Explaining environmental management system development: A stakeholder approach

Managerial changes are necessary for companies in the Dutch food industry and agribusiness to lessen the environmental impact of their activities. To identify the opportunities or limits of environmental management systems (EMSs), it is important to first understand what influence stakeholders have on EMS development. In an empirical research we found that developmental levels of internally oriented EMSs, which primarily aim at internal administrative procedures, are explained mainly by the frequency of contacts with governmental authorities. For this kind of EMSs, non-commercial stakeholder groups have a major influence on the corporate environmental policy. Externally oriented EMSs, which focus on joint efforts in supply chains, are influenced by commercial groups in the business network (like suppliers, clients and competitors). The development of externally oriented EMSs requires adjustments in the composition of and interaction with the stakeholder environment by governmental agencies as well as managers in the agri-food sector. Opening up towards the stakeholder environment, by (among others) an adjustment of the information system, integrated (supply-chain wide) auditing and licensing, can enhance cost-efficiency, transparency and sustainability

The influence of the chain and network information and communication structure on sustainable business development

This article links the public-private information and communication structure (IC-structure) and Ajzen¿s model of planned behaviour to explain the development of environmental management systems (EMSs). The structure of the IC-system, especially the public-private information exchange, can influence the priorities of managers in favour of environmental management development. From an survey under medium-sized companies in the Dutch agri-food sector we conclude that the setting of priorities by managers on environmental goals is not significantly influenced by the quality of communication between government and industry. Safeguarding the licence-to-produce makes the norms of non-governmental stakeholder groups of overruling importance for their strategic orientation. Therefore, governmental action to protect the environment should address the perceptions of ngo-stakeholders. For many medium-sized companies, a coercive rather than a co-operative governmental attitude should be adopted. This deviates from the present Dutch public policy, in which non-coercive instruments dominate

Imaging in interventional oncology, the better you see, the better you treat

Imaging and image processing is the fundamental pillar of interventional oncology in which diagnostic, procedure planning, treatment and follow-up are sustained. Knowing all the possibilities that the different image modalities can offer is capital to select the most appropriate and accurate guidance for interventional procedures. Despite there is a wide variability in physicians preferences and availability of the different image modalities to guide interventional procedures, it is important to recognize the advantages and limitations for each of them. In this review, we aim to provide an overview of the most frequently used image guidance modalities for interventional procedures and its typical and future applications including angiography, computed tomography (CT) and spectral CT, magnetic resonance imaging, Ultrasound and the use of hybrid systems. Finally, we resume the possible role of artificial intelligence related to image in patient selection, treatment and follow-up.Patholog

Routine versus on demand removal of the syndesmotic screw; A protocol for an international randomised controlled trial (RODEO-trial)

Background: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. Design: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. Discussion: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. Trial registration: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov (NCT02896998) on July 15th 2016

Separation of early afterdepolarizations from arrhythmogenic substrate in the isolated perfused hypokalaemic murine heart through modifiers of calcium homeostasis

In human type 1 diabetes (T1D) and in its murine model, the major histocompatibility complex (MHC) class II molecules, human leukocyte antigens (HLA)-DQ and -DR and their murine orthologues, IA and IE, are the major genetic determinants. In this report, we have ranked HLA class II molecule-associated T1D risk in a two-sided gradient from very high to very low. Very low risk corresponded to dominant protection from T1D. We predicted the protein structure of DQ by using the published crystal structures of different allotypes of the murine orthologue of DQ, IA. We discovered marked similarities both within, and cross species between T1D protective class II molecules. Likewise, the T1D predisposing molecules showed conserved similarities that contrasted with the shared patterns observed between the protective molecules. We also found striking inter-isotypic conservation between protective DQ, IA allotypes and protective DR4 subtypes. The data provide evidence for a joint action of the class II peptide-binding pockets P1, P4 and P9 in disease susceptibility and resistance with a main role for P9 in DQ/IA and for P1 and P4 in DR/IE. Overall, these results suggest shared epitope(s) in the target autoantigen(s), and common pathways in human and murine T1D

In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery

Purpose Although physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscal tear, 24% still opt for meniscal surgery. The aim was to identify those patients with a degenerative meniscal tear who will undergo surgery following physical therapy. Methods The data for this study were generated in the physical therapy arm of the ESCAPE trial, a randomized clinical trial investigating the effectiveness of surgery versus physical therapy in patients of 45-70 years old, with a degenerative meniscal tear. At 6 and 24 months patients were divided into two groups: those who did not undergo surgery, and those who did undergo surgery. Two multivariable prognostic models were developed using candidate predictors that were selected from the list of the patients' baseline variables. A multivariable logistic regression analysis was performed with backward Wald selection and a cut-off of p < 0.157. For both models the performance was assessed and corrected for the models' optimism through an internal validation using bootstrapping technique with 500 repetitions. Results At 6 months, 32/153 patients (20.9%) underwent meniscal surgery following physical therapy. Based on the multivariable regression analysis, patients were more likely to opt for meniscal surgery within 6 months when they had worse knee function, lower education level and a better general physical health status at baseline. At 24 months, 43/153 patients (28.1%) underwent meniscal surgery following physical therapy. Patients were more likely to opt for meniscal surgery within 24 months when they had worse knee function and a lower level of education at baseline at baseline. Both models had a low explained variance (16 and 11%, respectively) and an insufficient predictive accuracy. Conclusion Not all patients with degenerative meniscal tears experience beneficial results following physical therapy. The non-responders to physical therapy could not accurately be predicted by our prognostic models.Orthopaedics, Trauma Surgery and Rehabilitatio

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Environmental management in the Dutch food and beverage industry : a longitudinal study into the joint impact of business network and firm characteristics on the adoption of environmental management capabilities

The present study aims for a deeper understanding of the internal and external factors, such as firm strategy and pressure from the business network (government, buyers, suppliers, local inhabitants, etc.), that have an impact on the adoption of environmental management capabilities in firms in the Dutch food and beverage industry. A recent investigation by the Arthur D. Little Innovation High Ground Survey among 40 multinationals (Sony, Procter & Gamble, Vodafone, etc.) showed that managers in general expect that sustainability-driven innovation, such as environmentally product (re)design, has a growing potential to deliver value to business. However, only 5% indicated to pay attention to environmental issues in their strategic planning and decision-making. These figures would probably look even worse if small- and medium-sized firms were included. This thesis focuses on the commitment to the environment in terms of the adoption of environmental management capabilities. These comprise different environmental management items, such as an environmental action program, regular environmental auditing to evaluate strategic environmental targets, and an environmental database to keep record of environmental performance. In short, they reflect the capacity of the firm to take care of the environment on a structural basis. The study design integrates the outside-in and the inside-out perspective. According to the outside-in perspective, the firm’s competitiveness depends on industrial forces, such as rivalry among competitors and entrance of new market parties. External factors measured in this study are the different stakeholder influences from the business network, including government and societal groups as well as other chain and network actors, such as buyers, suppliers, consumers and bank and insurance firms. The inside-out perspective states that the firm’s competitiveness depends on acquiring valuable resources, competences, and (dynamic) capabilities to deal with the external influences. Internal factors measured in this study are firm characteristics, including firm strategy and enabling capabilities, such as internal communication on environmental issues. The central research question is formulated as follows: What is the joint impact of the business network (government, buyers, suppliers, customers, etc.) and firm characteristics on the adoption of environmental management capabilities in Dutch food and beverage firms? Semi-structured interviews are held with 13 environmental managers of different firms, while also two large-scale surveys are carried out in 2002 and 2005 in the Dutch food and beverage industry. The interviews are carried out to get more insight into environmental management practices. The aim of the survey questionnaires was to measure the business network influences on the attention for the environment, which formed the longitudinal backbone of the present study. However, the survey of 2002 concentrated on the relationship with government, as well. In total, 492 questionnaires could be used for the analyses, of which 386 originated from micro and small (5-50 employees) and 106 from medium-sized and large firms (50 or more employees). In 2005, special attention was paid to firm strategy and enabling capabilities. The survey included medium-sized and large firms only to get a more homogenous sample. In total, 100 questionnaires could be used. Differences between micro, small, medium-sized and large firms hare analyzed using t-tests. Furthermore, correlation and regression analyses are carried out. A cluster analysis is performed to get more insight in different firm profiles with respect to the joint impact of the business network and firm characteristics. A longitudinal analysis is carried out to get insight in changes with respect to business network impacts on the adoption of environmental management capabilities between 2002 and 2005. An increased impact of the business network is measured from 2002 to 2005. Interestingly, banks and insurance firms appeared to be important as well as chain actors and competitors. This might implicate that the attention for environmental issues in the business networks has extended from government and environmental organizations to include stakeholders that are of primary interest to attain commercial business goals. The perceived impact of environmental organizations was stronger in 2005 compared to 2002, which might reflect growing environmental concerns of society and also increased success of these organizations to get media attention for environmental issues. However, the results demonstrate also that government is (still) a dominant environmental stakeholder. Concerning the public-private relationship, public-private voluntary environmental agreements (or environmental covenants) and the contact intensity with (lower) government appeared to be important. Furthermore, the results demonstrate that firms with an innovative business strategy (i.e. prospector strategy) adopted more cradle-to-cradle environmental management capabilities, including attention for environmentally friendly product (re)design. Regarding the research question, a cluster analysis indicates that four different environmental taxonomies can be distinguished with respect to business network and firm characteristics. In conclusion, the present study shows that for micro and small firms, strong ties with government through frequent contacts with local governmental agencies are essential to stay informed about environmental regulations. Such regular contacts have as a side-effect that the understanding and consequently the appreciation of public environmental policy improves. Governmental agencies are therefore recommended to provide micro and small firms environmental information (e.g. through e-mails or news letters) and, more importantly, maintain frequency of visits even if no direct monitoring or control reasons exist. The micro and small firms typically lack expertise to fundamentally change their environmental behavior. Environmental training and education programs could therefore be organized to increase the expertise to deal with environmental measures. Furthermore, cooperative pilot projects on the implementation of clean technologies can serve as a platform for knowledge exchange. Intermediaries, such as branch-organizations, are important to be involved in these initiatives, since they can take care of the administrative consequences. In the medium-sized and large firms with a defensive environmental strategy, the adoption of environmental management capabilities is most likely provoked by command-and-control regulations, while voluntary public-private environmental initiatives can be used to support proactive firms. Environmental covenants can put a strong focus on innovation addressing environmental targets at the product level (e.g. percentage of recycled components or re-usable parts) and at the chain level (e.g. chain level energy reduction targets). Large firms in particular are able to stimulate their chain partners to be included in environmental initiatives, which is essential for environmentally friendly product (re)design and to achieve chain-oriented environmental targets