Armed with our 21st-century democracy-finder, suppose we speed back to 17th-century Europe. In one part of Europe or another, we will find roughly 200 regimes we can reasonably call independent states: relatively autonomous, centralized, and well-bounded governments exercising priority in some regards over all other organizations operating within their territories. On four counters marked “Breadth,” “Equality,” “Consultation,” and “Protection,” we take readings for the regimes we locate in a journey throughout the continent. Where and when do we encounter vigorous vibrations of democracy? Let's say we land in the year 1650. We might think it an auspicious year for democratic initiatives: except for continuing struggle between France and Spain the major disruptions of the Thirty Years' War have just ended with the Treaties of Westphalia, great fissures have opened in the Habsburg empire, and the success of their 16th-century rebellion against Spain has finally brought the northern Netherlands international recognition as a highly decentralized independent republic. What do we find? We find plenty of revolution and war, but few signs of settled democracy. Touring the British Isles, we discover a Scotland rebelling openly against English hegemony, and a Scottish military force in northern England backing Charles Stuart's claim to succeed his father Charles I; just last year, England's contentious revolutionaries united temporarily to decapitate King Charles. In Ireland, Catholic leaders are battling not only each other, but also the English invading force of Oliver Cromwell.
The headway towards the outstanding future can be realized with the productive cooperation among peoples and organizations. Inspired from the spirit of cooperation in the rapidly social changing communities, we propose an autonomous decentralized community (ADC) concept. It is a group of autonomous members, whereas each member has his own objectives, complies with the community obligations and cooperates with the others for achieving his own objectives. ADC system has to meet the heterogeneous and continuously changing requirements of the community service utilization and provision. It requires support for real-time communication among community members. Therefore, we propose an autonomous decentralized community communication technique. It satisfies the fairness by granted an equal opportunity among the community members. Moreover, it approves the scalability of the system regardless with the number of the community members.
The purpose of this study is to comprehensively examines the policy of local decentralization through some problems of decentralization reform in Korea. The reason is that a situation for implementing decentralization reform is not good enough to deal with fundamental issues(management of organization, human resource, finance, and legislation) in relation to the autonomy of local government. Under the circumstance, this study also evaluates the policy of integration or abolition for the local small business office, as a special local agency. Specifically, this study examines the meaning of local autonomy and some determinants, as pre-conditions, to obtain an effective local decentralization. Secondly, the research makes a comparison each role and function to support local small business between local small business office and local government. Thirdly, the research employs both a survey questionnaire to evaluate the satisfaction of customers or the quality of service, and case study research for small business supporting system through U.S.A, Japan, and U.K. The significance of this study is that it brings conceptual clarity to the dialog on improvement of decentralization reform and it represents an important research source for the development of further research on the role and function of local small business office, dealing with new small business supporting system based on the formation of local governance.
This note presents the methodology and \n findings of a field study on the financing needs of \n Madagascar's communes-the country's lowest but \n most institutionally advanced level of subnational \n government. Following a first round of municipal elections \n in 1995, more than 1,500 communes are now formally \n responsible for maintaining basic administrative services \n and social and economic infrastructure, including local \n waste disposal and sanitation. In addition, communes are \n responsible for identifying and coordinating local \n investments and for supporting implementation of the \n national Poverty Reduction Strategy at the local level. To \n finance these activities, communes receive population-based \n transfers and small conditional transfers, and can collect \n revenue from property, market, and consumption taxes as well \n as user charges. Yet little is known about how much these \n fiscal assignments satisfy local needs. As part of its \n policy dialogue with the government of Madagascar, the World \n Bank is engaged in extensive research that includes \n geographic mapping of social spending and a review of \n opportunities and obstacles to fiscal and sectoral \n decentralization. This research generated the following \n analysis of local and cross-sectoral service needs and \n available financing.
A GREAT deal has been made of student achievement data in international comparisons. Less information has been gathered about in various countries. We have a few field studies, such as those reported in The Teaching Gap, by James Stigler and James Hiebert, and in Knowing and Teaching Elementary Mathematics, by Liping Ma. Neither depicts a particularly robust portrait of what American know about mathematics or how to teach it. With the new emphasis on highly qualified teachers from the U.S. Department of Education, teacher quality has moved to center stage. Two new studies add a bit to our knowledge of here and abroad. The first is Teaching Mathematics in Seven Countries: Results from the TIMSS 1999 Video Study, in which videotapes of actually teaching eighth-grade mathematics in seven countries were studied. The report (NCES 2003013) was put together by Hiebert and a host of other researchers and is available at www.nces.ed.gov/timss. The second is Preparing Teachers Around the World, from Aubrey Wang, Ashaki Coleman, Richard Coley, and Richard Phelps of the ETS Policy Information Center. It is available at www.ets.org/research/pic/teachprep.pdf. In 1995, as part of the original TIMSS (Third International Mathematics and Science Study), videos of were made in three nations: Germany, Japan, and the United States. In general, U.S. and German focused on teaching procedures, while Japanese emphasized conceptual matters. One accidental finding cropped up when people coding the videos had a What the hell was that? reaction to noises on the tapes. Those noises were mostly interruptions by the intercom, visitors, etc. More than 30% of American classes suffered interruptions. Zero percent of Japanese classes suffered an intrusion. The TIMSS 1999 Video Study extends the original research to seven countries, adding Australia, the Czech Republic, Hong Kong, the Netherlands, and Switzerland and omitting Germany. (A more detailed summary of this study, by the TIMSS Video Mathematics Research Group, can be found in the June 2003 Kappan.) These countries all scored high or relatively high in TIMSS and TIMSS-R (Repeat). In TIMSS-R, only the Czech Republic did not have a score that was significantly higher than that of the U.S., which scored 502 as compared to the Czech Republic's 520. (The international average was 487.) Getting coders to agree on what they were seeing was difficult in the original study, and it was exponentially more difficult to get coders to agree about what they were seeing when viewing videos from seven countries. In addition, they might have missed something important, as overall judgments of quality did not correlate with judgments on the specific indicators of quality. (These results are from a presentation made at the annual meeting of the American Educational Research Association in April, not from the report itself.) Coders first looked at how much time in different countries spent introducing new content, practicing new content, or reviewing earlier content. American spent more time reviewing old material than anyone else except the Czechs. None of the countries spent a great deal of time practicing new material, but Japanese did allot 60% of their time to introducing new content. Only Japan's lessons were considered to be of high or moderate complexity, 39% and 45% respectively. The U.S. had the fewest lessons considered to be of high complexity (6%) and the third-highest number judged to be of low complexity (67%), behind Australia (77%) and the Netherlands (69%). Only Japanese offered many proofs. Twenty- six percent of the problems in any given lesson contained proofs, and 39% of the lessons contained at least one proof. Second-place Switzerland posted just 3% and 11% respectively. The researchers asked whether the lessons consisted of stating concepts, using procedures, or making connections between mathematical facts. …
In 1991, the Republic of Brazil asked the World Bank’s assistance in the decentralization program of its urban rail systems run by the Companhia Brasileira de Trens Urbanos (Brazilian Urban Trains Company-CBTU). The systems were to be transferred (decentralized) from the Federal Government to the local (State and Municipal) authorities. The local authorities agreed to receive the systems as long as they were rehabilitated and modernized but also requested that the Bank acted as “honest broker” between the parties and financed the program. The Bank agreed to embark in this program because it saw an opportunity to revitalize very important trunk corridors of the metropolitan regions which, if properly integrated with the existing bus systems and land use could greatly enhance mobility in the region, particularly for the main users who are low-income. From 1992-2002, the Bank lent more than US$1 billion for the decentralization program and follow ups in the States where decentralization was completed. This paper examines the main issues involved in a program of this nature, the institutional obstacles faced and the lessons learned.
Hernando de Soto, in The Mystery of Capital (de Soto 2000), shows that the poor of the world have, in his terminology, assets vastly in excess of their capital. In one study, de Soto’s associates surveyed neighborhoods in various poor countries, assessing the value of buildings which were not formally titled. The extrapolated value of just the informally owned buildings in the Third World amounted to $9.3 trillion – more than half the combined value of all publicly traded US companies. In identifying a crucial mystery – the failure of these assets to serve as capital for their owners – de Soto has identified a great opportunity for economic betterment.
This paper reviews Russian municipal budget revenues and expenditures reforms in 1992–2002. Recent tax reforms have resulted in the decrease of local fiscal autonomy. Municipal budget revenues have dropped sharply in relative as well as absolute terms. Despite significant formal expenditure powers Russian municipalities are completely financially dependent on higher-level governments. Within regions regional governments have continued to increasingly finance municipal social expenditures. The examination of possible scenarios of development after the enactment of the draft law"On the General Principles of the Organization of Local Self-governance in the Russian Federation" shows that the fiscal centralization trend will continue.
Basic education (primary and junior secondary schooling) in China has experienced phenomenal development in the reform era from the late 1970s. The most important reform policies; namely, decentralization of governance and diversification of finance, have been translated into an unprecedented scale of resource mobilization for schooling expansion. This article examines China’s education finance reform and basic education development. It analyzes international aid and assistance, particularly major basic education projects financed by the World Bank and other international organizations. The article argues that China is not necessarily “in the driving seat” in cooperation with the World Bank, and that the bank does not play purely “a pivotal positive role” in helping develop Chinese basic education. In spite of its huge aid and assistance in China, the bank, to a certain extent, also contributes to the formation of China’s bifurcated schooling system.
This paper examines government reform including decentralization and e-government services in Korea since 1990s. Since the full-scale implementation of local autonomy in Kim Young-sam Administration, Kim Dae-jung Administration, inaugurated in February 1998 just after financial crisis, launched an intensive reform program covering finance, corporate, labor, and public sectors. Among main reform strategies introduced according to New Public Management paradigm were reshuffling local governments, manpower reduction, delegation of central government's functions and resources, paperwork reduction, and so forth. In addition, e-government services were initiated as one of software-oriented reform strategies. In spite of some arguments, Kim Administration gained the performance of e-government as well as government reforms to a considerable degree. Roh Administration, taking office in February 2003, also made public the Roadmap to Government Innovation including decentralization and e-government. It is expected to contribute much to enhancing efficient and effective operation of local governments. Government reform, however, may confront with a contradiction between decentralization of central power and centralized e-government. Seamless integration of works and processes at all levels of government requires cross-agency collaboration and coordination carefully coupled from the central government. In order to mitigate this contradiction, it is recommended to develop a proper reference model for business and technology, which can be applied flexibly to the central and local government all together.
Decentralization looms large in any analysis of Canadian economic and social policy. This trend has been especially pronounced in the area of unemployment insurance (UI) and social assistance (SA) programmes. Provinces now manage SA programmes and retain 100% of any cost savings that they achieve, while the Federal government maintains full responsibility for the passive component of UI. Under a series of provincial-federal Labour Market Development Agreements, since 1997 most of Canada's provinces have taken over administrative responsibility for the employment benefit and support measures (EBSMs) targeted on UI beneficiaries. A number of articles have examined the implications for provincial SA systems of restrictive measures in the UI programme. This paper examines the possibility that provinces may shift actual and potential SA clients onto the insurance system (now called employment insurance, EI). It concludes that within the context of EBSMs, any cost-shifting of this ...
Ma and Chen have proposed an authenticated encryption scheme with public verifiability. The scheme claims that the TTP can publicly verify the sender's signature without running a zero knowledge proof protocol. The problem in verification which causes the TTP to reject a valid signature with non-negligible probability is pointed out.
This report presents an analysis of the application of the comprehensive development framework (CDF) principles to the process of preparation and implementation of the poverty reduction strategy paper (PRSP) in Burkina Faso. It is based on the work of the case study team that carried out a fieldwork in Burkina Faso in April and May 2002. Burkina Faso was chosen because it was one of the first countries to have completed a full PRSP, the cadre strategique de lutte contre la pauvrete (CSLP), and because it is highly dependent on international aid to finance its public budget. An objective of the Burkina Faso case study was to identify ways and means to strengthen local capacity to implement the CSLP in order to enhance the likelihood of Burkina Faso achieving the millennium development goals (MDGs). Translating budgetary resources into sustained poverty reduction outcomes will require Burkina Faso and its development partners to address two fundamental challenges: first, the quality of public service delivery will need to improve markedly and will need to engage the process of decentralization and the participation of civil society in implementation and monitoring development efforts at the local level. Second, the diversification of the economy from dependence on agriculture will need to be accelerated and the private sector needs to be enabled to perform better its role as the engine of growth and exports. The report is organized as follows: chapter one gives introduction. The second chapter provides a brief overview of the historical context and landmarks leading to the CDF principles and CSLP in Burkina Faso. Chapter three gives detailed analysis of each of the CDF principles in terms of how the principle is being applied, progress in executing the principle, and the major issues and challenges to be faced. Chapter four analyzes some specific issues and challenges of implementation and sequencing. The chapter concludes with a discussion of a simple scorecard by which the team attempted to rank the likelihood of achieving specific CSLP goals.
The aim of this research is to analyze factors influencing fiscal need and fiscal capacity autonomy era. Estimated result of two models, fiscal need and fiscal capacity showed a positive effect and significant at 1% level. The research finding are (i) these estimated models enrich the public finance references. the difference between fiscal need (FN) and fiscal capacity (FC) can be derived a fiscal gap (FG); (ii) the increasing of the fiscal expenditure need was larger than fiscal capacity; (iii) the districts/towns (kabupaten/kota) faced some 'trade-off', such as, between pattern if fiscal centralization and fiscal decentralization, between execution of program oriented and budget oriented, and between reduction of fiscal gap and uncertainly of aid allocation.
This article discusses the adjustment of large firms in France, in particular how they regionalized their production structures in the 1980s. Throughout the ‘Golden Age’, large firms had geographically reorganized their activities: strategic planning remained in Paris, while the actual production was decentralized into the provinces, primarily to address cost and labour conflict issues. When the large firms faced a profitability crisis in the 1980s, and the traditional state‐financed way out of the problems was no longer available, they saw in these proto‐regional production systems a chance to become more competitive. They relied on the decentralization policies of the governments in the 1980s, and used the second‐order effects of the new policies as a means to modernize their own operations. L'article examine l'adaptation des grandes entreprises françaises, notamment la régionalisation de leurs structures de production dans les années 1980. Durant ‘l'Age d'Or’, les grosses entreprises avaient réorganisé géographiquement leurs activités: la planification stratégique restait à Paris, tandis que la production réelle se décentralisait en province, principalement pour résoudre des problémes de couûts et de conflits sociaux. Lorsque ces grandes entreprises se heurtèrent à la crise de rentabilité des années 1980, alors que la solution traditionnelle de financement étatique n'existait plus, elles virent dans ces systèmes de production proto‐régionaux une chance d'améliorer leur compétitivité. Elles s'appuyèrent donc sur les politiques de décentralisation des gouvernements de l'époque, profitant des effets secondaires de ces initiatives pour moderniser leur propre fonctionnement.
The contribution of theology to control and accounting has been traced through the \nmonastic tradition demonstrating how the Cistercians used decentralized control of their \nextensive farms in contrast to the centralized control of the Benedictines (Knowles,1948). \nThe contribution of theology to political economy was traced by Weber and Tawney in \ntheir analysis of the Calvinist roots of liberal market capitalism and more subtly by Adam \nSmith in his ironic use of a phrase from Isaiah Ch 60 as the title for his seminal work on \nmarkets. \nThis paper reports upon a case of the interplay of theology and control and accountability \nwhich occurred as the Church of England set out to respond to a financial crisis. \nAccountability was theorized as stemming from the three elements of covenant, constitution \nand contract all of which were contested in the ground metaphor of autonomy. It \ndemonstrates how a group of financiers from within the evangelical tradition (which places \nstress on headship and control) led an attempt to create a new church governance body (a \nnational council) with strongly integrated central control and diminished democratic and \nconciliar participation. They had described the church as 'a cats cradle of autonomous and \nsemi autonomous organizations'. The case then demonstrates how the other theological \ntraditions (anglo-catholic and liberal) were mobilized , over a period of several years, to \npermit the new body to come into life but to unravel the proposed centralised control and \nto maintain the existing nature of governance and to enrich the complexity of the 'cat's \ncradle'. \nThe case analysis is based upon the theory of eco-systems (as a more formal view of the \ncat's cradle) to show how the loosely coupled nature of eco systems with their multiple \ntheological stances and their multi layered processes of relationships and accountabilities \nwere almost impervious to the attempt to shift them into an ordered and controlled \nhierarchy.
Fiji is currently implementing health care reforms with the first phase of reforms focusing on decentralization of the health system. Part of this effort focuses on looking at financing options. Some options for financing health care include private health insurance, social insurance, community financing, user-pays system (out-of-pocket), health savings accounts, government taxation and subsidies, and overseas loans and aid funding. This paper addresses all these options in detail and provides an analysis into each of these options relevance to Fiji and in some instances to other nations in the South Pacific region. Given the relative small populations of Fiji and its neighbouring nations, a regional approach to financing could prove more viable in the longer-term, however political, social, economic, legal and cultural issues will need to seriously explored.
Epidemiology of Acute Renal Failure The development of acute renal failure (ARF) in the hospital setting continues to be associated with poor outcomes (1–7). Over the last three decades, several experimental models have identified pathophysiologic mechanisms associated with ARF and have enhanced our understanding of the disease (8–10). It is evident that ARF can result from alterations in renal perfusion, changes in glomerular filtration, and tubular dysfunction, and that correction of these factors can ameliorate the effects of ARF (11,12). On the basis of the identification of the underlying mechanisms, several new potential interventions have been developed that have been shown to alter the course of incipient and established ARF in experimental models (13–15). Application of these findings has resulted in improvements in the prevention of ARF due to radiocontrast agents, aminoglycoside antibiotics, and rhabdomyolysis (16,17). Several other agents are now in advanced stages of development or initial phases of clinical trials (18,19). In concert, advances in dialysis have occurred with the availability of continuous renal replacement therapies in addition to intermittent hemodialysis and acute peritoneal dialysis (20–22). It is well recognized that uncomplicated ARF can usually be managed outside the intensive care unit (ICU) setting and carries a good prognosis, with mortality rates less than 5% to 10% (23,24). In contrast, ARF complicating nonrenal organ system failure in the ICU setting is associated with mortality rates of 50% to 70%, which has not changed for several decades (6,25–30). These figures are in sharp contrast to the experience with acute myocardial infarction (AMI), where in-hospital mortality rates have declined from the range of 50% to approximately 6% over the past 25 to 30 yr. Much of the credit for improved AMI outcomes has been attributed to the use of coronary care units, cardiac catheterization, aspirin, β-adrenergic antagonists, thrombolytic therapy, and, more recently, specialized percutaneous coronary interventions and glycoprotein IIb–IIIa inhibitors (31–34). In spite of improved dialytic technology, including the development and refinement of continuous renal replacement therapies for the most critically ill patients, we have seen no material change in the high mortality rates associated with ARF. Indeed, we have not demonstrated any pharmacologic or other intervention effective in the early management of ARF. Interventions that have been deemed ineffective (or potentially harmful) include the following: loop and osmotic diuretic agents (35,36), “renal dose” dopamine (37,38), atrial natriuretic peptide (39,40), insulin-like growth factor-1 (41), and endothelin receptor antagonists (42). Although ARF may develop in 5% or more of hospitalized patients, the heterogeneity of ARF and associated comorbidity make its study more difficult than AMI and other, more discrete conditions. Among the impediments to progress in ARF research is the lack of a uniform definition of ARF that might be used to compare and contrast observational studies, and to allow for rational design of clinical trials. Relatively few studies have examined the incidence of hospital-acquired ARF. The oft-cited study by Hou et al. (23) reported an ARF incidence estimate of 4.9%. Shusterman et al. (24) conducted a similar study identifying ARF in 1.9% of hospitalized patients. A follow-up study recently published by Hou and colleagues (43) showed an increase in incidence (7%), but a similar spectrum of risk factors. ARF in the ICU setting has also been characterized in the last two decades. Lian[Combining Tilde]o et al. (6) found ICU patients with ARF to have associated organ failure, sepsis, and other complications. It is well recognized that the development of ARF is associated with an increase in mortality (22,25,26,44,45). It is also known that patients with ARF as part of multiorgan failure have the highest mortality rates. In several studies, sepsis-related ARF had a significantly worse prognosis than ARF in the absence of sepsis (46,47). It is also recognized that untreated ARF may contribute to a higher incidence of new-onset sepsis (48). Definition of ARF The spectrum of definitions in published studies of ARF is striking, ranging from severe (e.g., ARF requiring dialysis) to relatively modest observable increases in serum creatinine concentration (e.g., increase in serum creatinine of 0.3 to 0.5 mg/dl above baseline). Solomon et al. (36) used the definition of an increase in serum creatinine of 0.5 mg/dl within 48 h of radiocontrast exposure in a widely cited study that showed a borderline significant difference in ARF among individuals given saline infusion versus furosemide or mannitol before radiocontrast exposure. However, neither the Solomon et al. study nor others that use this ARF definition (including the Tepel et al. (49) and Kay et al. (50) publications on N-acetyl cysteine) have shown an association between a transient change in serum creatinine and morbidity, or the likelihood of long-term recovery of renal function. Many other definitions of ARF have been applied; some are outlined in Table 1. The most liberal of definitions have been used in intervention studies aimed at ARF prevention, usually in the context of radiocontrast exposure, one of the few instances in which ARF can be anticipated.Table 1: Alternative ARF definitions from several published studiesSeveral of the definitions are extremely complex (see Lian[Combining Tilde]o et al. (6) and others) and could allow excessive subjectivity in ARF determination. These would likely be impractical for prospective, multicenter investigations. Moreover, none of the definitions used to date take into account the modifying effects of age, gender, and race on creatinine generation (and thereby serum creatinine concentration in ARF). It is noteworthy that creatinine generation is typically higher among individuals who are younger, male, and African American (51). Therefore, at the same decrement in GFR, persons with different demographic characteristics may be more likely to “qualify” with ARF diagnoses, particularly those definitions that require a minimum peak creatinine (e.g., 50% increase, to at least 2.0 mg/dl). By use of this definition, we found a twofold increase in the incidence of amphotericin B–associated ARF among men (52). Whether male gender is a true risk for ARF or simply a risk for being diagnosed with ARF is unclear. Regardless, the association of ARF with male gender highlights one of the limitations of the use of a definition of ARF that is creatinine based and not age, gender, and race adjusted. Changes in serum creatinine are not specific and do not discriminate the nature and type of renal insult (e.g., ischemic, nephrotoxic) or the site and extent of glomerular or tubular injury, and levels are relatively insensitive to small changes in GFR (53). Moreover, changes in serum creatinine may lag behind changes (decline or recovery) in GFR by several days. Finally, because serum creatinine is influenced by one of the potential interventions for ARF (e.g., creatinine is removed by dialysis), its specificity for renal recovery is even more problematic. Empiric Evidence of the Focus on Creatinine and Urine Output We recently completed an analysis focusing on correlates of timing of nephrology consultation for ARF in the ICU (54). To avoid the complexities of comparing individuals whose ARF developed during a complicated ICU stay, we restricted our analysis to those patients with evidence of ARF at ICU admission and excluded individuals designated as “do not resuscitate.” We considered a wide array of demographic, clinical, laboratory, and physiologic variables (including pulmonary artery catheter data in some patients). The serum creatinine concentration and urine output (either as a continuous variable or the dichotomous “oliguria”) (<400 ml/d) were associated with the timing of consultation. There was no relation between the timing of consultation and hospital service, medical history, physiologic parameters, other laboratory studies, or the presence or absence of organ system failure, despite the fact that many of these factors have been shown to predict mortality in ARF in other studies. In other words, empiric evidence demonstrates that the definitions used in published reports are operative in practice, with little attention to risk profiles or associated nonrenal organ system failure. Analogous Definitions in Other Conditions Conceptual Framework for Disease Definitions. Disease definitions may be used to ascertain the presence of a disease in an individual or a population, guide the nature and timing of diagnostic and therapeutic interventions, and, in individual patients, help determine prognosis. The presence of any disease is inferred from a combination of clinical symptoms and signs, and alterations in biologic markers that can be reproducibly measured. Measures defining a disease should be responsive to change, track the natural history of the disease, and provide an assessment of the severity of injury. Consequences of the untreated disease and its response to specific interventions are additional criteria that might be considered when evaluating the choice of variables to define and classify a disease. Most disease definitions rely on the presence of specific markers that are measurably altered in response to an injury, and the sensitivity and specificity of any definition depends on the criteria used. These “response variables” may appear at varying time points in the disease and help define the course of the disease. Ideally, the magnitude and pattern of change of the response variable correlate with disease outcomes. For instance, AMI can be diagnosed with the combination of chest pain and elevated cardiac troponins or creatine phosphokinase. Gradations in the severity of signs (including electrocardiography) and symptoms and the levels of troponin and creatine phosphokinase profile allow further classification of the disease spectrum (e.g., angina, unstable angina, demand ischemia, silent ischemia, myocardial infarction). A key feature for AMI is that the clinical presentation is directly related to an underlying event (i.e., coronary thrombosis). Moreover, the markers are sensitive, specific, and correlate with the severity of injury, even in the absence of typical clinical features. In contrast, sepsis is heterogeneous in its presentation and affects multiple organs, so no single marker can be used to define the presence or absence of disease. Recognizing this limitation, a functional definition for sepsis has been based on events in the natural history of the sepsis syndrome: systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock (55). In the absence of specific markers, effective definitions for a disease rely on multiple parameters, some of which represent the specific response to the disease, whereas others reflect nonspecific consequences of the disease. Disease severity is graded on the basis of the presence of specific parameters. For instance, the transition from sepsis to severe sepsis requires the presence of sepsis-related organ dysfunction. These graded definitions are more readily applied to classify populations, although they have also been used to guide interventions in individual patients and research subjects (56,57). The multidimensional definition and classification construct has been applied to several diseases where a single specific diagnostic criterion is not available or is otherwise unsuitable. For example, the Ranson criteria enable early classification of severe acute pancreatitis (58). These criteria rely on the presence of three or more of the 11 criteria evident within 48 h of admission. Criteria include age and a series of laboratory parameters that reflect consequences of disordered pancreatic function (i.e., hyperglycemia in absence of diabetes, hypocalcemia, azotemia, anemia, hypoalbuminemia, leukocytosis, elevations of the hepatic enzymes lactate dehydrogenase and aspartate aminotransferase) and physiologic variables (i.e., metabolic acidosis, hypoxia) to grade the response. Interestingly, serum amylase and lipase, enzymes directly related to pancreatic injury (and analogous to creatinine in ARF), are not included in the scoring system. The number of positive criteria are associated with mortality ranging from <5% for zero to two criteria to 100% for seven to eight criteria (58). Similarly, the Child-Pugh classification is a means of assessing the severity of hepatic cirrhosis (59). It assigns scores for each of three laboratory parameters (bilirubin, albumin, and prothrombin time) and two clinical criteria representing the consequences of liver failure (encephalopathy and ascites). The individual scores are summed and then grouped as <7 (A), 7 to 9 (B), and >9 (C). A Child-Pugh “C” classification forecasts survival of less than 12 mo. Cancer staging similarly uses the tumor node metastasis grading system to classify malignant disease. to of these classification is the lack of any single criterion to the disease and on the consequences of the disease and on other factors the course of the disease for We that ARF be in a similar in of of and organ ARF has more in with sepsis or pancreatitis than with of in For any the to the disease is and where and when the in the natural history of the disease. The whereas the could time points for variables should allow of the disease and provide a to determine the time course of the disease. Renal functional alterations many (e.g., and markers specific for the site and pattern of injury are Several new are to study ARF and are to be for studies et al. and et al. demonstrated that may be an early marker for renal injury specific for the renal et al. and et al. have new markers for disease, including a new that is found in urine injury. Other studies have a spectrum of markers for renal injury but none have been in a number of patients advances in likely provide new for assessment Several for changes in GFR each has markers may be the most and for assessment of changes in GFR and these markers are being to be a marker for changes in GFR but requires in the ICU and other that use contrast agents are being in experimental models of ARF and could provide on the and extent of and the presence of renal It is evident that of the site and extent of injury would a of the underlying severity of renal dysfunction, could and could help guide specific therapeutic of for of from Other to ARF It is evident that definitions of ARF that rely on serum creatinine and urine output do not the spectrum of ARF in clinical in they do not the clinical to for therapeutic Indeed, in the timing of to renal injury has to heterogeneity in intervention studies in ARF and may be for the lack of It is also recognized that of care (including the timing of of of and the use of likely the course and outcomes ARF. diagnostic and classification are to allow for advances in ARF research and clinical We on two but related we to the of and specific markers to the site and severity of renal injury and to track functional change over we to more define the course of ARF in a of and factors that the renal response to injury and outcomes from ARF. this increase diagnostic specificity and allow for more of For instance, the of radiocontrast and underlying renal function determine the of creatinine and incidence of In most elevations in serum creatinine are seen within 48 h radiocontrast exposure, so that the of a or early therapeutic intervention can be In contrast, when the nature and timing of insult are less well characterized (e.g., of in a with in serum creatinine and urine output are less of the pattern of with the response could help to guide the timing of specific interventions, and compare two or more interventions in clinical trials. We the heterogeneity of ARF and the absence of specific markers for renal injury, an effective diagnostic and classification should parameters other than the renal response to injury. organ system also affects the ARF For instance, serum creatinine levels may the severity of renal in hepatic failure with elevated levels and the for may further GFR In other and response factors have been in the definition and classification of disease (see and the Failure classification for sepsis Criteria To the to we should into several factors that to injury, the nature and timing of the the response of the to the and the consequences of the ARF We that a new definition for ARF should from each of these would to a more definition for the and would the assessment of interventions in this Table a definition for ARF that variables from each of the is grade an risk of classification of acute renal a for staging ARF that is based on the criteria within each We based grade on the risk of ARF from studies. We grade the nature and timing of the insult on the basis of of the specific insult and the time from the insult to the of We grade the response variables the criteria by the Acute We define nonrenal organ by organ failure scores Gradations in the and reflect levels of risk for an whereas those in the and reflect an severity of We that at each of individual patients would be graded within each On the basis of the in the patients would be into the of ARF and would stages during the course of the disease and in ARF et al. demonstrated three of ARF On the basis of these is widely that clinical ARF has three and The of each on the basis of the presence of disease and the nature and type of et al. and have recently a classification for ARF that phases for this and recovery in response has also been established in experimental ARF the response can be graded on the basis of for the and this is being as a therapeutic (e.g., may the response to the in renal function in ARF. For any given the pattern of ARF on or to injury and the nature and severity or of injury. The renal response is likely to be on these two factors and may in determine nonrenal organ dysfunction. the course is nonrenal organ further the renal of acute renal failure aimed at the and established ARF. from with individuals on the basis of may be to more define the time course of disease and time points for intervention is similar in to sepsis syndrome, where of have been for therapeutic The multicenter of the to be within h of the organ system failure the nature and timing of the insult in ARF were one could a specific therapeutic to ameliorate the injury and the within a known therapeutic the renal response can be can be and on the presence or absence of the underlying nonrenal organ dysfunction, specific interventions, as dialysis could be the These The definitions could be used to the presence of disease by the response variable graded for the for ARF and of the increase in serum creatinine of mg/dl with a grade of and an insult grade of is more likely to represent significant injury (and to be by more than the and insult were and an grade of a similar increase in serum creatinine might require dialytic A of versus course could be in diagnostic and classification in aimed at and The multidimensional can be with A with creatinine and no grade seen h a contrast grade with a urine output of and a follow-up serum creatinine of mg/dl grade with no nonrenal grade would be A 48 h a change in serum creatinine to mg/dl and a in urine output to evidence of On the basis of these two time is evident that this has a in renal representing an from the injury or injury. the for change in renal function based on the timing of the contrast would have been a to creatinine within the from the response would an of the initial injury A therapeutic intervention with a that could ameliorate injury or could then be for this In a example, a who coronary artery and replacement is The is with a creatinine of 2.0 mg/dl and a history of serum creatinine from to mg/dl with urine output ml/d) on an There was no in during or and has not any There was no evidence for or on is with on and requires two to a of is 7 mg/dl and serum On the basis of of is to have of to and diagnostic would be considered to be acute on renal failure. Many and care (and would not with dialysis or in this because the is urine and has no By use of the classification this would be the presence of and in renal a could be to dialytic although is no evidence on which to make this data on outcomes associated with patients in clinical would be more to than data on patients as acute on renal a Framework for and Although a more diagnostic and classification system would be to could also be used to of For example, in a comparing dialysis or one could that dialysis should for subjects with of or with of or A more and classification could new and markers from and investigations. For instance, were that predict the renal these could be included as new criteria in the Similarly, new injury markers could be included in the insult and provide more specific on the nature and severity of disease. Other markers of renal function (e.g., or of organ (e.g., could be included to other and The definitions are based on in other as acute liver disease, and The criteria are and to The could be applied to a or for individual The could also and However, are several limitations to (and our we that the are but the and of each to the definition and classification has not been We do not these are the or are others that to be We do not have markers for defining the consequences of renal dysfunction. We to define the nature and severity of underlying disease with the markers at We that the established for response variables are related to outcomes and are We the of the variables to determine additional definitions would be It is evident that studies to the of the definition in several However, we a new diagnostic and classification to help management and into this ARF continues to be a a significant of time for and to the that ARF to outcomes in the critically little progress has been in this of the key impediments to progress is the lack of a uniform definition for this disease. definitions that rely on changes in serum creatinine and urine output are neither nor We a new classification for ARF that from other in an to data and, we studies to the of construct and to the and of within each we (or a is not a On the we more in ARF effective interventions, and, mortality rates in the single study was by a from the for and by The to in Acute Renal Disease study the of of and