intervention

Is Histologic Thrombus Composition in Acute Stroke Linked to Stroke Etiology or to Interventional Parameters? [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Detailed insight into the composition of thrombi retrieved from patients with ischemic stroke by mechanical thrombectomy might improve pathophysiologic understanding and therapy. Thus, this study searched for links between histologic thrombus composition and stroke subtypes and mechanical thrombectomy results.

MATERIALS AND METHODS:

Thrombi from 85 patients who had undergone mechanical thrombectomy for acute ischemic stroke between December 2016 and March 2018 were studied retrospectively. Thrombi were examined histologically. Preinterventional imaging features, stroke subtypes, and interventional parameters were re-analyzed. Statistical analysis was performed with the Kruskal-Wallis test, Mann-Whitney U test, or Spearman correlation as appropriate.

RESULTS:

Cardioembolic thrombi had a higher percentage of macrophages and a tendency toward more platelets than thrombi of large-artery atherosclerotic stenosis (P = .021 and .003) or the embolic stroke of undetermined source (P = .037 and .099) subtype. Thrombi prone to fragmentation required the combined use of contact aspiration and stent retrieval (P = .021) and were associated with an increased number of retrieving maneuvers (P = .001), longer procedural times (P = .001), and a higher lymphocyte content (P = .035).

CONCLUSIONS:

We interpreted the higher macrophage and platelet content in cardioembolic thrombi compared with large-artery atherosclerotic stenosis or embolic stroke of undetermined source thrombi as an indication that the latter type might be derived from an atherosclerotic plaque rather than from an undetermined cardiac source. The extent of thrombus fragmentation was associated with a more challenging mechanical thrombectomy and a higher lymphocyte content of the thrombi. Thus, thrombus fragmentation not only might be caused by the recanalization procedure but also might be a feature of a lymphocyte-rich, difficult-to-retrieve subgroup of thrombi.




intervention

Glasgow Coma Scale on Presentation Predicts Outcome in Endovascular Treatment for Acute Posterior Large-Vessel Occlusion [INTERVENTIONAL]

SUMMARY:

Use of mechanical thrombectomy for stroke has increased since the publication of trials describing outcome improvement when used in the anterior circulation. These results, however, cannot be directly translated to the posterior circulation. While a high NIHSS score has demonstrated an association with poor outcomes in posterior stroke, the NIHSS is weighted toward hemispheric disease, and complex scores potentially delay definitive imaging diagnosis. We performed a retrospective analysis to ascertain whether any rapidly obtainable demographic or clinical and imaging data have a correlation with patient outcome postthrombectomy. Seventy-three cases were audited between September 2010 and October 2017. Presenting with a Glasgow Coma Scale score of >13 meant that the odds of reaching the primary end point of functional independence (defined as a 90-day modified Rankin Scale score of 0–2) were 5.70 times greater; similarly, presenting with a posterior circulation ASPECTS of >9 resulted in the odds of reaching the primary end point being 4.03 times greater. Older age correlated to a lower odds of independence (0.97, p = .04).




intervention

White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear.

MATERIALS AND METHODS:

In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0–2) and moderate-to-severe (van Swieten score, 3–4) white matter disease using logistic regression: 90-day mRS 3–6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery.

RESULTS:

Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58–79 years). A van Swieten score of 3–4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3–6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34–5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3–4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56–2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93–4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed.

CONCLUSIONS:

Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.




intervention

Contrast-Induced Acute Kidney Injury in Radiologic Management of Acute Ischemic Stroke in the Emergency Setting [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

The use of invasive cerebral angiography with CTA for active treatment of patients with suspected ischemic strokes has been increasing recently. This study aimed to identify the incidence of postcontrast acute kidney injury using baseline renal function when CTA and cerebral angiography were performed sequentially.

MATERIALS AND METHODS:

This retrospective observational study evaluated adults (18 years of age or older) with ischemic stroke who underwent CTA and cerebral angiography sequentially between 2010 and 2018. The incidence of postcontrast acute kidney injury was determined using the baseline estimated glomerular filtration rate. The value of the baseline estimated glomerular filtration rate at which the occurrence of postcontrast acute kidney injury increased was also determined.

RESULTS:

Postcontrast acute kidney injury occurred in 57/601 (9.5%) patients. Those with a baseline estimated glomerular filtration rate of <30 mL/min/1.73 m2 showed a higher incidence of acute kidney injury. Age, chronic kidney disease, medication (nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, statins, and insulin) use following contrast media exposure, and serum albumin affected the incidence of postcontrast acute kidney injury. The incidence of postcontrast acute kidney injury increased when the baseline estimated glomerular filtration rate was <43 mL/min/1.73 m2.

CONCLUSIONS:

Patients with low baseline renal function had the highest incidence of postcontrast acute kidney injury after CTA and cerebral angiography, but no fatal adverse effects were documented. Thus, patients suspected of having a stroke should be actively managed with respect to neurovascular function.




intervention

MRI Vessel Wall Imaging after Intra-Arterial Treatment for Acute Ischemic Stroke [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Vessel wall imaging is increasingly performed in the diagnostic work-up of patients with ischemic stroke. The aim of this study was to compare vessel wall enhancement after intra-arterial thrombosuction with that in patients not treated with thrombosuction.

MATERIALS AND METHODS:

From 2009 to 2017, forty-nine patients with an ischemic stroke underwent 7T MR imaging within 3 months after symptom onset as part of a prospective intracranial vessel wall imaging study. Fourteen of these patients underwent intra-arterial treatment using thrombosuction (intra-arterial treatment group). In the intra-arterial treatment group, vessel walls were evaluated for major vessel wall changes. All patients underwent pre- and postcontrast vessel wall imaging to assess enhancing foci of the vessel wall using coregistered subtraction images. A Wilcoxon signed rank test was performed to test for differences.

RESULTS:

In the intra-arterial treatment group, 11 of 14 patients (79%) showed vessel wall enhancement compared with 17 of 35 patients without intra-arterial treatment (49%). In the intra-arterial treatment group, more enhancing foci were detected on the ipsilateral side (n = 18.5) compared with the contralateral side (n = 3, P = .005). Enhancement was more often concentric on the ipsilateral side (n = 8) compared with contralateral side (n = 0, P = .01). No differences were found in the group without intra-arterial treatment between the number and configuration of ipsilateral and contralateral enhancing foci.

CONCLUSIONS:

Patients with intra-arterial treatment by means of thrombosuction showed more (concentric) enhancing foci of the vessel wall ipsilateral compared with contralateral to the treated artery than the patients without intra-arterial treatment, suggesting reactive changes of the vessel wall. This finding should be taken into account when assessing vessel wall MR images in patients with stroke.




intervention

Suspected Metallic Embolization Distal to Coiled Intracranial Aneurysms Detectable by Susceptibility-Weighted MR Imaging [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

After endovascular coiling of intracranial aneurysms, round dark parenchymal lesions believed to be particulate metal are sometimes encountered in MR imaging studies of the brain. We used SWI to assess the frequency of such occurrences, in addition to exploring likely causes and clinical implications.

MATERIALS AND METHODS:

We reviewed 700 MR imaging studies performed between September 2018 and March 2019 at our institution as follow-up monitoring of coiled intracranial aneurysms. Any sizeable (>5 mm) rounded dark-signal lesions encountered were presumed to be metallic. The magnitudes and locations of such lesions were recorded. In patients with these lesions, pertinent procedural documentation was screened for devices used, including coils, microcatheters, microguidewires, and stents. Medical records were also examined to determine whether any related symptoms ensued.

RESULTS:

Twenty patients (2.8%) exhibited a total of 25 lesions on SWI. Diameters ranged from 5 to 11 mm (median, 8 mm). All except 2 lesions were located in brain regions downstream from aneurysms, but all lesions occupied vascular territories of vessels used to place guiding catheters. Other than the Synchro 14, which was routinely deployed, no device was regularly used in patients with SWI-detectable lesions; and none of the affected patients developed focal neurologic symptoms as a consequence.

CONCLUSIONS:

Although the origins remain unclear, distal embolization of particulate metal distal to coiled cerebral aneurysms is occasionally observed on follow-up MR imaging studies. Such lesions, however, seem to have no apparent clinical impact.




intervention

Reliability of CT Angiography in Cerebral Vasospasm: A Systematic Review of the Literature and an Inter- and Intraobserver Study [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Computed tomography angiography offers a non-invasive alternative to DSA for the assessment of cerebral vasospasm following subarachnoid hemorrhage but there is limited evidence regarding its reliability. Our aim was to perform a systematic review (Part I) and to assess (Part II) the inter- and intraobserver reliability of CTA in the diagnosis of cerebral vasospasm.

MATERIALS AND METHODS:

In Part I, articles reporting the reliability of CTA up to May 2018 were systematically searched and evaluated. In Part II, 11 raters independently graded 17 arterial segments in each of 50 patients with SAH for the presence of vasospasm using a 4-category scale. Raters were additionally asked to judge the presence of any moderate/severe vasospasm (≥ 50% narrowing) and whether findings would justify augmentation of medical treatment or conventional angiography ± balloon angioplasty. Four raters took part in the intraobserver reliability study.

RESULTS:

In Part I, the systematic review revealed few studies with heterogeneous vasospasm definitions. In Part II, we found interrater reliability to be moderate at best ( ≤ 0.6), even when results were stratified according to specialty and experience. Intrarater reliability was substantial ( > 0.6) in 3/4 readers. In the per arterial segment analysis, substantial agreement was reached only for the middle cerebral arteries, and only when senior raters’ judgments were dichotomized (presence or absence of ≥50% narrowing). Agreement on the medical or angiographic management of vasospasm based on CTA alone was less than substantial ( ≤ 0.6).

CONCLUSIONS:

The diagnosis of vasospasm using CTA alone was not sufficiently repeatable among observers to support its general use to guide decisions in the clinical management of patients with SAH.




intervention

CT Angiography in Evaluating Large-Vessel Occlusion in Acute Anterior Circulation Ischemic Stroke: Factors Associated with Diagnostic Error in Clinical Practice [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

It is currently not completely clear how well radiologists perform in evaluating large-vessel occlusion on CTA in acute ischemic stroke. The purpose of this study was to investigate potential factors associated with diagnostic error.

MATERIALS AND METHODS:

Five hundred twenty consecutive patients with a clinical diagnosis of acute ischemic stroke (49.4% men; mean age, 72 years) who underwent CTA to evaluate large-vessel occlusion of the proximal anterior circulation were included. CTA scans were retrospectively reviewed by a consensus panel of 2 neuroradiologists. Logistic regression analysis was performed to investigate the association between several variables and missed large-vessel occlusion at the initial CTA interpretation.

RESULTS:

The prevalence of large-vessel occlusion was 16% (84/520 patients); 20% (17/84) of large-vessel occlusions were missed at the initial CTA evaluation. In multivariate analysis, non-neuroradiologists were more likely to miss large-vessel occlusion compared with neuroradiologists (OR = 5.62; 95% CI, 1.06–29.85; P = .04), and occlusions of the M2 segment were more likely to be missed compared with occlusions of the distal internal carotid artery and/or M1 segment (OR = 5.69; 95% CI, 1.44–22.57; P = .01). There were no calcified emboli in initially correctly identified large-vessel occlusions. However, calcified emboli were present in 4 of 17 (24%) initially missed or misinterpreted large-vessel occlusions.

CONCLUSIONS:

Several factors may have an association with missing a large-vessel occlusion on CTA, including the CTA interpreter (non-neuroradiologists versus neuroradiologists), large-vessel occlusion location (M2 segment versus the distal internal carotid artery and/or M1 segment), and large-vessel occlusion caused by calcified emboli. Awareness of these factors may improve the accuracy in interpreting CTA and eventually improve stroke outcome.




intervention

Drones: For When Medical Intervention Has to Get There Before an Ambulance Can

New York City study shows that drones could deliver life-saving medical supplies several minutes before an ambulance arrives




intervention

SunRice looks to environmental water, subsidies, government intervention as solutions for harvest

SunRice says it will guarantee Australian-grown rice returns to supermarkets in April if the Murray-Darling Basin Plan is changed so environmental water can be used to grow rice.




intervention

Deputy Attorney General James M. Cole Speaks at the U.N. Commission on Status of Women Event Entitled, "Intimate Partner Violence: Effective Interventions"

"Although there is still much work to be done, the United States has made significant strides in developing effective community responses to intimate partner violence that has stolen far too many promising futures – and shattered far too many lives," said Deputy Attorney General Cole.




intervention

Cost-effectiveness of <i>CYP2C19-</i>guided antiplatelet therapy in patients with acute coronary syndrome and percutaneous coronary intervention informed by real-world data




intervention

Effect of non-pharmaceutical interventions to contain COVID-19 in China




intervention

Promoting healthy lifestyle in Chinese college students: evaluation of a social media-based intervention applying the RE-AIM framework




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

U.S. Intervention in Russia-Saudi Impasse Isn't Tenable (Radio)

Meghan L. O’Sullivan, Professor of International Affairs at Harvard’s Kennedy School, former National Security Council advisor, and a Bloomberg Opinion columnist, discusses the oil market plunge, and the Russia-Saudi relationship. Hosted by Lisa Abramowicz and Paul Sweeney.




intervention

The Military Dynamics of the Syrian Civil War and Options for Limited U.S. Intervention


The crisis in Syria continues with no end in sight, and in the Saban Center's latest Middle East Memo, Breaking the Stalemate: The Military Dynamics of the Syrian Civil War and Options for Limited U.S. Intervention, Saban Center Senior Fellow Kenneth Pollack argues that until there is a breakthrough on the battlefield, there will be no breakthroughs at the negotiating table.

In his paper, Pollack lays out the military advantages and disadvantages of both the opposition and the regime's forces, and looks at how different opportunities for U.S. intervention can affect those critical dynamics. This analysis provides a much-needed counterpoint to the debate over the possible cost of U.S. options in Syria with an analysis of their likely impact on the conflict.

Highlights include:

  • The strengths and weaknesses of the opposition, including: greater numbers, a history of deprivation of political power, the aid of Islamist militias affiliated with the Muslim Brotherhood and Salafist groups, and support from Arab and Western countries.
     
  • The strengths and weaknesses of the regime, including: motivation to defend against a determined majority, a geographic advantage, the remnants of the Syrian armed forces, help of foreign contingents like Hizballah, and the support of foreign countries like Iran and reportedly Russia and China.
     
  • Options for U.S. interventions to break the stalemate, including:
    • Training and equipping the opposition.
    • Stopping the resupply of the regime in order to diminish its ability to generate firepower.
    • Attacking regime infrastructure targets, such as military bases, power-generation plants and transportation choke points like bridges.
    • Establishing and maintaining a no-fly zone.
    • Engaging in a tactical air campaign against regime ground forces.

Downloads

Image Source: © George Ourfalian / Reuters
      
 
 




intervention

Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa


INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

Downloads

Authors

Image Source: © Handout . / Reuters
      
 
 




intervention

Turkey’s intervention in Syria and the art of coercive diplomacy

       




intervention

Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa


INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

Downloads

Authors

Image Source: © Handout . / Reuters
     
 
 




intervention

The Euro-Area Crisis: Weighing Options for Unconventional IMF Interventions

Domenico Lombardi and Sarah Puritz Milsom explore the role of the International Monetary Fund in the eurozone crisis and review the policy options that the international community must consider to strategically and effectively address the current situation.

      
 
 




intervention

Everyone says the Libya intervention was a failure. They’re wrong.


Editors' Note: It has perhaps never been more important to question the prevailing wisdom on the 2011 United States-led intervention in Libya, writes Shadi Hamid. Even with the benefits of hindsight, he argues, many of the criticisms of the intervention fall short. This post originally appeared on Vox.

Libya and the 2011 NATO intervention there have become synonymous with failure, disaster, and the Middle East being a "shit show" (to use President Obama’s colorful descriptor). It has perhaps never been more important to question this prevailing wisdom, because how we interpret Libya affects how we interpret Syria and, importantly, how we assess Obama’s foreign policy legacy.

Of course, Libya, as anyone can see, is a mess, and Americans are reasonably asking if the intervention was a mistake. But just because it’s reasonable doesn’t make it right.

Most criticisms of the intervention, even with the benefit of hindsight, fall short. It is certainly true that the intervention didn’t produce something resembling a stable democracy. This, however, was never the goal. The goal was to protect civilians and prevent a massacre.

Critics erroneously compare Libya today to any number of false ideals, but this is not the correct way to evaluate the success or failure of the intervention. To do that, we should compare Libya today to what Libya would have looked like if we hadn’t intervened. By that standard, the Libya intervention was successful: The country is better off today than it would have been had the international community allowed dictator Muammar Qaddafi to continue his rampage across the country.

Critics further assert that the intervention caused, created, or somehow led to civil war. In fact, the civil war had already started before the intervention began. As for today’s chaos, violence, and general instability, these are more plausibly tied not to the original intervention but to the international community’s failures after intervention.

The very fact that the Libya intervention and its legacy have been either distorted or misunderstood is itself evidence of a warped foreign policy discourse in the U.S., where anything short of success—in this case, Libya quickly becoming a stable, relatively democratic country—is viewed as a failure.

NATO intervened to protect civilians, not to set up a democracy

As stated in the U.N. Security Council resolution authorizing force in Libya, the goal of intervention was "to protect civilians and civilian populated areas under threat of attack." And this is what was achieved.

In February 2011, anti-Qaddafi demonstrations spread across the country. The regime responded to the nascent protest movement with lethal force, killing more than 100 people in the first few days, effectively sparking an armed rebellion. The rebels quickly lost momentum, however.

I still remember how I felt in those last days and hours as Qaddafi’s forces marched toward Benghazi. In a quite literal sense, every moment mattered, and the longer we waited, the greater the cost.

It was frightening to watch. I didn’t want to live in an America where we would stand by silently as a brutal dictator—using that distinct language of genocidaires—announced rather clearly his intentions to kill. In one speech, Qaddafi called protesters "cockroaches" and vowed to cleanse Libya "inch by inch, house by house, home by home, alleyway by alleyway."

Already, on the eve of intervention, the death toll was estimated at somewhere between 1,000 and 2,000. (This was when the international community’s tolerance for Arab Spring–related mass killings was still fairly low.)

As Obama’s advisers saw it, there were two options for military action: a no-fly zone (which, on its own, wouldn’t do much to stop Qaddafi’s tanks) or a broader resolution that would allow the U.S. and its allies to take further measures, including establishing what amounted to a floating no-drive zone around rebel forces. The president went with the latter option.

The NATO operation lasted about seven months, with an estimated death toll of around 8,000, apparently most of them combatants on both sides (although there is some lack of clarity on this, since the Libyan government doesn’t clearly define "revolutionaries" or "rebel supporters"). A Human Rights Watch investigation found that at least 72 civilians were killed as a result of the NATO air campaign, definitively contradicting speculative claims of mass casualties from the Qaddafi regime.

Claims of "mission creep" have become commonplace, most forcefully articulated by the Micah Zenko of the Council on Foreign Relations. Zenko may be right, but he asserts rather than explains why mission creep is always a bad thing. It may be that in some circumstances, the scope of a mission should be defined more broadly, rather than narrowly.

If anything, it was the Obama administration’s insistence of minimizing the mission—including the absurd claim that it would take "days, not weeks"—that was the problem from the very start. Zenko and others never make clear how civilians could have been protected as long as Qaddafi was waging war on them.

What Libya would look like today if NATO hadn’t intervened

It’s helpful to engage in a bit of counterfactual history here. As Niall Ferguson notes in his book Virtual Alternatives, "To understand how it actually was, we therefore need to understand how it actually wasn’t."

Applied to the Libyan context, this means that we’re not comparing Libya, during or after the intervention, with some imagined ideal of stable, functioning democracy. Rather, we would compare it with what we judge, to the best of our ability, the most likely alternative outcome would have been had the U.S. not intervened.

Here’s what we know: By March 19, 2011, when the NATO operation began, the death toll in Libya had risen rapidly to more than 1,000 in a relatively short amount of time, confirming Qaddafi’s longstanding reputation as someone who was willing to kill his countrymen (as well as others) in large numbers if that’s what his survival required.

There was no end in sight. After early rebel gains, Qaddafi had seized the advantage. Still, he was not in a position to deal a decisive blow to the opposition. (Nowhere in the Arab Spring era has one side in a military conflict been able to claim a clear victory, even with massive advantages in manpower, equipment, and regional backing.)

Any Libyan who had opted to take up arms was liable to be captured, arrested, or killed if Qaddafi "won," so the incentives to accept defeat were nonexistent, to say nothing of the understandable desire to not live under the rule of a brutal and maniacal strongman.

The most likely outcome, then, was a Syria-like situation of indefinite, intensifying violence. Even President Obama, who today seems unsure about the decision to intervene, acknowledged in an August 2014 interview with Thomas Friedman that "had we not intervened, it’s likely that Libya would be Syria...And so there would be more death, more disruption, more destruction."

What caused the current Libyan civil war?

Critics charge that the NATO intervention was responsible for or somehow caused Libya’s current state of chaos and instability. For instance, after leaving the Obama administration, Philip Gordon, the most senior U.S. official on the Middle East in 2013-'15, wrote: "In Iraq, the U.S. intervened and occupied, and the result was a costly disaster. In Libya, the U.S. intervened and did not occupy, and the result was a costly disaster. In Syria, the U.S. neither intervened nor occupied, and the result is a costly disaster."

The problem here is that U.S. intervention did not, in fact, result in a costly disaster, unless we are using the word "result" to simply connote that one thing happened after a previous thing. The NATO operation ended in October 2011. The current civil war in Libya began in May 2014—a full two and a half years later. The intervention and today’s violence are of course related, but this does not necessarily mean there is a causal relationship.

To argue that the current conflict in Libya is a result of the intervention, one would basically need to assume that the outbreak of civil war was inevitable, irrespective of anything that happened in the intervening 30 months.

This makes it all the more important to distinguish between the intervention itself and the international community’s subsequent failure—a failure that nearly all the relevant actors acknowledge—to plan and act for the day after and help Libyans rebuild their shattered country.

Such measures include sending training missions to help the Libyan army restructure itself (only in late 2013 did NATO provide a small team of advisers) or even sending multinational peacekeeping forces; expanding the United Nations Support Mission in Libya’s (UNSMIL) limited advisory role; and pressuring the Libyan government to consider alternatives to a dangerous and destabilizing political isolation law.

While perhaps less sexy, the U.S. and its allies could have also weighed in on institutional design and pushed back against Libya’s adoption, backed by UNSMIL, of one of world’s most counterproductive electoral systems—single non-transferable vote—along with an institutional bias favoring independents. This combination exacerbated tribal and regional divisions while making power sharing even more difficult.

Finally, the U.S. could have restrained its allies, particularly the Gulf States and Egypt, from excessive meddling in the lead-up to and early days of the 2014 civil war.

Yet Libya quickly tumbled off the American agenda. That’s not surprising, given that the Obama administration has always been suspicious of not just military entanglements but any kind of prolonged involvement—diplomatic, financial, or otherwise—in Middle East trouble spots. Libya "was farmed out to the working level," according to Dennis Ross, who served as a special assistant to President Obama until November 2011.

There was also an assumption that the Europeans would do more. This was more than just a hope; it was an organizing principle of Obama administration engagement abroad. Analysts Nina Hachigian and David Shorr have called it the "Responsibility Doctrine": a strategy of "prodding other influential nations…to help shoulder the burdens of fostering a stable, peaceful world order."

This may be the way the world should operate, but as a set of driving assumptions, this part of the Obama doctrine has proven to be wrong at best, and rather dangerous at worst.

We may not like it—and Obama certainly doesn’t—but even when the U.S. itself is not particularly involved in a given conflict, at the very least it is expected to set the agenda, convene partners, and drive international attention toward an issue that would otherwise be neglected in the morass of Middle East conflicts. The U.S., when it came to Libya, did not meet this minimal standard.

Even President Obama himself would eventually acknowledge the failure to stay engaged. As he put it to Friedman: "I think we [and] our European partners underestimated the need to come in full force if you’re going to do this."

Yet it is worth emphasizing that even with a civil war, ISIS’s capture of territory, and as many as three competing "governments," the destruction in Libya still does not come close to the level of death and destruction witnessed in Syria in the absence of intervention.

In other words, even this "worst-case scenario" falls well short of actual worst-case scenarios. According to the Libya Body Count, around 4,500 people have so far been killed over the course of 22 months of civil war.

In Syria, the death toll is about 100 times that, with more than 400,000 killed, according to the Syrian Center for Policy Research.

We’re all consequentialists now

For the reasons outlined above, Libya’s descent into civil conflict—and the resulting power vacuum, which extremist groups like ISIS eagerly filled—wasn’t inevitable. But let’s hypothesize for a moment that it was. Would that undermine support for the original intervention?

The Iraq War, to cite the most obvious example, wasn’t wrong because it led to chaos, instability, and civil war in the country. It was wrong because the decision to intervene in the first place was not justified, being based as it was on faulty premises regarding weapons of mass destruction.

If Iraq had quickly turned out "well" and become a relatively stable, flawed, yet functioning democracy, would that have retroactively justified an unjustified war? Presumably not, even though we would all be happy that Iraq was on a promising path.

The near reverse holds true for Libya. The justness of military intervention in March 2011 cannot be undone or negated retroactively. This is not the way choice or morality operates (imagine applying this standard to your personal life). This may suggest a broader philosophical divergence: Obama, according to one of his aides, is a "consequentialist."

I suspect that this, perhaps more than narrower questions of military intervention, drives at least some of the revisionism over Libya’s legacy. If we were consequentialists, it would be nearly impossible to act anywhere without some sort of preordained guarantee that a conflict area—which likely hadn’t been "stable" for years or decades—could all of a sudden stabilize.

Was the rightness of stopping the Rwandan genocide dependent on whether Rwanda could realistically become a stable democracy after the genocide was stopped? And how could policymakers make that determination, when the stabilization of any post-conflict situation is dependent, in part, not just on factual assessments but on always uncertain questions of the international community’s political will—something that is up to politicians—in committing the necessary time, attention, and resources to helping shattered countries rebuild themselves?

The idea that Libya, because it had oil and a relatively small population, would have been a relatively easy case was an odd one. Qaddafi had made sure, well in advance, that a Libya without him would be woefully unprepared to reconstruct itself.

For more than four decades, he did everything in his power to preempt any civil society organizations or real, autonomous institutions from emerging. Paranoid about competing centers of influence, Qaddafi reduced the Libyan army to a personal fiefdom. Unlike other Arab autocracies, the state and the leader were inseparable.

To think that Libya wouldn’t have encountered at least some major instability over the course of transition from one-person rule to an uncertain "something else" is to have a view of political development completely detached from both history and reality.

A distorted foreign policy discourse

The way we remember Libya suggests that the way we talk about America’s role in the world has changed, and not for the better. Americans are probably more likely to consider the Libya intervention a failure because the U.S. was at the forefront of the NATO operation. So any subsequent descent into conflict, presumably, says something about our failure, which is something we’d rather not think about.

Outside of the foreign policy community, politicians are usually criticized for what they do abroad, rather than what they don’t do. As former Secretary of Defense Robert Gates put it, "[Qaddafi] was not a threat to us anywhere. He was a threat to his own people, and that was about it." If the U.S had decided against intervention, Libya would have likely reverted to some noxious combination of dictatorship and insurgency. But we could have shirked responsibility (a sort of inverse "pottery barn" principle—if you didn’t break it, you don’t have to fix it). We could have claimed to have "done no harm," even though harm, of course, would have been done.

There was a time when the United States seemed to have a perpetual bias toward action. The instinct of leaders, more often than not, was to act militarily even in relatively small conflicts that were remote from American national security interests. Our country’s tragic experience in Iraq changed that. Inaction came to be seen as a virtue. And, to be sure, inaction is sometimes virtuous. Libya, though, was not one of those times.

Authors

Publication: Vox
      
 
 




intervention

Scaling Up Development Interventions: A Review of UNDP's Country Program in Tajikistan

A key objective of the United Nations Development Programme (UNDP) is to assist its member countries in meeting the Millennium Development Goals (MDGs). UNDP pursues this objective in various ways, including through analysis and advice to governments on the progress towards the MDGs (such as support for the preparation and monitoring Poverty Reduction Strategies, or PRSs, in poor countries), assistance for capacity building, and financial and technical support for the preparation and implementation of development programs.

The challenge of achieving the MDGs remains daunting in many countries, including Tajikistan. To do so will require that all development partners, i.e., the government, civil society, private business and donors, make every effort to scale up successful development interventions. Scaling up refers to “expanding, adapting and sustaining successful policies, programs and projects on different places and over time to reach a greater number of people.” Interventions that are successful as pilots but are not scaled up will create localized benefits for a small number of beneficiaries, but they will fail to contribute significantly to close the MDG gap.

This paper aims to assess whether and how well UNDP is supporting scaling up in its development programs in Tajikistan. While the principal purpose of this assessment was to assist the UNDP country program director and his team in Tajikistan in their scaling up efforts, it also contributes to the overall growing body of evidence on the scaling up of development interventions worldwide.

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intervention

Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa


INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

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Image Source: © Handout . / Reuters
      
 
 




intervention

U.S. Intervention in Syria: Other Options besides Military Action


At the recent celebration of the 50th anniversary of Dr. Martin Luther King’s March on Washington, Dr. King's daughter, Rev. Bernice King, cited Syria and called for international approaches rooted in love and embodying her father's commitment to nonviolence.  It is truly ironic that, after President Obama lauded King's legacy on the steps of the Lincoln Memorial, the administration announced its plans for unilateral military action to address the Syrian government’s horrific use of chemical weapons.

The situation in Syria causes us to ask:  Have all nonviolent alternatives been exhausted in accomplishing the president’s goal of responding to the brutal crimes of the Assad regime while averting a new regional (potentially global) war?

While, to date, public discourse has focused on the pros and cons of a punitive military strike, has adequate attention been given to the probability that a cruise missile strike will prompt retaliatory action—threatened by Syria, Hezbollah and Iran—against the state of Israel?  Have we considered adequately that the spiral could continue to an unthinkable escalation, keeping in mind Dr. King’s admonition that violence begets violence?  As United Nations Secretary General Ban Ki-moon stated:  "Diplomacy should be given a chance and peace given a chance.”

In sum, before authorizing or taking military action, could Congress and the administration assure us that certain steps (such as the following) have been incorporated as part of a broader regional solution?

Engage nonmilitary options in a multilateral coalition—Rather than going it alone, has the U.S. exhausted all efforts to lead a multilateral coalition to stop and punish Syrian chemical weapons use by other means under international law?  Could the pending United Nations inspections report pave the way for further multilateral interventions, ranging from global sanctions on Syria to criminal prosecution of the Assad regime at The Hague?  Could a tough U.N. sanctions resolution in response to the regime’s criminal use of chemical weapons be issued in preparation for the U.N. General Assembly this month?

Make renewed attempts to engage Russia and China, together with Track II diplomacy partners—The Russians are as concerned as the U.S. about the delivery of materials of mass destruction into terrorist hands.  The International Institute for Sustained Dialogue (IISD), its Dartmouth Conference and other Track II partners could be engaged, along with multilateral and U.S.-Russia congressional exchanges (including China and our allies) to further diplomatic action and sanctions.   

Engage Middle East and global interfaith partners—The sectarian fault lines across the Middle East require serious interfaith dialogue guided by principles and values that are common to all the Abrahamic faiths, addressing the conflict through what has been called the “relationship paradigm" of sustained dialogue. Initiatives such as the U.S.-Islamic World Forum, interfaith endeavors by Pope Francis and the Saudi king’s new interfaith center should be tapped.  A Brookings research report with Terror Free Tomorrow on the soft power effects of interfaith engagement and service in hot spots like Nigeria and South Asia illustrates this largely untapped potential.

Executive Order on Track II diplomacy, interfaith and service initiatives—President Obama could issue an executive order directing the State Department, the Defense Department, the White House Offices on Faith-Based and Neighborhood Partnerships and Social Innovation and Civic Participation, the Peace Corps and other agencies to report in 30 days on strategies and Track II partners that could further support regional solutions in the Middle East and other global hot spots.  Stepped-up multilateral emergency humanitarian aid for the mounting number of refugees from the Syrian conflict could also be marshaled with the United Nations, the Arab League, NATO and the U.S. 

In taking this “road less traveled” by charting a nonviolent direct action campaign and multilateral coalition to punish Syria and strengthen partnerships for peace, President Obama and Congress would establish a higher ground and marshal moral force with potential to break the cycle of violence, thus continuing the trailblazing legacy of Nelson Mandela, Dr. King and Gandhi.

Authors

Image Source: © JAMES LAWLER DUGGAN / Reuters
      
 
 




intervention

Define Intervention

       




intervention

Scaling Up Development Interventions: A Review of UNDP's Country Program in Tajikistan

A key objective of the United Nations Development Programme (UNDP) is to assist its member countries in meeting the Millennium Development Goals (MDGs). UNDP pursues this objective in various ways, including through analysis and advice to governments on the progress towards the MDGs (such as support for the preparation and monitoring Poverty Reduction Strategies, or PRSs, in poor countries), assistance for capacity building, and financial and technical support for the preparation and implementation of development programs.

The challenge of achieving the MDGs remains daunting in many countries, including Tajikistan. To do so will require that all development partners, i.e., the government, civil society, private business and donors, make every effort to scale up successful development interventions. Scaling up refers to “expanding, adapting and sustaining successful policies, programs and projects on different places and over time to reach a greater number of people.” Interventions that are successful as pilots but are not scaled up will create localized benefits for a small number of beneficiaries, but they will fail to contribute significantly to close the MDG gap.

This paper aims to assess whether and how well UNDP is supporting scaling up in its development programs in Tajikistan. While the principal purpose of this assessment was to assist the UNDP country program director and his team in Tajikistan in their scaling up efforts, it also contributes to the overall growing body of evidence on the scaling up of development interventions worldwide.

Downloads