"And DPSIR begat DAPSI(W)R(M)!" - A unifying framework for marine environmental management.

The marine environment is a complex system formed by interactions between ecological structure and functioning, physico-chemical processes and socio-economic systems. An increase in competing marine uses and users requires a holistic approach to marine management which considers the environmental, economic and societal impacts of all activities. If managed sustainably, the marine environment will deliver a range of ecosystem services which lead to benefits for society. In order to understand the complexity of the system, the DPSIR (Driver-Pressure-State-Impact-Response) approach has long been a valuable problem-structuring framework used to assess the causes, consequences and responses to change in a holistic way. Despite DPSIR being used for a long time, there is still confusion over the definition of its terms and so to be appropriate for current marine management, we contend that this confusion needs to be addressed. Our viewpoint advocates that DPSIR should be extended to DAPSI(W)R(M) (pronounced dap-see-worm) in which Drivers of basic human needs require Activities which lead to Pressures. The Pressures are the mechanisms of State change on the natural system which then leads to Impacts (on human Welfare). Those then require Responses (as Measures). Furthermore, because of the complexity of any managed sea area in terms of multiple Activities, there is the need for a linked-DAPSI(W)R(M) framework, and then the connectivity between marine ecosystems and ecosystems in the catchment and further at sea, requires an interlinked, nested-DAPSI(W)R(M) framework to reflect the continuum between adjacent ecosystems. Finally, the unifying framework for integrated marine management is completed by encompassing ecosystem structure and functioning, ecosystem services and societal benefits. Hence, DAPSI(W)R(M) links the socio-ecological system of the effects of changes to the natural system on the human uses and benefits of the marine system. However, to deliver these sustainably in the light of human activities requires a Risk Assessment and Risk Management framework; the ISO-compliant Bow-Tie method is used here as an example. Finally, to secure ecosystem health and economic benefits such as Blue Growth, successful, adaptive and sustainable marine management Responses (as Measures) are delivered using the 10-tenets, a set of facets covering all management disciplines and approaches.

What are the costs and benefits of biodiversity recovery in a highly polluted estuary?

Biodiversity recovery measures have often been ignored when dealing with the restoration of degraded aquatic systems. Furthermore, biological valuation methods have been applied only spatially in previous studies, and not jointly on a temporal and spatial scale. The intense monitoring efforts carried out in a highly polluted estuary, in northern Spain (Nervión estuary), allowed for the economic valuation of the costs and the biological valuation of the benefits associated with a 21 years sewage scheme application. The analysis show that the total amount of money invested into the sewage scheme has contributed to the estuary's improvement of both environmental and biological features, as well as to an increase in the uses and services provided by the estuary. However, the inner and outer parts of the estuary showed different responses. An understanding of the costs and trajectories of the environmental recovery of degraded aquatic systems is increasingly necessary to allow policy makers and regulators to formulate robust, cost-efficient and feasible management decisions.

Identification, definition and quantification of goods and services provided by marine biodiversity: implications for the ecosystem approach.

This paper identifies and defines ecosystem goods and services provided by marine biodiversity. Case studies have been used to provide an insight into the practical issues associated with the assessment of marine ecosystem goods and services at specific locations. The aim of this research was to validate the definitions of goods and services, and to identify knowledge gaps and likely difficulties of quantifying the goods and services. A validated theoretical framework for the assessment of goods and services is detailed, and examples of the goods and services at a variety of case study areas are documented. These results will enable future assessments of marine ecosystem goods and services. It is concluded that the utilisation of this goods and services approach has the capacity to play a fundamental role in the Ecosystem Approach, by enabling the pressures and demands of society, the economy and the environment to be integrated into environmental management.

Vagal paraganglioma: the Jefferson experience.

Vagal paraganglioma is a rare tumor of neural crest origin. Although the literature is in agreement with regard to epidemiology, diagnosis, and tumor biology, there is some controversy over treatment modalities for these patients. We performed a nonrandomized retrospective study in a large single-institution series of patients (n = 19) in whom vagal paraganglioma was diagnosed. General statistics included age, male/female ratio, tumor size, and duration of follow-up. Other variables such as signs and symptoms at presentation, family history, multicentricity, metastatic disease, and secretion of catecholamines were included. CT scan, MRI, and angiography were used in combination for diagnostic purposes as well as for treatment planning. Preoperative embolization was performed in 5 of the more recently treated patients. Current issues regarding the use of preoperative embolization and choice of surgical approach were analyzed. In this article the possibility and sequela of vagus nerve-sparing procedures will be presented. Operative complications and postoperative morbidity related to cranial neuropathies will be discussed. The rationale for performing adjunct procedures, including cricopharyngeal myotomy and vocal fold medialization, to facilitate the rehabilitation of patients with postoperative cranial nerve deficits will be given. Our findings and recommendations will be compared with currently accepted treatment protocols in conjunction with a review of the literature.

Endoscopic repair of cerebrospinal fluid rhinorrhea.

Endoscopic repair of cerebrospinal fluid rhinorrhea is a promising alternative to traditional repair techniques. This article reports our experience with 21 cases (10 spontaneous, 8 iatrogenic, and 3 traumatic). Various diagnostic radiographic modalities were used, including computer-aided techniques. Most repairs were accomplished with a free fascial graft positioned in the epidural space. Postoperative lumbar drainage was used in 15 cases. Initial repair was successful in 18 cases (85.7%). In all 3 failures, the surgeon had difficulty with proper graft placement. Additionally, 2 of these cases were confounded by early inadvertent removal of the lumbar drain. All patients in whom the procedure failed underwent a second successful endoscopic repair. There were no major complications. In our experience endoscopic repair of cerebrospinal fluid rhinorrhea is a safe and effective approach that can be improved with computer-aided localization devices. Proper graft placement is critical, and lumbar drainage is an important adjunct in selected cases.

Revision endoscopic sinus surgery: the Thomas Jefferson University experience.

Since its introduction, functional endoscopic sinus surgery (FESS) has demonstrated success rates of 76% to 98%. A small group of the patients in whom initial FESS and optimal medical therapy fail require revision endoscopic sinus surgery (RESS). This group has recently been studied by several authors, and we have evaluated a group of 90 RESS patients selected from 753 consecutive primary FESS patients. Patients were followed for a mean of 22.8 months. Extent of disease, history of polyps, allergy, previous traditional endonasal sinus surgery, male gender, chronic steroid use, and the presence of a deviated septum all appeared to adversely affect RESS outcome. The surgeon's knowledge of the sinus anatomy is critical, especially in revision sinus cases in which landmarks are distorted or absent. In our review, RESS was associated with a 1% major complication rate and was successful in 67% of patients. Computer-assisted endoscopic sinus surgery integrates preoperative imaging with realtime endoscopic visualization, augments the surgeon's knowledge of anatomy, and helps to minimize patient risk.

Expression of the RET/PTC fusion gene as a marker for papillary carcinoma in Hashimoto's thyroiditis.

Hashimoto's thyroiditis is an inflammatory disease of the thyroid gland with autoimmune etiology. Patients afflicted with Hashimoto's have a higher risk of thyroid malignancies such as papillary thyroid carcinoma. In the present study, we investigated the frequency of papillary thyroid carcinoma specific genes in patients diagnosed with Hashimoto's disease. The newly identified oncogenes RET/PTC1 and RET/PTC3 provide useful and specific markers of the early stages of papillary carcinoma as they are highly specific for malignant cells. Using a sensitive and specific reverse transcriptase-polymerase chain reaction (RT-PCR) assay, we found messenger RNA (mRNA) expression for the RET/PTC1 and RET/PTC3 oncogenes in 95% of the Hashimoto's patients studied. All Hashimoto's patients presenting without histopathologic evidence of papillary thyroid cancer showed molecular genetic evidence of cancer. These data suggest that multiple, independent occult tumors exist in these patients at high frequency.

Laryngeal chondrosarcoma: diagnosis and management.

Chondrosarcoma of the larynx is a rare malignancy accounting for 0.5% of all laryngeal tumors. We report our approach to laryngeal chondrosarcoma and review the recent literature on the subject. Our review supports the previously held opinions about sites of origin, but draws new conclusions about symptoms. In addition, we examine the controversy of conservative surgery vs. total laryngectomy.

Tracheo-gastric fistula following gastric pull-up.

Tissue damage from gastric acid may be more prevalent than currently believed following gastric pull-up. An intense anti-acid medical regimen should be instituted peri- and postoperatively. In cases where significant peptic ulcer disease exists preoperatively, an alternative means of reconstruction following laryngo-pharyngo-esophagectomy should be considered.

Evaluation and treatment of frontal sinus fractures.

We treated twenty-three patients with blunt or penetrating wounds of the frontal sinus from 1978 through 1983. Nondisplaced anterior wall fractures were observed or explored. Posterior table fractures--with displacement confirmed by computed tomography or polycycloidal tomography--were explored. Either obliteration of the sinus or nasofrontal duct reconstruction with a Sewall-Boyden-McKnaught flap was selected, depending on the magnitude of duct injury. In all cases, the anterior wall was primarily reconstructed. All penetrating wounds with posterior table involvement were treated by cranialization of the frontal sinus and temporalis muscle obliteration of the nasofrontal ducts. Only one case of meningitis occurred, resulting in prolonged hospitalization.

CO2 laser surgery of the upper airway.

The use of CO2 laser surgery in otolaryngology has served as an effective tool to treat various lesions in the upper airway. This article discusses application of the CO2 laser to the upper airway, with specific reference to the larynx, nasal cavity, nasopharynx, and oropharynx.

Value of panendoscopy in determination of second primary cancer. A study of 451 cases of head and neck cancer.

A series of 451 consecutive patient records were reviewed. Of these, 43 had diagnoses of epidermoid carcinoma of the head and neck. Triple endoscopy, by flexible fiberoptic methods, was performed on all these patients and was critical in the determination of second primary carcinoma in eight patients. As panendoscopy shows no mortality and a low morbidity rate, it should be used in diagnosis of second primary tumors, despite a probable low percentage of second primary discovery; long-term patient survival demands use of all available resources in such diagnoses.

Acinic cell carcinoma of the oral cavity.

A rare case of acinic cell carcinoma of minor salivary gland origin within the oral cavity is reported in a 62-year-old woman. These tumors most commonly arise in the parotid gland and follow an insidious course requiring long-term follow-up. The gross and histologic features of the patient's tumor include pseudoencapsulation, mixed solid and acinar architecture, microcyst formation, and the presence of conspicuous diastase-fast and PAS-positive cytoplasmic granules, characteristic of lesions that have been called acinic cell carcinoma by a variety of authors. Surgical excision is the treatment of choice. However, following an incisional biopsy, the patient refused further surgical treatment and has remained clinically disease-free three years postoperatively.

Complications of intubation.

Endotracheal intubation with current inert low-pressure, high-volume cuffed tubes is a safe procedure associated with few complications in the vast majority of patients. However, complications related to mechanical difficulties and mucosal injury can occur even under ideal circumstances. Immediate complications are primarily associated with problems during intubation and extubation while early and late complications represent the short- and long-term effects of epithelial trauma.