Sustainable supply chain management in tourism

Sustainable supply chain management (SSCM) encapsulates the trend to use purchasing policies and practices to facilitate sustainable development at the tourist destination. Most research has focused on environmental aspects of manufacturing, while other aspects of sustainability or the challenges for the service sector are largely ignored. Yet SSCM is particularly important for tour operators, as the product depends on the activities of suppliers, such as accommodation, transport and activities. Therefore, tour operators' contribution to sustainable tourism will be more effective through the definition and implementation of policies that acknowledge responsibility for the impacts of suppliers. Exploratory research of SSCM practices amongst tour operators generated a wide range of examples of good practice across the whole supply chain, and recommendations are made for more widespread engagement. Copyright © 2006 John Wiley & Sons, Ltd and ERP Environment

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey

Objective: National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs). Methods: We carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively. Results: Small joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF. Conclusion: For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF

Nootropic Activity of Methanolic Extract of Evolvulus alsinoides Linn. Whole Plant in Mice with Sodium Nitrite Induced Amnesia: An Experimental Study

Introduction: Many ancient medical systems, including Ayurveda and Unani, have utilised plants as therapeutic agents for ages. Both structured and unstructured types of medicinal plants have been used extensively to treat a variety of illnesses, including cognitive impairment. One plant identified as having the ability to cure neurological conditions and enhance cognitive function is Evolvulus alsinoides Linn, also referred to as Vishnukranthi. Aim: To evaluate the effect of Evolvulus alsinoides methanolic extract in treating sodium nitrite-induced amnesia in male Swiss albino mice through behavioural, biochemical and histological parameters. Materials and Methods: This experimental study was conducted at ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Velappanchavadi, Chennai, Tamil Nadu, India. Healthy male Swiss albino mice weighing between 25 and 30 g were used as subjects. The experiment was designed to evaluate the potential cognitive-enhancing effects of Evolvulus alsinoides through two behavioral tests: the Elevated Plus Maze (EPM) test and the passive avoidance test. The EPM test is commonly employed to assess anxiety and memory by measuring the time animals spend in the open arms versus the closed arms of the maze. It also evaluates the total transitions made by the animals between the arms, providing insights into their exploratory and memory behaviour. Results: A notable difference was observed between the sodium nitrite-treated group (GSN) and the sodium nitrite-treated with piracetam group (GSNP), where the piracetam-treated mice (GSNP) exhibited a significant reduction (p-value=0.0001) in the number of transitions. The Evolvulus alsinoides-treated groups (GSNLD and GSNHD) showed a significant reduction in the number of transitions when compared to the GSN group. In the passive avoidance test, the comparison between GSN and groups GSNLD and GSNHD (treated with Evolvulus alsinoides) showed a statistically significant improvement in step-down latency in the treated groups. Biochemical parameters of brains indicated reduced GSH and AChE levels, which were considered supportive evidence for the behavioural parameters. Conclusion: These findings suggest that Evolvulus alsinoides may be a promising agent for the development of new treatments for memory impairment and cognitive disorders

Optical spectroscopy-based imaging techniques for the diagnosis of breast cancer: A novel approach

There have been substantial advancements in optical spectroscopy-based imaging techniques in recent years. These developments can potentially herald a transformational change in the diagnostic pathway for diseases such as cancer. In this paper, we review the clinical and engineering aspects of novel optical spectroscopy-based imaging tools. We provide a comprehensive analysis of optical and non-optical spectroscopy-based breast cancer diagnosis techniques vis-à-vis the current standard techniques such as X-Ray mammography, ultrasonography, and tissue biopsy. The recent advancements in optical spectroscopy-based imaging systems such as Transillumination Imaging (TI) and the various types of Diffuse Optical Imaging (DOI) systems (parallel-plate, bed-based, and handheld) are examined. The engineering aspects, including mechanical, electronics, optics, automatic interpretation using artificial intelligence (AI), and ergonomics are discussed. The abilities of these technologies for measuring several cancer biomarkers such as hemoglobin, water, lipid, collagen, oxygen saturation (SO2), and tissue oxygenation index (TOI) are investigated. This article critically assesses the diagnostic ability and practical deployment of these new technologies to differentiate between the normal and cancerous tissue

British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding:comorbidity medications used in rheumatology practice

BackgroundThe rationale behind this update on the 2016 BSR guidelines on prescribing anti-rheumatic drugs in pregnancy and breastfeeding [1, 2] was described in detail in the guideline scope [3]. In brief, despite the existence of additional evidence-based guidelines on prescribing/managing rheumatic disease in pregnancy [4-7] the information contained within them requires continual review to include emerging information on the safety of new and existing drugs in pregnancy.Chronic disease adversely affects pregnancy. Data from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), reports regularly from a national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths [8]. Data from 2017-19, found that 8.8 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy, and most women who died had multiple health problems or other vulnerabilities[8]. In all decisions regarding medication choices and changes, it is also important to consider the potential for deterioration in the mother's wellbeing through side effects or reduced disease control (and its adverse impact on the baby). Therefore, the exposure of the fetus to different drugs when switches are made must be balanced against possible fetal gains, and understanding the potential impact of reduced control of the medical disorder on a pregnancy is vital [9].Need for guidelinePatients with inflammatory rheumatic disease (IRD) should be counselled to achieve and then maintain remission or low disease activity before/during pregnancy to reduce the risk of adverse pregnancy outcomes [10]. This goal is primarily achieved through adjustment of therapy to ensure disease control with disease modifying anti-rheumatic drugs (DMARDs) and/or immunosuppressive drugs that are compatible with pregnancy. These medications are reviewed in the BSR &amp; BHPR guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids [11]. Many patients with IRD however, have an additional burden of pain and comorbid illness [12] that require treatment with other medications. The compatibility of various comorbidity medications relevant to rheumatic disease will be covered in this update. This updated information will provide advice for healthcare professionals and patients to ensure more confident prescribing in these scenarios and will highlight any medications that should be stopped and/or avoided in the reproductive age group unless highly effective contraception is used, in line with guidance issued by the Medicines and Healthcare Products Regulatory Agency (MHRA) and Faculty of Sexual and Reproductive Healthcare [13, 14]. Objectives of guidelineTo update the previous BSR guidelines on prescribing in pregnancy in rheumatic disease for the following drug categories: pain management; Non-steroidal anti-inflammatory drugs (NSAIDs) and low dose aspirin; anticoagulants; colchicine; dapsone; bisphosphonates; anti-hypertensives; and pulmonary vasodilators. This revised guideline was produced by consensus review of current evidence to answer specific questions in relation to each drug as follows. Should it be stopped pre-conception? Is it compatible with pregnancy? Is it compatible with breastmilk exposure? Where possible recommendations are made regarding compatibility with paternal exposure.Target audienceThe primary audience consists of health professionals in the UK directly involved in managing patients with rheumatic disease who are (or are planning to become) pregnant and/or breastfeeding, men planning to conceive, and patients who have unintentionally conceived whilst taking these medications. This audience includes rheumatologists, rheumatology nurses/allied health professionals, rheumatology speciality trainees and pharmacists, as well as the patients themselves. The guideline will also be useful to obstetricians, obstetric physicians, renal physicians, dermatologists and general practitioners who may prescribe these medications to patients in pregnancy. This guideline uses the terms “woman”, “maternal” or “mother” throughout. These should be taken to include people who do not identify as women but are pregnant or have given birth [15]. Where the term “breastfeeding” is used in this guideline it also refers to infant breastmilk exposure via other methods (e.g. expressed breastmilk, administered via a bottle).The areas the guideline does not coverThis guideline does not cover the management of infertility or acute pain relief during labour, hence morphine was excluded. Other drug categories: antimalarials; corticosteroids; disease modifying anti-rheumatic and immunosuppressive therapies; and biologic drugs are considered in another guideline (REF for part I). All recommendations in this guideline were formulated by the working group on the basis of published evidence at the time of the systematic literature search, and do not necessarily refer to licensing information or Summary of Product Characteristics for individual medications.Stakeholder InvolvementThis guideline was commissioned by the BSR Standards, Guidelines and Audit Working Group. A Guideline Working group (GWG) was created, consisting of a chair (IG), alongside representatives from relevant stakeholders (Table 1). In accordance with BSR policy, all members of the GWG made declarations of interest, available on the BSR website.Involvement and affiliations of stakeholder groups involved in guideline developmentThe GWG consisted of rheumatologists from a range of clinical backgrounds, various allied health professionals, other specialists in women’s health, lay members and representatives from the United Kingdom Tetralogy Information Service (UKTIS). All members of the working group contributed to the process for agreeing key questions, guideline content, recommendations and strength of agreement. <br/

Group motivational intervention in overweight/obese patients in primary prevention of cardiovascular disease in the primary healthcare area

Background The global mortality caused by cardiovascular disease increases with weight. The Framingham study showed that obesity is a cardiovascular risk factor independent of other risks such as type 2 diabetes mellitus, dyslipidemia and smoking. Moreover, the main problem in the management of weight-loss is its maintenance, if it is achieved. We have designed a study to determine whether a group motivational intervention, together with current clinical practice, is more efficient than the latter alone in the treatment of overweight and obesity, for initial weight loss and essentially to achieve maintenance of the weight achieved; and, secondly, to know if this intervention is more effective for reducing cardiovascular risk factors associated with overweight and obesity. Methods This 26-month follow up multi-centre trial, will include 1200 overweight/obese patients. Random assignment of the intervention by Basic Health Areas (BHA): two geographically separate groups have been created, one of which receives group motivational intervention (group intervention), delivered by a nurse trained by an expert phsychologist, in 32 group sessions, 1 to 12 fortnightly, and 13 to 32, monthly, on top of their standard program of diet, exercise, and the other (control group), receiving the usual follow up, with regular visits every 3 months. Discussion By addressing currently unanswered questions regarding the maintenance in weight loss in obesity/overweight, upon the expected completion of participant follow-up in 2012, the IMOAP trial should document, for the first time, the benefits of a motivational intervention as a treatment tool of weight loss in a primary care setting

Development of a gastroschisis core outcome set

Objective Outcome reporting heterogeneity impedes identification of gold standard treatments for children born with gastroschisis. Use of core outcome sets (COSs) in research reduces outcome reporting heterogeneity and ensures that studies are relevant to patients. The aim of this study was to develop a gastroschisis COS. Design and setting Systematic reviews and stakeholder nomination were used to identify candidate outcomes that were subsequently prioritised by key stakeholders in a three-phase online Delphi process and face-to-face consensus meeting using a 9-point Likert scale. In phases two and three of the Delphi process, participants were shown graphical and numerical representations of their own, and all panels scores for each outcome respectively and asked to review their previous score in light of this information. Outcomes were carried forward to the consensus meeting if prioritised by two or three stakeholder panels in the third phase of the Delphi process. The COS was formed from outcomes where ≥70% of consensus meeting participants scored the outcome 7–9 and <15% of participants scored it 1–3. Results 71 participants (84%) completed all phases of the Delphi process, during which 87 outcomes were assessed. Eight outcomes, mortality, sepsis, growth, number of operations, severe gastrointestinal complication, time on parenteral nutrition, liver disease and quality of life for the child, met criteria for inclusion in the COS. Conclusions Eight outcomes have been included in the gastroschisis COS as a result of their importance to key stakeholders. Implementing use of the COS will increase the potential for identification of gold standard treatments for the management of children born with gastroschisis

Sustainability reporting practices and their social impact to NGO funding in Italy

This study analyses the growing social trends of sustainability reporting practices in non-governmental organisations (NGOs). Taking a preliminary step toward NGO funding, we consider the current lack of information disclosure in existing reporting practices, which are diverse and unsustainable. We investigate key organisational information in order to discover any potential links between funding sources and disclosure practices. In Italy, today there is an on-going effort to encourage public engagement in civil society. A percentage-tax law allows taxpayers to dedicate ‘cinque per mille’ (one-half percent)of their income to NGOs, which is then deducted from their tax obligation (Hereafter, ‘5 per thousand’). Our primary research objective is to understand if there is a link between the ‘5 per thousand’ donations that NGOs receive for providing social impact, and their reporting practices. Therefore, we critically analyse if and how sustainable reporting practices are achieved within the top 100 most funded NGOs that receive the ‘5 per thousand’ donation. We examine public data from official government records published by the Italian Revenue Agency. The findings suggest that sustainability reporting offers a number of financial and social advantages, including social impact that builds trust towards the idea of civil society and its funders. © 2019 Elsevier Lt