405 resultados para Revisions
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BACKGROUND Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients. METHODS Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing. RESULTS Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period. CONCLUSION Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.
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The capital structure and regulation of financial intermediaries is an important topic for practitioners, regulators and academic researchers. In general, theory predicts that firms choose their capital structures by balancing the benefits of debt (e.g., tax and agency benefits) against its costs (e.g., bankruptcy costs). However, when traditional corporate finance models have been applied to insured financial institutions, the results have generally predicted corner solutions (all equity or all debt) to the capital structure problem. This paper studies the impact and interaction of deposit insurance, capital requirements and tax benefits on a bankÇs choice of optimal capital structure. Using a contingent claims model to value the firm and its associated claims, we find that there exists an interior optimal capital ratio in the presence of deposit insurance, taxes and a minimum fixed capital standard. Banks voluntarily choose to maintain capital in excess of the minimum required in order to balance the risks of insolvency (especially the loss of future tax benefits) against the benefits of additional debt. Because we derive a closed- form solution, our model provides useful insights on several current policy debates including revisions to the regulatory framework for GSEs, tax policy in general and the tax exemption for credit unions.
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Breastfeeding and the use of human milk are widely accepted as the most complete form of nutrition for infants. Breastfeeding is shown to be associated with many positive health outcomes for both infants and mothers. Healthy People 2000 goals to increase breastfeeding rates in the early postpartum period to 75% fell short, with only 64% of mothers meeting this objective. Lack of support from healthcare providers, and unsupportive hospital policies and practices are noted as barriers to the initiation and duration of breastfeeding. The purpose of this study was to evaluate implementation of the BFHI Ten Steps to Successful Breastfeeding at Texas Children's Hospital. ^ The Baby-Friendly Hospital Initiative (BFHI) was developed in 1991 by the World Health Organization and the United Nations Children's Fund (UNICEF) to ensure that healthcare facilities offering maternity services adhere to the Ten Steps of Successful Breastfeeding and the International Code of Marketing of Breast-Milk Substitutes, and create legislation to protect the rights of breastfeeding women. The instrument used in this study was the BFHI 100 Assessment Tool created by Dr. Laura Haiek, Director of Public Health in Monteregie, Quebec, and her staff at Health and Social Services Agency of Quebec. The BFHI 100 tool utilizes 100 different indicators of compliance with BFHI through questionnaires administered to staff and administrators, pregnant and postpartum mothers, and an observer. ^ The study concluded that although there is much room for improvement in educating breastfeeding mothers, overall, the mothers interviewed were satisfied with their level of care in regards to breastfeeding support. Areas of improvement include staff training, as some nursing staff admitted to relying on the lactation consultants to provide most of the breastfeeding education for mothers. Only a small percentage of mothers interviewed reported that their baby “roomed-in” on average of 22 hours per day during their hospital stay. Staff encouragement of the rooming-in practice will help to increase the proportion of mothers who allow their babies to room-in. The current breastfeeding policy will also need to be revised and strengthened to be compliant with the Ten Steps. Ideally, Baby-Friendly practices will become the norm after staff are trained and policy revisions are made. Staff training and acceptance of breastfeeding as optimal nutrition for infants are the most critical factors that will ultimately drive change for the organization. ^
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Study purpose. Genetic advances are significantly impacting healthcare, yet recent studies of ethnic group participation in genetic services demonstrate low utilization rates by Latinos. Limited genetic knowledge is a major barrier. The purpose of this study was to field test items in a Spanish-language instrument that will be used to measure genetic knowledge relevant to type 2 diabetes among members of the ethnically heterogeneous U.S. Latino community. Accurate genetic knowledge measurement can provide the foundation for interventions to enhance genetic service utilization. ^ Design. Three waves of cognitive interviews were conducted in Spanish to field test 44 instrument items Thirty-six Latinos, with 12 persons representative of Mexican, Central and South American, and Cuban heritage participated, including 7 males and 29 females between 22 and 60 years of age; 17 participants had 12 years or less of education. ^ Methods. Text narratives from transcriptions of audiotaped interviews were qualitatively analyzed using a coding strategy to indicate potential sources of response error. Through an iterative process of instrument refinement, codes that emerged from the data were used to guide item revisions at the conclusion of each phase; revised items were examined in subsequent interview waves. ^ Results. Inter-cultural and cross-cultural themes associated with difficulties in interpretation and grammatical structuring of items were identified; difficulties associated with comprehension reflected variations in educational level. Of the original 44 items, 32 were retained, 89% of which were revised. Six additional items reflective of cultural knowledge were constructed, resulting in a 38-item instrument. ^ Conclusions. Use of cognitive interviewing provided a valuable tool for detecting both potential sources of response error and cultural variations in these sources. Analysis of interview data guided successive instrument revisions leading to improved item interpretability and comprehension. Although testing in a larger sample will be essential to test validity and reliability, the outcome of field testing suggests initial content validity of a Spanish-language instrument to measure genetic knowledge relative to type 2 diabetes. ^ Keywords. Latinos, genetic knowledge, instrument development, cognitive interviewing ^
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As the requirements for health care hospitalization have become more demanding, so has the discharge planning process become a more important part of the health services system. A thorough understanding of hospital discharge planning can, then, contribute to our understanding of the health services system. This study involved the development of a process model of discharge planning from hospitals. Model building involved the identification of factors used by discharge planners to develop aftercare plans, and the specification of the roles of these factors in the development of the discharge plan. The factors in the model were concatenated in 16 discrete decision sequences, each of which produced an aftercare plan.^ The sample for this study comprised 407 inpatients admitted to the M. D. Anderson Hospital and Tumor Institution at Houston, Texas, who were discharged to any site within Texas during a 15 day period. Allogeneic bone marrow donors were excluded from the sample. The factors considered in the development of discharge plans were recorded by discharge planners and were used to develop the model. Data analysis consisted of sorting the discharge plans using the plan development factors until for some combination and sequence of factors all patients were discharged to a single site. The arrangement of factors that led to that aftercare plan became a decision sequence in the model.^ The model constructs the same discharge plans as those developed by hospital staff for every patient in the study. Tests of the validity of the model should be extended to other patients at the MDAH, to other cancer hospitals, and to other inpatient services. Revisions of the model based on these tests should be of value in the management of discharge planning services and in the design and development of comprehensive community health services.^
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Child welfare services have undergone many revisions and transformations since their initiation. Some scholars trace the beginning of child welfare in the United States to events such as a 1655 Massachusetts conviction for maltreatment leading to the death of a 12-year-old boy (Watkins, 1990). The predominant philosophy of child welfare has shifted over time from an early emphasis on child saving, to child protection, to family preservation. Building on family preservation, one of the current transformations in child welfare that is taking place in isolated pockets to whole states, is family-centered, neighborhood-based services. One force behind implementation of this transformation is the Family to Family Initiative of the Annie E. Casey Foundation. This paper places family-centered, neighborhood-based child welfare services within the historical context of development of child welfare and within the recent move to reinvent human services (Adams & Nelson, 1995). Against this backdrop, a locality-based implementation of the Family to Family Initiative is described.
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Documented risks of physical activity include reduced bone mineral density at high activity volume, and sudden cardiac death among adults and adolescents. Further illumination of these risks is needed to inform future public health guidelines. The present research seeks to 1) quantify the association between physical activity and bone mineral density (BMD) across a broad range of activity volume, 2) assess the utility of an existing pre-screening questionnaire among US adults, and 3) determine if pre-screening risk stratification by questionnaire predicts referral to physician among Texas adolescents. ^ Among 9,468 adults 20 years of age or older in the National Health and Nutrition Examination Survey (NHANES) 2007-2010, linear regression analyses revealed generally higher BMD at the lumbar spine and proximal femur with greater reported activity volume. Only lumbar BMD in women was unassociated with activity volume. Among men, BMD was similar at activity beyond four times the minimum volume recommended in the Physical Activity Guidelines. These results suggest that the range of activity reported by US adults is not associated with low BMD at either site. ^ The American Heart Association / American College of Sports Medicine Preparticipation Questionnaire (AAPQ) was applied to 6,661 adults 40 years of age or older from NHANES 2001-2004 by using NHANES responses to complete AAPQ items. Following AAPQ referral criteria, 95.5% of women and 93.5% of men would be referred to a physician before exercise initiation, suggesting little utility for the AAPQ among adults aged 40 years or older. Unnecessary referral before exercise initiation may present a barrier to exercise adoption and may strain an already stressed healthcare infrastructure. ^ Among 3181 athletes in the Texas Adolescent Athlete Heart Screening Registry, 55.2% of boys and 62.2% of girls were classified as high-risk based on questionnaire answers. Using sex-stratified contingency table analyses, risk categories were not significantly associated with referral to physician based on electrocardiogram or echocardiogram, nor were they associated with confirmed diagnoses on follow-up. Additional research is needed to identify which symptoms are most closely related to sudden cardiac death, and determine the best methods for rapid and reliable assessment. ^ In conclusion, this research suggests that the volume of activity reported by US adults is not associated with low BMD at two clinically relevant sites, casts doubts on the utility of two existing cardiac screening tools, and raises concern about barriers to activity erected through ineffective screening. These findings augment existing research in this area that may inform revisions to the Physical Activity Guidelines regarding risk mitigation.^
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Paleontological studies conducted subsequent to the completion of Leg 133 led to refinements of the biostratigraphy for the Leg 133 sites. These biostratigraphic refinements bear on the calculations of sedimentation rates and on the age-depth plots prepared for the Initial Reports volume for Leg 133. To make available the revised data to anyone who may wish to make use of it, the revised biostratigraphic information is presented here in tabulated form. Revised age-depth plots also are presented for all of the sites to facilitate comparison of sedimentation rate curves and to identify intervals where significant changes have been made based on post-cruise studies. The revised age-depth plots include calcareous nannofossils only, and the revised data have been taken from thechapters contributed for this volume (Gartner et al., 1993, doi:10.2973/odp.proc.sr.133.213.1993; Wei and Gartner, 1993, doi:10.2973/odp.proc.sr.133.216.1993). Planktonic foraminifer biostratigraphy revisions became available subsequently and could not be readily incorporated. The age-depth plots for Sites 812 through 818 were made with the (ADP) program provided to ODP by Dave Lazarus.
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Nearly complete Paleogene sedimentary sequences were recovered by Leg 114 to the subantarctic South Atlantic. Silicoflagellate assemblages from the Paleogene and immediately overlying lower Neogene from Sites 698 (Northeast Georgia Rise), 700 (East Georgia Basin), 702 (Islas Orcadas Rise), and 703 (Meteor Rise) were examined. The described assemblage from Hole 700B represents the most complete yet described from the Paleocene, encompassing planktonic foraminifer Zones Plb (upper part) through P4 and Subchrons C25N to C23N. All lower Eocene sediments are barren as a result of diagenesis, except for a single sample from Hole 698A. Middle Eocene silicoflagellates described from Hole 702B range in age from early middle Eocene (P10) to late Eocene (PI5), with correlations to Subchrons C21N to C18N. Hole 703A contains late Eocene through early Miocene assemblages, with paleomagnetic control from Subchrons C16R to C6AAN. Leg 114 biosiliceous sequences contain exceptionally diverse assemblages of silicoflagellates. Approximately 155 species and separate morphotypes are described from the Paleogene and earliest Neogene. New taxa described from Leg 114 sediments include Bachmannocena vetula n. sp., Corbisema animoparallela n. sp., Corbisema camara n. sp., Corbisema constricta spinosa n. subsp., Corbisema delicata n. sp., Corbisema hastata aha n. subsp., Corbisema praedelicata n. sp., Corbisema scapana n. sp., Corbisema triacantha lepidospinosa n. subsp., Dictyocha deflandreifurtivia n. subsp., Naviculopsis biapiculata nodulifera n. subsp., Naviculopsis cruciata n. sp., Naviculopsis pandalata n. sp., Naviculopsis primativa n. sp., and Naviculopsis trispinosa eminula n. subsp. Taxonomic revisions were made to the following taxa: Corbisema constricta constricta emended, Corbisema disymmetrica crenulata n. comb., Corbisema jerseyensis emended, and Distephanus antarcticus n. comb. Silicoflagellate assemblages from the Paleogene and earliest Neogene of Holes 698A, 699A, 700B, 702B, and 703A are the basis of a silicoflagellate zonation spanning the interval from 63.2 to 22.25 Ma. Silicoflagellate zones recognized in this interval include the Corbisema hastata hastata Zone, Corbisema hastata aha Zone, Dictyocha precarentis Zone, Naviculopsis constricta Zone, Naviculopsis foliacea Zone, Bachmannocena vetula Zone, Dictyocha grandis Zone, Naviculopsis pandalata Zone, Naviculopsis constricta-Bachmannocena paulschulzii Zone, Bachmannocena paulschulzii Zone, Naviculopsis trispinosa Zone with subzones a and b, Corbisema archangelskiana Zone, Naviculopsis biapiculata Zone, Distephanus raupii Zone, Distephanus raupii-Corbisema triacantha Zone, and Corbisema triacantha mediana Zone.
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En trabajos anteriores (Romero, 2008a y b, Alabart Lago, L., P. Díaz y G. Herrera, 2012, Alabart Lago, L. y Herrera, G., 2013) se intentó mostrar que el mecanismo interpretativo que propone la TR podría resultar adecuado como uno de los sistemas externos (también interpretativos) postulados por la GG, más precisamente, el sistema llamado CI. La relación que intentamos establecer tendrá en cuenta lo siguiente como marco teórico: a) En TR se afirma que la interpretación de un enunciado se deriva de las estructuras sintácticas, y esta derivación se realiza "en paralelo" con la derivación de estructuras llevada a cabo por las operaciones del componente sintáctico. b) En las últimas propuestas de la GG, extensiones y revisiones del PM propuesto en Chomsky (1995) no solo se dejan de lado los niveles de representación internos SP y ES sino también se considera prescindible la interfaz FL (Chomsky, 2005). Las estructuras generadas se transfieren a los sistemas externos en cuanto rasgos formales de las Categorías Funcionales son valorados. Mantendremos la noción de que el sistema computacional es relativamente irrestricto y que sus operaciones son condicionadas solo por Atracción y las llamadas "condiciones de legibilidad" impuestas por los sistemas externos, fundamentalmente el Principio de Interpretación Completa (PIC). c) Tendremos en cuenta la propuesta de Leonetti y Escandell Vidal (2004), que sostiene que las CCFF de la GG pueden considerarse equivalentes a las Categoría Procedimentales propuestas por la TR. En este sentido consideraremos válida la afirmación de Chomsky (1998) acerca de que las CCFF centrales (C, T, v y D) tienen propiedades semánticas. d) Otro factor que tendremos en cuenta es la noción de fase en la derivación, considerándola correcta en los términos expuestos en Chomsky (2001 y 2005) y Gallego (2007 y 2009), con ciertas modificaciones. Nuestra hipótesis puede resumirse en lo siguiente: Las operaciones de extracción de inferencias propuestas por TR se aplican durante la derivación sintáctica independientemente de que se haya transferido o no una fase. Es más, esperamos poder demostrar que algunos mecanismos inferenciales imponen ciertas condiciones que afectan a la valoración de los rasgos de las CCFF. Pretendemos también intentar mostrar que además de los núcleos de fase reconocidos, C y v, debe considerarse fase a SD, porque contiene rasgos específicos de cuyo cotejo y valoración se desprende el valor que recibirán otros rasgos en el curso de la derivación. Con estos fundamentos esperamos poder elaborar una descripción de cómo interactúan ambos sistemas en la derivación de una oración y la asignación (casi simultánea) de significado
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Esta tesis problematiza los vínculos entre las sociedades y sus entornos. "Ecología" y "Praxis Ambiental" constituyen dos polos en tensión. Son palabras que remiten a sistemas de entidades Ecología y Praxis Ambiental, lejos de constituirse desde una red semántica y simbólica afín, aparecen en las prácticas como términos muchas veces antagónicos. Vivimos en un mundo afectado por una crisis ambiental sin parangones producto de las intervenciones humanas en el contexto de las prácticas productivas capitalistas globalizadas. Esta tesis busca contrastar ciertas conceptualizaciones abstractas con los fenómenos concretos cuya contundencia se nos impone. Sigo un camino que parte de la revisión de la ecología como disciplina científica, su articulación (o no) con los movimientos ambientalista para, desde estos sitios de acción, investigación y movilización, avanzar sobre los temas que permanecen como problemas. Tomé como guía la problemática dualidad sobre la que se edificó el pensamiento y la praxis moderna: la escisión antagónica y excluyente entre sociedad y naturaleza, asociada a la idea del hombre como ser de máximo desarrollo, cuya cercanía a la razón permitía justificar su dominio sobre todo lo no-humano, fundamento de la evaluación de lo diferente en términos peyorativos. Exploro el modo en que "lo natural" se consideró como menos desarrollado, con potencialidades que sólo lograría en caso de estar dominado por un ser efectivamente desarrollado y adopto las revisiones en torno a conceptos claves como género, etnia y clase para discutir la noción de naturaleza que subyace en esa presunción de dominio. La metodología de estudio siguió algunas premisas. La primera de ellas es que la edificación de las ideas es un proceso eminentemente histórico. La segunda es que los conceptos, lejos de edificarse desde ejercicios abstractos, se constituyen en permanente vínculo con el plano de las prácticas. La tercera es que en el fondo de la red simbólica antes mencionada se encuentra el paternalismo como diferenciación fundamental. A modo de esquema general, las herramientas adoptadas para analizar escenarios y elaborar reflexiones pueden resumirse en los siguientes puntos:La indagación en las formas hegemónicas de discurso-dominio en la ecología científica. La apropiación de la perspectiva feminista como discurso contrahegemónico.La revisión de las formas específicas de dominio como clave reconstructiva.El análisis de las prácticas instituidas, en las prácticas científicas y las esferas de gobierno, a la luz de modos alternativos que implican el reconocimiento de prácticas sociales y saberes edificados desde la experiencia.A partir de remover la idea de naturaleza que subyace en las reflexiones problematizadas, impugno que la única organización social posible sea jerárquica. Desde aquí argumento en contra de uno de los principales argumentos totalitarios, la visión de los intereses de la naturaleza como opuestos a los humanos, destacando la necesidad de abandonar la dualidad para no llegar al consecuente incremento de formas opresivas. En el cierre desmonto el carácter construido de lo normal, desnaturalizo lo natural para repensarnos como seres humanos capaces de cambiar aquello que consideramos injusto.
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El presente artículo procura poner en consideración algunos elementos analíticos, presentes tanto en los estudios sociales de las elites como en las perspectivas sobre las clases sociales, que representan un aporte para la investigación de los procesos de estratificación social en general, y de los estratos superiores en particular. En esta dirección, se analizan los supuestos de los cuales derivan las dos principales perspectivas de clase, la relacional y la gradacional, así como las diferentes revisiones y reelaboraciones desarrolladas a lo largo del siglo XX. Por otro lado, se aborda críticamente el aporte de la perspectiva clásica de las elites y de algunos intentos de articulación entre dicho enfoque y la perspectiva de clase. El artículo concluye considerando algunas problematizaciones desarrolladas dentro de la bibliografía reciente sobre elites, con el fin de recuperar ciertos elementos analíticos valiosos para el estudio de los estratos superiores. En este sentido, intenta resaltar el aporte de los enfoques que procuran articular la dinámica de la reproducción con las de la recomposición e incluso disolución, operantes entre los grupos de elite y los estratos superiores
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Esta comunicación ilumina las huellas de Amelia C. Su historia de vida como telefonista es relevante para comprender la discriminación de las mujeres en el mercado laboral en los comienzos del siglo XX. Este artículo se enfocará en el estado conyugal como pauta de exclusión femenina. La estrategia utilizada por Amelia contra dicha pauta, si bien individual e incluso desesperada, detonó una serie de revisiones de la legislación existente que fueron apoyadas por distintos grupos de la sociedad. El corpus está basado en expedientes de la compañía telefónica en la que Amelia se desempeñó como empleada durante varios años y en el impacto que sus estrategias tuvieron en la prensa local.
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El discurso crítico de Ángel Rama experimenta a lo largo de su desarrollo una serie de complejas inflexiones, producto del diálogo permanente con nuevos vocabularios teóricos y la participación en debates acerca del estudio de la literatura latinoamericana. Este desplazamiento se puede reconstruir a partir de la comparación del sentido y del uso dado por Rama a tres conceptos centrales en su lectura: el público lector, la clase social y la cultura. Con el fin de analizar las implicancias de estas reformulaciones, se propone el abordaje de dos textos del autor: "Rodolfo Walsh: la narrativa en el conflicto de las culturas" (1976) y Transculturación narrativa en América Latina (1982). En ellos, la construcción prepositiva "de/para los pobres" permite reflexionar acerca de la serie de revisiones, adquisiciones y modulaciones que atraviesa su práctica crítica en tres instancias de su formulación.
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Esta entrevista de Teresa Basile a Juan Duchesne Winter explora las revisiones del trabajo de la crítica literaria latinoamericana en las últimas décadas focalizando en el contexto particular de Puerto Rico