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This chapter provides an overview of the model and presents an application of the model. It provides an overview of the community simulation model and also presents an application of the model. The chapter summarizes the types of problems the model has been used on and discusses future directions of model refinement. The driving force is the economic portion of the model which includes a community specific input-output model and a gravity model. A location quotient technique is applied to a regional or state input-output model to derive a community specific input-output model. The simulation model is extremely complex and takes a very knowledgeable regional economist to apply. Community leaders, thru a special committee appointed by the city council, requested that OSU conduct a detailed community simulation study. Data was gathered from the city of Miami concerning housing starts and demolitions.

BACKGROUND: Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS: A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (

The article examines approaches to resilience building adopted by 18 out of the 29 active oyster firms in Zeeland, the southwestern delta province of the Netherlands, where a highly dynamic natural environment exposes oyster growing to known but unpredictable environmental disturbances. Survey results reveal a range of actions across three interrelated areas of decision-making: maricultural practice, the business and the household. Closer analysis indicates two contrasting strategies for resilience building: a more cautious, cost saving approach adopted by the smaller ‘oyster farmer’ and a more adventurous approach based on vertical and horizontal integration favoured by ‘farmer traders’, often involving expansion into other forms of seafood production and trade. The actions of individual firms in seeking to build resilience within their own enterprises is not matched by collaborative initiatives nor, in the view of the industry, by government action.

Background: There is a lack of outcome data beyond local recurrence rates after primary treatment in rectal cancer, despite more information being necessary for clinical decision-making. We sought to determine patient selection, therapeutic modalities and outcomes of locally recurrent rectal cancer treated with curative intent. Methods: We searched MEDLINE (1990-2010) using the medical subject headings "rectal neoplasms" and "neoplasm recurrence, local." Selection of cohort studies was based on the primary intention of treatment and availability of at least 1 outcome variable. Results: We included 55 cohort studies comprising 3767 patients; 8 studies provided data on the rate of intentionally curative treatment from an unselected consecutive cohort of patients (481 of 1188 patients; 40%). Patients were symptomatic with pain in 50% (796 of 1607) of cases. Overall, 3088 of 3767 patients underwent resection. The R0 resection rate was 56% (1484 of 2637 patients). The rate of external beam radiotherapy was 100% in 9 studies, 0% in 5 studies, and ranged from 12% to 97% in 37 studies. Overall postoperative mortality was 2.2% (57 of 2515 patients). Five-year survival was at least 25%, with an upper limit of 41% in 11 of 18 studies including at least 50 resections. We found a significant increase in reported survival rates over time (r(2) = 0.214, p = 0.007). Conclusion: More uniformity in treatment protocols and reporting on outcomes for locally recurrent rectal cancer is warranted. The observed improvement of reported survival rates in time is probably related to better patient selection and optimized multimodality treatment in specialized centres

Aim Comparison of functional and surgical outcome of the J-pouch with the side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients. Method In a multicentre study, patients with a carcinoma of the lower two-thirds of the rectum were randomized to either a J-pouch or a side-to-end reconstruction. Primary outcome was function of the neorectum 1 year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC-QLQ-CR38 and SF-36) were to be completed by all participants preoperatively, and 4 and 12 months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15-point difference of the COREFO scale. Results In total, 107 patients were randomized, 55 in the J-pouch group and 52 in the side-to-end anastomosis group. The COREFO incontinence scale at 4 months and the total functional outcome at 4 and 12 months showed better results for the J-pouch group in comparison with the side-to-end anastomosis group. The remaining COREFO scales (frequency, social impact, stool-related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups. Conclusion The overall results of a coloanal J-pouch and a side-to-end anastomosis are comparable, although functional results are slightly better with a J-pouch. The side-to-end anastomosis is technically less demanding and therefore a justified alternative in sphincter-saving surgery.

OBJECTIVES: Preoperative radiotherapy followed by rectal resection with total mesorectal excision (TME) and colo-anal anastomosis severely compromises anorectal function, which has been attributed to a decrease in neorectal capacity and neorectal compliance. However, to what extent altered motility of the neorectum is involved, is still unknown. The aim of the study was to compare the motor response to (prolonged) filling of the (neo-) rectum in patients after preoperative radiotherapy and rectal resection with that in healthy volunteers (HV). METHODS: Neorectal function (J-pouch or side-to-end anastomosis) was studied in 15 patients (median age 61 years, 10 males) 5 months after short-term preoperative radiotherapy (5 x 5 Gy) and rectal resection with TME for rectal cancer and compared with that of 10 volunteers (median age 41 years, 7 males). Furthermore, patients with a colonic J-pouch anastomosis (n = 6) were compared with patients with a side-to-end anastomosis (n = 9). (Neo-) rectal sensitivity was assessed using a stepwise isovolumetric and isobaric distension protocol. (Neo-) rectal motility was determined during prolonged distension at the threshold of the urge to defecate. RESULTS: The neorectal volume of patients at the threshold of the urge to defecate (125 +/- 45 ml) was significantly lower when compared with that of HV (272 +/- 87 ml, P

Errors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care.To design and implement an interactive learning exercise to teach second year medical students about medication reconciliationNorthwestern University Feinberg School of Medicine, Chicago, IL PROGRAM DESCRIPTION: The Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history.At the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class.The Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.

SUMMARY The poultry industry is an essential part of the region’s economy in western Arkansas and eastern Oklahoma. With poultry production has come large amounts of poultry litter to the region. Some suggest excess nutrients from poultry litter have negatively affected water, lowering its usefulness for recreational purposes. This conflict has put the poultry industry at the heart of environmental litigation in the region. The purpose of this paper was to examine, first, the economic contributions of the poultry industry in the region and, second, the potential economic costs associated with meeting water quality standards by reducing the amount of poultry litter produced. Results show that the poultry industry as a whole supports over 34,000 jobs in the northern economic region of the study area and nearly 15,500 jobs in the central region. Results also indicate that the economic activity in the northern region could decrease by around 2% and by over 3% in the central region due to regulations on the use of poultry litter. These results are useful for those interested in the economic contribution of the poultry industry to the region, including poultry integrators and producers as well as to policymakers looking to balance environmental quality and economic development.

Context: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. Purpose: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. Methods: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. Findings: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6 985 033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3 094 547. The hospitals had a net change of $4 293 040 Conclusions: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.

ejd.2011.1293 Auteur(s) : K.M. OLDE LOOHUIS, A. DOEKSEN, BC VROUENRAETS bc.vrouenraets@slaz.nl Department of Surgery, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, 1006 AE Amsterdam, the Netherlands A 60-year-old single man presented at our outpatient clinic with a chronic wound measuring 30×15 cm on his left flank (figure 1A). The wound had started as a small ulcerating skin defect 10 years before presentation, and had slowly progressed over time, without healing tendency. Except for being [...]

collection efforts for these species in 2011, recommending commercial catch surveys as an option to improve data collection. Following from this Ekofish has taken the lead and has initiated a pilot data-collection project, in which commercial catch data will be collected aboard their twinrig vessels during one season for the species dab, lemon sole, turbot, and brill. The aim of this pilot project is to progress towards science-based management and MSC certification of the mentioned species. This project is carried out in collaboration with the NSF and IMARES. Phase one of this project explores the hurdles and the opportunities for fisheries management and stock assessment for the North Sea species brill, turbot, lemon sole and dab.

This study presents a detailed model for measuring the economic effects of the health sector on a local economy. The total effects of the health sector on employment, income, retail sales, and sales tax collection by health category (hospitals, doctors and dentists, nursing and residential facilities, other medical and health services, and pharmacies) is presented. The model's application in nine Oklahoma counties found that approximately 9 percent of the total employment for each county was directly working in the health sector. With multipliers ranging from 1.45 to 1.87 applied to measure the total effects, including secondary employment, the health sector accounted for approximately 14 percent of all employment. This study provides an overview of the model, which employs local data and county input-output multipliers. The study illustrates the usefulness and simplicity of the model by presenting results for Perry, OK.

People stay away from places where they don't feel safe. Today they tend to stay away from their own streets, the bones of the community. Many residents in New Zealand and Australian suburbs do not know their neighbours' names and hardly recognise their neighbours' children. In Australia, the alienation of residents from their neighbourhood is of such dramatic proportions that the Prime Minister announced a national committee whose agenda focuses on the question: Why are Australian suburbs so uninviting and hostile? In New Zealand, the government doesn't feel itself responsible for the decay of the suburb. Planning and urban design is not on the agenda since even state housing is seen more as a nuisance than a tool. Design restrictions are felt as limitations to the free market principle of the survival of the fittest (richest). What's wrong with the New Zealand suburb, is probably what's wrong with many suburbs all over the world. People are fencing themselves off, even literally; they don't trust the public space any more. What once formed the lifelines of a community are now barriers in between. This paper concentrates on the important role of social surveillance in the neighbourhood street as one of the proven remedies for fear and crime, and will suggest how this social surveillance can be improved through planning and design. It will also look at design opportunities for the restoration of the feeling of communal attachment to a place; this is particularly important for the revival of the ‘communal responsibility’ through ‘shared ownership’ which in turn can activate better social surveillance.

Laparoscopic resection for low rectal cancer remains controversial, and large randomized studies on oncologic outcome are lacking. The objective of this study was to analyze the short-term results of laparoscopic resection versus conventional total mesorectal excision (TME) for low rectal cancer (≤10 cm from the anal verge). The institutional colorectal surgery database was reviewed, and 166 consecutive patients operated for low rectal cancer between 2006 and 2011 were included in this analysis which focuses on the first 18 months of follow-up. Eighty patients underwent conventional TME, whereas 86 patients underwent laparoscopic TME. Patient characteristics were comparable between groups. Conversion rate was 17 %. Laparoscopic rectal resection resulted in significantly less blood loss (200 versus 475 ml, p =

Purpose: The purpose of this study was to prospectively compare rectal resection (RR) with colonic resection on sexual, urinary and bowel function and quality of life in both short-term and long-term. Methods: Eighty-three patients who underwent RR were compared to 53 patients who underwent a colonic resection leaving the rectum in situ (RIS). A questionnaire assessing sexual, urinary and bowel functioning with a quality of life questionnaire (SF-36) was sent to all participants preoperatively, 3 and 12 months postoperatively and approximately 8 years after the onset of the study. Results: Short-term dysfunction included diminished sexual activity in female RR patients at 3 months and significantly more erectile dysfunction in RR patients 1 year postoperatively. Long-term dysfunction included more frequent and more severe erectile dysfunction in RR patients compared to RIS patients. These short-term and long-term outcomes did not influence overall quality of life. The incidence of urinary dysfunction was comparable between both groups. Bowel functioning was significantly better in the RIS group compared to the RR group 3 months and 1 year postoperatively. Conclusions: Patients who underwent RR experienced up to 1 year postoperatively more sexual and bowel function problems than RIS patients. However, short-term and long-term dysfunction did not influence overall quality of life. Erectile dysfunction in male RR patients persisted in time, whereas other aspects of sexual, urinary and bowel function after RR and colonic resection are similar after a median follow-up of 8.5 years.

Comparison of functional and surgical outcome of the J-pouch with the side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients.In a multicentre study, patients with a carcinoma of the lower two-thirds of the rectum were randomized to either a J-pouch or a side-to-end reconstruction. Primary outcome was function of the neorectum 1 year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC-QLQ-CR38 and SF-36) were to be completed by all participants preoperatively, and 4 and 12 months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15-point difference of the COREFO scale.In total, 107 patients were randomized, 55 in the J-pouch group and 52 in the side-to-end anastomosis group. The COREFO incontinence scale at 4 months and the total functional outcome at 4 and 12 months showed better results for the J-pouch group in comparison with the side-to-end anastomosis group. The remaining COREFO scales (frequency, social impact, stool-related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups.The overall results of a coloanal J-pouch and a side-to-end anastomosis are comparable, although functional results are slightly better with a J-pouch. The side-to-end anastomosis is technically less demanding and therefore a justified alternative in sphincter-saving surgery.

Darmkanker is na borst- en longkanker de meest voorkomende vorm van kanker, en komt in toenemende mate voor in Nederland. Daarnaast stijgt het aantal goedaardige darmaandoeningen waarvoor veel patiënten een operatie moeten ondergaan. De chirurg heeft een leidende rol in de behandeling van kwaadaardige en goedaardige darmtumoren. Annemiek Doeksen gaat in op het uitvoeren van de technische procedure met het beste resultaat, zodat patiënten na de behandeling van de ziekte een betere kwaliteit van leven hebben. Ze behandelt ook de vroege herkenning en behandeling van complicaties, zodat de postoperatieve morbiditeit en sterfte verlaagd kunnen worden. Omdat de chirurg het directe resultaat ziet van zijn handelen op ziekte, kan hij een inschatting maken van de voor- en nadelen. De rol van de chirurg betreft daarom volgens Doeksen bij uitstek het kritisch beoordelen van bestaande behandelingen en protocollen.