Regional Consensus Research Articles

Coping with changing water resources: The case of the Syr Darya river basin in Central Asia

a b s t r a c t This paper discusses how climatic-hydrological and socio-political developments will affect water allocation in the Syr Darya river basin and which adaptation measures will be needed to cope with changing water resources. In view of the geo-political complexity, climate-driven changes in water availability are of particular importance in this region. Water shortages during summer will become more frequent as precipitation is expected to further decrease and glacial meltwater releases will decrease in the long-term due to reduced glacier volume. Being the main valve to the entire Syr Darya river system, the Toktogul reservoir in Kyrgyzstan could take over, at least partly, the role of glaciers as seasonal water redistributors, thus allowing the generation of energy in winter – benefiting upstream countries – and irrigation for large-scale agriculture in summer – benefiting downstream countries. To date, however, there is no regional consensus on a balanced reservoir management, which currently favours irrigation according to past Soviet priorities. Moreover, the perception of water as a ‘national concern’ in Central Asia discourages efforts towards cooperation between states at the regional level. So far, climate change adaptation has focused on technical rather than institutional solutions. We suggest that policy-relevant adaptation measures should include consistent data collection and dissemination, cross-sectoral collaboration, promotion of national responsibility and initiative, and agreeing on a regional strategy.

Regional consensus opinion for the management of Beta thalassemia major in the Arabian Gulf area

Thalassemia syndrome has diverse clinical presentations and a global spread that has far exceeded the classical Mediterranean basin where the mutations arose. The mutations that give rise to either alpha or beta thalassemia are numerous, resulting in a wide spectrum of clinical severity ranging from carrier state to life-threatening, inherited hemolytic anemia that requires regular blood transfusion. Beta thalassemia major constitutes a remarkable challenge to health care providers. The complications arising due to the anemia, transfusional iron overload, as well as other therapy-related complications add to the complexity of this condition. To produce this consensus opinion manuscript, a PubMed search was performed to gather evidence-based original articles, review articles, as well as published work reflecting the experience of physicians and scientists in the Arabian Gulf region in an effort to standardize the management protocol.

Multiple sclerosis in the Levant: a regional consensus statement

The epidemiology of multiple sclerosis (MS) is rapidly changing in many parts of the world. In a geographic area that was previously associated with low prevalence, recent studies showing high prevalence and fast rising incidence of MS in the Levant countries led us neurologists of this region to meet in a consensus panel, in order to share our latest findings in terms of MS epidemiology and consent on MS management in the Levant. Twelve neurologists and MS experts representing various countries of the Levant (Lebanon, Syria, Jordan and Iraq) have met in Beirut on the 17th of February 2013, shared their latest epidemiological findings, discussed recent MS aspects in the region, and drafted a consensus on MS management relevant to this geographic area.

Reviewing the development, evidence base, and application of the revised dengue case classification

With the example of dengue, an evidence-based approach to prospectively develop a case classification is described, gathering evidence for identifying strength and weaknesses of the existing model, collecting new data describing the disease as it occurs globally, further developing a new model that can be applied in practice and field testing the newly developed model in comparison to the previous model. For each step in this process, the highest available level of evidence has been applied. This process has been initiated by the World Health Organization’s (WHO) Special Programme for Research and Training in Tropical Diseases (TDR) and WHO’s Department for Control of Neglected Tropical Diseases (NTD), developing the following for dengue. Since the early 1970s, dengue has been classified into dengue fever, dengue haemorrhagic fever grades I and II and dengue shock syndrome grades III and IV (DF/DHF/DSS). However, in recent years, a growing number of dengue clinicians have questioned the shortcomings of this scheme. The issues have revolved around the complexity of confirming DHF in clinical practice, misclassifying severe cases as DF, and the emphasis on haemorrhage rather than plasma leakage as the underlying problem in most severe dengue cases. Step 1: A systematic literature review highlighted the shortcomings of the DF/DHF/DSS scheme: (1) difficulties in applying the criteria for DHF/DSS; (2) the tourniquet test has a low sensitivity for distinguishing between DHF and DF; and (3) most DHF criteria had a large variability in frequency of occurrence. Step 2: An analysis of regional and national dengue guidelines and their application in the clinical practice showed a need to re-evaluate and standardize guidelines as the actual ones showed a large variation of definitions, an inconsistent application by medical staff, and a lack of diagnostic facilities necessary for the DHF diagnosis in frontline services. Step 3: A prospective cohort study in seven countries, confirmed the difficulties in applying the DF/DHF/DSS criteria even in tertiary care hospitals, that DF/DHF/DSS do not represent levels of disease severity and that a clear distinction between severe dengue (defined by plasma leakage and/or severe haemorrhage, and/or organ failure) and (non-severe) dengue can be made using highly sensitive and specific criteria. In contrast, the sub-grouping of (non-severe) dengue into two further severity levels was only possible with criteria that gave approximately 70% sensitivity and specificity. Step 4: Three regional expert consensus groups in the Americas and Asia concluded that ‘dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome’ and that, revising the results of Step 3, DF/DHF/DSS is not related to disease severity. Step 5: In a global expert consensus meeting at WHO in Geneva/Switzerland the evidence collected in Steps 1–4 was reviewed and a revised scheme was developed and accepted, distinguishing: dengue with or without warning signs and severe dengue; the further field testing and acquisition of further prospective evidence of the revised scheme was recommended. Step 6: In 18 countries, the usefulness and applicability of the revised classification compared to the DF/DHF/DSS scheme were tested showing clear results in favour of the revised classification. Step 7: Studies are under way on the predictive value of warning signs for severe dengue and on criteria for the clinical diagnosis of dengue which will complete the evidence foundation of the revised classification. The analysis has shown that the revised dengue case classification is better able to standardize clinical management, raise awareness about unnecessary interventions, match patient categories with specific treatment instructions, and make the key messages of patient management understandable for all health care staff dealing with dengue patients. Furthermore, the evidence-based approach to develop prospectively the dengue case classification could be a model approach for other disease classifications.

The UN and Afghanistan: Contentions in Democratization and Statebuilding

Following more than a decade of NATO's intervention in Afghanistan, it is often argued that the UN, alongside its international partners and the Afghan government, has failed to facilitate good governance and a stable democratic political order. In charting the evolving UN role in ‘democratizing’ Afghanistan, this article analyses why this is so. The UN Assistance Mission in Afghanistan (UNAMA), facing considerable historical and institutional constraints, has had neither the will nor the capacity to implement its ambitious democratization mandate. Instead of aiming for a system of governance along ‘Western’ lines, it should focus primarily on promoting an appropriate, institutionalized, workable political order, regional consensus, and national reconciliation as the necessary foundations for bringing peace and stability to the country.

Immunohaematological reference values for HIV-negative healthy adults in Botswana

BackgroundClinical laboratories in Botswana have relied entirely on the reference intervals for normal immunohaematological values provided by manufacturers’ kits and textbooks.ObjectivesThe aim of this study was to determine the means, medians, 2.5th and 97.5th percentile reference intervals, for normal immunohaematological values in healthy adults in Botswana.MethodA total of 261 healthy participants comprising 126 men (48%) and 135 (52%) women were enrolled in the southern part of Botswana, and immunological and haematological laboratory parameters were measured.ResultsThe mean age was 28.8 (95% Confidence Interval [CI] 27.7–29.8) years, with a median of 27 years and a range 18–66 years. The mean haemoglobin level was significantly lower for women (12.4 g/dL; 95% CI 12.1% – 12.7%) than men (15.1 g/dL; 95% CI 14.9% – 15.3%). The women’s haemoglobin reference values (9.0 g/dL – 15.0 g/dL) levels were lower than observed in predominantly White populations (12.0 g/dL – 16.0 g/dL), but comparable with regional consensus reference intervals (9.5 g/dL – 15.8 g/dL) recently defined for East and Southern Africa.ConclusionThe established values provide an important tool for patient management and could influence decisions on inclusion of participants and adverse events in clinical trials conducted locally.

Companies, Cultures, and the Region: Interactions and Outcomes

European integration is based on the idea of regional differentiation. Therefore, a diverse range of specific regional cultures have to be accepted, and space for individual paths of regional development is required. This also influences economic competitiveness and innovation because regional differentiation enables complementarities and synergies. Nevertheless, this European idea is under pressure as the reality of European integration is more and more driven by the homogenization, standardization and deregulation that go hand in hand with increasing globalization. A strong commitment to local/regional traditions and specialities is therefore required to counterbalance these trends and thus reinforce the underlying European model. This idea was the starting point for a European 6th Framework Programme project on the interaction between regional culture and company culture (CURE—Corporate Culture and Regional Embeddedness). The focus was on the culture of firms being influenced by regional culture, as a potential strength—this regional culture needs to be activated and can thus only be fully realized via interaction with regional companies. Increasingly, this interaction is of special interest in regional innovation studies. There are as yet however few systematic empirical studies into these topics; in regional science empirical results are discussed which highlight the “weight” of regional culture, Saxenian’s (1994) comparative study on Silicon Valley and Route 128 being prime examples of the impact of regional cultures on company behaviour. Another example is provided by Maillat et al. (1996), who analyse the diverging development paths of the Swiss and French Jura Alps, demonstrating that regional consensus, shared future visions, common

Social capital as knowledge facilitator: evidence from Latvia

This paper investigates knowledge acquisition through social ties. This issue has proved important in organizational studies as a mechanism of value creation. Recently, it has also been identified in regional studies as a factor behind regional development and consensus building. Policies are therefore needed to support such knowledge acquisition. The approach is based on the concepts of knowledge as a ‘club good’, and of social capital, where the latter is seen as a set of assets which can overcome obstacles to knowledge exchange. A taxonomy of social capital and knowledge is proposed and relationships among the considered dimensions are hypothesized. A multivariate analysis at the individual level is applied to data collected in the Republic of Latvia, including a sensitivity analysis with regard to socio-demographic dimensions. The analysis underlines the low effect of social capital on complex forms of knowledge. Results also show a strong sensitivity for socio-demographic dimensions.

Identifying key performance indicators for nursing and midwifery care using a consensus approach

The aim of this study was to gain consensus on key performance indicators that are appropriate and relevant for nursing and midwifery practice in the current policy context. There is continuing demand to demonstrate effectiveness and efficiency in health and social care and to communicate this at boardroom level. Whilst there is substantial literature on the use of clinical indicators and nursing metrics, there is less evidence relating to indicators that reflect the patient experience. A consensus approach was used to identify relevant key performance indicators. A nominal group technique was used comprising two stages: a workshop involving all grades of nursing and midwifery staff in two HSC trusts in Northern Ireland (n = 50); followed by a regional Consensus Conference (n = 80). During the workshop, potential key performance indicators were identified. This was used as the basis for the Consensus Conference, which involved two rounds of consensus. Analysis was based on aggregated scores that were then ranked. Stage one identified 38 potential indicators and stage two prioritised the eight top-ranked indicators as a core set for nursing and midwifery. The relevance and appropriateness of these indicators were confirmed with nurses and midwives working in a range of settings and from the perspective of service users. The eight indicators identified do not conform to the majority of other nursing metrics generally reported in the literature. Furthermore, they are strategically aligned to work on the patient experience and are reflective of the fundamentals of nursing and midwifery practice, with the focus on person-centred care. Nurses and midwives have a significant contribution to make in determining the extent to which these indicators are achieved in practice. Furthermore, measurement of such indicators provides an opportunity to evidence of the unique impact of nursing/midwifery care on the patient experience.

Antepartum stillbirth in twins: a regional multi-centre audit of antenatal care

BackgroundTwins have a much higher stillbirth rate than singletons with causes of intrauterine death frequently unexplained. In the North of England the stillbirth rate in twins is higher than the...

Asian Regulatory Responses to the Global Financial Crisis

The global financial and economic crisis marks an important turning point for finance and the Asian growth model. Regional consensus is now supporting economic rebalancing away from the dominant focus on exports to developed markets toward more and more balanced economic structure supported by domestic and regional financial development. In relation to finance, the crisis highlights the neces-sity of addressing a range of issues across the region. First, Asian approaches to financial liberalization, prudential regulation, and financial innovation are likely to be closely considered around the world. At the same time, while the region has not been at the center of the global crisis—in contrast to the Asian financial crisis of 1997–98—it nonetheless provides an important opportunity to strengthen domestic and regional financial regulations. Second, beyond the postcrisis issues, and the prevention of systemic risk in particular, finance must continue to play a central role in supporting economic development and poverty reduction across the region. While the global crisis has highlighted once again the risks of finance, a central objective, across Asia, must be financial sector development to support economic growth and development. Third, in addition to domestic reform, the crisis provides an opportunity to enhance the international financial architecture, not only to improve its efficacy, but also to enhance the role of empowered Asian economies in global fora and institutions. At the same time, weaknesses in the international financial architecture suggest the need for Asian regional alternatives to address liquidity, liberalization, regulation, and exchange rate volatility.

Latin America: Democracy with Development

Former Peruvian President Alejandro Toledo analyzes two concurrent crises: 1) collapses in the U.S. housing and financial sectors that led to the global economic downturn; and 2) the rise of social discontent and institutional fragility in some Latin American countries. Toledo argues that these two failures are inversely related. In the first case, a lack of government regulation led to an economic crisis; in the second, a deficient distribution of economic prosperity has enabled the rise of several authoritarian governments. Toledo presents policy recommendations for preventing future economic and political crises, referring to the Social Agenda for Democracy in Latin America , a regional consensus authored by 20 former heads of state.

The Metropolitan Mayors Caucus: Institution Building in a Political Fragmented Metropolitan Region

The Mayors Caucus began as a forum to foster cooperation among the municipalities in the Chicago metropolitan region. After its establishment, the Mayors Caucus became a regional stakeholder, representing the mayors in coalitions with the region’s civic organizations, developing a legislative action team to pass legislation in the Illinois General Assembly, and serving as a forum for regional consensus building. This research is a case study of the development of the Mayors Caucus as a new institution established to overcome the region’s extreme government fragmentation and decades of city—suburban hostility.

Measuring the Effects of Consensus-building Processes with Methods of Intervention Research

In recent years, both environmental policy and research have emphasized the importance of involving the public in decision-making. This push for more participation is driven by considerable optimism about its ability to improve the quality of decisions and developments. There is, however, a lack of empirical research to support this assumption. The few studies that have attempted to measure the effect of public participation are of limited validity, as they were based on ex-post data mainly gained from expert assessments or document analysis. This paper reports on a recent study to measure and compare the effect of two consensus-building processes in a systematic and reliable way. This involved developing a new evaluation method based on the methodology of intervention research in environmental psychology. It was tested and applied in this study with two similarly designed consensus-building processes conducted in two neighbouring valleys of the Eastern Swiss Alps. These evaluation experiments showed that (a) the new evaluation method can measure and compare the effects of consensus-building processes in a differentiated and reliable way; and (b) consensus-building processes have systematic and partly statistically significant effects (at least in the short term) on several aspects of regional consensus. The initial results suggest that this new evaluation method is a promising way of obtaining reliable evidence about the societal effects of participatory processes.

Consenso del GEITDAH sobre el trastorno por déficit de atención/hiperactividad

In this article, the GEITDAH -the Spanish abbreviation of the Special Interest Group on Attention Deficit Hyper-activity Disorder (ADHD)- presents a consensus reached by experts in the management of ADHD from all over Spain. The consensus concerns fundamental aspects that should be the starting point for future local or regional consensus guides. Another aim of this consensus is also to reduce the amount of variability that occurs in the health care offered to patients with ADHD in our country, as well as to act as a stimulus in educational matters. That fact that it is not very long will make it more popular among greater numbers of people and this will allow these goals to be reached more effectively. The conclusions in the consensus guide have been constructed around an introduction dealing with basic aspects and recommendations for diagnosis, treatment (both pharmacological and psychotherapeutic), patient flow and organisational aspects.

The Regional and International Implications of Kosovo Independence

The support of the United States and some European Union countries for Kosovo's unilateral declaration of independence has in many ways contributed to a deterioration of the security situation in southeastern Europe. The fundamental strategic assumption of promoters of Kosovo's independence—that Kosovo was the last open question left over from the breakup of Yugoslavia—is likely to prove wrong. Thus, given the breakdown in the international and regional consensus on the contours of a legitimate Balkan political and security order, the instability of Kosovo and other states in the region is in reality likely to increase in the post-Kosovo independence period.

Risk-averse Regionalism

Looking for lessons for an emerging progressive regionalism, this article examines a stymied effort by a leading case of new regionalism to forge a regional consensus on affordable housing. It highlights a risk-averse streak in Portland, Oregon's regionalism, emerging when the region moved beyond implementation of state mandates in affordable housing. Such issues, with implications for social and economic equity, clearly engender controversy. Progressive action in these areas may require support from higher levels of government and a greater acceptance of conflict as a part of politics and governance, neither of which was on display in the Portland case.

A new world natural vegetation map for global change studies

We developed a new world natural vegetation map at 1 degree horizontal resolution for use in global climate models. We used the Dorman and Sellers vegetation classification with inclusion of a new biome: tropical seasonal forest, which refers to both deciduous and semi-deciduous tropical forests. SSiB biogeophysical parameters values for this new biome type are presented. Under this new vegetation classification we obtained a consensus map between two global natural vegetation maps widely used in climate studies. We found that these two maps assign different biomes in ca. 1/3 of the continental grid points. To obtain a new global natural vegetation map, non-consensus areas were filled according to regional consensus based on more than 100 regional maps available on the internet. To minimize the risk of using poor quality information, the regional maps were obtained from reliable internet sources, and the filling procedure was based on the consensus among several regional maps obtained from independent sources. The new map was designed to reproduce accurately both the large-scale distribution of the main vegetation types (as it builds on two reliable global natural vegetation maps) and the regional details (as it is based on the consensus of regional maps).

The experience of developing early childhood learning goals and outcomes in the Caribbean and the implications for curriculum development and implementation

This article describes the regional impetus to early childhood curriculum development in Caribbean Community (CARICOM) countries and discusses its prospects for effective implementation. The historical context in which pre‐school education has evolved is outlined. Regional research evidence for the enrichment of early childhood experience and for the priorities for improvement of learning environments for young children is cited. The challenge to build capacity at national level to develop and implement curriculum reform is described in the context of the policy steps taken to create an enabling environment through a regional consensus on Caribbean early learning goals and outcomes. Questions are raised about how effective curriculum reform can be in contexts in which it is not as yet supported by the attainment of other national development goals. The authors argue that the enabling environment has to be strengthened and priority needs to be given to the establishment of regulatory frameworks and mass teacher education.

North East Asia: Environmental Reform Needed

��� he concept of the region of North-East Asia (NEA) is relatively new— politically, economically, and environmentally. This region consists of six countries—the People’s Republic of China (PRC), Japan, the Russian Federation, the Republic of Korea (ROK), the Democratic People’s Republic of Korea (DPRK), and Mongolia. Today, serious national and transboundary environmental problems plague NEA with respect to issues such as long-distance transport of air pollutants, water pollution, deforestation, hazardous chemicals, and natural disasters. 1 More than ever before, regional cooperation will be necessary to address these problems. Since the 1992 Rio Earth Summit, “there has been a virtual explosion of regional activity for environmental protection of . . . NEA” 2 Such initiatives include the North-East Asian Subregional Programme of Environmental Cooperation (NEASPEC), the Tripartite Environment Ministers Meeting (TEMM), and the Tumen River Area Development Programme (TRADP). These initiatives were steps in the right direction. Prior to their creation, “environmental issues have largely remained in the diplomatic backwaters in East Asia, and have been of marginal concern compared to other national political and economic interests.” 3 Yet despite these efforts, NEA countries continue to be unable to achieve the necessary levels of cooperation that are needed to address these overwhelming problems. This situation is puzzling, given the fact that European regulatory regimes, which bear similar conditions and problems, have been successful. 4 One reason for NEA’s lack of success, noted in academic literature, has been the non-binding nature of these efforts, which have been “without clauses clearly describing official commitments for compliance and legal restrictions for non-compliance at either bilateral or multilateral cooperation.” 5 South Korea, for instance, has been reluctant to comply with environmental agreements that would result in high economic costs. 6 A lack of domestic and regional consensus on certain issues also contributes to the lack of regional cooperation. For example, there is no agreement with respect to transboundary acid deposition and the high economic costs of reducing emissions in NEA. The high economic costs of reducing emissions have also contributed to this problem. 7 An understanding of and sensitivity to NEA’s cultures and customs will no doubt contribute to