Complications of tracheobronchial foreign body aspiration in children: report of 5 cases and review of the literature

Foreign body aspiration (FBA) is one of leading causes of death in children, especially among those younger than 3 years of age. The inhalation of a foreign body may cause a wide variety of symptoms, and early diagnosis is highly associated with the successful removal of the inhaled foreign material. Despite the great advances in endoscopic procedures and anesthesia, a large number of difficulties and complications still result from foreign body aspiration. We describe 5 cases of serious acute complications following aspiration of foreign bodies that became lodged in the tracheobronchial tree, including pneumomediastinum, pneumothorax, total atelectasis, foreign body dislodgment, and need for thoracotomy in children admitted into our intensive care unit in 1999 and 2000; these were all situations that could have been prevented with early recognition and prompt therapeutic intervention.

Nutrition for the pediatric surgical patient: approach in the peri-operative period

Nutrition is essential for maintenance of physiologic homeostasis and growth. Hypermetabolic states lead to a depletion of body stores, with decreased immunocompetence and increased morbidity and mortality. The purpose of this paper is to provide an update regarding the provision of appropriate nutrition for the pediatric surgical patient, emphasizing the preoperative and postoperative periods. Modern nutritional support for the surgical patient comprises numerous stages, including assessment of nutritional status, nutritional requirements, and nutritional therapy. Nutritional assessment is performed utilizing the clinical history, clinical examination, anthropometry, and biochemical evaluation. Anthropometric parameters include body weight, height, arm and head circumference, and skinfold thickness measurements. The biochemical evaluation is conducted using determinations of plasma levels of proteins, including album, pre-albumin, transferrin, and retinol-binding protein. These parameters are subject to error and are influenced by the rapid changes in body composition in the peri-operative period. Nutritional therapy includes enteral and/or parenteral nutrition. Enteral feeding is the first choice for nutritional therapy. If enteral feeding is not indicated, parenteral nutrition must be utilized. In all cases, an individualized, adequate diet (enteral formula or parenteral solution) is obligatory to decrease the occurrence of overfeeding and its undesirable consequences.

Surgery information reduces anxiety in the pre-operative period

PURPOSE: Patients preparing to undergo surgery should not suffer needless anxiety. This study aimed to evaluate anxiety levels on the day before surgery as related to the information known by the patient regarding the diagnosis, surgical procedure, or anesthesia. METHOD: Patients reported their knowledge of diagnosis, surgery, and anesthesia. The Spielberger State-Trait Anxiety Inventory (STAI) was used to measure patient anxiety levels. RESULTS: One hundred and forty-nine patients were selected, and 82 females and 38 males were interviewed. Twenty-nine patients were excluded due to illiteracy. The state-anxiety levels were alike for males and females (36.10 ± 11.94 vs. 37.61 ± 8.76) (mean ± SD). Trait-anxiety levels were higher for women (42.55 ± 10.39 vs. 38.08 ± 12.25, P = 0.041). Patient education level did not influence the state-anxiety level but was inversely related to the trait-anxiety level. Knowledge of the diagnosis was clear for 91.7% of patients, of the surgery for 75.0%, and of anesthesia for 37.5%. Unfamiliarity with the surgical procedure raised state-anxiety levels (P = 0.021). A lower state-anxiety level was found among patients who did not know the diagnosis but knew about the surgery (P = 0.038). CONCLUSIONS: Increased knowledge of patients regarding the surgery they are about to undergo may reduce their state-anxiety levels.

Pulmonary artery catheter complications: report on a case of a knot accident and literature review

A particular event concerning a Swan-Ganz catheter complication is reported. A 41-year-old woman was admitted at the emergency room of our hospital with massive gastrointestinal bleeding. A total gastrectomy was performed. During the postoperative period in the intensive care unit , the patient maintained hemodynamic instability. Invasive hemodynamic monitoring with a pulmonary artery catheter was then indicated. During the maneuvers to insert the catheter, a true knot formation was identified at the level of the superior vena cava. Several maneuvers by radiological endovascular invasive techniques allowed removal of the catheter. The authors describe the details of this procedure and provide comments regarding the various techniques that were employed in overcoming this event. A comprehensive review of evidence regarding the benefits and risks of pulmonary artery catheterization was performed. The consensus statement regarding the indications, utilization, and management of the pulmonary artery catheterization that were issued by a consensus conference held in 1996 are also discussed in detail.

Urethral catheter removal 7 or 14 days after radical retropubic prostatectomy: clinical implications and complications in a randomized study

PURPOSE: To evaluate the hypothesis that a 7-day period of indwelling catheter after radical retropubic prostatectomy is effective and safe without the need of performing cystography. METHODS: In the period from January of 2000 to July of 2002, 73 patients underwent radical retropubic prostatectomy, and these patients were prospectively randomized in 2 groups: Group 1-37 patients who had the urethral catheter removed 7 days after the procedure, and Group 2-36 patients who had the catheter removed 14 days after the surgery. The 2 groups were similar, the surgeons and the technique were the same, and no cystography was performed to evaluate the presence of leaks. RESULTS: Two patients in Group 1 had bleeding and clot retention after having the catheter taken out in the seventh postoperative day and were managed by putting the catheter back in for 7 more days. Two patients in Group 2 developed bladder neck stricture and were treated by bladder neck incision with success. The continence rate was the same, with 2 cases of incontinence in each group. About 2 pads a day were used by the patients with incontinence. The average follow-up was 17.5 months (12-36 months). No urinary fistula, urinoma, or pelvic abscesses developed after catheter removal. Two patients were excluded from the analysis of this series: 1 died with a pulmonary embolus in the third postoperative day, and 1 developed a urinary suprapubic fistula before catheter withdrawal, which was maintained for 16 days. CONCLUSION: Withdrawal of the urethral catheter 7 days after radical retropubic prostatectomy, without performing cystography, has a low rate of short-term complications that are equivalent to withdrawal 14 days after the surgery.

Evolução, a curto prazo, do perfil do estado de nutrição no transplante hepático, em adultos : contributo para otimização da abordagem clínica e nutricional

RESUMO:Contexto: A avaliação do estado de nutrição do doente com indicação para transplante hepático (TH) deve ser abrangente, considerando o amplo espetro de situações clínicas e metabólicas. As alterações metabólicas relacionadas com a doença hepática podem limitar a aplicação de métodos de avaliação nutricional, subestimando a desnutrição. Após o TH, é expectável a reversão dos distúrbios metabólicos da doença hepática, pela melhoria da função do fígado. No entanto, algumas complicações metabólicas podem surgir após o TH, relacionadas com a má-nutrição, a desnervação hepática e o uso prolongado de imunossupressão, comprometendo os resultados clínicos a longo-prazo. A medição longitudinal e confiável do metabolismo energético e dos compartimentos corporais após o TH, avaliada em conjunto com fatores influentes no estado de nutrição, pode identificar precocemente situações de risco e otimizar e individualizar estratégias clínicas e nutricionais com vantagens no prognóstico. Objetivo: Avaliar longitudinalmente, a curto prazo, o estado de nutrição após o TH em doentes com insuficiência hepática por doença crónica e identificar os fatores, para além da cirurgia, que determinam diferentes evoluções do metabolismo energético e da composição corporal. Métodos: Foi estudada uma coorte de indivíduos com indicação para TH por doença hepática crónica, admitidos consecutivamente para TH ortotópico eletivo, durante 2 anos. Foram programados 3 momentos de avaliação: na última consulta pré-TH (T0), logo que adquirida autonomia respiratória e funcional após o TH (T1) e um mês após o TH (T2). Nesses momentos, foram medidos no mesmo dia: o suprimento nutricional por recordatório das últimas 24 horas, o estado de nutrição por Avaliação Subjetiva Global (ASG), o gasto energético em repouso (GER) por calorimetria indireta, a antropometria, a composição corporal por bioimpedância elétrica tetrapolar multifrequências e a força muscular por dinamometria de preensão palmar. O índice de massa magra (IMM) e a massa celular corporal (MCC) foram usados como indicadores do músculo esquelético e a percentagem de massa gorda (%MG) e o índice de massa gorda (IMG) como indicadores de adiposidade. O GER foi comparado com o estimado pelas fórmulas de Harris-Benedict para classificação do estado metabólico em:hipermetabolismo (GER medido >120% do GER estimado), normometabolismo (GER medido entre 80 e 120% do GER estimado) e hipometabolismo (GER medido <80% do GER estimado). Foi utilizada análise multivariável: por regressão logística, para identificar variáveis associadas à possibilidade (odds ratio – OR) de pertencer a cada grupo metabólico pré-TH; por regressão linear múltipla, para identificar variáveis associadas à variação dos compartimentos corporais no período pós-TH; e por modelos de efeitos mistos generalizados, para identificar variáveis associadas à evolução do GER e dos compartimentos corporais entre o período pré- e pós-TH. Resultados: Foram incluídos 56 indivíduos com idade, média (DP), 53,7 (8,5) anos, 87,5% do sexo masculino, 23,2% com doença hepática crónica de etiologia etanólica. Após o TH, em 60,7% indivíduos foi administrado regime imunossupressor baseado no tacrolimus. Os indivíduos foram avaliados [mediana (AIQ)] 90,5 (P25: 44,2; P75: 134,5) dias antes do TH (T0), 9,0 (P25: 7,0; P75: 12,0) dias após o TH (T1) e 36,0 (P25: 31,0; P75: 43,0) dias após o TH (T2). Após o TH houve melhoria significativa do estado de nutrição, com diminuição da prevalência de desnutrição classificada pela ASG (37,5% em T0, 16,1% em T2, p<0,001). Antes do TH, 41,1% dos indivíduos eram normometabólicos, 37,5% hipometabólicos e 21,4% hipermetabólicos. A possibilidade de pertencer a cada grupo metabólico pré-TH associou-se à: idade (OR=0,899, p=0,010) e desnutrição pela ASG (OR=5,038, p=0,015) para o grupo normometabólico; e índice de massa magra (IMM, OR=1,264, p=0,049) e etiologia viral da doença hepática (OR=8,297, p=0,019) para o grupo hipermetabólico. Não se obteve modelo múltiplo para o grupo de hipometabólico pré-TH, mas foram identificadas associações univariáveis com a história de toxicodependência (OR=0,282, p=0,047) e com a sarcopénia pré- TH (OR=8,000, p=0,040). Após o TH, houve normalização significativa e progressiva do estado metabólico, indicada pelo aumento da prevalência de normometabolismo (41,1% em T0, 57,1% em T2, p=0,040). Foram identificados diferentes perfis de evolução do GER após o TH, estratificado pelo estado metabólico pré-TH: no grupo hipometabólico pré-TH, o GER (Kcal) aumentou significativa e progressivamente (1030,6 em T0; 1436,1 em T1, p=0,001; 1659,2 em T2, p<0,001); no grupo hipermetabólico pré-TH o GER diminuiu significativa e progressivamente (2097,1 em T0; 1662,5 em T1, p=0,024; 1493,0 em T2, p<0.001); no grupo normometabólico não houve variações significativas. Os perfis de evolução do GER associaram-se com: peso corporal (β=9,6, p<0,001) e suprimento energético (β=13,6, p=0,005) na amostra total; com peso corporal (β=7,1, p=0,018) e contributo energético dos lípidos (β=18,9, p=0,003) no grupo hipometabólico pré-TH; e com peso corporal (β=14,1, p<0,001) e desnutrição pela ASG (β=-171,0, p=0,007) no grupo normometabólico pré-TH.Houve redução transitória dos compartimentos corporais entre T0 e T1, mas a maioria destes recuperou para valores semelhantes aos pré-TH. As exceções foram a água extracelular, que diminuiu entre T0 e T2 (média 18,2 L e 17,8 L, p=0,042), a massa gorda (média 25,1 Kg e 21,7 Kg, p<0,001) e o IMG (média 10,6 Kg.m-2 e 9,3 Kg.m-2, p<0,001) que diminuíram entre T1 e T2. Relativamente à evolução dos indicadores de músculo esquelético e adiposidade ao longo do estudo: a evolução do IMM associou-se com força de preensão palmar (β=0,06, p<0,001), creatininémia (β=2,28, p<0,001) e número total de fármacos administrados (β=-0,21, p<0,001); a evolução da MCC associou-se com força de preensão palmar (β=0,16, p<0,001), creatininémia (β=4,17, p=0,008) e número total de fármacos administrados (β=-0,46, p<0,001); a evolução da %MG associou-se com força de preensão palmar (β=-0,11, p=0,028), história de toxicodependência (β=-5,75, p=0,024), creatininémia (β=-5,91, p=0,004) e suprimento proteico (β=-0,06, p=0,001); a evolução do IMG associou-se com história de toxicodependência (β=- 2,64, p=0,019), creatininémia (β=-2,86, p<0,001) e suprimento proteico (β=-0,02, p<0,001). A variação relativa (%Δ) desses compartimentos corporais entre T1 e T2 indicou o impacto da terapêutica imunossupressora na composição corporal: o regime baseado na ciclosporina associou-se positivamente com a %Δ do IMM (β=23,76, p<0,001) e %Δ da MCC (β=26,58, p<0,001) e negativamente com a %Δ MG (β=-25,64, p<0,001) e %Δ do IMG (β=-25,62, p<0,001), relativamente ao regime baseado no tacrolimus. Os esteróides não influenciaram a evolução do GER nem com a dos compartimentos corporais. Conclusões: O estado de nutrição, avaliado por ASG, melhorou significativamente após o TH, traduzida pela diminuição da prevalência de desnutrição. O normometabolismo pré-TH foi prevalente e associou-se à menor idade e à desnutrição pré- TH. O hipometabolismo pré-TH associou-se à história de toxicodependência e à sarcopénia pré-TH. O hipermetabolismo pré-TH associou-se ao maior IMM e à etiologia viral da doença hepática. Após o TH, houve normalização progressiva do estado metabólico. Foram identificados três perfis de evolução do GER, associando-se com: peso corporal e suprimento energético na amostra total; peso corporal e contributo energético dos lípidos no grupo hipometabólico pré- TH; e peso corporal e desnutrição pela ASG no grupo normometabólico pré-TH. Foram identificados diferentes perfis de evolução da composição corporal após TH. A evolução do músculo esquelético associou-se positivamente com a força de preensão palmar e a creatininémia e negativamente com o número total de fármacos administrados. A evolução da adiposidade (%MG e IMG) associou-se inversamente com a história de toxicodependência, a creatininémia e o suprimento proteico; adicionalmente, a %MG associou-se inversamente com a força de preensão palmar. O regime baseado na ciclosporina associou-se independentemente com diminuição da adiposidade e aumento do músculo esquelético, comparativamente ao regime baseado no tacrolimus.---------------------------ABSTRACT:Background: The assessment of nutritional status in patients undergoing liver transplantation (LTx) should be comprehensive, accounting for the wide spectrum of the clinical and metabolic conditions. The metabolic disturbances related to liver disease may limit the precision and accuracy of traditional nutritional assessment methods underestimating the undernourishment. After LTx, it is expected that many metabolic derangements improve with the recovery of liver function. However, some metabolic complications arising after LTx, related to nutritional status, hepatic denervation, and prolonged immunosuppression, may compromise the longterm outcome. A reliable longitudinal assessment of both energy metabolism and body compartments after LTx, combined with assessments of other factors potentially affecting the nutritional status, may enable a better interpretation on the relationship between the metabolic and the nutritional status. These reliable assessments may precociously identify nutritional risk conditions and optimize and customize clinical and nutritional strategies improving the prognosis. Objective: To assess longitudinally the nutritional status shortly after orthotopic LTx in patients with chronic liver disease, and identify factors, beyond surgery, determining different energy metabolism and body composition profiles.Methods: A cohort of consecutive patients who underwent LTx due to chronic liver disease was studied within a period of two years. The assessments were performed in three occasions: at the last visit before LTx (T0), after surgery as soon as respiratory and functional autonomy was established (T1), and approximately one month after surgery (T2). On each occasion all assessments were performed on the same day, and included: the dietary assessment by 24- hour dietary recall, nutritional status by the Subjective Global Assessment (SGA), the resting energy expenditure (REE) by indirect calorimetry, anthropometry, body composition by multifrequency bioelectrical impedance analysis, and muscle strength by handgrip strength. Both the lean mass index (LMI) and body cell mass (BCM) were used as surrogates of skeletal muscle, and both the percentage of fat mass (%FM) and fat mass index (FMI) of adiposity. The REE was predicted according to the Harris and Benedict equation. Hypermetabolism was defined as a measured REE more than 120% of the predicted value; normometabolism as a measured REE within 80-120% of the predicted value; and hypometabolism as a measured REE less than 80% of the predicted value. Multiple regression analysis was used: by logistic regression to identify variables associated with odds of belong each pre-LTx metabolic groups; by linear multiple regression analysis to identify variables associated with body compartments relative variations (%Δ) in the post-LTx period; and by mixed effects models to identify variables associated with the REE and body compartments profiles pre- and post-LTx. Results: Fifty six patients with a mean (SD) of 53.7 (8.5) years of age were included, 87.5% were men and 23.2% with alcoholic liver disease. After LTx 60.7% individuals were assigned to tacrolimus-based immunosuppressive regimen. The patients were assessed at a median time (inter-quartil range) of 90.5 (P25 44.2; P75 134.5) days before LTx (T0), at a median time of 9.0 (P25 7.0; P75 12.0) (T1) and 36 (P25 31.0; P75 43.0) (T2) days after LTx. After LTx the nutritional status significantly improved: the SGA-undernourishment decreased from 37.5% (T0) to 16.1% (T2) (p<0.001). Before LTx, 41.1% patients were normometabolic, 37.5% hypometabolic, and 21.4% hypermetabolic. The predictors of each pre-LTx metabolic group were: age (OR=0.899, p=0.010) and SGA-undernourishment (OR=5.038, p=0.015) for the normometabolic group; and LMI (OR=1.264, p=0.049) and viral etiology of liver disease (OR=8.297, p=0.019) for the hypermetabolic group. No multiple model was found for the pre-LTx hypometabolic group, but univariate association was found with history of drug addiction (OR=0.282, p=0.047) and pre- LTx sarcopenia (OR=8.000, p=0.040). After LTx a significant normalization of the metabolic status occurred, indicated by the increase in the prevalence of normometabolic patients (from T0: 41.1% to T2: 57.1%, p=0.040). Different REE profiles were found with REE stratified by preoperative metabolic status: in the hypometabolic group a significant progressive increase in mean REE (Kcal) was observed (T0: 1030.6; T1: 1436.1, p=0.001; T2: 1659.2, p<0.001); in the hypermetabolic group, a significant progressive decrease in mean REE (Kcal) was observed (T0: 2097.1; T1: 1662.5, p=0.024; T2: 1493.0, p<0.001); and in the normometabolic group, no significant differences were found. The REE profiles were associated with: body weight (β- estimate=9.6, p<0.001) and energy intake (β-estimate=13.6, p=0.005) in the whole sample; with body weight (β-estimate=7.1, p=0.018) and %TEV from lipids (β-estimate=18.9, p=0.003) in the hypometabolic group; and with body weight (β-estimate=14.1, p<0.001), and SGAundernourishment (β-estimate=-171, p=0.007) in the normometabolic group. A transient decrease in most body compartments occurred from T0 to T1, with subsequent catch-up to similar preoperative values. Exceptions were the extracellular water, decreasing from T0 to T2 (mean 18.2 L to 17.8 L, p=0.042), the fat mass (mean 25.1 Kg to 21.7 Kg, p<0.001) and FMI (mean 10.6 Kg.m-2 to 9.3 Kg.m-2, p<0.001), decreasing from T1 to T2. Significant predictors of skeletal muscle and adiposity profiles were found: LMI evolution was associated with handgrip strength (β-estimate=0.06, p<0.001), serum creatinine (β- estimate=2.28, p<0.001) and number of medications (β-estimate=-0.21, p<0.001); BCM evolution was associated with handgrip strength (β-estimate=0.16, p<0.001), serum creatinine (β-estimate=4.17, p<0.001) and number of medications (β-estimate=-0.46, p<0.001); the %FM evolution was associated with handgrip strength (β-estimate=-0.11, p=0.028), history of drug addiction (β-estimate=-5.75, p=0.024), serum creatinine (β-estimate=-5.91, p=0.004) and protein intake (β-estimate=-0.06, p=0.001); and FMI evolution was associated with history of drug addiction (β-estimate=-2.64, p=0.019), serum creatinine (β-estimate=-2.86, p<0.001) and protein intake (β-estimate=-0.02, p<0.001). The %Δ of the aforementioned body compartments from T1 to T2 indicated the influence of immunosuppressive agents on body composition: the cyclosporine-based regimen, compared with tacrolimus-based regimen, was positively associated with %Δ LMI (β-estimate=23.76, p<0.001) and %Δ BCM (β- estimate=26.58, p<0.001), and inversely associated with %Δ FM (β-estimate=-25.64, p<0.001) and %Δ FMI (β-estimate=-25.62, p<0.001). No significant changes in REE or body composition were observed associated with dose or duration of steroid therapy. Conclusions: The SGA-assessed nutritional status improved shortly after LTx, with significant decrease in prevalence undernourished individuals. XXI Preoperative normometabolism was prevalent and was associated with younger age and SGAundernourishment before LTx. Preoperative hypometabolism was associated with history of drug addiction and pre-LTx sarcopenia. Preoperative hypermetabolism was associated with higher LMI and viral etiology of liver disease. A significant normalization of the metabolic status was observed after LTx. The REE profiles were positively predicted by body weight and energy intake in the whole sample, by body weight and percentage of energy intake from lipids in the preoperative hypometabolic patients, and by body weight and SGA–undernourishment in the preoperative normometabolic patients. Different body composition profiles were found after LTx. Skeletal muscle profile was positively associated with handgrip strength and serum creatinine, and inversely with the number of medications. The adiposity profile was inversely associated with history of drug addiction, serum creatinine and protein intake. Additionally, the %FM evolution was inversely associated with handgrip strength. The cyclosporine-based regimen, compared with tacrolimus-based regimen, was independently associated with skeletal muscle increase and adiposity decrease.

Continuidade e mudança. O sistema internacional no post‐Guerra Fria

O fim da Guerra Fria é um caso inédito de mudança pacífica da estrutura internacional, em que os Estados Unidos e a União Soviética transcendem a divisão bipolar para decidir os termos da paz no quadro das instituições que definem o modelo de ordenamento multilateral, consolidando a sua legitimidade. Nesse contexto, ao contrário dos casos precedentes de reconstrução internacional no fim de uma guerra hegemónica, o novo sistema do post-Guerra Fria, caracterizado pela unipolaridade, pela regionalização e pela homogeneização, forma-se num quadro de continuidade institucional. A ordem política do post-Guerra Fria é um sistema misto em que as tensões entre a hierarquia unipolar e a anarquia multipolar, a integração global e a fragmentação regional e a homogeneidade e a heterogeneidade política, ideológica e cultural condicionam as estratégias das potências. As crises internacionais vão pôr à prova a estabilidade da nova ordem e a sua capacidade para garantir mudanças pacíficas. A primeira década do post-Guerra Fria mostra a preponderância dos Estados Unidos e a sua confiança crescente, patente nas Guerras do Golfo Pérsico e dos Balcãs, bem como na crise dos Estreitos da Formosa. A reacção aos atentados do "11 de Setembro" revela uma tentação imperial da potência unipolar, nomeadamente com a invasão do Iraque, que provoca uma crise profunda da comunidade de segurança ocidental. A vulnerabilidade do centro da ordem internacional é confirmada pela crise constitucional europeia e pela crise financeira global. Essas crises não alteram a estrutura de poder mas aceleram a erosão da ordem multilateral e criam um novo quadro de possibilidades para a evolução internacional, que inclui uma escalada dos conflitos num quadro de multipolaridade regional, uma nova polarização entre as potências democráticas conservadoras e uma coligação revisionista autoritária, bem como a restauração de um concerto entre as principais potências internacionais.

The influence of fibre orientation on the post-cracking tensile behaviour of steel fibre reinforced self-compacting concrete

Adding fibres to concrete provides several advantages, especially in terms of controlling the crack opening width and propagation after the cracking onset. However, distribution and orientation of the fibres toward the active crack plane are significantly important in order to maximize its benefits. Therefore, in this study, the effect of the fibre distribution and orientation on the post-cracking tensile behaviour of the steel fibre reinforced self-compacting concrete (SFRSCC) specimens is investigated. For this purpose, several cores were extracted from distinct locations of a panel and were subjected to indirect (splitting) and direct tensile tests. The local stress-crack opening relationship (σ-w) was obtained by modelling the splitting tensile test under the finite element framework and by performing an Inverse Analysis (IA) procedure. Afterwards the σ-w law obtained from IA is then compared with the one ascertained directly from the uniaxial tensile tests. Finally, the fibre distribution/orientation parameters were determined adopting an image analysis technique.

The role of temporary accommodation buildings for post-disaster housing reconstruction

The number of houses damaged or destroyed after disasters is frequently large, and re-housing of homeless people is one of the most important tasks of reconstruction programmes. Reconstruction works often last long and during that time, it is essential to provide victims with the minimum conditions to live with dignity, privacy, and protection. This research intends to demonstrate the crucial role of temporary accommodation buildings to provide spaces where people can live and gradually resume their life until they have a permanent house. The study also aims to identify the main problems of temporary accommodation strategies and to discuss some principles and guidelines in order to reach better design solutions. It is found that temporary accommodation is an issue that goes beyond the simple provision of buildings, since the whole space for temporary settlement is important. Likewise, temporary accommodation is a process that should start before a disaster occurs, as a preventive pre-planning. In spite of being temporary constructions, these housing buildings are one of the most important elements to provide in emergency scenarios, contributing for better recovery and reconstruction actions.

Earnings management and stock price crashes post-crossdelisting

We test whether cross-delisted firms from the major U.S. stock exchanges experience an increase in crash risk associated with earnings management. Consistent with our prediction, we find that earnings management have a greater positive impact on stock price crash risk post-cross-delisting when compared to a sample of still cross-listed firms. Moreover, our results suggest that this effect is more pronounced for crossdelisted firms from countries with weaker investor protection and poorer quality of their information environment. We further examine whether managers’ ability to manipulate earnings increases post-cross-delisting around seasoned equity offerings. Our evidence shows that cross-delisted firms that engage in earnings management to inflate reported earnings prior to a seasoned equity offering are more likely to observe a subsequent stock price crash.

Post-operating performance of cross-delisted firms from U.S. stock exchanges

We investigate the long-term performance of cross-delisted firms from U.S. stock markets. Using a sample of foreign firms listed and delisted from U.S. stock exchange markets over 2000-2012, we examine the operating performance and the long-run stock returns performance of firms post-cross-delisting. Our results suggest that cross-delisted firms have less growth opportunities than matched cross-listed firms in the long run. Moreover, firms that cross-delist after the passage of Rule 12h-6 of 2007 exhibit a significant decline in operating performance. In contrast, before the adoption of the Rule 12h-6, cross-delisted firms seem to be affected by the cost of a U.S. listing in the precross -delisting period. In addition, we provide evidence that cross-delisted firms underperform their cross-listed peers; cross-delisted firms experience negative average abnormal returns, especially in the post-delisting period.

Scarless laparoscopic repair of epigastric hernia in children

Background Despite the small size of the incision, the scar left by open repair of epigastric hernia in children is unaesthetic. Few laparoscopic approaches to epigastric hernia repair have been previously proposed, but none has gain wide acceptance from pediatric surgeons. In this study, we present our experience with a scarless laparo- scopic approach using a percutaneous suturing technique for epigastric hernia repair in children. Methods Ten consecutive patients presenting with epi- gastric hernia 15 mm or further from the umbilicus were submitted to laparoscopic hernia repair. A 5-mm 308-angle laparoscope is introduced through a umbilical trocar and a 3-mm laparoscopic dissector is introduced through a stab incision in the right flank. After opening and dissecting the parietal peritoneum, the fascial defect is identified and closed using 2–0 polyglactin thread through a percutaneous suturing technique. Intraoperative and postoperative clinical data were collected. Results All patients were successfully submitted to la- paroscopic epigastric hernia repair. Median age at surgery was 79 months old and the median distance from the um- bilicus to the epigastric defect was 4 cm. Operative time ranged from 35 to 75 min. Every hernia was successfully closed without any incidents. Follow-up period ranges from 2 to 12 months. No postoperative complications or recurrence was registered. No scar was visible in these patients. Conclusion This scarless laparoscopic technique for epi- gastric hernia repair is safe and reliable. We believe this technique might become gold standard of care in the near future.

Three-dimensional technology facilitates surgical performance of novice laparoscopy surgeons: a quantitative assessment on a porcine kidney model

Objective To determine whether the use of 3-dimensional (3D) imaging translates into a better surgical performance of naïve urologic laparoscopic surgeons during pyeloplasty (PY) and partial nephrectomy (PN) procedures. Materials and Methods Eighteen surgeons without any previous laparoscopic experience were randomly assigned to perform PY and PN in a porcine model using initially 2-dimensional (2D) and 3D laparoscopy. A surgical performance score was rated by an "expert" tutor through a modified 5-item global rating scale contemplating operative field view, bimanual dexterity, efficiency, tissue handling, and autonomy. Overall surgical time, complications, subjective perception of participating surgeons, and inconveniences related to the 3D vision were recorded. Results No difference in terms if operative time was found between 2D or 3D laparoscopy for both the PY (P =.51) and the PN (P =.28) procedures. A better rate in terms of surgical performance score was noted by the tutors when the study participants were using 3D vs 2D, for both PY (3.6 [0.8] vs 3.0 [0.4]; P =.034) and PN (3.6 [0.51] vs 3.15 [0.63]; P =.001). No complications occurred in any of the procedures. Most (77.2%) of the participating na??ve laparoscopic surgeons had the perception that 3D laparoscopy was overall easier than 2D. Headache (18.1%), nausea (18.1%), and visual disturbance (18.1%) were the most common issues reported by the surgeons during 3D procedures. Conclusion Despite the absence of translation in a shorter operative time, the use of 3D technology seems to facilitate the surgical performance of naive surgeons during laparoscopic kidney procedures on a porcine model.

The effect of high-fat diet on rat’s mood, feeding behavior and response to stress

An association between obesity and depression has been indicated in studies addressing common physical (metabolic) and psychological (anxiety, low self-esteem) outcomes. Of consideration in both obesity and depression are chronic mild stressors to which individuals are exposed to on a daily basis. However, the response to stress is remarkably variable depending on numerous factors, such as the physical health and the mental state at the time of exposure. Here a chronic mild stress (CMS) protocol was used to assess the effect of high-fat diet (HFD)-induced obesity on response to stress in a rat model. In addition to the development of metabolic complications, such as glucose intolerance, diet-induced obesity caused behavioral alterations. Specifically, animals fed on HFD displayed depressive- and anxious-like behaviors that were only present in the normal diet (ND) group upon exposure to CMS. Of notice, these mood impairments were not further aggravated when the HFD animals were exposed to CMS, which suggest a ceiling effect. Moreover, although there was a sudden drop of food consumption in the first 3 weeks of the CMS protocol in both ND and HFD groups, only the CMS-HFD displayed an overall noticeable decrease in total food intake during the 6 weeks of the CMS protocol. Altogether, the study suggests that HFD impacts on the response to CMS, which should be considered when addressing the consequences of obesity in behavior.

A new page on the road book of inorganic mercury in fish body - tissue distribution and elimination following waterborne exposure and post-exposure periods

prova tipográfica / uncorrected proof