Developing MPA performance indicators with local stakeholders’ input in the Pacific Rim National Park Reserve,Canada

Along with an increase in the establishment of marine protected areas (MPAs), the need arises to assess if designated MPAs are achieving their goals and objectives. A first step in this process is the identification of MPA performance indicators against which to evaluate MPA management. This study investigates the development of MPA performance indicators using an in situ approach by including diverse stakeholder groups in the process. The results show that local stakeholders identify a range of MPA performance indicators in all stages of the management cycle and in diverse MPA indicators categories. Statistical analysis reveals that multiple groups identify distinct performance indicators. Fishermen groups primarily mention governance performance indicators in the planning and output stage. Other groups most often cite biophysical and social outcome performance indicators. The findings demonstrate distinct management expectations towards MPA performance among included stakeholder groups. The study also shows that the integration of multiple groups is necessary for the identification of MPA performance indicators as the groups identify distinct performance indicators.     

Community involvement in management for maintaining coral reef resilience and biodiversity in southern Caribbean marine protected areas

Climate change is posing new challenges to conservation because management policies on protected coral reefs are less effective than they were before the current ecosystem degradation. Coral reefs, the most diverse and complex marine ecosystem provide economic services for millions, but are seriously threatened worldwide because reef-building corals are experiencing bleaching phenomena and a steady decline in abundance. The resources of a Marine Protected Area (MPA) in Cartagena, Colombia, are in constant decline, despite a current management plan and on-site staff, urging new conservation actions. A multidisciplinary team gathered to evaluate management effectiveness including biophysical, socioeconomic and governance indicators. Coral cover and fish diversity and abundance were low both inside and outside the MPA, which suggests a limited efficiency of management. Currently, the MPA is a reef with low coral cover and high algae cover as well as large dead coral areas, which are generally signs of highly degraded reef habitats. Live coral cover in the MPA was represented by pioneer coral species such as Agaricia tenuifolia and Porites astreoides. Nonetheless, 35% of the scleractinian species sampled in the area harbored more than one zooxanthellae symbiont, which suggests potential resistance and resilience against coral bleaching. Maintenance of trophic structure and functional diversity is an important endeavor that should be a priority for management in order to allow ecosystem resilience. Social and governance indicators showed low-income levels and few opportunities for communities living in and around the park, low governability, weak communication among stakeholders and with authorities at different levels. As a result, problems related to over exploitation of resources were commonplace in the MPA. These results reflect low adaptive capacity of communities to comply with restrictive conservation rules, showing that establishment of a protected area is a necessary but insufficient condition to guarantee conservation goals. Ignoring the role of local communities only will exacerbate the problems associated with natural resources. Involvement of communities in strategic ecosystems management appears to be a requisite to improve effectiveness of protected areas, and participatory strategies, such as co-management, offer opportunities to improve governability while letting communities adapt to MPA needs.     

Customary management as precautionary and adaptive principles for protecting coral reefs in Oceania

Marine conservation programs in Oceania are increasingly turning to precautionary and adaptive management, particularly approaches which emphasize local participation and customary management. Although the application of community-based natural resource management is widespread in the region, the full integration of local knowledge and practices into the design, implementation, and monitoring of community-based conservation programs has been limited. There is also little empirical data to show whether or not community-based conservation projects are meeting their stated objectives. This paper summarizes an integrated method for selecting Marine Protected Area (MPA) sites and presents empirical evidence that illustrates how an MPA that was largely conceived using indigenous ecological knowledge and existing sea tenure governance (i.e., customary management practices), as part of a regional precautionary and adaptive community-based management plan, is showing signs of biological and social success. More generally, the paper shows how hybrid natural and social research approaches in tandem with customary management for designing MPAs can protect coral reefs in Oceania.     

依托六大平台 实施医疗质量与安全精准化监管

运用信息化手段实施精准化的医疗质量与安全监管正在被越来越多的医院管理者所重视和接受。通过建立授权管理平台、环节质控平台、指标监测平台、医疗安全管理平台、电子病历质控平台和信息交互平台,对临床信息进行收集、统计、分析,为医院决策和医疗管理提供数据支撑,并及时反馈应用到临床医疗服务中,形成戴明环（PDCA循环）管理机制,切实打造医疗质量和安全精准化监管系统。     

Differential Sensitivities of Fast- and Slow-Cycling Cancer Cells to Inosine Monophosphate Dehydrogenase 2 Inhibition by Mycophenolic Acid

As uncontrolled cell proliferation requires nucleotide biosynthesis, inhibiting enzymes that mediate nucleotide biosynthesis constitutes a rational approach to the management of oncological diseases. In practice, however, results of this strategy are mixed and thus elucidation of the mechanisms by which cancer cells evade the effect of nucleotide biosynthesis restriction is urgently needed. Here we explored the notion that intrinsic differences in cancer cell cycle velocity are important in the resistance toward inhibition of inosine monophosphate dehydrogenase (IMPDH) by mycophenolic acid (MPA). In short-term experiments, MPA treatment of fast-growing cancer cells effectively elicited G0/G1 arrest and provoked apoptosis, thus inhibiting cell proliferation and colony formation. Forced expression of a mutated IMPDH2, lacking a binding site for MPA but retaining enzymatic activity, resulted in complete resistance of cancer cells to MPA. In nude mice subcutaneously engrafted with HeLa cells, MPA moderately delayed tumor formation by inhibiting cell proliferation and inducing apoptosis. Importantly, we developed a lentiviral vector–based Tet-on label-retaining system that enables to identify, isolate and functionally characterize slow-cycling or so-called label-retaining cells (LRCs) in vitro and in vivo. We surprisingly found the presence of LRCs in fast-growing tumors. LRCs were superior in colony formation, tumor initiation and resistance to MPA as compared with fast-cycling cells. Thus, the slow-cycling compartment of cancer seems predominantly responsible for resistance to MPA.     

SIMS REIN: a multi-source information system for end-stage renal disease

In France, the prevalence of End-Stage Renal Disease (ESRD) is not precisely known. The sources of information are scattered and not coordinated. Consequently, care is ill adapted to meet the demand. The Multi-Source Information System is the basis of the Renal Epidemiology and Information Network (REIN). It is dedicated to improve and organise our medical and epidemiological knowledge of ESRD and to aid public health decision-making in this area. The proposed approach is based on the datawarehouses. This model allows a unified vision of scattered data into distinct databases, for a better management, be it particular (patient follow-up) or global (regional follow-up), with a finality of aid in decision-making. Several categories of problems were considered: the global conception of the information system, the organisation of the datawarehouse, which offers different viewpoints of the data, the integration of heterogeneous data coming from different sources, data exchange and definition of a specific ontology.     

No Reef Is an Island: Integrating Coral Reef Connectivity Data into the Design of Regional-Scale Marine Protected Area Networks

We integrated coral reef connectivity data for the Caribbean and Gulf of Mexico into a conservation decision-making framework for designing a regional scale marine protected area (MPA) network that provides insight into ecological and political contexts. We used an ocean circulation model and regional coral reef data to simulate eight spawning events from 2008–2011, applying a maximum 30-day pelagic larval duration and 20% mortality rate. Coral larval dispersal patterns were analyzed between coral reefs across jurisdictional marine zones to identify spatial relationships between larval sources and destinations within countries and territories across the region. We applied our results in Marxan, a conservation planning software tool, to identify a regional coral reef MPA network design that meets conservation goals, minimizes underlying threats, and maintains coral reef connectivity. Our results suggest that approximately 77% of coral reefs identified as having a high regional connectivity value are not included in the existing MPA network. This research is unique because we quantify and report coral larval connectivity data by marine ecoregions and Exclusive Economic Zones (EZZ) and use this information to identify gaps in the current Caribbean-wide MPA network by integrating asymmetric connectivity information in Marxan to design a regional MPA network that includes important reef network connections. The identification of important reef connectivity metrics guides the selection of priority conservation areas and supports resilience at the whole system level into the future.     

Cascade pattern recognition structure for improving quantitative assessment of estrogen receptor status in breast tissue carcinomas

OBJECTIVE: To develop and validate a computer-based approach for the quantitative assessment of estrogen receptor (ER) status in breast tissue specimens for breast cancer management. STUDY DESIGN: Microscopy images of 32 immunohistochemically (IHC) stained specimens of breast cancer biopsies were digitized and were primarily assessed for ER status (percentage of positively stained nuclei) by a histopathologist. A pattern recognition system was designed for automatically assessing the ER status of the IHC-stained specimens. Nuclei were automatically segmented from background by a pixel-based unsupervised clustering algorithm and were characterized as positively stained or unstained by a supervised classification algorithm. This cascade structure boosted the system's classification accuracy. RESULTS: System performance in correctly characterizing the nuclei was 95.48%. When specifying each case's ER status, system performance was statistically not significantly different to the physician's assessment (p = 0.13); when ranking each case to a particular 5-scale ER-scoring system (giving the chance of response to endocrine treatment), the system's score and the physician's score were in agreement in 29 of 32 cases. CONCLUSION: The need for reliable and operator independent ER-status estimation procedures may be served by the design of efficient pattern recognition systems to be employed as support opinion tools in clinical practice.     

A decade of marketing approval of gene and cell-based therapies in the United States,European Union and Japan: An evaluation of regulatory decision-making

There is a widely held expectation of clinical advance with the development of gene and cell-based therapies (GCTs). Yet, establishing benefits and risks is highly uncertain. We examine differences in decision-making for GCT approval between jurisdictions by comparing regulatory assessment procedures in the United States (US), European Union (EU) and Japan. A cohort of 18 assessment procedures was analyzed by comparing product characteristics, evidentiary and non-evidentiary factors considered for approval and post-marketing risk management. Product characteristics are very heterogeneous and only three products are marketed in multiple jurisdictions. Almost half of all approved GCTs received an orphan designation. Overall, confirmatory evidence or indications of clinical benefit were evident in US and EU applications, whereas in Japan approval was solely granted based on non-confirmatory evidence. Due to scientific uncertainties and safety risks, substantial post-marketing risk management activities were requested in the EU and Japan. EU and Japanese authorities often took unmet medical needs into consideration in decision-making for approval. These observations underline the effects of implemented legislation in these two jurisdictions that facilitate an adaptive approach to licensing. In the US, the recent assessments of two chimeric antigen receptor-T cell (CAR-T) products are suggestive of a trend toward a more permissive approach for GCT approval under recent reforms, in contrast to a more binary decision-making approach for previous approvals. It indicates that all three regulatory agencies are currently willing to take risks by approving GCTs with scientific uncertainties and safety risks, urging them to pay accurate attention to post-marketing risk management.     

Empowerment in family planning as viewed by Iranian women: a qualitative study

Women carry the primary responsibility for family planning in most parts of the world, and should be afforded the power of decision-making and control over their fertility. This study seeks to gain insight into Iranian women's perception of the meaning of empowerment in family planning. Using a qualitative study, seven focus group discussions and five individual interviews were conducted with 35 married Iranian women of reproductive age. The data were analysed using a conventional content analysis approach, in which themes and categories were explored to reveal women's experiences of empowerment in family planning. The results demonstrated four main categories: control over fertility plan, participative family planning, maintaining health and access to optimal family planning services. They viewed knowledge of family planning and autonomy of decision-making in fertility issues as essential elements for control of their fertility plan. Participants felt more empowered when joint family planning decisions were made with their partners in an atmosphere of agreement. Therefore, family planning policymakers should plan services with new approaches that focus on women's health and empowerment.     

Incorporating climate change adaptation into marine protected area planning

Climate change is increasingly impacting marine protected areas (MPAs) and MPA networks, yet adaptation strategies are rarely incorporated into MPA design and management plans according to the primary scientific literature. Here we review the state of knowledge for adapting existing and future MPAs to climate change and synthesize case studies (n = 27) of how marine conservation planning can respond to shifting environmental conditions. First, we derive a generalized conservation planning framework based on five published frameworks that incorporate climate change adaptation to inform MPA design. We then summarize examples from the scientific literature to assess how conservation goals were defined, vulnerability assessments performed and adaptation strategies incorporated into the design and management of existing or new MPAs. Our analysis revealed that 82% of real‐world examples of climate change adaptation in MPA planning derive from tropical reefs, highlighting the need for research in other ecosystems and habitat types. We found contrasting recommendations for adaptation strategies at the planning stage, either focusing only on climate refugia, or aiming for representative protection of areas encompassing the full range of expected climate change impacts. Recommendations for MPA management were more unified and focused on adaptative management approaches. Lastly, we evaluate common barriers to adopting climate change adaptation strategies based on reviewing studies which conducted interviews with MPA managers and other conservation practitioners. This highlights a lack of scientific studies evaluating different adaptation strategies and shortcomings in current governance structures as two major barriers, and we discuss how these could be overcome. Our review provides a comprehensive synthesis of planning frameworks, case studies, adaptation strategies and management actions which can inform a more coordinated global effort to adapt existing and future MPA networks to continued climate change.     

Population Connectivity Shifts at High Frequency within an Open-Coast Marine Protected Area Network

A complete understanding of population connectivity via larval dispersal is of great value to the effective design and management of marine protected areas (MPA). However empirical estimates of larval dispersal distance, self-recruitment, and within season variability of population connectivity patterns and their influence on metapopulation structure remain rare. We used high-resolution otolith microchemistry data from the temperate reef fish Hypsypops rubicundus to explore biweekly, seasonal, and annual connectivity patterns in an open-coast MPA network. The three MPAs, spanning 46 km along the southern California coastline were connected by larval dispersal, but the magnitude and direction of connections reversed between 2008 and 2009. Self-recruitment, i.e. spawning, dispersal, and settlement to the same location, was observed at two locations, one of which is a MPA. Self-recruitment to this MPA ranged from 50–84%; within the entire 60 km study region, self-recruitment accounted for 45% of all individuals settling to study reefs. On biweekly time scales we observed directional variability in alongshore current data and larval dispersal trajectories; if viewed in isolation these data suggest the system behaves as a source-sink metapopulation. However aggregate biweekly data over two years reveal a reef network in which H. rubicundus behaves more like a well-mixed metapopulation. As one of the few empirical studies of population connectivity within a temperate open coast reef network, this work can inform the MPA design process, implementation of ecosystem based management plans, and facilitate conservation decisions.     

"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

基于数据挖掘的门诊信息资源分析

目的：随着各级医院信息化建设的不断加强,医院的信息化水平也日益提高。目前各医院都有自己完善的信息化系统,在日常的门诊中,信息化系统积累了大量的门诊就诊数据,但长久以来这部分数据只是处于低层次的应用。对数据的深层次分析、加工以及对医院管理层的决策支持能力较弱。面对着这些宝贵的数据,医院迫切需要数据挖掘和分析工具从积累的就诊数据中分析出更深层次的、高价值的信息,从而为医院的管理决策提供高价值的决策信息。方法：以聚类算法进行数据挖掘建模,对某院门诊信息资源中有用字段进行挖掘分析。结果：根据数据挖掘模型进行挖掘分析,对有价值字段进行聚类分析,得到相关字段数据挖掘结果。结论：将得到相关字段数据挖掘结果进行分析,并将所分析的结果在医院管理决策和医疗质量管理等方面的应用进行探讨。     

基于CVM的山东海洋保护区生态系统多样性维持服务价值评估

选取山东济南(代表内陆城市)和青岛(代表沿海城市),基于条件价值法(CVM),对两市城镇居民进行问卷调查,通过建立支付意愿多元线性回归方程用以评估山东省城镇居民对维持山东88个海洋保护区永续存在的支付意愿,进而估算山东海洋保护区的生态系统多样性维持服务价值。研究发现,人均年收入较高,支付意愿较大;文化程度较低,支付意愿较小;男性比女性的支付意愿高;内陆城镇居民对于海洋保护区的人均支付意愿为102.15元,比沿海城镇居民的支付意愿高23.05元。2014年,山东全部88个海洋保护区的生态系统多样性维持服务价值为43.7亿元,平均0.497亿元/个。其中,12个自然保护区的价值为16.14亿元,平均1.35亿元/个;30个海洋特别保护区的价值为14.47亿元,平均0.489亿元/个;46个水产种质资源保护区的价值为12.9亿元,平均0.28亿元/个。结果表明:海洋自然保护区的生态系统多样性维持服务价值比海洋特别保护区和水产种质资源保护区高。在修订我国各类保护区的选划标准和管理目标时,应增加生态系统多样性维持服务价值并作为关键的选划指标。具有最高生态系统多样性维持服务价值的海域,宜选划为自然保护区,实施最严格的管理措施,确保其生态系统多样性维持服务价值增加,至少不降低。具有较高生态系统多样性维持服务价值的海域,因地制宜选划为海洋特别保护区或者海洋水产种质资源保护区,实施较严格的管理措施,确保其生态系统多样性维持服务价值不降低。     

基于融合理念的公立医院内部绩效考核体系探索研究

目的 建立与公立医院目标任务及外部绩效评价相匹配的内部绩效考核体系。方法 监控样本公立医院内部绩效考核体系的运行状态,对现行内部绩效考核体系的运行效果及医务人员反馈意见进行分析。调研管理部门、临床科室,访谈部门科室管理人员。结果 总结了现行内部绩效考核体系待改进的问题,提出基于医疗过程和医疗结果相结合进行全面评价、改进内部绩效工资测算方法、建立完善职能部门绩效评价体系、建立绩效沟通数据平台、融合政策执行评估的改进方案。结论 内部绩效考核体系的动态改进是公立医院实现医院目标任务、执行外部绩效评价的必然要求。     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Proteome analysis and morphological studies reveal multiple effects of the immunosuppressive drug mycophenolic acid specifically resulting from guanylic nucleotide depletion

Mycophenolic acid (MPA), one of the most promising immunosuppressive drugs recently developed, is a potent inhibitor of IMP dehydrogenase, the first committed step toward GMP synthesis. We found that all the drug effects on yeast cells were prevented by bypassing GMP synthesis, thus confirming the high specificity of MPA. Although the primary target of MPA is clearly identified, we aimed to further understand how GTP depletion leads to growth arrest and developed a new approach based on proteome analysis combined with overexpression studies. Essential proteins down-expressed in the presence of MPA were identified by protein two-dimensional gel analysis and subsequently overexpressed in yeast. Two such proteins, Cdc37p and Sup45p, when overexpressed allowed partial relief of MPA toxicity, strongly suggesting that their lower amount after MPA treatment significantly contributed to the MPA effect. These conserved proteins involved in cell cycle progression and translation are therefore important secondary targets for MPA. Our data establish that MPA effects occur through inhibition of a unique primary target resulting in guanine nucleotides depletion, thereby affecting multiple cellular processes.     

临床路径医疗管理模式的应用研究

对临床路径管理的现实需求、实施途径、问题与挑战等方面进行了论述。通过采用套餐的方式进行部署,以信息化平台作为实现手段是最为可行有效的办法。临床路径管理系统是多系统的集成平台,将会大大减少临床开医嘱时间;提高医务工作人员的工作效率;系统的预警功能将降低医疗差错的风险,确保医疗质量。在我国医药卫生体制改革和医疗保险制度逐步完善的背景下,临床路径具有巨大的实现价值和发展潜力。     

Risk-Based Approaches to Managing Contaminants in Catchments

Risk-based methods promise improved decision-making for managing of contaminants, such as salinity, sediments, nutrients, and toxicants, that can adversely affect the ecological condition of aquatic ecosystems. Two aspects of ecological risk assessment (ERA) and management—stakeholder involvement and more quantitative approaches to risk analysis—are particularly challenging. Stakeholder involvement is crucial both in the risk assessment process and the development, acceptance, and implementation of a risk management plan. Additionally, a number of quantitative approaches (particularly Bayesian approaches and multi-criteria decision-making) have been identified as having the potential to include expert-based inputs into risk-based decision-making. These offer promise for better inclusion of stakeholder knowledge and preferences into the decision-making process, and for improving the links between stakeholder inputs and potential risks to the ecological condition of the system. A major challenge for ecologists and natural resource managers is to make the ERA process more quantitative. Most ERAs conducted to date have been qualitative assessments that suffer from a number of deficiencies, the most serious being the lack of transparency and a reliance on subjective judgments. This article argues that the most productive way forward may be to use Bayesian methods to couple existing process-based models, empirical relationships based on good data, and expert opinion, to make the analysis of ecological risks more robust, consistent, and repeatable.