Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Longitudinal analysis of income-related health inequality

This paper considers the characterisation and measurement of income-related health inequality using longitudinal data. The paper elucidates the nature of the Jones and Lopez Nicholas (2004) index of “health-related income mobility” and explains the negative values of the index that have been reported in all the empirical applications to date. The paper further questions the value of their index to health policymakers and proposes an alternative index of “income-related health mobility” that measures whether the pattern of health changes is biased in favour of those with initially high or low incomes. We illustrate our work by investigating mobility in the General Health Questionnaire measure of psychological well-being over the first nine waves of the British Household Panel Survey from 1991 to 1999.

Développement d'indicateurs pour le contrat de prestations 2008 entre le Cipret et le Département de l'économie et de la santé (DES) : élaboration d'une théorie d'action du Cipret Genève selon le Modèle de catégorisation des résultats de Promotion Santé Suisse

[Table des matières] 1. Introduction. 2. Méthode. 3. Théorie d'action et plan de monitorage des résultats des activités du Cipret (Centre d'information et de prévention du tabagisme) : priorités pour l'année 2008: Axe 1: Informer sur les conséquences de la consommation de tabac et sur la promotion de la santé. Axe 2: Contribuer à la cohérence de la politique de santé publique en matière de tabac. Axe 3: Diminuer le nombre de nouveaux fumeurs. Axe 4: Aider au sevrage du tabac. Annexes.

The Impact of Higher Education Institution-Firm Knowledge Links on Firm-level Productivity in Britain

This paper estimates whether both sourcing knowledge from and/or cooperating on innovation with HEIs (Higher Education Institutions)1 impacts on establishment-level total factor productivity (TFP) using a dataset created by merging the UK government’s Community Innovation Survey (CIS) with the Annual Respondents Database (ARD). It also considers whether higher graduate employment (as a measure of human capital) also impacts positively on TFP at the establishment-level. Many studies have investigated the relationship between university-firm knowledge links and innovation (see, for example, Mansfield, 1991; Becker, 2003; Thorn et al, 2007). Most of these studies find a positive impact. Fewer studies have investigated the impact of university-firm knowledge links on productivity. Belderbos et al. (2004), using the Dutch CIS, find that cooperation with universities has no statistically significant impact on the growth of labour productivity. Medda et al. (2005) find no statistically significant effect of collaborative research undertaken by Italian manufacturing firms and universities on the growth of TFP. Arvanitis et al. (2008), using Swiss data, show that university-firm knowledge and technology transfer has both a direct impact on labour productivity and an indirect impact through its positive impact on innovation. In sum, there is as yet no clear consensus as to the impact of university-firm knowledge links on productivity.

The Prospects for Activity in the UKCS to 2035: the 2008 Perspective

NORTH SEA STUDY OCCASIONAL PAPER No. 109

Hodgkin's lymphoma mortality in the Americas, 1997-2008: Achievements and persistent inadequacies.

Although therapeutic advancements have made Hodgkin's lymphoma (HL) a largely curable disease, trends in HL mortality have been variable across countries. To provide updated information on HL mortality in the Americas, overall and 20-44 years age-standardized (world population) mortality rates from HL were derived for the 12 Latin American countries providing valid data to the World Health Organization database and with more than two million of inhabitants. For comparative purpose, data for the United States and Canada were also presented. Trends in mortality over the 1997 to 2008 period are based on joinpoint regression analysis. Declines in HL mortality were registered in all Latin American countries except in Venezuela. In most recent years, HL mortality had fallen to about 0.3/100,000 men and 0.2/100,000 women in Argentina, Brazil, Chile, Colombia, Ecuador and Guatemala, that is, to values similar to North America. Despite some declines, rates remained high in Cuba (1/100,000 men and 0.7/100,000 women), Costa Rica and Mexico as well as in Venezuela (between 0.5 and 0.6/100,000 men and between 0.3 and 0.5/100,000 women). In young adults, trends were more favorable in all Latin American countries except Cuba, whose rates remained exceedingly high (0.8/100,000 men and 0.6/100,000 women). Thus, appreciable declines in HL mortality were observed in most Latin America over the last decade, and several major countries reached values comparable to North America. Substantial excess mortality was still observed in Cuba, Costa Rica, Mexico and Venezuela, calling for urgent interventions to improve HL management in these countries.

La noción de jurisdicción en el Convenio Europeo de Derechos Humanos y su repercusión extraterritorial en el marco de los conflictos armados

Proyecto de investigación realizado a partir de una estancia en el Institut des Hautes Etudes Européennes, Francia, entre febrero y diciembre del 2007. El Consejo de Europa es una organización internacional que nació de los escombros de la Segunda Guerra Mundial, en 1949, con la voluntad de los Estados fundadores de unir más estrechamente a sus miembros, y con el objetivo fundamental de “salvaguardar y proteger los ideales y principios que son su patrimonio común, así como favorecer su progreso económico y social”. Cada uno de sus Estados Miembros reconoce el principio de la preeminencia del Derecho y el principio en virtud del cual, toda persona que se halle bajo su jurisdicción, ha de gozar de los derechos humanos y de las libertades fundamentales”. Por ello, la firma del Convenio Europeo de Derechos Humanos es condición indispensable para adherirse a la Organización. Como el derecho de reconocimiento de recurso individual y la jurisdicción del Tribunal son ahora, desde la entrada en vigor del Protocolo Nº 11, obligatorios para todo Estado parte al Convenio, cualquier persona sometida a la jurisdicción de cualquiera de los 46 Estados, puede acudir al Tribunal Europeo de Derechos Humanos para quejarse de la vulneración de sus derechos fundamentales. Esta cuestión implica que las reclamaciones relativas a los conflictos armados se examinan caso por caso, sin que el Tribunal pueda intervenir de otra forma que no sea, dentro del marco de sus competencias exclusivamente jurisdiccionales, mediante el examen de los casos concretos presentados ante él.

La problemática jurídica en la fotografía de prensa en España entre los años 1978-2008

El Treball Final de Carrera analitza el dret a la informació dintre de la fotografia de premsa espanyola durant els últims trenta anys fent una anàlisi jurídica i sintàctica d'algunes imatges representatives durant el període 1978-2008.

La Guerra asimétrica : olvidando la historia

Desde los años noventa del pasado siglo estamos asistiendo a la proliferación de estudios que se centran en el análisis de los conflictos bélicos más recientes y sobre todo desde el 11 de septiembre de 2001, también el fenoméno terrorista. Términos como "guerra asimétrica", "guerra irregular", "guerra sin restricciones", "guerras de cuarta generación" han pasado a formar parte del lenguaje común de políticos, militares y analistas. Igualmente, expresiones como "nuevas guerras", "nuevos conflictos" y otras similares han adquirido casi la categoria de auténticos "comodines" empleados de forma tan recurrente que no utilizarlos empieza a ser síntoma de excentricidad. Cabe aducir dos objeciones relevantes a esta proliferación conceptual. En primer lugar, que los diversos conceptos con que se intentan definir las guerras y conflictos más recientes, tienden a llamar de otra manera a lo que tradicionalmente se ha denominado "guerra irregular". En segundo lugar, la insistencia en el uso de adjetivo "nuevo" releva un a carencia en esta clase de estudios.