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.

The Brauer group and the second Abel-Jacobi map for 0-cycles on algebraic varieties

This paper focuses on the connection between the Brauer group and the 0-cycles of an algebraic variety. We give an alternative construction of the second l-adic Abel-Jacobi map for such cycles, linked to the algebraic geometry of Severi-Brauer varieties on X. This allows us then to relate this Abel-Jacobi map to the standard pairing between 0-cycles and Brauer groups (see [M], [L]), completing results from [M] in this direction. Second, for surfaces, it allows us to present this map according to the more geometrical approach devised by M. Green in the framework of (arithmetic) mixed Hodge structures (see [G]). Needless to say, this paper owes much to the work of U. Jannsen and, especially, to his recently published older letter [J4] to B. Gross.

Brain Tissue Hypoxia is a Strong Predictor of Outcome after Severe Traumatic Brain Injury Independent from Elevated Intracranial Pressure

Introduction: Low brain tissue oxygen pressure (PbtO2) is associated with worse outcome in patients with severe traumatic brain injury (TBI). However, it is unclear whether brain tissue hypoxia is merely a marker of injury severity or a predictor of prognosis, independent from intracranial pressure (ICP) and injury severity. Hypothesis: We hypothesized that brain tissue hypoxia was an independent predictor of outcome in patients wih severe TBI, irrespective of elevated ICP and of the severity of cerebral and systemic injury. Methods: This observational study was conducted at the Neurological ICU, Hospital of the University of Pennsylvania, an academic level I trauma center. Patients admitted with severe TBI who had PbtO2 and ICP monitoring were included in the study. PbtO2, ICP, mean arterial pressure (MAP) and cerebral perfusion pressure (CPP = MAP-ICP) were monitored continuously and recorded prospectively every 30 min. Using linear interpolation, duration and cumulative dose (area under the curve, AUC) of brain tissue hypoxia (PbtO2 < 15 mm Hg), elevated ICP >20 mm Hg and low CPP <60 mm Hg were calculated, and the association with outcome at hospital discharge, dichotomized as good (Glasgow Outcome Score [GOS] 4-5) vs. poor (GOS 1-3), was analyzed. Results: A total of 103 consecutive patients, monitored for an average of 5 days, was studied. Brain tissue hypoxia was observed in 66 (64%) patients despite ICP was < 20 mm Hg and CPP > 60 mm Hg (72 +/- 39% and 49 +/- 41% of brain hypoxic time, respectively). Compared with patients with good outcome, those with poor outcome had a longer duration of brain hypoxia (1.7 +/- 3.7 vs. 8.3 +/- 15.9 hrs, P<0.01), as well as a longer duration (11.5 +/- 16.5 vs. 21.6 +/- 29.6 hrs, P=0.03) and a greater cumulative dose (56 +/- 93 vs. 143 +/- 218 mm Hg*hrs, P<0.01) of elevated ICP. By multivariable logistic regression, admission Glasgow Coma Scale (OR, 0.83, 95% CI: 0.70-0.99, P=0.04), Marshall CT score (OR 2.42, 95% CI: 1.42-4.11, P<0.01), APACHE II (OR 1.20, 95% CI: 1.03-1.43, P=0.03), and the duration of brain tissue hypoxia (OR 1.13; 95% CI: 1.01-1.27; P=0.04) were all significantly associated with poor outcome. No independent association was found between the AUC for elevated ICP and outcome (OR 1.01, 95% CI 0.97-1.02, P=0.11) in our prospective cohort. Conclusions: In patients with severe TBI, brain tissue hypoxia is frequent, despite normal ICP and CPP, and is associated with poor outcome, independent of intracranial hypertension and the severity of cerebral and systemic injury. Our findings indicate that PbtO2 is a strong physiologic prognostic marker after TBI. Further study is warranted to examine whether PbtO2-directed therapy improves outcome in severely head-injured patients .

State of Iowa Transportation Map, 1952

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1953

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1954

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1955

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1956

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1957

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1958

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1959

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1960

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1961

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1962

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.

State of Iowa Transportation Map, 1963

This document is the State Map of Iowa, both front and back of the year in the title. All maps were are in pdf format and can be used as a historical reference.