Manual para el mantenimiento de puentes en Costa Rica

Proyecto Final de Graduación (Licenciatura en Ingeniería en Construcción) Instituto Tecnológico de Costa Rica, Escuela de Ingeniería en Construcción, 2019.El presente proyecto consiste en proponer un manual para el mantenimiento de los puentes en Costa Rica, considerando los daños más comunes identificados en el inventario nacional de puentes. Para la realización de este proyecto, se recopiló información acerca de los componentes de un puente, se investigó la gestión actual de los puentes en Costa Rica y se dio a conocer cómo está compuesto el inventario nacional de puentes. Además, se investigó cómo debe estar estructurado un programa de conservación de puentes y los beneficios que traería para el país. El segundo objetivo consistió en determinar los daños más comunes presentes en el inventario nacional de puentes. Para lograrlo, se extrajeron los 83 daños presentes en el Manual de Inspección de Puentes, se compararon y se encontró que diferentes elementos pueden tener los mismos daños, de esta forma, se hallaron 43 daños diferentes. El Programa de Evaluación de Estructuras de Puentes (PEEP) del TEC ha llevado a cabo inspecciones visuales del 100 % de los puentes en rutas nacionales (1669 puentes, los cuales conforman el inventario). Gracias a esta información, se logró determinar la repetitividad de los 43 daños y se tabularon los 16 más comunes. Además, se realizaron gráficos para analizar la condición de los elementos de los puentes. El tercer objetivo consistió en investigar las posibles causas y consecuencias que generan los 16 daños típicos en los puentes de Costa Rica. El cuarto objetivo se basó en proponer procedimientos de mantenimiento rutinario y periódico para los 16 daños más comunes. De esta manera, se desarrolló el Manual para el Mantenimiento de Puentes. Se espera que este manual sea de gran utilidad para que los ingenieros encargados del mantenimiento de puentes puedan ejecutar los procedimientos de la mejor manera, siguiendo buenas prácticas de ingeniería.The present project consists of a bridge maintenance manual proposal, considering the most common damages identified in the Costa Rican bridge inventory. First, information was gathered about bridge components, the current bridge management in Costa Rica was investigated and the national bridge inventory was made known. Also, the structure of a bridge conservation program and its benefits to the country were investigated. The second objective consisted in determining the most common damages of the national bridge inventory. To achieve it, the 83 damages of the Bridge Inspection Manual were extracted, compared and it was found that different bridge elements can have the same damages. So it was discovered that there are only 43 different damages. The Bridge Structures Evaluation Program (PEEP) from TEC, has carried out visual inspections of 1669 bridges on national routes, that represents 100% of the bridges from the national inventory. Thanks to this information, it was possible to determine the repetitiveness of the 43 damages, so the most common 16 were tabulated. In addition, graphs were made to analyze the condition of bridge elements. The aim of the third objective was to investigate the possible causes and consequences generated by the 16 typical damages on the Costa Rican bridges. The fourth objective was based on proposing routine and periodic maintenance procedures for the 16 most common damages. In this way, the Manual for the Maintenance of Bridges was developed. It is expected that this manual will be very useful for engineers in charge of bridge maintenance activities, so that they can execute maintenance procedures in the best way possible, following good engineering practices

Correlation of postoperative fluid balance and weight and their impact on outcomes.

Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes. All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0-3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression. One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0-1-2-3 was 1850 (IQR 1020-2540) mL, 2890 (IQR 1610-4000) mL, 3890 (IQR 2570-5380) mL, and 4000 (IQR 1890-5760) mL respectively, and median weight gain was 2.2 (IQR 0.3-4.3) kg, 3 (1.5-4.7) kg, and 3.9 (2.5-5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01-8.9, p = 0.049). Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications

Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.

OBJECTIVE: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. BACKGROUND: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. METHODS: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. RESULTS: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. CONCLUSIONS: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery

The "Real R0": A Resection Margin Smaller Than 0.1 cm is Associated with a Poor Prognosis After Oncologic Esophagectomy.

Although resection margin (R) status is a widely used prognostic factor after esophagectomy, the definition of positive margins (R1) is not universal. The Royal College of Pathologists considers R1 resection to be a distance less than 0.1 cm, whereas the College of American Pathologists considers it to be a distance of 0.0 cm. This study assessed the predictive value of R status after oncologic esophagectomy, comparing survival and recurrence among patients with R0 resection (> 0.1-cm clearance), R0+ resection (≤ 0.1-cm clearance), and R1 resection (0.0-cm clearance). The study enrolled all eligible patients undergoing curative oncologic esophagectomy between 2012 and 2018. Clinicopathologic features, survival, and recurrence were compared for R0, R0+, and R1 patients. Categorical variables were compared with the chi-square or Fisher's test, and continuous variables were compared with the analysis of variance (ANOVA) test, whereas the Kaplan-Meier method and Cox regression were used for survival analysis. Among the 160 patients included in this study, 113 resections (70.6%) were R0, 34 (21.3%) were R0+, and 13 (8.1%) were R1. The R0 patients had a better overall survival (OS) and disease-free survival (DFS) than the R0+ and R1 patients. The R0+ resection offered a lower long-term recurrence risk than the R1 resection, and the R status was independently associated with DFS, but not OS, in the multivariate analysis. Both the R0+ and R1 patients had significantly more adverse histologic features (lymphovascular and perineural invasion) than the R0 patients and experienced more distant and locoregional recurrence. Although R status is an independent predictor of DFS after oncologic esophagectomy, the < 0.1-cm definition for R1 resection seems more appropriate than the 0.0-cm definition as an indicator of poor tumor biology, long-term recurrence, and survival

18F- FDG PET/CT-derived parameters predict clinical stage and prognosis of esophageal cancer.

Although <sup>18</sup> F- FDG PET/CT is validated in baseline workup of esophageal cancer to detect distant metastases, it remains underused in assessing local staging and biology of the primary tumor. This study aimed to evaluate the association between <sup>18</sup> F- FDG PET/CT-derived parameters of esophageal cancer, and its clinico-pathological features and prognosis. All patients (n = 86) with esophageal adenocarcinoma or squamous cell cancer operated between 2005 and 2014 were analyzed. Linear regression was used to identify clinico-pathologic features of esophageal cancer associated with the tumor's maximal Standardized Uptake Value (SUV <sub>max</sub> ), Total Lesion Glycolysis (TLG) and Metabolic Tumor Volume (MTV). ROC curve analysis was performed to precise the optimal cutoff of each variable associated with a locally advanced (cT3/4) status, long-term survival and recurrence. Kaplan Meier curves and Cox regression were used for survival analyses. High baseline SUV <sub>max</sub> was associated with cT3/4 status and middle-third tumor location, TLG with a cT3/4 and cN+ status, whereas MTV only with active smoking. A cT3/4 status was significantly predicted by a SUV <sub>max</sub> > 8.25 g/mL (p < 0.001), TLG > 41.7 (p < 0.001) and MTV > 10.70 cm <sup>3</sup> (p < 0.01) whereas a SUV <sub>max</sub> > 12.7 g/mL was associated with an early tumor recurrence and a poor disease-free survival (median 13 versus 56 months, p = 0.030), particularly in squamous cell cancer. Baseline <sup>18</sup> F- FDG PET/CT has a high predictive value of preoperative cT stage, as its parameters SUV <sub>max</sub> , TLG and MTV can predict a locally advanced tumor with high accuracy. A SUV <sub>max</sub> > 12.7 g/mL may herald early tumor recurrence and poor disease-free survival

Translating Ultrasound into Clinical Practice for the Assessment of Swallowing and Laryngeal Function: A Speech and Language Pathology-Led Consensus Study

Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1–13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field

Preoperative hiatal hernia in esophageal adenocarcinoma; does it have an impact on patient outcomes?

The impact of hiatal hernia (HH) on oncologic outcomes of patients with esophageal adenocarcinoma (AC) remains unclear. The aim of this study was to assess the effect of pre-existing HH (≥3 cm) on histologic response after neoadjuvant treatment (NAT), overall (OS) and disease-free survival (DFS). All consecutive patients with oncological esophagectomy for AC from 2012 to 2018 in our center were eligible for assessment. Categorical variables were compared with the X <sup>2</sup> or Fisher's test, continuous ones with the Mann-Whitney-U test, and survival with the Kaplan-Meier and log-rank test. Overall, 101 patients were included; 33 (32.7%) had a pre-existing HH. There were no baseline differences between HH and non-HH patients. NAT was used in 81.8% HH and 80.9% non-HH patients (p = 0.910), most often chemoradiation (63.6% and 57.4% respectively, p = 0.423). Good response to NAT (TRG 1-2) was observed in 36.4% of HH versus 32.4% of non-HH patients (p = 0.297), whereas R0 resection was achieved in 90.9% versus 94.1% respectively (p = 0.551). Three-year OS was comparable for the two groups (52.4% in HH, 56.5% in non-HH patients, p = 0.765), as was 3-year DFS (32.7% for HH versus 45.6% for non-HH patients, p = 0.283). HH ≥ 3 cm are common in patients with esophageal AC, concerning 32.7% of all patients in this series. However, its presence was neither associated with more advanced disease upon diagnosis, worse response to NAT, nor overall and disease-free survival. Therefore, such HH should not be considered as risk factor that negatively affects oncological outcome after multimodal treatment of esophageal AC

Propuesta de plan de mercadeo para un centro de tutorías y recreación después de la escuela, en la provincia de Cartago

Proyecto de Graduación (Maestría en Administración de Empresas) Instituto Tecnológico de Costa Rica, Escuela de Administración de Empresas, 2018.In the present project the main objective was to developed a proposal for a marketing plan based on the Retailing Mix, for an after school tutoring and recreation center in Cartago ́s eastern district, with the title Do & Play After School. The area has a high academic offer with nine private primary schools, with a student population that ranges from 300 to 600 children per center. This is key since it presents a market opportunity. Regarding the potential consumers, it was determined that the target market were parents with school-age children in private schools located in Cartago and would be middle-upper class, middle class, and lower middle class. Currently there is no direct competition in the area. In the analysis for the indirect competition, it was determined that no institution or care center has a specialized focus on school-age children and does not meet the full offer as proposed in Do & Play After School. A market research was conducted through a probe of 69 effective surveys and it was determined that there is a need for the center and that it should be focused on helping children with their homework and provide tutoring. In addition, clubs are considered an added value, as well as the option of lunch and transportation. Once the technical, organizational, legal, environmental, financial and market studies were carried out, the proposal was developed and a communication and sales objectives were established. The necessary strategies for the application of the marketing plan were determined, to detail: As a service strategy, a value proposal was defined in which the trained personnel are highlighted as well as the help with homework, tutoring, clubs, food and transport. The price was determined according to a regular price strategy, fixed to the public based on the market research and the amount paid monthly in the two schools that were used for the research. For the promotion, advertising (open house and a stand at school festivals), direct marketing through email and interactive marketing, on Facebook and Instagram social networks would be applied. In terms of sales, a personalized strategy would be used, the client is known through the activities described in the CMI strategies and through inbound marketing. The characteristics of the employees are detailed according to the needs of the center, with trained personnel in the main areas of study that are taught in private schools. For the presentation of the service, the facilities and characteristics of the center are detailed. The meaning of the name, logo and colors of the center, are related to each other, seeking a unique purpose that is the welfare of the children who attend the center

Translating ultrasound into clinical practice for the assessment of swallowing and laryngeal function: A speech and language pathology-led consensus study

Joan Ma - ORCID: 0000-0003-2051-8360 https://orcid.org/0000-0003-2051-8360Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1–13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.Jodi Allen receives part-funding from the National Institute of Health Research (NIHR) Pre-Clinical Academic Fellowship Award. Gemma Clunie receives funding from the National Institute for Health Research (NIHR) Integrated Clinical Academic Clinical Doctoral Fellowship Programme and acknowledges the support and infrastructure provided by the NIHR Imperial Biomedical Research Centre. Anna Volkmer receives funding from the NIHR via a Development and Skills Award. Soren Lowell receives funding from the National Institute of Health (NIH) Research Enhancement Award (R15).https://doi.org/10.1007/s00455-022-10413-9aheadofprintaheadofprin