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The World Health Organization (WHO) has published a global priority list of antibiotic-resistant bacteria to guide research and development (R&D) of new antibiotics. Every pathogen on this list requires R&D activity, but some are more attractive for private sector investments, as evidenced by the current antibacterial pipeline. A “pipeline coordinator” is a governmental/non-profit organization that closely tracks the antibacterial pipeline and actively supports R&D across all priority pathogens employing new financing tools.
The need for new “pull” incentives to stimulate antibiotic R&D is widely recognized. Due to the global diversity of health systems, combined with different challenges faced by antibiotics used in different types of healthcare settings, there is no one-size-fits-all solution. Instead, different “pull” incentives should be tailored to local contexts, priorities, and antibiotic types. Policymakers and industry should collaborate to identify appropriate solutions at the local, regional, and global levels.
Assessment of mental capacity is, or should be, a regular part of daily
clinical practice in general hospitals. It is both particularly important
and potentially complex in relation to an older person with dementia wishing
to return home despite concern over perceived risk. Case law provides some
guidance, but an ethical duty remains for clinicians to develop and hone
their professional judgement in this increasingly important area of
ASEAN integration offers significant gains to all members. It allows them to capture the gains from interactions with other countries both within ASEAN and with the rest of the world so as to facilitate faster economic growth and improve living standards. The gains include those from freer trade in goods and services, from more open capital flows and from transfers in technology.
Increasing economic integration with other ASEAN countries and with the world brings these benefits, but it also involves more competition and change. For example:
• Market shares are continually evolving, and new suppliers continue to emerge in the home market and in third-country markets. China and its impact on world markets is the most recent startling example, but the same processes are at work within ASEAN as well.
• Not only does competitiveness in traditional products change, but also new products emerge. The finer division of production processes, the greater complexity in global supply chains and the growth of trade in components in the region are examples.
• There are new ways of organizing business and new forms of international business. The rise in significance of trade in services in its own right and as a complement to other forms of international business is an example.
• Foreign direct investment (FDI) has always been a critical part of the business-led integration of economies in East Asia. Businesses losing competitiveness in higher income countries have relocated offshore. Now new investors are emerging, and new partnership possibilities are developing. Examples are related to the growing flows of FDI from India and from China.
These changes are all sources of benefit, but the willingness of a community to open their economy demands a level of confidence about the ability to adjust to them. The importance of this confidence and its impact on the process of integration are key issues in capturing the gains from integration. We comment on the connections between community confidence, policy reform and economic integration below.
The First Access for Shock and Trauma (FAST 1) Sternal Intraosseous (IO) System is a vascular access device designed as an alternative to peripheral or central intravenous (IV) cannulation for the treatment of critically ill and injured adults. During the development of the device, key objectives included safety, speed of insertion, and ease of use with minimal training. This study evaluated these characteristics.
Ten experienced paramedics participated in a 90-minute training program for the use of the FAST 1 System at the Paramedic Academy of the Justice Institute of British Columbia. Then, the paramedics used thesystem in three simulated prehospital scenarios and evaluated the ease of use and compatibility of the training method with current practice using a 10-centimeter (cm) (3.94 inches (in)), visual analog scale.
The duration of the procedure from opening the package to initiation of fluid flow ranged 52–127 seconds (mean = 92 ±32 seconds). Placement accuracy was excellent, with a mean displacement of 2 mm (0.08 in) and 1 mm (0.04 in) in the vertical and horizontal planes, respectively. The paramedics rated the system highly in all areas. They considered the training “straight forward” and “comprehensive”. The possibility for interference between the IO system and cervical collars was reported, and several suggestions to remedy this and achieve other improvements were made.
Placement of the FAST 1 is fast, accurate, and easy to use. Paramedics had useful input concerning the design of the product.
Various aspects of trade and investment in air transport services are regulated by a series of bilateral agreements in which rights of market access are exchanged. Industry commentators have identified this system and the associated national ownership rules as well as the prevailing attitude of competition authorities (on merger policy and on airport pricing) as the most important factors limiting adjustment in the international air transport industry. These ‘pillars of stagnation’ are examined here. Features of the bilateral agreements in aviation that are similar to those of other preferential trading agreements are noted and linked to the slow pace of policy reform in this industry. The three ‘pillars’ are not independent, and effective liberalization of trade and investment in air transport services depends on complementary regulatory reform. Options are presented on ways in which these changes might be designed and introduced, and in what sequence that might be done. Air transport services are currently excluded from the WTO's General Agreement on Trade in Services (GATS), and an important enquiry is how multilateral commitments recorded in the GATS might support reform.
Although severe traumatic brain injury (sTBI) is a devastating condition with tremendous public health implications, the epidemiology of this disease has not previously been described in Canada. We sought to define the incidence, risk factors and outcome of patients suffering sTBI in a large Canadian region.
A population-based surveillance cohort design was utilized to identify all Calgary Heath Region residents who were victims of trauma with an injury severity score ³12. Subsequent application of a specific sTBI case definition defined the final cohort.
The annual incidence of sTBI was 11.4 per 100,000 population. The incidence of sTBI was significantly higher for males as compared to females [17.1 vs. 5.9 per 100,000; relative risk (RR) = 2.91, 95% confidence interval; 2.17, 3.94; p<0.0001]. There was a striking increase in the annual age specific population incidence of sTBI observed among those older than 74 years of age. The relative risk among the highest risk group of elderly (>85 years) males as compared to the lowest risk female group (50-64 years) was 19.78 (95% CI; 6.27, 62.3; p<0.0001). One hundred and eight patients died prior to hospital discharge for a mortality rate of 5.1 per 100,000 per year.
Severe traumatic brain injury is common among residents of the Calgary Health Region and is associated with a high mortality rate. Males and the elderly are at the highest risk for acquiring sTBI and may represent target groups for preventive efforts.
Les lÉsions cÉrÉbrales par traumatisme crânien sÉvère sont frÉquentes parmi les rÉsidents de la rÉgion sanitaire de Calgary et sont associÉes à une mortalitÉ ÉlevÉe. Les hommes et les personnes âgÉes sont les groupes les plus à risque et constituent des groupes cibles pour les interventions à visÉe prÉventive.
Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.
Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.
Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.
Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.
Carotid angioplasty and stenting:
Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.
It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.
Conifer needles, like many grasses, are infected by systemic fungal endophytes. Following suggestions made in the early 1980s that (1) conifer needle endophytes may produce anti-insectan compounds, and (2) population dynamics of the eastern spruce budworm in New Brunswick could not be completely explained based on existing knowledge, we discovered that a low percentage of needle endophytes made a range of known and new metabolites toxic to this insect. Here, we report that wound inoculations of toxigenic endophytes of seedlings from a breeding population of white spruce were successful across a range of genotypes. The needles colonized by a rugulosin-producing endophyte were found to contain rugulosin in concentrations that are effective in vitro at retarding the growth of spruce budworm larvae. Larvae presented with endophyte infected needles containing rugulosin do not gain as much weight as those eating uncolonized needles. This represents the first positive evidence that the kind of mutualism between toxigenic endophytes and grasses affecting insect herbivory also may occur in white spruce.
Aneurysms arising from lenticulostriate artery branches in moyamoya-type disease are challenging lesions to treat, due to their fragility and deep location. Surgery is difficult and endovascular options may be limited.
A 57-year-old woman presented with a right ganglionic parenchymal hemorrhage due to a ruptured lenticulostriate artery aneurysm associated with ipsilateral middle cerebral artery occlusion. The aneurysm and parent feeding artery were occluded using endovascular injection of N-butyl cyanoacrylate.
The aneurysm was successfully obliterated and although some glue did enter the more distal middle cerebral artery, there was no change in the patient's neurologic status.
In highly selected cases where lenticulostriate aneurysms cannot be directly accessed for surgery or endovascular coiling, obliteration with liquid acrylic glue may be considered as a therapeutic option.