L'accessibilité aux services de physiothérapie en clinique externe dans les centres hospitaliers du Québec

Des contraintes d’accessibilité aux services de physiothérapie en clinique externe ont été rapportées dans les établissements publics au Canada. Celles-ci se traduisent souvent par un temps d’attente élevé avant d’obtenir des services. Différentes stratégies ont été proposées afin de gérer les listes d’attente, mais leur impact sur le temps d’attente est méconnu, notamment dans le contexte des services de physiothérapie au Québec. Le but de cette étude était de documenter l’accessibilité aux services de physiothérapie en clinique externe dans les centres hospitaliers au Québec. Les objectifs spécifiques étaient de 1) décrire les caractéristiques organisationnelles en lien avec l’accessibilité aux services de physiothérapie, 2) quantifier le temps d’attente pour accéder aux services et 3) explorer l’association entre les caractéristiques organisationnelles et le temps d’attente. Une enquête a été réalisée dans les cliniques externes de physiothérapie des centres hospitaliers publics du Québec offrant des services à des adultes souffrant de troubles musculosquelettiques. Des données ont été obtenues auprès de 97 (99%) centres hospitaliers. Au moment de l’enquête, 18 245 personnes étaient sur les listes d’attente. Le temps d’attente médian était de plus de six mois dans 41% des centres hospitaliers. Parmi les pratiques organisationnelles et les stratégies de gestion de listes d’attente évaluées, les politiques en cas d’annulation ou d’absence (99%) et la priorisation des demandes (96%) étaient les plus utilisées. Selon les résultats d’analyses multivariées, seule l’utilisation d’une méthode de priorisation comprenant une rencontre d’évaluation et une intervention initiale était associée au temps d’attente (p=0,008). Les résultats de cette étude démontrent qu’une grande quantité de personnes sont inscrites sur les listes d’attente des services de physiothérapie et que le temps d’attente peut être très élevé. D’après nos résultats, l’implantation d’une méthode de priorisation comprenant une évaluation et une intervention pourrait permettre d’améliorer l’accès en temps opportun aux services de physiothérapie.

DISPATCHING AND RELOCATION OF EMERGENCY VEHICLES ON FREEWAYS: THEORIES AND APPLICATIONS

Resource allocation decisions are made to serve the current emergency without knowing which future emergency will be occurring. Different ordered combinations of emergencies result in different performance outcomes. Even though future decisions can be anticipated with scenarios, previous models follow an assumption that events over a time interval are independent. This dissertation follows an assumption that events are interdependent, because speed reduction and rubbernecking due to an initial incident provoke secondary incidents. The misconception that secondary incidents are not common has resulted in overlooking a look-ahead concept. This dissertation is a pioneer in relaxing the structural assumptions of independency during the assignment of emergency vehicles. When an emergency is detected and a request arrives, an appropriate emergency vehicle is immediately dispatched. We provide tools for quantifying impacts based on fundamentals of incident occurrences through identification, prediction, and interpretation of secondary incidents. A proposed online dispatching model minimizes the cost of moving the next emergency unit, while making the response as close to optimal as possible. Using the look-ahead concept, the online model flexibly re-computes the solution, basing future decisions on present requests. We introduce various online dispatching strategies with visualization of the algorithms, and provide insights on their differences in behavior and solution quality. The experimental evidence indicates that the algorithm works well in practice. After having served a designated request, the available and/or remaining vehicles are relocated to a new base for the next emergency. System costs will be excessive if delay regarding dispatching decisions is ignored when relocating response units. This dissertation presents an integrated method with a principle of beginning with a location phase to manage initial incidents and progressing through a dispatching phase to manage the stochastic occurrence of next incidents. Previous studies used the frequency of independent incidents and ignored scenarios in which two incidents occurred within proximal regions and intervals. The proposed analytical model relaxes the structural assumptions of Poisson process (independent increments) and incorporates evolution of primary and secondary incident probabilities over time. The mathematical model overcomes several limiting assumptions of the previous models, such as no waiting-time, returning rule to original depot, and fixed depot. The temporal locations flexible with look-ahead are compared with current practice that locates units in depots based on Poisson theory. A linearization of the formulation is presented and an efficient heuristic algorithm is implemented to deal with a large-scale problem in real-time.

Seeking transparency on allocation of kidneys from deceased donors

Kidney transplantation is the preferred treatment for many end stage renal disease patients; however, the small number of organs for transplantation does not allow all patients to have access to this scarce resource. An allocation system for deceased donor kidneys should be anchored to transparent policies and rules. It should take into account the relationship between supply and demand, hence seeking a balance between the higher net benefit of survival that can be provided by a particular organ and the transplant candidates’ waiting time (as well as the probability of being transplanted).

Otimização de controle de tráfego em grupo de elevadores com algoritmos bioinspirados

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Tecnologia, Departamento de Engenharia Mecânica, 2015.

Intelligent pipeline control - a simulation study in the automotive sector

Automotive producers are aiming to make their order fulfilment processes more flexible. Opening the pipeline of planned products for dynamic allocation to dealers/ customers is a significant step to be more flexible but the behaviour of such Virtual-Build-To-Order systems are complex to predict and their performance varies significantly as product variety levels change. This study investigates the potential for intelligent control of the pipeline feed, taking into account the current status of inventory (level and mix) and of the volume and mix of unsold products in the planning pipeline, as well as the demand profile. Five ‘intelligent’ methods for selecting the next product to be planned into the production pipeline are analysed using a discrete event simulation model and compared to the unintelligent random feed. The methods are tested under two conditions, firstly when customers must be fulfilled with the exact product they request, and secondly when customers trade-off a shorter waiting time for compromise in specification. The two forms of customer behaviour have a substantial impact on the performance of the methods and there are also significant differences between the methods themselves. When the producer has an accurate model of customer demand, methods that attempt to harmonise the mix in the system to the demand distribution are superior.

Endoscopic capacity in West Africa.

Background: Levels of endoscopic demand and capacity in West Africa are unclear. Objectives: This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered. Methods: In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiplechoice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done. Results: In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Exploração de escalonamentos óptimos na gestão de exames médicos

Uma das áreas de aplicação da optimização é a Engenharia Biomédica, pois a optimização intervém no estudo de próteses e implantes, na reconstrução tomográfica, na mecânica experimental, entre outras aplicações. Este projecto tem como principal objectivo a criação de um novo programa de marcação de exames médicos a fim de minimizar o tempo de espera na realização dos mesmos. É efectuada uma breve referência à teoria da optimização bem como à optimização linear e não-linear, aos algoritmos genéticos, que foram usados para a realização deste trabalho. É também apresentado um caso de estudo, formulado como um problema de optimização não linear com restrições. Com este estudo verificou-se que o escalonamento de exames médicos nunca poderá ser optimizado a 100por cento devido à quantidade de variáveis existentes, sendo que algumas delas não são passíveis de prever com antecedência.

Qualidade e triagem de Manchester : Estudo de caso Hospital CUF Descobertas

A saúde em Portugal encontra-se no caminho da mudança, rumo à excelência, pois questiona-se o sistema, a sua estrutura, os seus processos e os resultados. Uma das condições que mais influencia a competitividade entre instituições da saúde é a qualidade. Sendo a sociedade cada vez mais exigente, medi-la e avalia-la é um imperativo da época actual. O presente estudo teve como objectivo, contribuir para a realização de um diagnóstico de um processo de melhoria implementado num hospital privado de Lisboa - Hospital CUF Descobertas (HCD), no Serviço de Atendimento Permanente (SAP), à luz dos princípios da qualidade total. O procedimento da Triagem de Manchester é um processo que tem como principal objectivo o estabelecimento de prioridades, ou seja, identificar critérios de gravidade, de forma objectiva e sistematizada, que indicam a prioridade clínica com que o cliente deve ser atendido e o respectivo tempo de espera alvo recomendado até observação médica. Não se trata de estabelecer diagnósticos. Para o efeito, utilizou-se uma abordagem metodológica, suportada pelo modelo de auto-avaliação, designado Modelo Common Assessment Framework (CAF). Neste sentido, privilegiando-se a utilização dos critérios de meios deste modelo. Foi aplicado um questionário aos colaboradores do Serviço de Atendimento Permanente do Hospital CUF Descobertas. O Tratamento de dados estatísticos foi realizado com o apoio do SPSS, versão 16.0 e do Microsoft Excel. Os resultados deste estudo culminam com a identificação de pontos fortes, pontos fracos e sugestões de melhorias para o serviço em estudo. Neste sentido, este trabalho serviu de diagnóstico para se poder identificar em que ponto se situa e que rumo se deve seguir para se atingir um patamar de excelência relativamente à qualidade. Abstract: Health in Portugal finds itself on the path toward change, trying to find excellence while challenging the system and its structure, processes, and results. One of the conditions that most influences the competitiveness between the institutes of health is quality because society is becoming more demanding. Measuring and evaluating this change is happening in this current time. The present study has the objective of contributing and establishing a diagnostic tool relative to the process of improvement. This tool was used in a private hospital in Lisbon, Hospital CUF Descobertas, in the Emergency Room, in looking at the principles of total quality. This process designed through the Manchester Triage System has the main objective of the establishment of priorities through which we want to identify criteria of seriousness in an objective and systematic way that indicate a clinical priority with which the client is attended to in respect to the waiting time, giving a recommended time until medical observation. ln this sense, we do not diagnose patients in triage. For this effect, we used a methodological overview supported by the model of self-evaluation, the Common Assessment Framework (CAF}, in which we used the criteria: Leadership, Planning and Strategy, People, Resources and Processes. To arrive at this, a questionnaire was used by the collaborators of the emergency room of Hospital CUF Descobertas. The statistical analysis of the data was performed using SPSS version 16.0 and Microsoft Excel. The results of this study culminated with the identification of strong points, weak points, and suggestions for improvements for the work in study. ln this way, with this study, we can identify in where an organization finds itself and the path it should take in order to achieve a high level of quality excellence.

Towards a predictive model of Ca²⁺ puffs

We investigate key characteristics of Ca²⁺ puffs in deterministic and stochastic frameworks that all incorporate the cellular morphology of IP[subscript]3 receptor channel clusters. In a first step, we numerically study Ca²⁺ liberation in a three dimensional representation of a cluster environment with reaction-diffusion dynamics in both the cytosol and the lumen. These simulations reveal that Ca²⁺ concentrations at a releasing cluster range from 80 µM to 170 µM and equilibrate almost instantaneously on the time scale of the release duration. These highly elevated Ca²⁺ concentrations eliminate Ca²⁺ oscillations in a deterministic model of an IP[subscript]3R channel cluster at physiological parameter values as revealed by a linear stability analysis. The reason lies in the saturation of all feedback processes in the IP[subscript]3R gating dynamics, so that only fluctuations can restore experimentally observed Ca²⁺ oscillations. In this spirit, we derive master equations that allow us to analytically quantify the onset of Ca²⁺ puffs and hence the stochastic time scale of intracellular Ca²⁺ dynamics. Moving up the spatial scale, we suggest to formulate cellular dynamics in terms of waiting time distribution functions. This approach prevents the state space explosion that is typical for the description of cellular dynamics based on channel states and still contains information on molecular fluctuations. We illustrate this method by studying global Ca²⁺ oscillations.

O contributo da animação na qualidade de vida dos idosos do serviço de apoio domiciliário do centro comunitário de Estoi

Dissertação de Mestrado, Educação Social, Escola Superior de Educação e Comunicação, Universidade do Algarve, 2016

Motivating the use of public transit through a mobile glanceable display

With increasing concerns about the impact of global warming on human life, policy makers around the world and researchers have sought for technological solutions that have the potential to attenuate this process. This thesis describes the design and evaluation of an information appliance that aims to increase the use of public transportation. We developed a mobile glanceable display that, being aware of the user’s transportation routines, provides awareness cues about bus arrival time, grounded upon the vision of Ambient Intelligence. We present the design process we followed, from ideation to building a prototype and conducting a field study, and conclude with a set of guidelines for the design of relevant personal information systems. More specifically we seek to test the following hypotheses: 1) That the tangible prototype that provides ambient cues will be used more frequently than a similar purpose mobile app, 2) That the tangible prototype will reduce the waiting time at the bus stop, 3) That the tangible prototype will result to reduced anxiety on passengers, 4) That the tangible prototype will result to an increase in the perceived reliability of the transit service, 5) That the tangible prototype will enhance users’ efficiency in reading the bus schedules and 6) That the tangible prototype will make individuals more likely to use public transit. In a field study, we compare the tangible prototype against the mobile app and a control condition where participants were given no external support in obtaining bus arrival information, other than their existing routines. Using qualitative and quantitative data, we test the aforementioned hypotheses and explore users’ reactions to the prototype we developed.

Motivating the use of public transit through a mobile glanceable display

With increasing concerns about the impact of global warming on human life, policy makers around the world and researchers have sought for technological solutions that have the potential to attenuate this process. This thesis describes the design and evaluation of an information appliance that aims to increase the use of public transportation. We developed a mobile glanceable display that, being aware of the user’s transportation routines, provides awareness cues about bus arrival time, grounded upon the vision of Ambient Intelligence. We present the design process we followed, from ideation to building a prototype and conducting a field study, and conclude with a set of guidelines for the design of relevant personal information systems. More specifically we seek to test the following hypotheses: 1) That the tangible prototype that provides ambient cues will be used more frequently than a similar purpose mobile app, 2) That the tangible prototype will reduce the waiting time at the bus stop, 3) That the tangible prototype will result to reduced anxiety on passengers, 4) That the tangible prototype will result to an increase in the perceived reliability of the transit service, 5) That the tangible prototype will enhance users’ efficiency in reading the bus schedules and 6) That the tangible prototype will make individuals more likely to use public transit. In a field study, we compare the tangible prototype against the mobile app and a control condition where participants were given no external support in obtaining bus arrival information, other than their existing routines. Using qualitative and quantitative data, we test the aforementioned hypotheses and explore users’ reactions to the prototype we developed.

Índice del perfil del donante renal (KDPI) como factor pronóstico del trasplante

La enfermedad renal crónica ha aumentado a nivel mundial y nacional, mientras que el número de donantes viene en descenso, y los pacientes en lista de espera aumentan. Los donantes cadavéricos son una opción para estos pacientes, y han sido utilizados en últimos años para aumentar los órganos disponibles. La evaluación de la calidad de estos es importante para optimizar su uso. Estudio analítico tipo cohorte retrospectiva, cálculo de KDPI en donantes cadavéricos, seguimiento función renal creatinina sérica 1 mes, 3 meses, 6 meses y un año. Correlación supervivencia del injerto, función renal, KDPI y EPTS. Análisis de supervivencia y regresión logística con variables del donante, receptor y acto quirúrgico.

Traffic Signal Optimization of Urban Arterial Network by Vehicle-to-Infrastructure

Urbanization has occasionally been linked to negative consequences. Traffic light system in urban arterial networks plays an essential role to the operation of transport systems. The availability of new Intelligent Transportation System innovations paved the way for connecting vehicles and road infrastructure. GLOSA, or the Green Light Optimal Speed Advisory, is a recent integration of vehicle-to-everything (v2x) technology. This thesis emphasized GLOSA system's potential as a tool for addressing traffic signal optimization. GLOSA serves as an advisory to drivers, informing them of the speed they must maintain to reduce waiting time. The considered study area in this thesis is the Via Aurelio Saffi – Via Emilia Ponente corridor in the Metropolitan City of Bologna which has several signalized intersections. Several simulation runs were performed in SUMOPy software on each peak-hour period (morning and afternoon) using recent actual traffic count data. GLOSA devices were placed on a 300m GLOSA distance. Considering the morning peak-hour, GLOSA outperformed the actuated traffic signal control, which is the baseline scenario, in terms of average waiting time, average speed, average fuel consumption per vehicle and average CO2 emissions. A remarkable 97% reduction on both fuel consumption and CO2 emissions were obtained. The average speed of vehicles running through the simulation was increased as well by 7% and a time saved of 25%. Same results were obtained for the afternoon peak hour with a decrease of 98% on both fuel consumption and CO2 emissions, 20% decrease on average waiting time, and an increase of 2% in average speed. In addition to previously mentioned benefits of GLOSA, a 15% and 13% decrease in time loss were obtained during morning and afternoon peak-hour, respectively. Towards the goal of sustainability, GLOSA shows a promising result of significantly lowering fuel consumption and CO2 emissions per vehicle.

Anti-HLA antibody repertoire after IVIg infusion in highly sensitized patients waiting for kidney transplantation.

Polyclonal intravenous immunoglobulin (IVIg) treatment reduces crossmatch positivity and increases rates of transplantation in highly sensitised patients (HS). We quantified the panel reactive antibody (PRA) by microlymphocytotoxicity (MLCC), and we analysed anti-HLA class I and class II IgG specific antibody repertoire by Luminex before and after IVIg infusion alone in HS patients awaiting kidney transplantation. Five patients received three monthly infusions of 1 g/kg of IVIg. Serum samples collected pre and post IVIg treatment were submitted for PRA analysis by MLCC. Anti-class I and anti-class II antibody specificities were then tested by Luminex. We focused on the anti-HLA class I and class II antibodies directed against HLA expressed by a previous graft. We also analysed the anti-HLA antibody repertoire in three patients who had not received IVIg infusion. The PRA level determined by MLCC decreased significantly in one of the five patients, dropping from 40% to 17%. The Luminex assay showed fluctuations of the anti-HLA antibody levels over time, but no significant longterm modifications of the anti-HLA antibody repertoire were observed, even in the patient with a strong and prolonged reduction of the PRA determined by MLCC. Our results show that IVIg at 1 g/kg is not sufficient to reduce PRA and does not modify the repertoire of specific anti-HLA antibody determined by Luminex.