No / Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy. / E. LPQuiC Collaborator Group

Over the last two decades, the international community has taken on the task of rebuilding societies in the aftermath of mass-atrocities. Through a combination of trial and error and vigorous academic research, a relatively clear (and semi-malleable) blueprint of post-atrocity peacebuilding has developed. This includes setting up a temporary international transitional authority, establishing democracy, facilitating economic development, and holding war crime trials. Though there are volumes of studies which address the pragmatic strengths and weaknesses of these key elements of peacebuilding, to date political theorists have not critically analyzed the moral legitimacy of these policies. My thesis aims to fill this gap. The overarching question of this thesis is this: What moral duties does the international community have to post-atrocity societies? To answer this question, I critically examine the normative issues involved in the four key aspects of peacebuilding (identified above). Using the framework of just war theory and a cosmopolitan theory of fundamental human rights, I argue that, in most post-atrocity cases, the international community has duties to remove atrocity-committing regimes from power, occupy the target-state and act as a transitional authority, help facilitate the creation of democracy and economic development, and hold war crimes trials. These duties, of course, are extremely complicated and limited and these qualifications are examined and developed throughout. Running through the construction of my theory of post-atrocity duties is a clear message: we – the international community – have obligations to the victims and survivors of atrocities. In other words, providing assistance in the wake of mass-atrocities is not a supererogatory act of charity, rather, it is a duty which we owe to the victims of these horrible crimes.

Inter-governmental organisations (IGOs) are given mandates by states to perform particular tasks: from refugee protection to the management of migration to promoting development. As new global challenges arise, such as climate change, these organisations must decide whether to ignore them or change in response. But what drives inter-governmental organisations to move beyond their mandates, if it is not their member states? International Relations offers a limited account of if and how they will respond to new issue areas. Principal-agent theory treats IGOs as units with fixed preferences to expand and maximise their tasks and scope (Hawkins et al. 2006; Nielson and Tierney 2003; Pollack 2003). Meanwhile, sociological institutionalism argues that IOs are driven by a logic of appropriateness and staff will only support expansion if it fits coherently with their organisational identity and culture (Barnett and Coleman 2005). I build on these two theories and propose that IGO behaviour should be explained by organisational type. IGOs exist along a spectrum from normative to functional ideal-types. Normative IGOs have supervisory status over a body of international law, seek moral legitimacy and follow a logic of appropriateness. Functional IGOs are projectised organisations which seek pragmatic legitimacy and adopt a logic of consequences. I illustrate how IGO type interacts with the status of the new issue area to determine the timing, nature and extent of organisational change. I focus on the responses to climate change of three inter-governmental organisations: the United Nations High Commission for Refugees, a normative organisation; the International Organisation for Migration, a functional organisation; and the United Nations Development Programme, a hybrid organisation. IGO type has important implications for IR scholars and policy-makers as we look to these institutions to provide global solutions to global issues such as climate change, migration, refugees and development.

This thesis examines the role of international organizations (IOs) at the domestic level. While International Relations (IR) offers an extensive literature on IOs, with understandings of IOs ranging from instruments of states to autonomous actors, it tends to ignore the role of IOs working at the domestic level, with an 'on-the-ground' presence of their own, and what this means for the IO's relationship with the state. The thesis develops a heuristic framework for understanding what is called IO 'domestication', which outlines a range of ways an IO can work domestically. It then focuses on one type domestication in particular: surrogate statehood, or cases where an IO substitutes for the state by providing services, executing functions of governance, and assuming authority in a given locale. The framework identifies indicators of surrogacy, the conditions for IO surrogacy, and reasons why it is sustained. It also considers the various types of relationship that can emerge from IO surrogacy between the IO and the state, ranging from states that willingly choose to abdicate responsibility to the IO, to states that partner with the IO. Empirically, the thesis examines these relationships through the case studies of the United Nations High Commissioner for Refugees (UNHCR) in Kenya, Tanzania and Uganda, which present a spectrum of UNHCR’s surrogacy over time. Ultimately, the thesis puts forth a counterintuitive claim: IOs that take on surrogate state properties actually have less influence on the states in which they are working. The analysis draws on two mechanisms to help explain this outcome: marginalisation of the state, and responsibility shifting.

Paragraphs 138 to 140 of the Outcome Document of the 2005 UN World Summit not only elevated the element of prevention to a prominent place within the principle of “responsibility to protect” (R2P), but also restricted the scope of R2P to four specific crimes under international law: genocide, war crimes, ethnic cleansing, and crimes against humanity. This thesis explores the conceptual and practical consequences of linking R2P to the concept of international crimes, with a particular focus on the preventive dimension of R2P, the socalled “responsibility to prevent”. To date, much of what has been written about the “responsibility to prevent” borrows primarily from conflict prevention theory and practice. Such conflict prevention inspired accounts of the “responsibility to prevent” tend to depict the principle as a long-term agenda that seeks to build societies resilient to atrocity crimes; that rests primarily on pillars one (state responsibility) and two (international assistance and capacity-building); that is supportive rather than undermining of state sovereignty; and that can largely adhere to the traditional conflict prevention principles of impartiality, consent, and minimal coercion should more direct prevention efforts become necessary. Drawing on literature from criminology, this thesis develops an international crimes framework for operationalizing the preventive dimension of R2P. The framework, combined with three case studies of international crime prevention (Bosnia 1991-1995; Kenya 2007-08; and Libya 2011), challenges key assumptions of the conflict prevention accounts, arguing that linking R2P to the concept of international crimes turns the “responsibility to prevent” into a principle that is more focused on the short-term, rather than on so-called root causes of atrocity crimes; more focused on individuals, rather than on state structures and capacity; more partial regarding perpetrators and victims; and more coercive, intrusive, and controversial than is commonly acknowledged in academic writing and policy debates on the subject. More broadly, the thesis concludes that taking R2P’s focus on the prevention of international crimes seriously requires re-rethinking the “responsibility to prevent” in important respects.

The presented diploma thesis deals with the subject of non-medical rescue services. The main purpose is to analyze medical services provided by non-medical rescue services - especially Mountain Rescue Service and Mining Rescue Service. The theoretical part introduces the reader the activity of these two services provided in the Czech Republic from the perspective of organization, history, provided services, financing, legislation, professional training of the staff, and available equipment. The research part of the thesis is created on the basis of qualitative research using the method of content analysis of the statistically validates documents. The research results inform about the real extend of provided services, and give the concise information about the frequency and reasons of emergencies. This part of the thesis is completed with the information about the real education of the staff and short interview with leading managers. KEY WORDS Mountain Rescue Service, Mining Rescue Service, competence, training, organisation, emergencies, legislation.

Les urgences sanitaires de portée internationale font partie de ces risques que les Etats, pris isolément, ne peuvent gérer seul pour assurer la permanence du bien-être de leur population. Cette thèse explore alors la possibilité de pallier l'insuffisante intégration de la communauté internationale en matière de gestion de ce qui sera considéré comme des risques biologiques, par l'établissement d'un système de gouvernance internationale et globale fondée sur l'échange d'informations. Pour le fonctionnement de ce système, l'information doit être produite mais elle doit également avoir la possibilité juridique d'être échangée. Dans ce contexte, l'échange d'informations se doit d'être organisé de manière à tenir compte des caractères juridiques des informations utiles à la gestion de ces risques. L'étude des conditions de cet échange met alors en évidence le rôle essentiel du droit dans l'organisation des conditions de l'efficience de ces échanges, et dès lors dans le fonctionnement de ce système de gouvernance. Elle en montre aussi les limites. / Public health emergencies of international concern are part of those risks that can not be efficiently managed by States on their own to ensure the longstanding well-being of their population. This thesis explores the possibility to supersede the international community's lack of integration for the management of what will be considered as biological risks, by the designing of an international and global governance system based on the exchange of information. For the functionning of this system, information will need to be produced and have the capacity to be exchanged. In this context, information exchanges ought to be organised, in order to take into account the legal specifities of the information involved. The study will thus aim at emphasizing on the essential role of law in the organisation of those exchanges but also on its limitations.

Title: Analysis of interventions of detached units from Czech Armed Forces Objectives of work: to make overview of interventions of Czech Armed Forces for Integrated rescue system in the period 2001-2010 and divided by the nature of the emergencies. The results will be analysed in order to make conclusions in five areas: 1. overall use of Czech Armed Forces for Integrated rescue system 2. factors limiting use of Czech Armed Forces for Integrated rescue system 3. strengths and weaknesses in the internal management of Czech Armed Forces during deployment 4. cooperation of Czech Armed Forces and Integrated rescue system including a focus on functionality of established principles and algorithms required to deploy forces and equipment of Czech Armed Forces to rescue or liquidation operations. 5. financial costs of interventions of Czech Armed Forces for Integrated rescue system Method: Search in literature and writing the results in logical order. Procedures of reduced PEST analysis are used to assess the general risks of environment in the Czech Republic. The analytical part is processed with the help of elements of system analysis. Keywords: Integrated rescue system, Czech Arrned forces, natural disasters, epizootic, anthropogenic emergencies.

Human protection in emergencies is one of the topics, which is getting more public attention nowadays and its teaching at schools is strongly supported. The main authority providing this support is mostly the Fire Rescue Service of the Czech Republic. This institution organises various activities within the programme of population preparedness, for example educational books and booklets, videos etc. Raising the participation of the population in ensuring their own security is defined as one of the security interests in the Security strategy of the Czech Republic. It is also one of the key priorities listed in the Conception of the population protection till 2020 with the outlook to 2030. In the theoretical part of the master thesis, the basic information about the population protection, about the integrated rescue system, about the educational system and about the activities of individual authorities and institutions in the population protection education is summarised. This part of course summarizes also the problematics of the school subject Human Protection in Emergencies and of the teaching of this subject at schools, the tools needed for this teaching and also the possibilities, which teachers have to prepare for teaching this subject. The research part of the thesis elaborates on an analysis of teaching the subject Human Protection in Emergencies at primary schools in the Rokycany district. The research was carried out by formulating and evaluating questionnaires, analysing the schools' educational programmes and creating a SWOT analysis. On the basis of the obtained results, the research question was answered: "Which form does have the teaching of Human Protection in Emergencies at primary schools in the Rokycany district?" Currently, the teaching is carried out in other subjects, such as Natural sciences. The schools try to complete the classical teachers' explanations with debates with the employees of the integrated rescue system, excursions, or project days. The benefit of this thesis is the acquired complex overview about the teaching of the subject Human Protection in Emergencies at primary schools. The thesis could furthermore serve as a topic for future bachelor or master theses, with the focus of the research part on other areas of the Czech Republic.

INTRODUÇÃO: Laparotomias de emergência apresentam alto risco de complicações e evoluem com deiscência da aponeurose (DA) em até 14,9% dos casos. O uso profilático de tela no fechamento da parede abdominal reduz a incidência de hérnia incisional após cirurgias eletivas, sem aumento significativo de morbidade. Porém, não há estudos que comprovem seu benefício na prevenção de DA e seu uso ainda é controverso em laparotomias de emergência e em cirurgias contaminadas ou infectadas. OBJETIVOS: Avaliar se o uso profilático de tela no fechamento da parede abdominal reduz a incidência de DA em pacientes submetidos a laparotomia de emergência, assim como a morbidade de sua aplicação. MÉTODOS: Foi realizado um ensaio clínico randomizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Indivíduos com alto risco para DA e indicação de laparotomia mediana de emergência foram randomizados em grupos de sutura (síntese contínua da aponeurose com fio de polidioxanona e agulha de 36 mm, com objetivo de alcançar a relação entre os comprimentos do fio e da incisão igual ou superior a quatro) ou de tela profilática (síntese da aponeurose como no grupo de sutura, reforçada com tela pré-aponeurótica de polipropileno). Alto risco foi definido segundo escore de risco pré-operatório de Rotterdam adaptado. A equipe cirúrgica permaneceu cega no intraoperatório (randomização somente após síntese completa da aponeurose). RESULTADOS: De junho de 2015 a fevereiro de 2018, foram randomizados 145 pacientes, dos quais 30 foram excluídos (20,7%) por óbito ou reoperação nos primeiros 30 dias, não relacionados a intervenção do estudo; 52 foram alocados no grupo de sutura e 63 no de tela profilática. Ambos foram equivalentes quanto a dados demográficos e características clínicas, exceto idade, cuja média foi maior no grupo de sutura (66,1 anos vs 61,0 anos, p = 0,03). Os pacientes foram classificados como ASA III ou IV em 44 (38,3%) casos. Dentre as operações, 49 (42,6%) foram contaminadas ou infectadas, 63 (54,8%) envolveram a realização de ostomia e 89 (77,4%) foram cirurgias colorretais. Os tempos de internação hospitalar e em UTI foram semelhantes. O tempo operatório médio foi 50,8 minutos mais longo no grupo de tela profilática (p = 0,01). A DA ocorreu em sete casos do grupo de sutura (13,5%) e em nenhum do grupo de tela profilática (p = 0,003). Não houve diferença estatística em relação ao número de participantes que apresentou ocorrências de sítio cirúrgico (SSO) [15 (28,8%) vs 27 (42,9%), p = 0,12] ou ocorrências de sítio cirúrgico que necessitaram de intervenção (SSOPI) [9 (17,3%) vs 14 (22,2%), p = 0,51]. Porém, algumas SSO foram mais frequentes no grupo de tela profilática: seroma [3 (5,8%) vs 12 (19,0%), p = 0,03], infecção de sítio cirúrgico (SSI) [4 (7,7%) vs 13 (20,6%), p = 0,05] e deiscência superficial de ferida operatória [3 (5,8%) vs 15 (23,8%), p = 0,008]. Sete casos do grupo de tela profilática tiveram deiscência superficial com exposição de tela e foram tratados com curativos locais e cicatrização por segunda intenção, havendo resolução completa em menos de 90 dias. Nenhum caso necessitou de remoção completa da tela. Das SSO do grupo de tela profilática, 92,3% tiveram resolução espontânea ou com intervenções à beira-leito, o que aconteceu em 73,3% do grupo de sutura. CONCLUSÕES: A tela profilática pré-aponeurótica em laparotomias de emergência é segura e evita DA, com morbidade aceitável, em 30 dias / INTRODUCTION: Emergency laparotomies have a high risk of complication with reports of fascial dehiscence (FD) in up to 14.9% of cases. The use of onlay mesh in the closure of abdominal wall reduces incidence of incisional hernia after elective surgeries without increased morbidity. However, there are no studies demonstrating its benefit in FD prevention and its use is controversial in emergency laparotomies and in contaminated or infected surgeries. OBJECTIVES: To evaluate whether the use of onlay mesh in the closure of the abdominal wall reduces the incidence of FD in patients submitted to emergency laparotomy, as well as the morbidity of its application. METHODS: A randomized clinical trial was conducted at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Patients at high risk for FD and indication of emergency midline laparotomy were randomized either to the suture group (running suture with polidioxanone thread and 36 mm needle size, aiming to achieve suture-to-wound length ratio of 4:1) or to the prophylactic mesh group (fascial closure as in the suture group, reinforced with polypropylene onlay mesh). High risk was defined according to the adapted Rotterdam preoperative risk model. The surgical team was blinded to the groups during the intraoperative period (randomization occurred only after complete fascial suture). RESULTS: From June 2015 to February 2018, 145 patients were randomized, 30 of whom were excluded (20.7%) because of death or reoperation, not related to the mesh procedure, in the first 30 days; 52 were allocated in the suture group and 63 in the prophylactic mesh group. Both groups were equivalent for demographic data and clinical characteristics, except for age, whose mean was higher in the suture group (66.1 years vs 61.0 years, p = 0.03). Patients were classified as ASA III or IV in 44 (38.3%) cases. Among the operations, 49 (42.6%) were contaminated or infected, 63 (54,8%) involved ostomy formation and 89 (77.4%) were colorectal surgeries. Hospital length of stay (LOS) and intensive care unit LOS were similar. Mean operative time was 50.8 minutes longer in the prophylactic mesh group (p = 0.01). FD occurred in seven cases of the suture group (13.5%) and none in the prophylactic mesh group (p = 0.003). There was no statistical difference between the groups regarding the number of patients with surgical site occurrence (SSO) [15 (28.8%) vs 27 (42.9%), p = 0.12], or surgical site occurrences that required procedural interventions (SSOPI) [9 (17.3%) vs 14 (22.2%), p = 0.51]. However, some SSO were more frequent in the prophylactic mesh group: seroma [3 (5.8%) vs 12 (19.0%), p = 0.03], surgical site infection (SSI) [4 (7, 7%) vs 13 (20.6%), p = 0.05] and superficial wound dehiscence [3 (5.8%) vs 15 (23.8%), p = 0.008)]. Seven cases of the prophylactic mesh group had superficial wound dehiscence with mesh exposure, treated with local dressings and healing by second intention, with complete resolution in less than 90 days. No case required complete removal of mesh. Of the SSO in the prophylactic mesh group, 92.3% had spontaneous resolution or with bedside interventions; the same occurred in 73.3% of the suture group. CONCLUSIONS: The onlay prophylactic mesh in emergency laparotomy is safe and avoids FD, with acceptable morbidity in 30 days