Is modern medicine at risk of losing the plot?

Contemporary medicine has much to its credit, but has created an insatiable demand for new technologies and more health services, fed by commercial promotion, professional advocacy and sociopolitical pressure. Total health expenditure at the national level is now almost 10% of gross domestic product and is expected to top 16% by 2020. After recent inquiries into the failings of its public health system, the Queensland Government has committed itself to a 25% increase in expenditure on health over the next 5 years. But will it lead to better population health, and is it sustainable? The return-on-investment curve for modern health care may be flattening out, in an environment of growing numbers of older patients with chronic illnesses, maldistribution of services and hospital overcrowding. A change in thinking is required if current medical practice is to avoid imploding when confronted with the next major economic downturn. Health policy, service funding and clinical training must focus on critical appraisal of the effectiveness of health care technologies and the structure and financing of health care systems. Practising clinicians will be obliged to provide leadership in determining value for money in the choice of health care for specific patient populations and how that care is delivered.

Valutazione del rischio ecologico e sviluppo di strategie innovative per il monitoraggio della qualita’ dei corpi idrici: applicazione di un nuovo approccio integrato in un bacino pilota.

Freshwater is extremely precious; but even more precious than freshwater is clean freshwater. From the time that 2/3 of our planet is covered in water, we have contaminated our globe with chemicals that have been used by industrial activities over the last century in a unprecedented way causing harm to humans and wildlife. We have to adopt a new scientific mindset in order to face this problem so to protect this important resource. The Water Framework Directive (European Parliament and the Council, 2000) is a milestone legislative document that transformed the way that water quality monitoring is undertaken across all Member States by introducing the Ecological and Chemical Status. A “good or higher” Ecological Status is expected to be achieved for all waterbodies in Europe by 2015. Yet, most of the European waterbodies, which are determined to be at risk, or of moderate to bad quality, further information will be required so that adequate remediation strategies can be implemented. To date, water quality evaluation is based on five biological components (phytoplankton, macrophytes and benthic algae, macroinvertebrates and fishes) and various hydromorphological and physicochemical elements. The evaluation of the chemical status is principally based on 33 priority substances and on 12 xenobiotics, considered as dangerous for the environment. This approach takes into account only a part of the numerous xenobiotics that can be present in surface waters and could not evidence all the possible causes of ecotoxicological stress that can act in a water section. The mixtures of toxic chemicals may constitute an ecological risk not predictable on the basis of the single component concentration. To improve water quality, sources of contamination and causes of ecological alterations need to be identified. On the other hand, the analysis of the community structure, which is the result of multiple processes, including hydrological constrains and physico-chemical stress, give back only a “photograph” of the actual status of a site without revealing causes and sources of the perturbation. A multidisciplinary approach, able to integrate the information obtained by different methods, such as community structure analysis and eco-genotoxicological studies, could help overcome some of the difficulties in properly identifying the different causes of stress in risk assessment. In synthesis, the river ecological status is the result of a combination of multiple pressures that, for management purposes and quality improvement, have to be disentangled from each other. To reduce actual uncertainty in risk assessment, methods that establish quantitative links between levels of contamination and community alterations are needed. The analysis of macrobenthic invertebrate community structure has been widely used to identify sites subjected to perturbation. Trait-based descriptors of community structure constitute a useful method in ecological risk assessment. The diagnostic capacity of freshwater biomonitoring could be improved by chronic sublethal toxicity testing of water and sediment samples. Requiring an exposure time that covers most of the species’ life cycle, chronic toxicity tests are able to reveal negative effects on life-history traits at contaminant concentrations well below the acute toxicity level. Furthermore, the responses of high-level endpoints (growth, fecundity, mortality) can be integrated in order to evaluate the impact on population’s dynamics, a highly relevant endpoint from the ecological point of view. To gain more accurate information about potential causes and consequences of environmental contamination, the evaluation of adverse effects at physiological, biochemical and genetic level is also needed. The use of different biomarkers and toxicity tests can give information about the sub-lethal and toxic load of environmental compartments. Biomarkers give essential information about the exposure to toxicants, such as endocrine disruptor compounds and genotoxic substances whose negative effects cannot be evidenced by using only high-level toxicological endpoints. The increasing presence of genotoxic pollutants in the environment has caused concern regarding the potential harmful effects of xenobiotics on human health, and interest on the development of new and more sensitive methods for the assessment of mutagenic and cancerogenic risk. Within the WFD, biomarkers and bioassays are regarded as important tools to gain lines of evidence for cause-effect relationship in ecological quality assessment. Despite the scientific community clearly addresses the advantages and necessity of an ecotoxicological approach within the ecological quality assessment, a recent review reports that, more than one decade after the publication of the WFD, only few studies have attempted to integrate ecological water status assessment and biological methods (namely biomarkers or bioassays). None of the fifteen reviewed studies included both biomarkers and bioassays. The integrated approach developed in this PhD Thesis comprises a set of laboratory bioassays (Daphnia magna acute and chronic toxicity tests, Comet Assay and FPG-Comet) newly-developed, modified tacking a cue from standardized existing protocols or applied for freshwater quality testing (ecotoxicological, genotoxicological and toxicogenomic assays), coupled with field investigations on macrobenthic community structures (SPEAR and EBI indexes). Together with the development of new bioassays with Daphnia magna, the feasibility of eco-genotoxicological testing of freshwater and sediment quality with Heterocypris incongruens was evaluated (Comet Assay and a protocol for chronic toxicity). However, the Comet Assay, although standardized, was not applied to freshwater samples due to the lack of sensitivity of this species observed after 24h of exposure to relatively high (and not environmentally relevant) concentrations of reference genotoxicants. Furthermore, this species demonstrated to be unsuitable also for chronic toxicity testing due to the difficult evaluation of fecundity as sub-lethal endpoint of exposure and complications due to its biology and behaviour. The study was applied to a pilot hydrographic sub-Basin, by selecting section subjected to different levels of anthropogenic pressure: this allowed us to establish the reference conditions, to select the most significant endpoints and to evaluate the coherence of the responses of the different lines of evidence (alteration of community structure, eco-genotoxicological responses, alteration of gene expression profiles) and, finally, the diagnostic capacity of the monitoring strategy. Significant correlations were found between the genotoxicological parameter Tail Intensity % (TI%) and macrobenthic community descriptors SPEAR (p<0.001) and EBI (p<0.05), between the genotoxicological parameter describing DNA oxidative stress (ΔTI%) and mean levels of nitrates (p<0.01) and between reproductive impairment (Failed Development % from D. magna chronic bioassays) and TI% (p<0.001) as well as EBI (p<0.001). While correlation among parameters demonstrates a general coherence in the response to increasing impacts, the concomitant ability of each single endpoint to be responsive to specific sources of stress is at the basis of the diagnostic capacity of the integrated approach as demonstrated by stations presenting a mismatch among the different lines of evidence. The chosen set of bioassays, as well as the selected endpoints, are not providing redundant indications on the water quality status but, on the contrary, are contributing with complementary pieces of information about the several stressors that insist simultaneously on a waterbody section providing this monitoring strategy with a solid diagnostic capacity. Our approach should provide opportunities for the integration of biological effects into monitoring programmes for surface water, especially in investigative monitoring. Moreover, it should provide a more realistic assessment of impact and exposure of aquatic organisms to contaminants. Finally this approach should provide an evaluation of drivers of change in biodiversity and its causalities on ecosystem function/services provision, that is the direct and indirect contributions to human well-being.

A fuzzy expected value approach under generalized data envelopment analysis

Fuzzy data envelopment analysis (DEA) models emerge as another class of DEA models to account for imprecise inputs and outputs for decision making units (DMUs). Although several approaches for solving fuzzy DEA models have been developed, there are some drawbacks, ranging from the inability to provide satisfactory discrimination power to simplistic numerical examples that handles only triangular fuzzy numbers or symmetrical fuzzy numbers. To address these drawbacks, this paper proposes using the concept of expected value in generalized DEA (GDEA) model. This allows the unification of three models - fuzzy expected CCR, fuzzy expected BCC, and fuzzy expected FDH models - and the ability of these models to handle both symmetrical and asymmetrical fuzzy numbers. We also explored the role of fuzzy GDEA model as a ranking method and compared it to existing super-efficiency evaluation models. Our proposed model is always feasible, while infeasibility problems remain in certain cases under existing super-efficiency models. In order to illustrate the performance of the proposed method, it is first tested using two established numerical examples and compared with the results obtained from alternative methods. A third example on energy dependency among 23 European Union (EU) member countries is further used to validate and describe the efficacy of our approach under asymmetric fuzzy numbers.

Egységes kockázatkezelési módszertan kialakítása a villamosenergia-ipari átviteli rendszerirányító társaságnál (Development of an integrated risk management methodology for an electricity transmission system operator (TSO) company)

A felelős vállalatirányítás egyik stratégiai jelentőségű tényezője a vállalati szintű kockázatkezelés, mely napjaink egyik legnagyobb kihívást jelentő területe a vállalatvezetés számára. A hatékony vállalati kockázatkezelés nem valósulhat meg kizárólag az általános, nemzetközi és hazai szakirodalomban megfogalmazott kockázatkezelési alapelvek követése mentén, a kockázatkezelési rendszer kialakítása során figyelembe kell venni mind az iparági, mind az adott vállalatra jellemző sajátosságokat. Mindez különösen fontos egy olyan speciális tevékenységet folytató vállalatnál, mint a villamosenergia-ipari átviteli rendszerirányító társaság (transmission system operator, TSO). A cikkben a magyar villamosenergia-ipari átviteli rendszerirányító társasággal együttműködésben készített kutatás keretében előálló olyan komplex elméleti és gyakorlati keretrendszert mutatnak be a szerzők, mely alapján az átviteli rendszerirányító társaság számára kialakítottak egy új, területenként egységes kockázatkezelési módszertant (fókuszban a kockázatok azonosításának és számszerűsítésének módszertani lépéseivel), mely alkalmas a vállalati szintű kockázati kitettség meghatározására. _______ This study handles one of today’s most challenging areas of enterprise management: the development and introduction of an integrated and efficient risk management system. For companies operating in specific network industries with a dominant market share and a key role in the national economy, such as electricity TSO’s, risk management is of stressed importance. The study introduces an innovative, mathematically and statistically grounded as well as economically reasoned management approach for the identification, individual effect calculation and summation of risk factors. Every building block is customized for the organizational structure and operating environment of the TSO. While the identification phase guarantees all-inclusivity, the calculation phase incorporates expert techniques and Monte Carlo simulation and the summation phase presents an expected combined distribution and value effect of risks on the company’s profit lines based on the previously undiscovered correlations between individual risk factors.

Risk and benefits in lifestyle sports: parkour, law and social value

This paper examines the interrelationship between law and lifestyle sports, viewed through the lens of parkour. We argue that the literature relating to legal approaches to lifestyle sport is currently underdeveloped and so seek to partially fill this lacuna. Hitherto, we argue, the law has been viewed as a largely negative presence, seen particularly in terms of the ways in which counter-cultural activities are policed and regulated, and where such activities are viewed as transgressive or undesirable. We argue that this is a somewhat unsophisticated take on how the law can operate, with law constructed as an outcome of constraints to behaviour (where the law authorises or prohibits), distinct from the legal contexts, environments and spaces in which these relationships occur. We argue that the distinctive settings in which lifestyle sports are practiced needs a more fine-grained analysis as they are settings which bear, and bring to life, laws and regulations that shape how space is to be experienced. We examine specifically the interrelationship between risk and benefit and how the law recognises issues of social utility or value, particularly within the context of lifestyle sport. We seek to move from user-centred constructions of law as an imposition, to a more nuanced position that looks at parkour at the intersections of law, space and lifestyle sport, in order to reveal how law can be used to support and extend claims to space.

Leverage, Volatile Future Earnings Growth and Expected Stock Returns

We provide theory and evidence to complement Choi's [RFS, 2013] important new insights on the returns to equity in `value' firms. We show that higher future earnings growth ameliorates the value-reducing effect of leverage and, because the market for earnings is incomplete, reduces the earnings-risk sensitivity of the default option. Ceteris paribus, a levered firm with low (high) earnings growth is more sensitive to the first (second) of these effects thus generating higher (lower) expected returns. We demonstrate this by modeling equity as an Asian-style call option on net earnings and find significant empirical support for our hypotheses.

Consumers' accounts of perceived risk online and the influence of communication sources

The purpose of this paper is to extend marketing knowledge into perceived risk in online transactions beyond the current positivistic, hypotheses-driven research by providing qualitative insights into how individuals construct their accounts of perceived risk online. Additionally, the study reported in this paper aims to explore how communication sources influence both these subjective constructions and individuals' behavioural experiences with transaction activity on the web. Design/methodology/approach - The study was developed within a grounded theory method.Ten in-depth interviews were conducted which were analysed using constant comparison of incidents procedures to provide rich descriptions of the interviewees' subjective perceptions and lived experiences with online transaction activity. Findings - The findings provide insights into how the human clement is present in individuals'perceptions and constructions of their accounts of the risk involved online.The findings also identify the influence of mass communication sources on the construction of these accounts. The study provides insights into whether change agent communication sources, such as marketers or web designers,influence consumers' behaviours towards online transaction activity through mediating their perceptions of the risks involved. The study also reveals how social communication networks influence the interviewees' decisions to use the web (or transaction activities, in particular online purchasing, and how the group in this study might act as a communication source to influence others. Research limitations/Implications - While the findings cannot be generalised to the internet population overall, the sample used was able to provide relevant information regarding the phenomenon of interest. Future research should continue to examine perceived risk and the influence of communications sources, such as e-mail, discussion groups and virtual communities. Originality/value - The value of the paper lies in permitting the participants to account for perceived risk for themselves. The findings ex.plore what this means at increasing levels of personal relevance and the influence of communication sources to create, sustain or mediate perceptions of this phenomenon.

Fashion as consumer entrepreneurship : emergent risk culture, social network markets, and the launch of 'Vogue' in China

China has a reputation as an economy based on utility: the large-scale manufacture of low-priced goods. But useful values like functionality, fitness for purpose and efficiency are only part of the story. More important are what Veblen called ‘honorific’ values, arguably the driving force of development, change and value in any economy. To understand the Chinese economy therefore, it is not sufficient to point to its utilitarian aspect. Honorific status-competition is a more fundamental driver than utilitarian cost-competition. We argue that ‘social network markets’ are the expression of these honorific values, relationships and connections that structure and coordinate individual choices. This paper explores how such markets are developing in China in the area of fashion and fashion media. These, we argue, are an expression of ‘risk culture’ for high-end entrepreneurial consumers and producers alike, providing a stimulus to dynamic innovation in the arena of personal taste and comportment, as part of an international cultural system based on constant change. We examine the launch of Vogue China in 2005, and China’s reception as a fashion player among the international editions of Vogue, as an expression of a ‘decisive moment’ in the integration of China into an international social network market based on honorific values.

Value creation and value capture fro open source software publisher : a new business model based on mutualisation

Key topics: Since the birth of the Open Source movement in the mid-80's, open source software has become more and more widespread. Amongst others, the Linux operating system, the Apache web server and the Firefox internet explorer have taken substantial market shares to their proprietary competitors. Open source software is governed by particular types of licenses. As proprietary licenses only allow the software's use in exchange for a fee, open source licenses grant users more rights like the free use, free copy, free modification and free distribution of the software, as well as free access to the source code. This new phenomenon has raised many managerial questions: organizational issues related to the system of governance that underlie such open source communities (Raymond, 1999a; Lerner and Tirole, 2002; Lee and Cole 2003; Mockus et al. 2000; Tuomi, 2000; Demil and Lecocq, 2006; O'Mahony and Ferraro, 2007;Fleming and Waguespack, 2007), collaborative innovation issues (Von Hippel, 2003; Von Krogh et al., 2003; Von Hippel and Von Krogh, 2003; Dahlander, 2005; Osterloh, 2007; David, 2008), issues related to the nature as well as the motivations of developers (Lerner and Tirole, 2002; Hertel, 2003; Dahlander and McKelvey, 2005; Jeppesen and Frederiksen, 2006), public policy and innovation issues (Jullien and Zimmermann, 2005; Lee, 2006), technological competitions issues related to standard battles between proprietary and open source software (Bonaccorsi and Rossi, 2003; Bonaccorsi et al. 2004, Economides and Katsamakas, 2005; Chen, 2007), intellectual property rights and licensing issues (Laat 2005; Lerner and Tirole, 2005; Gambardella, 2006; Determann et al., 2007). A major unresolved issue concerns open source business models and revenue capture, given that open source licenses imply no fee for users. On this topic, articles show that a commercial activity based on open source software is possible, as they describe different possible ways of doing business around open source (Raymond, 1999; Dahlander, 2004; Daffara, 2007; Bonaccorsi and Merito, 2007). These studies usually look at open source-based companies. Open source-based companies encompass a wide range of firms with different categories of activities: providers of packaged open source solutions, IT Services&Software Engineering firms and open source software publishers. However, business models implications are different for each of these categories: providers of packaged solutions and IT Services&Software Engineering firms' activities are based on software developed outside their boundaries, whereas commercial software publishers sponsor the development of the open source software. This paper focuses on open source software publishers' business models as this issue is even more crucial for this category of firms which take the risk of investing in the development of the software. Literature at last identifies and depicts only two generic types of business models for open source software publishers: the business models of ''bundling'' (Pal and Madanmohan, 2002; Dahlander 2004) and the dual licensing business models (Välimäki, 2003; Comino and Manenti, 2007). Nevertheless, these business models are not applicable in all circumstances. Methodology: The objectives of this paper are: (1) to explore in which contexts the two generic business models described in literature can be implemented successfully and (2) to depict an additional business model for open source software publishers which can be used in a different context. To do so, this paper draws upon an explorative case study of IdealX, a French open source security software publisher. This case study consists in a series of 3 interviews conducted between February 2005 and April 2006 with the co-founder and the business manager. It aims at depicting the process of IdealX's search for the appropriate business model between its creation in 2000 and 2006. This software publisher has tried both generic types of open source software publishers' business models before designing its own. Consequently, through IdealX's trials and errors, I investigate the conditions under which such generic business models can be effective. Moreover, this study describes the business model finally designed and adopted by IdealX: an additional open source software publisher's business model based on the principle of ''mutualisation'', which is applicable in a different context. Results and implications: Finally, this article contributes to ongoing empirical work within entrepreneurship and strategic management on open source software publishers' business models: it provides the characteristics of three generic business models (the business model of bundling, the dual licensing business model and the business model of mutualisation) as well as conditions under which they can be successfully implemented (regarding the type of product developed and the competencies of the firm). This paper also goes further into the traditional concept of business model used by scholars in the open source related literature. In this article, a business model is not only considered as a way of generating incomes (''revenue model'' (Amit and Zott, 2001)), but rather as the necessary conjunction of value creation and value capture, according to the recent literature about business models (Amit and Zott, 2001; Chresbrough and Rosenblum, 2002; Teece, 2007). Consequently, this paper analyses the business models from these two components' point of view.

Can risk management boost the supply of affordable housing development and management?

Purpose: The purpose of this paper is to analyse the risk management process conducted by some private and not-for-profit affordable housing providers in South East Queensland, and draw conclusions about the relationship between risk assessments/responses and past experiences.----- Design/methodology/approach: In-depth interviews of selected non-government housing providers have been conducted to facilitate an understanding of their approach to risk assessment in developing and in managing affordable housing projects. Qualitative data are analysed using thematic analysis to find emerging themes suggested by interview participants.----- Findings: The paper finds that informal risk management process is used as part of normal business process in accordance with industry standards. Many interviewees agree that the recognition of financial risk and the fear of community rejection of such housing projects have restrained them from committing to such investment projects. The levels of acceptance of risk are not always consistent across housing providers which create opportunities to conduct multi-stakeholder partnership to reduce overall risk.----- Research limitations/implications: The paper has implications for developers or investors who seek to include affordable housing as part of their portfolio. However, data collected in the study are a cross-section of interviews that will not include the impact on recent tax incentives offers by the Australian Commonwealth Government.----- Practical implications: The study suggests that implementing improvements to the risk mitigation and management framework may assist in promoting the supply of affordable housing by non-government providers.----- Originality/value: The focus of the study is the interaction between partnerships and risk management in development and management of affordable rental housing.

The malnutrition screening tool is a useful tool for identifying malnutrition risk in residential aged care

Background: The Malnutrition Screening Tool (MST) is a valid nutrition screening tool in the acute hospital setting but has not been assessed in residential aged care facilities. The aim of this secondary analysis was to determine whether the MST could be a useful nutrition screening tool when compared with a full nutrition assessment by Subjective Global Assessment (SGA) in the residential aged care setting. ----- Methods: Two hundred and eighty-five residents (29% male; mean age: 84 ± 9 years) from eight residential aged care facilities in Australia participated. A secondary analysis of data collected during a nutrition intervention study was conducted. The MST consists of two questions related to recent weight loss and appetite. While the MST was not specifically applied, weight loss and appetite information was available and an estimated MST score (0-5) calculated. Nutritional status was assessed by a research assistant trained in using SGA. ----- Results: Malnutrition prevalence was 42.8% (122 malnourished out of 285 residents). Compared to the SGA, the MST was an effective predictor of nutritional risk (sensitivity = 83.6%, specificity = 65.6%, positive predictive value = 0.65, negative predictive value =0.84). ----- Conclusions: The components of the MST have acceptable sensitivity and specificity suggesting it can play a valuable role in quickly identifying malnutrition risk in the residential aged care setting. Further prospective research using the MST tool against a broader array of objective and subjective nutritional parameters is required to confirm its validity as a screening tool in aged care settings.