Adaptive management? Observations of knowledge coordination in the communication practice of Swedish game management

Modern management of natural resources is guided by the normative theory of adaptive management (AM). Behind this theory lies a strong, albeit implicit, expectation that organisations aiming for AM have the capacity to communicate in a way that facilitates the required coordination of the knowledge perspectives involved. The aim of this article is to discuss the extent to which the communication practice of Swedish game management organisations facilitates coordination of knowledge corresponding to AM. Based on operationalizations of communicative rationality and agonistic pluralism, we use the concepts 'discursive closure' and 'discursive opening' to investigate how the coordination of knowledge is carried out through communication in relatively recently established organisations, the Swedish Game Management Delegations (GMDs). We analyse four communication episodes from GMD meetings and notice that multiple perspectives were expressed (discourse openings) but were not evaluated in a communicative rational way before being closed. The consequences of these closures were that knowledge perspectives with potential relevance, but with unclear validity for game management, were not elaborated upon, in terms of their truth, intelligibility, legitimacy or sincerity, which inhibited AM. The concepts of discursive closure and discursive opening proved useful for investigating communicative capacity. An important question which needs to be addressed to improve communicative capacity for AM is whether it would be practically possible to keep to the agenda and rules of the GMD meetings and still admit discursive openings about differences in perspectives

Ezetimibe added to statin therapy after acute coronary syndromes

BACKGROUND: Statin therapy reduces low-density lipoprotein (LDL) cholesterol levels and the risk of cardiovascular events, but whether the addition of ezetimibe, a nonstatin drug that reduces intestinal cholesterol absorption, can reduce the rate of cardiovascular events further is not known. METHODS: We conducted a double-blind, randomized trial involving 18,144 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and had LDL cholesterol levels of 50 to 100 mg per deciliter (1.3 to 2.6 mmol per liter) if they were receiving lipid-lowering therapy or 50 to 125 mg per deciliter (1.3 to 3.2 mmol per liter) if they were not receiving lipid-lowering therapy. The combination of simvastatin (40 mg) and ezetimibe (10 mg) (simvastatin-ezetimibe) was compared with simvastatin (40 mg) and placebo (simvastatin monotherapy). The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization ( 6530 days after randomization), or nonfatal stroke. The median follow-up was 6 years. RESULTS: The median time-weighted average LDL cholesterol level during the study was 53.7 mg per deciliter (1.4 mmol per liter) in the simvastatin-ezetimibe group, as compared with 69.5 mg per deciliter (1.8 mmol per liter) in the simvastatin-monotherapy group (P<0.001). The Kaplan-Meier event rate for the primary end point at 7 years was 32.7% in the simvastatin-ezetimibe group, as compared with 34.7% in the simvastatin-monotherapy group (absolute risk difference, 2.0 percentage points; hazard ratio, 0.936; 95% confidence interval, 0.89 to 0.99; P = 0.016). Rates of pre-specified muscle, gallbladder, and hepatic adverse effects and cancer were similar in the two groups. CONCLUSIONS: When added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. Moreover, lowering LDL cholesterol to levels below previous targets provided additional benefit