Consultoria del procés de logística interna del laboratori d'anàlisis clíniques a l'Hospital General de Vic

Com a resultat de les politiques i estratègies de col·laboració entre la universitat de Vic i de l’hospital i de la voluntat de realitzar activitats formatives conjuntes , s’estableix un línia de treball orientada a l’estudi i anàlisi de la situació logística interna actual del laboratori d’anàlisis clíniques de l’Hospital General de Vic. El treball es centra en el procés intern del laboratori i l’abast de l’estudi es troba limitat a les àrees especifiques d’hematologia i coagulació i bioquímica. D’aquestes dues àrees el treball realitza un estudi exhaustiu del seu procés intern, identifica les seves activitats i la seva metodologia de treball amb l’objectiu d’elaborar el Value Stream Map de cadascuna de les àrees. Les àrees de Microbiologia, Banc de Sang i Urgències resten fora d’aquest estudi exhaustiu tot i que són presents en el treball per la inevitable interacció que tenen en la globalitat del procés. El treball es centra bàsicament en els processos automatitzats tot i que els processos que es duen a terme en el laboratori són tant automatitzats com manuals. També es limita al sistema productiu intern del laboratori tot i la interacció que té aquest sistema intern amb altres centres productius del sistema com ara són els centres d’atenció primària, els diversos hospitals i centres d’atenció sociosanitària. El laboratori es troba immers en el moment de l’elaboració d’aquest treball en un situació de canvi i millora del seus processos interns que consisteixen principalment en la substitució de part la maquinària actual que obliguen a la definició d’un nou layout i d’una nova distribució de la producció a cada màquina. A nivell extern també s’estan produint millores en el sistema informàtic de gestió que afecten a part del seu procés. L’objectiu del treball és donar visibilitat total al procés de logística interna actual del laboratori, identificant clarament com són i quina seqüència tenen els processos logístics interns i els mètodes de treball actuals, tant de recursos màquina com recursos persona, per poder identificar sota una perspectiva de generació de valor, aquells punts concrets de la logística interna que poden ser millorats en quant a eficiència i productivitat amb l’objectiu que un cop identificats es puguin emprendre accions i/o projectes de millora. El treball finalitza amb un anàlisis final del procés logística interna des d’una òptica Lean. Per fer-ho, identifica aquelles activitats que no aporten valor al procés o MUDA i les classifica en set categories i es realitzen diverses propostes de millora com són la implantació d’un flux continu , anivellat i basat en un concepte pull , identifica activitats que poden ser estandarditzades i/o simplificades i proposa modificacions en les infraestructures físiques per donar major visibilitat al procés. L’aspecte humà del procés es planteja des d’un punt de vist de metodologia, formació, comunicació i aplicació de les 5S.

Rediseño de una línea de ensamblaje de contactores eléctricos aplicando principios y técnicas de producción ajustada

El presente documento describe un caso real de una línea de ensamblaje de minicontactores eléctricos. En su situación inicial, la línea no alcanzaba los requerimientos de los clientes en cuanto a flexibilidad y capacidad, lo que se manifestaba en retrasos en los plazos de entrega a clientes. A partir del análisis basado en principios de producción ajustada y de la aplicación de técnicas lean, se rediseñó la línea de modo que se resolvieran los problemas iniciales. Adicionalmente, la línea vio incrementada su productividad, redujo la superficie ocupada, incorporó un sistema de aprovisionamiento cíclico, mejoró la ergonomía y redujo el inventario en cursonecesario para su funcionamiento.

Peut-on accepter les progrès en sciences biomèdicales sans progrès en éthique ? [Can we take for granted medical progress without progress in ethics ?].

Since the mid 20th century progress in biomedical science has been punctuated by the emergence of bioethics which has fashioned the moral framework of its application to both research and clinical practice. Can we, however, consider the advent of bioethics as a form of progress marking the advances made in biomedical science with an adequate ethical stamp? The argument put forward in this chapter is based on the observation that, far from being a mark of progess, the development of bioethics runs the risk of favouring, like modern science, a dissolution of the links that unite ethics and medicine, and so of depriving the latter of the humanist dimensions that underlie the responsibilities that fall to it. Faced with this possible pitfall, this contribution proposes to envisage as a figure of moral progress, consubstantial with the development of biomedical science, an ethical approach conceived as a means of social intervention which takes the first steps towards an ethics of responsibility integrating the bioethical perspective within a hermeneutic and deliberative approach. By the yardstick of a prudential approach, it would pay particular attention to the diverse sources of normativity in medical acts. It is suggested that this ethical approach is a source of progress insofar as it constitutes an indispensable attitude of watchfulness, which biomedical science can lean on as it advances, with a view to ensuring that the fundamental link uniting ethics and medicine is maintained.

Fat oxidation kinetics during exercise in obese individuals

Introduction An impaired ability to oxidize fat may be a factor in the obesity's aetiology (3). Moreover, the exercise intensity (Fatmax) eliciting the maximal fat oxidation rate (MFO) was lower in obese (O) compared with lean (L) individuals (4). However, difference in fat oxidation rate (FOR) during exercise between O and L remains equivocal and little is known about FORs during high intensities (>60% ) in O compared with L. This study aimed to characterize fat oxidation kinetics over a large range of intensities in L and O. Methods 12 healthy L [body mass index (BMI): 22.8±0.4] and 16 healthy O men (BMI: 38.9±1.4) performed submaximal incremental test (Incr) to determine whole-body fat oxidation kinetics using indirect calorimetry. After a 15-min resting period (Rest) and 10-min warm-up at 20% of maximal power output (MPO, determined by a maximal incremental test), the power output was increased by 7.5% MPO every 6-min until respiratory exchange ratio reached 1.0. Venous lactate and glucose and plasma concentration of epinephrine (E), norepinephrine (NE), insulin and non-esterified fatty acid (NEFA) were assessed at each step. A mathematical model (SIN) (1), including three variables (dilatation, symmetry, translation), was used to characterize fat oxidation (normalized by fat-free mass) kinetics and to determine Fatmax and MFO. Results FOR at Rest and MFO were not significantly different between groups (p≥0.1). FORs were similar from 20-60% (p≥0.1) and significantly lower from 65-85% in O than in L (p≤0.04). Fatmax was significantly lower in O than in L (46.5±2.5 vs 56.7±1.9 % respectively; p=0.005). Fat oxidation kinetics was characterized by similar translation (p=0.2), significantly lower dilatation (p=0.001) and tended to a left-shift symmetry in O compared with L (p=0.09). Plasma E, insulin and NEFA were significantly higher in L compared to O (p≤0.04). There were no significant differences in glucose, lactate and plasma NE between groups (p≥0.2). Conclusion The study showed that O presented a lower Fatmax and a lower reliance on fat oxidation at high, but not at moderate, intensities. This may be linked to a: i) higher levels of insulin and lower E concentrations in O, which may induce blunted lipolysis; ii) higher percentage of type II and a lower percentage of type I fibres (5), and iii) decreased mitochondrial content (2), which may reduce FORs at high intensities and Fatmax. These findings may have implications for an appropriate exercise intensity prescription for optimize fat oxidation in O. References 1. Cheneviere et al. Med Sci Sports Exerc. 2009 2. Holloway et al. Am J Clin Nutr. 2009 3. Kelley et al. Am J Physiol. 1999 4. Perez-Martin et al. Diabetes Metab. 2001 5. Tanner et al. Am J Physiol Endocrinol Metab. 2002

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Activation of peroxisome proliferator-activated receptor beta/delta inhibits lipopolysaccharide-induced cytokine production in adipocytes by lowering nuclear factor-kappaB activity via extracellular signal-related kinase 1/2.

OBJECTIVE: Chronic activation of the nuclear factor-kappaB (NF-kappaB) in white adipose tissue leads to increased production of pro-inflammatory cytokines, which are involved in the development of insulin resistance. It is presently unknown whether peroxisome proliferator-activated receptor (PPAR) beta/delta activation prevents inflammation in adipocytes. RESEARCH DESIGN AND METHODS AND RESULTS: First, we examined whether the PPARbeta/delta agonist GW501516 prevents lipopolysaccharide (LPS)-induced cytokine production in differentiated 3T3-L1 adipocytes. Treatment with GW501516 blocked LPS-induced IL-6 expression and secretion by adipocytes and the subsequent activation of the signal transducer and activator of transcription 3 (STAT3)-Suppressor of cytokine signaling 3 (SOCS3) pathway. This effect was associated with the capacity of GW501516 to impede LPS-induced NF-kappaB activation. Second, in in vivo studies, white adipose tissue from Zucker diabetic fatty (ZDF) rats, compared with that of lean rats, showed reduced PPARbeta/delta expression and PPAR DNA-binding activity, which was accompanied by enhanced IL-6 expression and NF-kappaB DNA-binding activity. Furthermore, IL-6 expression and NF-kappaB DNA-binding activity was higher in white adipose tissue from PPARbeta/delta-null mice than in wild-type mice. Because mitogen-activated protein kinase-extracellular signal-related kinase (ERK)1/2 (MEK1/2) is involved in LPS-induced NF-kappaB activation in adipocytes, we explored whether PPARbeta/delta prevented NF-kappaB activation by inhibiting this pathway. Interestingly, GW501516 prevented ERK1/2 phosphorylation by LPS. Furthermore, white adipose tissue from animal showing constitutively increased NF-kappaB activity, such as ZDF rats and PPARbeta/delta-null mice, also showed enhanced phospho-ERK1/2 levels. CONCLUSIONS: These findings indicate that activation of PPARbeta/delta inhibits enhanced cytokine production in adipocytes by preventing NF-kappaB activation via ERK1/2, an effect that may help prevent insulin resistance.

Maximal aerobic power during running and cycling in obese and non-obese children.

The maximal aerobic capacity while running and cycling was measured in 22 prepubertal children (mean age +/- SD 9.5 +/- 0.8 years): 14 obese (47.3 +/- 10 kg) and 8 non-obese (31.1 +/- 6.1 kg). Oxygen consumption (VO2) and carbon dioxide production were measured by an open circuit method. Steady state VO2 was determined at different levels of exercise up to the maximal power on the cycloergometer (92 W in obese and 77 W in non-obese subjects) and up to the maximal running speed on the treadmill at a 2% slope (8.3 km/h in obese and 9.0 km/h in lean children). Expressed in absolute values, the VO2max in obese children was significantly higher than in controls (1.55 +/- 0.29 l/min versus 1.23 +/- 0.22 l/min, p < 0.05) for the treadmill test and comparable in the two groups (1.4 +/- 0.2 l/min versus 1.16 +/- 0.2 l/min, ns) for the cycloergometer test. When VO2max was expressed per kg fat free mass, the difference between the two groups disappeared for both tests. These data suggest that obese children had no limitation of maximal aerobic power. Therefore, the magnitude of the workload prescribed when a physical activity program is intended for the therapy of childhood obesity, it should be designed to increase caloric output rather than to improve cardiorespiratory fitness.

Marked association between obesity and glomerular hyperfiltration: a cross-sectional study in an African population.

BACKGROUND: Obesity and African American ethnicity are established independent risk factors for the development of chronic kidney disease. No data exist about the association between obesity and renal hemodynamics in the African region. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 301 nondiabetic participants (97 lean, 108 overweight, and 96 obese) of African descent with a positive family history of hypertension from the Seychelles islands. PREDICTOR: Body mass index (BMI). OUTCOMES: Glomerular hyperfiltration, glomerular filtration rate (GFR), effective renal plasma flow (ERPF), and filtration fraction. MEASUREMENTS: GFR and ERPF were measured using inulin and para-aminohippurate clearances, respectively. Participants' baseline demographics, laboratory data, and blood pressure were measured using standard techniques. RESULTS: The prevalence of glomerular hyperfiltration (defined as GFR >or=140 mL/min) increased across BMI categories (7.2%, 14.8%, and 27.1% for lean, overweight, and obese participants, respectively; P < 0.001). Higher BMI was associated with higher median GFR (99, 110, and 117 mL/min for lean, overweight, and obese participants, respectively; P < 0.001), ERPF (424, 462, and 477 mL/min, respectively; P = 0.01), and filtration fraction (0.23, 0.24, and 0.25; P < 0.001). Multivariate analyses adjusting for age, sex, blood pressure, fasting glucose level, and urinary sodium excretion and accounting for familial correlations confirmed the associations between high BMI (>25 kg/m(2)) and increased GFR, ERPF, and filtration fraction. No association between BMI categories and GFR was found with adjustment for body surface area. LIMITATIONS: Participants had a positive family history of hypertension. CONCLUSION: Overweight and obesity are associated with increased GFR, ERPF, and filtration fraction and a high prevalence of glomerular hyperfiltration in nondiabetic individuals of African descent. The absence of associations between BMI categories and GFR indexed for body surface area raises questions regarding the appropriateness of indexing GFR for body surface area in overweight populations.

Brachial or wrist blood pressure in obese patients: which is the best?

OBJECTIVE: Blood pressure (BP) measured in obese patients with a large arm circumference using a cuff of standard width may be overestimated. METHODS: We compared in this study the BP readings obtained with oscillometric devices at the left arm (OMRON HEM 705-CP) and the left wrist (OMRON R6) (Omron Medizintechnik, Mannheim, Germany) in lean (n=15) and obese (n=11) patients. RESULTS: No difference was found in diastolic BP between the two groups, nor between the arm and the wrist. Systolic BP measured at the arm was, however, significantly lower in obese (99+/-9 mmHg, mean+/-SD) than in lean (107+/-14 mmHg; P<0.001) patients, whereas systolic BP determined at the wrist averaged 106 mmHg in both groups. CONCLUSION: The use of validated wrist BP measuring devices appears therefore particularly appealing in obese individuals with a large arm circumference