Multidisciplinary Approach

This study presents the results of a multidisciplinary approach, using hydrogeochemical, isotopic and ecotoxicological analyses, performed to assess the nature and suitability for use of Paranhos and Salgueiros spring waters (Porto city, NW Portugal). Based on the surface activities located along the course of the springs, 23 water samples were collected. All the samples were analysed for major element concentrations. The isotopic techniques employed included d 2 H, d 18 O and 3 H. Standard acute bioassays with Daphnia magna were also performed. The hydrogeochemical analyses showed a nitrate and sulphateenriched composition for these groundwaters, resulting mainly from urban drainage and sewer leakage. In the ecotoxicological analyses, no significant mortality was observed in any of the tests performed. The results obtained in this study suggest that Porto urban groundwater could be suitable for irrigation uses.

Anthropogenically-derived increases in atmospheric greenhouse gas concentrations have been implicated in recent climate change, and are projected to substantially impact the climate on a global scale in the future. For marine and freshwater systems, increasing concentrations of greenhouse gases are expected to increase surface temperatures, lower pH, and cause changes to vertical mixing, upwelling, precipitation, and evaporation patterns. The potential consequences of these changes for harmful algal blooms (HABs) have received relatively little attention and are not well understood. Given the apparent increase in HABs around the world and the potential for greater problems as a result of climate change and ocean acidification, substantial research is needed to evaluate the direct and indirect associations between HABs, climate change, ocean acidification, and human health. This research will require a multidisciplinary approach utilizing expertise in climatology, oceanography, biology, epidemiology, and other disciplines. We review the interactions between selected patterns of large-scale climate variability and climate change, oceanic conditions, and harmful algae.

Introduction: Merkel cell carcinoma (MCC) of the skin is a rare, aggressive, malignant neuroendocrine neoplasm. The tumor classically demonstrates positive immunohistochemistry (IHC) staining for chromogranin A(ChrA), cytokeratin 20 (CK20), neuron specific enolase (NSE) and/or achaete-acute complex-like 1 (MASH1). The newly identified Merkel cell polyomavirus (MCPyV) has been found to be associated with most MCC cases. The primary histologic differential diagnoses of cutaneous MCC is small cell primary bronchogenic carcinoma (SCLC); moreover, both are of neuroendocrine origin. SCLC accounts for approximately 10-15% of all primary lung cancer cases; this histologic subtype is a distinct entity with biological and oncological features distinct from non-small cell lung cancer (NSCLC). In contradistinction to MCC, SCLC is classically IHC positive for cytokeratin 7 (CK7) and transcription factor (TTF-1). Similar to SCLC, MCC cell lines may be classified into two different biochemical subgroups designated as Classic and Variant. In our review and case report, we aim to emphasize the importance of a multidisciplinary approach to the approach to this difficult differential diagnosis. We also aim to comment about features of the cells of origin of MCC and SCLC; to summarize the microscopic features of both tumors; and to review their respective epidemiologic, clinical, prognostic and treatment features. We want to emphasize the initial workup study of the differential diagnosis patient, including evaluating clinical lymph nodes, a clinical history of any respiratory abnormality, and chest radiogram. If a diagnosis of primary cutaneous MCC is confirmed, classic treatment includes excision of the primary tumor with wide margins, excision of a sentinel lymph node, and computed tomography, positron emission tomography and/or Fluorine-18fluorodeoxyglucose positron emission tomography scan studies.

The application of blood conservation strategies to minimise or avoid allogeneic blood transfusion is seen internationally as a desirable objective. Bloodless surgery is a relatively new practice that facilitates that goal. However, the concept is either poorly understood or evokes negative connotations. Bloodless surgery is a term that has evolved in the medical literature to refer to a peri-operative team approach to avoid allogeneic transfusion and improve patient outcomes. Starting as an advocacy in the early 1960s, it has now grown into a serious practice being embraced by internationally respected clinicians and institutions. Central to its success is a coordinated multidisciplinary approach. It encompasses the peri-operative period with surgeons, anaesthetists, haematologists, intensivists, pathologists, transfusion specialists, pharmacists, technicians, and operating room and ward nurses utilising combinations of the numerous blood conservation techniques and transfusion alt...

Because, globally, HIV is transmitted mainly by sexual practices and intravenous drug use and because of a long asymptomatic period, healthcare-associated HIV transmission receives little attention even though an estimated 5.4% of global HIV infections result from contaminated injections alone. It is an important personal issue for healthcare workers, especially those who work with unsafe equipment or have insufficient training. They may acquire HIV occupationally or find themselves before courts, facing severe penalties for causing HIV infections. Prevention of blood-borne nosocomial infections such as HIV differs from traditional infection control measures such as hand washing and isolation and requires a multidisciplinary approach. Since there has not been a review of healthcare-associated HIV contrasting circumstances in poor and rich regions of the world, the aim of this article is to review and compare the epidemiology of HIV in healthcare facilities in such settings, followed...

Construction is a very complex process. It involves a multidisciplinary approach. There has been concern that construction projects are running behind schedule and many have failed resulting in a loss of money. It is important for construction industries to have a proper management ...

Within the context of a biopsychosocial model of the treatment of depressive episodes, a multidisciplinary approach is needed. Clinical pathways have been developed and implemented in hospitals to support multidisciplinary teamwork. The aim of this study is to explore current practice for the treatment of depressive episodes in Flemish psychiatric hospitals. Current practice in different hospitals is studied to get an idea of the similarities (outlined as a pathway) and the differences in the treatment of depressive episodes. A convenience sample of 11 Flemish psychiatric hospitals participated in this qualitative study. Semi-structured interviews were conducted with different types of health care professionals (n = 43). The websites of the hospitals were searched for information on their approach to treating depressive episodes. A flow chart was made including the identified stages of the pathway: pre-admission, admission (observation and treatment), discharge and follow-up care. The characteristics of each stage are described. Although the stages are identified in all hospitals, differences between hospitals on various levels of the pathway exist. Hospitals emphasized the individual approach of each patient. The results point to a biopsychosocial approach to treating depressive episodes. This study outlined current practice as a pathway for Flemish inpatients with depressive episodes. Within the context of surveillance of quality and quantity of care, this study may encourage hospitals to consider developing clinical pathways.

We describe the identification of novel rapamycin derivatives present as low-level impurities in active pharmaceutical ingredients using an integrated, multidisciplinary approach. Rapamycin, a fermentation-derived natural product is itself used clinically and provides the starting material for several rapamycin analog drugs, typically used in oncology. LC-MS proved a sensitive means to analyze impurity profiles in batches of rapamycin. MS fragmentation was used to gain structural insight into these impurities, usually fermentation by-products, structurally very similar to rapamycin. In cases where MS fragmentation was unable to provide unambiguous structural identification, the impurities were isolated and purified using orthogonal HPLC methods. Using the higher mass sensitivity of small-volume NMR microprobes, submilligram amounts of isolated impurities were sufficient for further characterization by multidimensional NMR spectroscopy. Full assignment of the 1 H and 13 C NMR signals revealed the structure of these impurities at an atomic level. This systematic workflow enabled the identification of several novel rapamycin congeners from active pharmaceutical ingredient without the need for large-scale isolation of impurities. For illustration, two novel rapamycin derivatives are described in this study: 12-ethyl-rapamycin and 33-ethyl-rapamycin, which exemplify previously unreported modifications on the carbon skeleton of the rapamycin macrocycle. The methodologies described here can be of wide use for identification of closely related structures found; for example as fermentation by-products, metabolites or degradants of natural product-based drugs.

At present, the side effects associated with antiretroviral treatment are the main reasons for discontinuation of this kind of therapy, both in clinical trials and in regular clinical practise.On the other hand, due to the change of direction that our profession has suffered in recent years, we face the need to establish a different relationship with the patient, achieving direct

Introduction Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately. Materials and methods Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards. Results Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. “Functional hemodynamic monitoring” requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding. Conclusions Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

pH is one of the key parameters that determines heavy metal mobility in soils, sediments and waste materials. In many respects leaching behaviour as reflected by the pH stat leaching tests provide a better means of assessing environmental impact than analysis of total elemental composition. This paper discusses the use of pH stat leaching tests as a tool to assess the potential mobilisation of trace metals from soils, sediments and waste materials. The possibilities of pH stat leaching tests are illustrated by means of different examples.

Wetlands perform functions that support the generation of ecologically, socially and economically important values. European legislation has increasingly recognised the importance of preserving wetland ecosystems. The Water Framework Directive (WFD) embodies many of the existing directives that have implications for wetlands. The EU funded EVALUWET project (European Valuation and Assessment tooL sUpporting Wetland Ecosystem legislaTion) aims to develop and implement an operational wetland evaluation decision support system to support European policy objectives. A multidisciplinary approach is adopted combining expertise from natural and social scientists.

A 39-year-old-woman was treated successfully by a combination of endobronchial and bronchial artery embolization for massive hemorrhage originating from the posterior segment of the right upper lobe. Endobronchial embolization was performed using a silicone spigot placed via fl exible bronchoscopy in order to prevent alveolar inundation preceding and during the time of bronchial artery embolization. Massive hemorrhage is a rare and severe condition associated with a high mortality that requires rapid intervention and management. We describe a case that emphasizes the effi cacy of a multidisciplinary approach including the use of a new bronchoscopic technique.

The Rimicaris exoculata dominates the megafauna of some of the Mid Atlantic ridge hydrothermal vent sites. This species harbors a rich community of bacterial epibionts inside its gill chamber. Literature data indicate that a single 16S rRNA phylotype dominates this epibiotic community, and is assumed to be a sulfide-oxidizing bacteria. However attempts of cultivation were not successful and did not allow to confirm it. The aim of our study was to test the hypothesis of sulfide oxidation in the gill chamber, by a multidisciplinary approach, using in vivo experiments at in situ pressure in the presence of sulfide, microscopic observations and a molecular survey. Morphology of microorganisms, before and after treatment, was analyzed to test the effect of sulfide depletion and re-exposure. Our observations, as well as molecular data indicate a wider diversity than previously described for this shrimp's epibiotic community. We observed occurrence of bacterial intracellular sulfur-and iron-enriched granules and some methanotrophic-like bacteria cells for the first time. Genes that are characteristic of methaneoxidizing (pmoA) and sulfide-oxidizing (APS) bacteria were identified. These results suggest that three metabolic types (iron, sulfide and methane oxidation) may co-occur within the epibiont community associated with Rimicaris exoculata. As this shrimp colonizes chemically contrasted environments, the relative abundance of each metabolic type could vary according to the local availability of reduced compounds.

Abstract A multidisciplinary approach is being used to identify and validate virulence factors and determinants of bacteria of the Burkholderia cepacia complex (Bcc). Bcc is a group of problematic opportunistic pathogenic bacteria, particularly among cystic fibrosis patients, ...

Usually, women suffering from chronic pelvic pain experience it for some time and do not seek treatment until the pain becomes so severe that it adversely affects a woman’s normal daily functioning, preventing her from maintaining a normal lifestyle and leading to development of chronic pain syndrome. Chronic pelvic pain syndrome is often accompanied by behavioral disorders, cognitive, psychoemotional and sexual disorders, as well as symptoms of dysfunction of the lower urinary and digestive systems, pelvic organs, gynecological dysfunction, which are the result of neurobiological, physiological and sometimes anatomical changes in the body and central nervous system.
Often a gynecologist automatically focuses exclusively on gynecological organs, assuming that they are the cause of the problem, but most often the cause of chronic pelvic pain is a group of factors. Disorders of the gastrointestinal, urological, and musculoskeletal systems are at least as common as disorders of the reproductive system in women with chronic pelvic pain. Therefore, diagnostic measures should be aimed at identifying all the causes which requires doctors to take a multidisciplinary approach to the diagnosis and management of chronic pelvic pain. The causes of the problem in most cases can be identified by a thorough history taking and physical examination, which should be more detailed than usual. As a diagnostic tool, it can minimize the need for expensive laboratory testing and imaging or risky surgery. The use of specialized assessment forms and questionnaires for chronic pelvic pain can be important and useful to ensure coverage of all critical points.
When planning a diagnostic plan for women with chronic pelvic pain, it is important to consider the key role of the nervous system in the perception of pain. Experiencing pain for a long period of time can change how the brain perceives and processes pain signals, leading to an amplification of pain and cross-organ sensitization.
Complicated differential diagnosis often causes the absence of a definitive diagnosis in most patients who complain of chronic pelvic pain. Therefore, during the first visit of the patient, it is sometimes impossible to immediately determine the cause of pain. Because the causes of many disorders associated with chronic pelvic pain have not been identified, most clinicians treat them empirically. Therefore, in the presence of several etio-pathogenetic factors, treatment of only some of them will lead to incomplete relief.
The definition of «chronic pelvic pain» can hide many diseases, the detection of which requires the involvement of a multidisciplinary team of gynecologists, urologists, gastroenterologists, nephrologists, vascular surgeons, orthopedists, psychiatrists, psychologists and doctors of other specialties. However, it is mostly gynecologists who are the first to come into contact with this pathology because, in most cases, women who suffer from chronic pelvic pain first turn to them for help. That is why they should be the main members of the multidisciplinary team and take responsibility for its creation. Unfortunately, physicians often lack an interdisciplinary approach to the management of chronic pelvic pain, which complicates comprehensive assessment, diagnosis, and treatment and leads to frustration among women who go from one specialist to another without an adequate solution to their problem.

The theoretical and conceptual basis for behavior analysis emerged from the fields of
experimental psychology, physiology, and philosophy, effectively melding theory with
scientific rigor. Behavior analysis has since expanded from controlled laboratories into
applied settings, including hospitals, clinics, schools, family homes, and communities.
Much of the early research in applied behavior analysis (ABA) included participants
with mental health disorders and developmental disabilities. ABA research for persons
with developmental disabilities is vibrant and expansive; however, there is a paucity of
recent research in behavior analytic assessment and treatment for persons with mental
health diagnoses. This article describes how ABA technology can advance mental
health services for children and adults utilizing a multidisciplinary approach to link
professionals from psychology, psychiatry, and other associated disciplines to optimize
patient outcomes. Discussion focuses on historic applications of behavior analysis,
opportunities, and barriers in the mental health field, and ways in which ABA can
contribute to a multidisciplinary treatment approach.

The indigenous soil knowledge among the Fulani subsistence farmers in two villages of northern Burkina Faso is examined, analysed and assessed with the aim of evaluating its adequacy for sustaining soil fertility and for the appropriateness of tapping indigenous knowledge in development programmes. The analytical framework is a multidisciplinary approach combining soil science and anthropology. The results show a high degree of consistency between the science-based western soil classification and the Fulani soil classification although the routes of generation are different. The farmers are aware of and active in management of soil fertility based on their experience, but express no thorough understanding of the mechanisms of plant growth. The soil knowledge is applied in the farming strategies which, as a primary aim, seek to minimize the risk of harvest failure. However, the analysis also suggests that the knowledge is no part of a 'free-standing' knowledge body which can be separated from the actual agricultural performance. The farmers express a general concern about the present state of the environment and degradation processes; however, there is no motivation to take active control of and manage the bush area. This is in contrast with the way millet cultivators actively manage their fields. An explanation of this is suggested by the division between the two Fulani ethnic subgroups, the FulBe who are the former masters and the RimayBe, the former slaves.

In this paper, we review the recent advances of CMOS-based capacitive sensors for Lab-on-chip (LoC) applications. LoC design is a multidisciplinary approach of adapting classical biochemical assays to a miniaturized platform by exploiting advances in microelectronic and microfluidic technologies. By offering low cost and integrated devices, CMOS based LoCs could be amenable to a large number of biological and biochemical assays for disease diagnostics and biotechnology in the near future. While an exhaustive, all-encompassing review of CMOSbased LoCs is beyond the scope of this review, we have focused on the design and implementation of CMOS-based capacitive sensor LoCs for the most important biochemical applications. For each application, the corresponding biochemical sensing layer, interface circuit and microfluidic packaging technique are discussed based on the recent literature studies.

The feasibility of microalgae production for biodiesel was discussed. Although algae are not yet produced at large scale for bulk applications, there are opportunities to develop this process in a sustainable way. It remains unlikely, however, that the process will be developed for biodiesel as the only end product from microalgae. In order to develop a more sustainable and economically feasible process, all biomass components (e.g. proteins, lipids, carbohydrates) should be used and therefore biorefi ning of microalgae is very important for the selective separation and use of the functional biomass components. If biorefi ning of microalgae is applied, lipids should be fractionated into lipids for biodiesel, lipids as a feedstock for the chemical industry and w -3 fatty acids, proteins and carbohydrates for food, feed and bulk chemicals, and the oxygen produced should be recovered also. If, in addition, production of algae is done on residual nutrient feedstocks and CO 2 , and production of microalgae is done on a large scale against low production costs, production of bulk chemicals and fuels from microalgae will become economically feasible.

Multidisciplinary team care is becoming more popular for complex health issues, including pelvic floor dysfunction. We conducted a retrospective review of the records of 207 patients attending a multidisciplinary pelvic floor dysfunction clinic. A telephone survey was also conducted. The outcomes investigated included conservative versus surgical management, comorbidities, number of specialists seen, and subjective patient feedback. The average patient was 59.9 years old and travelled an average distance of 128.6 km to attend the clinic. Common clinical presentations were urge urinary incontinence (58.9%) and stress urinary incontinence (54.6%). Ninety-three of 178 patients (52.2%) presented with at least two comorbidities. At the time of data collection, 52.2% of patients had opted for surgical management, 27.5% had chosen conservative management, and the remainder remained undecided. One hundred sixty-five women participated in the telephone survey and their responses were grouped...

A consequence of improved survival of very premature babies is increasing numbers of children presenting to Orthopaedic surgeons with spastic diplegia.The majority of these children can walk but gait abnormalities are common and the natural progression is from muscle spasticity to contracture and eventual bony deformity. This results in increasingly ine⁄cient gait as the child grows and gains weight. Intervention is initially by spasticity management, enhanced (over recent years) since the advent of Botulinum toxin type A, and later surgical intervention to both contracted muscles and bony deformities. Instrumented gait analysis is a prerequisite of surgery and all deformities should be addressed simultaneously. Surgery should only be considered once the child's function has plateaued, usually between the age of seven and ten. Satisfactory results require patient and carer compliance in what is an intensive rehabilitation involving a multidisciplinary approach.

I n this document, we discuss the diagnostic approach to disabilities associated with prenatal alcohol exposure. Fetal alcohol spectrum disorder (FASD), along with its most visible presentation, fetal alcohol syndrome (FAS), is a serious health and social concern to Canadians. FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioural and learning disabilities with lifelong implications. The term FASD is not intended for use as a clinical diagnosis. FASD is the result of maternal alcohol consumption during pregnancy and has implications for the affected person, the mother, the family and the community. Since FAS was first described in 1973, 1 it has become apparent that it is complex; affected people exhibit a wide range of expression, from severe growth restriction, intellectual disability, birth defects and characteristic dysmorphic facial features to normal growth, facial features and intellectual abilities, but with lifelong deficits in several domains of brain function. FASD requires a medical diagnosis in the context of a multidisciplinary assessment. FASD itself is not a diagnostic term. The purpose of this paper is to review and clarify the use of the current diagnostic systems and make recommendations on their application for diagnosis of FASD-related disabilities in people of all ages. For a description of the characteristics and the natural course of FASD, consult some of the broader reviews. 2-7 Epidemiology of FASD The prevalence of FAS in the United States has been reported as 1-3 per 1000 live births and the rate of FASD as 9.1 per 1000 live births. 8-11 However, diagnosis may often be delayed or missed entirely. 2 There are no national statistics on the rates of FASD in Canada, although studies have estimated its prevalence in small populations. In an isolated Aboriginal community in British Columbia, FASD prevalence was 190 per 1000 live births. 12 In northeastern Manitoba, an incidence of about 7.2 per 1000 live births was found. 13 In another Manitoba study in a First Nations community, 14 the prevalence of FAS and partial FAS was estimated to be 55-101 per 1000. In their survey, Asante and Nelms-Matzke 15 estimated the rate of FAS and related effects at 46 per 1000 native Canadian children in the Yukon and 25 per 1000 in northern British Columbia. Based on referrals to a diagnostic clinic in Saskatchewan, the rate of FAS was estimated at 0.589 per 1000 live births in 1988-1992 and 0.515 per 1000 in 1973-1977. 16 However, none of these data should be generalized to other communities, other populations or the Canadian population in general. Risk factors A common misconception is that FASD is associated with ethnocultural background. However, the data suggest that risk factors for prenatal alcohol exposure include higher maternal age and lower education level, prenatal exposure to cocaine and smoking, custody changes, lower socioeconomic status and paternal drinking and Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis Abstract THE DIAGNOSIS OF FETAL ALCOHOL SPECTRUM DISORDER (FASD) is complex and guidelines are warranted. A subcommittee of the Public Health Agency of Canada's National Advisory Committee on Fetal Alcohol Spectrum Disorder reviewed, analysed and integrated current approaches to diagnosis to reach agreement on a standard in Canada. The purpose of this paper is to review and clarify the use of current diagnostic systems and make recommendations on their application for diagnosis of FASD-related disabilities in people of all ages. The guidelines are based on widespread consultation of expert practitioners and partners in the field. The guidelines have been organized into 7 categories: screening and referral; the physical examination and differential diagnosis; the neurobehavioural assessment; and treatment and follow-up; maternal alcohol history in pregnancy; diagnostic criteria for fetal alcohol syndrome (FAS), partial FAS and alcohol-related neurodevelopmental disorder; and harmonization of Institute of Medicine and 4-Digit Diagnostic Code approaches. The diagnosis requires a comprehensive history and physical and neurobehavioural assessments; a multidisciplinary approach is necessary. These are the first Canadian guidelines for the diagnosis of FAS and its related disabilities, developed by broad-based consultation among experts in diagnosis.

Problem-based learning is now a widespread teaching method in disciplines where students must learn to apply knowledge, not just acquire it. In the undergraduate curriculum in Aeronautics and Astronautics at MIT, problem-based learning and designbuild experiences are integrated throughout the program. In an early freshman-year experience, Introduction to Aerospace and Design, students design, build, and fly radiocontrolled lighter-than-air (LTA) vehicles. In the sophomore-year Unified Engineering course, students design, build, and fly radio-controlled electric propulsion aircraft. In a course on Aerodynamics, a case study from either industry or government is used to provide an authentic problem. Upper-level capstone courses are entirely problem-based. In these PBL experiences, students identify problems of interest to them and experiment to find solutions, as well as design complex systems that integrate engineering fundamentals in a multidisciplinary approach. This paper describes several problembased learning experiences in undergraduate aerospace engineering at MIT within a fourlevel framework for categorizing problems. It presents the learning theories that underlie the success of PBL, identifies the basic characteristics of PBL, critical features in the design of problems, and effective methods for assessing PBL.

Complex regional pain syndrome (CRPS) is still a puzzling disease. Although pathophysiologic understanding has improved, not every aspect of this challenging neuropathic pain syndrome has been explored. Typical symptoms of CRPS are sensory, motor, and autonomic dysfunctions. In most cases, CRPS occurs after a fracture, limb trauma, or lesion of the peripheral or central nervous system. Sometimes, symptoms develop without any trauma. Recent pathophysiologic concepts basically consider three major mechanisms: enhanced peripheral neurogenic inflammation, dysfunction of the sympathetic nervous system, and structural reorganization in the central nervous system. Moreover, a genetic predisposition may explain increased vulnerability. Treatment usually requires a multidisciplinary approach, including medical and nonmedical therapies. The common therapeutic aim is to maintain or restore normal function of the affected extremity. Beyond highlighting pathophysiologic concepts, this article describes recent therapeutic approaches.

The rates of relapse and death remain high in gastric cancer patients, especially in advanced stages. Local relapses in the tumour bed and regional lymph nodes, peritoneal spread as abdominal carcinomatosis, and distant metastasis are common mechanisms of failure after a R0 resection. To overcome this, a multidisciplinary approach has been prompted. In recent years, multidisciplinary treatment has been strengthened by some randomised controlled trials and it is now considered the standard by most groups, although the improvement in long-term survival rates achieved is still limited. This new therapeutic approach in gastric cancer is rapidly evolving and has led to a series of controversies on the best strategy to follow. Some of these controversies are discussed in this paper.

The diagnosis of breast cancer can cause a significant anxiety in someone's life. The care of the breast cancer patient requires in many centres. The care of breast cancer patient is undertaken as a joint venture between the surgeon, medical oncologist, radiotherapist, pathologist and allied health professionals such as the clinical nurse specialist as well as counsellors. This is a case of a 39-years-old Malay woman presented to HUSM with a history of ulcerating breast lump with bloody pus discharge on the right breast. An initial mammogram study showed lesion suspicious of malignancy, and histopathological examination was consistent with invasive ductal carcinoma. She received neoadjuvant chemotherapy before proceeding to right modified radical mastectomy with axillary clearance and immediate chest wall reconstruction. Detailed discussion on the diagnosis, treatment, surgical intervention and progress of the patient with reference to available literature reviews are presented.

En Sinkhole occurrence in the perityrrhenian areas of Central Italy seems to be strongly related to a peculiar geological and hydrogeological framework, characterized by the co-existence and interaction of different issues considered to trigger the sinkhole genesis. Several sinkholes prone areas have been recognized in the Latium region, a few of them being located in the surrounding areas of Rome. The most recent of such catastrophic phenomena occurred on January 2001 about 30 Km east of Rome, close to the Marcellina village, on a small plain at the foothills of the Lucretili Mts. carbonatic ridge. In this paper preliminary geological and hydrogeological data concerning the Marcellina area are discussed, in order to analyze the role of each issue characterizing it as a "sinkhole prone area". A possible conceptual model for cover collapse sinkhole genesis in groundwater discharge areas is then briefly outlined, focusing on the Campagna Romana peculiar geological and hydrog...

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One of the most difficult problems that humanity currently faces is the sustainable development of our society, i.e. how to meet the needs of the present without compromising the ability of future generations to meet their own needs. Solving this challenge requires a multidisciplinary approach where researchers with different backgrounds combine their efforts. As software engineers, we can contribute to these efforts by offering existing software requirements modeling and analysis techniques as a means to integrate sustainability requirements in decision-making processes. In this paper, we use a popular language for modeling early requirements as a way to visualize the impact of alternative options on sustainability goals and to analyze the conflicts between sustainability and other problem-specific objectives. We apply this idea to the decision-making activities pertaining to the organization of the ICSE'09 conference itself. We find that the modeling activity significantly facilitates exploration, understanding and comparison of large numbers of possible sustainability measures and allows for better informed and justified decisions.

Background Crop production in China has been greatly improved by increasing phosphorus (P) fertilizer input, but overuse of P by farmers has caused low use efficiency, increasing environmental risk and accumulation of P in soil. From 1980 to 2007, average 242 kg P ha−1 accumulated in soil, resulting in average soil Olsen P increasing from 7.4 to 24.7 mg kg−1. China is facing huge challenges to improve P use efficiency through optimizing corresponding technology and policies. The problem is exacerbated because people have been shifting their diet from plant-based to animalenriched foods. This results in higher P load in the food chain and lower P use efficiency. Scope A multidisciplinary approach has been used to improve P management at the field and national level in China. Management strategies based on the soil and on the plant rhizosphere have been developed to increase efficient use of P. A national soil testing and fertilizer recommendation program has been used since 2005 to control build-up and maintenance of P levels. Interac-tions between root growth and the rhizosphere have been manipulated in intercropping systems and plant genetic traits have been exploited. Phosphorus surplus is highly associated with animal concentrated feed. Conclusions The P-saving potential by the integrated P management strategies of P flow reaches 1.46 Mt P in 2050 compared to 2005.

Marine methane vents and cold seeps are common features along continental margins worldwide, serving as localized sites for methane release and colonization by microbial and chemosynthetic megafaunal communities. The Eel River Basin (ERB), located on the continental slope off Northern California, contains active methane vents and seep-associated chemosynthetic biological communities (CBC) on the crests of anticlines in f 520-m water depth. Seep-related features on the seafloor have a patchy distribution and include active bubbling vents, chemosynthetic clam beds, and sulfide-oxidizing bacterial mats. Methane sources supplying local seeps are heterogeneous on all spatial scales and support a large and diverse microbial assemblage involved in the anaerobic oxidation of methane (AOM).

The objective was to assess the incidence and consequences of medication errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous quality improvement approach, a 2-year prospective cohort study was undertaken using an adverse incident reporting scheme. A multidisciplinary committee analysed medication error reports, classifying them according to type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reported medication errors in the study period, during which 682 patients were admitted for 5315 inpatient days. Errors were more seven times likely to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the rotation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, but only 4 had overt clinical consequences. Excluding prevented errors and appropriate deviations from prescribed therapy, there were 117 actual medication errors (1/5.8 admissions, or 1/45 inpatient days). During the 2nd year of the scheme, the incidence of all reported errors, administration errors and serious errors fell, but the prescription error rate remained constant. Conclusions Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients’ treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

Mechanical/Industrial Engineering students at Higher Technical School of Industrial Engineering (ETSII) of Technical University of Madrid (UPM) receive an in-depth knowledge of mechanical design and manufacturing processes, but the increasing interaction with other engineering branches, induces the need to integrate concepts which allow students to make an integral design of new products, and thereby facilitate their subsequent integration into multidisciplinary engineering teams in industry. Complex engineering projects are usually carried out by the assimilation of different work teams, which could even be located geographically distant. Collaborative Web environments are proven to be ideal knowledge repositories, as it has seen in Academia and in Industry. The work here presented reproduces the organization of actual engineering projects, and brings it into the classroom. This new way of developing Project Work documentation and discussion has helped students become self-directed learners who internalize specific topics from different subjects, programmes and courses with their own interests, and has been considered as an easy alternative to promote active learning, not only in this area but in other courses. Project were launched in the engineering disciplines, each offering possibilities for the application of specific skills in the following courses: TEC -Manufacturing Technology-, CAD -Computer Aided Design-, SIM -Simulation in Mechanical Engineering-, and FAB -Fabrication / Manufacturing. TEC and SIM are applied in the Mechanical Engineering programme at ETSII, while FAB is part of the Industrial Engineering programme; finally CAD is voluntarily employed by students in different semesters and programmes. The new approach is oriented towards inducing collaboration within multidisciplinary teams. This paper describes the experience of collaboration among students and teachers in order to develop multidisciplinary projects, and to reproduce as closely as possib- - le, the team's integration into a company environment. A new methodology based on student interaction and content development in a Wiki environment has been developed. The collaborative server has allowed creating an “out-of-the-classroom” active discussion forum for students of different teams /topics, and to compile an important “project work” portfolio. This experience has been very satisfactory for students and teachers, who have participated with enthusiasm due to the exit of the well-distributed work and the easiness of use of the selected platform (Wiki). The quality of the developed projects has been dramatically improved due to the integration of the results provided by the different teams.

Background. Aims and Scope Lakes developing in volcano craters can become highly acidic through the influx of volcanic gases, yielding one of the chemically most extreme natural environments on earth. The Kawah Ijen crater lake in East Java (Indonesia) has a pH 〈 0.3. It is the source of the extremely acid and metal-polluted river Banyupahit (45 km). The lake has a significant impact on the river ecosystem as well as on a densely populated area downstream, where agricultural fields are irrigated with water with a pH between 2.5 and 3.5. The chemistry of the river water seemed to have changed over the past decade and the negative effect in the irrigation area increased. A multidisciplinary approach was used to investigate the altered situation and to get insight in the water chemistry and the hydrological processes influencing these alterations. Moreover, a first investigation of the effects of the low pH on ecosystem health and human health was performed. Methods Water samples were taken at different sites along the river and in the irrigation area. Sampling for macroinvertebrates was performed at the same sites. Samples of soil and crop were taken in the irrigation area. All samples were analysed for metals (using ICP-AES) and other elements, and concentrations were compared to local and international standards. Results and Discussion The river carries a very high load of SO4, NH4, PO4, Cl, F, Fe, Cu, Pb, Zn, Al and other potentially toxic elements. Precipitation and discharge data over the period of 1980 – 2000 clearly show that the precipitation on the Ijen plateau influences water chemistry of the downstream river. Metal concentrations in the river water exceed the concentrations mentioned in Indonesian and international quality guidelines, even in the downstream river and the irrigation area. Some metal concentrations are extremely high, especially iron (up to 1600 mg/l) and aluminium (up to 3000 mg/l). The food-webs in the acidic parts of the river are highly underdeveloped. No invertebrates were present in the extremely acid water and, at pH 2.3, only chironomids were found. This also holds true for the river water with pH 3.3 in the downstream area. Agricultural soils in the irrigation area have a pH of 3.9 compared to a pH of 7.0 for soils irrigated with neutral water. Decreased yields of cultivated crops are probably caused by the use of Al containing acid irrigation water. Increased levels of metals (especially Cd, Co, Ni and Mn) are found in different foodstuffs, but still remain within acceptable ranges. Considering local residents” diets, Cd levels may lead to an increased risk for the human health. Fluoride exposure is of highest concern, with levels in drinking water exceeding guideline values and a lot of local residents suffering from dental fluorosis. Conclusions, Recommendations and Outlook In short, our data indicate that the Ijen crater lake presents a serious threat to the environment as well as human health and agricultural production.

The influence of the mode of anaesthesia on outcome of geriatric patients with hip fractures is a controversial issue in the medical literature. In the light of an ageing society, a conclusive answer to this question is of growing importance. The purpose of this review was to assess the effect of neuroaxial and general anaesthesia on mortality and morbidity in geriatric patients sustaining a hip fracture. Following a current literature search within the Pubmed and Cochrane database (1967–2010), 34 randomised controlled trials, 14 observational studies and eight reviews/meta-analysis publications were included. Potentially outcome-influencing factors such as mortality, deep vein thrombosis, pulmonary embolism, postoperative confusion and other anaesthesia-related outcomes were evaluated. After analysing the current literature with 56 references, covering 18,715 patients with hip fracture, it can be concluded that spinal anaesthesia is associated with significantly reduced early mortality, fewer incidents of deep vein thrombosis, less acute postoperative confusion, a tendency to fewer myocardial infarctions, fewer cases of pneumonia, fatal pulmonary embolism and postoperative hypoxia. General anaesthesia has the advantages of having a lower incidence of hypotension and a tendency towards fewer cerebrovascular accidents compared to neuroaxial anaesthesia. Otherwise, general anaesthesia and respiratory diseases were significant predictors of morbidity in hip fracture patients. These data suggest that regional anaesthesia is the preferred technique, but the limited evidence available does not permit a definitive conclusion to be drawn for mortality or other outcomes. For hip fracture surgery, the choice of anaesthesia (general or neuroaxial) is made by the anaesthesiologist and is based on the patient’s preference, comorbidities, potential general postoperative complications and the clinical experience of the anaesthesiologist. The overall therapeutic approach in hip fracture care should be determined jointly by the orthopaedic surgeon, the geriatrician and the anaesthesiologist (multidisciplinary approach).

This workshop reports on the results of a three-year European research project (URGE-Project) funded under the EU Fifth Framework, which examines means of improving the quality of life in urban regions through urban greening initiatives. Urban greening is examined by taking a multidisciplinary approach, looking at the planning, economic, ecological and social aspects to describe the theoretical basis that underpins the work and to develop a set of criteria which serve as a foundation for developing evaluative tools applicable throughout Europe. Work was undertaken by a consortium of 12 partners and data gathered from 15 case study cities. Outputs include a practitioner manual, which reports on the findings, and practical tools, which allow critical evaluation of urban green at both city and site scales.