Using the National Institute of Health Stroke Scale to Predict Dysphagia in Acute Ischemic Stroke

Background and Purpose: Oropharyngeal dysphagia is a common manifestation in acute stroke. Aspiration resulting from difficulties in swallowing is a symptom that should be considered due to the frequent occurrence of aspiration pneumonia that could influence the patient's recovery as it causes clinical complications and could even lead to the patient's death. The early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. This study aimed to create an algorithm to identify patients at risk of developing dysphagia following acute ischemic stroke in order to be able to decide on the safest way of feeding and minimize the complications of stroke using the National Institutes of Health Stroke Scale (NHISS). Methods: Clinical assessment of swallowing was performed in 50 patients admitted to the emergency unit of the University Hospital, Faculty of Medicine of Ribeirao Preto, Sao Paulo, Brazil, with a diagnosis of ischemic stroke, within 48 h after the beginning of symptoms. Patients, 25 females and 25 males with a mean age of 64.90 years (range 26-91 years), were evaluated consecutively. An anamnesis was taken before the patient's participation in the study in order to exclude a prior history of deglutition difficulties. For the functional assessment of swallowing, three food consistencies were used, i.e. pasty, liquid and solid. After clinical evaluation, we concluded whether there was dysphagia. For statistical analysis we used the Fisher exact test, verifying the association between the variables. To assess whether the NIHSS score characterizes a risk factor for dysphagia, a receiver operational characteristics curve was constructed to obtain characteristics for sensitivity and specificity. Results: Dysphagia was present in 32% of the patients. The clinical evaluation is a reliable method of detection of swallowing difficulties. However, the predictors of risk for the swallowing function must be balanced, and the level of consciousness and the presence of preexisting comorbidities should be considered. Gender, age and cerebral hemisphere involved were not significantly associated with the presence of dysphagia. NIHSS, Glasgow Coma Scale, and speech and language changes had a statistically significant predictive value for the presence of dysphagia. Conclusions: The NIHSS is highly sensitive (88%) and specific (85%) in detecting dysphagia; a score of 12 may be considered as the cutoff value. The creation of an algorithm to detect dysphagia in acute ischemic stroke appears to be useful in selecting the optimal feeding route while awaiting a specialized evaluation. Copyright (C) 2012 S. Karger AG, Basel

CRITICAL POINTS OF THE PRODUCTION PROCESS OF SOLID WOOD FLOORING

The quality concepts represent one of the important factors for the success of organizations and among these concepts the stabilization of the production process contributes to the improvement, waste reduction and increased competitiveness. Thus, this study aimed to evaluate the production process of solid wood flooring on its predictability and capacity, based on its critical points. Therefore, the research was divided into three stages. The first one was the process mapping of the company and the elaboration of flowcharts for the activities. The second one was the identification and the evaluation of the critical points using FMEA (Failure Mode and Effect Analysis) adapted methodology. The third one was the evaluation of the critical points applying the statistical process control and the determination of the process capability for the C-pk index. The results showed the existence of six processes, two of them are critical. In those two ones, fifteen points were considered critical and two of them, related with the dimension of the pieces and defects caused by sandpaper, were selected for evaluation. The productive process of the company is unstable and not capable to produce wood flooring according to the specifications and, therefore these specifications should be reevaluated.

Resíduos sólidos urbanos: impactos socioambientais e perspectiva de manejo sustentável com inclusão social

Com a Rio+20 retoma-se a discussão de estratégias para conciliar desenvolvimento com proteção dos ecossistemas. Um tema apenas tangenciado nessas discussões é o gerenciamento dos resíduos sólidos urbanos. Diante da institucionalização da Política Nacional de Resíduos Sólidos, busca-se contribuir para esse debate, bem como apontar caminhos para o enfrentamento dessa questão, privilegiando a inclusão social. Para isso, foram utilizados documentos e informações sobre a gestão de resíduos sólidos, e a literatura científica especializada. Observa-se que o inadequado gerenciamento dos resíduos sólidos gera impactos imediatos no ambiente e na saúde, assim como contribui para mudanças climáticas. Considerando as limitações das opções de destinação final para os resíduos, é imprescindível minimizar as quantidades produzidas por meio da redução, reutilização e reciclagem. Nesse contexto, destaca-se o papel dos catadores, que vêm realizando um trabalho de grande importância ambiental. Dadas as fragilidades desse segmento populacional, é preciso delinear políticas públicas que tornem a atividade de catação mais digna e com menos riscos e que, ao mesmo tempo, garantam renda, para assim caminhar rumo a um desenvolvimento mais saudável, justo e sustentável.

Examining the Justification for Residential Recycling

Municipalities in the United States have for the past two decades initiated two policies to reduce residential solid waste generation by increasing recycling. The first policy, implemented in over 4,000 municipalities in the United States, requires households to pay a fee for each unit of garbage presented at the curb for collection. The second policy, initiated in 8,875 municipalities, subsidizes household recycling efforts by providing free curbside collection of certain recyclable materials. Both initiatives serve as examples of incentive-based environmental policies favored by many economists. But before economists can celebrate this wide-spread adoption of incentive-based environmental policies, further examination reveals that potentially inefficient command and control policies have been more instrumental in promoting recycling than might be commonly known. This article examines the empirical lessons gained from studying twenty years of solid waste policy in the United States and argues for the replacement of several state recycling mandates with a system of state and/or national landfill taxes.

A critical assessment of the National Institutes of Health Consensus Development Program against the eras which shaped it

This research study offers a critical assessment of NIH's Consensus Development Program (CDP), focusing upon its historical and valuative bases and its institutionalization in response to social and political forces. The analysis encompasses systems-level, as well as interpersonal factors in the adoption of consensus as the mechanism for resolving scientific controversies in clinical practice application. Further, the evolution of the CDP is also considered from an ecological perspective as a reasoned adaptation by NIH to pressures from its supporters and clients for translating biomedical research into medical practice. The assessment examines federal science policy and institutional designs for the inclusion of the public interest and democratic deliberation.^ The study relies on three distinct approaches to social research. Conventional historical methods were utilized in the interpretation of social and political influences across eras on the evolution of the National Institutes of Health and its response to demands for accountability and relevance through its Consensus Development Program. An embedded single-case study was utilized for an empirical examination of the CDP mechanism through five exemplar conferences. Lastly, a sociohistorical approach was taken to the CDP in order to consider its responsiveness to the values of the eras which created and shaped it. An exploration of organizational behavior with considerations for institutional reform as a response to continuing political and social pressure, it is a study of organizational birth, growth, and response to demands from its environment. The study has explanatory import in its attempt to account for the creation, timing, and form of the CDP, relative to political, institutional, and cultural pressures, and predictive import thorough its historical view which provides a basis for informed speculation on the playing out of tensions between extramural and intermural scientists and the current demands for health care reform. ^

A study of the association between timing of solid food introduction in infants and overweight and obesity in pre-school aged children in NHANES 2003-2008

Background. Previous studies suggest an association between timing of introduction of solid food and increased risk of obesity in pre-school aged children, but no study included a representative sample of US children. We sought to examine whether there was any association between the timing of solid food introduction and overweight/obesity in pre-school aged children. Design/methods. Cross-sectional study of a nationally representative sample (N=2050) of US children aged 2 to 5 years with information on infant feeding practices and measured weight and height from the National Health and Nutrition Examination Survey 2003–2008. The main outcome measure was BMI for age and sex ≥ 85th percentile. The main exposure was timing of solid food introduction at < 4, 4–5, or ≥ 6 months of age. Binomial logistic regression was used in the analysis controlling for child's sex, birth weight and breastfeeding status as well as maternal age at birth, smoking status and socio-demographic variables. Results. Two thousand and fifty children were included in the sample; 51% male and 49% female; 57.1% Non-Hispanic White, 21.9% Hispanic, 14.0% Non-Hispanic Black, and 7% other race/ethnicity. Twenty-two percent of the children were overweight or obese. Sixty-nine percent were breastfed or fed breast milk at birth and 36% continued breastfeeding for ≥ six months. Solid foods were introduced before 4 months of age for 11.2% of the children; 30.3% received solid foods between 4 to 5 months; with 58.6% receiving solid foods at 6 months or later. Timing of solid food introduction was not associated with weight status (OR= 1.36, 95% CI [0.83–2.24]). Formula-fed infants and infants breastfed for < 4 months had increased odds of overweight and obesity (OR=1.54, 95% CI [1.05–2.27] and OR= 1.60, 95% CI [1.05–2.44], respectively) when compared to infants breastfed for ≥ 6 months. Conclusion. Timing of solid food introduction was not associated with weight status in a national sample of US children ages 2 to 5 years. More focus should be placed on promoting breastfeeding and healthy infant feeding practices as strategies to prevent obesity in children. ^

Induction of solid tumor differentiation by the peroxisome proliferator-activated receptor-γ ligand troglitazone in patients with liposarcoma

Agonist ligands for the nuclear receptor peroxisome proliferator-activated receptor-γ have been shown to induce terminal differentiation of normal preadipocytes and human liposarcoma cells in vitro. Because the differentiation status of liposarcoma is predictive of clinical outcomes, modulation of the differentiation status of a tumor may favorably impact clinical behavior. We have conducted a clinical trial for treatment of patients with advanced liposarcoma by using the peroxisome proliferator-activated receptor-γ ligand troglitazone, in which extensive correlative laboratory studies of tumor differentiation were performed. We report here the results of three patients with intermediate to high-grade liposarcomas in whom troglitazone administration induced histologic and biochemical differentiation in vivo. Biopsies of tumors from each of these patients while on troglitazone demonstrated histologic evidence of extensive lipid accumulation by tumor cells and substantial increases in NMR-detectable tumor triglycerides compared with pretreatment biopsies. In addition, expression of several mRNA transcripts characteristic of differentiation in the adipocyte lineage was induced. There was also a marked reduction in immunohistochemical expression of Ki-67, a marker of cell proliferation. Together, these data indicate that terminal adipocytic differentiation was induced in these malignant tumors by troglitazone. These results indicate that lineage-appropriate differentiation can be induced pharmacologically in a human solid tumor.

Highly efficient electro-gene therapy of solid tumor by using an expression plasmid for the herpes simplex virus thymidine kinase gene

We report successful electro-gene therapy (EGT) by using plasmid DNA for tumor-bearing mice. Subcutaneously inoculated CT26 tumor was subjected to EGT, which consists of intratumoral injection of a naked plasmid encoding a marker gene or a therapeutic gene, followed by in vivo electroporation (EP). When this treatment modality is carried out with the plasmid DNA for the green fluorescent protein gene, followed by in vivo EP with the optimized pulse parameters, numerous intensely bright green fluorescent signals appeared within the tumor. EGT, by using the “A” fragment of the diphtheria toxin gene significantly inhibited the growth of tumors, by about 30%, on the flank of mice. With the herpes simplex virus thymidine kinase gene, followed by systemic injection of ganciclovir, EGT was far more effective in retarding tumor growth, varying between 50% and 90%, compared with the other controls. Based on these results, it appears that EGT can be used successfully for treating murine solid tumors.

National burden of disease in India from indoor air pollution

In the last decade, a number of quantitative epidemiological studies of specific diseases have been done in developing countries that for the first time allow estimation of the total burden of disease (mortality and morbidity) attributable to use of solid fuels in adult women and young children, who jointly receive the highest exposures because of their household roles. Few such studies are available as yet for adult men or children over 5 years. This paper evaluates the existing epidemiological studies and applies the resulting risks to the more than three-quarters of all Indian households dependent on such fuels. Allowance is made for the existence of improved stoves with chimneys and other factors that may lower exposures. Attributable risks are calculated in reference to the demographic conditions and patterns of each disease in India. Sufficient evidence is available to estimate risks most confidently for acute respiratory infections (ARI), chronic obstructive pulmonary disease (COPD), and lung cancer. Estimates for tuberculosis (TB), asthma, and blindness are of intermediate confidence. Estimates for heart disease have the lowest confidence. Insufficient quantitative evidence is currently available to estimate the impact of adverse pregnancy outcomes (e.g., low birthweight and stillbirth). The resulting conservative estimates indicate that some 400–550 thousand premature deaths can be attributed annually to use of biomass fuels in these population groups. Using a disability-adjusted lost life-year approach, the total is 4–6% of the Indian national burden of disease, placing indoor air pollution as a major risk factor in the country.

Proposta de um modelo de gestão de resíduos industriais para o setor calçadista de Franca-SP com vistas à Política Nacional de Resíduos Sólidos

Criado inicialmente com a função básica de proteção aos pés, o calçado tornou-se um objeto de desejo e um acessório essencial de moda. Entre 1950 a 2015, estima-se que a produção mundial passe de 2,5 bilhões de pares produzidos para 25 bilhões de pares por ano, crescimento bem maior do que a população mundial. O couro, principal matéria-prima para a confecção de calçados, caracteriza-se por gerar grandes quantidades de resíduos ao longo de toda a cadeia produtiva. Especificamente na indústria coureiro-calçadista, o problema concentra-se nos elevados volumes de resíduos gerados na atividade produtiva, podendo causar desperdícios e grandes volumes de resíduos a serem descartados, envolvendo, principalmente, questões financeiras e ambientais. Países como Alemanha e Estados Unidos possuem legislação específica sobre a gestão de resíduos desde os anos 1970. No Brasil, depois de mais de 20 anos de tramitação no Congresso Nacional, em 2010, foi instituída a Política Nacional de Resíduos Sólidos, que reúne princípios, objetivos, instrumentos, diretrizes e metas, que deverão ser adotados pelos governos nas esferas federal, estadual e municipal, bem como pelas empresas com vistas à gestão integrada e ao gerenciamento ambientalmente adequado dos resíduos sólidos. Dessa forma, o objetivo desta tese foi desenvolver um modelo de gestão de resíduos industriais para o setor calçadista de Franca-SP com vistas à Política Nacional de Resíduos Sólidos. O desenvolvimento do modelo teve como ponto de partida um estudo bibliográfico sobre o assunto e, na sequência, por intermédio de uma pesquisa aplicada, conseguiu-se, em um primeiro momento, analisar a situação atual para compreender o modelo de gestão de resíduos vigente e realizar uma pesquisa de diagnóstico dos resíduos industriais do setor. Tal pesquisa possibilitou verificar que atualmente, esses resíduos, são enviados em sua totalidade para aterros sanitários, possibilitou também sua quantificação e cálculos dos custos envolvidos para transporte e destinação. Na sequência, realizaram-se estudos sobre a viabilidade técnica e financeira para tratamento térmico desses resíduos e a busca de benchmark no setor. O estudo também proporcionou uma contribuição de caráter mais prático e/ou gerencial ao recomendar diretrizes para a elaboração de um plano de gestão integrada de resíduos industriais para o setor, e uma proposta de gestão compartilhada dos resíduos industriais entre a entidade de classe e as indústrias calçadistas, com vistas à eliminação de envio desses resíduos para aterros. Dessa forma, contribuiu também para a elaboração do Plano Municipal de Gestão Integrada de Resíduos Sólidos do município em questão. Nesse sentido, após as análises e desdobramentos das etapas anteriores, foi possível propor um modelo de gestão de resíduos industriais, bem como demonstrar sua viabilidade técnica e financeira. Tal modelo foi denominado \"Modelo de Equiparação de Custos com Eficiência Ambiental\".

Concording EU trade and production data over time. National Bank of Belgium Working Paper No. 239, December 2012

This paper provides concordance procedures for product-level trade and production data in the EU and examines the implications of changing product classifications on measured product adding and dropping at Belgian firms. Using the algorithms developed by Pierce and Schott (2012a, 2012b), the paper develops concordance procedures that allow researchers to trace changes in coding systems over time and to translate product-level production and trade data into a common classification that is consistent both within a single year and over time. Separate procedures are created for the eightdigit Combined Nomenclature system used to classify international trade activities at the product level within the European Union as well as for the eight-digit Prodcom categories used to classify products in European domestic production data. The paper further highlights important differences in coverage between the Prodcom and Combined Nomenclature classifications which need to be taken into account when generating combined domestic production and international trade data at the product level. The use of consistent product codes over time results in less product adding and dropping at continuing firms in the Belgian export and production data.

Eastern Policy of the EU: the Visegrad Countries' Perspective. OSW Point of View, February 2003

1. After its enlargement, scheduled for 2004, the European Union will face a completely new situation at its eastern borders. This new situation calls for a new concept of the EU eastern activities, i.e. for development of the new Eastern Policy of the EU. 2. Due to a number of specific features such as geographical location, closeness of ties, direct risk factors etc., the Visegrad countries will and should be particularly interested in the process of formulating the new EU Eastern Policy. Consequently, they should be the co-makers of this policy. 3. The new EU Eastern Policy should differ fundamentally from the Union's traditional eastern relations. Firstly, its scope should not cover the entire CIS area: instead, the policy should focus on some of the European successor states of the former Soviet Union, namely Belarus, Russia and Ukraine, as well as Moldova, following the accession of Romania. It does not seem advisable to exclude the Russian Federation from this policy and to develop and implement a separate policy towards it. The new Eastern Policy should be an autonomous component and one of the most important elements in the overall foreign policy of the EU. 4. Secondly, the new Eastern Policy should be founded on the following two pillars: a region-oriented strategy, which could be called the Eastern Dimension, and reshaped strategies for individual countries. The Eastern Dimension should set up a universal framework of co-operation, defining its basic mechanisms and objectives. These should include: the adaptation assistance programme, JHA, transborder co-operation, social dialogue and transport infrastructures. The approach, however, should be kept flexible, taking into account the specific situation of each country. This purpose should be served by keeping in place the existing bilateral institutional contacts between the EU and each of its eastern neighbours, and by developing a national strategy for each neighbour.

Micro-based evidence of EU competitiveness: The CompNet Database. National Bank of Belgium Working Paper No. 253, March 2014

Drawing from confidential firm-level balance sheets in 11 European countries, the paper presents a novel sectoral database of comparable productivity indicators built by members of the Competitiveness Research Network (CompNet) using a newly developed research infrastructure. Beyond aggregate information available from industry statistics of Eurostat or EU KLEMS, the paper provides information on the distribution of firms across several dimensions related to competitiveness, e.g. productivity and size. The database comprises so far 11 countries, with information for 58 sectors over the period 1995-2011. The paper documents the development of the new research infrastructure, the construction of the database, and shows some preliminary results. Among them, it shows that there is large heterogeneity in terms of firm productivity or size within narrowly defined industries in all countries. Productivity, and above all, size distribution are very skewed across countries, with a thick left-tail of low productive firms. Moreover, firms at both ends of the distribution show very different dynamics in terms of productivity and unit labour costs. Within-sector heterogeneity and productivity dispersion are positively correlated to aggregate productivity given the possibility of reallocating resources from less to more productive firms. To this extent, we show how allocative efficiency varies across countries, and more interestingly, over different periods of time. Finally, we apply the new database to illustrate the importance of productivity dispersion to explain aggregate trade results.

Effectiveness and transmission of the ECB’s balance sheet policies. National Bank of Belgium Working Paper No. 275, December 2014

We estimate the effects of exogenous innovations to the balance sheet of the ECB since the start of the financial crisis within a structural VAR framework. An expansionary balance sheet shock stimulates bank lending, stabilizes financial markets, and has a positive impact on economic activity and prices. The effects on bank lending and output turn out to be smaller in the member countries that have been more affected by the financial crisis, in particular those countries where the banking system is less well-capitalized.

Comparing fiscal multipliers across models and countries in Europe. National Bank of Belgium Working Paper No. 278, March 2015

This paper employs fifteen dynamic macroeconomic models maintained within the European System of Central Banks to assess the size of fiscal multipliers in European countries. Using a set of common simulations, we consider transitory and permanent shocks to government expenditures and different taxes. We investigate how the baseline multipliers change when monetary policy is transitorily constrained by the zero nominal interest rate bound, certain crisis-related structural features of the economy such as the share of liquidity-constrained households change, and the endogenous fiscal rule that ensures fiscal sustainability in the long run is specified in terms of labour income taxes instead of lump-sum taxes.