Bakgrund: Inom vården hanteras dagligen stora mängder material och det är av stor vikt att rätt material är på rätt plats, i rätt tid, i rätt mängd och med rätt kvalitet för att en så god vård som möjligt ska kunna erbjudas. För att säkerställa effektiva och välfungerande gods- och informationsflöden med hög servicenivå inom vården, krävs det förståelse för hur flödena fungerar, hur dessa är relaterade till varandra samt hur de samverkar. Det är en stor fördel för en organisation att kartlägga sina flöden då man genom en kartläggning kan identifiera kvalitetsbrister samt orsakerna till dessa och därefter vidta förbättringsåtgärder som resulterar i kvalitetsökningar. Syfte: Detta examensarbete avser att göra en nulägesbeskrivning med hjälp av flödekartläggningar av regionservice godsflöde och informationsflöde av förbrukningsmaterial. Syftet är att identifiera de nuvarande kvalitetsbristerna och orsakerna till dessa samt föreslå åtgärder som ska leda till förbättringar. Metod: Denna fallstudie har utgått från en kvalitativ undersökningsdesign där data har samlats in genom ostrukturerade intervjuer, semistrukturerade intervjuer samt deltagande observationer. För att möjliggöra identifieringar av kvalitetsbrister och de bakomliggande orsakerna till dessa upprättades flödeskartläggningar respektive orsak-verkandiagram som har legat till grund för förbättringsåtgärderna. Slutsatser: I studien framgår det att majoriteten av kvalitetsbristerna som uppstår i flödet av förbrukningsmaterial beror på att det saknas ett aktivt informationsutbyte mellan aktörerna, att rätt förutsättningar och utrustningar för spårning av godset inte finns tillgängligt samt att kvalitetskontroller inte genomförs. Utifrån dessa bakomliggande orsaker har tre åtgärder som tillsammans utgör grunden till ett bra logistikflöde och skapar förutsättningar för mer3 (106)effektiva och välfungerande gods- och informationsflöden föreslagits. För att regionservice ska kunna ha kontroll över flödet av förbrukningsmaterial och erhålla en högre kvalitet krävs det att de implementerar ett godsspårningssystem som kommer kunna säkerställa denna kvalitet genom att felen som uppstår i flödet snabbt kan spåras och åtgärdas. Godsspårningssystemet bör sedan kompletteras av ett informationssystem som skapar förutsättningar för en god kommunikation och informationstillgänglighet som på så sätt kan effektivisera informationsflödet och stärka samarbetet mellan de involverade aktörerna. Genom att kvalitetskontroller genomförs regelbundet i hela flödet kan även fel och brister upptäckas och minimeras. / Background: A large amounts of material is handled on a daily basis in health care and it is of great importance that the right material is at the right place at the right time, in the right quantity and the right quality in order to be able to offer as good care as possible. In order to ensure efficient and functional flows of goods and flows of information with a high level of service, it requires an understanding of how the flows operate, how they are related to each other and how they interact. It is beneficial for an organization to map their flows since it can help identify quality deficiencies and their causes and thereafter take improvement measures that increases the quality. Purpose: This thesis intends to describe the present situation through a flow mapping of the flow of materials of consumption in Regionservice. The aim is to identify existing quality deficiencies and their causes to thereafter be able to recommend measures that will result in improvements. Method: This case study is based on a qualitative research design where data were collected through unstructured interviews, semi-structured interviews and participating observations. In order to enable identifications of quality deficiencies and the underlying causes of these, flow mappings and cause-effect diagrams were established and have been the basis of the improvement measures. Conclusions: This study indicates that the majority of the quality defeiciencies that occur in the flow of materials of consumption is due to the lack of an active exchange of information between the actors, the right conditions and equipments for tracking the goods and that quality controls are not implemented. Based on these underlying causes there are three measures that have been suggested that together form the foundation for an optimal logistics 5 (106) and creates conditions for more efficient and functional flows of goods and information. In order for Regionservice to be able to control the flow of materials of consumption and obtain a higher quality, they are required to implement a tracking system that will ensure this quality since the deficincies that occur in the flow can be tracked and fixed. The tracking system should be complemented by an information system that creates oppurtunites for good communication and information accessibility which will enhance the cooperation between the actors involved. By conducting quality controls regularly throughout the flow, faults and deficiencies can be discovered and minimized.

<p>Predmet disertacije jeste optimizacija digitalne slike kada<br />ograničenje nije vezano za način reprodukcije već za samog posmatrača,<br />odnosno optimizacija opaženog kvaliteta digitalne slike od strane<br />osoba sa poremećajima viđenja boja. Predloženi model optimizacije<br />slike poboljšava distinkciju boja i opseg boja slike za korisnike sa<br />različitim težinama poremećaja viđenja boja uz očuvanje prirodnosti<br />slike. Metodološki okvir ispitivanja, koji uključuje kvantitativnu<br />analizu računarskih simulacija, analizu eye-tracking podataka i<br />subjektivno ocenjivanje poboljšanja opaženog kvaliteta test slika,<br />daje sistematičnu i pouzdanu verifikaciju efektnosti predloženih<br />metoda adaptacije boja slike.</p> / <p>The subject of the thesis was the digital image optimization when an<br />observer represents the main image reproduction limitation or, in other<br />words, the optimization of the perceived image quality by individuals with<br />colour vision deficiencies. The proposed image optimization model enhances<br />colour distinction and gamut for users with different severities of colourblindness<br />while preserving the image naturalness. The used methodological<br />framework, including a quantitative analysis of computer simulations, an<br />analysis of eye-tracking data and a subjective evaluation of the perceived<br />image quality, provides systematic and reliable effectiveness verification of<br />the proposed colour adaptation methods.</p>

Carências nutricionais são ocorrências comuns em grande proporção de crianças do mundo e reconhecidamente um dos grandes problemas da saúde pública brasileira. Alguns estudos têm relatado que os escores mental e motor de crianças com carências nutricionais são mais baixos do que aqueles obtidos pelas crianças sem carências. As Escalas Bayley, publicadas pela primeira vez em 1969 e revisadas em 1993, constituem-se em instrumento adequado para a avaliação de crianças de um a quarenta e dois meses de idade, e são amplamente utilizadas em estudos que avaliam efeitos de carências nutricionais. Desta forma, o objetivo deste trabalho foi verificar a aplicabilidade da Escala de Avaliação do Comportamento Infantil (BRS), uma das três escalas que constituem as Escalas Bayley, na avaliação de crianças de creche com carência nutricional. A amostra foi constituída por 50 crianças de ambos os sexos, com idades que variaram entre 7 e 41 meses, provenientes de duas creches filantrópicas do município de Ribeirão Preto – SP. Um grupo de 23 crianças com deficiência proteico-calórica ou de ferro, consideradas de leve a moderada, segundo o Z-score < +1, proposto pela OMS e níveis de hemoglobina acima de 8 mg/dL, foi comparado a outro de 27 crianças sem estas deficiências. Através da avaliação do comportamento foram obtidos índices referentes ao comportamento geral, o controle emocional, a atenção/exitabilidade, a orientação/engajamento e a qualidade motora das crianças. Tais índices são apresentados em forma de percentil, sendo possível, segundo Bayley (1993), a classificação em: comportamento dentro dos limites normais (índice ? percentil 26), ou seja, esperado para sua idade; comportamento questionável (índice entre o percentil 11 e o 25), que sugere possível prejuízo e merece maior investigação; e comportamento não-ótimo (índice ? percentil 10), que evidencia atraso ou prejuízo em uma ou mais áreas importantes. Os resultados obtidos revelaram que o grupo controle era de maior faixa etária (30 meses) que o grupo carente nutricional (23 meses), e que as crianças do grupo controle apresentavam um comportamento geral frente a situação de teste melhor que do que as crianças do grupo carente nutricional (p=0.03), principalmente no fator Orientação/Engajamento (p=0.01): Afeto positivo (p=0.03), Energia (p=0.005), Entusiasmo acerca das tarefas (p=0.04), Engajamento social (p=0.03); e nos itens Afeto negativo (p=0.04) e Movimento lento e atrasado (p=0.005). Estes resultados são consistentes com aqueles já apresentados na literatura, nos quais as crianças com carências nutricionais são descritas como menos ativas, mais inibidas e tímidas, menos responsivas, atentas, vocalizando e movimentando-se menos. Concluiu-se que os itens relacionados à avaliação comportamental, aplicados e cotados como proposto originalmente, foram sensíveis para diferenciar grupos com e sem alterações nutricionais leves ou moderadas, embora as Escalas Bayley do Desenvolvimento Infantil requeiram ainda adaptação às condições sociais e culturais brasileiras. Tais resultados sugerem ainda que esta escala pode ser útil em outras condições clínicas, assim como para a avaliação do desempenho de grupos pós procedimentos de recuperação nutricional. / Nutritional deficiencies are common occurrences among a large proportion of children all over the world and are recognized to be one of the great public health problems in Brazil. Some studies have reported that the mental and motor scores of children with nutritional deficiencies are lower than those of children with no deficiencies. The Bayley Scales, first published in 1969 and revised in 1993, are an appropriate instrument for the evaluation of children aged one to forty months and are widely used in studies that evaluate the effects of nutritional deficiencies. Thus, the objective of the present study was to determine the applicability of the Behavioral Rating Scale (BRS), one of the three scales forming the Bayley Scales, for the evaluation of day-care center children with nutritional deficiencies. The sample consisted of 50 children of both sexes aged 7 to 41 months, from two philanthropic day-care centers in the municipality of Ribeirão Preto – SP. A group of 23 children with protein-calorie or iron deficiency considered to be mild to moderate according to a Z-score < +1 proposed by the WHO and with hemoglobin levels above 8 mg/dL, was compared to a group of children without these deficiencies. Indices referring to general behavior, emotional control, attention/excitability, orientation/engagement, and motor quality of the children were obtained by behavioral evaluation. These indices are presented in percentile form and, according to Bayley (1993), it is possible to classify them as behavior within normal limits (index ? 26th percentile), i.e., expected for age, questionable behavior (index between the 11th and 25th percentile), suggesting possible impairment and requiring more investigation, and non-optimal behavior (index ? 10th percentile), which demonstrates delay or impairment in one or more important areas. The results obtained revealed that the control group was in an older age range (30 months) than the group with nutritional deficiency (23 months), and that the children in the control group presented a better general behavior in the test situation than the children in the group with nutritional deficiency (p=0.03), especially regarding the Orientation/Engagement factor (p=0.01): Positive affect (p=0.03), Energy (p=0.005), Enthusiasm about tasks (p=0.04), Social engagement (p=0.03); and in the items Negative affect (p=0.04) and Slow and delayed movement (p=0.005). These results are consistent with those reported in literature studies in which children with nutritional deficiencies are described as less active, more inhibited and shy, less responsive and attentive, and vocalizing and moving less. We conclude that the items related to behavioral evaluation, applied and scored as originally proposed, were sensitive in differentiating between groups with and without mild or moderate nutritional alterations, although the Bayley Scales for Childhood Development still require adaptation to the Brazilian social and cultural conditions. These results also suggest that this scale can be useful for other clinical conditions and for the evaluation of performance of groups submitted to procedures or nutritional recovery.

Made available in DSpace on 2015-04-22T22:06:23Z (GMT). No. of bitstreams: 1 luisa margareth.pdf: 2189953 bytes, checksum: 547072437d316a42d6f06d3278b65deb (MD5) Previous issue date: 2013-03-01 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / INTRODUCTION: The Politics of Brazilian Food and Nutrition 2012 ensures: "Food and nutrition are the basic requirements for the promotion and protection of health, enabling the full potential of human growth and development, quality of life and citizenship". OBJECTIVE: Develop curves of nutritional deficiencies through research of consumer trends, food pattern and adult nutritional Maroons of riparian areas in the Lower Amazon Oriximiná Municipality, Pará. METHODS: Cross-sectional, descriptive and analytical with descriptive and inferential statistics. RESULTS: A sample of 274 individuals, of whom 50.2% were female. The mean age 41.6 ± 15.3 years, weight 63.2 ± 10.9 kg, height 156.7 ± 8.9 cm and body mass index (BMI) of 25.8 ± 3.9 kg / m . The majority (47.7%) had completed 4 years of schooling and 6.3% were illiterate. Among the foods consumed (5 or more times a week): cassava flour, fish, soybean oil, sugar and coffee (infusion) and consumed less than 5 times per week to cassava and banana; Among foods are rarely eaten rice, beans, beef, pork, poultry and game, eggs, milk, soft drinks and snacks / chips. Performed three meals per day 93.8% and only 5.5% and 0.7% carried four five meals, respectively. Food consumption per capita of the last 24 hours shows that the cassava flour was the most consumed by all communities (average 201.0 g) followed by rice (16,0 g) and Beju (9,0 g). Only one community reported consumption of vegetables and vegetable consumption and the mean at 0.34 g; Fruits with higher consumption: banana (11,0 g), chestnut of Pará (6,0 g) and acerola juice in the form of (13,0 g); Only four communities beans consumed, amounting to an average of 8,0 g. In the group of meat, draws attention to high fish consumption in all communities, and the average per capita consumption of this food in 517.0 g. The average energy consumption of 1572.5 ± 546.8 Kcal. The percentage intakes of carbohydrates, proteins and lipids, total calories, were similar between the sexes, with no statistical difference. The values of consumption trend (shown in curves) showed that there was highly significant adjustment to Energy (p = 0.01032 *), protein (p <0.001 *), fat (p = 0.0032 *), Carbohydrate (p = <0.001 *) , cholesterol (p = 0.0213 *), calcium (p <0.001 *), iron (p = 0.0022 *) and zinc (p <0.001 *), however, each type of nutrient with its specific characteristic for Excess or Deficiency as tracks age; Tended to lack of consumption: energy (kcal), fat (%), calcium, zinc, and iron Carbohydrate varied with sex, protein and cholesterol were overweight throughout the sample. CONCLUSION: Dietary intake is monotonous, with inadequate macronutrients and micronutrients and low in fiber to the reference set; demonstrating not meet the caloric balance and nutritional needs of the sample. There is a need for new design methodologies to estimate the nutritional needs of traditional Amazonian, living in socially vulnerable, which take into consideration the specificity of livelihood and access to food. / INTRODUÇÃO: A Política Nacional de Alimentação e Nutrição 2012 assegura: A alimentação e nutrição constituem requisitos básicos para a promoção e a proteção da saúde, possibilitando a afirmação plena do potencial de crescimento e desenvolvimento humano, com qualidade de vida e cidadania . OBJETIVO: Elaborar curvas de carências nutricionais através da investigação das tendências de consumo, padrão alimentar e nutricional de adultos quilombolas de áreas ribeirinhas do Baixo Amazonas no Município de Oriximiná, Pará. METODOLOGIA: Estudo transversal, descritivo e analítico com estatística descritiva e inferencial. RESULTADOS: Amostra de 274 indivíduos, sendo 50,2% do sexo feminino. A média de idade 41,6 ±15,3 anos; peso 63,2 ±10,9 kg, estatura 156,7 ±8,9cm e Índice de Massa Corpórea (IMC) de 25,8 ±3,9 kg/m. A maioria (58,0%) tinha até quatro anos de escolaridade e 6,3% eram analfabetos.Entre os alimentos consumidos (Cinco ou mais vezes por semana): a farinha de mandioca, peixes,óleo de soja, açúcar e café (infusão) e os consumidos menos de cinco vezes por semana a macaxeira e a banana; Entre os alimentos raramente consumidos estão o arroz, o feijão, as carnes bovina, suína, de aves e de caça, ovos, leite, refrigerantes e salgados/frituras. Realizavam três refeições por dia 93,8% e somente 5,5% e 0,7% realizavam quatro e cinco refeições, respectivamente. O consumo alimentar per capita das últimas 24 horas, evidencia que a farinha de mandioca foi a mais consumida por todas as comunidades (média 201,0g); Apenas uma comunidade referiu o consumo de hortaliças, verduras e legumes ficando a média de consumo em 0,3g; Frutas com maior consumo: banana (11,0g), castanha do Pará (6,0g) e acerola na forma de suco (13,0g); Somente quatro comunidades consumiram feijão, perfazendo a média de 8,0g. No grupo das carnes, chama a atenção o elevado consumo de peixe em todas as comunidades, ficando o consumo médio per capita deste alimento em 517,0g. O consumo médio de energia 1572,5 ± 546,8 Kcal. As ingestões percentuais de carboidratos, proteínas e lipídios, no total de calorias, foram semelhantes entre os sexos, não havendo diferença estatística. Os valores de tendência de consumo (representados nas curvas) mostraram que houve ajuste altamente significante para Energia (p=0.01032*), Proteína (p<0.001*), Gordura (p=0.0032*), Carboidrato (p=<0.001*), Colesterol (p=0.0213*), Cálcio (p<0.001*), Ferro (p=0.0022*) e Zinco (p<0.001*), entretanto, cada tipo de nutriente com sua característica específica para Excesso ou Carência conforme as faixas etárias; Apresentou tendência de consumo para carência: energia (k/cal), gordura (%), cálcio, zinco;Carboidrato e ferro variaram com o sexo; A proteína e o colesterol apresentaram excesso em toda a amostra. CONCLUSÃO: O consumo alimentar é monótono, com inadequação de macronutrientes e micronutrientes, e baixo teor de fibras para os referencia estabelecidas; demonstrando não atender ao balanço calórico e as necessidades nutricionais da amostra estudada. Há necessidade da concepção de novas metodologias para estimar as necessidades nutricionais de populações tradicionais amazônicas que vivem em situação de vulnerabilidade social, que levem em consideração a especificidade do modo de vida e o acesso ao alimento.

Vulnerable older adults residing in nursing homes continue to experience poor care outcomes due to nurse staffing levels that are below the levels required for maintaining their well-being. Studies have shown that patient care outcomes in nursing homes are related to nurse staffing standards/levels, which are affected by profit maximization on adherence to registered nurses and licensed nurse staffing standards. The purpose of this descriptive study was to determine if there was a relationship between adherence to staffing standards and care outcomes in for-profit (FP) and not-for-profit religious-based (NFPRB) nursing homes using the profit maximization theory. Research questions focused on the relationships that profit maximization and nurse staffing standards had on the quality of care outcomes measures and the differences between the nursing homes on these variables. Secondary data were collected from public database and analyzed using the descriptive and inferential statistics, nonparametric tests, and binary logistic regression. Findings showed that profit measures were not related to staffing standards and care outcome measures in the NFPRB. There was a significant relationship between FP nursing homes and standards to care outcomes in FP but not in the NFPRB nursing homes. FP nursing homes did worse than NFPRB on care outcomes. Further research, using qualitative and mixed methodologies, is needed to study the effects of profit measures on nursing home care outcomes. The results of this study can effect positive social change by informing policy makers and healthcare professionals/leaders, and, by reducing adverse events, untimely death, and positively affecting the quality of care and life of the frail and vulnerable older adults residing in nursing homes.

<p>Today there are many students with behavioral and developmental disorders in schools. One of these disorders is ADHD. The medical designation ADHD stands for Attention Deficit Hyperactivity Disorder. I have chosen to research how two students with ADHD can be included in a fifth grade classroom.</p><p>This research paper addresses the issues surrounding the student’s day-to-day life with a focus on the classroom. It also discusses pedagogical methods, resources, and support, as well as social relationships, and routines in relation to the students in question. In order to develop a more complete understanding of the two students and their situation, I have chosen to do a qualitative study where I’ve observed the students in their classroom for four days, and interviewed the adults that interact with the students the most on a day to day basis. The interviewees include the students’ classroom teacher, their assistant teacher, as well as the students’ mothers.</p><p>I begin the paper by describing ADHD, as well as the potential causes and treatments. I also present the two predominant opinions regarding the source of ADHD that exist in Sweden today. The first is a biological perspective, which states that ADHD is passed on genetically, and the second is a sociological perspective, which states that ADHD is acquired through exposure to a range of social and environmental factors. However, I have based my research on the biological perspective because it is currently the most widely accepted, and because the biological model of explanation is the model most of the current literature is based on.</p><p>As a result of my research, I have concluded that students with ADHD can have a wide range of different symptoms despite having the same diagnosis. Hellström states that teachers should be aware that all students with ADHD are unique individuals, and it is therefore difficult to prescribe a general set of guidelines to follow when working with such students. One must take each individual’s needs into consideration and decide which methods and solutions work best for each particular individual (Hellström 2007, s. 1). Hellström’s statement is consistent with the conclusions I came to after conducting my research. The classroom teacher saw the students as very different individuals and adapted their education according to their very different needs despite the fact that they have the same diagnosis.</p>

Today there are many students with behavioral and developmental disorders in schools. One of these disorders is ADHD. The medical designation ADHD stands for Attention Deficit Hyperactivity Disorder. I have chosen to research how two students with ADHD can be included in a fifth grade classroom. This research paper addresses the issues surrounding the student’s day-to-day life with a focus on the classroom. It also discusses pedagogical methods, resources, and support, as well as social relationships, and routines in relation to the students in question. In order to develop a more complete understanding of the two students and their situation, I have chosen to do a qualitative study where I’ve observed the students in their classroom for four days, and interviewed the adults that interact with the students the most on a day to day basis. The interviewees include the students’ classroom teacher, their assistant teacher, as well as the students’ mothers. I begin the paper by describing ADHD, as well as the potential causes and treatments. I also present the two predominant opinions regarding the source of ADHD that exist in Sweden today. The first is a biological perspective, which states that ADHD is passed on genetically, and the second is a sociological perspective, which states that ADHD is acquired through exposure to a range of social and environmental factors. However, I have based my research on the biological perspective because it is currently the most widely accepted, and because the biological model of explanation is the model most of the current literature is based on. As a result of my research, I have concluded that students with ADHD can have a wide range of different symptoms despite having the same diagnosis. Hellström states that teachers should be aware that all students with ADHD are unique individuals, and it is therefore difficult to prescribe a general set of guidelines to follow when working with such students. One must take each individual’s needs into consideration and decide which methods and solutions work best for each particular individual (Hellström 2007, s. 1). Hellström’s statement is consistent with the conclusions I came to after conducting my research. The classroom teacher saw the students as very different individuals and adapted their education according to their very different needs despite the fact that they have the same diagnosis.

In this study, structural vulnerability of reinforced concrete frame structures by considering the country&ndash / specific characteristics is investigated to manage the earthquake risk and to develop strategies for disaster mitigation. Low&ndash / rise and mid&ndash / rise reinforced concrete structures, which constitute approximately 75% of the total building stock in Turkey, are focused in this fragility&ndash / based assessment. The seismic design of 3, 5, 7 and 9&ndash / story reinforced concrete frame structures are carried out according to the current earthquake codes and two dimensional analytical models are formed accordingly. The uncertainty in material variability is taken into account in the formation of structural simulations. Frame structures are categorized as poor, typical or superior according to the specific characteristics of construction practice and the observed seismic performance after major earthquakes in Turkey. The demand statistics in terms of maximum interstory drift ratio are obtained for different sets of ground motion records. The capacity is determined in terms of limit states and the corresponding fragility curves are obtained from the probability of exceeding each limit state for different levels of ground shaking. The results are promising in the sense that the inherent structural deficiencies are reflected in the final fragility functions. Consequently, this study provides a reliable fragility&ndash / based database for earthquake damage and loss estimation of reinforced concrete building stock in urban areas of Turkey.

Η βαριατρική χειρουργική είναι η μόνη διαδικασία που μπορεί να εφαρμοσθεί προκειμένου να επιτευχθεί μόνιμη απώλεια βάρους στην πλειονότητα των ασθενών με υπερ-νοσογόνο παχυσαρκία (130). Οι βαριατρικές χειρουργικές επεμβάσεις ορίζονται ως περιοριστικές, δυσαπορροφητικές ή περιοριστικές και δυσαπορροφητικές ταυτόχρονα. Οι περιοριστικού τύπου χειρουργικές επεμβάσεις έχουν συνδεθεί με αυξημένα ποσοστά αποτυχίας όσον αφορά στην απώλεια βάρους στους υπερ-παχύσαρκους ασθενείς, με αποτέλεσμα να παρατηρείται προοδευτική αύξηση της εφαρμογής βαριατρικών εγχειρήσεων δυσαπορροφητικού τύπου σε όλο τον κόσμο για αυτήν την υπο-ομάδα παχυσαρκίας (100, 108, 130, 131). Παρά την απώλεια βάρους που μπορεί να επιτευχθεί με αυτές τις χειρουργικές επεμβάσεις, οι μετεγχειρητικές ανεπάρκειες σε πρωτεΐνη, σίδηρο, βιταμίνες, άλατα και λιποδιαλυτές βιταμίνες αποτελούν σύνηθες φαινόμενο και απαιτούν χορήγηση συμπληρωμάτων προκειμένου να διατηρηθούν σε φυσιολογικά επίπεδα. Οι ανεπάρκειες αυτές οφείλονται στη δυσαπορρόφηση που προκύπτει από τη χειρουργική παράκαμψη τμημάτων του γαστρεντερικού σωλήνα, όπου τα διάφορα διατροφικά συστατικά απορροφούνται (118). Αν και αναμενόμενες, οι μεταβολικές ανωμαλίες πολύ συχνά δε διαγιγνώσκονται ή υποεκτιμούνται. Τα βιβλιογραφικά δεδομένα που αναφέρονται στις διατροφικές ανεπάρκειες που παρατηρούνται μετά τις βαριατρικές εγχειρήσεις είναι περιορισμένα, και απαρτίζονται από αναφορές σε μεμονωμένα περιστατικά ασθενών (124-126), από επισκοπήσεις αποτελεσμάτων παλαιότερων ερευνών (118, 132) και από περιστασιακές προοπτικές μελέτες (118, 131). Αν και υπάρχουν αρκετές πληροφορίες για διατροφικά συστατικά, όπως είναι η πρωτεϊνη, ο σίδηρος, η βιταμίνη Β12, το φυλλικό οξύ και το ασβέστιο (118, 131), τα στοιχεία που παρατίθενται για τις λιποδιαλυτές βιταμίνες είναι ελάχιστα και ελλιπή. Αυτό οφείλεται σε σημαντικό βαθμό στη δυσκολία απομόνωσης και προσδιορισμού των λιποδιαλυτών βιταμινών από τον ορό του αίματος, διαδικασία αρκετά επίπονη, δαπανηρή και χρονοβόρα. Οι περισσότεροι χειρούργοι προσπαθούν να ελέγξουν με έμμεσο τρόπο τα επίπεδα των λιποδιαλυτών βιταμινών, όπως για παράδειγμα με παρακολούθηση των τιμών της PTH, άνοδος της οποίας συνηγορεί σε πιθανή ελάττωση των επιπέδων της βιταμίνης D3 (133), ή με παρακολούθηση του χρόνου προθρομβίνης των ασθενών ανά τακτά χρονικά διαστήματα, αύξηση του οποίου μπορεί να υποδεικνύει την ελάττωση των επιπέδων της βιταμίνης Κ (134). Στις περισσότερες περιπτώσεις, η ανεπάρκεια των λιποδιαλυτών βιταμινών γίνεται αντιληπτή μόνο από τις κλινικές της εκδηλώσεις ( 124, 125, 135). Σκοπός αυτής της εργασίας ήταν η προεγχειρητική εκτίμηση των επιπέδων λιποδιαλυτών βιταμινών στο αίμα υπερ-παχύσαρκων ασθενών που υποβλήθηκαν σε δυσαπορροφητική επέμβαση κατά Roux-en-Y γαστρικής παράκαμψης με χολοπαγκρεατική εκτροπή, καθώς και η μετεγχειρητική παρακολούθησή τους για ένα έτος, ώστε να καταστεί δυνατή η άμεση εκτίμηση της κατάστασης των ασθενών ως προς τα αποθέματα βιταμίνης A, D E και Κ και να διερευνηθεί κατά πόσο η χειρουργικά προκαλούμενη δυσαπορρόφηση λίπους επηρεάζει την απορρόφησή και τα επίπεδα των λιποδιαλυτών βιταμινών στο αίμα. / Background: Bariatric surgery seems to be the only effective approach for the long-term management of morbid obesity. Weight loss after Roux-en-Y Gastric Bypass with Biliopancreatic Diversion (RYGBP/BPD) is mainly due to decreased calorie absorption secondary to fat malabsorption. Fat malabsorption may also cause essential fat-soluble vitamin deficiencies which may become clinically significant if not recognized and properly treated. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. In this work, an investigation was undertaken to examine preoperative and short-term (1 year) postoperative levels of fat-soluble vitamins in patients undergoing RYGBP/BPD. Methods: Study population consisted of 15 super-obese (BMI>50kg/m2) patients who had undergone RYGBP/BPD. Routine postoperative daily supplementation consisted of 4000 IU (1200 μg) vitamin A, 2000 IU (50 μg) vitamin D3, 10 mg vitamin E and 2000 mg calcium. Preoperative and postoperative serum levels of fat-soluble vitamins A, D3, 25(OH)D3, E, K2, were measured in these patients by HPLC. Results: All vitamin levels tended to decrease with time after RYGBP/BPD operation despite that all patients were taking daily multivitamin supplements p.o. postoperatively. One year after the bariatric operation, a significant decrease (P<0.05) in D3, 25(OH)D3, E and K2 levels was observed compared to the preoperative levels. This decrease led to vitamin deficiency one year after the operation, the incidence of which was 7,7% for vitamin A, 41.7% for vitamin 25(OH) D3 and 27.3% for K2. Concerning vitamin E, all patients had lower than normal levels even before operation and the deficiency insisted even after operation, despite the administration of vitamin supplements to the patients. The low preoperative serum vitamin E levels in the patients confirmed that obese individuals are at high risk of vitamin E deficiency. Conclusions: The serum levels of fat-soluble vitamins A, D, E and K decreased with time following RYGBP/BPD operation in morbidly obese patients, despite that the patients received vitamin supplements postoperatively. The results of our study indicate that patients undergoing the RYGBP/BPD operation need long-term postoperative monitoring of serum fat-soluble vitamin levels. This will facilitate the administration of appropriate doses of multivitamin supplements to these patients, preventing vitamin deficiency to become of clinical significance.

Ο στόχος της παρούσας μελέτης ήταν η σύγκριση των αποτελεσμάτων και των μεταβολικών επιπλοκών της γαστρικής παράκαμψης Roux-en-Y και μιας εκδοχής της χολοπαγκρεατικής εκτροπής σε έναν αποκλειστικά non-superobese πληθυσμό. Τα κύρια χαρακτηριστικά της χολοπαγκρεατικής εκτροπής ήταν: γαστρικός θύλακος 15 ± 5 pml, χολοπαγκρεατική έλικα 200 cm, κοινό κανάλι 100 cm και διατροφική έλικα το λοιπό λεπτό έντερο. Τα κύρια χαρακτηριστικά της RYGBP ήταν: γαστρικός θύλακος 15 ± 5 ml, χολοπαγκρεατική έλικα 60 cm, Roux έλικα 100 cm και κοινό κανάλι το υπόλοιπο μήκος του λεπτού εντέρου. Από 130 ασθενείς με BMI 35-50 kg/m2, οι 65 υποβλήθηκαν σε RYGBP και οι 65 σε BPD. ΄Ολοι οι ασθενείς ολοκλήρωσαν το δεύτερο μετεγχειρητικό έτος. Η μέση απώλεια υπερβάλλοντος βάρους (excess weight loss, %EWL) ήταν καλύτερη μετά από BPD καθόλη τη διάρκεια του follow-up, ενώ στα 2 χρόνια η EWL ήταν > 50% στο 100% των ασθενών της BPD σε σύγκριση με το 88.7% της RYGBP. Η παθολογική ανοχή γλυκόζης, η υπερχοληστερολαιμία, η υπερτριγλυκεριδαιμία και η υπνική άπνοια παρουσίασαν πλήρη ύφεση και στις δύο ομάδες, αλλά τα μέσα επίπεδα ολικής χοληστερόλης ήταν σημαντικά χαμηλότερα μετά από BPD στα 2 χρόνια. Ο διαβήτης υποχώρησε πλήρως σε όλους τους ασθενείς της BPD και σε 7 στους 10 ασθενείς της RYGBP. Δεν παρατηρήθηκαν στατιστικά σημαντικές διαφορές στις πρώιμες και όψιμες μη μεταβολικές επιπλοκές. Υποαλβουμιναιμία παρατηρήθηκε σε 1 ασθενή της RYGBP (1.5%) και σε 6 ασθενείς της BPD (9.2%). Μόνο ένας ασθενής από κάθε ομάδα χρειάστηκε νοσηλεία και ολική παρεντερική διατροφή. Συμπεραίνουμε πως οι μεταβολικές επιπλοκές μετά από BPD δεν ήταν σοβαρές και δεν παρουσίαζαν στατιστικά σημαντική διαφορά ανάμεσα στις δύο ομάδες, οπότε και οι δύο επεμβάσεις είναι ασφαλείς και αποτελεσματικές σε non-superobese πληθυσμούς, αλλά η BPD είναι πιο αποτελεσματική στην απώλεια βάρους και στην επίλυση του διαβήτη και της υπερχοληστερολαιμίας. / The aim of the present study was the comparison of the effectiveness and the metabolic complications of Roux-en-Y gastric bypass (RYGBP) versus a variant of biliopancreatic diversion (BPD) in an exclusively non-superobese population. The main characteristics of the BPD were: gastric pouch 15 ± 5 ml, biliopancreatic limb 200 cm, common channel 100 cm and alimentary limb the remainder of the small intestine. The main characteristics of the RYGBP were: gastric pouch 15 ± 5 ml, biliopancreatic limb 60 cm, Roux limb 100 cm and common channel the remainder of the small intestine. Of 130 patients with BMI 35-50 kg/m2, 65 underwent RYGBP and 65 underwent BPD. All patients completed their second postoperative year. Mean excess weight loss (EWL) was better after BPD at all time periods, and the %EWL was > 50% in all BPD patients compared to 88.7% of RYGBP patients. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at second year. Diabetes completely resolved in all BPD patients and in 7 of the 10 RYGBP patients. No statistically significant differences were observed between the two groups in early and late non-metabolic complications. Hypoalbuminemia occured in only 1 patient after RYGBP (1.5%) and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. We conclude that the metabolic complications that occured following this type of BPD were not severe nor significantly different between the two groups, therefore both operations can be considered safe and effective for non-superobese patients, but BPD is more effective in weight loss as well as the resolution of diabetes and hypercholesterolemia.