Chapter III: Management of cardiovascular risk factors and medical therapy

Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations.

Mainstreaming a Decade's Experiences in Watershed Management to Meet the Challenges of Environmental Change in the Hindu Kush-Himalayas

Like other mountain areas in the world, the Hindu Kush-Himalayan (HKH) region is particularly vulnerable to climate change. Ongoing climate change processes are projected to have a high impact on the HKH region, and accelerated warming has been reported in the Himalayas. These climate change impacts will be superimposed on a variety of other environmental and social stresses, adding to the complexity of the issues. The sustainable use of natural resources is crucial to the long-term stability of the fragile mountain ecosystems in the HKH and to sustain the socio-ecological resilience that forms the basis of sustainable livelihoods in the region. In order to be prepared for these challenges, it is important to take stock of previous research. The ‘People and Resource Dynamics Project’ (PARDYP), implemented by International Centre for Integrated Mountain Development (ICIMOD), provides a variety of participatory options for sustainable land management in the HKH region. The PARDYD project was a research for development project that operated in five middle mountain watersheds across the HKH – two in Nepal and one each in China, India, and Pakistan. The project ran from 1996 to 2006 and focused on addressing the marginalisation of mountain farmers, the use and availability of water, issues relating to land and forest degradation and declining soil fertility, the speed of regeneration of degraded land, and the ability of the natural environment to support the growing needs of the region’s increasing population. A key learning from the project was that the opinion of land users is crucial to the acceptance (and, therefore, successful application) of new technologies and approaches. A major challenge at the end of every project is to promote knowledge sharing and encourage the cross-fertilization of ideas (e.g., in the case of PARDYP, with other middle mountain inhabitants and practitioners in the region) and to share lessons learned with a wider audience. This paper will highlight how the PARDYP findings, including ways of addressing soil fertility and water scarcity, have been mainstreamed in the HKH region through capacity building (international, regional, and national training courses), networking, and the provision of backstopping services. In addition, in view of the challenges in watershed management in the HKH connected to environmental change, the lessons learned from the PARDYP are now being used by ICMOD to define and package climate change proof technology options to address climate change adaptation.

Study protocol: Transition from localized low back pain to chronic widespread pain in general practice: identification of risk factors, preventive factors and key elements for treatment--a cohort study

Background Chronic localized pain syndromes, especially chronic low back pain (CLBP), are common reasons for consultation in general practice. In some cases chronic localized pain syndromes can appear in combination with chronic widespread pain (CWP). Numerous studies have shown a strong association between CWP and several physical and psychological factors. These studies are population-based cross-sectional and do not allow for assessing chronology. There are very few prospective studies that explore the predictors for the onset of CWP, where the main focus is identifying risk factors for the CWP incidence. Until now there have been no studies focusing on preventive factors keeping patients from developing CWP. Our aim is to perform a cross sectional study on the epidemiology of CLBP and CWP in general practice and to look for distinctive features regarding resources like resilience, self-efficacy and coping strategies. A subsequent cohort study is designed to identify the risk and protective factors of pain generalization (development of CWP) in primary care for CLBP patients. Methods/Design Fifty-nine general practitioners recruit consecutively, during a 5 month period, all patients who are consulting their family doctor because of chronic low back pain (where the pain is lasted for 3 months). Patients are asked to fill out a questionnaire on pain anamnesis, pain-perception, co-morbidities, therapy course, medication, socio demographic data and psychosomatic symptoms. We assess resilience, coping resources, stress management and self-efficacy as potential protective factors for pain generalization. Furthermore, we raise risk factors for pain generalization like anxiety, depression, trauma and critical life events. During a twelve months follow up period a cohort of CLBP patients without CWP will be screened on a regular basis (3 monthly) for pain generalization (outcome: incident CWP). Discussion This cohort study will be the largest study which prospectively analyzes predictors for transition from CLBP to CWP in primary care setting. In contrast to the typically researched risk factors, which increase the probability of pain generalization, this study also focus intensively on protective factors, which decrease the probability of pain generalization.

Ethnosciences - A step towards the integration of scientific and non-scientific forms of knowledge in the management of natural resources for the future

Integration of indigenous knowledge and ethnoscientific approaches into contemporary frameworks for conservation and sustainable management of natural resources will become increasingly important in policies on an international and national level. We set the scene on how this can be done by exploring the key conditions and dimensions of a dialogue between ‘ontologies’ and the roles, which ethnosciences could play in this process. First, the roles which ethnosciences in the context of sustainable development were analysed, placing emphasis on the implications arising when western sciences aspire to relate to indigenous forms of knowledge. Secondly, the contributions of ethnosciences to such an ‘inter-ontological dialogue’ were explored, based on an ethnoecological study of the encounter of sciences and indigenous knowledge in the Andes of Bolivia, and reviewed experiences from mangrove systems in Kenya, India and Sri Lanka, and from case-studies in other ecosystems world-wide.

Intentional replantation for the management of maxillary sinusitis

AIM: To present a case that emphasizes the importance of the use of intentional replantation as a technique to successfully treat a periapical lesion and an odontogenic maxillary sinusitis through the alveolus at the same time. SUMMARY: This case report presents a patient with odontogenic maxillary sinusitis secondary to periapical disease of a maxillary molar that had previously received root canal treatment. The molar was extracted, with drainage and rinsing of the maxillary sinus. The apices were resected extra-orally, the retrograde cavities prepared with ultrasound and retrograde fillings of silver amalgam placed. The tooth was then replanted. After 2 years, the patient was asymptomatic, periapical radiography showed no evidence of root resorption and computed tomography scanning demonstrated the resolution of maxillary sinusitis. Key learning points: *When root canal treatment or periapical surgery cannot be undertaken or has failed, intentional replantation may be considered. *This alternative treatment may be predictable in certain cases.

Moving from sustainable management to sustainable governance of natural resources: The role of social learning processes in rural India, Bolivia and Mali

The present paper discusses a conceptual, methodological and practical framework within which the limitations of the conventional notion of natural resource management (NRM) can be overcome. NRM is understood as the application of scientific ecological knowledge to resource management. By including a consideration of the normative imperatives that arise from scientific ecological knowledge and submitting them to public scrutiny, ‘sustainable management of natural resources’ can be recontextualised as ‘sustainable governance of natural resources’. This in turn makes it possible to place the politically neutralising discourse of ‘management’ in a space for wider societal debate, in which the different actors involved can deliberate and negotiate the norms, rules and power relations related to natural resource use and sustainable development. The transformation of sustainable management into sustainable governance of natural resources can be conceptualised as a social learning process involving scientists, experts, politicians and local actors, and their corresponding scientific and non-scientific knowledges. The social learning process is the result of what Habermas has described as ‘communicative action’, in contrast to ‘strategic action’. Sustainable governance of natural resources thus requires a new space for communicative action aiming at shared, intersubjectively validated definitions of actual situations and the goals and means required for transforming current norms, rules and power relations in order to achieve sustainable development. Case studies from rural India, Bolivia and Mali explore the potentials and limitations for broadening communicative action through an intensification of social learning processes at the interface of local and external knowledge. Key factors that enable or hinder the transformation of sustainable management into sustainable governance of natural resources through social learning processes and communicative action are discussed.

Price risk management in the copper market using commodity derivatives and options strategies

Metals price risk management is a key issue related to financial risk in metal markets because of uncertainty of commodity price fluctuation, exchange rate, interest rate changes and huge price risk either to metals’ producers or consumers. Thus, it has been taken into account by all participants in metal markets including metals’ producers, consumers, merchants, banks, investment funds, speculators, traders and so on. Managing price risk provides stable income for both metals’ producers and consumers, so it increases the chance that a firm will invest in attractive projects. The purpose of this research is to evaluate risk management strategies in the copper market. The main tools and strategies of price risk management are hedging and other derivatives such as futures contracts, swaps and options contracts. Hedging is a transaction designed to reduce or eliminate price risk. Derivatives are financial instruments, whose returns are derived from other financial instruments and they are commonly used for managing financial risks. Although derivatives have been around in some form for centuries, their growth has accelerated rapidly during the last 20 years. Nowadays, they are widely used by financial institutions, corporations, professional investors, and individuals. This project is focused on the over-the-counter (OTC) market and its products such as exotic options, particularly Asian options. The first part of the project is a description of basic derivatives and risk management strategies. In addition, this part discusses basic concepts of spot and futures (forward) markets, benefits and costs of risk management and risks and rewards of positions in the derivative markets. The second part considers valuations of commodity derivatives. In this part, the options pricing model DerivaGem is applied to Asian call and put options on London Metal Exchange (LME) copper because it is important to understand how Asian options are valued and to compare theoretical values of the options with their market observed values. Predicting future trends of copper prices is important and would be essential to manage market price risk successfully. Therefore, the third part is a discussion about econometric commodity models. Based on this literature review, the fourth part of the project reports the construction and testing of an econometric model designed to forecast the monthly average price of copper on the LME. More specifically, this part aims at showing how LME copper prices can be explained by means of a simultaneous equation structural model (two-stage least squares regression) connecting supply and demand variables. A simultaneous econometric model for the copper industry is built: {█(Q_t^D=e^((-5.0485))∙P_((t-1))^((-0.1868) )∙〖GDP〗_t^((1.7151) )∙e^((0.0158)∙〖IP〗_t ) @Q_t^S=e^((-3.0785))∙P_((t-1))^((0.5960))∙T_t^((0.1408))∙P_(OIL(t))^((-0.1559))∙〖USDI〗_t^((1.2432))∙〖LIBOR〗_((t-6))^((-0.0561))@Q_t^D=Q_t^S )┤ P_((t-1))^CU=e^((-2.5165))∙〖GDP〗_t^((2.1910))∙e^((0.0202)∙〖IP〗_t )∙T_t^((-0.1799))∙P_(OIL(t))^((0.1991))∙〖USDI〗_t^((-1.5881))∙〖LIBOR〗_((t-6))^((0.0717) Where, Q_t^D and Q_t^Sare world demand for and supply of copper at time t respectively. P(t-1) is the lagged price of copper, which is the focus of the analysis in this part. GDPt is world gross domestic product at time t, which represents aggregate economic activity. In addition, industrial production should be considered here, so the global industrial production growth that is noted as IPt is included in the model. Tt is the time variable, which is a useful proxy for technological change. A proxy variable for the cost of energy in producing copper is the price of oil at time t, which is noted as POIL(t ) . USDIt is the U.S. dollar index variable at time t, which is an important variable for explaining the copper supply and copper prices. At last, LIBOR(t-6) is the 6-month lagged 1-year London Inter bank offering rate of interest. Although, the model can be applicable for different base metals' industries, the omitted exogenous variables such as the price of substitute or a combined variable related to the price of substitutes have not been considered in this study. Based on this econometric model and using a Monte-Carlo simulation analysis, the probabilities that the monthly average copper prices in 2006 and 2007 will be greater than specific strike price of an option are defined. The final part evaluates risk management strategies including options strategies, metal swaps and simple options in relation to the simulation results. The basic options strategies such as bull spreads, bear spreads and butterfly spreads, which are created by using both call and put options in 2006 and 2007 are evaluated. Consequently, each risk management strategy in 2006 and 2007 is analyzed based on the day of data and the price prediction model. As a result, applications stemming from this project include valuing Asian options, developing a copper price prediction model, forecasting and planning, and decision making for price risk management in the copper market.

Information integration and management through the design and construction phases of a project life cycle

Information management is a key aspect of successful construction projects. Having inaccurate measurements and conflicting data can lead to costly mistakes, and vague quantities can ruin estimates and schedules. Building information modeling (BIM) augments a 3D model with a wide variety of information, which reduces many sources of error and can detect conflicts before they occur. Because new technology is often more complex, it can be difficult to effectively integrate it with existing business practices. In this paper, we will answer two questions: How can BIM add value to construction projects? and What lessons can be learned from other companies that use BIM or other similar technology? Previous research focused on the technology as if it were simply a tool, observing problems that occurred while integrating new technology into existing practices. Our research instead looks at the flow of information through a company and its network, seeing all the actors as part of an ecosystem. Building upon this idea, we proposed the metaphor of an information supply chain to illustrate how BIM can add value to a construction project. This paper then concludes with two case studies. The first case study illustrates a failure in the flow of information that could have prevented by using BIM. The second case study profiles a leading design firm that has used BIM products for many years and shows the real benefits of using this program.

Resource management in location aware cognitive radio networks

Dynamic spectrum access (DSA) aims at utilizing spectral opportunities both in time and frequency domains at any given location, which arise due to variations in spectrum usage. Recently, Cognitive radios (CRs) have been proposed as a means of implementing DSA. In this work we focus on the aspect of resource management in overlaid CRNs. We formulate resource allocation strategies for cognitive radio networks (CRNs) as mathematical optimization problems. Specifically, we focus on two key problems in resource management: Sum Rate Maximization and Maximization of Number of Admitted Users. Since both the above mentioned problems are NP hard due to presence of binary assignment variables, we propose novel graph based algorithms to optimally solve these problems. Further, we analyze the impact of location awareness on network performance of CRNs by considering three cases: Full location Aware, Partial location Aware and Non location Aware. Our results clearly show that location awareness has significant impact on performance of overlaid CRNs and leads to increase in spectrum utilization effciency.

Management of infusion reactions in clinical trials and beyond: the US and EU perspectives

Monoclonal antibodies have expanded our cancer-fighting armamentarium in both the United States and Europe. While in general, monoclonal antibodies are well tolerated and do not have significant overlapping side effects with traditional cytotoxic agents, severe infusion reactions (IRs)--sometimes severe enough to be life threatening--have been reported. The pathophysiology of severe infusion reactions associated with monoclonal antibodies is poorly understood, but mechanisms are beginning to be elucidated. Geographic differences in the incidence of IRs have become apparent. Understanding the risk, recognizing the signs and symptoms, and being ready to promptly manage severe IRs are key for the clinician to avoid unnecessarily discontinuing these effective anticancer agents and prevent potentially tragic consequences for their patients. To date, clinical trials have incorporated monoclonal antibodies into combinations with standard cytotoxic regimens; it is expected that in time clinical trials will be testing promising new combinations utilizing multiple targeted agents, resulting in improved toxicity profiles and efficacy for cancer patients.

The Risk Management of Minimum Return Guarantees

Contracts paying a guaranteed minimum rate of return and a fraction of a positive excess rate, which is specified relative to a benchmark portfolio, are closely related to unit-linked life-insurance products and can be considered as alternatives to direct investment in the underlying benchmark. They contain an embedded power option, and the key issue is the tractable and realistic hedging of this option, in order to rigorously justify valuation by arbitrage arguments and prevent the guarantees from becoming uncontrollable liabilities to the issuer. We show how to determine the contract parameters conservatively and implement robust risk-management strategies.

Richness of Lichen Species, Especially of Threatened Ones, Is Promoted by Management Methods Furthering Stand Continuity

Lichens are a key component of forest biodiversity. However, a comprehensive study analyzing lichen species richness in relation to several management types, extending over different regions and forest stages and including information on site conditions is missing for temperate European forests. In three German regions (Schwäbische Alb, Hainich-Dün, Schorfheide-Chorin), the so-called Biodiversity Exploratories, we studied lichen species richness in 631 forest plots of 400 m2 comprising different management types (unmanaged, selection cutting, deciduous and coniferous age-class forests resulting from clear cutting or shelterwood logging), various stand ages, and site conditions, typical for large parts of temperate Europe. We analyzed how lichen species richness responds to management and habitat variables (standing biomass, cover of deadwood, cover of rocks). We found strong regional differences with highest lichen species richness in the Schwäbische Alb, probably driven by regional differences in former air pollution, and in precipitation and habitat variables. Overall, unmanaged forests harbored 22% more threatened lichen species than managed age-class forests. In general, total, corticolous, and threatened lichen species richness did not differ among management types of deciduous forests. However, in the Schwäbische-Alb region, deciduous forests had 61% more lichen species than coniferous forests and they had 279% more threatened and 76% more corticolous lichen species. Old deciduous age classes were richer in corticolous lichen species than young ones, while old coniferous age-classes were poorer than young ones. Overall, our findings highlight the importance of stand continuity for conservation. To increase total and threatened lichen species richness we suggest (1) conserving unmanaged forests, (2) promoting silvicultural methods assuring stand continuity, (3) conserving old trees in managed forests, (4) promoting stands of native deciduous tree species instead of coniferous plantations, and (5) increasing the amount of deadwood in forests.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.