Laparoscopic versus open splenectomy in the management of hematologic diseases

Splenectomy is the best available treatment for severe forms of hereditary spherocytosis, idiopathic thrombocytopenic purpura, and other hematologic conditions when these prove refractory to conservative management. It has been employed for many decades with low mortality and favorable remission rates. The use of laparoscopic splenectomy in recent years has been rapidly and even enthusiastically adopted in this field. However, the exact role of laparoscopic versus open surgery for hematologic diseases is still debated. In this study of 58 adult patients, laparoscopic procedures were compared with conventional splenectomies for similar indications. METHODS: All patients were operated on within an 8-year period. Subjects underwent similar procedures under the supervision of the same surgical school and were compared regarding age, gender, body mass index, and diagnosis. Laparoscopically managed cases (Group I, n = 30) were prospectively followed according to a written protocol, whereas the same investigation was retrospectively done with regard to traditional laparotomy (Group II, n = 28). Methods included general and demographic findings, duration and technical steps of operation, blood loss, weight of spleen, need for conversion (in minimally invasive subjects), intraoperative and postoperative complications, time until realimentation, postoperative hospitalization, mortality, and late follow-up including recurrence rate. RESULTS: Idiopathic thrombocytopenic purpura was the surgical indication in over 50% of the patients in both groups, but familial spherocytosis, thalassemia, myelodysplasia, and lymphomas were also represented in this series. Laparoscopic procedures took more time to perform (P = 0.004), and postoperative hospitalization was 2 days shorter, but this difference was not statistically significant. Postoperative hematocrit and volume of blood transfusions was equivalent, although the laparoscopic cases had a somewhat lower preoperative hematocrit (NS) and displayed better recovery for this measurement (P = 0.03). More patients in Group I were able to accept oral food on the first day than subjects undergoing conventional operations (P < 0.05). Relatively few conversions were necessary during the minimally invasive surgeries (13.3%), and postoperative early and late complications as well as recurrences occurred in similar proportions. Also, the mean weight of the spleen was not statistically different between the groups, although there was a marked numerical tendency toward larger masses in conventional procedures. No spleen in Group I exceeded 2.0 kg, whereas in Group II values up to 4.0 kg occurred, and the mean weight was 50% higher in the latter group. CONCLUSIONS: 1) Minimally invasive splenectomy was essentially comparable to open surgery with regard to safety, efficacy, and late results; 2) Advantages concerning shorter postoperative hospitalization could not be shown, despite earlier food intake and a non-significant tendency toward earlier discharge; 3) This new modality should be considered an option in cases of hematologic conditions whenever the spleen is not hugely enlarged.

Implementation of the I.S. EN 16001:2009 energy management standard into GlaxoSmithKline (GSK) Ltd, Cork

As manufacturers face an increasingly competitive environment, they seek out opportunities to reduce production costs without negatively affecting the yield or the quality of their finished products. The challenge of maintaining high product quality while simultaneously reducing production costs can often be met through investments in energy efficient technologies and energy efficiency practices. Energy management systems can offer both technological and best practice efficiencies in order to achieve substantial savings. A strong energy management system provides a solid foundation for an organisation to reduce production costs and improve site efficiency. The I.S EN16001 energy management standard specifies the requirements for establishing, implementing, maintaining and improving an energy management system and represents the latest best practice for energy management in Ireland. The objective of the energy management system is to establish a systematic approach for improving energy performance continuously. The I.S EN16001 standard specifies the requirements for continuous improvement through using energy more efficiently. The author analysed how GlaxoSmithKline’s (GSK) pharmaceutical manufacturing facility in Cork implemented the I.S. EN16001 energy management system model, and defined how energy saving opportunities where identified and introduced to improve efficiency performance. The author performed an extensive literature research in order to determine the current status of the pharmaceutical industry in Ireland, the processes involved in pharmaceutical manufacturing, the energy users required for pharmaceutical manufacturing and the efficiency measures that can be applied to these energy users in order to reduce energy consumption. The author then analysed how energy management standards are introduced to industry and critically analysed the driving factors for energy management performance in Ireland through case studies. Following an investigation as to how the I.S. EN16001 energy management standard is operated in GSK, a critical analysis of the performance achieved by the GSK energy management system is undertaken in order to determine if implementing the I.S EN16001 standard accelerates achieving energy savings. Since its introduction, the I.S. EN16001 model for energy management has enabled GSK to monitor, target and identify energy efficiency opportunities throughout the site. The model has put in place an energy management system that is continuously reviewed for improvement and to date has reduced GSK’s site operations cost by over 30% through technical improvements and generating energy awareness for smarter energy consumption within the GSK Cork site. Investment in I.S. EN16001 has proved to be a sound business strategy for GSK especially in today's manufacturing environment.

Application of Fuzzy Variables for Systems of Management Decision Support

The following article describes an approach covering the variety of opinions and uncertainties of estimates within the chosen technique of decision support. Mathematical operations used for assessment of options are traced to operations of working with functions that are used for assessment of possible options of decision-making. Approach proposed could be used within any technique of decision support based on elementary mathematical operations. In this article the above-mentioned approach is described under analytical hierarchy process.

World fishing fleets : an analysis of distant-water fleet operations, past, present, future. prepared by William B. Folsom, David J. Rovinsky, Dennis M. Weidner.

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World fishing fleets : an analysis of distant-water fleet operations, past, present, future. prepared by U.S. Embassies overseas ; assembled by Frederick H. Beaudry, William B. Folsom, David J. Rovinsky.

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World fishing fleets : an analysis of distant-water fleet operations, past, present, future. prepared by Milan Kravanja, Ellen Shapiro.

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Analyse de la prise en charge médicale et de l'impact économique des patients ayant présentés des coûts extrêmes dans un hôpital universitaire [Analysis of the medical management and the economic impact of patients who have represented extreme costs at a university hospital]

Les coûts de traitement de certains patients s'avèrent extrêmement élevés, et peuvent faire soupçonner une prise en charge médicale inadéquate. Comme I'évolution du remboursement des prestations hospitalières passe à des forfaits par pathologie, il est essentiel de vérifier ce point, d'essayer de déterminer si ce type de patients peut être identifié à leur admission, et de s'assurer que leur devenir soit acceptable. Pour les années 1995 et 1997. les coûts de traitement dépassant de 6 déviations standard le coût moyen de la catégorie diagnostique APDRG ont été identifiés, et les dossiers des 50 patients dont les coûts variables étaient les plus élevés ont été analysés. Le nombre total de patients dont I'hospitalisation a entraîné des coûts extrêmes a passé de 391 en 1995 à 328 patients en 1997 (-16%). En ce qui concerne les 50 patients ayant entraîné les prises en charge les plus chères de manière absolue, les longs séjours dans de multiples services sont fréquents, mais 90% des patients sont sortis de l'hôpital en vie, et près de la moitié directement à domicile. Ils présentaient une variabilité importante de diagnostics et d'interventions, mais pas d'évidence de prise en charge inadéquate. En conclusion, les patients qualifiés de cas extrêmes sur un plan économique, ne le sont pas sur un plan strictement médical, et leur devenir est bon. Face à la pression qu'exercera le passage à un mode de financement par pathologie, les hôpitaux doivent mettre au point un système de revue interne de I'adéquation des prestations fournies basées sur des caractéristiques cliniques, s'ils veulent garantir des soins de qualité. et identifier les éventuelles prestations sous-optimales qu'ils pourraient être amenés à délivrer. [Auteurs] Treatment costs for some patients are extremely high and might let think that medical care could have been inadequate. As hospital financing systems move towards reimbursement by diagnostic groups, it is essential to assess whether inadequate care is provided, to try to identify these patients upon admission, and make sure that their outcome is good. For the years 1995 and 1997, treatment costs exceeding by 6 standard deviations the average cost of their APDRG category were identified, and the charts of the 50 patients with the highest variable costs were analyzed. The total number of patients with such extreme costs diminished from 391 in 1995 to 328 in 1997 (-16%). For the 50 most expensive patients, long stays in several services were frequent, but 90% of these patients left the hospital alive, and about half directly to their home. They presented an important variation in diagnoses and operations, but no evidence for inadequate care. Thus, patients qualified as extreme from an economic perspective cannot be qualified as such from a medical perspective, and their outcome is good. To face the pressure linked with the change in financing system, hospitals must develop an internal review system for assessing the adequacy of care, based on clinical characteristics, if they want to guarantee good quality of care and identify potentially inadequate practice.

Environmental management for the control of Triatoma dimidiata (Latreille, 1811), (Hemiptera: Reduviidae) in Costa Rica: a pilot project

An ecological control method, using environmental management operations, based on biological and behavioral characteristics of Triatoma dimidiata (Latreille, 1811), was implemented as a pilot project in an area of Costa Rica where the bug is prevalent. The sample was represented by 20 houses with peridomestic colonies (two also had indoor infestation), divided in two equivalent groups of 10 each. In one group we intervened the houses, i.e. all objects or materials that were serving as artificial ecotopes for the bugs were removed, and the second group was used as control houses. After a year of periodic follow up, it became evident that in those houses with a modified environment the number of insects had decreased notoriously even after the first visits and this was more evident after a period of 12.5 to 13.5 months in which no insects were detected in eight of the houses. It also became clear that in this group of houses, recolonization by wild bugs from the surrounding areas, became more difficult, probably due to the absence of protection from bug predators. In the control houses, with the exception of three in which the inhabitants decided to intervene on their own, and another house with a peculiar situation, the insect populations remained the same or even showed a tendency to increase, as confirmed at the end of the experiment. We believe that the method is feasible, low costing and non contaminating. It could be used successfully in other places where T. dimidiata is common and also in countries where other species colonize peridomestic areas of homes. Environmental management of this kind should seek the participation of the members of the communities, in order to make it a more permanent control measure.

Exploring Cross-layer power management for PGAS applications on the SCC platform

Technological limitations and power constraints are resulting in high-performance parallel computing architectures that are based on large numbers of high-core-count processors. Commercially available processors are now at 8 and 16 cores and experimental platforms, such as the many-core Intel Single-chip Cloud Computer (SCC) platform, provide much higher core counts. These trends are presenting new sets of challenges to HPC applications including programming complexity and the need for extreme energy efficiency.In this work, we first investigate the power behavior of scientific PGAS application kernels on the SCC platform, and explore opportunities and challenges for power management within the PGAS framework. Results obtained via empirical evaluation of Unified Parallel C (UPC) applications on the SCC platform under different constraints, show that, for specific operations, the potential for energy savings in PGAS is large; and power/performance trade-offs can be effectively managed using a cross-layerapproach. We investigate cross-layer power management using PGAS language extensions and runtime mechanisms that manipulate power/performance tradeoffs. Specifically, we present the design, implementation and evaluation of such a middleware for application-aware cross-layer power management of UPC applications on the SCC platform. Finally, based on our observations, we provide a set of recommendations and insights that can be used to support similar power management for PGAS applications on other many-core platforms.

Accidental cross-clamping of the superior vena cava: management and BIS evolution.

The case of a 38-year old man with recurrent adenocarcinoma of the right lung and infiltration of the thoracic wall, who underwent a right pneumonectomy with thoracic wall resection, is described. Dissection of the right pulmonary hilous was extremely difficult due to the previous operations. The superior vena cava (SVC) was accidentally ligated, resulting in profound hypotension and increased venous pressure in the internal jugular vein. Immediate blood aspiration through a 8.5-French introducer sheath lowered the venous congestion. After the SVC was cross-clamped, the Bispectral Index (BIS) acutely decreased to 0 and remained low during the resuscitation. Over the next 5 hours, BIS was directly affected by mean arterial pressure. Four days postoperatively, the patient was neurologically intact.

Tillage Management and Soil Organic Matter, 2005

Tillage systems play a significant role in agricultural production throughout Iowa and the Midwest. It has been well documented that increased tillage intensities can reduce soil organic matter in the topsoil due to increased microbial activity and carbon (C ) oxidation. The potential loss of soil organic matter due to tillage operations is much higher for high organic matter soils than low organic matter soils. Tillage effects on soil organic matter can be magnified through soil erosion and loss of soil productivity. Soil organic matter is a natural reservoir for nutrients, buffers against soil erosion, and improves the soil environment to sustain soil productivity. Maintaining soil productivity requires an agriculture management system that maintains or improves soil organic matter content. Combining cropping systems and conservation tillage practices, such as no-tillage, strip-tillage, or ridge-tillage, are proven to be very effective in improving soil organic matter and soil quality.

Management of major accidents with on-site 144 dispatcher

Introduction: An excellent coordination between firefighters, policemen and medical rescue is the key to success in the management of major accidents. In order to improve and assist the medical teams engaged on site, the Swiss "medical command and control system" for rescue operations is based on a binomial set up involving one head emergency doctor and one head rescue paramedic, both trained in disaster medicine. We have recently experimented an innovative on-site "medical command and control system", based on the binomial team, supported by a dedicated 144 dispatcher. Methods: A major road traffic accident took place on the highway between Lausanne and Vevey on April 9th 2008. We have retrospectively collected all data concerning the victims as well as the logistics and dedicated structures, reported by the 144, the Hospitals, the Authority of the State and the Police and Fire Departments. Results: The 72-car pileup caused one death and 26 slightly injured patients. The management on the accident site was organized around a tripartite system, gathering together the medical command and control team with the police and fire departments. On the medical side, 16 ambulances, 2 medical response teams (SMUR), the Rega crew and the medical command and control team were dispatched by the 144. On that occasion an advanced medical command car equipped with communication devices and staffed with a 144 dispatcher was also engaged, allowing efficient medical regulation directly from the site. Discussion: The specific skills of one doctor and one paramedic both trained for disaster's management proved to be perfectly complementary. The presence of a dispatcher on site with a medical command car also proved to be useful, improving orders transmission from the medical command team to all other on- and off-site partners. It relieved the need of repeated back-and-forth communication with the 144, allowing both paramedic and doctor to focus on strategy and tactics rather than communication and logistics.

Optimal management of microgrids

Desenvolupament dels models matemàtics necessaris per a controlar de forma òptima la microxarxa existent als laboratoris del Institut de Recerca en Energia de Catalunya. Els algoritmes s'implementaran per tal de simular el comportament i posteriorment es programaran directament sobre els elements de la microxarxa per verificar el seu correcte funcionament.. Desenvolupament dels models matemàtics necessaris per a controlar de forma òptima la microxarxa existent als laboratoris del Institut de Recerca en Energia de Catalunya. Els algoritmes s'implementaran per tal de simular el comportament i posteriorment es programaran directament sobre els elements de la microxarxa per verificar el seu correcte funcionament.

Análisis y mejora de los procesos excepcionales de una multinacional del sector de la electrónica utilizando la metodología Business Process Management

El presente documento ilustra la aplicación de la metodología Business Process Managementpara el caso de una empresa multinacional del sector de la electrónica. Para ello se han tomado los procesos excepcionales de Supply Chain Operations en el área EMEA (Europa, Oriente Medio y África). Se ha analizado la situación inicial, donde la aparición de incidencias de calidad en productos terminados y listos para entregar a clientes generaba una serie de acciones descoordinadas y con resultados insatisfactorios. Todos los departamentos implicados comprometían recursos, tiempo y esfuerzo, sin estar alineados entre sí. A partir de la aplicación sistemática de la metodología BPM definida en 10 fases, se ha desarrollado una solución completa para los procesos excepcionales. El documento describe con detalle en proceso de Reflash y la documentación necesaria para poner el proceso bajo control y en mejora continua.

The Impact of Digitization on the Management of Administrative Procedures : The Case of Building Permits

Information and Communication Technologies provide public administrations new ways to meet their users' needs. At the same time, e-Government practices support the public sector in improving the quality of service provision and of its internal operations. In this paper we discuss the impacts of digitization on the management of administrative procedures. The theoretical framework and the research model that we will use in this study help us tackle the question of how digitization transforms administrative procedures as, for example, in terms of time and roles. The multiplicity of institutions involved in issuing building permits led us to consider this administrative procedure as a very interesting case study. An online survey was first addressed to Swiss civil servants to explore the field, and here we present some of its results. We are currently undertaking an in-depth case study of the building permit procedures in three Swiss Cantons, which we will also present in this paper. We will conclude with a discussion and the future steps of this project.