International recommendations on the diagnosis and treatment of patients with acquired hemophilia A.

Acquired hemophilia A (AHA) is a rare bleeding disorder characterized by autoantibodies directed against circulating coagulation factor (F) VIII. Typically, patients with no prior history of a bleeding disorder present with spontaneous bleeding and an isolated prolonged aPTT. AHA may, however, present without any bleeding symptoms, therefore an isolated prolonged aPTT should always be investigated further irrespective of the clinical findings. Control of acute bleeding is the first priority, and we recommend first-line therapy with bypassing agents such as recombinant activated FVII or activated prothrombin complex concentrate. Once the diagnosis has been achieved, immediate autoantibody eradication to reduce subsequent bleeding risk should be performed. We recommend initial treatment with corticosteroids or combination therapy with corticosteroids and cyclophosphamide and suggest second-line therapy with rituximab if first-line therapy fails or is contraindicated. In contrast to congenital hemophilia, no comparative studies exist to support treatment recommendations for patients with AHA, therefore treatment guidance must rely on the expertise and clinical experience of specialists in the field. The aim of this document is to provide a set of international practice guidelines based on our collective clinical experience in treating patients with AHA and contribute to improved care for this patient group.

Management of bleeding and coagulopathy following major trauma: an updated European guideline.

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Discrimination in Bankruptcy Situations

In a bankruptcy situation, not all claimants are affected in the same way. In particular, some depositors may enter into a situation of personal bankruptcy if they lose part of their investments. Events of this kind may lead to a social catastrophe. We propose discrimination among the claimants as a possible solution. A fact considered in the American bankruptcy law (among others) that establishes some discrimination on the claimants, or the Santander Bank that in the Madoff’s case reimbursed only the deposits to its particular customers. Moreover, the necessity of discriminating has already been mentioned in different contexts by Young (1988), Bossert (1995), Thomson (2003) and Pulido et al. (2002, 2007), for instance. In this paper, we take a bankruptcy solution as the reference point. Given this initial allocation, we make transfers from richer to poorer with the purpose of distributing not only the personal incurred losses as evenly as possible but also the transfers in a progressive way. The agents are divided into two groups depending on their personal monetary value (wealth, net-income, GDP or any other characteristic). Then, we impose a set of Axioms that bound the maximal transfer that each net-contributor can make and each net-receiver can obtain. Finally, we define a value discriminant solution, and we characterize it by means of the Lorenz criterion. Endogenous convex combinations between solutions are also considered. Keywords: Bankruptcy, Discrimination, Compensation, Rules JEL classification: C71, D63, D71.

Infornut® Process; improves accessibility to diagnosis and nutritional support for the malnourished hospitalized patient; impact on management indicators; two-year assessment.

Introduction: The high prevalence of disease-related hospital malnutrition justifies the need for screening tools and early detection in patients at risk for malnutrition, followed by an assessment targeted towards diagnosis and treatment. At the same time there is clear undercoding of malnutrition diagnoses and the procedures to correct it Objectives: To describe the INFORNUT program/ process and its development as an information system. To quantify performance in its different phases. To cite other tools used as a coding source. To calculate the coding rates for malnutrition diagnoses and related procedures. To show the relationship to Mean Stay, Mortality Rate and Urgent Readmission; as well as to quantify its impact on the hospital Complexity Index and its effect on the justification of Hospitalization Costs. Material and methods: The INFORNUT® process is based on an automated screening program of systematic detection and early identification of malnourished patients on hospital admission, as well as their assessment, diagnoses, documentation and reporting. Of total readmissions with stays longer than three days incurred in 2008 and 2010, we recorded patients who underwent analytical screening with an alert for a medium or high risk of malnutrition, as well as the subgroup of patients in whom we were able to administer the complete INFORNUT® process, generating a report for each.

Effect of immune pressure on hepatitis C virus evolution: insights from a single-source outbreak.

The host's immune response to hepatitis C virus (HCV) can result in the selection of characteristic mutations (adaptations) that enable the virus to escape this response. The ability of the virus to mutate at these sites is dependent on the incoming virus, the fitness cost incurred by the mutation, and the benefit to the virus in escaping the response. Studies examining viral adaptation in chronic HCV infection have shown that these characteristic immune escape mutations can be observed at the population level as human leukocyte antigen (HLA)-specific viral polymorphisms. We examined 63 individuals with chronic HCV infection who were infected from a single HCV genotype 1b source. Our aim was to determine the extent to which the host's immune pressure affects HCV diversity and the ways in which the sequence of the incoming virus, including preexisting escape mutations, can influence subsequent mutations in recipients and infection outcomes. Conclusion: HCV sequences from these individuals revealed 29 significant associations between specific HLA types within the new hosts and variations within their viruses, which likely represent new viral adaptations. These associations did not overlap with previously reported adaptations for genotypes 1a and 3a and possibly reflected a combination of constraint due to the incoming virus and genetic distance between the strains. However, these sites accounted for only a portion of the sites in which viral diversity was observed in the new hosts. Furthermore, preexisting viral adaptations in the incoming (source) virus likely influenced the outcomes in the new hosts.

Shoulder strength imbalances as injury risk in handball.

This study was conducted to analyze whether internal (IR) and external (ER) rotator shoulder muscles weakness and/or imbalance collected through a preseason assessment could be predictors of subsequent shoulder injury during a season in handball players. In preseason, 16 female elite handball players (HPG) and 14 healthy female nonathletes (CG) underwent isokinetic IR and ER strength test with use of a Con-Trex® dynamometer in a seated position with 45° shoulder abduction in scapular plane, at 60, 120 and 240°/s in concentric and at 60°/s in eccentric, for both sides. An imbalanced muscular strength profile was determined using -statistically selected cut-offs from CG values. For HPG, all newly incurred shoulder injuries were reported during the season. There were significant differences between HPG and CG only for dominant eccentric IR strength, ER/IR ratio at 240°/s and for IRecc/ERcon ratio. In HPG, IR and ER strength was higher, and ER/IR ratios lower for dominant than for nondominant side. The relative risk was 2.57 (95%CI: 1.60-3.54; P<0.05) if handball players had an imbalanced muscular strength profile. In youth female handball players IR and ER muscle strength increases on the dominant side without ER/IR imbalances; and higher injury risk was associated with imbalanced muscular strength profile.

Importância da Gestão de Créditos na gestão da Tesouraria das Empresas

A gestão de Crédito é um tema que vem chamando a atenção dos administradores, já que é considerado um instrumento de gestão muito importante no processo competitivo e para o equilíbrio das empresas. O estudo em causa tem como objectivo principal analisar a importância e os impactos da Gestão de Crédito na Tesouraria das empresas, através de um estudo de caso da empresa Electra, SA. Os resultados do estudo mostram que os problemas de tesouraria podem ser de natureza estrutural e conjuntural. A gestão de tesouraria de curto prazo é o mais importante instrumento de gestão financeira que avalia e controla a actividade corrente das empresas, permitindo em tempo oportuno a tomada de decisões, perspectivando uma gestão eficiente, o equilíbrio financeiro e a eficácia organizacional. O tema em estudo pretende realçar a importância que a gestão de créditos tem na gestão da tesouraria de curto prazo, já que este tem como principal função para além da gestão do realizável (créditos), a gestão do disponível, do stock, das dívidas a terceiros a curto prazo. Uma boa gestão de crédito (realizável) permite de uma forma directa ganhos de eficiência a nível da gestão do disponível, na gestão dos stocks e de forma indirecta influencia as decisões a nível da gestão das dívidas a terceiros de curto prazo. Credit management is a subject that has been growing in the administrator’s attention, as it’s considered to be a somewhat important management tool on the competitive process as well as on the company’s balance. The present case study on Electra S.A, aims for the importance and impact analysis of Credit Management on the company’s cashier. The study results demonstrate that the cashier issues can be structure and conjuncture related. The short term cashier management is the most important financial management tool, which assesses and controls the company’s current activity, enabling timely decision making process, foreseeing an efficient management, the financial equilibrium and the organization efficiency. This paper’s main goal is to enhance the credit management importance on the short term cashier management, as the latter’s main goal, apart from the credit management is to administer the availability, the stock and short term third party debts. A good credit management enables a direct efficiency improvement at the availability management level, on the stock management and indirectly influences the decisions taken at the short term third party debt management level.

State of Iowa Public Drinking Water Program 1996 Annual Compliance Report, December 1997

This report contains information about Iowa's public drinking water program for the calendar year 1996. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 1997 Annual Compliance Report, June 1998

This report contains information about Iowa's public drinking water program for the calendar year 1997. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 1998 Annual Compliance Report, June 1999

This report contains information about Iowa's public drinking water program for the calendar year 1998. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 1999 Annual Compliance Report, June 2000

This report contains information about Iowa's public drinking water program for the calendar year 1999. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 2000 Annual Compliance Report, June 2001

This report contains information about Iowa's public drinking water program for the calendar year 2000. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 2001 Annual Compliance Report, September 2002

This report contains information about Iowa's public drinking water program for the calendar year 2001. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 2002 Annual Compliance Report, December 2003

This report contains information about Iowa's public drinking water program for the calendar year 2002. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.

State of Iowa Public Drinking Water Program 2003 Annual Compliance Report, June 2004

This report contains information about Iowa's public drinking water program for the calendar year 2003. Included in the report are descriptions of Iowa's systems, monitoring and reporting requirements of the systems, and violations incurred during the year. This report meets the federal Safe Drinking Water Act's requirement of an annual report on violations of national primary drinking water regulations by public water supply systems in Iowa.