A Novel Approach to Major Surgery: Tracking Its Pathophysiologic Footprints.

BACKGROUND: To study the 'metabolic profile' of different surgical procedures and correlate it with pertinent surgical details and postoperative complications. METHODS: We conducted a prospective pilot study of 70 patients, ten for each of the seven following groups: (1) laparoscopic cholecystectomy, (2) incisional hernia repair, (3) laparoscopic and (4) open colon surgery, (5) upper gastrointestinal, (6) hepatic, and (7) pancreatic resections. Biochemical assessment included white blood cell count (WBC), C-reactive protein (CRP), glucose, triglycerides (TG), albumin (Alb), and pre-albumin (Pre-Alb), from the day before surgery until 5 days thereafter. Biological markers were compared for major versus minor surgery groups, which were defined on a clinical basis. Univariable analysis was used to identify risk factors for postoperative complications and p < 0.05 was the significance threshold. RESULTS: Common findings in all surgery groups were the acute inflammatory response (↑: WBC, CRP, ↓: TG, Alb, pre-Alb). Using cut-off values of 240 min operative (OR) time and 300 ml estimated blood loss (EBL), laparoscopic cholecystectomy, incisional hernia repair, and laparoscopic colectomy could be distinguished from open colectomy, upper gastrointestinal, liver, and pancreas resections. In a biochemical level, increased CRP and reduced postoperative Alb levels were highly discriminative of all types of 'major surgery.' Significant risk factors for postoperative complications were age, male gender, malignancy, longer OR time, higher blood loss, high CRP, and low Alb levels. CONCLUSIONS: Biochemically, CRP and Alb levels can help quantify the magnitude of the surgical trauma, which is correlated with adverse outcomes.

Capability matrix – Identifying and evaluating the key capabilities of purchasing and supply management

Organizations gain resources, skills and technologies to find out the ultimate mix of capabilities to be a winner in the competitive market. These are all important factors that need to be taken into account in organizations operating in today's business environment. So far, there are no significant studies on the organizational capabilities in the field of PSM. The literature review shows that the PSM capabilities need to be studied more comprehensively. This study attempts to reveal and fill this gap by providing the PSM capability matrix that identifies the key PSM capabilities approached from two angles: there are three primary PSM capabilities and nine subcapabilities and, moreover, the individual and organizational PSM capabilities are identified and evaluated. The former refers to the PSM capability matrix of this study which is based on the strategic and operative PSM capabilities that complement the economic ones, while the latter relates to the evaluation of the PSM capabilities, such as the buyer profiles of individual PSM capabilities and the PSMcapability map of the organizational ones. This is a constructive case study. The aim is to define what the purchasing and supply management capabilities are and how they can be evaluated. This study presents a PSM capability matrix to identify and evaluate the capabilities to define capability gaps by comparing the ideal level of PSM capabilities to the realized ones. The research questions are investigated with two case organizations. This study argues that PSM capabilities can be classified into three primary categories with nine sub-categories and, thus, a PSM capability matrix with four evaluation categories can be formed. The buyer profiles are moreover identified to reveal the PSM capability gap. The resource-based view (RBV) and dynamic capabilities view (DCV) are used to define the individual and organizational capabilities. The PSM literature is also used to define the capabilities. The key findings of this study are i) the PSM capability matrix to identify the PSM capabilities, ii) the evaluation of the capabilities to define PSM capability gaps and iii) the presentation of the buyer profiles to identify the individual PSM capabilities and to define the organizational PSM capabilities. Dynamic capabilities are also related to the PSM capability gap. If a gap is identified, the organization can renew their PSM capabilities and, thus, create mutual learning and increase their organizational capabilities. And only then, there is potential for dynamic capabilities. Based on this, the purchasing strategy, purchasing policy and procedures should be identified and implemented dynamically.

Percepción del dolor en pacientes postoperados de cirugía cardiaca

Pain is defined as an unpleasant sensory or emotional experience, associated with tissue damage, that is a reality linked to the surgical procedure and the postoperative period. Objective: Knowing the degree of pain experienced by patients after cardiac surgery, depending on the type of intervention they underwent, over the post-operative period in an intensive care unit (ICU). Method: Descriptive observational study. Pain was assessed by the visual analog scale (VAS), going from 0 to 10, thereby obtaining the first VAS1 assessment at 2 h post-extubation and every 8 hours thereafter up to 48 hours or until discharge to floor VAS7. It included patients having undergone cardiac surgery [valve surgery, bypass, combined procedure (including valve surgery and bypass) and mediastinitis]. Data were processed using Spss.v 20. Results: 120 patients 70 years old on average (standard deviation (SD): 13.3 years old) were included, out of which 70% were male. 40.8% of them had underwent bypass coronary revascularization. Patients subjected to the bypass technique showed an VAS1 mean value of 4.35 (SD: 2.45), unlike those subjected to valve surgery, who showed a mean value of 2.89 (SD: 2.27), those subjected to the combined procedure, who showed a mean value of 3.87 (SD: 2.90), and those with mediastinitis, who showed a mean value of 3.33 (SD: 3.51); (p < 0.031). 28.5% of patients had underwent revascularization (n = 49 ) by an internal mam mary artery (IMA) graft. These patients showed a mean value for VAS1 of 5.4 (SD: 1.89), unlike those who had underwent a combined procedure [IMA and saphenous vein (SV)], who showed a mean value of 3.9 (SD: 2.6), and those who had underwent a SV procedure , who showed a mean value of 3.5 (SD: 2.1); (p < 0.045). Conclusions: Patients having underwent bypass and IMA procedures perceive more pain than in other cardiac surgery and graft interventions

Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants.

Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

'Fast-implantable' aortic valve implantation and concomitant mitral procedures.

Concomitant aortic and mitral valve replacement or concomitant aortic valve replacement and mitral repair can be a challenge for the cardiac surgeon: in particular, because of their structure and design, two bioprosthetic heart valves or an aortic valve prosthesis and a rigid mitral ring can interfere at the level of the mitroaortic junction. Therefore, when a mitral bioprosthesis or a rigid mitral ring is already in place and a surgical aortic valve replacement becomes necessary, or when older high-risk patients require concomitant mitral and aortic procedures, the new 'fast-implantable' aortic valve system (Intuity valve, Edwards Lifesciences, Irvine, CA, USA) can represent a smart alternative to standard aortic bioprosthesis. Unfortunately, this is still controversial (risk of interference). However, transcatheter aortic valve replacements have been performed in patients with previously implanted mitral valves or mitral rings. Interestingly, we learned that there is no interference (or not significant interference) among the standard valve and the stent valve. Consequently, we can assume that a fast-implantable valve can also be safely placed next to a biological mitral valve or next to a rigid mitral ring without risks of distortion, malpositioning, high gradient or paravalvular leak. This paper describes two cases: a concomitant Intuity aortic valve and bioprosthetic mitral valve implantation and a concomitant Intuity aortic valve and mitral ring implantation.

Apical access and closure devices for transapical transcatheter heart valve procedures.

The majority of transcatheter aortic valve implantations, structural heart procedures and the newly developed transcatheter mitral valve repair and replacement are traditionally performed either through a transfemoral or a transapical access site, depending on the presence of severe peripheral vascular disease or anatomic limitations. The transapical approach, which carries specific advantages related to its antegrade nature and the short distance between the introduction site and the cardiac target, is traditionally performed through a left anterolateral mini-thoracotomy and requires rib retractors, soft tissue retractors and reinforced apical sutures to secure, at first, the left ventricular apex for the introduction of the stent-valve delivery systems and then to seal the access site at the end of the procedure. However, despite the advent of low-profile apical sheaths and newly designed delivery systems, the apical approach represents a challenge for the surgeon, as it has the risk of apical tear, life-threatening apical bleeding, myocardial damage, coronary damage and infections. Last but not least, the use of large-calibre stent-valve delivery systems and devices through standard mini-thoracotomies compromises any attempt to perform transapical transcatheter structural heart procedures entirely percutaneously, as happens with the transfemoral access site, or via a thoracoscopic or a miniaturised video-assisted percutaneous technique. During the past few years, prototypes of apical access and closure devices for transapical heart valve procedures have been developed and tested to make this standardised successful procedure easier. Some of them represent an important step towards the development of truly percutaneous transcatheter transapical heart valve procedures in the clinical setting.

Barn owl feathers as biomonitors of mercury: sources of variation in sampling procedures.

Given their central role in mercury (Hg) excretion and suitability as reservoirs, bird feathers are useful Hg biomonitors. Nevertheless, the interpretation of Hg concentrations is still questioned as a result of a poor knowledge of feather physiology and mechanisms affecting Hg deposition. Given the constraints of feather availability to ecotoxicological studies, we tested the effect of intra-individual differences in Hg concentrations according to feather type (body vs. flight feathers), position in the wing and size (mass and length) in order to understand how these factors could affect Hg estimates. We measured Hg concentration of 154 feathers from 28 un-moulted barn owls (Tyto alba), collected dead on roadsides. Median Hg concentration was 0.45 (0.076-4.5) mg kg(-1) in body feathers, 0.44 (0.040-4.9) mg kg(-1) in primary and 0.60 (0.042-4.7) mg kg(-1) in secondary feathers, and we found a poor effect of feather type on intra-individual Hg levels. We also found a negative effect of wing feather mass on Hg concentration but not of feather length and of its position in the wing. We hypothesize that differences in feather growth rate may be the main driver of between-feather differences in Hg concentrations, which can have implications in the interpretation of Hg concentrations in feathers. Finally, we recommend that, whenever possible, several feathers from the same individual should be analysed. The five innermost primaries have lowest mean deviations to both between-feather and intra-individual mean Hg concentration and thus should be selected under restrictive sampling scenarios.

Evaluation of occupational and patient dose in cerebral angiography procedures

Objective The present study was aimed at estimating the doses received by physicians and patients during cerebral angiography procedures in a public hospital of Recife, PE, Brazil. Materials and Methods The study sample included 158 adult patients, and during the procedures the following parameters were evaluated: exposure parameters (kV, mAs), number of acquired images, reference air kerma value (Ka,r) and air kerma-area product (PKA). Additionally, the physicians involved in the procedures were evaluated as for absorbed dose in the eyes, thyroid, chest, hands and feet. Results The results demonstrated that the doses to the patients' eyes region were relatively close to the threshold for cataract occurrence. As regards the physicians, the average effective dose was 2.6 µSv, and the highest effective dose recorded was 16 µSv. Conclusion Depending on the number of procedures, the doses received by the physicians may exceed the annual dose limit for the crystalline lenses (20 mSv) established by national and international standards. It is important to note that the high doses received by the physicians are due to the lack of radiation protection equipment and accessories, such as leaded curtains, screens and protective goggles.

Managing through measurement : A framework for successful operative level performance measurement

The research around performance measurement and management has focused mainly on the design, implementation and use of performance measurement systems. However, there is little evidence about the actual impacts of performance measurement on the different levels of business and operations of organisations, as well as the underlying factors that lead to a positive impact of performance measurement. The study thus focuses on this research gap, which can be considered both important and challenging to cover. The first objective of the study was to examine the impacts of performance measurement on different aspects of management, leadership and the quality of working life, after which the factors that facilitate and improve performance and performance measurement at the operative level of an organisation were examined. The second objective was to study how these factors operate in practice. The third objective focused on the construction of a framework for successful operative level performance measurement and the utilisation of the factors in the organisations. The research objectives have been studied through six research papers utilising empirical data from three separate studies, including two sets of interview data and one of quantitative data. The study applies mainly the hermeneutical research approach. As a contribution of the study, a framework for successful operative level performance measurement was formed by matching the findings of the current study and performance measurement theory. The study extents the prior research regarding the impacts of performance measurement and the factors that have a positive effect on operative level performance and performance measurement. The results indicate that under suitable circumstances, performance measurement has positive impacts on different aspects of management, leadership, and the quality of working life. The results reveal that for example the perception of the employees and the management of the impacts of performance measurement on leadership style differ considerably. Furthermore, the fragmented literature has been reorganised into six factors that facilitate and improve the performance of the operations and employees, and the use of performance measurement at the operative level of an organisation. Regarding the managerial implications of the study, managers who operate around performance measurement can utilise the framework for example by putting the different phases of the framework into practice.

Posada en funcionament d'una oficina de tramitació ràpida (OTRA) de la Direcció General d'Indústria, del Govern de les Illes Balears

La Direcció General d’Indústria té com a principal finalitat el control de les instal•lacions i de diferents activitats de l’àmbit industrial; exerceix aquesta funció mitjançant la tramitació de documentacions tècniques i la inspecció. Com tota Administració Pública, es troba en un entorn molt dinàmic, on només les empreses més competitives poden subsistir i els ciutadans tenen noves necessitats molt diferents de les de fa un temps. Ambdós, empreses i ciutadans, exigeixen serveis de qualitat a un sector públic que no té altra alternativa que caminar en la mateixa direcció. L’objectiu d’aquest treball és planificar una sèrie d’accions estratègiques que permetran la millora dels serveis oferts a fi de complir amb les expectatives de la ciutadania. S’ha realitzat una anàlisi interna i de l’entorn de l’organització, el resultat de la qual ha estat la detecció d’una sèrie de punts de millora. A continuació s’ha definit una pla operatiu de qualitat, emmarcat dins del segon Pla Estratègic de Qualitat del Govern de les Illes Balears, amb tres propostes d’actuació: la separació de funcions, la tramitació ràpida d’expedients i el pla de formació. Les propostes esmentades constitueixen les bases d’una nova unitat orgànica (Oficina de Tramitació Ràpida), el model organitzatiu de la qual queda definit en els diferents apartats del treball. Igualment, s’hi descriu el procés de posada en funcionament dels distints procediments que es vagin adaptant al nou sistema i la planificació dels treballs a dur a terme, que seguiran el cicle de la qualitat de Deming, és a dir, planificar, fer, verificar i actuar.

Analytical procedures for determining Pb and Sr isotopic compositions in water samples by ID-TIMS

Few articles deal with lead and strontium isotopic analysis of water samples. The aim of this study was to define the chemical procedures for Pb and Sr isotopic analyses of groundwater samples from an urban sedimentary aquifer. Thirty lead and fourteen strontium isotopic analyses were performed to test different analytical procedures. Pb and Sr isotopic ratios as well as Sr concentration did not vary using different chemical procedures. However, the Pb concentrations were very dependent on the different procedures. Therefore, the choice of the best analytical procedure was based on the Pb results, which indicated a higher reproducibility from samples that had been filtered and acidified before the evaporation, had their residues totally dissolved, and were purified by ion chromatography using the Biorad® column. Our results showed no changes in Pb ratios with the storage time.

Synthesis of quinoxaline 1,4-di-N-oxide derivatives on solid support using room temperature and microwave-assisted solvent-free procedures

We describe the synthesis of 12 new ethyl and methyl quinoxaline-7-carboxylate 1,4-di-N-oxide derivatives on solid supports with room temperature and microwave-assisted solvent-free procedures. Results show that solid supports have good catalytic activity in the formation of quinoxaline 1,4-di-N-oxide derivatives. We found that florisil and montmorillonite KSF and K10 could be used as new, easily available, inexpensive alternatives of catalysts. Additionally, room temperature and microwave-irradiation solvent-free synthesis was more efficient than a conventional procedure (Beirut reaction), reducing reaction time and increasing yield.