Abstract It is noted that the major driving forces of development of subacute care market include the prospective payment system such as DRGs TW-DRGs payment policy started in January of 2010, and will be completely implemented during the coming 5 years. And it is expected that some of the untoward reactions of the medical care providers will change its structure and behavior in response to the financial fluctuation and operation risks¡Athis conditions give birth to the subacute care market. The purpose of the study includes (1)Estimation of the potential subacute care market raising by the impletement of the TW-DRGs payment policy. (2)How can the present medical service providers pave the way to joint the subacute care market. (3)Is there a chance to establish a new service model according to the operation circumstance in Taiwan!? Our study of subacute care and these issures involved an extensive literatures and documents review as well as interviews with knowledgeable experts from around the sourthern part of the country (including professor of medical college and management college, CEO of hospitals and nursing facilities and officer of public health department ) quantiatative analysis of the collected data was done. We came to a conclusion that there will be enomerous demand of subacute care market and there is no so-called subacute care provider noted in the Taiwan medical service system. The imbalance between demand and supplyment will lead to a chance of developing a new service model acccoding to the specific requirement of the people. Since patients and providers will response to the payment system designed and executed by the policy-maker of the government, our suggestion of policy implication about setting up the subacute care system include : 1. Defining subacute care clearly. 2. Recognizing proper requirements of providers. 3. Identifying rational clinical approach. 4. Improving patient placement and transfer process. 5. Ensuring that the care is reimbursed adequately and appropriately. Key Words: TW-DRGs¡ASubacute Care¡AStrategy

The effects of induced subacute ruminal acidosis (SARA) using grain pellet-based (GPI) and alfalfa pellet-based diet models on systemic immunological parameters were evaluated in nonlactating Holstein cows. The systemic immunological parameters analysed in this study included rectal temperature, blood cell leukogram, expression of lipopolysaccharide (LPS) recognition receptors on leukocytic cells, and plasma and serum proteins. Also, blood biochemistry was analysed. There were no significant differences in rectal temperature, blood cell leukogram, expression of LPS recognition receptors and fibrinogen or haptoglobin concentrations between control and SARA induction treatments. Concentrations of serum amyloid A and lipopolysaccharide-binding protein increased while total protein concentrations decreased in response to GPI SARA compared to control. Blood glucose and urea concentrations increased and decreased, respectively, with GPI SARA treatment. Grain pellet-induced SARA resulted in changes to serum proteins and acute phase proteins but did not affect other systemic immunological parameters suggesting a localized inflammatory response was initiated.

The effects of induced subacute ruminal acidosis (SARA) using grain pellet-based (GPI) and alfalfa pellet-based diet models on systemic immunological parameters were evaluated in nonlactating Holstein cows. The systemic immunological parameters analysed in this study included rectal temperature, blood cell leukogram, expression of lipopolysaccharide (LPS) recognition receptors on leukocytic cells, and plasma and serum proteins. Also, blood biochemistry was analysed. There were no significant differences in rectal temperature, blood cell leukogram, expression of LPS recognition receptors and fibrinogen or haptoglobin concentrations between control and SARA induction treatments. Concentrations of serum amyloid A and lipopolysaccharide-binding protein increased while total protein concentrations decreased in response to GPI SARA compared to control. Blood glucose and urea concentrations increased and decreased, respectively, with GPI SARA treatment. Grain pellet-induced SARA resulted in changes to serum proteins and acute phase proteins but did not affect other systemic immunological parameters suggesting a localized inflammatory response was initiated.

L'acidose ruminale latente (ou acidose sub-clinique) est une préoccupation majeure pour la nutrition des ruminants à haut potentiel de production. Cet état se caractérise par une instabilité du microbiote et des fermentations ruminales qui s’orientent variablement vers le propionate et/ou le butyrate. L’une des stratégies de prévention de l’acidose latente consiste à distribuer dans l’alimentation des ruminants des probiotiques capables de rééquilibrer le microbiote et les fermentations ruminales (dans un sens favorable pour l’animal). L’analyse de la bibliographie montre toutefois que l’effet des probiotiques, et plus particulièrement des bactéries probiotiques (BP), est variable et parfois contradictoire ce qui serait probablement lié à l’instabilité du microbiote. Afin d’étudier la possibilité de prévenir l’acidose latente par les bactéries propioniques et/ou lactiques, nous avons émis l’hypothèse que leur efficacité dépend des orientations fermentaires dans le rumen. Des acidoses latentes butyrique et propionique caractérisées par des profils fermentaires et microbiens distincts ont été développées chez le mouton non productif et la vache laitière pour étudier l’effet et le mode d’action de la bactérie propionique P63 seule ou associée aux lactobacilles Lb. plantarum ou Lb. rhamnosus (P63, Lp + P63 et Lr + P63) sur le fonctionnement de l’écosystème ruminal et les performances animales. Chez le mouton en situation d’acidose propionique, les BP utilisées ont amélioré le pH ruminal via une réduction de la proportion en lactobacilles. Chez la vache laitière, la stabilisation du pH a été associée à une moindre disponibilité en hydrogène susceptible d’être transformé en protons, suite à une augmentation de la propionogenèse et/ou de la densité bactérienne, deux voies consommatrices d’hydrogène. Au cours de l’acidose latente butyrique, l’amélioration du pH n’a été observée que chez les moutons supplémentés avec Lp + P63. Cet effet semblait être dû à une diminution des acides gras volatils et de la proportion en S. bovis mais aussi à un pH initial faible (pH < 5,5) probablement optimal pour l’action des BP ; ce qui n’était pas le cas chez les vaches pour lesquelles le pH initial était compris entre 5,9 et 6,1. En revanche, l’efficacité digestive a été augmentée par l’association de P63 aux lactobacilles chez la vache laitière. L’association Lp + P63 a augmenté les activités fibrolytiques (cellulase, xylanase) et la digestibilité de la matière organique, tandis que Lr + P63 a amélioré la digestion des fibres et a diminué la production de méthane de 25%. Nous n’avons pas observé d’effet sur les performances zootechniques, ce qui serait probablement dû au dispositif expérimental en carré Latin qui n’est peut-être pas optimal pour mettre en évidence l’effet des BP. Nos résultats sont les premiers à démontrer l’efficacité des bactéries probiotiques pour sécuriser et/ou améliorer la digestion des rations et réduire la production de méthane chez le ruminant en acidose, et l’association de P63 avec les souches de Lactobacillus sont les plus efficaces. Enfin, nous avons validé notre hypothèse selon laquelle l’effet et le mode d’action des bactéries probiotiques pour prévenir l’acidose dépendent des orientations fermentaires dans le rumen. / Subacute ruminal acidosis (SARA) is a major concern for the nutrition of high-producing ruminants. This digestive disorder is characterized by the instability of the microbial ecosystem and fermentations which are oriented towards propionate and/or butyrate at the expense of acetate (propionic or butyric SARA). Among the strategies used to prevent SARA, supplementation with direct-fed microbials (DFMs) is thought to be able to balance the ruminal microbiota and fermentation. The analysis of the literature shows that the effect of DFMs, especially bacterial ones, is variable and sometimes contradictory which is probably related to the instability of the microbiota. To investigate the possibility of preventing SARA by propionibacteria and/or lactobacilli based DFMs, we hypothesized that their effectiveness depends on the ruminal fermentation patterns. Butyric and propionic SARA, characterized by distinct microbial and fermentation profiles, have been developed in non-productive sheep and lactating dairy cows to investigate the effects and mode of action of the Propionibacterium P63 alone or in conjunction with the lactobacilli strains Lb. plantarum or Lb. rhamnosus (P63, P63 and Lp + Lr + P63) on the ruminal ecosystem and animal performances. During the propionic SARA induced in sheep, the DFMs used increased the ruminal pH with a concomitant reduction in the lactobacilli population. In dairy cows, the pH stabilization was associated with a lower availability of hydrogen capable of being transformed into protons, following a stimulation of propionogenesis and/or bacterial growth that consume hydrogen. During butyric SARA, improvement in pH was observed only in sheep supplemented with Lp + P63. This effect appeared to be due to a decrease in VFA production and S. bovis proportion. Moreover, the lower initial pH (pH <5.5) was probably optimal for DFMs action, which was not the case for the dairy cows for which the initial pH was between 5.9 and 6.1. For the dairy cows, diet digestion was improved when P63 and lactobacilli association were fed. Indeed, Lp + P63 increased the fibrolytic activities (cellulase, xylanase) and digestibility of organic matter, while Lr + P63 improved fiber digestion and decreased methane production by 25%. We did not observe any effect on animal performances, which was probably due to the Latin square design that is not the best to evaluate the DFMs effects on animal performances. Our results are the first to demonstrate the effectiveness of bacterial DFMs to secure and/or improve diet digestion and reduce methane production in ruminants. Moreover, it seems that the association of P63 with the lactobacilli strains is more effective. Finally, we validated our hypothesis that the effect and mode of action of bacterial DFMs to prevent SARA is conditioned by ruminal fermentation patterns.

The benefits of brief-duration, early exercise programs in stroke have been shown, but the effects of longer-duration aerobic training early after stroke have not been examined. The purpose of this study was to determine the effects of an early aerobic exercise program that extended beyond inpatient into outpatient rehabilitation on aerobic capacity, walking parameters (walking distance, speed, and symmetry), health-related quality of life, and balance. Patients in the subacute phase after stroke (n = 15) with mild to moderate impairment received aerobic exercise in addition to conventional rehabilitation. The study participants demonstrated significant improvement in aerobic and walking capacity, peak work rate, quality of life, balance, and gait velocity from baseline to midpoint. However, no difference was found between midpoint and final. This early aerobic exercise program following stroke significantly improved aerobic capacity, walking ability, quality of life and balance during the inpatient period although no further improvement was observed during the outpatient period.

The benefits of brief-duration, early exercise programs in stroke have been shown, but the effects of longer-duration aerobic training early after stroke have not been examined. The purpose of this study was to determine the effects of an early aerobic exercise program that extended beyond inpatient into outpatient rehabilitation on aerobic capacity, walking parameters (walking distance, speed, and symmetry), health-related quality of life, and balance. Patients in the subacute phase after stroke (n = 15) with mild to moderate impairment received aerobic exercise in addition to conventional rehabilitation. The study participants demonstrated significant improvement in aerobic and walking capacity, peak work rate, quality of life, balance, and gait velocity from baseline to midpoint. However, no difference was found between midpoint and final. This early aerobic exercise program following stroke significantly improved aerobic capacity, walking ability, quality of life and balance during the inpatient period although no further improvement was observed during the outpatient period.

This work helps to determine the extent of immune system involvement in the adaptive response to subacute ruminal acidosis (SARA) in three parts. The first (Chapter 2) uses non-lactating cows to study specific changes in inflammatory protein expression in which SARA is created. The second (Chapter 3), uses the same model as Chapter 2. However, in this case, lactating cows are used to help establish the time course for adaptation to acidosis. The third part (Chapter 4) delineates the genomic changes that occur in the rumen epithelium when a therapeutic intervention is introduced using exogenous supplemental butyrate. In the first experiment, the expression of the extracellular matrix (ECM) proteins type IV collagen and laminin β1 decreased, and the monocarboxylate transporter MCT1, increased during the acidotic challenge. Nuclear factor of activated T-cells, NFATc2, and tumour necrosis factor alpha (TNF-α) decreased while interleukin-1 beta (IL-1β) increased during the experimental treatment period. Chapter 3 measured lipopolysaccharide (LPS) and its carrier, LPS binding protein, LBP, which were found to be elevated due to SARA. Moreover, NFATc2 was reduced during this period. Exogenous butyrate resulted in increased plasma LBP, plasma beta hydroxyl butyrate (BHBA), and ruminal butyrate. Milk parameters (total protein and fat) were unaffected by treatment, as were rumen LPS, acetate, valerate, isovalerate, and isobutyrate. Moreover, exogenous butyrate increased gene transcription of genes involved in non-specific host defences (NHSD) such as mucin, and remodelling (RM), such as matrix metallopeptidase 16 (MMP16), and decreased the transcription of genes of the immune response (IR), such as nuclear factor kappa B2 (NFκB2). Together, these three experiments have demonstrated that although wound healing is mediated by the immune system in more severe models of epithelial damage, our model of SARA did not involve full-thickness, penetrating lesions and hence did not involve the systemic immune system to such a degree than was previously thought. In addition, we were able to demonstrate that the addition of butyrate to this model of grain-induced acidosis was beneficial, as it decreased the local inflammatory response and helped the epithelium adapt to its harsher environment. / Agriculture and Agri-Food Canada, the National Sciences and Engineering Council of Canada (NSERC), the Ontario Ministry of Agriculture, Food and Rural Affairs (OMAFRA), the Canadian Dairy Commission (CDC), and the Dairy Farmers of Ontario (DFO).

En France, on estime à 150 000 le nombre d’accident vasculaire cérébraux par an. Avec un coût de 8,3 milliards d’euros, c’est devenu une problématique de santé publique. Les dépenses sont, entre autres, lié aux séquelles, car 43,2 % sortent d’hospitalisation en étant dépendant physiquement.Ces séquelles vont séquelle vont être à l’origine de limitations, provoquant un cercle vicieux d’inactivité, et amenant un déconditionnement. Pour lutter contre ce déconditionnement, il semble pertinent de respecter les recommandations des sociétés savantes en termes d’activité physique (AP). Néanmoins en retour à domicile, très peu de patients atteignent le minimum d’AP requis. L’éducation thérapeutique du patient (ETP) semble être une option pertinente pour remédier à ce problème.Ce travail de recherche s’est donc intéressé à l’effet d’un programme ETP à l’AP chez des patients en phase subaigue. Le programme était effectué au domicile des patients, et était composé de visites à domicile et d’appels téléphoniques. L’AP était contrôlée grâce à un actimètre et des livrets de suivi.Après les 6 mois du programme, il ressort une augmentation du périmètre de marche, mais pas d’impact sur la force des membres inférieurs, la composition corporelle, la fatigue et la dépression.Les principales caractéristiques des patients volontaires à un programme ETP à l’AP étaient la persistance de la fatigue, la dépression, peu de séquelles neuro-motrices physiques et un fort soutien de l’entourage. Enfin, au cours des 6 mois de suivi, les patients ont maintenu des durées d’AP qui étaient au-dessus des recommandations en termes d’AP. / In France, we estimate at 150,000 the number of cerebral vascular accident per year. With a cost of 8.3 billion euros, it has become a public health issue. The expenses are, among others, related to legacy, as 43.2% leave hospital being physically dependent.These effects will aftereffect will cause limitations, causing a vicious cycle of inactivity and deconditioning bringing. To fight against this deconditioning, it seems appropriate to follow the recommendations of learned societies in terms of physical activity (PA). Yet back home, very few patients reach the minimum required AP. Therapeutic patient education (TPE) seems to be a relevant option to address this problem.This research is therefore interested in the effect of ETP to the AP in patients with subacute phase. The program was conducted in patients' homes, and consisted of home visits and phone calls. The PA was controlled through a actimeter and monitoring booklets.After 6 months of the program, it appears an increase in the walking distance, but no impact on the strength of lower limbs, body composition, fatigue and depression.The main characteristics of volunteer patients to ETP to the PA were persistent fatigue, depression, few physical neuro-motor sequelae and strong support from the entourage.Finally, during the 6 months follow-up, patients maintained durations of AP which were above recommendations in terms of AP.

Author's name: Bc. Sára Miczová Supervisor:: Mgr. Miriama Dědková, DiS Opponent: Thesis title: Occupational therapy practise guidelines in patients with functional upper limb impairment after stroke in subacute phase To be able to provide occupational therapy intervention of high quality the occupatioal therpaists should rely on relevant standards of clinical care and clinical guidelines. (Švestková, 2018). Occupational therapists as well as other members of the interdisciplinar team provide professional care to the patients recovering from stroke. Those patients often have to deal with upper limb impairment which leads to decrese of quality of life. Relevant studies focused on this topic were searched via key words in PubMed, Web of Science and OVID Evidence Based Medicine Reviews databasis. The criterias of selection were: public access to the content, english language which were mainly focused on stroke patients rehabilitation. The suggestion of guideline was created based on methods accepted by department. The occupational therapist as well as physiotherapeutist of early rehabilitation were included in the process of creating the guideline using the GRADE programme for it. Only 48 out of 4054 studies were used, these were divided into two cathegories, one being the cathegory of assessment, the...

Objetivou-se adequar modelo de indução de acidose ruminal por ácidos graxos de cadeia curta (ARAGCC), com uso de polpa cítrica (PC), para bovinos mais pesados, assim como avaliar o metabolismo ruminal, alterações comportamentais, clínicas e diagnósticas. Para o primeiro objetivo foram utilizadas três vacas Nelore (544,2 &#177; 47 kg), com cânula ruminal, e alimentadas, duas vezes ao dia, com 75% de feno e de 25% concentrados. A dose fixa de PC (1,65% do peso vivo) administrada na cânula ruminal gerou inicialmente acidose láctica ruminal e após adequações apurou-se a fórmula (g de PC = Peso corporal 0,75 x 54,7) que provocou adequado quadro de ARAGCC (pH ruminal entre 5,8 e 5,2 com duração mínima de 5h). No 2º experimento foram empregados outros 10 animais da mesma raça, sexo e peso semelhantes, com a mesma alimentação, por no mínimo 45 dias antes da indução, acompanhando-se o consumo de matéria seca (CMS). No dia anterior à indução e nos próximos três dias foram registrados, a cada 5 min, o tempo de ruminação (TR), ingestão de alimentos (TIG) e ócio (decúbito e em estação), assim como o pH ruminal, por meio de bólus intraruminal de mensuração contínua. No decorrer do 1º dia foram coletadas amostras de fluido ruminal, sangue, fezes e urina e realizado exame clínico em oito momentos (zero, 3, 6, 9, 12, 15, 18 e 24h). Nove horas após o oferecimento matinal dos alimentos foram mensurados os movimentos ruminais (MR) no 2º e 3º dias. O pH ruminal na ARAGCC foi sempre inferior ao período basal, com duração da acidose de 547 &#177; 215 min, pH mínimo de 5,38 &#177; 0,16 e pH médio durante a acidose de 5,62 &#177; 0,1. Essa foi provocada principalmente por AGCC (máximo de 118,4 &#177; 9,3 mM/L), com máxima produção de ácido láctico (7,17mM/L) e de ácido láctico D (0,56 mM/L) na 6ª h. A osmolaridade foi máxima na 3ª h (405,5 &#177; 45,2 mOsm/L) influenciada pelo ácido láctico e teor de glicose ruminal. O CMS foi reduzido de 10 &#177; 1,23 kg no período basal em 66,3% no 1º d e 48% no 2º d regularizando-se no 3º. Quanto menor o pH médio da ARAGCC (R2 = 0,679), o TR (R2 = 0,807) a MR (R2 = 0,739) e quanto maior a osmolaridade ruminal (R2 = 0,5461) menor o CMS. O tempo para consumir 1 kg de MS aumentou de 32 &#177; 4 min no tempo basal para 94 no 1º d e 90 min no 2º d, normalizando-se no 3º. O TR foi reduzido de 450 &#177; 68 min no período basal em 58,4% no 1º d, em 48,7% no 2º d e em 20,9% no 3º d e foi influenciado positivamente pelo pH médio (R2 = 0,807). Os animais não modificaram o tempo de ócio em estação, mas aumentaram o tempo o de decúbito em relação ao período basal (380 &#177; 60 min) em 38,9% no 1º d em 26,6 % no 2º, regularizando-se no 3º. O decúbito foi mais prolongado quanto menor foi o pH ruminal mínimo (R2 = 0,466) e o grau de depressão neurológica (R2 = 0,616). Quanto menor o pH mínimo (R2 = 0,639) e maior o teor de lactato L ruminal (R2 = 0,373) maior o grau de depressão neurológica. O potencial de oxirredução, a acidez titulável e o tempo de redução de azul de metileno, em conjunto com o pH ruminal, podem auxiliar no diagnóstico da ARAGCC. / Thirteen, rumen cannulated, Nellore cows (544.2 &#177; 47 kg) were used in two different studies. The first one was carried out to set up a standard model for induction of rumen acidosis by short chain fatty acid (RASCFA) in heavier cattle (n= 3 cows) with the use of citrus pulp (CF) (1.65% BW of CF into the rumen). The remaining, studied the effect of RASCFA on ruminal metabolism, behavior changes, clinical and diagnostics aspects (n=10). The cows were housed in individual tie stalls and fed twice a day 75% coast-cross hay and 25% commercial concentrates, for 45d before the trials, with feed intake (FI) monitored. The standard model caused initially rumen lactic acidosis, but after some corrections (g CP = BW 0.75 x 54.7) induced RASCFA adequately (rumen pH between 5.8 and 5.2 for at least 5h). On the day before and for three consecutive days after induction the following variables were recorded every 5 min: time spending for rumination (TR), for feeding intake (TFI), for idle laying down (ILD) or idle standing (IS). On the day before and during the day of induction an intraruminal bolus for measuring rumen, pH each 5 min, were installed. Rumen fluid, blood, fecal and urine samples were collected and clinical examination carried out every three hour on the day of induction. Rumen movements (RM) were also recorded on the 2ndand 3rd d 9h after the morning feeding. The rumen pH of RASCFA was always lower than the basal time and the lasting of acidosis was 547 &#177; 215 min, minimum pH 5.38 &#177; 0.16 and the average pH during acidosis 5.62 &#177; 0.1. The rumen acidosis was caused mainly by SCFA (maximum 118.4 &#177; 9.3 mM/L), L-lactic acid (7.17mM/L) and D-lactic acid (0.56 mM/L) on the 6thh. Osmolality was maximum at the 3rdh (405.5 &#177; 45.2 mOsm/L) mostly caused by lactic acid and glucose. FI was reduced 66.3 % on the 1std and 48% on the 2ndd returning to normal status on the 3rd d (basal 10 &#177; 1,23 kg). The FI was positively influenced by the average rumen pH (R2 = 0.679), the RM (R2 = 0.807), and MR (R2 = 0.739), but negatively by the rumen osmolality (R2 = 0.546). The time for consumption of 1 kg DM was higher on the 1std (94 min) and 2nd d (90 min) but recovery on the 3rd d (basal 32 &#177; 4 min). The TR was reduced on the 1st d (58.4%), 2nd d (48.7%) and 3rd d (20.9) (basal 450 &#177; 68 min) and was mostly positively influenced by the average rumen pH (R2 = 0.8077). The IS hasnt change, but ILD time increased by 38.9% on the 1std, 26.6% on the 2ndd returning to normal on the 3rdd (basal 380 &#177; 60 min). The ILD time was negatively influenced by the minimum rumen pH (R2 = 0.466) and the neurological depression status (R2 = 0.616). The neurological depression status was positively influenced by the rumen minimum pH (R2 = 0.639) and positively by the level of rumen L-lactic acid (R2 = 0.3733). The tests of redox potential, titratable acidity and time for reduction of methylene blue, along with rumen pH, are good alternatives for diagnosing RASCFA.