Exercise Prescription for Patients with Non-specific Chronic Low Back Pain: a Qualitative Study of Patients' Experiences in Decision Making

Background The culture of current clinical practice calls for collaboration between therapists and patients, sharing power and responsibility. This paper reports on the findings of a qualitative study of exercise prescription for patients with NSCLBP, taking into account issues such as decision making and how this accords with patient preferences and experiences. Objective To understand the treatment decision making experiences, information and decision support needs of patients with NSCLBP who have been offered exercise as part of their management plan. Design A qualitative study using a philosophical hermeneutic approach. Methods Semi-structured interviews with eight patients (including use of brief patient vignettes) was undertaken to explore their personal experiences of receiving exercise as part of the management of their NSCLBP, and their involvement in decisions regarding their care. Findings The findings provide a detailed insight into patients’ perceptions and experiences of receiving exercise-based management strategies. Four themes were formed from the texts: (1) patients’ expectations and patients’ needs are not synonymous, (2) information is necessary but often not sufficient, (3) not all decisions need to be shared, and (4) wanting to be treated as an individual. Conclusions Shared decision making did not appear to happen in physiotherapy clinical practice, but equally may not be what every patient wants. The overall feeling of the patients was that the therapist was dominant in structuring the interactions, leaving the patients feeling disempowered to question and contribute to the decision making.

Toimintolaskennan hyödyntäminen prosessijohtamisen tukena julkisen sektorin terveydenhuolto-organisaatiossa

Tämän tutkielman tavoitteena on tutkia toimintolaskennan ja toimintojohtamisen käyttöä sekä hyödyntämistä prosessijohtamisen tukena. Työssä keskitytään tarkastelemaan ilmiötä julkisen sektorin terveydenhuoltoalalla. Tutkielmassa sovelletaan kvalitatiivista eli laadullista tutkimusmenetelmää. Tutkielma koostuu kahdesta osasta. Teoriaosassa käsitellään alan kirjallisuutta tieteellisten artikkelien valossa. Empiriaosassa selvitettiin tutkittavan organisaation kustannus- ja toimintolaskennan hyödyntämisestä prosessijohtamisen tukena. Aineistonkeruu empiirisen osion osalta toteutettiin avoimina ja strukturoimattomina haastatteluina. Tutkielman tuloksina muodostui ymmärrys organisaation kustannuslaskennan nykytilanteesta ja hyödyntämismahdollisuuksista prosessienkehittämisessä. Kustannus- ja toimintolaskentaa hyödynnetään nykyisin pääasiassa hinnoittelupäätöksiin. Kustannustietoja ei systemaattisesti hyödynnetä prosessienkehittämisessä eikä arvioitaessa potentiaalisia kehitys- ja parannuskohteita. Toimintolaskennan erityispiirteet tukevat kuitenkin sitä, että toimintolaskenta sopii terveydenhuolto-organisaatioon kustannuslaskentamalliksi. Voidaan todeta kustannuslaskennan tukevan Lean- kehitystyön kohdentamista ja tuloksien arviointia.

Farm practices to manage the impact of severe tropical cyclone damage on banana production – a case study from tropical Australia

Most Australian banana production occurs on the north-eastern tropical coast between latitudes 15-18°S, and can experience summer cyclone activity. Damage from severe tropical cyclones has serious impact on banana-based livelihoods. The most significant impacts include immediate loss of production and income for several months, the region-wide synchronization of cropping and the expense of rehabilitating affected plantations. Severe tropical cyclones have directly affected the main production region twice in recent years Tropical Cyclone (TC) Larry (Category 4) in March 2006 and TC Yasi (Category 5) in February 2011. Based on TC Larry experiences, pre- and post-cyclone farm practices were developed to reduce these impacts in future cyclonic events. The main pre-cyclone farm practice focused on maintaining production units and an earlier return to fruit production by partially or completely removing the plant canopy to reduce wind resistance. Post-cyclone farm practices focused on managing the industry-wide crop synchronization using crop timing techniques to achieve a staggered return to cropping by scheduling production to provide continuous fruit supply. With TC Yasi in 2011, some banana producers implemented these practices, allowing them to examine their effectiveness in reducing cyclonic impacts. Additional research and development activities were conducted to refine our understanding of their effectiveness and improve their application for future cyclonic events. Based on these activities and farm-based observations, suggested practice-based management strategies can be developed to help reduce the impact of severe tropical cyclones in the future. Canopy removal maintained banana plants as productive units, and provided earlier but smaller bunches, generating earlier-than-expected income. Queensland producers expressed willingness to adopt canopy removal for future cyclone threats where appropriate, despite its labor-intensiveness. Mechanization would allow larger scale adoption. Implementing a staggered cropping program successfully achieved a consistent, continuous fruit supply after a cyclone impact. Both techniques should be applicable to other cyclone-prone regions.

Considering climate change in the development of marine protected areas

Marine ecosystems are facing a diverse range of threats, including climate change, prompting international efforts to safeguard marine biodiversity through the use of spatial management measures. Marine Protected Areas (MPAs) have been implemented as a conservation tool throughout the world, but their usefulness and effectiveness is strongly related to climate change. However, few MPA programmes have directly considered climate change in the design, management or monitoring of an MPA network. Under international obligations, EU, UK and national targets, Scotland has developed an MPA network that aims to protect marine biodiversity and contribute to the vision of a clean, healthy and productive marine environment. This is the first study to critically analyse the Scottish MPA process and highlight areas which may be improved upon in further iterations of the network in the context of climate change. Initially, a critical review of the Scottish MPA process considered how ecological principles for MPA network design were incorporated into the process, how stakeholder perceptions were considered and crucially what consideration was given to the influence of climate change on the eventual effectiveness of the network. The results indicated that to make a meaningful contribution to marine biodiversity protection for Europe the Scottish MPA network should: i) fully adopt best practice ecological principles ii) ensure effective protection and iii) explicitly consider climate change in the management, monitoring and future iterations of the network. However, this review also highlighted the difficulties of incorporating considerations of climate change into an already complex process. A series of international case studies from British Columbia, Canada; central California, USA; the Great Barrier Reef, Australia and the Hauraki Gulf, New Zealand, were then conducted to investigate perceptions of how climate change has been considered in the design, implementation, management and monitoring of MPAs. The key lessons from this study included: i) strictly protected marine reserves are considered essential for climate change resilience and will be necessary as scientific reference sites to understand climate change effects ii) adaptive management of MPA networks is important but hard to implement iii) strictly protected reserves managed as ecosystems are the best option for an uncertain future. This work provides new insights into the policy and practical challenges MPA managers face under climate change scenarios. Based on the Scottish and international studies, the need to facilitate clear communication between academics, policy makers and stakeholders was recognised in order to progress MPA policy delivery and to ensure decisions were jointly formed and acceptable. A Delphi technique was used to develop a series of recommendations for considering climate change in Scotland’s MPA process. The Delphi participant panel was selected for their knowledge of the Scottish MPA process and included stakeholders, policy makers and academics with expertise in MPA research. The results from the first round of the Delphi technique suggested that differing views of success would likely influence opinions regarding required management of MPAs, and in turn, the data requirements to support management action decisions. The second round of the Delphi technique explored this further and indicated that there was a fundamental dichotomy in panellists’ views of a successful MPA network depending upon whether they believed the MPAs should be strictly protected or allow for sustainable use. A third, focus group round of the Delphi Technique developed a feature-based management scenario matrix to aid in deciding upon management actions in light of changes occurring in the MPA network. This thesis highlights that if the Scottish MPA network is to fulfil objectives of conservation and restoration, the implications of climate change for the design, management and monitoring of the network must be considered. In particular, there needs to be a greater focus on: i) incorporating ecological principles that directly address climate change ii) effective protection that builds resilience of the marine and linked social environment iii) developing a focused, strong and adaptable monitoring framework iv) ensuring mechanisms for adaptive management.

Modelling the development of an online learning resource by health care professionals

The aim of this study was to model the process of development for an Online Learning Resource (OLR) by Health Care Professionals (HCPs) to meet lymphoedema-related educational needs, within an asset-based management context. Previous research has shown that HCPs have unmet educational needs in relation to lymphoedema but details on their specific nature or context were lacking. Against this background, the study was conducted in two distinct but complementary phases. In Phase 1, a national survey was conducted of HCPs predominantly in community, oncology and palliative care services, followed by focus group discussions with a sample of respondents. In Phase 2, lymphoedema specialists (LSs) used an action research approach to design and implement an OLR to meet the needs identified in Phase 1. Study findings were analysed using descriptive statistics (Phase 1), and framework, thematic and dialectic analysis to explore their potential to inform future service development and education theory. Unmet educational need was found to be specific to health care setting and professional group. These resulted in HCPs feeling poorly-equipped to diagnose and manage lymphoedema. Of concern, when identified, lymphoedema was sometimes buried for fear of overwhelming stretched services. An OLR was identified as a means of addressing the unmet educational needs. This was successfully developed and implemented with minimal additional resources. The process model created has the potential to inform contemporary leadership theory in asset-based management contexts. This doctoral research makes a timely contribution to leadership theory since the resource constraints underpinning much of the contribution has salience to current public services. The process model created has the potential to inform contemporary leadership theory in asset-based management contexts. Further study of a leadership style which incorporates cognisance of Cognitive Load Theory and Self-Determination Theory is suggested. In addition, the detailed reporting of process and how this facilitated learning for participants contributes to workplace education theory

The Cost of Co-viability in the Australian Northern Prawn Fishery

Fisheries management must address multiple, often conflicting objectives in a highly uncertain context. In particular, while the bio-economic performance of trawl fisheries is subject to high levels of biological and economic uncertainty, the impact of trawling on broader biodiversity is also a major concern for their management. The purpose of this study is to propose an analytical framework to formally assess the trade-offs associated with balancing biological, economic and non-target species conservation objectives. We use the Australian Northern Prawn Fishery (NPF), which is one of the most valuable federally managed commercial fisheries in Australia, as a case study. We develop a stochastic co-viability assessment of the fishery under multiple management objectives. Results show that, due to the variability in the interactions between the fishery and the ecosystem, current management strategies are characterized by biological and economic risks. Results highlight the trade-offs between respecting biological, economic and non-target species conservation constraints at each point in time with a high probability and maximizing the net present value of the fishery.

Assessment of a data-limited, multi-species shark fishery in the Great Barrier Reef Marine Park and south-east Queensland

The status of five species of commercially exploited sharks within the Great Barrier Reef Marine Park (GBRMP) and south-east Queensland was assessed using a data-limited approach. Annual harvest rate, U, estimated empirically from tagging between 2011 and 2013, was compared with an analytically-derived proxy for optimal equilibrium harvest rate, UMSY Lim. Median estimates of U for three principal retained species, Australian blacktip shark, Carcharhinus tilstoni, spot-tail shark, Carcharhinus sorrah, and spinner shark, Carcharhinus brevipinna, were 0.10, 0.06 and 0.07 year-1, respectively. Median U for two retained, non-target species, pigeye shark, Carcharhinus amboinensis and Australian sharpnose shark, Rhizoprionodon taylori, were 0.27 and 0.01 year-1, respectively. For all species except the Australian blacktip the median ratio of U/UMSY Lim was <1. The high vulnerability of this species to fishing combined with life history characteristics meant UMSY Lim was low (0.04-0.07 year-1) and that U/UMSY Lim was likely to be > 1. Harvest of the Australian blacktip shark above UMSY could place this species at a greater risk of localised depletion in parts of the GBRMP. Results of the study indicated that much higher catches, and presumably higher U, during the early 2000s were likely unsustainable. The unexpectedly high level of U on the pigeye shark indicated that output-based management controls may not have been effective in reducing harvest levels on all species, particularly those caught incidentally by other fishing sectors including the recreational sector. © 2016 Elsevier B.V.

Cerebral misery perfusion diagnosed using hypercapnic blood-oxygenation-level-dependent contrast functional magnetic resonance imaging: a case report

Introduction Cerebral misery perfusion represents a failure of cerebral autoregulation. It is animportant differential diagnosis in post-stroke patients presenting with collapses in the presence of haemodynamically significant cerebrovascular stenosis. This is particularly the case when cortical or internal watershed infarcts are present. When this condition occurs, further investigation should be done immediately. Case presentation A 50-year-old Caucasian man presented with a stroke secondary to complete occlusion of his left internal carotid artery. He went on to suffer recurrent seizures. Neuroimaging demonstrated numerous new watershed-territory cerebral infarcts. No source of arterial thromboembolism was demonstrable. Hypercapnic blood-oxygenation-level-dependent-contrast functional magnetic resonance imaging was used to measure his cerebrovascular reserve capacity. The findings were suggestive of cerebral misery perfusion. Conclusions Blood-oxygenation-level-dependent-contrast functional magnetic resonance imaging allows the inference of cerebral misery perfusion. This procedure is cheaper and more readily available than positron emission tomography imaging, which is the current gold standard diagnostic test. The most evaluated treatment for cerebral misery perfusion is extracranial-intracranial bypass. Although previous trials of this have been unfavourable, the results of new studies involving extracranial-intracranial bypass in high-risk patients identified during cerebral perfusion imaging are awaited. Cerebral misery perfusion is an important and under-recognized condition in which emerging imaging and treatment modalities present the possibility of practical and evidence-based management in the near future. Physicians should thus be aware of this disorder and of recent developments in diagnostic tests that allow its detection.

A Framework for Energy-Efficiency in Smart Home Environments

Part 7: Cyber-Physical Systems

Avaliação do desempenho segundo a metodologia do balanced scorecard: aplicação à gestão hospitalar no Algarve

Dissertação de mest. em Gestão Empresarial, Faculdade de Economia, Univ. do Algarve, 2004

Avaliação ambiental de manguezais adjacentes aos campos petrolíferos de Macau e Serra (RN), como subsídio às medidas mitigadoras ao processo erosivo

Among the various effects caused by the climate change and human intervention, the mangrove ecosystem changes through of the years has been worth mentioning, which hasn t known which are the pros and cons for the adjacent coastal and estuarine environments yet. It happens due to the present dynamism in these areas, besides of the difficult understanding of the processes associated with evolution. This study aimed to environmentally evaluate adjacent mangroves from the Macau and Serra oil fields, located on Rio Grande do Norte northern coast, to support the mitigating actions related to the containment of the erosive process, as well as, according to the principles of the Clean Development Mechanism (CDM), to assess the amount of atmospheric carbon sequestered by the studied ecosystem. An inventory was conducted through mangrouve mapping which has supplied this research, especially regarding to the structural characterization of mangrove areas. To understand the local mangrove behavior in a greater level detail, techniques of remote sensing, GIS and GPS were used to make an analogy between the current and past states of the mangrove studied, allowing to make anticipated projections for the future impacts or changes in that region. This study combined data from multispectral LANDSAT 5 TM, Landsat 7 ETM+ with radar microwave data from SAR RADARSAT-1, which increased the interpretation capacity of the data from optical sensor systems. The interpretations have been supported by the data field, representing a better and innovative methodology for the environmental and taxonomic characterization of mangrove forests considered. The results reveal that mangroves of the Ponta do Tubarão Sustainable Development Reserve are biologically representative areas and providing a variety of benefits, especially for local communities, constituting the priority sites for actions development aimed at conservation. They also have been showing the necessity to make mitigating measures in order to recover degraded areas through reforestation or creating new areas of mangrove, as currently 7.1% of the mangrove forests studied are dead or in an advanced state of decomposition. The amount of atmospheric carbon sequestered proved very significant when analyzed for the whole area, which is able to sequester atmospheric 4,294,458 Ton CO2 per year

Does Landscape Context Affect Habitat Value? The Importance of Seascape Ecology in Back-reef Systems

Seascape ecology provides a useful framework from which to understand the processes governing spatial variability in ecological patterns. Seascape context, or the composition and pattern of habitat surrounding a focal patch, has the potential to impact resource availability, predator-prey interactions, and connectivity with other habitats. For my dissertation research, I combined a variety of approaches to examine how habitat quality for fishes is influenced by a diverse range of seascape factors in sub-tropical, back-reef ecosystems. In the first part of my dissertation, I examined how seascape context can affect reef fish communities on an experimental array of artificial reefs created in various seascape contexts in Abaco, Bahamas. I found that the amount of seagrass at large spatial scales was an important predictor of community assembly on these reefs. Additionally, seascape context had differing effects on various aspects of habitat quality for the most common reef species, White grunt Haemulon plumierii. The amount of seagrass at large spatial scales had positive effects on fish abundance and secondary production, but not on metrics of condition and growth. The second part of my dissertation focused on how foraging conditions for fish varied across a linear seascape gradient in the Loxahatchee River estuary in Florida, USA. Gray snapper, Lutjanus griseus, traded food quality for quantity along this estuarine gradient, maintaining similar growth rates and condition among sites. Additional work focused on identifying major energy flow pathways to two consumers in oyster-reef food webs in the Loxahatchee. Algal and microphytobenthos resource pools supported most of the production to these consumers, and body size for one of the consumers mediated food web linkages with surrounding mangrove habitats. All of these studies examined a different facet of the importance of seascape context in governing ecological processes occurring in focal habitats and underscore the role of connectivity among habitats in back-reef systems. The results suggest that management approaches consider the surrounding seascape when prioritizing areas for conservation or attempting to understand the impacts of seascape change on focal habitat patches. For this reason, spatially-based management approaches are recommended to most effectively manage back-reef systems.

Variability in the international normalised ratio (INR) in patients with antiphospholipid syndrome and positive lupus anticoagulant: should the INR targets be higher?

El síndrome antifosfolípido es un desorden autoinmune caracterizado por hipercoagulabilidad que requiere terapia anticoagulante como pilar fundamental, siendo la warfarina el tratamiento de elección en los casos que requieren manejo por largos periodos. Sin embargo, los pacientes con anticoagulante lúpico positivo representan un reto porque tienen mayor riesgo de presentar eventos trombóticos, sumado a que el seguimiento con el International Normalized Ratio (INR) no es confiable, ya que estos anticuerpos generan interferencia con las pruebas de laboratorio basadas en fosfolípidos, como es el caso del tiempo de protrombina (PT) con INR basal prolongado, incluso antes del inicio de la terapia anticoagulante. Por tal razón, se ilustra el caso de una paciente con síndrome antifosfolípido primario y anticoagulante lúpico positivo quien ha presentado múltiples episodios trombóticos, a pesar de recibir terapia anticoagulante. Además se hace una revisión de la literatura disponible y se postulan nuevas metas de INR en estos pacientes diferentes de las que se plantean actualmente.

Relación entre la calificación de los elementos de un sistema de gestión y los indicadores de accidentalidad en empresas del sector de la construcción en Colombia

El presente estudio tiene como objetivo determinar la relación que existe entre la implementación de un sistema de gestión de seguridad y salud en el trabajo (SGSST), y la frecuencia y la severidad de la accidentalidad en la industria de la construcción en Colombia. Para ello se seleccionaron 35 empresas que realizan actividades relacionadas con la edificación, infraestructura e interventoría, que hubiesen implementado un SGSST para la intervención de los riesgos de accidentes y que contaran con la evaluación del mismo. La evaluación del SGSST está enmarcada en cinco dimensiones o criterios: planeación, política, implementación, manejo integral del accidente y revisión por la gerencia. Cada una evaluada a través de diferentes requisitos y se presentan en una escala de 1 a 10, siendo 10 el nivel más alto del cumplimiento por requisito. Teniendo los resultados de esta calificación, la tasa (proporción entre los accidentes reportados y los trabajadores de cada empresa) y los días de incapacidad (ausentismo por accidente de trabajo), se realizó un análisis de las medidas descriptivas consolidado por las empresas del estudio: tendencia central y dispersión para número de trabajadores, tasa de accidentalidad, días de incapacidad y el resultado de los totales de cada criterio de la evaluación y el gran total. Para estudiar la relación entre los resultados de la evaluación y los indicadores de tasa y días, se llevó a cabo un análisis de correlación y regresión lineal entre los indicadores de accidentalidad y los resultados de las puntuaciones de los criterios. Esta correlación se realizó tanto para la primera evaluación como para la segunda. En las dos mediciones las correlaciones fueron negativas mostrando que existe una disminución en la tasa de accidentalidad y días de incapacidad entre una evaluación y la otra. En el análisis de regresión, en la primera evaluación por cada unidad que aumentó la calificación global, se presentó una reducción de la tasa de frecuencia de 0.140. En la segunda evaluación por cada unidad que aumentó la calificación global, la tasa se redujo en 0.159. Ambos hallazgos soportan la necesidad de implementar un SGSST para ayudar a reducir el número inaceptable de lesiones y enfermedades en la industria de la construcción.

Identificación de las relaciones reales y posibles entre la administración basada en modelos, la ciencia computacional de la organización y la ingeniería emergente en el contexto de la gestión organizacional

Las teorías administrativas se han basado, casi sin excepción, en los fundamentos y los modelos de la ciencia clásica (particularmente, en los modelos de la física newtoniana). Sin embargo, las organizaciones actualmente se enfrentan a un mundo globalizado, plagado de información (y no necesariamente conocimiento), hiperconectado, dinámico y cargado de incertidumbre, por lo que muchas de las teorías pueden mostrar limitaciones para las organizaciones. Y quizá no por la estructura, la lógica o el alcance de las mismas, sino por la falta de criterios que justifiquen su aplicación. En muchos casos, las organizaciones siguen utilizando la intuición, las suposiciones y las verdades a medias en la toma de decisiones. Este panorama pone de manifiesto dos hechos: de un lado, la necesidad de buscar un método que permita comprender las situaciones de cada organización para apoyar la toma de decisiones. De otro lado, la necesidad de potenciar la intuición con modelos y técnicas no tradicionales (usualmente provenientes o inspiradas por la ingeniería). Este trabajo busca anticipar los pilares de un posible método que permita apoyar la toma de decisiones por medio de la simulación de modelos computacionales, utilizando las posibles interacciones entre: la administración basada en modelos, la ciencia computacional de la organización y la ingeniería emergente.