**4. Discussion**

The research question was analyzed and addressed from the perspective of the following dimensions: (1) Market Dimension: Companies that address their strategies mostly around marketing (market) have a lower development of endogenous processes. This shows that there is less progression in obtaining a long-term competitive advantage, but rather in achieving an immediate market position; (2) Organization Dimension: This should be the most relevant dimension because it is in the organization where business strategy is defined. However, this is not evidenced in the case of the Chilean construction industry; (3) Project Dimension: The management of sustainable processes allows evaluating and improving performance or environmental risks of future projects, although in practice this is not addressed; (4) Processes Dimension: An additional precedent is market pressure, which forces a public relations' reaction from the company, with the subsequent disregard of internal processes, especially present in the residential construction industry.

Although mining construction companies are aware of potential environmental damage, they tend to only respond in compliance with either world-class standards or industry sustainability requirements. All business strategies are directly assessed by society and can generate positive or negative effects if decisions are not properly sized; the cost of inaction could destroy the company's social position with significant consequences for the business.

The importance and understanding of the Marketing sub-dimension is observed in all dimensions of the companies surveyed. However, this importance declines in the following order: organization, project and process, which is consistent with the importance given to the market, along with less intra-organizational promotion. Although a great deal of effort is focused on the Market, there is a gap in (a) understanding the social responsibility-related needs and demands raised by the market; and (b) incorporating bottom-up knowledge from workers who already have ideas about the transformation of sustainable processes. To address these issues in practice, it is important to have innovative employees with the ability and vision to redesign products, processes and business models. Above all, these employees must be able to coherently justify why this journey is a meaningful one [74].

Figure 4 shows a gradual change within the organization, starting with the strategic decision and projecting to the process dimension to conceive the market dimension. This ideal situation takes the shape of a snail; this is compared with the survey's results, privileging the market's public relations response, which takes a more diffuse and disorganized shape (stain) in the direction opposite from the snail. This represents a rapid adaptation of the processes needed to meet the project requirements through design, construction and facilities, albeit in the absence of the traceability of the company's strategic decisions (senior management), which seems diminished in relation to these sub-dimensions. It is interesting to pay attention to the points projecting outside the snail, which both indicate the current situation and show Chilean construction firms' lack of a sustainable strategic plan. Decisions that contribute to defining sustainable construction strategies must be conceived as part of a system involving the whole company. One common mistake is to address decisions separately. The policy should be transversal, primarily adopted in the internal process and then projected to the market. Good decisions should not be conceived separately because this makes them more diffuse and increases the

risk of inaccurate results; neither should independent decisions be fused together. Synergies should be found so that the result is successful.

**Figure 4.** Comparison of endogenous change (ideal, snail-shaped) versus approach based on market response (current situation, irregularly shaped).

Despite the undisputable importance of waste management and recycling, the construction industry takes time to incorporate efficient internal processes, thus placing endogenous strategies at a disadvantage. This is seen in the fact that Construction is the most highly evaluated dimension (average score of 13.25, see Rankings in Table 5), and other dimensions have lower scores, such as Service (9.25), Acquisition and Supply Chain (8.83) and Finance (8.41). Thus, there is greater concern for the delivery of energy-efficient installations to the market. In contrast, water and material recycling from companies' own construction processes are not favored with the same intensity, which reveals the companies' lack of interest in endogenous change.

One of the advantages of endogenous change is the transmission of a company's own knowledge and culture toward the organization and the market, along with the implementation of strategies focused on the project that incorporates sustainable processes. As seen in this study's results, influence is exerted from the company's core. However, it should be exerted from the senior management level in response to the strategic definition.

Respondents not only adhere to the immediate need to rethink strategies but also visualize fertile ground for implementing sustainable strategies; this is indicated by the 79% who responded that the new sustainable business model is "Applicable in the company". Nevertheless, respondents also recognize the implied positive impact on society and the economic benefit for the company, evidenced by the 88% support for the "Importance of Sustainability".

Thirty-six percent of respondents indicated that they favor energy-efficient solutions because of new building requirements or new market demands. The residential construction sector is gradually realizing that has to move towards sustainability because (a) construction operations interfere with society and affect the community's quality of life; (b) certain processes are more beneficial for workers; (c) certain practices are economically viable; and (d) they can achieve greater profitability and social acceptance in the process.

The structured function of sustainability, defined as a permanent role, has a significant impact on both the supply chain and the sustainability of services. The reason is that the Sustainability Function is responsible for disseminating strategy from the senior management level and coordinating all of the company's processes with an economic, social and environmental approach, boosting actions in the primary processes in which practices should be internalized. Notwithstanding, the Sustainability Function is the least valued sub-dimension (7.85, see Table 5). The sustainability role is important in (a) sustaining a plan of activities aimed at involving workers based on different approaches; (b) adequately communicating senior management's vision; (c) transferring intra-organizational knowledge; (d) encouraging practices through incentives; (e) developing policies; (f) managing technical counterparts; (g) consistently articulating processes; and (h) guiding efforts and collecting and transmitting new social, economic and environmental requirements.

Although adaptation to this context seems irreversible, companies can dangerously delay this change until they are not experiencing regulatory pressure. This traditional approach could put the company at a disadvantage compared with competing companies that have accepted the impending change and have decided both to act and to be consistent with the sustainable model. Therefore, conceiving a sustainable vision and acting accordingly will confer a competitive advantage, provided the company reacts in time.

It should be noted that the process of generating strategies is a learning and dynamic process; therefore, it involves a permanent adjustment in which decisions can also be reversed for consistency with the results of other decisions. Practices that are applied as part of a sustainable process should be supported by major decisions involving other overall aspects of the process, probably driven by the market but strengthened by internal processes.

To identify how sustainability has been incorporated into companies operating in Chile, Ernst and Young surveyed 407 business executives from different sectors (e.g., retail, mining, energy, manufacturing, and telecommunications). When asked whether their companies have implemented a sustainability strategy, 51% answered "yes". This is a surprising answer because most of the surveyed companies do not have a sustainability strategy that includes this area in their core business, which should be aligned with their strategy [75]. When comparing this survey with the construction industry survey presented in this paper, it is evident that the construction industry has delayed longer in implementing sustainable strategies. Only 32% of respondents had an overall assessment of their companies' sustainability strategies, thereby demonstrating that the construction industry takes more time than other industries to incorporate sustainable strategies. This is consistent with the degree of importance attributed to sustainability. However, companies do recognize the importance and applicability of providing a high degree of value to sustainability in the company.

Similar results are found worldwide. International studies show agreement about CEOs of different productive sectors about the relevance of corporate sustainability for the business model, while their attitude towards sustainability has increased significantly. For example, the report "A New Era of Sustainability" [76] shows the results of a survey conducted to 766 CEOs of 13 productive sectors in 100 countries. This report reveals that 93% of 766 CEOs believe that taking care of sustainability issues in advance will be critical to their businesses' future success, whereas 96% believe that sustainability issues should be fully integrated into their companies' strategy and operations [76]. This report also shows a significant increase of the CEOs attitude toward sustainability which increases from 72% in 2007 to 96% in 2010. Other survey based-study carried out by the Massachusetts Institute of Technology in 2012 involved 2874 managers and executives from 113 countries [77]. The study shows that 70% of firms have incorporated sustainability on their management agendas, while 66% of respondents indicates that sustainability was crucial to be competitive under today's market and social demands. Moreover, this study found 31% of companies are currently profiting from sustainable business practices. The results of these international and national studies as well as the results shown in this paper agree that companies' commitment toward sustainability is increasing significantly because this is key for competitive advantages and company's long-term permanence.


**Jia-Fong Jhang**

Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 97047, Taiwan<EMAIL_ADDRESS>Tel.: +886-3865-1825

Received: 16 September 2019; Accepted: 31 October 2019; Published: 4 November 2019

**Abstract:** Treatment for patients with interstitial cystitis/bladder pain syndrome (IC/BPS) is always challenging for urologists. The main mechanism of the botulinum toxin A (BoNT-A) is inhibition of muscle contraction, but the indirect sensory modulation and anti-inflammatory effect in the bladder also play important roles in treating patients with IC/BPS. Although current guidelines consider BoNT-A injection to be a standard treatment, some practical issues remain debatable. Most clinical evidence of this treatment comes from retrospective uncontrolled studies, and only two randomized placebo-control studies with limited patient numbers have been published. Although 100 U BoNT-A is effective for most patients with IC/BPS, the potential efficacy of 200 U BoNT-A has not been evaluated. Both trigone and diffuse body BoNT-A injections are effective and safe for IC/BPS, although comparison studies are lacking. For IC/BPS patients with Hunner's lesion, the efficacy of BoNT-A injection remains controversial. Most patients with IC/BPS experience symptomatic relapse at six to nine months after a BoNT-A injection, although repeated injections exhibit a persistent therapeutic effect in long-term follow-up. Further randomized placebo-controlled studies with a larger number of patients are needed to support BoNT-A as standard treatment for patients with IC/BPS.

**Keywords:** interstitial cystitis; inflammation; treatment; Botulinum toxin

**Key Contribution:** This review summarized the mechanisms of using botulinum toxin for interstitial cystitis, and presented several clinical debatable practical issues which should be noticed by clinicians.


*2.10. Statistical Analysis*

The data derived from control and ZIKV-infected placentae obtained from the relative mean fluorescence intensity images and Western blot densitometry analysis were compared for statistically significant differences using the Mann-Whitney *U* test. The variances obtained with claudin-4 results were equal among the two groups; therefore, we applied a Student's *t*-test to include effect size estimations; since both groups had similar standard deviations, we used Cohen's *d*. For the Western blots of occludin, the data were further analyzed to include effect size estimation with Glass'delta, since each group had a different standard deviation. The Graphs were generated with GraphPad Prism 5.01 software (GraphPad Prism 5.01, La Jolla, CA, USA, 2007).