Strategies for achieving global collective action on antimicrobial resistance.

Global governance and market failures mean that it is not possible to ensure access to antimicrobial medicines of sustainable effectiveness. Many people work to overcome these failures, but their institutions and initiatives are insufficiently coordinated, led and financed. Options for promoting global collective action on antimicrobial access and effectiveness include building institutions, crafting incentives and mobilizing interests. No single option is sufficient to tackle all the challenges associated with antimicrobial resistance. Promising institutional options include monitored milestones and an inter-agency task force. A global pooled fund could be used to craft incentives and a special representative nominated as an interest mobilizer. There are three policy components to the problem of antimicrobials--ensuring access, conservation and innovation. To address all three components, the right mix of options needs to be matched with an effective forum and may need to be supported by an international legal framework.

Les dysfonctionnements de la gouvernance et du marché à l'échelle mondiale se traduisent par une impossibilité de garantir l'accès à des médicaments antimicrobiens durablement efficaces. De nombreuses personnes s'emploient à pallier ces dysfonctionnements, mais leurs institutions et leurs initiatives manquent de coordination, de direction et de moyens financiers. La création d'institutions, l'élaboration de mesures d'incitation et la mobilisation des parties intéressées font partie des options possibles pour promouvoir une action collective mondiale sur l'accès aux antimicrobiens et sur leur efficacité. Aucune option isolée ne suffira à venir à bout de tous les problèmes associés à la résistance aux antimicrobiens. Parmi les options institutionnelles prometteuses, il convient de mentionner le suivi des étapes importantes et une équipe spéciale interorganisations. Des fonds mis en commun à l'échelle mondiale pourraient être utilisés pour élaborer des mesures d'incitation et un représentant spécial pourrait être chargé de mobiliser les parties intéressées. Le problème des antimicrobiens comporte trois aspects stratégiques: garantir l'accès, la conservation et l'innovation. Pour agir à l'égard de ces trois aspects, il est nécessaire d'associer les options, harmonieusement combinées, à une structure efficace et, peut-être, de les inscrire dans un cadre juridique international.

Los fracasos de gobernanza mundial y de los mercados significan que no es posible garantizar el acceso a medicamentos antimicrobianos de efectividad sostenible. Muchas personas trabajan para solucionar estos problemas, pero sus instituciones e iniciativas no están lo suficientemente coordinadas, guiadas y financiadas. Las opciones para promocionar una acción colectiva global en cuanto al acceso a los antimicrobianos y la efectividad incluyen la creación de instituciones, la elaboración de incentivos y la movilización de intereses. Ninguna opción por sí sola es suficiente para afrontar todos los desafíos asociados con la resistencia a los antimicrobianos. Las opciones institucionales prometedoras incluyen hitos supervisados y un grupo de acción interinstitucional. Se podría utilizar un fondo combinado global para elaborar incentivos y nominar un representante especial como un movilizador de intereses. El problema de los antimicrobianos tiene tres componentes de las políticas: asegurar el acceso, la conservación y la innovación. Para abordar los tres componentes se necesita que la mezcla correcta de opciones se una a un foro efectivo, y podría necesitar el apoyo de un marco legal internacional.

[Assessment of complications of major orthopedic surgery: comparison of indobufen, calcium heparin, and low molecular heparin]. / Valutazione delle complicanze in chirurgia ortopedica maggiore: confronto tra indobufene, eparina calcica ed eparina a basso peso molecolare.

OBJECTIVE: Evaluation of incidence of postoperative thrombotic and haemorrhagic complications in autotrasfused patients undergoing blood predepositing, hemodilution, intra and postoperative blood saving and treated with indobufen, heparin calcine and low molecular weight heparin (enoxeparin). EXPERIMENTAL DESIGN: Comparative study. Length of follow up: 6 months. SETTING: Three division of Orthopaedic Surgery related to 1st Anaesthesiology and Intensive Care Unit of Rizzoli Orthopaedic Institute. PATIENTS: 980 consecutive patients admitted to hospital from 1-1-1992 to 30-6-1994 (321 males and 159 females), aged between 20 and 90 years (mean 62 +/- 11 years), with basal hemoglobin at 13.4 +/- 1.4 g/dI (range 6.7-17.9), who had undergone antithromboembolic prophylaxis with indobufen (Indo, 668), heparin calcine (CaHe, 200) and low molecular weight heparin (LMWH). INTERVENTIONS: Total hip (714) and knee (121) arthroprosthesis and hip replacements (cup 33, stem 10, cup and stem 102). MEASUREMENTS: The incidence of death, thromboembolic complications (pulmonary embolism, deep vein thrombosis), hemorrhage (hematoma and homologous transfusions), cardiac ischaemia. ANOVA and contingency tables (CT) were used for statistical. RESULTS: The absence of complications was significantly greater in patients treated with indobufen (Indo 94.3% vs CaHe 83.5% vs LMWH 85.7%, CT: p = 0.0001); the incidence of thromboembolic complications was significantly higher in patients treated with heparin calcine and low molecular weight heparin; in patients treated with heparin calcine the incidence of haemorrhagic complications was significantly higher. Due to bleeding brought about by the use of heparin calcine, one patient with coronary heart disease suffered from anemia and severe hypotensions by myocardiac infarction and cardiogenous shock which led to the patient's death. The use of homologous transfusions was significantly higher in patients treated with heparin calcine (Indo 4.2% vs CaHe 14.5% vs LMWH 4.5%, CT: p = 0.0001). CONCLUSIONS: In patients undergoing autotransfusion and hemodilution, indobufen has a lower of haemorrhagic complications compared to heparine calcine and low molecular weight heparin and it is more effective in the prevention of thrombotic complications at clinical evidence.