Ethische dilemma’s bij eigen regie: oproep tot reflectie

De decentralisaties in zorg en welzijn moeten bijdragen aan een transitie van verzorgingsstaat naar participatiesamenleving. Van burgers wordt verwacht dat zij eigen regie voeren. Ten eerste door langer voor zichzelf te zorgen en een beroep te doen op hun eigen omgeving als ze hulp nodig hebben. Ten tweede door, als er wel professionele ondersteuning nodig is, ook daarin een actieve rol te vervullen. Eigen regie wordt vooral positief gelabeld door beleidsmakers: het levert zorggebruikers meer autonomie op, laat de zorg beter aansluiten bij de vraag en bespaart ook nog eens kosten. Eigen regie is daarmee een hoerawoord waar je met goed fatsoen niet tegen kan zijn. In deze bijdrage laten we echter zien dat het stimuleren van eigen regie zorgverleners confronteert met ethische dilemma’s. Reflectie op deze dilemma’s is van groot belang om op die manier recht te doen aan verschillende waarden in de zorg

A Comparative Study on the Reactivity of Various Ketohexoses to Furanics in Methanol

The acid-catalysed dehydration of the four 2-ketohexoses (fructose, sorbose, tagatose and psicose) to furanics was studied in methanol (65 gL(-1) substrate concentration, 17 and 34 mm sulfuric acid, 100 degrees C) with Avantium high-throughput technology. Significant differences in the reactivities of the hexoses and yields of 5-hydroxymethylfurfural (HMF) and its methyl ether (MMF) were observed. Psicose and tagatose were the most reactive, and psicose also afforded the highest combined yield of MMF and HMF of approximately 55% at 96% sugar conversion. Hydroxyacetylfuran and its corresponding methyl ether were formed as byproducts, particularly for sorbose and tagatose, with a maximum combined yield of 8% for sorbose. The formation of hydroxyacetylfuran was studied through C-13 NMR spectroscopy with labelled sorbose, which provided new insights into the reaction mechanism

A novel free-fall reactor for (catalytic) pyrolysis of biomass and plastics

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Kinetic Study on the Sulfuric Acid-Catalyzed Conversion of d -Galactose to Levulinic Acid in Water

Levulinic acid is an interesting building block for biofuel (additives) and biobased chemicals. It is accessible by an acid-catalyzed reaction of a wide variety of carbohydrates. We here report a kinetic study on the conversion of d-galactose to levulinic acid in aqueous solutions with sulfuric acid as the catalyst. The experiments were carried out in a broad range of temperatures (140-200 °C), initial concentrations of galactose (0.055-1.110 M), and concentrations of sulfuric acid (0.05-1 M). The experimental data were modeled using a power-law approach, and good agreement between the experimental data and the model was obtained. The maximum yield of levulinic acid (54 mol %) was achieved at 130-140 °C, low initial galactose concentrations (0.055 M), and high acid concentrations (1 M). With the kinetic information available, the most suitable reactor configuration was determined, and it is predicted that a continuously stirred-tank reactor is preferred over a plug-flow reactor. The findings presented here may also be applicable to the kinetic modeling of levulinic acid synthesis from more complex biomass sources such as lignocellulosic (woody) and aquatic (e.g., seaweed) biomass

What methods are used to promote patient and family involvement in healthcare regulation? A multiple case study across four countries

Background In the regulation of healthcare, the subject of patient and family involvement figures increasingly prominently on the agenda. However, the literature on involving patients and families in regulation is still in its infancy. A systematic analysis of how patient and family involvement in regulation is accomplished across different health systems is lacking. We provide such an overview by mapping and classifying methods of patient and family involvement in regulatory practice in four countries; Norway, England, the Netherlands, and Australia. We thus provide a knowledge base that enables discussions about possible types of involvement, and advantages and difficulties of involvement encountered in practice. Methods The research design was a multiple case study of patient and family involvement in regulation in four countries. The authors collected 1) academic literature if available and 2) documents of regulators that describe user involvement. Based on the data collected, the authors from each country completed a pre-agreed template to describe the involvement methods. The following information was extracted and included where available: 1) Method of involvement, 2) Type of regulatory activity, 3) Purpose of involvement, 4) Who is involved and 5) Lessons learnt. Results Our mapping of involvement strategies showed a range of methods being used in regulation, which we classified into four categories: individual proactive, individual reactive, collective proactive, and collective reactive methods. Reported advantages included: increased quality of regulation, increased legitimacy, perceived justice for those affected, and empowerment. Difficulties were also reported concerning: how to incorporate the input of users in decisions, the fact that not all users want to be involved, time and costs required, organizational procedures standing in the way of involvement, and dealing with emotions. Conclusions Our mapping of user involvement strategies establishes a broad variety of ways to involve patients and families. The four categories can serve as inspiration to regulators in healthcare. The paper shows that stimulating involvement in regulation is a challenging and complex task. The fact that regulators are experimenting with different methods can be viewed positively in this regard

Mechanistic Investigations into the Catalytic Levulinic Acid Hydrogenation, Insight in H/D Exchange Pathways, and a Synthetic Route to d₈-?-Valerolactone

gamma-Valerolactone (GVL) is readily accessible by catalytic hydrogenation of carbohydrate-derived levulinic acid (LA) and is an attractive biobased chemical with a wide range of applications in both the chemical (e.g., as biomass-derived solvent) and the transportation fuel sector. In this study, we used isotopic labeling experiments to provide insights into the catalytic hydrogenation pathways involved in the conversion of LA to GVL under different reaction conditions using water as an environmentally benign solvent and Ru/C as a readily available catalyst. H-2 NMR experiments combined with quantum chemical calculations revealed that deuterium atoms can be incorporated at different positions as well as the involvement of the different intermediates 4-hydroxypentanoic acid and alpha-angelica lactone (alpha-AL). The insight provided by these studies revealed an as of yet unexploited sequential deuteration route to synthesize fully deuterated LA and GVL. The route starts by the conversion of LA to alpha-AL followed by a selective deuteration of the acidic protons of alpha-AL by H/D exchange with D2O. Subsequent ring-opening in D2O (d(2)-AL to d(3)-LA) and exchange of the remaining protons of d(3)-LA via a keto-enol tautomerization by heating in D2O under acidic conditions gives d(8)-LA. Finally, the d(8)-LA is catalytically reduced at low temperature using Ru/C with D-2 in D2O to d(8)-GVL

Biobased Furanics:Kinetic Studies on the Acid Catalyzed Decomposition of 2-Hydroxyacetyl Furan in Water Using Bronsted Acid Catalysts

Biobased furanics like 5-hydroxymethylfurfural (5-1-IMF) are interesting platform chemicals for the synthesis of biofuel additives and polymer precursors. 5-HMF is typically prepared from C6 ketoses like fructose, psicose, sorbose and tagatose. A known byproduct is 2-hydroxyacetylfuran (2-HAF), particularly when using sorbose and psicose as the reactants. We here report an experimental and kinetic modeling study on the rate of decomposition of 2-HAF in a typical reaction medium for 5-HMF synthesis (water, Bronsted acid), with the incentive to gain insights in the stability of 2-HAF. A total of 12 experiments were performed (batch setup) in water with sulfuric acid as the catalyst (100-170 degrees C, C-H2SO4 ranging between 0.033 and 1.37 M and an initial 2-HAF concentration between 0.04 and 0.26 M). Analysis of the reaction mixtures showed a multitude of products, of which levulinic acid (LA) and formic acid (FA) were the most prominent (Y-max,Y-FA = 24 mol %, Y-max,Y-LA = 10 mol %) when using HCI. In contrast, both LA and FA were formed in minor amounts when using H2SO4 as the catalyst. The decomposition reaction of 2-HAF using sulfuric acid was successfully modeled (R-2 = 0.9957) using a first-order approach in 2-1-IAF and acid. The activation energy was found to be 98.7 ( 2.2) kJ mol(-1)

Government Influence on Patient Organizations

Patient organizations increasingly play an important role in health care decision-making in Western countries. The Netherlands is one of the countries where this trend has gone furthest. In the literature some problems are identified, such as instrumental use of patient organizations by care providers, health insurers and the pharmaceutical industry. To strengthen the position of patient organizations government funding is often recommended as a solution. In this paper we analyze the ties between Dutch government and Dutch patient organizations to learn more about the effects of such a relationship between government and this part of civil society. Our study is based on official government documents and existing empirical research on patient organizations. We found that government influence on patient organizations has become quite substantial with government influencing the organizational structure of patient organizations, the activities these organizations perform and even their ideology. Financing patient organizations offers the government an important means to hold them accountable. Although the ties between patient organizations and the government enable the former to play a role that can be valued as positive by both parties, we argue that they raise problems as well which warrant a discussion on how much government influence on civil society is acceptable

Novel Route to Produce Hydrocarbons from Woody Biomass Using Molten Salts

[Image: see text] The thermochemical decomposition of woody biomass has been widely identified as a promising route to produce renewable biofuels. More recently, the use of molten salts in combination with pyrolysis has gathered increased interest. The molten salts may act as a solvent, a heat transfer medium, and possibly also a catalyst. In this study, we report experimental studies on a process to convert woody biomass to a liquid hydrocarbon product with a very low oxygen content using molten salt pyrolysis (350–450 °C and atmospheric pressure) followed by subsequent catalytic conversions of the liquids obtained by pyrolysis. Pyrolysis of woody biomass in molten salt (ZnCl(2)/NaCl/KCl with a molar composition of 60:20:20) resulted in a liquid yield of 46 wt % at a temperature of 450 °C and a molten salt/biomass ratio of 10:1 (mass). The liquids are highly enriched in furfural (13 wt %) and acetic acid (14 wt %). To reduce complexity and experimental issues related to the production of sufficient amounts of pyrolysis oils for further catalytic upgrading, model studies were performed to convert both compounds to hydrocarbons using a three-step catalytic approach, viz., (i) ketonization of acetic acid to acetone, (ii) cross-aldol condensation between acetone and furfural to C(8)–C(13) products, followed by (iii) a two-stage catalytic hydrotreatment of the latter to liquid hydrocarbons. Ketonization of acetic acid to acetone was studied in a continuous setup over a ceria–zirconia-based catalyst at 250 °C. The catalyst showed no signs of deactivation over a period of 230 h while also achieving high selectivity toward acetone. Furfural was shown to have a negative effect on the catalyst performance, and as such, a separation step is required after pyrolysis to obtain an acetic-acid-enriched fraction. The cross-aldol condensation reaction between acetone and furfural was studied in a batch using a commercial Mg/Al hydrotalcite as the catalyst. Furfural was quantitatively converted with over 90% molar selectivity toward condensed products with a carbon number between C(8) and C(13). The two-stage hydrotreatment of the condensed product consisted of a stabilization step using a Ni-based Picula catalyst and a further deep hydrotreatment over a NiMo catalyst, in both batch setups. The final product with a residual 1.5 wt % O is rich in (cyclo)alkanes and aromatic hydrocarbons. The overall carbon yield for the four-step approach, from pinewood biomass to middle distillates, is 21%, assuming that separation of furfural and acetic acid after the pyrolysis step can be performed without losses

Using institutional theory to analyse hospital responses to external demands for finance and quality in five european countries

OBJECTIVES: Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands. METHODS: An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals. RESULTS: How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures. CONCLUSIONS: The development of hospital leaders' skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required