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

Using Cost Observation to Regulate Bureaucratic Firms

We study regulation of a bureaucratic provider of a public good in the presence of moral hazard and adverse selection. By bureaucratic we mean that it values output in itself, and not only profit. Three different financing systems are studied - cost reimbursement, prospective payment, and the optimal contract. In all cases, the output level increases with the bureaucratic bias. We find that the optimal contract is linear in cost (fixed payment plus partial cost-reimbursement). A stronger preference for high output reduces the tendency of the firm to announce a high cost (adverse selection), allowing a more powered incentive scheme (a lower fraction of the costs is reimbursed), which alleviates the problem of moral hazard.Procurement, Regulation, Adverse selection, Moral hazard, Bureaucracy

Are Covered Bonds Different from Asset Securitization Bonds?

This is the first study comparing the financial characteristics and pricing processes of asset securitization (AS) and covered bonds (CB) . Using a sample of 6,191 AS bonds and 1 1,471 CB issued by Western European banks between January 1, 2000 and October 31, 2012, we find that AS and CB are not priced in integrated bond markets. Our results show that credit spreads are higher for ABS than for public CB in both pre - and crisis periods. Considering bonds backed by mortgages, w e only find evidence of CB credit spread s being lower than those of AS bonds during the pre - crisis period. Both AS and CB credit spreads are driven by collateral type , credit rating is the most important pricing factor for AS bonds, and we document that not only specific effects related to issuance , but also macro factors and exogenous events are relevant drivers for CB credit spreads. Further more, while the first CB purchase programme led to lower mortgage CB credit spreads, the second programme did not have the ECB ’s desired effects . Finally, we find that the ECB’s second programme reduces ABS spreads significantly for tranches issued by non - German banks.info:eu-repo/semantics/publishedVersio

Regulating a monopolist with unknown bureaucratic tendencies

We determine the optimal contract for the regulation of a bureaucratic firm in the case in which the bureaucratic bias is firm's private information. We find that output is distorted upward when the bureaucratic bias is low, downward when it is high, and equals a reference output when it is intermediate (in this case, the participation constraint is binding). We also determine an endogenous reference output (equal to the expected output, which depends on the reference output), and find that the response of output to cost is null in the short-run (in which the reference output is fixed) whenever the managers' types are in the intermediate range and negative in the long-run (after the adjustment of the reference output to equal expected output).Procurement, Regulation, Adverse selection, Bureaucracy, Reservation utility

Five really easy steps to build a homemade low-cost simulator

Published online march 2012Aim. The aim of this study was to evaluate how simple it is to build a homemade low-cost simulator using a simple 5-step scheme. Methods. A scheme explaining how to build an endoscopic surgery simulator in 5 easy steps was presented to 26 surgeons. The simulator required a pair of scissors and easy-to-find materials. Its total cost was less than €35. The participants assessed the simulator using common endoscopic training toys or ex vivo tissue and completed an anonymous query comparing it with other commercial simulators that they had experienced before. Results. In all, 84.6% found the simulator really easy to build. Every participant felt that he or she could do the same simulator themselves. Comparing with other commercial available box simulators, the majority of participants found the homemade simulator easier to (a) mount and dismount, (b) transport, (c) clean, and (d) use when practicing alone. Conclusions. Anyone can build its own simulator for a small amount of money.The author(s) received no financial support for the research, authorship, and/or publication of this article

Natural Orifice Transesophageal Endoscopic Surgery: State of the Art

The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome

Automatic pre-bended customized prosthesis for pectus excavatum minimal invasive surgery correction

Pectus excavatum is the most common deformity of the thorax. A minimally invasive surgical correction is commonly carried out to remodel the anterior chest wall, by employing an intrathoracic convex prosthesis in substernal position. The process of prosthesis modeling and bending still remains an area of improvement. The authors developed a new system, i3DExcavatum, which can automatically model and bend the bar preoperatively based on a thoracic CT-scan. This paper presents a comparison between automatic and manual bending. The i3DExcavatum was used to personalize prosthesis for 41 patients who underwent pectus excavatum surgical correction between 2007 and 2012. Regarding the anatomic variations, the soft tissue thicknesses external to the ribs show that symmetric or asymmetric patients have always asymmetric variations by comparing both patients’ sides. It highlighted that the prosthesis bar should be modeled according to each patient ribs position and dimension. The average differences between the skin and costal line curvature lengths were 84±4 mm and 96±11mm, for male and female patients, respectively. On the other hand, the i3DExcavatum ensured a smooth curvature of the surgical prosthesis and was capable to predict and simulate a virtual shape and size of the bar for asymmetric or symmetric patients. In conclusion, the i3DExcavatum allows preoperative personalization according to the thoracic morphology of each patient. It reduces surgery time and minimizes the margin error induced by the manual bended bar shape that only uses a template that copies the chest wall curvature

The Portuguese Montado as a High Nature Farming System: an Interdisciplinary Methodology Linking Grazing Management to Biodiversity Value

The Portuguese montado, an agro-silvo pastoral system derived from the Mediterranean forest ecosystems, is broadly considered a High Nature Value Farming System (HNV). These semi-natural systems significantly depend on the agricultural management. Consequently, its natural value and environmental qualities are closely related to the different farming practices adopted by land managers. Within these, grazing has a particular relevance since extensive livestock production is currently one of the most important economic activities associated with these systems, presenting a pronounced variability, both in terms of intensity and variety of animal species and breeds. In the region of Alentejo, Southern Portugal, there are several types of montado in different natural conditions (soils, climate, and topography) and managed, currently and over time, in very distinct ways. The high variability underlying these systems, both in biophysical and management contexts, can result in an impact of completely different levels on the sustainability of the system and consequently, on its natural values. Using birds as models for assessing the levels of biodiversity and starting from the research question: How to differentiate between a montado with and without HNV? In this paper we intend to present an innovative interdisciplinary methodology built up to assess the relationship between grazing management and biodiversity values, in a case study - a specific type of montado. Considering the complexity and fuzziness of these Mediterranean systems, defining a grazing management compatible with the existence of a high biodiversity value, poses a great challenge which requires the integration of different scientific perspectives and cross disciplines. However, the greatest difficulty in implementing this new approach probably lies in adopting the methodologies arising from these distinct fields of knowledge in a coherent manner

Portugal e Arquitetura de Segurança da África Austral e a Globalização da Guerra Fria (1949-1975)

Esta investigação em Relações Internacionais (RI), na vertente de Estudos de Segurança e Estratégia, analisa o resultado de uma dialética de vontades, materializada pela resistência portuguesa à descolonização na África Austral, entre 1949 e 1975, à qual se opôs, em reação, um conjunto crescente de atores, estatais e não-estatais, e com influência regional ou global. Do confronto, com Portugal ao centro, resultou uma arquitetura de segurança sistémica e de geometria variável, que “arrastou” a Guerra Fria para o espaço austral, globalizando-a. Para o efeito, fazendo uso de uma estratégia qualitativa e de um raciocínio dedutivo, ancorado nos conceitos de estratégia, arquitetura de segurança e Guerra Fria, analisam-se três subperíodos. Um primeiro (1949-1960), designado de “mobilização”, no qual Portugal procurou capacitar, holisticamente, os seus instrumentos de poder. Um segundo (1961-1969), intitulado de “confronto”, moldado pela guerra em dois (Angola e Moçambique) dos três teatros de operações e que atraiu um amplo leque de atores, que, direta e indiretamente, uniram os níveis estatal, regional e global, lançando as bases para uma aliança defensiva entre Portugal, a África do Sul e a Rodésia. O terceiro subperíodo (1970-1975), denominado de “queda e consequências”, dá corpo aos efeitos sistémicos de uma oposição de vontades, prolongada no tempo e internacionalizada, conduzindo à formalização do Exercício ALCORA. A lassidão da resistência precipitou a queda do regime, reconfigurando uma arquitetura securitária que expôs as “amarras” regionais e da Guerra Fria. Portugal moldou, assim, a Guerra Fria, sendo, desde o início, uma extensão ocidental em África e um “elemento deixando em contacto”, no esforço secundário do conflito entre blocos. Da investigação resultam 14 contributos para o conhecimento, no campo teórico e de aplicação. Ao nível teórico, destaca-se a abordagem às RI através da guerra, em desalinhamento com o mainstream. No campo de aplicação, sublinha-se a criação do Modelo de Arquitetura de Segurança @plicado à África Austral Portuguesa (MAS@AAP). A guerra do Ultramar foi muito mais do que uma guerra em África. Foi uma parte da Guerra Fria.This research in International Relations (IR), in the field of Security Studies and Strategy, analyzes the result of a dialectic of wills, materialized by the Portuguese resistance to decolonization in Southern Africa, between 1949 and 1975, to which a growing set of actors, state and non-state, and with regional or global influence were opposed in reaction. From the confrontation, centered in Portugal, has resulted an architecture of systemic security and variable geometry, which “dragged” the Cold War into Southern Africa, globalizing it. For this purpose, making use of a qualitative strategy and deductive approach, anchored in the concepts of strategy, security architecture and the Cold War, three sub-periods are analyzed. The first (1949-196), called “mobilization”, in which Portugal sought to, holistically, prepare and adapt its instruments of power. A second (1961-1969), entitled “confrontation”, shaped by the war in two of the three theaters of operations (Angola and Mozambique) and which attracted a wide range of actors who directly and indirectly linked state, regional, and global levels, laying the foundations for a defensive alliance between Portugal, South Africa and Rhodesia. The third subperiod (1970-1975), called “fall and consequences”, embodies the systemic effects of an opposition of wills, prolonged in time and internationalized, leading to the formalization of the ALCORA Exercise. Lassitude precipitated the fall of the regime, reconfiguring a security architecture that, due to Angola, exposed the regional and Cold War “ties”. Thus, Portugal shaped the Cold War, being, since the beginning, a western extension in Africa and an “element left in contact”, in the secondary effort of the conflict between blocks. The research resulted in 14 contributions to knowledge in the theoretical and also the application field. At the theoretical level, one highlights the creation of the Model of Security Architecture @applied to Portuguese Southern Africa (MAS@AAP) and the approach to IR through war, in misalignment with the mainstream. In the field of application, it is stressed that Colonial War was much more than a war. It was part of the Cold War