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Mattias Hildén, Per Wretenberg, Wilhelmina Ekström Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Stockholm, Sweden Purpose: The Physiological and Operation Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and P (Portsmouth)-POSSUM predict the risks of complications and mortality 30 days after surgery. The purpose of this study was to evaluate the POSSUM and P-POSSUM scoring systems in patients who underwent surgery for a total hip or knee replacement. Patients and methods: A total of 227 patients with an elective primary total hip or knee replacement were included. The predicted postoperative morbidity was analyzed in these patients and compared with the observed value 30 days after surgery. Logistic regression analysis was used to assess the correlation of variables and outcome. Results: The number of patients undergoing total hip or knee replacement was equally distributed with a mean age of 66.4±12.5 years; 57% of patients were females. Postoperative complications occurred in 49 patients, and POSSUM predicted 49 cases with an observed-over-expected ratio of 1.0. The average total POSSUM score was 27.4±4.4 in patients with complications and 26.8±3.5 in patients without complications (P=0.340). Wound infection (n=18), urinary tract infection (n=7), and pulmonary embolus (n=5) were the most common complications. The operation magnitude variable had the highest mean POSSUM score making it the most relevant variable. Age and blood loss and echocardiogram had the largest variance among the assessed variables. Conclusion: POSSUM accurately predicted morbidities in patients undergoing elective primary total hip or knee replacement. The risk for wound infection, urinary retention, and pulmonary embolus should be considered during hospitalization. The computerized POSSUM system provides case-mix-adjusted morbidity predictions for groups and, hence, serves as a useful tool for surgical audits and large-scale benchmarking. Keywords: physical status, operation severity, case-mix, prediction, total joint replacement

Erythromyrin acistrate (EA)—a new ester of erythromycin—was compared with erythromycin base as cnterocoated pellets in capsules (EB enterocapsules) and enterocoated tablets of erythromycin base (EB enterotablets) in the treatment of respiratory tract infections. The present double-blind, multicentre study, conducted in eight occupational health centres, included 474 patients; 236 treated with EA, 117 with EB enterocapsules and 121 with EB enterotablets. The diagnoses included tonsillitis, sinusitis, otitis media, bronchitis and pneumonia. The patients were examined on admission and at the end of the treatment. The dosage of EA was 400 mg tid and that of the two erythromycin base preparations 500 mg tid. The treatment was given for seven to 14 days. In the EA-group, 97% of patients were clinically cured by the end of the treatment, while the cure rates for EB enterocapsules and EB enterotablets were 95% and 94%, respectively. Gastrointestinal side effects were reported by 36% of the patients on EA, 54% on EB enterocapsules and 50% on EB enterotablets. Discontinuations due to adverse effects occurred in 8% in the EA, in 21 % in the EB enterocapsule and in 12% in the EB enterotablet groups. All three preparations were thus equally effective, but EA caused statistically significantly less gastrointestinal side effects overall (P>0.01), especially nausea (P>0.01) and abdominal pain (P>0.05), than the two formulations containing erythromycin base. Also discontinuations due to side effects occurred statistically significantly less frequently in the EA-group. [ABSTRACT FROM PUBLISHER]

Adaptation is increasingly recognised as essential when dealing with the adverse impacts of climate change on societies, economies and the environment. However, there is insufficient information about the effectiveness of adaption policies, measures and actions. For this reason, the establishment of monitoring programmes is considered to be necessary. Such programmes can contribute to knowledge, learning and data to support adaptation governance. In the European Union (EU), member states are encouraged to develop National Adaptation Strategies (NASs). The NASs developed so far vary widely because of differing views, approaches and policies. A number of member states have progressed to monitoring and evaluating the implementation of their NAS. It is possible to identify key elements in these monitoring programmes that can inform the wider policy learning process. In this paper, four generic building blocks for creating a monitoring and evaluation programme are proposed: (1) definition of the system of interest, (2) selection of a set of indicators, (3) identification of the organisations responsible for monitoring and (4) definition of monitoring and evaluation procedures. The monitoring programmes for NAS in three member states-Finland, the UK and Germany-were analysed to show how these elements have been used in practice, taking into account their specific contexts. It is asserted that the provision of a common framework incorporating these elements will help other member states and organisations within them in setting up and improving their adaptation monitoring programmes.

We analyze how metaphors are used in presenting and debating novel technologies that could influence the climate and thereby also future climate change policies. We show that metaphors strengthen a policy-related storyline, while metaphors are rarer in purely descriptive accounts. The choice of metaphor frames the technologies. War metaphors are used equally in arguments that are for, against and neutral with respect to the further development of geoengineering, but differences arise in the use of metaphors related to controllability, health and mechanisms. Controllability metaphors are often used in justifying further research and development of good governance practices, whereas health metaphors tend to be used against the very idea of geoengineering by portraying technological interventions in the climate as an emblematic case of an unacceptable development. These findings suggest that metaphors are early indications of restrictions in the interpretative flexibility that influences future governance of geoengineering and geoengineering research., (© The Author(s) 2013.)

To call for integration in risk assessment and governance as a self-evident goal is deceptively easy. For more insight, we ask: what level and kind of integration and for what purposes is needed and sufficient? What opportunities and obstacles can be identified for integrative treatment of risks? What causes and impacts are there of developments in risk integration? To answer these questions we investigate the socio-political processes and factors surrounding integrated risk assessment and risk governance through a combination of literature reviews and original research. We emphasize regulatory assessment and governance of risks associated with chemicals in the EU, but we link them with other areas to better grasp options and problems in integration. We relate the problems to political factors and barriers in sector and vertical integration, including deviating interests, and further to conflicting information, concepts and mindsets. Risk assessment and risk governance involve varying notions of risks and knowledge, with tensions between stressor- or impact-oriented, exclusive or inclusive, positivist or relativist, and fixed or reflexive notions and approaches. These tensions influence the trajectories of integration between sectors, actors and regions, constraining the fulfillment of ideals of integrated governance. We conclude that risk assessment and governance can be integrated, harmonized and innovated to a limit only, but this limit is variable and flexible, and provides opportunities especially if attention is paid to the socio-political contexts, value choices and decision structures in each case. Generally, the results underline a reflexive approach whereby the meanings, framings and implications of risk integration are probed in open processes of deliberation and negotiation, as a learning process to transcend the formal and prescriptive modes of regulation and knowledge generation., (Copyright 2009 Elsevier B.V. All rights reserved.)

This paper addresses obstacles and opportunities for the development and application of novel methods for integrated assessment of cumulative risks from chemicals, exemplified by the REACH legislation of the EU, in the context of multiple stressors and of chemicals policy. We examine the role of such methods in connection with REACH by models of integration and innovation of risk information in multi-actor risk governance; analyses of key documents on REACH; and interviews with EU regulators and stakeholders. We first explain the emergence of REACH as a response to tensions in EU chemicals, environmental and other policies. We then analyze the present configuration of REACH particularly in relation to key dimensions of risk integration: across stressors; exposed organisms; and impacts. Among the policy aspects of integrated risk information, we focus on its interaction with management and the contesting framings and interpretations of assessment. Avenues and barriers are identified for integrated treatment of risks under REACH and with other instruments. We emphasize how bounded, formal and static assessments interact with open and informal approaches that have more flexibility in integrating risks in new ways. We conclude with a generalizing discussion on the role of novel methods of integrated risk assessment in the development of reflexive and participatory governance under REACH and beyond., (Copyright 2010 Elsevier B.V. All rights reserved.)