Stroke Unit Management and Revascularisation in Acute Ischemic Stroke

Background: Stroke affects one in six people throughout their lifetimes and is the most frequent cause of disability in adults. Several recanalization therapies have emerged and the management of patients in stroke units has improved over the last decades. Summary: This article examines the current treatment options for stroke patients, summarizing the key clinical evidence, as well as listing the complications and practical issues related to each of these main treatment options. Key Messages: Recent advances in the treatment of acute stroke include developments in intravenous thrombolysis (IVT), intra-arterial treatment and bridging therapies. Clinical Implications: Treatment within a stroke unit reduces mortality and disability regardless of age, sex and stroke severity. IVT is widely available and reduces disability when initiated within 4.5 h after the onset of symptoms. The major limitations of IVT are the low recanalization rates and the narrow time frame. Intra-arterial treatment, especially when using newly developed stent-retrievers, achieves very high recanalization rates. It is restricted by its limited availability and by the longer time span required to initiate therapy. Bridging both therapies is a promising approach that combines the advantages of both therapies, but the superiority of this approach remains to be proven. Future strategies to reduce the burden of acute stroke in Europe should focus on immediate access to acute stroke care and dedicated stroke units for all patients.

New perioperative fluid and pharmacologic management protocol results in reduced blood loss, faster return of bowel function, and overall recovery.

Cystectomy and urinary diversion have high morbidity, and strategies to reduce complications are of utmost importance. Epidural analgesia and optimized fluid management are considered key factors contributing to successful enhanced recovery after surgery. In colorectal surgery, there is strong evidence that an intraoperative fluid management aiming for a postoperative zero fluid balance results in lower morbidity including a faster return of bowel function. Recently, a randomized clinical trial focusing on radical cystectomy demonstrated that a restrictive intraoperative hydration combined with a concomitant administration of norepinephrine reduced intraoperative blood loss, the need for blood transfusion and morbidity. The purpose of this review is to highlight specific anesthesiological aspects which have been shown to improve outcome after RC with urinary diversion.

Grassland management intensification weakens the associations among the diversities of multiple plant and animal taxa

Land-use intensification is a key driver of biodiversity change. However, little is known about how it alters relationships between the diversities of different taxonomic groups, which are often correlated due to shared environmental drivers and trophic interactions. Using data from 150 grassland sites, we examined how land-use intensification (increased fertilization, higher livestock densities, and increased mowing frequency) altered correlations between the species richness of 15 plant, invertebrate, and vertebrate taxa. We found that 54% of pairwise correlations between taxonomic groups were significant and positive among all grasslands, while only one was negative. Higher land-use intensity substantially weakened these correlations (35% decrease in r and 43% fewer significant pairwise correlations at high intensity), a pattern which may emerge as a result of biodiversity declines and the breakdown of specialized relationships in these conditions. Nevertheless, some groups (Coleoptera, Heteroptera, Hymenoptera and Orthoptera) were consistently correlated with multidiversity, an aggregate measure of total biodiversity comprised of the standardized diversities of multiple taxa, at both high and low land-use intensity. The form of intensification was also important; increased fertilization and mowing frequency typically weakened plant–plant and plant–primary consumer correlations, whereas grazing intensification did not. This may reflect decreased habitat heterogeneity under mowing and fertilization and increased habitat heterogeneity under grazing. While these results urge caution in using certain taxonomic groups to monitor impacts of agricultural management on biodiversity, they also suggest that the diversities of some groups are reasonably robust indicators of total biodiversity across a range of conditions. Read More: http://www.esajournals.org/doi/10.1890/14-1307.1

Shaping Institutions for Natural Resource Management

This InfoResources Focus tries to clarify challenges people face when shaping institutions for sustainable NRM and discusses key elements for implementing processes of institutional change. Emphasis is put on local institutions embedded in national, regional and global institutional schemes.

Coupled human and natural system dynamics as key to the sustainability of Lake Victoria's ecosystem services

East Africa’s Lake Victoria provides resources and services to millions of people on the lake’s shores and abroad. In particular, the lake’s fisheries are an important source of protein, employment, and international economic connections for the whole region. Nonetheless, stock dynamics are poorly understood and currently unpredictable. Furthermore, fishery dynamics are intricately connected to other supporting services of the lake as well as to lakeshore societies and economies. Much research has been carried out piecemeal on different aspects of Lake Victoria’s system; e.g., societies, biodiversity, fisheries, and eutrophication. However, to disentangle drivers and dynamics of change in this complex system, we need to put these pieces together and analyze the system as a whole. We did so by first building a qualitative model of the lake’s social-ecological system. We then investigated the model system through a qualitative loop analysis, and finally examined effects of changes on the system state and structure. The model and its contextual analysis allowed us to investigate system-wide chain reactions resulting from disturbances. Importantly, we built a tool that can be used to analyze the cascading effects of management options and establish the requirements for their success. We found that high connectedness of the system at the exploitation level, through fisheries having multiple target stocks, can increase the stocks’ vulnerability to exploitation but reduce society’s vulnerability to variability in individual stocks. We describe how there are multiple pathways to any change in the system, which makes it difficult to identify the root cause of changes but also broadens the management toolkit. Also, we illustrate how nutrient enrichment is not a self-regulating process, and that explicit management is necessary to halt or reverse eutrophication. This model is simple and usable to assess system-wide effects of management policies, and can serve as a paving stone for future quantitative analyses of system dynamics at local scales.

Capacity Building in the Use of Geospatial Tools for Natural Resource Management in Tajikistan: Inception report

The sustainable management of natural resources is a key issue for sustainable development of a poor, mountainous country such as Tajikistan. In order to strengthen its agricultural and infrastructural development efforts and alleviate poverty in rural areas, spatial information and analysis are of crucial importance to improve priority setting and decision making efficiency. However, poor access to geospatial data and tools, and limited capacity in their use has greatly constrained the ability of governmental institutions to effectively assess, plan, and monitor natural resources management. The Centre for Development and Environment (CDE) has thus been mandated by the World Bank Group to provide adequate technical support to the Community Agriculture and Watershed Management Project (CAWMP). This support consists of a spatial database on soil degradation trends in 4 watersheds, capacity development in and awareness creation about geographic information technology and a spatial data exchange hub for natural resources management in Tajikistan. CDE’s support has started in July 2007 and will last until December 2007 with a possible extension in 2008.

Economic benefits and costs of Sustainable Land Management Technologies: An analysis of WOCAT's global data

Perceived profitability is a key factor in explaining farmers' decision to adopt or not adopt sustainable land management (SLM) technologies. Despite this importance, relatively little is known about the economics of SLM. This paper contributes to the literature by analysing data on costs and perceived cost/benefit ratios of SLM technologies. Data are taken from the World Overview of Conservation Approaches and Technologies technology database and cover 363 case studies conducted in a variety of countries between 1990 and 2012. Based on an in-depth descriptive analysis, we determine what costs accrue to local stakeholders and assess perceived short-term and long-term cost/benefit ratios. Our results show that a large majority of the technologies in our sample are perceived as being profitable: 73% were perceived to have a positive or at least neutral cost/benefit ratio in the short term, while 97% were perceived to have a positive or very positive cost/benefit ratio in the long term. An additional empirical analysis confirms that economic factors are key determinants of land users' decisions to adopt or not adopt SLM technologies. We conclude that a wide range of existing SLM practices generate considerable benefits not only for land users, but for other stakeholders as well. High initial investment costs associated with some practices may, however, constitute a barrier to their adoption; short-term support for land users can help to promote these practices where appropriate.

Analysing factors determining the adoption of environmental management measures on the highlands of Ethiopia

A study was conducted on the highlands of Ethiopia to identify and analyse the factors determining the adoption of environmental management measures. In 1985, Ethiopia was classified into low –and high-potential areas based on the suitability of the natural environment for rain-fed agriculture. To address these objectives, case study areas were selected from low-potential and high-potential areas randomly. Data were collected through face-to-face interview and key informants, focus group discussion and field observation. In the low-potential areas, the physical environment ‒ particularly soil and forest environments have shown substantial recovery. Similarly, the water environment has improved. However, in the high-potential areas sampled, these resources are still being degraded. Clear understanding of the benefits of soil conservation structures by farmers, active involvement and technical support from the government and full and genuine participation of farmers in communal environmental resources management activities were found to be main factors in the adoption of environmental management measures.

A multi-level stakeholder approach to sustainable land management

Soils provide us with over 90% of all human food, livestock feed, fibre and fuel on Earth. Soils, however, have more than just productive functions. The key challenge in coming years will be to address the diverse and potentially conflicting demands now being made by human societies and other forms of life, while ensuring that future generations have the same potential to use soils and land of comparable quality. In a multi-level stakeholder approach, down-to-earth action will have to be supplemented with measures at various levels, from households to communities, and from national policies to international conventions. Knowledge systems, both indigenous and scientific, and related research and learning processes must play a central role. Ongoing action can be enhanced through a critical assessment of the impact of past achievements, and through better cooperation between people and institutions.

The Role of Forest Soils in a Northern New England Effluent Management System

The Carrabassett Valley Sanitary District in Carrabassett Valley, Maine has utilized both a forest spray irrigation system and a Snowfluent™ system for the treatment of their wastewater effluent. This study was designed to evaluate potential changes in soil properties after approximately 20 years of treatment in the forested spray irrigation site and three years of treatment in the field Snowfluent™ site. In addition, grass yield and composition were evaluated on the field study sites. After treatment with effluent or Snowfluent™, soils showed an increase in soil exchangeable Ca, Mg, Na, and K, base saturation, and pH. While most constituents were higher in treated soils, available P was lower in treated soils compared to the controls. This difference was attributed to higher rates of P mineralization from soil organic matter due to an irrigation effect of the treatment, depleting available P pools despite the P addition with the treatment. Most of the differences due to treatment were greatest at the surface and diminished with depth. Depth patterns in soil properties mostly reflected the decreasing influence of organic matter and its decomposition products with depth as evidenced by significantly higher total C in the surface compared to lower horizons. There were decreasing concentrations of total N, and exchangeable or extractable Ca, Mg, Na, K, Mn, Zn, and P with depth. In addition, there was decreasing BS with depth, driven primarily by declining exchangeable Ca and Mg. Imgation with Snowfluent™ altered the chemical composition of the grass on the site. All element concentrations were significantly higher in the grass foliage except for Ca. The differences were attributed to the additional nutrients and moisture derived from the Snowfluent™. The use of forest spray imgation and Snowfluent™ as a wastewater treatment strategy appears to work well. The soil and vegetation were able to retain most of the applied nutrients, and do not appear to be moving toward saturation. Vegetation management may be a key tool for managing nutrient accumulation on the grass sites as the system ages.

A MANAGEMENT INFORMATION SYSTEM AND EVALUATION SCHEME FOR THE UNIVERSITY OF TEXAS EMPLOYEE ASSISTANCE PROGRAMS

Early Employee Assistance Programs (EAPs) had their origin in humanitarian motives, and there was little concern for their cost/benefit ratios; however, as some programs began accumulating data and analyzing it over time, even with single variables such as absenteeism, it became apparent that the humanitarian reasons for a program could be reinforced by cost savings particularly when the existence of the program was subject to justification.^ Today there is general agreement that cost/benefit analyses of EAPs are desirable, but the specific models for such analyses, particularly those making use of sophisticated but simple computer based data management systems, are few.^ The purpose of this research and development project was to develop a method, a design, and a prototype for gathering managing and presenting information about EAPS. This scheme provides information retrieval and analyses relevant to such aspects of EAP operations as: (1) EAP personnel activities, (2) Supervisory training effectiveness, (3) Client population demographics, (4) Assessment and Referral Effectiveness, (5) Treatment network efficacy, (6) Economic worth of the EAP.^ This scheme has been implemented and made operational at The University of Texas Employee Assistance Programs for more than three years.^ Application of the scheme in the various programs has defined certain variables which remained necessary in all programs. Depending on the degree of aggressiveness for data acquisition maintained by program personnel, other program specific variables are also defined. ^

Integrating diabetes self-management with the health goals of older adults: A qualitative exploration

Objective. This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management. Methods: Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate. ^ Results. Participants’ provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management. ^ Conclusion. Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals. ^ Practice implications. When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support.^

Interview forms for integrating education for conservation in marine protected areas management in Colombia

Environmental Education (EE) is a key component in any marine protected area management. However, its visibility and action plans are still poorly developed and structured as a clear element in management procedures. The objective of this study is to contribute with a methodological route that integrates EE to the existing model of management planning and strategies, taking the Colombian National Natural Parks System as a case study. The creation of the route is proposed as a participatory research with different stakeholders in order to respond to the specific conservation needs and goals for the National Parks System. The EE national diagnosis has shown that its integration within the parks management structure is a first priority need, being a converging result on the two case studies on National Parks from the Pacific Coast of Colombia. The diagnosis also demonstrates that communication, participation, training and evaluation have to be reinforced, linking the community and stakeholders involved in the park management to the whole EE process. The proposed methodology route has been agreed upon by the National Parks staff and incorporates advice and recommendations from different stakeholders, in order to better include the park users. This step will help us to advance toward sustainable management in marine and coastal protected areas elsewhere, taking into account not only the biological but also the social-cultural prism. The main challenges in the management and conservation of coastal and marine ecosystems today are discussed.

Executive Managers in Large Mexican Family Businesses

The involvement of members of owners' families in the running of large family businesses in Mexico is decreasing. Although family members still hold key posts such as that of CEO, other executive posts tend to be delegated to professional salaried managers. Top managers, including family members, share some common characteristics. They are young compared with managers in other developed countries, their quality as human resources is high, and many of them are graduates of overseas MBA courses. Most of them are sufficiently experienced. Improvement of quality among top managers is a recent phenomenon in Mexico, and has been encouraged mainly by the following two factors. First, globalization of business activities was promoted by intense competition among firms under conditions of market liberalization. In order to equip themselves with the ability to cope with the globalization of their operations, large family businesses tried hard to improve the quality of top management, by training and educating existing managers, and/or by recruiting managers in the outside labor market. Second, developments in the Mexican economy during the 1990s led to a growth in the labor market for top managers Thus, business restructuring caused by bankruptcy, as well as mergers and acquisitions, privatization and so on, led to the dismissal of business managers who then entered the labor market in large numbers. The increasing presence of these managers in the labor market helped family businesses to recruit well-qualified senior executives.

Family Business in Mexico: Responses to Human Resource Limitations and Management Succession

Indigenous firms in Mexico, as in most developing countries, take the shape of family businesses. Regardless of size, the most predominant ones are those owned and managed by one or more families or descendent families of the founders. From the point of view of economics and business administration, family business is considered to have variety of limitations when it seeks to grow. One of the serious limitations is concerning human resource, which is revealed at the time of management succession. Big family businesses in Mexico deal with human resource limitations adopting measures such as the education and training of the successors, the establishment of management structure that makes control by the owner family possible and divisions of roles among the owner family members, and between the owner family members and the salaried managers. Institutionalization is a strategy that considerable number of family businesses have adopted in order to undergo the succession process without committing serious errors. Institutionalization is observed in such aspects as the establishment of the requisite condition to be met by the candidate of future successor and the screening by an institution which is independent of the owner family. At present these measures allow for the continuation of family businesses in an extremely competitive environment.