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Agency: Cordis | Branch: H2020 | Program: IA | Phase: MG-5.5a-2015 | Award Amount: 19.31M | Year: 2016

The cities of Madrid, Stockholm, Munich, Turku and Ruse have formed the CIVITAS ECCENTRIC consortium to tackle the challenges of mobility in suburban districts and clean, silent and CO2 free city logistics. In many cities, these two important areas have received less attention in urban mobility policies. Though European cities have made significant steps forward in making city centres attractive and liveable urban nodes, there is a remaining conflict between providing high quality public space and meeting the accessibility requirements for freight deliveries. The suburban areas have remained largely unaddressed with a much higher car usage as a consequence. Recent or expected urban growth processes are posing additional pressure to peri-central areas, which face the specific challenges of: Becoming sufficiently appealing to avoid an unnecessary traffic flow towards to the city centre; Providing sustainable and high quality mobility options to enable and encourage car independent lifestyles; and Planning the urban future according to carbon neutral mobility principles. ECCENTRIC will demonstrate and test the potential and replicability of integrated and inclusive urban planning approaches, innovative policies and emerging technologies to reach sustainable urban mobility objectives. The solutions will be implemented in 5 living laboratory areas in the outskirts that face high population growth and an increasing pressure on the existing transport networks. As highlighted in the SUMPs of the ECCENTRIC cities, this action on a wider geographical scale than the city centre is needed in order to meet the targets of the Transport White Paper in terms of air quality, energy use and CO2 emissions, road casualties and wide uptake of clean vehicles. To reach CO2 free city logistics by 2030, ECCENTRIC will test clean vehicles and fuels, formulate new regulations and services and develop consolidation solutions in close partnerships with the private sector.

News Article | November 22, 2016

With her hand stretched upward, the elderly storekeeper in batik dress and white headscarf indicates the height of the waters that poured into her home in Jakarta’s great flood of 2007. Sukaesih is a diminutive figure, but she points to a ridge on the doorframe about two metres above the threshold. The 60-year-old grandmother, who like many Indonesians goes by only one name, lives in the down-at-heel waterfront neighbourhood of Muara Baru. Her front room-turned-store, where she sells soft drinks and the clove kretek cigarettes beloved of locals, looks unassuming, but is at ground zero for the city’s battle for survival. Just across the alleyway is the stone seawall that was reinforced and heightened after 2007, but is already cracking, buckling and leaking. The fortification is all that stands between these homes and the waters of Jakarta Bay, which lap just beneath the rim on the other side. Filthy water already seeps through the cracks continuously, leaving streams of muddy run-off flowing in front of Sukaesih’s shop. When tides are high, the water pours over. “We live with this reality every day,” Sukaesih says, looking out at the embankment. “Water comes in through the wall all the time, and it comes over the top whenever there’s a high tide.” The biggest problem, however, is that the seawall itself – the only thing protecting Sukaesih’s community from inundation – is sinking. Forget Venice, which is slowly dropping into its watery foundations at an estimated rate of 2mm per year. That’s a drop in the ocean compared to Indonesia’s capital, particularly its northern belt, where four million people live in neighbourhoods that are now up to four metres below sea level. Areas of north Jakarta, including the seawall designed to protect them, are sinking at an estimated 25cm a year. “I have been here since 1981 but I don’t know how long we can stay. The water gets higher every year,” Sukaesih says – referring to the danger that is, in fact, posed by the ground sinking beneath her feet. Jakarta is sinking because of subsidence. The city does not pipe in enough drinkable water, so Jakartans rely largely on wells which extract water from shallow aquifers. The result: the land above it collapses. The problem is exacerbated by the explosion of new apartment blocks, shopping malls and even government offices, which – despite official restrictions on groundwater extraction – not only draw water from this porous ground but also add to the weight compacting it. The concretisation of Jakarta has also led to increased run-off, making flooding worse while not replenishing the ground water supplies. As the sinking continues at a rate unparalleled in any other urban area in the world, the danger of a catastrophic flood grows, caused not by devastating seawater surges or storms – but by monsoon rain-swollen rivers bursting their banks because gravity no longer helps them flow out into the bay. There is a desperate need to supply potable water to the city from reservoirs to the east and west. But while plans for pipelines remain in the pipeline, some experts claim Jakarta is careening towards the point of no return. Set in a basin of low-lying plains criss-crossed by 13 rivers, Jakarta – home to 10 million, with a total of 30 million living in the sprawl of Greater Jakarta – owes its existence to its waterfront location and geography. The natural harbour was for several centuries an important port for its Hindu and then Muslim rulers, before Dutch settlers seized control and established the trading post of Batavia as capital of their East Indies territories. The perils of flooding are as old as the city. The Dutch, the masters of such challenges at home, built a network of canals in an attempt to control the flow of waters, but never mastered them. Now, as the city sinks so dramatically, Dutch engineers and businessmen are again offering their proposals to defeat encroaching waters and reclaim land. “We all knew that Jakarta was sinking back in the 90s and indeed earlier, but nobody was that worried or really had any idea of the extent,” says JanJaap Brinkman, a hydrologist with the Dutch research institute Deltares, who has spent most of his adult life working on Jakarta’s watery woes. “Then came the floods in 2007. When we studied the data and looked at the mapping, we discovered the city was sinking not perhaps by a centimetre or so per year, as had previously been thought, but by 5-10cm on average, and much more in places.” With more than 50 people dead and 300,000 forced to evacuate their homes as waters covered more than a third of the city, 2007 was a startling wake-up call. The solution on paper was simple – the city must supply clean piped water, and end its dependency on groundwater extraction. Tokyo did just that in the 1960s after sinking more than four metres during the 20th century. Within a decade, says Brinkman, pointing to graphs on his laptop, that downward trajectory was permanently halted. But in Jakarta, there has been no significant progress in the nine years after the floods, thanks to a combination of financial restraints, competing infrastructure demands, and the sclerotic impact of the highly decentralised system of government introduced in response to the Suharto dictatorship. Brinkman, his good humour at times tested by this inertia, says there are now only two years left to act, or it will be too late to save northern Jakarta from disaster. There is another dramatic and controversial plan to save the world’s fastest-sinking city from itself: the so-called Giant Sea Wall and Great Garuda projects. At the heart of the proposals – with an estimated cost of as much as $40 billion – is a massive dike arcing 25 miles across Jakarta Bay which would create a vast manmade lagoon, with a new coastal megacity to be built around it on reclaimed land. The project, officially known as the National Capital Integrated Coastal Development (NCICD) programme, was backed with aid from the Dutch government, embraced by Indonesia’s president Joko Widodo, a former governor of Jakarta, and is now being championed by a Dutch-led consortium. The land reclamation dates back to a stalled plan from the President Suharto era to create 17 new islets off the city’s coastline. But it has morphed into a much more ambitious concept for a colossal new waterfront city, fanning out from sea wall in the shape of a garuda – the mythical bird of Hindu origin that is the country’s national symbol – with a multilane ring road for the perennially traffic-clogged capital running along its rim. From above, the designers’ illustrations for the Great Garuda project are redolent of the artificial Palm islands off the shore of Dubai. Its prospective developers also looked closer to home for inspiration, planning to build glitzy skyscrapers, luxury flats, shopping malls and attractions similar to Singapore’s Sentosa Island. Champions say the Giant Sea Wall will soon be the only way to save the city from catastrophic floods sweeping across the northern belt of land, with the new islands providing the financing by tapping into the monies of property development tycoons. But the schemes are now mired in lawsuits, scandals and moral controversy – particularly over the mass evictions of traditional fishing villages and waterfront communities, many of which have been bulldozed flat. Critics – a broad coalition of Indonesian scientists, land activists and local residents – say it is an outlandish and unnecessary project that would wreak environmental and social disaster. They argue the lives of traditional fishing communities are being destroyed as mass evictions are imposed, with whole neighbourhoods razed and residents relocated more than 10 miles away. They also claim that walling off the bay would turn it into a “septic lagoon” of trapped freshwater. With little sewage treatment for the river water pouring into the bay, this corporate attempt to “sanitise” Jakarta’s waterfront could end up having exactly the opposite effect. What is not in dispute is the need for urgent action. Just in front of the old fortification at Muara Baru, thick new pilings are being driven into the seafloor to provide a higher and stronger defence against the waters. Few people object to this, the start of Phase A of NCICD programme. “This is the ‘no regrets’ stage, as everyone agrees that we need to do this now,” says Tuty Kusumawati, head of the Jakarta planning department, as she pores over maps and diagrams of the waterfront. To deal with the freshwater flooding, heavily polluted and rubbish-strewn rivers are being widened, dredged, cleaned and protected with new concrete barriers, in initiatives ordered by Basuki Tjahaja Purnama, the governor known to all by his nickname, Ahok. For the smaller rivers that have already sunk too far to flow out to sea, pumping stations and polders are being built, with reservoirs to hold water at times of heavy rain and flooding. But some experts say there aren’t large enough pumps or sufficient land available to deal with the larger rivers – hence the call for more dramatic intervention. When presented with the proposal for the Giant Sea Wall, the Indonesian government asked the Dutch consultants to deliver a more ambitious concept to accompany it. From that request, the design for the Great Garuda was born. The Netherlands is an undisputed bastion of international expertise on fighting the seas and land reclamation. But in its former colony, some critics have expressed scepticism about the motives of the Dutch government-funded consultants and businessmen proposing such a colossal scheme. Victor Coenen, the project manager for Witteveen+Bos, the engineering consultancy that heads the Giant Sea Wall consortium, shrugs off the criticism. “Fine, if they don’t want our help, then we can go elsewhere,” he says. “But it is the Indonesian government that has asked for Dutch assistance to deal with the flooding, and it is Dutch government money that is helping.” This week’s visit to Indonesia by a high-profile Dutch trade mission, headed by the prime minister, Mark Rutte, is giving fresh impetus to the debate. The Save the Jakarta Bay Coalition, an alliance of groups opposed to the scheme, has written to Rutte spelling outs their fears and criticisms. “The Dutch are well known for their flood mitigation measures,” the letter notes. “These measures adopt a complex approach, which follows the principles of environmental and social protection and good governance. [But] what is happening in Indonesia is entirely the opposite. We are deeply concerned about the livelihood loss and infringement of human rights, as well as irreparable environmental damage, caused by the project. “We therefore stress that, if your government and the Indonesian government insist on building the NCICD, tens of thousands of people connected to small-scale fisheries will lose their livelihood.” The widening and fortification of the city’s rivers has already seen the eviction of thousands from kampung communities that have sprung up along its rivers and reservoirs. Bulldozers are often deployed with just a few days notice and residents ordered to move to new concrete public housing, often miles away from the waterfront where they work. According to Brinkman, however, “There are only two options, retreat or advance. We either abandon and evacuate north Jakarta, which is a non-starter, or we advance out into the bay with the seawall.” At Muara Baru, Coenen outlines the arguments for NCICD’s Phase B – the Giant Sea Wall – as he conducts a tour of the current fortifications. “In the old days, the water ran out to sea,” he says. “Now water collects in the city from several of these rivers. It can’t get out so we pump it out. But for the large rivers, we need ever-higher riverbanks and ever-bigger pumping stations and storage lakes. “We can’t build up riverbanks that are five or seven metres above the neighbouring communities, and there is not enough space onshore for the pumping lakes. So we’re proposing the Giant Sea Wall to create what is effectively a giant pumping lake offshore. Then we can then lower the water level, so those rivers can flow again.” But this part of the project has been met with scepticism by some prominent Indonesian scientists. Alan Koropitan, professor of oceanography at Bogor Agricultural University, contends the solution for Jakarta Bay is “restoration, not reclamation”. He says building an outer sea wall and manmade islands would create greater pollution and sedimentation as waters are trapped inside the dike, rather than being flushed out to sea. “If, instead, we can restore the bay and its polluted waters, that would mean something good for civilisation in Indonesia. I believe that a new economy will come from that – in tourism, aquaculture and fisheries.” Muslim Muin, head of coastal engineering research at the Bandung Institute of Technology, is equally unimpressed with the multibillion-dollar proposal. “If the Giant Sea Wall is built, it would inflict huge construction and operational costs and serious environmental costs. Even worse, it would exacerbate Jakarta’s flood risk. “By building the reservoir, the circulation of water will drastically decrease and even reach a point when it becomes stagnant water. The natural cleansing process would no longer happen,” he adds, citing the water-borne malarial epidemics of Dutch days. Coenen too acknowledges the environmental dangers of a “septic lagoon” that could be created by walling off the bay. But he contends that the wall should be accompanied by measures such as water sanitation. “The point really is that very soon, we will have no choice,” he adds. It is not just an environmental controversy, however. The Giant Sea Wall plans have become entwined with ever-more ambitious, and contentious, schemes for a radical facelift for the whole waterfront. The residential move south away from Jakarta’s coast began with Dutch colonialists in the 19th century, who preferred to live in greener areas less prone to disease and flooding. It was a trend that continued after independence in 1945, with most Indonesians choosing to live in what is now South, East and West Jakarta. That left behind a coastline dominated by the city’s industrial port and harbour, and populated by fishermen’s slum dwellings. The notable exception was the Indonesian-Chinese community that plays a powerful role in the country’s business world, including property development. The city’s ethnic Chinese have long lived near the bay and many influential families are based there in exclusive gated communities and nautical-themed luxury apartment blocks bearing names such as Regatta and Green City. Talk of a new waterfront city of 17 manmade islets, jutting up to two miles out into the bay, began in the mid-1990s. The project stalled after the Asian economic crisis but was later revived with an added twist – it could be deployed to garner private funding for the NCICD in a country where government coffers are always stretched. Huge industrial dredgers moved into the bay to discharge their loads and start creating the first four islands in 2013, but that work was brought to a jarring halt last April. A moratorium was declared in the wake of a high-profile and ongoing corruption case involving a company executive from one of the showpiece developments bribing a local parliamentarian over zoning laws. The prosecutions exposed murky financial ties between the developers and Jakarta city budgets. The government said the reclamation would start again in September, but as yet there has been no more work on the scheme. So the four part-built islands sit in Jakarta Bay, unfinished and off-limits. Visitors entering the air-conditioned oasis of the Riverwalk Bay shopping mall, at the base of the Green City complex in the waterfront Pluit district, can cast their eye over a model (pictured above) of how the NCICD’s “Island G” – marketed as Pluit City – looks in the designers’ eyes. It is a futuristic extravaganza of gleaming modernist high-rises, gated villa compounds and yacht marinas. A security guard hovers to enforce the “no photographs” rule, so for a close-up view of Island G, it is necessary to head out into the bay with Suhali bin Urip, a local fisherman who has worked these waters for 30 years. The 58-year-old Suhali – his face creased beyond his years by decades at sea under the tropical sun – is a prominent voice in the “no reclamation” campaign. “We’re the ones who live and work here, but nobody is consulting us about our futures,” he says. “The elite, the politicians and the rich, are making the decisions, but they don’t care about us or understand us.” Suhali lives with his family in the fishing village of Muara Angke, where men make on average $25 to $40 a month working on boats that are now forced to venture ever-further out to sea in search of a catch. Shanty dwellings of plywood, breeze blocks and corrugated metal, often lashed together by rope or metal fixtures furnished from scrap, are precariously balanced on wooden stilts over a waterfront that serves as toilet and rubbish dump. Suhali’s small wooden skiff, its paint peeling and decking loose, is tethered at the end of a rickety path of bamboo poles and old door frames. He yanks a few times on the starting cord of the outboard engine, and we sputter off into the bay towards our target – our progress in these sensitive waters observed by a police motorboat. The future Pluit City soon comes into view, although for now the islet is no more than a low spit of reclaimed sand sitting a few feet above water level, with the Regatta and Green City developments looming on the skyline behind it. “I used to fish just here,” Suhali says, his tiny boat bobbing offshore. “But now they are building this land in our waters, there are no fish left to catch here.” During our trip, we encounter only one fisherman casting his nets – as much in hope as expectation of a catch. The only other person working out here is a scavenger in a rowing boat, collecting washed-up plastic products to sell for recycling. In ongoing lawsuits objecting to the island reclamation scheme, the Jakarta Legal Aid association has argued these new islands are occupying traditional fishing grounds, while the sediment and dredging work have driven away fish from the remaining waters. Back onshore, the pervasive smell of salted fish, boiled first over open furnaces, then laid out to dry in the tropical heat, wafts across from nearby processing warehouses. “Our family has been working here for three generations, but you can be sure they won’t want us here if they go ahead with these grand plans,” says Haji Hernoto, 44. “They won’t like the smell or the sight of us.” Asked who “they” are, his wife Sitiwardah adds: “Oh you know, the rich, the politicians, the developers … The Chinese who are going to buy these apartments.” Her comments reflect resentment and division not just over class and money, but also ethnicity. The waterfront developers are nearly all Chinese-Indonesians – as is Ahok, the blunt-speaking governor – while the local communities facing displacement are overwhelmingly Indonesian Muslims. Furthermore, the swanky new developments planned for the manmade islands are being marketed not just at affluent Indonesians but, with a particular thrust, at overseas Chinese buyers from Singapore, Malaysia, Hong Kong and mainland China, via aspirational television advertising that gushes in Mandarin about the vision of a “new lifestyle” in Pluit City. While the battle over the shape of Jakarta’s seafront is still being waged, its governor is already making his mark with controversial measures to tackle flooding challenges inland. The city’s rivers have long been throttled by both rubbish and people. Tens of thousands of Jakartans set up home near and beside water, sometimes building out on stilts. These unofficial kampungs developed into thriving, if dirt-poor, communities where people live and work. Some residents used the water to dump their rubbish and their sewage, resulting in a foul-smelling, insanitary and unsightly network of rivers and canals that also contributed to the city’s chronic floods, as their waters could not drain properly and their flow was narrowed by the encroachment of homes and factories. Of course, many other Jakartans also contributed to the pollution problem, but it was these impoverished kampung that took the official blame. Ahok deployed squadrons of workers to clean the rivers of their choking surface carpets of rubbish and water hyacinths. It is one of several “quality of life” initiatives that also include establishing a city hotline that locals can call to report problems. But in the governor’s brusque, “get it done” approach to city planning, he has also overseen mass evictions from overcrowded waterside kampung. Officials said the location of homes on the edge of waterways compounded flooding risks, while the residents were in direct danger from the inundations. Ahok has followed advice from consultants to widen and raise the rivers and install levees, so that storm-swollen waters can flow out to sea or be stored safely. Across Jakarta, such concrete slabs are being put in place in riverbanks by heavy-lifting equipment. At City Hall, Kusumawati, the planning chief, outlines the plans for rehousing residents from riversides, as well as detailed projects to employ fishing communities displaced from the seafront. “We are looking after our citizens,” she says. “These new homes are better than the slums where many have lived.” Coenen, meanwhile, offers a blunt assessment of the challenge facing Jakarta. “It’s unfortunate, but you have to destroy some areas to save the city,” he says. “These are technical solutions to technical problems. But the city also needs social solutions to social problems.” His words are of no comfort to residents of areas such as the Akuarium neighbourhood, near the old Sunda Kelapa harbour at the mouth of the Ciliwung river. Hundreds of homes, including some not next to the water, were demolished here earlier this year as residents and security forces clashed. Today, Akuarium resembles a scene from a wartime blitz. Many locals are still squatting among the debris, while some are rebuilding homes from salvaged metal and brick on the ruins of their old ones. The suspicion is widespread that they were evicted to make way for tourist projects in an area near old red-tiled Dutch buildings of the colonial era, rather than to keep rivers flowing and combat flooding. Officials have told evictees to move to subsidised apartments in low-cost, concrete public housing blocks that are being built across the city. But the new housing offered to some slum residents is up to 12 miles away, in locations that would take the people of Akuarium far away from the waters where they work in the fishery and tourism businesses. “We’ve been offered no compensation, despite their promises, and were told we must move to new apartment buildings in Cakung,” says Johariah, a mother-of-10, referring to a district far inland. Johariah ekes out a living to support her family by selling salted fish. Others living amid the debris tell a similar story; that they rely on being close to the water. The abrupt manner of the house clearances, with bulldozer squads dispatched along with armed police protection after only a few hours’ notice, has deepened the anger – as have rows over ownership and compensation. The authorities describe these kampung residents as squatters on government land. But many have lived here for years, even decades, and insist their right to residence was approved by city agencies that levied annual property taxes. Some angrily wave their tax bills; others say they bought their homes and even received bank loans for them. “They say we did not have the right to be here, but I paid for my home,” says Johariah. “You can’t treat us like this.” Graffiti denouncing Ahok – as he is known to friend and foe alike – is daubed across the walls here. Islamist parties have capitalised on the outrage to fuel their campaign against the governor, who is the most prominent Christian in the world’s most populous Muslim nation, and enjoys high popularity ratings in much of the city. Last week, police named him as a criminal suspect in a blasphemy investigation, for an aside he made about his political opponents citing the Koran. The governor, who is running for re-election in February, now faces prosecution on charges that can carry up to five years in jail. The case is expected further to complicate Jakarta’s waterfront facelift plans. For now, reclamation work on the 17 islets remains on hold, amid reported splits within the president’s cabinet – although Jokowi’s support is expected to win the day. It is telling that Luhut Pandjaitan, the co-ordinating maritime minister and a close confidant of the president, has insisted the moratorium will be lifted. “There is no reason for us not to continue with the reclamation of the North Jakarta coast,” he said in September. “It is estimated that all of North Jakarta will sink below sea level by 2030,” the president himself said at a cabinet meeting earlier this year. “Because of that, the development of the capital’s seaside, which has been delayed for so long, is the answer for Jakarta.” But a follow-up cabinet session, expected to take place in late October to confirm the government’s position on the NCICD, did not materialise. In the always opaque world of Indonesian politics, the power battles behind the scenes remain hidden. There is now speculation that the decision on the Giant Sea Wall will be delayed for a year or more, allowing time for further investigations into the impact on the environment and the people of the seafront. The Great Garuda development that was supposed to take flight from that dike could be grounded even longer. Back in the ruins of Akuarium, as Johariah surveys the scene from her makeshift fish stand, local tour guides lead European visitors through the rubble, en route from the nearby maritime museum to the boat dock for the old harbour. It is a jarring juxtaposition in the struggle over Jakarta’s waterfront future. And all the time, as the view of the crumbling seawall from Sukaesih’s shopfront shows all too clearly, this city is still sinking. Do you live in Jakarta? Share your ideas, thoughts, stories and pictures of the city here. You can also contribute on Twitter and Instagram using the hashtag #GuardianJakarta

PURPOSE OF REVIEW: To define why a standardized bleeding definition is required and discuss the merits of the Bleeding Academic Research Consortium (BARC) definitions. RECENT FINDINGS: In acute coronary syndromes, bleeding is related to increased mortality, myocardial infarction, and stroke. As newer antiplatelet and antithrombotic agents are developed for the treatment of cardiovascular disease, bleeding rates will increase. Multiple bleeding definitions have been used in trials and registries. This makes comparisons across studies difficult. In order to standardize definitions, the Bleeding Academic Research Consortium (BARC) has developed a consensus classification for bleeding. Six types are hierarchically defined from type 0 in which there is no bleeding to type 5 with fatal bleeding. Type 1 is in which the patient does not seek treatment. Type 2 is in which intervention or admission to hospital occurs. Type 3a is overt bleeding plus hemoglobin drop of 3 to less than 5 g/dl or transfusion. Type 3b is overt bleeding plus hemoglobin drop of at least 5 g/dl, cardiac tamponade, bleeding requiring surgical intervention or intravenous vasoactive agents. Type 3c is intracranial hemorrhage or intraocular bleeding compromising vision. Type 4 is coronary artery bypass grafting-related bleeding and type 5 is fatal bleeding. SUMMARY: The BARC definition will have wide applicability in trials, registries, and clinical practice. Although prospective validation is required, the definition will allow uniform reporting and comparison across studies. © 2011 Lippincott Williams & Wilkins, Inc.

Lipoprotein-associated phospholipase A2 (Lp-PLA2) levels are associated with coronary heart disease (CHD) in healthy individuals and in patients who have had ischemic events. The Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) study randomized 9014 patients with cholesterol levels of 4.0 to 7.0 mmol/L to placebo or pravastatin 3 to 36 months after myocardial infarction or unstable angina and showed a reduction in CHD and total mortality. We assessed the value of baseline and change in Lp-PLA2 activity to predict outcomes over a 6-year follow-up, the effect of pravastatin on Lp-PLA2 levels, and whether pravastatin treatment effect was related to Lp-PLA2 activity change. Lp-PLA2 was measured at randomization and 1 year, and levels were grouped as quartiles. The prespecified end point was CHD death or nonfatal myocardial infarction. Baseline Lp-PLA2 activity was positively associated with CHD events (P < 0.001) but not after adjustment for 23 baseline factors (P = 0.66). In 6518 patients who were event free at 1 year, change in Lp-PLA2 was a significant independent predictor of subsequent CHD events after adjustment for these risk factors, including LDL cholesterol and LDL cholesterol changes (P < 0.001). Pravastatin reduced Lp-PLA2 by 16% compared with placebo (P < 0.001). After adjustment for Lp-PLA2 change, the pravastatin treatment effect was reduced from 23% to 10% (P = 0.26), with 59% of the treatment effect accounted for by changes in Lp-PLA2. Similar reductions in treatment effect were seen after adjustment for LDL cholesterol change. Reduction in Lp-PLA2 activity during the first year was a highly significant predictor of CHD events, independent of change in LDL cholesterol, and may account for over half of the benefits of pravastatin in the LIPID study.

Webster M.W.I.,Green City
Current Opinion in Cardiology | Year: 2011

PURPOSE OF REVIEW: Diabetes is an increasingly prevalent risk factor for coronary and other vascular disease. Recent trials in patients with diabetes have examined the effects of intensive glycemic control on cardiovascular outcomes, and treatment of common concomitant risk factors, in particular hypertension and dyslipidemia. Optimal revascularization strategies have also been examined. RECENT FINDINGS: Intensive glycemic control has a beneficial effect on microvascular but not macrovascular endpoints, with one major trial reporting increased mortality out to 5 years with intensive treatment. Similarly, aggressive lowering of SBP to below 120 mmHg produced no advantage over treatment to 130-140 mmHg. Statins are the best treatment for diabetic dyslipidemia, with little benefit from adding a fibrate. Medical treatment may be appropriate for many with diabetes and stable coronary disease. When revascularization is needed, coronary bypass graft surgery has an advantage over percutaneous coronary intervention in those at the severe end of the coronary disease spectrum. SUMMARY: Patients with type 2 diabetes often have multiple cardiovascular risk factors and require multiple cardiac and diabetes medications. Caution over aggressive glucose and blood pressure lowering is needed, at least with currently available drugs. © 2011 Lippincott Williams & Wilkins, Inc.

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an uncommon inherited myocardial disorder characterised by fibro-fatty inflammation affecting the right and left ventricles. It most commonly presents with palpitations or syncope but sudden death may occur, especially in young males. Methods: Diagnosis is not possible with a single test and may be difficult. Task Force criteria agreed in 1994 comprise major and minor criteria spanning structural abnormalities, ECG appearances, arrhythmias, family history of premature death and myocardial histology. Modified criteria were introduced in 2010 to improve sensitivity. Results: Arrhythmogenic right ventricular cardiomyopathy is a desmosomal disease. Mutations have been detected in five desmosomal genes, most frequently in plakophilin-2 (PKP2) and multiple mutations are also reported. Antiarrhythmic drugs such as sotalol and amiodarone may improve symptoms but are unproven to increase survival. An implantable defibrillator is appropriate in individuals surviving cardiac arrest or sustained ventricular tachycardia, but there is not yet consensus about prophylactic treatment of Task Force positive but asymptomatic individuals. Conclusions: Arrhythmogenic right ventricular cardiomyopathy is more common than previously believed. Preliminary evidence supports improved sensitivity without loss of specificity using the revised Task Force criteria. The genetics of the disease are complex but should ultimately advance diagnosis and management. © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand.

Purpose of Review: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a risk factor as strong as low-density lipoprotein (LDL) cholesterol. Therapies targeting Lp-PLA2 in plasma and plaque are now being developed. This article will review these data. Recent Findings: Lp-PLA2 is intimately involved in the development of atherosclerosis and is found in vulnerable human plaques. Multiple epidemiological studies have shown that Lp-PLA2 is related to the occurrence of myocardial infarction (MI), stroke and vascular death.Darapladib is a novel oral compound that selectively inhibits Lp-PLA2 in plasma and in human plaques. Darapladib has also been shown to halt necrotic core progression in coronary arteries over a 12-month period and to have few adverse effects. Summary: Two large phase III trials are randomizing 26 000 patients to darapladib or placebo with chronic coronary heart disease or following an acute coronary syndrome. The primary composite outcomes are cardiovascular death, MI or stroke and results should be available in 2012. Darapladib has the potential to improve patient outcomes in addition to evidence-based treatments by modulating mechanisms of disease that have not been addressed by current therapies. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Stewart R.A.H.,Green City
Current Opinion in Cardiology | Year: 2011

PURPOSE OF REVIEW: To review the large phase 3 clinical trials that compare direct thrombin or factor Xa inhibitors with dose-adjusted warfarin in patients with atrial fibrillation who have an increased risk of stroke. RECENT FINDINGS: In large clinical trials, the oral direct thrombin inhibitor ximelagatran and the long-acting factor Xa inhibitor idraparinux were effective for reducing the risk of thromboembolic stroke, but were not marketed because of liver toxicity and excessive bleeding, respectively. In separate clinical trials, the oral direct thrombin inhibitor dabigatran etexilate and the short-acting oral factor Xa inhibitor rivaroxaban were noninferior or superior to dose-adjusted warfarin for prevention of thromboembolic stroke and systemic embolism, without increasing the risk of bleeding, and were well tolerated. Apixaban, another oral factor Xa inhibitor, is effective in reducing thromboembolic stroke compared with aspirin alone. Results of a trial comparing apixaban with dose-adjusted warfarin are awaited. SUMMARY: Dabigatran and rivaroxaban are effective, safe alternatives to dose-adjusted warfarin for reducing thromboembolic risk in patients with atrial fibrillation at high risk of stroke. © 2011 Lippincott Williams & Wilkins, Inc.

Kent T.,Green City
Journal of Forensic Identification | Year: 2010

A move to standardizing protocols for fingerprint reagent testing would benefit both researchers and those responsible for implementing techniques operationally. Some possible sampling protocols and testing methods and procedures are outlined and discussed.

News Article | August 24, 2016

Manhattan skyscrapers, rather than rustic rural towns, are quickly becoming the picture of sustainable living in the twenty-first century. San Francisco, Copenhagen and Singapore each top their regions in the Green City Index (see As sites of innovation and economic dynamism, these places exemplify a blend of density and livability that large, prosperous cities in the 'global south', such as Mumbai in India and São Paulo in Brazil, increasingly emulate. A few decades ago, cities were seen as sustainability problems rather than solutions. Then, as concerns about suburban sprawl, shanty towns and climate change grew, so too did awareness that clustering people in energy-efficient buildings and walkable, shady neighbourhoods makes cities more pleasant to live in and better for the global environment. But the prevailing model of urban sustainability is too narrow. Although the social, economic and ecological issues behind sustainability problems are regional or global in scale, urban policy usually addresses single ecological issues in individual neighbourhoods. Focusing on dense cities and their affluent areas ignores social movements and their advocacy for quality-of-life issues such as housing and commuting, which have direct ecological consequences. Targeting specific districts ignores the often negative regional and global impacts of local environmental, or 'greening', improvements. Spatially, sustainability research and policymaking should shift focus from city centres to urban regions and global networks of production, consumption and distribution. Socially, policymakers should incorporate equity into every stage of the urban-policy process, from research to formulation to implementation. From the revitalization of city parks to urban bicycle-sharing programmes, urban sustainability interventions tend to be conceived, implemented and evaluated one municipality or neighbourhood at a time. Yet urban environmental processes occur on much larger scales. Projects that benefit one district may have negative impacts next door. One example is environmental gentrification. As districts become greener, they become more desirable and expensive. The premiums placed on neighbourhood amenities — such as walkability, public transport and the proximity of parks, farmers' markets and 'greenways' such as hiking trails and bike paths — by residents who can afford to pursue them raise the cost of living. Social displacement can result. Policies that encourage these improvements tend not to be linked to a broader social-equity agenda, so low- and middle-income residents are forced into peripheral neighbourhoods where population densities are lower, commutes are longer and environmental problems are more common. Many sustainability gains are simply a regressive redistribution of amenities across places. For example, in North American cities such as New York and San Francisco, poor districts have long suffered from the dumping of industrial-waste, low air quality and a lack of green spaces. In recent years, often in response to community activism, policymakers have tried to create shadier streets and more recreational space, to improve public transport and greenway access, and to build mixed-use eco-friendly housing in such neighbourhoods. New York City has made efforts to green East Harlem, western Queens and Red Hook in Brooklyn. Yet poor people are frequently priced out and must move1. In Europe, the German city of Freiburg has been internationally recognized for its achievements in renewable energy, public transport, participatory planning and pedestrianized, energy-efficient districts. As the metropolitan region has become more desirable and expensive, more of its workforce has turned to the cheaper suburbs for housing. The city has grown more socially homogenous, while beyond its boundaries commuting has skyrocketed, as have the associated carbon emissions2. Greening has come at the expense of community stability and racial and economic diversity, and has undermined regional environmental goals. These patterns hold around the world. Studies have shown that in several cities, the social costs of climate adaptation fall mainly on disadvantaged groups. Examples include Medellín, Colombia; Jakarta, Indonesia; Dhaka, Bangladesh; and Boston, Massachusetts. Climate-adaptation plans fail to engage poor communities and often recommend relocating them to unsafe areas where they would be more vulnerable to droughts, heat, flooding and disease. Meanwhile, wealthy residents who set the planning agenda benefit from new land-use regulations and protective infrastructure. From Boston to Dhaka, resources earmarked for climate-adaptation are concentrated in wealthy districts and the risks are exacerbated elsewhere3. Post-industrial cities highlight their sustainability triumphs in terms of building density, extensive public-transport networks and the presence of knowledge-intensive, high-tech firms, all of which drive down locally produced pollution and carbon emissions. But even high-tech workplaces depend on polluting activities elsewhere. Computers and smartphones produce growing global flows of electronic waste that concentrate their toxic by-products — such as the trace amounts of beryllium and mercury in mobile phones — in poor communities in the developing world. Guiyu in China used to be a small rice-growing village, but was transformed in the 1990s into the world's largest processing zone for electronic waste. Local water rapidly became undrinkable4. Even information in 'the cloud' has an environmental impact. Data centres account for 2% of global greenhouse-gas emissions; their power usage is expected to triple in the next decade5. And much financial and high-tech activity consists of coordinating resource extraction and manufacturing activities that have moved to other parts of the globe. Apple designs its iPhones in California, but 84% of the embodied carbon emissions of the phones come from their production in China, South Korea and other countries, mostly in Asia. The low-carbon footprints prized by cities such as San Francisco and Seattle are little more than accounting tricks. The main method of carbon counting attributes to urban areas only the emissions resulting from in-city activities and regional power plants. Few studies count the full life cycle of emissions for all goods and services consumed by individuals and groups in cities, or emissions resulting from air travel. Those that do are telling. Consumption-based carbon counts for Shanghai, Seattle, San Francisco and London find more than double the per capita emissions of standard calculations. Almost 80% of San Franciscans' greenhouse-gas emissions, for example, are produced outside the city6 (see 'Remote impacts'). The apparent low-carbon benefits of density fall dramatically when income and lifestyle are controlled for. Upper-income urban residents in the United States and Europe tend to consume more imported goods and services, fly more often, and drive out of the city more often than people living on lower incomes7. In the United Kingdom, during the explosion of low-cost air travel from the late 1980s to the early 2000s, the number of working-class passengers flying out of London increased by around 60%; wealthy passengers' trips increased by nearly 150%. Although prosperous urban residents may commute by bicycle or public transport — the forms of low-carbon living most commonly cultivated by sustainability projects such as Freiburg's eco-neighbourhoods — their carbon footprints are enlarged greatly by their consumption practices and leisure travel. Economic activity and urban density in post-industrial cities are inextricably linked with global networks of production, consumption and distribution. It has become conventional wisdom that city leaders are more nimble and less ideological than their national counterparts. These two qualities, the story goes, allow leaders such as New York's former mayor Michael Bloomberg and former Bogotá mayor Enrique Peñalosa, along with networks such as the C40 Large Cities Leadership Group, to take the lead in confronting global sustainability challenges — even as international treaty efforts and national policymaking stall. This 'urban turn' in policy and discourse captures important truths. But it obscures the fact that municipalities are more nimble because they wield less power. Municipal governments lack access to industrial policy, welfare systems and tax regimes. They have limited control over consumption patterns and large-scale infrastructure. And cities are bound by competitive pressures that pit them against each other in the pursuit of capital investment and talented workers. Municipalities thus tend to pursue sustainability policies that are also economic-development policies, and these disproportionately focus on affluent central business districts or residential areas designed to attract skilled professionals. This challenges, for instance, the good intent of the United Nations' Sustainable Development Goals for cities. Reaching these goals requires strong national policy commitments to new regional infrastructure programmes, cash transfers to poor people, and local governance reform across urban regions. State, provincial and national governments can apply sustainability policies across local jurisdictional lines. In the aftermath of Hurricane Sandy, which hit the US east coast in 2012, some of the dozens of small municipalities on the New Jersey Shore independently attempted to build new 'hard' seawalls, despite concerns that these would displace storm surges to their neighbours. Only higher levels of government can prevent such 'beggar-thy-neighbour' local politics. And grass-roots groups bring about change from the bottom up. Community-based organizations, city-wide non-profit organizations and ad hoc social movements shape cities' built environment and lifestyle. But these groups are often overlooked in discussions about sustainability policy because most of them do not frame their work in environmental terms. They are more likely to speak of a broader 'right to the city'. Advocates for affordable housing and mass transit are proposing exactly the types of intervention that shrink individuals' carbon footprints and improve community resilience8. But they are rarely seen as prospective allies by green policymakers. Sustainability efforts that are indifferent to concerns about affordability and that lack support from community members are less just and less likely to succeed. In New York City, an effort to implement a congestion charge in central Manhattan failed in the face of public opposition. New Yorkers in outer boroughs viewed the plan as elitist and indifferent to the concerns of poorer commuters. Still, some fledgling coalitions around equity and sustainability are emerging. Last year in São Paulo, a historic drought and state mismanagement of scarce water resources led housing movements and environmentalists — long at odds over how to deal with precarious waterside settlements — to come together around a common agenda of housing and water justice9. First, urban environmental researchers need to supplement neighbourhood-specific and city-centric10 measurements, such as walkability or commuting by public transport, with ones that better capture the broader dimensions of ecological sustainability and social equity. For instance, studies of changes to local transit systems should analyse the knock-on effects in regional housing and labour markets. Second, multicity low-carbon policy networks such as the C40 and climate-focused organizations such as the World Resources Institute in Washington DC should insist on — and support — all large cities carrying out standardized, consumption-based carbon-footprint analyses. As well as providing more accurate accounts of specific cities' carbon footprints, this would underscore the extent to which emissions levels are correlated with class and income. Third, policymakers should treat social equity and ecological effectiveness as mutually reinforcing dynamics in urban sustainability. They should bring the widest range of social movements to the table and see those groups' demands — such as revitalizing rent regulation and public housing — as central. This would entail more frequent meetings of larger groups of stakeholders and different metrics of policy success. But it would also yield more creative, sophisticated and encompassing policies that would have broader public support. Only by expanding the spatial and social dimensions of urban policymaking can it be made truly sustainable and equitable.

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