Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy. METHODS: ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model. RESULTS: The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were euro922 per patient. Mean total costs were euro56 083 per patient in the ERAS group and euro63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were euro9139 and euro13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151). CONCLUSION: ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.

Monitoring of the training load and recovery parameters in competitive swimmers

Nombreux sont les groupes de recherche qui se sont intéressés, ces dernières années, à la manière de monitorer l'entraînement des sportifs de haut niveau afin d'optimaliser le rendement de ce dernier tout en préservant la santé des athlètes. Un des problèmes cardinaux d'un entraînement sportif mal conduit est le syndrome du surentraînement. La définition du syndrome susmentionné proposée par Kreider et al. est celle qui est actuellement acceptée par le « European College of Sport Science » ainsi que par le « American College of Sports Medicine», à savoir : « An accumulation of training and/or non-training stress resulting in long-term decrement in performance capacity with or without related physiological and psychological signs and symptoms of maladaptation in which restoration of performance capacity may take several weeks or months. » « Une accumulation de stress lié, ou non, à l'entraînement, résultant en une diminution à long terme de la capacité de performance. Cette dernière est associée ou non avec des signes et des symptômes physiologiques et psychologiques d'inadaptation de l'athlète à l'entraînement. La restauration de ladite capacité de performance peut prendre plusieurs semaines ou mois. » Les recommandations actuelles, concernant le monitoring de l'entraînement et la détection précoce du syndrome du surentrainement, préconisent, entre autre, un suivi psychologique à l'aide de questionnaires (tel que le Profile of Mood State (POMS)), un suivi de la charge d'entraînement perçue par l'athlète (p.ex. avec la session rating of perceived exertion (RPE) method selon C. Foster), un suivi des performances des athlètes et des charges d'entraînement effectuées ainsi qu'un suivi des problèmes de santé (blessures et maladies). Le suivi de paramètres sanguins et hormonaux n'est pas recommandé d'une part pour des questions de coût et de faisabilité, d'autre part car la littérature scientifique n'a, jusqu'ici, pas été en mesure de dégager des évidences à ce sujet. A ce jour, peu d'études ont suivi ces paramètres de manière rigoureuse, sur une longue période et chez un nombre d'athlète important. Ceci est précisément le but de notre étude.

A natureza das substâncias de referência na avaliação de massas molares de resinas PBLH por meio de cromatografia de exclusão por tamanho e osmometria de pressão de vapor

The SEC and VPO behaviour of hydroxyl-terminated polybutadiene resins was investigated using toluene as solvent and polybutadiene and polystyrene as standards. The results show that molar mass obtained depend on the nature of the standards used in the calibration, specialy in SEC analysis.

Preparo de óxido de nióbio suportado em alumina por deposição química em fase vapor: caracterização por espectroscopia vibracional e termogravimetria

Alumina supported niobium oxide was prepared by chemical vapor deposition (CVD) of NbCl5. The alumina was calcined and pretreated at differents temperatures in order to vary the density of OH groups on the surface which was determined by thermogravimetric analysis. A good correlation was found between the amount of anchored niobium and the total number of anionic sites (oxide and hydroxyl groups) on the surface of the alumina. The infrared spectra on the OH stretching region indicate that OH groups coordinated to at least one tetrahedral aluminum were more reactive towards NbCl5.

Different Plasma Markers of Inflammation Are Influenced by Immune Recovery and cART Composition or Intensification in Treated HIV Infected Individuals

Abstract Background HIV-1 infection increases plasma levels of inflammatory markers. Combination antiretroviral therapy (cART) does not restore inflammatory markers to normal levels. Since intensification of cART with raltegravir reduced CD8 T-cell activation in the Discor-Ral and IntegRal studies, we have evaluated the effect of raltegravir intensification on several soluble inflammation markers in these studies. Methods Longitudinal plasma samples (0–48 weeks) from the IntegRal (n = 67, 22 control and 45 intensified individuals) and the Discor-Ral studies (44 individuals with CD4 T-cell counts<350 cells/µl, 14 control and 30 intensified) were assayed for 25 markers. Mann-Whitney, Wilcoxon, Spearman test and linear mixed models were used for analysis. Results At baseline, different inflammatory markers were strongly associated with HCV co-infection, lower CD4 counts and with cART regimens (being higher in PI-treated individuals), but poorly correlated with detection of markers of residual viral replication. Although raltegravir intensification reduced inflammation in individuals with lower CD4 T-cell counts, no effect of intensification was observed on plasma markers of inflammation in a global analysis. An association was found, however, between reductions in immune activation and plasma levels of the coagulation marker D-dimer, which exclusively decreased in intensified patients on protease inhibitor (PI)-based cART regimens (P = 0.040). Conclusions The inflammatory profile in treated HIV-infected individuals showed a complex association with HCV co-infection, the levels of CD4 T cells and the cART regimen. Raltegravir intensification specifically reduced D-dimer levels in PI-treated patients, highlighting the link between cART composition and residual viral replication; however, raltegravir had little effect on other inflammatory markers.

Recovery of Hemicelluloses from Wood Hydrolysates by Membrane Filtration

Hemicelluloses are among the most important natural resources that contain polysaccharides. In this study the separation and purification of hemicelluloses from water extraction liquors containing wood hemicelluloses, lignin compounds and monosaccharide by using membrane filtration was investigated. The isolation of the hemicelluloses from the wood hydrolysates was performed in two steps: concentration of high molar mass hemicelluloses by ultrafiltration and separation of low molar mass hemicelluloses from monomeric sugars using tight ultrafiltration membranes. The purification of the retained hemicelluloses was performed by diafiltration. During the filtration experiments, the permeate flux through ultrafiltration and tight ultrafiltration membranes was relatively high. The fouling ability of the used membranes was relatively low. In our experiments, the retention of hemicelluloses using two filtration steps was almost complete. The separation of monosaccharides from hemicelluloses was relatively high and the purification of hemicelluloses by diafiltration was highly efficient. The separation of lignin from hemicelluloses was partially achieved. Diafiltration showed potential to purify retained hemicelluloses from lignin and other organics. The best separation of lignin from hemicelluloses in the first filtration step was obtained using the UC005 membrane. The GE-5 and ETNA01PP membranes showed potential to purify and separate lignin from hemicelluloses. However, the feed solution of the second filtration stages (from different ultrafiltration membranes) affected the permeate flux and the separation of various extracted compounds from hemicelluloses. The GE-5 and ETNA01PP membranes gave the efficient purification of the hemicelluloses when using diafiltration. Separation of degraded xylan from glucomannan (primary spruce hemicelluloses) was also possible using membrane filtration. The best separation was achieved using the GE-5 membrane. The retention of glucomannan was three times higher than xylan retention.

A geração química de vapor em espectrometria atômica

The historical development of atomic spectrometry techniques based on chemical vapor generation by both batch and flow injection sampling formats is presented. Detection via atomic absorption spectrometry (AAS), microwave induced plasma optical emission spectrometry (MIP-OES), inductively coupled plasma optical emission spectrometry (ICP-OES) , inductively coupled plasma mass spectrometry (ICP-MS) and furnace atomic nonthermal excitation spectrometry (FANES) are considered. Hydride generation is separately considered in contrast to other methods of generation of volatile derivatives. Hg ¾ CVAAS (cold vapor atomic absorption spectrometry) is not considered here. The current state-of-the-art, including extension, advantages and limitations of this approach is discussed.

Apolipoprotein E and Recovery from Traumatic Brain Injury

The outcome from traumatic brain injury (TBI) is variable and only partly explained by known prognostic factors. This is especially true for predicting long-term outcome. Genetic factors may influence the brain`s susceptibility to injury or capacity for repair and regeneration. To examine the association of apolipoproteinE (apoE) genotype with long-term outcome, hippocampal volumes and general brain atrophy, we determined the apoE genotype from 61 TBI patients who had been injured over on average 31 years earlier. The long-term outcome was evaluated with repeated neuropsychological testing and by applying various measures of everyday functioning and quality of life. Magnetic resonance imaging (MRI) based volumetric analyses of the hippocampus and lateral ventricles were performed. In the prospective study, the purpose was to examine the association between apoE genotype and visibility of traumatic brain lesions during the first year after TBI and the ability of apoE genotype, the Glasgow Coma Score (GCS), MRI findings and duration of posttraumatic amnesia (PTA) to predict the one-year outcome. Thirty-three patients with TBI were studied and the outcome was evaluated with the Head Injury Symptom Checklist (HISC) and the Glasgow Outcome Scale extended version (GOS-E) scores one year after the injury. MRI and apoE genotyping were carried out. After three decades, neither hippocampal nor lateral ventricle volumes differed significantly in those patients with the apoE ε4 allele vs those without this allele, but the TBI patients with the apoE ε4 allele showed significantly poorer general cognitive level than those without this allele. This decline was wholly accounted for by a subgroup of patients who had developed incident or clinical dementia. In the prospective study the apoE genotype was not associated with visible MRI changes or outcome. The duration of PTA and acute MRI were the best predictors of one-year outcome in TBI. A portion of the TBI patients with the apoE ε4 allele seem to be at risk of long-term cognitive decline. This association may involve mechanisms other than those responsible for the development of brain atrophy. The early MRI and PTA have an important role in assessing the injury severity and prognosis.

Catalisadores Ni/Al2O3 promovidos com molibdênio para a reação de reforma a vapor de metano

Mo-promoted Ni/Al2O3 catalysts for the methane steam reforming reaction were studied in this work. The Ni/Al2O3 catalysts were prepared by precipitation and molibdenum was added by impregnation up to 2%wt. The solids were tested using a micro-reactor under two H2Ov/C conditions and were characterized by ICP-OES, XRD, N2 adsoption, H2 chemisorption and TPR. NiO and NiAl2O4 phases were observed and the metallic area decreased with the increase of the Mo content. From the catalytic tests high stability was verified for H2Ov/C=4.0. On the other hand, only the catalyst containing 0,05% Mo stayed stable during 30 hours of the test at H2Ov/C=2.0.

Offdesign operation of kraft recovery boiler

A model to solve heat and mass balances during the offdesign load calculations was created. These equations are complex and nonlinear. The main new ideas used in the created offdesign model of a kraft recovery boiler are the use of heat flows as torn iteration variables instead of the current practice of using the mass flows, vectorizing equation solving, thus speeding up the process, using non dimensional variables for solving the multiple heat transfer surface problem and using a new procedure for calculating pressure losses. Recovery boiler heat and mass balances are reduced to vector form. It is shown that these vectorized equations can be solved virtually without iteration. The iteration speed is enhanced by the use of the derived method of calculating multiple heat transfer surfaces simultaneously. To achieve this quick convergence the heat flows were used as the torn iteration parameters. A new method to handle pressure loss calculations with linearization was presented. This method enabled less time to be spent calculating pressure losses. The derived vector representation of the steam generator was used to calculate offdesign operation parameters for a 3000 tds/d example recovery boiler. The model was used to study recovery boiler part load operation and the effect of the black liquor dry solids increase on recovery boiler dimensioning. Heat flows to surface elements for part load calculations can be closely approximated with a previously defined exponent function. The exponential method can be used for the prediction of fouling in kraft recovery boilers. For similar furnaces the firing of 80 % dry solids liquor produces lower hearth heat release rate than the 65 % dry solids liquor if we fire at constant steam flow. The furnace outlet temperatures show that capacity increase with firing rate increase produces higher loadings than capacity increase with dry solids increase. The economizers, boiler banks and furnaces can be dimensioned smaller if we increase the black liquor dry solids content. The main problem with increased black liquor dry solids content is the decrease in the heat available to superheat. Whenever possible the furnace exit temperature should be increased by decreasing the furnace height. The increase in the furnace exit temperature is usually opposed because of fear of increased corrosion.

Music-supported training is more efficient than functional motor training for recovery of fine motor skills in stroke patients

MOTOR IMPAIRMENTS ARE COMMON AFTER STROKE but efficacious therapies for these dysfunctions are scarce. Extending an earlier study on the effects of music-supported training (MST), behavioral indices of motor function were obtained before and after a series of training sessions to assess whether this new treatment leads to improved motor functions. Furthermore, music-supported training was contrasted to functional motor training according to the principles of constraint-induced therapy (CIT). In addition to conventional physiotherapy, 32 stroke patients with moderately impaired motor function and no previous musical experience received 15 sessions of MST over a period of three weeks, using a manualized, step-bystep approach. A control group consisting of 15 patients received 15 sessions of CIT in addition to conventional physiotherapy. A third group of 30 patients received exclusively conventional physiotherapy and served as a control group for the other three groups. Fine as well as gross motor skills were trained by using either a MIDI-piano or electronic drum pads programmed to emit piano tones. Motor functions were assessed by an extensive test battery. MST yielded significant improvement in fine as well as gross motor skills with respect to speed, precision, and smoothness of movements. These improvements were greater than after CIT or conventional physiotherapy. In conclusion, with equal treatment intensity, MST leads to more pronounced improvements of motor functions after stroke than CIT.

Efeito do teor metálico em catalisadores Co/Al2O3 aplicados à reação de reforma a vapor de etanol

The development of cobalt catalysts to produce hydrogen from ethanol is the goal of this investigation. Co/Al2O3 catalysts were prepared by impregnation and characterized by atomic absorption, nitrogen adsorption, X-ray diffraction, Raman spectroscopy, temperature programmed reduction and carbon analysis. The catalysts contained Co3O4 oxide and Co3+ and Co2+ species interacting with alumina. The cobalt load affects the crystal size and the crystalline structure and higher Co loads influence the reaction mechanism, changing the selectivity of the catalysts, decreasing the amount of CO produced and avoiding the formation of products catalyzed by the support. The ethanol conversion was 50-70% with 10-<1% of CO in the hydrogen.