The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitisA and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitisB in perforated diverticulitis (NTR2037)

Background: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy. The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). Methods/Design: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and powe

Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation

As inadequações do sistema tradicional de custos em um novo ambiente de fabricação

Este trabalho apresenta os principais problemas relativos à ampla utilização de Sistemas de Custos tradicionais em um ambiente de produção que se caracteriza pela inovação na adoção de novas tecnologias, tanto em nível geral como TQC. JIT, CIM - quanto em uiveis específicos - tais como CAD, CAE. CAPP. MRP. MRPII, SPC. CNC. Robótica e FMS. Demonstra-se, portanto, a necessidade de Sistemas de Custos que atendam adequadamente suas funções, com participação efetiva na busca pela excelência gerencial das empresas.<br>This work presents the main problems related to the use of traditional cost systems in a production environment that distinguish itself by the adoption of new technologies such as TOC. JIT. CIM. as well as CAD. CAE. MRP. MRPII. SPC. CNC. Raboncs and FMS, in especific terms. It is also demonstrated the need of adequaling cost systems to its functions. In this way. this updated Cost System supplies an effective contribution to the search for the company's management excellence

Leitura recombinativa de pseudopalavras impressas em pseudoalfabeto: similaridade entre palavras e extensão da unidade ensinada

Controle discriminativo por elementos textuais é requisito para a leitura de palavras novas (leitura recombinativa). Este estudo empregou pseudopalavras ditadas e impressas em pseudo-alfabeto para avaliar os efeitos da similaridade entre palavras e da extensão da unidade textual ensinada sobre o desenvolvimento de leitura recombinativa. No Experimento 1 universitários aprenderam relações condicionais entre pseudopalavras ditadas e impressas que diferiam das incorretas em 25% ou 75% dos elementos. No Experimento 2 outros universitários aprenderam a relacionar letras ou sílabas ditadas às correspondentes modalidades impressas e subsequentemente aprenderam relações envolvendo pseudopalavras. A aquisição das discriminações foi mais rápida na Condição Diferença 75%; a leitura recombinativa dependeu da quantidade de palavras ensinadas (Exp.1). A leitura foi mais precisa após a aprendizagem de sílabas, mas ocorreu mais recombinação após a aprendizagem de letras (Exp. 2). Combinar o ensino de palavras dissimilares e de unidades menores que a palavra pode acelerar a leitura recombinativa.Discriminative control by textual elements is a requisite for reading new words (recombinative reading). This study used pseudowords printed with pseudo-alphabet to evaluate the effects of the similarity between words and the size of teaching units on the development of recombinative reading. In Exp. 1, undergraduate students learned conditional relations between spoken and printed pseudowords which differed from incorrect words in 25% and 75% of the elements. In Exp. 2, undergraduate students learned to relate spoken letters or syllables to the corresponding printed units and afterwards they learned the conditional relations with pseudowords. The acquisition of discriminations was faster during the Condition 75%; recombinative reading was related to the amount of trained words (Exp. 1). Reading accuracy was higher after learning syllables, but more recombinative reading occurred after learning letters (Exp. 2). The teaching that combines dissimilar words and units smaller than words may accelerate recombinative reading.La discrimination des textuels est essentielle pour la lecture de nouveaux mots (lecture recombinant). Cette étude a employé des pseudomots dictés et imprimés avec un pseudo-alphabet pour étudier les effets de la similitude entre les mots et de lextension de lunité textuelle enseignée sur le développement de la lecture recombinant. Dans lExp. 1, universitaires ont appris des relations conditionnelles entre pseudomots dictés et imprimés qui ont différé des mots incorrects dans 25% et 75% des éléments. Dans l´Exp. 2, dautres universitaires ont appris a relation des lettres ou des syllabes dictées à correspondantes imprimées et après ils ont appris les relations avec les pseudo-mots. Lacquisition des discriminations était plus rapide à Condition Différence 75%; la lecture recombinante a été liée à la quantité de mots enseignés (Exp. 1). La lecture a montré plus dexactitude juste après lapprentissage des relations avec des syllabes, mais la lecture recombinante a été favorisée par lapprentissage des lettres. Combiner lenseignement des mots plus différents et des unités denseignement petites peut accélérer la lecture recombinante.El control discriminatorio por elementos textuales es necesario para que se lea nuevas palabras (lectura con recombinación). Ese estudio utilizó pseudopalabras impresas en pseudo-alfabeto para investigar los efectos de la semejanza entre palabras y del tamaño de la unidad textual enseñada sobre el desarrollo de la lectura con recombinación. En el Exp. 1 universitarios aprendieron relaciones condicionales entre pseudopalabras dictadas e impresas que se diferenciaban de las palabras incorrectas en 25% y 75% de los elementos. En el Exp. 2, otros estudiantes aprendieron a relacionar letras o sílabas dictadas con sus correspondientes unidades impresas y después aprendieron las relaciones involucrando las pseudopalabras. Adquisición de las discriminaciones fue más rápida en la Condición Diferencia 75%; la lectura con recombinación estuvo relacionada con la cantidad de palabras entrenadas (Exp.1). Exp. 2 demostró mayor precisión de lectura después de la aprendizaje de silabas, pero la lectura con recombinación fue favorecida por la aprendizaje de letras. Conciliar la enseñanza de palabras disímiles y de unidades más pequeñas que palabras puede acelerarse la lectura con recombinación