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Purpose As evacuation is one of the most used response actions to such disasters, it is essential to understand correctly what a resilient evacuation would mean. One critical factor in evacuation resilience is the resilience level of evacuation infrastructures. Also, UN sustainable development has a goal to build resilient infrastructures. This study aims to investigate the characteristics of resilient evacuation infrastructures. Design/methodology/approach A systematic methodology for reviewing articles has been implemented to understand how vulnerable cities can be more prepared, especially for pedestrian evacuation. Findings This study has developed an evacuation scoring system framework for pedestrians to investigate evacuation infrastructure in terms of different resilience features, such as redundancy, safe-to-fail, readiness and capacity. The most practical evacuation system will be estimated. The output of this study can provide insight into a final output to provide the features of a successful pedestrian evacuation system for future policy drafting for infrastructure strategy decision-makers. Practical implications Climate change has made the risks of natural hazards such as tsunamis more intense for humans. Many people in the world live in hazardous environments and are susceptible to disasters. A community must be prepared to mitigate the destructive event and quickly respond to be called resilient. Originality/value This is an original work. The researcher has gone through a deep literature review and developed a cluster showing the features a resilient evacuation infrastructure should have.

There is growing interest in using serious games for a wide range of applications, from water resources management, to surgery simulations, to pilot training. At the same time, there is rapidly growing interest in the water-energy-food/land-climate nexus, where interactions in one sector can lead to impacts in other sectors, some of which may be hard to predict due to complexity and feedback. However, common practice still revolves around sectoral silos, with relatively little interaction or consideration of wider impacts. Serious games could help erode some of these silos, fostering efforts towards holistic policy making that accounts for systemic impacts of policy decisions in a safe space, where potential impacts (unforeseen or otherwise) can be explored and assessed without real consequences. One current major point of criticism of some serious games is their lack of policy relevance. SIM4NEXUS (www.sim4nexus.eu) is an ongoing H2020 research project that will develop policy-relevant serious games for 12 case studies in scale from sub-national to global. This is being achieved by close case study stakeholder involvement at every step in the process, from qualitative system design and conceptualisation, policy analysis and selection, quantitative model development and serious game testing and playing. SIM4NEXUS covers five nexus sectors (water, energy, land, food and climate) and develops quantitative, scientifically-robust system dynamics models to quantify and explore the nexus relationships for each of the 12 cases. In this way, models can explore the impacts of changes in one sector (e.g. due to policy actions) both within that sector and on all other related nexus sectors. The SIM4NEXUS serious games ‘play’ the underlying models, but in a way accessible to others not familiar or involved with the model development process. Through intelligent game design and the link to the quantitative models, nexus-wide policy and climate impacts can be clearly and effectively communicated to stakeholders and policy makers in each case study while also being fun to play, offering opportunity for nexus exploration in an educational setting. This work details the entire process in SIM4NEXUS, going from system conceptualisation, through quantitative model development and ending up at the serious game, emphasising the constant stakeholder collaboration to ensure that the research and outputs remain relevant and accessible.

Many people in the world live in hazardous environments and are susceptible to disasters. In the time of a destructive event, a resilient community must be prepared to mitigate the event and quickly respond. An effective mitigation plan can lead to fewer fatalities and damages. One of the most critical tasks for mitigation is the evacuation process. Wherein short notice time, overcrowding, bottlenecks in infrastructure and challenging terrain and topography may worsen the situation. Amongst other things, the evacuation process encompasses transportation infrastructures referred to as corridors, signs, pedestrian footpaths, and/or shelter infrastructures for keeping people safe. Evacuation infrastructure can also become damaged after the event; therefore, it’s imperative to have a robust assessment of different evacuation infrastructures. This study will investigate the characteristics of the available evacuation infrastructure and outline the general drawbacks. A systematic methodology for reviewing articles has been implemented to understand how vulnerable cities can be more prepared, especially for pedestrian evacuation. An evacuation scoring system for pedestrians will be developed to investigate evacuation infrastructure in terms of different resilience features, such as redundancy, safe to fail, readiness, capacity. The most practical evacuation system will be estimated, with a final output being to provide the features of a successful pedestrian evacuation system for future policy use.

In this article, we evaluate property flood resilience (PFR) to manage pluvial and combined tidal/ fluvial flood risks. We achieve this by evaluating flood risk and intervention targeting strategies across a case study in Bristol (UK) using data types generally available for preliminary option assessment. We investigate opportunities for mitigating flood damages within catchments using PFR and evaluate two targeting strategies: Installing PFR across strategic areas of a catchment and targeting interventions at specific high‐risk properties. We find that individually targeting PFR is more effective than focusing resources on specific high‐risk areas. Targeting pluvial flood measures at individual properties across our case study provides an average annual benefit per property of approximately £750 more than applying zonal targeting, supporting use of high‐resolution modelling in surface water management, and highlighting the applicability of PFR to manage damages at specific high‐risk properties which may not fall under the protection of community level defences. A similar approach provides the best outcomes for fluvial targeting; however, the hazard is more concentrated and so a zonal targeting approach may be more acceptable. Overall, we find resistance based PFR an effective intervention to mitigate damages, however complementary strategies are required when managing extreme flooding.

The results of recent climate projections for the city of Barcelona show a relevant increment of the maximum rainfall intensities for the period 2071&ndash, 2100. Considering the city as a system of systems, urban resilience is strictly linked to the proper functioning of urban services and the knowledge of the cascading effects that may occur in the case of the failure of one or more critical infrastructures of a particular strategic sector. In this context, the aim of this paper is to assess urban resilience through the analysis of the behavior of the main urban services in case of pluvial floods for current and future rainfall conditions due to climate change. A comprehensive flood risk assessment including direct, indirect, tangible and intangible impacts has been performed using cutting edge sectorial and integrated models to analyze the resilience of different urban services (urban drainage, traffic, electric and waste sectors) and their cascade effects. In addition, the paper shows how the information generated by these models can be employed to feed a more holistic analysis to provide a general overview of the city&rsquo, s resilience in the case of extreme rainfall events. According to the obtained results, Barcelona could suffer a significant increase of socio-economic impacts due to climate change if adaptation measures are not adopted. In several cases, these impacts have been geographically distributed showing the specific situation of each district of the city for current and future scenarios. This information is essential for the justification and prioritization of the implementation of adaptation measures.

This paper outlines the work carried out within the RESCCUE (RESilience to cope with Climate Change in Urban ArEas) project that is, in part, examining the impacts of climate-driven hazards on critical services and infrastructures within cities. In this paper, we examined the methods employed to assess the impacts of pluvial flooding events for varying return periods for present-day (Baseline) and future Climate Change with no adaptation measures applied (Business as Usual) conditions on traffic flows within cities. Two cities were selected, Barcelona and Bristol, with the former using a meso-scale and the latter a micro-scale traffic model. The results show how as the severity of flooding increases the disruption/impacts on traffic flows increase and how the effects of climate change will increase these impacts accordingly.

Expanding populations and increased urbanisation are causing a strain on cities worldwide as they become more frequently and more severely affected by extreme weather conditions. Critical services and infrastructure are feeling increasing pressure to be maintained in a sustainable way under these combined stresses. Methods to better cope with these demanding factors are greatly needed now, and with the predicted impacts of climate change, further adaptation will become essential for the future. All cities comprise a complex of interdependent systems representing critical operations that cannot function properly independently, or be fully understood in isolation of one another. The consequences of localised flooding can become much more widespread due to the inter-relation of these connected systems. Due to reliance upon one another and this connectedness, an all-encompassing assessment is appropriate. Different model representations are available for different services and integrating these enables consideration of these cascading effects. In the case study city of Bristol, 1D and 2D hydraulic modelling predicting the location and severity of flooding has been used in conjunction with modelling of road traffic and energy supply by linking models established for these respective sectors. This enables identification of key vulnerabilities to prioritise resources and enhance city resilience against future sea-level rise and the more intense rainfall conditions anticipated.

RESCCUE is an H2020 research project that aims to help cities around the world to become more resilient to physical, social, and economic challenges, using the water sector as the central point of the approach. Since 2016, RESCCUE has been developing methodologies and tools to support cities increase their resilience. The three RESCCUE cities, Barcelona, Bristol, and Lisbon, have become a testing platform for the cutting-edge technologies developed in RESCCUE but these are also ready to be deployed to different types of cities, with different climate change pressures. This paper presents some of the main outputs generated by RESCCUE. From climate change scenarios to dissemination tools, and from sectorial models to Resilience Action Plans (RAPs), the outputs that have been produced are very diverse, but special focus is put on the urban water cycle and urban floods. All the project results have a common goal: to increase the resilience of cities from around the world, by offering the methodologies and tools so anyone can take advantage of using them and replicate the RESCCUE results. This research was funded by Horizon2020 Programme, Grant Agreement No. 700174. This paper presents some of the results achieved in the framework of the RESCCUE project (Resilience to Cope with Climate Change in Urban Areas—A multisectoral approach focusing on water) (www.resccue.eu). RESCCUE is a research project funded by the European Commission under the H2020 program, and its main goal is to provide methodologies and tools for the evaluation, planning and management of urban resilience in the context of climate change.

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This study proposes a modelling framework of integrated one-dimensional (1D) and two-dimensional (2D) hydrodynamic modelling to evaluate the effectiveness of sponge city construction at community scale. Through a case study in Zhuhai, we integrate Stormwater Management Model (SWMM) and Cellular Automata Dual-DraInagE Simulation (CADDIES) 2D model to analyze the rainfall-runoff process involving green infrastructures. SWMM is applied to analyze the change of surface runoff control effects before and after the implementation of sponge city low impact development (LID) facilities, and CADDIES is adopted to simulate the propagation of excess runoff on the surface. The results show that the LID facilities can effectively reduce the runoff volume of small and medium-sized rainfall events since the maximum runoff reduction rate is 94.4%. For long-term operation, the LID can capture 52.9% of annual rainfall volume and reduce annual runoff by 28.0%. However, the CADDIES 2D model simulations indicate that LID facilities have little effect on flood alleviation in specific regions under extreme rainfall conditions. In addition, we compared the modelling performance using four different terrain Digital Elevation Model (DEM) resolutions and found that 1 m terrain DEM resolution can produce comparable results to 0.25 m DEM with a fraction of computational time. We also find that the MIKE FLOOD model and the integrated model of SWMM and CADDIES 2D can obtain similar simulation results, the p-value = 0.09 which is >0.05, but SWMM-CADDIES integrated model is more suitable for small-scale simulation.

Water, land, food, energy, and climate are all interconnected, comprising a coherent system (the ‘Nexus’), dominated by complexity and feedback. The interactions between these different nexus components and their responses to climate change conditions are complicated as each feedback into the other. Consequently future policies should take into account the whole Nexus, when it comes to ascertain their long term impact on the system. This paper presents the conception of a System Dynamic Model (SDM) representing the Nexus, populating it with data from various sources (including output from specific thematic models covering different Nexus components), under different climate change and socioeconomic pathway scenarios. The SDM is then converted into R scripting to be included in the Knowledge Elicitation Engine (KEE) communicating with a Serious Game (SG). Models and games are built specifically for ten Case Studies, at regional, national, continental and global level. The SG is being developed for decision making for local stakeholders to study and get acquainted to long term impacts of different policies on the Nexus. In this paper the regional Case Study of Sardinia is presented as proof of concept.

Impacts from floods in urban areas can be diverse and wide ranging. These can include the loss of human life, infrastructure and property damages, as well as other kinds of nuisance and inconvenience to urban life. Hence, the ability to identify and quantify wider ranging effects from floods is of the utmost importance to urban flood managers and infrastructure operators. The present work provides a contribution in this direction and describes a methodological framework for analysing cascading effects from floods that has been applied for the Sukhumvit area in Bangkok (Thailand). It demonstrates that the effects from floods can be much broader in their reach and magnitude than the sole impacts incurred from direct and immediate losses. In Sukhumvit, these include loss of critical services, assets and goods, traffic congestion and delays in transportation, loss of business and income, disturbances and discomfort to the residents, and all these can be traced with the careful analysis of cascading effects. The present work explored the use of different visualization options to present the findings. These include a casual loop diagram, a HAZUR resilience map, a tree diagram and GIS maps.

Water, energy, food, land and climate form a tightly-connected nexus in which actions on one sector impact other sectors, creating feedbacks and unanticipated consequences. This is especially because at present, much scientific research and many policies are constrained to single discipline/sector silos that are often not interacting (e.g., water-related research/policy). However, experimenting with the interaction and determining how a change in one sector could impact another may require unreasonable time frames, be very difficult in practice and may be potentially dangerous, triggering any one of a number of unanticipated side-effects. Current modelling often neglects knowledge from practice. Therefore, a safe environment is required to test the potential cross-sectoral implications of policy decisions in one sector on other sectors. Serious games offer such an environment by creating realistic ‘simulations’, where long-term impacts of policies may be tested and rated. This paper describes how the ongoing (2016–2020) Horizon2020 project SIM4NEXUS will develop serious games investigating potential plausible cross-nexus implications and synergies due to policy interventions for 12 multi-scale case studies ranging from regional to global. What sets these games apart is that stakeholders and partners are involved in all aspects of the modelling definition and process, from case study conceptualisation, quantitative model development including the implementation and validation of each serious game. Learning from playing a serious game is justified by adopting a proof-of-concept for a specific regional case study in Sardinia (Italy). The value of multi-stakeholder involvement is demonstrated, and critical lessons learned for serious game development in general are presented.

Land, food, energy, water and climate are linked and interconnected into a Nexus, characterized by complexity and feedbacks. An integrated management of the Nexus is critical to understand conflicts/synergies and secure efficient and sustainable use of resources, especially under climate change. The Nexus perspective is applied to Sardinia, as regional case study, to better understand and improve integrated resource management and relevant policy initiatives. Vulnerability of Sardinia Nexus is assessed under several climate projections by articulated balances of resources (water, energy) availability and sustainable development goals, at regional and sub-regional scales, accounting for demands and conflicts among key economic sectors (agriculture, hydro-power, tourism).

Members of the Armed Forces may be exposed to drugs, or combinations of drugs, with the potential to prolong the QRS or QT intervals. The effect of this is to increase the likelihood of developing dangerous ventricular tachyarrhythmias, including ventricular tachycardia, torsades de pointes or ventricular fibrillation. Common examples of the pharmacological agents associated include antibiotics, antiemetics and antimalarials. Genetic predisposition, electrolyte disturbance, anaesthesia and trauma may exacerbate the proarrhythmic effect of these medications. Screening of recruits does not detect all those with a genetic predisposition to drug-associated arrhythmias, so vigilance in preventing this iatrogenic disorder and recognising and appropriately managing it when present is important. This article explains the physiological basis of arrhythmogenesis, outlines the clinical features and provides guidance on investigation and management, with particular reference to military patients.

Volunteer geographical information (VGI) either in the context of citizen science, active crowdsourcing and even passive crowdsourcing has been proven useful in various societal domains such as natural hazards, health status, disease epidemic and biological monitoring. Nonetheless, the variable degrees or unknown quality due to the crowdsourcing settings are still an obstacle for fully integrating these data sources in environmental studies and potentially in policy making. The data curation process in which a quality assurance (QA) is needed is often driven by the direct usability of the data collected within a data conflation process or data fusion (DCDF) combining the crowdsourced data into one view using potentially other data sources as well. Using two examples, namely land cover validation and inundation extent estimation, this paper discusses the close links between QA and DCDF in order to determine whether a disentanglement can be beneficial or not to a better understanding of the data curation process and to its methodology with respect to crowdsourcing data. Far from rejecting the usability quality criterion, the paper advocates for a decoupling of the QA process and the DCDF step as much as possible but still in integrating them within an approach analogous to a Bayesian paradigm.

Volunteer geographical information (VGI), either in the context of citizen science or the mining of social media, has proven to be useful in various domains including natural hazards, health status, disease epidemics, and biological monitoring. Nonetheless, the variable or unknown data quality due to crowdsourcing settings are still an obstacle for fully integrating these data sources in environmental studies and potentially in policy making. The data curation process, in which a quality assurance (QA) is needed, is often driven by the direct usability of the data collected within a data conflation process or data fusion (DCDF), combining the crowdsourced data into one view, using potentially other data sources as well. Looking at current practices in VGI data quality and using two examples, namely land cover validation and inundation extent estimation, this paper discusses the close links between QA and DCDF. It aims to help in deciding whether a disentanglement can be possible, whether beneficial or not, in understanding the data curation process with respect to its methodology for future usage of crowdsourced data. Analysing situations throughout the data curation process where and when entanglement between QA and DCDF occur, the paper explores the various facets of VGI data capture, as well as data quality assessment and purposes. Far from rejecting the usability ISO quality criterion, the paper advocates for a decoupling of the QA process and the DCDF step as much as possible while still integrating them within an approach analogous to a Bayesian paradigm.

Summary Regular grids are commonly used in 2D flood modelling due to wide availability of terrain models and low pre-processing required for input preparation. Despite advances in both computing software and hardware, high resolution flood modelling remains computationally demanding when applied to a large study area when the available time and resources are limited. Traditional grid coarsening approach may reduce not only the computing demands, but also the accuracy of results due to the loss of detailed information. To keep key features that affect flow propagation within coarse grid, the approach proposed and tested in this paper adopts multiple layers in flood modelling to reflect individual flow paths separated by buildings within a coarse grid cell. The cell in each layer has its own parameters (elevation, roughness, building coverage ratio, and conveyance reduction factors) to describe itself and the conditions at boundaries with neighbourhood cells. Results of tests on the synthetic case study and the real world urban area show that the proposed multi-layered approach greatly improves the accuracy of coarse grid modelling with an insignificant additional computing cost. The proposed approach has been tested in conjunction with the UIM model by taking the high resolution results as the benchmark. The implementation of the proposed multi-layered methodology to any regular grid based 2D model would be straightforward.

Summary The latest information and communications technology has enabled flood modelling in urban areas using high quality terrain data to simulate the detailed flow dynamics in local areas. However, the computational cost rises exponentially as the resolution goes finer. The advance of computing hardware is still a limiting factor for large-scale area or risk/uncertainty analysis modelling with fine resolution that describes the details of building features. Grid coarsening is the straightforward way to reduce the computing efforts for 2D flood modelling. The traditional approach to grid coarsening usually takes the average elevation of a fine grid as the new terrain model for the coarse grid. This approach often results in loss of information that introduces errors to modelling. In this study, the building features in coarse grids were abstracted using the building coverage ratio (BCR) and the conveyance reduction factor (CRF) parameters in a 2D model to simulate flooding in urban areas. The outcome of 2D case studies showed the proposed model can minimise the errors due to terrain averaging and provide a much better accuracy of modelling results at a marginally increased computing cost.

BACKGROUND: Surveillance indicators of influenza activity have generally provided robust comparative trend data for England. These indicators became less reliable, however, for monitoring trends in activity, or comparisons with previous years, during the influenza pandemic in 2009 because of changes in the perception of risk and changes in the systems of healthcare delivery. An approach was developed to estimate the number of cases of influenza-like illness (ILI) occurring because of infection with pandemic influenza virus. METHODS AND FINDINGS: The number of cases was estimated each week in England on the basis of total number of patients consulting healthcare services with ILI; estimates of the proportion of individuals in the community experiencing an ILI-seeking health care; and the proportion of these positive on laboratory testing. Almost 800,000 cases (range 375,000-1.6 million) of symptomatic ILI cases were estimated to have occurred over the course of the two waves of pandemic activity in England. More cases were estimated to have occurred in the second wave than in the first. CONCLUSIONS: These results underestimate the total number of infections as they do not include asymptomatic infections nor those with mild illness not meeting the definition of a case of ILI. Nevertheless, the case number estimates provide a useful indicator of the trend in influenza activity and weekly data were extensively used in media reports. Although surveillance methods differ between countries, the approach of synthesising available data sources to produce an overall estimate of case numbers could be applied more widely to provide comparative data.

Objective To investigate factors associated with variations in diagnoses of primary, secondary and early latent syphilis in England and Wales. Methods Data were derived from two sources: diagnoses made in genitourinary medicine clinics reported on form KC60, and information collected through National Enhanced Syphilis Surveillance (NESS). Multinomial regression modelling was used for data analysis. Results Between 1999 and 2008, 12 021 NESS reports were received, 54% of KC60 reports. The dominant profile of the epidemic was one of white men who have sex with men aged 35–44, often co-infected with HIV, centred in larger cities. During this period, the proportion of primary cases increased over time, while the proportion of secondary cases fell. Primary cases exceeded secondary cases by 2004. The proportion of early latent cases remained relatively stable over time and tended to be lower than that of primary and secondary infection. Patients who attended because they had symptoms of infection, had been identified through partner notification, were HIV positive, and were UK born were more likely to present with primary or secondary infection than with early latent infection. A higher proportion of early latent cases were seen among patients who were Asian, had contacted sexual partners through saunas, bars and the internet, had untraceable partners, and had acquired infection in Manchester. Conclusions The continuing syphilis epidemic indicates that control has only been partially effective, with ongoing transmission being sustained. Intensive and targeted efforts delivered locally are required to interrupt further transmission.

SUMMARYUncertainties exist regarding the population risks of hospitalization due to pandemic influenza A(H1N1). Understanding these risks is important for patients, clinicians and policy makers. This study aimed to clarify these uncertainties. A national surveillance system was established for patients hospitalized with laboratory-confirmed pandemic influenza A(H1N1) in England. Information was captured on demographics, pre-existing conditions, treatment and outcomes. The relative risks of hospitalization associated with pre-existing conditions were estimated by combining the captured data with population prevalence estimates. A total of 2416 hospitalizations were reported up to 6 January 2010. Within the population, 4·7 people/100 000 were hospitalized with pandemic influenza A(H1N1). The estimated hospitalization rate of cases showed a U-shaped distribution with age. Chronic kidney disease, chronic neurological disease, chronic respiratory disease and immunosuppression were each associated with a 10- to 20-fold increased risk of hospitalization. Patients who received antiviral medication within 48 h of symptom onset were less likely to be admitted to critical care than those who received them after this time (adjusted odds ratio 0·64, 95% confidence interval 0·44–0·94,P=0·024). In England the risk of hospitalization with pandemic influenza A(H1N1) has been concentrated in the young and those with pre-existing conditions. By quantifying these risks, this study will prove useful in planning for the next winter in the northern and southern hemispheres, and for future pandemics.

Incorporation of evidence based medicine into the undergraduate curriculum varies from school to school. The purpose of this study was to determine if an online course in evidence based medicine run concurrently with the clinical clerkships in the 3rd year of undergraduate medical education provided effective instruction in evidence based medicine (EBM).During the first 18 weeks of the 3rd year, students completed 6 online, didactic modules. Over the next 24 weeks, students developed questions independently from patients seen during clerkships and then retrieved and appraised relevant evidence. Online, faculty mentors reviewed student assignments submitted throughout the course to monitor progress. Mastery of the skills of EBM was assessed prior to and at the conclusion of the course using the Fresno test of competency.Paired data were available from 139 students. Postcourse test scores (M= 77.7; 95% CI = 59-96.4) were significantly higher than precourse scores (M= 66.6; 95% CI = 46.5-86.7), p.001. Paired evaluations demonstrated an average improvement of 11.1 +/- 20.0 points. All of the students submitted 4 independently derived questions and successfully retrieved and appraised evidence.Medical students successfully acquired and independently applied EBM skills following extended, online, faculty mentored instruction. This method of instruction provided uniform instruction across geographic sites and medical specialties and permitted efficient use of faculty time.

Summary Objectives Mr Alexander Litvinenko died in a London hospital on 23 November 2006, allegedly from poisoning with the radionuclide polonium-210 ( 210 Po). Associated circumstances required an integrated response to investigate the potential risk of internal contamination for individuals exposed to contaminated environments. Study design Descriptive study. Methods Contaminated locations presenting a potential risk to health were identified through environmental assessment by radiation protection specialists. Individuals connected with these locations were identified and assessed for internal contamination with 210 Po. Results In total, 1029 UK residents were identified, associated with the 11 most contaminated locations. Of these, 974 were personally interviewed and 787 were offered urine tests for 210 Po excretion. Overall, 139 individuals (18%) showed evidence of probable internal contamination with 210 Po arising from the incident, but only 53 (7%) had assessed radiation doses of 1 mSv or more. The highest assessed radiation dose was approximately 100 mSv. Conclusions Although internal contamination with 210 Po was relatively frequent and was most extensive among individuals associated with locations judged a priori to pose the greatest risk, a high degree of assurance could be given to UK and international communities that the level of health risk from exposure to the radionuclide in this incident was low.

The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes.2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006).The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus.The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained.The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refillor=2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation70% and cardiac index 3.3-6.0 L/min/m.

SUMMARYIt is more than 25 years since the first case of AIDS was reported in the United Kingdom. In December 1981 a gay man was referred to a London hospital with opportunistic infections indicative of immunosuppression. National surveillance began the following year, in September 1982, with the notification of deaths and clinical reports of AIDS and Kaposi's sarcoma plus laboratory reports of opportunistic infections. Since then epidemiological surveillance systems have evolved, adapting to, and taking advantage of advances in treatments and laboratory techniques. The introduction of the HIV antibody test in 1984 led to the reporting of HIV-positive tests by laboratories and the establishment of an unlinked anonymous survey in 1990 measuring undiagnosed HIV infection among gay men attending sexual health clinics. The widespread use of highly active antiretroviral therapies (HAART) since 1996 has averted many deaths among HIV-positive gay men and has also resulted in a large reduction in AIDS cases. This led to a need for an enumeration of gay men with HIV accessing NHS treatment and care services (1995 onwards), more clinical information on HIV diagnoses for epidemiological surveillance (2000 onwards) and the routine monitoring of drug resistance (2001 onwards). Twenty-five years after the first case of AIDS was reported, gay and bisexual men remain the group at greatest risk of acquiring HIV in the United Kingdom. Latest estimates suggest that in 2004, 26 500 gay and bisexual men were living with HIV in the United Kingdom, a quarter of whom were undiagnosed. In this review, we examine how national surveillance systems have evolved over the past 25 years in response to the changing epidemiology of HIV/AIDS among gay and bisexual men in the United Kingdom as well as advances in laboratory techniques and medical treatments. We also reflect on how they will need to continue evolving to effectively inform health policy in the future.

This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥?16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.

The study of cognitive radio (CR) techniques in SatCom research activities is still in its infancy. In this context, the CoRaSat (Cognitive Radio for Satellite Communications) project aims, for the first time, at investigating, developing, and demonstrating CR techniques in SatCom systems for a more efficient utilization of spectrum. In this chapter, an overview of the scenarios analyzed in the CoRaSat project is provided. In particular, Ka-, Ku-, S-, and C-band scenarios are considered and characterized taking into account the market and business frameworks, the regulatory and standardization frameworks, and the technology framework. The methodology applied in the CoRaSat project for scenario selection is provided as well, and preliminary system architecture is defined for the selected Ka-band scenarios. Useful conclusions for further analysis are also drawn.

This paper presents initial results of the recently kicked-off FP7 ICT STREP project “CoRaSat” (Cognitive Radio for Satellite Communications) [1]. Focus is put on the preliminary identification of the scenarios which are suitable for the applicability of Cognitive Radio technology over Satellite Communications (SatCom). The considered frequency bands include Ka-band, Ku-band, C-band and S-band, where regulatory and coordination constraints exist. An initial mapping of broadband and narrowband SatCom use cases on each identified scenario is also provided. Moreover, several challenges associated to the applicability of Cognitive Radio over SatCom in the identified scenarios are presented, which form the basis of the market/business, regulatory, standardization and technological framework of CoRaSat. Furthermore, ongoing and future work of the CoRaSat project is outlined.

SummaryMany drugs and substances are associated with headache, although this does not prove causality. Headache can be precipitated by acute exposure to vasodilators, non-steroidal anti-inflammatory drugs and alcohol. Drugs are also associated with intracranial hypertension (e.g. tetracyclines) and

A small number of UK nationals who have a low, unrecognised or unacknowledged risk for HIV present late in the course of HIV infection; often after frequent attendances to primary care physicians. Information from in-depth interviews with individuals diagnosed with HIV in England, Wales and Northern Ireland (EW&NI) was analysed. Those diagnosed because of HIV-related symptoms (late diagnoses) were compared with those diagnosed for other reasons. Of the 286 individuals interviewed, 157 (55%) had HIV-related symptoms at the time of diagnosis, and 129 were tested for other reasons. A greater proportion of those diagnosed late were male and older. Of the 157 late diagnoses, 77 were considered to have acquired HIV heterosexually in the UK, 19 heterosexually abroad, 16 through 'high-risk' behaviours, 15 heterosexually by a 'high-risk' partner, four through blood transfusion and the remainder through an unusual or unknown route. A significantly higher proportion of those diagnosed late had had a long-standing relationship. None had been informed by a current or ex-partner of their HIV status. Primary care physicians should consider HIV as a possibility when patients without an apparent risk for HIV-infection present with symptoms indicative of possible immune suppression. Sensitive partner notification practices that enable a greater number of individuals to inform their partners should be explored.

Relatively little is known about the sexual health needs of men who have sex with men (MSM) born abroad who reside in the UK. We describe here the epidemiology of HIV among MSM born outside the UK and diagnosed with HIV in England and Wales. Reports of HIV diagnoses in England and Wales received at the Health Protection Agency Centre for Infections were analysed. Between 2000 and 2003, 6386 MSM were diagnosed with HIV in England and Wales. Country of birth was recorded for 3571 (56%). Of those with country of birth reported, 2598 (73%) were born in the UK and 973 (27%) abroad. Of those born abroad (973), 424 (44%) were born in Europe, 141 (15%) in Africa, 104 (11%) in South/Central America and the remainder in other regions. Where reported (949), 69% of MSM born abroad were White, 12% other/mixed, 9% Black Caribbean and 7% Black African. Probable country of infection was reported for 612 MSM born abroad: 52% were infected in the UK, 43% in their region of birth and 5% in another region. Men born abroad represent a significant proportion of HIV diagnoses among MSM in England and Wales. More than half probably acquired their HIV infection in the UK, strengthening the call for targeted HIV prevention and sexual health promotion among MSM who are not born in England and Wales.

To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (EW).Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth.Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in EW, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in EW were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%.Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in EW; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in EW was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in EW.

To examine trends in rates of diagnoses of HIV and other sexually transmitted infections (STIs) in men who have sex with men (MSM) in England and Wales between 1997 and 2002.Estimates of the MSM population living in England and Wales, London and the rest of England and Wales were applied to surveillance data, providing rates of diagnoses of HIV and STIs and age group specific rates for HIV and uncomplicated gonorrhoea.Between 1997 and 2002, rates of diagnoses of HIV and acute STIs in MSM increased substantially. Rates in London were higher than elsewhere. Rises in acute STIs were similar throughout England and Wales, except for uncomplicated gonorrhoea and infectious syphilis, with greater increases outside London. Rates of gonorrhoea diagnoses doubled between 1999 and 2001 (661/100,000, 1271/100,000, p0.001) in England and Wales followed by a slight decline to 1210/100,000 (p=0.03) in 2002-primarily the result of a decline in diagnoses among men aged 25-34 (1340/100,000, 1128/100,000, p0.001) and 35-44 (924/100,000, 863/100,000, p=0.03) in London. HIV was the third most common STI diagnosed in MSM in England and Wales and the second in London, with the highest rate (1286/100,000) found among men aged 35-44 in London in 2002.Rates of diagnosis of HIV and other STIs have increased substantially among MSM in England and Wales. Increases show heterogeneity by infection, geography, and age over time. Rates in London were twice those seen elsewhere, with greatest changes over time. The observed changes reflect concomitant increases in high risk behaviour documented in behavioural surveillance survey programmes.