Cumulative costs for the prosthetic reconstructions and maintenance in young adult patients with birth defects affecting the formation of teeth

OBJECTIVES: To assess retrospectively the cumulative costs for the long-term oral rehabilitation of patients with birth defects affecting the development of teeth. METHODS: Patients with birth defects who had received fixed reconstructions on teeth and/or implants > or =5 years ago were asked to participate in a comprehensive clinical, radiographic and economic evaluation. RESULTS: From the 45 patients included, 18 were cases with a cleft lip and palate, five had amelogenesis/dentinogenesis imperfecta and 22 were cases with hypodontia/oligodontia. The initial costs for the first oral rehabilitation (before the age of 20) had been covered by the Swiss Insurance for Disability. The costs for the initial rehabilitation of the 45 cases amounted to 407,584 CHF (39% for laboratory fees). Linear regression analyses for the initial treatment costs per replaced tooth revealed the formula 731 CHF+(811 CHF x units) on teeth and 3369 CHF+(1183 CHF x units) for reconstructions on implants (P<.001). Fifty-eight percent of the patients with tooth-supported reconstructions remained free from failures/complications (median observation 15.7 years). Forty-seven percent of the patients with implant-supported reconstructions remained free from failures/complications (median observation 8 years). The long-term cumulative treatment costs for implant cases, however, were not statistically significantly different compared with cases reconstructed with tooth-supported fixed reconstructions. Twenty-seven percent of the initial treatment costs were needed to cover supportive periodontal therapy as well as the treatment of technical/biological complications and failures. CONCLUSION: Insurance companies should accept to cover implant-supported reconstructions because there is no need to prepare healthy teeth, fewer tooth units need to be replaced and the cumulative long-term costs seem to be similar compared with cases restored on teeth.

Chirurgische Maßnahmen zur Wiederherstellung der Körperform und -kontur nach massiver Gewichtsreduktion

The consequences of massive weight loss through bariatric procedures as well as diet are overall positive. However, the sequelae of massive weight loss present themselves as soft tissue redundancies in the areas of the lower abdomen, upper thigh, upper arm and breast as well as face and neck. This condition presents significant mechanical, physical and social day-to-day limitations for the quality of life of these patients. Surgical techniques are indicated for the reconstruction of the body shape and therapy of the above named problems and the coexistent psychosocial component. These surgical techniques involve dermolipectomies in different body areas and can lead to significant improvement. In view of the worldwide increase of adipositas and the increasing need for bariatric surgery, a parallel increase in demand for such reconstructive post-bariatric interventions can be foreseen. Early and precise information is crucial for the patients before engaging in weight reduction, as is the coverage of the costs of the resulting secondary reconstructive body contouring interventions by the insurance companies.

Benefits and challenges in practice-oriented psychotherapy research in Germany: The TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy

Objective: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. Method: Both projects and their results indicating high effect sizes are briefly described. Results: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. Conclusions: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system

Swiss national guideline for reimbursement of enzyme replacement therapy in late-onset Pompe disease.

Glycogen storage disease type II is a rare multi-systemic disorder characterised by an intracellular accumulation of glycogen due a mutation in the acid alpha glucosidase (GAA) gene. The level of residual enzyme activity, the genotype and other yet unknown factors account for the broad variation of the clinical phenotype. The classical infantile form is characterised by severe muscle hypotonia and cardiomyopathy leading to early death. The late-onset form presents as a limb girdle myopathy with or without pulmonary dysfunction. Enzyme replacement therapy (ERT) with recombinant human GAA (rhGAA) in infants is life saving. In contrast, therapeutic efficacy of rhGAA in the late-onset form is modest. High expenses of rhGAA, on-going infusions and poor pharmacokinetic efficacy raised a discussion of the cost effectiveness of ERT in late-onset Pompe disease in Switzerland. This discussion was triggered by a Swiss federal court ruling which confirmed the reluctance of a health care insurer not to reimburse treatment costs in a 67-year-old female suffering from Pompe disease. As a consequence of this judgement ERT was stopped by all insurance companies in late-onset Pompe patients in Switzerland regardless of their clinical condition. Subsequent negotiations lead to the release of a national guideline of the management of late-onset Pompe disease. Initiation and limitation of ERT is outlined in a national Pompe registry. Reimbursement criteria are defined and individual efficacy of ERT with rhGAA is continuously monitored.

Pediatric obesity: Managed care collaborating with providers to improve diagnosis and treatment

Child overweight and obesity reaches across ethnic, cultural, socioeconomic and regional barriers. It must be assessed, diagnosed and treated to help families make sustainable behavior changes. Treatment recommendations have been made to address pediatric overweight and obesity. They include screening for risk factors, monitoring BMI trends and educating patients and families to make small sustainable changes. Health insurance companies can play a meaningful role in supporting and facilitating provider education and behavior change to diagnose, treat and prevent pediatric overweight and obesity.^ The aims of this thesis were: (1) Describe a disease management program that uses evidence-based practices to create provider behavior change related to pediatric obesity screening, diagnosis and treatment. (2) Identify ways to improve the implementation of the program based on the perceptions of participating clinicians.^ A literature review was completed to evaluate current recommendations for screening and treating pediatric obesity using the Ovid data base. The evidenced-based recommendations were compared against the practices of the Healthy Lifestyles Program (HeLP). The literature confirmed that HeLP is following evidence-based recommendations for assessment, diagnosis and treatment of pediatric obesity.^ A Children’s Mercy Family Health Partners focus group was convened to create a provider survey. The goals of the survey were to assess providers’ perception of the Healthy Lifestyles Program (HeLP). The survey was sent out through email using Survey Monkey. All survey responses were anonymous. The survey was sent to a total of 80 providers who had completed HeLP. Twenty-five percent responded. The survey results were evaluated to make recommendations for HeLP.^ Results of the survey included motivating factors for participation in HeLP. Concern about the increasing prevalence of pediatric obesity was a frequent motivator for participation. Provider barriers to obesity diagnosis were evaluated. Lack of time during clinic visits a frequent barrier to obesity diagnosis. ^ In conclusion several recommendations for the HeLP were made based on survey results. It is recommended that the program evaluate methods and tools for facilitating effective weight management follow up visits. Promotional materials should highlight the increasing prevalence of pediatric obesity when advertising HeLP. These recommendations will be used to refine the current Healthy Lifestyles Program.^

Climate variability effects on field crops in Iberian Peninsula. Predictability

La presente Tesis constituye un avance en el conocimiento de los efectos de la variabilidad climática en los cultivos en la Península Ibérica (PI). Es bien conocido que la temperatura del océano, particularmente de la región tropical, es una de las variables más convenientes para ser utilizado como predictor climático. Los océanos son considerados como la principal fuente de almacenamiento de calor del planeta debido a la alta capacidad calorífica del agua. Cuando se libera esta energía, altera los regímenes globales de circulación atmosférica por mecanismos de teleconexión. Estos cambios en la circulación general de la atmósfera afectan a la temperatura, precipitación, humedad, viento, etc., a escala regional, los cuales afectan al crecimiento, desarrollo y rendimiento de los cultivos. Para el caso de Europa, esto implica que la variabilidad atmosférica en una región específica se asocia con la variabilidad de otras regiones adyacentes y/o remotas, como consecuencia Europa está siendo afectada por los patrones de circulaciones globales, que a su vez, se ven afectados por patrones oceánicos. El objetivo general de esta tesis es analizar la variabilidad del rendimiento de los cultivos y su relación con la variabilidad climática y teleconexiones, así como evaluar su predictibilidad. Además, esta Tesis tiene como objetivo establecer una metodología para estudiar la predictibilidad de las anomalías del rendimiento de los cultivos. El análisis se centra en trigo y maíz como referencia para otros cultivos de la PI, cultivos de invierno en secano y cultivos de verano en regadío respectivamente. Experimentos de simulación de cultivos utilizando una metodología en cadena de modelos (clima + cultivos) son diseñados para evaluar los impactos de los patrones de variabilidad climática en el rendimiento y su predictibilidad. La presente Tesis se estructura en dos partes: La primera se centra en el análisis de la variabilidad del clima y la segunda es una aplicación de predicción cuantitativa de cosechas. La primera parte está dividida en 3 capítulos y la segundo en un capitulo cubriendo los objetivos específicos del presente trabajo de investigación. Parte I. Análisis de variabilidad climática El primer capítulo muestra un análisis de la variabilidad del rendimiento potencial en una localidad como indicador bioclimático de las teleconexiones de El Niño con Europa, mostrando su importancia en la mejora de predictibilidad tanto en clima como en agricultura. Además, se presenta la metodología elegida para relacionar el rendimiento con las variables atmosféricas y oceánicas. El rendimiento de los cultivos es parcialmente determinado por la variabilidad climática atmosférica, que a su vez depende de los cambios en la temperatura de la superficie del mar (TSM). El Niño es el principal modo de variabilidad interanual de la TSM, y sus efectos se extienden en todo el mundo. Sin embargo, la predictibilidad de estos impactos es controversial, especialmente aquellos asociados con la variabilidad climática Europea, que se ha encontrado que es no estacionaria y no lineal. Este estudio mostró cómo el rendimiento potencial de los cultivos obtenidos a partir de datos de reanálisis y modelos de cultivos sirve como un índice alternativo y más eficaz de las teleconexiones de El Niño, ya que integra las no linealidades entre las variables climáticas en una única serie temporal. Las relaciones entre El Niño y las anomalías de rendimiento de los cultivos son más significativas que las contribuciones individuales de cada una de las variables atmosféricas utilizadas como entrada en el modelo de cultivo. Además, la no estacionariedad entre El Niño y la variabilidad climática europea se detectan con mayor claridad cuando se analiza la variabilidad de los rendimiento de los cultivos. La comprensión de esta relación permite una cierta predictibilidad hasta un año antes de la cosecha del cultivo. Esta predictibilidad no es constante, sino que depende tanto la modulación de la alta y baja frecuencia. En el segundo capítulo se identifica los patrones oceánicos y atmosféricos de variabilidad climática que afectan a los cultivos de verano en la PI. Además, se presentan hipótesis acerca del mecanismo eco-fisiológico a través del cual el cultivo responde. Este estudio se centra en el análisis de la variabilidad del rendimiento de maíz en la PI para todo el siglo veinte, usando un modelo de cultivo calibrado en 5 localidades españolas y datos climáticos de reanálisis para obtener series temporales largas de rendimiento potencial. Este estudio evalúa el uso de datos de reanálisis para obtener series de rendimiento de cultivos que dependen solo del clima, y utilizar estos rendimientos para analizar la influencia de los patrones oceánicos y atmosféricos. Los resultados muestran una gran fiabilidad de los datos de reanálisis. La distribución espacial asociada a la primera componente principal de la variabilidad del rendimiento muestra un comportamiento similar en todos los lugares estudiados de la PI. Se observa una alta correlación lineal entre el índice de El Niño y el rendimiento, pero no es estacionaria en el tiempo. Sin embargo, la relación entre la temperatura del aire y el rendimiento se mantiene constante a lo largo del tiempo, siendo los meses de mayor influencia durante el período de llenado del grano. En cuanto a los patrones atmosféricos, el patrón Escandinavia presentó una influencia significativa en el rendimiento en PI. En el tercer capítulo se identifica los patrones oceánicos y atmosféricos de variabilidad climática que afectan a los cultivos de invierno en la PI. Además, se presentan hipótesis acerca del mecanismo eco-fisiológico a través del cual el cultivo responde. Este estudio se centra en el análisis de la variabilidad del rendimiento de trigo en secano del Noreste (NE) de la PI. La variabilidad climática es el principal motor de los cambios en el crecimiento, desarrollo y rendimiento de los cultivos, especialmente en los sistemas de producción en secano. En la PI, los rendimientos de trigo son fuertemente dependientes de la cantidad de precipitación estacional y la distribución temporal de las mismas durante el periodo de crecimiento del cultivo. La principal fuente de variabilidad interanual de la precipitación en la PI es la Oscilación del Atlántico Norte (NAO), que se ha relacionado, en parte, con los cambios en la temperatura de la superficie del mar en el Pacífico Tropical (El Niño) y el Atlántico Tropical (TNA). La existencia de cierta predictibilidad nos ha animado a analizar la posible predicción de los rendimientos de trigo en la PI utilizando anomalías de TSM como predictor. Para ello, se ha utilizado un modelo de cultivo (calibrado en dos localidades del NE de la PI) y datos climáticos de reanálisis para obtener series temporales largas de rendimiento de trigo alcanzable y relacionar su variabilidad con anomalías de la TSM. Los resultados muestran que El Niño y la TNA influyen en el desarrollo y rendimiento del trigo en el NE de la PI, y estos impactos depende del estado concurrente de la NAO. Aunque la relación cultivo-TSM no es igual durante todo el periodo analizado, se puede explicar por un mecanismo eco-fisiológico estacionario. Durante la segunda mitad del siglo veinte, el calentamiento (enfriamiento) en la superficie del Atlántico tropical se asocia a una fase negativa (positiva) de la NAO, que ejerce una influencia positiva (negativa) en la temperatura mínima y precipitación durante el invierno y, por lo tanto, aumenta (disminuye) el rendimiento de trigo en la PI. En relación con El Niño, la correlación más alta se observó en el período 1981 -2001. En estas décadas, los altos (bajos) rendimientos se asocian con una transición El Niño - La Niña (La Niña - El Niño) o con eventos de El Niño (La Niña) que están finalizando. Para estos eventos, el patrón atmosférica asociada se asemeja a la NAO, que también influye directamente en la temperatura máxima y precipitación experimentadas por el cultivo durante la floración y llenado de grano. Los co- efectos de los dos patrones de teleconexión oceánicos ayudan a aumentar (disminuir) la precipitación y a disminuir (aumentar) la temperatura máxima en PI, por lo tanto el rendimiento de trigo aumenta (disminuye). Parte II. Predicción de cultivos. En el último capítulo se analiza los beneficios potenciales del uso de predicciones climáticas estacionales (por ejemplo de precipitación) en las predicciones de rendimientos de trigo y maíz, y explora métodos para aplicar dichos pronósticos climáticos en modelos de cultivo. Las predicciones climáticas estacionales tienen un gran potencial en las predicciones de cultivos, contribuyendo de esta manera a una mayor eficiencia de la gestión agrícola, seguridad alimentaria y de subsistencia. Los pronósticos climáticos se expresan en diferentes formas, sin embargo todos ellos son probabilísticos. Para ello, se evalúan y aplican dos métodos para desagregar las predicciones climáticas estacionales en datos diarios: 1) un generador climático estocástico condicionado (predictWTD) y 2) un simple re-muestreador basado en las probabilidades del pronóstico (FResampler1). Los dos métodos se evaluaron en un caso de estudio en el que se analizaron los impactos de tres escenarios de predicciones de precipitación estacional (predicción seco, medio y lluvioso) en el rendimiento de trigo en secano, sobre las necesidades de riego y rendimiento de maíz en la PI. Además, se estimó el margen bruto y los riesgos de la producción asociada con las predicciones de precipitación estacional extremas (seca y lluviosa). Los métodos predWTD y FResampler1 usados para desagregar los pronósticos de precipitación estacional en datos diarios, que serán usados como inputs en los modelos de cultivos, proporcionan una predicción comparable. Por lo tanto, ambos métodos parecen opciones factibles/viables para la vinculación de los pronósticos estacionales con modelos de simulación de cultivos para establecer predicciones de rendimiento o las necesidades de riego en el caso de maíz. El análisis del impacto en el margen bruto de los precios del grano de los dos cultivos (trigo y maíz) y el coste de riego (maíz) sugieren que la combinación de los precios de mercado previstos y la predicción climática estacional pueden ser una buena herramienta en la toma de decisiones de los agricultores, especialmente en predicciones secas y/o localidades con baja precipitación anual. Estos métodos permiten cuantificar los beneficios y riesgos de los agricultores ante una predicción climática estacional en la PI. Por lo tanto, seríamos capaces de establecer sistemas de alerta temprana y diseñar estrategias de adaptación del manejo del cultivo para aprovechar las condiciones favorables o reducir los efectos de condiciones adversas. La utilidad potencial de esta Tesis es la aplicación de las relaciones encontradas para predicción de cosechas de la próxima campaña agrícola. Una correcta predicción de los rendimientos podría ayudar a los agricultores a planear con antelación sus prácticas agronómicas y todos los demás aspectos relacionados con el manejo de los cultivos. Esta metodología se puede utilizar también para la predicción de las tendencias futuras de la variabilidad del rendimiento en la PI. Tanto los sectores públicos (mejora de la planificación agrícola) como privados (agricultores, compañías de seguros agrarios) pueden beneficiarse de esta mejora en la predicción de cosechas. ABSTRACT The present thesis constitutes a step forward in advancing of knowledge of the effects of climate variability on crops in the Iberian Peninsula (IP). It is well known that ocean temperature, particularly the tropical ocean, is one of the most convenient variables to be used as climate predictor. Oceans are considered as the principal heat storage of the planet due to the high heat capacity of water. When this energy is released, it alters the global atmospheric circulation regimes by teleconnection1 mechanisms. These changes in the general circulation of the atmosphere affect the regional temperature, precipitation, moisture, wind, etc., and those influence crop growth, development and yield. For the case of Europe, this implies that the atmospheric variability in a specific region is associated with the variability of others adjacent and/or remote regions as a consequence of Europe being affected by global circulations patterns which, in turn, are affected by oceanic patterns. The general objective of this Thesis is to analyze the variability of crop yields at climate time scales and its relation to the climate variability and teleconnections, as well as to evaluate their predictability. Moreover, this Thesis aims to establish a methodology to study the predictability of crop yield anomalies. The analysis focuses on wheat and maize as a reference crops for other field crops in the IP, for winter rainfed crops and summer irrigated crops respectively. Crop simulation experiments using a model chain methodology (climate + crop) are designed to evaluate the impacts of climate variability patterns on yield and its predictability. The present Thesis is structured in two parts. The first part is focused on the climate variability analyses, and the second part is an application of the quantitative crop forecasting for years that fulfill specific conditions identified in the first part. This Thesis is divided into 4 chapters, covering the specific objectives of the present research work. Part I. Climate variability analyses The first chapter shows an analysis of potential yield variability in one location, as a bioclimatic indicator of the El Niño teleconnections with Europe, putting forward its importance for improving predictability in both climate and agriculture. It also presents the chosen methodology to relate yield with atmospheric and oceanic variables. Crop yield is partially determined by atmospheric climate variability, which in turn depends on changes in the sea surface temperature (SST). El Niño is the leading mode of SST interannual variability, and its impacts extend worldwide. Nevertheless, the predictability of these impacts is controversial, especially those associated with European climate variability, which have been found to be non-stationary and non-linear. The study showed how potential2 crop yield obtained from reanalysis data and crop models serves as an alternative and more effective index of El Niño teleconnections because it integrates the nonlinearities between the climate variables in a unique time series. The relationships between El Niño and crop yield anomalies are more significant than the individual contributions of each of the atmospheric variables used as input in the crop model. Additionally, the non-stationarities between El Niño and European climate variability are more clearly detected when analyzing crop-yield variability. The understanding of this relationship allows for some predictability up to one year before the crop is harvested. This predictability is not constant, but depends on both high and low frequency modulation. The second chapter identifies the oceanic and atmospheric patterns of climate variability affecting summer cropping systems in the IP. Moreover, hypotheses about the eco-physiological mechanism behind crop response are presented. It is focused on an analysis of maize yield variability in IP for the whole twenty century, using a calibrated crop model at five contrasting Spanish locations and reanalyses climate datasets to obtain long time series of potential yield. The study tests the use of reanalysis data for obtaining only climate dependent time series of simulated crop yield for the whole region, and to use these yield to analyze the influences of oceanic and atmospheric patterns. The results show a good reliability of reanalysis data. The spatial distribution of the leading principal component of yield variability shows a similar behaviour over all the studied locations in the IP. The strong linear correlation between El Niño index and yield is remarkable, being this relation non-stationary on time, although the air temperature-yield relationship remains on time, being the highest influences during grain filling period. Regarding atmospheric patterns, the summer Scandinavian pattern has significant influence on yield in IP. The third chapter identifies the oceanic and atmospheric patterns of climate variability affecting winter cropping systems in the IP. Also, hypotheses about the eco-physiological mechanism behind crop response are presented. It is focused on an analysis of rainfed wheat yield variability in IP. Climate variability is the main driver of changes in crop growth, development and yield, especially for rainfed production systems. In IP, wheat yields are strongly dependent on seasonal rainfall amount and temporal distribution of rainfall during the growing season. The major source of precipitation interannual variability in IP is the North Atlantic Oscillation (NAO) which has been related in part with changes in the Tropical Pacific (El Niño) and Atlantic (TNA) sea surface temperature (SST). The existence of some predictability has encouraged us to analyze the possible predictability of the wheat yield in the IP using SSTs anomalies as predictor. For this purpose, a crop model with a site specific calibration for the Northeast of IP and reanalysis climate datasets have been used to obtain long time series of attainable wheat yield and relate their variability with SST anomalies. The results show that El Niño and TNA influence rainfed wheat development and yield in IP and these impacts depend on the concurrent state of the NAO. Although crop-SST relationships do not equally hold on during the whole analyzed period, they can be explained by an understood and stationary ecophysiological mechanism. During the second half of the twenty century, the positive (negative) TNA index is associated to a negative (positive) phase of NAO, which exerts a positive (negative) influence on minimum temperatures (Tmin) and precipitation (Prec) during winter and, thus, yield increases (decreases) in IP. In relation to El Niño, the highest correlation takes place in the period 1981-2001. For these decades, high (low) yields are associated with an El Niño to La Niña (La Niña to El Niño) transitions or to El Niño events finishing. For these events, the regional associated atmospheric pattern resembles the NAO, which also influences directly on the maximum temperatures (Tmax) and precipitation experienced by the crop during flowering and grain filling. The co-effects of the two teleconnection patterns help to increase (decrease) the rainfall and decrease (increase) Tmax in IP, thus on increase (decrease) wheat yield. Part II. Crop forecasting The last chapter analyses the potential benefits for wheat and maize yields prediction from using seasonal climate forecasts (precipitation), and explores methods to apply such a climate forecast to crop models. Seasonal climate prediction has significant potential to contribute to the efficiency of agricultural management, and to food and livelihood security. Climate forecasts come in different forms, but probabilistic. For this purpose, two methods were evaluated and applied for disaggregating seasonal climate forecast into daily weather realizations: 1) a conditioned stochastic weather generator (predictWTD) and 2) a simple forecast probability resampler (FResampler1). The two methods were evaluated in a case study where the impacts of three scenarios of seasonal rainfall forecasts on rainfed wheat yield, on irrigation requirements and yields of maize in IP were analyzed. In addition, we estimated the economic margins and production risks associated with extreme scenarios of seasonal rainfall forecasts (dry and wet). The predWTD and FResampler1 methods used for disaggregating seasonal rainfall forecast into daily data needed by the crop simulation models provided comparable predictability. Therefore both methods seem feasible options for linking seasonal forecasts with crop simulation models for establishing yield forecasts or irrigation water requirements. The analysis of the impact on gross margin of grain prices for both crops and maize irrigation costs suggests the combination of market prices expected and the seasonal climate forecast can be a good tool in farmer’s decision-making, especially on dry forecast and/or in locations with low annual precipitation. These methodologies would allow quantifying the benefits and risks of a seasonal weather forecast to farmers in IP. Therefore, we would be able to establish early warning systems and to design crop management adaptation strategies that take advantage of favorable conditions or reduce the effect of adverse conditions. The potential usefulness of this Thesis is to apply the relationships found to crop forecasting on the next cropping season, suggesting opportunity time windows for the prediction. The methodology can be used as well for the prediction of future trends of IP yield variability. Both public (improvement of agricultural planning) and private (decision support to farmers, insurance companies) sectors may benefit from such an improvement of crop forecasting.

La protección civil municipal: análisis de los distintos tipos de gestión y propuesta metodológica de planificación

Mediante la elaboración de esta tesis doctoral se pretende diseñar un sistema para la realización del plan de autoprotección en industrias con riesgo de incendio dentro de un polígono industrial. Para desarrollar esta línea de investigación se realizará una investigación cartográfica así como un reconocimiento visual de las distintas empresas industriales, de actividades heterogéneas, seleccionadas por su emplazamiento y condiciones. Este tipo de industria es esencial en el sistema económico nacional, ya que dota de recursos y servicios al tejido social, además de tener una relación directa con la generación de riqueza y por tanto incide de forma positiva en el empleo de cualquier región. Estas razones y otras son determinantes para fomentar el progreso, si bien nunca a expensas de la seguridad de los empleados que hacen posible la línea de producción así como de los posibles viandantes que transcurran por la zona de impacto en caso de incidentes como por ejemplo un incendio que afecte a cualquiera de los locales y/o empresas que se emplazen en los denominados polígonos industriales. La tesis incluye trabajos experimentales de los que se extraen recomendaciones y conclusiones encaminadas a la optimización de la instrumentalización utilizada, las técnicas de observación, diseño y cálculo necesarias que determinarán el acercamiento al método propuesto para nuestra valoración del riesgo por incendio. Las posibles emergencias que pueden darse a nivel de industrias localizadas en polígonos industriales son diversas y numerosas. De todas ellas se elige abordar el caso de “incendio” por su casuística más numerosa. No obstante, la planificación orientada desde el prisma de la investigación de esta tesis puede estenderse a cualquier otro riesgo, lo que se aportará como líneas futuras de investigación. Las aproximaciones y etapas de los trabajos que forman parte de esta investigación se han integrado en cada capítulo y son las siguientes: En primer lugar un capítulo de Introducción, en el que se realiza una reflexión justificada de la elección del tema tratado, se formula la hipótesis de partida y se enumeran los distintos objetivos que se pretenden alcanzar. En el segundo capítulo, titulado Aspectos de la Protección Civil en la Constitución Española de 1978, se ha realizado un estudio exhaustivo de la Constitución en todo lo relacionado con el ámbito de la protección, haciendo especial énfasis en las distintas competencias según el tipo de administración que corresponda en cada caso, así como las obligaciones y deberes que corresponden a los ciudadanos en caso de catástrofe. Así mismo se analizan especialmente los casos de Guerra y el estado de Alarma. En el tercer capítulo, titulado Repuesta de las administraciones públicas ante emergencias colectivas, se trata de formular el adecuado sistema de repuesta que sería preciso para tratar de mitigar desastres y catástrofes. Se analizan los distintos sistemas de gestión de emergencias constatando en cada caso los pros y los contras de cada uno. Se pretende con ello servir de ayuda en la toma de decisiones de manera coherente y racional. El capítulo cuarto, denominado Planes Locales de emergencia. Estudio en las distintas administraciones, se ha pormenorizado en la presentación así como puesta en funcionamiento de los planes, comparando los datos obtenidos entre ellos para concluir en un punto informativo que nos lleva a la realidad de la planificación. Para la realización y desarrollo de los capítulos 5 y 6, llamados Análisis de la Norma Básica de Autoprotección y Métodos de evaluación del riesgo de Incendio, se estudia la normativa actual en autoprotección prestando atención a los antecedentes históricos así como a todas las figuras que intervienen en la misma. Se analizan los distintos métodos actuales para la valoración del riesgo por incendio en industrias. Este aspecto es de carácter imprescindible en la protección civil de los ciudadanos pero también es de especial importancia en las compañías aseguradoras. En el capítulo 7, Propuesta metodológica, se propone y justifica la necesidad de establecer una metodología de estudio para estos casos de riesgo por incendio en industrias para así, acortar el tiempo de respuesta de los servicios de emergencia hasta la zona, así como dotar de información imprescindible sobre el riesgo a trabajadores y transeúntes. El último capítulo se refiere a las Conclusiones, donde se establecen y enuncian una serie de conclusiones y resultados como consecuencia de la investigación desarrollada, para finalizar esta tesis doctoral enunciando posibles desarrollos y líneas de investigación futuros. ABSTRACT The development of this thesis is to design a system for the implementation of the plan of self-protection in industries with risk of fire in an industrial park. To develop this line of research will be done cartographic research as well as visual recognition of the distinct and heterogeneous industrial companies selected by its location and conditions. This type of industry is an essential part in the economic national system providing economic resources to society as well as with a direct relationship in unemployment. For this reason it is crucial to promote their progress, but never at the expense of the security of the employees that make the line of production as well as possible walkers that pass by the area of impact in the event of a fire affecting the company. The thesis includes experimental works which are extracted recommendations and conclusions aimed at optimization of used exploit, techniques of observation, design and calculation needed to determine the approach to the method proposed for our assessment of the risk from fire. The approaches and stages of works that are part of this research have been integrated into each chapter and are as follows: In the first chapter, holder introduction, perform a supporting reflection of the choice of the subject matter, is formulated the hypothesis of departure and listed the different objectives that are intended to achieve. In the second chapter, holder aspects of Civil Protection in the Spanish Constitution of 1978, examines an exhaustive study of the Constitution in everything related to the scope of protection. With an emphasis on individual skills according to the type of management with corresponding in each case, as well as the obligations and duties which correspond to citizens in the event of a catastrophe. Also analyzes the particular cases of war and the State of alarm. In the third chapter, holder public administrations collective emergency response, discussed trafficking in defining the proper system response that would be precise to address disasters and catastrophes. We discusses the different systems of emergency management in each case, we pretend the pros and cons of each. We tried that this serve as decision-making aid coherent and rational way. The fourth chapter is holder Local Emergency Plans (LEP). Study on the different administrations, has detailed in the presentation as well as operation of the LEP, comparing the data between them to conclude in an information point that leads us to the reality of planning. For the realization and development of chapters 5 and 6, holder Analysis of the basic rule of self-protection and fire risk assessment methods, paying attention to the historical background as well as all the figures involved in the same studies with the current rules of self-protection. The current methods for the estimation of the risk are analyzed by fire in industries. This aspect is essential in the civil protection of the citizens, but it is also of special importance for insurance companies. The seventh chapter, holder Methodological proposal, we propose and justifies the need to establish a methodology for these cases of risk by fire in industries. That shorts the response time of emergency services to the area, and provides essential information about the risk to workers and walkers. The last chapter refers to the Conclusions, laying down a series of results as a consequence of the previous chapters to complete billing possible developments and research future.

Diseño arquitectónico y protección en caso de incendio: desarrollo normativo español en materia de evacuación en los siglos XIX y XX

Esta es la búsqueda de respuestas a esa duda constante: De dónde venimos y que hemos ido dejando por el camino. ¿Está todo claro en este recorrido o hemos actuado por acumulación de errores heredados de procesos anteriores? Es la investigación a través del descubrimiento de nuestro pasado, de nuestros orígenes en materia de seguridad de protección contra incendios, y sobre todo de ejecución de una arquitectura pensada para ser recorrida con mayor seguridad y ser evacuada en un tiempo razonable. El trabajo investiga, a nivel nacional, la evolución de la sociedad y sus efectos sobre la manera de interpretar el problema de la seguridad contra incendios en los edificios. El interés fundamentalmente es poner en claro todos aquellos aspectos que afectan a la evacuación de las personas. Para ello se han estudiado los principales hitos de actuación, las preocupaciones principales surgidas en cada momento y las soluciones adoptadas. Se ha comprobado su aplicación o su demora hasta que se ha producido el siguiente gran suceso que ha motivado una nueva revisión de los procedimientos de diseño y control. En primer lugar, tratando de relacionar los incendios fundamentales que han influido en nuestra forma de abordar el problema en distintos momentos de la historia de España. En segundo lugar, haciendo un recorrido sobre la figura del arquitecto y su participación en los medios de control y legislación sobre la manera de intervenir en el servicio de incendios o de resolver los edificios en materia de protección contra incendios o evacuación de sus ocupantes. En definitiva, descubriendo los escritos de algunos especialistas, fundamentales para entender nuestra manera de abordar el problema de la protección en los edificios, a lo largo de la historia. Se ha revisado como se han producido los siniestros más importantes en teatros y otros locales públicos .Analizando la forma en que los arquitectos implicados han tratado de resolver las posibles deficiencias ante el riesgo. Se trata de la tipología edificatoria donde, por primera vez, surge la preocupación por adoptar medidas y procedimientos de seguridad en caso de incendio. Resultan locales con una importante siniestralidad, donde se desarrolla la principal actividad lúdica del momento, y que por el importante número de personas que albergan, son fuente de preocupación entre el público y las autoridades. Otras cuestiones en un tema tan amplio, que quedan simplemente esbozadas en este trabajo de investigación, son los procedimientos de los sistemas de extinción, la estructura organizativa de la ciudad, las primeras sociedades de seguros de incendios, la aparición de patentes a partir del desarrollo industrial del siglo XIX. Todo ello, con el hilo conductor de la reglamentación que se ha ido elaborando al respecto. Al principio, sobre espectáculos públicos, acotando el punto de partida en la materia de nuestra reglamentación. Anticipando sistemas constructivos y datos dimensionales de la evacuación. Llegados a mediados del siglo XX, abordando otros usos. Haciendo seguimiento de la modernización de los procesos edificatorios y la reglamentación sectorial. Recabando información de las organizaciones profesionales que comienzan a reclamar una coordinación nacional de los sistemas preventivos y que desemboca en el Proyecto de Reglamento de prevención contra el fuego que nunca será publicado. Toda esta etapa, plagada de documentos de carácter voluntario u obligatorio, local y nacional, van definiendo los criterios dimensionales con los que debe resolverse los elementos arquitectónicos susceptibles de servir para la evacuación. Se trata de una etapa intensa en documentación, cambiante, sujeta a los criterios que establecen los países del entorno más avanzados en la materia. Las dos últimas décadas del siglo, acotadas por la transición política y varios siniestros de graves consecuencias, definen el proceso normativo que culmina con el código técnico de la edificación que hoy conocemos. Es un periodo de aprendizaje y asimilación del capítulo de la seguridad, donde los métodos son variados. Donde la intencionalidad última es trasladar un sistema prescriptivo a un modelo prestacional propio de la madurez en el análisis del tema y en las corrientes de los países del entorno. ABSTRACT This is the search for answers to that constant question: Where do we come from and what have left along the way? Has everything been clear on this journey, or have we acted as a result of a collection of errors learned from prior processes? This has been research through exploration of our past, of our origins regarding fire protection safety, and, above all, of the endeavour to utilize architecture aimed at offering the highest level of safety and evacuation in a reasonable time. This project has researched society’s change nationwide and its effects on how to interpret the difficulty of fire protection safety in buildings. Its focus has fundamentally been to clarify those aspects that affect the evacuation of people. To this end, the main milestones of action, the principal concerns that have arisen at each step, and the solutions taken have all been studied. A check was performed on their application; or their delay until a significant event occurred that prompted a new revision of design and control procedures. Firstly, this was done by attempting to connect the main fires that have influenced how we handle the problem at different times in Spain’s history. Secondly, an examination was done on the figure of the architect and his participation in the means of control and legislation on how to intercede in fire services, or how the architect finds solutions for buildings in terms of fire protection, or the evacuation of their occupants. In short, the written works of certain specialists, who are essential to our understanding of how to deal with the problem of protection in buildings, were explored throughout history. A study was done on the most significant disasters in theatres and other public establishments. This was done by analysing the way the architects involved have aimed to solve possible points liable to risk. It is a classification of building where, for the first time, the concern arose to adopt safety measures and procedures in the event of fires. Public establishments with considerable accident rates emerged. Here the main entertainment activities of the time took place. These spaces were a source of worry among the public and authorities due to the high number of persons they accommodated. Other issues in such an extensive subject, which are only outlined in this research study, are procedures in extinguishing systems, the organizational structure of cities, the first fire insurance companies, and the appearance of patents after the industrial development of the 19th century. All of these aspects are joined by the common thread of regulations that have been created in this matter. At the beginning, these regulations were for public shows, thus defining the starting point for our regulations. This was done in anticipation of structural systems and size data of evacuations. With the arrival of the mid-20th century, different uses were addressed. A modernization of construction processes and the industry regulations were tracked. Information was gathered from professional organizations that began to demand a national coordination of prevention systems which led to the Regulation Project on fire prevention which will never be published. Throughout this stage, replete with voluntary and compulsory documents, both on the local and national level, the dimensional criteria to be used in the resolution of architectural elements open to use in evacuation were defined. This was a period that was filled with documentation, change, and subject to the criteria that the most advanced countries in the field established in this regard. The final two decades of the century, marked by political transition and several accidents with grave consequences, defined the regulation process that culminated with the building technical code known today. This was a period of learning and understanding in the chapter of safety, where the methods are varied. In this chapter, the ultimate goal is to insert a prescriptive-based standard into a performance-based code suitable for cultivated experience in analysis of the subject and the tendencies in countries dealing with this field.

As entidades fechadas de previdência complementar enquanto instrumentos de atuação do Estado na economia

Com as transformações ocorridas nas últimas décadas do século XX, notadamente a expansão financeira pela qual passou o capitalismo, o enfraquecimento fiscal dos Estados nacionais e o questionamento aos sistemas de previdência pública por repartição, ganham importância em todo o mundo os fundos de pensão. Estes fundos, ao lado de outros investidores institucionais, como seguradoras e fundos de investimentos, passam a cumprir papel central no mercado acionário e também no mercado de títulos públicos e privados. Com o objetivo de realizar lucros para pagar benefícios de aposentadoria para os seus participantes, os fundos de pensão arrecadam e concentram poupança privada pulverizada, transformando-a em um ativo poderoso. No Brasil, as Entidades Fechadas de Previdência Complementar nomenclatura jurídica dos fundos de pensão possuem um total de 702 bilhões de reais em ativos, que se concentram nas três maiores entidades do país: Previ, Petros e Funcef. Em comum, estes três fundos têm o fato de serem patrocinados por empresas estatais, o que, pela legislação vigente, dá ao Poder Executivo a competência de indicar metade de seus dirigentes, incluindo o seu presidente que possui voto de desempate. O presente trabalho pesquisou o papel que estas três EFPCs cumprem enquanto instrumento de atuação do Estado no domínio econômico, especialmente para o provimento de fundos para o desenvolvimento. Para isso, primeiramente, o estudo explora o movimento de expansão financeira do capitalismo e a crise no padrão de desenvolvimento brasileiro. Depois, investiga de maneira sistemática o arcabouço jurídico que regula os fundos de pensão; e, por fim, analisa a alocação dos seus investimentos e o perfil dos seus dirigentes.

Planos de saúde e envelhecimento populacional: um modelo viável?

O presente trabalho versa sobre a relação presente e futura dos planos de saúde com os idosos. Tem como pressupostos iniciais a existência de uma janela demográfica de oportunidades que será encerrada, conforme estimativa do IBGE, em 2020 e o fato de o modelo de atenção à saúde por planos de saúde se encontrar em expansão. Diante da realidade de envelhecimento populacional, pergunta-se: Os planos de saúde são um modelo viável para a garantia da atenção à saúde dos idosos? As respostas a essa questão foram construídas adotando-se como método de trabalho a análise de doutrina, jurisprudência, legislação e, quando necessário, fontes não tradicionais do Direito como os dados de órgãos de pesquisa demográficos e econômicos, a imprensa e as associações setoriais. Inicialmente tratou-se do funcionamento do setor de planos de saúde, desde a sua origem, indicando-se que historicamente sempre manteve uma relação simbiótica com o Estado, em especial com os recursos públicos. Para tanto, foram explorados temas como o ressarcimento ao SUS, o uso da estrutura dos hospitais públicos pelos planos de saúde e a existência de subsídios, abatimentos e outras formas de financiamento público das atividades deste setor. No capítulo seguinte se detalhou a questão do envelhecimento populacional, apresentando-se a legislação pertinente, os dados que revelam a composição presente e estimada da população brasileira, os principais problemas de saúde que afetam os idosos e os impactos da mudança de perfil demográfico para a política de saúde. No capítulo 3 evidenciou-se a já problemática relação dos planos de saúde com os idosos, permeada por discriminações na contratação, cobrança de mensalidades proibitivas e reajustes expulsivos, presença de cláusulas abusivas em contratos antigos, judicialização dos reajustes por mudança de faixa etária e conflitos decorrentes da prevalência da contratação na forma coletiva. Por fim, no derradeiro capítulo concluiu-se que o modelo de planos de saúde não é viável para a garantia da atenção à saúde do idoso, sendo urgente que haja uma discussão sobre qual modelo de saúde o país deseja sob pena de que as conquistas decorrentes da afirmação da saúde como direito fundamental se percam. Há características inerentes ao setor que o aparta dos idosos e, portanto, da nova realidade demográfica do país, como a prática da seleção de risco, a cobrança de mensalidades com preços insustentáveis para os idosos, o foco no modelo curativo de atenção à saúde e o afastamento da prevenção. Por outro lado, o cenário se agrava por conta das recorrentes falhas na regulação e na regulamentação, e pelo tratamento cindido, na prática, da política de saúde como se não fosse una e não devesse funcionar em harmonia, independentemente da fonte de financiamento. Há, portanto, um alto risco de que a situação dos idosos nos planos de saúde se torne insustentável, dando margem a medidas imediatistas ampliadoras dos subsídios públicos aos planos de saúde. A contrarreforma sanitária, entendida como o retrocesso das ações e dos serviços de saúde ao modelo anterior à Constituição Federal, é um perigo a ser considerado e combatido.

Provincetown Harbor, Cape Cod, Massachusetts, 1841 (Raster Image)

This layer is a georeferenced raster image of the historic paper map entitled: Chart of Cape Cod Harbor and the adjacent coast of Provincetown and Truro, reduced from the original of James D. Graham and published under the patronage of the Boston Marine Insurance Companies by I.W.P. Lewis ; surveyed and projected by J.D. Graham ; W.J. Stone, sc.. It was published in 1841. Scale 1:21,120. Covers Cape Cod from Truro to Provincetown including Provincetown Harbor, Massachusetts. The image inside the map neatline is georeferenced to the surface of the earth and fit to the Massachusetts State Plane Coordinate System, Mainland Zone (in Feet) (Fipszone 2001). All map collar and inset information is also available as part of the raster image, including any inset maps, profiles, statistical tables, directories, text, illustrations, or other information associated with the principal map. This map is a nautical chart showing coastal features such as harbors, light houses, ocean bottom types, points, inlets, coves, wharves, high and low tide marks, and more. Depths are shown by soundings and contours. Shows also land features: buildings with names of landowners, roads, drainage, and more. Relief is shown by hachures. This layer is part of a selection of digitally scanned and georeferenced historic maps of Massachusetts from the Harvard Map Collection. These maps typically portray both natural and manmade features. The selection represents a range of regions, originators, ground condition dates (1755-1922), scales, and purposes. The digitized selection includes maps of: the state, Massachusetts counties, town surveys, coastal features, real property, parks, cemeteries, railroads, roads, public works projects, etc.

Bank bonus compromise bodes ill for the Single Supervisory Mechanism. CEPS Commentary, 8 March 2013

The European Parliament has probably won a Pyrrhic victory with its position on bank bonuses, argues CEPS CEO Karel Lannoo in this new Commentary. In return, EU member states got what they wanted with the new Capital Requirements Directive (CRD IV): no binding leverage ratio; mortgage risk weightings and capital add-ons to be determined by member states; and no obligatory consolidated capital position for bank-insurance companies. In other words, Banking Union will start out with capital rules that are more like Emmental cheese than a single rulebook. This is a huge encumbrance for a well-functioning Single Supervisory Mechanism (SSM), and makes a single resolution mechanism impossible.

Defining Europe's Capital Markets Union. Bruegel Policy Contribution Issue 2014/12, 13 November 2014

The new European Commission has signalled that it will work to create a ‘capital markets union’. This is understood as an agenda to expand the non-bank part of Europe’s financial system, which is currently underdeveloped. The aim in the short term is to unlock credit provision as banks are deleveraging, and in the longer term, to favour a more diverse, competitive and resilient financial system. Direct regulation of individual non-bank market segments (such as securitisation, private placements or private equity) might be useful at the margin, but will not per se lead to significant capital markets development or the rebalancing of Europe’s financial system away from the current dominance by banks. To reach these goals, the capital markets union agenda must be broadened to address the framework conditions for the development of individual market segments. Six possible areas for policy initiative are, in increasing order of potential impact and political difficulty: regulation of securities and specific forms of intermediation; prudential regulation, especially of insurance companies and pension funds; regulation of accounting, auditing and financial transparency requirements that apply to companies that seek external finance; a supervisory framework for financial infrastructure firms, such as central counterparties, that supports market integration; partial harmonisation and improvement of insolvency and corporate restructuring frameworks;and partial harmonisation or convergence of tax policies that specifically affect financial investment.

O Risco Percebido e Coberto pelas Seguradoras

Os Portugueses desde imemoráveis tempos gostam de partir à descoberta de mundos novos, fazemo-lo pelas mais variadas razões, no entanto, neste trabalho iremos apenas analisar os riscos associados ao turismo de lazer. Os atentados de Nova Iorque em 11 Setembro 2001, Síndrome Respiratório Grave em HongKong em Fevereiro de 2003, o Tsunami no oceano Indico em Dezembro 2004, a erupção vulcânica na Islândia em Abril de 2010 ou os atentados de Paris em 13 de Novembro 2015, estas datas ficaram marcadas para sempre, lemos e relemos inúmeros depoimentos de pessoas que se encontravam de férias nestas cidades e pensamos e se fossemos nós? Os primeiros registos da atividade seguradora datam do ano 5.000 A.C. inicialmente seguravam transportes de mercadorias, hoje em dia podem cobrir “qualquer coisa”. Com a perceção dos riscos que hoje em dia podem ocorrer numa viagem, será que as Seguradoras estão preparadas para minimizar os mesmos? E qual a perceção dos riscos para quem viaja. Para o efeito realizou-se um estudo exploratório por suporte a uma amostra de conveniência que reuniu 152 observações. Análises descritivas e testes não paramétricos foram aplicados para definir quais os riscos mais percebidos e quais os que os turistas portugueses pretendem ver cobertos. Concluiu-se que as pessoas que dão maior importância aos Risco de Saúde e Financeiro são os que efetuam seguros de viagem, já as que dão maior importância aos Risco Equipamento, Risco Politico, Risco Psicológico e Risco de Satisfação são as que optam por não fazer seguro.

Private pensions : millions of workers lose Federal benefit protection at retirement : report to the chairman, Committee on Banking, Housing, and Urban Affairs, U.S. Senate /

"GAO/HRD-91-79."