Implications of Imaging Criteria for the Management and Treatment of Intraductal Papillary Mucinous Neoplasms - Benign versus Malignant Findings

OBJECTIVES Evaluation of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiation of pancreatic intraductal papillary mucinous neoplasm (IPMN) subtypes based on objective imaging criteria. METHODS Fifty-eight patients with 60 histologically confirmed IPMNs were included in this retrospective study. Eighty-three imaging studies (CT,n = 42; MRI,n = 41) were analysed by three independent blinded observers (O1-O3), using established imaging criteria to assess likelihood of malignancy (-5, very likely benign; 5, very likely malignant) and histological subtype (i.e., low-grade (LGD), moderate-grade (MGD), high-grade dysplasia (HGD), early invasive carcinoma (IPMC), solid carcinoma (CA) arising from IPMN). RESULTS Forty-one benign (LGD IPMN,n = 20; MGD IPMN,n = 21) and 19 malignant (HGD IPMN,n = 3; IPMC,n = 6; solid CA,n = 10) IPMNs located in the main duct (n = 6), branch duct (n = 37), or both (n = 17) were evaluated. Overall accuracy of differentiation between benign and malignant IPMNs was 86/92 % (CT/MRI). Exclusion of overtly malignant cases (solid CA) resulted in overall accuracy of 83/90 % (CT/MRI). The presence of mural nodules and ductal lesion size ≥30 mm were significant indicators of malignancy (p = 0.02 and p < 0.001, respectively). CONCLUSIONS Invasive IPMN can be identified with high confidence and sensitivity using CT and MRI. The diagnostic problem that remains is the accurate radiological differentiation of premalignant and non-invasive subtypes. KEY POINTS • CT and MRI can differentiate benign from malignant forms of IPMN. • Identifying (pre)malignant histological IPMN subtypes by CT and MRI is difficult. • Overall, diagnostic performance with MRI was slightly (not significantly) superior to CT.

Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification

OBJECTIVE To analyze the prevalence of urinary tract endometriosis (UTE) in patients with deep infiltrating endometriosis (DIE) and to define potential criteria for preoperative workup. DESIGN Retrospective study. SETTING University hospital. PATIENT(S) Six hundred ninety-seven patients with endometriosis. INTERVENTION(S) Excision of all endometriotic lesions. MAIN OUTCOME MEASURE(S) Correlation of preoperative features and intraoperative findings in patients with UTE. RESULT(S) Out of 213 patients presenting DIE, 52.6% suffered from UTE. In patients with ureteral endometriosis, symptoms were not specific. Among the patients with bladder endometriosis, 68.8% complained of urinary symptoms compared to 7.9% in the group of patients without UTE. In patients with rectovaginal endometriosis, the probability of ureterolysis showed a linear correlation with the size of the nodule. We found that 3 cm in diameter provided a specific cutoff value for the likelihood of ureteric involvement. CONCLUSION(S) The prevalence of UTE has often been underestimated. Preoperative questioning is important in the search for bladder endometriosis. The size of the nodule is one of the few reliable criteria in preoperative assessment that can suggest ureteric involvement. We propose a classification of ureteral endometriosis that will allow the standardization of terminology and help to compare the outcome of different surgical treatment in randomized studies.

The Effect of Incidental Consolidation on Management and Outcomes in COPD Exacerbations: Data from the European COPD Audit

OBJECTIVE There is controversy regarding the significance of radiological consolidation in the context of COPD exacerbation (eCOPD). While some studies into eCOPD exclude these cases, consolidation is a common feature of eCOPD admissions in real practice. This study aims to address the question of whether consolidation in eCOPD is a distinct clinical phenotype with implications for management decisions and outcomes. PATIENTS AND METHODS The European COPD Audit was carried out in 384 hospitals from 13 European countries between 2010 and 2011 to analyze guideline adherence in eCOPD. In this analysis, admissions were split according to the presence or not of consolidation on the admission chest radiograph. Groups were compared in terms of clinical and epidemiological features, existing treatment, clinical care utilized and mortality. RESULTS 14,111 cases were included comprising 2,714 (19.2%) with consolidation and 11,397 (80.8%) without. The risk of radiographic consolidation increased with age, female gender, cardiovascular diseases, having had two or more admissions in the previous year, and sputum color change. Previous treatment with inhaled steroids was not associated. Patients with radiographic consolidation were significantly more likely to receive antibiotics, oxygen and non-invasive ventilation during the admission and had a lower survival from admission to 90-day follow-up. CONCLUSIONS Patients admitted for COPD exacerbation who have radiological consolidation have a more severe illness course, are treated more intensively by clinicians and have a poorer prognosis. We recommend that these patients be considered a distinct subset in COPD exacerbation.

Clinical Practice Recommendations For The Management And Prevention Of Cisplatin-Induced Hearing Loss Using Pharmacogenetic Markers

Currently no pharmacogenomics-based criteria exist to guide clinicians in identifying individuals who are at risk of hearing loss from cisplatin-based chemotherapy. This review summarizes findings from pharmacogenomic studies that report genetic polymorphisms associated with cisplatin-induced hearing loss and aims to (1) provide up-to-date information on new developments in the field; (2) provide recommendations for the use of pharmacogenetic testing in the prevention, assessment and management of cisplatin-induced hearing loss in children and adults; and (3) identify knowledge gaps to direct and prioritize future research. These practice recommendations for pharmacogenetic testing in the context of cisplatin-induced hearing loss reflect a review and evaluation of recent literature and are designed to assist clinicians in providing optimal clinical care for patients receiving cisplatin based chemotherapy.

Contractual Difficulties in Environmental Management and the Protection of Biodiversity: The Case of Conservation and Mitigation Banking

This paper offers a principal-agent model of feasible private contracting in mitigation and conservation banking aimed at the protection of natural habitat and bio-diversity of US wetlands and uplands. It is shown that while it is straightforward to design an incentive contract, such a contract may not achieve the federally mandated objective of no net loss of habitat. This is because the minimum payment required as an economic incentive to private agents may be greater than what they should receive for the habitat values that they actually created in the field. This possible problem is shown to derive from nonconvexity in the production possibility set between the biological value of land as natural habitat and in non-habitat uses such as in urban development. The paper concludes with a consideration of several institutional devises that may promote the convergence of private contracting and the attainment of no net loss. These include the payment of subsidies, greater accuracy in the identification of actual quality by the principal, and the use of several incentive alignment devises.

Exploring intra-commonwealth goods and services trade

A background paper for the Commonwealth Secretariat by Anirudh Shingal and Mohammad Razzaque: Existing work examining the trade effect of commonwealth membership does not account for sample selection, unobserved heterogeneity and multilateral resistance in estimation, leading to biased estimates. Our analyses improve on all these fronts. Unlike earlier work, we also consider services trade and assemble a much larger sample of trading partners (242 x 242, over 1995-2010). Commonwealth membership is found to increase goods exports by 18.5-33.2% and services exports by 42.8% in our results, ceteris paribus and on average. Our analyses on the determinants of intra-commonwealth trade suggest the positive role of common language (only for goods trade) and colonial relationships as well as the negative impact of geography, thereby confirming that commonwealth member states are not natural trading partners for each other. Finally, being one of Australia, Canada or the UK is associated with 98.2% greater merchandise trade than the commonwealth average; however, a similar effect is not observed for services trade.

FIWARE Lab: managing resources and services in a cloud federation supporting future internet applications

Real-world experimentation facilities accelerate the development of Future Internet technologies and services, advance the market for smart infrastructures, and increase the effectiveness of business processes through the Internet. The federation of facilities fosters the experimentation and innovation with larger and more powerful environment, increases the number and variety of the offered services and brings forth possibilities for new experimentation scenarios. This paper introduces a management solution for cloud federation that automates service provisioning to the largest possible extent, relieves the developers from time-consuming configuration settings, and caters for real-time information of all information related to the whole lifecycle of the provisioned services. This is achieved by proposing solutions to achieve the seamless deployment of services across the federation and ability of services to span across different infrastructures of the federation, as well as monitoring of the resources and data which can be aggregated with a common structure, offered as an open ecosystem for innovation at the developers' disposal. This solution consists of several federation management tools and components that are part of the work on Cloud Federation conducted within XIFI project to build the federation of cloud infrastructures for the Future Internet Lab (FIWARE Lab). We present the design and implementation of the solution-concerned FIWARE Lab management tools and components that are deployed within a federation of 17 cloud infrastructures distributed across Europe.

Balancing management and preservation of mediterranean scattered oak woodlands (Dehesas) in human-dominated landscapes

Los sistemas agroforestales mediterráneos tienen una gran importancia ecológica y socioeconómica, y mantienen altos valores medioambientales y de diversidad biológica a la vez que producen importantes servicios ecosistémicos. Estos sistemas han sido testigos de diversos cambios rápidos y drásticos en su gestión y aprovechamiento durante el último siglo. La mayor parte de la investigación desarrollada en esta tesis doctoral ha sido llevada a cabo en las dehesas españolas. Esta tesis nos muestra: i) la evidencia de la existencia de un cambio global del estrato arbóreo y del manejo del pastoreo en el todo el área de distribución de la dehesa durante los últimos 60 años; ii) la importancia del papel que juega el arbolado disperso y el adecuado manejo del ganado en la mejora de la producción, calidad y diversidad de las comunidades herbáceas, que a su vez, un pasto herbáceo bien desarrollado es importante para la rentabilidad del sistema, evaluando estos efectos bajo distintos escenarios de clima y calidad de estación; y iii) la evidencia de la falta de regeneración en sistemas agroforestales mediterráneos bajo distintos tipos de manejo del pastoreo, y además se evalúa el crecimiento y desarrollo de las pocas plántulas existentes que serán las que aseguren la viabilidad y persistencia y de estos sistemas. El arbolado disperso de estos sistemas ha experimentado una reducción importante en su densidad arbórea y fracción de cabida cubierta durante el periodo entre 1950-1980 donde tuvieron lugar importantes transformaciones en la actividad agropecuaria. La cabaña ganadera de ovino disminuyó drásticamente en los años 70 en comparación a la de bovino que desde entonces ha aumentado progresivamente hasta la actualidad. Por otro lado, el mismo tipo de manejo del ganado doméstico (especialmente bovino) durante bastante tiempo (mínimo 30 años) provocó una reducción significativa de la densidad de las plántulas. Además la probabilidad de ocurrencia y la intensidad de daños por herbivoría fue mayor bajo pastoreo bovino (con daños más intensos y consistentes) que bajo pastoreo ovino o sin pastoreo doméstico (presencia de ciervos). También el patrón de crecimiento de las plantas jóvenes estuvo afectado por el tipo de manejo, generando plántulas achaparradas en el caso del bovino y plántulas esbeltas favoreciendo el crecimiento en altura en el caso del ovino. La presencia de un arbolado disperso generó una mayor diversidad y variación en la producción de las comunidades herbáceas según las condiciones de disponibilidad de agua. Especialmente, el ecotono como microhábitat sostuvo altos valores de diversidad herbácea. La presencia del ganado bajo pastoreo continuo de intensidad moderada a alta, especialmente el bovino, incrementó los rendimientos de producción y diversidad del estrato herbáceo. Los resultados de esta tesis nos muestran la importancia que tiene la existencia de un equilibrio entre la producción y la conservación de los sistemas agroforestales mediterráneos para obtener una producción sostenible de servicios ecosistémicos mientras se asegura la perpetuación del sistema a largo plazo. Es crucial diseñar planes de gestión incorporando objetivos de conservación que integren técnicas silvopastorales apropiadas para poder aplicar en los sistemas agroforestales mediterráneos. ABSTRACT Mediterranean scattered oak woodlands have great ecological and socio-economic importance, supporting high environmental and amenity values, and relatively rich biological diversity while producing important ecosystem services. They have been witnesses of different and fast changes developed in the last century. Most of the research developed in this dissertation has conducted within dehesas. This thesis provides: i) the global change evidence of the tree layer and grazing management experienced in the land-use range of a Mediterranean scattered oak woodland (dehesa) over the last 60 years; ii) the important role of scattered trees and adequate management grazing in the improvement of grassland yield, quality and diversity - which it is important, in turn, for the system profitability - under different climate scenarios and site quality; and iii) the lack of oak regeneration evidence under some given representative management regimes and how is the growth development of these plants to assure the viability and persistence of Mediterranean scattered oak woodlands. Tree layer experienced a significant reduction in dehesas during 1950-1980 period where the highest human impacts took place. Sheep herd decreased drastically during the 1970s and, in contrast, cattle have been increasing gradually since then. On the other hand, same livestock grazing management (especially cattle) during long time (minimum 30 years) within Mediterranean scattered oak woodlands reduced strongly the density of young oak plants and showed high probability of herbivory occurrence and intensity. Young plant growth pattern was greatly modified by livestock. Cattle grazing generated stunted plants and sheep grazing generated slender plants favoring the height growth. Microsites created by large trees modified the herbaceous yield according the water availability of the year and generated high plant diversity within herbaceous communities. Especially, ecotone microsite supported high values of herbaceous diversity. The presence of livestock species increased the herbaceous yield and maintained a more diverse community under continuous grazing at both moderate and high intensities; especially cattle. Thus, around the influence of scattered trees there is a high amount of different interactions among livestock, trees and grasslands maintaining and enhancing the quality of whole dehesa system. The results of this thesis highlight how important is balancing management and preservation of Mediterranean scattered oak woodlands to obtain the optimum ecosystem services while the system conservation is assured for a long-term. It is crucial to design management plans with conservation goals that include appropriate silvopastoral practices in Mediterranean scattered oak woodlands.

Balancing management and preservation of mediterranean scattered oak woodlands (Dehesas) in human-dominated landscapes

Los sistemas agroforestales mediterráneos tienen una gran importancia ecológica y socioeconómica, y mantienen altos valores medioambientales y de diversidad biológica a la vez que producen importantes servicios ecosistémicos. Estos sistemas han sido testigos de diversos cambios rápidos y drásticos en su gestión y aprovechamiento durante el último siglo. La mayor parte de la investigación desarrollada en esta tesis doctoral ha sido llevada a cabo en las dehesas españolas. Esta tesis nos muestra: i) la evidencia de la existencia de un cambio global del estrato arbóreo y del manejo del pastoreo en el todo el área de distribución de la dehesa durante los últimos 60 años; ii) la importancia del papel que juega el arbolado disperso y el adecuado manejo del ganado en la mejora de la producción, calidad y diversidad de las comunidades herbáceas, que a su vez, un pasto herbáceo bien desarrollado es importante para la rentabilidad del sistema, evaluando estos efectos bajo distintos escenarios de clima y calidad de estación; y iii) la evidencia de la falta de regeneración en sistemas agroforestales mediterráneos bajo distintos tipos de manejo del pastoreo, y además se evalúa el crecimiento y desarrollo de las pocas plántulas existentes que serán las que aseguren la viabilidad y persistencia y de estos sistemas. El arbolado disperso de estos sistemas ha experimentado una reducción importante en su densidad arbórea y fracción de cabida cubierta durante el periodo entre 1950-1980 donde tuvieron lugar importantes transformaciones en la actividad agropecuaria. La cabaña ganadera de ovino disminuyó drásticamente en los años 70 en comparación a la de bovino que desde entonces ha aumentado progresivamente hasta la actualidad. Por otro lado, el mismo tipo de manejo del ganado doméstico (especialmente bovino) durante bastante tiempo (mínimo 30 años) provocó una reducción significativa de la densidad de las plántulas. Además la probabilidad de ocurrencia y la intensidad de daños por herbivoría fue mayor bajo pastoreo bovino (con daños más intensos y consistentes) que bajo pastoreo ovino o sin pastoreo doméstico (presencia de ciervos). También el patrón de crecimiento de las plantas jóvenes estuvo afectado por el tipo de manejo, generando plántulas achaparradas en el caso del bovino y plántulas esbeltas favoreciendo el crecimiento en altura en el caso del ovino. La presencia de un arbolado disperso generó una mayor diversidad y variación en la producción de las comunidades herbáceas según las condiciones de disponibilidad de agua. Especialmente, el ecotono como microhábitat sostuvo altos valores de diversidad herbácea. La presencia del ganado bajo pastoreo continuo de intensidad moderada a alta, especialmente el bovino, incrementó los rendimientos de producción y diversidad del estrato herbáceo. Los resultados de esta tesis nos muestran la importancia que tiene la existencia de un equilibrio entre la producción y la conservación de los sistemas agroforestales mediterráneos para obtener una producción sostenible de servicios ecosistémicos mientras se asegura la perpetuación del sistema a largo plazo. Es crucial diseñar planes de gestión incorporando objetivos de conservación que integren técnicas silvopastorales apropiadas para poder aplicar en los sistemas agroforestales mediterráneos. ABSTRACT Mediterranean scattered oak woodlands have great ecological and socio-economic importance, supporting high environmental and amenity values, and relatively rich biological diversity while producing important ecosystem services. They have been witnesses of different and fast changes developed in the last century. Most of the research developed in this dissertation has conducted within dehesas. This thesis provides: i) the global change evidence of the tree layer and grazing management experienced in the land-use range of a Mediterranean scattered oak woodland (dehesa) over the last 60 years; ii) the important role of scattered trees and adequate management grazing in the improvement of grassland yield, quality and diversity - which it is important, in turn, for the system profitability - under different climate scenarios and site quality; and iii) the lack of oak regeneration evidence under some given representative management regimes and how is the growth development of these plants to assure the viability and persistence of Mediterranean scattered oak woodlands. Tree layer experienced a significant reduction in dehesas during 1950-1980 period where the highest human impacts took place. Sheep herd decreased drastically during the 1970s and, in contrast, cattle have been increasing gradually since then. On the other hand, same livestock grazing management (especially cattle) during long time (minimum 30 years) within Mediterranean scattered oak woodlands reduced strongly the density of young oak plants and showed high probability of herbivory occurrence and intensity. Young plant growth pattern was greatly modified by livestock. Cattle grazing generated stunted plants and sheep grazing generated slender plants favoring the height growth. Microsites created by large trees modified the herbaceous yield according the water availability of the year and generated high plant diversity within herbaceous communities. Especially, ecotone microsite supported high values of herbaceous diversity. The presence of livestock species increased the herbaceous yield and maintained a more diverse community under continuous grazing at both moderate and high intensities; especially cattle. Thus, around the influence of scattered trees there is a high amount of different interactions among livestock, trees and grasslands maintaining and enhancing the quality of whole dehesa system. The results of this thesis highlight how important is balancing management and preservation of Mediterranean scattered oak woodlands to obtain the optimum ecosystem services while the system conservation is assured for a long-term. It is crucial to design management plans with conservation goals that include appropriate silvopastoral practices in Mediterranean scattered oak woodlands.

Quality management, environmental management and firm performance in the Spanish hotel industry

Comunicación presentada en el XVI Simposio Internacional de Turismo y Ocio, ESADE, 23 mayo 2007.

Implementing the Physical Literacy Component of the 2015 Ontario Health and Physical Education Curriculum: Is the Stage Set?

Introduction: Current physical activity levels among children and youth are alarmingly low; a mere 7% of children and youth are meeting the Canadian Physical Activity Guidelines (Colley et al., 2011), which means that the vast majority of this population is at risk of developing major health problems in adulthood (Janssen & Leblanc, 2010). These high inactivity rates may be related to suboptimal experiences in sport and physical activity stemming from a lack of competence and confidence (Lubans, Morgan, Cliff, Barnett, & Okely, 2010). Developing a foundation of physical literacy can encourage and maintain lifelong physical activity, yet this does not always occur naturally as a part of human growth (Hardman, 2011). An ideal setting to foster the growth and development of physical literacy is physical education class. Physical education class can offer all children and youth an equal opportunity to learn and practice the skills needed to be active for life (Hardman, 2011). Elementary school teachers are responsible for delivering the physical education curriculum, and it is important to understand their will and capacity as the implementing agents of physical literacy development curriculum (McLaughlin, 1987). Purpose: The purpose of this study was to explore the physical literacy component of the 2015 Ontario Health and Physical Education curriculum policy through the eyes of key informants, and to explore the resources available for the implementation of this new policy. Methods: Qualitative interviews were conducted with seven key informants of the curriculum policy development, including two teachers. In tandem with the interviews, a resource inventory and curriculum review were conducted to assess the content and availability of physical literacy resources. All data were analyzed through the lens of Hogwood and Gunn’s (1984) 10 preconditions for policy implementation. Results: Participants discussed how implementation is affected by: accountability, external capacity, internal capacity, awareness and understanding of physical literacy, implementation expertise, and policy climate. Discussion: Participants voiced similar opinions on most issues, and the overall lack of attention given to physical education programs in schools will continue to be a major dilemma when trying to combat such high physical inactivity levels.

Exploring complementarities between goods and services trade in trade agreements

More than three decades of research on trade costs and goods trade have unveiled fundamental insights into the determinants, the nature and the consequences of goods trade agreements. A cottage literature has also evolved studying similar issues from a services trade perspective, but the two-way interaction between goods and services trade has not been explored formally. We bridge this gap by providing a formal treatment of the inter-linkages between goods and services trade. The model provides insights into how trade agreements impact goods and services trade. We also explore the impact of the complementarities of goods and services agreements on goods and services trade empirically using bilateral goods and services trade data for OECD and BRICS trading partners over 1995-2010.

Integrated motorist information (IMIS) feasibility and design study. Phase II: generalized methodology for IMIS feasibility studies. Volume 2--validation and application of feasibility study handbook. Final report.

Federal Highway Administration, Office of Research and Development, Washington, D.C.

First principles of household management and cookery : a text-book for schools and families /

Includes sections on household cleaning and nutrition. Sample recipes: Beef stew, Oyster soup, Custard.