Adaptation to climate change induced flooding in Dutch municipalities

This chapter provides a local perspective to adaptation strategies by investigating the effect of institutional capacity on local initiatives within a multi-government context. It focuses on the first research question: what is the current and projected role for local-level government within a multi-level governance model for climate adaptation? Climate change also involves an increase of climatic disasters and extreme weather events. Climate change mitigation is one of the motivations for the joint mitigation project, but adaptation has no separate role. Local-level preparedness for climate change impacts in the Netherlands is influenced by many internal and external factors. The chapter also focuses on the local-level civil preparedness more thoroughly by describing the role for local government within a multilevel governance model for climate adaptation. It addresses the second principal research question: how far does institutional capacity influence the possibilities and limitations for developing local adaptation strategies, and how can this capacity be expanded

The Scope of Action for Local Climate Policy: The Case of Norway

One of the key features of the post-Rio era has been how global environmental governance is mediated between local, national and global levels of government. In this article, we draw on experiences from local climate policy planning in Norway in order to discuss the ways in which climate change enters into a municipal policy setting. Based on the Norwegian case, supplemented with knowledge gained from an international literature review, we present a typology of six different categories of local climate policy. We highlight that local actors can both play the role as a structure for the implementation of national or international climate objectives, as well as that of being policy actors taking independent policy initiatives. We emphasize how the relationship between national and local authorities is a crucial factor if climate policy as a specific local responsibility should be further strengthened. (c) 2007 by the Massachusetts Institute of Technology.

Identification of Patients With Variants in TPMT and Dose Reduction Reduces Hematologic Events During Thiopurine Treatment of Inflammatory Bowel Disease

BACKGROUND & AIMS: More than 20% of patients with inflammatory bowel disease (IBD) discontinue thiopurine therapy because of severe adverse drug reactions (ADRs); leukopenia is one of the most serious ADRs. Variants in the gene encoding thiopurine S-methyltransferase (TPMT) alter its enzymatic activity, resulting in higher levels of thiopurine metabolites, which can cause leukopenia. We performed a prospective study to determine whether genotype analysis of TPMT before thiopurine treatment, and dose selection based on the results, affects the outcomes of patients with IBD. METHODS: In a study performed at 30 Dutch hospitals, patients were assigned randomly to groups that received standard treatment (control) or pretreatment screening (intervention) for 3 common variants of TPMT (TPMT*2, TPMT*3A, and TPMT*3C). Patients in the intervention group found to be heterozygous carriers of a variant received 50% of the standard dose of thiopurine (azathioprine or 6-mercaptopurine), and patients homozygous for a variant received 0%-10% of the standard dose. We compared, in an intention-to-treat analysis, outcomes of the intervention (n = 405) and control groups (n = 378) after 20 weeks of treatment. Primary outcomes were the occurrence of hematologic ADRs (leukocyte count < 3.0*10(9)/L or reduced platelet count < 100*10(9)/L) and disease activity (based on the Harvey-Bradshaw Index for Crohn's disease [n = 356] or the partial Mayo score for ulcerative colitis [n = 253]). RESULTS: Similar proportions of patients in the intervention and control groups developed a hematologic ADR (7.4% vs 7.9%; relative risk, 0.93; 95% confidence interval, 0.57-1.52) in the 20 weeks of follow-up evaluation; the groups also had similar mean levels of disease activity (P = .18 for Crohn's disease and P = .14 for ulcerative colitis). However, a significantly smaller proportion of carriers of the TPMT variants in the intervention group (2.6%) developed hematologic ADRs compared with patients in the control group (22.9%) (relative risk, 0.11; 95% confidence interval, 0.01-0.85). CONCLUSIONS: Screening for variants in TPMT did not reduce the proportions of patients with hematologic ADRs during thiopurine treatment for IBD. However, there was a 10-fold reduction in hematologic ADRs among variant carriers who were identified and received a dose reduction, compared with variant carriers who did not, without differences in treatment efficacy. ClinicalTrials.gov number: NCT00521950