Open Abdomen: The Surgeons’ Challenge

An open abdomen is defined as purposely foregoing fascial closure of the abdomen after the cavity is opened. Management of complex abdominal problems with the open abdomen and temporary abdominal closure techniques has become a common and valuable tool in surgery. Several challenging clinical situations can necessitate leaving the abdominal cavity open after surgery, resulting in an open abdomen. The indications for open abdomen are as follows: Damage control for life-threatening intraabdominal bleeding, severe acute pancreatitis, severe abdominal sepsis, and prevention and treatment of the abdominal compartment syndrome. Damage control surgery is based on a rapid control of bleeding and focuses on reversing physiologic exhaustion in a critically ill or injured patient. In severe abdominal sepsis, the intervention should be abbreviated due to suboptimal local conditions for healing and global susceptibility to spiraling organ failure. Abdominal compartment syndrome (ACS) is commonly encountered and the only solution is decreasing the pressure by decompressive laparotomy. Open abdomen is associated with significant complications, including wound infection, fluid and protein loss, a catabolic state, loss of abdominal wall domain, and development of enteroatmospheric fistula; however, if the indications are clear, it can become a most valuable resource in treating these conditions

Good practice guide for calibrating a hydrophone "in situ" with a non-omnidirectional source at 10 kHz (26-34)

The aim of this paper is to provide the basis for the calibration of a hydrophonePeer ReviewedPostprint (published version

Sustainability assessment of transport infrastructure projects: a review of existing tools and methods

Attempts to integrate sustainability in the decision-making process for transport infrastructure projects continue to gain momentum. A number of tools and methodological frameworks are available — such as rating systems, traditional decision-making techniques, checklists, and different evaluation frameworks and models. While these tools are highly valuable, some practical issues remain unsolved. There is also a need for more standardized tools to appraise the sustainability of transport projects. This paper is a presentation of a review on the current assessment tools of sustainability applied to transport infrastructure projects. The preliminary part of the paper is an explanatory and comparative analysis of the tools and methods in terms of their effectiveness to appraise sustainability. The analysis is a critical evaluation of the current state of the art to identify the limitations of existing approaches, point out new areas of research, and propose a sustainability appraisal agenda for the future

Social and Distributional Effects of Public Transport Fares and Subsidy Policies: Case of Madrid

Despite the widespread implementation of urban transport subsidies in many cities, there are still only a limited evaluation of the equity of these policies and scarce quantitative assessment of their distributional incidence. This research contributes to filling this gap by developing a practical approach to evaluate the impact of fare subsidization on vertical equity. This paper implements a two-step methodology. First, two main indicators were developed to measure the social impact of the travel pass, a highly subsidized fare, to determine the effectiveness of the policy in reaching lower-income citizens. Second, by using the latest disaggregated data from a transportation survey, in Madrid, Spain, a multiple regression model revealed that travel pass usage (TPU) depended mainly on income level and accessibility to public transport. The results show that the accessibility level has a positive effect on the TPU indicator, whereas income level has a negative influence. Because income level is shown to play the most significant role in influencing public transport use, the subsidy policy associated with the travel pass in the city can be considered progressive, since it effectively targets economically disadvantaged groups. This fact suggests that subsidies for public transport in Madrid tend to favor vertical equity

Análisis del servicio de atención al cliente de la corporación nacional de telecomunicaciones EP del cantón Milagro provincia del Guayas.

La importancia del servicio es fundamental para todo empresa, ya que de éste depende que la institución adquiera o disminuya sus clientes, debido a que si se presta una mala atención se generará una mala publicidad por parte de los clientes “mal atendidos”, lo cual ocasionará una mala imagen para la empresa. Pero así mismo, se puede producir el efecto contrario, brindando un buen servicio, los clientes hablarán bien de la empresa y los recomendarán, porque las personas consideran el buen trato y la cordialidad como un valor agregado al producto que van a recibir, esto servirá de ayuda positiva porque nos permite captar nuevos clientes. De acuerdo a la investigación realizada en la Corporación Nacional de Telecomunicaciones EP, respecto al servicio al cliente, llegando a la conclusión que el servicio que presentan no es del todo bueno, debido a que existen bastante quejas, más comúnmente con la telefonía fija, pero aun así los consumidores lo aceptan como bueno, debido que su mayor satisfacción es el precio, lo cuales son los más económicos del mercado, y porque existe otras alternativas válidas que ayuda a que este mal servicio pase desapercibido. Los resultados obtenidos demuestran que el consumidor se refleja satisfecho con un servicio que lo considera regular, pero nuestra pregunta es ¿qué respalda ese razonamiento? y al estudiar los datos nos damos cuenta que una misma necesidad está siendo satisfecha por diferente proveedores en los cuales para la mente del consumidor unos suplen a otros, saltando a los concepto de costo y servicio. Esto se genera por la percepción y los paradigmas de cada cliente hacia el producto o la empresa

Helping decision-makers select the most adequate road infrastructure design from the point of view of sustainability: a practical approach

In recent years, a number of tools have been developed aimed at assessing the socio-economic and environmental feasibility of roadway projects. However, there is still no standardised or commonly accepted methodology to assure the most sustainable design in the appraisal and evaluation of roads over their life-cycle. The introduction of the multidimensional perspectives of sustainability in the appraisal of road projects is still an unresolved aspect. This research identifies strengths and weaknesses of sustainability assessment tools ?including ratings systems, traditional decision-making techniques (e.g. cost benefit analysis, multicriteria decision analysis, among others), checklists and different evaluation frameworks and models for roadways; describes to what extent they integrate sustainability as a whole; and summarizes valuable lessons to learn from them. On the basis of this analysis, it points out a number of methodological issues that need to be addressed before valid road sustainability assessments can be conducted. To response to these issues, this research develops a composite decision support model based on combining cost-benefit analysis (CBA) with multi- criteria decision analysis (MCDA) to accurately appraise sustainability of road projects. This methodology is applied to a case study dealing with the construction of a new roadway in the northwest of Spain. The outcome demonstrates that the approach is a valuable sustainability assessment tool

Procediment per mesurar camps electromagnetics en ambients docents

La tecnologia sense fils LAN (Local Area Network) com es Wi-Fi, es una de les mes utilitzades per donar servei d'acces a Internet en un gran nombre d'escoles arreu del mon, aixo es degut al preu mes barat enfront de tecnologies d'acces per cable. D'altra banda Wi-Fi ofereix flexibilitat i mobilitat als usuaris. D'acord amb l'ultim informe Eurobarometre del 2008, sobre xarxes de comunicacions electroniques i serveis, realitzat per la Direccio General per a la Societat d'Informacio i Mitjans de Comunicacio de la Comissio Europea, un 68% de les llars en Espanya utilitzen un sistema de tecnologia Wi-Fi com acces a Internet. Tot i aixo, comencen a escoltar-se veus denunciant els perills que poden suposar per a la salut les tecnologies sense fils a les escoles. La seva justificacio es que molts cientifics han fet experiments d'exposicio a les radiacions electromagnetiques amb nivells similars o mes baixos que els de la tecnologia Wi-Fi i han trobat implicacions que afecten la salut. Volen que es prohibeixi a les escoles l'acces a Internet amb tecnologia Wi-Fi i s'instal?lin tecnologies d'acces cablades. L'octubre de 2010, el sindicat espanyol CCOO exigia controls periodics sobre radiacions Wi-Fi en les escoles. El 2001, el govern espanyol va transposar en un Reial Decret els nivells d'exposicio a camps electromagnetics recomanats per la Unio Europea. Tot i que fent calculs es pot demostrar que els nivells d'exposicio a les radiofrequencies dels aparells Wi-Fi son menors que els regulats en el Reial Decret, moltes associacions de pares volen que es prenguin mesures de nivells d'exposicio en les escoles on estudien els seus fills. La noticia, en maig de 2011, de l'Agencia Internacional per a la Recerca del Cancer (IARC), agencia de l'Organitzacio Mundial de la Salut (OMS), que ha classificat els Camps Electromagnetics de Radiofrequencia en el grup 2B, com a possible carcinogen per als humans, ha fet incrementar la preocupacio dels familiars dels alumnes. La realitzacio d'aquest treball es justifica per una banda en la necessitat de prendre mesures de nivells d'exposicio per intentar tranquil?litzar a les families dels alumnes, d'altra banda en el fet que els nivells d'intensitat de camp electric amidats, poden tenir molta dispersio a causa del procediment de mesura utilitzat, de la propia tecnologia sense fils i de l'equipament utilitzat per prendre les mesures de nivells d'exposicio. Els objectius d'aquest treball son: ? Dissenyar un procediment de mesura que pugui servir com a instruccio tecnica per a la presa d'aquestes en ambients docents, intentant que la dispersio en els nivells d'exposicio no sigui massa elevada. Al mateix temps que fer una guia didactica per a persones sense coneixements tecnics. ? Prendre les mesures d'exposicio d'acord amb la normativa vigent actualment. La base del procediment de mesura esta en concordanca amb la legislacio espanyola, fent algunes modificacions per adaptar-la a la tecnologia Wi-Fi. Per tal de comprovar el procediment de mesura, s'han pres mesures reals en una escola, aconseguint uns resultats acceptables. Les conclusions mes destacables que es poden extreure son: 1. Els nivells d'exposicio provocats pels sistemes de telecomunicacio amb tecnologia Wi-Fi, compleixen els valors de referencia de la legislacio actual. 2. Els nivells mes alts d'exposicio a les aules, son provocats pels ordinadors portatils dels alumnes. 3. La dispersio maxima dels valors amidats valids, amitjanats en un periode de 6 minuts, es de 8,3 dB

Seeking factors to increase the public’s acceptability of road-pricing schemes: case study of Spain

User acceptability has become a critical issue for the successful implementation of transport pricing measures and policies. Although several studies have addressed the public acceptability of road pricing, little evidence can be found of the effects of pricing strategies. The acceptability of alternative schemes for a toll network already in operation is an issue to be tackled. This paper contributes to the limited literature in this field by exploring perceptions toward road-pricing schemes among toll road users. On the basis of a nationwide survey of toll road users in Spain, the study developed several binomial logit models to analyze user acceptability of three approaches: express toll lanes, a time-based pricing approach, and a flat fee (vignette) system. The results show notable differences in user acceptability by the type of charging scheme proposed. Express toll lanes were more acceptable by travelers who perceived greater benefits from saving travel time. The acceptability of time-based approaches (peak versus off-peak) decreased for users who felt forced to use the toll road, whereas this was not an aspect that significantly influenced users’ support for flat fee schemes. In addition, a flat fee strategy was more acceptable for long-distance trips and truck drivers who regularly used the toll facilities. The results from this analysis can inform policy makers and planners for the promotion of more efficient, socially inclusive, and publicly acceptable road-pricing schemes

Manejo de la lesión de la vena hepática media durante la colecistectomía laparoscópica: reporte de un caso

Antecedentes La colecistectomía continúa siendo la primera opción para el tratamiento de la colelitiasis sintomática. Especialmente en pacientes con colecistitis aguda, un enfoque laparoscópico se ha convertido en la opción de tratamiento estándar. Las complicaciones intraoperatorias de la colecistectomía laparoscópica incluyen: lesión del conducto biliar, daño a los órganos y sangrado debido a una lesión vascular. La hemorragia difícil durante la colecistectomía laparoscópica ocurre en 0.1 a 1.9% de todos los casos. Además de las lesiones importantes de los vasos, la vasculatura del lecho de la vesícula biliar se informa como un sitio de lesión común, principalmente secundaria a lesiones de vena hepática media. Presentación del caso Presentamos un informe del caso de un paciente tomado para una colecistectomía laparoscópica. Durante el procedimiento, se produce una lesión involuntaria de la vena hepática media. Aquí describimos el enfoque de manejo seleccionado para este tipo de lesión. Discusión Recomendamos una disección cuidadosa durante los pasos finales de una colecistectomía laparoscópica. Después del conducto quístico y la ligadura de la arteria quística, los cirujanos a menudo se relajan de manera inapropiada durante la última parte de la disección. Durante esta disección final, si no se tiene cuidado, pueden perderse y lesionarse pequeñas estructuras vasculares.Background Cholecystectomy continues to be the first choice for the treatment of symptomatic cholelithiasis. Especially in patients with acute cholecystitis, a laparoscopic approach has become the standard treatment option. Intraoperative complications of laparoscopic cholecystectomy include: bile duct injury, organ damage, and bleeding due to vascular injury. Difficult hemorrhage during laparoscopic cholecystectomy occurs in 0.1 to 1.9% of all cases. Besides major vessel injuries, gallbladder bed vasculature is reported as a common injury site, mostly secondary to middle hepatic vein lesions. Case Presentation We present a case report of a patient taken for a laparoscopic cholecystectomy. During the procedure, inadvertent middle hepatic vein injury occurs. Here we describe the management approach selected for this type of injury. Discussion We recommend careful dissection during the final steps of a laparoscopic cholecystectomy. Following cystic duct and cystic artery ligation, surgeons often inappropriately relax through the last part of the dissection. During this final dissection, if care is not taken, small vascular structures can be missed and injured