The Next 10 years in the Management of Peripheral Artery Disease: Perspectives from The 'PAD 2009' Conference

OBJECTIVES: To briefly inform on the conclusions from a conference on the next 10 years in the management of peripheral artery disease (PAD). DESIGN OF THE CONFERENCE: International participation, invited presentations and open discussion were based on the following issues: Why is PAD under-recognised? Health economic impact of PAD; funding of PAD research; changes of treatment options? Aspects on clinical trials and regulatory views; and the role of guidelines. RESULTS AND CONCLUSIONS: A relative lack of knowledge about cardiovascular risk and optimal management of PAD patients exists not only among the public, but also in parts of the health-care system. Specialists are required to act for improved information. More specific PAD research is needed for risk management and to apply the best possible evaluation of evidence for treatment strategies. Better strategies for funding are required based on, for example, public/private initiatives. The proportion of endovascular treatments is steadily increasing, more frequently based on observational studies than on randomised controlled trials. The role of guidelines is therefore important to guide the profession in the assessment of most relevant treatment.

The precipitous decline of the ortolan bunting Emberiza hortulana: time to build on scientific evidence to inform conservation management

In recent decades there has been a marked decline in most ortolan bunting Emberiza hortulana populations in temperate Europe, with many regional populations now extinct or on the brink of extinction. In contrast, Mediterranean and, as far as we know, eastern European popula-tions seem to have remained relatively stable. The causes of decline remain unclear but include: habitat loss and degradation, and related reduction in prey availability; climate change on the breeding grounds; altered population dynamics; illegal captures during migration; and environmental change in wintering areas. We review the current knowledge of the biology of the ortolan bunting and discuss the proposed causes of decline in relation to the different population trends in temperate and Mediterranean Europe. We suggest new avenues of research to identify the factors limiting ortolan bunting populations. The main evidence-based conservation measure that is likely to enhance habitat quality is the creation of patches of bare ground to produce sparsely vegetated foraging grounds in invertebrate-rich grassy habitats close to breeding areas.

Perceptions of water conditions and management in the Sonora River Basin, Sonora, Mexico

The effects of climate change are expected to be very severe in arid regions. The Sonora River Basin, in the northwestern state of Sonora, Mexico, is likely to be severely affected. Some of the anticipated effects include precipitation variability, intense storm events, higher overall temperatures, and less available water. In addition, population in Sonora, specifically the capital city of Hermosillo, is increasing at a 1.5% rate and current populations are near 700,000. With the reduction in water availability and an increase in population, Sonora, Mexico is expected to experience severe water resource issues in the near future. In anticipation of these changes, research is being conducted in an attempt to improve water management in the Sonora River Basin, located in the northwestern part of Sonora. This research involves participatory modeling techniques designed to increase water manager awareness of hydrological models and their use as integrative tools for water resource management. This study was conducted as preliminary research for the participatory modeling grant in order to gather useful information on the population being studied. This thesis presents research from thirty-four in-depth interviews with water managers, citizens, and agricultural producers in Sonora, Mexico. Data was collected on perceptions of water quantity and quality in the basin, thoughts on current water management practices, perceptions of climate change and its management, experience with, knowledge of, and trust in hydrological models as water management tools. Results showed that the majority of interviewees thought there was not enough water to satisfy their daily needs. Most respondents also agreed that the water available was of good quality, but that current management of water resources was ineffective. Nearly all interviewees were aware of climate change and thought it to be anthropogenic. May reported experiencing higher temperatures, precipitation changes, and higher water scarcity and attributed those fluctuations to climate change. 65% of interviewees were at least somewhat familiar with hydrological models, though only 28% had ever used them or their output. Even with model usage results being low, 100% of respondents believed hydrological models to be very useful water management tools. Understanding how water, climate change, and hydrological models are perceived by this population of people is essential to improving their water management practices in the face of climate change.

[New insights into diagnosis and management of gestational diabetes mellitus: recommendations of the Swiss Society for Endocrinology and Diabetes]

Physiology and current knowledge about gestational diabetes which led to the adoption of new diagnostic criterias and blood glucose target levels during pregnancy by the Swiss Society for Endocrinology and Diabetes are reviewed. The 6th International Workshop Conference on Gestational Diabetes mellitus in Pasedena (2008) defined new diagnostic criteria based on the results of the HAPO-Trial. These criteria were during the ADA congress in New Orleans in 2009 presented. According to the new criteria there is no need for screening, but all pregnant women have to be tested with a 75 g oral glucose tolerance test between the 24th and 28th week of pregnancy. The new diagnostic values are very similar to the ones previously adopted by the ADA with the exception that only one out of three values has to be elevated in order to make the diagnosis of gestational diabetes. Due to this important difference it is very likely that gestational diabetes will be diagnosed more frequently in the future. The diagnostic criteria are: Fasting plasma glucose > or = 5.1 mmol/l, 1-hour value > or = 10.0 mmol/l or 2-hour value > or = 8.5 mmol/l. Based on current knowledge and randomized trials it is much more difficult to define glucose target levels during pregnancy. This difficulty has led to many different recommendations issued by diabetes societies. The Swiss Society of Endocrinology and Diabetes follows the arguments of the International Diabetes Federation (IDF) that self-blood glucose monitoring itself lacks precision and that there are very few randomized trials. Therefore, the target levels have to be easy to remember and might be slightly different in mmol/l or mg/dl. The Swiss Society for Endocrinology and Diabetes adopts the tentative target values of the IDF with fasting plasma glucose values < 5.3 mM and 1- and 2-hour postprandial (after the end of the meal) values of < 8.0 and 7.0 mmol/l, respectively. The last part of these recommendations deals with the therapeutic options during pregnancy (nutrition, physical exercise and pharmaceutical treatment). If despite lifestyle changes the target values are not met, approximately 25 % of patients have to be treated pharmaceutically. Insulin therapy is still the preferred treatment option, but metformin (and as an exception glibenclamide) can be used, if there are major hurdles for the initiation of insulin therapy.

Meeting the Challenges of Transdisciplinary Knowledge Production for Sustainable Water Governance

Increasing pressure on mountain water resources is making it necessary to address water governance issues in a transdisciplinary way. This entails drawing on different disciplinary perspectives, different types of knowledge, and different interests to answer complex governance questions. This study identifies strategies for addressing specific challenges to transdisciplinary knowledge production aiming at sustainable and reflective water governance. The study draws on the experiences of 5 large transdisciplinary water governance research projects conducted in Austria and Switzerland (Alp-Water-Scarce, MontanAqua, Drought-CH, Sustainable Water Infrastructure Planning, and an integrative river management project in the Kamp Valley). Experiences were discussed and systematically analyzed in a workshop and subsequent interviews. These discussions identified 4 important challenges to interactions between scientists and stakeholders—ensuring stakeholder legitimacy, encouraging participation, managing expectations, and preventing misuse of data and research results—and explored strategies used by the projects to meet them. Strategies ranged from key points to be considered in stakeholder selection to measures that enhance trustful relationships and create commitment.

Catheter removal versus retention in the management of catheter-associated enterococcal bloodstream infections

BACKGROUND Enterococci are an important cause of central venous catheter (CVC)-associated bloodstream infections (CA-BSI). It is unclear whether CVC removal is necessary to successfully manage enterococcal CA-BSI. METHODS A 12-month retrospective cohort study of adults with enterococcal CA-BSI was conducted at a tertiary care hospital; clinical, microbiological and outcome data were collected. RESULTS A total of 111 patients had an enterococcal CA-BSI. The median age was 58.2 years (range 21 to 94 years). There were 45 (40.5%) infections caused by Entercoccus faecalis (among which 10 [22%] were vancomycin resistant), 61 (55%) by Enterococcus faecium (57 [93%] vancomycin resistant) and five (4.5%) by other Enterococcus species. Patients were treated with linezolid (n=51 [46%]), vancomycin (n=37 [33%]), daptomycin (n=11 [10%]), ampicillin (n=2 [2%]) or quinupristin/dalfopristin (n=2 [2%]); seven (n=6%) patients did not receive adequate enterococcal treatment. Additionally, 24 (22%) patients received adjunctive gentamicin treatment. The CVC was retained in 29 (26.1%) patients. Patients with removed CVCs showed lower rates of in-hospital mortality (15 [18.3%] versus 11 [37.9]; P=0.03), but similar rates of recurrent bacteremia (nine [11.0%] versus two (7.0%); P=0.7) and a similar post-BSI length of hospital stay (median days [range]) (11.1 [1.7 to 63.1 days] versus 9.3 [1.9 to 31.8 days]; P=0.3). Catheter retention was an independent predictor of mortality (OR 3.34 [95% CI 1.21 to 9.26]). CONCLUSIONS To the authors' knowledge, the present article describes the largest enterococcal CA-BSI series to date. Mortality was increased among patients who had their catheter retained. Additional prospective studies are necessary to determine the optimal management of enterococcal CA-BSI.

Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

Developing and Integrating the Management of Elder Abuse in Primary Practice: A Case Study Using A Web-Based CME Course Format

Introduction: As the population in the United States continues to age, more attention in primary practice settings is now devoted toward managing the care of the elderly. The occurrence of elder abuse is a growing problem. It is a condition many professionals in primary care may be ill prepared with the knowledge or resources to identify and manage. [See PDF for complete abstract]

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records.

BACKGROUND: We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. METHODS: We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. RESULTS: All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. CONCLUSION: If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Observed management practices in relation to the risk of infection with paratuberculosis and to the spread of Mycobacterium avium subsp. paratuberculosis in Swiss dairy and beef herds

Abstract BACKGROUND: Many studies have been conducted to define risk factors for the transmission of bovine paratuberculosis, mostly in countries with large herds. Little is known about the epidemiology in infected Swiss herds and risk factors important for transmission in smaller herds. Therefore, the presence of known factors which might favor the spread of paratuberculosis and could be related to the prevalence at animal level of fecal shedding of Mycobacterium avium subsp. paratuberculosis were assessed in 17 infected herds (10 dairy, 7 beef). Additionally, the level of knowledge of herd managers about the disease was assessed. In a case-control study with 4 matched negative control herds per infected herd, the association of potential risk factors with the infection status of the herd was investigated. RESULTS: Exposure of the young stock to feces of older animals was frequently observed in infected and in control herds. The farmers' knowledge about paratuberculosis was very limited, even in infected herds. An overall prevalence at animal level of fecal shedding of Mycobacterium avium subsp. paratuberculosis of 6.1% was found in infected herds, whereby shedders younger than 2 years of age were found in 46.2% of the herds where the young stock was available for testing. Several factors related to contamination of the heifer area with cows' feces and the management of the calving area were found to be significantly associated with the within-herd prevalence. Animal purchase was associated with a positive herd infection status (OR = 7.25, p = 0.004). CONCLUSIONS: Numerous risk factors favoring the spread of Mycobacterium avium subsp. paratuberculosis from adult animals to the young stock were observed in infected Swiss dairy and beef herds, which may be amenable to improvement in order to control the disease. Important factors were contamination of the heifer and the calving area, which were associated with higher within-herd prevalence of fecal shedding. The awareness of farmers of paratuberculosis was very low, even in infected herds. Animal purchase in a herd was significantly associated with the probability of a herd to be infected and is thus the most important factor for the control of the spread of disease between farms.

Towards a Transfer Model of Scientific and Technological Knowledge: the Case of Mexico

This paper shows the development of a science-technological knowledge transfer model in Mexico, as a means to boost the limited relations between the scientific and industrial environments. The proposal is based on the analysis of eight organizations (research centers and firms) with varying degrees of skill in the practice of science-technological knowledge transfer, and carried out by the case study approach. The analysis highlights the synergistic use of the organizational and technological capabilities of each organization, as a means to identification of the knowledge transfer mechanisms best suited to enabling the establishment of cooperative processes, and achieve the R&D and innovation activities results.

Riding out of the storm: How to deal with the complexity of grid and cloud management

Over the last decade, Grid computing paved the way for a new level of large scale distributed systems. This infrastructure made it possible to securely and reliably take advantage of widely separated computational resources that are part of several different organizations. Resources can be incorporated to the Grid, building a theoretical virtual supercomputer. In time, cloud computing emerged as a new type of large scale distributed system, inheriting and expanding the expertise and knowledge that have been obtained so far. Some of the main characteristics of Grids naturally evolved into clouds, others were modified and adapted and others were simply discarded or postponed. Regardless of these technical specifics, both Grids and clouds together can be considered as one of the most important advances in large scale distributed computing of the past ten years; however, this step in distributed computing has came along with a completely new level of complexity. Grid and cloud management mechanisms play a key role, and correct analysis and understanding of the system behavior are needed. Large scale distributed systems must be able to self-manage, incorporating autonomic features capable of controlling and optimizing all resources and services. Traditional distributed computing management mechanisms analyze each resource separately and adjust specific parameters of each one of them. When trying to adapt the same procedures to Grid and cloud computing, the vast complexity of these systems can make this task extremely complicated. But large scale distributed systems complexity could only be a matter of perspective. It could be possible to understand the Grid or cloud behavior as a single entity, instead of a set of resources. This abstraction could provide a different understanding of the system, describing large scale behavior and global events that probably would not be detected analyzing each resource separately. In this work we define a theoretical framework that combines both ideas, multiple resources and single entity, to develop large scale distributed systems management techniques aimed at system performance optimization, increased dependability and Quality of Service (QoS). The resulting synergy could be the key 350 J. Montes et al. to address the most important difficulties of Grid and cloud management.

Development of the infrastructure for a multi-agent traffic management system simulation

This document contains detailed description of the design and the implementation of a multi-agent application controlling traffic lights in a city together with a system for simulating traffic and testing. The goal of this thesis is to design and build a simplified intelligent and distributed solution to the problem with the traffic in the big cities following different good practices in order to allow future refining of the model of the real world. The problem of the traffic in the big cities is still a problem that cannot be solved. Not only is the increasing number of cars a reason for the traffic jams, but also the way the traffic is organized. Usually, the intersections with traffic lights are replaced by roundabouts or interchanges to increase the number of cars that can cross the intersection in certain time. But still there are places where the infrastructure cannot be changed and the traffic light semaphores are the only way to control the car flows. In real life, the traffic lights have a predefined plan for change or they receive information from a centralized system when and how they have to change. But what if the traffic lights can cooperate and decide on their own when and how to change? Using this problem, the purpose of the thesis is to explore different agent-based software engineering approaches to design and build a non-conventional distributed system. From the software engineering point of view, the goal of the thesis is to apply the knowledge and use the skills, acquired during the various courses of the master program in Software Engineering, while solving a practical and complex problem such as the traffic in the cities.

Analysing the complexity of the model-based decision making processes within the industrial management context

PURPOSE The decision-making process plays a key role in organizations. Every decision-making process produces a final choice that may or may not prompt action. Recurrently, decision makers find themselves in the dichotomous question of following a traditional sequence decision-making process where the output of a decision is used as the input of the next stage of the decision, or following a joint decision-making approach where several decisions are taken simultaneously. The implication of the decision-making process will impact different players of the organization. The choice of the decision- making approach becomes difficult to find, even with the current literature and practitioners’ knowledge. The pursuit of better ways for making decisions has been a common goal for academics and practitioners. Management scientists use different techniques and approaches to improve different types of decisions. The purpose of this decision is to use the available resources as well as possible (data and techniques) to achieve the objectives of the organization. The developing and applying of models and concepts may be helpful to solve managerial problems faced every day in different companies. As a result of this research different decision models are presented to contribute to the body of knowledge of management science. The first models are focused on the manufacturing industry and the second part of the models on the health care industry. Despite these models being case specific, they serve the purpose of exemplifying that different approaches to the problems and could provide interesting results. Unfortunately, there is no universal recipe that could be applied to all the problems. Furthermore, the same model could deliver good results with certain data and bad results for other data. A framework to analyse the data before selecting the model to be used is presented and tested in the models developed to exemplify the ideas. METHODOLOGY As the first step of the research a systematic literature review on the joint decision is presented, as are the different opinions and suggestions of different scholars. For the next stage of the thesis, the decision-making process of more than 50 companies was analysed in companies from different sectors in the production planning area at the Job Shop level. The data was obtained using surveys and face-to-face interviews. The following part of the research into the decision-making process was held in two application fields that are highly relevant for our society; manufacturing and health care. The first step was to study the interactions and develop a mathematical model for the replenishment of the car assembly where the problem of “Vehicle routing problem and Inventory” were combined. The next step was to add the scheduling or car production (car sequencing) decision and use some metaheuristics such as ant colony and genetic algorithms to measure if the behaviour is kept up with different case size problems. A similar approach is presented in a production of semiconductors and aviation parts, where a hoist has to change from one station to another to deal with the work, and a jobs schedule has to be done. However, for this problem simulation was used for experimentation. In parallel, the scheduling of operating rooms was studied. Surgeries were allocated to surgeons and the scheduling of operating rooms was analysed. The first part of the research was done in a Teaching hospital, and for the second part the interaction of uncertainty was added. Once the previous problem had been analysed a general framework to characterize the instance was built. In the final chapter a general conclusion is presented. FINDINGS AND PRACTICAL IMPLICATIONS The first part of the contributions is an update of the decision-making literature review. Also an analysis of the possible savings resulting from a change in the decision process is made. Then, the results of the survey, which present a lack of consistency between what the managers believe and the reality of the integration of their decisions. In the next stage of the thesis, a contribution to the body of knowledge of the operation research, with the joint solution of the replenishment, sequencing and inventory problem in the assembly line is made, together with a parallel work with the operating rooms scheduling where different solutions approaches are presented. In addition to the contribution of the solving methods, with the use of different techniques, the main contribution is the framework that is proposed to pre-evaluate the problem before thinking of the techniques to solve it. However, there is no straightforward answer as to whether it is better to have joint or sequential solutions. Following the proposed framework with the evaluation of factors such as the flexibility of the answer, the number of actors, and the tightness of the data, give us important hints as to the most suitable direction to take to tackle the problem. RESEARCH LIMITATIONS AND AVENUES FOR FUTURE RESEARCH In the first part of the work it was really complicated to calculate the possible savings of different projects, since in many papers these quantities are not reported or the impact is based on non-quantifiable benefits. The other issue is the confidentiality of many projects where the data cannot be presented. For the car assembly line problem more computational power would allow us to solve bigger instances. For the operation research problem there was a lack of historical data to perform a parallel analysis in the teaching hospital. In order to keep testing the decision framework it is necessary to keep applying more case studies in order to generalize the results and make them more evident and less ambiguous. The health care field offers great opportunities since despite the recent awareness of the need to improve the decision-making process there are many opportunities to improve. Another big difference with the automotive industry is that the last improvements are not spread among all the actors. Therefore, in the future this research will focus more on the collaboration between academia and the health care sector.