Multi-agent based modeling and simulation of complex system in hospital

This study puts forward a method to model and simulate the complex system of hospital on the basis of multi-agent technology. The formation of the agents of hospitals with intelligent and coordinative characteristics was designed, the message object was defined, and the model operating mechanism of autonomous activities and coordination mechanism was also designed. In addition, the Ontology library and Norm library etc. were introduced using semiotic method and theory, to enlarge the method of system modelling. Swarm was used to develop the multi-agent based simulation system, which is favorable for making guidelines for hospital's improving it's organization and management, optimizing the working procedure, improving the quality of medical care as well as reducing medical charge costs.

The effect of the Madden-Julian Oscillation on station rainfall and river level in the Fly River system, Papua New Guinea

The Madden-Julian oscillation (MJO) is the dominant mode of intraseasonal variability in tropical rainfall on the large scale, but its signal is often obscured in individual station data, where effects are most directly felt at the local level. The Fly River system, Papua New Guinea, is one of the wettest regions on Earth and is at the heart of the MJO envelope. A 16 year time series of daily precipitation at 15 stations along the river system exhibits strong MJO modulation in rainfall. At each station, the difference in rainfall rate between active and suppressed MJO conditions is typically 40% of the station mean. The spread of rainfall between individual MJO events was small enough such that the rainfall distributions between wet and dry phases of the MJO were clearly separated at the catchment level. This implies that successful prediction of the large-scale MJO envelope will have a practical use for forecasting local rainfall. In the steep topography of the New Guinea Highlands, the mean and MJO signal in station precipitation is twice that in the satellite Tropical Rainfall Measuring Mission 3B42HQ product, emphasizing the need for ground-truthing satellite-based precipitation measurements. A clear MJO signal is also present in the river level, which peaks simultaneously with MJO precipitation input in its upper reaches but lags the precipitation by approximately 18 days on the flood plains.

Equations to predict methane emissions from cows fed at maintenance energy level in pasture-based systems

Ruminant production is a vital part of food industry but it raises environmental concerns, partly due to the associated methane outputs. Efficient methane mitigation and estimation of emissions from ruminants requires accurate prediction tools. Equations recommended by international organizations or scientific studies have been developed with animals fed conserved forages and concentrates and may be used with caution for grazing cattle. The aim of the current study was to develop prediction equations with animals fed fresh grass in order to be more suitable to pasture-based systems and for animals at lower feeding levels. A study with 25 nonpregnant nonlactating cows fed solely fresh-cut grass at maintenance energy level was performed over two consecutive grazing seasons. Grass of broad feeding quality, due to contrasting harvest dates, maturity, fertilisation and grass varieties, from eight swards was offered. Cows were offered the experimental diets for at least 2 weeks before housed in calorimetric chambers over 3 consecutive days with feed intake measurements and total urine and faeces collections performed daily. Methane emissions were measured over the last 2 days. Prediction models were developed from 100 3-day averaged records. Internal validation of these equations, and those recommended in literature, was performed. The existing in greenhouse gas inventories models under-estimated methane emissions from animals fed fresh-cut grass at maintenance while the new models, using the same predictors, improved prediction accuracy. Error in methane outputs prediction was decreased when grass nutrient, metabolisable energy and digestible organic matter concentrations were added as predictors to equations already containing dry matter or energy intakes, possibly because they explain feed digestibility and the type of energy-supplying nutrients more efficiently. Predictions based on readily available farm-level data, such as liveweight and grass nutrient concentrations were also generated and performed satisfactorily. New models may be recommended for predictions of methane emissions from grazing cattle at maintenance or low feeding levels.

Continuous and High-Level In Vivo Delivery of Endostatin From Recombinant Cells Encapsulated in TheraCyte (R) Immunoisolation Devices

Endostatin (ES) is a potent inhibitor of angiogenesis and tumor growth. Continuous ES delivery of ES improves the efficacy and potency of the antitumoral therapy. The TheraCyte (R) system is a polytetrafluoroethylene (PTFE) semipermeable membrane macroencapsulation system for implantation of genetically engineered cells specially designed for the in vivo delivery of therapeutic proteins, such as ES, which circumvents the problem of limited half-life and variation in circulating levels. In order to enable neovascularization at the tissues adjacent to the devices prior to ES secretion by the cells inside them, we designed a scheme in which empty TheraCyte (R) devices were preimplanted SC into immunodeficient mice. Only after healing (17 days later) were Chinese hamster ovary cells expressing ES injected into the preimplanted devices. In another model for device implantation, the cells expressing ES where loaded into the immunoisolation devices prior to implantation into the animals, and the TheraCyte (R) were then immediately implanted SC into the mice. Throughout the 2-month study, constant high ES levels of up to 3.7 mu g/ml were detected in the plasma of the mice preimplanted with the devices, while lower but also constant levels of ES (up to 2.1 mu g/ml plasma) were detected in the mice that had received devices preloaded with the ES-expressing cells. Immunohistochemistry using anti-ES antibody showed reaction within the device and outside it, demonstrating that ES, secreted by the confined recombinant cells, permeated through the membrane and reached the surrounding tissues.

Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda : a randomised controlled equivalence trial

BACKGROUND: Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians. METHODS: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14-28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model. The predefined equivalence range was -4% to 4%. The trial was registered at ClinicalTrials.gov, number NCT01844024. FINDINGS: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was -0·8% (95% CI -2·9 to 1·4), falling within the predefined equivalence range (-4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded. INTERPRETATION: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives' involvement in treatment of incomplete abortion with misoprostol at district level would increase access to safe post-abortion care. FUNDING: The Swedish Research Council, Karolinska Institutet, and Dalarna University.

Women's acceptability of misoprostol treatment for incomplete abortion by midwives and physicians : secondary outcome analysis from a randomized controlled equivalence trial at district level in Uganda

OBJECTIVE: This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians. METHODS: This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14-28 days following treatment. Analysis of women's overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024. RESULTS: From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded. CONCLUSIONS: Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women. TRIAL REGISTRATION: ClinicalTrials.gov NCT01844024.

Barriers and facilitators in the provision of post-abortion care at district level in central Uganda : a qualitative study focusing on task sharing between physicians and midwives

Background: Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians' and midwives' perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care. Methods: In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach. Results: Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified. Conclusions: Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

Elections and fiscal policy at the municipal level in Brazil

Esta tese contribui para a literatura sobre ciclos políticos de negócios ao estudar as relações entre eleições, limites à reeleição, partidos e política fiscal em 3.393 municípios brasileiros entre 2001 e 2008. Os resultados mostram que prefeitos de primeiro mandato aumentam receitas totais e mantém níveis razoáveis de gastos durante as eleições, preservando ou até aumentando o balanço orçamentário. Eles também alteram sua alocação orçamentária reduzindo despesas correntes (e.g. pessoal) e aumentando despesas de capital (e.g. investimentos) à medida que as eleições se aproximam. Em realidade, apenas prefeitos de primeiro mandato parecem se beneficiar de aumentos oportunistas nas variáveis fiscais, especialmente em despesas correntes e de pessoal. No entanto, prefeitos de primeiro mandato não são necessariamente menos responsáveis fiscalmente do que prefeitos de segundo mandato ao longo da gestão (anos não eleitorais) ou durante as eleições. Nesse sentido, eleições com prefeitos de primeiro e segundo mandatos parecem promover condições competitivas que potencialmente aumentam a responsabilização eleitoral e fiscal. Essa tese também aponta para uma significativa associação entre ciclos fiscais oportunistas e partidários no nível local no Brasil. Durante as eleições, partidos de direita aumentam o balanço orçamentário, enquanto partidos de esquerda aumentam despesas de capital e reduzem despesas correntes, mas nesse último caso não tanto quanto os demais partidos. Ao fazerem isso, esses partidos atendem parcialmente às preferências dos eleitores. Durante o mandato (anos não eleitorais), entretanto, partidos de direita apresentam um balanço orçamentário levemente mais baixo, enquanto partidos de esquerda investem menos do que os demais partidos, e essas políticas não são favorecidas pelos eleitores. De forma geral, esse estudo mostra que os eleitores no Brasil reconhecem uma administração fiscalmente responsável, e têm uma preferência por mais receitas e gastos públicos, especialmente premiando maiores despesas de capital e investimentos ao longo do mandato político e aumentos em receitas e despesas correntes no ano eleitoral. De qualquer modo, as preferências fiscais dos eleitores são independentes das preferências ideológicas.

Impact of worksite health-promotion programs in hospital admission costs and medical leaves in a sample of brazilian companies

Programas de saúde e bem-estar têm sido adotados por empresas como forma de melhorar a saúde de empregados, e muitos estudos descrevem retornos econômicos positivos sobre os investimentos envolvidos. Entretanto, estudos mais recentes com metodologia melhor têm demonstrado retornos menores. O objetivo deste estudo foi investigar se características de programas de saúde e bem-estar agem como preditores de custos de internação hospitalar (em Reais correntes) e da proporção de funcionários que têm licença médica, entre Abril de 2014 e Maio de 2015, em uma amostra não-aleatória de empresas no Brasil, através de parceria com uma empresa gestora de ‘big data’ para saúde. Um questionário sobre características de programas de saúde no ambiente de trabalho foi respondida por seis grandes empresas brasileiras. Dados retirados destes seis questionários (presença e idade de programa de saúde, suas características – inclusão de atividades de screening, educação sobre saúde, ligação com outros programas da empresa, integração do programa à estrutura da empresa, e ambientes de trabalho voltado para a saúde – e a adoção de incentivos financeiros para aderência de funcionários ao programa), bem como dados individuais de idade, gênero e categoria de plano de saúde de cada empregado , foram usados para construir um banco de dados com mais de 76.000 indivíduos. Através de um modelo de regressão múltipla e seleção ‘stepwise’ de variáveis, a idade do empregado foi positivamente associada e a idade do programa de saúde e a categoria ‘premium’ de plano de saúde do funcionário foram negativamente associadas aos custos de internação hospitalar (como esperado). Inesperadamente, a inclusão de programas de screening e iniciativas de educação de saúde nos programas de saúde e bem-estar nas empresas foram identificados como preditores positivos significativos para custos de admissão hospitalar. Para evitar a inclusão errônea de licenças-maternidade, apenas os dados de licença médica de pacientes do sexo masculino foram analisados (dados disponíveis apenas para duas entre as companhias incluídas, com um total de 18.957 pacientes do sexo masculino). Analisando estes dados através de um teste Z para comparação de proporções, a empresa com programa de saúde que inclui atividades voltadas a cessação de hábitos ruins (como tabagismo e etilismo), controle de diabetes e hipertensão, e que adota incentivos financeiros para a aderência de funcionários ao programa tem menor proporção de empregados com licençca médica no período analisado, quando comparada com a outra empresa que não tem estas características (também conforme esperado). Entretanto, a companhia com menor proporção de funcionários com licença médica também foi aquela que adota programa de screening entre as atividades de seu programa de saúde. Potenciais fontes de ameaça à validade interna e externa destes resultados são discutidas, bem como possíveis explicações para a associação entre programas de screening e educação médica a piores indicadores de saúde nesta amostra de companhias são discutidas. Novos estudos com melhor desenho, com amostras maiores e randômicas são necessários para validar estes resultados e possivelmente melhorar a validade interna e externa destes resultados.

Leukocytes respiratory burst and lysozyme level in pacu (Piaractus mesopotamicus Holmberg, 1887)

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Effects of energy level in finisher diets and slaughter age of on the performance and carcass yield in broiler chickens

Male broilers were used to evaluate the effects of different energy levels in finisher diets and age of slaughter on performance, production pattern and carcass yield. Experimental design was a 2x3 factorial arrangement: energy level (ME) in the finisher diet (3,200 and 3,600 kcal ME/kg) and age of slaughter (42, 49 and 56 days), resulting in six treatments with four replicates. The finisher diet was fed only in the last week of the growing period. Characteristics evaluated were feed consumption (FC), body weight gain (WG), feed conversion (FC), energy intake (EI), caloric conversion (CC), efficiency production index, production pattern, and carcass yield. The results showed better WG and CC for broilers fed 3,200 kcal ME/kg finisher diet. Broilers slaughtered at 42 and 49 days of age had better performance and higher annual production than broilers slaughtered at 56 days of age. Carcass yield was influenced by slaughter age and better breast yield was seen at 49 and 56 days than at 42 days of age. It was concluded that 3,200 kcal ME/kg induced the best overall performance. Poultry houses were efficiently used when broilers were slaughtered at 42 days of age. Meat:bone ratio was improved for broilers slaughtered at 49 and 56 days of age.

Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality?

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Occurrence of tooth injuries in patients treated in hospital environment in the region of Aracatuba, Brazil during a 6-year period

Dental trauma has been considered as a public health problem that affects mainly children and youngsters and due to its impact on the patient's quality of life. This study presents the results of a 6-year survey of the occurrence and characteristics of dental trauma in patients admitted to the Service of Surgery and Oral and Maxillofacial Traumatology of the School of Dentistry of Aracatuba (UNESP, Brazil) after emergency care in hospital facilities in the region of Aracatuba, SP, Brazil. For such purpose, the clinical files of patients treated at the Service between 1999 and 2005 were reviewed. Information regarding gender, age, number of traumatized teeth, etiology and diagnosis of the trauma was collected from the files of patients with tooth injuries and recorded in case report forms specifically designed for this purpose. The results showed that from a total of 4112 patients admitted to the Service within the surveyed period, 266 (6.5%) had tooth injuries (172 males - 64.7%; 94 females - 35.3%). The total number of traumatized teeth was 496. Most patients belonged to the 16-20 year-old age group (20.3%) and the most frequent causes of tooth injuries were bicycle accidents (28.6%), motorcycle accidents (19.2%) and falls (18.8%). Injuries to the periodontal tissues were the most frequent type of tooth injuries (408 teeth; 82.26%), occurring in 118 primary and 290 permanent teeth. Among the injuries to the periodontal tissues, avulsion was the most common (32.86%) (29.41% for primary and 34.0% for permanent teeth), followed by extrusive luxation (19.15%) (25.21% for primary and 17.24% for permanent teeth). In conclusion, in the surveyed population, cases of tooth injuries were more frequent in males aged 16-20 years old due to cyclist accidents with predominance of injuries to the periodontal tissues, in particular, avulsions.