessment of treatment results by studying anteroposterior and normal lateral views of cervical spine were were taken every month. The clinical characteristics and the surgical treatment strategies of these patients were analyzed. In operation group, 9 cases were followed up for 6 to 18 months, all patients did not failed in internal fixation and fusion. AISA neurological score and neurological function significantly improved. Three days after operation the average Cobb angle was -1.29 ° (preoperative 54.24 °). In conservative group, the average Cobb angle was -5.41 ° (before treatment 11.20 °) 4 months after the treatment. The symptoms of neck shoulder and back pain disappeared, and all patients were followed up for 3 to 24 months, with no recurrence of symptoms. In the early period of cervical kyphosis, adopt

  1. Effects of Frequent Glove Change on Outcomes of Orthopaedic Surgical Procedures - A Multicenter Study on Surgical Gloves

    Nishit Palo

    2017-10-01

    Full Text Available Introduction: Intact surgical gloves are a barrier to microorganisms migration between surgical team members and the patient. The surgical gloves are changed at various junctures but the effects of changing gloves during surgical procedures on various surgical parameters or clinical outcomes are not established. Aim: To determine rationale of glove change during orthopaedic procedures, differences amongst surgical parameters with and without changing the surgical gloves and whether frequent glove change affected surgical parameters or clinical outcomes. Materials and Methods: A prospective multicenter study conducted at three centers from January 2014 to January 2016. A 250 patients were divided into 2 groups (n=125 each in Group 1, surgical team operated with regular changing of gloves. In Group 2, only 1 set of double gloves were worn throughout the procedure. Surgical parameters or clinical outcomes were assessed for both the groups. Statistical analyses included the median, mode, range, Interquartile Range (IQR and sample standard deviation (s and independent-samples t-test. Bacterial counts were expressed as median with (IQR. Results: Surgical Timing Difference was 10 (S.D.- 4.2 minutes more in Group-1 (<0.05, Surgical Cost was higher in Group-1 by Rs.150-450 (<0.05. Outer glove micro-perforation rate was 5.85% and 8.15% in group-1 and 2 respectively with no inner glove perforation or Surgical Site Infections. Outer glove micro perforations were proportional to duration of surgery; operations lasting 120-210 and 61-120 minutes had 66.6% and 37.2% micro perforation rates respectively (p<0.05. Conclusion: Under standard operating conditions, procedures performed without glove change are shorter and cost effective than procedures performed with regular glove change with similar surgical and functional results. Judicious use of surgical gloves is a patient and environment friendly option, thereby reducing the hospital’s biomedical waste load.

  2. A novel surgical strategy for secondary hyperparathyroidism: Purge parathyroidectomy.

    Shan, Cheng-Xiang; Qiu, Nian-Cun; Zha, Si-Luo; Liu, Miao-E; Wang, Qiang; Zhu, Pei-Pei; Du, Zhi-Peng; Xia, Chun-Yan; Qiu, Ming; Zhang, Wei

    2017-07-01

    This study was intended to demonstrate the feasibility and efficacy of purge parathyroidectomy (PPTX) for patients with secondary hyperparathyroidism (SHPT). The "seed, environment, and soil" medical hypothesis was first raised, following review of the literatures, to demonstrate the possible causes of persistence or recurrence of SHPT after parathyroidectomy. Subsequently, the novel surgical strategy of PPTX was proposed, which involves comprehensive resection of the fibro-fatty tissues, including visible or invisible parathyroid, within the region surrounded by the thyroid cartilage, bilateral carotid artery sheath, and the brachiocephalic artery. The perioperative information and clinical outcomes of patients who underwent PPTX from June 2016 to December 2016 were analyzed. In total, PPTX was performed safely in nine patients with SHPT from June 2016 to December 2016. The operative time for PPTX ranged from 95 to 135 min, and blood loss ranged from 20 to 40 mL. No patients with perioperative death, bleeding, convulsions, or recurrent laryngeal nerve injury were reported. The preoperative concentration of PTH ranged from 1062 to 2879 pg/mL, and from 12.35 to 72.69 pg/mL on the first day after surgery. In total, 37 parathyroid glands were resected. The postoperative pathologic examination showed that supernumerary or ectopic parathyroid tissues were found within the "non-parathyroid" tissues in three patients. No cases encountered persistence or recurrence of SHPT, or severe hypocalcemia during the follow-up period. PPTX involves comprehensive resection of supernumerary and ectopic parathyroid tissues, which may provide a more permanent means of reducing PTH levels. Copyright © 2017. Published by Elsevier Ltd.

  3. How do you tell whether a change in surgical technique leads to a change in outcome?

    Vickers, Andrew J; Cronin, Angel M; Masterson, Timothy A; Eastham, James A

    2010-04-01

    Surgeons routinely evaluate and modify their surgical technique to improve patient outcome. It is also common for surgeons to analyze results before and after a change in technique to determine whether the change led to better results. Simple comparison of results before and after surgical modification may be confounded by the surgical learning curve. We developed a statistical method applicable to analyzing before/after surgical studies. We used simulation studies to compare different statistical analyses of before/after studies. We evaluated a simple 2-group comparison of results before and after the modification by the chi-square test and a novel bootstrap method that adjusts for the surgical learning curve. In the presence of the learning curve a simple 2-group comparison almost always showed an ineffective surgical modification to be of benefit. When the surgical modification was harmful, leading to a 10% decrease in the success rate, 2-group comparison nonetheless showed a statistically significant improvement in outcome about 80% of the time. The bootstrap method had only moderate power but did not show that ineffective surgical modifications were beneficial more than would be expected by chance. Simplistic approaches to the analysis of before/after surgical studies may lead to grossly erroneous results under the surgical learning curve. A straightforward alternative statistical method allows investigators to separate the effects of the learning curve from those of the surgical modification. Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  4. Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies

    Sanchis-Alfonso, Vicente; Montesinos-Berry, Erik; Ramirez-Fuentes, Cristina; Leal-Blanquet, Joan; Gelber, Pablo E; Monllau, Joan Carles

    2017-01-01

    Patellar instability is a common clinical problem encountered by orthopedic surgeons specializing in the knee. For patients with chronic lateral patellar instability, the standard surgical approach is to stabilize the patella through a medial patellofemoral ligament (MPFL) reconstruction. Foreseeably, an increasing number of revision surgeries of the reconstructed MPFL will be seen in upcoming years. In this paper, the causes of failed MPFL reconstruction are analyzed: (1) incorrect surgical indication or inappropriate surgical technique/patient selection; (2) a technical error; and (3) an incorrect assessment of the concomitant risk factors for instability. An understanding of the anatomy and biomechanics of the MPFL and cautiousness with the imaging techniques while favoring clinical over radiological findings and the use of common sense to determine the adequate surgical technique for each particular case, are critical to minimizing MPFL surgery failure. Additionally, our approach to dealing with failure after primary MPFL reconstruction is also presented. PMID:28251062

  5. Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies

    Sanchis-Alfonso, Vicente; Montesinos-Berry, Erik; Ramirez-Fuentes, Cristina; Leal Blanquet, Joan; Gelber, Pablo-Eduardo; Monllau García, Juan Carlos

    2017-01-01

    Patellar instability is a common clinical problem encountered by orthopedic surgeons specializing in the knee. For patients with chronic lateral patellar instability, the standard surgical approach is to stabilize the patella through a medial patellofemoral ligament (MPFL) reconstruction. Foreseeably, an increasing number of revision surgeries of the reconstructed MPFL will be seen in upcoming years. In this paper, the causes of failed MPFL reconstruction are analyzed: (1) incorrect surgical ...

  6. Relationship between job stress level and coping strategies used by Hong Kong nurses working in an acute surgical unit.

    Wang, Wenru; Kong, Amelia Wai Man; Chair, Sek Ying

    2011-11-01

    The aim of this study is to explore the relationship between job stress and coping strategies of Hong Kong nurses working in an acute surgical unit. This is a descriptive correlational study. Data were collected from 98 Hong Kong surgical nurses using the Nursing Stress Scale and the Jalowiec Coping Scale. Results showed that workload (M = 15.36), lack of support (M = 13.32), and inadequate preparation (M = 12.33) are the most common stressors for Hong Kong surgical nurses. The most frequent strategies used by nurses to cope with stress can be characterized as evasive (M = 19.23), confrontive (M = 17.46), and optimistic (M = 15.81), all of which are also rated as the most effective strategies in reducing stress levels. Only the confrontive, optimistic, supportant, and emotive coping strategies reveal significant correlations (p stress levels of nurses, whereas the evasive, fatalistic, palliative, and self-reliant strategies showed no significant correlation with stress levels (p > .05). Recognizing the impacts of job-related stress and making use of effective coping methods play a vital role in reducing nurse's stress. A change in leadership styles from the managerial level and reallocation of manpower may help reduce job stress. The use of confrontive and optimistic coping strategies in reducing job-related stress for surgical nurses should be advocated and promoted in their daily work. Copyright © 2011 Elsevier Inc. All rights reserved.

  7. The surgical management of the rheumatoid spine: Has the evolution of surgical intervention changed outcomes?

    Robin Bhatia

    2014-01-01

    Full Text Available Context: Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years. Aims: The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years. Materials and Methods: A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis. Results: A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%. Conclusion: We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.

  8. Surgical strategies in patients with gallbladder cancer: nihilism to optimism.

    Sikora, Sadiq S; Singh, Rajneesh K

    2006-06-15

    Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer. Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease. Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few. Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity. Copyright 2006 Wiley-Liss, Inc.

  9. Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs.

    Dietl, Charles A; Russell, John C

    2016-01-01

    The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate. Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies. Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

  10. Strategies in the Surgical Management of Atrial Fibrillation

    Leanne Harling

    2011-01-01

    Full Text Available Atrial fibrillation (AF is associated with substantial morbidity, mortality, and economic burden and confers a lifetime risk of up to 25%. Current medical management involves thromboembolism prevention, rate, and rhythm control. An increased understanding of AF pathophysiology has led to enhanced pharmacological and medical therapies; however this is often limited by toxicity, variable symptom control, and inability to modulate the atrial substrate. Surgical AF ablation has been available since the original description of the Cox Maze procedure, either as a standalone or concomitant intervention. Advances in novel energy delivery systems have allowed the development of less technically demanding procedures potentially eliminating the need for median sternotomy and cardiopulmonary bypass. Variations in the definition, duration, and reporting of AF have produced methodological limitations impacting on the validity of interstudy comparisons. Standardization of these parameters may, in future, allow us to further evaluate clinical endpoints and establish the efficacy of these techniques.

  11. [Surgery for pancreatic cancer: Evidence-based surgical strategies].

    Sánchez Cabús, Santiago; Fernández-Cruz, Laureano

    2015-01-01

    Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

  12. Surgical Management of the Giant Pannus: Indications, Strategies, and Outcomes.

    Michaels, Joseph; Coon, Devin; Calotta, Nicholas A; Peter Rubin, J

    2018-04-01

    The obesity pandemic continues to produce an inexorable increase in the number of patients requiring surgical treatment of obesity and obesity-related complications. Along with this growing number of patients, there is a concomitant increase in the complexity of management. One particular example is the treatment of patients with an exceptionally large and morbid pannus. In this report, we detail the management of seven patients suffering from a giant pannus. Medical and surgical variables were assessed. A quality of life questionnaire was administered pre- and postoperatively. All seven patients suffered some obesity-related medical morbidity and six of seven (86%) had local complications of the giant pannus. Each patient underwent giant panniculectomy [resection weight > 13. 6 kg (30 lb)]. The mean resection weight was 20.0 kg. Four of seven (57%) patients experienced postoperative complications, with two (29%) requiring re-operation and blood transfusion. Six patients were available for long-term follow-up; 100% of participants indicated an increased quality of life while five (83%) reported additional postoperative weight loss, increase in exercise frequency and walking ability, and improved ability to work. Our results indicate that giant panniculectomy is a challenging and risky procedure, but careful patient selection and intraoperative scrutiny can ameliorate these risks and afford patients a dramatically improved quality of life. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

  13. Strategy for Climate Change Adaptation

    Rasmussen, Torben Valdbjørn

    2013-01-01

    . This absence of an agreement calls for adaptation to climate change. Emphasis should be put on buildings, as they play a vital economic and social role in society and are vulnerable to climate change. Therefore, the building stock deserves its own policy and implementation plans as well as tools that enable...... adequate and cost-efficient adaptation to climate change. This paper explains the need for climate change adaptation of the building stock and suggests a pattern for a strategic approach to how to reach the climate change adaptation needed. The suggested and presented need of a strategic approach is based...... on three main initiatives consisting of the need to examine the potential impacts of climate change on the building stock, the need to assess and develop a roadmap of current and future adaptation measures that can withstand the effects of climate change, and the need to engage relevant stakeholders...

  14. Strategy for Climate Change Adaptation

    Rasmussen, Torben Valdbjørn

    2014-01-01

    . This absence of an agreement calls for adaptation to climate change. Emphasis should be put on buildings, as they play a vital economic and social role in society and are vulnerable to climate change. Therefore, the building stock deserves its own policy and implementation plans as well as tools that enable...... adequate and cost-efficient adaptation to climate change. This paper explains the need for climate change adaptation of the building stock and suggests a pattern for a strategic approach to how to reach the climate change adaptation needed. The suggested and presented need of a strategic approach is based...... on three main initiatives consisting of the need to examine the potential impacts of climate change on the building stock, the need to assess and develop a roadmap of current and future adaptation measures that can withstand the effects of climate change, and the need to engage relevant stakeholders...

  15. Management: A Strategy for Change.

    White, Herbert S.

    1978-01-01

    Traces the recent history of libraries and mentions loss of status, insufficient funds, insufficient evaluation methods, and unspecified goals as major contributors to contemporary management problems. Also outlined is a management strategy, which includes public relations, long-range and short-range goals, and budget and financing. (JVP)

  16. Surgical resident learning styles have changed with work hours.

    Quillin, Ralph C; Cortez, Alexander R; Pritts, Timothy A; Hanseman, Dennis J; Edwards, Michael J; Davis, Bradley R

    2016-01-01

    The Accreditation Council for Graduate Medical Education instituted the 80-h workweek for residency programs in 2003. This presented a unique challenge for surgery residents who must acquire a medical and technical knowledge base during training. Therefore, learning should be delivered in an environment congruent with an individual's learning style. In this study, we evaluated the learning styles of general surgery residents to determine how learning styles changed after the implementation to the 80-h workweek. Kolb learning style inventory was taken by general surgery residents at the University of Cincinnati's Department of Surgery, and results from 1999-2012 were analyzed. Statistical analysis was performed using the chi-squared, logistic regression and Wilcoxon rank-sum test. Significance was defined as a P value of learning styles after the institution of the 80-h workweek to converging (43.9%) and accommodating (40.4%, P learning. This change paralleled the transition to a more team-based approach to patient care with the implementation of the 80-h workweek. These findings are important for surgical educators to consider in the development of surgical resident curriculum. Copyright © 2016 Elsevier Inc. All rights reserved.

  17. A review of current strategies to reduce intraoperative bacterial contamination of surgical wounds

    Dohmen, Pascal M.; Konertz, Wolfgang

    2007-01-01

    Surgical site infections are a mean topic in cardiac surgery, leading to a prolonged hospitalization, and substantially increased morbidity and mortality. One source of pathogens is the endogenous flora of the patient?s skin, which can contaminate the surgical site. A number of preoperative skin care strategies are performed to reduce bacterial contamination like preoperative antiseptic showering, hair removal, antisepsis of the skin, adhesive barrier drapes, and antimicrobial prophylaxis. Fu...

  18. Current strategies in surgical myocardial revascularization: Indian perspective

    Sameer Kumar

    2013-01-01

    A retrospective analysis was carried out of 172 patients who underwent CABG at INHS Asvini between 01 Jan 2008 and 31 May 2013.39% had Left Main Coronary artery disease, 85% patient had triple vessel disease, 56% were diabetics, 12% had undergone stenting in recent past. Beating heart strategy was used in 10%, average no of grafts per patient was 2.3 with LIMA and Radial artery being used as a conduit in 84% and 4% respectively. 4.6% patients succumbed in post-operative period.

  19. CEPF strategy for climate change issues

    2004-10-01

    With its strategy for climate change issues CEPF points out the importance of sustainable forest management and the renewable material wood in the context of future climate change policies. Reflecting the view of 16 Million Family forest owners of 23 countries in Europe, on how to combat climate change, this strategy should assist the EU Commission in identifying important issues for consideration in preparing its report for the spring 2005 European Council

  20. [Surgical treatment of Marfan syndrome; late results and new strategy].

    Aomi, S; Nonoyama, M; Tomioka, H; Endo, M; Nagashima, H; Sakomura, Y; Aoka, Y; Kasanuki, H; Kurosawa, H

    2002-07-01

    deaths also occurred in 8 (13%) patients who underwent a replacement of the aortic arch, descending thoracic or thoracoabdominal aorta, with no cases of paraplegia reported. In all cases, the replacement was extensive. The observed 10-year survival rate was 70% with a freedom from reoperation of 64%. Although dissection did not reduce the observed survival rate, the 10-year freedom from reoperation was significantly decreased at 49% (p = 0.0007). (1) Surgery is indicated for AAE when the maximum diameter of the aneurysm prior to onset of dissection is 5 cm. In the case of aortic arch without dissection, the Bentall operation with simultaneous arch replacement should be aggressively performed in order to minimize the future risk of vascular events and to eliminate the need for extensive replacement in a reoperation, a procedure which is associated with a high level of risk. (2) Extensive replacement which is associated with poor results should be avoided where possible and, instead, scheduled staged surgery should be aggressively performed in the early stage when the maximum diameter of the aneurysm in the descending aorta is 5 cm or less. (3) By paying adequate attention to patient education, outpatient follow-up using detailed diagnostic imaging, drug therapy, periodic late surveillance, expedition of scheduled surgery, and to the basic approach as well as endeavoring to improve surgical results by the use of new methods of treatment, it is anticipated that further improvement will be observed in late results.

  1. Using a change model to reduce the risk of surgical site infection.

    Burden, Mel

    2016-09-22

    A surgical site infection (SSI) surveillance module completed in 2014 highlighted that infection rates for breast surgery inpatients and readmissions at an acute trust had increased to 2.2%, from 0.5% in 2012. The national benchmark for 2014 established by Public Health England (PHE) was 1.0%. This demonstrated a greater than fourfold absolute increase in SSI for breast surgery during these periods. The infection rate could have been due to chance, but warranted investigation. The results were presented to the breast team and used to drive practice transformation through audit and observation, identifying areas of change to improve patient safety. The project used a recognised 8-step model for leading change developed by John Kotter, a professor at Harvard Business School and world-renowned change expert. The project presented opportunities to promote infection prevention while implementing care improvement strategies and behaviour change in partnership with the breast team.

  2. Action strategy paper : climate change and energy

    2008-10-01

    This strategy paper considers how the Chicago Metropolitan Agency for Planning (CMAP) might incorporate goals to reduce greenhouse gas (GHG) emissions, prepare for climate change impacts on transportation systems, and reduce energy with in the GO TO ...

  3. Pectus bar removal: surgical technique and strategy to avoid complications.

    Park, Hyung Joo; Kim, Kyung Soo

    2016-01-01

    Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus excavatum. Based on our experience with one of the largest scale data, we would like to address the important issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal, and strategies to avoid complications. Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55. The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary's Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a retrospective chart review without revealing any patients' personal data. Our technique involved straightening of the bar in a supine position. The overall mean duration of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years (range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers aged 12-20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients (2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar removal earlier than initially planned. The most common adverse reaction after bar removal was wound seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients (0.49%), and seven of these required redo repair (0.38%). Pectus bar removal is a safe and straightforward procedure with a

  4. Surgical strategy for giant pituitary adenoma based on evaluation of fine feeding system and angioarchitecture

    Yoshikazu Ogawa, M.D., Ph.D.

    2017-06-01

    Conclusion: Major blood supply was different from the normal supply to the anterior pituitary gland and did not necessarily correspond to tumor shape and extension. Surgical strategy should be established based on the tumor feeding systems and hemodynamics in giant pituitary adenomas.

  5. Strategies to accommodate resident work-hour restrictions: impact on surgical education.

    Freiburg, Carter; James, Ted; Ashikaga, Takamura; Moalem, Jacob; Cherr, Greg

    2011-01-01

    The introduction of duty-hour restrictions has impacted surgical training. Several strategies were introduced by training programs in response to these restrictions. The purpose of this study was to assess the various strategies employed by residency programs to comply with work-hour restrictions with respect to the impact on the quality of surgical education. A national survey was developed and distributed to resident members of the Resident and Associate Society of the American College of Surgeons in all accredited residency programs across North America. Questions in the survey addressed 10 separate accommodation strategies used by training programs to adhere to resident work-hour restrictions. Resident respondents completed a 5-point Likert scale rating each strategy according to its impact on surgical education (detrimental, not very helpful, neutral, somewhat helpful, and very helpful). A total of 599 (9.7%) responses were received from 6186 members of the Resident Associate Society. The use of health information technology (IT), nurse practitioners, and physician assistants were most highly rated. Hiring clinical fellows, establishing nonteaching services, and shift-work scheduling were the three most poorly rated accommodations to work-hour restrictions with respect to resident education. Hospital IT and nonphysician care providers were rated by residents to optimize surgical education in the current work-hour limitation environment. We infer that strategies which lead to increased efficiency and redistribution of resident workload allow surgical trainees to spend more time on activities perceived to have higher educational value. Copyright © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

  6. Social Media: Changing the Paradigm for Surgical Education.

    Petrucci, Andrea M; Chand, Manish; Wexner, Steven D

    2017-09-01

    The role of social media (SoMe) in surgical education is emerging as a tool that augments and complements traditional learning. As SoMe usage has steadily increased in our personal and professional lives, it is no surprise that it has permeated into surgical education. Different SoMe sites offer distinct platforms from which knowledge can be transmitted, while catering to various learning styles. The purpose of this review is to outline the various SoMe platforms and their use in surgical education. Moreover, it will discuss their effectiveness in teaching and learning surgical knowledge and skills as well as other potential roles SoMe has to offer to improve surgical education.

  7. Influence of Preoperative Chemoradiotherapy on the Surgical Strategy According to the Clinical T Stage of Patients With Rectal Cancer

    Park, In Ja; Lee, Jong Lyul; Yoon, Yong Sik; Kim, Chan Wook; Lim, Seok-Byung; Lee, Jong Seok; Park, Seong Ho; Park, Jin Hong; Kim, Jong Hoon; Yu, Chang Sik; Kim, Jin Cheon

    2015-01-01

    Abstract The aim of this study was to evaluate the pathologic responses and changes to surgical strategies following preoperative chemoradiotherapy (PCRT) in rectal cancer patients according to their clinical T stage (cT). The use of PCRT has recently been extended to less advanced disease. The authors enrolled 650 patients with cT2 to 4 mid and low rectal cancer who received both PCRT and surgical resection. The rate of total regression and the proportion of local excision were compared according to the cT category. The 3-year recurrence-free survival (RFS) rate was compared using the log-rank test according to patient cT category, pathologic stage, and type of surgical treatment. Patients with cT2 were older (P = 0.001), predominately female (P = 0.028), and had low-lying rectal cancer (P = 0.008). Pathologic total regression was achieved most frequently in cT2 patients (54% of cT2 versus 17.6% of cT3 versus 8.2% of cT4; P rectal cancer, optimal surgical treatment may be achieved with the tailored use of PCRT. PMID:26717384

  8. Helsinki Metropolitan Area Climate Change Adaptation Strategy

    NONE

    2012-07-01

    The Helsinki Metropolitan Area Climate Change Adaptation Strategy has been prepared in close cooperation with the four cities of the metropolitan area (Helsinki, Espoo, Vantaa and Kauniainen), the Helsinki Region Environmental Services Authority HSY and other municipal, regional and state level organisations. In the strategy, strategic starting points and policies with which the metropolitan area prepares for the consequences of climate change, are compiled. The Helsinki Metropolitan Area adaptation strategy concentrates on the adaptation of the built and urban environment to the changing climate. The vision of the strategy is climate proof city - the future is built now. The strategy aims to (1) assess the impacts of climate change in the area, (2) prepare for the impacts of climate change and to extreme weather events and (3) to reduce the vulnerabilities of the area to climate variability and change. The target is to secure the well-being of the citizens and the functioning of the cities also in the changing climate conditions. The preparation of the adaptation strategy started in 2009 by producing the background studies. They include the regional climate and sea level scenarios, modelling of river floods in climate change conditions and a survey of climate change impacts in the region. Also, existing programmes, legislation, research and studies concerning adaptation were collected. The background studies are published in a report titled 'The Helsinki metropolitan area climate is changing - Adaptation strategy background studies' (in Finnish) (HSY 2010). HSY coordinated the strategy preparation. The work was carried out is close cooperation with the experts of the metropolitan area cities, regional emergency services, Ministry of the Environment, Helsinki Region Transport Authority and other regional organisations. The strategy work has had a steering group that consists of representatives of the cities and other central cooperation partners. The

  9. A New Strategy for Mitigating Climate Change

    Kaya, Y.; Akimoto, K./ Oda, J.

    2007-07-01

    This paper proposes a new strategy for mitigating climate change, both in short term and in long term. The basic character of the strategy is action oriented with multi-country collaboration, while the Framework Convention on Climate Change (FCCC) and Kyoto protocol is numerical target oriented within United Nation Framework. The introductory part of the paper briefly describes deficits of FCCC and Kyoto protocol and the needs of a different strategy for mitigating climate change. Then the short term strategy is focused on energy conservation and its effectiveness for mitigating climate change is illustrated by estimating the potential of reducing CO{sub 2} emission when intense collaboration is achieved for distributing main energy conservation measures in power generation and key industries among Asia Pacific Partnership countries. The long term strategy is developing novel types of renewables among countries. Geoheat and space solar power systems (SSPS) are candidates which may be developed among major developed countries. Necessity of international collaboration is stressed for R and D of these candidate renewables. (auth)

  10. Place of surgical resection in the treatment strategy of gastrointestinal neuroendocrine tumors.

    Gaujoux, Sébastien; Sauvanet, Alain; Belghiti, Jacques

    2012-09-01

    Neuroendocrine tumors (NET) are usually slow-growing neoplasms carrying an overall favorable prognosis. Surgery, from resection to transplantation, remains the only potential curative option for these patients, and should always be considered. Nevertheless, because of very few randomized controlled trials available, the optimal treatment for these patients remains controversial, especially regarding the place of surgery. We herein discuss the place of surgical resection in the treatment strategy in neuroendocrine tumors of the digestive tract.

  11. Climate changes and farmers' endogenous adaptation strategies ...

    It has been claimed that climate changes impact studies often assume certain adaptations and little explicit examination of how, when, why, and under what conditions they occur. This research aims at analysing the endogenous strategies developed by farmers in agricultural land and crop management. With random ...

  12. The Changing Career Strategies of Managers.

    Wilson, Tony; Davies, Goronwy

    1999-01-01

    Faced with reduced employment security, managers are redefining careers to include work/personal life balance. Changes in any area can cause revision of career strategies. Depending on how they define careers, managers recognize career development as an individual, not an organizational, responsibility. (SK)

  13. Impact of the surgical strategy on the incidence of C5 nerve root palsy in decompressive cervical surgery.

    Theresa Krätzig

    Full Text Available Our aim was to identify the impact of different surgical strategies on the incidence of C5 palsy.Degenerative cervical spinal stenosis is a steadily increasing morbidity in the ageing population. Postoperative C5 nerve root palsy is a common complication with severe impact on the patients´ quality of life.We identified 1708 consecutive patients who underwent cervical decompression surgery due to degenerative changes. The incidence of C5 palsy and surgical parameters including type and level of surgery were recorded to identify predictors for C5 nerve palsy.The overall C5 palsy rate was 4.8%, with 18.3% of cases being bilateral. For ACDF alone the palsy rate was low (1.13%, compared to 14.0% of C5 palsy rate after corpectomy. The risk increased with extension of the procedures. Hybrid constructs with corpectomy plus ACDF at C3-6 showed significantly lower rates of C5 palsy (10.7% than corpectomy of two vertebrae (p = 0.005. Multiple regression analysis identified corpectomy of C4 or C5 as a significant predictor. We observed a lower overall incidence for ventral (4.3% compared to dorsal (10.9% approaches (p<0.001. When imaging detected a postoperative shift of the spinal cord at index segment C4/5, palsy rate increased significantly (33.3% vs. 12.5%, p = 0.034.Extended surgical strategies, such as dorsal laminectomies, multilevel corpectomies and procedures with extensive spinal cord shift were shown to display a high risk of C5 palsy. The use of extended procedures should therefore be employed cautiously. Switching to combined surgical methods like ACDF plus corpectomy can reduce the rate of C5 palsy.

  14. The application of digital surgical diagnosis and treatment technology: a promising strategy for surgical reconstruction of craniomaxillofacial defect and deformity.

    Wang, Li-ya; Du, Hong-ming; Zhang, Gang; Tang, Wei; Liu, Lei; Jing, Wei; Long, Jie

    2011-12-01

    The craniomaxillofacial defect and deformity always leads to serious dysfunction in mastication and facial contour damage, significantly reducing patients' quality of life. However, surgical reconstruction of a craniomaxillofacial hard tissue defect or deformity is extremely complex and often does not result in desired facial morphology. Improving the result for patients with craniomaxillofacial defect and deformity remains a challenge for surgeons. Using digital technology for surgical diagnosis and treatment may help solve this problem. Computer-assisted surgical technology and surgical navigation technology are included in the accurate digital diagnosis and treatment system we propose. These technologies will increase the accuracy of the design of the operation plan. In addition, the intraoperative real-time navigating location system controlling the robotic arm or advanced intelligent robot will provide accurate, individualized surgical treatment for patients. Here we propose the hypothesis that a digital surgical diagnosis and treatment technology may provide a new approach for precise surgical reconstruction of complicated craniomaxillofacial defect and deformity. Our hypothesis involves modern digital surgery, a three-dimensional navigation surgery system and modern digital imaging technology, and our key aim is to establish a technological platform for customized digital surgical design and surgical navigation for craniomaxillofacial defect and deformity. If the hypothesis is proven practical, this novel therapeutic approach could improve the result of surgical reconstruction for craniomaxillofacial defect and deformity for many patients. Copyright © 2011 Elsevier Ltd. All rights reserved.

  15. Unlocking the “black box” of practice improvement strategies to implement surgical safety checklists: a process evaluation

    Gillespie BM

    2017-04-01

    Full Text Available Brigid M Gillespie,1–3 Kyra Hamilton,4 Dianne Ball,5 Joanne Lavin,6 Therese Gardiner,6 Teresa K Withers,7 Andrea P Marshall1–3 1School of Nursing & Midwifery, Griffith University, Gold Coast, 2Gold Coast University Hospital and Health Service, Southport, 3Nursing & Midwifery Education & Research Unit (NMERU, National Centre of Research Excellence in Nursing, Menzies Health Institute of Queensland, Griffith University, Gold Coast, 4School of Applied Psychology, Griffith University, Mt Gravatt, 5Communio Pty Ltd, Sydney, 6Nursing & Midwifery Education & Research Unit, 7Surgical and Procedural Services, Gold Coast University Hospital and Health Service, Southport, Australia Background: Compliance with surgical safety checklists (SSCs has been associated with improvements in clinical processes such as antibiotic use, correct site marking, and overall safety processes. Yet, proper execution has been difficult to achieve.Objectives: The objective of this study was to undertake a process evaluation of four knowledge translation (KT strategies used to implement the Pass the Baton (PTB intervention which was designed to improve utilization of the SSC. Methods: As part of the process evaluation, a logic model was generated to explain which KT strategies worked well (or less well in the operating rooms of a tertiary referral hospital in Queensland, Australia. The KT strategies implemented included change champions/opinion leaders, education, audit and feedback, and reminders. In evaluating the implementation of these strategies, this study considered context, intervention and underpinning assumptions, implementation, and mechanism of impact. Observational and interview data were collected to assess implementation of the KT strategies relative to fidelity, feasibility, and acceptability. Results: Findings from 35 structured observations and 15 interviews with 96 intervention participants suggest that all of the KT strategies were consistently

  16. Changing Identities and Socio Economic Strategies

    Singla, Rashmi; Fabricius, Anne Sophie; Holm, Anne

    Changing Identities and Socio Economic Strategies: South Asian Diasporic Youth in Scandinavia   Rashmi Singla,  Anne Sophie Fabricius & Anne Holm This paper throws light on the rapid cultural transformations as well as continuity among the South Asian youth in Scandinavia, primarily in Denmark....... Based on two interdisciplinary empirical studies, it investigates some socioeconomic aspects of the South Asian diaspora in Denmark. The first longitudinal study explored young adults’ economic strategies in relation to their country of origin. The first wave investigation was conducted in the mid-1990s...

  17. Overview of current surgical strategies for aortic disease in patients with Marfan syndrome.

    Miyahara, Shunsuke; Okita, Yutaka

    2016-09-01

    Marfan syndrome is a heritable, systemic disorder of the connective tissue with a high penetrance, named after Dr. Antoine Marfan. The most clinically important manifestations of this syndrome are cardiovascular pathologies which cause life-threatening events, such as acute aortic dissections, aortic rupture and regurgitation of the aortic valve or other artrioventricular valves leading to heart failure. These events play important roles in the life expectancy of patients with this disorder, especially prior to the development of effective surgical approaches for proximal ascending aortic disease. To prevent such catastrophic aortic events, a lower threshold has been recommended for prophylactic interventions on the aortic root. After prophylactic root replacement, disease in the aorta beyond the root and distal to the arch remains a cause for concern. Multiple surgeries are required throughout a patient's lifetime that can be problematic due to distal lesions complicated by dissection. Many controversies in surgical strategies remain, such as endovascular repair, to manage such complex cases. This review examines the trends in surgical strategies for the treatment of cardiovascular disease in patients with Marfan syndrome, and current perspectives in this field.

  18. Canada's National Implementation Strategy on Climate Change

    2000-10-01

    This document describes the national implementation strategy which is a part of the coordinated national response to climate change. The approach was developed from the National Climate Change process, established by the federal, provincial and territorial ministers responsible for energy and the environment, based on an examination of the impacts, costs and benefits of implementing the Kyoto Protocol, as well as the options for addressing climate change. The Strategy involves (1) taking action to reduce risks and to improve our understanding of risks associated with climate change, (2) institution of a national framework that includes individual and joint action, while recognizing jurisdictional flexibility in responding to unique circumstances, (3) adopting a phased approach, (4) progressive action in response to changing domestic and international circumstances, (5) clear understanding of the necessary relationship between international and national strategies, (6) developing an understanding of the implications of emission reduction targets and major options, including cross-cutting policy approaches such as emissions trading and allocation of responsibility for reducing emissions. The Strategy uses a risk-management approach that attempts to limit the risks of climate change while maximizing opportunities for Canada to contribute to global and national solutions. This approach incorporates improving scientific and analytical understanding and co-ordinating national and international action and a phased approach to implementation. This policy document focuses on Phase One actions which consist of five connected themes, i. e. enhancing awareness and understanding, promoting technology development and innovation, governments leading by example, investing in knowledge and building the foundation, and encouraging action. Future phases will be linked to greater international certainty based on ratification of the Kyoto Protocol, the actions of our trading partners

  19. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

    Anderson, Deverick J.; Podgorny, Kelly; Berríos-Torres, Sandra I.; Bratzler, Dale W.; Dellinger, E. Patchen; Greene, Linda; Nyquist, Ann-Christine; Saiman, Lisa; Yokoe, Deborah S.; Maragakis, Lisa L.; Kaye, Keith S.

    2014-01-01

    PURPOSE Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2 PMID:24799638

  20. Addressing the burden of post-conflict surgical disease - strategies from the North Caucasus.

    Lunze, Karsten; Lunze, Fatima I

    2011-01-01

    The 2004 terror attack on a school in Beslan, North Caucasus, with more than 1300 children and their families taken hostage and 334 people killed, ended after extreme violence. Following the disaster, many survivors with blast ear injuries developed complications because no microsurgery services were available in the region. Here, we present our strategies in North Ossetia to strengthen subspecialty surgical care in a region of instable security conditions. Disaster modifies disease burden in an environment of conflict-related health-care limitations. We built on available secondary care and partnered international with local stakeholders to reach and treat victims of a humanitarian disaster. A strategy of mutual commitment resulted in treatment of all consenting Beslan victims with blast trauma sequelae and of non disaster-related patients. Credible, sustained partnerships and needs assessments beyond the immediate phases after a disaster are essential to facilitate a meaningful transition from humanitarian aid to capacity building exceeding existing insufficient standards. Psychosocial impacts of disaster might constitute a barrier to care and need to be assessed when responding to the burden of surgical disease in conflict or post-conflict settings. Involving local citizen groups in the planning process can be useful to identify and access vulnerable populations. Integration of our strategy into broader efforts might strengthen the local health system through management and leadership.

  1. Biomedical engineering strategies for peripheral nerve repair: surgical applications, state of the art, and future challenges.

    Pfister, Bryan J; Gordon, Tessa; Loverde, Joseph R; Kochar, Arshneel S; Mackinnon, Susan E; Cullen, D Kacy

    2011-01-01

    Damage to the peripheral nervous system is surprisingly common and occurs primarily from trauma or a complication of surgery. Although recovery of nerve function occurs in many mild injuries, outcomes are often unsatisfactory following severe trauma. Nerve repair and regeneration presents unique clinical challenges and opportunities, and substantial contributions can be made through the informed application of biomedical engineering strategies. This article reviews the clinical presentations and classification of nerve injuries, in addition to the state of the art for surgical decision-making and repair strategies. This discussion presents specific challenges that must be addressed to realistically improve the treatment of nerve injuries and promote widespread recovery. In particular, nerve defects a few centimeters in length use a sensory nerve autograft as the standard technique; however, this approach is limited by the availability of donor nerve and comorbidity associated with additional surgery. Moreover, we currently have an inadequate ability to noninvasively assess the degree of nerve injury and to track axonal regeneration. As a result, wait-and-see surgical decisions can lead to undesirable and less successful "delayed" repair procedures. In this fight for time, degeneration of the distal nerve support structure and target progresses, ultimately blunting complete functional recovery. Thus, the most pressing challenges in peripheral nerve repair include the development of tissue-engineered nerve grafts that match or exceed the performance of autografts, the ability to noninvasively assess nerve damage and track axonal regeneration, and approaches to maintain the efficacy of the distal pathway and targets during the regenerative process. Biomedical engineering strategies can address these issues to substantially contribute at both the basic and applied levels, improving surgical management and functional recovery following severe peripheral nerve injury.

  2. [Ladder step strategy for surgical repair of congenital concealed penis in children].

    Wang, Fu-Ran; Zhong, Hong-Ji; Chen, Yi; Zhao, Jun-Feng; Li, Yan

    2016-11-01

    To assess the feasibility of the ladder step strategy in surgical repair of congenital concealed penis in children. This study included 52 children with congenital concealed penis treated in the past two years by surgical repair using the ladder step strategy, which consists of five main steps: cutting the narrow ring of the foreskin, degloving the penile skin, fixing the penile skin at the base, covering the penile shaft, and reshaping the prepuce. The perioperative data of the patients were prospectively collected and statistically described. Of the 52 patients, 20 needed remodeling of the frenulum and 27 received longitudinal incision in the penoscrotal junction to expose and deglove the penile shaft. The advanced scrotal flap technique was applied in 8 children to cover the penile shaft without tension, the pedicled foreskin flap technique employed in 11 to repair the penile skin defect, and excision of the webbed skin of the ventral penis performed in another 44 to remodel the penoscrotal angle. The operation time, blood loss, and postoperative hospital stay were 40-100 minutes, 5-30 ml, and 3-6 days, respectively. Wound bleeding and infection occurred in 1 and 5 cases, respectively. Follow-up examinations at 3 and 6 months after surgery showed that all the children had a satisfactory penile appearance except for some minor complications (2 cases of penile retraction, 2 cases of redundant ventral skin, and 1 case of iatrogenic penile curvature). The ladder step strategy for surgical repair of congenital concealed penis in children is a simple procedure with minor injury and satisfactory appearance of the penis.

  3. Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system.

    Gramlich, Leah M; Sheppard, Caroline E; Wasylak, Tracy; Gilmour, Loreen E; Ljungqvist, Olle; Basualdo-Hammond, Carlota; Nelson, Gregg

    2017-05-19

    Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS). ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation. Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time. Using the

  4. Surgical management of spinal intramedullary tumors: radical and safe strategy for benign tumors.

    Takami, Toshihiro; Naito, Kentaro; Yamagata, Toru; Ohata, Kenji

    2015-01-01

    Surgery for spinal intramedullary tumors remains one of the major challenges for neurosurgeons, due to their relative infrequency, unknown natural history, and surgical difficulty. We are sure that safe and precise resection of spinal intramedullary tumors, particularly encapsulated benign tumors, can result in acceptable or satisfactory postoperative outcomes. General surgical concepts and strategies, technical consideration, and functional outcomes after surgery are discussed with illustrative cases of spinal intramedullary benign tumors such as ependymoma, cavernous malformation, and hemangioblastoma. Selection of a posterior median sulcus, posterolateral sulcus, or direct transpial approach was determined based on the preoperative imaging diagnosis and careful inspection of the spinal cord surface. Tumor-cord interface was meticulously delineated in cases of benign encapsulated tumors. Our retrospective functional analysis of 24 consecutive cases of spinal intramedullary ependymoma followed for at least 6 months postoperatively demonstrated a mean grade on the modified McCormick functional schema of 1.8 before surgery, deteriorating significantly to 2.6 early after surgery ( 6 months after surgery). The risk of functional deterioration after surgery should be taken into serious consideration. Functional deterioration after surgery, including neuropathic pain even long after surgery, significantly affects patient quality of life. Better balance between tumor control and functional preservation can be achieved not only by the surgical technique or expertise, but also by intraoperative neurophysiological monitoring, vascular image guidance, and postoperative supportive care. Quality of life after surgery should inarguably be given top priority.

  5. Idiopathic Intracranial Hypertension After Surgical Treatment of Cushing Disease: Case Report and Review of Management Strategies.

    Wagner, Jeffrey; Fleseriu, Cara M; Ibrahim, Aly; Cetas, Justin S

    2016-12-01

    Idiopathic intracranial hypertension (IIH) in patients with Cushing disease (CD), after treatment, is rarely described, in adults. The cause is believed to be multifactorial, potentially related to a relative decrease in cortisol after surgical resection or medical treatment of a corticotroph pituitary adenoma. We investigate our center's CD database (140 surgically and 60 medically [primary or adjunct] treated patients) for cases of IIH, describe our center's experience with symptomatic IIH, and review treatment strategies in adults with CD after transsphenoidal resection. We present the case of a 22-year-old woman who presented with worsening headache, nausea, vomiting, blurry vision, diplopia, visual loss, and facial numbness 14 weeks after surgical resection of adrenocorticotropic hormone-positive pituitary adenoma. Her CD had been in remission since surgery, with subsequent adrenal insufficiency (AI), which was initially treated with supraphysiologic glucocorticoid replacement, tapered down to physiologic doses at the time the IIH symptoms developed. Symptomatic IIH is rare in adult patients but can be severe and result in permanent vision loss. A high index of suspicion should be maintained and a fundus examination is necessary to exclude papilledema, whenever there are suggestive symptoms that initially may overlap with AI. It is possible that some cases of mild IIH are misdiagnosed as GC withdrawal or AI; however, further studies are needed. Treatment consists of reinitiation of higher steroid doses together with acetazolamide with or without cerebrospinal fluid diversion and the priority is to preserve vision and reverse any visual loss. Published by Elsevier Inc.

  6. EU energy and climate change strategy

    Graça Carvalho, Maria da

    2012-01-01

    This paper will summarise the European Strategy for Energy and Climate Change. In current international negotiations Europe has proposed a 20% reduction in GHG (greenhouse gases) in the developed countries by 2020 or 30% should there be an international agreement in the domain. However it is important to define measures to achieve the targets. One of the principal tools is to improve energy efficiency under the energy efficiency action plan, which will help to achieve a 20% energy saving by 2020. On the other hand, the amount of energy from renewable sources consumed in Europe will have to rise from its current level of 8.5%–20% by 2020. These are ambitious but achievable targets. Nonetheless, these can only be achieved through strong investment in areas of the knowledge triangle which strengthens research and innovation in the energy sector in Europe. The paper covers European Energy and Climate Change Policy, the European Strategic Energy Technology plan, the consequences of the Lisbon Treaty, European and national Road maps to a low carbon economy, the Energy Efficiency Plan for 2011 and finishes with a brief consideration of the EU’s energy infrastructure priorities. -- Highlights: ► This paper summarises the European Strategy for Energy and Climate Change. ► Reduction of GHG emissions by 30%-international agreement or −20% without agreement. ► Use of 20% of renewable energies by 2020. ► Increase of energy efficiency of 20% by 2020. ► Consolidating of the internal energy market.

  7. Simulation-Based Learning Strategies to Teach Undergraduate Students Basic Surgical Skills: A Systematic Review.

    Theodoulou, Iakovos; Nicolaides, Marios; Athanasiou, Thanos; Papalois, Apostolos; Sideris, Michail

    2018-02-16

    We aimed to identify and critically appraise all literature surrounding simulation-based learning (SBL) courses, to assess their relevance as tools for undergraduate surgical education, and create a design framework targeted at standardizing future SBL. We performed a systematic review of the literature using a specific keyword strategy to search at MEDLINE database. Of the 2371 potentially eligible titles, 472 were shortlisted and only 40 explored active interventions in undergraduate medical education. Of those, 20 were conducted in the United States, 9 in Europe and 11 in the rest of the world. Nineteen studies assessed the effectiveness of SBL by comparing students' attributes before and after interventions, 1 study assessed a new tool of surgical assessment and 16 studies evaluated SBL courses from the students' perspectives. Of those 40 studies, 12 used dry laboratory, 7 wet laboratory, 12 mixed, and 9 cadaveric SBL interventions. The extent to which positive results were obtained from dry, wet, mixed, and cadaveric laboratories were 75%, 57%, 92%, and 100%, respectively. Consequently, the SBL design framework was devised, providing a foundation upon which future SBL interventions can be designed such that learning outcomes are optimized. SBL is an important step in surgical education, investing in a safer and more efficient generation of surgeons. Standardization of these efforts can be accelerated with SBL design framework, a comprehensive guide to designing future interventions for basic surgical training at the undergraduate level. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

  8. Surgical management of perforated duodenal ulcer: the changing scene.

    Plummer, J M; McFarlane, M E C; Newnham

    2004-12-01

    To determine the management of perforated duodenal ulcer at the University Hospital of the West Indies (UHWI) in this era of Helicobacter pylori, the medical records of all patients seen at the UHWI during the period July 1997 to June 2002 with an intra-operative diagnosis of perforated peptic ulcer were reviewed The records were analyzed for the following: age, gender, duration of symptoms, non-steroidal anti-inflammatory drug (NSAID) use, smoking status, operative repair duration of hospitalization, Helicobacter pylori status and medical therapy, peri-operative complications, mortality and recurrence. Ninety per cent of the cases were males. All females in whom perforation occurred were age 50 years and older compared to males where 58% of cases presented before age 50 years. Perforations in acute ulcers occurred in 80% of cases. The majority of patients were male smokers. Non-steroidal anti-inflammatory drug use was also an important risk factor in elderly females. Simple surgical closure and standard triple therapy antibiotics to eradicate Helicobacter pylori was the most common treatment offered. Mortality was one per cent and follow-up poor but 11% of patients had documented recurrent peptic ulceration. In this study population, perforated duodenal ulcer occured overwhelmingly in males less than 50 years of age. There is a trend towards exclusive simple surgical closure and H pylori eradication at the UHWI for patients with perforated duodenal ulcer but this needs to be supported by documentation of H pylori prevalence in the population of patients presenting with perforated peptic ulcers.

  9. Conservation strategies, sustainable development and climate change

    Manning, E.; Rizzo, B.; Wiken, E.

    1990-01-01

    The relationship between conservation strategies, sustainable development and climatic change is discussed. A broad conceptual model of environment-economy relationships is introduced, which can aid in understanding the sources of the stresses put on the environment and the ability of the environment to respond. The supply side of the model introduces the concept of the environment as a source of environmental functions, each distinguishable part of which can be described in terms of a range of biological or physical variables. These functions have the potential to produce an extensive range of goods, services, values, etc. The demand side of the model is population powered and anthropocentric. Transformation functions occur to alter the supply to satisfy the demand, and may range from picking an apple to combinations of transport, combination, distillation and packaging of many different substances. Climate change can be viewed as one of the most significant feedbacks from our demands on the resource base, most particularly from the transformation functions used. Conservation strategies are a means to try to address concerns with all areas of the system embodied in the model. 36 refs., 4 figs

  10. Surgical and Pathological Changes after Radiofrequency Ablation of Thyroid Nodules

    Chiara Dobrinja

    2015-01-01

    Full Text Available Background. Radiofrequency ablation (RFA has been recently advocated as an effective technique for the treatment of symptomatic benign thyroid nodules. It is not known to what extent it may affect any subsequent thyroid surgery and/or histological diagnosis. Materials and Methods. RFA was performed on 64 symptomatic Thy2 nodules (benign nodules and 6 symptomatic Thy3 nodules (follicular lesions/follicular neoplasms. Two Thy3 nodules regrew after the procedure, and these patients accepted to undergo a total thyroidectomy. Here we present how RFA has affected the operation and the final pathological features of the surgically removed nodules. Results and Conclusions. RFA is effective for the treatment of Thy2 nodules, but it should not be recommended as first-line therapy for the treatment of Thy3 nodules (irrespective of their mutational status, as it delays surgery in case of malignancy. Moreover, it is unknown whether RFA might promote residual tumor progression or neoplastic progression of Thy3 lesions. Nevertheless, here we show for the first time that one session of RFA does not affect subsequent thyroid surgery and/or histological diagnosis.

  11. Glycemic control strategies and the occurrence of surgical site infection: a systematic review.

    Domingos, Caroline Maria Herrero; Iida, Luciana Inaba Senyer; Poveda, Vanessa de Brito

    2016-01-01

    To analyze the evidence available in the scientific literature regarding the relationship between the glycemic control strategies used and the occurrence of surgical site infection in adult patients undergoing surgery. This is a systematic review performed through search on the databases of CINAHL, MEDLINE, LILACS, Cochrane Database of Systematic Reviews and EMBASE. Eight randomized controlled trials were selected. Despite the diversity of tested interventions, studies agree that glycemic control is essential to reduce rates of surgical site infection, and should be maintained between 80 and 120 mg/dL during the perioperative period. Compared to other strategies, insulin continuous infusion during surgery was the most tested and seems to get better results in reducing rates of surgical site infection and achieving success in glycemic control. Tight glycemic control during the perioperative period benefits the recovery of surgical patients, and the role of the nursing team is key for the successful implementation of the measure. Analisar as evidências disponíveis na literatura científica sobre a relação entre as estratégias de controle glicêmico efetuadas e a ocorrência de infecção do sítio cirúrgico em pacientes adultos submetidos à cirurgia. Trata-se de revisão sistemática, por meio das bases de dados CINAHL, MEDLINE, LILACS, Cochrane Database of Systematic Reviews e EMBASE. Foram selecionados oito ensaios clínicos randomizados. Apesar da diversidade de intervenções testadas, os estudos concordam que o controle glicêmico é essencial para a redução das taxas de infecção do sítio cirúrgico e deve ser mantido entre 80 e 120 mg/dL durante o perioperatório. A infusão contínua de insulina no transoperatório foi a mais testada e parece obter melhores resultados na redução das taxas de infecção do sítio cirúrgico e sucesso no controle glicêmico comparada às demais estratégias. O controle glicêmico rigoroso durante o perioperat

  12. Using Appreciative Inquiry to Discover and Deliver Change for Surgical Technology Students

    Cabai, Katherine A.

    2012-01-01

    The purpose of this study was to examine efficacious teaching-learning strategies that community college stakeholders employ that enhance surgical technology student outcomes. Knowles's adult learning theory, constructivist theory, and appreciative inquiry served as the theoretical foundation for this study. Discovering effective aspects and…

  13. Sex change strategy and the aromatase genes.

    Gardner, L; Anderson, T; Place, A R; Dixon, B; Elizur, A

    2005-04-01

    Sequential hermaphroditism is a common reproductive strategy in many teleosts. Steroid production is known to mediate both the natural and induced sex change, yet beyond this the physiology directing this process has received little attention. Cytochrome P450 aromatase is a key enzyme in the hormonal pathway catalysing the conversion of sex steroids, androgens to oestrogens, and thus is highly relevant to the process of sex change. This study reports the isolation of cDNA sequences for aromatase isoforms CYP19A1 and CYP19A2 from teleost species representing three forms of sexual hermaphroditism: Lates calcarifer (protandry), Cromileptes altivelis (protogyny), and Gobiodon histrio (bi-directional). Deduced amino acid analysis of these isoforms with other reported isoforms from gonochoristic (single sex) teleosts revealed 56-95% identity within the same isoform while only 48-65% identity between isoforms irrespective of species and sexual strategy. Phylogenetic analysis supported this result separating sequences into isoform exclusive clades in spite of species apparent evolutionary distance. Furthermore, this study isolates 5' flanking regions of all above genes and describes putative cis-acting elements therein. Elements identified include steroidogenic factor 1 binding site (SF-1), oestrogen response element (ERE), progesterone response element (PRE), androgen response element (ARE), glucocorticoid response elements (GRE), peroxisome proliferator-activated receptor alpha/retinoid X receptor alpha heterodimer responsive element (PPARalpha/RXRalpha), nuclear factor kappabeta (NF-kappabeta), SOX 5, SOX 9, and Wilms tumor suppressor (WTI). A hypothetical in vivo model was constructed for both isoforms highlighting potential roles of these putative cis-acting elements with reference to normal function and sexual hermaphroditism.

  14. Towards reducing thrombogenicity of LVAD therapy: optimizing surgical and patient management strategies

    Chivukula, Venkat Keshav; Lafzi, Ali; Mokadam, Nahush; Beckman, Jennifer; Mahr, Claudius; Aliseda, Alberto

    2017-11-01

    Unfavourable hemodynamics in heart failure patients implanted with left ventricular assist devices (LVAD), due to non-optimal surgical configurations and patient management, strongly influence thrombogenicity. This is consistent with the increase in devastating thromboembolic complications (specifically thrombosis and stroke) in patients, even as the risk of thrombosis inside the device decreases with modern designs. Inflow cannula and outflow graft surgical configurations have been optimized via patient-specific modeling that computes the thrombogenic potential with a combination of Eulerian (endothelial) wall shear stress and Lagrangian (platelet shear history) tracking. Using this view of hemodynamics, the benefits of intermittent aortic valve opening (promoting washout and reducing stagnant flow in the aortic valve region) have been assessed in managing the patient's residual native cardiac output. The use of this methodology to understand the contribution of the hemodynamics in the flow surrounding the LVAD itself to thrombogenesis show promise in developing holistic patient-specific management strategies to minimize stroke risk and enhance efficacy of LVAD therapy. Funded in part by an AHA postdoctoral fellowship 16POST30520004.

  15. Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: Beyond palliative treatments.

    Sandoval, Julio; Gomez-Arroyo, Jose; Gaspar, Jorge; Pulido-Zamudio, Tomas

    2015-10-01

    Despite significant advances in pharmacological treatments, pulmonary arterial hypertension remains an incurable disease with an unreasonably high morbidity and mortality. Although specific pharmacotherapies have shifted the survival curves of patients and improved exercise endurance as well as quality of life, it is also true that these pharmacological interventions are not always accessible (particularly in developing countries) and, perhaps most importantly, not all patients respond similarly to these drugs. Furthermore, many patients will continue to deteriorate and will eventually require an additional, non-pharmacological, intervention. In this review we analyze the role of atrial septostomy and Potts anastomosis in the management of patients with pulmonary arterial hypertension, we summarize the current worldwide clinical experience (case reports and case series), and discuss why these interventional/surgical strategies might have a therapeutic role beyond that of a "bridge" to transplantation. Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  16. Perceived age change after aesthetic facial surgical procedures quantifying outcomes of aging face surgery.

    Chauhan, Nitin; Warner, Jeremy P; Adamson, Peter A

    2012-01-01

    To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent.

  17. Oculomotor nerve palsy by posterior communicating artery aneurysms: influence of surgical strategy on recovery.

    Güresir, Erdem; Schuss, Patrick; Seifert, Volker; Vatter, Hartmut

    2012-11-01

    Resolution of oculomotor nerve palsy (ONP) after clipping of posterior communicating artery (PCoA) aneurysms has been well documented. However, whether additional decompression of the oculomotor nerve via aneurysm sac dissection or resection is superior to pure aneurysm clipping is the subject of much debate. Therefore, the objective in the present investigation was to analyze the influence of surgical strategy--specifically, clipping with or without aneurysm dissection--on ONP resolution. Between June 1999 and December 2010, 18 consecutive patients with ruptured and unruptured PCoA aneurysms causing ONP were treated at the authors' institution. Oculomotor nerve palsy was evaluated on admission and at follow-up. The electronic database MEDLINE was searched for additional data in published studies of PCoA aneurysms causing ONP. Two reviewers independently extracted data. Overall, 8 studies from the literature review and 6 patients in the current series (121 PCoA aneurysms) met the study inclusion criteria. Ninety-four aneurysms were treated with simple aneurysm neck clipping and 27 with clipping plus aneurysm sac decompression. The surgical strategy, simple aneurysm neck clipping versus clipping plus oculomotor nerve decompression, had no effect on full ONP resolution on univariate (p = 0.5) and multivariate analyses. On multivariate analysis, patients with incomplete ONP at admission were more likely to have full resolution of the palsy than were those with complete ONP at admission (p = 0.03, OR = 4.2, 95% CI 1.1-16). Data in the present study indicated that ONP caused by PCoA aneurysms improves after clipping without and with oculomotor nerve decompression. The resolution of ONP is inversely associated with the initial severity of ONP.

  18. Secular trends in mortality associated with new therapeutic strategies in surgical critical illness.

    Hartl, Wolfgang H; Wolf, Hilde; Schneider, Christian P; Küchenhoff, Helmut; Jauch, Karl-Walter

    2007-10-01

    Since 1999 randomized controlled trials have shown that new therapeutic strategies, such as strict glycemic control, increased use of noninvasive ventilation and of lung-protective ventilation, and early goal-oriented shock therapy, may reduce mortality in selected groups of critically ill patients. Whether these benefits can be translated to a surgical clinical setting is unclear. We wanted to evaluate longitudinally the successive routine implementation of new therapeutic measures and its effect on postsurgical patients admitted to the intensive care unit. We performed a retrospective analysis on data collected prospectively from March 1, 1993 through February 28, 2005. A cohort of 1,802 consecutive cases requiring intensive care therapy for more than 4 days was analyzed. A significant decrease in mortality was observed in the last years of the study. With adjustment for relevant covariates, treatment after the implementation of new therapeutic strategies was identified as an independent factor linked with a reduced risk of death (odds ratio [OR] .518; 95% confidence interval [CI] .337-.796), whereas older age (OR 1.030; 95% CI 1.015-1.045), a high severity score on admission (OR 1.155; 95% CI 1.113-1.198) or during intensive care unit stay (OR 1.187; 95% CI 1.145-1.231), a high number of failing organs (OR 1.918; 95% CI 1.635-2.250), and peritonitis (OR 3.277; 95% CI 2.046-5.246) were independently associated with death. Implementing of a variety of new therapeutic measures into routine care of critically ill surgical patients was associated with improved survival after 2001.

  19. Identifying optimal postmarket surveillance strategies for medical and surgical devices: implications for policy, practice and research.

    Gagliardi, Anna R; Umoquit, Muriah; Lehoux, Pascale; Ross, Sue; Ducey, Ariel; Urbach, David R

    2013-03-01

    Non-drug technologies offer many benefits, but have been associated with adverse events, prompting calls for improved postmarket surveillance. There is little empirical research to guide the development of such a system. The purpose of this study was to identify optimal postmarket surveillance strategies for medical and surgical devices. Qualitative methods were used for sampling, data collection and analysis. Stakeholders from Canada and the USA representing different roles and perspectives were first interviewed to identify examples and characteristics of different surveillance strategies. These stakeholders and others they recommended were then assembled at a 1-day nominal group meeting to discuss and prioritise the components of a postmarket device surveillance system, and research needed to achieve such a system. Consultations were held with 37 participants, and 47 participants attended the 1-day meeting. They recommended a multicomponent system including reporting by facilities, clinicians and patients, supported with some external surveillance for validation and real-time trials for high-risk devices. Many considerations were identified that constitute desirable characteristics of, and means by which to implement such a system. An overarching network was envisioned to broker linkages, establish a shared minimum dataset, and support communication and decision making. Numerous research questions were identified, which could be pursued in tandem with phased implementation of the system. These findings provide unique guidance for establishing a device safety network that is based on existing initiatives, and could be expanded and evaluated in a prospective, phased fashion as it was developed.

  20. Advanced surgical strategy for giant mediastinal germ cell tumor in children

    Shigehisa Fumino

    2017-12-01

    Conclusions: Resectability is the most important predictor of outcomes for MGCTs. Preoperative 3D-CT and CPS can enable complete resection and ensure surgical safety. Well-functioned surgical team is critical success factor in such advanced surgery.

  1. Self-regulated learning strategies used in surgical clerkship and the relationship with clinical achievement.

    Turan, Sevgi; Konan, Ali

    2012-01-01

    Self-regulated learning indicates students' skills in controlling their own learning. Self-regulated learning, which a context-specific process, emphasizes autonomy and control. Students gain more autonomy with respect to learning in the clinical years. Examining the self-regulated learning skills of students in this period will provide important clues about the level at which students are ready to use these skills in real-life conditions. The self-regulated learning strategies used by medical students in surgical clerkship were investigated in this study and their relation with clinical achievement was analyzed. The study was conducted during the surgery clerkship of medical students. The participation rate was 94% (309 students). Motivated Strategies for Learning Questionnaire (MSLQ), a case-based examination, Objective Structured Clinical Examination (OSCE), and tutor evaluations for assessing achievement were used. The relationship between the Motivated Strategies for Learning Questionnaire scores of the students and clinical achievement was analyzed with multilinear regression analysis. The findings showed that students use self-regulated learning skills at medium levels during their surgery clerkship. A relationship between these skills and OSCE scores and tutor evaluations was determined. OSCE scores of the students were observed to increase in conjunction with increased self-efficacy levels. However, as students' beliefs regarding control over learning increased, OSCE scores decreased. No significant relationship was defined between self-regulated learning skills and case-based examination scores. We observed that a greater self-efficacy for learning resulted in higher OSCE scores. Conversely, students who believe that learning is a result of their own effort had lower OSCE scores. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

  2. The surgical treatment strategy and results of parasellar meningiomas in the era of radiosurgery

    Iwai, Yoshiyasu; Yamanaka, Kazuhiro; Morikawa, Toshie; Ishiguro, Tomoya; Honda, Yuji; Matsuzaka, Yasuhiro; Komiyama, Masaki; Yasui, Toshihiro

    2003-01-01

    We evaluated the surgical treatment results of parasellar meningiomas in the era of radiosurgery. We treated 24 patients of parasellar meningiomas surgically. The median age was 60 yrs (ranging from 29 to 82 yrs). The most common tumor location was the sphenoid ridge in 12 patients and the tuberculum sellae in 7 patients. The pterional approach using fronto-temporal craniotomy was performed for all patients. The residual or recurrent tumors were treated by gamma knife radiosurgery (GKS). We are able to follow up these cases for a median of 3.8 yrs (ranging from 1 to 8 yrs) after the operations. The radicality of tumor resection was Simpson grade II in 13 patients (54%), grade III in 3 patients (13%) and grade IV in 7 patients (33%). Clinical improvement was achieved in 81% of the patients. Of the patients who had visual disturbance preoperatively, 8 patients (73%) showed improvement, but 3 patients suffered deterioration postoperatively. None of the patients died. One patient suffered transient memory disturbance and one patient suffered mild facial numbness postoperatively. Boost radiosurgery for the residual tumors was performed for six patients and tumor growth control was able to be achieved in all patients, with a median of 3.1 years follow-up period (ranging from 0.5 to 6 yrs). Five patients with tumor regrowth or recurrence were treated by GKS. We recommend fronto-temporal craniotomy with nonradical resection for parasellar meningiomas and radiosurgery for residual and recurrent tumors. This strategy will achieve good functional outcome with long-term tumor growth control. (author)

  3. Using Networks For Changing Innovation Strategy: The Case of IBM

    K. Dittrich (Koen); G.M. Duysters (Geert); A-P. de Man (Ard-Pieter)

    2004-01-01

    textabstractLarge-scale strategic change projects in companies may be supported by using alliance networks. This paper shows that IBM’s change from an exploitation strategy towards an exploration strategy required a radically different network strategy as well. By entering into more non-equity

  4. Reading strategy instruction and teacher change: Implications for ...

    I report on teacher change in the context of a reading strategy instruction intervention. Reading Strategy Instruction (RSI) was implemented by three teachers, new to the concept, over a period of 15 weeks. ... AJOL African Journals Online.

  5. Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies.

    König, M A; Jehan, S; Boszczyk, A A; Boszczyk, B M

    2012-05-01

    U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy. A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome. Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2-34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss. From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.

  6. Clinical and Surgical Strategies for Avoiding or Reducing Allogeneic Blood Transfusions.

    Dos Santos, Antonio Alceu; Baumgratz, Jose Francisco; Vila, Jose Henrique Andrade; Castro, Rodrigo Moreira; Bezerra, Rodrigo Freire

    2016-04-01

    Blood transfusions have still been used as a standard therapy to treat severe anemia. Current evidences point to both excessive allogeneic blood consumption and decreased donations, which result in reduced stocks in blood banks. Several studies have increasingly suggested a more restrictive transfusion practice for blood products. Currently, a number of autologous blood conservation protocols in surgeries have been noted. We report a case of severe anemia with 2.9 g/dL hemoglobin, which was successfully handled without using the standard therapy to treat anemia with hemotransfusions. Such a case of severe anemia condition resulted after the patient was submitted to ascending aortic aneurism repair, valvar aortic replacement, reimplantation of right coronary ostium, followed by a coronary artery bypass grafting and several postoperative complications. The main clinical and surgical strategies used in this case to avoid blood transfusions were acute normovolemic hemodilution, intraoperative blood cell salvage, and meticulous hemostasis, beyond epsilon-aminocaproic acid, desmopressin, prothrombin complex concentrate, human fibrinogen concentrate, factor VIIa recombinant, erythropoietin and hyperoxic ventilation.

  7. Prenatal stress changes learning strategies in adulthood.

    Schwabe, Lars; Bohbot, Veronique D; Wolf, Oliver T

    2012-11-01

    It is well known that stressful experiences may shape hippocampus-dependent learning and memory processes. However, although most studies focused on the impact of stress at the time of learning or memory testing, very little is known about how stress during critical periods of brain development affects learning and memory later in life. In this study, we asked whether prenatal stress exposure may influence the engagement of hippocampus-dependent spatial learning strategies and caudate nucleus-dependent response learning strategies in later life. To this end, we tested healthy participants whose mothers had experienced major negative life events during their pregnancy in a virtual navigation task that can be solved by spatial and response strategies. We found that young adults with prenatal stress used rigid response learning strategies more often than flexible spatial learning strategies compared with participants whose mothers did not experience major negative life events during pregnancy. Individual differences in acute or chronic stress do not account for these findings. Our data suggest that the engagement of hippocampal and nonhippocampal learning strategies may be influenced by stress very early in life. Copyright © 2012 Wiley Periodicals, Inc.

  8. When supply chain strategy changes, what doesn't change?

    Sochocki, L; Kaminski, P

    1999-02-01

    Although implementation of an assemble-to-order supply chain strategy can often improve customer service, the transition to an assemble-to-order system requires many new processes, organizations, and skills. This article, in describing how Etec Systems, a leader in patterning solutions for the semiconductor and electronics industries, has implemented an assemble-to-order strategy, illuminates some of the issues that will be faced by any company choosing such a strategy.

  9. Firms dealing with regulatory change: innovation and political influence strategies

    Wesseling, Joeri; Farla, Jacco; Hekkert, Marko

    2014-01-01

    Firm-level strategies, particularly political strategies, are overlooked in transition studies. Therefore, we study how car manufacturers combine and change their innovation and political influence strategies in response to a technology-forcing regulation that attempts to drive transition. We use

  10. Surgical strategy for intra- and extra-vertebral dumbbell-shaped tumors

    SUN Li-yong

    2013-12-01

    Full Text Available Objective To investigate the clinical features and surgical strategy of intra- and extra-vertebral dumbbell-shaped tumors. Methods Clinical data of 39 patients with intra- and extra-vertebral tumor were retrospectively studied. The tumors were removed via posterior midline approach in 33 patients, and via posterior combined with anterior approach in 6 patients. Thirty patients underwent tumor resection and internal fixation. Lateral mass screw fixation was performed in the level of C3-7, while the pedicular screw fixation was performed in the level of C2 and thoracic and lumbar segment. Results Tumors were totally excised in all the cases. The patients were followed-up for 6 months to 5 years with an average of 18.67 months. Pain relief occured in 29 cases, of whom the average Visual Analogue Scale (VAS score decreased from (7.51 ± 1.05 before surgery to (3.17 ± 1.17 24 h after surgery (P < 0.05. The numbness area emerged or enlarged in 12 cases and was unchanged in 3 cases. The average American Spinal Injury Association (ASIA sensation score decreased from (218.67 ± 2.80 before surgery to (213.33 ± 2.16 24 h after surgery (P < 0.05, but it increased to (216.78 ± 1.47 6 months after operation (P < 0.05. The motor function improved in 18 cases, and ASIA motor function score improved from (92.33 ± 1.63 before surgery to (95.05 ± 1.41 6 months after operation (P < 0.05. No tumor recurrence and secondary spinal deformity were found. Conclusion Most cases of dumbbell-shaped intra- and extra-vertebral tumor can be totally removed with one-session microsurgery. In the cases with bony erosion caused by tumor and facetectomy, concurrent internal fixation and fusion were recommended in order to maintain spinal stability.

  11. The turn team: a novel strategy for reducing pressure ulcers in the surgical intensive care unit.

    Still, Mary D; Cross, Linda C; Dunlap, Martha; Rencher, Rugenia; Larkins, Elizabeth R; Carpenter, David L; Buchman, Timothy G; Coopersmith, Craig M

    2013-03-01

    Pressure ulcers cause significant morbidity and mortality in the surgical intensive care unit (SICU). The purpose of this study was to determine if a dedicated team tasked with turning and repositioning all hemodynamically stable SICU patients could decrease the formation of pressure ulcers. A total of 507 patients in a 20-bed SICU in a university hospital were assessed for pressure ulcers using a point prevalence strategy, between December 2008 and September 2010, before and after implementation of a team tasked with turning and repositioning all hemodynamically stable patients every 2 hours around the clock. At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001). The preintervention group included 34 stage I and II ulcers and 8 higher stage ulcers. After implementation of the turn team, there were 7 stage I and II ulcers and 5 higher stage ulcers. The average Braden score was 16.5 in the preintervention group and 13.4 in the postintervention group (p = 0.04), suggesting that pressure ulcers were occurring in higher risk patients after implementation of the turn team. A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  12. [Deep alkali burns: Evaluation of a two-step surgical strategy].

    Devinck, F; Deveaux, C; Bennis, Y; Deken-Delannoy, V; Jeanne, M; Martinot-Duquennoy, V; Guerreschi, P; Pasquesoone, L

    2018-04-10

    Chemical burns are rare but often lead to deep cutaneous lesions. Alkali agents have a deep and long lasting penetrating power, causing burns that evolve over several days. The local treatment for these patients is excision of the wound and split thickness skin graft. Early excision and immediate skin grafting of alkali burns are more likely to be complicated by graft failure and delayed wound healing. We propose a two-step method that delays skin grafting until two-three days after burn wound excision. Our population included 25 controls and 16 cases. Men were predominant with a mean age of 41.9 years. In 78% of cases, burns were located on the lower limbs. The mean delay between the burn and excision was 16.5 days. In cases, the skin graft was performed at a mean of 11.3 days after the initial excision. We did not unveil any significant difference between both groups for the total skin surface affected, topography of the burns and the causal agent. Wound healing was significantly shorter in cases vs controls (37.5 days vs 50.3 days; P<0.025). Furthermore, we observed a decreased number of graft failures in cases vs controls (13.3% vs 46.7%; P=0.059). Our study shows the relevance of a two-step surgical strategy in patients with alkali chemical burns. Early excision followed by interval skin grafting is associated with quicker wound healing and decreased rate of graft failure. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

  13. Growing assisted migration: Synthesis of a climate change adaptation strategy

    Mary I. Williams; R. Kasten Dumroese

    2013-01-01

    Assisted migration may be necessary as a climate change adaptation strategy for native plant species that are less adaptive or mobile. Moving plants has been practiced a long time in human history, but movement of species in response to climate change is a new context. First proposed in 1985, assisted migration has gained attention since 2007 as a strategy to prevent...

  14. Using Networks For Changing Innovation Strategy: The Case of IBM

    Dittrich, Koen; Duysters, Geert; Man, Ard-Pieter

    2004-01-01

    textabstractLarge-scale strategic change projects in companies may be supported by using alliance networks. This paper shows that IBM’s change from an exploitation strategy towards an exploration strategy required a radically different network strategy as well. By entering into more non-equity alliances, involving new partners in the network and loosening the ties with existing partners, IBM supported its transformation from a hardware manufacturing company to a global service provider and so...

  15. Preoperative diagnosis and surgical strategy in congenital auditory ossicular malformation of 26 ears

    Kanazawa, Yuji; Naito, Yasushi; Shinohara, Shogo; Fujiwara, Keizo; Kikuchi, Masahiro; Yamazaki, Hiroshi; Kurihara, Risa; Kishimoto, Ippei

    2012-01-01

    We retrospectively analyzed 26 ears of 21 subjects having auditory ossicular malformation and who had undergone auditory reconstruction between April 2004 and December 2010 at our clinic. We checked preoperative condition, pathological classification, surgical procedure, and hearing improvement. We could predict pathological conditions precisely from preoperative computed tomography (CT), including incudostapedial disconnection (9/12, 75%) and malleus and/or incus fixation (7/12, 58%), which tended to be present in external ear malformation, and stapes footplate fixation (0/12, 0%). We could not, however, predict complex malformation (0/8, 0%). Overall success was 90% (18/20) in the 20 ears observed for at least 1 year. In the 2 ears without improved hearing, the first had congenital cholesteatoma and no stapes superstructure, was treated with type IV tympanoplasty. The second had malleus, incus, and stapes fixation and discontinuity between the incus and stapes, and was treated with type III tympanoplasty and stapes mobilization. Preoperative diagnosis is difficult in mixed congenital auditory ossicular malformation, especially stapes footplate fixation, possibly requiring unexpected procedures, with a poor hearing outcome. Preoperative status must thus be evaluated precisely using hearing, tympanometry, acoustic reflex test, and CT. Temporal bone CT and external ear findings are useful in diagnosing middle-ear malformation. Subjects' informed consent should also be obtained due to the possible need for changing procedure based on findings during surgery. (author)

  16. Interrupting the natural history of diabetes mellitus: lifestyle, pharmacological and surgical strategies targeting disease progression.

    Khavandi, Kaivan; Brownrigg, Jack; Hankir, Mohammed; Sood, Harpreet; Younis, Naveed; Worth, Joy; Greenstein, Adam; Soran, Handrean; Wierzbicki, Anthony; Goldsmith, David J

    2014-01-01

    In recent decades we have seen a surge in the incidence of diabetes in industrialized nations; a threat which has now extended to the developing world. Type 2 diabetes is associated with significant microvascular and macrovascular disease, with considerable impact on morbidity and mortality. Recent evidence has cast uncertainty on the benefits of very tight glycaemic goals in these individuals. The natural history of disease follows an insidious course from disordered glucose metabolism in a pre-diabetic state, often with metabolic syndrome and obesity, before proceeding to diabetes mellitus. In the research setting, lifestyle, pharmacological and surgical intervention targeted against obesity and glycaemia has shown that metabolic disturbances can be halted and indeed regressed if introduced at an early stage of disease. In addition to traditional anti-diabetic medications such as the glinides, sulphonylureas and the glitazones, novel therapies manipulating the endocannabinoid system, neurotransmitters, intestinal absorption and gut hormones have shown dual benefit in weight loss and glycaemic control normalisation. Whilst these treatments will not and should not replace lifestyle change, they will act as invaluable adjuncts for weight loss and aid in normalising the metabolic profile of individuals at risk of diabetes. Utilizing novel therapies to prevent diabetes should be the focus of future research, with the aim of preventing the challenging microvascular and macrovascular complications, and ultimately cardiovascular death.

  17. Complete Expulsion of Testicular Prosthesis via the Scrotum: A Case-Based Review of the Preventive Surgical Strategies

    Jack Donati-Bourne

    2015-01-01

    Full Text Available Testicular prostheses are regularly used in urological surgery and are important for postoperative psychological well-being in many patients undergoing orchiectomy. One of the recognised complications of this procedure is graft extrusion, which can result in significant morbidity for patients and require operative reintervention. Whilst most cases of extrusion involve upward graft migration to the external inguinal ring or direct displacement through the scrotal skin, we present an unusual case of complete expulsion of testicular implant three weeks postoperatively through a previously healthy scrotum. During surgical insertion of testicular prostheses, the urological surgeon must carefully consider the different surgical strategies at each step of the operation to prevent future extrusion of the graft. A stepwise review of the preventive surgical strategies to reduce the risk of graft extrusion encompasses the choice of optimal surgical incision, the technique of dissection to create the receiving anatomical pouch, the method of fixation of the implant within the receiving hemiscrotum, and the adoption of good postoperative care measures in line with the principles of sound scrotal surgery.

  18. CHANGE MANAGEMENT STRATEGIES RELATED TO THE GLOBAL ENVIRONMENT COMPLEXITY

    Elena DOVAL

    2016-12-01

    Full Text Available The changes in organizations appear as a reaction to the organizational environment changes. In order to manage these changes successfully, the managers need to anticipate and design alternative strategies by preparing different options.  Nevertheless, the complexity of the global environment forces the managers to adopt strategies for their organizations that are facilitating the creation of new strategic competences and competitive advantages to face the environmental rapid changes. In this context, this paper is aiming to illustrate the main directions the change management may consider to change the organization strategies in order to harmonize them to the external environment, such as: integration versus externalization, flexible specialization and flexible organization, standardization versus adaptation, market segmentation, relationship building and maintaining and communication integration.  However, the new strategies are based on a changed attitude of the managers towards the competitive advantage that is dynamic and focused on creation rather then to operations.

  19. Advancing medical-surgical nursing practice: improving management of the changing patient condition.

    Monroe, Heidi; Plylar, Peggy; Krugman, Mary

    2014-01-01

    Higher patient acuities and more novice nurses on medical-surgical units have Educators focused on achieving positive outcomes with changes in patient condition. An educational program was developed to enhance nurses' knowledge, skill, and confidence in assessing hemodynamics, recognizing early signs of instability, and administering vasoactive medications. The program was successful with significant knowledge improvement as well as an increased use of the Medical Emergency Team while maintaining a low number of code calls.

  20. Innovative contracting strategies for combating climate change.

    2011-11-01

    The state of Maryland has made a strong commitment to combating climate change and reducing : greenhouse gas emissions. This research investigated the state of practice of innovative contracting : solutions to reduce emissions from highway constructi...

  1. An adaptive strategy to climate change

    rsamir

    there is growing evidence about the impacts of climate change on freshwater availability, water accessibility, water ... Other economic sectors would also be affected such as employment, tourism and income. Source: ... Socio-economic Impact.

  2. Farmers Ideas of Climate Change and Strategies for Adaptation in ...

    Farmers Ideas of Climate Change and Strategies for Adaptation in Northern Part of Katsina State. ... The study reveals that changes in temperature and precipitation cause changes in crop varieties, changes in planting dates, a shorter growing season, and increased use of water conservation techniques. Various adaptation ...

  3. GEF climate change operational strategy: Whither UNDP?

    Hosier, R.

    1996-12-31

    The paper discusses aspects of the implementation of the program for climatic change which has been come about as part of the U.N. Framework Convention on Climate Change. Initial effort has focused on providing strategic information and help to countries, on achieving offsets in greenhouse gas emissions by energy conservation or carbon sinking, and an emphasis on development of renewable energy supplies. The U.N. Development Agency has limited funding to help support startup on projects submitted. Specific examples are discussed in the areas of energy conservation and energy efficiency, adoption of renewable energy sources, and reducing the long-term costs of low greenhouse gas-emitting energy technologies.

  4. Flexible management: strategies for the changing workforce.

    Michaels, B

    1994-01-01

    In the year 2000, managers will supervise employees whose career aspirations differ drastically from their own. Success not only will be measured by salary and status, but will be tied to a person's family relationships. Twenty years ago, most managers were not concerned with the family problems of their subordinates. This notion is now out of date. The family responsibilities of staff have a direct effect on the company's productivity. An employee who is worried about the care of an elderly parent, or concerned with the safety of a preteen home alone after school, is unlikely to give full attention to the task at hand. Flexible management is a cost-effective way of dealing with these issues. Managers who have the skills to be flexible and the strategies to work with employees for a win-win situation will reduce distractions and tardiness and gain productivity and loyalty.

  5. Policy entrepreneurs and strategies for change

    Brouwer, Stijn; Huitema, Dave

    2018-01-01

    Despite the fact that we currently witness an increasing interest in the study of the role of agency in policy dynamics, it remains in many respects a puzzle how policy change can be explained, let alone directed. This paper focusses intently on the concept, incidence, and strategic behaviour of

  6. Microvascular Decompression for Classical Trigeminal Neuralgia Caused by Venous Compression: Novel Anatomic Classifications and Surgical Strategy.

    Wu, Min; Fu, Xianming; Ji, Ying; Ding, Wanhai; Deng, Dali; Wang, Yehan; Jiang, Xiaofeng; Niu, Chaoshi

    2018-05-01

    Microvascular decompression of the trigeminal nerve is the most effective treatment for trigeminal neuralgia. However, when encountering classical trigeminal neuralgia caused by venous compression, the procedure becomes much more difficult, and failure or recurrence because of incomplete decompression may become frequent. This study aimed to investigate the anatomic variation of the culprit veins and discuss the surgical strategy for different types. We performed a retrospective analysis of 64 consecutive cases in whom veins were considered as responsible vessels alone or combined with other adjacent arteries. The study classified culprit veins according to operative anatomy and designed personalized approaches and decompression management according to different forms of compressive veins. Curative effects were assessed by the Barrow Neurological Institute (BNI) pain intensity score and BNI facial numbness score. The most commonly encountered veins were the superior petrosal venous complex (SPVC), which was artificially divided into 4 types according to both venous tributary distribution and empty point site. We synthetically considered these factors and selected an approach to expose the trigeminal root entry zone, including the suprafloccular transhorizontal fissure approach and infratentorial supracerebellar approach. The methods of decompression consist of interposing and transposing by using Teflon, and sometimes with the aid of medical adhesive. Nerve combing (NC) of the trigeminal root was conducted in situations of extremely difficult neurovascular compression, instead of sacrificing veins. Pain completely disappeared in 51 patients, and the excellent outcome rate was 79.7%. There were 13 patients with pain relief treated with reoperation. Postoperative complications included 10 cases of facial numbness, 1 case of intracranial infection, and 1 case of high-frequency hearing loss. The accuracy recognition of anatomic variation of the SPVC is crucial for the

  7. Strategies change as nuclear plant construction declines

    Knight, H.B.

    1980-01-01

    As conditions in the nuclear industry change some companies are taking a positive approach to falling orders by moving into the area of servicing existing plant. How Newport News Industrial Corporation has made just such a move by offering preventive maintenance services is described. The company has several advantages to offer: large existing facilities and a wide range of skills available from their 23000 employees. (author)

  8. Misconceptions in Electricity and Conceptual Change Strategy

    Yunus Karakuyu

    2011-12-01

    Full Text Available This research is about the contribution of conceptual change texts in accompanying with the concept mapping instruction to tenth-grade students‟ understanding of electricity concepts, and their retention of this understanding. Electricity concepts test are improved as a result of interview with teachers who observe students problems and literature search about this topic. The test was applied as pre-test, post-test, and delayed post-test total of 66 tenth-grade students in two classes of the same high school in center of Afyonkarahisar, taught by the same teacher. Electricity is the subject of tenth-grade according to the new secondary physics program. The experimental group was 32 students who received conceptual change texts in accompanying with concept mapping instruction in a class. The control group was a class of 34 students who received traditional instruction. In this study besides practice, previous information and the ability of logical thinking formed the other independent variations. Conclusions show that logical thinking, treatment and previous knowledge about concepts of electricity make a major contribution on students‟ understanding of these concepts. Result shows that in terms of keeping in mind, concept change texts in accompanying with concept map teaching better than traditional education

  9. Winds of change: corporate strategy, climate change and oil multinationals

    Kolk, A.; Levy, D.L.

    2001-01-01

    Behind pessimistic expectations regarding the future of an international climate treaty, substantial changes can be observed in company positions. Multinationals in the oil and car industries are increasingly moving toward support for the Kyoto Protocol, and take measures to address climate change.

  10. [The "window" surgical exposure strategy of the upper anterior cervical retropharyngeal approach for anterior decompression at upper cervical spine].

    Wu, Xiang-Yang; Zhang, Zhe; Wu, Jian; Lü, Jun; Gu, Xiao-Hui

    2009-11-01

    To investigate the "window" surgical exposure strategy of the upper anterior cervical retropharyngeal approach for the exposure and decompression and instrumentation of the upper cervical spine. From Jan. 2000 to July 2008, 5 patients with upper cervical spinal injuries were treated by surgical operation included 4 males and 1 female with and average age of 35 years old ranging from 16 to 68 years. There were 2 cases of Hangman's fractures (type II ), 2 of C2.3 intervertebral disc displacement and 1 of C2 vertebral body tuberculosis. All patients underwent the upper cervical anterior retropharyngeal approach through the "window" between the hypoglossal nerve and the superior laryngeal nerve and pharynx and carotid artery. Two patients of Hangman's fractures underwent the C2,3 intervertebral disc discectomy, bone graft fusion and internal fixation. Two patients of C2,3 intervertebral disc displacement underwent the C2,3 intervertebral disc discectomy, decompression bone graft fusion and internal fixation. One patient of C2 vertebral body tuberculosis was dissected and resected and the focus and the cavity was filled by bone autografting. C1 anterior arch to C3 anterior vertebral body were successful exposed. Lesion resection or decompression and fusion were successful in all patients. All patients were followed-up for from 5 to 26 months (means 13.5 months). There was no important vascular and nerve injury and no wound infection. Neutral symptoms was improved and all patient got successful fusion. The "window" surgical exposure surgical technique of the upper cervical anterior retropharyngeal approach is a favorable strategy. This approach strategy can be performed with full exposure for C1-C3 anterior anatomical structure, and can get minimally invasive surgery results and few and far between wound complication, that is safe if corresponding experience is achieved.

  11. Economic and clinical contributions of an antimicrobial barrier dressing: a strategy for the reduction of surgical site infections.

    Leaper, David; Nazir, Jameel; Roberts, Chris; Searle, Richard

    2010-01-01

    In patients at risk of surgical site infection (SSI), there is evidence that an antimicrobial barrier dressing (Acticoat* ) applied immediately post-procedure is effective in reducing the incidence of infection. The objective of this study was to assess when it is appropriate to use an antimicrobial barrier dressing rather than a post-operative film dressing, by evaluating the net cost and budget impact of the two strategies. An economic model was developed, which estimates expected expenditure on dressings and the expected costs of surgical site infection during the initial inpatient episode, based on published literature on the pre-discharge costs of surgical infection and the efficacy of an antimicrobial barrier dressing in preventing SSI. At an SSI risk of 10%, an antimicrobial barrier dressing strategy is cost neutral if the incidence of infection is reduced by at least 9% compared with a post-operative film dressing. At 35% efficacy, expenditure on dressings would be higher by £30,760 per 1000 patients, and the cost of treating infection would be lower by £111,650, resulting in a net cost saving of £80,890. The break-even infection risk for cost neutrality is 2.6%. Although this cost analysis is based on published data, there are limitations in methodology: the model is dependent on and subject to the limitations of the data used to populate it. Further studies would be useful to increase the robustness of the conclusions, particularly in a broader range of surgical specialties. A strategy involving the use of an antimicrobial barrier dressing in patients at moderate (5-10%) or high (>10%) risk of infection appears reasonable and cost saving in light of the available clinical evidence.

  12. Regional climate change strategies and initiatives

    Archer, Emma RM

    2017-10-01

    Full Text Available of stabilising greenhouse gas (GHG) concentrations at a level that would inhibit human-induced global warming and climate change. More recently, all 15 member states have signed the Paris Agreement, which aims to reduce GHG emissions in order to limit global... (but are not limited to) feed-in tariffs for renewable energy; removal of fossil fuel subsidies; “polluter pays” and “user pays” taxes; as well as discussions around green market incentivisation (very much an emerging conversation). These obviously...

  13. Exploring Psychotherapy Clients' Independent Strategies for Change While in Therapy

    Mackrill, Thomas

    2008-01-01

    Psychotherapy research usually describes how client change is caused by therapist interventions. This article describes how clients change by continuing to use and revising the strategies for change that they bring with them when they first enter therapy. This article presents data from a qualitative diary study of psychotherapy. Three cases…

  14. Awareness of climate change and indigenous coping strategies of ...

    The study assessed the awareness and indigenous coping mechanism employed by women crop farmers to cope with climate change in Kogi State, Nigeria. Respondents' socioeconomic characteristic, level of awareness about climate change, and indigenous coping strategies to climate change as well as activities of ...

  15. National strategy for climate change adaptation

    2010-01-01

    This book expresses the French State's view on the way to deal with the issue of climate change adaptation. After having recalled the ineluctability of some observed changes, the actors involved in this adaptation, and some guideline principles to implement adaptation, a first chapter describes the context: international mobilization, climate data evolution, definition of new criteria and critical thresholds, relationship between adaptation, alleviation and sustainable development, tensions between long and short terms. It discusses the objectives: public security and health, alleviation of inequalities with respect to risks, cost reduction, natural heritage preservation. Nine strategic axes are then identified: to develop knowledge, to strengthen the survey system, to inform, to educate and to make all actors aware, to promote a territory-based approach, to finance adaptation actions, to use regulatory and law instruments, to support voluntary approaches and the dialogue with private actors, to take the overseas peculiarity into account, and to contribute to international exchanges. The next chapters are respectively dealing with transverse approaches (water, risk prevention, health, and biodiversity), sector-based insights (agriculture, energy and industry, transports, building and housing, tourism, banks and insurance companies), medium-based approach (cities, littoral and seas, mountain, forest). The last part deals with the implementation issue

  16. Assessing climate change impacts and adaptation strategies for ...

    Assessing climate change impacts and adaptation strategies for smallholder agricultural systems in Uganda. ... from encroaching on swamps, which is one of the reported adaptation strategies to climate related stresses. Improving productivity of important crops (bananas for southwest, and sweet potatoes and bananas

  17. Adaptation Strategies to Climate Change by Food Crop Farmers in ...

    ... constraints to farmers adaptation strategies. Inputs supply to the local farmers should also come with government subsidy. This will go a long way in alleviating the sufferings of the farmers, as regards inadequate supply and delivery of agricultural inputs. Key words: Adaptation, Strategies, Climate, Change, Food, Crop,

  18. Reading Strategy Instruction and Teacher Change: Implications for Teacher Training

    Klapwijk, Nanda M.

    2012-01-01

    I report on teacher change in the context of a reading strategy instruction intervention. Reading Strategy Instruction (RSI) was implemented by three teachers, new to the concept, over a period of 15 weeks. Observations of these teachers showed that a multitude of factors affect the uptake of RSI as part of everyday teaching practice, and that…

  19. Towards a national adaptation strategy in view of climate changes

    E. DOUKAKIS

    2004-06-01

    • The general national adaptation principles. The presentation analyses all the above concepts and proposes specific guidelines to formulate a Greek National Adaptation Strategy to mitigate the impacts of anthropogenic climate changes.

  20. The professionalism curriculum as a cultural change agent in surgical residency education.

    Hochberg, Mark S; Berman, Russell S; Kalet, Adina L; Zabar, Sondra R; Gillespie, Colleen; Pachter, H Leon

    2012-01-01

    Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as "slightly better" or "much better" compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as "much better" compared with 5 years ago. All 3 assessment methods suggest that residents feel increasingly

  1. Strategy of Surgical Management of Peripheral Neuropathy Form of Diabetic Foot Syndrome in Ghana

    W. M. Rdeini

    2014-01-01

    Full Text Available Introduction. Foot disorders such as ulceration, infection, and gangrene which are often due to diabetes mellitus are some major causes of morbidity and high amputation. Aim. This study aims to use a group of methods for the management of diabetic foot ulcers (DFU in order to salvage the lower limb so as to reduce the rate of high amputations of the lower extremity. Materials and Methods. A group of different advanced methods for the management of DFU such as sharp debridement of ulcers, application of vacuum therapy, and other forms of reconstructive plastic surgical procedures were used. Data collection was done at 3 different hospitals where the treatments were given. Results. Fifty-four patients with type 2 diabetes mellitus were enrolled in the current study: females n=37 (68.51% and males n=17 (31.49% with different stages of PEDIS classification. They underwent different methods of surgical management: debridement, vacuum therapy (some constructed from locally used materials, and skin grafting giving good and fast results. Only 4 had below knee amputations. Conclusion. Using advanced surgical wound management including reconstructive plastic surgical procedures, it was possible to reduce the rate of high amputations of the lower limb.

  2. Different surgical strategies for chronic pancreatitis significantly improve long-term outcome: a comparative single center study

    Hildebrand P

    2010-08-01

    Full Text Available Abstract Objective In general, chronic pancreatitis (CP primarily requires conservative treatment. The chronic pain syndrome and complications make patients seek surgical advice, frequently after years of progression. In the past, surgical procedures involving drainage as well as resection have been employed successfully. The present study compared the different surgical strategies. Patients and Methods From March 2000 until April 2005, a total of 51 patients underwent surgical treatment for CP at the Department of surgery, University of Schleswig-Holstein, Campus Lübeck. Out of those 51 patients, 39 (76.5% were operated according to the Frey procedure, and in 12 cases (23.5% the Whipple procedure was performed. Patient data were documented prospectively throughout the duration of the hospital stay. The evaluation of the postoperative pain score was carried out retrospectively with a validated questionnaire. Results Average operating time was 240 minutes for the Frey group and 411 minutes for the Whipple group. The medium number of blood transfusions was 1 in the Frey group and 4.5 in the Whipple group. Overall morbidity was 21% in the Frey group and 42% in the Whipple group. 30-day mortality was zero for all patients. During the median follow-up period of 50 months, an improvement in pain score was observed in 93% of the patients of the Frey group and 67% of the patients treated according to the Whipple procedure. Conclusion The results show that both the Frey procedure as well as partial pancreaticoduodenectomy are capable of improving chronic pain symptoms in CP. As far as later endocrine and exocrine pancreatic insufficiency is concerned, however, the extended drainage operation according to Frey proves to be advantageous compared to the traditional resection procedure by Whipple. Accordingly, the Frey procedure provides us with an organ-preserving surgical procedure which treats the complications of CP sufficiently, thus being an

  3. Strategies facilitating practice change in pediatric cancer: a systematic review.

    Robinson, Paula D; Dupuis, Lee L; Tomlinson, George; Phillips, Bob; Greenberg, Mark; Sung, Lillian

    2016-09-01

    By conducting a systematic review, we describe strategies to actively disseminate knowledge or facilitate practice change among healthcare providers caring for children with cancer and we evaluate the effectiveness of these strategies. We searched Ovid Medline, EMBASE and PsychINFO. Fully published primary studies were included if they evaluated one or more professional intervention strategies to actively disseminate knowledge or facilitate practice change in pediatric cancer or hematopoietic stem cell transplantation. Data extracted included study characteristics and strategies evaluated. In studies with a quantitative analysis of patient outcomes, the relationship between study-level characteristics and statistically significant primary analyses was evaluated. Of 20 644 titles and abstracts screened, 146 studies were retrieved in full and 60 were included. In 20 studies, quantitative evaluation of patient outcomes was examined and a primary outcome was stated. Eighteen studies were 'before and after' design; there were no randomized studies. All studies were at risk for bias. Interrupted time series was never the primary analytic approach. No specific strategy type was successful at improving patient outcomes. Literature describing strategies to facilitate practice change in pediatric cancer is emerging. However, major methodological limitations exist. Studies with robust designs are required to identify effective strategies to effect practice change. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  4. The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy.

    Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C

    2013-01-01

    Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform

  5. Determinants of climate change adaptive strategies among small ...

    Identified adaptation strategies used by farmers to mitigate the effect of climate change included planting beside the river(86%), planting disease and pest resistant crop (73%) and changes on planting and harvesting dates(63%). Results of Tobit regression analysis showed that level of education, farm size and access to ...

  6. Impacts of climate change, variability and adaptation strategies on ...

    Impacts of climate change, variability and adaptation strategies on agriculture in semi arid areas of Tanzania: The case of Manyoni District in Singida Region, Tanzania. ... The changes have affected crops and livestock in a number of ways resulting in reduced productivity. Empirical analysis of rainfall suggest decreasing ...

  7. Ecosystem stewardship: sustainability strategies for a rapidly changing planet

    F. Stuart Chapin; Stephen R. Carpenter; Gary P. Kofinas; Carl Folke; Nick Abel; William C. Clark; Per Olsson; D. Mark Stafford Smith; Brian Walker; Oran R. Young; Fikret Berkes; Reinette Biggs; J. Morgan Grove; Rosamond L. Naylor; Evelyn Pinkerton; Will Steffen; Frederick J. Swanson

    2010-01-01

    Ecosystem stewardship is an action-oriented framework intended to foster the social-ecological sustainability of a rapidly changing planet. Recent developments identify three strategies that make optimal use of current understanding in an environment of inevitable uncertainty and abrupt change: reducing the magnitude of, and exposure and sensitivity to, known stresses...

  8. Climate change adaptation strategies by small-scale farmers in ...

    Mburu

    Climate change is a great environmental challenge facing humanity today. In Yatta District, residents report frequent crop failures, water shortages and relief food has become a frequent feature of their life. This study examines the adaptation strategies to climate change adopted by the dry-land farming communities in Yatta ...

  9. Climate change adaptation strategies by local farmers in Kilombero ...

    This article examines current adaptation strategies developed by local farmers against climate change effects in Kilombero District. Research questions guided the study include; what are the past and current climatic stresses? What are local farmers' perception on climate change and response to the adverse climatic ...

  10. The impact of surgical strategies on outcomes for pediatric chronic pancreatitis.

    Sacco Casamassima, Maria G; Goldstein, Seth D; Yang, Jingyan; Gause, Colin D; Abdullah, Fizan; Meoded, Avner; Makary, Martin A; Colombani, Paul M

    2017-01-01

    To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief. Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated. Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7-20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2-5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006-0.57; OR 0.07; 95%, CI 0.01-0.89). However, these associations were not present in multivariate analysis. In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.

  11. Strategy of Surgical Resection for Glioma Based on Intraoperative Functional Mapping and Monitoring

    TAMURA, Manabu; MURAGAKI, Yoshihiro; SAITO, Taiichi; MARUYAMA, Takashi; NITTA, Masayuki; TSUZUKI, Shunsuke; ISEKI, Hiroshi; OKADA, Yoshikazu

    2015-01-01

    A growing number of papers have pointed out the relationship between aggressive resection of gliomas and survival prognosis. For maximum resection, the current concept of surgical decision-making is in “information-guided surgery” using multimodal intraoperative information. With this, anatomical information from intraoperative magnetic resonance imaging (MRI) and navigation, functional information from brain mapping and monitoring, and histopathological information must all be taken into account in the new perspective for innovative minimally invasive surgical treatment of glioma. Intraoperative neurofunctional information such as neurophysiological functional monitoring takes the most important part in the process to acquire objective visual data during tumor removal and to integrate these findings as digitized data for intraoperative surgical decision-making. Moreover, the analysis of qualitative data and threshold-setting for quantitative data raise difficult issues in the interpretation and processing of each data type, such as determination of motor evoked potential (MEP) decline, underestimation in tractography, and judgments of patient response for neurofunctional mapping and monitoring during awake craniotomy. Neurofunctional diagnosis of false-positives in these situations may affect the extent of resection, while false-negatives influence intra- and postoperative complication rates. Additionally, even though the various intraoperative visualized data from multiple sources contribute significantly to the reliability of surgical decisions when the information is integrated and provided, it is not uncommon for individual pieces of information to convey opposing suggestions. Such conflicting pieces of information facilitate higher-order decision-making that is dependent on the policies of the facility and the priorities of the patient, as well as the availability of the histopathological characteristics from resected tissue. PMID:26185825

  12. Strategies for sustainable management of renewable resources during environmental change.

    Lindkvist, Emilie; Ekeberg, Örjan; Norberg, Jon

    2017-03-15

    As a consequence of global environmental change, management strategies that can deal with unexpected change in resource dynamics are becoming increasingly important. In this paper we undertake a novel approach to studying resource growth problems using a computational form of adaptive management to find optimal strategies for prevalent natural resource management dilemmas. We scrutinize adaptive management, or learning-by-doing, to better understand how to simultaneously manage and learn about a system when its dynamics are unknown. We study important trade-offs in decision-making with respect to choosing optimal actions (harvest efforts) for sustainable management during change. This is operationalized through an artificially intelligent model where we analyze how different trends and fluctuations in growth rates of a renewable resource affect the performance of different management strategies. Our results show that the optimal strategy for managing resources with declining growth is capable of managing resources with fluctuating or increasing growth at a negligible cost, creating in a management strategy that is both efficient and robust towards future unknown changes. To obtain this strategy, adaptive management should strive for: high learning rates to new knowledge, high valuation of future outcomes and modest exploration around what is perceived as the optimal action. © 2017 The Author(s).

  13. Hemorheological changes in ischemia-reperfusion: an overview on our experimental surgical data.

    Nemeth, Norbert; Furka, Istvan; Miko, Iren

    2014-01-01

    Blood vessel occlusions of various origin, depending on the duration and extension, result in tissue damage, causing ischemic or ischemia-reperfusion injuries. Necessary surgical clamping of vessels in vascular-, gastrointestinal or parenchymal organ surgery, flap preparation-transplantation in reconstructive surgery, as well as traumatological vascular occlusions, all present special aspects. Ischemia and reperfusion have effects on hemorheological state by numerous ways: besides the local metabolic and micro-environmental changes, by hemodynamic alterations, free-radical and inflammatory pathways, acute phase reactions and coagulation changes. These processes may be harmful for red blood cells, impairing their deformability and influencing their aggregation behavior. However, there are still many unsolved or non-completely answered questions on relation of hemorheology and ischemia-reperfusion. How do various organ (liver, kidney, small intestine) or limb ischemic-reperfusionic processes of different duration and temperature affect the hemorheological factors? What is the expected magnitude and dynamics of these alterations? Where is the border of irreversibility? How can hemorheological investigations be applied to experimental models using laboratory animals in respect of inter-species differences? This paper gives a summary on some of our research data on organ/tissue ischemia-reperfusion, hemorheology and microcirculation, related to surgical research and experimental microsurgery.

  14. [Change of paradigms in the surgical treatment of complex thoracic aortic disease].

    Herold, Ulf; Tsagakis, Konstantinos; Kamler, Markus; Massoudy, Parwis; Assenmacher, Eva; Eggebrecht, Holger; Buck, Thomas; Jakob, Heinz

    2006-08-01

    One of the main issues in complex thoracic aortic disease, requiring the replacement of the ascending aorta, the entire aortic arch and the descending aorta, is the vast amount of surgery necessary to cure the patient. Though one-stage repair is feasible by a clamshell thoracotomy, the associated surgical trauma and perioperative morbidity limit this approach to younger patients only. Classic surgical repair consist of a two-stage strategy, whereby, in the first step, the ascending aorta and the aortic arch are replaced via a midline sternotomy. In the second step, via a lateral thoracotomy, the descending aorta is replaced. The two stages may sum up to a mortality of 20%; furthermore, the waiting period between the stages is associated with a mortality rate of 10% of its own. Additionally, the two-stage strategy has an inherent limitation, due to the comorbidity and advanced age of the majority of patients. Therefore, the second stage cannot be offered to up to 30% of patients. New developments and improvements in aortic surgery were introduced to overcome these shortcomings and to simplify the surgical repair. The "elephant trunk" principle, introduced by Borst et al. in 1983, was an important step to facilitate surgical repair, but still required the second step. With the introduction of endovascular repair of thoracic aortic disease with stent grafts implanted retrograde via the femoral artery, new therapeutic concepts emerged. In the late 1990s, two Japanese groups reported first trials to stabilize the free-floating "elephant trunk" prosthesis by implantation of nitinol stent grafts into the vascular graft. The applied devices were purely custom-made and nonstandardized. The availability of industrially made and CE-marked stent-graft devices raised the possibility to apply them in open aortic arch surgery. The experience with stent-graft devices implanted antegrade into the descending aorta (Medtronic Talent) was reported first by the Essen and the Vienna

  15. Immediate postoperative outcome of orthognathic surgical planning, and prediction of positional changes in hard and soft tissue, independently of the extent and direction of the surgical corrections required

    Donatsky, Ole; Bjørn-Jørgensen, Jens; Hermund, Niels Ulrich

    2011-01-01

    orthognathic correction using the computerised, cephalometric, orthognathic, surgical planning system (TIOPS). Preoperative cephalograms were analysed and treatment plans and prediction tracings produced by computerised interactive simulation. The planned changes were transferred to models and finally...... with the presently included soft tissue algorithms, the current study shows relatively high mean predictability of the immediately postoperative hard and soft tissue outcome, independent of the extent and direction of required orthognathic correction. Because of the relatively high individual variability, caution...

  16. Using goal setting as a strategy for dietary behavior change.

    Cullen, K W; Baranowski, T; Smith, S P

    2001-05-01

    Recent reviews have noted that behavioral theory-based nutrition education programs are more successful at achieving food behavior change than knowledge-based programs and that a clear understanding of the mechanisms of behavior change procedures enable dietetics professionals to more effectively promote change. Successful dietary behavior change programs target 1 or more of the personal, behavioral, or environmental factors that influence the behavior of interest and apply theory-based strategies to influence or change those factors. Goal setting is a strategy that is frequently used to help people change. A 4-step goal-setting process has been identified: recognizing a need for change; establishing a goal; adopting a goal-directed activity and self-monitoring it; and self-rewarding goal attainment. The applications of goal setting in dietary interventions for adults and children are reviewed here. Because interventions using goal setting appear to promote dietary change, dietitians should consider incorporating the goal-setting strategies to enhance the behavior change process in nutrition education programs.

  17. Bladder changes after several coverage modalities in the surgically induced model of myelomeningocele in lambs.

    Burgos, L; Encinas, J L; García-Cabezas, M Á; Peiró, J L; López-Santamaría, M; Jaureguízar, E

    2014-01-01

    To assess the presence of early bladder abnormalities in a prenatally corrected and uncorrected animal model of Myelomeningocele (MMC). A MMC-like lesion was surgically created in 18 fetal lambs between the 60th and the 80th day of gestation. Eight of them did not undergo fetal repair (group A), three were repaired with an open two-layer closure (group B), three using BioGlue® (groupC) and four fetoscopically (group D). At term, bladders were examined macroscopically and histopathological changes were assessed using H-E and Masson Trichrome. Five animals in group A (5/8, 62%), two in group B (2/3, 66%), one in group C (1/3, 33%) and one in group D (1/4, 25%) survived. Macroscopically bladders in group A were severely dilated and showed thinner walls. Microscopically they showed a thin layer of colagenous tissue (Blue layer. BL) lying immediately subjacent to the urothelium. The muscular layers were thinner. Non compliant pattern with thick wall and low capacity was also found in the non corrected model. Group B and the control showed preservation of muscular layers and absence of BL. Groups C and D presented BL but also preservation of muscular layers. Bladder changes in a surgically-induced model of MMC can be described using histopathological data. Both extremes of bladder changes can be observed in the model. These changes were completely prevented with open fetal surgery and partially with other coverage modalities. Copyright © 2013 AEU. Published by Elsevier Espana. All rights reserved.

  18. Reading strategy instruction and teacher change: implications for teacher training

    Klapwijk, Nanda M

    2012-01-01

    I report on teacher change in the context of a reading strategy instruction intervention. Reading Strategy Instruction (RSI) was implemented by three teachers, new to the concept, over a period of 15 weeks. Observations of these teachers showed that a multitude of factors affect the uptake of RSI as part of everyday teaching practice, and that teachers seem to move through distinct phases in their uptake of RSI. The article focuses on teachers' reaction to RSI and highlights a number of issue...

  19. Sinking into the Sea? Climate Change and AOSIS Strategies

    Højland, Camille Marie Risager; Svendsen, Gert Tinggaard

    2017-01-01

    that a small actor like AOSIS plays in protecting the citizens of its member states rather than free ride on larger actors. Which strategies should AOSIS use to encourage an even more ambitious climate policy in the future? We suggest five relevant strategies: 1) Introduction of sanctions in the Paris...... Agreement, 2) A CO2 tax, 3) Subsidising new green technology, 4) That AOSIS should look for coalition partners, e.g. China, and 5) Even stronger focus on the linkage between climate change and future migration. Employing such strategies may save the SIDS from sinking into the sea and, at the same time......, secure the target level from the Paris Agreement....

  20. Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children.

    Park, Hoon; Park, Kwang Won; Park, Kun Bo; Kim, Hyun Woo; Eom, Nam Kyu; Lee, Dong Hoon

    2017-07-01

    The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity. © Copyright: Yonsei University College of Medicine 2017

  1. Strategy and clinical significance of interventional management before surgical therapy for massive hemorrhage of gastrointestinal tract

    Hu Tingyang; Yu Wenqiang; Mao Yingmin; Yuan Jianhua; CChen Fanghong; Luo Zuyan; Ding Xiaonan; Zhou Bing; Ding Zhongxiang

    2009-01-01

    Objective: To discuss the clinical value of interventional management before surgical therapy for massive gastrointestinal hemorrhage, and to compare the clinical efficacy and re-bleeding rate between hypophysin infusion group and embolization group. Methods: During the period of June 1998-Apr. 2009, 31 patients with massive gastrointestinal hemorrhage in our institution underwent preoperative interventional managements before they received surgical treatment. According to DSA manifestations, the patients underwent transarterial hypophysin infusion or transcatheter embolization as interventional management. The clinical efficacy of interventional procedures and its influence on the surgery were evaluated, and the hemostasis rate and re-bleeding rate were compared the two kind of intervention managements. The numeration data were analyzed with Fisher's exact test, and the SPSS 11.0 was used as statistical software. Results: The interventional managements were successfully performed in all the 31 patients, with a total hemostasis rate of 83.9% (26/31) and a total re-bleeding rate 30.7% (8/26). The hemostasis rate and re-bleeding rate of hypophysin infusion group and embolization group were 69.2% (9/ 13), 94.4% (17/18) and 44.4% (4/9), 23.7% (4/17), respectively. All the 31 patients received surgery after interventional therapy, of which selective operation was carried out in 20. Neither surgery-related or intervention-related serious complications nor death occurred. Conclusion: Preoperative interventional managements can provide patients with massive gastrointestinal hemorrhage with valuable chance of a successful surgery, enable the physician to take a selective operation to replace an emergency one,as a result, the surgical risk will be greatly reduced. Therefore, it is worth popularizing the preoperative interventional managements in clinical practice. (authors)

  2. The Role of mPOS System in Process Change and Strategy Change: A Situated Change Perspective

    Yao Chin Lin; Nhu-Hang Ha; Kuo-Sung Lin

    2015-01-01

    The purpose of this study is to revisit the relationship among information technology (IT), Process, and Strategy. We focus on the impact of mobile Point of Sales (mPOS) on changing of operational processes in the restaurant industry. This study investigates the changing of IT strategy and service strategy. The research model was developed based on the literature (strategic alignment model and situated change perspective) and inputs from the restaurant industry and IT experts. The data of thi...

  3. Change in MSW characteristics under recent management strategies in Taiwan.

    Chang, Yu-Min; Liu, Chien-Chung; Hung, Chao-Yang; Hu, Allen; Chen, Shiao-Shing

    2008-12-01

    Reduction and recycling initiatives such as producer responsibility and pay-as-you-throw are being implemented in Taiwan. This paper presents a study assessing the impact of recently implemented municipal solid waste (MSW) reduction and recycling management strategies on the characteristics of waste feedstock for incineration in Taiwan. Through the periodic sampling of two typical MSW incineration plants, proximate and ultimate analyses were conducted according to standard methods to explore the influence of MSW reduction and recycling management strategies on incineration feed waste characteristics. It was observed that the annual amount of MSW generated in 2005 decreased by about 10% compared to 2003 and that the characteristics of MSW have changed significantly due to recent management strategies. The heating value of the MSW generated in Taiwan increased yearly by about 5% after program implementation. A comparison of the monthly variations in chemical concentrations indicated that the chlorine content in MSW has changed. This change results from usage reduction of PVC plastic due to the recycling fund management (RFM) program, and the food waste as well as salt content reduction due to the total recycling for kitchen garbage program. This achievement will improve the reduction of dioxin emissions from MSW incineration. In summary, management strategies must be conducted in tandem with the global trend to achieve a zero-waste-discharge country. When implementing these strategies and planning for future MSW management systems, it is important to consider the changes that may occur in the composition and characteristics of MSW over time.

  4. Changing practices in the surgical management of hyperparathyroidism - A 10-year review.

    2012-01-31

    AIM: Parathyroid surgery has undergone a paradigm shift over the last decade, with a move from traditional bilateral neck exploration to minimally invasive parathyroidectomy (MIP), and increasing reliance on pre- and intra-operative localization of overactive glands. We aimed to assess changing surgical practices and their impact on the management of parathyroid disease in a tertiary referral centre in the West of Ireland. METHODS: A retrospective cohort analysis of those patients undergoing a surgical intervention for parathyroid disease in the period between 1999 and 2009 in our centre was carried out. Data was analysed using PASW (v18) software. RESULTS: 248 procedures were performed, increasing from an annual rate of 6 in 1999 to 45 in 2009. 129 procedures were completed by minimally invasive means, following the introduction of MIP in 2003. Single-gland disease accounted for 87% of cases (n = 216) with carcinomas in 2 patients (0.8%). Pre-operative localization had disappointing diagnostic value, with high false negative rates for both ultrasound (37.3%) and Sestamibi Scanning (35.81%). Intra-operative adjuncts were more helpful, with intra-operative Parathyroid hormone monitoring facilitating curative resection of adenomas in 94.03% at 10 min. Median length of post-operative stay has significantly decreased from 6 days in 1999 to 1 night only in 2009 (p < 0.01, ANOVA). Those patients undergoing MIP had shorter stay than the open group (1.71 days -v-4.73, p = 0.003,t-test). CONCLUSION: The practice in our centre has shifted to a less invasive approach. Increased utilisation of intra-operative adjuncts has facilitated this change, and resulted in favourable changes in length of stay, extent of dissection, and number of patients treated.

  5. Changes in surgical procedures for acromioclavicular joint dislocation over the past 30 years.

    Takase, Katsumi; Yamamoto, Kengo

    2013-10-01

    Generally, surgical treatment is recommended for Rockwood type 5 traumatic acromioclavicular joint dislocations. Since 1980, the authors have performed the modified Dewar procedure, the modified Cadenat procedure, and anatomical reconstruction of the coracoclavicular ligaments for this injury. The goal of this study was to determine the ideal surgical procedure for acromioclavicular joint dislocations by comparing these 3 procedures. The modified Dewar procedure was performed on 55 patients (Dewar group), the modified Cadenat procedure was performed on 73 patients (Cadenat group), and anatomical reconstruction of the coracoclavicular ligaments was performed on 11 patients (reconstruction group). According to the UCLA scoring system, therapeutic results averaged 27.3 points in the Dewar group, 28.2 in the Cadenat group, and 28.4 in the reconstruction group. The incidence of residual subluxation or dislocation in the acromioclavicular joint was evaluated at final radiographic follow-up. Subluxation occurred in 21 patients in the Dewar group, 18 in the Cadenat group, and 3 in the reconstruction group. Dislocation occurred in 3 patients in the Dewar group. Osteoarthritic changes in the acromioclavicular joint occurred in 20 patients in the Dewar group, 9 in the Cadenat group, and 1 in the reconstruction group. The modified Cadenat procedure can provide satisfactory therapeutic results and avoid postoperative failure or loss of reduction compared with the modified Dewar procedure. However, the modified Cadenat procedure does not anatomically restore the coracoclavicular ligaments. Anatomic restoration of both coracoclavicular ligaments can best restore acromioclavicular joint function. Copyright 2013, SLACK Incorporated.

  6. Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

    Jacob Dietmar

    2008-11-01

    Full Text Available Abstract Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics.

  7. Managing strategic change--strategy, culture and action.

    Johnson, G

    1992-02-01

    One of the major problems facing senior executives is that of effecting significant strategic change in their organizations. This paper develops a number of explanatory frameworks which address the links between the development of strategy in organizations, dimensions of corporate culture and managerial action. In considering such linkages, and by illustrating them with examples from work undertaken in companies, the paper also seeks to advance our understanding of the problems and means of managing strategic change.

  8. Changes in hospital competitive strategy: a new medical arms race?

    Devers, Kelly J; Brewster, Linda R; Casalino, Lawrence P

    2003-02-01

    To describe changes in hospitals' competitive strategies, specifically the relative emphasis placed on strategies for competing along price and nonprice (i.e., service, amenities, perceived quality) dimensions, and the reasons for any observed shifts. This study uses data gathered through the Community Tracking Study site visits, a longitudinal study of a nationally representative sample of 12 U.S. communities. Research teams visited each of these communities every two years since 1996 and conducted between 50 to 90 semistructured interviews. Additional information on hospital competition and strategy was gathered from secondary data. We found that hospitals' strategic emphasis changed significantly between 1996-1997 and 2000-2001. In the mid-1990s, hospitals primarily competed on price through "wholesale" strategies (i.e., providing services attractive to managed care plans). By 2000-2001, nonprice competition was becoming increasingly important and hospitals were reviving "retail" strategies (i.e., providing services attractive to individual physicians and the patients they serve). Three major factors explain this shift in hospital strategy: less than anticipated selective contracting and capitated payment; the freeing up of hospital resources previously devoted to horizontal and vertical integration strategies; and, the emergence and growth of new competitors. Renewed emphasis on nonprice competition and retail strategies, and the service mimicking and one-upmanship that result, suggest that a new medical arms race is emerging. However, there are important differences between the medical arms race today and the one that occurred in the 1970s and early 1980s: the hospital market is more concentrated and price competition remains relatively important. The development of a new medical arms race has significant research and policy implications.

  9. Climate change adaptation strategies by small-scale farmers in ...

    Mburu

    SPSS) ... were financial constraints (93.4%), lack of relevant skills (74.5%) and lack of ... Key words: Climate change, small-scale farmers, adaptation strategies. ... investment in irrigation infrastructure, high post-harvest ..... 72.0 School drop out.

  10. Climate Change Mitigation and Adaptation Strategies Used by ...

    The majority (73.6%) of the farmers opined that in recent times, flooding had increased which is an indication of climate change. Reduction in the use of generator to get power in the farmers' houses (69.1%) and crop rotation practices (67.3%) were mitigation and adaptation strategies employed by the farmers against the ...

  11. The oil industry and climate change: strategies and ethical dilemmas

    Hove, S. van den; Le Menestrel, M.; Bettignies, H.C. de

    2002-01-01

    This paper explores the different climate change strategies chosen by three major multinational oil corporations: ExxonMobil, TotalFinaElf and BP Amoco. They are referred to, as the 'fight against emission constraints,' 'wait and see,' and 'proactive' strategies, respectively. The justifications given to support these strategies are identified. They cover the business, scientific, political, economic, technological and social dimensions. In a business ethics framework, the issue of climate change brings forth an ethical dilemma for the oil industry, in the form of a tension between profits and CO 2 emissions. The strategies are analysed as three attitudes towards this dilemma: (i) placing priority on the business consequences while weakening the perception that anthropogenic greenhouse gas emissions are causing climate change; (ii) avoiding responsibility; and (iii) placing priority on the need for a modification of the business process while limiting the negative effect in terms of business consequences. In conclusion, we propose that beyond the ethical issues proper to climate change itself, additional ethical issues are raised if society at large is instrumentalised by an industry in its search for profit. Publicly gauging and valorising the ethical commitment of a corporation appear as ways of inducing more collaborative and proactive attitudes by business actors. (Author)

  12. The oil industry and climate change. Strategies and ethical dilemmas

    Van den Hove, S.; Le Menestrel, Marc; De Bettignies, Henri-Claude

    2002-01-01

    This paper explores the different climate change strategies chosen by three major multinational oil corporations: ExxonMobil, TotalFinaElf and BP Amoco. They are referred to, as the 'fight against emission constraints,' 'wait and see', and 'proactive' strategies, respectively. The justifications given to support these strategies are identified. They cover the business, scientific, political, economic, technological and social dimensions. In a business ethics framework, the issue of climate change brings forth an ethical dilemma for the oil industry, in the form of a tension between profits and CO2 emissions. The strategies are analysed as three attitudes towards this dilemma: (1) placing priority on the business consequences while weakening the perception that anthropogenic greenhouse gas emissions are causing climate change; (2) avoiding responsibility; and (3) placing priority on the need for a modification of the business process while limiting the negative effect in terms of business consequences. In conclusion, we propose that beyond the ethical issues proper to climate change itself, additional ethical issues are raised if society at large is instrumentalised by an industry in its search for profit. Publicly gauging and valorising the ethical commitment of a corporation appear as ways of inducing more collaborative and proactive attitudes by business actors

  13. Implementing a Redesign Strategy: Lessons from Educational Change.

    Basom, Richard E., Jr.; Crandall, David P.

    The effective implementation of school redesign, based on a social systems approach, is discussed in this paper. A basic assumption is that the interdependence of system elements has implications for a complex change process. Seven barriers to redesign and five critical issues for successful redesign strategy are presented. Seven linear steps for…

  14. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis.

    McDermott, F D

    2014-01-01

    The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management.

  15. Clinical results of a new strategy (modified CHIVA) for surgical treatment of anterior accessory great saphenous varicose veins.

    Maldonado-Fernández, Nicolás; Linares-Palomino, Jose Patricio; López-Espada, Cristina; Martínez-Gámez, Francisco Javier; Ros-Díe, Eduardo

    2016-03-01

    Traditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins. This non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale. The baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4-6. The new strategy was applied to all cases. 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4 mm anterior saphenous to 3.4 mm by one year (p <0.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5 mm and obesity were identified as predictors of worse clinical and hemodynamic outcome. This modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively. Copyright © 2015 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

  16. Emergency medicine journal impact factor and change compared to other medical and surgical specialties.

    Reynolds, Joshua C; Menegazzi, James J; Yealy, Donald M

    2012-11-01

    A journal impact factor represents the mean number of citations per article published. Designed as one tool to measure the relative importance of a journal, impact factors are often incorporated into academic evaluation of investigators. The authors sought to determine how impact factors of emergency medicine (EM) journals compare to journals from other medical and surgical specialties and if any change has taken place over time. The 2010 impact factors and 5-year impact factors for each journal indexed by the Thomson Reuters ISI Web of Knowledge Journal Citation Reports (JCR) were collected, and EM, medical, and surgical specialties were evaluated. The maximum, median, and interquartile range (IQR) of the current impact factor and 5-year impact factor in each journal category were determined, and specialties were ranked according to the summary statistics. The "top three" impact factor journals for each specialty were analyzed, and growth trends from 2001 through 2010 were examined with random effects linear regression. Data from 2,287 journals in 31 specialties were examined. There were 23 EM journals with a current maximum impact factor of 4.177, median of 1.269, and IQR of 0.400 to 2.176. Of 23 EM journals, 57% had a 5-year impact factor available, with a maximum of 4.531, median of 1.325, and IQR of 0.741 to 2.435. The top three EM journals had a mean standard deviation (±SD) impact factor of 3.801 (±0.621) and median of 4.142 and a mean (±SD) 5-year impact factor of 3.788 (±1.091) and median of 4.297, with a growth trend of 0.211 (95% confidence interval [CI] = 0.177 to 0.245; p journals ranked no higher than 24th among 31 specialties. Emergency medicine journals rank low in impact factor summary statistics and growth trends among 31 medical and surgical specialties. © 2012 by the Society for Academic Emergency Medicine.

  17. Transperineal Ultrasound as a Tool to Plan Surgical Strategies in Pediatric Urology: Back to the Future?

    de Jesus, Lisieux Eyer; Fazecas, Tatiana; Ribeiro, Bianca G; Dekermacher, Samuel

    2017-06-01

    To demonstrate the usefulness and advantages of transperineal ultrasound (TPUS) on planning the surgical tactics to treat childhood pelviperineal disease (CPPD). A cohort of CPPD is reviewed to provide a pictorial review of TPUS as imaging method variety of CPPD. Other imaging methods are compared with TPUS. TPUS studies of patients showing different conditions on the spectrum of pelviperineal malformation are shown in detail (pictorial review, graphically shown-see figures in the article and as supplementary material), highlighting the advantages of the method and comparing TPUS findings with other imaging techniques. Magnetic resonance imaging, contrast genitograms, voiding cystourethrography, and genital or urologic endoscopy have some important disadvantages, especially radiation exposure, high cost, not easily available equipment, and the need of general anesthesia or deep sedation in children. TPUS is easily available, including in impoverished environments, portable, painless, reproducible, inexpensive, and capable of providing detailed and specific information about pelviperineal malformation with accuracy. Data provided by TPUS are comparable with other imaging techniques (Table 1). Its main disadvantage is the dependency on the expertise of the operator to obtain high-quality, well-interpreted images. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials.

    Zhao, Xin; Cui, Naiqiang; Wang, Ximo; Cui, Yunfeng

    2017-03-01

    Chronic pancreatitis (CP) is a common and frequently occurring disease. Pancreaticoduodenectomy (PD), pylorus-preserving pancreaticoduodenectomy (PPPD), and duodenum-preserving pancreatic head resection (DPPHR) are important treatment options for patients with chronic pancreatitis. The Beger and Frey procedures are 2 main duodenum-preserving techniques in duodenum-preserving pancreatic head resection (DPPHR) strategies. We conducted this systematic review and meta-analysis to compare the clinical efficacy of DPPHR versus PD, the Beger procedure versus PD, the Frey procedure versus PD, and the Beger procedure versus the Frey procedure in the treatment of pancreatitis. The optimal surgical option for chronic pancreatitis is still under debate. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of different surgical strategies for chronic pancreatitis. Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched with the limitations of human subjects and randomized controlled trials (RCTs) text. Data were extracted by 2 of the coauthors independently and analyzed using the RevMan statistical software, version 5.3. Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool was used to assess the risk of bias. Seven studies involving a total of 385 patients who underwent the surgical treatments were assessed. The methodological quality of the trials ranged from low to moderate and included PD (n = 134) and DPPHR (n = 251 [Beger procedure = 100; Frey procedure = 109; Beger or Frey procedure = 42]). There were no significant differences between DPPHR and PD in post-operation mortality (RR = 2.89, 95% CI = 0.31-26.87, P = 0.36), pain relief (RR = 1.09, 95% CI = 0.94-1.25, P = 0.26), exocrine insufficiency (follow-up time > 60 months: RR = 0.91, 95% CI = 0.72-1.15, P

  19. Surgical orthodontics.

    Strohl, Alexis M; Vitkus, Lauren

    2017-08-01

    The article reviews some commonly used orthodontic treatments as well as new strategies to assist in the correction of malocclusion. Many techniques are used in conjunction with surgical intervention and are a necessary compliment to orthognathic surgery. Basic knowledge of these practices will aid in the surgeon's ability to adequately treat the patient. Many orthodontists and surgeons are eliminating presurgical orthodontics to adopt a strategy of 'surgery first' orthodontics in orthognathic surgery. This has the benefit of immediate improvement in facial aesthetics and shorter treatment times. The advent of virtual surgical planning has helped facilitate the development of this new paradigm by making surgical planning faster and easier. Furthermore, using intraoperative surgical navigation is improving overall precision and outcomes. A variety of surgical and nonsurgical treatments may be employed in the treatment of malocclusion. It is important to be familiar with all options available and tailor the patient's treatment plan accordingly. Surgery-first orthodontics, intraoperative surgical navigation, virtual surgical planning, and 3D printing are evolving new techniques that are producing shorter treatment times and subsequently improving patient satisfaction without sacrificing long-term stability.

  20. Porter's generic strategies, discontinuous environments, and performance: a longitudinal study of changing strategies in the hospital industry.

    Lamont, B T; Marlin, D; Hoffman, J J

    1993-12-01

    Changes in generic strategies in response to discontinuous environments have been relatively ignored in the management literature. This study reports an examination of the relationships between Porter's (1980) generic strategies, discontinuous environments, and performance. Archival data for 1984 and 1988 were collected for 172 acute care hospitals in Florida in order to test these relationships. To examine fully the performance impact of changes in strategy in a discontinuous environment, a longitudinal research design that identified a firm's strategy at two points in time, 1984 and 1988, was used. Results indicate that firms with a proper strategy environment fit performed the highest, firms that did not change their strategy had no change in performance, and firms that changed their strategy toward a proper strategy environment showed an increase in performance. Findings support the notion that hospitals with appropriate strategy-environment combinations will exhibit higher performance.

  1. Reading strategy instruction and teacher change: implications for teacher training

    Nanda M Klapwijk

    2012-01-01

    Full Text Available I report on teacher change in the context of a reading strategy instruction intervention. Reading Strategy Instruction (RSI was implemented by three teachers, new to the concept, over a period of 15 weeks. Observations of these teachers showed that a multitude of factors affect the uptake of RSI as part of everyday teaching practice, and that teachers seem to move through distinct phases in their uptake of RSI. The article focuses on teachers' reaction to RSI and highlights a number of issues that are important to the implementation of RSI, not the least of which is that a clear need exists for changes to in-service teacher training and support and pre-service teacher training. In an effort to address these training issues the article contains specific recommendations for pre-service teacher training in particular.

  2. Business Responses to Climate Change. Identifying Emergent Strategies

    Kolk, A.; Pinkse, J.

    2005-01-01

    Companies face much uncertainty about the competitive effects of the recently adopted Kyoto Protocol on global climate change and the current and future regulations that may emerge from it. Companies have considerable discretion to explore different market strategies to address global warming and reduce greenhouse gas emissions. This article examines these strategic options by reviewing the market-oriented actions that are currently being taken by 136 large companies that are part of the Global 500. There are six different market strategies that companies use to address climate change and that consist of different combinations of the market components available to managers. Managers can choose between more emphasis on improvements in their business activities through innovation or employ compensatory approaches such as emissions trading. They can either act by themselves or work with other companies, NGOs, or (local) governments

  3. Cognitive debiasing 2: impediments to and strategies for change.

    Croskerry, Pat; Singhal, Geeta; Mamede, Sílvia

    2013-10-01

    In a companion paper, we proposed that cognitive debiasing is a skill essential in developing sound clinical reasoning to mitigate the incidence of diagnostic failure. We reviewed the origins of cognitive biases and some proposed mechanisms for how debiasing processes might work. In this paper, we first outline a general schema of how cognitive change occurs and the constraints that may apply. We review a variety of individual factors, many of them biases themselves, which may be impediments to change. We then examine the major strategies that have been developed in the social sciences and in medicine to achieve cognitive and affective debiasing, including the important concept of forcing functions. The abundance and rich variety of approaches that exist in the literature and in individual clinical domains illustrate the difficulties inherent in achieving cognitive change, and also the need for such interventions. Ongoing cognitive debiasing is arguably the most important feature of the critical thinker and the well-calibrated mind. We outline three groups of suggested interventions going forward: educational strategies, workplace strategies and forcing functions. We stress the importance of ambient and contextual influences on the quality of individual decision making and the need to address factors known to impair calibration of the decision maker. We also emphasise the importance of introducing these concepts and corollary development of training in critical thinking in the undergraduate level in medical education.

  4. Legitimately seeking differences: The case of climate change strategies

    Bui, B.; Fowler, C. [Victoria Univ. of Wellington (New Zealand)

    2009-07-01

    In 2002, the New Zealand Government announced its intention to introduce a carbon tax as part of its response to climate change. Following the review of New Zealand climate change policies, the proposed carbon tax was ruled out in 2005 and other measures were investigated. In October 2007, the government announced its new climate change policy package, a fundamental part of which is the domestic cap-and-trade Emissions Trading Scheme (ETS). The scheme is currently being revised by the Government, with a report due August 2009. The government's climate change policy and the ETS in particular, represent significant changes in regulatory and societal expectations of the way in which businesses will account for the impact of their carbon emissions on the natural environment. The New Zealand electricity generators are among the most heavily impacted by the Government's climate change policy due to the scale of carbon emissions from electricity generation. This study utilizes institutional theory and the concept of legitimate differentiation, using a resource-based view, to examine and explain the changes in the electricity generators' carbon-strategy related environmental management and reporting practices as a result of regulatory, societal and financial pressures arising from the Government's climate change policy as it changed between 2002 and 2008. A study of organizations' reactions to climate change regulations is timely because the phenomenon of changing regulation is worldwide and far-reaching in scale. As such, the findings from a New Zealand study of electricity companies are releavant to many countries and organizations. Two generators that are among the firms with highest levels of carbon emissions in the New Zealand electricity industry (NZEI) are selected for in-depth analysis. Each company is first analyzed longitudinally (2001-2008) to discern changes in their internal environmental structures, systems and strategies to account

  5. Changes in Thiol-Disulfide Homeostasis of the Body to Surgical Trauma in Laparoscopic Cholecystectomy Patients.

    Polat, Murat; Ozcan, Onder; Sahan, Leyla; Üstündag-Budak, Yasemin; Alisik, Murat; Yilmaz, Nigar; Erel, Özcan

    2016-12-01

    We aimed to investigate the short-term effect of laparoscopic surgery on serum thiol-disulfide homeostasis levels as a marker of oxidant stress of surgical trauma in elective laparoscopic cholecystectomy patients. Venous blood samples were collected, and levels of native thiols, total thiols, and disulfides were determined with a novel automated assay. Total antioxidant capacity (measured as the ferric-reducing ability of plasma) and serum ischemia modified albumin, expressed as absorbance units assayed by the albumin cobalt binding test, were determined. The major findings of the present study were that native thiol (283 ± 45 versus 241 ± 61 μmol/L), total thiol (313 ± 49 versus 263 ± 67 μmol/L), and disulfide (14.9 ± 4.6 versus 11.0 ± 6.1 μmol/L) levels were decreased significantly during operation and although they increased, they did not return to preoperation levels 24 hours after laparoscopic surgery compared to the levels at baseline. Disulfide/native thiol and disulfide/total thiol levels did not change during laparoscopic surgery. The decrease in plasma level of native and total thiol groups suggests impairment of the antioxidant capacity of plasma; however, the delicate balance between the different redox forms of thiols was maintained during surgery.

  6. A review of Thailand's strategies for global climate change

    Boonchalermkit, S.

    1994-01-01

    Thailand is greatly concerned about global climate change, which is caused primarily by the burning of fossil fuels, deforestation and the release of chlorofluorocarbons. The country itself is not currently a major contributor to global climate change. However, as Thailand's economy expands and its burning of fossil fuels increases, the country's contribution to global climate change could increase. Thailand's use of primary energy supplies grew at an average rate of 13.4 percent per year in the period 1985 to 1990. The rapid, sustained growth was due to the overall pace of growth in the economy and the expansion of industrial, construction, and transportation activities. The primary energy demand was approximately 31,600 kilotons of oil equivalent (KTOE) in 1990. The transportation sector accounted for the largest proportion of energy demand at 30 percent. Within the next 15 years, the power sector is expected to overtake the transportation sector as the largest consumer of energy. Petroleum is currently the predominant source of energy in Thailand, accounting for 56 percent of the primary energy demand. Thailand recognizes that it has an important part to play in finding solutions to minimizing emissions of greenhouse gases and identifying viable response strategies. Thus, in this paper the authors will present several policy strategies relevant to climate change in Thailand and discuss how they have been implemented and enforced. Policies concerning forestry, energy, and environment are reviewed in detail in this paper

  7. Terrestrial ecosystem responses to global change: A research strategy

    NONE

    1998-09-01

    Uncertainty about the magnitude of global change effects on terrestrial ecosystems and consequent feedbacks to the atmosphere impedes sound policy planning at regional, national, and global scales. A strategy to reduce these uncertainties must include a substantial increase in funding for large-scale ecosystem experiments and a careful prioritization of research efforts. Prioritization criteria should be based on the magnitude of potential changes in environmental properties of concern to society, including productivity; biodiversity; the storage and cycling of carbon, water, and nutrients; and sensitivity of specific ecosystems to environmental change. A research strategy is proposed that builds on existing knowledge of ecosystem responses to global change by (1) expanding the spatial and temporal scale of experimental ecosystem manipulations to include processes known to occur at large scales and over long time periods; (2) quantifying poorly understood linkages among processes through the use of experiments that manipulate multiple interacting environmental factors over a broader range of relevant conditions than did past experiments; and (3) prioritizing ecosystems for major experimental manipulations on the basis of potential positive and negative impacts on ecosystem properties and processes of intrinsic and/or utilitarian value to humans and on feedbacks of terrestrial ecosystems to the atmosphere.

  8. Behavioral Change Strategies for Improving Complementary Feeding and Breastfeeding.

    Osendarp, Saskia J M; Roche, Marion L

    2016-01-01

    Improving infant and young child feeding (IYCF) practices, including breastfeeding and complementary feeding, has been identified as one of the most effective interventions to improve child survival, stunting and wasting. Evidence from randomized controlled trials suggests that effective promotion of breastfeeding and complementary feeding, with or without food provision, has the potential to improve IYCF practices and child nutrition. However, in many countries, breastfeeding practices and complementary feeding practices are still far from optimal. The lack of implementation of available, effective, affordable interventions in scale-up programs is in part attributed to a lack of innovative, creative and effective behavioral change strategies that enable and encourage caregivers. Successful behavioral change strategies should be based on a rigorous situational analysis and formative research, and the findings and insights of formative research should be used to further design interventions that address the identified barriers and enablers, to select delivery channels, and to formulate appropriate and effective messages. In addition, successful behavioral change interventions should a priori define and investigate the program impact pathway to target behavioral change and should assess intermediary behavioral changes and indicators to learn why the expected outcome was achieved or not achieved by testing the program theory. The design of behavioral change communication must be flexible and responsive to shifts in societies and contexts. Performance of adequate IYCF also requires investments to generate community demand through social mobilization, relevant media and existing support systems. Applying these principles has been shown to be effective in improving IYCF practices in Vietnam, Bangladesh and Ethiopia and is recommended to be adopted by other programs and countries in order to accelerate progress in improving child nutrition. © 2016 S. Karger AG, Basel.

  9. "Beating osteoARThritis": development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis

    Smink, A.J.; Ende, C.H.; Vliet-Vlieland, Th.P.M.; Swierstra, B.A.; Kortland, J.H.; Bijlsma, J.W.; Voorn, T.B.; Schers, H.J.; Bierma-Zeinstra, S.M.; Dekker, J.

    2011-01-01

    Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an

  10. "Beating osteoARThritis": Development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis

    Smink, A.J.; Ende, C.H.M. van den; Vliet Vlieland, T.P.M.; Swierstra, B.A.; Kortland, J.H.; Bijlsma, J.W.J.; Voorn, T.B.; Schers, H.J.; Bierma-Zeinstra, S.M.; Dekker, J.

    2011-01-01

    Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an

  11. Testicular neoplasia in undescended testes of cryptorchid boys-does surgical strategy have an impact on the risk of invasive testicular neoplasia?

    Cortes, Dina; Thorup, Jørgen Mogens; Petersen, Bodil Laub

    2004-01-01

    We investigated whether or not surgical strategy has an impact on the risk of invasive testicular neoplasia in cases of cryptorchidism. We made a database study of the incidence of testicular neoplasia at surgery for cryptorchidism in childhood, and evaluated if such abnormalities were found......, p placed...

  12. R and D investment strategy for climate change

    Blanford, Geoffrey J.

    2009-01-01

    The economic costs of stabilizing greenhouse gas concentrations over the coming century depend critically on the development of new technologies in the energy sector. Our research and development (R and D) investment strategy is the control variable for technology availability. This paper proposes an analytic framework for determining optimal R and D investment allocation and presents some numerical results to demonstrate the implementation of the methodology. The value of technological advance in three targeted areas-fossil-based generation, renewables, and carbon capture and storage-is represented by the increase in expected welfare in the presence of an emissions policy constraint of initially uncertain stringency. R and D expenditure increases the probability of advance. Optimal investment is determined by its relationship with success probability, which is assumed to exhibit decreasing returns to scale, relative to the value of success. While the numerical results are speculative, the paper offers insights into the nature of an optimal technology strategy for addressing climate change. (author)

  13. CHANGES IN COPING STRATEGY IN THE SCHOOL AGE CHILDREN

    M. A. Alieva

    2018-01-01

    Full Text Available The objective of the study: to investigate the changes in preferable coping-strategies during treatment of the school-age children in a TB sanatorium. 77 patients (children and adolescents were enrolled into the study, they all had rehabilitation due to respiratory tuberculosis. All patients were divided into two groups: 8-12 years old (17 boys and 13 girls and 13-17 years old (24 boys and 23 girls. Coping strategies in the school-age children were investigated twice: at admission and discharge from the sanatorium, using a questionnaire adapted by N.A. Sirota and V.N. Yaltonsky and modified by R. M. Granovskaya and I.M. Nikolskaya. Analysis of the structure of the responses identified a group of patients who were oriented in the direction from the problem. This group presented a lower number of scores of the problem solution scale and a higher number of scores in the scales of avoidance, denial, fantasy formation. The other group of patients, focused in the direction towards the problem, characterized by a higher number of scores of the scales of problem solution and communication and a lower number of scores for the scales of denial and fantasy formation. Statistically significant changes were observed in the scale assessing communication (p = 0.03; there was a statistically significant reduction in the scores reflecting avoidance and denial (p < 0.001. There were no significant changes in the other scores. 

  14. 77 FR 76034 - National Water Program 2012 Strategy: Response to Climate Change

    2012-12-26

    ... Strategy: Response to Climate Change AGENCY: Environmental Protection Agency (EPA). ACTION: Notice of... Program 2012 Strategy: Response to Climate Change'' (2012 Strategy). The Strategy describes a set of long-term visions and goals for the management of water resources in light of climate change and charts key...

  15. eHealth Applications Promising Strategies for Behavior Change

    Noar, Seth M

    2012-01-01

    eHealth Applications: Promising Strategies for Behavior Change provides an overview of technological applications in contemporary health communication research, exploring the history and current uses of eHealth applications in disease prevention and management. This volume focuses on the use of these technology-based interventions for public health promotion and explores the rapid growth of an innovative interdisciplinary field. The chapters in this work discuss key eHealth applications by presenting research examining a variety of technology-based applications. Authors Seth M. Noar and Nancy

  16. Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical and Technical Considerations for Successful Outcomes

    Sonia Tewani Orcutt

    2016-03-01

    Full Text Available Preoperative portal vein embolization (PVE is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other’s techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient’s anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications and how to avoid the complications in each step is of great importance for safe and successful PVE, and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

  17. Anterolateral Approach for Central Thoracic Disc Prolapse-Surgical Strategies Used to Tackle Differing Operative Findings: 3-Dimensional Operative Video.

    Patel, Krunal; Budohoski, Karol P; Kenyon, Olivia R P; Barone, Damiano G; Santarius, Thomas; Kirollos, Ramez W; Mannion, Richard J; Trivedi, Rikin A

    2018-04-02

    Thoracic disc prolapses causing cord compression can be challenging. For compressive central disc protrusions, a posterior approach is not suitable due to an unacceptable level of cord manipulation. An anterolateral transthoracic approach provides direct access to the disc prolapse allowing for decompression without disturbing the spinal cord. In this video, we describe 2 cases of thoracic myelopathy from a compressive central thoracic disc prolapse. In both cases, informed consent was obtained. Despite similar radiological appearances of heavy calcification, intraoperatively significant differences can be encountered. We demonstrate different surgical strategies depending on the consistency of the disc and the adherence to the thecal sac. With adequate exposure and detachment from adjacent vertebral bodies, soft discs can be, in most instances, separated from the theca with minimal cord manipulation. On the other hand, largely calcified discs often present a significantly greater challenge and require thinning the disc capsule before removal. In cases with significant adherence to dura, in order to prevent cord injury or cerebrospinal fluid leak a thinned shell can be left, providing total detachment from adjacent vertebrae can be achieved. Postoperatively, the first patient, with a significantly calcified disc, developed a transient left leg weakness which recovered by 3-month follow-up. This video outlines the anatomical considerations and operative steps for a transthoracic approach to a central disc prolapse, whilst demonstrating that computed tomography appearances are not always indicative of potential operative difficulties.

  18. Adaptation Strategies and Resilience to Climate Change of Historic Dwellings

    Carlos Rubio-Bellido

    2015-03-01

    Full Text Available Historic city centres have a large amount of dwellings in Europe, which were built to provide a comfortable shelter with the absence of mechanical means. The knowledge of climate responsive design strategies can play a significant role in reducing the energy demand of extant buildings, paving the way for its sustainable development in the face of the rising threat to its occupants of climate change. The residential architecture, developed, in most cases, in dense urban centres, was built using both available materials and traditional and academic construction technologies. This paper thoroughly investigates the extant urban conglomerate in Cádiz and analyses, in a qualitative and quantitative manner, which bioclimatic design strategies were applied and the city’s adaptation for future climate scenarios. The results indicate that historic housing in Cádiz is creatively adapted to the local natural conditions by means of a combination of climate responsive strategies, and there is significant scope for improvement in the ongoing response to global warming.

  19. Bay State announces growth strategies to cope with changes

    Anon.

    1996-01-01

    A top executive for New England's biggest independent gas distributor says deregulation of the utility industry offers unprecedented opportunities for growth, but getting there will radically change the way it does business. To achieve dramatic growth, Bay State Gas Co. needs to base their strategies on anticipating the changes in the industry and aggressively positioning themselves to capture the new opportunities that the new business environment is creating. This includes: accelerating the unbundling of transportation service all the way to the residential customer level; forging strategic relationships with retail energy product and service companies as a means of increasing throughput on Bay State's system; implementing performance-based rates that provide financial incentives for lowering costs and improving customer service; accelerating the implementation of sophisticated information systems to streamline key business processes; and aggressively expanding Bay State's nonregulated Energy Products and Services business. These steps are discussed

  20. Change and Continuity in Indonesian Islamist Ideology and Terrorist Strategies

    Adam James Fenton

    2015-04-01

    Full Text Available The “Islamisation” of Indonesia has exerted a transformative force on every aspect of Indonesian society. That process continues today. It has created streams of change and continuity in thoughts, ideologies and practices, of enormous complexity. Strict doctrinal interpretation of Koranic text is not a new phenomenon, contrary to what some reports in the mass media might suggest. Its roots stretch back at least as far as the 1800s with the outbreak of violent conflicts between those urging a stricter, scripturalist application of Islam, and those adhering to traditionalist and colonialist ideologies --culminating in the Padri war of West Sumatra of 1821-38. Indicating an ostensible continuity of ideology, modern extremist ideologues, such as Abu Bakar Bashir, urge their followers toward violent conflict and terrorist actions based on an ideology of strict “Middle Eastern” interpretation of fundamental Islamic tenets. This paper argues that the strategies of those carrying out radical and violent ideologies are undergoing change, as are the strategies of the authorities tasked with combating them. Radical groups have displayed a shift away from large-scale, attacks on symbolic foreign targets towards low-level violence primarily aimed at law enforcement authorities. Authorities, on the other hand, have shown a greater tendency to shoot dead those suspected of involvement with violent radical groups. This paper will examine the changing strategies of violent radical groups and the continuity, and evolution, of the underlying Islamic ideology that provides religious justification for their violent acts. The paper will argue that engaging Indonesia’s politically active youth in an ideological dialogue on Islamism and democracy provides the best prospect for disengagement from, and breaking the cycle of recruitment for, radical violence and terrorism.[Proses panjang Islamisasi di Indonesia telah menghasilkan kekuatan transformatif di

  1. Task demands determine comparison strategy in whole probe change detection.

    Udale, Rob; Farrell, Simon; Kent, Chris

    2018-05-01

    Detecting a change in our visual world requires a process that compares the external environment (test display) with the contents of memory (study display). We addressed the question of whether people strategically adapt the comparison process in response to different decision loads. Study displays of 3 colored items were presented, followed by 'whole-display' probes containing 3 colored shapes. Participants were asked to decide whether any probed items contained a new feature. In Experiments 1-4, irrelevant changes to the probed item's locations or feature bindings influenced memory performance, suggesting that participants employed a comparison process that relied on spatial locations. This finding occurred irrespective of whether participants were asked to decide about the whole display, or only a single cued item within the display. In Experiment 5, when the base-rate of changes in the nonprobed items increased (increasing the incentive to use the cue effectively), participants were not influenced by irrelevant changes in location or feature bindings. In addition, we observed individual differences in the use of spatial cues. These results suggest that participants can flexibly switch between spatial and nonspatial comparison strategies, depending on interactions between individual differences and task demand factors. These findings have implications for models of visual working memory that assume that the comparison between study and test obligatorily relies on accessing visual features via their binding to location. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

  2. A Climate Change Adaptation Strategy for Management of ...

    Sea level rise is causing shoreline erosion, increased coastal flooding, and marsh vulnerability to the impact of storms. Coastal marshes provide flood abatement, carbon and nutrient sequestration, water quality maintenance, and habitat for fish, shellfish, and wildlife, including species of concern, such as the saltmarsh sparrow (Ammodramus caudacutus). We present a climate change adaptation strategy (CCAS) adopted by scientific, management, and policy stakeholders for managing coastal marshes and enhancing system resiliency. A common adaptive management approach previously used for restoration projects was modified to identify climate-related vulnerabilities and plan climate change adaptive actions. As an example of implementation of the CCAS, we describe the stakeholder plans and management actions the US Fish and Wildlife Service and partners developed to build coastal resiliency in the Narrow River Estuary, RI, in the aftermath of Superstorm Sandy. When possible, an experimental BACI (before-after, control-impact) design, described as pre- and post-sampling at the impact site and one or more control sites, was incorporated into the climate change adaptation and implementation plans. Specific climate change adaptive actions and monitoring plans are described and include shoreline stabilization, restoring marsh drainage, increasing marsh elevation, and enabling upland marsh migration. The CCAS provides a framework and methodology for successfully managing coa

  3. The Role of mPOS System in Process Change and Strategy Change: A Situated Change Perspective

    Yao Chin Lin

    2015-10-01

    Full Text Available The purpose of this study is to revisit the relationship among information technology (IT, Process, and Strategy. We focus on the impact of mobile Point of Sales (mPOS on changing of operational processes in the restaurant industry. This study investigates the changing of IT strategy and service strategy. The research model was developed based on the literature (strategic alignment model and situated change perspective and inputs from the restaurant industry and IT experts. The data of this study are collected from observation and face-to-face interviews with both business and IT personnel from 10 restaurants in Taiwan. The findings of this study provide a comprehensive view about the ways processes change once restaurants implements mPOS. We also figure out the impact of this change on IT strategy and service strategy. This study’s results shed new light on IT implementation. Researchers need to look at IT in different ways and suggest suitable solutions for practitioners.

  4. Advance strategy for climate change adaptation and mitigation in cities

    Varquez, A. C. G.; Kanda, M.; Darmanto, N. S.; Sueishi, T.; Kawano, N.

    2017-12-01

    An on-going 5-yr project financially supported by the Ministry of Environment, Japan, has been carried out to specifically address the issue of prescribing appropriate adaptation and mitigation measures to climate change in cities. Entitled "Case Study on Mitigation and Local Adaptation to Climate Change in an Asian Megacity, Jakarta", the project's relevant objectives is to develop a research framework that can consider both urbanization and climate change with the main advantage of being readily implementable for all cities around the world. The test location is the benchmark city, Jakarta, Indonesia, with the end focus of evaluating the benefits of various mitigation and adaptation strategies in Jakarta and other megacities. The framework was designed to improve representation of urban areas when conducting climate change investigations in cities; and to be able to quantify separately the impacts of urbanization and climate change to all cities globally. It is comprised of a sophisticated, top-down, multi-downscaling approach utilizing a regional model (numerical weather model) and a microscale model (energy balance model and CFD model), with global circulation models (GCM) as input. The models, except the GCM, were configured to reasonably consider land cover, urban morphology, and anthropogenic heating (AH). Equally as important, methodologies that can collect and estimate global distribution of urban parametric and AH datasets are continually being developed. Urban growth models, climate scenario matrices that match representative concentration pathways with shared socio-economic pathways, present distribution of socio-demographic indicators such as population and GDP, existing GIS datasets of urban parameters, are utilized. From these tools, future urbanization (urban morphological parameters and AH) can be introduced into the models. Sensitivity using various combinations of GCM and urbanization can be conducted. Furthermore, since the models utilize

  5. Three-dimensional dental arch changes of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusion

    Peixoto,Adriano Porto; Pinto,Ary dos Santos; Garib,Daniela Gamba; Gonçalves,João Roberto

    2014-01-01

    INTRODUCTION: This study assessed the three-dimensional changes in the dental arch of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusions at three different periods. METHODS: Landmarks previously identified on upper and lower dental casts were digitized on a three-dimensional digitizer MicroScribe-3DX and stored in Excel worksheets in order to assess the width, length and depth of patient's dental arches. RESULTS: During orthodontic preparation, the m...

  6. Cognitive and Technical Skill Assessment in Surgical Education: a Changing Horizon.

    Vergis, Ashley; Hardy, Krista

    2017-04-01

    Assessment is an integral component of training and credentialing surgeons for practice. Traditional methods of cognitive and technical appraisal are well established but have clear shortcomings. This review outlines the components of the surgical care assessment model, identifies the deficits of current evaluation techniques, and discusses novel and emerging technologies that attempt to ameliorate this educational void.

  7. Managing organizational change: strategies for the female health care supervisor.

    Davies, G

    1990-07-01

    In responding to resistance to change in the current health care organization, the new female supervisor can learn to support her staff in encountering and accepting these changes. The strategies and skills discussed above are characteristic of a supervisory style that may naturally occur for women, but also can be incorporated into the leadership style of men in health care management today. Health care leaders of tomorrow must work from an androgynous framework in which the behavior patterns and responses of each gender are learned and used appropriately by both men and women. Sargent suggests that the best managers are androgynous and that this is the inevitable wave of the future. Whether man or woman, a supervisor should learn, accept, and use methods that are characteristic of both sexes to be successful in managing people. Women and men must learn from each other's strengths and share these diverse skills. Given that women now outnumber men in health care management positions and organizations are changing to a more nurturing environment, the androgynous supervisor will be the successful leader of the future. Finally, women in health care supervisory positions have the potential to bring change where it is badly needed. Women in these roles often have a system wide view of health care policy issues that recognizes less federal commitment to social programs. Many women in health care positions believe that the issues of children, women, the elderly, the poor, and the homeless need focused attention. The growing number of women in health care supervisory and leadership roles is an important factor in changing national health policy for the benefit of these groups.(ABSTRACT TRUNCATED AT 250 WORDS)

  8. Climate Change and Public Health Surveillance: Toward a Comprehensive Strategy.

    Moulton, Anthony Drummond; Schramm, Paul John

    Climate change poses a host of serious threats to human health that robust public health surveillance systems can help address. It is unknown, however, whether existing surveillance systems in the United States have adequate capacity to serve that role, nor what actions may be needed to develop adequate capacity. Our goals were to review efforts to assess and strengthen the capacity of public health surveillance systems to support health-related adaptation to climate change in the United States and to determine whether additional efforts are warranted. Building on frameworks issued by the Intergovernmental Panel on Climate Change and the Centers for Disease Control and Prevention, we specified 4 core components of public health surveillance capacity relevant to climate change health threats. Using standard methods, we next identified and analyzed multiple assessments of the existing, relevant capacity of public health surveillance systems as well as attempts to improve that capacity. We also received information from selected national public health associations. Multiple federal, state, and local public health agencies, professional associations, and researchers have made valuable, initial efforts to assess and strengthen surveillance capacity. These efforts, however, have been made by entities working independently and without the benefit of a shared conceptual framework or strategy. Their principal focus has been on identifying suitable indicators and data sources largely to the exclusion of other core components of surveillance capacity. A more comprehensive and strategic approach is needed to build the public health surveillance capacity required to protect the health of Americans in a world of rapidly evolving climate change. Public health practitioners and policy makers at all levels can use the findings and issues reviewed in this article as they lead design and execution of a coordinated, multisector strategic plan to create and sustain that capacity.

  9. Climate Change and Public Health Surveillance: Toward a Comprehensive Strategy

    Moulton, Anthony Drummond; Schramm, Paul John

    2017-01-01

    Context Climate change poses a host of serious threats to human health that robust public health surveillance systems can help address. It is unknown, however, whether existing surveillance systems in the United States have adequate capacity to serve that role, nor what actions may be needed to develop adequate capacity. Objective Our goals were to review efforts to assess and strengthen the capacity of public health surveillance systems to support health-related adaptation to climate change in the United States and to determine whether additional efforts are warranted. Methods Building on frameworks issued by the Intergovernmental Panel on Climate Change and the Centers for Disease Control and Prevention, we specified 4 core components of public health surveillance capacity relevant to climate change health threats. Using standard methods, we next identified and analyzed multiple assessments of the existing, relevant capacity of public health surveillance systems as well as attempts to improve that capacity. We also received information from selected national public health associations. Findings Multiple federal, state, and local public health agencies, professional associations, and researchers have made valuable, initial efforts to assess and strengthen surveillance capacity. These efforts, however, have been made by entities working independently and without the benefit of a shared conceptual framework or strategy. Their principal focus has been on identifying suitable indicators and data sources largely to the exclusion of other core components of surveillance capacity. Conclusions A more comprehensive and strategic approach is needed to build the public health surveillance capacity required to protect the health of Americans in a world of rapidly evolving climate change. Public health practitioners and policy makers at all levels can use the findings and issues reviewed in this article as they lead design and execution of a coordinated, multisector strategic

  10. [Relationship between Work Ⅱ type of congenital first branchial cleft anomaly and facial nerve and surgical strategies].

    Zhang, B; Chen, L S; Huang, S L; Liang, L; Gong, X X; Wu, P N; Zhang, S Y; Luo, X N; Zhan, J D; Sheng, X L; Lu, Z M

    2017-10-07

    Objective: To investigate the relationship between Work Ⅱ type of congenital first branchial cleft anomaly (CFBCA) and facial nerve and discuss surgical strategies. Methods: Retrospective analysis of 37 patients with CFBCA who were treated from May 2005 to September 2016. Among 37 cases with CFBCA, 12 males and 25 females; 24 in the left and 13 in the right; the age at diagnosis was from 1 to 76 ( years, with a median age of 20, 24 cases with age of 18 years or less and 13 with age more than 18 years; duration of disease ranged from 1 to 10 years (median of 6 years); 4 cases were recurren after fistula resection. According to the classification of Olsen, all 37 cases were non-cyst (sinus or fistula). External fistula located over the mandibular angle in 28 (75.7%) cases and below the angle in 9 (24.3%) cases. Results: Surgeries were performed successfully in all the 37 cases. It was found that lesions located at anterior of the facial nerve in 13 (35.1%) cases, coursed between the branches in 3 cases (8.1%), and lied in the deep of the facial nerve in 21 (56.8%) cases. CFBCA in female with external fistula below mandibular angle and membranous band was more likely to lie deep of the facial nerve than in male with external fistula over the mandibular angle but without myringeal web. Conclusions: CFBCA in female patients with a external fistula located below the mandibular angle, non-cyst of Olsen or a myringeal web is more likely to lie deep of the facial nerve. Surgeons should particularly take care of the protection of facial nerve in these patients, if necessary, facial nerve monitoring technology can be used during surgery to complete resection of lesions.

  11. Transmission dynamics of carbapenemase-producing Klebsiella pneumoniae and anticipated impact of infection control strategies in a surgical unit.

    Vana Sypsa

    Full Text Available BACKGROUND: Carbapenemase-producing Klebsiella pneumoniae (CPKP has been established as important nosocomial pathogen in many geographic regions. Transmission from patient to patient via the hands of healthcare workers is the main route of spread in the acute-care setting. METHODOLOGY/PRINCIPAL FINDINGS: Epidemiological and infection control data were recorded during a prospective observational study conducted in a surgical unit of a tertiary-care hospital in Greece. Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter. The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number R(0 (average number of secondary cases per primary case in the absence of infection control and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings. Eighteen of 850 patients were colonized with CPKP on admission and 51 acquired CPKP during hospilazation. R(0 reached 2 and exceeded unity for long periods of time under the observed hand hygiene compliance (21%. The minimum hand hygiene compliance level necessary to control transmission was 50%. Reduction of 60% to 90% in colonized patients on admission, through active surveillance culture, contact precautions and isolation/cohorting, in combination with 60% compliance in hand hygiene would result in rapid decline in CPKP prevalence within 8-12 weeks. Antibiotics restrictions did not have a substantial benefit when an aggressive control strategy was implemented. CONCLUSIONS/SIGNIFICANCE: Surveillance culture on admission and isolation/cohorting of colonized patients coupled with moderate hand hygiene compliance and contact precautions may lead to rapid control of CPKP in endemic and hyperendemic healthcare settings.

  12. Transmission Dynamics of Carbapenemase-Producing Klebsiella Pneumoniae and Anticipated Impact of Infection Control Strategies in a Surgical Unit

    Sypsa, Vana; Psichogiou, Mina; Bouzala, Georgia-Aikaterina; Hadjihannas, Linos; Hatzakis, Angelos; Daikos, Georgios L.

    2012-01-01

    Background Carbapenemase-producing Klebsiella pneumoniae (CPKP) has been established as important nosocomial pathogen in many geographic regions. Transmission from patient to patient via the hands of healthcare workers is the main route of spread in the acute-care setting. Methodology/Principal Findings Epidemiological and infection control data were recorded during a prospective observational study conducted in a surgical unit of a tertiary-care hospital in Greece. Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter. The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number R0 (average number of secondary cases per primary case in the absence of infection control) and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings. Eighteen of 850 patients were colonized with CPKP on admission and 51 acquired CPKP during hospilazation. R0 reached 2 and exceeded unity for long periods of time under the observed hand hygiene compliance (21%). The minimum hand hygiene compliance level necessary to control transmission was 50%. Reduction of 60% to 90% in colonized patients on admission, through active surveillance culture, contact precautions and isolation/cohorting, in combination with 60% compliance in hand hygiene would result in rapid decline in CPKP prevalence within 8–12 weeks. Antibiotics restrictions did not have a substantial benefit when an aggressive control strategy was implemented. Conclusions/Significance Surveillance culture on admission and isolation/cohorting of colonized patients coupled with moderate hand hygiene compliance and contact precautions may lead to rapid control of CPKP in endemic and hyperendemic healthcare settings. PMID:22859965

  13. Evaluation of the Influential Factors in Cancelling Surgical Operations and Developing Management Strategies to Reduce these Factors in Shahid Kamyab Hospital of Mashhad, Iran during 2012-2013

    Amir Ashkan Nasiripour

    2017-04-01

    Conclusion: According to the results, most of the causes of surgery cancellation were patient-related. Therefore, it is suggested that patient evaluation be performed by surgeons and anesthesiologists prior to the surgical operation in order to prevent clinical problems during the surgery, offer insurance strategies, and solve the problems relating to the healthcare costs for the less privileged patients, especially those requiring surgery after accidents.

  14. [Variants of choice of surgical treatment of chronic pancreatitis in consideration of morphological changes in the pancreas].

    Priadko, A S; Maĭstrenko, N A; Romashchenko, P N

    2014-01-01

    The results of examination and treatment of 445 patients with chronic pancreatitis were analyzed. It was established, that 298 (67%) patients had indications for treatment in the conditions of surgical hospital. The patients were divided into three groups according to the modified pancreatitis classification of Marseilles-Rome 1988. There were the calcifying form (n = 78), obstructive form (n = 81), inflammatory form (n = 139). The application of modern methods of diagnostics and treatment of chronic pancreatitis allowed modifying the classification by selection of subgroups for each form of the disease. It was stated, that the substantiation of variants of surgical treatment of chronic pancreatitis in consideration of morphological changes in the pancreas could improve the possibilities of medical care plan for patients with minimal complications and good quality of life in long-term period of time.

  15. Morphologic and biochemical changes in male rat lung after surgical and pharmacological castration

    M.S. Ojeda

    2000-03-01

    Full Text Available The morphology of the rat lung was studied by light microscopy in different situations: after surgical and pharmacological castration and after administration of testosterone to the castrated rat to determine if the androgen is required to maintain the normal morphology of the lung. We also determined the effect of flutamide on the phospholipid composition of both the surfactant and microsomes of the lung. Rats were separated into five groups: I - control non-castrated rats, II - castrated rats sacrificed 21 days after castration, III - castrated rats that received testosterone daily from day 2 to day 21 after castration, IV - castrated rats that received testosterone from day 15 to day 21 after castration, and V - control rats injected with flutamide for 7 days. The amount of different phospholipids in the surfactant and microsomes of the lung was measured in group I and V rats. At the light microscopy level, the surgical and pharmacological castration provoked alterations in the morphology of the lung, similar to that observed in human lung emphysema. The compositions of surfactant and microsomes of the lung were similar to those previously reported by us for the surgically castrated rats. These results indicate that androgens are necessary for the normal morphology as well as for some metabolic aspects of the lung.

  16. China's strategy for energy development and climate change mitigation

    He Jiankun; Yu Zhiwei; Zhang Da

    2012-01-01

    In recent years, China has made great efforts in energy saving and carbon emission reduction by pushing forward domestic sustainable development along with global climate change mitigation. The efforts have paid off with a dramatic decrease in carbon intensity. Nevertheless, China is still confronted with tough challenges in emission control due to the fast pace of industrialization, large total historical emission and high growth rate of emissions. Therefore, China should give priority to energy saving by improving energy efficiency and sectoral structure adjustment and upgrade, and develop sustainable and renewable energy to optimize energy mix and its carbon content. China should continue to regard significant reduction of energy intensity and carbon intensity as the main objective in the near future, strive to achieve peak emissions around 2030, and realize a relatively sharp emissions reduction by 2050 in order to address climate change to meet the goal of making the warming less than 2°. During the 12th Five Year Plan (FYP), China will further strengthen measures to control the amount of energy consumption, establish a statistics, accounting and evaluation system of carbon emissions, and promote a market-based carbon emissions trading mechanism to facilitate the low-carbon transformation of China's economy. - Highlights: ► This paper studies China's strategy for energy development and climate change mitigation. ► We suggest that China should focus on reducing the energy intensity and carbon intensity of GDP, and optimization of energy mix in the near term. ► In the long term, China should achieve the peak emission around 2030, and realize a relative sharp emission reduction by 2050. ► The paper also concludes some important measures which China should take during the 12th Five-Year-Plan (2011–2015).

  17. Changes in patient's quality of life comparing conservative and surgical treatment of venous leg ulcers.

    Jankūnas, Vytautas; Rimdeika, Rytis; Jasenas, Marius; Samsanavicius, Donatas

    2004-01-01

    Leg ulcers of different etiology disable up to 1% of total population, and up to 15% individuals over 70 years old. It is an old disease, which troubles the patients and medical personnel and is hard to cure. It might take several years to cure the ulcer fully. Most of the patients with leg ulcers are being treated at home, not in the outpatient departments or hospitals; therefore there is not much information on how the ulcer affects the patient's everyday life and its quality. The researchers often analyze only the financial part of this disorder forgetting its human part: pain, social isolation, and decreased mobility. There are many questionnaires and methods to analyze the quality of life of the patients with leg ulceration. It is often unclear if we should treat the ulcer conservatively for a long time or if part of resources should be used for operation (skin grafting) and the time of treatment should be shortened. To see the advantage of both methods and the influence of the ulcer treatment to the quality of life we decided to estimate the functionality of surgical and conservative treatment. We have analyzed the case histories and the data of special questionnaires of 44 patients, which were treated in Department of Plastic Surgery and Burns of Kaunas University of Medicine Hospital in the period of 2001 January-2004 February and had large trophic leg ulcers (m=254 cm2) for 6 months or more. Ten patients were treated conservatively and 34 patients were treated by skin grafting. All of them were interviewed after 3-6 months. We found that the pain in the place of the ulcers has decreased for the patients, who were treated surgically. By making the differences of the pain more exact we found out, that the patients have been feeling pain before the operation and when interviewing them the second time they told that they felt discomfort, not pain. The intensity of pain remained the same for the patients treated conservatively. The regression of pain also

  18. Colorectal surgery and surgical site infection: is a change of attitude necessary?

    Elia-Guedea, Manuela; Cordoba-Diaz de Laspra, Elena; Echazarreta-Gallego, Estibaliz; Valero-Lazaro, María Isabel; Ramirez-Rodriguez, Jose Manuel; Aguilella-Diago, Vicente

    2017-07-01

    Surgical site infection (SSI) can be as high as 30% in patients undergoing colorectal surgery and is associated with an increase in morbidity and mortality. The aim of this study is to evaluate the impact of a set of simple preventive measures that have resulted in a reduction in surgical site infection in colorectal surgery. Prospective study with two groups of patients treated in the colorectal unit of the "Clinico Universitario Lozano Blesa" hospital in Zaragoza. One group was subject to our measures from February to May 2015. The control group was given conventional treatment within a time period of 3 months before the set of measures were implemented. One hundred forty-nine patients underwent a major colorectal surgical procedure. Seventy (47%) belonged to the control group and were compared to the remaining 79 patients (53% of the total), who were subject to our treatment bundle in the period tested. Comparing the two groups revealed that our set of measures led to a general reduction in SSI (31.4 vs. 13.6%, p = 0.010) and in superficial site infection (17.1 vs. 2.5%, p = 0.002). As a consequence, the postoperative hospital stay was shortened (10.0 vs. 8.0 days, p = 0.048). However, it did not, the number of readmissions nor the re-operation rate. SSI was clearly related to open surgery. The preventive set of measures applied in colorectal surgery led to a significant reduction of the SSI and of the length of hospital stay.

  19. Terrestrial Ecosystem Responses to Global Change: A Research Strategy

    Ecosystems Working Group,

    1998-09-23

    Uncertainty about the magnitude of global change effects on terrestrial ecosystems and consequent feedbacks to the atmosphere impedes sound policy planning at regional, national, and global scales. A strategy to reduce these uncertainties must include a substantial increase in funding for large-scale ecosystem experiments and a careful prioritization of research efforts. Prioritization criteria should be based on the magnitude of potential changes in environmental properties of concern to society, including productivity; biodiversity; the storage and cycling of carbon, water, and nutrients; and sensitivity of specific ecosystems to environmental change. A research strategy is proposed that builds on existing knowledge of ecosystem responses to global change by (1) expanding the spatial and temporal scale of experimental ecosystem manipulations to include processes known to occur at large scales and over long time periods; (2) quantifying poorly understood linkages among processes through the use of experiments that manipulate multiple interacting environmental factors over a broader range of relevant conditions than did past experiments; and (3) prioritizing ecosystems for major experimental manipulations on the basis of potential positive and negative impacts on ecosystem properties and processes of intrinsic and/or utilitarian value to humans and on feedbacks of terrestrial ecosystems to the atmosphere. Models and experiments are equally important for developing process-level understanding into a predictive capability. To support both the development and testing of mechanistic ecosystem models, a two-tiered design of ecosystem experiments should be used. This design should include both (1) large-scale manipulative experiments for comprehensive testing of integrated ecosystem models and (2) multifactor, multilevel experiments for parameterization of process models across the critical range of interacting environmental factors (CO{sub 2}, temperature, water

  20. Commentary: one strategy for building public trust in changing times.

    Dauphinee, W Dale; Tamblyn, Robyn; Cruess, Sylvia R; Cruess, Richard L

    2010-06-01

    Major health care reforms are being debated in the United States. While these debates address issues of access and cost, the systems-based problems of patient safety, continuous quality improvement, and an integrated approach to continuing professional development (CPD) remain traditional opportunities for the profession to directly improve health care and maintain professional accountability. Such challenges can be addressed independently of proposed reforms and offer an opportunity for the profession to build greater public trust. Given recent evidence questioning many assumptions behind individually focused CPD, and as physicians' work shifts into group and team contexts, it is an opportune time to address better CPD strategies within emerging group and team settings.The first strategic change requires a focus on managing the development of the individual physician's educational growth into a systems-oriented approach based on better information and feedback within groups of practitioners and health care teams. Second, the renewal of the linked visions of professional collegiality and accountability with professional regulation needs to be seen as a collective responsibility across key organizations within the profession's normal accountability framework. Thus, the professional colleges, certifying boards, and regulatory authorities need to collaborate with the CDP community in refocusing their collective activities to promote the profession's traditional role of improving the quality of care and maintaining the public's trust in these times of intense policy debate.

  1. Behavioral Change and Building Performance: Strategies for Significant, Persistent, and Measurable Institutional Change

    Wolfe, Amy K.; Malone, Elizabeth L.; Heerwagen, Judith H.; Dion, Jerome P.

    2014-04-01

    The people who use Federal buildings — Federal employees, operations and maintenance staff, and the general public — can significantly impact a building’s environmental performance and the consumption of energy, water, and materials. Many factors influence building occupants’ use of resources (use behaviors) including work process requirements, ability to fulfill agency missions, new and possibly unfamiliar high-efficiency/high-performance building technologies; a lack of understanding, education, and training; inaccessible information or ineffective feedback mechanisms; and cultural norms and institutional rules and requirements, among others. While many strategies have been used to introduce new occupant use behaviors that promote sustainability and reduced resource consumption, few have been verified in the scientific literature or have properly documented case study results. This paper documents validated strategies that have been shown to encourage new use behaviors that can result in significant, persistent, and measureable reductions in resource consumption. From the peer-reviewed literature, the paper identifies relevant strategies for Federal facilities and commercial buildings that focus on the individual, groups of individuals (e.g., work groups), and institutions — their policies, requirements, and culture. The paper documents methods with evidence of success in changing use behaviors and enabling occupants to effectively interact with new technologies/designs. It also provides a case study of the strategies used at a Federal facility — Fort Carson, Colorado. The paper documents gaps in the current literature and approaches, and provides topics for future research.

  2. Forest Service Global Change Research Strategy, 2009-2019 Implementation Plan

    Allen Solomon; Richard A. Birdsey; Linda A. Joyce

    2010-01-01

    In keeping with the research goals of the U.S. Global Change Research Program, the climate change strategy of the U.S. Department of Agriculture (USDA), and the climate change framework of the Forest Service, this Forest Service Global Change Research Strategy, 2009-2019 Implementation Plan (hereafter called the Research Plan), was written by Forest Service Research...

  3. Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design.

    Alexander M Aiken

    Full Text Available In low-income countries, Surgical Site Infection (SSI is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals.We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design.From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these.Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.

  4. Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design.

    Aiken, Alexander M; Wanyoro, Anthony K; Mwangi, Jonah; Juma, Francis; Mugoya, Isaac K; Scott, J Anthony G

    2013-01-01

    In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals. We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design. From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these. Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.

  5. Three-dimensional dental arch changes of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusion

    Adriano Porto Peixoto

    2014-08-01

    Full Text Available INTRODUCTION: This study assessed the three-dimensional changes in the dental arch of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusions at three different periods. METHODS: Landmarks previously identified on upper and lower dental casts were digitized on a three-dimensional digitizer MicroScribe-3DX and stored in Excel worksheets in order to assess the width, length and depth of patient's dental arches. RESULTS: During orthodontic preparation, the maxillary and mandibular transverse dimensions measured at the premolar regions were increased and maintained throughout the follow-up period. Intercanine width was increased only in the upper arch during orthodontic preparation. Maxillary arch length was reduced during orthodontic finalization, only. Upper and lower arch depths were stable in the study periods. Differences between centroid and gingival changes suggested that upper and lower arch premolars buccaly proclined during the pre-surgical period. CONCLUSIONS: Maxillary and mandibular dental arches presented transverse expansion at premolar regions during preoperative orthodontic preparation, with a tendency towards buccal tipping. The transverse dimensions were not altered after surgery. No sagittal or vertical changes were observed during the follow-up periods.

  6. Three-dimensional dental arch changes of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusion.

    Peixoto, Adriano Porto; dos Santos Pinto, Ary; Garib, Daniela Gamba; Gonçalves, João Roberto

    2014-01-01

    This study assessed the three-dimensional changes in the dental arch of patients submitted to orthodontic-surgical treatment for correction of Class II malocclusions at three different periods. Landmarks previously identified on upper and lower dental casts were digitized on a three-dimensional digitizer MicroScribe-3DX and stored in Excel worksheets in order to assess the width, length and depth of patient's dental arches. During orthodontic preparation, the maxillary and mandibular transverse dimensions measured at the premolar regions were increased and maintained throughout the follow-up period. Intercanine width was increased only in the upper arch during orthodontic preparation. Maxillary arch length was reduced during orthodontic finalization, only. Upper and lower arch depths were stable in the study periods. Differences between changes in centroid and gingival points suggested that upper and lower premolars buccaly proclined during the pre-surgical period. Maxillary and mandibular dental arches presented transverse expansion at premolar regions during preoperative orthodontic preparation, with a tendency towards buccal tipping. The transverse dimensions were not altered after surgery. No sagittal or vertical changes were observed during the follow-up periods.

  7. Surgical Assisting

    ... instruction, including: Microbiology Pathophysiology Pharmacology Anatomy and physiology Medical terminology Curriculum . Course content includes: Advanced surgical anatomy Surgical microbiology Surgical pharmacology Anesthesia methods and agents Bioscience Ethical ...

  8. Exploring the Interconnectedness among Strategy Development, Shared Mental Models, Organisational Learning and Organisational Change

    Malan, Renee

    2011-01-01

    The cognitive psychological processes related to learning and change behaviour are factors that impact on organisational strategy development. Strategy development is dependent on strategic thinking that is reciprocally influenced by shared mental models, organisational learning and organisational change. Although strategy development, shared…

  9. Breast Cancer Surgery: Comparing Surgical Groups and Determining Individual Differences in Postoperative Sexuality and Body Change Stress

    Yurek, Debora; Farrar, William; Andersen, Barbara L.

    2007-01-01

    Women diagnosed and surgically treated for regional breast cancer (N = 190) were studied to determine the sexual and body change sequelae for women receiving modified radical mastectomy (MRM) with breast reconstruction in comparison with the sequelae for women receiving breast-conserving therapy (BCT) or MRM without breast reconstruction. The sexuality pattern for women receiving reconstructive surgery was one that was significantly different—with lower rates of activity and fewer signs of sexual responsiveness—than that for women in either of the other groups. Significantly higher levels of traumatic stress and situational distress regarding the breast changes were reported by the women receiving an MRM in contrast to the women treated with BCT. Using a model to predict sexual morbidity, regression analyses revealed that individual differences in sexual self-schema were related to both sexual and body change stress outcomes. PMID:10965644

  10. Horizontal infection control strategy decreases methicillin-resistant Staphylococcus aureus infection and eliminates bacteremia in a surgical ICU without active surveillance.

    Traa, Maria X; Barboza, Lorena; Doron, Shira; Snydman, David R; Noubary, Farzad; Nasraway, Stanley A

    2014-10-01

    Methicillin-resistant Staphylococcus aureus infection is a significant contributor to morbidity and mortality in hospitalized patients worldwide. Numerous healthcare bodies in Europe and the United States have championed active surveillance per the "search and destroy" model. However, this strategy is associated with significant economic, logistical, and patient costs without any impact on other hospital-acquired pathogens. We evaluated whether horizontal infection control strategies could decrease the prevalence of methicillin-resistant S. aureus infection in the ICU, without the need for active surveillance. Retrospective, observational study in the surgical ICU of a tertiary care medical center in Boston, MA, from 2005 to 2012. A total of 6,697 patients in the surgical ICU. Evidence-based infection prevention strategies were implemented in an iterative fashion, including 1) hand hygiene program with refresher education campaign, 2) chlorhexidine oral hygiene program, 3) chlorhexidine bathing, 4) catheter-associated bloodstream infection program, and 5) daily goals sheets. The prevalence of methicillin-resistant S. aureus infection fell from 2.66 to 0.69 per 1,000 patient days from 2005 to 2012, an average decrease of 21% per year. The biggest decline in rate of infection was detected in 2008, which may suggest that the catheter-associated bloodstream infection prevention program was particularly effective. Among 4,478 surgical ICU admissions over the last 5 years, not a single case of methicillin-resistant S. aureus bacteremia was observed. Aggressive multifaceted horizontal infection control is an effective strategy for reducing the prevalence of methicillin-resistant S. aureus infection and eliminating methicillin-resistant S. aureus bacteremia in the ICU without the need for active surveillance and decontamination.

  11. Arctic Sea Ice Trafficability - New Strategies for a Changing Icescape

    Dammann, Dyre Oliver

    Sea ice is an important part of the Arctic social-environmental system, in part because it provides a platform for human transportation and for marine flora and fauna that use the ice as a habitat. Sea ice loss projected for coming decades is expected to change ice conditions throughout the Arctic, but little is known about the nature and extent of anticipated changes and in particular potential implications for over-ice travel and ice use as a platform. This question has been addressed here through an extensive effort to link sea ice use and key geophysical properties of sea ice, drawing upon extensive field surveys around on-ice operations and local and Indigenous knowledge for the widely different ice uses and ice regimes of Utqiagvik, Kotzebue, and Nome, Alaska.. A set of nine parameters that constrain landfast sea ice use has been derived, including spatial extent, stability, and timing and persistence of landfast ice. This work lays the foundation for a framework to assess and monitor key ice-parameters relevant in the context of ice-use feasibility, safety, and efficiency, drawing on different remote-sensing techniques. The framework outlines the steps necessary to further evaluate relevant parameters in the context of user objectives and key stakeholder needs for a given ice regime and ice use scenario. I have utilized this framework in case studies for three different ice regimes, where I find uses to be constrained by ice thickness, roughness, and fracture potential and develop assessment strategies with accuracy at the relevant spatial scales. In response to the widely reported importance of high-confidence ice thickness measurements, I have developed a new strategy to estimate appropriate thickness compensation factors. Compensation factors have the potential to reduce risk of misrepresenting areas of thin ice when using point-based in-situ assessment methods along a particular route. This approach was tested on an ice road near Kotzebue, Alaska, where

  12. [Is the structure of surgical clinics in Germany changing? A current investigation into the structure of surgical clinics in the Federal Republic of Germany].

    Lob, G; Lob, T; Bauer, H; Niethard, F; Polonius, J; Siebert, H

    2009-04-01

    Medical developments have led to extensive specialization in the field of surgery. This has already been reflected for many years in altered structure and organization forms of surgical clinics. Indispensable quality standards, statutory general conditions, increasing competition in service providers and health insurance with transparency of the service procedure all intensify this trend. The aim of this investigation was, therefore, to determine how far this differentiation of service supply in the field of surgery is also reflected in the area and in surgical departments and clinics of basic and routine supply. To achieve this, all available published information on the structure and organization of surgical clinics in the Federal Republic of Germany was classified according to current departmentalization into "undivided" or general/visceral surgery facilities compared to orthopedic/trauma surgery departments.

  13. Abortion - surgical

    Suction curettage; Surgical abortion; Elective abortion - surgical; Therapeutic abortion - surgical ... Surgical abortion involves dilating the opening to the uterus (cervix) and placing a small suction tube into the uterus. ...

  14. Change Strategies and Associated Implementation Challenges: An Analysis of Online Counselling Sessions.

    Rodda, Simone N; Hing, Nerilee; Hodgins, David C; Cheetham, Alison; Dickins, Marissa; Lubman, Dan I

    2017-09-01

    Self-change is the most frequent way people limit or reduce gambling involvement and often the first choice of people experiencing gambling-related problems. Less well known is the range of change strategies gamblers use and how these are selected, initiated or maintained. This study examined change strategies discussed in counselling transcripts from 149 clients who accessed a national online gambling help service in Australia. Using thematic analysis, we identified the presence of six change strategies; cash control and financial management, social support, avoiding or limiting gambling, alternative activities, changing thoughts and beliefs, and self-assessment and monitoring. Four implementation issues were also identified; a mismatch between need and strategy selection or maintenance; importance and readiness versus the cost of implementation; poor or unplanned transitions between strategies; and failure to review the helpfulness of strategies resulting in premature abandonment or unhelpful prolonged application. This study is the first to identify change strategies discussed in online counselling sessions. This study suggests change strategies are frequently discussed in online counselling sessions and we identified multiple new actions associated with change strategies that had not previously been identified. However, multiple implementation issues were identified and further work is required to determine the helpfulness of change strategies in terms of their selection, initiation and maintenance.

  15. Climate Change Mitigation and Adaptation Strategies Used by ...

    E M IGBOKWE

    This study examined the strategies employed by farmers to mitigate the effects of .... development targets like Nigeria's aspiration to be among the twenty best performing economies of .... structured interview schedule was used to collect data.

  16. Changing currents: a strategy for understanding and predicting the changing ocean circulation.

    Bryden, Harry L; Robinson, Carol; Griffiths, Gwyn

    2012-12-13

    Within the context of UK marine science, we project a strategy for ocean circulation research over the next 20 years. We recommend a focus on three types of research: (i) sustained observations of the varying and evolving ocean circulation, (ii) careful analysis and interpretation of the observed climate changes for comparison with climate model projections, and (iii) the design and execution of focused field experiments to understand ocean processes that are not resolved in coupled climate models so as to be able to embed these processes realistically in the models. Within UK-sustained observations, we emphasize smart, cost-effective design of the observational network to extract maximum information from limited field resources. We encourage the incorporation of new sensors and new energy sources within the operational environment of UK-sustained observational programmes to bridge the gap that normally separates laboratory prototype from operational instrument. For interpreting the climate-change records obtained through a variety of national and international sustained observational programmes, creative and dedicated UK scientists should lead efforts to extract the meaningful signals and patterns of climate change and to interpret them so as to project future changes. For the process studies, individual scientists will need to work together in team environments to combine observational and process modelling results into effective improvements in the coupled climate models that will lead to more accurate climate predictions.

  17. Early rehabilitation treatment combined with equinovarus foot deformity surgical correction in stroke patients: safety and changes in gait parameters.

    Giannotti, Erika; Merlo, Andrea; Zerbinati, Paolo; Longhi, Maria; Prati, Paolo; Masiero, Stefano; Mazzoli, Davide

    2016-06-01

    Equinovarus foot deformity (EVFD) compromises several prerequisites of walking and increases the risk of falling. Guidelines on rehabilitation following EVFD surgery are missing in current literature. The aim of this study was to analyze safety and adherence to an early rehabilitation treatment characterized by immediate weight bearing with an ankle-foot orthosis (AFO) in hemiplegic patients after EVFD surgery and to describe gait changes after EVFD surgical correction combined with early rehabilitation treatment. Retrospective observational cohort study. Inpatient rehabilitation clinic. Forty-seven adult patients with hemiplegia consequent to ischemic or haemorrhagic stroke (L/R 20/27, age 56±15 years, time from lesion 6±5 years). A specific rehabilitation protocol with a non-articulated AFO, used to allow for immediate gait training, started one day after EVFD surgery. Gait analysis (GA) data before and one month after surgery were analyzed. The presence of differences in GA space-time parameters, in ankle dorsiflexion (DF) values and peaks at initial contact (DF at IC), during stance (DF at St) and swing (DF at Sw) were assessed by the Wilcoxon Test while the presence of correlations between pre- and post-operative values by Spearman's correlation coefficient. All patients completed the rehabilitation protocol and no clinical complications occurred in the sample. Ankle DF increased one month after surgery at all investigated gait phases (Wilcoxon Test, Prehabilitation associated with surgical procedure is safe and may be suitable to correct EVFD by restoring both the neutral heel foot-ground contact and the ankle DF peaks during stance and swing at one month from surgery. The proposed protocol is a safe and potentially useful rehabilitative approach after EVFD surgical correction in stroke patients.

  18. A change in strategy: Static emotion recognition in Malaysian Chinese

    Chrystalle B.Y. Tan

    2015-12-01

    Full Text Available Studies have shown that while East Asians focused on the center of the face to recognize identities, participants adapted their strategy by focusing more on the eyes to identify emotions, suggesting that the eyes may contain salient information pertaining to emotional state in Eastern cultures. However, Western Caucasians employ the same strategy by moving between the eyes and mouth to identify both identities and emotions. Malaysian Chinese have been shown to focus on the eyes and nose more than the mouth during face recognition task, which represents an intermediate between Eastern and Western looking strategies. The current study examined whether Malaysian Chinese continue to employ an intermediate strategy or shift towards an Eastern or Western pattern (by fixating more on the eyes or mouth respectively during an emotion recognition task. Participants focused more on the eyes, followed by the nose then mouth. Directing attention towards the eye region resulted in better recognition of certain own- than other-race emotions. Although the fixation patterns appear similar for both tasks, further analyses showed that fixations on the eyes were reduced whereas fixations on the nose and mouth were increased during emotion recognition, indicating that participants adapt looking strategies based on their aims.

  19. Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair.

    Grayson, Jessica W; Jeyarajan, Hari; Illing, Elisa A; Cho, Do-Yeon; Riley, Kristen O; Woodworth, Bradford A

    2017-05-01

    Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques. Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up. Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes. Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches. © 2017 ARS-AAOA, LLC.

  20. Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis.

    Joshua Montroy

    Full Text Available The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR and 95% confidence intervals (CI.Eleven articles reporting on 35 health care institutions were included. Nine (82% of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72-0.91, deep (pRR 0.82; 95% CI0.64-1.05 and organ space (pRR 1.15; 95% CI 0.96-1.37 infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39-0.77; deep pRR 0.61, 95% CI 0.50-0.75, and organ space pRR 0.60, 95% CI 0.50-0.71. Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.

  1. 2009 Climate Change Research Strategy: Rocky Mountain Research Station

    Forest Service U.S. Department of Agriculture

    2010-01-01

    Climate change and shifting demographics influence the landscape and the social and economic systems of the Interior West. Climate change impacts are already evident, as seen in declining snowpacks, changes in runoff timing and intensity, increasing fire frequency and severity, increasing drought frequency and severity, and rising temperatures.

  2. A Case Study of Change Strategies Implemented in a Turnaround Elementary School

    Colson, Jo Ann

    2012-01-01

    This case study examined the change strategies in a turnaround school at the elementary level to understand and describe how change occurred and was sustained at this campus. This study examined the factors which contributed to the change in academic success of students, examined beliefs about change that led to the change process, identified the…

  3. Integrated energy planning: Strategies to mitigate climate change

    Ortiz, Johnny N; Sheffield, John W [University of Missouri-Rolla (United States)

    1997-07-01

    The framework convention on climate change, signed by more than 150 governments worldwide in June 1992, calls on parties to the convention undertaken inventories of national sources and sinks of greenhouse gases and to develop plans for responding to climate change. The energy sector is comprised of the major energy demand sectors (industry, residential and commercial, transport and agriculture), and the energy supply sector, which consists of resource extraction, conversion, and delivery of energy products. Greenhouse Gas (GHG) emissions occur at various points in the sector, from resource extraction to end use application, and accordingly, options for mitigation exist at various points. In most countries, will be a major focus of GHG mitigation analysis. The primary focus of this paper is on the identification of strategies that can mitigate climate changes on the basis of integrated energy planing analysis. The overall approach follows a methodology developed by the U.S. Country Studies Program under the framework of the Convention's commitments. It involves the development of scenarios based on energy uses and evaluation of specific technologies that can satisfy demands for energy services. One can compare technologies based on their relative cost to achieve a unit of GHG reduction and other features of interest. This approach gives equal weight to both energy supply and energy demand options. A variety of screening criteria including indicators of cost-effectiveness as well as non-economic analysis concerns, can be used to identify and assess promising options, which can then be combined to create one or more scenarios. Mitigation scenarios are evaluated against the backdrop of a baseline scenario, which simulates assumed to take place in the absence of mitigation efforts. Mitigation scenarios can be designed to meet specific emission reduction targets or to simulate the effect of specific policy inventions. The paper ends with an application using a

  4. The effect of hard tissue surgical changes on soft tissue displacement: a pilot CBCT study

    Leonardo Koerich

    Full Text Available ABSTRACT Introduction: This pilot study had as main objective to test the reliability of a new method to evaluate orthognathic surgery outcomes and also, to understand the effect of hard tissue changes on soft tissue displacement. Methods: The sample consisted of eight patients that underwent bimaxillary advancement and had CBCT at two time points (before surgery and 6-8 months follow-up. Voxel-based cranial base superimposition was used to register the scans. A different technique of iterative closest point (ICP was used to measure and correlate the changes. The average displacement of 15 areas (4 hard tissue and 11 soft tissue were measured twice. Results: ICC was > 0.99 for all areas. Changes in the tip of the nose did not correlate with changes in any maxillary area, whereas soft tissue A point, A point and upper lips had correlation with several areas. The highest correlation for the maxilla was between the upper lip and the left/right supra cheilion (p< 0.001, r= 0.91 and p< 0.001, r= 0.93, respectively. In the mandible, the majority of the correlations involved soft tissue pogonion, pogonion and lower incisors, with the strongest one between pogonion and lower incisors (p< 0.001, r= 0.98. Conclusion: With the proper case selection, ICP is a reliable method that can be used to assess three-dimensional changes.

  5. Climate change adaptation strategies by small-scale farmers in ...

    Mburu

    Some of these strategies had serious adverse environmental impacts on social, economic and biophysical domains of the .... Women farmers in Peru take advantage of the knowledge inherited from ancient Peruvian .... is listed in the IUCN Red List (2010) as a near threatened species. Sand harvesting. The results show that ...

  6. Climate change adaptation strategies by small-scale farmers in ...

    Mburu

    Some of these strategies had serious adverse environmental impacts on social, economic and biophysical domains of the environment ..... self-help groups, establishing kitchen gardens, storing fodder and turning to goat milk as ways of ... Aquatic life poisoning by oil/fuel spills. 3. 3.3. Environmental conservation skills and.

  7. Classroom Management Strategies for Difficult Students: Promoting Change through Relationships

    Beaty-O'Ferrall, Mary Ellen; Green, Alan; Hanna, Fred

    2010-01-01

    Teachers in middle level schools face overwhelming demands and challenges in their classrooms. They are expected to know content and pedagogy, develop engaging lessons that meet the needs of diverse learners, and use a variety of instructional strategies that will boost student achievement while they simultaneously develop positive relationships…

  8. The Effects of Hemodynamic Changes on Pulse Wave Velocity in Cardiothoracic Surgical Patients

    Yurie Obata

    2016-01-01

    Full Text Available The effect of blood pressure on pulse wave velocity (PWV is well established. However, PWV variability with acute hemodynamic changes has not been examined in the clinical setting. The aim of the present study is to investigate the effect of hemodynamic changes on PWV in patients who undergo cardiothoracic surgery. Using data from 25 patients, we determined blood pressure (BP, heart rate (HR, and the left ventricular outflow tract (LVOT velocity-time integral. By superimposing the radial arterial waveform on the continuous wave Doppler waveform of the LVOT, obtained by transesophageal echo, we were able to determine pulse transit time and to calculate PWV, stroke volume (SV, cardiac output (CO, and systemic vascular resistance (SVR. Increases in BP, HR, and SVR were associated with higher values for PWV. In contrast increases in SV were associated with decreases in PWV. Changes in CO were not significantly associated with PWV.

  9. Is flood defense changing in nature? Shifts in the flood defense strategy in six European countries

    Mathilde Gralepois

    2016-12-01

    Full Text Available In many countries, flood defense has historically formed the core of flood risk management but this strategy is now evolving with the changing approach to risk management. This paper focuses on the neglected analysis of institutional changes within the flood defense strategies formulated and implemented in six European countries (Belgium, England, France, the Netherlands, Poland, and Sweden. The evolutions within the defense strategy over the last 30 years have been analyzed with the help of three mainstream institutional theories: a policy dynamics-oriented framework, a structure-oriented institutional theory on path dependency, and a policy actors-oriented analysis called the advocacy coalitions framework. We characterize the stability and evolution of the trends that affect the defense strategy in the six countries through four dimensions of a policy arrangement approach: actors, rules, resources, and discourses. We ask whether the strategy itself is changing radically, i.e., toward a discontinuous situation, and whether the processes of change are more incremental or radical. Our findings indicate that in the European countries studied, the position of defense strategy is continuous, as the classical role of flood defense remains dominant. With changing approaches to risk, integrated risk management, climate change, urban growth, participation in governance, and socioeconomic challenges, the flood defense strategy is increasingly under pressure to change. However, these changes can be defined as part of an adaptation of the defense strategy rather than as a real change in the nature of flood risk management.

  10. Marketing strategies in financial crisis : with change in mobile phone technology

    Shabbir, Rizwan; Ur Rehman, Attiq

    2010-01-01

    The financial crisis has affected every economy during the last decade thus under this changing environment that effect the marketing strategies and these strategies began to change according to the buying behavior of the people. In this research the consumer perspective is examined with the change in mobile phone technology. This is an industry of constant change and innovation in which manufacturers are continually developing new technologies for consumers. As the buying behavior of the con...

  11. Employee participation and learning, a strategy for changes

    Kofoed, L.B.; Jensen, Lars Peter; Rosenørn, T.U.

    1998-01-01

    . The beginning of the change process where all actors are assumed to use all their potentials in developing their future organization is described. The different employee groups need to learn to participate. An important point is to use the change process to establish a learning culture. Experiments based...... on reflective learning in an "experimentarium" as support for the change process, and the positive results obtained are discussed....

  12. Comparative evaluation of structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis.

    Rana, Surinder Singh; Bhasin, Deepak Kumar; Rao, Chalapathi; Sharma, Ravi; Gupta, Rajesh

    2014-01-01

    Patients with acute necrotizing pancreatitis may develop pancreatic insufficiency and this is commonly seen in patients who have undergone surgery for pancreatic necrosis. Owing to the paucity of relative data, we retrospectively evaluated the structural and functional changes in the pancreas after endoscopic and surgical management of pancreatic necrosis. The records of patients who underwent endoscopic transmural drainage of walled off pancreatic necrosis (WOPN) over the last 3 years and who completed at least 6 months of follow up were analyzed. Structural and functional changes in these patients were compared with 25 historical surgical controls (operated in 2005-2006). Twenty six patients (21 M; mean age 35.4±8.1 years) who underwent endoscopic drainage for WOPN were followed up for 22.3±8.6 months. During the follow up, five (19.2%) patients developed diabetes with 3 patients requiring insulin and 1 patient with steatorrhea requiring pancreatic enzyme supplementation. The pancreatic fluid collection (PFC) recurred in 1 patient whose stents spontaneously migrated out. On follow up, in the surgery group, 2 (8%) patients developed steatorrhea and 11 (44%) developed diabetes. Five (20%) of these patients had recurrence of PFC. On comparison of follow up results of endoscopic drainage with surgery, recurrence rates as well as frequency of endocrine and exocrine insufficiency was lower in the endoscopic group but difference was not significant. Structural and functional impairment of pancreas is seen less frequently in patients with pancreatic necrosis treated endoscopically compared to patients undergoing surgery, although the difference was insignificant. Further studies with large sample size are needed to confirm these initial results.

  13. Change to earlier surgical interventions: contemporary management of unilateral vocal fold paralysis.

    Costello, Declan

    2015-06-01

    The management of unilateral vocal fold paralysis has undergone significant changes in the last 2 decades. This has largely been made possible by advances in endoscope technology and new injectable materials. This article will cover the main changes in management of patients with unilateral vocal fold paralysis and summarize the recent literature in relation to early intervention in this group. Several recent studies have suggested that early vocal fold injection medialization reduces the likelihood of needing open laryngeal framework surgery in future. Early injection medialization appears to give good long-term results with few complications and minimizes the need for future laryngeal framework surgery. It should be considered in centres wherein the equipment and trained staff are available.

  14. Strategies for university improvement: The research profile change ...

    Universities worldwide experience continual change in order to achieve what is perceived as improvement. In these changes, there is usually an emphasis on the research function of a university, and the literature contains a number of themes in this regard. We contribute by presenting a detailed case study of a ...

  15. Assessment of Climate Change Adaptive Strategies in Small ...

    Animals are intrinsically dependent on the environment, and any fluctuations in weather and climate can affect them through water and land changes, such as desertification, feed and water availability. Climate change will not only impact the health and welfare of animals, but also the more than a billion people who depend ...

  16. Leading School Change: Nine Strategies to Bring Everybody on Board

    Whitaker, Todd

    2010-01-01

    Make positive and immediate changes in your school with the support of your entire staff. New from acclaimed speaker and bestselling author Todd Whitaker ("What Great Teachers Do Differently, Dealing with Difficult Parents"), Leading School Change provides principals, assistant principals, district superintendents, and other educators with…

  17. Analysis of farmers' adaptation strategies to climate change in cocoa ...

    Changing climate and weather patterns are predicted to have severe negative impacts on food production, food security and natural resources in the immediate and coming years. Climate change alters the development of cocoa pods, insect pests and pathogens which translate into lower crop yields and impact farm ...

  18. Forest Service Global Change Research Strategy, 2009-2019

    Allen Solomon; Richard Birdsey; Linda A. Joyce; Jennifer Hayes

    2009-01-01

    In keeping with the research goals of the U.S. Climate Change Science Program, the Research and Development agenda of the Forest Service, U.S. Department of Agriculture (USDA), helps define climate change policy and develop best management practices for forests (both rural and urban) and grasslands. These actions are taken to sustain ecosystem health, adjust management...

  19. Europe adapts to climate change: Comparing National Adaptation Strategies

    Biesbroek, G. Robbert; Swart, Rob J.; Carter, Timothy R.

    2010-01-01

    For the last two decades, European climate policy has focused almost exclusively on mitigation of climate change. It was only well after the turn of the century, with impacts of climate change increasingly being observed, that adaptation was added to the policy agenda and EU Member States started...

  20. Effective Strategies for Talking about Climate Change in the Classroom

    Busch, K. C.; Osborne, Jonathan

    2014-01-01

    Teaching about climate science presents some unique challenges. Unlike many other science topics, mitigation and adaptation to climate change will require students to take action. This article outlines five major challenges to communicating about climate change in the classroom, drawing on research in environmental psychology: scepticism,…

  1. Biomechanical investigation of different surgical strategies for the treatment of rib fractures using a three-dimensional human respiratory model.

    Shih, Kao-Shang; Truong, Thanh An; Hsu, Ching-Chi; Hou, Sheng-Mou

    2017-11-02

    Rib fracture is a common injury and can result in pain during respiration. Conservative treatment of rib fracture is applied via mechanical ventilation. However, ventilator-associated complications frequently occur. Surgical fixation is another approach to treat rib fractures. Unfortunately, this surgical treatment is still not completely defined. Past studies have evaluated the biomechanics of the rib cage during respiration using a finite element method, but only intact conditions were modelled. Thus, the purpose of this study was to develop a realistic numerical model of the human rib cage and to analyse the biomechanical performance of intact, injured and treated rib cages. Three-dimensional finite element models of the human rib cage were developed. Respiratory movement of the human rib cage was simulated to evaluate the strengths and limitations of different scenarios. The results show that a realistic human respiratory movement can be simulated and the predicted results were closely related to previous study (correlation coefficient>0.92). Fixation of two fractured ribs significantly decreased the fixation index (191%) compared to the injured model. This fixation may provide adequate fixation stability as well as reveal lower bone stress and implant stress compared with the fixation of three or more fractured ribs.

  2. Water brief — An adaptive strategy to climate change | IDRC ...

    2011-01-04

    Jan 4, 2011 ... Historically, the Earth's climate has changed many times with events such as ice ages ... Participatory GIS for resource management in Africa: Taking stock. This ICT4D article series features results from innovative research on ...

  3. Incorporating climate change into corporate business strategies. Conference proceedings

    NONE

    1997-12-31

    This document contains the papers presented at the International Climate Change Conference and Technologies Exhibition June 12-13, 1997. Topics include energy supply and electricity generation; forestry and agriculture; and the chemical, energy, and manufacturing industries.

  4. climate change adaptation strategies by local farmers in kilombero

    Osondu

    climatic stresses? What are institutions and political structures influencing local farmer's adaptive capacity? ... ability of the systems to adjust to climate change and has three ..... seedlings, and use of improved seed varieties. Political structures ...

  5. 77 FR 19661 - Draft National Water Program 2012 Strategy: Response to Climate Change

    2012-04-02

    ... 2012 Strategy: Response to Climate Change AGENCY: Environmental Protection Agency (EPA). ACTION: Notice... change challenges to its mission of protecting human health and the environment. Climate change alters... even temporal nature of effects, climate change will pose challenges to various aspects of water...

  6. [Animals' clever adaptation strategy for seasonal changes in environment].

    Ikegami, Keisuke; Yoshimura, Takashi

    2015-08-01

    Organisms living outside of tropical zones experience seasonal changes in environment. Organisms are using day length as a calendar to change their physiology and behavior such as seasonal breeding, hibernation, migration, and molting. A comparative biology approach revealed underlying mechanisms of vertebrate seasonal reproduction. Here we review the current understanding of vertebrate seasonal reproduction. We Aso describe the involvement of tissue-specific post-translational modification in functional diversification of a hormone.

  7. Universal precautions: employee resistance and strategies for planned organizational change.

    Kearns, K P; Hogg, M

    1988-01-01

    Health care organizations have been strongly encouraged to design and implement procedures to prevent the spread of HIV/AIDS in the workplace. The procedures will have a dramatic impact on the work habits of health care workers and may even challenge some dominant health care values. Therefore, precautionary procedures are likely to meet with mixed reactions and, perhaps, outright resistance from health care workers. This article identifies some plausible causes for employee resistance to precautionary procedures. After describing the dilemma in terms of competing values and conflicting objectives, some practical managerial strategies for reconciling differences and securing broad-based commitment to preventive policies and procedures are proposed.

  8. Intraoperative biopsy of the major cranial nerves in the surgical strategy for adenoid cystic carcinoma close to the skull base.

    Tarsitano, Achille; Pizzigallo, Angelo; Gessaroli, Manlio; Sturiale, Carmelo; Marchetti, Claudio

    2012-02-01

    Adenoid cystic carcinoma of the salivary glands has a propensity for perineural invasion, which could favor spread along the major cranial nerves, sometimes to the skull base and through the foramina to the brain parenchyma. This study evaluated the relationship between neural spread and relapse in the skull base. During surgery, we performed multiple biopsies with extemporaneous examination of the major nerves close to the tumor to guide the surgical resection. The percentage of actuarial local control at 5 years for patients with a positive named nerve and skull base infiltration was 12.5%, compared with 90.0% in patients who were named nerve-negative and without infiltration of the skull base (P = .001). Our study shows that local control of disease for patients who are named nerve-positive with skull base infiltration is significantly more complex compared with patients who are named nerve-negative without infiltration of the skull base. Copyright © 2012. Published by Mosby, Inc.

  9. Urban Planning and Climate Change: Adaptation and Mitigation Strategies

    Fulvia Pinto

    2014-05-01

    Full Text Available Climate change is a current phenomenon: the temperatures rise, rainfall patterns are changing, glaciers melt and the average global sea level is rising. It is expected that these changes will continue and that the extreme weather events, such as floods and droughts, will become more frequent and intense. The impact and vulnerability factors for nature, for the economy and for our health are different, depending on the territorial, social and economic aspects. The current scientific debate is focused on the need to formulate effective policies for adaptation and mitigation to climate change. The city plays an important role in this issue: it emits the most greenhouse gas emissions (more than 60% of the world population currently lives in urban areas and the city is more exposed and vulnerable to the impacts of climate change. Urban planning and territorial governance play a crucial role in this context: the international debate on the sustainability of urban areas is increasing. It’s necessary to adapt the tools of building regulations to increase the quality of energy - environment of the cities.

  10. Climate change perceptions and local adaptation strategies of hazard-prone rural households in Bangladesh

    G.M. Monirul Alam; Khorshed Alam; Shahbaz Mushtaq

    2017-01-01

    Adaptation is a key strategy that can alleviate the severity of climate change impacts on agriculture and food production. Adaptation strategies are unlikely to be effective without an understanding of the farmers’ perceptions of climate change. This paper explores the local knowledge of adaptation in response to the perceived impacts of climate change and climatic hazards using a survey of 380 resource-poor riverbank erosion-prone households in Bangladesh. The results indicate that the respo...

  11. Land use and climate change adaptation strategies in Kenya

    Adimo, A.O.; Njoroge, J.B.; Claessens, L.F.G.; Wamocho, L.S.

    2012-01-01

    Climate variability and change mitigation and adaptation policies need to prioritize land users needs at local level because it is at this level that impact is felt most. In order to address the challenge of socio-economic and unique regional geographical setting, a customized methodological

  12. Organic Farming as a Strategy for Climate Change Adaptation and ...

    For climate change adaptation, OF systems have a strong potential for building resilient food systems through farm diversification and building soil fertility with organic matter. In developing countries, OF offers alternatives to energy-intensive production inputs such as synthetic fertilizers which are limited for poor rural ...

  13. The Scanfin Merger: Technology, Strategy and Change (Case D)

    Smith, Pernille; Carugati, Andrea; Giangreco, Antonio

    . In order to do so, he has been commanded to overcome the barriers between business and IT people and to act pro-actively to achieve the necessary business changes. At the start of the project, however, Olaf Dahlberg, the Norwegian CIO, is fired brutally after making a comment on the IT line co...

  14. Strategies to bring about change: a longitudinal study on challenges ...

    In general, they were receiving more financial support than before from their immediate and extended family or were supporting themselves. One important change since 2003 was that nine of the 14 had since received a state-provided child welfare grant for at least some years. Also, those who said they had previously ...

  15. Strategies for Organizational Change from Group Homes to Individualized Supports

    Walker, Pam

    2012-01-01

    Organizations are increasingly looking to convert from facility-based services for adults with developmental disabilities to individualized supports. Such conversion involves not only a change in services but a transformation of organizational culture. This qualitative study involved four organizations that have made sustained efforts to…

  16. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion.

    Jesani, Aliza; DiBiase, Andrew T; Cobourne, Martyn T; Newton, Timothy

    2014-09-01

    Whereas the psychosocial benefits of orthognathic treatment for the individual patient are established, there is little data relating to social perceptions in relation to changes in facial appearance as a result of combined orthodontic and orthognathic treatment. This study aimed to investigate the social impact of combined orthodontic-orthognathic surgical correction for class III malocclusion in Caucasian subjects. This cross-sectional study compared perceptions of facial appearance prior to and after orthognathic correction of class III malocclusion. Eighty undergraduate students were shown photographs of four Caucasian subjects (2 male and 2 female) pre- and post-orthognathic class III correction. Observers were asked to rate these subjects in relation to four different outcomes: (i) social competence (SC); (ii) intellectual ability (IA); (iii) psychological adjustment (PA); (iv) attractiveness. A mixed-model analysis of variance (ANOVA) was calculated to determine the effect of each variable. Statistically significant differences were found in ratings of the same face before and after treatment. After treatment, faces were rated as more psychologically adjusted, more sociable, more likely to be successful and more attractive; with the mean psychological adjustment rating being associated with the most change (before treatment=8.06 [SD 2.30]; after treatment=6.64 [SD 2.03], t=2.04, pclass III malocclusion in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive. Copyright © 2014 Elsevier Ltd. All rights reserved.

  17. Forest fires are changing: let’s change the fire management strategy

    Bovio G

    2017-08-01

    Full Text Available Forest fires in Italy are changing. More frequent heatwaves and drought increase the flammability of the vegetation; the abandonment of rural land produces 30.000 ha of newly afforested areas each year; and the wildland-urban interface is expanding with the sprawl of urbanized areas. However, forest fires are rarely understood and managed in their complexity. The public opinion is often misinformed on the causes and consequences of fires in the forest. Moreover, fire management relies almost exclusively on extinction and emergency response, resulting in high costs and limited efficacy versus extreme fire seasons. We advocate to increase the role and investments in wildfire prevention, which can be carried out by fuel-oriented silviculture, such as facilitating less flammable species or prescribed burning, in order to reduce the flammability of the vegetation and mitigate fire intensity in high-leverage areas. A centralized structure is necessary to implement such a strategy and coordinate the competences and actions of all local administrations and actors involved.

  18. The efficacy and utilisation of preoperative multiparametric magnetic resonance imaging in robot-assisted radical prostatectomy: does it change the surgical dissection plan?

    Tavukçu, Hasan Hüseyin; Aytaç, Ömer; Balcı, Numan Cem; Kulaksızoğlu, Haluk; Atuğ, Fatih

    2017-12-01

    We investigated the effect of the use of multiparametric prostate magnetic resonance imaging (mp-MRI) on the dissection plan of the neurovascular bundle and the oncological results of our patients who underwent robot-assisted radical prostatectomy. We prospectively evaluated 60 consecutive patients, including 30 patients who had (Group 1), and 30 patients who had not (Group 2) mp-MRI before robot-assisted radical prostatectomy. Based on the findings of mp-MRI, the dissection plan was changed as intrafascial, interfascial, and extrafascial in the mp-MRI group. Two groups were compared in terms of age, prostate-specific antigen (PSA), Gleason sum scores and surgical margin positivity. There was no statistically significant difference between the two groups in terms of age, PSA, biopsy Gleason score, final pathological Gleason score and surgical margin positivity. mp-MRI changed the initial surgical plan in 18 of 30 patients (60%) in Group 1. In seventeen of these patients (56%) surgical plan was changed from non-nerve sparing to interfascial nerve sparing plan. In one patient dissection plan was changed to non-nerve sparing technique which had extraprostatic extension on final pathology. Surgical margin positivity was similar in Groups 1, and 2 (16% and 13%, respectively) although, Group 1 had higher number of high- risk patients. mp-MRI confirmed the primary tumour localisation in the final pathology in 27 of of 30 patients (90%). Preoperative mp-MRI effected the decision to perform a nerve-sparing technique in 56% of the patients in our study; moreover, changing the dissection plan from non-nerve-sparing technique to a nerve sparing technique did not increase the rate of surgical margin positivity.

  19. Evaluation of median nerve T2 signal changes in patients with surgically treated carpal tunnel syndrome.

    Samanci, Yavuz; Karagöz, Yeşim; Yaman, Mehmet; Atçı, İbrahim Burak; Emre, Ufuk; Kılıçkesmez, Nuri Özgür; Çelik, Suat Erol

    2016-11-01

    To determine the accuracy of median nerve T2 evaluation and its relation with Boston Questionnaire (BQ) and nerve conduction studies (NCSs) in pre-operative and post-operative carpal tunnel syndrome (CTS) patients in comparison with healthy volunteers. Twenty-three CTS patients and 24 healthy volunteers underwent NCSs, median nerve T2 evaluation and self-administered BQ. Pre-operative and 1st year post-operative median nerve T2 values and cross-sectional areas (CSAs) were compared both within pre-operative and post-operative CTS groups, and with healthy volunteers. The relationship between MRI findings and BQ and NCSs was analyzed. The ROC curve analysis was used for determining the accuracy. The comparison of pre-operative and post-operative T2 values and CSAs revealed statistically significant improvements in the post-operative patient group (pT2 values at all levels and BQ values, and positive and negative correlations were also found regarding T2 values and NCS findings in CTS patients. The receiver operating characteristic curve analysis for defined cut-off levels of median nerve T2 values in hands with severe CTS yielded excellent accuracy at all levels. However, this accuracy could not be demonstrated in hands with mild CTS. This study is the first to analyze T2 values in both pre-operative and post-operative CTS patients. The presence of increased T2 values in CTS patients compared to controls and excellent accuracy in hands with severe CTS indicates T2 signal changes related to CTS pathophysiology and possible utilization of T2 signal evaluation in hands with severe CTS. Copyright © 2016 Elsevier B.V. All rights reserved.

  20. Arresting Strategy Based on Dynamic Criminal Networks Changing over Time

    Junqing Yuan

    2013-01-01

    Full Text Available We investigate a sequence of dynamic criminal networks on a time series based on the dynamic network analysis (DNA. According to the change of networks’ structure, networks’ variation trend is analyzed to forecast its future structure. Finally, an optimal arresting time and priority list are designed based on our analysis. Better results can be expected than that based on social network analysis (SNA.

  1. Farmers' Perception of Climate Change and Coping Strategies ...

    The results of t-test analysis showed significant difference between how the females and males perceived the effect of climate change with regards to rainfall ending early (t(138)=2.5; p<0.05) and time spent to look for water for cooking food has increased(t(138)=2.2;p<0.05). A multi-media enlightenment campagn of the ...

  2. Responding to climate change: A toolbox of management strategies

    D. Cole; N.L. Stephenson; C.I. Millar

    2010-01-01

    Climate change and its effects are writ large across the landscape and in the natural and cultural heritage ofparks and wilderness. They always have been and always will be. The sculpted walls of Yosemite National Park and the jagged scenery ofthe Sierra Nevada wilderness would not be as spectacular if periods of glaciation had not been followed by periods of...

  3. Fronto-orbital feminization technique. A surgical strategy using fronto-orbital burring with or without eggshell technique to optimize the risk/benefit ratio.

    Villepelet, A; Jafari, A; Baujat, B

    2018-05-04

    The demand for facial feminization is increasing in transsexual patients. Masculine foreheads present extensive supraorbital bossing with a more acute glabellar angle, whereas female foreheads show softer features. The aim of this article is to describe our surgical technique for fronto-orbital feminization. The mask-lift technique is an upper face-lift. It provides rejuvenation by correcting collapsed features, and fronto-orbital feminization through burring of orbital rims and lateral canthopexies. Depending on the size of the frontal sinus and the thickness of its anterior wall, frontal remodeling is achieved using simple burring or by means of the eggshell technique. Orbital remodeling comprises a superolateral orbital opening, a reduction of ridges and a trough at the lateral orbital rim to support the lateral canthopexy. Frontal, corrugator and procerus myectomies, plus minimal scalp excision, complete the surgery. Our technique results in significant, natural-looking feminization. No complications were observed in our series of patients. The eggshell technique is an alternative to bone flap on over-pneumatized sinus. Fronto-orbital feminization fits into a wider surgical strategy. It can be associated to rhinoplasty, genioplasty, mandibular angle remodeling, face lift and laryngoplasty. Achieving facial feminization in 2 or 3 stages improves psychological and physiological tolerance. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

  4. Multimodality treatment strategies have changed prognosis of peritoneal metastases

    Lungoci, Corneliu; Mironiuc, Aurel Ion; Muntean, Valentin; Oniu, Traian; Leebmann, Hubert; Mayr, Max; Piso, Pompiliu

    2016-01-01

    For a long time, treatment of peritoneal metastases (PM) was mostly palliative and thus, this status was link with “terminal status/despair”. The current multimodal treatment strategy, consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), has been strenuously achieved over time, but seems to be the best treatment option for PM patients. As we reviewed the literature data, we could emphasize some milestones and also, controversies in the history of proposed multimodal treatment and thus, outline the philosophy of this approach, which seems to be an unusual one indeed. Initially marked by nihilism and fear, but benefiting from a remarkable joint effort of human and material resources (multi-center and -institutional research), over a period of 30 years, CRS and HIPEC found their place in the treatment of PM. The next 4 years were dedicated to the refinement of the multimodal treatment, by launching research pathways. In selected patients, with requires training, it demonstrated a significant survival results (similar to the Hepatic Metastases treatment), with acceptable risks and costs. The main debates regarding CRS and HIPEC treatment were based on the oncologists’ perspective and the small number of randomized clinical trials. It is important to statement the PM patient has the right to be informed of the existence of CRS and HIPEC, as a real treatment resource, the decision being made by multidisciplinary teams. PMID:26798438

  5. Flexibility to contingency changes distinguishes habitual and goal-directed strategies in humans.

    Lee, Julie J; Keramati, Mehdi

    2017-09-01

    Decision-making in the real world presents the challenge of requiring flexible yet prompt behavior, a balance that has been characterized in terms of a trade-off between a slower, prospective goal-directed model-based (MB) strategy and a fast, retrospective habitual model-free (MF) strategy. Theory predicts that flexibility to changes in both reward values and transition contingencies can determine the relative influence of the two systems in reinforcement learning, but few studies have manipulated the latter. Therefore, we developed a novel two-level contingency change task in which transition contingencies between states change every few trials; MB and MF control predict different responses following these contingency changes, allowing their relative influence to be inferred. Additionally, we manipulated the rate of contingency changes in order to determine whether contingency change volatility would play a role in shifting subjects between a MB and MF strategy. We found that human subjects employed a hybrid MB/MF strategy on the task, corroborating the parallel contribution of MB and MF systems in reinforcement learning. Further, subjects did not remain at one level of MB/MF behaviour but rather displayed a shift towards more MB behavior over the first two blocks that was not attributable to the rate of contingency changes but rather to the extent of training. We demonstrate that flexibility to contingency changes can distinguish MB and MF strategies, with human subjects utilizing a hybrid strategy that shifts towards more MB behavior over blocks, consequently corresponding to a higher payoff.

  6. Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home.

    Dexter, Franklin; Wachtel, Ruth E

    2014-05-01

    The Perioperative Surgical Home is a model adopted by the American Society of Anesthesiologists to increase quality and patient safety and to decrease costs. This Special Article is about the latter topic. Using narrative review, we show that there are two principal opportunities for net cost reduction. One opportunity is to reduce unnecessary interventions that do not have potential to benefit patients (e.g., preoperative laboratory studies in healthy patients undergoing low-risk surgery and use of substantial fresh gas flows with volatile anesthetics). The other opportunity is to optimize staff scheduling, case scheduling, and staff assignment. These two are the same as the principal ways that a positive return on investment can be achieved from use of an anesthesia information management system. Three other opportunities are much less likely to achieve as large (if any) net cost reduction among all patients but may at some hospitals. These are to reduce cancellations, operating room times, and/or hospital postoperative lengths of stay.

  7. Surgical lighting

    Knulst, A.J.

    2017-01-01

    The surgical light is an important tool for surgeons to create and maintain good visibility on the surgical task. Chapter 1 gives background to the field of (surgical) lighting and related terminology. Although the surgical light has been developed strongly since its introduction a long time ago,

  8. Climate Change Impacts and Adaptation Strategies in Northwest China

    ZHAO Hong-Yan; LIU Cai-Hong; LI Yan-Chun; FANG Jian-Gang; LI Lin; LI Hong-Mei; ZHENG Guang-Fen; DENG Zhen-Yong; DONG An-Xiang; GUO Jun-Qin; ZHANG Cun-Jie; SUN Lan-Dong; ZHANG Xu-Dong; LIN Jing-Jing; WANG You-Heng; FANG Feng; MA Peng-Li

    2014-01-01

    Climate change resulted in changes in crop growth duration and planting structure, northward movement of planting region, and more severe plant diseases and insect pests in Northwest China. It caused earlier seeding for spring crop, later seeding for autumn crop, accelerated crop growth, and reduced mortality for winter crop. To adapt to climate change, measures such as optimization of agricultural arrangement, adjustment of planting structure, expansion of thermophilic crops, and development of water-saving agriculture have been taken. Damaging consequences of imbalance between grassland and livestock were enhanced. The deterioration trend of grassland was intensified; both grass quantity and quality declined. With overgrazing, proportions of inferior grass, weeds and poisonous weeds increased in plateau pastoral areas. Returning farmland to grazing, returning grazing to grassland, fence enclosure and artificial grassland construction have been implemented to restore the grassland vegetation, to increase the grassland coverage, to reasonably control the livestock carrying capacity, to prevent overgrazing, to keep balance between grassland and livestock, and to develop the ecological animal husbandry. In Northwest China, because the amount of regional water resources had an overall decreasing trend, there was a continuous expansion in the regional land desertification, and soil erosion was very serious. A series of measures, such as development of artificial precipitation (snow), water resources control, regional water diversion, water storage project and so on, were used effectively to respond to water deficit. It had played a certain role in controlling soil erosion by natural forest protection and returning farmland to forest and grassland. In the early 21st century, noticeable achievements had been made in prevention and control of desertification in Northwest China. The regional ecological environment has been improved obviously, and the desertification trend

  9. One Strategy for Reducing Uncertainty in Climate Change Communications

    Romm, J.

    2011-12-01

    Future impacts of climate change are invariably presented with a very wide range of impacts reflecting two different sets of uncertainties. The first concerns our uncertainty about precisely how much greenhouse gas emissions humanity will emit into the atmosphere. The second concerns our uncertainty about precisely what impact those emissions will have on the climate. By failing to distinguish between these two types of uncertainties, climate scientists have not clearly explained to the public and policymakers what the scientific literature suggests is likely to happen if we don't substantially alter our current emissions path. Indeed, much of climate communications has been built around describing the range of impacts from emissions paths that are increasingly implausible given political and technological constraints, such as a stabilization at 450 or 550 parts per million atmospheric of carbon dioxide. For the past decade, human emissions of greenhouse gases have trended near the worst-case scenarios of the Intergovernmental Panel on Climate Change, emissions paths that reach 800 ppm or even 1000 ppm. The current policies of the two biggest emitters, the United States and China, coupled with the ongoing failure of international negotiations to come to an agreement on restricting emissions, suggests that recent trends will continue for the foreseeable future. This in turn suggests that greater clarity in climate change communications could be achieved by more clearly explaining to the public what the scientific literature suggests the range of impacts are for our current high emissions path. This also suggests that more focus should be given in the scientific literature to better constraining the range of impacts from the high emissions scenarios.

  10. Smart energy strategies. Meeting the climate change challenge

    2008-01-01

    This book published by the Energy Science Center (ESC) at the Swiss Federal Institute of Technology (ETH) in Zurich presents a wide selection of reports on how the challenge of dealing with climate change can be met. The 69 reports included cover a wide range of topics ranging from traffic modelling, biofuels and electrification of power trains, through demand-side management, electricity production and distribution and life cycle assessment, to the integration of wind power and renewable energy technologies. Also, climate policy matters are dealt with as are nano-technology applications in the energy area and the integration of energy conversion and production processes and waste management

  11. Smart energy strategies. Meeting the climate change challenge

    NONE

    2008-07-01

    This book published by the Energy Science Center (ESC) at the Swiss Federal Institute of Technology (ETH) in Zurich presents a wide selection of reports on how the challenge of dealing with climate change can be met. The 69 reports included cover a wide range of topics ranging from traffic modelling, biofuels and electrification of power trains, through demand-side management, electricity production and distribution and life cycle assessment, to the integration of wind power and renewable energy technologies. Also, climate policy matters are dealt with as are nano-technology applications in the energy area and the integration of energy conversion and production processes and waste management.

  12. The American College of Surgeons/Association of Program Directors in Surgery National Skills Curriculum: adoption rate, challenges and strategies for effective implementation into surgical residency programs.

    Korndorffer, James R; Arora, Sonal; Sevdalis, Nick; Paige, John; McClusky, David A; Stefanidis, Dimitris

    2013-07-01

    The American College of Surgeons/Association of Program Directors in Surgery (ACS/APDS) National Skills Curriculum is a 3-phase program targeting technical and nontechnical skills development. Few data exist regarding the adoption of this curriculum by surgical residencies. This study attempted to determine the rate of uptake and identify implementation enablers/barriers. A web-based survey was developed by an international expert panel of surgical educators (5 surgeons and 1 psychologist). After piloting, the survey was sent to all general surgery program directors via email link. Descriptive statistics were used to determine the residency program characteristics and perceptions of the curriculum. Implementation rates for each phase and module were calculated. Adoption barriers were identified quantitatively and qualitatively using free text responses. Standardized qualitative methodology of emergent theme analysis was used to identify strategies for success and details of support required for implementation. Of the 238 program directors approached, 117 (49%) responded to the survey. Twenty-one percent (25/117) were unaware of the ACS/APDS curriculum. Implementation rates for were 36% for phase I, 19% for phase II, and 16% for phase III. The most common modules adopted were the suturing, knot-tying, and chest tube modules of phase I. Over 50% of respondents identified lack of faculty protected time, limited personnel, significant costs, and resident work-hour restrictions as major obstacles to implementation. Strategies for effective uptake included faculty incentives, adequate funding, administrative support, and dedicated time and resources. Despite the availability of a comprehensive curriculum, its diffusion into general surgery residency programs remains low. Obstacles related to successful implementation include personnel, learner, and administrative issues. Addressing these issues may improve the adoption rate of the curriculum. Copyright © 2013 Mosby, Inc

  13. Scaling Factor Estimation Using Optimized Mass Change Strategy, Part 2: Experimental Results

    Fernández, Pelayo Fernández; Aenlle, Manuel López; Garcia, Luis M. Villa

    2007-01-01

    The mass change method is used to estimate the scaling factors, the uncertainty is reduced when, for each mode, the frequency shift is maximized and the changes in the mode shapes are minimized, which in turn, depends on the mass change strategy chosen to modify the dynamic behavior of the struct...

  14. Ecological Footprint in relation to Climate Change Strategy in Cities

    Belčáková, Ingrid; Diviaková, Andrea; Belaňová, Eliška

    2017-10-01

    Ecological footprint determines how much natural resources are consumed by an individual, city, region, state or all inhabitants of our planet in order to ensure their requirements and needs. It includes all activities, from food consumption, housing, transport to waste produced and allows us to compare particular activities and their impacts on the environment and natural resources. Ecological footprint is important issue for making sustainable development concept more popular using simplifications, which provide the public with basic information on situation on our planet. Today we know calculations of global (worldwide), national and local ecological footprints. During our research in cities, we were concentrated on calculation of city’s ecological footprint. The article tries to outline theoretical and assumptions and practical results of climate change consequences in cities of Bratislava and Nitra (Slovakia), to describe potential of mitigating adverse impacts of climate change and to provide information for general and professional public on theoretical assumptions in calculating ecological footprint. The intention is to present innovation of ecological footprint calculation, taking into consideration ecological stability of a city (with a specific focus on micro-climate functions of green areas). Present possibilities to reduce ecological footprint are presented.

  15. Psychological aspects of eating behavior as predictors of 10-y weight changes after surgical and conventional treatment of severe obesity: results from the Swedish Obese Subjects intervention study.

    Konttinen, Hanna; Peltonen, Markku; Sjöström, Lars; Carlsson, Lena; Karlsson, Jan

    2015-01-01

    There is a need for a better understanding of the factors that influence long-term weight outcomes after bariatric surgery. We examined whether pretreatment and posttreatment levels of cognitive restraint, disinhibition, and hunger and 1-y changes in these eating behaviors predict short- and long-term weight changes after surgical and conventional treatments of severe obesity. Participants were from an ongoing, matched (nonrandomized) prospective intervention trial of the Swedish Obese Subjects (SOS) study. The current analyses included 2010 obese subjects who underwent bariatric surgery and 1916 contemporaneously matched obese controls who received conventional treatment. Physical measurements (e.g., weight and height) and questionnaires (e.g., Three-Factor Eating Questionnaire) were completed before the intervention and 0.5, 1, 2, 3, 4, 6, 8, and 10 y after the start of the treatment. Structural equation modeling was used as the main analytic strategy. The surgery group lost more weight and reported greater decreases in disinhibition and hunger at 1- and 10-y follow-ups (all P women) and experienced larger 1-y decreases in these behaviors (β = 0.31-0.48, P women) lost more weight 2, 6, and 10 y after surgery. In control patients, larger 1-y increases in cognitive restraint predicted a greater 2-y weight loss in both sexes. A higher tendency to eat in response to various internal and external cues shortly after surgery predicted less-successful short- and long-term weight outcomes, making postoperative susceptibility for uncontrolled eating an important indicator of targeted interventions. © 2015 American Society for Nutrition.

  16. Hydropower, an integral part of Canada's climate change strategy

    Fortin, P.

    1999-01-01

    The development and implementation of a climate change policy could be among the most far-reaching environmental initiatives ever embarked upon in Canada and abroad. If Canada is to stabilize or reduce its Greenhouse Gas (GHG) emissions over the long term, a significant adjustment to Canadian industry will be required as we move away from fossil fuel-intensive and GHG producing activities. Future hydroelectric projects provide Canada with a unique opportunity to significantly reduce the costs associated with stabilizing its GHG emissions. In addition, the energy storage and dispatchability associated with hydropower can support development of other low emitting renewable resources such as wind and solar. This document discusses the potential role of hydropower as a tool to reduce emissions, recommends action to reduce barriers facing hydropower and comments on some of the policy tools available to manage Canada's GHG emissions. (author)

  17. Three-dimensional evaluation of soft tissue changes in the orofacial region after tooth-borne and bone-borne surgically assisted rapid maxillary expansion

    Nada, R.M.; Loon, B. van; Maal, T.J.J.; Berge, S.J.; Mostafa, Y.A.; Kuijpers-Jagtman, A.M.; Schols, J.G.J.H.

    2013-01-01

    OBJECTIVES: This study seeks to three-dimensionally assess soft tissue changes in the orofacial region following tooth-borne and bone-borne surgically assisted rapid maxillary expansion (SARME). MATERIALS AND METHODS: This prospective cohort study included 40 skeletally mature patients with

  18. Economic analysis of adaptive strategies for flood risk management under climate change

    Pol, van der T.D.; Ierland, van E.C.; Gabbert, S.G.M.

    2017-01-01

    Climate change requires reconsideration of flood risk management strategies. Cost-benefit analysis (CBA), an economic decision-support tool, has been widely applied to assess these strategies. This paper aims to describe and discuss probabilistic extensions of CBA to identify welfare-maximising

  19. F:ACTS! : Forms for adapting to climate change through territorial strategies : the handbook

    Garcia, A.M.; Ónega, J.; Crecente, R.; Holst, van F.; Abts, E.; Timmermans, W.; Stolk, M.

    2014-01-01

    The F:ACTS! project contributed to generating knowledge on how to develop territorial strategies to adapt to climate change, facilitating the interchange of experience and information among its 14 partners across 8 countries. Integrated territorial strategies incorporate local diversity since they

  20. Predictive factors for lymph node metastasis in poorly differentiated early gastric cancer and their impact on the surgical strategy

    Li, Hua; Lu, Ping; Lu, Yang; Liu, Cai-Gang; Xu, Hui-Mian; Wang, Shu-Bao; Chen, Jun-Qing

    2008-01-01

    AIM: To identify the predictive clinicopathological factors for lymph node metastasis (LNM) in poorly differentiated early gastric cancer (EGC) and to further expand the possibility of using endoscopic mucosal resection (EMR) for the treatment of poorly differentiated EGC. METHODS: Data were collected from 85 poorly-differentiated EGC patients who were surgically treated. Association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. RESULTS: Univariate analysis showed that tumor size (OR = 5.814, 95% CI = 1.050 - 32.172, P = 0.044), depth of invasion (OR = 10.763, 95% CI = 1.259 - 92.026, P = 0.030) and lymphatic vessel involvement (OR = 61.697, 95% CI = 2.144 - 175.485, P = 0.007) were the significant and independent risk factors for LNM. The LNM rate was 5.4%, 42.9% and 50%, respectively, in poorly differentiated EGC patients with one, two and three of the risk factors, respectively. No LNM was found in 25 patients without the three risk factors. Forty-four lymph nodes were found to have metastasis, 29 (65.9%) and 15 (34.1%) of the lymph nodes involved were within N1 and beyond N1, respectively, in 12 patients with LNM. CONCLUSION: Endoscopic mucosal resection alone may be sufficient to treat poorly differentiated intramucosal EGC (≤ 2.0 cm in diameter) with no histologically-confirmed lymphatic vessel involvement. When lymphatic vessels are involved, lymph node dissection beyond limited (D1) dissection or D1+ lymph node dissection should be performed depending on the tumor location. PMID:18636670

  1. Surgical weight loss as a life-changing transition: The impact of interpersonal relationships on post bariatric women.

    Ficaro, Irene

    2018-04-01

    Surgical Weight Loss as A Life-changing Transition: The Impact of Interpersonal Relationships on Post-Bariatric Women BACKGROUND: Although women account for 80% of patients having bariatric surgery (BS), the complex psychosocial mechanisms that accompany this transformation process have not been well established. The purpose of this study is to explore the lived experience of women transitioning in their interpersonal relationships post BS. A semi-structured interview with four questions was used. Six women, from six to 12 months post BS, were interviewed. The interviews were recorded, transcribed and analyzed using thematic analysis. By seeking support systems prior to undergoing BS, adequate social support was received during their recovery period. Attending bariatric support group meetings and using social media were significant to these women's satisfactory recovery. Relationship adjustments were sometimes needed, but overall these women established fulfilling social lives. Within the first year post bariatric surgery, women began to gain emotional strength and inspire others to lose weight as well. By inquiring about the psychosocial concerns of women who have undergone BS, healthcare providers can provide a more practical wellness plan. Copyright © 2017. Published by Elsevier Inc.

  2. Assessment of patient’s anxiety and expectation associated with hemodynamic changes during surgical procedure under local anesthesia

    Marcos Vinícius Mendes DANTAS

    Full Text Available Abstract Introduction The dental patient’s anxiety and expectation may significantly alter their vital signs. The use of local anesthetics associated with a vasoconstrictor may also alter the vital signs of these patients, promoting hemodynamic changes that may result in emergency situations. Objective To evaluate the influence of anxiety of patients submitted to third molar extraction and the use of different anesthetic substances with adrenaline on their vital signs (oxygen saturation, heart rate, and systolic and diastolic blood pressure in different moments. Material and method Forty patients answered the questionnaire of the Dental Anxiety Scale (Corah’s Scale and fear (KleinKnecht’s Scale and were submitted to third molar extraction in two surgical times for the use of articaine or mepivacaine, both associated with adrenaline. The results were analyzed by ANOVA followed by Tukey post hoc test, Student's t test, and Pearson's correlation coefficients (α=0.05. Result There was no significant differences in saturation or heart rate. The blood pressure showed significant variations during time for both anesthetics, however mepivacaine resulted in a longer postoperative time to restore blood pressure. Patients with high or moderate anxiety and high fear index were those who had positive correlations with the highest blood pressure values. Conclusion Anxiety and fear positively influence the increase in blood pressure. Mepivacaine promoted a greater resistance to the return of normal vital signs, especially blood pressure levels.

  3. RELATIONSHIPS BETWEEN INITIAL PROBING DEPTH AND CHANGES IN THE CLINICAL PARAMETERS FOLLOWING NON-SURGICAL PERIODONTAL TREATMENT IN CHRONIC PERIODONTITIS

    Süleyman Emre MESELİ

    2017-10-01

    Full Text Available Purpose: The aim of this study was to evaluate the relationship between initial probing depth (IPD and changes in clinical parameters following non-surgical periodontal treatment (NPT in chronic periodontitis patients. Subjects and Methods: A total of 1672 periodontal pockets having 3mm≤IPD≤9mm of depth in 15 chronic periodontitis patients were included. NPT consisting of oral hygiene instructions, scaling and root planing was applied in two sessions. Probing depth (PD, clinical attachment level, gingival recessions (GR were measured before and eight weeks after treatment. Pocket sites were grouped according to their IPD and root number as single- or multi-rooted teeth. Results: Other than the sites having 3 mm IPD, PD reduction and GR increase were significant in all groups (p<0.001. Attachment gains (AG were significant in all single-rooted teeth (p<0.001 again except those having IPD=3mm. However, AG was significant in multi-rooted teeth having only 7mm≤IPD≤9mm (p<0.05. Positive correlations were observed between IPD and PD reduction, GR increase and AG in single-rooted teeth (p<0.001. Furthermore, positive correlations were found between IPD and PD reduction and GR increase in multi-rooted teeth (p<0.001, but there was no correlation between IPD and AG. Conclusion: NPT may lead to positive association between IPD and PD reduction as well as GR increase, which is independent from tooth root anatomy.

  4. Left ventricular remodeling and change of systolic function after closure of patent ductus arteriosus in adults: device and surgical closure.

    Jeong, Young-Hoon; Yun, Tae-Jin; Song, Jong-Min; Park, Jung-Jun; Seo, Dong-Man; Koh, Jae-Kon; Lee, Se-Whan; Kim, Mi-Jeong; Kang, Duk-Hyun; Song, Jae-Kwan

    2007-09-01

    Left ventricular (LV) remodeling and predictors of LV systolic function late after closure of patent ductus arteriosus (PDA) in adults remain to be clearly demonstrated. In 45 patients with PDA, including 28 patients who received successful occlusion using the Amplatzer device (AD group) (AGA, Golden Valley, MN) and 17 patients who received surgical closure (OP group), echocardiography studies were performed before closure and 1 day (AD group) or within 7 days (OP group) after closure, and then were repeated at > or = 6 months (17 +/- 13 months). In both groups, LV ejection fraction (EF) and end-diastolic volume index were significantly decreased immediately after closure, whereas end-systolic volume index did not change. During the long-term follow-up period, end-systolic as well as end-diastolic volume indices decreased significantly in both groups and LV EF recovered compared to the immediate postclosure state. However, LV EF remained low compared to the preclosure state. Five patients (11.1%) including 3 patients in the AD group and 2 patients in the OP group showed persistent late LV systolic dysfunction (EF or = 62% had a sensitivity of 72% and a specificity of 83% for predicting late normal LV EF after closure. Left ventricular EF remains low late after PDA closure compared with preclosure state in adults. Preclosure LV EF is the best index to predict late postclosure LV EF.

  5. Proposing mitigation strategies for reducing the impact of rice cultivation on climate change in Egypt

    Eman Hasan

    2013-10-01

    The research results revealed that farmer acceptance or participation in applying different mitigation strategies is the cornerstone of this aspect. Meanwhile farmer awareness is essential for adaptation with climate change.

  6. Mainstreaming climate change adaptation strategies into New York State Department of Transportation's operations : final report.

    2011-10-31

    This study identifies climate change adaptation strategies and recommends ways of mainstreaming them into planned actions, including legislation, policies, programs and projects in all areas and at all levels within the New York State Department of T...

  7. Mainstreaming climate change adaptation strategies into New York State Department of Transportation's operations.

    2011-10-31

    This study identifies climate change adaptation strategies and recommends ways of mainstreaming them into planned actions, including legislation, policies, programs and projects in all areas and at all levels within the New York State Department of T...

  8. Non-surgical care in patients with hip or knee osteoarthritis is modestly consistent with a stepped care strategy after its implementation.

    Smink, Agnes J; Bierma-Zeinstra, Sita M A; Schers, Henk J; Swierstra, Bart A; Kortland, Joke H; Bijlsma, Johannes W J; Teerenstra, Steven; Voorn, Theo B; Dekker, Joost; Vliet Vlieland, Thea P M; van den Ende, Cornelia H M

    2014-08-01

    To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care. A 2-year observational prospective cohort study. General practices in the region of Nijmegen in the Netherlands. Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP). Multifaceted interventions were developed to implement the strategy. Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments. Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS in 58% of the patients, which was mainly caused by the underuse of lifestyle advice and dietary therapy. In 57% of the consultations, the patient reported to have been advised to make a follow-up appointment. No determinants that influenced all three aspects of care were identified. Consistency with the SCS was found in about half of the patients for each of the three aspects of care. Health care can be further optimized by encouraging GP s to use X-rays more appropriately and to make more use of lifestyle advice, dietary therapy and follow-up appointments. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

  9. RECOMMENDATIONS FOR THE DISTRIBUTION STRATEGY IN CHANGING MARKET ENVIRONMENT : Case: Belgian Brewery Van Honsebrouck in Russia

    Louckx, Yulia

    2014-01-01

    The efficient distribution strategy formulation becomes vital to the success and survival of any organization, especially when it is involved in international trade. Today’s world is particularly challenging due to rapidly changing market conditions. Therefore, in order to able to compete, satisfy customers, and meet the needs of other stakeholders profitably, it is crucial for any company to make profound market environment analyses, react to changes in the market and adjust strategies accor...

  10. Diagnostic imaging in oncology: New challenges and changing strategies

    Castellino, Ronald A.; Schwartz, Lawrence H.

    1997-01-01

    Diagnostic radiology and nuclear medicine studies, both imaging and therapeutic, play important roles in screening, staging, monitoring of treatment, and in long term surveillance of oncologic patients. Frequently, information from these studies, as well as from ancillary data (such as the clinical examination and laboratory studies) overlap, and it is sometimes unclear which tests and examinations to perform. Current changes in the delivery and funding of health care are prompting all specialties to evaluate their patterns of care. Some of the important questions to be addressed in medical imaging include: Which studies are pertinent at initial staging, e.g., those that impact patient management, serve as important baselines for comparison with subsequent studies, etc? How sensitive and specific are these studies, e.g., when can they obviate the need for more invasive confirmatory exams? What are the critical questions in monitoring response to therapy, e.g., the significance of the 'post treatment residual mass' and ways to elucidate its etiology? Which tests should be performed in surveillance for disease relapse, and how frequently should they be done? Purpose/Objective: To develop a set of guidelines for developing rational approaches for utilizing diagnostic imaging studies

  11. Developing tools and strategies for communicating climate change

    Bader, D.; Yam, E. M.; Perkins, L.

    2011-12-01

    Research indicates that the public views zoos and aquariums as reliable and trusted sources for information on conservation. Additionally, visiting zoos and aquariums helps people reconsider their connections to conservation issues and solutions. The Aquarium of the Pacific, an AZA-accredited institution that serves the most ethnically diverse population of all aquariums in the nation, is using exhibit space, technology, public programming, and staff professional development to present a model for how aquariums can promote climate literacy. Our newest galleries and programs are designed to immerse our visitors in experiences that connect our live animal collection to larger themes on ocean change. The Aquarium is supporting our new programming with a multifaceted staff professional development that exposes our interpretive staff to current climate science and researchers as well as current social science on public perception of climate science. Our staff also leads workshops for scientists; these sessions allow us to examine learning theory and develop tools to communicate science and controversial subjects effectively. Through our partnerships in the science, social science, and informal science education communities, we are working to innovate and develop best practices in climate communication.

  12. Diagnostic imaging in oncology: New challenges and changing strategies

    Castellino, Ronald; Schwartz, Lawrence H.

    1996-01-01

    Purpose/Objective: To develop a set of guidelines for developing rational approaches for utilizing diagnostic imaging studies. Diagnostic radiology and nuclear medicine studies, both imaging and therapeutic, play important roles in screening, staging, monitoring of treatment, and in long term surveillance of oncologic patients. Frequently, information from these studies, as well as from ancillary data (such as the clinical examination and laboratory studies) overlap, and it is sometimes unclear which tests and examinations to perform. Current changes in the delivery and funding of health care are prompting all specialties to evaluate their patterns of care. Some of the important questions to be addressed in medical imaging include: Which studies are pertinent at initial staging, e.g., those that impact patient management, serve as important baselines for comparison with subsequent studies, etc? How sensitive and specific are these studies, e.g., when can they obviate the need for more invasive confirmatory exams? What are the critical questions in monitoring response to therapy, e.g., the significance of the 'post treatment residual mass' and ways to elucidate its etiology? Which tests should be performed in surveillance for disease relapse, and how frequently should they be done?

  13. Changes in anteroposterior position and inclination of the maxillary incisors after surgical-orthodontic treatment of skeletal class III malocclusions.

    Zou, Bingshuang; Zhou, Yang; Lowe, Alan A; Li, Huiqi; Pliska, Benjamin

    2015-12-01

    The purpose of this study was to evaluate and compare the anteroposterior (AP) position and inclination of the maxillary incisors in subjects with class I normal occlusion and a harmonious profile with patients with skeletal class III malocclusions, and to investigate the changes in maxillary incisor inclination and AP position after surgical-orthodontic treatment in class III patients. Sixty-five subjects (35 female and 30 male; mean age: 21.8 ± 3.89 years) with normal profiles and class I skeletal and dental patterns were selected as a control sample. Sixty-seven patients (38 female and 29 male; mean age: 21.3 ± 3.31 years) with skeletal and dental class III malocclusions who sought surgical-orthodontic treatment were used as the study sample. Subjects were asked to smile and profile photographs were taken with the head in a natural position and the maxillary central incisors and the forehead in full view; cephalograms were taken and superimposed on the profile pictures according to the outline of the forehead and nose. Forehead inclination, maxillary incisor facial inclination and the AP position of the maxillary central incisor relative to the forehead (FAFFA) were measured on the integrated images and statistical analyses were performed. In both groups, there were no significant male/female differences in either the maxillary central incisor inclination or AP position. Female subjects had a significantly steeper forehead inclination compared with males (P 0.05). In the control group, 84.6% had the facial axial point (FA) of their maxillary central incisors positioned between lines through the forehead facial axis (FFA) point and the glabella. In the study group, however, 79.1% had the maxillary central incisors positioned posterior to the line through the FFA point and the difference with the control group was statistically significant (P 0.05). With the integrated radiograph-photograph method, the lateral cephalogram was reoriented, which makes it possible

  14. Adaptation to climate change. Strategy and policy; Aanpassing aan klimaatverandering. Strategie en beleid

    NONE

    2012-11-15

    The Court of Audit investigated the Dutch 'climate adaptation policy', or the measures taken to adapt to the impacts of climate change Netherlands and thus reduce its vulnerability [Dutch] De Algemene Rekenkamer heeft onderzoek gedaan naar het Nederlandse 'klimaatadaptatiebeleid', oftewel naar de maatregelen die worden getroffen om Nederland aan te passen aan de gevolgen van de klimaatverandering en zodoende minder kwetsbaar te maken.

  15. A risk to himself: attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical-surgical units.

    MacNeela, Pádraig; Scott, P Anne; Treacy, Margaret; Hyde, Abbey; O'Mahony, Rebecca

    2012-04-01

    Psychiatric patients are liable to stereotyping by healthcare providers. We explored attitudes toward caring for psychiatric patients among 13 nurses working in general hospitals in Ireland. Participants thought aloud in response to a simulated patient case and described a critical incident of a patient for whom they had cared. Two attitudinal orientations were identified that correspond to stereotypical depictions of risk and vulnerability. The nurses described psychosocial care strategies that were pragmatic rather than authentically person-centered, with particular associations between risk-oriented attitudes and directive nursing care. Nurses had expectations likely to impede relationship building and collaborative care. Implications arising include the need for improved knowledge about psychiatric conditions and for access to professional development in targeted therapeutic communication skills. Copyright © 2012 Wiley Periodicals, Inc.

  16. USGS global change science strategy: A framework for understanding and responding to climate and land-use change

    Burkett, Virginia R.; Taylor, Ione L.; Belnap, Jayne; Cronin, Thomas M.; Dettinger, Michael D.; Frazier, Eldrich L.; Haines, John W.; Kirtland, David A.; Loveland, Thomas R.; Milly, Paul C.D.; O'Malley, Robin; Thompson, Robert S.

    2011-01-01

    This U.S. Geological Survey (USGS) Global Change Science Strategy expands on the Climate Variability and Change science component of the USGS 2007 Science Strategy, “Facing Tomorrow’s Challenges: USGS Science in the Coming Decade” (U.S. Geological Survey, 2007). Here we embrace the broad definition of global change provided in the U.S. Global Change Research Act of 1990 (Public Law 101–606,104 Stat. 3096–3104)—“Changes in the global environment (including alterations in climate, land productivity, oceans or other water resources, atmospheric chemistry, and ecological systems) that may alter the capacity of the Earth to sustain life”—with a focus on climate and land-use change.There are three major characteristics of this science strategy. First, it addresses the science required to broadly inform global change policy, while emphasizing the needs of natural-resource managers and reflecting the role of the USGS as the science provider for the Department of the Interior and other resource-management agencies. Second, the strategy identifies core competencies, noting 10 critical capabilities and strengths the USGS uses to overcome key problem areas. We highlight those areas in which the USGS is a science leader, recognizing the strong partnerships and effective collaboration that are essential to address complex global environmental challenges. Third, it uses a query-based approach listing key research questions that need to be addressed to create an agenda for hypothesis-driven global change science organized under six strategic goals. Overall, the strategy starts from where we are, provides a vision for where we want to go, and then describes high-priority strategic actions, including outcomes, products, and partnerships that can get us there. Global change science is a well-defined research field with strong linkages to the ecosystems, water, energy and minerals, natural hazards, and environmental health components of the USGS Science Strategy

  17. The Climate Change Strategy Gap: Crafting a Strategic Framework for the Department of Defense

    2016-03-24

    infrastructure in place to provide water for the current rural population, as their resources are diminishing as well.62 The population in Yemen is...decelerate its contributions to climate change within its purview and to mitigate the effects of climate change on its facilities and infrastructure ...of climate change on its facilities and infrastructure . However, the 2015 National Security Strategy specifically cites climate change as a threat

  18. Three-dimensional aesthetic assessment of class II patients before and after orthognathic surgery and its association with quantitative surgical changes.

    Storms, A S; Vansant, L; Shaheen, E; Coucke, W; de Llano-Pérula, M Cadenas; Jacobs, R; Politis, C; Willems, G

    2017-12-01

    The aim of this study was to compare evaluations of the aesthetic outcome of class II orthognathic patients, as performed by observers with varying expertise using three-dimensional (3D) facial images, and to examine the relationship of aesthetic ratings in relation to quantitative surgical changes. Pre- and postoperative 3D facial images of 20 surgically treated class II patients (13 female, 7 male) were assessed for aesthetics by orthodontists, maxillofacial surgeons, and laypeople. Attractiveness ratings for the lips, chin, and overall facial aesthetics were evaluated on a 5-point Likert scale. Correlation between the aesthetic scores was obtained and quantitative surgical changes were examined. For all groups of observers, significant improvements in attractiveness scores were found, especially for the chin assessment. Orthodontists perceived the greatest improvement and laypeople the smallest. Overall, laypeople scored higher with less variability, but with lower intra- and inter-observer agreement. No significant correlation was found between the aesthetic improvement and soft tissue surgical changes. To avoid patient dissatisfaction, it is important to bear in mind that the demands and perception of aesthetic improvement after orthognathic surgery are higher for clinicians than for the general public. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

  19. The Efficacy and Utilisation of Preoperative Magnetic Resonance Imaging in Robot-assisted Radical Prostatectomy: Does it Change the Surgical Dissection Plan? A Preliminary Report

    Hasan Hüseyin Tavukçu

    2015-06-01

    Full Text Available Purpose: We investigated the effect of prostate magnetic resonance imaging (MRI on the dissection plan of the neurovascular bundle and the oncological results of our patients who underwent robotic radical prostatectomy operation. Materials and Methods: We prospectively evaluated 30 consecutive patients, 15 of whom had prostate MRI before the operation, and 15 of whom did not. With the findings of MRI, the dissection plan was changed as intrafascial, interfascial, and extrafascial technique in the MRI group. Two groups were compared in terms of age, prostate-specific antigen (PSA, and Gleason scores (GSs. Surgical margin status was also checked with the final pathology. Results: There was no significant difference between the two groups in terms of age, PSA, biopsy GS, and final pathological GS. MRI changed the initial surgical plan to a nerve-sparing technique in 7 of the 15 patients. Only one patient in the MRI group had a positive surgical margin on bladder neck. MRI was confirmed as the primary tumour localisation in the final pathology in 93.3% of patients. Conclusion: Preoperative prostate MRI influenced the decision to carry out a nerve-sparing technique in 46% of the patients in our study; however, the change to a nerve-sparing technique did not seem to compromise the surgical margin positivity.

  20. Resilience, human agency and climate change adaptation strategies in the Arctic

    Sejersen, Frank

    2009-01-01

    and work with a number of barriers for resilience. The objective of the article is first to address the position of institutional barriers in the studies and strategies. Second the article analyses the role human agency is ascribed in proposed strategies and projects in Nunavut and Greenland. With a focus......  In the Arctic, indigenous peoples, researchers and governments are working to develop climate change adaptation strategies due to the rapid changes in sea ice extent, weather conditions and in the ecosystem as such. These strategies are often based on specific perceptions of vulnerability...... on institutions and human agency the question is not only ‘how do people manage to adapt?' but moreover ‘what constrains people in pursuing a given adaptation strategy?' The article introduces the concept of double agency which stresses two different aspects of human agency that can be used to understand...

  1. Farmers’ Adaptation Strategies to Climate Change and Their Implications in the Zou Department of South Benin

    Adégnandjou Mahouna Roland Fadina

    2018-01-01

    Full Text Available Climate change is a global phenomenon. Its impact on agricultural activities in developing countries has increased dramatically. Understanding how farmers perceive climate change and how they adapt to it is very important to the implementation of adequate policies for agricultural and food security. This paper aims to contribute to an understanding of farmers’ adaptation choices, determinants of the adaptation choices and the long-term implications of the adaptation choices. Data were collected from 120 respondents in the Zou Department of Benin. A binary logit model was used to analyze the factors influencing household decisions to adapt to climate change. Multinomial logistic regression analysis was estimated to analyze the factors influencing households’ choice of adaptation strategies to climate change. The results show that farmers have a developed perception of climate change. These changes are translated by rainfall disturbances (rainfall delays, early cessation, bad rainfall distribution etc., shortening of the small dry season, increasing of temperature and sometimes, violent winds. The survey reveals that Benin farmers adopt many strategies in response to climate change. These strategies include “Crop–livestock diversification and other good practices (mulching, organic fertilizer,” “Use of improved varieties, chemical fertilizers and pesticides,” “Agroforestry and perennial plantation” and “Diversification of income-generating activities.” The findings also reveal that most of the respondents use these strategies in combination. From the binary logit model, we know that “farming experience” and “educational level of household head” positively influence adaptation decisions. The result of the multinomial logit analysis shows that farming experience, educational level, farm size and gender have a significant impact on climate change adaptation strategies. Based on in-depth analysis of each strategy, we

  2. How does a change in the control room design affect diagnostic strategies in nuclear power plants?

    Kim, Dong Young; Kim, Jonghyun

    2014-01-01

    Recently, main control rooms have been considerably changed by modern computer techniques. Some of the features that distinguish digital control rooms from conventional, analog rooms in nuclear power plants include advanced alarm systems, graphic information display systems, computerized procedure systems, and soft control. These features can bring changes in operator tasks, changing the characteristics of tasks or creating new tasks for operators. It is especially expected that these features may bring out changes in the operator's diagnostic tasks and strategies in a digital control room as compared with an analog control room. This study investigates the differences in the operator's diagnostic tasks and strategies in analog and digital control rooms. This study also attempts to evaluate how new systems in a digital control room affect diagnostic strategies. Three different approaches, which are complementary, are used to identify diagnostic strategies in the digital control room and in the analog control room: (1) observation in the simulator, (2) interview with operators, and (3) a literature review. The results show that the digital control room introduces new diagnosis strategies compared with the analog control room while also changing the characteristics of the strategies, mostly by gaining more support from the computerized system. (author)

  3. [Surgery for benign goiter in Germany: fewer operations, changed resectional strategy, fewer complications].

    Dralle, H; Stang, A; Sekulla, C; Rusner, C; Lorenz, K; Machens, A

    2014-03-01

    The increase of certain operations in the wake of the introduction of the German Diagnosis-Related Groups (G-DRG) system rekindled debate on the risk-benefit profile of what is widely being perceived as a too high number of thyroidectomies for benign goiter in Germany. The numbers of thyroidectomy for benign goiter from 2005-2011 were obtained from the Federal Bureau of Statistics ("Statistisches Bundesamt"). For the purpose of the study, the following operation and procedure key (OPS) codes were selected: hemithyroidectomy (OPS code 5-061); partial thyroid resection (OPS code 5-062); total thyroidectomy (OPS code 5-063); and thyroid surgeries via sternotomy (OPS code 5-064). The rates of permanent hypoparathyroidism and vocal cord palsy were calculated based on two prospective multicenter evaluation studies conducted in 1998-2001 (PETS 1) and 2010-2013 (PETS 2) in Germany. Between 2005 and 2011, the number of thyroidectomies for benign thyroid goiter decreased by 8 %, and the age-standardized surgery rate decreased by 6 % in men (2005: 599 per 1 million; 2011: 565 per 1 million) and 11 % in women (2005: 1641 per 1 million; 2011: 1463 per 1 million). At the same time, the rates of partial and subtotal thyroidectomy decreased by 59 % in men and 64 % in women, whereas the rates of hemithyroidectomy and total thyroidectomy increased by 65 % (113 %) in men and 42 % (97 %) in women. Despite a greater proportion of thyroidectomies over time, the approximated rates for postoperative hypoparathyroidism were reduced from 2.98 to 0.83 % and for postoperative vocal cord palsy from 1.06 to 0.86 %. Irrespective of that decline, either complication was more frequent after total than after subtotal thyroidectomy. The total number of thyroid surgeries due to benign goiter has decreased substantially in Germany from 2005 through 2011. Despite changes in the resectional strategy with an increase in the total number thyroidectomies and a decrease of subtotal

  4. Surgical smoke.

    Fan, Joe King-Man; Chan, Fion Siu-Yin; Chu, Kent-Man

    2009-10-01

    Surgical smoke is the gaseous by-product formed during surgical procedures. Most surgeons, operating theatre staff and administrators are unaware of its potential health risks. Surgical smoke is produced by various surgical instruments including those used in electrocautery, lasers, ultrasonic scalpels, high speed drills, burrs and saws. The potential risks include carbon monoxide toxicity to the patient undergoing a laparoscopic operation, pulmonary fibrosis induced by non-viable particles, and transmission of infectious diseases like human papilloma virus. Cytotoxicity and mutagenicity are other concerns. Minimisation of the production of surgical smoke and modification of any evacuation systems are possible solutions. In general, a surgical mask can provide more than 90% protection to exposure to surgical smoke; however, in most circumstances it cannot provide air-tight protection to the user. An at least N95 grade or equivalent respirator offers the best protection against surgical smoke, but whether such protection is necessary is currently unknown.

  5. Novel experimental surgical strategy to prevent traumatic neuroma formation by combining a 3D-printed Y-tube with an autograft.

    Bolleboom, Anne; de Ruiter, Godard C W; Coert, J Henk; Tuk, Bastiaan; Holstege, Jan C; van Neck, Johan W

    2018-02-09

    OBJECTIVE Traumatic neuromas may develop after nerve injury at the proximal nerve stump, which can lead to neuropathic pain. These neuromas are often resistant to therapy, and excision of the neuroma frequently leads to recurrence. In this study, the authors present a novel surgical strategy to prevent neuroma formation based on the principle of centro-central anastomosis (CCA), but rather than directly connecting the nerve ends to an autograft, they created a loop using a 3D-printed polyethylene Y-shaped conduit with an autograft in the distal outlets. METHODS The 3D-printed Y-tube with autograft was investigated in a model of rat sciatic nerve transection in which the Y-tube was placed on the proximal sciatic nerve stump and a peroneal graft was placed between the distal outlets of the Y-tube to form a closed loop. This model was compared with a CCA model, in which a loop was created between the proximal tibial and peroneal nerves with a peroneal autograft. Additional control groups consisted of the closed Y-tube and the extended-arm Y-tube. Results were analyzed at 12 weeks of survival using nerve morphometry for the occurrence of neuroma formation and axonal regeneration in plastic semi-thin sections. RESULTS Among the different surgical groups, the Y-tube with interposed autograft was the only model that did not result in neuroma formation at 12 weeks of survival. In addition, a 13% reduction in the number of myelinated axons regenerating through the interposed autograft was observed in the Y-tube with autograft model. In the CCA model, the authors also observed a decrease of 17% in the number of myelinated axons, but neuroma formation was present in this model. The closed Y-tube resulted in minimal nerve regeneration inside the tube together with extensive neuroma formation before the entrance of the tube. The extended-arm Y-tube model clearly showed that the majority of the regenerating axons merged into the Y-tube arm, which was connected to the autograft

  6. Geography Teachers and Climate Change: Emotions about Consequences, Coping Strategies, and Views on Mitigation

    Hermans, Mikaela

    2016-01-01

    It has been indicated that teachers' emotions about climate change and their views on mitigation influence their instruction and students' engagement in mitigation actions. The aim of the study is to explore Finnish secondary geography teachers' emotions about the consequences of climate change, their strategies for coping with these emotions, and…

  7. Assessing climate change impacts and adaptation strategies for smallholder agricultural systems in Uganda

    Bagamba, F.; Bashaasha, B.; Claessens, L.F.G.; Antle, J.

    2012-01-01

    The debate on whether climate change will impact on peoples’ livelihoods and, hence, the need to act is essentially over and has instead shifted to the development of strategies needed by different regions and countries to adapt to climate change effects. However, there is still scanty information

  8. Strategies for Developing Positive Behaviour Management. Teacher Behaviour Outcomes and Attitudes to the Change Process

    Hayes, Ben; Hindle, Sarah; Withington, Paul

    2007-01-01

    This paper describes an extended action research project run in a large secondary school over an 18-month period. The work was part of a wider strategy for change within the school. The data presented here describes some of the features of the change process and reflections on its impact. A key aim was to challenge and enable teachers to modify…

  9. Surgical strategies in polytraumatized patients with femoral shaft fractures - comparing a German and an Australian level I trauma centre.

    Andruszkow, Hagen; Dowrick, Adam S; Frink, Michael; Zeckey, Christian; Krettek, Christian; Hildebrand, Frank; Edwards, Elton R; Mommsen, Philipp

    2013-08-01

    Femoral shaft fractures are one of the most common injuries in multiple trauma patients. Due to their prognostic relevance, there is an ongoing controversial discussion as to the optimal treatment strategy in terms of Damage Control Orthopaedics (DCO) and Early Total Care (ETC). We aimed to describe the differences in fracture management and clinical outcome of multiple trauma patients with concomitant femoral shaft fractures treated at a German and an Australian level I trauma centre using the same inclusion criteria. Polytraumatized patients (ISS ≥ 16) with a femoral shaft fracture aged ≥ 16 years treated at a German and an Australian trauma centre between 2003 and 2007 were included. According to ETC and DCO management principles, we evaluated demographic parameters as well as posttraumatic complications and clinical outcome. Seventy-three patients were treated at the German and 134 patients at the Australian trauma centre. DCO was performed in case of increased injury severity in both hospitals. Prolonged mechanical ventilation time, and length of ICU and hospital stay were demonstrated in DCO treatment regardless of the trauma centre. No differences concerning posttraumatic complications and survival were found between both centres. Survival of patients after DCO was similar to those managed using ETC despite a greater severity of injury and lower probability of survival. There was no difference in the incidence of ARDS. DCO was, however, associated with a greatly increased length of time on mechanical ventilation and length of stay in the ICU. We found no differences concerning patient demographics or clinical outcomes in terms of incidence of ARDS, MODS, or mortality. As such, we propose that comparability between German and Australian trauma populations is justified. Despite a higher ISS in the DCO group, there were no differences in posttraumatic complications and survival depending on ETC or DCO treatment. Further research is required to confirm

  10. Changes in competitive strategies due to deregulation and privatization in the petroleum industry: a comparative study

    Teixeira Carneiro, J.M.; Moutinho Dos Santos, E.

    1999-01-01

    This article is part of a series of four dedicated to the study of the global oil competition game through the analytical framework proposed by Michael Porter, from the University of Harvard. By means of a questionnaire answered by top executives in ten oil companies, the authors investigate the changes in the competitive strategy of these companies in the downstream side of the oil business due to deregulation and privatization. The paper starts by establishing the relationship between Porter's generic competitive strategies and specific competitive methods. Then, it describes how companies have changes their competitive methods after privatization and major deregulation. Changes in the industry structure are also analyzed. (authors)

  11. Assessment of the changes in quality of life of patients with class II and III deformities during and after orthodontic-surgical treatment.

    Baherimoghaddam, T; Tabrizi, R; Naseri, N; Pouzesh, A; Oshagh, M; Torkan, S

    2016-04-01

    The aim of this longitudinal study was to assess and compare the oral health-related quality of life (OHRQoL) of patients with class II and III deformities during and after orthodontic-surgical treatment. Thirty class III and 28 class II patients were evaluated at baseline (T0), just prior to surgery (T1), at 6 months after surgery (T2), and at 12 months after debonding (T3). OHRQoL was assessed using the Oral Health Impact Profile (OHIP-14). Friedman two-way analysis of variance and the Wilcoxon signed-rank test were performed to compare the relative changes in OHRQoL during treatment. Significant changes in the overall OHIP-14 scores were observed during and after orthodontic-surgical treatment in both groups. During the pre-surgical stage, psychological discomfort and psychological disability decreased in class III patients, and class II patients experienced a significant deterioration in psychological discomfort during the same period. Six months after surgery, patients in both groups showed improvements in psychological discomfort, social disability, and handicap. Physical disability and functional limitation showed further improvement at 12 months after debonding in class II patients. This study reaffirms that orthodontic-surgical treatment has a significant effect on the OHRQoL of class III and class II patients. Copyright © 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

  12. Flexibility to contingency changes distinguishes habitual and goal-directed strategies in humans.

    Julie J Lee

    2017-09-01

    Full Text Available Decision-making in the real world presents the challenge of requiring flexible yet prompt behavior, a balance that has been characterized in terms of a trade-off between a slower, prospective goal-directed model-based (MB strategy and a fast, retrospective habitual model-free (MF strategy. Theory predicts that flexibility to changes in both reward values and transition contingencies can determine the relative influence of the two systems in reinforcement learning, but few studies have manipulated the latter. Therefore, we developed a novel two-level contingency change task in which transition contingencies between states change every few trials; MB and MF control predict different responses following these contingency changes, allowing their relative influence to be inferred. Additionally, we manipulated the rate of contingency changes in order to determine whether contingency change volatility would play a role in shifting subjects between a MB and MF strategy. We found that human subjects employed a hybrid MB/MF strategy on the task, corroborating the parallel contribution of MB and MF systems in reinforcement learning. Further, subjects did not remain at one level of MB/MF behaviour but rather displayed a shift towards more MB behavior over the first two blocks that was not attributable to the rate of contingency changes but rather to the extent of training. We demonstrate that flexibility to contingency changes can distinguish MB and MF strategies, with human subjects utilizing a hybrid strategy that shifts towards more MB behavior over blocks, consequently corresponding to a higher payoff.

  13. Subjective well-being in times of social change: congruence of control strategies and perceived control.

    Grümer, Sebastian; Silbereisen, Rainer K; Heckhausen, Jutta

    2013-01-01

    This paper investigates the association between perceptions of broader changes in the social-ecological context and individuals' subjective well-being (SWB). Macro-level societal changes such as globalization or demographic change give rise to new demands for individual functioning at work and/or in the family. Such new demands associated with social change are stressful and likely to be related to lower levels of SWB. Being active agents, individuals attempt to deal with social change and its increasing demands to protect their SWB. The present study investigates which kinds of control strategies are most effective in protecting one's SWB. Specifically, we predicted that control strategies of goal engagement will be most effective under conditions of perceived high control, and control strategies of goal disengagement will be most effective under conditions of perceived low control. In a large sample of 2537 German adults, work- and family-related demands associated with social change were found to be negatively linked to SWB. Moreover and in line with the motivational theory of lifespan development, control strategies of goal engagement and disengagement were beneficial for SWB to the extent that they matched the perceived control of the demands associated with social change.

  14. Climate change perceptions and local adaptation strategies of hazard-prone rural households in Bangladesh

    G.M. Monirul Alam

    2017-01-01

    Full Text Available Adaptation is a key strategy that can alleviate the severity of climate change impacts on agriculture and food production. Adaptation strategies are unlikely to be effective without an understanding of the farmers’ perceptions of climate change. This paper explores the local knowledge of adaptation in response to the perceived impacts of climate change and climatic hazards using a survey of 380 resource-poor riverbank erosion-prone households in Bangladesh. The results indicate that the respondents’ perceptions of changes in the climate and of extreme climatic events are similar to the observed climate data. Households have recognized the impacts on their livelihood and resources, resulting in an increased sense of vulnerability. To build resilience, households have undertaken a range of farming and non-farming adaptation strategies, which vary significantly among the farming groups. The important adaptation strategies include adopting new crop varieties, changing planting time, homestead gardening, planting trees and migration. Improved access to finance and to information about appropriate strategies appears to be crucial to support adaptation processes locally and thus to enhance the resilience of vulnerable households.

  15. Organizational models as configurations of structure, culture, leadership, control, and change strategy

    Janićijević Nebojša

    2017-01-01

    Full Text Available Starting from the axioms of consistency, stability, contingency, and configuration, research on organizational structure, culture, control, leadership, and change management strategy has shown that their typical configurations, or models, can be differentiated according to the same two criteria: distribution of power and dominant organizational dimension. On the one hand there are models of structure, culture, control, leadership, and change management strategy that are based on an unequal, or authoritarian, distribution of power within organizations, while on the other hand there are models that are based on democratic, or equal, distribution of power. Also, on the one hand there are models of structure, culture, control, leadership, and change strategy that are based on work structure and tasks, while on the other hand there are models of these organizational components that are based on social structure, people, and their relationships. Harmonization of typical configurations of organizational structure, culture, control, leadership, and change strategy occurs due to the harmonization of the differentiation criteria. Based on this harmonization, four organizational models have been identified as typical configurations of structure, culture, control, leadership, and change strategy: the autocratic, bureaucratic, innovative, and task models. Each of these models is effective in a different environmental contingency.

  16. Visualizing Changes in Strategy Use across Attempts via State Diagrams: A Case Study

    Deirdre Kerr

    2016-01-01

    Full Text Available Game log data have great potential to provide actionable information about the in-game behavior of players. However, these low-level behavioral data are notoriously difficult to analyze due to the challenges associated with extracting meaning from sparse data stored at such a small grain size. This paper describes a three-step solution that uses cluster analysis to determine which strategies players use to solve levels in the game, sequence mining to identify changes in strategy across multiple attempts at the same level, and state transition diagrams to visualize the strategy sequences identified by the sequence mining. In the educational video game used in this case study, cluster analysis successfully identified 15 different in-game strategies. The sequence mining found an average of 40 different sequences of strategy use per level, which the state transition diagrams successfully displayed in an interpretable way.

  17. Beyond Individual Behaviour Change: The Role of Power, Knowledge and Strategy in Tackling Climate Change

    Kenis, Anneleen; Mathijs, Erik

    2012-01-01

    Individual behaviour change is fast becoming a kind of "holy grail" to tackle climate change, in environmental policy, the environmental movement and academic literature. This is contested by those who claim that social structures are the main problem and who advocate collective social action. The objective of the research presented in…

  18. Strategy implementation and organizational change in healthcare organizations - a distributed change leadership perspective

    Holm, Anna B.; Ulhøi, John Parm

    This paper examines some theoretical underpinnings of distributed leadership and its ability to serve as change leadership during the process of major organizational changes in healthcare organizations. The study was initiated as part of a larger research project on distributed leadership (DL......) in the healthcare sector, financed by a research grant addressing both empirical and theoretical questions. The paper clarifies the relationship between distributed leadership and change leadership, and more specifically, the characteristics of distributed leadership in the change leadership process. We also...... propose a distributed change leadership (DCL) model that permits further development of research design and empirical studies of DCL. On a more general side, with this paper we shed more light on some aspects of leadership patterns in healthcare, where there is a distinct gap....

  19. Organisational change stressors and nursing job satisfaction: the mediating effect of coping strategies.

    Teo, Stephen T T; Pick, David; Newton, Cameron J; Yeung, Melissa E; Chang, Esther

    2013-09-01

    To examine the mediating effect of coping strategies on the consequences of nursing and non-nursing (administrative) stressors on the job satisfaction of nurses during change management. Organisational change can result in an increase in nursing and non-nursing-related stressors, which can have a negative impact on the job satisfaction of nurses employed in health-care organisations. Matched data were collected in 2009 via an online survey at two time-points (six months apart). Partial least squares path analysis revealed a significant causal relationship between Time 1 administrative and role stressors and an increase in nursing-specific stressors in Time 2. A significant relationship was also identified between job-specific nursing stressors and the adoption of effective coping strategies to deal with increased levels of change-induced stress and strain and the likelihood of reporting higher levels of job satisfaction in Time 2. The effectiveness of coping strategies is critical in helping nurses to deal with the negative consequences of organisational change. This study shows that there is a causal relationship between change, non-nursing stressors and job satisfaction. Senior management should implement strategies aimed at reducing nursing and non-nursing stress during change in order to enhance the job satisfaction of nurses. © 2013 John Wiley & Sons Ltd.

  20. Policy Entrepreneurs and Change Strategies: Lessons from Sixteen Case Studies of Water Transitions around the Globe

    Sander Meijerink

    2010-06-01

    Full Text Available This paper focuses on the role of policy entrepreneurs in realizing water policy transitions. The central questions are to what extent have policy entrepreneurs played a role in realizing major change in water policies, who are these policy entrepreneurs, and what strategies have they used to bring about change? The policy science literature suggests that policy entrepreneurs have an "arsenal" of possible strategies for achieving change. Based on a comparative analysis of water policy changes in 15 countries around the globe and the European Union, we investigate which strategies have in practice been used by policy entrepreneurs, to what effect, and which lessons for managing water transitions we can draw from this. The comparative case analysis shows that individuals play complementary roles; hence, entrepreneurship in water management is often collective entrepreneurship. Strategies of coalition building, the manipulation of decision making forums, and the strategic framing of issues and windows are crucial to understanding water policy change, which suggests that the management of water policy transitions is a highly political game. We conclude by listing recommendations for those who would like to direct water policy change.

  1. A strategy for implementing genomics into nursing practice informed by three behaviour change theories.

    Leach, Verity; Tonkin, Emma; Lancastle, Deborah; Kirk, Maggie

    2016-06-01

    Genomics is an ever increasing aspect of nursing practice, with focus being directed towards improving health. The authors present an implementation strategy for the incorporation of genomics into nursing practice within the UK, based on three behaviour change theories and the identification of individuals who are likely to provide support for change. Individuals identified as Opinion Leaders and Adopters of genomics illustrate how changes in behaviour might occur among the nursing profession. The core philosophy of the strategy is that genomic nurse Adopters and Opinion Leaders who have direct interaction with their peers in practice will be best placed to highlight the importance of genomics within the nursing role. The strategy discussed in this paper provides scope for continued nursing education and development of genomics within nursing practice on a larger scale. The recommendations might be of particular relevance for senior staff and management. © 2016 John Wiley & Sons Australia, Ltd.

  2. Taking a climate chance: a procedural critique of Vietnam's climate change strategy.

    Fortier, François

    2010-01-01

    This article asks through what processes and for which interests the emerging Vietnamese climate change strategy is being designed, and if, ultimately, it is likely or not to be effective in the face of the looming threat. Through a review of an emerging body of literature and field observations, the paper finds the strategy partial and problematic in several ways. Its technocratic process prevents a pluralist representation of interests, obfuscating and perpetuating sectorial ones, at the expense of a more transparent and democratic resource allocation. The strategy therefore reflects and reinforces existing power relations in both politics and production. It feeds into a business-as-usual complacency, protecting national and international interests vested in unchallenged continuity, even when considering post-carbon technological fixes, which largely serve to expand capital accumulation opportunities. The article concludes that the national climate change strategy provides an illusion of intervention and security, but largely fails to identify and mitigate the underlying causes of climate change, or to lay the ground for a robust mid- and long-term adaptation strategy that can cope with yet unknown levels of climatic and other structural changes.

  3. Influence of the management strategy model on estimating water system performance under climate change

    Francois, Baptiste; Hingray, Benoit; Creutin, Jean-Dominique; Hendrickx, Frederic

    2015-04-01

    The performance of water systems used worldwide for the management of water resources is expected to be influenced by future changes in regional climates and water uses. Anticipating possible performance changes of a given system requires a modeling chain simulating its management. Operational management is usually not trivial especially when several conflicting objectives have to be accounted for. Management models are therefore often a crude representation of the real system and they only approximate its performance. Estimated performance changes are expected to depend on the management model used, but this is often not assessed. This communication analyzes the influence of the management strategy representation on the performance of an Alpine reservoir (Serre-Ponçon, South-East of France) for which irrigation supply, hydropower generation and recreational activities are the main objectives. We consider three ways to construct the strategy named as clear-, short- and far-sighted management. They are based on different forecastability degrees of seasonal inflows into the reservoir. The strategies are optimized using a Dynamic Programming algorithm (deterministic for clear-sighted and implicit stochastic for short- and far-sighted). System performance is estimated for an ensemble of future hydro-meteorological projections obtained in the RIWER2030 research project (http://www.lthe.fr/RIWER2030/) from a suite of climate experiments from the EU - ENSEMBLES research project. Our results show that changes in system performance is much more influenced by changes in hydro-meteorological variables than by the choice of strategy modeling. They also show that a simple strategy representation (i.e. clear-sighted management) leads to similar estimates of performance modifications than those obtained with a representation supposedly closer to real world (i.e. the far-sighted management). The Short-Sighted management approach lead to significantly different results, especially

  4. State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change.

    Spahn, Joanne M; Reeves, Rebecca S; Keim, Kathryn S; Laquatra, Ida; Kellogg, Molly; Jortberg, Bonnie; Clark, Nicole A

    2010-06-01

    Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation

  5. An adaptation strategy of sandland peasants in Yogyakarta toward climate change

    Rusdiyana, E.; Suminah

    2018-03-01

    This study aims to explore and describe the adaptation strategies of sandland peasants toward climate change. Qualitative research method was employed and the data were collected through observation. In addition, the recording of the data, interview and the validity of data were determined by triangulation of sources. The results of the research showed that the adaptation strategies of sandland peasants toward climate change were; (1) the adjustment of crop varieties, (2) the utilization of productive crops as wind breaking, and (3) the irrigation system using “sumur panthek”.

  6. Farmers´ perceptions of climate change and agricultural adaptation strategies in rural Sahel

    Mertz, Ole; Mbow, Cheikh; Reenberg, Anette

    2009-01-01

    Farmers in the Sahel have always been facing climatic variability at intra- and inter-annual and decadal time scales. While coping and adaptation strategies have traditionally included crop diversification, mobility, livelihood diversification, and migration, singling out climate as a direct driver...... of changes is not so simple. Using focus group interviews and a household survey, this study analyzes the perceptions of climate change and the strategies for coping and adaptation by sedentary farmers in the savanna zone of central Senegal. Households are aware of climate variability and identify wind...

  7. Embracing technology? Using change management strategies to improve the use of continuous lateral rotation therapy.

    Cybulski, Pamela; Zantinge, Johanna; Abbott-McNeil, Deanna

    2006-01-01

    The purpose of this quality improvement initiative was to improve the utilization of continuous lateral rotation therapy (CLRT) in a nine-bed community hospital ICU within the context of a nurse-driven protocol. Nursing focus groups, analyzed using a strength, weakness, opportunity, threat (SWOT) approach, resulted in the implementation of four interventions over seven weeks. Change management strategies guided all aspects of the project. Results showed a modest increase in the utilization of CLRT. This initiative demonstrates that change management strategies may assist with the incorporation of technology into nursing practice by increasing empowerment and creating an attachment to and responsibility for outcomes.

  8. Changes in life satisfaction and self-esteem in patients with adolescent idiopathic scoliosis with and without surgical intervention.

    Zhang, Jingtao; He, Dawei; Gao, Juan; Yu, Xiuchun; Sun, Haining; Chen, Ziqiang; Li, Ming

    2011-04-20

    Pre-/poststudy comparing surgical and nonsurgical treatment. To identify whether orthopedic spinal surgery can effectively improve life satisfaction and self-esteem in patients with adolescent idiopathic scoliosis. There have been many studies about the effect of spinal deformity and its various treatments on the mental health of patients with adolescent idiopathic scoliosis. Scoliosis has been reported to have a negative effect on the life quality and mental health of patients. It has also been reported that no matter what the treatment, the existence of scoliosis is a risk factor for depression. However, there has been no report on whether orthopedic spinal surgery affects the life satisfaction and self-esteem of scoliosis patients. Forty-six patients with Cobb angles of more than 30° were recruited from a group of patients that were treated from January 2007 to August 2007. Twenty-one patients with Cobb angles of more than 40° underwent surgical correction while the remaining patients received regular observation (n = 11) or bracing (n = 14). Self-esteem and life satisfaction were assessed before and approximately 1 year after treatment using previously validated scales. There were no between-group differences in age, sex, or major curve location between the surgically and nonsurgically treated groups. The major curve Cobb angle decreased significantly following treatment in the surgically treated (52° ± 10° to 15° ± 8°, P life satisfaction (8 ± 1 vs. 7 ± 10); however, preintervention self-esteem scores were significantly higher in the nonsurgically treated group (28 ± 4 vs. 25 ± 3, P = 0.008). Postintervention, both life satisfaction (9 ± 1) and self-esteem (31 ± 2) scores improved significantly (P Self-esteem levels decreased significantly in the nonsurgically treated group (P self-esteem and life satisfaction scores were significantly higher in the surgically treated than the nonsurgically treated group (P self-esteem and life satisfaction.

  9. Perception, Mitigation and Adaptation Strategies of Irrigated Paddy Farmer Community to Face Climate Change

    Siska Rasiska Suantapura

    2016-06-01

    Full Text Available Climate change has a real impact on the condition of agriculture in developing countries, including Indonesia. Irrigated paddy farmers are the ones really feeling the impact of climate change. Therefore, we need to understand the perceptions, mitigation and adaptation strategies of irrigated paddy farmer community to face climate change. The study is conducted in Indramayu and Tasikmalaya Regency in West Java by using descriptive survey method, regression analysis and path analysis through Structural Equation Modelling approach with Lisrel TM 8.5. The results showes that: (1 changes to climate variability affects the productivity of rice; (2 perception of irrigated paddy farmer community on climate change and its affects are influenced by internal and external factors; and (3 adaptation strategy are influenced by internal and external factors, whereas no mitigation strategy. Therefore, mitigation and adaptation strategies with site specific location are very necessary improving climate information services, increasing empowerment of farmers through field schools, and providing the provision of facilities that are practical and adaptive to climate.

  10. Identifying Effective Strategies for Climate Change Education: The Coastal Areas Climate Change Education (CACCE) Partnership Audiences and Activities

    Ryan, J. G.; Feldman, A.; Muller-Karger, F. E.; Gilbes, F.; Stone, D.; Plank, L.; Reynolds, C. J.

    2011-12-01

    Many past educational initiatives focused on global climate change have foundered on public skepticism and disbelief. Some key reasons for these past failures can be drawn directly from recognized best practices in STEM education - specifically, the necessity to help learners connect new knowledge with their own experiences and perspectives, and the need to create linkages with issues or concerns that are both important for and relevant to the audiences to be educated. The Coastal Areas Climate Change Education (CACCE) partnership has sought to follow these tenets as guiding principles in identifying critical audiences and developing new strategies for educating the public living in the low-lying coastal areas of Florida and the Caribbean on the realities, risks, and adaptation and mitigation strategies for dealing with the regional impacts of global climate change. CACCE is currently focused on three key learner audiences: a) The formal education spectrum, targeting K-12 curricula through middle school marine science courses, and student and educator audiences through coursework and participatory research strategies engaging participants in a range of climate-related investigations. b) Informal science educators and outlets, in particular aquaria and nature centers, as an avenue toward K-12 teacher professional development as well as for public education. c) Regional planning, regulatory and business professionals focused on the built environment along the coasts, many of whom require continuing education to maintain licensing and/or other professional certifications. Our current activities are focused on bringing together an effective set of educational, public- and private-sector partners to target the varied needs of these audiences in Florida and the U.S. Caribbean, and tailoring an educational plan aimed at these stakeholder audiences that starts with the regionally and topically relevant impacts of climate change, and strategies for effective adaptation and

  11. Volatility measurement with directional change in Chinese stock market: Statistical property and investment strategy

    Ma, Junjun; Xiong, Xiong; He, Feng; Zhang, Wei

    2017-04-01

    The stock price fluctuation is studied in this paper with intrinsic time perspective. The event, directional change (DC) or overshoot, are considered as time scale of price time series. With this directional change law, its corresponding statistical properties and parameter estimation is tested in Chinese stock market. Furthermore, a directional change trading strategy is proposed for invest in the market portfolio in Chinese stock market, and both in-sample and out-of-sample performance are compared among the different method of model parameter estimation. We conclude that DC method can capture important fluctuations in Chinese stock market and gain profit due to the statistical property that average upturn overshoot size is bigger than average downturn directional change size. The optimal parameter of DC method is not fixed and we obtained 1.8% annual excess return with this DC-based trading strategy.

  12. Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies

    Iwarsson, Jenny

    2014-01-01

    A typical goal of voice therapy is a behavioral change in the patient’s everyday speech. The SLP’s plan for voice therapy should therefore optimally include strategies for automatization. The aim of the present study was to identify and describe factors that promote behavioral learning and habit...... are described and discussed from a learning theory perspective. Nine factors that seem to be relevant to facilitate behavioral learning and habit change in voice therapy are presented, together with related practical strategies and theoretical underpinnings. These are: 1) Cue-altering; 2) Attention exercises; 3...... change in voice behavior and have the potential to affect patient compliance and thus therapy outcome. Research literature from the areas of motor and behavioral learning, habit formation, and habit change was consulted. Also, specific elements from personal experience of clinical voice therapy...

  13. Surgical Treatment of Hepatocellular Carcinoma

    Zamora-Valdes, Daniel; Taner, Timucin; Nagorney, David M.

    2017-01-01

    Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach. PMID:28975836

  14. Surgical strategies in endocrine tumors

    Schreinemakers, J.M.J.

    2010-01-01

    Endocrine surgery has become more custom-made throughout the years. Endocrine tumors can be sporadic or develop as part of familial syndromes. Several familial syndromes are known to cause endocrine tumors. The most common are multiple endocrine neoplasia (MEN) syndromes type 1, 2A and 2B. This

  15. Integrated ocean management as a strategy to meet rapid climate change: the Norwegian case.

    Hoel, Alf Håkon; Olsen, Erik

    2012-02-01

    The prospects of rapid climate change and the potential existence of tipping points in marine ecosystems where nonlinear change may result from them being overstepped, raises the question of strategies for coping with ecosystem change. There is broad agreement that the combined forces of climate change, pollution and increasing economic activities necessitates more comprehensive approaches to oceans management, centering on the concept of ecosystem-based oceans management. This article addresses the Norwegian experience in introducing integrated, ecosystem-based oceans management, emphasizing how climate change, seen as a major long-term driver of change in ecosystems, is addressed in management plans. Understanding the direct effects of climate variability and change on ecosystems and indirect effects on human activities is essential for adaptive planning to be useful in the long-term management of the marine environment.

  16. Foraging strategies of the Galapagos Marine Iguana (Amblyrhynchus Cristatus): adapting behavioral rules to ontogenetic size change

    Wikelski, Martin; Trillmich, Fritz

    1994-01-01

    Ontogenetic development in reptiles entails major changes in size-related foraging options. We studied the changes in foraging behavior of marine iguanas. In this species, size increases about twenty- to hundredfold from hatching to full adult size. The foraging strategy of marine iguanas was studied at Miedo on Santa Fe Island in the Galapagos archipelago During low tide, large marine iguanas (>250 mm snout vent length (SVL)) foraged more in the lower intertidal than small ones (

  17. Managing the Transformation: A Change Management Strategy for U.S. Marine Corps Expeditionary Energy Initiatives

    2017-12-01

    sensegiving in transformational change processes from the bottom up. Higher Education , 65(6), 761–780. doi:10.1007/s10734-012-9575-7 Kezar, A...NAVAL POSTGRADUATE SCHOOL MONTEREY, CALIFORNIA THESIS Approved for public release. Distribution is unlimited. MANAGING THE TRANSFORMATION : A...DATE December 2017 3. REPORT TYPE AND DATES COVERED Master’s thesis 4. TITLE AND SUBTITLE MANAGING THE TRANSFORMATION : A CHANGE MANAGEMENT STRATEGY

  18. Climate change effects and adaptation strategies in the wine sector: a quantitative literature review

    Sandro Sacchelli

    2016-12-01

    Full Text Available This paper presents a quantitative literature review focusing on how scientific research analysed climate change impact on wine chain as well as potential adaptation strategies. The work is based on content analysis and text mining and takes into account researches from 1990 to 2015. A particular emphasis was given to the evaluation of suggested or implemented adaptation strategies at both global and national levels. Data were analysed using cluster analysis, multidimensional scaling and specificity evaluation. Results show that the study of climate change impacts on the wine sector is a recently emerging research topic. Adaptation strategies have not yet been explored thoroughly in the literature, and in-depth uncertainty quantification is also needed. Finally, additional research gaps and potential future issues are suggested.

  19. Climate Change Adaptation Strategies and Constraints in Northern Ghana: Evidence of Farmers in Sissala West District

    Clifford James Fagariba

    2018-05-01

    Full Text Available Research findings indicate that most African countries are vulnerable to climate change as a result of challenges such as poverty, weather extremes, and insufficient governmental agricultural support. For this reason, the researchers used the Sissala West District as a case study to determine factors influencing farmers’ adaptation to climate change and strategies used to avert climate change impact. A total of 330 small-scale farmers were sampled for survey and 150 key informants were used in focus group discussions. Utilizing the logistic regression model, the study indicated irregular rainfall, high temperature, weather information, and high evaporation as the factors that highly influenced farmers’ ability to adapt to climate change. A Weighted Average Index used to measure weather extremes revealed that drought and temperature had the highest level of occurrence. Furthermore, climate change adaptation strategies assessed in the study showed that agroforestry practices, drought-resistant crops, and mulching were the most preferred methods. The study concluded that farmers’ ability to adapt to climate change can be improved if the Environmental Protection Agency and the Ministry of Food and Agriculture intensify climate adaptation campaigns, increase access to weather information, and train farmers on adaptable strategies including, but not limited to, alternative sources of livelihood.

  20. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

    Clarke, Christina M; Persaud, Drepaul David

    2011-03-01

    Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.

  1. A Minimax Regret Analysis of Flood Risk Management Strategies Under Climate Change Uncertainty and Emerging Information

    Pol, van der T.D.; Gabbert, S.; Weikard, H.P.; Ierland, van E.C.; Hendrix, E.M.T.

    2017-01-01

    This paper studies the dynamic application of the minimax regret (MR) decision criterion to identify robust flood risk management strategies under climate change uncertainty and emerging information. An MR method is developed that uses multiple learning scenarios, for example about sea level rise

  2. Influence of change in sales networks on a firm’s sales strategy

    Sandau, A. (Alexander)

    2014-01-01

    Abstract This research revolves around two major theoretical topics: international network and international sales. The study aims to combine both distinct research areas in order to understand how changes in the sales network influence the sales strategy of the firm. The focus is hereby on born global companies respectively international new ventures. ...

  3. Contextualising Change through a Common Strategy: Lecturers' Perceptions and Key Role in Supporting Academic Reform

    Kindelan, Paz; Martin, Ana

    2014-01-01

    European universities are currently going through a process of change in order to meet the common goals set for higher education by the European Commission. They are revising their educational models to adjust them to the guidelines of the "Bologna Process" and are devising an institutional strategy for its implementation. In practical…

  4. Role of media and peers on body change strategies among adult men: is body size important?

    McCabe, Marita P; McGreevy, Shauna J

    2011-01-01

    There has been limited previous research that has examined the role of sociocultural influences on body change strategies among adult men. The current study investigated the role of specific types of messages (encouragement, teasing and modelling) from peers and the media on the strategies to change weight among adult men. Differences were evaluated between 526 men aged from 18 to 60 years from three groups (normal weight, overweight and obese) on body image, body change strategies and messages about their body received from peers and the media. Men were primarily drawn from United States, Australia and Europe. Results showed that messages received by men regarding losing weight or increasing muscle size differed according to weight. Body image and media messages were the strongest predictors of losing weight, whereas body image importance and messages from peers were the strongest predictors of increasing muscles. These findings highlight the importance of sociocultural influences on body change strategies among adult males. Copyright © 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

  5. Implementing an Open Source Learning Management System: A Critical Analysis of Change Strategies

    Uys, Philip M.

    2010-01-01

    This paper analyses the change and innovation strategies that Charles Sturt University (CSU) used from 2007 to 2009 during the implementation and mainstreaming of an open source learning management system (LMS), Sakai, named locally as "CSU Interact". CSU was in January 2008 the first Australian University to implement an open source…

  6. Surgical intervention in patients with necrotizing pancreatitis

    Besselink, MG; de Bruijn, MT; Rutten, JP; Boermeester, MA; Hofker, HS; Gooszen, HG

    Background: This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands. Methods: This retrospective study included all 106 consecutive patients who had surgical treatment for

  7. Selective magnetic resonance imaging (MRI) in invasive lobular breast cancer based on mammographic density: does it lead to an appropriate change in surgical treatment?

    Bansal, Gaurav J; Santosh, Divya; Davies, Eleri L

    2016-01-01

    The purpose of this study was to evaluate whether high mammographic density can be used as one of the selection criteria for MRI in invasive lobular breast cancer (ILC). In our institute, high breast density has been used as one of the indications for performing MRI scan in patients with ILC. We divided the patients in two groups, one with MRI performed pre-operatively and other without MRI. We compared their surgical procedures and analyzed whether surgical plan was altered after MRI. In case of alteration of plan, we analyzed whether the change was adequate by comparing post-operative histological findings. Between 2011 and 2015, there were a total of 1601 breast cancers with 97 lobular cancers, out of which 36 had pre-operative MRI and 61 had no MRI scan. 12 (33.3%) had mastectomy following MRI, out of which 9 (25%) had change in surgical plan from conservation to mastectomy following MRI. There were no unnecessary mastectomies in the MRI group. However, utilization of MRI in this cohort of patients did not reduce reoperation rate (19.3%). Lobular carcinoma in situ (LCIS) was identified in 60% of reoperations on post-surgical histology. Patients in the "No MRI" group had higher mastectomy rate 26 (42.6%), which was again appropriate. High mammographic density is a useful risk stratification criterion for selective MRI in ILC within a multidisciplinary team meeting setting. Provided additional lesions identified on MRI are confirmed with biopsy, pre-operative MRI does not cause unnecessary mastectomies. Used in this selective manner, reoperation rates were not eliminated, albeit reduced when compared to literature. High mammographic breast density can be used as one of the selection criteria for pre-operative MRI in ILC without an increase in inappropriate mastectomies with potential time and cost savings. In this cohort, re-excisions were not reduced markedly with pre-operative MRI.

  8. Favorable surgical outcomes of aldosterone-producing adenoma based on lateralization by CT imaging and hypokalemia: a non-AVS-based strategy.

    Li, Hai; Liu, Jianbin; Feng, Xiujuan; Liu, Liehua; Wei, Guohong; Cao, Xiaopei; Li, Yanbing

    2017-12-01

    To test the efficacy of a strategy based on CT imaging and clinical characteristics on lateralizing origin of excess aldosterone secretion in primary aldosteronism. Consecutive patients with diagnosed primary hyperaldosteronism from June 2006 to July 2012 in our center underwent adrenal surgeries without pre-operational adrenal venous sampling (AVS) if all the three criteria were met: (1) round- or oval-shaped occupational lesion of low density after contrast enhancement with diameter >1 cm on CT scan was located in one adrenal gland; (2) unequivocally normal contralateral adrenal gland; (3) serum potassium level lower than 3.5 mmol/L. Subjects who had received operation were taken into analysis and follow-ups. One hundred and twenty-five patients fulfilled the criteria and were recruited into our research. One hundred and twenty-two operated patients (97.6%) experienced complete resolution of hypokalemia as well as resolution or improvement in hypertension with reduction in antihypertensive medication, while 3 patients (2.4%) failed to obtain normal kalemia and continued on spironolactone therapy. At a median of 65-month (range 21-93) follow-up of these 122 subjects, 27 patients dropped out (22.1%). The 95 responding patients reported no episodes of paralysis or confirmed hypokalemia or any supplementation of potassium. Multivariate linear correlation analysis showed that plasma potassium level was correlated inversely with tumor diameter (r = -0.258, 95% CI -0.076, -0.514, p = 0.037) and basal plasma aldosterone level (r = -0.251, 95% CI -0.040, -0.464, p = 0.042). Most patients with typical unilateral adrenal macroadenomas, normal contralateral glands and hypokalemia could attain favorable surgical therapeutic outcomes without pre-operational AVS lateralization.

  9. The effectiveness of strategies to change organisational culture to improve healthcare performance.

    Parmelli, Elena; Flodgren, Gerd; Schaafsma, Mary Ellen; Baillie, Nick; Beyer, Fiona R; Eccles, Martin P

    2011-01-19

    Organisational culture is an anthropological metaphor used to inform research and consultancy and to explain organisational environments. Great emphasis has been placed during the last years on the need to change organisational culture in order to pursue effective improvement of healthcare performance. However, the precise nature of organisational culture in healthcare policy often remains underspecified and the desirability and feasibility of strategies to be adopted has been called into question. To determine the effectiveness of strategies to change organisational culture in order to improve healthcare performance.To examine the effectiveness of these strategies according to different patterns of organisational culture. We searched the following electronic databases for primary studies: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Sociological Abstracts, Web of Knowledge, PsycINFO, Business and Management, EThOS, Index to Theses, Intute, HMIC, SIGLE, and Scopus until October 2009. The Database of Abstracts of Reviews of Effectiveness (DARE) was searched for related reviews. We also searched the reference lists of all papers and relevant reviews identified, and we contacted experts in the field for advice on further potential studies. We considered randomised controlled trials (RCTs) or well designed quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) meeting the quality criteria used by the Cochrane Effective Practice and Organisation of Care Group (EPOC). Studies should be set in any type of healthcare organisation in which strategies to change organisational culture in order to improve healthcare performance were applied. Our main outcomes were objective measures of professional performance and patient outcome. At least two review authors independently applied the criteria for inclusion and exclusion criteria to scan titles and

  10. Workshop approach for developing climate change adaptation strategies and actions for natural resource management agencies in the United States

    Jessica E. Halofsky; David L Peterson; Michael J. Furniss; Linda A. Joyce; Constance I. Millar; Ronald P. Neilson

    2011-01-01

    Concrete ways to adapt to climate change are needed to help land-management agencies take steps to incorporate climate change into management and take advantage of opportunities to balance the negative effects of climate change. Because the development of adaptation tools and strategies is at an early stage, it is important that ideas and strategies are disseminated...

  11. Using a social justice and health framework to assess European climate change adaptation strategies.

    Boeckmann, Melanie; Zeeb, Hajo

    2014-11-28

    Climate change puts pressure on existing health vulnerabilities through higher frequency of extreme weather events, changes in disease vector distribution or exacerbated air pollution. Climate change adaptation policies may hold potential to reduce societal inequities. We assessed the role of public health and social justice in European climate change adaptation using a three-fold approach: a document analysis, a critical discourse analysis of a subgroup of strategies, and a ranking of strategies against our social justice framework. The ranking approach favored planning that includes various adaptation types, social issues and infrastructure changes. Themes on values identified in the five subgroup documents showed that risks are perceived as contradictory, technology is viewed as savior, responsibilities need to be negotiated, and social justice is advocated by only a few countries. Of 21 strategy documents assessed overall, those from Austria, England and Sweden received the highest scores in the ranking. Our qualitative assessment showed that in European adaptation planning, progress could still be made through community involvement into adaptation decisions, consistent consideration of social and demographic determinants, and a stronger link between infrastructural adaptation and the health sector. Overall, a social justice framework can serve as an evaluation guideline for adaptation policy documents.

  12. Consultation paper : Nova Scotia's renewed energy strategy and climate change action plan

    2007-10-01

    The Nova Scotia Department of Energy is seeking to create a sustainable and prosperous Nova Scotia that is responsive to climate change. The purpose of this report was to inform public discussion around two upcoming documents, namely the renewed energy strategy focusing on broad energy policy and a climate change action plan for Nova Scotia to reduce greenhouse gas emissions. The report discussed mitigation measures, as it is closely tied with energy use. The consultation process to inform the two documents was to include public forums and direct stakeholder consultation. The report discussed Nova Scotia's strategy for dealing with climate change and the world of energy. Recent changes in energy prices, exploration, awareness, and emerging but uncertain technologies were presented. Long term planning and a review of policy changes were also addressed. The report also presented options for a renewed energy strategy and discussed air quality; energy conservation and efficiency; electricity; natural gas; energy opportunities; government action; and government intervention. Submissions were also sought as input to the discussion paper. refs., tabs., figs., appendices

  13. Scaling Factor Estimation Using an Optimized Mass Change Strategy, Part 1: Theory

    Aenlle, Manuel López; Fernández, Pelayo Fernández; Brincker, Rune

    2007-01-01

    In natural input modal analysis, only un-scaled mode shapes can be obtained. The mass change method is, in many cases, the simplest way to estimate the scaling factors, which involves repeated modal testing after changing the mass in different points of the structure where the mode shapes are known....... The scaling factors are determined using the natural frequencies and mode shapes of both the modified and the unmodified structure. However, the uncertainty on the scaling factor estimation depends on the modal analysis and the mass change strategy (number, magnitude and location of the masses) used to modify...

  14. The role of uncertainty in climate change adaptation strategies — A Danish water management example

    Refsgaard, J.C.; Arnbjerg-Nielsen, Karsten; Drews, Martin

    2013-01-01

    We propose a generic framework to characterize climate change adaptation uncertainty according to three dimensions: level, source and nature. Our framework is different, and in this respect more comprehensive, than the present UN Intergovernmental Panel on Climate Change (IPCC) approach and could...... are epistemic (reducible) by nature but uncertainties on adaptation measures are complex, with ambiguity often being added to impact uncertainties. Strategies to deal with uncertainty in climate change adaptation should reflect the nature of the uncertainty sources and how they interact with risk level...

  15. Effect of surgical drill guide and irrigans temperature on thermal bone changes during drilling implant sites - thermographic analysis on bovine ribs.

    Marković, Aleksa; Lazić, Zoran; Mišić, Tijana; Šćepanović, Miodrag; Todorović, Aleksandar; Thakare, Kaustubh; Janjić, Bojan; Vlahović, Zoran; Glišić, Mirko

    2016-08-01

    During drilling implant sites, mechanical energy is converted into thermal one resulting in transient rise in temperature of surrounding bone. The temperature of 47°C exeeding one minute impairs osseointegration, compromises mechanical properties of the local bone and could cause early implant failure. This in vitro study aimed to assess the effect of surgical drill guide and temperature of irrigans on thermal changes of the local bone during drilling implant sites, and to test the influence of irrigans temperature on the temperature of surgical drill guide. A total of 48 specimens obtained from bovine ribs were randomly allocated to four experimental conditions according to the 2 x 2 factorial design: drill guide (with or without) and saline (at 25°C or 5°C). Real-time infrared thermography was used as a method for temperature measurement. The primary outcome was bone temperature change during drilling implant sites measured at 3 osteotomy depths, whereas the second one was change in the temperature of the drill guide. Data were analyzed by Brunner and Langer nonparametric analysis and Wilcoxon test. The effect of drill guide on the changes of bone temperature was significant at the entrance of osteotomy, whereas the effect of saline temperature was significant at all osteotomy levels (p 0.05). Guided surgery and irrigation with saline at 25°C were associated with the highest bone temperature increase. Increase in drill guide temperature was significantly higher when saline at 25°C was used (p < 0.001). Guided implant site preparation generates higher temperature of the local bone than conventional drilling, not exceeding the threshold for thermal bone necrosis. Although saline at room temperature provides sufficient heat control during drilling, cooled saline is more effective regardless the use of surgical drill guide.

  16. Effect of surgical drill guide and irrigans temperature on thermal bone changes during drilling implant sites - thermographic analysis on bovine ribs

    Marković Aleksa

    2016-01-01

    Full Text Available Background/Aim. During drilling implant sites, mechanical energy is converted into thermal one resulting in transient rise in temperature of surrounding bone. The temperature of 47°C exeeding one minute impairs osseointegration, compromises mechanical properties of the local bone and could cause early implant failure. This in vitro study aimed to assess the effect of surgical drill guide and temperature of irrigans on thermal changes of the local bone during drilling implant sites, and to test the influence of irrigans temperature on the temperature of surgical drill guide. Methods. A total of 48 specimens obtained from bovine ribs were randomly allocated to four experimental conditions according to the 2 x 2 factorial design: drill guide (with or without and saline (at 25°C or 5°C. Real-time infrared thermography was used as a method for temperature measurement. The primary outcome was bone temperature change during drilling implant sites measured at 3 osteotomy depths, whereas the second one was change in the temperature of the drill guide. Data were analyzed by Brunner and Langer nonparametric analysis and Wilcoxon test. Results. The effect of drill guide on the changes of bone temperature was significant at the entrance of osteotomy, whereas the effect of saline temperature was significant at all osteotomy levels (p 0.05. Guided surgery and irrigation with saline at 25°C were associated with the highest bone temperature increase. Increase in drill guide temperature was significantly higher when saline at 25°C was used (p < 0.001. Conclusion. Guided implant site preparation generates higher temperature of the local bone than conventional drilling, not exceeding the threshold for thermal bone necrosis. Although saline at room temperature provides sufficient heat control during drilling, cooled saline is more effective regardless the use of surgical drill guide.

  17. Maintenance strategies and safety on a deregulated market. Mapping of changes in maintenance strategies and their possible consequences

    Kecklund, Lena

    2004-11-01

    The overall purpose of the project was to make a survey of the changes in the Swedish nuclear power plants over the last five years. There is a risk that nuclear power companies after a deregulation will focus especially on reducing operation and maintenance costs and that the changes could have a negative effect on the reactor safety. The task has involved summarising the actual changes, describing the present situation, the need for future development and the differences between the plants as well as identifying possible reactor safety related risks. The survey has been carried out in a broad perspective, studying the changes in equipment, maintenance strategies and the work situation of the staff. Three case studies were carried out at the Swedish nuclear power plants. Documentation from the companies has been analysed and a selection of in total 27 'informed' employees in different positions have been interviewed in total. The project also included a fourth case study concerning railway traffic. This branch of business is interesting because of its longer experience on a deregulated and competitive market. Conclusions concerning the companies individually as well as similarities and differences between them are presented in this report. Results: There have been more changes both in strategy and organisation in the last five years than during the preceding 5-10-year-period and the pace has been relatively rapid. The deregulation of the electricity market was implemented January 1997 and became the main motive force for the changes. The staffing has been reduced or unchanged and the work demands have increased. The maintenance skills have been redistributed within the organisation. New methods and equipment, i.e. RCM, and programmable systems make increased demands for analytical and theoretical competence. In the short term, job satisfaction and motivation have in some cases been negatively influenced by the new organisation forms, according to several of the

  18. Soil mapping and processes models to support climate change mitigation and adaptation strategies: a review

    Muñoz-Rojas, Miriam; Pereira, Paulo; Brevik, Eric; Cerda, Artemi; Jordan, Antonio

    2017-04-01

    As agreed in Paris in December 2015, global average temperature is to be limited to "well below 2 °C above pre-industrial levels" and efforts will be made to "limit the temperature increase to 1.5 °C above pre-industrial levels. Thus, reducing greenhouse gas emissions (GHG) in all sectors becomes critical and appropriate sustainable land management practices need to be taken (Pereira et al., 2017). Mitigation strategies focus on reducing the rate and magnitude of climate change by reducing its causes. Complementary to mitigation, adaptation strategies aim to minimise impacts and maximize the benefits of new opportunities. The adoption of both practices will require developing system models to integrate and extrapolate anticipated climate changes such as global climate models (GCMs) and regional climate models (RCMs). Furthermore, integrating climate models driven by socio-economic scenarios in soil process models has allowed the investigation of potential changes and threats in soil characteristics and functions in future climate scenarios. One of the options with largest potential for climate change mitigation is sequestering carbon in soils. Therefore, the development of new methods and the use of existing tools for soil carbon monitoring and accounting have therefore become critical in a global change context. For example, soil C maps can help identify potential areas where management practices that promote C sequestration will be productive and guide the formulation of policies for climate change mitigation and adaptation strategies. Despite extensive efforts to compile soil information and map soil C, many uncertainties remain in the determination of soil C stocks, and the reliability of these estimates depends upon the quality and resolution of the spatial datasets used for its calculation. Thus, better estimates of soil C pools and dynamics are needed to advance understanding of the C balance and the potential of soils for climate change mitigation. Here

  19. Implementing adaptation strategies by legal, economic and planning instruments on climate change

    Albrecht, Eike; Missler-Behr, Magdalena; Schmidt, Michael; Spyra, Simon P.N. (eds.) [Brandenburg Univ. of Technology Cottbus-Senftenberg (Germany)

    2014-07-01

    The causes and effects of climate change are just as varied as the proposed solutions and approaches for dealing with the problem. Given the global character of climate change, comprehensive global cooperation is called for that leads to effective and appropriate international action in accordance with the respective responsibilities. These will inevitably differ depending on the capabilities and the social and economic situations of the respective actors. The contributions in this book present a variety of ideas, approaches and tools regarding the adaptation to climate change in specific countries and regions. In addition to examining (existing) legal instruments, they also focus on the implementation of economic instruments and planning tools, as well as their (further) development. Rather than simply discussing strategies to counteract climate change by reducing emissions, the authors also search for ways of actively adapting to climate change.

  20. Implementing adaptation strategies by legal, economic and planning instruments on climate change

    Albrecht, Eike; Missler-Behr, Magdalena; Schmidt, Michael; Spyra, Simon P.N.

    2014-01-01

    The causes and effects of climate change are just as varied as the proposed solutions and approaches for dealing with the problem. Given the global character of climate change, comprehensive global cooperation is called for that leads to effective and appropriate international action in accordance with the respective responsibilities. These will inevitably differ depending on the capabilities and the social and economic situations of the respective actors. The contributions in this book present a variety of ideas, approaches and tools regarding the adaptation to climate change in specific countries and regions. In addition to examining (existing) legal instruments, they also focus on the implementation of economic instruments and planning tools, as well as their (further) development. Rather than simply discussing strategies to counteract climate change by reducing emissions, the authors also search for ways of actively adapting to climate change.

  1. Assessing Strategies for Urban Climate Change Adaptation: The Case of Six Metropolitan Cities in South Korea

    Jae-Seung Lee

    2018-06-01

    Full Text Available As interest in climate change adaptation grows, an increasing number of national and local governments are developing adaptation strategies. This study assesses the strategies for urban climate change adaptation of municipal governments in South Korea. The adaptation plans and budget expenditures of six metropolitan cities in South Korea were compared, based on the Implementation Plan for Climate Change Adaptation Strategy (IPCCAS 2012–2016 and annual expenditure reports of each city. The results show that the actual implementation of these adaptation programs varied vis-à-vis the original plans, in terms of the level of overall expenditure and sector-specific expenditure. The following findings were drawn from the analysis: First, in most cases, the highest adaptation priorities were disaster/infrastructure, water management, and the health sector. Second, actual expenditure on climate change adaptation programs was smaller than the planned budget in the IPCCAS. Third, the prioritized sectors matched for planning and implementation in Seoul, Daegu, Daejeon, and Incheon, but not in Busan and Ulsan. Fourth, the adaptation programs of South Korean metropolitan cities do not seem to have been well-tailored to each case.

  2. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change.

    Swanson, R Chad; Cattaneo, Adriano; Bradley, Elizabeth; Chunharas, Somsak; Atun, Rifat; Abbas, Kaja M; Katsaliaki, Korina; Mustafee, Navonil; Mason Meier, Benjamin; Best, Allan

    2012-10-01

    While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. We argue that a comprehensive systems perspective should guide health practice, education, research and policy. We propose key 'systems thinking' tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organizations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organization within health systems, from families and communities to national ministries of health. While our categorization is necessarily incomplete, this initial effort will provide a valuable contribution to the health systems strengthening debate, as the need for a more systemic, rigorous perspective in health has never been greater.

  3. Changes of Changes: Personal Life Strategy in the Context of Regional Social and Labour Policy: Purchase of Accommodation

    Nadezhda Sergeevna Zemlyanukhina

    2016-03-01

    Full Text Available This is the first of three articles in cycle that is dedicated to the regional aspect of change of Russians life strategy in solving the important personal problems like provision of housing, acquisition of income in terms of the profession and merited pension maintenance in the context of the current and prospective changes. The first article concentrates on the solution of housing problem by young Russians and young families. The methods, which are accessible for the citizens of Saratov, were analyzed in terms of the hardest ways without privileges and government support: pledge, housing rent and deposit. The authors presented the digital data on comparison between the popular pledge of OJSC Sberbank and similar ones at the start conditions of housing rent and deposits. Theyve specified the possibility of the reducing time and the amount of payment of the purchased apartment from 20 years, where is the amount of overpayment is 1 850 498, to 4.5-7 years, altogether without overpayments. The basic risks when using discussed ways of the accommodation purchase were demonstrated and specific examples of risks in Saratov were given. There are no absolute priorities when choosing the way of the accommodation purchase, there are examples in the article of a sharp increase of the efficiency within the pledge, and the rent on condition that only one factor has changed. Besides, there are examples of mixed ways including social housing and service housing. Nowadays there is a psychological aspect of the underestimate of the cost-effectively housing rent. As a result we made a conclusion that in spite of the real impossibility to plan and predict the changes, the success of individual strategy of life in solving housing and other important problems depends on the perception and understanding of the changes, on the early use for practical purposes and on the existing life stereotypes.

  4. Enhanced change detection performance reveals improved strategy use in avid action video game players.

    Clark, Kait; Fleck, Mathias S; Mitroff, Stephen R

    2011-01-01

    Recent research has shown that avid action video game players (VGPs) outperform non-video game players (NVGPs) on a variety of attentional and perceptual tasks. However, it remains unknown exactly why and how such differences arise; while some prior research has demonstrated that VGPs' improvements stem from enhanced basic perceptual processes, other work indicates that they can stem from enhanced attentional control. The current experiment used a change-detection task to explore whether top-down strategies can contribute to VGPs' improved abilities. Participants viewed alternating presentations of an image and a modified version of the image and were tasked with detecting and localizing the changed element. Consistent with prior claims of enhanced perceptual abilities, VGPs were able to detect the changes while requiring less exposure to the change than NVGPs. Further analyses revealed this improved change detection performance may result from altered strategy use; VGPs employed broader search patterns when scanning scenes for potential changes. These results complement prior demonstrations of VGPs' enhanced bottom-up perceptual benefits by providing new evidence of VGPs' potentially enhanced top-down strategic benefits. Copyright © 2010 Elsevier B.V. All rights reserved.

  5. Hemodynamic and oxygenation changes in surgical intensive care unit patients with fever and fever lowering nursing interventions.

    Çelik, Sevim; Yildirim, Ismail; Arslan, Ibrahim; Yildirim, Sinan; Erdal, Fatih; Yandi, Yunus Emre

    2011-12-01

    The purpose of this study was to determine the effects of fever and nursing interventions to lower fever on hemodynamic values and oxygenation in febrile (temperature greater than 38.3°C) surgical intensive care unit patients. This retrospective study was conducted in 53 febrile patients out of 519 patients admitted to the surgical intensive care unit at a university hospital. Data were obtained from the medical records, laboratory files and nursing notes. Statistical analysis of the data was analyzed by repeated measures analysis of variance and a paired sample t-test. The average hourly urine output (F = 5.46; P = 0.002) and systolic blood pressure (F = 2.87; P = 0.03) were significantly lower after fever onset. Heart rate, respiratory rate, positive end-expiratory pressure settings and FiO(2) settings were unchanged after the development of fever. Diastolic blood pressure and oxygen saturation had non-statistically significant decreases. Nursing interventions for febrile patients consisted of medication administration (69.8%), ice (62.3%) and sponging with tepid water (62.3%). The present results showed that fever was associated with an increase in heart rate, decreased systolic arterial pressure, mean arterial pressure, oxygen saturation and hourly urine output. © 2011 Blackwell Publishing Asia Pty Ltd.

  6. Comparison of Strategies for Climate Change Adaptation of Water Supply and Flood Control Reservoirs

    Ng, T. L.; Yang, P.; Bhushan, R.

    2016-12-01

    With climate change, streamflows are expected to become more fluctuating, with more frequent and intense floods and droughts. This complicates reservoir operation, which is highly sensitive to inflow variability. We make a comparative evaluation of three strategies for adapting reservoirs to climate-induced shifts in streamflow patterns. Specifically, we examine the effectiveness of (i) expanding the capacities of reservoirs by way of new off-stream reservoirs, (ii) introducing wastewater reclamation to augment supplies, and (iii) improving real-time streamflow forecasts for more optimal decision-making. The first two are hard strategies involving major infrastructure modifications, while the third a soft strategy entailing adjusting the system operation. A comprehensive side-by-side comparison of the three strategies is as yet lacking in the literature despite the many past studies investigating the strategies individually. To this end, we developed an adaptive forward-looking linear program that solves to yield the optimal decisions for the current time as a function of an ensemble forecast of future streamflows. Solving the model repeatedly on a rolling basis with regular updating of the streamflow forecast simulates the system behavior over the entire operating horizon. Results are generated for two hypothetical water supply and flood control reservoirs of differing inflows and demands. Preliminary findings suggest that of the three strategies, improving streamflow forecasts to be most effective in mitigating the effects of climate change. We also found that, in average terms, both additional reservoir capacity and wastewater reclamation have potential to reduce water shortage and downstream flooding. However, in the worst case, the potential of the former to reduce water shortage is limited, and similarly so the potential of the latter to reduce downstream flooding.

  7. Management strategies for coral reefs and people under global environmental change: 25 years of scientific research.

    Comte, Adrien; Pendleton, Linwood H

    2018-03-01

    Coral reef ecosystems and the people who depend on them are increasingly exposed to the adverse effects of global environmental change (GEC), including increases in sea-surface temperature and ocean acidification. Managers and decision-makers need a better understanding of the options available for action in the face of these changes. We refine a typology of actions developed by Gattuso et al. (2015) that could serve in prioritizing strategies to deal with the impacts of GEC on reefs and people. Using the typology we refined, we investigate the scientific effort devoted to four types of management strategies: mitigate, protect, repair, adapt that we tie to the components of the chain of impact they affect: ecological vulnerability or social vulnerability. A systematic literature review is used to investigate quantitatively how scientific effort over the past 25 years is responding to the challenge posed by GEC on coral reefs and to identify gaps in research. A growing literature has focused on these impacts and on management strategies to sustain coral reef social-ecological systems. We identify 767 peer reviewed articles published between 1990 and 2016 that address coral reef management in the context of GEC. The rate of publication of such studies has increased over the years, following the general trend in climate research. The literature focuses on protect strategies the most, followed by mitigate and adapt strategies, and finally repair strategies. Developed countries, particularly Australia and the United States, are over-represented as authors and locations of case studies across all types of management strategies. Authors affiliated in developed countries play a major role in investigating case studies across the globe. The majority of articles focus on only one of the four categories of actions. A gap analysis reveals three directions for future research: (1) more research is needed in South-East Asia and other developing countries where the impacts of

  8. The Impact of changed organizational structures- on middle managers' perception of strategy and people management

    Madsen, Mona Toft; Madsen, Henning

    Much research on organizational change and middle management has emphasized the idea of flatter more performance- and customer focused organizations, in which middle managers’ main responsibilities concern elements of organizational change and development such as strategy involvement, and managing...... people. An important condition for this is, however, that middle managers also perceive such responsibilities as important. This paper is based on a survey of Managers in Danish organizations. Findings with different but related angels are highlighted here. First, only a small percentage of participating...... managers reported that the amount of managerial levels had actually been reduced in the last three years. Secondly, middle managers who had experienced such a reduction perceived aspects of strategy and organizational development as more important. Thirdly, such a reduction did not introduce significant...

  9. Indoor-atmospheric radon-related radioactivity affected by a change of ventilation strategy

    Kobayashi, Tuneo

    2006-01-01

    The present author has kept observation for concentrations of atmospheric radon, radon progeny and thoron progeny for several years at the campus of Fukushima Medical University. Accidentally, in the midst of an observation term, i.e., February 2005, the facility management group of the university changed a strategy for the manner of ventilation, probably because of a recession: tidy everyday ventilation of 7:30-24:00 into shortened weekday ventilation of 8:00-21:00 with weekend halts. This change of ventilation manner brought a clear alteration for the concentrations of radon-related natural radioactivity in indoor air. The present paper concerns an investigation of the effect of the ventilation strategy on the indoor-atmospheric radon-related radioactivity. (author)

  10. Management strategies in anticipation of climatic change and the resulting impact on wetlands

    Clay, R.; Neraasen, T.; Coley, R.

    1991-01-01

    Two significant impacts of climate change could affect waterfowl. Climate changes that induce dryness and reduce surface water would have a detrimental effect on waterfowl production capabilities. Global warming could also increase sea levels and flood critical waterfowl overwintering habitat. Strategies undertaken by Ducks Unlimited, a waterfowl conservation organization, to respond to the threat posed by global warming to waterfowl are reviewed. Ducks Unlimited will continue to assist with wetland restoration and preservation throughout the Great Plains. Strategies to enhance retention include converting marginally arable land to permanent forage, forage backflooding, and encouragement of zero and minimum tillage operations. Improved efficiency of irrigation projects is important to foster water conservation. Widespread surface water drainage should be discouraged, by combinations of legislation and economic incentives. Ducks Unlimited is refocusing its activites on parts of Alberta, Saskatchewan and Manitoba that are likely to have relatively wetter conditions under climatic warming

  11. Climate change on the Colorado River: a method to search for robust management strategies

    Keefe, R.; Fischbach, J. R.

    2010-12-01

    The Colorado River is a principal source of water for the seven Basin States, providing approximately 16.5 maf per year to users in the southwestern United States and Mexico. Though the dynamics of the river ensure Upper Basin users a reliable supply of water, the three Lower Basin states (California, Nevada, and Arizona) are in danger of delivery interruptions as Upper Basin demand increases and climate change threatens to reduce future streamflows. In light of the recent drought and uncertain effects of climate change on Colorado River flows, we evaluate the performance of a suite of policies modeled after the shortage sharing agreement adopted in December 2007 by the Department of the Interior. We build on the current literature by using a simplified model of the Lower Colorado River to consider future streamflow scenarios given climate change uncertainty. We also generate different scenarios of parametric consumptive use growth in the Upper Basin and evaluate alternate management strategies in light of these uncertainties. Uncertainty associated with climate change is represented with a multi-model ensemble from the literature, using a nearest neighbor perturbation to increase the size of the ensemble. We use Robust Decision Making to compare near-term or long-term management strategies across an ensemble of plausible future scenarios with the goal of identifying one or more approaches that are robust to alternate assumptions about the future. This method entails using search algorithms to quantitatively identify vulnerabilities that may threaten a given strategy (including the current operating policy) and characterize key tradeoffs between strategies under different scenarios.

  12. EC strategy against climatic change. Estrategia de la CE pava hacer frente al cambio climatico

    Carrillo, D

    1992-10-01

    On the 20 October 1990 the joint council of ministers of the environment and energy decided to adopt as a community objective, to fight the greenhouse effect and its consequent climatic change, the establishment of the level of CO[sub 2] emissions in the year 2000 at the levels of 1990. This objective was to be reached by a mixed strategy, comprising control measures at community level, complemented by other actions nationally.

  13. Communicating the Urgency and Challenge of Global Climate Change: Lessons Learned and New Strategies

    Dilling, L.; Moser, S. C.

    2004-12-01

    Climate change can sometimes be characterized as a "creeping environmental problem"--it is complex and long-term, involves long system lags, lacks the immediacy of everyday experience and thus is hard to perceive, and feels overwhelming to most individuals. Climate change thus does not typically attain the status of an urgent concern, taking priority over other matters for individuals, organizations or in the policy arena. We review the major reasons behind this lack of urgency, and document the observed consequences of previous communication strategies, including lack of public understanding, indifference, confusion, fear and uncertainty. We find that certain emotional motivators such as fear and guilt, while oft-employed, do not actually result in improved recognition of the urgency of the issue, nor do they typically result in action. Rather, positive and engaging approaches may be more likely to achieve this goal. We propose seven strategies to improve the communication of climate change and its urgency: 1) Abide by basic communication rules and heed the warnings of communication experts; 2) Address the emotional and the temporal components of "urgency"; 3) Increase the persuasiveness of the message; 4) Use trusted messengers-broaden the circle; 5) Use opportunities well; 6) Tap into individual and cultural strengths and values; and 7) Unite and Conquer. The multi-faceted nature of the proposed strategies reflects the unique challenges of the climate change issue as well as the need to engage all levels and sectors of societies in the solution, from individuals, to businesses, to governments. These strategies and results emerged from a multi-disciplinary, academic/practitioner workshop on the topic held at NCAR in summer 2004.

  14. The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review.

    Parmelli, Elena; Flodgren, Gerd; Beyer, Fiona; Baillie, Nick; Schaafsma, Mary Ellen; Eccles, Martin P

    2011-04-03

    Organisational culture is an anthropological metaphor used to inform research and consultancy and to explain organisational environments. In recent years, increasing emphasis has been placed on the need to change organisational culture in order to improve healthcare performance. However, the precise function of organisational culture in healthcare policy often remains underspecified and the desirability and feasibility of strategies to be adopted have been called into question. The objective of this review was to determine the effectiveness of strategies to change organisational culture in order to improve healthcare performance. We searched the following electronic databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Sociological Abstracts, Web of Knowledge, PsycINFO, Business and Management, EThOS, Index to Theses, Intute, HMIC, SIGLE, and Scopus until October 2009. The Database of Abstracts of Reviews of Effectiveness (DARE) was searched for related reviews. We also searched the reference lists of all papers and relevant reviews identified, and we contacted experts in the field for advice on further potential studies. We considered randomised controlled trials (RCTs) or well designed quasi-experimental studies (controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series (ITS) analyses). Studies could be set in any type of healthcare organisation in which strategies to change organisational culture in order to improve healthcare performance were applied. Our main outcomes were objective measures of professional performance and patient outcome. The search strategy yielded 4,239 records. After the full text assessment, two CBA studies were included in the review. They both assessed the impact of interventions aimed at changing organisational culture, but one evaluated the impact on work-related and personal outcomes while the other measured clinical outcomes. Both were at high risk of

  15. Habitat-based conservation strategies cannot compensate for climate-change-induced range loss

    Wessely, Johannes; Hülber, Karl; Gattringer, Andreas; Kuttner, Michael; Moser, Dietmar; Rabitsch, Wolfgang; Schindler, Stefan; Dullinger, Stefan; Essl, Franz

    2017-11-01

    Anthropogenic habitat fragmentation represents a major obstacle to species shifting their range in response to climate change. Conservation measures to increase the (meta-)population capacity and permeability of landscapes may help but the effectiveness of such measures in a warming climate has rarely been evaluated. Here, we simulate range dynamics of 51 species from three taxonomic groups (vascular plants, butterflies and grasshoppers) in Central Europe as driven by twenty-first-century climate scenarios and analyse how three habitat-based conservation strategies (establishing corridors, improving the landscape matrix, and protected area management) modify species' projected range size changes. These simulations suggest that the conservation strategies considered are unable to save species from regional extinction. For those persisting, they reduce the magnitude of range loss in lowland but not in alpine species. Protected area management and corridor establishment are more effective than matrix improvement. However, none of the conservation strategies evaluated could fully compensate the negative impact of climate change for vascular plants, butterflies or grasshoppers in central Europe.

  16. Strategies of petroleum companies facing climate change issues; Strategies des compagnies petrolieres face a la problematique du changement climatique

    Gervais, St.

    2005-05-01

    The oil industry is particularly concerned with the issue of climate change. The implementation of Greenhouse Gases (GHG) reduction policies can be perceived as an additional environmental constraint for the management of the production chain. It is also represents a first step towards a possible decarbonization of the economy. In the long-term, the fight against global warming calls thus into question the activity level of petroleum companies. Confronted with this, still uncertain, new environmental deal, some petroleum multinationals adopt proactive behaviors, e.g. with voluntary commitments to reduce GHG emissions, or with investments in alternative technologies. First of all, we present the potential economic impacts of the Kyoto Protocol on oil industry. Then, we conduct a comparative analysis of the 'Kyoto risk' for the five largest multinationals of this sector according to their activities and their geographical implantations. Then, for the purpose to interpreting proactive strategies of firms such as BP and Shell, we examine various explanations including 'win-win', public image and the response to broad societal needs. This leads us to formalize the proactive behavior as an anticipatory management of carbon contestability, particularly perceptible in financial markets. Lastly, we try to justify economically investments of companies in the field of alternative energy sources and technologies through the lens of real options theory and by a management of the exhaustible fossil resources. (author)

  17. Strategies of petroleum companies facing climate change issues; Strategies des compagnies petrolieres face a la problematique du changement climatique

    Gervais, St

    2005-05-01

    The oil industry is particularly concerned with the issue of climate change. The implementation of Greenhouse Gases (GHG) reduction policies can be perceived as an additional environmental constraint for the management of the production chain. It is also represents a first step towards a possible decarbonization of the economy. In the long-term, the fight against global warming calls thus into question the activity level of petroleum companies. Confronted with this, still uncertain, new environmental deal, some petroleum multinationals adopt proactive behaviors, e.g. with voluntary commitments to reduce GHG emissions, or with investments in alternative technologies. First of all, we present the potential economic impacts of the Kyoto Protocol on oil industry. Then, we conduct a comparative analysis of the 'Kyoto risk' for the five largest multinationals of this sector according to their activities and their geographical implantations. Then, for the purpose to interpreting proactive strategies of firms such as BP and Shell, we examine various explanations including 'win-win', public image and the response to broad societal needs. This leads us to formalize the proactive behavior as an anticipatory management of carbon contestability, particularly perceptible in financial markets. Lastly, we try to justify economically investments of companies in the field of alternative energy sources and technologies through the lens of real options theory and by a management of the exhaustible fossil resources. (author)

  18. The performance challenge: a strategy for change, a strategy for implementation, 1991-1996. Le defi performance: une strategie de changement, une strategie d'implantation, 1991-1996

    1990-11-01

    In the spring of 1990, Hydro-Quebec put into action a plan for change whose objective was to improve overall performance. To carry out this objective, a performance analysis of the company was prepared and strategies were recommended. The analysis showed that performance was unsatisfactory and that comparable companies whose performance has improved have integrated into a coherent system all the elements of management related to their mission, their culture, to the competence of their employees, and to their structures and systems. Hydro-Quebec then decided to adopt a strategy for change which was sufficiently global so that any measures taken for improvement would be integrated into a harmonious, coherent, and well-performing whole. This strategy is based on quality management: total satisfaction at least cost of all the needs of internal and external clients; mastery of work processes; employee mobilization; an orientation toward the customer; management as a function of facts; and respect for the person. To carry out the overall strategy, Hydro-Quebec has formed an action plan which clearly identifies the fields where action is necessary, the actions to be done, and the various stages needed to carry out these actions. Improvement teams are being integrated into this overall strategy. 4 figs.

  19. Climate Change and Energy Sustainability. Which Innovations in European Strategies and Plans

    Rocco Papa

    2014-05-01

    Full Text Available In recent years, the effects of climate change on urban areas have pushed more and more policy-makers and urban planners to deal with the management of territorial transformations in a systemic and multi-sector perspective, due to the complexity of the issue. In order to enhance the urban governance of climate change and cope with environmental sustainability, the concept of resilience can be used. In this perspective, the present work has a double purpose: on the one hand to reflect on he need to adopt a new comprehension/interpretive approach to the study of the city, which embraces the concept of resilience, and on the other hand to perform a reading of European strategies and plans oriented to mitigate the effects of climate change and to achieve the goals of energy and environmental sustainability. This paper describes some of the results of the knowledge framework of the Project Smart Energy Master for the energy management of territory financed by PON 04A2_00120 R & C Axis II, from 2012 to 2015 aimed at supporting local authorities in the development of strategies for the reduction of energy consumption through actions designed to change behavior (in terms of use and energy consumption and to improve the energy efficiency of equipment and infrastructure. The paper is divided into three parts: the first is oriented to the definition of the new comprehension/interpretive approach; the second illustrates a series of recent innovations in planning tools of some European States due to the adoption of the concept of resilience; the third, finally, describes and compares the most innovative energy and environmental strategies aimed at contrasting and/or mitigate the effects of climate change, promoted in some European and Italian cities.

  20. Ethical implications of co-benefits rationale within climate change mitigation strategy

    Rita Vasconcellos Oliveira

    2016-10-01

    Full Text Available Climate change mitigation effort is being translated into several actions and discourses that make collateral benefits and their rationale increasingly relevant for sustainability, in such a way that they are now a constant part of the political agenda. Taking a border and consensual perspective, co-benefits are considered here to be emerging advantages of the implementation of measures regarding the lowering of greenhouse gases.Departing from the analysis of policy documents referring to two European urban transportation strategies, the emergent co-benefits are problematized and discussed to better understand their moral aspect. Further ethical reflection is conducted after an analysis of some unintended consequences of co-benefits rationale coming from the mentioned examples. The focus is primarily on the challenges of an integrative moral justification for co-benefits and also for their role in the climate change mitigation effort. We also discuss the limitations of the current normative models that frame co-benefits rationale, from a moral viewpoint and in relation to the overall climate change mitigation strategy.In this article, we propose the concepts of well-being and freedom, as portrayed by Capabilities Approach, as possible guiding notions for the moral and social evaluation of goodness of these emergent benefits and their rationale too. Additionally, some preliminary conclusions are drawn regarding the potential of the presented concepts to favour the climate change mitigation action. Finally, a scenario is drawn where Capabilities Approach is the moral guideline for co-benefits rationale showing this way its potential in terms of enhancing climate change mitigation strategy.

  1. [Surgical assessment of complications after thyroid gland operations].

    Dralle, H

    2015-01-01

    The extent, magnitude and technical equipment used for thyroid surgery has changed considerably in Germany during the last decade. The number of thyroidectomies due to benign goiter have decreased while the extent of thyroidectomy, nowadays preferentially total thyroidectomy, has increased. Due to an increased awareness of surgical complications the number of malpractice claims is increasing. In contrast to surgical databases the frequency of complications in malpractice claims reflects the individual impact of complications on the quality of life. In contrast to surgical databases unilateral and bilateral vocal fold palsy are therefore at the forefront of malpractice claims. As guidelines are often not applicable for the individual surgical expert review, the question arises which are the relevant criteria for the professional expert witness assessing the severity of the individual complication. While in surgical databases major complications after thyroidectomy, such as vocal fold palsy, hypoparathyroidism, hemorrhage and infections are equally frequent (1-3 %), in malpractice claims vocal fold palsy is significantly more frequent (50 %) compared to hypoparathyroidism (15 %), hemorrhage and infections (about 5 % each). To avoid bilateral nerve palsy intraoperative nerve monitoring has become of utmost importance for surgical strategy and malpractice suits alike. For surgical expert review documentation of individual risk-oriented indications, the surgical approach and postoperative management are highly important. Guidelines only define the treatment corridors of good clinical practice. Surgical expert reviews in malpractice suits concerning quality of care and causality between surgical management, complications and sequelae of complications are therefore highly dependent on the grounds and documentation of risk-oriented indications for thyroidectomy, intraoperative and postoperative surgical management.

  2. Age-dependent Changes in the Articular Cartilage and Subchondral Bone of C57BL/6 Mice after Surgical Destabilization of Medial Meniscus.

    Huang, Henry; Skelly, Jordan D; Ayers, David C; Song, Jie

    2017-02-09

    Age is the primary risk factor for osteoarthritis (OA), yet surgical OA mouse models such as destabilization of the medial meniscus (DMM) used for evaluating disease-modifying OA targets are frequently performed on young adult mice only. This study investigates how age affects cartilage and subchondral bone changes in mouse joints following DMM. DMM was performed on male C57BL/6 mice at 4 months (4 M), 12 months (12 M) and 19+ months (19 M+) and on females at 12 M and 18 M+. Two months after surgery, operated and unoperated contralateral knees were harvested and evaluated using cartilage histology scores and μCT quantification of subchondral bone plate thickness and osteophyte formation. The 12 M and 19 M+ male mice developed more cartilage erosions and thicker subchondral bone plates after DMM than 4 M males. The size of osteophytes trended up with age, while the bone volume fraction was significantly higher in the 19 M+ group. Furthermore, 12 M females developed milder OA than males as indicated by less cartilage degradation, less subchondral bone plate sclerosis and smaller osteophytes. Our results reveal distinct age/gender-dependent structural changes in joint cartilage and subchondral bone post-DMM, facilitating more thoughtful selection of murine age/gender when using this surgical technique for translational OA research.

  3. Age-dependent Changes in the Articular Cartilage and Subchondral Bone of C57BL/6 Mice after Surgical Destabilization of Medial Meniscus

    Huang, Henry; Skelly, Jordan D.; Ayers, David C.; Song, Jie

    2017-01-01

    Age is the primary risk factor for osteoarthritis (OA), yet surgical OA mouse models such as destabilization of the medial meniscus (DMM) used for evaluating disease-modifying OA targets are frequently performed on young adult mice only. This study investigates how age affects cartilage and subchondral bone changes in mouse joints following DMM. DMM was performed on male C57BL/6 mice at 4 months (4 M), 12 months (12 M) and 19+ months (19 M+) and on females at 12 M and 18 M+. Two months after surgery, operated and unoperated contralateral knees were harvested and evaluated using cartilage histology scores and μCT quantification of subchondral bone plate thickness and osteophyte formation. The 12 M and 19 M+ male mice developed more cartilage erosions and thicker subchondral bone plates after DMM than 4 M males. The size of osteophytes trended up with age, while the bone volume fraction was significantly higher in the 19 M+ group. Furthermore, 12 M females developed milder OA than males as indicated by less cartilage degradation, less subchondral bone plate sclerosis and smaller osteophytes. Our results reveal distinct age/gender-dependent structural changes in joint cartilage and subchondral bone post-DMM, facilitating more thoughtful selection of murine age/gender when using this surgical technique for translational OA research. PMID:28181577

  4. Adaptation Strategies of Wheat to Climate Change (Case Study: Ahvaz Region

    M. Delghandi

    2016-10-01

    Full Text Available Introduction In recent years human activities induced increases in atmospheric carbon dioxide (CO2. Increases in [CO2] caused global warming and Climate change. Climate change is anticipated to cause negative and adverse impacts on agricultural systems throughout the world. Higher temperatures are expected to lead to a host of problems. On the other hand, increasing of [CO2] anticipated causing positive impacts on crop yield. Considering the socio-economic importance of agriculture for food security, it is essential to undertake assessments of how future climate change could affect crop yields, so as to provide necessary information to implement appropriate adaptation strategies. In this perspective, the aim of this study was to assess potential climate change impacts and on production for one of the most important varieties of wheat (chamran in Khouzestan plain and provide directions for possible adaptation strategies. Materials and Methods: For this study, The Ahvaz region located in the Khuzestan province of Iran was selected. Ahvaz has a desert climate with long, very hot summers and mild, short winters. At first, thirteen GCM models and two greenhouse gases emission (GHG scenarios (A2 and B1 was selected for determination of climate change scenarios. ∆P and ∆T parameters at monthly scale were calculated for each GCM model under each GHG emissions scenario by following equation: Where ∆P, ∆T are long term (thirty years precipitation and temperature differences between baseline and future period, respectively. average future GCM temperature (2015-2044 for each month, , average baseline period GCM temperature (1971-2000 for each month, , average future GCM precipitation for each month, , average baseline period GCM temperature (1971-2000 for each month and i is index of month. Using calculated ∆Ps for each month via AOGCM models and Beta distribution, Cumulative probability distribution function (CDF determined for generated ∆Ps.

  5. Authentic Leadership: Strategy of the Implementation of Madrasah Management of Change

    Aan Komariah

    2017-12-01

    Full Text Available Implementing the management of madrasah change starts from an authentic leadership. Authentic leadership is the identity of a head of madrasah in developing value-based educational system. His identity is seen from his sincerity in working, his kindness in treating people and the sharpness of his mind in determining the future of the organization. The authentic leadership of madrasah should represent the identity of moslem morality with work orientation on the sincerity of being a STAF+B (Siddiq, Tablig, Amanah, Fathonah + Brave leader. Leading the madrasah in the context of implementing management of change is not enough to be pious but it requires courage to take strategic and innovative decisions in realizing a qualified madrasah. This research aims to find an authentic leadership strategy model for management of change by head of madrasah. The research was conducted on the head of madrasah in Pangandaran Regency. The results show that the application of authentic leadership can build madrasah changes by empowering the Professional Learning Community (PLC in which 4CS strategy is implemented in a reciprocal (cumsuis-Casing, Communicating, Competencies, Contribution, Sample. The followers can identify who the authentic leader is by finding the integrity of identity that represents in: his mind is vision; his heart is good and his legs work hard.

  6. Strategies for implementing and sustaining therapeutic lifestyle changes as part of hypertension management in African Americans.

    Scisney-Matlock, Margaret; Bosworth, Hayden B; Giger, Joyce Newman; Strickland, Ora L; Harrison, R Van; Coverson, Dorothy; Shah, Nirav R; Dennison, Cheryl R; Dunbar-Jacob, Jacqueline M; Jones, Loretta; Ogedegbe, Gbenga; Batts-Turner, Marian L; Jamerson, Kenneth A

    2009-05-01

    African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP.

  7. Classical Ecological Restoration and its Current Challenges: Assisted Migration as an Adaptation Strategy to Climate Change

    Pilar A. Gómez-Ruiz

    2017-06-01

    Full Text Available Ecological restoration is a very active area in ecology and of great importance for ecosystems management. Despite of being a relatively young discipline, the classical concepts of restoration seem, at present, impractical considering the great challenges generated by modification and destruction of ecosystems. This is due to anthropic activities (deforestation, change of land use, pollution and global climate change. In the classic definition of restoration, the objective is to recover the degraded ecosystem to the same conditions of a historical reference state. However, nowadays the ecosystems return to a state prior to the disturbances seems unviable, because the thresholds of resilience have already been overcome. Additionally, climate change is causing environmental changes at an unprecedented rate. For this reason, ecological restoration needs to unite efforts of diverse actors to recover ecosystems that can be sustainable and functional in the future, where the species could be able to tolerate the environmental conditions that will exist in the long term. Assisted migration has been proposed as a conservation strategy; it is defined as the translocation of species to new locations outside their known range of distribution. In the current context of loss of diversity and ecosystems, this strategy could be fundamental for the formation of new communities that can later become novel ecosystems where species that are fundamental to the dynamics of ecosystems can persist and, at the same time, recover function, structure and resilience.

  8. Facilitating behavioral learning and habit change in voice therapy--theoretic premises and practical strategies.

    Iwarsson, Jenny

    2015-12-01

    A typical goal of voice therapy is a behavioral change in the patient's everyday speech. The SLP's plan for voice therapy should therefore optimally include strategies for automatization. The aim of the present study was to identify and describe factors that promote behavioral learning and habit change in voice behavior and have the potential to affect patient compliance and thus therapy outcome. Research literature from the areas of motor and behavioral learning, habit formation, and habit change was consulted. Also, specific elements from personal experience of clinical voice therapy are described and discussed from a learning theory perspective. Nine factors that seem to be relevant to facilitate behavioral learning and habit change in voice therapy are presented, together with related practical strategies and theoretical underpinnings. These are: 1) Cue-altering; 2) Attention exercises; 3) Repetition; 4) Cognitive activation; 5) Negative practice; 6) Inhibition through interruption; 7) Decomposing complex behavior; 8) The 'each time-every time' principle; and 9) Successive implementation of automaticity.

  9. Climate Change Adaptation Strategies and Farm-level Efficiency in Food Crop Production in Southwestern, Nigeria

    Otitoju, MA.

    2014-01-01

    Full Text Available Food crop yields depend largely on prevailing climate conditions, especially in Africa, where rain-fed agriculture predominate. The extent to which climate impacts are felt depends principally on the adaptation measures used by farmers. This study focused on the effect of climate change adaptation strategies on farm-level technical efficiency. The study used primary data collected from 360 randomly selected farmers in Southwest Nigeria. Cobb-Douglass stochastic frontier production model was used to analyse the data. Multiple cropping, land fragmentation, multiple planting dates, mulching and cover cropping were the major climate change adaptation strategies employed by the farmers. While land fragmentation and multiple planting dates had significant positive relationships, years of climate change awareness and social capital had significant inverse relationships, with technical inefficiency. This may be because while land fragmentation may hinder farm mechanization, multiple planting dates may increase the monotonousness and drudgery of farming. On the other hand, social capital and climate change awareness could help ameliorate the effects of, particularly, land fragmentation through resource pooling. It is therefore recommended that the farmers be encouraged to form cooperative societies so as to leverage their resource status through collective efforts.

  10. Early change in coping strategies in responsive treatments for borderline personality disorder: A mediation analysis.

    Kramer, Ueli; Keller, Sabine; Caspar, Franz; de Roten, Yves; Despland, Jean-Nicolas; Kolly, Stéphane

    2017-05-01

    Difficulty in emotion regulation is a hallmark feature of patients with borderline personality disorder (BPD). Therefore, change in the frequency of certain patients' coping strategies-aiming at emotion regulation-are among the most promising mechanisms of change in treatments for BPD. In parallel, it was highlighted that therapist responsiveness significantly contributed to outcome across treatment approaches (Stiles, 2009). Based on a randomized controlled trial (Kramer et al., 2014), the present process-outcome mediation analysis aims at examining the patient's early change in frequency of coping strategies-in particular the decrease in behavioral forms of coping-as potential mechanism of change in responsive treatments for BPD. A total of 57 patients with BPD were included in the present analysis, out of whom 27 were randomly assigned to a 10-session psychiatric treatment and 30 to a 10-session psychiatric treatment augmented with the responsive intervention of the motive-oriented therapeutic relationship (Caspar, 2007). The 1st, 5th, and 9th session of each therapy were transcribed and analyzed using the Coping Action Pattern Rating Scale (Perry et al., 2005; 171 sessions analyzed in total), a validated observer-rated method for assessing coping strategies in the therapy process. Psychological distress was assessed using the OQ-45 at intake, after Session 5, and after Session 10. The results confirmed a responsiveness effect associated with the motive-oriented therapeutic relationship and showed a significant decrease in frequency of behavioral forms of coping, F(1, 54) = 3.09, p = .05, d = .56, which was not different between the 2 conditions. In addition, we demonstrated that the early decrease in behavioral forms of coping between Sessions 1 and 5 partially mediated the link between the group assignment and the change in psychological distress between Sessions 5 and 10. These results shed light on the centrality of therapist responsiveness in treatments for

  11. One Health – a strategy for resilience in a changing arctic

    Bruce A. Ruscio

    2015-09-01

    Full Text Available The circumpolar north is uniquely vulnerable to the health impacts of climate change. While international Arctic collaboration on health has enhanced partnerships and advanced the health of inhabitants, significant challenges lie ahead. One Health is an approach that considers the connections between the environment, plant, animal and human health. Understanding this is increasingly critical in assessing the impact of global climate change on the health of Arctic inhabitants. The effects of climate change are complex and difficult to predict with certainty. Health risks include changes in the distribution of infectious disease, expansion of zoonotic diseases and vectors, changing migration patterns, impacts on food security and changes in water availability and quality, among others. A regional network of diverse stakeholder and transdisciplinary specialists from circumpolar nations and Indigenous groups can advance the understanding of complex climate-driven health risks and provide community-based strategies for early identification, prevention and adaption of health risks in human, animals and environment. We propose a regional One Health approach for assessing interactions at the Arctic human–animal–environment interface to enhance the understanding of, and response to, the complexities of climate change on the health of the Arctic inhabitants.

  12. Assessment of Clmate Change Mitigation Strategies for the Road Transport Sector of India

    Singh, N.; Mishra, T.; Banerjee, R.

    2017-12-01

    India is one of the fastest growing major economies of the world. It imports three quarters of its oil demand, making transport sector major contributor of greenhouse gas (GHG) emissions. 40% of oil consumption in India comes from transport sector and over 90% of energy demand is from road transport sector. This has led to serious increase in CO2 emission and concentration of air pollutants in India. According to Intergovernmental Panel on Climate Change (IPCC), transport can play a crucial role for mitigation of global greenhouse gas emissions. Therefore, assessment of appropriate mitigation policies is required for emission reduction and cost benefit potential. The present study aims to estimate CO2, SO2, PM and NOx emissions from the road transport sector for the base year (2014) and target year (2030) by applying bottom up emission inventory model. Effectiveness of different mitigation strategies like inclusion of natural gas as alternate fuel, penetration of electric vehicle as alternate vehicle, improvement of fuel efficiency and increase share of public transport is evaluated for the target year. Emission reduction achieved from each mitigation strategies in the target year (2030) is compared with the business as usual scenario for the same year. To obtain cost benefit analysis, marginal abatement cost for each mitigation strategy is estimated. The study evaluates mitigation strategies not only on the basis of emission reduction potential but also on their cost saving potential.

  13. Interactive effects of environmental change and management strategies on regional forest carbon emissions.

    Hudiburg, Tara W; Luyssaert, Sebastiaan; Thornton, Peter E; Law, Beverly E

    2013-11-19

    Climate mitigation activities in forests need to be quantified in terms of the long-term effects on forest carbon stocks, accumulation, and emissions. The impacts of future environmental change and bioenergy harvests on regional forest carbon storage have not been quantified. We conducted a comprehensive modeling study and life-cycle assessment of the impacts of projected changes in climate, CO2 concentration, and N deposition, and region-wide forest management policies on regional forest carbon fluxes. By 2100, if current management strategies continue, then the warming and CO2 fertilization effect in the given projections result in a 32-68% increase in net carbon uptake, overshadowing increased carbon emissions from projected increases in fire activity and other forest disturbance factors. To test the response to new harvesting strategies, repeated thinnings were applied in areas susceptible to fire to reduce mortality, and two clear-cut rotations were applied in productive forests to provide biomass for wood products and bioenergy. The management strategies examined here lead to long-term increased carbon emissions over current harvesting practices, although semiarid regions contribute little to the increase. The harvest rates were unsustainable. This comprehensive approach could serve as a foundation for regional place-based assessments of management effects on future carbon sequestration by forests in other locations.

  14. Modeling change in learning strategies throughout higher education: a multi-indicator latent growth perspective.

    Coertjens, Liesje; Donche, Vincent; De Maeyer, Sven; Vanthournout, Gert; Van Petegem, Peter

    2013-01-01

    The change in learning strategies during higher education is an important topic of research in the Student Approaches to Learning field. Although the studies on this topic are increasingly longitudinal, analyses have continued to rely primarily on traditional statistical methods. The present research is innovative in the way it uses a multi-indicator latent growth analysis in order to more accurately estimate the general and differential development in learning strategy scales. Moreover, the predictive strength of the latent growth models are estimated. The sample consists of one cohort of Flemish University College students, 245 of whom participated in the three measurement waves by filling out the processing and regulation strategies scales of the Inventory of Learning Styles--Short Versions. Independent-samples t-tests revealed that the longitudinal group is a non-random subset of students starting University College. For each scale, a multi-indicator latent growth model is estimated using Mplus 6.1. Results suggest that, on average, during higher education, students persisting in their studies in a non-delayed manner seem to shift towards high-quality learning and away from undirected and surface-oriented learning. Moreover, students from the longitudinal group are found to vary in their initial levels, while, unexpectedly, not in their change over time. Although the growth models fit the data well, significant residual variances in the latent factors remain.

  15. Modeling change in learning strategies throughout higher education: a multi-indicator latent growth perspective.

    Liesje Coertjens

    Full Text Available The change in learning strategies during higher education is an important topic of research in the Student Approaches to Learning field. Although the studies on this topic are increasingly longitudinal, analyses have continued to rely primarily on traditional statistical methods. The present research is innovative in the way it uses a multi-indicator latent growth analysis in order to more accurately estimate the general and differential development in learning strategy scales. Moreover, the predictive strength of the latent growth models are estimated. The sample consists of one cohort of Flemish University College students, 245 of whom participated in the three measurement waves by filling out the processing and regulation strategies scales of the Inventory of Learning Styles--Short Versions. Independent-samples t-tests revealed that the longitudinal group is a non-random subset of students starting University College. For each scale, a multi-indicator latent growth model is estimated using Mplus 6.1. Results suggest that, on average, during higher education, students persisting in their studies in a non-delayed manner seem to shift towards high-quality learning and away from undirected and surface-oriented learning. Moreover, students from the longitudinal group are found to vary in their initial levels, while, unexpectedly, not in their change over time. Although the growth models fit the data well, significant residual variances in the latent factors remain.

  16. Implementing a university e-learning strategy: levers for change within academic schools

    Rhona Sharpe

    2006-12-01

    Full Text Available This paper describes the implementation of an e-learning strategy at a single higher education institution in terms of the levers used to promote effective uptake and ensure sustainable embedding. The focus of this work was at the level of the academic school using a range of change practices including the appointment of school-based learning technologists and e-learning champions, supporting schools to write their own strategies, a pedagogical framework of engaging with e-learning, and curriculum development and evaluation of school-supported projects. It is clear that the implementation of the e-learning strategy has led to a large and increasing proportion of our students experiencing blended learning. In addition, there are initial indications that this has enhanced some learning and teaching processes. Where there has been sustainable embedding of effective e-learning, the following levers were identified as particularly important: flexibility in practices that allow schools to contextualise their plans for change, the facilitation of communities of key staff and creating opportunities for staff to voice and challenge their beliefs about e-learning.

  17. Adapting to climate change in forest based land use systems: A guide to strategy

    Secrett, C M

    1997-12-31

    The prospect of climate change and sea level rise as a result of greenhouse gas emissions presents a serious challenge to decision-makers concerned with ensuring sustainable development. This report provides a guide to means of reducing the potential impact of the global warming problem on the forest sector whilst ensuring that more immediate development priorities are met. The most effective response strategy will be one that simultaneously brings both immediate development and longer-term adaptive benefits. This report outlines ways of constructing an adaptive response strategy that can help achieve these ends. The approach is referred to as sustainable adaptation. A prototype methodological framework of the sustainable adaptation approach has been provided with the summary. The first priority of sustainable adaption is to base climate change responses on actions that meet basic ecological and social needs now and in the future. Solutions should necessarily include relieving current development pressures in the tropical forest sector. The key is to couple adaptive responses to climate change with sustainable development solutions to present-day forest use problems. Implementing adaptive land-use policies and management practices which are likely to minimise the adverse impacts of anticipated climate change should meet current sustainable management goals. Implementing sustainable land-use and forestry management practices should meet adaptation goals. This report presents a discussion of the fundamental issues underlying the development of a sustainable adaptation strategy and a prototype methodological framework. The findings are based on case studies conducted in Central America (Costa Rica and Nicaragua); SADCC countries in Africa (Zimbabwe, Botswana, Tanzania); and Asia (Vietnam). 450 refs

  18. Adapting to climate change in forest based land use systems: A guide to strategy

    Secrett, C.M.

    1996-12-31

    The prospect of climate change and sea level rise as a result of greenhouse gas emissions presents a serious challenge to decision-makers concerned with ensuring sustainable development. This report provides a guide to means of reducing the potential impact of the global warming problem on the forest sector whilst ensuring that more immediate development priorities are met. The most effective response strategy will be one that simultaneously brings both immediate development and longer-term adaptive benefits. This report outlines ways of constructing an adaptive response strategy that can help achieve these ends. The approach is referred to as sustainable adaptation. A prototype methodological framework of the sustainable adaptation approach has been provided with the summary. The first priority of sustainable adaption is to base climate change responses on actions that meet basic ecological and social needs now and in the future. Solutions should necessarily include relieving current development pressures in the tropical forest sector. The key is to couple adaptive responses to climate change with sustainable development solutions to present-day forest use problems. Implementing adaptive land-use policies and management practices which are likely to minimise the adverse impacts of anticipated climate change should meet current sustainable management goals. Implementing sustainable land-use and forestry management practices should meet adaptation goals. This report presents a discussion of the fundamental issues underlying the development of a sustainable adaptation strategy and a prototype methodological framework. The findings are based on case studies conducted in Central America (Costa Rica and Nicaragua); SADCC countries in Africa (Zimbabwe, Botswana, Tanzania); and Asia (Vietnam). 450 refs

  19. Rhetorical Strategies of Consumer Activists: Reframing Market Offers to Promote Change

    Daiane Scaraboto

    2013-10-01

    Full Text Available Consumer researchers have most frequently looked at the influence the marketplace has on consumers’ identity projects, while the reverse process – how consumers’ identity projects influence the marketplace and general culture – is an important issue that has received less attention. Aiming to contribute to the development of this literature, we conduct a qualitative netnographic investigation of the Fat Acceptance Movement, an online-based movement led by consumer-activists who attempt to change societal attitudes about people who are fat. Our main goal is, therefore, to investigate how consumer activists who congregate online, that is, cyberactivists, reframe market offers while attempting to promote market and cultural change. We identify several rhetorical strategies employed by online consumer activists in their quests to change themselves, other consumers, and the broader culture. Our findings advance consumer research on how consumers may mobilize resources to initiate and promote self-, market-, and cultural transformations.

  20. Self-employed nurses as change agents in healthcare: strategies, consequences, and possibilities.

    Wall, Sarah

    2014-01-01

    The purpose of this paper is to report on ethnographic research that investigated how self-employed nurses perceive the contemporary healthcare field, what attributes they possess that facilitate their roles as change agents, what strategies they use to influence change, and what consequences they face for their actions, thus contributing to what is known about organizational change in institutionalized settings such as healthcare. Focussed ethnography was used to explore self-employed nurses' work experiences and elucidate the cultural elements of their social contexts, including customs, ideologies, beliefs, and knowledge and the ways that these impact upon the possibilities for change in the system. These self-employed nurses reflected on the shortcomings in the healthcare system and took entrepreneurial risks that would allow them to practice nursing according to their professional values. They used a number of strategies to influence change such as capitalizing on opportunities, preparing themselves for innovative work, managing and expanding the scope of nursing practice, and building new ideas on foundational nursing knowledge and experience. They had high job satisfaction and a strong sense of contribution but they faced significant resistance because of their non-traditional approach to nursing practice. Despite dramatic restructuring in the Canadian healthcare system, the system remains physician-centered and hospital-based. Nursing's professional potential has been largely untapped in any change efforts. Self-employed nurses have positioned themselves to deliver care based on nursing values and to promote alternative conceptions of health and healthcare. This study offers a rare exploration of this unique form of nursing practice and its potential to influence health system reform.

  1. Understanding the relationship of maternal health behavior change and intervention strategies in a Nicaraguan NGO network.

    Valadez, Joseph J; Hage, Jerald; Vargas, William

    2005-09-01

    Few studies of community interventions examine independent effects of investments in: (1) capital (i.e., physical, human and social capital), and (2) management systems (e.g., monitoring and evaluation systems (M&E)) on maternal and child health behavior change. This paper does this in the context of an inter-organizational network. In Nicaragua, international non-governmental organizations (NGOs) and local NGOs formed the NicaSalud Federation. Using Lot Quality Assurance Sampling (LQAS), 14 member organizations took baselines measures of maternal safe motherhood and child health behavior indicators during November 1999 and August 2000, respectively, and final evaluation measures in December 2001. In April 2002, retrospective interviews were conducted with supervisors and managers in the 14 organizations to explore changes made to community health strategies, factors associated with the changes, and impacts they attributed to participating in NicaSalud. Physical capital (density of health huts), human capital (density and variety of paramedical personnel) and social capital (density of health committees) were associated with pregnant women attending antenatal care (ANC) 3+ times, and/or retaining ANC cards. The variety of paramedic personnel was also associated with women making post-partum visits to clinics. Physical capital (density of health huts) and social capital (density of health committees and mothers' clubs) were associated with child diarrhea case management indicators. One safe motherhood indicator (delivery of babies by a clinician) was not associated with intervention strategies. At the management level, NicaSalud's training of members to use LQAS for M&E was associated with the number of strategic and tactical changes they subsequently made to interventions (organizational learning). Organizational learning was related to changes in maternal and child health behaviors of the women (including changes in the proportion using post-partum care). As the

  2. Three-Dimensional Assessment of Early Surgical Outcome in Repaired Unilateral Cleft Lip and Palate: Part 1. Nasal changes.

    Ayoub, Ashraf

    2010-08-11

    Abstract Objective: To evaluate 3D nasal morphology following primary reconstruction in children with unilateral cleft lip and palate relative to contemporaneous non-cleft data Design: Prospective, cross-sectional, controlled study. Setting: Glasgow Dental Hospital & School, Faculty of Medicine, Glasgow University Patients and Participants: Two groups of 3-year old children (21 with unilateral cleft lip and palate and 96 controls) with facial images taken using a 3D vision based capture technique. Methods: 3D images of the face were reflected so the cleft was on the left side to create a homogenous group for statistical analysis. Three-dimensional co-ordinates of anthropometric landmarks were extracted from facial images by a single operator. A set of linear measurements was utilised to compare cleft and control subjects on right and left sides, adjusting for sex differences Results: the mean nasal base width and the width of the nostril floor on right and left sides differed significantly between control and Unilateral Cleft Lip and Palate (UCLP) groups. The measurements were greater in UCLP children. The difference in the mean nasal height and mean nasal projection between the groups were not statistically significant. Mean columellar lengths were different between the left and right sides in UCLP cases. Conclusions: There were significant nasal deformities following the surgical repair of UCLP. Keywords: child, cleft lip and palate, three-dimensional imaging.

  3. Surgical competence.

    Patil, Nivritti G; Cheng, Stephen W K; Wong, John

    2003-08-01

    Recent high-profile cases have heightened the need for a formal structure to monitor achievement and maintenance of surgical competence. Logbooks, morbidity and mortality meetings, videos and direct observation of operations using a checklist, motion analysis devices, and virtual reality simulators are effective tools for teaching and evaluating surgical skills. As the operating theater is also a place for training, there must be protocols and guidelines, including mandatory standards for supervision, to ensure that patient care is not compromised. Patients appreciate frank communication and honesty from surgeons regarding their expertise and level of competence. To ensure that surgical competence is maintained and keeps pace with technologic advances, professional registration bodies have been promoting programs for recertification. They evaluate performance in practice, professional standing, and commitment to ongoing education.

  4. Strategy changing penalty promotes cooperation in spatial prisoner’s dilemma game

    Jin Qing; Wang Zhen; Wang Zhen; Wang Yiling

    2012-01-01

    Many classical studies suggest that punishment is a useful way to promote cooperation in the well-mixed public goods game, whereas relative evidence in the research of spatial prisoner’s dilemma game is absent. To address this issue, we introduce a mechanism of strategy changing penalty, combining memory and penalty during the update process, into spatial prisoner’s dilemma game. We find that increasing penalty rate or memory length is able to promote the evolution of cooperation monotonously. Compared with traditional version, recorded penalty could facilitate cooperation better. Moreover, through examining the process of evolution, we provide an interpretation for this promotion phenomenon, namely, the effect of promotion can be warranted by an evolution resonance of standard deviation of fitness coefficient. Finally, we validate our results by studying the impact of uncertainty within strategy adoptions on the evolution of cooperation. We hope that our work may shed light on the understanding of the cooperative behavior in the society.

  5. Regional adaptation strategies to climate change: Guidelines for urban planning in Serbia

    Maruna Marija

    2012-01-01

    Full Text Available The problems of climate change significantly alter the character of urban planning. While changes in the planning process are aimed at mechanisms for urgent action in the transformed circumstances in the sense of a deeper understanding of the causes of phenomena and prediction of future changes, modification of specific measures suppose to be related to the regulatory framework for new and existing construction that will lead to reduction in carbon dioxide emissions and the development of resistance to settlements' extreme impacts. The focus has shifted to land-use planning and the development and application of building regulations. It is considered that planning at the local level is an appropriate instrument for solving the problem of climate impacts in the community. In general, urban planning is an instrument of implementation of national strategies for mitigation and adaptation at the local level. Successful implementation of the strategy is based on a developed vertical and horizontal institutional and procedural coordination. In the circumstances of specific context of post-socialist urban restructuring, which is characterized by a lack of developed institutions and appropriate procedures, it is difficult to expect the entire application of prescribed procedures and harmonization of vertical and horizontal spatial development policies. Accordingly, it is recommended that policies be aimed at short-term improvements that are based on existing climate risk management and short-term projections of climate impacts. Among the main recommendations of the regional climate change adaptation strategies related to policy-makers in the field of urban development is to establish new and efficient use of existing legislation in the field of environment and planning. It is believed that most countries in the region have adequate legislation and efforts should be directed towards more effective implementation of existing planning and building

  6. Climate change, adaptation strategies and mobility: evidence from four settlements in Senegal

    Sall, Mohamadou [Universite Cheikh Anta Diop de Dakar (Senegal); Tall, Serigne Mansour [ONU-Habitat (UN); Tandian, Aly [Universite Gaston Berger de Saint-Louis (Senegal); Samb, Al Assane

    2011-11-15

    This research investigates the impact of climate change on the mobility of people in four settlements in Senegal: Ngueye Ngueye, Gandiole, the Senegal River delta and Ourossogui. A qualitative approach involving semi-structured interviews and focus groups was used to determine how daily life in these communities is being affected by environmental change. Some migrants spend long periods as far afield as Mauritania, the Gambia or Spain, while others stay closer to home, going to places like Saint-Louis, Dakar and Mbour for short periods. Mobility is an opportunity for migrants to generate funds and send money home. It is a key factor in adaptation to climate change, as a strategy for survival and for diversifying incomes. The problems encountered in the ecological study zones are not entirely due to climate change, for migration is also triggered by factors such as the opening of the breach in Saint-Louis or lack of support for rural development. However, climate change is certainly accelerating disruptions and transformations in the study sites. Moreover, while migrants' financial transfers help improve daily life for some families, they also increase socio-economic inequalities between households that include migrants and those that do not. People are moving away from (but not necessarily abandoning) purely agricultural livelihoods and seeking to diversify their sources of income. This may come from migration, or from artisanal activities undertaken in the locality - such as metalwork, woodwork, sewing or hairdressing. Another option that many women have taken is using micro-credit facilities to start processing local produce, crushing groundnuts and preparing cereals to sell at the weekly markets. Other adaptation strategies are developed and adopted through technical innovations or awareness-raising and educational activities. These activities often require institutional support from the State or from NGOs involved in implementing projects and helping

  7. Coping with child hunger in Canada: have household strategies changed over a decade?

    McIntyre, Lynn; Bartoo, Aaron C; Pow, Jody; Potestio, Melissa L

    2012-11-05

    To determine if household coping strategies for child hunger in Canada have changed over a decade (1996-2007). We applied t-tests to data derived from Cycle 2 (1996-1997; n=8165) and Cycle 7 (2006-2007; n=15,961) of the National Longitudinal Survey of Children and Youth (NLSCY) to determine changes in household coping strategies for child hunger. Data were restricted to households with children aged 2-9 years, allowing for cross-sectional analysis of two independent samples. Logistic regression was employed to estimate the odds of reporting child hunger for socio-demographic characteristics and the odds of using different coping strategies. The national prevalence of child hunger fell from 1.5% in 1997 to 0.7% in 2007 (phunger (increased child age and household size, lack of home ownership, low household income, lone-parent status, family dysfunction) and hunger frequency (regular versus occasional) were similar in both NLSCY cycles. Utilization of food banks and other community resources as a method of coping with child hunger remained static despite an increase in national food banks/affiliated agencies in Canada (2,141 in 1998 to 3,540 in 2007). In contrast, there was an increased reliance on reducing household food variety, an internal coping mechanism, to manage child hunger (17.6% Cycle 2 to 35.1% Cycle 7; p=0.03). Community outreach programs between 1997 and 2007 had little impact on coping strategies utilized by households facing child hunger. Our results indicate that current initiatives fail to reach these families.

  8. Envisioning Adaptive Strategies to Change: Participatory Scenarios for Agropastoral Semiarid Systems in Nicaragua

    Federica Ravera

    2011-03-01

    Full Text Available Historically, the semiarid social-ecological systems of the dry Central American corridor have proven resilient to pressures. However, in the last century, these systems have experienced huge environmental and socioeconomic changes that have increased the vulnerability of local livelihoods to shocks. New approaches are needed to capture complex, uncertain, cross-scale and nonlinear relationships among drivers of change and vulnerability. Therefore, to tackle this challenge, we have applied a participatory and interdisciplinary methodological framework of vulnerability assessment to a case study in northern Nicaragua. We triangulated a range of information and data from participatory and scientific research to explore historical and current drivers of changes that affect the system's components and indicators of vulnerability, represented in a 3-dimensional space in terms of ecological resilience, the socioeconomic ability of individuals to adapt to change, and an institutional capacity to buffer and respond to crisis. A projection of climatic changes combined with a participatory scenario analysis helped, then, to heuristically analyze tendencies of vulnerability in the future and to explore what policy options might enhance the system's adaptive capacity to face new pressures. Our work primarily contributes to an empirical understanding of key factors that influence vulnerability and learning about local strategies to adapt to change in semiarid agropastoral systems in Central America. We also make a methodological contribution by testing the use of a multidimensional vulnerability framework as a way of stimulating discussion among researchers, local stakeholders, and policy makers.

  9. More Becomes Less: Management Strategy Has Definitely Changed over the Past Decade of Splenic Injury—A Nationwide Population-Based Study

    Soo, Kwan-Ming; Lin, Tsung-Ying; Chen, Chao-Wen; Kuo, Liang-Chi; Wang, Jaw-Yuan; Lee, Wei-Che; Lin, Hsing-Lin

    2015-01-01

    Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X 2, P = 0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, P < 0.001, CI 1.017–1.049), with or without CT obtained (OR 0.347, P = 0.026, CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346, P = 0.043, CI 1.010–1.842). Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality. PMID:25629032

  10. Efficient local behavioral-change strategies to reduce the spread of epidemics in networks

    Bu, Yilei; Gregory, Steve; Mills, Harriet L.

    2013-10-01

    It has recently become established that the spread of infectious diseases between humans is affected not only by the pathogen itself but also by changes in behavior as the population becomes aware of the epidemic, for example, social distancing. It is also well known that community structure (the existence of relatively densely connected groups of vertices) in contact networks influences the spread of disease. We propose a set of local strategies for social distancing, based on community structure, that can be employed in the event of an epidemic to reduce the epidemic size. Unlike most social distancing methods, ours do not require individuals to know the disease state (infected or susceptible, etc.) of others, and we do not make the unrealistic assumption that the structure of the entire contact network is known. Instead, the recommended behavior change is based only on an individual's local view of the network. Each individual avoids contact with a fraction of his/her contacts, using knowledge of his/her local network to decide which contacts should be avoided. If the behavior change occurs only when an individual becomes ill or aware of the disease, these strategies can substantially reduce epidemic size with a relatively small cost, measured by the number of contacts avoided.

  11. Influence of smallholder farmers’ perceptions on adaptation strategies to climate change and policy implications in Zimbabwe

    Jiri Obert

    2017-01-01

    Full Text Available Smallholder agricultural production is largely affected by climate change and variability. Despite the negative effects brought by climate variability, smallholder farmers are still able to derive livelihoods. An understanding of factors that influence farmers’ responses and adaptation to climate variability can improve decision making for governments and development partners. This study investigated farmers’ perceptions and adaptation strategies to climate change and how these influence adaptation policies at local level. A survey was conducted with 100 households randomly selected from Chiredzi district. Data collected was used to derive farmer perceptions to climate change as well as the influence of their perceptions and subsequent adaptation methods to ensuing local agricultural adaptation measures and policies. The results indicated that smallholder farmers perceived general reduction in long-term annual rainfall and rising local average temperatures. Adverse trends in rainfall and average temperature perceived by farmers were consistent with empirical data. These perceptions and other socio-economic factors helped to shape smallholder farmer agricultural adaptation strategies. Policy implications are that the government and development partners should seek ways to assist autonomous adaptations by farmers through investments in planned adaptation initiatives.

  12. Concurrent inhibition of TGF-beta and mitogen driven signaling cascades in Dupuytren's disease - Non-surgical treatment strategies from a signaling point of view

    Krause, C.; Kloen, P.

    2012-01-01

    Dupuytren's disease (DD) is a benign progressive fibro-proliferative disorder of the fascia palmaris of the hand. Currently, treatment consists of surgical excision with a relatively high recurrence rate and risk of complications. To improve long-term outcome of DD treatment, research focus has

  13. Optimizing patient flow in a large hospital surgical centre by means of discrete-event computer simulation models.

    Ferreira, Rodrigo B; Coelli, Fernando C; Pereira, Wagner C A; Almeida, Renan M V R

    2008-12-01

    This study used the discrete-events computer simulation methodology to model a large hospital surgical centre (SC), in order to analyse the impact of increases in the number of post-anaesthetic beds (PABs), of changes in surgical room scheduling strategies and of increases in surgery numbers. The used inputs were: number of surgeries per day, type of surgical room scheduling, anaesthesia and surgery duration, surgical teams' specialty and number of PABs, and the main outputs were: number of surgeries per day, surgical rooms' use rate and blocking rate, surgical teams' use rate, patients' blocking rate, surgery delays (minutes) and the occurrence of postponed surgeries. Two basic strategies were implemented: in the first strategy, the number of PABs was increased under two assumptions: (a) following the scheduling plan actually used by the hospital (the 'rigid' scheduling - surgical rooms were previously assigned and assignments could not be changed) and (b) following a 'flexible' scheduling (surgical rooms, when available, could be freely used by any surgical team). In the second, the same analysis was performed, increasing the number of patients (up to the system 'feasible maximum') but fixing the number of PABs, in order to evaluate the impact of the number of patients over surgery delays. It was observed that the introduction of a flexible scheduling/increase in PABs would lead to a significant improvement in the SC productivity.

  14. Assessment of impact of climate change and adaptation strategies on maize production in Uganda

    Kikoyo, Duncan A.; Nobert, Joel

    2016-06-01

    Globally, various climatic studies have estimated a reduction of crop yields due to changes in surface temperature and precipitation especially for the developing countries which is heavily dependent on agriculture and lacks resources to counter the negative effects of climate change. Uganda's economy and the wellbeing of its populace depend on rain-fed agriculture which is susceptible to climate change. This study quantified the impacts of climate change and variability in Uganda and how coping strategies can enhance crop production against climate change and/or variability. The study used statistical methods to establish various climate change and variability indicators across the country, and uses the FAO AquaCrop model to simulate yields under possible future climate scenarios with and without adaptation strategies. Maize, the most widely grown crop was used for the study. Meteorological, soil and crop data were collected for various districts representing the maize growing ecological zones in the country. Based on this study, it was found that temperatures have increased by up to 1 °C across much of Uganda since the 1970s, with rates of warming around 0.3 °C per decade across the country. High altitude, low rainfall regions experience the highest level of warming, with over 0.5 °C/decade recorded in Kasese. Rainfall is variable and does not follow a specific significant increasing or decreasing trend. For both future climate scenarios, Maize yields will reduce in excess of 4.7% for the fast warming-low rainfall climates but increase on average by 3.5% for slow warming-high rainfall regions, by 2050. Improved soil fertility can improve yields by over 50% while mulching and use of surface water management practices improve yields by single digit percentages. The use of fertilizer application needs to go hand in hand with other water management strategies since more yields as a result of the improved soil fertility leads to increased water stress, especially

  15. Decision strategies for handling the uncertainty of future extreme rainfall under the influence of climate change

    Gregersen, Ida Bülow; Arnbjerg-Nielsen, Karsten

    2012-01-01

    Several extraordinary rainfall events have occurred in Denmark within the last few years. For each event, problems in urban areas occurred as the capacity of the existing drainage systems were exceeded. Adaptation to climate change is necessary but also very challenging as urban drainage systems...... are characterized by long technical lifetimes and high, unrecoverable construction costs. One of the most important barriers for the initiation and implementation of the adaptation strategies is therefore the uncertainty when predicting the magnitude of the extreme rainfall in the future. This challenge is explored...

  16. Medical library downsizing administrative, professional, and personal strategies for coping with change

    Schott, Michael

    2005-01-01

    Learn how to stay ahead of the game when budgets and staff are cut Medical Library Downsizing: Administrative, Professional, and Personal Strategies for Coping with Change explores corporate downsizing and other company-wide events as they relate to medical librarians in their organization. This training manual is designed to help librarians prepare for a new era where shrinking budgets, inflated journal costs, and the increasing demand for new and expensive services now put salaries and jobs at risk. While focused on health care issues, this book will appeal to a general library audience and

  17. Surgical Navigation

    Azarmehr, Iman; Stokbro, Kasper; Bell, R. Bryan

    2017-01-01

    Purpose: This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indicatio...

  18. Surgical Instrument

    Dankelman, J.; Horeman, T.

    2009-01-01

    The present invention relates to a surgical instrument for minimall-invasive surgery, comprising a handle, a shaft and an actuating part, characterised by a gastight cover surrounding the shaft, wherein the cover is provided with a coupler that has a feed- through opening with a loskable seal,

  19. Combating the effects of climatic change on forests by mitigation strategies

    Dieter Matthias

    2010-11-01

    Full Text Available Abstract Background Forests occur across diverse biomes, each of which shows a specific composition of plant communities associated with the particular climate regimes. Predicted future climate change will have impacts on the vulnerability and productivity of forests; in some regions higher temperatures will extend the growing season and thus improve forest productivity, while changed annual precipitation patterns may show disadvantageous effects in areas, where water availability is restricted. While adaptation of forests to predicted future climate scenarios has been intensively studied, less attention was paid to mitigation strategies such as the introduction of tree species well adapted to changing environmental conditions. Results We simulated the development of managed forest ecosystems in Germany for the time period between 2000 and 2100 under different forest management regimes and climate change scenarios. The management regimes reflect different rotation periods, harvesting intensities and species selection for reforestations. The climate change scenarios were taken from the IPCC's Special Report on Emission Scenarios (SRES. We used the scenarios A1B (rapid and successful economic development and B1 (high level of environmental and social consciousness combined with a globally coherent approach to a more sustainable development. Our results indicate that the effects of different climate change scenarios on the future productivity and species composition of German forests are minor compared to the effects of forest management. Conclusions The inherent natural adaptive capacity of forest ecosystems to changing environmental conditions is limited by the long life time of trees. Planting of adapted species and forest management will reduce the impact of predicted future climate change on forests.

  20. Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices.

    Lee, Christopher S; Gelow, Jill M; Chien, Christopher V; Hiatt, Shirin O; Bidwell, Julie T; Denfeld, Quin E; Grady, Kathleen L; Mudd, James O

    Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD. The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD. The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05). There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.

  1. Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention.

    Panter-Brick, Catherine; Clarke, Sian E; Lomas, Heather; Pinder, Margaret; Lindsay, Steve W

    2006-06-01

    Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (psocial ecology-of behaviour practices that are the bedrock of health interventions.

  2. Contextualising change through a common strategy: Lecturers' perceptions and key role in supporting academic reform

    Kindelan, Paz; Martin, Ana

    2014-05-01

    European universities are currently going through a process of change in order to meet the common goals set for higher education by the European Commission. They are revising their educational models to adjust them to the guidelines of the "Bologna Process" and are devising an institutional strategy for its implementation. In practical terms, this means aligning former national degrees and diplomas to standard European Bachelor and Masters degrees and PhD doctorates, by creating acknowledged professional qualification benchmarks that also include adjusted course lengths and contents. This process, in the end, mostly affects academic staff members who have a fundamental role to play in carrying out the pedagogical reforms on the teaching front. Besides presenting a commentary on the institutional approach of one particular technical university in Spain, the purpose of this paper is to propose, from the authors' point of view as lecturers, a strategy which has the potential to create a favourable atmosphere for carrying out such a reform. The article's main objective is to highlight a series of action points which may serve to reinforce and advance the main institutional strategy by relying on the powerful influence of its academic staff members.

  3. The impact of climate change on the strategies of the electricity industry

    2000-01-01

    This report is a compilation of the results of a questionnaire survey conducted among eight companies from the E7 and six electricity companies outside the E7, investigating how each company, within its own particular circumstances, deals with the climate change issue as a business issue, and the specific actions that are being taken by major electric companies to alleviate the effect of greenhouse gas emissions. In doing this survey, the E7 companies expect that the results demonstrate the role of electricity as an important means to reduce greenhouse gas emissions, the seriousness with which electric companies in both Annex I and non-Annex I countries view climate change mitigation measures as an important aspect of their corporate strategies, and the extent of cooperation among companies in the electricity sector worldwide as an effective and practical approach to reducing greenhouse gas emissions. 7 refs., 6 tabs., 11 figs

  4. Frequent change of procedure during coronary artery bypass surgery suggests insufficient preoperative diagnostic strategy

    Eckardt, Rozy; Kjeldsen, Bo Juel; Thayssen, Per

    2007-01-01

    We sought to evaluate how often and in what way surgeons change peroperatively their preoperative coronary artery bypass grafting strategy and to what degree these changes affect postoperative graft patency. A series of 109 patients with stable angina pectoris and at least one occluded coronary...... a discrepancy in 22% of the patients, resulting in a lower or higher number of grafts than pre-operatively estimated. The difference in shift rates between the three sites, left anterior descending, left circumflex, and right coronary artery, was significant (P=0.014). Patency rates were highest when only...... preoperatively planned grafts were inserted. When shifts occurred, no matter in which direction, it resulted in a decreased patency rate of the inserted grafts. This finding was significant for LAD (P=0.037). Our findings might indicate the necessity of future studies with the use of scintigraphy or fractional...

  5. Climate change in semi-arid Malawi: Perceptions, adaptation strategies and water governance

    Miriam K. Joshua

    2016-04-01

    Full Text Available Climate change and variability are a threat to sustainable agricultural production in semi-arid areas of Malawi. Overdependence on subsistence rain-fed agriculture in these areas calls for the identification of sustainable adaptation strategies. A study was therefore conducted in Chikwawa, a semi-arid district in southern Malawi, to: (1 assess community’s perception of a changing climate against empirical evidence, (2 determine their local adaptive measures, (3 evaluate the potential of irrigated agriculture as an adaptive measure in household food security and (4 challenges over access to available water resources. The study employed focus group discussions and key informant interviews to assess people’s perceptions of climate change and variability and their desired interventions. To validate the people’s perceptions, rainfall and temperature data for the period 1960–2010 were analysed. A participatory complete randomised experimental design in both rain-fed and dry season–irrigated conditions was conducted to assess a maize cropping system that would improve adaptation. The study established persistent declining yields from rain-fed production in part because of perennial rainfall failure. In response, the community has shifted its focus to irrigation as an adaptation strategy, which has in turn triggered water conflicts in the community over the control of the resource. Water legislation however fails to adequately provide for rules governing sharing of water resources between various stakeholders. This article therefore recommends development of an appropriate institutional framework that forms a strong basis for equitable distribution of water for irrigation in areas most vulnerable to extreme climate events – including droughts and floods. Keywords: Food Security; Climate Change and Variability; Rainfall Variability; Irrigation; Water Resources; Governance Crisis

  6. Scenarios Simulation of Spatio-Temporal Land Use Changes for Exploring Sustainable Management Strategies

    Yu Zhang

    2018-03-01

    Full Text Available Land use and land cover change have received considerable attention from global researchers in recent decades. The conflicts between different development strategies for land uses have become a problem that urgently needs to be solved, especially in those regions with a fragile ecological environment. The development of scenario simulations is essential in order to highlight possible alternative pathways for the future under the backgrounds of urbanization, economic growth and ecological protection. This study simulated land use changes for Tekes in 2020 with the Conversion of Land Use and its Effects at Small regional extent (CLUE-S model under a ‘business as usual’ scenario, cropland protection scenario, ecological security scenario, and artificial modification scenario. The results indicated that the spatial patterns of the land use types were explained well by the environment variables, and the selected models had a satisfactory accuracy in this study. The requirements and the patterns were quite different owing to the variation of the major objectives of the four scenarios. In addition to the constraint rules of the land use transformation, the hot point for land use change was its spatial coherency. Areas near to an existing land use type were more likely to transform to that type than those farther away. The increased cropland and urban land were mainly located around the current cropland and urban land while forests and grassland were more likely to occur in places with flat terrain and good hydrological conditions. The results could contribute to better insight into the relationships between land use changes and their driving factors and provide a scientific basis for regional management strategies and sustainable land use development.

  7. Teaching strategies and conceptual change in a professional development program for science teachers of K--8

    Shen, Ji

    This case study investigates two consecutive science courses for teachers of K-8 in a professional development program at Washington University. It aims (1) to trace the processes of the teachers' conceptual change; (2) to analyze the teaching strategies by course instructors; and (3) to try to establish possible links between the two. To achieve this goal, I build a modeling theory to account for the observations. The main body of the study consists of four sub-cases. The first two cases instantiate the elements of the modeling theory. The opening case of balance shows that learning tools and task structures shape the learning outcome, and discusses cycles of modeling. The case also delineates the strategy that the instructors employed---moving from concrete experience to abstract explanation. The second case of buoyancy demonstrates that the modeling theory is able to explain the origins and forming mechanism of the alternative conceptions held by the teachers. It also shows that the teaching strategies of using alternative conceptions, applying analogies and following a logical sequence helped the teachers build new models. The last two cases demonstrate the ways of improving the competence of modelers. The third case of physical models emphasizes the metacognition of the learner who builds models. It illustrates that teachers' level of self-awareness in learning is increased when the models are physical. It shows that the creativity of modeling is rooted in agency, curiosity, communicability, and confidence, and that a chain of transformation among models is the key of systematizing and forming knowledge. The last case of frames of reference tries to answer the question "what is the justification of models if there are alternatives?" The teachers employed different forms of justification which relied heavily on common sense, authority, relativism, and pragmatism, all of which are not rational. While discussing both the positive and negative traits of these

  8. ANALYTICAL AND SCIENTIFIC REVIEW OF PROJECTS AND PROGRAMMES ON CHANGES STRATEGY IMPLEMENTATION

    MLODETSKYY V. R.

    2017-01-01

    Full Text Available Formulation of the problem. Sustainable and successful functioning of the organization in today's competitive market conditions is possible if the organization is an open dynamic system capable of timely and adequately adapt to changes in the environment, this organization should initiate the implementation of innovations, both in production and organizational structure. Most suited for these conditions are project-oriented organizations, when the program's development strategy is developed with a detailed individual relatively independent stages, which are implemented as part of projects. In accordance with the development and improvement of the organization of control systems in the direction of increasing emphasis on the development strategy in relation to operating activities is an important task. Goal and tasks. Explore the hierarchical control system of project-oriented organization towards establishing information flows combine program management system with project management subsystems, included in this program. Conclusions. Concretized the concept of "program" and "project" as a result assumed that the program management is a permanent process in the organization that is adaptable to external changes, and project management (as defined is temporary, so the project management structure are subject to program management structures and are not permanent in the organization's management system.

  9. Changes in photosynthetic performance and antioxidative strategies during maturation of Norway maple (Acer platanoides L.) leaves.

    Lepeduš, Hrvoje; Gaća, Vlatka; Viljevac, Marija; Kovač, Spomenka; Fulgosi, Hrvoje; Simić, Domagoj; Jurković, Vlatka; Cesar, Vera

    2011-04-01

    Different structural and functional changes take place during leaf development. Since some of them are highly connected to oxidative metabolism, regulation of reactive oxygen species (ROS) abundance is required. Most of the reactive oxygen species ROS in plant cells are produced in chloroplasts as a result of highly energetic reactions of photosynthesis. The aim of our study was to examine the changes in concentration of oxidative stress parameters (TBARS - thiobarbituric acid-reacting substances and protein carbonyls) as well as antioxidative strategies during development of maple (Acer platanoides L.) leaves in the light of their enhanced photosynthetic performance. We reveal that biogenesis of the photosynthetic apparatus during maple leaf maturation corresponded with oxidative damage of lipids, but not proteins. In addition, antioxidative responses in young leaves differed from that in older leaves. Young leaves had high values of non-photochemical quenching (NPQ) and catalase (CAT, EC 1.11.1.6) activity which declined during the maturation process. Developing leaves were characterized by an increase in TBARS level, the content of non-enzymatic antioxidants as well as ascorbate peroxidase activity (APX, EC 1.11.1.11), while the content of protein carbonyls decreased with leaf maturation. Fully developed leaves had the highest lipid peroxidation level accompanied by a maximum in ascorbic acid content and superoxide dismutase activity (SOD, EC1.15.1.1). These observations imply completely different antioxidative strategies during leaf maturation enabling them to perform their basic function. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

  10. Switch between life history strategies due to changes in glycolytic enzyme gene dosage in Saccharomyces cerevisiae.

    Wang, Shaoxiao; Spor, Aymé; Nidelet, Thibault; Montalent, Pierre; Dillmann, Christine; de Vienne, Dominique; Sicard, Delphine

    2011-01-01

    Adaptation is the process whereby a population or species becomes better fitted to its habitat through modifications of various life history traits which can be positively or negatively correlated. The molecular factors underlying these covariations remain to be elucidated. Using Saccharomyces cerevisiae as a model system, we have investigated the effects on life history traits of varying the dosage of genes involved in the transformation of resources into energy. Changing gene dosage for each of three glycolytic enzyme genes (hexokinase 2, phosphoglucose isomerase, and fructose-1,6-bisphosphate aldolase) resulted in variation in enzyme activities, glucose consumption rate, and life history traits (growth rate, carrying capacity, and cell size). However, the range of effects depended on which enzyme was expressed differently. Most interestingly, these changes revealed a genetic trade-off between carrying capacity and cell size, supporting the discovery of two extreme life history strategies already described in yeast populations: the "ants," which have lower glycolytic gene dosage, take up glucose slowly, and have a small cell size but reach a high carrying capacity, and the "grasshoppers," which have higher glycolytic gene dosage, consume glucose more rapidly, and allocate it to a larger cell size but reach a lower carrying capacity. These results demonstrate antagonist pleiotropy for glycolytic genes and show that altered dosage of a single gene drives a switch between two life history strategies in yeast.

  11. Spot market natural gas strategies and reliability dealing with changing industry conditions

    McClure, D.C.

    1992-01-01

    Many in the energy industry thought the natural gas buying game had finally settled down to a predictable pattern in the 90's. After a tumultuous decade in the 80's they are ready to turn their attention to new challenges such as electricity wheeling and cogeneration. They were wrong. There is plenty of change left in the natural gas industry for the rest of the century. This growth will dramatically increase the number of options available to Energy Buyers, giving them new flexibility to design programs that meet goals for cost reduction, supply reliability, and administrative effort. However, with new options also come the responsibility for choices. Energy Managers of well designed gas programs will make these choices after careful consideration of the pro's and con's of each option. In short, the effective Buyer will develop a natural gas strategy. This report will begin by reviewing the basic types of change occurring in the industry, and then discuss some of the varied strategy options available to the Energy Buyer

  12. Climate change adaptation strategies for federal forests of the Pacific Northwest, USA: ecological, policy, and socio-economic perspectives

    Thomas A. Spies; Thomas W. Giesen; Frederick J. Swanson; Jerry F. Franklin; Denise Lach; K. Norman. Johnson

    2010-01-01

    Conserving biological diversity in a changing climate poses major challenges for land managers and society. Effective adaptive strategies for dealing with climate change require a socioecological systems perspective. We highlight some of the projected ecological responses to climate change in the Pacific Northwest, U.S.A and identify possible adaptive actions that...

  13. Antimicrobial prescribing patterns of surgical speciality in a tertiary care hospital in India: Role of persuasive intervention for changing antibiotic prescription behaviour

    Chand Wattal

    2017-01-01

    Full Text Available Background: Inappropriate use of antibiotics globally has been linked to increase in antibiotic resistance. Objectives: This interventional study assessed the impact of antibiotic prescription feedback and focus group discussions (FGD on hospital-based prescribers before and after the FGD. Study Design: The present study was performed at a tertiary care centre in New Delhi, wherein 45 units from surgical specialities were included for FGD. Thirty-five units were assessed for the antibiotic usage during 12 months pre-intervention and 3 and 6 months post-intervention period. The outcome measured was a change in antibiotic prescription rates reflected as daily defined doses per 100 bed days as defined by the World Health Organisation. Results: Reduction in the level of antibiotic consumption was observed in 15 of 35 units (42.85% during the 3 months post-intervention period, which was significant (P < 0.05 in 3/35 (8.57% surgical units. A significant reduction (P < 0.05 was observed for the units of endoscopic gynaecology, super-speciality and transplant surgery units B and C, and orthopaedic unit C during the 6 months period. Decreasing trend (P < 0.05 was observed in 2/35 (5.71% units during the entire period. Overall reduction of antibiotic consumption (1.88% was observed, with an increase in the use of low-end antibiotics and a decrease in the use of high-end antibiotics. Conclusion: The present study clearly demonstrates a weak impact of FGD in changing antibiotic prescribing behaviour. Further analysis of the sustainability of FGD and its long-term impact on antimicrobial resistance needs to be evaluated. The effect of continuous educational sessions and multifaceted interventions cannot be ignored.

  14. Change of practice patterns in urology with the introduction of the Da Vinci surgical system: the Greek NHS experience in debt crisis era.

    Deligiannis, Dimitros; Anastasiou, Ioannis; Mygdalis, Vasileios; Fragkiadis, Evangelos; Stravodimos, Konstantinos

    2015-03-31

    To determine the attitudinal change for urologic surgery in Greece since the introduction of the da Vinci Surgical System (DVS). We describe contemporary trends at public hospital level, the initial Greek experience, while at the same time Greece is in economic crisis and funding is under austerity measures. We retrospectively analyzed annualized case log data on urologic procedures, between 2008 (installation of the DVS) and 2013, from "Laiko'' Hospital in Athens. We evaluated, using summary statistics, trends and institutional status regarding robot-assisted surgery (RAS). We also analyzed the relationship between the introduction of RAS and change in total volume of procedures performed. 1578 of the urological procedures performed at "Laiko'' Hospital were pooled, 1342 (85%) being open and 236 RAS (15%). We observed a 6-fold increase in the number of RAS performed, from 7% of the total procedural volume (14/212) in 2008 to 30% (96/331) in 2013. For radical prostatectomy, in 2008 2% were robot-assisted and 98% open while in 2013, 46% and 54% respectively. Pyeloplasty was performed more often using the robot-assisted method since 2010. RAS-dedicated surgeons increased both RAS and the total number of procedures they performed. From 86 in 2008 to 145 in 2013, with 57% of them being RAS in 2013 as compared to 13 % in 2008. Robot-assisted surgery has integrated into the armamentarium for urologic surgery in Greece at public hospital level. Surgical robot acquisition is also associated with increased volume of procedures, especially prostatectomy, despite the ongoing debate over cost-effectiveness, during economic crisis and International Monetary Fund (IFN) era.

  15. Change of practice patterns in urology with the introduction of the Da Vinci surgical system: the Greek NHS experience in debt crisis era

    Dimitros Deligiannis

    2015-03-01

    Full Text Available Objective: To determine the attitudinal change for urologic surgery in Greece since the introduction of the da Vinci Surgical System (DVS. We describe contemporary trends at public hospital level, the initial Greek experience, while at the same time Greece is in economic crisis and funding is under austerity measures. Materials and Methods: We retrospectively analyzed annualized case log data on urologic procedures, between 2008 (installation of the DVS and 2013, from “Laiko’’ Hospital in Athens. We evaluated, using summary statistics, trends and institutional status regarding robot-assisted surgery (RAS. We also analyzed the relationship between the introduction of RAS and change in total volume of procedures performed. Results: 1578 of the urological procedures performed at “Laiko’’ Hospital were pooled, 1342 (85% being open and 236 RAS (15%. We observed a 6-fold increase in the number of RAS performed, from 7% of the total procedural volume (14/212 in 2008 to 30% (96/331 in 2013. For radical prostatectomy, in 2008 2% were robot-assisted and 98% open while in 2013, 46% and 54% respectively. Pyeloplasty was performed more often using the robot-assisted method since 2010. RAS-dedicated surgeons increased both RAS and the total number of procedures they performed. From 86 in 2008 to 145 in 2013, with 57% of them being RAS in 2013 as compared to 13 % in 2008. Conclusions: Robot-assisted surgery has integrated into the armamentarium for urologic surgery in Greece at public hospital level. Surgical robot acquisition is also associated with increased volume of procedures, especially prostatectomy, despite the ongoing debate over cost-effectiveness, during economic crisis and International Monetary Fund (IFN era.

  16. Book review: Policy Entrepreneurs and Strategies for Change: The Case of Water Management in the Netherlands

    Meissner, Richard

    2015-07-01

    Full Text Available are Stijn’s ‘new typology’ of policy entrepreneur strategies (pp. 54–64), under four categories: attention- and support-seeking strategies, linking strategies, relational management strategies and arena strategies (p. 64). I am not sure whether Stijn...

  17. Surgical Strategies in the Treatment of Gynecomastia Grade I-II: The Combination of Liposuction and Subcutaneous Mastectomy Provides Excellent Patient Outcome and Satisfaction.

    Schröder, Lars; Rudlowski, Christian; Walgenbach-Brünagel, Gisela; Leutner, Claudia; Kuhn, Walther; Walgenbach, Klaus-Jürgen

    2015-07-01

    Gynecomastia (GM) is a benign condition with glandular tissue enlargement of the male breast. GM is classified into 4 grades of increasing severity. We describe a series of GM grade I-II, diagnosed, treated surgically and analyzed regarding feasibility, complication rate, and satisfaction. From 2005 to 2012, a chart review was performed for 53 patients. Preoperative examination included endocrine and urological examination and exclusion of other pathological conditions. The surgical technique consisted of liposuction through an inframammarian-fold incision and excision of the glandular tissue by a minimal periareolar approach. A total number of 53 male patients with 104 breasts were available for analysis. By liposuction, a median of 300 ml (range: 10-1000 ml) was aspirated from each breast and 25.1 g (range: 3-233 g) gland tissue was resected. Surgery lasted between 25 and 164 min per patient (median: 72 min). 2 postoperative hemorrhages occurred (n = 2, 3.8%). 2 patients underwent re-operation due to cosmetic reasons (n = 2, 3.8%). This analysis demonstrates that treatment of GM grade I-II can easily be performed by liposuction combined with subcutaneous resection of the glandular tissue as a minimally invasive and low-impact surgical treatment with a low rate of complications and excellent patient satisfaction. Preoperative workup is important to rule out specific diseases or malignancy causing the GM.

  18. The Climaware project: Impacts of climate change on water resources management - regional strategies and European view

    Thirel, Guillaume; D'Agostino, Daniela; Démerliac, Stéphane; Dorchies, David; Flörke, Martina; Jay-Allemand, Maxime; Jost, Claudine; Kehr, Katrin; Perrin, Charles; Scardigno, Alessandra; Schneider, Christof; Theobald, Stephan; Träbing, Klaus

    2014-05-01

    Climate projections produced with CMIP5 and applied by the Intergovernmental Panel on Climate Change (IPCC) in its fifth assessment report indicate that changes in precipitation and temperature are expected to occur throughout Europe in the 21th century, with a likely decrease of water availability in many regions. Besides, water demand is also expected to increase, in link with these expected climate modifications, but also due to socio-economic and demographic changes. In this respect, the use of future freshwater resources may not be sustainable from the current water management perspective. Therefore adaptation strategies will most likely be needed to cope with these evolutions. In this context, the main objective of the ClimAware project (2010-2013 - www.uni-kassel.de/fb14/wasserbau/CLIMAWARE/, a project implemented within the IWRM-NET Funding Initiative) was to analyse the impacts of climate change (CC) on freshwater resources at the continental and regional scales and to identify efficient adaptation strategies to improve water management for various socio-economic sectors. This should contribute to a more effective implementation of the Water Framework Directive (WFD) and its instruments (river basin management plans, programmes of measures). The project developed integrated measures for improved freshwater management under CC constraints. More specifically, the objectives of the ClimAware project were to: • elaborate quantitative projections of changes in river flows and consequences such as flood frequency, drought occurrence and sectorial water uses. • analyse the effect of CC on the hydromorphological reference conditions of rivers and therefore the definition of "good status". • define management rules/strategies concerning dam management and irrigation practices on different time perspectives. • investigate uncertainties in climate model - scenario combinations. The research approach considered both European and regional perspectives, to get

  19. Climate change and eHealth: a promising strategy for health sector mitigation and adaptation

    Åsa Holmner

    2012-06-01

    Full Text Available Climate change is one of today's most pressing global issues. Policies to guide mitigation and adaptation are needed to avoid the devastating impacts of climate change. The health sector is a significant contributor to greenhouse gas emissions in developed countries, and its climate impact in low-income countries is growing steadily. This paper reviews and discusses the literature regarding health sector mitigation potential, known and hypothetical co-benefits, and the potential of health information technology, such as eHealth, in climate change mitigation and adaptation. The promising role of eHealth as an adaptation strategy to reduce societal vulnerability to climate change, and the link's between mitigation and adaptation, are also discussed. The topic of environmental eHealth has gained little attention to date, despite its potential to contribute to more sustainable and green health care. A growing number of local and global initiatives on ‘green information and communication technology (ICT’ are now mentioning eHealth as a promising technology with the potential to reduce emission rates from ICT use. However, the embracing of eHealth is slow because of limitations in technological infrastructure, capacity and political will. Further research on potential emissions reductions and co-benefits with green ICT, in terms of health outcomes and economic effectiveness, would be valuable to guide development and implementation of eHealth in health sector mitigation and adaptation policies.

  20. Climate change and eHealth: a promising strategy for health sector mitigation and adaptation

    Holmner, Åsa; Rocklöv, Joacim; Ng, Nawi; Nilsson, Maria

    2012-01-01

    Climate change is one of today's most pressing global issues. Policies to guide mitigation and adaptation are needed to avoid the devastating impacts of climate change. The health sector is a significant contributor to greenhouse gas emissions in developed countries, and its climate impact in low-income countries is growing steadily. This paper reviews and discusses the literature regarding health sector mitigation potential, known and hypothetical co-benefits, and the potential of health information technology, such as eHealth, in climate change mitigation and adaptation. The promising role of eHealth as an adaptation strategy to reduce societal vulnerability to climate change, and the link's between mitigation and adaptation, are also discussed. The topic of environmental eHealth has gained little attention to date, despite its potential to contribute to more sustainable and green health care. A growing number of local and global initiatives on ‘green information and communication technology (ICT)’ are now mentioning eHealth as a promising technology with the potential to reduce emission rates from ICT use. However, the embracing of eHealth is slow because of limitations in technological infrastructure, capacity and political will. Further research on potential emissions reductions and co-benefits with green ICT, in terms of health outcomes and economic effectiveness, would be valuable to guide development and implementation of eHealth in health sector mitigation and adaptation policies. PMID:22679398

  1. Dynamic modelling of water demand, water availability and adaptation strategies for power plants to global change

    Koch, Hagen; Voegele, Stefan

    2009-01-01

    According to the latest IPCC reports, the frequency of hot and dry periods will increase in many regions of the world in the future. For power plant operators, the increasing possibility of water shortages is an important challenge that they have to face. Shortages of electricity due to water shortages could have an influence on industries as well as on private households. Climate change impact analyses must analyse the climate effects on power plants and possible adaptation strategies for the power generation sector. Power plants have lifetimes of several decades. Their water demand changes with climate parameters in the short- and medium-term. In the long-term, the water demand will change as old units are phased out and new generating units appear in their place. In this paper, we describe the integration of functions for the calculation of the water demand of power plants into a water resources management model. Also included are both short-term reactive and long-term planned adaptation. This integration allows us to simulate the interconnection between the water demand of power plants and water resources management, i.e. water availability. Economic evaluation functions for water shortages are also integrated into the water resources management model. This coupled model enables us to analyse scenarios of socio-economic and climate change, as well as the effects of water management actions. (author)

  2. Leadership change: A case study analysis of strategy and control systems development

    Alaudin Ahmadasri

    2017-01-01

    Full Text Available This paper reports on how a change of leadership at the CEO-level influences strategic practices and control systems development. The case study describes how the new chief executive developed and communicated his vision and strategy through control systems and structural change. The findings indicate that senior employees’ involvement in strategic plan development (through SLT mechanism in this case brought clarity and assurance to them. Meetings are important control mechanisms to structure the sharing of information and to enhance employee commitment and help decision making. It is argued leadership manifests through the interactions of leader with employees in many control practices. The findings have implications for family-owned businesses that are facing imminent change in leadership. They benefit founders/top managers that are about to change leadership of entrepreneurial firm to the next level by highlighting the importance of preparing leader’s capacity for an effective leadership role. The study also highlights some important factors which are seldom discussed in control theories.

  3. Dental work force strategies during a period of change and uncertainty.

    Brown, L J

    2001-12-01

    Both supply and demand influence the ability of the dental work force to adequately and efficiently provide dental care to a U.S. population growing in size and diversity. Major changes are occurring on both sides of the dental care market. Among factors shaping the demand for dental care are changing disease patterns, shifting population demographics, the extent and features of third-party payment, and growth of the economy and the population. The capacity of the dental work force to provide care is influenced by enhancements of productivity and numbers of dental health personnel, as well as their demographic and practice characteristics. The full impact of these changes is difficult to predict. The dentist-to-population ratio does not reflect all the factors that must be considered to develop an effective dental work force policy. Nationally, the dental work force is likely to be adequate for the next several years, but regional work force imbalances appear to exist and may get worse. Against this backdrop of change and uncertainty, future dental work force strategies should strive for short-term responsiveness while avoiding long-term inflexibility. Trends in the work force must be continually monitored. Thorough analysis is required, and action should be taken when necessary.

  4. The Empowerment Strategy for The Food Crop Farmers in Anticipating The Climate Change

    Efriyani Sumastuti

    2015-12-01

    Full Text Available In Indonesia, the climate change and the global warming like changes in the pattern and distribution of the rainfall give impacts on agricultural production at large, especially in the food crops. These also cause droughts, floods, landslides, forest fires, rising temperatures in urban areas, and rising sea levels. The above impacts are felt by the farmers because those can lead to a decrease in production even the crop failure. This research aims to develop an empowerment strategy of the food crop farmers in anticipating the climate change in Central Java. The data used is the primary data obtained through in-depth interviews with key-person and the Focus Group Discussion (FGD. The Analysis Hierarchy Process (AHP is conducted to determine the program priorities and strate gies. The result of research shows that anticipating the climate change should be synergistically conducted in four aspects: human resources, technology, institutional and production, by involving various groups in the society. Various groups can be grouped into academics, businessmen / private sectors, government and community of food crop farmers / society.

  5. Values under seige in Mexico: strategies for sheltering traditional values from change.

    Hubbell, L J

    1993-01-01

    The adverse economic conditions of inflation and falling oil prices over the late 1970s and 1980s in Mexico forced many middle-class married women out of the home and into the workplace in order to help the family maintain its socioeconomic standing. Although this phenomenon ran directly against the traditional Mexican cultural construction of gender and family, many Uruapan middle-class couples had no alternative and rationalized the change by concealing, reinterpreting, or not directly challenging traditional values. Sections discuss the dilemma of middle-class families, Mexican middle-class adaptation to wives' employment, strategies for existing change in values, and the open acceptance of changed values. The author's comments and conclusions are based largely upon interviews with 16 married women of the period. It is concluded that even though the middle class resists them, changes have taken place over the past 20 years in the acceptance of married women in the workplace, the sharing of domestic work, fertility control, and equality between spouses in family decision making. It remains to be seen, however, whether these women will stop working and return to their formerly exclusive roles of wives and mothers if and when economic conditions improve in Mexico.

  6. A Health Care Project Management Office's Strategies for Continual Change and Continuous Improvement.

    Lavoie-Tremblay, Mélanie; Aubry, Monique; Richer, Marie-Claire; Cyr, Guylaine

    Health care organizations need project and change management support in order to achieve successful transformations. A project management office (PMO) helps support the organizations through their transformations along with increasing their capabilities in project and change management. The aim of the present study was to extend understanding of the continuous improvement mechanisms used by PMOs and to describe PMO's strategies for continual change and continuous improvement in the context of major transformation in health care. This study is a descriptive case study design with interviews conducted from October to December 2015 with PMO's members (3 managers and 1 director) and 3 clients working with the PMO after a major redevelopment project ended (transition to the new facility). Participants suggested a number of elements including carefully selecting the members of the PMO, having a clear mandate for the PMO, having a method and a discipline at the same time as allowing openness and flexibility, clearly prioritizing projects, optimizing collaboration, planning for everything the PMO will need, not overlooking organizational culture, and retaining the existing support model. This study presents a number of factors ensuring the sustainability of changes.

  7. Changes in motor unit recruitment strategy during pain alters force direction.

    Tucker, Kylie J; Hodges, Paul W

    2010-10-01

    Motor unit (MU) recruitment is altered (decreased discharge rate and cessation of discharge in some units, and recruitment of new units) in force-matched contractions during pain compared to contractions performed before pain. As MU's within a motoneurone pool have different force direction properties we hypothesised that altered MU recruitment during experimental knee pain would change the force vector (total force (F(T)): amplitude and angle) generated by the quadriceps. Force was produced at two levels during 1 × 60-s and 3 × 10-s isometric contractions of knee extensors, and recorded by two force transducers at right angles. This enabled calculation of both F(E) (extension force) and F(T). MU recruitment was recorded from the medial and lateral vastii with four fine-wire electrodes. Pain was induced by hypertonic saline injection in the infra-patella fat pad. Nine subjects matched F(E) and six subjects also matched both medial and lateral forces (F(T)) before and during pain. Changes in MU discharge pattern (decreased discharge rate (Precruitment of new units) during pain were associated with a ∼5° change in absolute force angle. As force angle changed in both directions (left/right) for individual subjects with pain there was no change in average F(T) amplitude between conditions. When both medial and lateral forces were matched MU discharge rate decreased (Punits ceased firing or were newly recruited during pain. Change in motoneurone recruitment during pain alters direction of muscle force. This may be a strategy to avoid pain or protect the painful part. Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.

  8. Increasing of Urban Radiation due to Climate Change and Reduction Strategy using Vegetation

    Park, C.; Lee, D.; Heo, H. K.; Ahn, S.

    2017-12-01

    Urban Heat Island (UHI) which means urban air temperature is higher than suburban area is one of the most important environmental issues in Urban. High density of buildings and high ratio of impervious surfaces increases the radiation fluxes in urban canopy. Furthermore, climate change is expected to make UHI even more seriously in the future. Increased irradiation and air temperature cause high amount of short wave and long wave radiation, respectively. This increases net radiation negatively affects heat condition of pedestrian. UHI threatens citizen's health by increasing violence and heat related diseases. For this reason, understanding how much urban radiation will increase in the future, and exploring radiation reduction strategies is important for reducing UHI. In this research, we aim to reveal how the radiation flux in the urban canyon will change as the climate change and determine how much of urban vegetation will be needed to cover this degradation. The study area is a commercial district in Seoul where highly populated area. Due to the high density of buildings and lack of urban vegetation, this area has a poor thermal condition in summer. In this research, we simulate the radiation flux on the ground using multi-layer urban canopy model. Unlike conventionally used urban canopy model to simulate radiation transfer using vertically single layer, the multi-layer model we used here, enables to consider the vertical heterogeneous of buildings and urban vegetation. As a result, net radiation of urban ground will be increase 2.1 W/m² in the 2050s and 2.7 W/m² in the 2100s. And to prevent the increase of radiation, it is revealed that the urban vegetation should by increased by 10%. This research will be valuable in establishing greening planning as a strategy to reduce UHI effect.

  9. Delivering step change improvements to UK low level waste strategy - 16188

    Dean, Jason; Rossiter, David

    2009-01-01

    The UK Nuclear Industry continues to produce significant quantities of Low Level Waste (LLW) as decommissioning projects generating waste become more prevalent. Current infrastructure and projected increasing waste volumes will deliver a volumetric shortfall of storage capacity in the near future. Recently established as a standalone site licence company, the Low Level Waste Repository (LLWR) near Drigg, in West Cumbria (formerly operated and owned by British Nuclear Group) is tasked with managing the safe treatment and disposal of LLW in the UK, on behalf of the Nuclear Decommissioning Authority (NDA). The problem is complex involving many stakeholders with potentially different priorities. Previously, most nuclear waste generators operated independently with limited integration with other similar organisations. However, the current financial, programme and technical pressures require collaborative working to facilitate a step-change improvement in LLW management. Achieving this quickly is as much of a challenge as delivering robust cost effective technical solutions. NDA is working in partnership with LLWR to develop a LLW Strategy for the Nuclear Industry and has in parallel commissioned a number of studies by the National Nuclear Laboratory (NNL), looking at opportunities to share best practice. A National Strategy Group has been established to develop a working partnership between the Nuclear Decommissioning Authority, LLW Repository Ltd, Regulators, Stakeholders and LLW Consignors, promoting innovation, value for money, and robust implementation of the waste hierarchy (avoid-reduce-re-use-recycle). Additionally the LLWR supported by the NNL have undertaken a comprehensive strategic review of the UK's LLW management activities. Initial collaborative work has provided for the first time a detailed picture of the existing strategic baseline and identified significant national benefits from improving the way LLW is forecasted, characterised, segregated, and

  10. Health coping strategies of the people vulnerable to climate change in a resource-poor rural setting in Bangladesh

    Haque, Md Aminul; Budi, Aji; Azam Malik, Ahmad; Suzanne Yamamoto, Shelby; Louis, Val?rie R; Sauerborn, Rainer

    2013-01-01

    Background Among the many challenges faced by the people of Bangladesh, the effects of climate change are discernibly threatening, impacting on human settlement, agricultural production, economic development, and human health. Bangladesh is a low-income country with limited resources; its vulnerability to climate change has influenced individuals to seek out health coping strategies. The objectives of the study were to explore the different strategies/measures people employ to cope with clima...

  11. Device-length changes and implant function following surgical implantation of the KineSpring in cadaver knees

    McNicholas MJ

    2015-01-01

    Full Text Available Michael J McNicholas,1 Stefan M Gabriel,2 Anton G Clifford,2 Evelyne M Hasler2 1Aintree University Hospital, Teaching Hospital, Major Trauma Centre, NHS Foundation Trust, Liverpool, UK; 2Moximed, Hayward, CA, USA Introduction: The KineSpring implant system has been shown to provide load reductions at the medial compartment of the knee, and has demonstrated clinical success in reducing pain and increasing function in patients with medial knee osteoarthritis. These results depend on the ability of the KineSpring to rotate, lengthen, and shorten to accommodate knee motions, and in response to knee position and loading. Purpose: The present study was undertaken to determine length changes of the implanted KineSpring in response to a range of knee positions, external knee loads, and placements by different orthopedic surgeons. Materials and methods: KineSpring system components were implanted in ten cadaver leg specimens by ten orthopedic surgeons, and absorber-length changes were measured under combined loading and in different positions of the knee. Results and conclusion: Spring compression consistent with knee-load reduction, and device lengthening and shortening to accommodate knee loads and motions were seen. These confirm the functionality of the KineSpring when implanted medially to the knee. Keywords: KineSpring, knee, function, preservation, offloading, osteoarthritis

  12. Establishment of an indicator concept for the German strategy on adaptation to climate change

    Schoenthaler, Konstanze; Andrian-Werburg, Stefan von; Wulfert, Katrin [Bosch und Partner GmbH, Muenchen (Germany); Luthardt, Vera; Kreinsen, Beatrice; Schultz-Sternberg, R.; Hommel, Robert [Hochschule fuer Nachhaltige Entwicklung Eberswalde (Germany)

    2010-11-15

    Even if we succeed in achieving the EU target of reducing global warming to 2 C, it will be absolutely essential to adapt to changing climatic conditions. The greenhouse gases currently present in the atmosphere will influence the climate in coming decades. The day on which it is quite clear which climatic scenario prevails, so that it is possible to model all relevant processes down to regional level, will be the day on which it is too late to adapt to the actual scenario. Our endeavours to adapt to climate change do not mean, however, that we can neglect to take measures in order to reduce the output of greenhouse gases. It is important to remember that on their own, neither adaptation nor mitigation can prevent the grave impacts resulting from climate change. In fact, they complement each other meaningfully thus helping to alleviate the risks of climate change. On 17th December 2008 the German Federal Cabinet adopted the DAS (German Strategy for the Adaptation to Climate Change), (Bundesregierung 2008). The DAS has created the framework for adapting to the consequences of climate change in Germany. First and fore-most, the DAS contributes its guidelines at Federal level, to provide a guideline for agents at other levels. The Strategy lays the foundation for a medium-term process. In conjunction with the individual Federal States and other groups representing various sectors of society, the Strategy provides a step-by-step assessment of the risks of climate change. Furthermore, it states the potential requirements for action, and defines the appropriate goals and potential adaptation measures to be developed and implemented in this process. In due course, the Federal Environment Agency (UBA) will design a comprehensive set of tools to support and advance the DAS. An integral part of this will be the Special Information System 'Adaptation' (FISKA) and an Indicator System to aid adaptation. The latter is one of the key tasks identified for the DAS. As far

  13. The politics of indigeneity: Indigenous strategies for inclusion in climate change negotiations

    Doolittle Amity

    2010-01-01

    Full Text Available Indigenous environmental activists have clearly articulated their views on global climate change policy. The content of these views was explored during the 10-day 2008 World Conservation Congress (WCC in Barcelona. Data were primarily collected through interviews and participant observation. In addition, policy statements and declarations made by indigenous environmental activists from 2000 to 2009 were analysed to place the perspectives of indigenous leaders and environmental activists in the context of their decade-long struggle to gain negotiating power at the United Nations Framework Convention on Climate Change. This study examines the rhetorical strategies indigenous leaders from around the world use to gain political recognition and legitimacy in climate change negotiations. Two core principles, relating to a particular representation of indigenous environmental knowledge are identified as fundamental rhetorical tools. These are a belief that the earth is a living being with rights and the conviction that it is the responsibility of indigenous peoples to protect the earth from over-exploitation. However, reference to indigenous environmental knowledge is not the only rhetorical mechanism used by indigenous leaders in the climate debates. When faced with specific United Nations policies to combat climate change that could have a profound impact on their land rights, some indigenous leaders adopt a more confrontational response. Fearing that new polices would reinforce historical trends of marginalisation, indigenous leaders seeking recognition in climate change debates speak less about their ecological knowledge and responsibility to the earth and more about their shared histories of political and economic marginalisation and land dispossession, experienced first through colonialism and more recently through globalisation.

  14. Climate change science education across schools, campuses, and centers: strategies and successes

    Merrill, J.; Harcourt, P.; Rogers, M.; Buttram, J.; Petrone, C.; Veron, D. E.; Sezen-Barrie, A.; Stylinski, C.; Ozbay, G.

    2016-02-01

    With established partnerships in higher education, K-12, and informal science education communities across Delaware and Maryland, the NSF-funded MADE CLEAR project (Maryland Delaware Climate Change Education, Assessment, and Research) has instituted a suite of professional development strategies to bring climate change science into science education methods courses, K-12 classrooms, university lecture halls, and public park facilities. MADE CLEAR partners have provided consistent climate literacy topics (mechanisms, human contributions, local and global impacts, mitigation and adaptation) while meeting the unique needs of each professional community. In-person topical lectures, hands-on work with classroom materials, seed funding for development of new education kits, and on-line live and recorded sessions are some of the tools employed by the team to meet those needs and build enduring capacity for climate change science education. The scope of expertise of the MADE CLEAR team, with climate scientists, educators, learning scientists, and managers has provided not only PD tailored for each education audience, but has also created, fostered, and strengthened relationships across those audiences for long-term sustainability of the newly-built capacity. Specific examples include new climate change programs planned for implementation across Delaware State Parks that will be consistent with middle school curriculum; integration of climate change topics into science methods classes for pre-service teachers at four universities; and active K-12 and informal science education teams working to cooperatively develop lessons that apply informal science education techniques and formal education pedagogy. Evaluations by participants highlight the utility of personal connections, access to experts, mentoring and models for developing implementation plans.

  15. The diversity of gendered adaptation strategies to climate change of Indian farmers: A feminist intersectional approach.

    Ravera, Federica; Martín-López, Berta; Pascual, Unai; Drucker, Adam

    2016-12-01

    This paper examines climate change adaptation and gender issues through an application of a feminist intersectional approach. This approach permits the identification of diverse adaptation responses arising from the existence of multiple and fragmented dimensions of identity (including gender) that intersect with power relations to shape situation-specific interactions between farmers and ecosystems. Based on results from contrasting research cases in Bihar and Uttarakhand, India, this paper demonstrates, inter alia, that there are geographically determined gendered preferences and adoption strategies regarding adaptation options and that these are influenced by the socio-ecological context and institutional dynamics. Intersecting identities, such as caste, wealth, age and gender, influence decisions and reveal power dynamics and negotiation within the household and the community, as well as barriers to adaptation among groups. Overall, the findings suggest that a feminist intersectional approach does appear to be useful and worth further exploration in the context of climate change adaptation. In particular, future research could benefit from more emphasis on a nuanced analysis of the intra-gender differences that shape adaptive capacity to climate change.

  16. Effects of climate change on rice production and strategies for adaptation in southern China

    Jin, Z.; Ge, D.; Chen, H.; Fang, J. [Jiangsu Academy of Agricultural Sciences (China)

    1995-12-31

    The CERES-rice (Oryza sativa L.) model was calibrated and validated for nine sites in southern China to examine its suitability to model rice production in this area, using agronomic data from more than three successive years. After determining the genetic coefficients for the cultivars, the CERES-rice model was run a second time for the same locations for a time period of 20 to 30 yr. The model used local climate data (1958--1986) and doubled-CO{sub 2} climate change scenarios generated from the Goddard Institute for Space Studies (GISS), Geophysical Fluid dynamics Laboratory (GFDL), and United Kingdom Meteorological Office (UKMO) global climate models (GCMs), with and without supplemental irrigation(to model paddy and upland rice, respectively). The study estimated the potential impacts of climate change on rice production by comparing the base runs with the runs under the three doubled-CO{sub 2} GCM scenarios and it considered the physiological effects of CO{sub 2} on rice growth in each GCM scenario. Finally, the study examined several strategies for adapting to climate change.

  17. Changes in cigarette expenditure minimising strategies before and after a cigarette tax increase.

    Choi, Kelvin; Boyle, Raymond G

    2018-01-01

    Smokers use cigarette expenditure minimising strategies (CEMS) to alleviate the effect of tax increases on their cigarette expenses. We examined changes in smokers' CEMS use before and after a 2013 Minnesota $1.75 cigarette tax increase. Data were from representative samples of smokers who participated in the Minnesota Adult Tobacco Survey 2010 (n=948) and 2014 (n=1229). Participants indicated CEMS used in the past year from a list. Weighted multiple logistic regressions were used to examine changes in prevalence of each CEMS use over time adjusting for demographics and cigarette consumption. Characteristics associated with CEMS use in 2014 were examined. Between 2010 and 2014, more smokers tried to save money on cigarettes by rolling their own cigarettes (from 19% to 29%), using other tobacco products (from 13% to 25%), and buying cigarettes from cheaper places (from 48% to 55%). Yet, fewer smokers used coupons/promotions (from 63% to 50%) and bought cigarettes by the carton (from 39% to 32%). These changes varied somewhat by race/ethnicity and education, for example, more smokers with tax increase. Regulations that would reduce CEMS use could boost the effectiveness of cigarette tax increases. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  18. Climate change implications of shifting forest management strategy in a boreal forest ecosystem of Norway.

    Bright, Ryan M; Antón-Fernández, Clara; Astrup, Rasmus; Cherubini, Francesco; Kvalevåg, Maria; Strømman, Anders H

    2014-02-01

    Empirical models alongside remotely sensed and station measured meteorological observations are employed to investigate both the local and global direct climate change impacts of alternative forest management strategies within a boreal ecosystem of eastern Norway. Stand-level analysis is firstly executed to attribute differences in daily, seasonal, and annual mean surface temperatures to differences in surface intrinsic biophysical properties across conifer, deciduous, and clear-cut sites. Relative to a conifer site, a slight local cooling of −0.13 °C at a deciduous site and −0.25 °C at a clear-cut site were observed over a 6-year period, which were mostly attributed to a higher albedo throughout the year. When monthly mean albedo trajectories over the entire managed forest landscape were taken into consideration, we found that strategies promoting natural regeneration of coniferous sites with native deciduous species led to substantial global direct climate cooling benefits relative to those maintaining current silviculture regimes – despite predicted long-term regional warming feedbacks and a reduced albedo in spring and autumn months. The magnitude and duration of the cooling benefit depended largely on whether management strategies jointly promoted an enhanced material supply over business-as-usual levels. Expressed in terms of an equivalent CO2 emission pulse at the start of the simulation, the net climate response at the end of the 21st century spanned −8 to −159 Tg-CO2-eq., depending on whether near-term harvest levels increased or followed current trends, respectively. This magnitude equates to approximately −20 to −300% of Norway's annual domestic (production) emission impact. Our analysis supports the assertion that a carbon-only focus in the design and implementation of forest management policy in boreal and other climatically similar regions can be counterproductive – and at best – suboptimal if boreal forests are to be used as a

  19. Does investment in leaf defenses drive changes in leaf economic strategy? A focus on whole-plant ontogeny.

    Mason, Chase M; Donovan, Lisa A

    2015-04-01

    Leaf defenses have long been studied in the context of plant growth rate, resource availability, and optimal investment theory. Likewise, one of the central modern paradigms of plant ecophysiology, the leaf economics spectrum (LES), has been extensively studied in the context of these factors across ecological scales ranging from global species data sets to temporal shifts within individuals. Despite strong physiological links between LES strategy and leaf defenses in structure, function, and resource investment, the relationship between these trait classes has not been well explored. This study investigates the relationship between leaf defenses and LES strategy across whole-plant ontogeny in three diverse Helianthus species known to exhibit dramatic ontogenetic shifts in LES strategy, focusing primarily on physical and quantitative chemical defenses. Plants were grown under controlled environmental conditions and sampled for LES and defense traits at four ontogenetic stages. Defenses were found to shift strongly with ontogeny, and to correlate strongly with LES strategy. More advanced ontogenetic stages with more conservative LES strategy leaves had higher tannin activity and toughness in all species, and higher leaf dry matter content in two of three species. Modeling results in two species support the conclusion that changes in defenses drive changes in LES strategy through ontogeny, and in one species that changes in defenses and LES strategy are likely independently driven by ontogeny. Results of this study support the hypothesis that leaf-level allocation to defenses might be an important determinant of leaf economic traits, where high investment in defenses drives a conservative LES strategy.

  20. Asthma management simulation for children: translating theory, methods, and strategies to effect behavior change.

    Shegog, Ross; Bartholomew, L Kay; Gold, Robert S; Pierrel, Elaine; Parcel, Guy S; Sockrider, Marianna M; Czyzewski, Danita I; Fernandez, Maria E; Berlin, Nina J; Abramson, Stuart

    2006-01-01

    Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

  1. Rational choice and the political bases of changing Israeli counterinsurgency strategy.

    Brym, Robert J; Andersen, Robert

    2011-09-01

    Israeli counterinsurgency doctrine holds that the persistent use of credible threat and disproportionate military force results in repeated victories that eventually teach the enemy the futility of aggression. The doctrine thus endorses classical rational choice theory's claim that narrow cost-benefit calculations shape fixed action rationales. This paper assesses whether Israel's strategic practice reflects its counterinsurgency doctrine by exploring the historical record and the association between Israeli and Palestinian deaths due to low-intensity warfare. In contrast to the expectations of classical rational choice theory, the evidence suggests that institutional, cultural and historical forces routinely override simple cost-benefit calculations. Changing domestic and international circumstances periodically cause revisions in counterinsurgency strategy. Credible threat and disproportionate military force lack the predicted long-term effect. © London School of Economics and Political Science 2011.

  2. Can investments in health systems strategies lead to changes in immunization coverage?

    Brenzel, Logan

    2014-04-01

    National immunization programs in developing countries have made major strides to immunize the world's children, increasing full coverage to 83% of children. However, the World Health Organization estimates that 22 million children less than five years of age are left unvaccinated, and coverage levels have been plateauing for nearly a decade. This paper describes the evidence on factors contributing to low vaccination uptake, and describes the connection between these factors and the documented strategies and interventions that can lead to changes in immunization outcomes. The author suggests that investments in these areas may contribute more effectively to immunization coverage and also have positive spill-over benefits for health systems. The paper concludes that while some good quality evidence exists of what works and may contribute to immunization outcomes, the quality of evidence needs to improve and major gaps need to be addressed.

  3. Surgical Instrument Sets for Special Operations Expeditionary Surgical Teams.

    Hale, Diane F; Sexton, Justin C; Benavides, Linda C; Benavides, Jerry M; Lundy, Jonathan B

    The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments. 2017.

  4. Age-associated changes in obstacle negotiation strategies: Does size and timing matter?

    Maidan, I; Eyal, S; Kurz, I; Geffen, N; Gazit, E; Ravid, L; Giladi, N; Mirelman, A; Hausdorff, J M

    2018-01-01

    Tripping over an obstacle is one of the most common causes of falls among older adults. However, the effects of aging, obstacle height and anticipation time on negotiation strategies have not been systematically evaluated. Twenty older adults (ages: 77.7±3.4years; 50% women) and twenty young adults (age: 29.3±3.8years; 50% women) walked through an obstacle course while negotiating anticipated and unanticipated obstacles at heights of 25mm and 75mm. Kinect cameras captured the: (1) distance of the subject's trailing foot before the obstacles, (2) distance of the leading foot after the obstacles, (3) clearance of the leading foot above the obstacles, and (4) clearance of the trailing foot above the obstacles. Linear-mix models assessed changes between groups and conditions. Older adults placed their leading foot closer to the obstacle after landing, compared to young adults (p<0.001). This pattern was enhanced in high obstacles (group*height interaction, p=0.033). Older adults had lower clearance over the obstacles, compared to young adults (p=0.007). This was more pronounced during unanticipated obstacles (group*ART interaction, p=0.003). The distance of the leading foot and clearance of the trailing foot after the obstacles were correlated with motor, cognitive, and functional abilities. These findings suggest that there are age-related changes in obstacle crossing strategies that are dependent on the specific characteristics of the obstacle. The results have important implications for clinical practice, suggesting that functional exercise should include obstacle negotiation training with variable practice of height and available response times. Further studies are needed to better understand the effects of motor and cognitive abilities. Copyright © 2017 Elsevier B.V. All rights reserved.

  5. A structural equation model to integrate changes in functional strategies during old-field succession.

    Vile, Denis; Shipley, Bill; Garnier, Eric

    2006-02-01

    From a functional perspective, changes in abundance, and ultimately species replacement, during succession are a consequence of integrated suites of traits conferring different relative ecological advantages as the environment changes over time. Here we use structural equations to model the interspecific relationships between these integrated functional traits using 34 herbaceous species from a Mediterranean old-field succession and thus quantify the notion of a plant strategy. We measured plant traits related to plant vegetative and reproductive size, leaf functioning, reproductive phenology, seed mass, and production on 15 individuals per species monitored during one growing season. The resulting structural equation model successfully accounts for the pattern of trait covariation during the first 45 years post-abandonment using just two forcing variables: time since site abandonment and seed mass; no association between time since field abandonment and seed mass was observed over these herbaceous stages of secondary succession. All other predicted traits values are determined by these two variables and the cause-effect linkage between them. Adding pre-reproductive vegetative mass as a third forcing variable noticeably increased the predictive power of the model. Increasing the time after abandonment favors species with increasing life span and pre-reproductive biomass and decreasing specific leaf area. Allometric coefficients relating vegetative and reproductive components of plant size were in accordance with allometry theory. The model confirmed the trade-off between seed mass and seed number. Maximum plant height and seed mass were major determinants of reproductive phenology. Our results show that beyond verbal conceptualization, plant ecological strategies can be quantified and modeled.

  6. USGS Environmental health science strategy: providing environmental health science for a changing world: public review release

    Bright, Patricia R.; Buxton, Herbert T.; Balistrieri, Laurie S.; Barber, Larry B.; Chapelle, Francis H.; Cross, Paul C.; Krabbenhoft, David P.; Plumlee, Geoffrey S.; Sleeman, Jonathan M.; Tillitt, Donald E.; Toccalino, Patricia L.; Winton, James R.

    2012-01-01

    disasters. * Strategic Science Action 2. - Enhance methods to anticipate, prepare for, and identify environmental, ecological, and related health impacts of future disasters. This strategy is one of seven USGS science strategies developed concurrently: * Climate and Land Use Change * Core Science Systems * Ecosystems * Energy and Mineral Resources * Environmental Health * Natural Hazards * Water. This strategy describes how USGS will address the highest priority environmental health issues facing the Nation. The ultimate intended outcome of this science strategy is prevention and reduction of adverse impacts to the quality of the environment, the health of our living resources, and human health. Communication with, and receiving input from, partners and stakeholders regarding their science needs is essential for successful implementation of this strategy. It is incumbent on USGS to reach out to all stakeholders to ensure that USGS efforts are focused on the highest priority environmental health issues and that products are provided in the most timely and usable form to all those who can use them. USGS must reach out to the scientific community, internally and externally, to ensure that our efforts are integrated with and take full advantage of the activities of others.

  7. Mirror image extradural hematoma in elderly population: management strategy with surgical bilateral or unilateral evacuation or conservative treatment modality with literature review

    Satyarthee Guru Dutta

    2017-12-01

    Full Text Available Extradural hematomas (EDH represent one of common imaging findings in cases sustaining traumatic brain injury. Bilateral extradural haematoma is considered rare and even rarer in elder people male. Bilateral extradural hematoma is usually acute, and generally associated with severe traumatic head injury. Mirror-image extradural hematomas (MEDH constitute a special type of bilateral extradural hamatomas, which is placed anatomically symmetrically on both the sides of the intracranial compartment, requires prompt diagnosis and emergent surgical intervention as it carry high mortality if evacuation of hematoma is not carried out expeditely. The mortality rate still remains higher in comparison to unilateral single extradural hematomas. The postoperative outcome depends on preoperative neurological status, total volume of blood, accurate diagnosis and prompt shifting to neurosurgical facility, expatiation of surgical procedure, pre- hospital care. Authors report a case of a - 65-year-old man who presented with acute simultaneous bilateral extradural haematomas following road traffic accident, underwent bilateral trephine craniotomy and simultaneous evacuation on both side led to good recovery.

  8. Changes after surgically-assisted maxillary expansion (SARME) to the dentoalveolar, palatal and nasal structures by using tooth-borne distraction devices.

    Seeberger, Robin; Kater, Wolfgang; Schulte-Geers, Michael; Davids, Rolf; Freier, Kolja; Thiele, Oliver

    2011-07-01

    Different devices are available to aid surgically-assisted maxillary expansion. In this study we have evaluated the changes to the anchoring teeth, the hard palate, and the lower nasal passage made by tooth-borne distraction devices. Thirty-one patients (mean (SD) age 28 (2) years) with deficiencies in the transverse width of the maxilla were examined by computed tomography and cone beam scans before and after operation. The data were analysed with the help of Wilcoxon's signed rank test and Spearman's r correlation. The mean (SD) distraction width was 6.5 (2.3) mm. All anchorage teeth were tilted (pdistraction width, with changes in the intercoronal and interapical distances of the anchoring premolars (pdistraction width and the overall gain in width of the lower nasal passage (pmaxillary expansion with tooth-borne devices has significant effects on the anchoring teeth, the nasal floor, and the hard palate. Both tilting of the teeth and an evenly distributed movement of the segments were seen. Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

  9. Evaluation of co-benefits from combined climate change and air pollution reduction strategies

    Leitao, Joana; Van Dingenen, Rita; Dentener, Frank; Rao, Shilpa

    2014-05-01

    The connection of climate change and air pollution is becoming more relevant in the process of policy making and implementation of emission control strategies because of resulting co-benefits and trade-offs. Some sectors, such as fossil fuel combustion, are sources of both pollutants (NOx and PM) as well as greenhouse gas (CO2). Additionally, the use of wood burning as biofuel to reduce climate impact may in fact deteriorate air quality. Furthermore, several air pollutants are important radiative forcers and regulating their emissions impacts on climate. It is evident that both problems need to be undertaken with a common strategy and the existence of cross-policy with co-benefits may encourage their implementation. The LIMITS FP7 project (http://www.feem-project.net/limits/index.html) was designed with the main goal of assessing strategies for reduction of GHG emissions so that the 2°C target can be achieved. The work developed focus on the evaluation of the implementation of strategies analysing several aspects of different scenarios, namely: the feasibility of low carbon scenarios in terms of available technologies and infrastructure, the required financial mechanisms, and also the co-benefits regarding energy security, economic development and air pollution. For the latter, five integrated assessment models (IAMs) provided greenhouse gases and pollutant emission values for several scenarios. These were based on air pollution scenarios defined according to stringency and implementation of future global legislation. They which were also combined with 2 climate policy scenarios (no climate policy and 2.8 W/m2 target). The former are mostly focused on non-climate policies and technical control measures for emissions of air pollutants, such as PM2.5, NOx and SO2, with their emission factors harmonized between the IAMs. With the global air quality source-receptor model TM5-FASST the impact of the resulting emissions was analysed and the co-benefits of combined

  10. Object-Based Change Detection in Urban Areas: The Effects of Segmentation Strategy, Scale, and Feature Space on Unsupervised Methods

    Lei Ma

    2016-09-01

    Full Text Available Object-based change detection (OBCD has recently been receiving increasing attention as a result of rapid improvements in the resolution of remote sensing data. However, some OBCD issues relating to the segmentation of high-resolution images remain to be explored. For example, segmentation units derived using different segmentation strategies, segmentation scales, feature space, and change detection methods have rarely been assessed. In this study, we have tested four common unsupervised change detection methods using different segmentation strategies and a series of segmentation scale parameters on two WorldView-2 images of urban areas. We have also evaluated the effect of adding extra textural and Normalized Difference Vegetation Index (NDVI information instead of using only spectral information. Our results indicated that change detection methods performed better at a medium scale than at a fine scale where close to the pixel size. Multivariate Alteration Detection (MAD always outperformed the other methods tested, at the same confidence level. The overall accuracy appeared to benefit from using a two-date segmentation strategy rather than single-date segmentation. Adding textural and NDVI information appeared to reduce detection accuracy, but the magnitude of this reduction was not consistent across the different unsupervised methods and segmentation strategies. We conclude that a two-date segmentation strategy is useful for change detection in high-resolution imagery, but that the optimization of thresholds is critical for unsupervised change detection methods. Advanced methods need be explored that can take advantage of additional textural or other parameters.

  11. Model-based scenario planning to develop climate change adaptation strategies for rare plant populations in grassland reserves

    Laura Phillips-Mao; Susan M. Galatowitsch; Stephanie A. Snyder; Robert G. Haight

    2016-01-01

    Incorporating climate change into conservation decision-making at site and population scales is challenging due to uncertainties associated with localized climate change impacts and population responses to multiple interacting impacts and adaptation strategies. We explore the use of spatially explicit population models to facilitate scenario analysis, a conservation...

  12. Behavior Change Strategies for Successful Long-Term Weight Loss: Focusing on Dietary and Physical Activity Adherence, Not Weight Loss

    Hongu, Nobuko; Kataura, Martha P.; Block, Linda M.

    2011-01-01

    This article helps Extension professionals guide individuals in a successful long-term weight loss program. A program should focus on behavioral changes (improving eating habits and physical activity), not just weight loss. In order to do this, Extension professionals should implement behavior change strategies that motivate individuals to…

  13. Changes in Student Perceptions and Study Strategies Over Time in a Veterinary Clinical Pathology Course Using Case-Based Instruction.

    Fernandez, Nicole J; Wagg, Catherine R; Warren, Amy L

    2018-06-13

    Veterinary students are challenged to develop new, nonlinear ways of thinking as they learn diagnostic reasoning skills. To support this process, we use real-life cases in our clinical pathology course. Changes in student perceptions regarding the use of cases and changes in study strategies over time have not been previously investigated or compared to student grades. Students participated in three voluntary online surveys that included 4-point Likert scale questions and open-ended questions on the helpfulness of cases for learning and study strategies used during the course. We used Friedman tests to detect any differences in perceptions over time; McNemar's test and "Wilcoxon signed-rank tests were used to detect any differences in study strategies over time. Fisher's exact tests'were used to examine the association between the Likert scale responses and grades in quartiles. Before beginning the course, 29% of students responded that cases were very helpful to their learning, with similar "responses for helpfulness in applying course material and grasping important concepts. There was a significant trend of increasing positivity over the duration of the course, with 74% responding that cases were very helpful at the end of the course. The most-reported study strategy was working individually on cases before the midterm (74% of students), and the most helpful study strategy was attending class regularly (88% reported it as very "helpful). Study strategies did not change significantly over time. Overall, perceptions and study strategies did not vary significantly with grades.

  14. Novice medical students: individual patterns in the use of learning strategies and how they change during the first academic year.

    Fabry, Götz; Giesler, Marianne

    2012-01-01

    Adequate use of different learning strategies is one of the most important prerequisites of academic success. The actual use of learning strategies is the result of an interaction between individual and situational variables. Against this background we conducted a longitudinal study with first year medical students to investigate whether individuals show different patterns in their use of learning strategies and whether these patterns change during the first academic year. Medical students (N=175, 58% female) were surveyed three times in their first academic year regarding their use of learning strategies. A hierarchical cluster analysis (Ward) was conducted in order to identify groups of students with different patterns of learning strategies. We identified four different patterns in approaches to learning among novice medical students ("easy-going", "flexible", "problematic" and "hardworking" learners). Compared to their peers, the problematic learners had the worst final school grades. In addition changes in the use of learning strategies were identified, most of them occurred during the first term. Students start their academic studies with different patterns of learning strategies; the characteristics of these patterns change during the first academic year. Further research is necessary to better understand how individual and situational variables determine students' learning.

  15. Enabling long-term oceanographic research: Changing data practices, information management strategies and informatics

    Baker, Karen S.; Chandler, Cynthia L.

    2008-09-01

    Interdisciplinary global ocean science requires new ways of thinking about data and data management. With new data policies and growing technological capabilities, datasets of increasing variety and complexity are being made available digitally and data management is coming to be recognized as an integral part of scientific research. To meet the changing expectations of scientists collecting data and of data reuse by others, collaborative strategies involving diverse teams of information professionals are developing. These changes are stimulating the growth of information infrastructures that support multi-scale sampling, data repositories, and data integration. Two examples of oceanographic projects incorporating data management in partnership with science programs are discussed: the Palmer Station Long-Term Ecological Research program (Palmer LTER) and the United States Joint Global Ocean Flux Study (US JGOFS). Lessons learned from a decade of data management within these communities provide an experience base from which to develop information management strategies—short-term and long-term. Ocean Informatics provides one example of a conceptual framework for managing the complexities inherent to sharing oceanographic data. Elements are introduced that address the economies-of-scale and the complexities-of-scale pertinent to a broader vision of information management and scientific research.

  16. Videogame training strategy-induced change in brain function during a complex visuomotor task.

    Lee, Hyunkyu; Voss, Michelle W; Prakash, Ruchika Shaurya; Boot, Walter R; Vo, Loan T K; Basak, Chandramallika; Vanpatter, Matt; Gratton, Gabriele; Fabiani, Monica; Kramer, Arthur F

    2012-07-01

    Although changes in brain function induced by cognitive training have been examined, functional plasticity associated with specific training strategies is still relatively unexplored. In this study, we examined changes in brain function during a complex visuomotor task following training using the Space Fortress video game. To assess brain function, participants completed functional magnetic resonance imaging (fMRI) before and after 30 h of training with one of two training regimens: Hybrid Variable-Priority Training (HVT), with a focus on improving specific skills and managing task priority, or Full Emphasis Training (FET), in which participants simply practiced the game to obtain the highest overall score. Control participants received only 6 h of FET. Compared to FET, HVT learners reached higher performance on the game and showed less brain activation in areas related to visuo-spatial attention and goal-directed movement after training. Compared to the control group, HVT exhibited less brain activation in right dorsolateral prefrontal cortex (DLPFC), coupled with greater performance improvement. Region-of-interest analysis revealed that the reduction in brain activation was correlated with improved performance on the task. This study sheds light on the neurobiological mechanisms of improved learning from directed training (HVT) over non-directed training (FET), which is related to visuo-spatial attention and goal-directed motor planning, while separating the practice-based benefit, which is related to executive control and rule management. Copyright © 2012 Elsevier B.V. All rights reserved.

  17. Will Transition of Staple Food Strategy in China Really Mitigate Global Climate Change?

    Liu, B.; Zhao, D.

    2017-12-01

    With the increase in agricultural demand, reducing greenhouse gas (GHG) emissions is a vital challenge in mitigating climate change. Potato staple food strategy in China introduced by Ministry of Agriculture in 2015 is to gradually adjust staple food structure, which provides an opportunity to meet with the challenge. Apart from staple food structure, difference on energy, material input, geography, and crop management are essential to determine agriculture's contribution to climate change. In this study, we conduct a life cycle analysis of four staple foods in China, namely rice, wheat, maize, and potato, to develop crop-specific estimates of GHG emissions and GHG intensity by using `Production intensity' (carbon dioxide equivalent emissions per kilocalorie produced), to help us understand potential synergies and frictions between food producing and climate mitigation. Data used in this study is on city / province levels if city level is unavailable in 2015. First, we evaluate GHG reductions due to transition of staple food structure in China. Staple food GHG emissions in China are 546.90 Tg CO2e yr-1 in 2015, with 47.6%, 21.9%, 27.3% and 3.2% from rice, wheat, maize and potato. Mean production intensity of staple food is 0.45 Mg CO2e M kcal-1 in 2015. Maize leads the intensity with 0.77 Mg CO2e M kcal-1, followed by rice (0.49 Mg CO2e M kcal-1), wheat (0.28 Mg CO2e M kcal-1) and potato (0.24 Mg CO2e M kcal-1). After staple food structure adjustment, 25 Tg CO2e yr-1 (4.2%) reduction will be accomplished in 2020 without any crop management improvement. Further reduction (33.3% - 40.4%) could be achieved with crop management improvement. In addition, because of staple food structure switching, native rice production will decline, which might lead to more export from countries with higher production intensity. Estimated emission leakage from rice import is 30.10 Tg CO2e yr-1, exceeds emission reduction in native China. Therefore, potato staple food strategy could

  18. Ancient cellular structures and modern humans: change of survival strategies before prolonged low solar activity period

    Ragulskaya, Mariya; Rudenchik, Evgeniy; Gromozova, Elena; Voychuk, Sergei; Kachur, Tatiana

    The study of biotropic effects of modern space weather carries the information about the rhythms and features of adaptation of early biological systems to the outer space influence. The influence of cosmic rays, ultraviolet waves and geomagnetic field on early life has its signs in modern biosphere processes. These phenomena could be experimentally studied on present-day biological objects. Particularly inorganic polyphosphates, so-called "fossil molecules", attracts special attention as the most ancient molecules which arose in inanimate nature and have been accompanying biological objects at all stages of evolution. Polyphosphates-containing graves of yeast's cells of Saccharomyces cerevisiae strain Y-517, , from the Ukrainian Collection of Microorganisms was studied by daily measurements during 2000-2013 years. The IZMIRAN daily data base of physiological parameters dynamics during 2000-2013 years were analyzed simultaneously (25 people). The analysis showed significant simultaneous changes of the statistical parameters of the studied biological systems in 2004 -2006. The similarity of simultaneous changes of adaptation strategies of human organism and the cell structures of Saccharomyces cerevisiae during the 23-24 cycles of solar activity are discussed. This phenomenon could be due to a replacement of bio-effective parameters of space weather during the change from 23rd to 24th solar activity cycle and nonstandard geophysical peculiarities of the 24th solar activity cycle. It could be suggested that the observed similarity arose as the optimization of evolution selection of the living systems in expectation of probable prolonged period of low solar activity (4-6 cycles of solar activity).

  19. FTO genotype, dietary protein, and change in appetite: the Preventing Overweight Using Novel Dietary Strategies trial.

    Huang, Tao; Qi, Qibin; Li, Yanping; Hu, Frank B; Bray, George A; Sacks, Frank M; Williamson, Donald A; Qi, Lu

    2014-05-01

    A common obesity-risk variant rs9939609 in the fat mass- and obesity-associated (FTO) gene was recently shown to affect appetite, and the gene is sensitive to the regulation of amino acids. We examined the interaction between FTO genotype and protein intake on the long-term changes in appetite in a randomized controlled trial. We genotyped FTO rs9939609 in 737 overweight adults in the 2-y Preventing Overweight Using Novel Dietary Strategies trial and assessed 4 appetite-related traits including cravings, fullness, hunger, and prospective consumption. We showed that dietary protein significantly modified genetic effects on changes in food cravings and appetite scores at 6 mo after adjustment for age, sex, ethnicity, baseline body mass index, weight change, and baseline value for respective outcomes (P-interaction = 0.027 and 0.048, respectively). The A allele was associated with a greater decrease in food cravings and appetite scores in participants with high-protein-diet intake (P = 0.027 and 0.047, respectively) but not in subjects in the low-protein-diet group (P = 0.384 and 0.078, respectively). The weight regain from 6 to 24 mo attenuated gene-protein interactions. Protein intakes did not modify FTO genotype effects on other appetite measures. Our data suggest that individuals with the FTO rs9939609 A allele might obtain more benefits in a reduction of food cravings and appetite by choosing a hypocaloric and higher-protein weight-loss diet. This trial was registered at clinicaltrials.gov as NCT00072995.

  20. Drivers of change in hunter offtake and hunting strategies in Sendje, Equatorial Guinea.

    Gill, David J C; Fa, John E; Rowcliffe, J Marcus; Kümpel, Noëlle F

    2012-12-01

    Economic development in Africa is expected to increase levels of bushmeat hunting through rising demand for meat and improved transport infrastructure. However, few studies have tracked long-term changes in hunter behavior as a means of testing this prediction. We evaluated changes in hunter behavior in a rural community in Equatorial Guinea over a period of rapid national economic growth, during which time road access to the regional capital greatly improved. We conducted offtake surveys (Supporting Information) over 3 7-week periods at the same time of year in 1998, 2003, and 2010 and conducted hunter and household interviews (Supporting Information) in 2003 and 2010. We tested whether relations existed among catch, hunting effort, hunting strategy, and income earned through hunting and other livelihoods in 2003 and 2010. Although village offtake increased from 1775 kg in 1998 to 4172 kg in 2003, it decreased in 2010 to 1361 kg. Aggregate catch per unit effort (i.e., number of carcasses caught per hunter and per trap) decreased from 2003 to 2010, and the majority of hunters reported a decrease in abundance of local fauna. Although these results are indicative of unsustainable hunting, cumulative changes in offtake and catch per unit effort were driven by a contraction in the total area hunted following an out-migration of 29 of the village's hunters, most of whom left to gain employment in the construction industry, after 2003. Hunters operating in both 2003 and 2010 hunted closer to the village because an increased abundance of elephants posed a danger and because they desired to earn income through other activities. Our study provides an example of national economic development contributing to a reduction in the intensity and extent of hunting. ©2012 Society for Conservation Biology.

  1. Land use strategies to mitigate climate change in carbon dense temperate forests.

    Law, Beverly E; Hudiburg, Tara W; Berner, Logan T; Kent, Jeffrey J; Buotte, Polly C; Harmon, Mark E

    2018-04-03

    Strategies to mitigate carbon dioxide emissions through forestry activities have been proposed, but ecosystem process-based integration of climate change, enhanced CO 2 , disturbance from fire, and management actions at regional scales are extremely limited. Here, we examine the relative merits of afforestation, reforestation, management changes, and harvest residue bioenergy use in the Pacific Northwest. This region represents some of the highest carbon density forests in the world, which can store carbon in trees for 800 y or more. Oregon's net ecosystem carbon balance (NECB) was equivalent to 72% of total emissions in 2011-2015. By 2100, simulations show increased net carbon uptake with little change in wildfires. Reforestation, afforestation, lengthened harvest cycles on private lands, and restricting harvest on public lands increase NECB 56% by 2100, with the latter two actions contributing the most. Resultant cobenefits included water availability and biodiversity, primarily from increased forest area, age, and species diversity. Converting 127,000 ha of irrigated grass crops to native forests could decrease irrigation demand by 233 billion m 3 ⋅y -1 Utilizing harvest residues for bioenergy production instead of leaving them in forests to decompose increased emissions in the short-term (50 y), reducing mitigation effectiveness. Increasing forest carbon on public lands reduced emissions compared with storage in wood products because the residence time is more than twice that of wood products. Hence, temperate forests with high carbon densities and lower vulnerability to mortality have substantial potential for reducing forest sector emissions. Our analysis framework provides a template for assessments in other temperate regions. Copyright © 2018 the Author(s). Published by PNAS.

  2. Land use strategies to mitigate climate change in carbon dense temperate forests

    Hudiburg, Tara W.; Berner, Logan T.; Kent, Jeffrey J.; Buotte, Polly C.; Harmon, Mark E.

    2018-01-01

    Strategies to mitigate carbon dioxide emissions through forestry activities have been proposed, but ecosystem process-based integration of climate change, enhanced CO2, disturbance from fire, and management actions at regional scales are extremely limited. Here, we examine the relative merits of afforestation, reforestation, management changes, and harvest residue bioenergy use in the Pacific Northwest. This region represents some of the highest carbon density forests in the world, which can store carbon in trees for 800 y or more. Oregon’s net ecosystem carbon balance (NECB) was equivalent to 72% of total emissions in 2011–2015. By 2100, simulations show increased net carbon uptake with little change in wildfires. Reforestation, afforestation, lengthened harvest cycles on private lands, and restricting harvest on public lands increase NECB 56% by 2100, with the latter two actions contributing the most. Resultant cobenefits included water availability and biodiversity, primarily from increased forest area, age, and species diversity. Converting 127,000 ha of irrigated grass crops to native forests could decrease irrigation demand by 233 billion m3⋅y−1. Utilizing harvest residues for bioenergy production instead of leaving them in forests to decompose increased emissions in the short-term (50 y), reducing mitigation effectiveness. Increasing forest carbon on public lands reduced emissions compared with storage in wood products because the residence time is more than twice that of wood products. Hence, temperate forests with high carbon densities and lower vulnerability to mortality have substantial potential for reducing forest sector emissions. Our analysis framework provides a template for assessments in other temperate regions. PMID:29555758

  3. A study of the post-surgical volumetric changes of oropharyngeal visceral cavity, upper airway and the respiratory function of in mandibular setback surgery

    Ooto, Hiroyuki

    2007-01-01

    It has been reported that the narrowing of pharyngeal airway caused by mandibular setback surgery may associate the upper respiratory tract dysfunctions such as sleep apnea/hypopnea. However, there has been no clear relevance between morphological changes of pharyngeal airway in two dimensional evaluation and the onset of postoperative upper airway dysfunction. The aim of this study is to evaluate volumetric change and relevance of oropharyngeal visceral cavity and upper airway with three-dimensional CT (3DCT) and upper airway function before and after mandibular setback surgery. Thirty three patients (6 males and 27 females) who have had mandibular setback surgery were allocated in this study. The difference between pre- and postoperative position of mandibular bone and hyoid bone as well as volume of airway, and oropharyngeal visceral cavity were measured using 3DCT remodeling images. The evaluation of upper airway function was performed Polysomnograph (PSG) pre- and post surgically. These data were corrected just before the operation, just before discharge (10.2±1.8 days after the operation) and 1 year later. After mandibular setback surgery, the volume of airway and oropharyngeal visceral cavity had significantly decreased. However, there was no correlation in the quantity of mandibular setback and reduction of airway volume. PSG, aggravation of apnea hypopnea index (AHI) was confirmed among 7 out of 26 samples (27%) in the postoperative early stage. In addition, aggravation of minimum SpO 2 , desaturation index and outbreak time of snoring were detected. At the early stage of postoperation, the airway volume decreased and the airway function took a turn for the worse. On the other hand both were recognized to have tendency to recover after 1 year. In this study, there was no correlation in the amount of change of the volume of the airway, oropharyngeal visceral cavity and aggravation of upper airway function. Moreover it was suggested that age and other

  4. Changing strategy and implementation of a new treatment protocol for cleft palate surgery in "Maria Sklodowska Curie" (MSC) Children's Hospital, Bucharest, Romania.

    Spataru, Radu; Mark, Hans

    2014-12-01

    In "Maria Sklodowska Curie" (MSC) Children's Hospital, Bucharest, Romania, cleft palate repair has been performed according to von Langenbeck since 1984. The speech was good in most patients but wide clefts had a high percentage of fistulas, abnormal speech due to short length and limited mobility of the soft palate. In 2009, the protocol was changed to Gothenburg Delayed Hard Palate Closure, (DHPC) technique. The present evaluation was performed to study the implementation of this technique. One hundred and sixty-eight patients with cleft palate were admitted, 89 isolated cleft palate (ICP), 53 unilateral (UCLP) and 26 bilateral (BCLP). In these, 228 surgical interventions were performed. Soft Palate Repair (SPR) and Hard Palate Repair (HPR) were performed with the DHPC procedure. The transfer to this technique was successfully performed in three steps: one team visit to Gothenburg by a surgeon from MSC and two visits by surgeons from Gothenburg to the MSC. Patients with SPR and HPR were operated on without major complications and there were no differences in results between Gothenburg surgeons and MSC surgeons. The interventions with SPR and HPR technique were proven to be easy to teach and learn and successfully performed without major complications. For cleft patients at MSC hospital it has meant earlier surgery, less re-operations and complications. This report shows a successful change of strategy for palatal repair with improved outcome regarding surgery. In future, speech and growth will be followed on a regular basis and will be compared with results from the Gothenburg Cleft Team.

  5. Implementation of surgical quality improvement: auditing tool for surgical site infection prevention practices.

    Hechenbleikner, Elizabeth M; Hobson, Deborah B; Bennett, Jennifer L; Wick, Elizabeth C

    2015-01-01

    Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. The purpose of this work was to develop an auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. This was a retrospective cohort study using electronic medical records. We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). We investigated 59 patients with surgical site infections and 49 patients without surgical site infections. First, overall compliance rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of system-level changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0°C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. This study was conducted on a small surgical cohort within a select subspecialty. The

  6. Out of the Crisis. A radical change of strategy for the Eurozone

    Andrea Ginzburg

    2017-06-01

    Full Text Available The paper argues that the crisis, mistakenly interpreted as a standard fiscal/balance of payments problem, was generated by the incomplete nature of the European institutions and a disregard for the consequences of differences in the stages of development of the member countries. The ideological pre-conception that markets are self-equilibrating through price competition has been used to justify disastrous internal devaluation policies in the belief that an austerity regime associated with institutions close to those assumed to prevail in 'core' countries would create the 'right' environment for resuming growth in the periphery. An analysis of the main phases of the development of European countries since the second post-war period provides evidence of wide differences in the productive structures of the countries of the centre and the southern periphery of Europe at the start of the Europeanization process. These differences entailed an asymmetric capacity of countries at differing levels of development to adjust to external shocks. This longer-term perspective helps us better to assess the limitations of the two alternatives that have been suggested to steer the EZ economy out of its present quagmire: internal devaluation (wage flexibility in the deficit (Southern European countries, or expansion of internal demand in 'core' countries (Germany. Both measures, it is argued, do not go to the root of the development and debt sustainability problems of Southern European countries, which continue to lack a sufficiently broad and differentiated productive structure. Given the differences in the levels of development of the various EU countries and their varying capacities to cope with change, fiscal policy should be assigned two complementary targets: the role of actively promoting — through investment —the removal of development bottlenecks and the renewal of the productive base, and a redistributive and compensative function. This new strategy

  7. Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage

    Shekar Meera

    2006-11-01

    Full Text Available Abstract Background Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+ approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania Methods We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1 during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999; and (2 three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002. A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked. Results Coverage of vitamin A supplementation among 1–2 year old children increased from 13% [95% CI 10–18%] in 1999 to 76% [95%CI 72–81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70% (p = 0.04. Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations. Conclusion Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a

  8. Robot-Assisted Laparoscopic Radical Prostatectomy for Patients with Prostatic Cancer and Factors Promoting Installation of the Robotic Surgical Equipment-Questionnaire Survey

    塚本, 泰司; 田中, 滋

    2015-01-01

    We conducted a questionnaire survey of hospitals with robot-assisted surgical equipment to study changes of the surgical case loads after its installation and the managerial strategies for its purchase. The study included 154 hospitals (as of April 2014) that were queried about their radical prostatectomy case loads from January 2009 to December 2013, strategies for installation of the equipment in their hospitals, and other topics related to the study purpose. The overall response rate of ho...

  9. Adjusting tourist destination marketing strategy according to the changes in the environment: Case study Bukovicka sSpa

    Riznić Dejan T.; Cvijanović Janko; Vojnović Boško

    2014-01-01

    Tourist destinations are compelled to create new business opportunities constantly in order to respond to the challenges that arise under the influence of a number of changes in the environment. Few of them are supporting the requirements for analyzing and creating a sustainable business and marketing strategies. The paper starts with the analysis of relevant theory and practice in decisionmaking and choosing the marketing strategy of the tourist destination, pointing to the importance of con...

  10. The Changing Patterns of Advertising Strategy by Japanese Business Firms in the U.S. Market: Content Analysis

    Norihiko Suzuki

    1980-01-01

    This article analyzes the changing pattern of advertisement strategy by Japanese business firms in the U.S. market. Taking the advertisement activities of four major industrial sectors that appeared in both Business Week and Newsweek during the 1965–1977 period as samples, this article has found that the Japanese advertisement strategy in the U.S. market has passed sequentially through the following four stages: (1) Nationality-Supportive, (2) Product-Attributes, (3) Challenge and Responses, ...

  11. Changes in urological surgical techniques

    Oktay Üçer

    2010-06-01

    Full Text Available Recently, laparoscopic and afterwards robotic techniques have constituted most of urologic surgery procedures. Open surgery may give place to robotic surgery due to possible widespread use of robots in the future. Studies, that compare these two techniques are usually designed about radical prostatectomy, since it is the most common operation performed by using these techniques. In literature,robotic surgery seems more advantageous than other techniques but the most important disadvantage of this technique is cost-effective problems. In present review,history of open, laparoscopic and robotic surgery, and comparison of advantages, disadvantages and cost of these techniques have been discussed with literature.

  12. Livestock in a changing climate: production system transitions as an adaptation strategy for agriculture

    Weindl, Isabelle; Lotze-Campen, Hermann; Popp, Alexander; Müller, Christoph; Schmitz, Christoph; Rolinski, Susanne; Havlík, Petr; Herrero, Mario

    2015-01-01

    Livestock farming is the world’s largest land use sector and utilizes around 60% of the global biomass harvest. Over the coming decades, climate change will affect the natural resource base of livestock production, especially the productivity of rangeland and feed crops. Based on a comprehensive impact modeling chain, we assess implications of different climate projections for agricultural production costs and land use change and explore the effectiveness of livestock system transitions as an adaptation strategy. Simulated climate impacts on crop yields and rangeland productivity generate adaptation costs amounting to 3% of total agricultural production costs in 2045 (i.e. 145 billion US$). Shifts in livestock production towards mixed crop-livestock systems represent a resource- and cost-efficient adaptation option, reducing agricultural adaptation costs to 0.3% of total production costs and simultaneously abating deforestation by about 76 million ha globally. The relatively positive climate impacts on grass yields compared with crop yields favor grazing systems inter alia in South Asia and North America. Incomplete transitions in production systems already have a strong adaptive and cost reducing effect: a 50% shift to mixed systems lowers agricultural adaptation costs to 0.8%. General responses of production costs to system transitions are robust across different global climate and crop models as well as regarding assumptions on CO 2 fertilization, but simulated values show a large variation. In the face of these uncertainties, public policy support for transforming livestock production systems provides an important lever to improve agricultural resource management and lower adaptation costs, possibly even contributing to emission reduction. (letter)

  13. Innovative Strategies for Building Community Resilience: Lessons from the Frontlines of Climate Change Capacity-Building

    Abrash Walton, A.

    2017-12-01

    There is broad scientific consensus that climate change is occurring; however, there is limited implementation of measures to create resilient local communities (Abrash Walton, Simpson, Rhoades, & Daniels, 2016; Adger, Arnell, & Tompkins, 2005; Glavovic & Smith, 2014; Moser & Ekstrom, 2010; Picketts, Déry, & Curry, 2014). Communities that are considered climate leaders in the United States may have adopted climate change plans, yet few have actually implemented the policies, projects and recommendations in those plans. A range of innovative, education strategies have proven effective in building the capacity of local decision makers to strengthen community resilience. This presentation draws on the results of two years of original research regarding the information and support local decision makers require for effective action. Findings are based on information from four datasets, with more than 600 respondents from 48 U.S. states and 19 other countries working on local adaptation in a range of capacities. These research results can inform priority setting for public policy, budget setting, and action as well as private sector funding and investment. The presentation will focus, in particular, on methods and results of a pioneering Facilitated Community of Practice model (FCoP) for building climate preparedness and community resilience capacity, among local-level decision makers. The FCoP process includes group formation and shared capacity building experience. The process can also support collective objective setting and creation of structures and processes for ongoing sustainable collaboration. Results from two FCoPs - one fully online and the other hybrid - suggest that participants viewed the interpersonal and technical assistance elements of the FCoP as highly valuable. These findings suggest that there is an important need for facilitated networking and other relational aspects of building capacity among those advancing resilience at the local level.

  14. Stakeholders' participatory diagnosis of climate change impacts on subsistence agriculture in Sikkim, India, for identifying adaptation strategies

    Azhoni, A.; Goyal, M. K.

    2017-12-01

    Narrowing the gap between research, policy making and implementing adaptation remains a challenge in many parts of the world where climate change is likely to severely impact subsistence agriculture. This research aims to narrow this gap by matching the adaptation strategies being framed by policy makers and perspectives of consultants and researchers which are expected to be implemented by development agencies farmers in the state of Sikkim in India. Our case study examined the framing and implementation of State Action Plan on Climate Change through semi-structured interviews carried out with decision makers in the State Government, Scientific Organisations, consultants, local academia, implementing and development agencies, and farmers for whom the adaptation strategies are targeted. Using Social Network and Stakeholder Analysis approach, this research unravels the complexities of perceiving climate change impacts, identifying adaptation strategies, and implementing climate change adaptation strategies. While farmers are less aware about the global phenomenon of climate change impacts for their subsistence livelihood, their knowledge of the local conditions and their close interaction with the State Government Agriculture Department provides them an access to new and high value crops. Although important steps are initiated through the Sikkim State Action Plan on Climate Change it is yet to deliver effective means of adaptation implementation and identifying the networks of close coordination between the various implementing agencies will likely to pay rich dividends. While Sikkim being a small and hilly state with specific contextual challenges of climate change impacts, the results from this study highlights how the internal and external networks between various types of stakeholders informs decision makers in identifying local impacts of climate change and plan adaptation strategies.

  15. Regional Approach for Linking Ecosystem Services and Livelihood Strategies Under Climate Change of Pastoral Communities in the Mongolian Steppe Ecosystem

    Ojima, D. S.; Galvin, K.; Togtohyn, C.

    2012-12-01

    Dramatic changes due to climate and land use dynamics in the Mongolian Plateau affecting ecosystem services and agro-pastoral systems in Mongolia. Recently, market forces and development strategies are affecting land and water resources of the pastoral communities which are being further stressed due to climatic changes. Evaluation of pastoral systems, where humans depend on livestock and grassland ecosystem services, have demonstrated the vulnerability of the social-ecological system to climate change. Current social-ecological changes in ecosystem services are affecting land productivity and carrying capacity, land-atmosphere interactions, water resources, and livelihood strategies. The general trend involves greater intensification of resource exploitation at the expense of traditional patterns of extensive range utilization. Thus we expect climate-land use-land cover relationships to be crucially modified by the social-economic forces. The analysis incorporates information about the social-economic transitions taking place in the region which affect land-use, food security, and ecosystem dynamics. The region of study extends from the Mongolian plateau in Mongolia. Our research indicate that sustainability of pastoral systems in the region needs to integrate the impact of climate change on ecosystem services with socio-economic changes shaping the livelihood strategies of pastoral systems in the region. Adaptation strategies which incorporate integrated analysis of landscape management and livelihood strategies provides a framework which links ecosystem services to critical resource assets. Analysis of the available livelihood assets provides insights to the adaptive capacity of various agents in a region or in a community. Sustainable development pathways which enable the development of these adaptive capacity elements will lead to more effective adaptive management strategies for pastoral land use and herder's living standards. Pastoralists will have the

  16. Factors Affecting Physician Satisfaction and Wisconsin Medical Society Strategies to Drive Change.

    Coleman, Michele; Dexter, Donn; Nankivil, Nancy

    2015-08-01

    Physicians' dissatisfaction in their work is increasing, which is affecting the stability of health care in America. The Wisconsin Medical Society (Society) surveyed 1016 Wisconsin physicians to determine the source of their dissatisfaction. The survey results indicate Wisconsin physicians are satisfied when it comes to practice environment, work-life balance, and income. In addition, they are extremely satisfied when it comes to rating their ability to provide high quality care, and they have identified some benefits related to the adoption of electronic health records. However, they are feeling burned out, very unsatisfied with the amount of time spent in direct patient care compared to indirect patient care, and that they are spending too much time on administrative and data entry tasks. In terms of future workforce, many physicians are either unsure or would not recommend the profession to a prospective medical student. Electronic health records serve as both a satisfier and dissatisfier and as a potential driver for future physician satisfaction interventions. Changes at the institutional, organizational, and individual levels potentially could address the identified dissatisfiers and build upon the satisfiers. The Society identifies 12 strategies to improve upon the physician experience.

  17. Change in the foraging strategy of female South American sea lions (Carnivora: Pinnipedia after parturition

    Massimiliano Drago

    2010-08-01

    Full Text Available This study tests the hypothesis that female South American sea lions shift from off-shore, pelagic prey to coastal, benthic prey after parturition in order to reduce the foraging trip duration and hence the time pups remain unattended on the beach during early lactation. The δ13C and δ15N values of the serum and blood cells of 26 South American sea lion suckling pups from northern Patagonia were used to track the dietary changes of their mothers from late pregnancy to early lactation, after correction for differential isotopic fractionation between tissues. Primary producers and potential prey species were also analysed to establish a baseline for interpreting the stable isotope concentration of serum and blood cells. Isotopic ratios revealed a generalized increase in the consumption of coastal-benthic prey after parturition. Such a generalized post-partum shift will allow females to spend more time on land and look after their pups. The effects of this foraging strategy on the nutritional quality of the female’s diet are discussed.

  18. Transformation by design: nursing workforce innovation and reduction strategies in turbulent times of change.

    Palazzo, Mary O

    2015-01-01

    The evolution of care delivery from an acute care and inpatient standard to the outpatient setting and health promotion model is generating the need for innovative workforce and infrastructure adjustments to meet the new paradigm of population health management. Successful transformation of the nursing workforce necessitates a positive style of thinking that addresses rational concerns during times of difficult transition. Nurse leaders are called to recognize and appreciate the strengths of the nursing workforce by involving them in the course of change through collaboration, planning, and discussion. One unique way to plan and develop new care delivery models is to adopt the framework used in health facility planning and design for new services, units, or hospitals. This framework is flexible and can be adjusted easily to meet the objectives of a small nursing workforce innovation project or expanded to encompass the needs of a large-scale hospital transformation. Structured questioning further helps the team to identify barriers to care and allows for the development of new concepts that are objective and in accord with evidence-based practice and data. This article explores the advantages and disadvantages of implementing innovative workforce redesign and workforce reduction strategies.

  19. Dynamics of the European refining and petrochemical industry. Strategies, structure and change

    Steenbakkers, K.

    1997-01-01

    The changes in the market position of producers engaged in the oil refining and basic petrochemical industry on the Western European market are the central theme of this book. Analysis of this reshuffling process among these actors is conducted on three levels. First, research is carried out at the level of world regions. In order to understand the reorganization of oil refining and basic petrochemical production in Western Europe, it is necessary to explore the recent aggregate dynamics of these activities on a global scale. Second, the differences in strategic behaviour are exanuned at the level of groups of market participants, namely the major oil companies, the chemical companies, the state-owned companies from both consumer and producer countries, and the independents. Finally, the investment/disinvestment decisions in the Western European oil refining and basic petrochemical industry are investigated at the level of the individual firm. Particular emphasis is placed upon explaining why companies active in the sectors under study have followed different strategies, although they have been confronted with similar adverse market conditions in Western Europe during the last decades. 341 refs

  20. Strategies for changing negative public attitudes toward organ donation in the People's Republic of China

    Shumin X

    2013-12-01

    Full Text Available Xie Shumin,1 Stephanie Mu-Lian Woo,2 Zhang Lei3 1Department of Otolaryngology Head and Neck Surgery, The Second Xiangya Hospital of Central South University, Changsha, People's Republic of China; 2Harvard University, Cambridge, Massachusetts, USA; 3Department of Thoracic Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, People's Republic of China Abstract: In recent decades, the demand for organ transplantation has risen rapidly worldwide, due to an increased incidence of vital organ failure. However, the scarcity of organs appropriate for transplantation has led to an organ shortage crisis. This article retrospectively reviews strategies to change negative public attitudes toward organ donation in the People's Republic of China. We strongly believe that efforts to publicize knowledge of organ donation, promote family discussions, train medical staff and students, establish incentive systems, and implement regulatory oversight may combat unfavorable Chinese public opinion toward organ donation and transplantation, thus potentially increasing the organ donation rate in the People's Republic of China. Keywords: influencing factors, attitudes, organ transplantation, organ failure