Large-grain scintillator screens for proton radiography.

Protons from the Los Alamos Neutron Science Center have been used for pulsed radiography in dynamic experiments for the past 25 years. Pulses of protons are imaged on a scintillator, and the light from these images is captured by fast gated cameras. The need for fast, bright scintillators has led to some compromises in image quality due to tiling the scintillators and backgrounds with totally internally reflected light. We show how large-grain scintillator screens, made using a thin plastic binder, solve these problems.

Correcting implicit solvation at metal/water interfaces through the incorporation of competitive water adsorption.

Conventional continuum solvation models are ubiquitous in computational catalysis, including for describing metal/water interfaces, which are relevant to both solution-phase heterogeneous catalysis and electrocatalysis. Nonetheless, we find that such continuum models qualitatively fail to describe both the adsorption free energy and conformational preference for many organic molecules at such interfaces, largely due to the failure of continuum models to incorporate the role of competitive water adsorption. We develop a simple phenomenological model that accounts for competitive water adsorption and show that the model, when used in conjunction with continuum solvation, provides a dramatic improvement in the description of both adsorption and conformational preference. The model is also extended to additionally incorporate the influence of applied potential at the electrode surface, thus facilitating computationally efficient applications to scenarios including electrocatalysis.

Optical and electronic functionality arising from controlled defect formation in nanoscale complex oxide lateral epitaxy.

Epitaxial crystallization of complex oxides provides the means to create materials with precisely selected composition, strain, and orientation, thereby controlling their functionalities. Extending this control to nanoscale three-dimensional geometries can be accomplished via a three-dimensional analog of oxide solid-phase epitaxy, lateral epitaxial crystallization. The orientation of crystals within laterally crystallized SrTiO3 systematically changes from the orientation of the SrTiO3 substrate. This evolution occurs as a function of lateral crystallization distance, with a rate of approximately 50° µm-1. The mechanism of the rotation is consistent with a steady-state stress of tens of megapascal over a 100-nanometer scale region near the moving amorphous/crystalline interface arising from the amorphous-crystalline density difference. Second harmonic generation and piezoelectric force microscopy reveal that the laterally crystallized SrTiO3 is noncentrosymmetric and develops a switchable piezoelectric response at room temperature, illustrating the potential to use lateral crystallization to control the functionality of complex oxides.

The Impact of Electron Donating and Withdrawing Groups on Electrochemical Hydrogenolysis and Hydrogenation of Carbonyl Compounds.

The hydrogenolysis or hydrodeoxygenation of a carbonyl group, where the C═O group is converted to a CH2 group, is of significant interest in a variety of fields. A challenge in electrochemically achieving hydrogenolysis of a carbonyl group with high selectivity is that electrochemical hydrogenation of a carbonyl group, which converts the C═O group to an alcohol group (CH-OH), is demonstrated not to be the initial step of hydrogenolysis. Instead, hydrogenation and hydrogenolysis occur in parallel, and they are competing reactions. This means that although both hydrogenolysis and hydrogenation require adding H atoms to the carbonyl group, they involve different intermediates formed on the electrode surface. Thus, revealing the difference in intermediates, transition states, and kinetic barriers for hydrogenolysis and hydrogenation pathways is the key to understanding and controlling hydrogenolysis/hydrogenation selectivity of carbonyl compounds. In this study, we aimed to identify features of reactant molecules that can affect their hydrogenolysis/hydrogenation selectivity on a Zn electrode that was previously shown to promote hydrogenolysis over hydrogenation. In particular, we examined the electrochemical reduction of para-substituted benzaldehyde compounds with substituent groups having different electron donating/withdrawing abilities. Our results show a strikingly systematic impact of the substituent group where a stronger electron-donating group promotes hydrogenolysis and a stronger electron-withdrawing group promotes hydrogenation. These experimental results are presented with computational results explaining the substituent effects on the thermodynamics and kinetics of electrochemical hydrogenolysis and hydrogenation pathways, which also provide critically needed information and insights into the transition states involved with these pathways.

[Translation into French and republication of: "Recurrent venous thromboembolism in anticoagulated cancer patients: diagnosis and treatment"]. / Traduction et republication de : « Maladie thromboembolique veineuse récidivante chez les patients cancéreux anticoagulés : diagnostic et traitement ¼.

Patients with cancer are at significantly increased risk of venous thromboembolism (VTE), due both to the impact of malignant disease itself and to the impact of certain anticancer drugs on haemostasis. This is true both for first episode venous thromboembolism and recurrence. The diagnosis and management of VTE recurrence in patients with cancer poses particular challenges, and these are reviewed in the present article, based on a systematic review of the relevant scientific literature published over the last decade. Furthermore, it is uncertain whether diagnostic algorithms for venous thromboembolism, validated principally in untreated non-cancer patients, are also valid in anticoagulated cancer patients: the available data suggests that clinical decision rules and D-dimer testing perform less well in this clinical setting. In patients with cancer, computed tomography pulmonary angiography and venous ultrasound appear to be the most reliable diagnostic tools for diagnosis of pulmonary embolism and deep vein thrombosis respectively. Options for treatment of venous thromboembolism include low molecular weight heparins (at a therapeutic dose or an increased dose), fondaparinux or oral direct factor Xa inhibitors. The choice of treatment should take into account the nature (pulmonary embolism or VTE) and severity of the recurrent event, the associated bleeding risk, the current anticoagulant treatment (type, dose, adherence and possible drug-drug interactions) and cancer progression.

Human activities shape global patterns of decomposition rates in rivers.

Rivers and streams contribute to global carbon cycling by decomposing immense quantities of terrestrial plant matter. However, decomposition rates are highly variable and large-scale patterns and drivers of this process remain poorly understood. Using a cellulose-based assay to reflect the primary constituent of plant detritus, we generated a predictive model (81% variance explained) for cellulose decomposition rates across 514 globally distributed streams. A large number of variables were important for predicting decomposition, highlighting the complexity of this process at the global scale. Predicted cellulose decomposition rates, when combined with genus-level litter quality attributes, explain published leaf litter decomposition rates with high accuracy (70% variance explained). Our global map provides estimates of rates across vast understudied areas of Earth and reveals rapid decomposition across continental-scale areas dominated by human activities.

Stable Pentagonal Layered Palladium Diselenide Enables Rapid Electrosynthesis of Hydrogen Peroxide.

Electrosynthesis of hydrogen peroxide (H2O2) via the two-electron oxygen reduction reaction (2e- ORR) is promising for various practical applications, such as wastewater treatment. However, few electrocatalysts are active and selective for 2e- ORR yet are also resistant to catalyst leaching under realistic operating conditions. Here, a joint experimental and computational study reveals active and stable 2e- ORR catalysis in neutral media over layered PdSe2 with a unique pentagonal puckered ring structure type. Computations predict active and selective 2e- ORR on the basal plane and edge of PdSe2, but with distinct kinetic behaviors. Electrochemical measurements of hydrothermally synthesized PdSe2 nanoplates show a higher 2e- ORR activity than other Pd-Se compounds (Pd4Se and Pd17Se15). PdSe2 on a gas diffusion electrode can rapidly accumulate H2O2 in buffered neutral solution under a high current density. The electrochemical stability of PdSe2 is further confirmed by long device operational stability, elemental analysis of the catalyst and electrolyte, and synchrotron X-ray absorption spectroscopy. This work establishes a new efficient and stable 2e- ORR catalyst at practical current densities and opens catalyst designs utilizing the unique layered pentagonal structure motif.

Predicting Emission Spectra of Heteroleptic Iridium Complexes Using Artificial Chemical Intelligence.

We report a deep learning-based approach to accurately predict the emission spectra of phosphorescent heteroleptic [Ir( C ∧ N ${{\rm{C}}^\wedge {\rm{N}}}$ )2( N ∧ N ${{\rm{N}}^\wedge {\rm{N}}}$ )]+ complexes, enabling the rapid discovery of novel Ir(III) chromophores for diverse applications including organic light-emitting diodes and solar fuel cells. The deep learning models utilize graph neural networks and other chemical features in architectures that reflect the inherent structure of the heteroleptic complexes, composed of C ∧ N ${{\rm{C}}^\wedge {\rm{N}}}$ and N ∧ N ${{\rm{N}}^\wedge {\rm{N}}}$ ligands, and are thus geared towards efficient training over the dataset. By leveraging experimental emission data, our models reliably predict the full emission spectra of these complexes across various emission profiles, surpassing the accuracy of conventional DFT and correlated wavefunction methods, while simultaneously achieving robustness to the presence of imperfect (noisy, low-quality) training spectra. We showcase the potential applications for these and related models for in silico prediction of complexes with tailored emission properties, as well as in "design of experiment" contexts to reduce the synthetic burden of high-throughput screening. In the latter case, we demonstrate that the models allow us to exploit a limited amount of experimental data to explore a wide range of chemical space, thus leveraging a modest synthetic effort.

Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients.

BACKGROUND: Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels. METHODS: CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events. RESULTS: Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03). CONCLUSION: Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive. FUNDING: French Ministry of Health. CLINICALTRIALS: gov number: NCT01808911.

Robust unfolding of MeV x-ray spectra from filter stack spectrometer data.

We present an inversion method capable of robustly unfolding MeV x-ray spectra from filter stack spectrometer (FSS) data without requiring an a priori specification of a spectral shape or arbitrary termination of the algorithm. Our inversion method is based upon the perturbative minimization (PM) algorithm, which has previously been shown to be capable of unfolding x-ray transmission data, albeit for a limited regime in which the x-ray mass attenuation coefficient of the filter material increases monotonically with x-ray energy. Our inversion method improves upon the PM algorithm through regular smoothing of the candidate spectrum and by adding stochasticity to the search. With these additions, the inversion method does not require a physics model for an initial guess, fitting, or user-selected termination of the search. Instead, the only assumption made by the inversion method is that the x-ray spectrum should be near a smooth curve. Testing with synthetic data shows that the inversion method can successfully recover the primary large-scale features of MeV x-ray spectra, including the number of x-rays in energy bins of several-MeV widths to within 10%. Fine-scale features, however, are more difficult to recover accurately. Examples of unfolding experimental FSS data obtained at the Texas Petawatt Laser Facility and the OMEGA EP laser facility are also presented.

The World Rugby and International Rugby Players Contact Load Guidelines: From conception to implementation and the future.

Managing training load in rugby union is crucial for optimising performance and injury prevention. Contact training warrants attention because of higher overall injury and head impact risk, yet players must develop physical, technical, and mental skills to withstand the demands of the game. To help coaches manage contact loads in professional rugby, World Rugby and International Rugby Players convened an expert working group. They conducted a global survey with players to develop contact load guidelines. This commentary aims to describe the contact load guidelines and their implementation, and identify areas where future work is needed to support their evolution.

¿Es la mitomicina C superior al 5-fluorouracilo como antimetabolito en la trabeculectomía para el glaucoma? / Is mytomicyn better than 5-fluorouracil as antimetabolite in trabeculectomy for glaucoma?

INTRODUCCIÓN: La trabeculectomía es considerada la intervención de elección en pacientes con glaucoma con indicación de manejo quirúrgico. Dentro de los factores asociados al fracaso de este tratamiento se encuentra la cicatrización postoperatoria. Para disminuir este factor se han usado distintos antimetabolitos, en particular el 5-fluorouracilo y la mitomicina C. Si bien ambos se consideran efectivos, no está claro si existen diferencias entre ambos en relación al éxito de la trabeculectomía y los efectos adversos. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis, preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyen 17 estudios primarios, de los cuales, 12 corresponden a ensayos aleatorizados. Concluimos que el uso de mitomicina C podría lograr una mayor disminución de la presión intraocular e incrementar la tasa de éxito calificado en comparación con el 5-fluorouracilo. Sin embargo, su uso podría asociarse a una mayor incidencia de complicaciones.

INTRODUCTION: Trabeculectomy is considered the standard for glaucoma surgery. Postoperative scarring is one the factors associated with surgery failure. Different antimetabolites have been used in order to reduce this risk, particularly 5-fluorouracil and mitomycin C. Although both are considered effective, it is not clear if they are different in terms of success of trabeculectomy and adverse effects. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews including 17 studies overall, of which 12 were randomized trials. We concluded mitomycin C might be more effective in reducing intraocular pressure and increasing qualified success compared to 5-fluorouracil. However, its use might be associated to a higher risk of complications.

¿Tienen algún rol los cannabinoides en el control del glaucoma? / Do cannabinoids play a role in the control of glaucoma?

INTRODUCCIÓN: El uso de cannabinoides en diversas condiciones clínicas es hoy un tema de debate. Se ha planteado su uso para el control del glaucoma. Sin embargo, existe controversia sobre su real efectividad y seguridad. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyen 3 estudios primarios, todos correspondientes a ensayos aleatorizados. Concluimos que, si bien los cannabinoides podrían disminuir la presión intraocular, lo hacen de forma transitoria y se asocian a efectos adversos frecuentes.

INTRODUCTION: The use of cannabinoids in diverse clinical conditions is today a subject of debate. Its use has been proposed for the control of glaucoma. However, there is controversy about its real effectiveness and safety. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including three studies overall, all of them randomized controlled trials. We concluded that although cannabinoids could decrease intraocular pressure, the effect would be transient and associated with frequent adverse effects.

¿Es la válvula Ahmed superior al implante Baerveldt como derivación acuosa para el manejo del glaucoma? / Is Ahmed valve superior to Baerveldt implant as an aqueous shunt for the treatment of glaucoma?

Resumen INTRODUCCIÓN: La derivación acuosa ha surgido como una técnica alternativa a la trabeculectomía, considerada la cirugía de elección en pacientes con glaucoma. Actualmente, se considera que la principal indicación de esta técnica es ante el fracaso de la trabeculectomía o en tipos de glaucoma que tienen alto riesgo de fracasar. La válvula Ahmed y el implante Baerveldt son las derivaciones acuosas más utilizadas. Sin embargo, no está claro cuáles son las diferencias entre estas dos alternativas. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud a nivel mundial, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron 10 estudios primarios, de los cuales dos son ensayos aleatorizados. Concluimos que la válvula Ahmed probablemente logra una menor disminución de la presión intraocular; podría lograr un menor éxito calificado y probablemente necesita más reintervenciones que el implante Baerveldt. Respecto al perfil de seguridad, la válvula Ahmed no se presenta claramente superior ni inferior al implante Baerveldt.

Abstract INTRODUCTION: Aqueous shunt has emerged as an alternative technique to trabeculectomy, considered the standard for glaucoma surgery. Currently, it is mainly indicated after failure of trabeculectomy or in glaucoma with high risk of failure. The Ahmed valve and the Baerveldt implant are the most commonly used aqueous shunts. However, it is not clear whether there are differences between them. METHODS.: o answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including 10 studies overall, of which two were randomized trials. We concluded the Ahmed valve probably achieves a lower decrease in intraocular pressure, might lead to less qualified success and probably needs more reinterventions than the Baerveldt implant. Regarding safety profile, the Ahmed valve is not clearly superior or inferior to the Baerveldt implant.

Derivación acuosa versus trabeculectomía para el manejo del glaucoma / Aqueous shunt versus trabeculectomy for treatment of glaucoma

INTRODUCCIÓN: La derivación acuosa ha surgido como una técnica alternativa a la trabeculectomía, la cual se considera el tratamiento estándar para cirugía de glaucoma. Actualmente, su principal indicación es en el glaucoma con trabeculectomía fallida o en algunos tipos de glaucoma con alto riesgo de fracaso. Sin embargo, aún existe controversia con respecto a su efectividad en comparación con la trabeculectomía. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron nueve estudios primarios, de los cuales, cuatro corresponden a ensayos aleatorizados. Concluimos que la derivación acuosa podría aumentar el éxito calificado en comparación con la trabeculectomía, pero que no está claro si tiene algún efecto sobre el resto de los desenlaces críticos para la toma de decisión, porque la certeza de la evidencia es muy baja.

INTRODUCTION: Aqueous shunt has emerged as an alternative technique to trabeculectomy, which is considered the standard treatment for glaucoma surgery. Currently, it is mainly indicated after failure of trabeculectomy or in some types of glaucoma with high risk of failure. However, there is still controversy regarding its effectiveness compared to trabeculectomy. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including nine studies overall, of which four were randomized trials. We concluded that aqueous shunt might increase the qualified success compared to trabeculectomy, but it is not clear whether it has any effect on the rest of the critical outcomes for decision-making because the certainty of the evidence is very low.

Dietas pós-eclosão suplementadas com fontes de gordura e acrescidas de taurina e glicina sobre a morfometria intestinal e o desempenho de frangos de corte de um a 21 dias / Post-hatch diets supplemented with sources of fat and added taurine and glycine on the intestinal morphology and performance of broilers at 1 to 21 days

O objetivo deste estudo foi avaliar o efeito do fornecimento de dietas pós-eclosão suplementadas com diferentes fontes de gordura insaturada e adicionadas ou não de taurina e glicina sobre o desempenho produtivo, a biometria e a morfometria do intestino delgado de pintos de corte de um a 21 dias de idade. Foram utilizados 480 pintos de corte machos de um dia de idade da linhagem Cobb. O delineamento foi inteiramente ao acaso, em esquema fatorial 2 x 4, com e sem suplementação de taurina e glicina e quatro dietas (controle, óleo de peixe, de soja e de girassol), totalizando oito tratamentos com seis repetições de 10 aves cada. As rações experimentais foram fornecidas de zero a quatro dias de idade. O desempenho zootécnico foi avaliado ao alojamento e aos quatro, sete e 21 dias de idade. Nestas mesmas datas, foram sacrificadas duas aves por unidade experimental para biometria do intestino e histomorfometria da mucosa do intestino. A adição de diferentes fontes de gordura e a suplementação de glicina e taurina às dietas de transição não influenciaram o desempenho produtivo de um a 21 dias. A suplementação das dietas com glicina e taurina alterou a morfologia da mucosa intestinal, principalmente do duodeno, resultando em maior comprimento do vilo e relação vilo:cripta. Entretanto, parte dos efeitos positivos depende do tipo de óleo adicionado, mostrando que dietas pós-eclosão acrescidas de fontes de lipídios podem ser benéficas no desenvolvimento da capacidade funcional do intestino de frangos de corte.(AU)

The aim of this study was to assess post-hatch diets supplemented with different sources of unsaturated fat and added or not with taurine and glycine on the productive performance, biometry and morphology of small intestine of chicks from 1 to 21 days of age. Four hundred and eighty (480) one day old male broiler Cobb chicks were used. The experimental design was completely randomized in a factorial 2 x 4, with and without supplemental taurine and glycine and 4 diets (control, fish, soy and sunflower oil), totaling six treatments with six repetitions of 10 birds each. The experimental diets were supplied from 0 to 4 days old. The performance was evaluated in housing and 4, 7 and 21 days of age. On these same dates, 2 birds per experimental unit were sacrificed for gut biometrics and histomorphometry of intestinal mucosa. The addition of different sources of fat, glycine and taurine supplementation on transition diets did not influence productive performance from 1 to 21 days. Supplementation of diets with glycine and taurine altered the morphology of the intestinal mucosa, mainly of the duodenum, resulting in greater length of villi and villi: crypt ratio. However, the positive effects depend on the type of oil added, showing that post-hatch diets increased with lipid sources may be beneficial in the development of the functional capacity of the intestine of broilers.(AU)

Psychosomatic rehabilitación: a must in secondary health care

El estudio de evaluación sobre los tratamientos psicosomáticos de pacientes hospitalizados descritos aquí muestra- en lo que se refiere a la catamnesis de un año como también a la de tres años- resultados sorprendentemente positivos. Los logros tan positivos aparecen no sólo en el campo de los parámetros subjetivos (mejoría en las quejas, estado de salud precibido subjetivamente, capacidad de trabajo), sino también en relación con variables de importancia para los costos (p. ej. número de consultas con médicos, días de trabajo perdidos debido a la enfermedad, días en el hospital) que llevan a ahorrar costos. Parece que mediante la aplicación de estos tratamientos psicosomaticos se pueden iniciar importantes procesos de maduración que van más allá del mero alivio de los síntomas y que ellos tienen un efecto positivo en las actitudes y aspectos emocionales por una parte, así como también en un nivel conductual por la otra parte . En la práctica actual se fomentan y -al parecer- también (al menos en parte) se implementan cambios en las actitudes hacia uno mismo, cambios en la forma de mirar los propios síntomas, diferentes formas de tratar con la gente y cambios en los modos de conducirse frente a la propia salud. Nuestros resultados indican que los tratamientos de pacientes hospitalizados dirigidos a proporcionar "ayuda para ayudarse a uno mismo" y que refuerzan la propia responsabilidad del paciente para mejorarse pueden hacer una importante contribución dentro de la cadena de rehabilitación. En vista de la duración relativamente corta de la terapia y las características bastante desfavorables de los pacientes (cronicidad, características no-Yavis), estos hallazgos -a pesar de todas sus limitaciones metodológicas- pueden ser considerados alentadores con respecto a la tarea de rehabilitación en clínicas psicosomáticas y aún más, pueden demostrar la importante contribución de la medicina psicosomática dentro del nivel secundario de cuidado de la salud en los años venideros