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Background: This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). Methods: Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70–79 years) and older patients (≥80 years). Results: IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65–1.29], p =.596 and OR 1.22 [95% CI: 0.61–2.46], p =.508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (−0.14 days [95% CI: −0.29 to 0.01], p =.071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (−0.28 days [95% CI: −0.62 to 0.05], p =.069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (−0.36 days [95% CI: −0.71 to −0.004], p =.048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. Conclusion: ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.

Background: This individual-patient data meta-Analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. Methods: The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. Results: Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD)-3.23 (95 per cent c.i.-4.62 to-1.85) days; P < 0.001) and solid (-3.84 (-5.09 to-2.60) days; P < 0.001) intake, time to passage of first stool (MD-1.38 (-1.82 to-0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to-1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD)-0.04, 95 per cent c.i.-0.08 to-0.01; P = 0.015), less delayed gastric emptying (RD-0.11,-0.22 to-0.01; P = 0.039) and a shorter duration of hospital stay (MD-2.33 (-2.98 to-1.69) days; P < 0.001) without a higher readmission rate. Conclusion: ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.

BACKGROUND: Surgical resection followed by adjuvant mFOLFIRINOX (5-fluorouracil with leucovorin, irinotecan, and oxaliplatin) is currently the standard of care for patients with resectable pancreatic cancer. The main concern regarding adjuvant chemotherapy is that only half of patients actually receive adjuvant treatment. Neoadjuvant chemotherapy, on the other hand, guarantees early systemic treatment and may increase chemotherapy use and thereby improve overall survival. Furthermore, it may prevent futile surgery in patients with rapidly progressive disease. However, some argue that neoadjuvant therapy delays surgery, which could lead to progression towards unresectable disease and thus offset the potential benefits. Comparison of perioperative (i.e., neoadjuvant and adjuvant) with (only) adjuvant administration of mFOLFIRINOX in a randomized controlled trial (RCT) is needed to determine the optimal approach. METHODS: This multicenter, phase 3, RCT will include 378 patients with resectable pancreatic ductal adenocarcinoma with a WHO performance status of 0 or 1. Patients are recruited from 20 Dutch centers and three centers in Norway and Sweden. Resectable pancreatic cancer is defined as no arterial contact and ≤ 90 degrees venous contact. Patients in the intervention arm are scheduled for 8 cycles of neoadjuvant mFOLFIRINOX followed by surgery and 4 cycles of adjuvant mFOLFIRINOX (2-week cycle of oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 150 mg/m2 at day 1, followed by 46 h continuous infusion of 5-fluorouracil 2400 g/m2). Patients in the comparator arm start with surgery followed by 12 cycles of adjuvant mFOLFIRINOX. The primary outcome is overall survival by intention-to-treat. Secondary outcomes include progression-free survival, resection rate, quality of life, adverse events, and surgical complications. To detect a hazard ratio of 0.70 with 80% power, 252 events are needed. The number of events is expected to be reached after the inclusion of

Real-world structural optimisation problems involve multiple loading conditions and design constraints, with responses typically depending on states of discretised governing equations. Generally, one uses gradient-based nested analysis and design approaches to solve these problems. Herein, solving both physical and adjoint problems dominates the overall computational effort. Although not commonly detected, real-world problems can contain linear dependencies between encountered physical and adjoint loads. Manually keeping track of such dependencies becomes tedious as design problems become increasingly involved. This work proposes using a Linear Dependency Aware Solver (LDAS) to detect and exploit such dependencies. The proposed algorithm can efficiently detect linear dependencies between all loads and obtain the exact solution while avoiding unnecessary solves entirely and automatically. Illustrative examples demonstrate the need and benefits of using an LDAS, including a run-time experiment., Computational Design and Mechanics, Materials Innovation Institute

BackgroundNeoadjuvant therapy has several potential advantages over upfront surgery in patients with localized pancreatic cancer; more patients receive systemic treatment, fewer patients undergo futile surgery, and R0 resection rates are higher, thereby possibly improving overall survival (OS). Two recent randomized trials have suggested benefit of neoadjuvant chemoradiotherapy over upfront surgery, both including single-agent chemotherapy regimens. Potentially, the multi-agent FOLFIRINOX regimen (5-fluorouracil with leucovorin, irinotecan, and oxaliplatin) may further improve outcomes in the neoadjuvant setting for localized pancreatic cancer, but randomized studies are needed. The PREOPANC-2 trial investigates whether neoadjuvant FOLFIRINOX improves OS compared with neoadjuvant gemcitabine-based chemoradiotherapy and adjuvant gemcitabine in resectable and borderline resectable pancreatic cancer patients.MethodsThis nationwide multicenter phase III randomized controlled trial includes patients with pathologically confirmed resectable and borderline resectable pancreatic cancer with a WHO performance score of 0 or 1. Resectable pancreatic cancer is defined as no arterial and <= 90 degrees venous involvement; borderline resectable pancreatic cancer is defined as <= 90 degrees arterial and <= 270 degrees venous involvement without occlusion. Patients receive 8cycles of neoadjuvant FOLFIRINOX chemotherapy followed by surgery without adjuvant treatment (arm A), or 3cycles of neoadjuvant gemcitabine with hypofractionated radiotherapy (36Gy in 15 fractions) during the second cycle, followed by surgery and 4cycles of adjuvant gemcitabine (arm B). The primary endpoint is OS by intention-to-treat. Secondary endpoints include progression-free survival, quality of life, resection rate, and R0 resection rate. To detect a hazard ratio of 0.70 with 80% power, 252 events are needed. The number of events is expected to be reached after inclusion of 368 eligible patients as

The stringent and conflicting requirements imposed on optomechanical instruments and the ever-increasing need for higher resolution and quality imagery demands a tightly integrated system design approach. Our aim is to drive the thermomechanical design of multiple components through the optical performance of the complete system. To this end, we propose a new method combining structural-thermal-optical performance analysis and topology optimization while taking into account both component and system level constraints. A 2D two-mirror example demonstrates that the proposed approach is able to improve the system’s spot size error by 95% compared to uncoupled system optimization while satisfying equivalent constraints., Structural Optimization and Mechanics

European Union (EU) citizenship is both about a legal status – a set of civil, social, economic and political rights complementing one’s national citizenship – and about being an active participating member of the EU political community. EU citizenship includes therefore influencing decisionmaking on rules, policies and practices that effect one’s own national and local societies. The opportunities and capacities to exercise these rights and to participate differ between countries, between groups and in time. Social, cultural and economic trends, national or regional crises, as well as national and EU policy responses to these trends and crises, create potentially new inequalities, new barriers, but possibly new opportunities too. Although we cannot predict the future, we can prepare ourselves for different thinkable futures. Through this study we intend to feed the discussion on what might happen with EU citizenship in different circumstances. Moreover, by doing so we also want to stimulate the discussion on what repertoires of action by which actors in what circumstances might protect, foster or boost EU citizenship in these alternative futures. With that in mind, we conducted a scenario study. A scenario is a story about how the future might unfold for organizations, issues, nations or even for the world. The scenario method is originated in the military sphere and was adapted and further developed by consulting firms and companies in the 1950s and 1960s. Pioneering work was conducted in the 1970s by the oil company Shell (Meinert, 2014, p.8). According to Shell (2008, pp.12-19), a scenario study should be carried out to (1) confront assumptions, (2) recognise degrees of uncertainty, (3) widen perspectives, and (4) address dilemmas and conflicts. Over the years, many companies as well as public organisations and governments confronted with the necessity of long-term investment or strategic decisions in a rapidly changing environment followed Shell’s exam

Tools and frameworks for executing impact assessments are useful to provide policy and decision makers with knowledge and guidance. This might help in identifying possible barriers – but also opportunities – for exercising European Union citizenship. Impact assessment is the systematic ex-ante evaluation of the likely or possible consequences of policies, project, programs and other forms of regulation. The existing Impact Assessment guideline in ‘Better Regulation guidelines’ (European Commission, 2015) focus on economic, social and environmental impacts. EU citizenship impacts need to be added to this list to overcome barriers for EU citizenship. Therefore, in the working paper (D11.1) ‘Assessing policy implications for EU citizenship’ (Bakker et al., 2016) options for an impact assessment framework for EU citizenship are explored. In the paper favorable impact assessment approaches are identified even as elements that should be included in the framework and what requirements the framework should meet. However, before to establish an impact assessment framework for EU citizenship, it is necessary to develop indicators to assess EU citizenship. These indicators need to be formulated based on existing (impact assessment) guidelines and documents and based on outcomes of the bEUcitizen project so far. Therefore, we analysed all the deliverables of the bEUcitizen project so far to determine whether attention needs to be paid to specific topics in an impact assessment framework for EU citizenship. Annex I shows an overview of the analyzed deliverables and their topics. In this report, we sketch an overview of the most remarkable topics from the deliverables. This leads towards impact assessment indicators for EU citizenship, which will be the starting point for the Impact Assessment tool for policymakers on the European and the national level (deliverable 11.3).

Since the Treaty of Maastricht (1992), every person holding the nationality of a European Union (EU) Member State is automatically a citizen of the EU and is granted an additional set of rights. In 2007, the Lisbon Treaty strengthened EU citizenship by making the EU Charter of Fundamental Rights legally binding and by expanding the opportunities for democratic participation and increasing the visibility of EU citizen rights. Citizens are and must be at the heart of European integration. Therefore, it is important to make citizens’ lives easier, to help them understand their rights and involve them in a debate on the Europe they want to live in and build for future generations (European Commission, 2013, p.3). At the same time, the European Commission has noted in its 2010 EU citizenship report and in its 2013 EU citizenship report that citizens face difficulties in exercising their rights and are not always aware of the rights they legally possess (European Commission, 2010; European Commission, 2013). To overcome possible barriers and stimulate opportunities for exercising EU citizenship an impact assessment for new policies and regulations might be useful. However, existing Commissions impact assessment guidelines do not focus on EU citizenship impacts. The focus is on economic, social and environmental impacts. Therefore, it is necessary to include EU citizenship. Bakker et al. (2016, p.12) note: “An impact assessment guideline where EU citizenship is included will make decision makers aware of risks for new barriers for citizens when exercising their citizenship rights and, in an ideal world, make them aware of what policies and regulations offer increased opportunities for exercising these rights. In the long term, this leads to a European administrative reality in which it is more easy and common for individual citizens to exercise their EU citizen rights”. To develop an impact assessment framework that focuses on EU citizenship too, different steps ar

Since the Treaty of Maastricht (1992) all nationals of EU member states hold EU citizenship too. EU citizens hold EU citizenship rights in addition to their national rights. These rights include civil, social, economic and political rights. Holding these rights does not guarantee actual participation: there are, for instance, increasingly concerns about (too) low voter turnout and a (too) low number of citizens participating in other activities related to political decision making. Therefore, there seems to be a quest for a European civic culture. Citizenship education, and more specifically European citizenship education, is seen as an important instrument to stimulate the development of a European civic culture. This study shows that (governmental) policies and practices of citizenship education differ widely between the seven examined countries (the Netherlands, Croatia, France, Germany, Ireland, Spain and Hungary). Citizenship education practices are, for instance, deeply related to the type of the democratic development, type of the democratic regime and social issues within the polity. Furthermore, the education practices show great variety of available teaching modules both in formal and informal way. There also seems to be a certain paradox between acknowledging the importance that civic education has for society, and political readiness to acknowledge that specific training is needed for teachers to be eligible to qualitatively educate and prepare students for their roles as active citizens. However, all countries share a very similar approach regarding to the European dimension of citizenship: it is a highly neglected area within the national curriculum. The focus is dominantly on the factual and theoretical knowledge on the EU and especially its institutions rather than the promotion of values and the training of skills needed to exercise EU citizenship rights and needed for development of active, participating EU citizens. Hence, European citizen

The design of high performance instruments often involves the attenuation of poorly damped resonant modes. Current design methods typically rely on informed trial and error based modifications to improve dynamic performance. In this contribution, we present a multi-material topology optimization as an alternative, systematic methodology to design structures with optimized damping characteristics. A parametric, level set-based topology optimization is employed to simultaneously distribute structural and viscoelastic material to optimize the structure’s damping characteristics. To model the viscoelastic behavior a complex-valued material modulus is applied. The structural loss factor is determined from the complex-valued eigensolutions and its value is maximized during the optimization. We demonstrate the performance of the optimization by maximizing the damping of a cantilever beam., Structural Optimization and Mechanics

The design of high performance instruments often involves the attenuation of poorly damped resonant modes. These resonant modes are a limiting factor to the performance of these instruments. Current design approaches typically start from a baseline design and introduce stiffening or damping reinforce- ments to tune and/or damp these modes. However, the influence on the structural damping of these reinforcements is difficult to predict and often results in trial and error-based design approaches for the design of damping reinforcements. A common solution is to introduce viscoelastic material in baseline designs to increase structural damping. These materials dissipate energy when subjected to deformation and should therefore be located at positions which undergo large deformations during vibration. Typically, the viscoelastic material is placed in conventional (un)constrained layer damping configurations. However, to achieve optimized damping characteristics both the location as well as the geometry of viscoelastic material should be optimized. In this thesis, a multi-material topology optimization routine is presented as a systematic method- ology to develop structures with optimal damping characteristics. The proposed method applies a multi-material, parametric level set-based approach to simultaneously distribute structural and vis- coelastic material within the design domain. The developed optimization routine allows for the design of freeform, viscoelastic dampers without the limitation to conventional (un)constrained layer damp- ing configurations and is thereby able to achieve improved damping characteristics. The structural loss factor is applied as a performance measure to compare the damping between different viscoelastically damped structures and as objective function during the optimization. The viscoelastic material behavior is represented by a complex-valued material modulus, which results in a complex-valued eigenvalue problem. The formulation of the s, Precision and Microsystems Engineering, Mechanical, Maritime and Materials Engineering

RIVM rapport:Om de kwaliteit van thuisbevallingen in Nederland in kaart te brengen en te verbeteren, is een set van 23 indicatoren gedefinieerd. Voorbeelden zijn het percentage bevallingen waarbij de verloskundige niet aanwezig is, het percentage doorverwijzingen naar een specialist en het percentage bevallingen waarbij de kraamhulp niet op tijd aanwezig is. Het onderzoek is uitgevoerd in opdracht van de Inspectie voor de Gezondheidszorg (IGZ), die in overleg met de beroepsgroepen indicatoren zal overnemen om beter toezicht te kunnen houden. De indicatoren zijn bepaald door een werkgroep bestaande uit vertegenwoordigers van de beroepsgroepen, de IGZ en het RIVM. De Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV) heeft enkele jaren geleden instrumenten ingevoerd (het kwaliteitsregister, het praktijkanalyse-instrument en praktijkcertificering) om de kwaliteit van de verloskundigepraktijk te verbeteren. Een volgende stap is de kwaliteit van de zorg zichtbaar maken aan de hand van indicatoren. Indicatoren kunnen een meer gedetailleerd inzicht geven in onderdelen van de zorg dan de bestaande kwaliteitstoets. Het zijn meetbare elementen van zorgverlening die een aanwijzing geven over de kwaliteit van die zorg. Om tot de indicatoren te komen, zijn eerst de risicogebieden binnen de eerstelijnsverloskunde bepaald. Vervolgens zijn op basis van literatuurgegevens en richtlijnen conceptindicatoren samengesteld. Daarna is de groslijst voorgelegd aan experts uit het veld. Zij beoordeelden de conceptindicatoren op kwaliteit en haalbaarheid in de dagelijkse praktijk., In order to monitor the quality of home care deliveries in the Netherlands, a set of 23 quality indicators has been defined. The quality indicators include percentages for deliveries without the presence of a midwife, referrals to an obstetrician and deliveries without the presence of a maternity assistant. This research was commissioned by the Netherlands Health Care Inspectorate (IGZ), which, after consultation and agreement with professional groups, will adopt some indicators for their surveillance purposes. The indicators were defined by a steering committee comprising members of the Royal Dutch Organization of Midwives (KNOV), the Association of Obstetric Active General Practitioners (VVAH), a practising midwife, the IGZ, and researchers from the National Institute for Public Health and the Environment (RIVM). Several years ago, the KNOV introduced methods to improve the quality of midwifery care; these included the quality register and practice accreditation. In line with this, the next step will be to use indicators to monitor the quality of midwifery care. Compared to existing quality instruments, indicators are useful for gaining detailed insight into certain aspects of midwifery care. Indicators are measures that reflect, or indicate, the state of health care. The steering committee first identified thirteen quality domains. Subsequently, based on the literature and existing guidelines, a list of possible indicators was generated. This list was then judged by experts from the field. The indicators were judged on their relevance to clinical practice. In addition, their feasibility for the health care professional for deriving information from routinely collected data was judged.

Het lijkt niet logisch: eerst een leeg kantoorpand of ander bouwwerk verbouwen om het geschikt te maken voor een andere functie, om het na een aantal jaren weer terug te verbouwen naar de oorspronkelijke functie. Toch kan het een interessante optie zijn voor (naar verwachting) langdurig leegstaande panden. Bijvoorbeeld als de kantorenmarkt een tijdelijke dip vertoont en naar verwachting over enkele jaren weer aantrekt. Of wanneer een kantorenpark op de schop wordt genomen en gebouwen enkele jaren leeg staan, in afwachting van een grondige renovatie. Tijdelijke bewoning kan dan veelvoorkomende ellende zoals kraken, verpaupering en vandalisme voorkomen. Inkomsten uit tijdelijke verhuur kan de huurderving door leegstand voor een deel compenseren. Een andere situatie waarin tijdelijk transformeren zinvol kan zijn, is herbestemming in afwachting van sloop. Nederland kent hiervan diverse voorbeelden. Verschillende organisaties hebben zich gespecialiseerd in tijdelijk wonen. De meeste hiervan richten zich op antikraak: met minimale voorzieningen wordt het voor een beperkt aantal personen (zonder gebruiksvergunning) mogelijk om te wonen. Voorbeelden van organisaties die een vrijkomend pand volledig benutten en volgens de wettelijke regels aanpakken, zijn Bureau Magnus (voorheen Stichting Tijdelijke Huisvesting Utrecht), dat landelijk actief is, en de Stichting Tijdelijk Wonen (STW) in Utrecht. Het zal duidelijk zijn dat tijdelijke transformatie beperkingen oplegt aan de investeringsruimte en niet voor iedere doelgroep geschikt is. In dit hoofdstuk beschrijven we enkele ervaringen met tijdelijk transformeren., Accepted manuscript, Real Estate Management