Du paraphe à la ratification : les défis de la mise en œuvre de l'APE UE-CARIFORUM

Le 16 décembre 2007, à la Barbade, quinze États parmi les seize pays membres du Forum des Caraïbes (CARIFORUM), – excepté Cuba – paraphaient un accord de partenariat économique (APE) complet avec la Commission européenne. Le fait est d’autant plus notable, que les Caraïbes sont la seule « région » à avoir conclu un accord complet avec l’Union Européenne à l’échéance de la période de négociations qui s’est terminée le 31 décembre 2007. Cette contribution s’organise en trois parties. La première partie rappelle les conditions juridiques d’entrée en vigueur et de mise en œuvre de l’accord. La deuxième partie propose d’identifier les intérêts commerciaux et géostratégiques en présence du côté européen comme du côté caribéen et de discerner quelle a été la stratégie de négociations suivie par les négociateurs caribéens, ayant conduit au choix d’un APE complet. Enfin, la troisième partie évalue le contenu de l’accord dans les principaux domaines pour déterminer ses avantages, ses inconvénients et les points litigieux

Jacques TENIER. Intégrations régionales et mondialisation : complémentarité ou contradiction

Le présent ouvrage s’intéresse particulièrement au processus de « régionalisation » qu’engendre l’accélération du mouvement de mondialisation depuis les années 1990. L’auteur met l’accent sur l’articulation et la rencontre des deux phénomènes jugés complémentaires : la mondialisation économique apparaît ici comme un facteur de structuration, de rapprochement des pays au sein de zones géographiques délimitées dont l’objectif est tantôt d’anticiper le libre-échange mondial et d’amortir les choc..

an international survey before and during the COVID-19 pandemic

Funding Information: The Société Française d’Anesthésie et de Réanimation (SFAR), Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), Sociedad Argentina de Terapia Intensiva (SATI), Sociedad Chilena de Medicina Intensiva (SOCHIMI), Associação de Medicina Intensiva Brasileira (AMIB-Net) and the Brazilian Research in Intensive Care Network (BricNet) supported this survey. We would also like to thank our friend Tiago Rocha for making the amazing logo for this study. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES)—Finance Code 001. Publisher Copyright: © 2022, The Author(s).Background: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. Methods: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. Results: We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. Conclusions: Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.publishersversionpublishe

The relationship between the European Union and the organisations of economic regional integration from Latin America and the caribbean basin - which mutations ?

Depuis 1999, l’Union européenne a inauguré une nouvelle approche dans ses relations avec l’Amérique latine et les Caraïbes. A cet égard, le premier sommet Union européenne – Amérique latine – Caraïbes, dit « sommet de Rio » marque un tournant grâce au lancement du « partenariat stratégique ». Dans ce cadre, toutes les organisations régionales d’intégration économique situées dans cette zone géographique, et non pas uniquement le MERCOSUR, apparaissent comme des partenaires importants. Le changement obéit autant à des contraintes externes qu’à une stratégie extérieure. Dans le domaine des échanges commerciaux, le but déclaré est d’atteindre « une libéralisation mutuelle des échanges » sur une base équitable et mutuellement profitable tout en défendant certaines valeurs communes. Cependant, le cadre juridique longtemps en vigueur s’est avéré inadapté à l’avènement d’une ambition économique et politique d’une telle ampleur. Par conséquent, l’Union européenne se trouve confrontée au défi de réformer les cadres juridiques de ses relations avec les organisations régionales d’intégration économique d’Amérique latine et des Caraïbes. La thèse analyse l’évolution et la restructuration actuelles des instruments juridiques des relations entre l’Union européenne l’Amérique latine et les Caraïbes.Since 1999, the European Union began a new competitive approach in its relationships with Latin America and the Caribbean. In this respect, the first step has been made in the European Union-Latin America and Caribbean’ Summit [Rio Summit (1999)] with the launch of a new partnership called “Strategic Partnership”. In this context, all organisations of regional economic integration – not only the MERCOSUR the most competitive one – are considered as important partners. The change is due to external constraints as well as an external strategy. In the field of commercial exchanges, the goal is to attempt “mutual liberalisation of exchanges” on a fair and mutually profitable basis, defending at the same time “common values”. However, the traditional legal framework of the relations is obviously unsuitable for such an ambitious economic and political project. So, from a legal aspect, the European Union is confronted with the challenge of reforming the contractual frameworks of its relations with regional economic integrations in Latin America and in the Caribbean. The issue concerns an analysis of the evolution and restructuring of existing legal instruments of the European Union’s relations with Latin America and the Caribbean.Desde 1999, la Unión Europea instauró un nuevo enfoque en sus relaciones con América Latina y el Caribe. En este enfoque llamado “estratégico”, todas las organiza-ciones comarcales de integración económicas ubicadas en esta zona geográfica y no úni-camente el MERCOSUR, se pueden ver como interlocutores importantes. La primera cumbre Unión Europea /América latina/Caribe (cumbre de Rio) es una fecha importante en la evolución de las relaciones gracias al lanzamiento “de la colaboración estratégica”. En lo que toca a los intercambios comerciales, la meta declarada es alcanzar una “liberalización mutual de los intercambios” a partir de una base equitativa y mutualmente provechosa de-fendiendo a la vez ciertos valores comunes. Sin embargo, el marco jurídico en vigor durante una larga temporada se ha reve-lado inadecuado para el advenimiento de una ambición económica y política de esta impor-tancia. Por consiguiente, la Unión Europea se enfrenta hoy en día al desafío jurídico de la renovación del marco convencional de sus relaciones con las organizaciones de integración económica de América Latina y del Caribe. El asunto se refiere a un análisis de las rela-ciones exteriores de la Unión Europea desde el punto de vista de los desafíos jurídicos. Utilizamos el análisis sistémico para poner de relieve los factores explicativos de la evolu-ción y de la reestructuración actuales de los instrumentos jurídicos de las relaciones entre la Unión Europea y América-Latina Caribe

Varia

Fruit d’un long processus de maturation expliquant, en partie, le retard pris dans sa livraison, le numéro 16 de Pouvoirs dans la Caraïbe est aussi l’aboutissement d’une série de travaux scientifiques menés au sein du CRPLC. Les thèmes qui y sont abordés tissent la trame d’une vie scientifique interne à laquelle le laboratoire s’efforce d’associer quelques-uns des meilleurs spécialistes. Ces thèmes tournent le plus souvent autour de la question du fonctionnement de l’Etat dans les territoires périphériques de la République ; question qui n’a cessé d’alimenter les séminaires et les réflexions organisés ou animés par les membres de l’équipe

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction

Health status after invasive or conservative care in coronary and advanced kidney disease

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of &lt;30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, 120.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, 122.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, 121.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, 122.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used