Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients

Résumé Introduction : Les patients nécessitant une prise en charge prolongée en milieu de soins intensifs et présentant une évolution compliquée, développent une réponse métabolique intense caractérisée généralement par un hypermétabolisme et un catabolisme protéique. La sévérité de leur atteinte pathologique expose ces patients à la malnutrition, due principalement à un apport nutritionnel insuffisant, et entraînant une balance énergétique déficitaire. Dans un nombre important d'unités de soins intensifs la nutrition des patients n'apparaît pas comme un objectif prioritaire de la prise en charge. En menant une étude prospective d'observation afin d'analyser la relation entre la balance énergétique et le pronostic clinique des patients avec séjours prolongés en soins intensifs, nous souhaitions changer cette attitude et démonter l'effet délétère de la malnutrition chez ce type de patient. Méthodes : Sur une période de 2 ans, tous les patients, dont le séjour en soins intensifs fut de 5 jours ou plus, ont été enrôlés. Les besoins en énergie pour chaque patient ont été déterminés soit par calorimétrie indirecte, soit au moyen d'une formule prenant en compte le poids du patient (30 kcal/kg/jour). Les patients ayant bénéficié d'une calorimétrie indirecte ont par ailleurs vérifié la justesse de la formule appliquée. L'âge, le sexe le poids préopératoire, la taille, et le « Body mass index » index de masse corporelle reconnu en milieu clinique ont été relevés. L'énergie délivrée l'était soit sous forme nutritionnelle (administration de nutrition entérale, parentérale ou mixte) soit sous forme non-nutritionnelle (perfusions : soluté glucosé, apport lipidique non nutritionnel). Les données de nutrition (cible théorique, cible prescrite, énergie nutritionnelle, énergie non-nutritionnelle, énergie totale, balance énergétique nutritionnelle, balance énergétique totale), et d'évolution clinique (nombre des jours de ventilation mécanique, nombre d'infections, utilisation des antibiotiques, durée du séjour, complications neurologiques, respiratoires gastro-intestinales, cardiovasculaires, rénales et hépatiques, scores de gravité pour patients en soins intensifs, valeurs hématologiques, sériques, microbiologiques) ont été analysées pour chacun des 669 jours de soins intensifs vécus par un total de 48 patients. Résultats : 48 patients de 57±16 ans dont le séjour a varié entre 5 et 49 jours (motif d'admission : polytraumatisés 10; chirurgie cardiaque 13; insuffisance respiratoire 7; pathologie gastro-intestinale 3; sepsis 3; transplantation 4; autre 8) ont été retenus. Si nous n'avons pu démontrer une relation entre la balance énergétique et plus particulièrement, le déficit énergétique, et la mortalité, il existe une relation hautement significative entre le déficit énergétique et la morbidité, à savoir les complications et les infections, qui prolongent naturellement la durée du séjour. De plus, bien que l'étude ne comporte aucune intervention et que nous ne puissions avancer qu'il existe une relation de cause à effet, l'analyse par régression multiple montre que le facteur pronostic le plus fiable est justement la balance énergétique, au détriment des scores habituellement utilisés en soins intensifs. L'évolution est indépendante tant de l'âge et du sexe, que du status nutritionnel préopératoire. L'étude ne prévoyait pas de récolter des données économiques : nous ne pouvons pas, dès lors, affirmer que l'augmentation des coûts engendrée par un séjour prolongé en unité de soins intensifs est induite par un déficit énergétique, même si le bon sens nous laisse penser qu'un séjour plus court engendre un coût moindre. Cette étude attire aussi l'attention sur l'origine du déficit énergétique : il se creuse au cours de la première semaine en soins intensifs, et pourrait donc être prévenu par une intervention nutritionnelle précoce, alors que les recommandations actuelles préconisent un apport énergétique, sous forme de nutrition artificielle, qu'à partir de 48 heures de séjour aux soins intensifs. Conclusions : L'étude montre que pour les patients de soins intensifs les plus graves, la balance énergétique devrait être considérée comme un objectif important de la prise en charge, nécessitant l'application d'un protocole de nutrition précoce. Enfin comme l'évolution à l'admission des patients est souvent imprévisible, et que le déficit s'installe dès la première semaine, il est légitime de s'interroger sur la nécessité d'appliquer ce protocole à tous les patients de soins intensifs et ceci dès leur admission. Summary Background and aims: Critically ill patients with complicated evolution are frequently hypermetabolic, catabolic, and at risk of underfeeding. The study aimed at assessing the relationship between energy balance and outcome in critically ill patients. Methods: Prospective observational study conducted in consecutive patients staying 5 days in the surgical ICU of a University hospital. Demographic data, time to feeding, route, energy delivery, and outcome were recorded. Energy balance was calculated as energy delivery minus target. Data in means+ SD, linear regressions between energy balance and outcome variables. Results: Forty eight patients aged 57±16 years were investigated; complete data are available in 669 days. Mechanical ventilation lasted 11±8 days, ICU stay 15+9 was days, and 30-days mortality was 38%. Time to feeding was 3.1 ±2.2 days. Enteral nutrition was the most frequent route with 433 days. Mean daily energy delivery was 1090±930 kcal. Combining enteral and parenteral nutrition achieved highest energy delivery. Cumulated energy balance was between -12,600+ 10,520 kcal, and correlated with complications (P<0.001), already after 1 week. Conclusion: Negative energy balances were correlated with increasing number of complications, particularly infections. Energy debt appears as a promising tool for nutritional follow-up, which should be further tested. Delaying initiation of nutritional support exposes the patients to energy deficits that cannot be compensated later on.

State of Iowa Long-Term Economic Recovery Strategy Prepared for the Economic Development Administration, U.S. Department of Commerce, October 2010

The Rebuild Iowa Office (RIO) continues to coordinate the state‘s recovery effort from the storms, tornadoes and floods of 2008. Much has been accomplished since the Office‘s last quarterly report was issued in July 2010. State funding has been disbursed to help Iowans with unmet needs and housing. Local governments and entities are utilizing millions of federal dollars so thousands of disaster-impacted homeowners can be offered a buyout. More infrastructure projects are under construction and new neighborhoods are being built with mitigation efforts in mind. However, as Iowa continues to celebrate many successes along the road to recovery, it must also address the numerous challenges that are encountered along the path. Recovering from the state‘s largest disaster must be looked at as a marathon, not a sprint. Over the past three months, the RIO has especially remained focused on helping small business owners impacted by the 2008 disasters. Many disaster-affected businesses have reopened their doors, however their debt load continues to be overwhelming and many still struggle with the timeliness of the disbursement of funds. This report describes how programs and recent modifications are working to assist recovering businesses. This report contains updates on housing progress while outlining the complexities behind certain programs and the bottlenecks communities are facing due to strict federal guidelines for implementation. This following pages also describe how Iowa is implementing Smart Planning principles, publicizing flood awareness through outreach efforts and preparing a blueprint for the state to follow when future disasters occur. As always, the RIO recognizes and thanks the countless leaders and front-line workers from local, regional, state and federal government, businesses, non-profit organizations and private citizens that have provided input, support and leadership. Their dedication to Iowa‘s disaster recovery has made the plans and projects on the following pages possible.

Un modelo de riesgo de crédito basado en opciones compuestas con barrera. Aplicación al mercado continuo español

In this work the valuation methodology of compound option written on a downand-out call option, developed by Ericsson and Reneby (2003), has been applied to deduce a credit risk model. It is supposed that the firm has a debt structure with two maturity dates and that the credit event takes place when the assets firm value falls under a determined level called barrier. An empirical application of the model for 105 firms of Spanish continuous market is carried out. For each one of them its value in the date of analysis, the volatility and the critical value are obtained and from these, the default probability to short and long-term and the implicit probability in the two previous probabilities are deduced. The results are compared with the ones obtained from the Geskemodel (1977).

Viabilidad del sistema de pensiones y reformas por el lado de los ingresos: una aproximación intergeneracional

Este artículo, mediante el método de la Contabilidad Generacional, examina la viabilidad a largo plazo y los efectos sobre la redistribución intergeneracional de la renta del sistema de pensiones español. Dado la enorme deuda acumulada, que se traslada a las generaciones futuras, se explora la posibilidad de introducir políticas de reforma por el lado de los ingresos que pretenden mitigar la fuerte dependencia demográfica de las finanzas de la Seguridad Social. El principal resultado obtenido es que la gravedad de la crisis demográfica hace que estos tipos de medidas estudiadas sean claramente insuficientes para restaurar el equilibrio intergeneracional.

Iowa Natural Resources, Agency Performance Plan, FY2013

The work of the Department of Natural Resources impacts the lives of all Iowans. Iowans deserve a clean environment and quality natural areas for public use and enjoyment. This report reflects the progress made during fiscal year 2013 (FY13) toward our goals and provides information regarding the condition of our state’s natural resources and the effectiveness of our programs. In FY13, we continued to improve collaboration with other executive branch agencies. The DNR and DOT work very closely on the issuance of permits needed for road and bridge constructions, but recently we have also been working together to meet the administrative needs of the agencies. The DNR is working closely with the DOT to adopt an Electronic Records Management System used by the DOT. This system will improve accessibility to public documents and reduce the amount of paper files retained in storage. The DNR also continues to improve collaboration with other agencies, such as the Iowa Economic Development Authority as we work closely with them on business development in the state. The DNR strives to continually improve our customer service and how we can meet Iowan’s needs. As an example, the online reservation system for campground reservations has grown over the past eight years so that now 88% of the camping reservations are made online. The DNR continues to improve our online presence and accessibility. In FY13 the Iowa Legislature approved paying off the State’s bond debt used to construct Honey Creek Resort State Park. By removing this debt, the DNR will be able to focus more on the future of the Resort, rather than the past debt. Finally, in August of 2012, the DNR was faced with a tragic accident, where a seasonal parks employee died after rolling a mower into a lake. This incident has caused us to establish a Safety Program at the DNR and to review all of our departmental safety trainings, programs, and equipment. By focusing on our employee’s safety and well being, it is another way that we can demonstrate that at the DNR, our employees are our greatest asset.

Five essays on bankruptcy

Chapter 2 Bankruptcy Initiation In The New Era of Chapter 11 2.1 Abstract The bankruptcy act of 1978 placed corporate managers (as debtor in possession) in control of the bankruptcy process. Between 2000 and 2001 managers apparently lost this control to secured creditors. This study examines financial ratios of firms filing for bankruptcy between 1993 and 2004 and tests the hypothesis that the change from manager to creditor control created or exacerbated the managerial (and dominant creditor) incentive to delay bankruptcy filing. We find a clear deterioration in the financial conditions of firms filing after 2001. This is consistent with managers (or creditors who control them) delaying filing for bankruptcy. We also observe patterns of operating losses and liquidations that suggest adverse economic consequences from such delay. Chapter 3 Bankruptcy Resolution: Priority of Claims with the Secured Creditor in Control 3.1 Abstract We present new evidence on the violation of priority of claims in bankruptcy using a sample of 222 firms that tiled for Chapter 11 bankruptcy over the 1993-2004 period. Our study reveals a dramatic reduction in the violations of priority of claims compared to research on prior periods. These results are consistent with changes in both court practices and laws transferring power to the secured creditors over our sample period. We also find an increase in the time from the date of a bankruptcy filing to reaching plan confirmation where priority is not violated. Chapter 4 Bankruptcy Resolution: Speed, APR Violations and Delaware 4.1 Abstract We analyze speed of bankruptcy resolution on a sample of 294 US firms filing for bankruptcy in the 1993-2004 period. We find strong association between type of Chapter II filing and speed of bankruptcy resolution. We also find that violations to the absolute priority rule reduce the time from bankruptcy filing to plan confirmation. This is consistent with the hypothesis that creditors are willing to grant concessions in exchange for faster bankruptcy resolution. Furthermore, after controlling for the type of filing and violations to the absolute priority rule, we do not find any difference in the duration of the bankruptcy process for firms filing in Delaware, New York, or other bankruptcy districts. Chapter 5 Financial Distress and Corporate Control 5.1 Abstract We examine the replacement rates of directors and executives in 63 firms filing for bank ruptcy during the 1995-2002 period. We find that over 76% of directors and executives are replaced in the four year period from the year prior to the bankruptcy filing through three years after. These rates are higher than those found in prior research and is consistent with changes in bankruptcy procedures and practice (i.e. the increased secured creditors control over the process due to both DIP financing and changes in the Uniform Commercial Code) having a significant impact on the corporate governance of firms in financial distress. Chapter 6 Financial Statement Restatements: Decision to File for Bankruptcy 6.1 Abstract On a sample of 201 firms that restated their financial statements we analyze the process of regaining investor trust in a two year period after the restatement. We find that 20% of firms that restate their financial statements tile for bankruptcy or restructure out of court. Our results also indicate that the decisions to change auditor or management is correlated with a higher probability of failure. Increased media attention appears to partly explain the decision of firms to restructure their debt or tile for bankruptcy.

Financial reforms and capital flows: Insights from general equilibrium

As a result of debt enforcement problems, many high-productivity firms in emergingeconomies are unable to pledge enough future profits to their creditors and this constrains thefinancing they can raise. Many have argued that, by relaxing these credit constraints, reformsthat strengthen enforcement institutions would increase capital flows to emerging economies. Thisargument is based on a partial equilibrium intuition though, which does not take into account theorigin of any additional resources that flow to high-productivity firms after the reforms. We showthat some of these resources do not come from abroad, but instead from domestic low-productivityfirms that are driven out of business as a result of the reforms. Indeed, the resources released bythese low-productivity firms could exceed those absorbed by high-productivity ones so that capitalflows to emerging economies might actually decrease following successful reforms. This resultprovides a new perspective on some recent patterns of capital flows in industrial and emergingeconomies.

Raison et déraison de la loyauté familiale: un cas clinique

Le concept de loyauté appliquée à l'univers de la thérapie familiale est énormément tributaire de la pensée de Boszormenyi-Nagy. Il semble le placer dans un registre humaniste mais immanent. Si on se réfère à son origine étymologique, la loyauté implique l'obligation légale de tenir la parole donnée. Les enfants apprennent tôt à être loyaux. Leurs comportements réparateurs à l'égard des parents, même négligents ou violents, sont considérés comme l'expression d'une loyauté transmise. L'auteur s'interroge sur l'articulation entre une loyauté comme qualité morale du sujet qui choisit de se soumettre à la loi, à la parole donnée et un conditionnement obligé qui contraint le sujet à assumer des comportements « déraisonnables ». Les avancées de la neurobiologie permettent de répondre, tout au moins en partie, à une telle question. The concept of loyalty in the field of the family therapy is in debt to Boszormenyi-Nagy's work. According to his thought, loyalty commitment is the result of a humanistic but immanent believe. Etymologically, loyalty implies legal commitment to fulfill the promise. Children learn in their early years to be loyal. Reparations towards their parents, even if neglecting or violent, are considered the expression of a transmitted loyalty. The author questions the articulation between loyalty as a moral quality of the subject who chooses to accept the law and the given word, and a forced conditioning which brings the subject to adopt "un-reasonable" behaviors. Recent advances in neuroscience enable us to answer this question, at to some extent.

2015-16 Student Loan Repayment and Forgiveness Programs

Many loan repayment and incentive programs are available to encourage college students and graduates to enter into and continue to work in designated high-need careers. More and more Iowans are reaping the rewards of these federal, state and private programs that help reduce student loan debt while allowing them to pursue their career goals. Some programs make payments directly to the recipient’s student loan servicer to reduce the balance owed (loan repayment), while others may provide the option of an income stipend or bonus for eligible recipients who meet specified employment and other criteria. This guide provides information on many of the federal and state loan repayment and incentive programs currently available.

1010-005 Bloody Run Creek Watershed Final Report

The City of Marquette lies in the 65,000 acre Mississippi River watershed, and is surrounded by steep bluffs. Though scenic, controlling water runoff during storm events presents significant challenges. Flash-flooding from the local watershed has plagued the city for decades. The people of Marquette have committed to preserve the water quality of key natural resources in the area including the Bloody Run Creek and associated wetlands by undertaking projects to control the spread of debris and sediment caused by excess runoff during area storm events. Following a July 2007 storm (over 8” of rain in 24 hours) which caused unprecedented flood damage, the City retained an engineering firm to study the area and provide recommendations to eliminate or greatly reduce uncontrolled runoff into the Bloody Run Creek wetland, infrastructure damage and personal property loss. Marquette has received Iowa Great Places designation, and has demonstrated its commitment to wetland preservation with the construction of Phase I of this water quality project. The Bench Area Storm Water Management Plan prepared by the City in 2008 made a number of recommendations to mitigate flash flooding by improving storm water conveyance paths, detention, and infrastructure within the Bench area. Due to steep slopes and rocky geography, infiltration based systems, though desirable, would not be an option over surface based systems. Runoff from the 240 acre watershed comes primarily from large, steep drainage areas to the south and west, flowing to the Bench area down three hillside routes; designated as South East, South Central and South West. Completion of Phase I, which included an increased storage capacity of the upper pond, addressed the South East and South Central areas. The increased upper pond capacity will now allow Phase II to proceed. Phase II will address runoff from the South West drainage area; which engineers have estimated to produce as much water volume as the South Central and South East areas combined. Total costs for Phase I are $1.45 million, of which Marquette has invested $775,000, and IJOBS funding contributed $677,000. Phase II costs are estimated at $617,000. WIRB funding support of $200,000 would expedite project completion, lessen the long term debt impact to the community and aid in the preservation of the Bloody Run Creek and adjoining wetlands more quickly than Marquette could accomplish on its own.

La diversificación del riesgo en los mercados de deuda pública de la zona euro

El objetivo de este trabajo es el análisis del impacto de la unión monetaria en las oportunidades de diversificación del riesgo de las carteras de deuda pública en la zona euro. Para ello, examinamos la existencia de tendencias comunes en la evolución de la rentabilidad a 10 años de los países de la UE-15 durante el período 1994-2008. A pesar de que encontramos evidencia a favor de la conintegración múltiple, los resultados apoyan la existencia de más de una única tendencia entre las rentabilidades a largo plazo de los países de la UE-15. Además, cuando centramos nuestro anàlisis en los países de la zona euro, aunque la interdependencia aumenta, seguimos rechazando la existencia de una única tendencia común. Estos resultados tienen importantes implicaciones para los inversores en términos de sus posibilidades de diversificar el riesgo en un contexto de una moneda única.

Cinema and the Work of Doré

According to Ray Harryhausen, a special effects expert in the film industry, "Gustave Doré would have made a great director of photography . . . He saw things from the point of view of the camera." Doré's work has had a permanent impact on the imaginative realm of film since its very early days. In return, the silver screen has etched Doré into the 20th century imagination. Almost every film about the Bible since The Life and Passion of Jesus Christ produced by Pathé in 1902 refers to his illustrations, and every film adaptation of Dante or Don Quixote has used him as a model, from Georg Wilhelm Pabst and Orson Welles to Terry Gilliam. All films dealing with life in London in the Victorian era by directors ranging from David Lean, to Roman Polanski and Tim Burton draw on the visions in London: a pilgrimage for their sets. A large number of dream fantastical or phantasmagorical scenes take their inspiration from Doré's graphic world, beginning with Georges Méliès' A Trip to the Moon in 1902. In the realm of cartoons and animation, Walt Disney owes a huge debt to Doré. Doré primal forests, from Atala in particular, were also used in the various versions of King Kong from 1933 to the 2005 film by Peter Jackson, who had already drawn on Doré for The Lord of the Rings. Jean Cocteau was also indebted to the illustrations for Perrault's Fairy Tales for his Beauty and the Beast (1945), as was George Lucas for the character Chewbacca in Star Wars (1977) and even the Harry Potter film series. Through his influence on film history, Doré shaped the mass culture imagination.

Sahayrityksen laajentamisen kannattavuus

Diplomityön tavoitteena oli selvittää sahayrityksen tuotantokapasiteetin laajentamisen taloudellisia edellytyksiä, rajoitteita ja seurauksia. Teoriaosassa määritellään ensimmäiseksi kasvukykyinen yritys, joka on kannattava, maksuvelvoitteista suoriutuva ja vakavarainen. Toiseksi analysoidaan, kuinka tuotantovolyymin kasvattaminen näkyy sahan taseessa käyttöomaisuuden ja käyttöpääoman kasvuna. Kolmanneksi tarkastellaan vieraan pääoman tarvetta ja pääomakustannusten vaikutusta kapasiteettilaajennuksen kannattavuuteen.Neljänneksi tarkastellaan tuotantokapasiteetin laajentamisen kannattavuutta, kun käyttöomaisuutta hankitaan vuokraamalla tai toimintoja ulkoistetaan. Teoriaosan lopuksi määritellään periaatteet, kuinka nopeasti yritys voi kasvattaa liiketoimintaa vaarantamatta maksuvalmiutta, vakavaraisuutta ja kannattavuutta. Empiriaosassa tutkitaan 22 suomalaisen sahan tillinpäätöstietoja vuodelta 2003 ja kuvataan, miten erot kokoluokassa vaikuttavat sahojen kustannus- ja taserakenteeseen.Taseen osalta mittakaavaetua ei ollut havaittavissa. Tuloslaskelman osalta mittakaavaetua saavutettiin henkilökulujen osalta sahoilla, joiden liikevaihto asettui välille 15 - 25 Meur. Muilta osin pääoma- ja kustannuserät joko kasvoivat vakioisesti tai vaihtelivat satunnaisesti. Maksuvalmius perustui sahatoimialalla pääasiassa ostovelkojen ja muun lyhytaikaisen vieraan pääoman käyttöön.

Sovereign default, domestic banks and financial institutions

We present a model of sovereign debt in which, contrary to conventional wisdom, government defaultsare costly because they destroy the balance sheets of domestic banks. In our model, better financial institutionsallow banks to be more leveraged, thereby making them more vulnerable to sovereign defaults.Our predictions: government defaults should lead to declines in private credit, and these declines should belarger in countries where financial institutions are more developed and banks hold more government bonds.In these same countries, government defaults should be less likely. Using a large panel of countries, we findevidence consistent with these predictions.

Yrityssaneerauksen asettamat Iiiketoimintastrategian laatimiselle

Työssä on tutkittu yrityssaneerauksen alla olevan pienyrityksen selviytymistä vuodesta 2003 vuoteen 2006. Työ jakaantuu teoreettiseen osaan, jossa esitellään käytetyt menetelmät ja käytännölliseen osaan, jossa niitä sovelletaan yritykseen. Työssä on erotettu mahdollisuuksien mukaan yrityksen taloudellinen tilanne ja velanmaksukyky yrityksen muusta liiketoiminnasta ja liiketoiminnan suunnittelusta. Pääpaino on yrityksen liiketoimintojen organisoinnilla ja toimintaympäristön ja sen vaikutusten analysoinnilla. Yritysanalyysin avulla voidaan luoda yritykselle Iiiketoimintasuunnitelma, korjata ja selittää sen tekemiä strategisia ratkaisuja, sekä luoda käytäntöjä tiedonvälittymiseen yritykseltä velkojatoimikunnalle valvojan kautta yrityssaneerausprosessin aikana.