Beyond EA Frameworks: Towards an Understanding of the Adoption of Enterprise Architecture Management

Enterprise architectures (EA) are considered promising approaches to reduce the complexities of growing information technology (IT) environments while keeping pace with an ever-changing business environment. However, the implementation of enterprise architecture management (EAM) has proven difficult in practice. Many EAM initiatives face severe challenges, as demonstrated by the low usage level of enterprise architecture documentation and enterprise architects' lack of authority regarding enforcing EAM standards and principles. These challenges motivate our research. Based on three field studies, we first analyze EAM implementation issues that arise when EAM is started as a dedicated and isolated initiative. Following a design-oriented paradigm, we then suggest a design theory for architecture-driven IT management (ADRIMA) that may guide organizations to successfully implement EAM. This theory summarizes prescriptive knowledge related to embedding EAM practices, artefacts and roles in the existing IT management processes and organization.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Advances in the hospital management of patients following an out of hospital cardiac arrest.

The outcome for patients after an out-of-hospital cardiac arrest (OHCA) has been poor over many decades and single interventions have mostly resulted in disappointing results. More recently, some regions have observed better outcomes after redesigning their cardiac arrest pathways. Optimised resuscitation and prehospital care is absolutely key, but in-hospital care appears to be at least as important. OHCA treatment requires a multidisciplinary approach, comparable to trauma care; the development of cardiac arrest pathways and cardiac arrest centres may dramatically improve patient care and outcomes. Besides emergency medicine physicians, intensivists and neurologists, cardiologists are playing an increasingly crucial role in the post-resuscitation management, especially by optimising cardiac output and undertaking urgent coronary angiography/intervention.

Dietary and lifestyle interventions in the management of the metabolic syndrome: present status and future perspective.

OBJECTIVE: To review the mechanisms underlying the metabolic syndrome, or syndrome X, in humans, and to delineate dietary and environmental strategies for its prevention. DESIGN: Review of selected papers of the literature. RESULTS: Hyperinsulinemia and insulin resistance play a key role in the development of the metabolic syndrome. Strategies aimed at reducing insulin resistance may be effective in improving the metabolic syndrome. They include low saturated fat intake, consumption of low-glycemic-index foods, physical exercise and prevention of obesity. CONCLUSIONS: Future research, in particular the genetic basis of the metabolic syndrome and the interorgan interactions responsible for insulin resistance, is needed to improve therapeutic strategies for the metabolic syndrome.

A discrete forest in a continuous landscape : investigating interactions between natural resource management and sustainable development

Summary Forests are key ecosystems of the earth and associated with a large range of functions. Many of these functions are beneficial to humans and are referred to as ecosystem services. Sustainable development requires that all relevant ecosystem services are quantified, managed and monitored equally. Natural resource management therefore targets the services associated with ecosystems. The main hypothesis of this thesis is that the spatial and temporal domains of relevant services do not correspond to a discrete forest ecosystem. As a consequence, the services are not quantified, managed and monitored in an equal and sustainable manner. The thesis aims were therefore to test this hypothesis, establish an improved conceptual approach and provide spatial applications for the relevant land cover and structure variables. The study was carried out in western Switzerland and based primarily on data from a countrywide landscape inventory. This inventory is part of the third Swiss national forest inventory and assesses continuous landscape variables based on a regular sampling of true colour aerial imagery. In addition, land cover variables were derived from Landsat 5 TM passive sensor data and land structure variables from active sensor data from a small footprint laserscanning system. The results confirmed the main hypothesis, as relevant services did not scale well with the forest ecosystem. Instead, a new conceptual approach for sustainable management of natural resources was described. This concept quantifies the services as a continuous function of the landscape, rather than a discrete function of the forest ecosystem. The explanatory landscape variables are therefore called continuous fields and the forest becomes a dependent and function-driven management unit. Continuous field mapping methods were established for land cover and structure variables. In conclusion, the discrete forest ecosystem is an adequate planning and management unit. However, monitoring the state of and trends in sustainability of services requires them to be quantified as a continuous function of the landscape. Sustainable natural resource management iteratively combines the ecosystem and gradient approaches. Résumé Les forêts sont des écosystèmes-clés de la terre et on leur attribue un grand nombre de fonctions. Beaucoup de ces fonctions sont bénéfiques pour l'homme et sont nommées services écosystémiques. Le développement durable exige que ces services écosystémiques soient tous quantifiés, gérés et surveillés de façon égale. La gestion des ressources naturelles a donc pour cible les services attribués aux écosystèmes. L'hypothèse principale de cette thèse est que les domaines spatiaux et temporels des services attribués à la forêt ne correspondent pas à un écosystème discret. Par conséquent, les services ne sont pas quantifiés, aménagés et surveillés d'une manière équivalente et durable. Les buts de la thèse étaient de tester cette hypothèse, d'établir une nouvelle approche conceptuelle de la gestion des ressources naturelles et de préparer des applications spatiales pour les variables paysagères et structurelles appropriées. L'étude a été menée en Suisse occidentale principalement sur la base d'un inventaire de paysage à l'échelon national. Cet inventaire fait partie du troisième inventaire forestier national suisse et mesure de façon continue des variables paysagères sur la base d'un échantillonnage régulier sur des photos aériennes couleur. En outre, des variables de couverture ? terrestre ont été dérivées des données d'un senseur passif Landsat 5 TM, ainsi que des variables structurelles, dérivées du laserscanning, un senseur actif. Les résultats confirment l'hypothèse principale, car l'échelle des services ne correspond pas à celle de l'écosystème forestier. Au lieu de cela, une nouvelle approche a été élaborée pour la gestion durable des ressources naturelles. Ce concept représente les services comme une fonction continue du paysage, plutôt qu'une fonction discrète de l'écosystème forestier. En conséquence, les variables explicatives de paysage sont dénommées continuous fields et la forêt devient une entité dépendante, définie par la fonction principale du paysage. Des méthodes correspondantes pour la couverture terrestre et la structure ont été élaborées. En conclusion, l'écosystème forestier discret est une unité adéquate pour la planification et la gestion. En revanche, la surveillance de la durabilité de l'état et de son évolution exige que les services soient quantifiés comme fonction continue du paysage. La gestion durable des ressources naturelles joint donc l'approche écosystémique avec celle du gradient de manière itérative.

Améliorer la prise en charge de l'hypertension arterielle en favorisant la collaboration avec les pharmaciens et les infirmières [Team-based care involving pharmacists and nurses to improve the management of hypertension].

Only half of hypertensive patients has controlled blood pressure. Chronic kidney disease (CKD) is also associated with low blood pressure control, 25-30% of CKD patients achieving adequate blood pressure. The Community Preventive Services Task Force has recently recommended team-based care to improve blood pressure control. Team-based care of hypertension involves facilitating coordination of care among physician, pharmacist and nurse and requires sharing clinical data, laboratory results, and medications, e.g., electronically or by fax. Based on recent studies, development and evaluation of team-based care of hypertensive patients should be done in the Swiss healthcare system.

Clinical management of immunocompetent hospitalized patients with community-acquired pneumonia.

Background: Clinical practices and guidelines may differ regarding the management of inpatients with community-acquired pneumonia (CAP). Methods: The management of 152 consecutive CAP inpatients (70+/-17 years) admitted to a teaching hospital was analyzed retrospectively and compared with published data and an evidence-based guideline developed at our institution. Results: Of the patients studied, 64% had a high prognostic score index (PSI), 14% were admitted to the ICU, and 4.6% died. Initially, patients received either a one-drug (47%) or a two-drug (53%) antibiotic regimen. None of the 20 PSI parameters, and neither the PSI nor admission to the ICU, was associated with the initial antibiotic regimen. Agreement between current practice and our guideline was low (kappa=0.16). Following the recommendations would have led to a decrease of 51% in the initial two-drug regimen. The duration of i.v. antibiotherapy was higher in patients following the two-drug regimen (142+/-150 vs. 102+/-60 h, P<0.05). Chest physiotherapy (CP) and bronchodilatators (BD) were prescribed in 72% and 54% of cases, respectively (median duration 10 days). Conclusions: The variations observed in the clinical management of CAP inpatients were not in agreement with published guidelines. The overuse of a two-drug regimen, CP, and BD necessitates the development and implementation of evidence-based guidelines proposing detailed steps for the management of CAP inpatients.

Prise en charge de l'hépatite B chronique: un défi en évolution constante [Management of chronic hepatitis B].

Chronic hepatitis B predisposes to the development of cirrhosis and hepatocellular carcinoma. Treatment of chronic hepatitis B is aimed at halting viral replication and, thereby, hepatic inflammation. Treatment indication should be established carefully and with full knowledge of the advantages and limitations of currently available antiviral drugs. Patients on long-term nudcleos(t)ide analogue treatment should be followed regularly in order to avoid the appearance of antiviral resistance. The purpose of this review is to provide a concise overview of the diagnosis and management of chronic hepatitis B.

Facteurs de risque fracturaire, nouveaux traitements: comment evolue la prise en charge de l'ostéoporose de la personne agée [Fracture risk, new treatments: how does the management of the osteoporosis of elderly change?]

Osteoporosis of elderly is a growing medical, economic and health-care problem. It is due to the increase of the life expectancy and the number of osteoporotic fractures. With the new Swiss-specific tool FRAX and the development of inpatients fracture trajectory, we can better identify patients with high risk of fracture. An appropriate treatment can be proposed more quickly. The follow-up of bone markers increases the treatment efficiency. With a better identification, treatment and follow-up of osteoporosis of elderly patients, we can ameliorate the patient's quality of life and decrease the number of osteoporotic fractures with a good cost-effectiveness ratio.

Management of nanomaterials safety in research environment

Despite numerous discussions, workshops, reviews and reports about responsible development of nanotechnology, information describing health and environmental risk of engineered nanoparticles or nanomaterials is severely lacking and thus insufficient for completing rigorous risk assessment on their use. However, since preliminary scientific evaluations indicate that there are reasonable suspicions that activities involving nanomaterials might have damaging effects on human health; the precautionary principle must be applied. Public and private institutions as well as industries have the duty to adopt preventive and protective measures proportionate to the risk intensity and the desired level of protection. In this work, we present a practical, 'user-friendly' procedure for a university-wide safety and health management of nanomaterials, developed as a multi-stakeholder effort (government, accident insurance, researchers and experts for occupational safety and health). The process starts using a schematic decision tree that allows classifying the nano laboratory into three hazard classes similar to a control banding approach (from Nano 3 - highest hazard to Nano1 - lowest hazard). Classifying laboratories into risk classes would require considering actual or potential exposure to the nanomaterial as well as statistical data on health effects of exposure. Due to the fact that these data (as well as exposure limits for each individual material) are not available, risk classes could not be determined. For each hazard level we then provide a list of required risk mitigation measures (technical, organizational and personal). The target 'users' of this safety and health methodology are researchers and safety officers. They can rapidly access the precautionary hazard class of their activities and the corresponding adequate safety and health measures. We succeed in convincing scientist dealing with nano-activities that adequate safety measures and management are promoting innovation and discoveries by ensuring them a safe environment even in the case of very novel products. The proposed measures are not considered as constraints but as a support to their research. This methodology is being implemented at the Ecole Polytechnique de Lausanne in over 100 research labs dealing with nanomaterials. It is our opinion that it would be useful to other research and academia institutions as well. [Authors]

International consensus guidelines on the management of cytomegalovirus in solid organ transplantation.

Cytomegalovirus (CMV) remains one of the most common infections after solid organ transplantation, resulting in significant morbidity, graft loss, and occasional mortality. Management of CMV varies considerably among transplant centers. A panel of experts on CMV and solid organ transplant was convened by The Infectious Diseases Section of The Transplantation Society to develop evidence and expert opinion-based consensus guidelines on CMV management including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues.

Peripheral dual-energy X-ray absorptiometry in the management of osteoporosis: the 2007 ISCD Official Positions.

Peripheral assessment of bone density using photon absorptiometry techniques has been available for over 40 yr. The initial use of radio-isotopes as the photon source has been replaced by the use of X-ray technology. A wide variety of models of single- or dual-energy X-ray measurement tools have been made available for purchase, although not all are still commercially available. The Official Positions of the International Society for Clinical Densitometry (ISCD) have been developed following a systematic review of the literature by an ISCD task force and a subsequent Position Development Conference. These cover the technological diversity among peripheral dual-energy X-ray absorptiometry (pDXA) devices; define whether pDXA can be used for fracture risk assessment and/or to diagnose osteoporosis; examine whether pDXA can be used to initiate treatment and/or monitor treatment; provide recommendations for pDXA reporting; and review quality assurance and quality control necessary for effective use of pDXA.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

Pharmacotherapeutic management of locally advanced prostate cancer: current status.

Locally advanced prostate cancer (LAPC) is a heterogeneous entity usually embracing T3-4 and/or pelvic lymph-node-positive disease in the absence of established metastases. Outcomes for LAPC with single therapies have traditionally been poor, leading to the investigation of adjuvant therapies. Prostate cancer is a hormonally sensitive tumour, which usually responds to pharmacological manipulation of the androgen receptor or its testosterone-related ligands. As such, androgen deprivation therapy (ADT) has become an important adjuvant strategy for the treatment of LAPC, particularly for patients managed primarily with radiotherapy. Such results have generally not been replicated in surgical patients. With increased use of ADT has come improved awareness of the numerous toxicities associated with long-term use of these agents, as well as the development of strategies for minimizing ADT exposure and actively managing adverse effects. Several trials are exploring agents to enhance radiation cell sensitivity as well as the application of adjuvant docetaxel, an agent with proven efficacy in the metastatic, castrate-resistant setting. The recent work showing activity of cabazitaxel, sipuleucel-T and abiraterone for castrate-resistant disease in the post-docetaxel setting will see these agents investigated in conjunction with definitive surgery and radiotherapy.

Stratégies thérapeutiques pour le traitement des gliomes [Therapeutic strategies for the management of gliomas]

The management of gliomas remains challenging and requires a multidisciplinary approach that involves neurosurgeons, radiation therapists and oncologists. For patients with glioblastomas, progress has been made in recent years with the introduction of a combined modality treatment associating radiation therapy and concomitant chemotherapy with the novel alkylating agent temozolomide. This combination resulted in a significant prolongation of survival and increase in the number of patients with survival well beyond two years. Since then, interest in developing new agents in this disease has dramatically increased. In parallel, molecular markers, such as methylation status of MGMT or identification of the translocation of 1p and 19q in oligodendrogliomas have allowed to identify distinct subtypes with exquisite response to treatment or different prognosis. These developments have implications for the development of clinical trials of new potential drug treatments. In this article, we provide a review of the current management of low- and high-grade gliomas, including astrocytomas, oligodendrogliomas and glioblastomas and provide an outlook into future potential therapies.