Resilience management guidelines for critical infrastructures, translating resilience theory into practical and useful interventions

Resilience goes beyond safety and risk management encompassing the ability of organisations to proactively adapt to expected and unexpected situations (crisis, opportunities and changes). The literature on resilience is overwhelming, our systematic literature survey identified 300 different definitions on resilience, diverse developments. Hence, there is a need to translate this fragmented body of knowledge into consolidated practical solutions. The purpose of this paper is to introduce the final version of resilience management guidelines produced in the H2020 DARWIN project. Through a multidisciplinary approach, involving experts in the field of resilience, crisis and risk management and service providers in the Air Traffic Management, healthcare domains as well as representatives from other domains, the DARWIN project has produced evolving resilience management guidelines (DRMG). These guidelines are not prescriptive. Instead they enable organizations to have a critical view on their own crisis management activities. The DRMG are available in different formats for easy usage and maintenance to avoid them being dust-collectors on a shelf. In this way, organizations can adapt, adopt and integrate the guidelines into their own existing management practices and procedures. Through an iterative development process involving academia and practitioners, the guidelines are constructed around Capability Cards (CCs). The evaluation in pilot exercises and other activities involved 247 practitioners from 22 countries explored the possibility to adapt the CCs to the Healthcare and Air Traffic Management domains. It also consider the feasibility of generalizing them to other Critical Infrastructure domains. Our achievement is the current version of guidelines proposing practical interventions that end-users find useful. This paper represents and invitation to explore the content of the guidelines, to encourage its use and further developments of the resilience management

MALDI-TOF: Introduction in routine of a system for the rapid identification of microorganisms

Introduction. MALDI-TOF (Matrix Assisted Laser Desorption/Ionization-Time of Flight) is an recently introduced technique for the rapid identification of microorganisms by mass spectrometry (1,3) (Fig.1).The aim of this work was the evaluation and validation of the MALDI-TOF method (Bruker Daltonics) for inclusion in the routine workflow of a clinical microbiology laboratory. Methods.We analyzed strains isolated from different clinical specimens. For each species of microorganism we calculated the percentage of agreement by comparing the identification of MALDI-TOF with that obtained using the methods currently in use in the laboratory. In case of discordant results the conclusive identification was carried out by sequencing of 16S ribosomal DNA (Tab.3) using the MicroSeq identification system 500 (Applied Biosystems) (2). Alpha-hemolytic streptococci were instead identified by the ATB galleries (BioMerieux).ATCC strains were used as Quality Control. Results. 1340 strains were analyzed, including 479 enterobacteria, 188 gram-negative bacilli, 189 staphylococci, 140 enterococci, 84 Haemophilus spp, 114 streptococci, 40 yeasts and 106 less common microorganisms. Gramnegative bacteria, enterococci, Staphylococcus aureus, beta-hemolytic streptococci and yeasts showed full agreement (Tab.1 e Tab.2). In addition, MALDI-TOF has proved a reliable method for identification of fastidious germs such as Legionella, Branhamella, Neisseriae, Listeria monocytogenes, Corynebacteria, and anaerobes.Alpha-hemolytic streptococci were but in most cases identified as S. pneumoniae. Conclusions. The identification by mass spectrometry allows to obtain reliable results in minutes for most of the organisms isolated from the routine. Considerable importance for the performance of the system plays the quality of the database in the instrument. The high percentage of concordance between identification with the standard methods and MALDI-TOF allowed the introduction of this method in routine workflow with the exception of alpha hemolytic streptococci for which the current system of identification is still in use

Resilience Management Guidelines for Critical Infrastructures, Practical Solutions Addressing Expected and Unexpected Events

Crises and disasters (Eyjafjallajökull and Deepwater Horizon 2010, Fukushima Daiichi 2011, and more recently the wildfire in Sweden 2018) have made it obvious that a more resilient approach to preparing for and dealing with such events is needed. This paper presents the results of the H2020 DARWIN project, which contributes to improving responses to expected and unexpected crises affecting critical infrastructures and social structures, whether man-made events (e.g. cyber-attacks) or natural events (e.g. earthquakes). The main result of the Darwin project is the creation of the DARWIN Resilience Management Guidelines (DRMG). The DRMG are evolving guidelines, designed to improve the ability of stakeholders to monitor, anticipate and learn from crises, and thereby allow them to adapt and respond more effectively and operate more efficiently during disasters. These guidelines are not prescriptive. Instead, they enable organizations to have a critical view of their own crisis management activities. The target beneficiaries of DARWIN are crisis management managers and practitioners responsible for public safety, such as critical infrastructures and service providers, which might be affected by a crisis, as well as the public and media. The DRMG are not meant to be dust-collectors on a shelf. To this end, they have been made into a variety of formats to support their evolution, ease of use and maintenance. Within this paper, the reader is introduced to the DRMG in its different formats, as well as a host of innovative tools (e.g. DRMG Wiki, serious gaming, training packages) developed by the project to support resilience management learning and the uptake of the guidelines. A multidisciplinary approach is applied, involving experts in the field of resilience, crisis and risk management, social media, and service providers in the air traffic management and healthcare domains. To ensure transnational, cross-sector applicability, long-term relevance and uptake of project results, the DARWIN Community of Practitioners (DCoP) has been established, with membership including experts and end users from different fields of expertise and from across multiple critical infrastructure domains. The DCoP has been involved in an iterative development and evaluation process to provide feedback on the results. The evaluation in pilot exercises and other activities involved 247 practitioners from 22 countries. The DCoP members contributed with knowledge and experience ensuring the feasibility of adapting them to other critical infrastructure domains. Our achievement is the current version of guidelines and associated innovative tools proposing practical interventions that end-users find useful. This paper includes testimonials of end-users within and outside the consortium. This document represents an invitation to explore the content of the guidelines, to encourage its use and further developments of the resilience management. Concluding Paper of the H2020 DARWIN Project as published 25 March 2019 on www.h2020darwin.e

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to < 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of & GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P < 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo