Impacte d'un programa d'informació sobre l'elaboració del document de voluntats anticipades

Tot i que en el nostre territori comptem des de els anys 80 amb diferents models de Document de Voluntats Anticipades (DVA), aquests continuen essent desconeguts tant per la ciutadania com pels professionals de la salut. Aquesta situació ha fet que ens plantegem com a objectiu d’aquest estudi descriure si existeix la correlació entre el fet de proporcionar informació sobre el DVA i la motivació per la seva realització. En aquest estudi hem agafat com a mostra els usuaris del servei de psicogeriatria de la Fundació Sociosanitaria de Manresa l’Hospital de Sant Andreu de Manresa, tenint en compte les recomanacions del Document Sitges del 2005 i d’altres autors que recomanen fer el DVA en situació de demència lleu o moderada. També s’ha tingut present l’elevada prevalença d’aquesta patologia. S'ha dissenyat un assaig clínic comunitari amb aleatorització de dos consultoris d'un servei de psicogeriatria. Els metges del consultori assignat al grup control feien el tractament habitual en relació al DVA, és a dir, no informar els pacients atesos sobre l'existència i característiques del DVA, i els metges del consultori assignat al grup intervenció donaven informació reglada als seus pacients sobre el DVA. En el moment de la inclusió es registrava informació sociodemogràfica i clínica per poder classificar els participants i, també a tots els subjectes inclosos en l'assaig, al cap de tres setmanes se'ls feia una enquesta telefònica per avaluar l'opinió i el coneixement sobre el DVA. De les respostes de l’enquesta podem extreure com a resultats que més del 90% dels subjectes del grup control no coneixen el DVA. També s’observa de manera significativa com les persones del grup intervenció parlen amb el metge,la infermera i/o la família sobre la dependència i la mort, tenint en compte que la mort i la dependència continuen sent un tema tabú, i que la majoria de la població de l’estudi no planifiquen com volen ser atesos. Tanmateix s’observa com un 2’3 % tenia fet el DVA i un 22’7% manifesten la seva voluntat de realitzar-lo. Amb aquest estudi es conclou que el fet de proporcionar informació sobre el DVA als usuaris del servei de psicogeriatria afavoreix que aquests estiguin motivats per la realització d’aquest document; al mateix temps també afavoreix la planificació de les cures i el parlar sobres temes com la mort i/o la dependència amb la família, el metge la infermera.

Discounting Arduousness

[cat] Hi ha una literatura creixent que considera desviacions del descompte exponencial estàndar. En aquest article combinem preferències temporalment inconsistents (descompte no constant) amb preferències recursives. Aquest formalisme l’apliquem a les propietats relatives a la demanda del que anomenem bens ardus. La justificació del descompte no estàndar proposat ve donada pel fet que la producció i el consum no són separables per a aquest tipus de bens. L’esforç implica que els individus descompten el consum d’aquests bens d’una manera especial, amb la presència de preferències esbiaixades i d’un ajustament recursiu dinàmic. D’aquesta manera, la voluntat de realitzar un esforç, caracteritzada per un factor de descompte, resulta endògena.

Evaluation of Bridge Replacement Alternatives for the County Bridge System, HR-365 August 1994

Recent reports have indicated that 23.5 percent of the nation's highway bridges are structurally deficient and 17.7 percent are functionally obsolete. A significant number of these bridges are on the Iowa county road system. The objective of the investigation described in this report was to identify, review and evaluate replacement bridges currently being used by various counties in Iowa and surrounding states. Iowa county engineers, county engineers in neighboring states as well as private manufacturers of bridge components, and regional precad prestressed concrete manufacturers were contacted to determine the most common replacement bridge types being used. Depending upon the findings of the review, possible improvements and/or new replacement bridge systems were to be proposed. A questionnaire was developed and sent to county engineers in Iowa and several counties in surrounding states. The results of the questionnaire showed that the most common replacement bridges in Iowa are the continuous concrete slab and prestressed concrete bridges. The primary reason these types are used is because of the availability of standard designs and because of their ease of maintenance. Counties seldom construct these types of bridges using their own labor forces, but instead contract the work. However, county forces are used to construct steel stringer, precast reinforced concrete and timber bridges. In general, 69 percent of the counties indicate an ability and willingness to use their own forces to design and construct relatively short span bridges (i.e., 40 A or less) provided the construction procedures are relatively simple. Several unique replacement bridge types used in Iowa that are constructed by county forces are documented and presented in this report. Sufficient details are provided to allow county engineers to determine if some of these bridges could be used to resolve some of their own replacement bridge problems. Where possible, cost information has also been provided. Each of these bridge types were evaluated for various criteria (e.g., cost effectiveness, conformance to AASI-ITO standards, range of sizes, etc.) by a panel of four Iowa county engineers; a summary of this critique is included. After evaluating the questionnaire responses from the counties and evaluating the various bridge replacement concepts currently in use, one new bridge replacement concept and one modification of a current Iowa county bridge replacement concept were developed. Both of these concepts would utilize county labor forces.

Can routine offering of influenza vaccination in office-based settings reduce racial and ethnic disparities in adult influenza vaccination?

BACKGROUND: Influenza vaccination remains below the federally targeted levels outlined in Healthy People 2020. Compared to non-Hispanic whites, racial and ethnic minorities are less likely to be vaccinated for influenza, despite being at increased risk for influenza-related complications and death. Also, vaccinated minorities are more likely to receive influenza vaccinations in office-based settings and less likely to use non-medical vaccination locations compared to non-Hispanic white vaccine users. OBJECTIVE: To assess the number of "missed opportunities" for influenza vaccination in office-based settings by race and ethnicity and the magnitude of potential vaccine uptake and reductions in racial and ethnic disparities in influenza vaccination if these "missed opportunities" were eliminated. DESIGN: National cross-sectional Internet survey administered between March 4 and March 14, 2010 in the United States. PARTICIPANTS: Non-Hispanic black, Hispanic and non-Hispanic white adults living in the United States (N = 3,418). MAIN MEASURES: We collected data on influenza vaccination, frequency and timing of healthcare visits, and self-reported compliance with a potential provider recommendation for vaccination during the 2009-2010 influenza season. "Missed opportunities" for seasonal influenza vaccination in office-based settings were defined as the number of unvaccinated respondents who reported at least one healthcare visit in the Fall and Winter of 2009-2010 and indicated their willingness to get vaccinated if a healthcare provider strongly recommended it. "Potential vaccine uptake" was defined as the sum of actual vaccine uptake and "missed opportunities." KEY RESULTS: The frequency of "missed opportunities" for influenza vaccination in office-based settings was significantly higher among racial and ethnic minorities than non-Hispanic whites. Eliminating these "missed opportunities" could have cut racial and ethnic disparities in influenza vaccination by roughly one half. CONCLUSIONS: Improved office-based practices regarding influenza vaccination could significantly impact Healthy People 2020 goals by increasing influenza vaccine uptake and reducing corresponding racial and ethnic disparities.

Tentative de suicide des adolescents: accueil, evaluation, orientation [Suicide attempt: encounter, evaluation, orientation].

Le suicide et les tentatives de suicide des adolescents sont des enjeux de santé publique majeurs. En s'appuyant sur le modèle de soins développé à Genève, nous décrivons les différents temps nécessaires pour accueillir, évaluer et orienter un adolescent pris dans un mouvement suicidaire. Un temps d'accueil et d'évaluation pédiatrique, puis un temps d'évaluation psychiatrique et enfin un temps d'orientation à l'issue duquel est proposée une prise en charge spécifique. En fonction des caractéristiques cliniques du jeune (impulsivité, symptomatologie anxio-dépressive...), de sa capacité d'engagement dans les soins et de la qualité des liens du réseau, la prise en charge sera soit ambulatoire intensive, soit hospitalière. Suicide and suicide attempts of adolescents are major public health issues. Based on a model of care developed in Geneva, we describe the conditions necessary to evaluate and guide a teenager trapped in a suicidal behavior. First of all, there must be some time dedicated to pediatric assessement followed by a psychiatric evaluation and finally, the adolescent can be oriented toward specific treatment. Depending on the clinical characteristics of the young adolescent and according to his willingness to engage himself in intensive follow-up (impulsivity, anxious?--depressive symptomatology...), cares will be given either as outpatient with close monitoring or inpatient.

Assessment of driving capability through the use of clinical and psychomotor tests in relation to blood cannabinoids levels following oral administration of 20 mg dronabinol or of a cannabis decoction made with 20 or 60 mg Delta9-THC.

Delta(9)-Tetrahydrocannabinol (THC) is frequently found in the blood of drivers suspected of driving under the influence of cannabis or involved in traffic crashes. The present study used a double-blind crossover design to compare the effects of medium (16.5 mg THC) and high doses (45.7 mg THC) of hemp milk decoctions or of a medium dose of dronabinol (20 mg synthetic THC, Marinol on several skills required for safe driving. Forensic interpretation of cannabinoids blood concentrations were attempted using the models proposed by Daldrup (cannabis influencing factor or CIF) and Huestis and coworkers. First, the time concentration-profiles of THC, 11-hydroxy-Delta(9)-tetrahydrocannabinol (11-OH-THC) (active metabolite of THC), and 11-nor-9-carboxy-Delta(9)-tetrahydrocannabinol (THCCOOH) in whole blood were determined by gas chromatography-mass spectrometry-negative ion chemical ionization. Compared to smoking studies, relatively low concentrations were measured in blood. The highest mean THC concentration (8.4 ng/mL) was achieved 1 h after ingestion of the strongest decoction. Mean maximum 11-OH-THC level (12.3 ng/mL) slightly exceeded that of THC. THCCOOH reached its highest mean concentration (66.2 ng/mL) 2.5-5.5 h after intake. Individual blood levels showed considerable intersubject variability. The willingness to drive was influenced by the importance of the requested task. Under significant cannabinoids influence, the participants refused to drive when they were asked whether they would agree to accomplish several unimportant tasks, (e.g., driving a friend to a party). Most of the participants reported a significant feeling of intoxication and did not appreciate the effects, notably those felt after drinking the strongest decoction. Road sign and tracking testing revealed obvious and statistically significant differences between placebo and treatments. A marked impairment was detected after ingestion of the strongest decoction. A CIF value, which relies on the molar ratio of main active to inactive cannabinoids, greater than 10 was found to correlate with a strong feeling of intoxication. It also matched with a significant decrease in the willingness to drive, and it matched also with a significant impairment in tracking performances. The mathematic model II proposed by Huestis et al. (1992) provided at best a rough estimate of the time of oral administration with 27% of actual values being out of range of the 95% confidence interval. The sum of THC and 11-OH-THC blood concentrations provided a better estimate of impairment than THC alone. This controlled clinical study points out the negative influence on fitness to drive after medium or high dose oral THC or dronabinol.

Iowa Rail Route Alternatives Analysis, June 1998

The development of new rail systems in the first part of the 21st century is the result of a wide range of trends that are making it increasingly difficult to maintain regional mobility using the two dominant intercity travel modes, auto and air. These trends include the changing character of the economic structure of industry. The character of the North American industrial structure is moving rapidly from a manufacturing base to a service based economy. This is increasing the need for business travel while the increase in disposable income due to higher salaries has promoted increased social and tourist travel. Another trend is the change in the regulatory environment. The trend towards deregulation has dramatically reduced the willingness of the airlines to operate from smaller airports and the level of service has fallen due to the creation of hub and spoke systems. While new air technology such as regional jets may mitigate this trend to some degree in medium-size airports, smaller airports will continue to lose out. Finally, increasing environmental concerns have reduced the ability of the automobile to meet intercity travel needs because of increased suburban congestion and limited highway capacity in big cities. Against this background the rail mode offers new options due to first, the existing rail rights-of-way offering direct access into major cities that, in most cases, have significant capacity available and, second, a revolution in vehicle technology that makes new rail rolling stock faster and less expensive to purchase and operate. This study is designed to evaluate the potential for rail service making an important contribution to maintaining regional mobility over the next 30 to 50 years in Iowa. The study evaluates the potential for rail service on three key routes across Iowa and assesses the impact of new train technology in reducing costs and improving rail service. The study also considers the potential for developing the system on an incremental basis. The service analysis and recommendations do not involve current Amtrak intercity service. That service is presumed to continue on its current route and schedule. The study builds from data and analyses that have been generated for the Midwest Rail Initiative (MWRI) Study. For example, the zone system and operating and capital unit cost assumptions are derived from the MWRI study. The MWRI represents a cooperative effort between nine Midwest states, Amtrak and the Federal Railroad Administration (FRA) contracting with Transportation Economics & Management Systems, Inc. to evaluate the potential for a regional rail system. The 1 The map represents the system including the decision on the Iowa route derived from the current study. Iowa Rail Route Alternatives Analysis TEMS 1-2 system is to offer modern, frequent, higher speed train service to the region, with Chicago as the connecting hub. Exhibit 1-1 illustrates the size of the system, and how the Iowa route fits in to the whole.

Discounting Arduousness

[cat] Hi ha una literatura creixent que considera desviacions del descompte exponencial estàndar. En aquest article combinem preferències temporalment inconsistents (descompte no constant) amb preferències recursives. Aquest formalisme l’apliquem a les propietats relatives a la demanda del que anomenem bens ardus. La justificació del descompte no estàndar proposat ve donada pel fet que la producció i el consum no són separables per a aquest tipus de bens. L’esforç implica que els individus descompten el consum d’aquests bens d’una manera especial, amb la presència de preferències esbiaixades i d’un ajustament recursiu dinàmic. D’aquesta manera, la voluntat de realitzar un esforç, caracteritzada per un factor de descompte, resulta endògena.

Citizens' preferences for brand name drugs for treating acute and chronic conditions: a pilot study.

Background: Generic drugs have been advocated to decrease the proportion of healthcare costs devoted to drugs, but are still underused. Objective: To assess citizens' preferences for brand name drugs (BNDs) compared with generic drugs for treating acute and chronic conditions. Methods: A questionnaire with eight hypothetical scenarios describing four acute and four chronic conditions was developed, with willingness to pay (WTP) determined using a payment card system randomized to ascending (AO) or descending order (DO) of prices. The questionnaire was distributed with an explanation sheet, an informed consent form and a pre-stamped envelope over a period of 3 weeks in 19 community pharmacies in Lausanne, Switzerland. The questionnaire was distributed to every third customer who also had health insurance, understood French and was aged =16 years (up to a maximum of ten customers per day and 100 per pharmacy). The main outcome measure was preferences assessed by WTP for BNDs as compared with generics, and impact of participants' characteristics on WTP. Results: Of the 1800 questionnaires, 991 were distributed and 393 returned (pharmacy participation rate?=?55%, subject participation rate?=?40%, overall response rate?=?22%); 51.7% were AO and 48.3% DO. Participants were predominantly women (62.6%) and of median age 62 years (range 16-90). The majority (70%) declared no WTP for BNDs as compared with generics. WTP was higher in people with an acute disease than in those with a chronic disease, did not depend on the type of chronic disease, and was higher in people from countries other than Switzerland. Conclusions: Most citizens visiting pharmacies attribute no added value to BNDs as compared with generics, although some citizen characteristics affected WTP. These results could be of interest to several categories of decision makers within the healthcare system.

Public health education in Europe: old and new challenges

The purpose of this article is to discuss some of the current challenges faced by European schools of public health. Perhaps most remarkable on the continent is the diversity, the magnitude, and the rapidity of the developments in public health education since the Second World War. This article discusses its evolution, its main characteristics and the underlying rationale with several examples. Further, it addresses specific aspects of the future development, namely the collaboration of academic schools with practice-oriented institutions, as well as the interactions between the constituent disciplines of public health. The Bologna process on post-graduate education in Europe has had an important impact on the overall design of most schools. There is a willingness to develop public health in each country of the European region and there is a need to develop common strategies to reach high standards in teaching, training and researching in all disciplines related to public health.

Protocol de viabilitat socioecològica del llop : àrea d'estudi de la Vall d'Alinyà

Aquest estudi analitza diferents variables ecològiques i socials amb l’objectiu de determinar la viabilitat de l’espècie Canis lupus en el territori que compren la Vall d’Alinyà, i definir unes pautes per extrapolar aquest tipus d’anàlisis a altres àrees d’estudi. El llop va desaparèixer de Catalunya a causa de la forta pressió antròpica exercida sobre l’espècie en el passat. En l’última dècada, s’han donat indicis d’una possible reaparició del súper depredador en el territori català. Com a mètode per a la cerca del llop s’ha experimentat amb l’ús de gossos de rastreig per a la cerca i diferenciació de rastres de llop, aquesta és una tècnica innovadora no utilitzada anteriorment per a aquest tipus d’objectiu. L’exploració de les inquietuds dels ramaders i caçadors de la zona, mostra una bona predisposició a la reaparició de l’animal. Malgrat no s’ha detectat llop amb els mètodes emprats, es demostra que li és viable d’establir-se a la zona.

Similarity in food cleaning techniques within matrilines in wild vervet monkeys.

Social learning and the formation of traditions rely on the ability and willingness to copy one another. A central question is under which conditions individuals adapt behaviour to social influences. Here, we demonstrate that similarities in food processing techniques emerge on the level of matrilines (mother-offspring) but not on the group level in an experiment on six groups of wild vervet monkeys that involved grapes covered with sand. Monkeys regularly ate unclean grapes but also used four cleaning techniques more similarly within matrilines: rubbing in hands, rubbing on substrate, open with mouth, and open with hands. Individual cleaning techniques evolved over time as they converged within matrilines, stabilised at the end and remained stable in a follow-up session more than one year later. The similarity within matrilines persisted when we analyzed only foraging events of individuals in the absence of other matriline members and matriline members used more similar methods than adult full sisters. Thus, momentary conversion or purely genetic causation are unlikely explanations, favouring social learning as mechanism for within matriline similarities. The restriction of traditions to matriline membership rather than to the group level may restrict the development of culture in monkeys relative to apes or humans.

Quality of Learners' Time and Learning Performance Beyond Quantitative Time-on-Task

Peer-reviewed

Associations between online pornography and sexual behavior among adolescents: myth or reality?

This study aimed to compare the sexual behavior of adolescents who were or were not exposed to online pornography, to assess to what extent the willingness of exposure changed these possible associations, and to determine the profiles of youths who were exposed to online pornography. Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health, a self-administered cross-sectional, paper and pencil questionnaire. From the 7529 adolescents aged 16-20 years, 6054 (3283 males) used the Internet during the previous month and were eligible for our study. Males were divided into three groups (wanted exposure, 29.2%; unwanted exposure, 46.7%; no exposure, 24.1%) whereas females were divided into two groups (exposure, 35.9%; no exposure, 64.1%). The principal outcome measures were demographic characteristics, Internet use parameters and risky sexual behaviors. Risky sexual behaviors were not associated with online pornography exposure in any of the groups, except that males who were exposed (deliberately or not) had higher odds of not having used a condom at last intercourse. Bi/homosexual orientation and Internet use parameters were not associated either. Additionally, males in the wanted exposure group were more likely to be sensation-seekers. On the other hand, exposed girls were more likely to be students, higher sensation-seekers, early maturers, and to have a highly educated father. We conclude that pornography exposure is not associated with risky sexual behaviors and that the willingness of exposure does not seem to have an impact on risky sexual behaviors among adolescents.

Politique fédérale des agglomérations dans les domaines des transports et de l'urbanisation

La croissance de la population, de l'économie et des transports individuels motorisés, particulièrement depuis la seconde moitié du 20ème siècle, ont notamment comme corollaire le développement urbanistique hors des frontières de la ville-centre et la formation des agglomérations. Ces zones urbaines sont stratégiques puisqu'elles accueillent une part toujours plus importante de la population et représentent le moteur de l'économie nationale. Toutefois, le développement des agglomérations et de la mobilité individuelle motorisée ne va pas sans poser de nombreux problèmes, dont la résolution nécessite de les aborder à l'échelle de l'agglomération, en coordonnant les transports et l'urbanisation. Notre système politique fédéral se définit notamment par une répartition des compétences dans une multitude de domaines entre les trois niveaux institutionnels de la Confédération, des cantons et des communes. Cette réalité est particulièrement vraie en matière d'aménagement du territoire. Il est à noter que les plus petites unités institutionnelles (les communes) conservent encore aujourd'hui des prérogatives importantes dans ce domaine. Au début des années 2000, la Confédération a développé une politique publique en faveur de ces zones stratégiques. Au moyen du fonds d'infrastructure, la politique fédérale des agglomérations dans les domaines des transports et de l'urbanisation est une politique publique incitative. Le dépôt, par les agglomérations, d'un projet respectant un cahier des charges précis et proposant des mesures de coordination entre les transports et l'urbanisation, permet d'obtenir un cofinancement fédéral du transport d'agglomération. Parmi les projets d'agglomération de première génération présentés à la Confédération, certains ont obtenu le cofinancement, d'autres pas. Le dimensionnement trop généreux des surfaces à bâtir fut notamment un facteur d'échec du projet d'agglomération de Fribourg, alors que la capacité à développer l'urbanisation à l'intérieur de l'agglomération fut un facteur de succès du projet Lausanne-Morges. L'analyse des projets d'agglomération Riviera et Monthey-Aigle, qui sont des projets de deuxième génération, confrontée à des entretiens avec des urbanistes et des responsables politiques, permet d'identifier leurs faiblesses et leurs atouts. Le projet d'agglomération Riviera présente une complémentarité des territoires et un grand potentiel de développement, mais aussi un manque de cohésion des partenaires du projet. Quant au projet Monthey-Aigle, il existe une réelle volonté politique de trouver des solutions aux conflits, mais les possibilités de développer les transports publics sont faibles. Dans le cadre de l'examen fédéral de ces deux projets d'agglomération, les éléments précités pourraient être des facteurs d'échec ou de succès. La politique publique fédérale invite les agglomérations à penser le développement de leurs transports et de leur urbanisation à un niveau global. La prise de hauteur et la coordination politique que cela suppose sont à même d'améliorer le lieu de vie des trois-quarts de la population suisse et de préserver le moteur de l'économie nationale. The growth of population, economy and personal motorised transportation, most particularly since the second half of the 20th century, has, as a consequence, induced an expansion of urban areas outside the borders of cities and encouraged the formation of urban agglomerations. These urban zones are of strategic importance as they attract an increasingly large population and represent a real driver of the national economy. However, the development of these agglomerations and the motorised mobility of their inhabitants cause numerous problems which require solutions to be adopted at the level of the agglomeration involving the interconnection of transport and urbanisation. Our federal political system is characterised by a distribution of responsibilities in many domains among the three institutional levels, namely the Confederation, the cantons and the communes. This is particularly the case of territorial developments. It should be noted that the smallest institutional units, the communes, still hold today important responsibilities in this area. At the beginning of the years 2000, the Confederation has developed a public policy in favour of these strategic zones. Through the establishment of an infrastructure fund, the federal policy in favour of urban agglomerations in the areas of transport and urbanisation aims at providing incentives to agglomerations. The submission by the agglomeration of a project containing a clear description of tasks and measures to integrate transport and urbanisation can result in a cofinancing participation by the Confederation in this project. Among the projects of first generation which had been submitted to the Confederation, some have received the cofinancing, others have not. The too generous dimension of the building areas in the project submitted by the agglomeration of Fribourg was a factor of its failure, while the capacity to develop urbanisation within the agglomeration was a factor of success for the Lausanne-Morges project. The analysis of the projects of the agglomerations Riviera and Monthey-Aigle which are projects of the second generation, as well as the interviews of urbanists and concerned officials have allowed us to identify their strengths and weaknesses. The Riviera project provides a complementary approach and a high potential of territorial developments, but at the same time denotes a lack of cohesion among partners of the project. With respect to the project Monthey-Aigle, there is a real political willingness to resolve conflicts, but the potential for the development of public transports is small. In the consideration by the Confederation of these two projects, the factors mentioned above may bring success or failure. The federal public policy incites the agglomerations to conceive the development of their transportation and urbanisation plans at a global level. The elevation of interests and the political coordination that this requires can improve the place of living of ¾ of the Swiss population and preserve the engine of growth of the national economy.