“Aspetti generali e disciplina applicabile dal 1 gennaio 2015. I profili fiscali del commercio elettronico diretto e indiretto”

Il fenomeno dell'e-commerce è ormai massimamente diffuso ragion per cui richiede particolari riflessioni sugli aspetti fiscali che ne caratterizzano l'applicazione e l'inquadramento nel sistema sistema ordinamentale tributario del nostro Paese. In particolare l'interesse ricade sulla disciplina applicabile dal primo gennaio 2015

Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis

BACKGROUND: The authors studied the effects of the beach chair (BC) position, 10 cm H2O positive end-expiratory pressure (PEEP), and pneumoperitoneum on respiratory function in morbidly obese patients undergoing laparoscopic gastric banding. METHODS: The authors studied 20 patients (body mass index 42 +/- 5 kg/m2) during the supine and BC positions, before and after pneumoperitoneum was instituted (13.6 +/- 1.2 mmHg). PEEP was applied during each combination of position and pneumoperitoneum. The authors measured elastance (E,rs) of the respiratory system, end-expiratory lung volume (helium technique), and arterial oxygen tension. Pressure-volume curves were also taken (occlusion technique). Patients were paralyzed during total intravenous anesthesia. Tidal volume (10.5 +/- 1 ml/kg ideal body weight) and respiratory rate (11 +/- 1 breaths/min) were kept constant throughout. RESULTS: In the supine position, respiratory function was abnormal: E,rs was 21.71 +/- 5.26 cm H2O/l, and end-expiratory lung volume was 0.46 +/- 0.1 l. Both the BC position and PEEP improved E,rs (P < 0.01). End-expiratory lung volume almost doubled (0.83 +/- 0.3 and 0.85 +/- 0.3 l, BC and PEEP, respectively; P < 0.01 vs. supine zero end-expiratory pressure), with no evidence of lung recruitment (0.04 +/- 0.1 l in the supine and 0.07 +/- 0.2 in the BC position). PEEP was associated with higher airway pressures than the BC position (22.1 +/- 2.01 vs. 13.8 +/- 1.8 cm H2O; P < 0.01). Pneumoperitoneum further worsened E,rs (31.59 +/- 6.73; P < 0.01) and end-expiratory lung volume (0.35 +/- 0.1 l; P < 0.01). Changes of lung volume correlated with changes of oxygenation (linear regression, R2 = 0.524, P < 0.001) so that during pneumoperitoneum, only the combination of the BC position and PEEP improved oxygenation. CONCLUSIONS: The BC position and PEEP counteracted the major derangements of respiratory function produced by anesthesia and paralysis. During pneumoperitoneum, only the combination of the two maneuvers improved oxygenatio

Preoperative changes of forced vital capacity due to body position do not correlate with postoperative respiratory function in obese subjects

Background: Obese patients are at risk of developing postoperative pulmonary complications. We hypothesized that preoperative changes in dynamic spirometry due to body posture would correlate with the drop of forced vital capacity (FVC) measured early after surgery. Methods: 30 consecutive morbidly obese patients undergoing gastric banding were investigated. All subjects were studied the day before surgery (T0) and on postoperative day one (T1). Forced Vital Capacity (FVC) was measured, together with heart rate, mean arterial pressure and respiratory rate. At T0 measurements were taken in a random fashion with subjects in upright and in supine position. Subjects were then investigated after surgery in the supine position (T1). Postoperative pain was assessed at T1 using visual analogue scale. Intraoperative variables were also collected. Results: Body Mass Index (BMI) of the investigated subjects was 43.9 \ub1 5.7 Kg/m2 (range 33.8 - 60); their age was 40 \ub1 8 years. All dynamic spirometric data decreased significantly from upright to supine position (P < 0.05) and after surgery from 3.07 L (2.77 - 3.71) to 1.50 (1.15 - 2.12) (FVC T0 supine vs. T1, P < 0.05). Changes of FVC due to body position did not correlate with changes of FVC occurring after surgery (R2 = 0.105, P = 0.081). When subjects were stratified by the median postoperative drop of FVC (45.74%), preoperative (anthropometric and spirometric data), intraoperative (ventilatory settings and hemodynamics) and postoperative (FVC and pain) parameters were similar between groups. The duration of pneumoperitoneum was correlated with the drop of FVC (R2 = 0.551, P < 0.05). Conclusions: The derangement of FVC that occurs in obese subjects after gastric banding is not predictable before surgery from anthropometric or spirometric data. The duration of pneumoperitoneum significantly contributes to postoperative impairment of respiratory functio

Forschungs- und Entwicklungsarbeiten zu einer einzelkationenspezifischen Membran zur Wiedergewinnung von Rohstoffen durch Elektrodialyse Schlussbericht. Abschlussdatum: September 1983

TIB: RN 2598 (84-163)+a / FIZ - Fachinformationszzentrum Karlsruhe / TIB - Technische InformationsbibliothekSIGLEDEGerman