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The challenge of sustainable urban development entails integration of environmental interests in decision-making about urban plans. In practice, this is not always successful. This dissertation offers explanations and suggests some strategies for further improvement. Three different perspectives are adopted, that were derived from environmental policy integration theory. Analysis identified five explanatory factors influencing the extent to which integration of urban environmental quality into decision-making about urban plans is successful. Moreover, the more holistic view resulting from combining the three perspectives sheds a novel light on the complexity of integration. It appears that the conception of sustainable urban development as integrating economic, social and environmental interests is too simple. First, because urban environmental quality itself consists of multiple dimensions that must be integrated. Second, because these dimensions involve processes at multiple spatial and administrative scale levels. And third, because urban environmental quality dimensions, in as far as they are subjective, rest on personal preferences of the many people involved in and affected by urban development, preferences that also vary across time. We term this ‘qualitative multiplicity’. This qualitative multiplicity of sustainable urban development causes the five factors explaining why integration of environmental interests in urban planning is sometimes problematic to act in concert, making it impossible to address one of them without also influencing at least some of the other factors. In practice, this may very well occur in cases of compact inner-city redevelopment, where the competition between environmental quality and other – social and economic – interests is most severe: high-density, mixed-use, inner-city redevelopments in areas that are heavily burdened by environmental impacts. Here, rigid environmental quality standards are sometimes found to be all too restrictive. Devolution of the authority to set urban environmental quality objectives can then be a useful approach if the problematic quality aspects involve mainly local processes. If, however, higher-level spatial scales are involved, devolution expectedly leads to insufficient attention to all relevant quality aspects or to coordination problems between the local administrative level and the appropriate higher ones. It is suggested that at least three conditions must be met in order to take advantage of such an approach locally, without risking loss of urban environmental quality from a wider perspective. A first prerequisite is adequate governance capacity to initiate and manage the multi-actor participatory process with all relevant stakeholders and interests. This includes the capability to invoke windows of opportunity for integration of environmental interests by helping actors to connect and reframe policy issues. Second, local-level decision-making can do with clear guidance as to managing qualitative multiplicity. Guidelines can take the form of simple area-dependent proxies for the complex concept of urban environmental quality, in combination with procedural regulations that clearly describe municipalities’ room for manoeuvre and insure optimal participation of all relevant actors. The third condition is that a knowledge infrastructure is in place making available all relevant information for managing urban environmental quality. Finally, better understanding of the qualitative multiplicity of sustainable urban development nuances the call for flexibility in dealing with environmental quality standards

Treatment of haemothorax

SummaryHaemothorax is a problem commonly encountered in medical practice and is most frequently related to open or closed chest trauma or to invasive procedures of the chest. Spontaneous haemothorax is less common and can have various causes, such as the use of anticoagulants, neoplasia, and rupture of pleural adhesions. Identification by radiography and thoracentesis is indicated and treatment of the underlying trauma should start immediately. After insertion of a large chest tube, antibiotic prophylaxis in trauma patients should be administered for 24 h.Further treatment depends on the haemodynamic stability of the patient, the volume of evacuated blood and the occurrence of persistent blood loss. Surgical exploration by VATS or thoracotomy is necessary if >1.500 ml of blood has accumulated and/or an ongoing production of >200 ml of blood per hour is observed. If the haemorrhage is less severe, careful investigation into the underlying cause must be performed and blood should be evacuated by tube thoracostomy. If clotted blood retained in spite of tube thoracostomy, intrapleural fibrinolytic therapy can be applied to breakdown clots and adhesions. If conservative treatment is insufficient, a surgical approach with VATS or thoracotomy is indicated to prevent subsequent complications

Current generation time-of-flight 18F-FDG PET/CT provides higher SUVs for normal adrenal glands, while maintaining an accurate characterization of benign and malignant glands

OBJECTIVE: Modern PET/CT scanners have significantly improved detectors and fast time-of-flight (TOF) performance and this may improve clinical performance. The aim of this study was to analyze the impact of a current generation TOF PET/CT scanner on standardized uptake values (SUV), lesion-background contrast and characterization of the adrenal glands in patients with suspected lung cancer, in comparison with literature data and commonly used SUV cut-off levels. METHODS: We included 149 adrenal glands from 88 patients with suspected lung cancer, who underwent (18)F-FDG PET/CT. We measured the SUV(max) in the adrenal gland and compared this with liver SUV(mean) to calculate the adrenal-to-liver ratio (AL ratio). Results were compared with literature derived with older scanners, with SUV(max) values of 1.0 and 1.8 for normal glands [1, 2]. Final diagnosis was based on histological proof or follow-up imaging. We proposed cut-off values for optimal separation of benign from malignant glands. RESULTS: In 127 benign and 22 malignant adrenal glands, SUV(max) values were 2.3 ± 0.7 (mean ± SD) and 7.8 ± 3.2 respectively (p < 0.01). Corresponding AL ratios were 1.0 ± 0.3 and 3.5 ± 1.4 respectively (p < 0.01). With a SUV(max) cut-off value of 3.7, 96 % sensitivity and 96 % specificity was reached. An AL ratio cut-off value of 1.8 resulted in 91 % sensitivity and 97 % specificity. The ability of both SUV(max) and AL ratio to separate benign from malignant glands was similar (AUC 0.989 vs. 0.993, p = 0.22). CONCLUSIONS: Compared with literature based on the previous generation of PET scanners, current generation TOF (18)F-FDG PET/CT imaging provides higher SUVs for benign adrenal glands, while it maintains a highly accurate distinction between benign and malignant glands. Clinical implementation of current generation TOF PET/CT requires not only the use of higher cut-off levels but also visual adaptation by PET readers

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