Days spent in acute care hospitals at the end of life of cancer patients in four Swiss cantons: a retrospective database study (SAKK 89/09).

Number of days spent in acute hospitals (DAH) at the end of life is regarded as an important care quality indicator for cancer patients. We analysed DAH during 90 days prior to death in patients from four Swiss cantons. Claims data from an insurance provider with about 20% market share and patient record review identified 2086 patients as dying of cancer. We calculated total DAH per patient. Multivariable generalised linear modelling served to evaluate potential explanatory variables. Mean DAH was 26 days. In the multivariable model, using complementary and alternative medicine (DAH = 33.9; +8.8 days compared to non-users) and canton of residence (for patient receiving anti-cancer therapy, Zürich DAH = 22.8 versus Basel DAH = 31.4; for other patients, Valais DAH = 22.7 versus Ticino DAH = 33.7) had the strongest influence. Age at death and days spent in other institutions were additional significant predictors. DAH during the last 90 days of life of cancer patients from four Swiss cantons is high compared to most other countries. Several factors influence DAH. Resulting differences are likely to have financial impact, as DAH is a major cost driver for end-of-life care. Whether they are supply- or demand-driven and whether patients would prefer fewer days in hospital remains to be established.

Comparison of clinical and economic outcomes between high-intensity care and hospice care for the end-of-life melanoma patients

The intensity of care for patients at the end-of-life is increasing in recent years. Publications have focused on intensity of care for many cancers, but none on melanoma patients. Substantial gaps exist in knowledge about intensive care and its alternative, hospice care, among the advanced melanoma patients at the end of life. End-of-life care may be used in quite different patterns and induce both intended and unintended clinical and economic consequences. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases to identify patients aged 65 years or older with metastatic melanoma who died between 2000 and 2007. We evaluated trends and associations between sociodemographic and health services characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy and costs. Survival, end-of-life costs, and incremental cost-effectiveness ratio were evaluated using propensity score methods. Costs were analyzed from the perspective of Medicare in 2009 dollars. In the first journal Article we found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), no significant fluctuation in use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P =0.07 for trend). Enrollment in short-term (1-3 days) hospice care use increased, while long-term hospice care (≥ 4 days) remained stable. Patients living in the SEER Northeast and South regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery and radiation therapy. In the second journal article, of 611 patients identified for this study, 358 (59%) received no hospice care after their diagnosis, 168 (27%) received 1 to 3 days of hospice care, and 85 (14%) received 4 or more days of hospice care. The median survival time was 181 days for patients with no hospice care, 196 days for patients enrolled in hospice for 1 to 3 days, and 300 days for patients enrolled for 4 or more days (log-rank test, P < 0.001). The estimated hazard ratios (HR) between 4 or more days hospice use and survival were similar within the original cohort Cox proportional hazard model (HR, 0.62; 95% CI, 0.49-0.78, P < 0.0001) and the propensity score-matched model (HR, 0.61; 95% CI, 0.47-0.78, P = 0.0001). Patients with ≥ 4 days of hospice care incurred lower end-of-life costs than the other two groups ($14,298 versus $19,380 for the 1- to 3-days hospice care, and $24,351 for patients with no hospice care; p < 0.0001). In conclusion, Surgery and hospice care use increased over the years of this study while the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma. Patients diagnosed with advanced melanoma who enrolled in ≥ 4 days of hospice care experienced longer survival than those who had 1-3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs.^

Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

The new challenges of end-of-life tyres management systems: a Spanish case study

Directive 2008/98/EC released by the European Union represents a significant step forward in all relevant aspects of waste management. Under the already established, extended produced responsibility (EPR) principle, new policies have been enunciated to continuously achieve better overall environmental performance of key products throughout their life phases. This paper discusses how the directive is being articulated in Spain by the main integrated management system (IMS) for end-of-life (EOL) tyres since its creation in 2006. Focusing on the IMS technological, economic and legal aspects, the study provides a global perspective and evaluation of how the IMS is facing the current issues to resolve, the new challenges that have appeared and the management vision for the coming years.

Systematic Approach for the selection of monitoring technologies in CO2 geological storage projects. Application of multicriteria decision making

Geologic storage of carbon dioxide (CO2) has been proposed as a viable means for reducing anthropogenic CO2 emissions. Once injection begins, a program for measurement, monitoring, and verification (MMV) of CO2 distribution is required in order to: a) research key features, effects and processes needed for risk assessment; b) manage the injection process; c) delineate and identify leakage risk and surface escape; d) provide early warnings of failure near the reservoir; and f) verify storage for accounting and crediting. The selection of the methodology of monitoring (characterization of site and control and verification in the post-injection phase) is influenced by economic and technological variables. Multiple Criteria Decision Making (MCDM) refers to a methodology developed for making decisions in the presence of multiple criteria. MCDM as a discipline has only a relatively short history of 40 years, and it has been closely related to advancements on computer technology. Evaluation methods and multicriteria decisions include the selection of a set of feasible alternatives, the simultaneous optimization of several objective functions, and a decision-making process and evaluation procedures that must be rational and consistent. The application of a mathematical model of decision-making will help to find the best solution, establishing the mechanisms to facilitate the management of information generated by number of disciplines of knowledge. Those problems in which decision alternatives are finite are called Discrete Multicriteria Decision problems. Such problems are most common in reality and this case scenario will be applied in solving the problem of site selection for storing CO2. Discrete MCDM is used to assess and decide on issues that by nature or design support a finite number of alternative solutions. Recently, Multicriteria Decision Analysis has been applied to hierarchy policy incentives for CCS, to assess the role of CCS, and to select potential areas which could be suitable to store. For those reasons, MCDM have been considered in the monitoring phase of CO2 storage, in order to select suitable technologies which could be techno-economical viable. In this paper, we identify techniques of gas measurements in subsurface which are currently applying in the phase of characterization (pre-injection); MCDM will help decision-makers to hierarchy the most suitable technique which fit the purpose to monitor the specific physic-chemical parameter.

An universal system to de-orbit satellites at end of life

A 3-year Project financed by the European Commission is aimed at developing a universal system to de-orbit satellites at their end of life, as a fundamental contribution to limit the increase of debris in the Space environment. The operational system involves a conductive tapetether left bare to establish anodic contact with the ambient plasma as a giant Langmuir probe. The Project will size the three disparate dimensions of a tape for a selected de-orbit mission and determine scaling laws to allow system design for a general mission. Starting at the second year, mission selection is carried out while developing numerical codes to implement control laws on tether dynamics in/off the orbital plane; performing numerical simulations and plasma chamber measurements on tether-plasma interaction; and completing design of subsystems: electronejecting plasma contactor, power module, interface elements, deployment mechanism, and tether-tape/end-mass. This will be followed by subsystems manufacturing and by currentcollection, free-fall, and hypervelocity impact tests.

Influence of proportion and particle size gradation of rubber from end-of-life tires on mechanical, thermal and acoustic properties of plaster-rubber mortars

This work presents the main experimental results obtained from the study of plaster test pieces and boards with addition of various volumetric rubber fractions from mechanical grinding of end-of-life tires (ELTs), in three different particle size gradations. It includes a description of the materials employed, and their proportions. The physical and mechanical properties, as well as the thermal conductivity and acoustic insulation properties are analyzed. Experimental results obtained for specimens with addition of recycled rubber are compared with similar ones, carried out on specimens of plaster of identical features without any addition, evaluating the influence of the particle size and mixture proportions. An improvement in thermal and acoustic performance has been obtained as well as a reduction in density, and as a result, some constructive applications for paving and slabs in rehabilitation works are proposed.

Proceso metodológico para optimizar la toma de decisiones en el proyecto de envolventes arquitectónicas multicapa = Methodological process for the optimization of the decision making in multilayer building envelope projects

La presente tesis doctoral se enmarca dentro del concepto de la sistematización del conocimiento en arquitectura, más concretamente en el campo de las construcciones arquitectónicas y la toma de decisiones en la fase de proyecto de envolventes arquitectónicas multicapa. Por tanto, el objetivo principal es el establecimiento de las bases para una toma de decisiones informadas durante el proyecto de una envolvente multicapa con el fin de colaborar en su optimización. Del mismo modo que la historia de la arquitectura está relacionada con la historia de la innovación en construcción, la construcción está sujeta a cambios como respuesta a los fracasos anteriores. En base a esto, se identifica la toma de decisiones en la fase de proyecto como el estadio inicial para establecer un punto estratégico de reflexión y de control sobre los procesos constructivos. La presente investigación, conceptualmente, define los parámetros intervinientes en el proyecto de envolventes arquitectónicas multicapa a partir de una clasificación y sistematización de todos los componentes (elementos, unidades y sistemas constructivos) utilizados en las fachadas multicapa. Dicha sistematización se materializa en una hoja matriz de datos en la que, dentro de una organización a modo de árbol, se puede acceder a la consulta de cada componente y de su caracterización. Dicha matriz permite la incorporación futura de cualquier componente o sistema nuevo que aparezca en el mercado, relacionándolo con aquellos con los que comparta ubicación, tipo de material, etc. Con base en esa matriz de datos, se diseña la sistematización de la toma de decisiones en la fase de proyecto de una envolvente arquitectónica, en concreto, en el caso de una fachada. Operativamente, el resultado se presenta como una herramienta que permite al arquitecto o proyectista reflexionar y seleccionar el sistema constructivo más adecuado, al enfrentarse con las distintas decisiones o elecciones posibles. La herramienta se basa en las elecciones iniciales tomadas por el proyectista y se estructura, a continuación y sucesivamente, en distintas aproximaciones, criterios, subcriterios y posibilidades que responden a los distintos avances en la definición del sistema constructivo. Se proponen una serie de fichas operativas de comprobación que informan sobre el estadio de decisión y de definición de proyecto alcanzados en cada caso. Asimismo, el sistema permite la conexión con otros sistemas de revisión de proyectos para fomentar la reflexión sobre la normalización de los riesgos asociados tanto al proprio sistema como a su proceso constructivo y comportamiento futuros. La herramienta proporciona un sistema de ayuda para ser utilizado en el proceso de toma de decisiones en la fase de diseño de una fachada multicapa, minimizando la arbitrariedad y ofreciendo una cualificación previa a la cuantificación que supondrá la elaboración del detalle constructivo y de su medición en las sucesivas fases del proyecto. Al mismo tiempo, la sistematización de dicha toma de decisiones en la fase del proyecto puede constituirse como un sistema de comprobación en las diferentes fases del proceso de decisión proyectual y de definición de la envolvente de un edificio. ABSTRACT The central issue of this doctoral Thesis is founded on the framework of the concept of the systematization of knowledge in architecture, in particular, in respect of the field of building construction and the decision making in the design stage of multilayer building envelope projects. Therefore, the main objective is to establish the bases for knowledgeable decision making during a multilayer building envelope design process, in order to collaborate with its optimization. Just as the history of architecture is connected to the history of innovation in construction, construction itself is subject to changes as a response to previous failures. On this basis, the decisions made during the project design phase are identified as the initial state to establish an strategic point for reflection and control, referred to the constructive processes. Conceptually, this research defines the parameters involving the multilayer building envelope projects, on the basis of a classification and systematization for all the components (elements, constructive units and constructive systems) used in multilayer façades. The mentioned systematization is materialized into a data matrix sheet in which, following a tree‐like organization, the access to every single component and its characterization is possible. The above data matrix allows the future inclusion of any new component or system that may appear in the construction market. That new component or system can be put into a relationship with another, which it shares location, type of material,… with. Based on the data matrix, the systematization of the decision making process for a building envelope design stage is designed, more particularly in the case of a façade. Putting this into practice, it is represented as a tool which allows the architect or the designer, to reflect and to select the appropriate building system when facing the different elections or the different options. The tool is based on the initial elections taken by the designer. Then and successively, it is shaped on the form of different operative steps, criteria, sub‐criteria and possibilities which respond to a different progress in the definition of the building construction system. In order to inform about the stage of the decision and the definition reached by the project in every particular case, a range of operative sheets are proposed. Additionally, the system allows the connection with other reviewing methods for building projects. The aim of this last possibility is to encourage the reflection on standardization of the associated risks to the building system itself and its future performance. The tool provides a helping system to be used during the decision making process for a multilayer façade design. It minimizes the arbitrariness and offers a qualification previous to the quantification that will be done with the development of the construction details and their bill of quantities, that in subsequent project stages will be executed. At the same time, the systematization of the mentioned decision making during the design phase, can be found as a checking system in the different stages of the decision making design process and in the different stages of the building envelope definition.

Sport-Specific Practice and the Development of Expert Decision-Making in Team Ball Sports

The role of sport-specific practice in the development of decision-making expertise in the sports of field hockey, netball, and basketball was examined. Fifteen expert decision-makers and 13 experienced non-expert athletes provided detailed information about the quantity and type of sport-specific and other related practice activities they had undertaken throughout their careers. Experts accumulated more hours of sport-specific practice from age 12 years onwards than did non-experts, spending on average some 13 years and 4,000 hours on concentrated sport-specific practice before reaching international standard. A significant negative correlation existed between the number of additional activities undertaken and the hours of sportspecific training required before attaining expertise, suggesting a functional role for activities other than sport-specific training in the development of expert decision-making.