Risk factors associated with the longevity of multi-rooted teeth. Long-term outcomes after active and supportive periodontal therapy

AIM To investigate risk factors for the loss of multi-rooted teeth (MRT) in subjects treated for periodontitis and enrolled in supportive periodontal therapy (SPT). MATERIAL AND METHODS A total of 172 subjects were examined before (T0) and after active periodontal therapy (APT)(T1) and following a mean of 11.5 ± 5.2 (SD) years of SPT (T2). The association of risk factors with loss of MRT was analysed with multilevel logistic regression. The tooth was the unit of analysis. RESULTS Furcation involvement (FI) = 1 before APT was not a risk factor for tooth loss compared with FI = 0 (p = 0.37). Between T0 and T2, MRT with FI = 2 (OR: 2.92, 95% CI: 1.68, 5.06, p = 0.0001) and FI = 3 (OR: 6.85, 95% CI: 3.40, 13.83, p < 0.0001) were at a significantly higher risk to be lost compared with those with FI = 0. During SPT, smokers lost significantly more MRT compared with non-smokers (OR: 2.37, 95% CI: 1.05, 5.35, p = 0.04). Non-smoking and compliant subjects with FI = 0/1 at T1 lost significantly less MRT during SPT compared with non-compliant smokers with FI = 2 (OR: 10.11, 95% CI: 2.91, 35.11, p < 0.0001) and FI = 3 (OR: 17.18, 95% CI: 4.98, 59.28, p < 0.0001) respectively. CONCLUSIONS FI = 1 was not a risk factor for tooth loss compared with FI = 0. FI = 2/3, smoking and lack of compliance with regular SPT represented risk factors for the loss of MRT in subjects treated for periodontitis.

Major challenges in clinical management of TB/HIV co-infected patients in Eastern Europe compared with Western Europe and Latin America.

INTRODUCTION Rates of both TB/HIV co-infection and multi-drug-resistant (MDR) TB are increasing in Eastern Europe (EE). Data on the clinical management of TB/HIV co-infected patients are scarce. Our aim was to study the clinical characteristics of TB/HIV patients in Europe and Latin America (LA) at TB diagnosis, identify factors associated with MDR-TB and assess the activity of initial TB treatment regimens given the results of drug-susceptibility tests (DST). MATERIAL AND METHODS We enrolled 1413 TB/HIV patients from 62 clinics in 19 countries in EE, Western Europe (WE), Southern Europe (SE) and LA from January 2011 to December 2013. Among patients who completed DST within the first month of TB therapy, we linked initial TB treatment regimens to the DST results and calculated the distribution of patients receiving 0, 1, 2, 3 and ≥4 active drugs in each region. Risk factors for MDR-TB were identified in logistic regression models. RESULTS Significant differences were observed between EE (n=844), WE (n=152), SE (n=164) and LA (n=253) for use of combination antiretroviral therapy (cART) at TB diagnosis (17%, 40%, 44% and 35%, p<0.0001), a definite TB diagnosis (culture and/or PCR positive for Mycobacterium tuberculosis; 47%, 71%, 72% and 40%, p<0.0001) and MDR-TB prevalence (34%, 3%, 3% and 11%, p <0.0001 among those with DST results). The history of injecting drug use [adjusted OR (aOR) = 2.03, (95% CI 1.00-4.09)], prior TB treatment (aOR = 3.42, 95% CI 1.88-6.22) and living in EE (aOR = 7.19, 95% CI 3.28-15.78) were associated with MDR-TB. For 569 patients with available DST, the initial TB treatment contained ≥3 active drugs in 64% of patients in EE compared with 90-94% of patients in other regions (Figure 1a). Had the patients received initial therapy with standard therapy [Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (RHZE)], the corresponding proportions would have been 64% vs. 86-97%, respectively (Figure 1b). CONCLUSIONS In EE, TB/HIV patients had poorer exposure to cART, less often a definitive TB diagnosis and more often MDR-TB compared to other parts of Europe and LA. Initial TB therapy in EE was sub-optimal, with less than two-thirds of patients receiving at least three active drugs, and improved compliance with standard RHZE treatment does not seem to be the solution. Improved management of TB/HIV patients requires routine use of DST, initial TB therapy according to prevailing resistance patterns and more widespread use of cART.

Dental fear and satisfaction with dental services in Switzerland.

OBJECTIVES Dental satisfaction is associated with continuity of dental care, compliance with dentist advice, and positive health outcomes. It is expected that people with higher dental fear might have less dental satisfaction because of more negative dental experiences. The objective of this study was to examine satisfaction and reasons for satisfaction with dental practitioners in Switzerland and variations by dental fear. METHODS A national sample of 1,129 Swiss residents aged 15-74 (mean = 43.2 years) completed a personal interview at their home with questions assessing dental fear, dental service use, general satisfaction with their dentist, and reasons for satisfaction or dissatisfaction. RESULTS Overall, 47.9 percent of participants responded that they were satisfied with their dentist and 47.6 percent that they were very satisfied. Satisfaction differed significantly by gender, language spoken, region of residence, and educational attainment. Greater dental fear was significantly associated with greater dissatisfaction with the dentist. The percentage of people who were very satisfied with the dentist ranged from 56.0 percent among people with no fear to 30.5 percent for participants with "quite a lot" of fear but was higher (44.4 percent) for people who stated that they were "very much" afraid of the dentist. The most common reasons attributed for satisfaction with dentists were interpersonal characteristics of the dentist and staff. People with "quite a lot" of fear were found to endorse these sentiments least. CONCLUSIONS Although higher dental fear was associated with more dissatisfaction with the dentist, the level of satisfaction among fearful individuals in Switzerland is still high.

General Practitioners' vitamin K antagonist monitoring is associated with better blood pressure control in patients with hypertension - a cross-sectional database study.

BACKGROUND Patients requiring anticoagulation suffer from comorbidities such as hypertension. On the occasion of INR monitoring, general practitioners (GPs) have the opportunity to control for blood pressure (BP). We aimed to evaluate the impact of Vitamin-K Antagonist (VKA) monitoring by GPs on BP control in patients with hypertension. METHODS We cross-sectionally analyzed the database of the Swiss Family Medicine ICPC Research using Electronic Medical Records (FIRE) of 60 general practices in a primary care setting in Switzerland. This database includes 113,335 patients who visited their GP between 2009 and 2013. We identified patients with hypertension based on antihypertensive medication prescribed for ≥6 months. We compared patients with VKA for ≥3 months and patients without such treatment regarding BP control. We adjusted for age, sex, observation period, number of consultations and comorbidity. RESULTS We identified 4,412 patients with hypertension and blood pressure recordings in the FIRE database. Among these, 569 (12.9 %) were on Phenprocoumon (VKA) and 3,843 (87.1 %) had no anticoagulation. Mean systolic and diastolic BP was significantly lower in the VKA group (130.6 ± 14.9 vs 139.8 ± 15.8 and 76.6 ± 7.9 vs 81.3 ± 9.3 mm Hg) (p < 0.001 for both). The difference remained after adjusting for possible confounders. Systolic and diastolic BP were significantly lower in the VKA group, reaching a mean difference of -8.4 mm Hg (95 % CI -9.8 to -7.0 mm Hg) and -1.5 mm Hg (95 % CI -2.3 to -0.7 mm Hg), respectively (p < 0.001 for both). CONCLUSIONS In a large sample of hypertensive patients in Switzerland, VKA treatment was independently associated with better systolic and diastolic BP control. The observed effect could be due to better compliance with antihypertensive medication in patients treated with VKA. Therefore, we conclude to be aware of this possible benefit especially in patients with lower expected compliance and with multimorbidity.

Diagnosis and workup of 522 consecutive patients with neuroendocrine neoplasms in Switzerland.

BACKGROUND Neuroendocrine neoplasms (NENs) are difficult to diagnose. We used SwissNET data to characterise NEN patients followed in the two academic centres of western Switzerland (WS), and to compare them with patients followed in eastern Switzerland (ES) as well as with international guidelines. METHOD SwissNET is a prospective database covering data from 522 consecutive patients (285 men, 237 women) from WS (n = 99) and ES (n = 423). RESULTS Mean ± SD age at diagnosis was 59.0 ± 15.7 years. Overall, 76/522 experienced a functional syndrome, with a median interval of 1.0 (IQR: 1.0-3.0) year between symptoms onset and diagnosis. A total of 51/522 of these tumours were incidental. The primary tumour site was the small intestine (29%), pancreas (21%), appendix (18%) and lung (11%) in both regions combined. In all, 513 functional imaging studies were obtained (139 in WS, 374 in ES). Of these, 381 were 111In-pentetreotide scintigraphies and 20 were 68Ga-DOTATOC PET. First line therapy was surgery in 87% of patients, medical therapy (biotherapy or chemotherapy) in 9% and irradiation in 3% for both regions together. CONCLUSION Swiss NEN patients appear similar to what has been described in the literature. Imaging by somatostatin receptor scintigraphy (SRS) is widely used in both regions of Switzerland. In good accordance with published guidelines, data on first line therapy demonstrate the crucial role of surgery. The low incidence of biotherapy suggests that long-acting somatostatin analogues are not yet widely used for their anti-proliferative effects. The SwissNET initiative should help improve compliance with ENETS guidelines in the workup and care of NEN patients.

Human rights and international trade

Economic globalization and respect for human rights are both highly topical issues. In theory, more trade should increase economic welfare and protection of human rights should ensure individual dignity. Both fields of law protect certain freedoms: economic development should lead to higher human rights standards, and UN embargoes are used to secure compliance with human rights agreements. However the interaction between trade liberalisation and human rights protection is complex, and recently, tension has arisen between these two areas. Do WTO obligations covering intellectual property prevent governments from implementing their human rights obligations, including rights to food or health? Is it fair to accord the benefits of trade subject to a clean human rights record? This book first examines the theoretical framework of the interaction between the disciplines of international trade law and human rights. It builds upon the well-known debate between Professor Ernst-Ulrich Petersmann, who construes trade obligations as human rights, and Professor Philip Alston, who warns of a merger and acquisition of human rights by trade law. From this starting point, further chapters explore the differing legal matrices of the two fields and examine how cooperation between them might be improved, both in international law-making and institutions,in dispute settlement. The interaction between trade and human rights is then explored through seven case studies:freedom of expression and competition law; IP protection and health; agricultural trade and the right to food; trade restrictions on conflict WHO convention on tobacco control; and, finally, human rights conditionalities in preferential trade schemes.

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

The Texas driver responsibility program: A preliminary analysis of the impact on impaired driving and trauma system funding

Objective. In 2003, the State of Texas instituted the Driver Responsibility Program (TDRP), a program consisting of a driving infraction point system coupled with a series of graded fines and annual surcharges for specific traffic violations such as driving while intoxicated (DWI). Approximately half of the revenues generated are earmarked to be disbursed to the state's trauma system to cover uncompensated trauma care costs. This study examined initial program implementation, the impact of trauma system funding, and initial impact on impaired driving knowledge, attitudes and behaviors. A model for targeted media campaigns to improve the program's deterrence effects was developed. ^ Methods. Data from two independent driver survey samples (conducted in 1999 and 2005), department of public safety records, state health department data and a state auditor's report were used to evaluate the program's initial implementation, impact and outcome with respect to drivers' impaired driving knowledge, attitudes and behavior (based on constructs of social cognitive theory) and hospital uncompensated trauma care funding. Survey results were used to develop a regression model of high risk drivers who should be targeted to improve program outcome with respect to deterring impaired driving. ^ Results. Low driver compliance with fee payment (28%) and program implementation problems were associated with lower surcharge revenues in the first two years ($59.5 million versus $525 million predicted). Program revenue distribution to trauma hospitals was associated with a 16% increase in designated trauma centers. Survey data demonstrated that only 28% of drivers are aware of the TDRP and that there has been no initial impact on impaired driving behavior. Logistical regression modeling suggested that target media campaigns highlighting the likelihood of DWI detection by law enforcement and the increased surcharges associated with the TDRP are required to deter impaired driving. ^ Conclusions. Although the TDRP raised nearly $60 million in surcharge revenue for the Texas trauma system over the first two years, this study did not find evidence of a change in impaired driving knowledge, attitudes or behaviors from 1999 to 2005. Further research is required to measure whether the program is associated with decreased alcohol-related traffic fatalities. ^

A practice-based culminating experience with Texas Children's Hospital: A hospital's journey to baby-friendly status

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. ^

Sex, drugs, and STIs: Syphilis infection and hepatitis B vaccine compliance among illicit drug users in Houston

Although the association between syphilis infection status and compliance with the hepatitis B virus vaccine has been the focus of investigation, there is a lack of data regarding the association between syphilis infection and HBV vaccine compliance. The author investigated the association between the exposure of syphilis infection and the outcome of HBV vaccine completion, defined as degree of constancy and accuracy with which a patient follows a prescribed regimen. A cohort design was employed using interview and serological data from the Drugs, AIDS, STDs, Hepatitis (DASH) Research Project; analysis was restricted to HIV and HBV seronegative (at baseline), illicit drug users residing in Harris County. Syphilis negative and syphilis positive infection status was determined from the serological data while covariates and outcome information were determined from the DASH Project Questionnaire; enrolled subjects (n=1160) were selected from the data. Association between exposure and outcome was assessed with logistic regression adjusted for data-based confounders. ^ A prevalence of 7% and 71% was found for syphilis and HBV vaccine compliance, respectively. When measuring the actual association between syphilis infection status and HBV vaccine compliance, an odds ratio of 1.49 (95% CI: 0.86, 2.72) was obtained. There was a non-significant association between these two variables. 78% of the study population was syphilis positive and completed the vaccine series compared to 70% of the population that was syphilis negative and received all three doses. This finding confirms that there is a difference between syphilis positive and negative drug users with respect to HBV vaccine compliance. The fact that differences were found in these drug users with respect to vaccine schedule supports the idea that sub-group differences may exist and thus merits further investigation. If these differences are confirmed, it is recommended that STI interventions identify community characteristics of their samples and target populations based on practices specific to that community. ^

Secondary data analysis of lead screening compliance in high-risk children

Introduction. Despite the ban of lead-containing gasoline and paint, childhood lead poisoning remains a public health issue. Furthermore, a Medicaid-eligible child is 8 times more likely to have an elevated blood lead level (EBLL) than a non-Medicaid child, which is the primary reason for the early detection lead screening mandate for ages 12 and 24 months among the Medicaid population. Based on field observations, there was evidence that suggested a screening compliance issue. Objective. The purpose of this study was to analyze blood lead screening compliance in previously lead poisoned Medicaid children and test for an association between timely lead screening and timely childhood immunizations. The mean months between follow-up tests were also examined for a significant difference between the non-compliant and compliant lead screened children. Methods. Access to the surveillance data of all childhood lead poisoned cases in Bexar County was granted by the San Antonio Metropolitan Health District. A database was constructed and analyzed using descriptive statistics, logistic regression methods and non-parametric tests. Lead screening at 12 months of age was analyzed separately from lead screening at 24 months. The small portion of the population who were also related were included in one analysis and removed from a second analysis to check for significance. Gender, ethnicity, age of home, and having a sibling with an EBLL were ruled out as confounders for the association tests but ethnicity and age of home were adjusted in the nonparametric tests. Results. There was a strong significant association between lead screening compliance at 12 months and childhood immunization compliance, with or without including related children (p<0.00). However, there was no significant association between the two variables at the age of 24 months. Furthermore, there was no significant difference between the median of the mean months of follow-up blood tests among the non-compliant and compliant lead screened population for at the 12 month screening group but there was a significant difference at the 24 month screening group (p<0.01). Discussion. Descriptive statistics showed that 61% and 56% of the previously lead poisoned Medicaid population did not receive their 12 and 24 month mandated lead screening on time, respectively. This suggests that their elevated blood lead level may have been diagnosed earlier in their childhood. Furthermore, a child who is compliant with their lead screening at 12 months of age is 2.36 times more likely to also receive their childhood immunizations on time compared to a child who was not compliant with their 12 month screening. Even though there was no statistical significant association found for the 24 month group, the public health significance of a screening compliance issue is no less important. The Texas Medicaid program needs to enforce lead screening compliance because it is evident that there has been no monitoring system in place. Further recommendations include a need for an increased focus on parental education and the importance of taking their children for wellness exams on time.^

A review of the Malaria Chemoprophylaxis Compliance Program at ExxonMobil Corporation

ExxonMobil, a Fortune 500 oil and gas corporation, has a global workforce with employees assigned to projects in areas at risk for infectious diseases, particularly malaria. As such, the corporation has put in place a program to protect the health of workers and ensure their safety in malaria endemic zones. This program is called the Malaria Control Program (MCP). One component of this program is the more specific Malaria Chemoprophylaxis Compliance Program (MCCP), in which employees enroll following consent to random drug testing for compliance with the company's chemoprophylaxis requirements. Each year, data is gathered on the number of employees working in these locations and are selected randomly and tested for chemoprophylaxis compliance. The selection strives to test each eligible worker once per year. Test results that come back positive for the chemoprophylaxis drug are considered "detects" and tests that are negative for the drug and therefore show the worker is non-compliant at risk for severe malaria infection are considered "non-detect". ^ The current practice report used aggregate data to calculate statistics on test results to reflect compliance among both employees and contractors in various malaria-endemic areas. This aggregate, non-individualized data has been compiled and reflects the effectiveness and reach of ExxonMobil's Malaria Chemoprophylaxis Compliance Program. In order to assess compliance, information on the number of non-detect test results was compared to the number of tests completed per year. The data shows that over time, non-detect results have declined in both employee and contractor populations, and vary somewhat by location due to size and scope of the MCCP implemented in-country. Although the data indicate a positive trend for the corporation, some recommendations have been made for future implementation of the program.^

Considerations in Determining the Cost of Measurement Uncertainty Associated with Dimensional Tolerances Verification

The verification of compliance with a design specification in manufacturing requires the use of metrological instruments to check if the magnitude associated with the design specification is or not according with tolerance range. Such instrumentation and their use during the measurement process, has associated an uncertainty of measurement whose value must be related to the value of tolerance tested. Most papers dealing jointly tolerance and measurement uncertainties are mainly focused on the establishment of a relationship uncertainty-tolerance without paying much attention to the impact from the standpoint of process cost. This paper analyzes the cost-measurement uncertainty, considering uncertainty as a productive factor in the process outcome. This is done starting from a cost-tolerance model associated with the process. By means of this model the existence of a measurement uncertainty is calculated in quantitative terms of cost and its impact on the process is analyzed.

Sistema de gestión de residuos de construcción y demolición en obras de edificación residencial. Buenas prácticas en la ejecución de obra

En el sector de la edificación, las grandes constructoras comienzan a considerar aspectos medioambientales, no limitándose a lo establecido por la legislación vigente, y buscando la implementación de buenas prácticas. Si bien este hecho es una realidad para las grandes empresas constructoras, todavía falta que la gran mayoría de las empresas del sector (pequeñas y medianas) adopten ésta tendencia. En este sentido, las publicaciones y estadísticas consultadas revelan que el sector de la construcción sigue siendo el sector con menor número de Sistemas de Gestión Ambiental (SGA) certificados en comparación con otros sectores industriales, debido principalmente a las peculiaridades de su actividad. Por otra parte, el sector de la construcción genera grandes cantidades de residuos de construcción y demolición (RCD). Aunque, en los últimos años la actividad de la construcción ha disminuido, debido a la crisis económica del país, no hay que olvidar todos los problemas causados por este tipo de residuos, o mejor dicho, por su gestión. La gestión de los RCD actual está lejos de alcanzar la meta propuesta en la Directiva Marco de Residuos (DMR), la cual exige un objetivo global para el año 2020 en el que el 70% de todos los RCD generados deberán ser reciclados en los países de la UE. Pero, la realidad es que sólo el 50% de la RCD generados en la Unión Europea se recicla. Por este motivo, en los últimos años se ha producido una completa modificación del régimen jurídico aplicable a los RCD, incorporando importantes novedades a nuestro ordenamiento interno como son: la redacción de un Estudio de gestión de RCD (en fase de diseño) y un Plan de gestión de RCD (en fase de ejecución). Entre estas medidas destaca el poder conocer, con la antelación suficiente, la cantidad y el momento en que los RCD son generados, para así poder planificar la gestión más adecuada para cada categoría de RCD. Es por ello que el desarrollo de cualquier instrumento que determine la estimación de RCD así como iniciativas para su control debe ser considerado como una herramienta para dar respuestas reales en el campo de la sostenibilidad en la edificación. Por todo lo anterior, el principal objetivo de la Tesis Doctoral es mejorar la gestión actual de los RCD, a través de la elaboración e implementación en obra de un Sistema de gestión de RCD en fase de ejecución que podrá ser incluido en el Sistema de Gestión Ambiental de las empresas constructoras. Para ello, se ha identificado la actividad que más residuo genera, así como las diferentes categorías de RCD generadas durante su ejecución, a través del análisis de nueve obras de edificación de nueva planta. Posteriormente, se han determinado y evaluado, en función de su eficacia y viabilidad, veinte buenas prácticas encaminadas a reducir la generación de RCD. También, se han identificado y evaluado, en función de su coste económico, cinco alternativas de gestión para cada categoría de RCD generada. Por último, se ha desarrollado e implementado un Sistema de Gestión de RCD en una empresa de construcción real. En definitiva, el Sistema de Gestión de RCD propuesto contiene una herramienta de estimación de RCD y también proporciona una relación de buenas prácticas, según su viabilidad y eficacia, sobre los aspectos más significativos en cuanto a la gestión de RCD se refiere. El uso de este Sistema de gestión de RCD ayudará a los técnicos de la construcción en el desarrollo de los documentos "Estudio de gestión de RCD " y "Plan de gestión de RCD " - requeridos por ley -. Además, el Sistema promueve la gestión ambiental de la empresa, favoreciendo la cohesión del proceso constructivo, estableciendo responsabilidades en el ámbito de RCD y proporcionando un mayor control sobre el proceso. En conclusión, la implementación de un sistema de gestión de RCD en obra ayuda a conseguir una actividad de edificación, cuyo principal objetivo sea la generación de residuos cero. ABSTRACT Currently, in the building sector, the main construction companies are considering environmental issues, not being limited to the current legislation, and seeking the implementation of good practices. While this fact is a reality for large construction companies, still the vast majority of construction companies (small and medium enterprises) need to accept this trend. In this sense, official publications and statistics reveal that the construction sector remains with the lowest number of certified Environmental Management Systems (EMS) compared to other industrial sectors, mainly due to the peculiarities of its activity. Moreover, the construction industry in Spain generates large volumes of construction and demolition waste (CDW) achieving a low recycling rate compared to other European Union countries and to the target set for 2020. Despite the complete change in the legal regime for CDW in Spain, there are still several difficulties for their application at the construction works. Among these difficulties the following can be highlighted: onsite segregation, estimating CDW generation and managing different CDW categories. Despite these difficulties, the proper CDW management must be one of the main aspects considered by construction companies in the EMS. However, at present the EMS used in construction companies consider very superficially CDW management issues. Therefore, current EMS should go a step further and include not only procedures for managing CDW globally, but also specific procedures for each CDW category, taking into account best practices for prevention, minimization and proper CDW management in order to achieve building construction works with zero waste generation. The few scientific studies analysing EMS implementation in construction enterprises focus on studying the benefits and barriers of their implementation. Despite the drawbacks found, implementing an EMS would bring benefits such as improving the corporate image in relation to the environment, ensuring compliance with the law or reducing environmental risks. Also, the international scientific community has shown great interest in defining models to estimate in advance the CDW that will be generated during the building construction or rehabilitation works. These studies analyse the overall waste generation and its different CDW categories. However, despite the many studies found on CDW quantification, analysing its evolution throughout the construction activities is a factor that must be further studied and discussed in greater depth, as results would be of great significance when planning the CDW management. According to the scientific studies analysing the implementation of good environmental practices in construction sites, it seems that, in general, the CDW collection system is done in a decentralized manner by each subcontracted company. In addition, the corporate image generated when poor practices are done may adversely affect the company's reputation and can result in loss of contracts. Finally, although there are numerous guides and manuals of good practices for CDW management, no references have been found implementing these measures in the Environmental Management System of the construction companies. From all the above, this thesis aims to provide answers to reduce the environmental impact caused by CDW generation in building construction works, in order to get a building process with zero waste generation. In this sense, is essential to generate new knowledge in order to implement a system which can carry out comprehensive management of CDW generated onsite, at the design stage until the end of its life cycle, taking into account both technical and economic criteria. Therefore, the main objective of this thesis is to define and implement a CDW management system for residential building construction works, helping construction agents not only to manage the CDW in accordance with current legislation, but also minimizing their generation on site by applying best practices, resulting in achieving the goal of zero waste in building works.

Modelo para la gestión de la ordenación territorial en el Ecuador en el marco de su Constitución

Ecuador, país sudamericano, aprobó en el año 2008 una Constitución en la que subyace un modelo de desarrollo humano multidimensional y alternativo al vigente. Sus dimensiones sociales, económicas, políticas, culturales y ambientales se encuentran en los textos correspondientes a los “Derechos”, “Régimen de Desarrollo” y “Régimen del Buen Vivir”; en tanto que las dimensiones territoriales se hallan expuestas en la “Organización Territorial del Estado”, conformada por regiones, provincias, cantones y parroquias rurales, con sus respectivos gobiernos autónomos descentralizados, a los que la misma Constitución les atribuye, entre otras, las competencias exclusivas de “planificar el desarrollo” y “formular los correspondientes planes de ordenamiento territorial”, y al Estado central la “planificación nacional”. No obstante, el marco legal dictado posteriormente -que otorga al Estado central la competencia de ordenación territorial, mediante la “Estrategia Territorial Nacional”-, no logra regular con eficacia, efectividad y eficiencia este ejercicio competencial, incluyendo en esta condición a los lineamientos técnicos dictados por el organismo nacional de planificación; volviendo urgente la vigencia de una ley que lo asuma, pero que demanda previamente el diseño de un modelo de gestión de estas competencias, propósito al cual procura contribuir el presente trabajo. Su estructura es la siguiente: Capítulo 1: “La problemática, objetivos y antecedentes”, en cuya formulación se destaca el estudio del marco jurídico y técnico vigente en relación a la ordenación territorial, partiendo de una breve visión sobre los empeños previos en Ecuador por adoptarla, y que se complementa con una evaluación preliminar de la experiencia vivida por los gobiernos autónomos descentralizados al formular y gestionar sus primeros planes de desarrollo y de ordenación territorial, en acatamiento del mandato constitucional. Luego se avanza en la definición del objetivo general del trabajo y de un conjunto coherente de objetivos específicos. Concluye este capítulo con el análisis del estado de la cuestión: los antecedentes sobre la ordenación territorial en América Latina, en el marco de sus predecesoras históricas. Capítulo 2: “Diseño del modelo de gestión”, que se inicia con el planteamiento de la metodología a seguir, condicionada especialmente por los propios textos constitucionales que vinculan en la relación de “correspondencia” a la ordenación territorial con la planificación del desarrollo y en consecuencia con el ejercicio de las competencias sectoriales asignadas por ella misma a los diferentes niveles de gobierno. Efectivamente, tal relación supone básicamente que la planificación del desarrollo adquiera el carácter de global, total, vale decir integral, en el sentido de que igualmente contemple sus dimensiones territoriales y que la planificación de éstas se integre a la de las dimensiones sociales, económicas, políticas, culturales y ambientales, de manera tal que en cada uno de los niveles la planificación del desarrollo sea un proceso único y un todo. Por estas condiciones, el diseño en cuestión demanda el tratamiento previo de los aspectos contemplados por la metodología en relación con la conceptualización y ordenamiento de la planificación y gestión del modelo de desarrollo humano previsto por la Constitución para los distintos niveles territoriales, seguido del análisis y evaluación del reparto competencial. En este marco se diseña el modelo de gestión en siete componentes específicos que definen los objetivos estratégicos generales a los cuales apuntará la ordenación territorial, estructuran con sus figuras –los planes–, un sistema integrado de alcance nacional, entienden al propio territorio bajo una visión sistémica y proponen un esquema metodológico general para la redacción de tales instrumentos. Luego se aborda en calidad de tema clave, la articulación con la planificación del desarrollo, el establecimiento de las dimensiones territoriales sectoriales y globales de ordenación en cada nivel territorial, que posibilita a su vez la formulación de los contenidos de las determinaciones de los planes y la definición de un conjunto de lineamientos para su gestión. Capítulo 3. “Verificación”, que se ha concretado en la puesta a consideración de un selecto grupo de expertos nacionales en ordenación territorial, el modelo propuesto siguiendo los procedimientos recomendados para este tipo de consultas. Capítulo 4. “Conclusiones Generales”, esto es, un conjunto coherente de proposiciones que condensan los resultados alcanzados en los diferentes capítulos precedentes y que demuestran la validez del modelo propuesto. ABSTRACT Ecuador approved a constitution, by 2008, where a multidimensional human development model, different to the one in force, underlies. Its social, economic, political, cultural and environmental dimensions are at the entries for "Rights", "Development Scheme" and "Rules of Good Living"; while the territorial dimensions are given by the "Territorial Organization of the State" section, consisting of regions, provinces, cantons and rural parishes, with their respective autonomous governments, to which the Constitution conferred, inter alia, the exclusive powers of "development planning" and "land use plan formulation," while the central state has the "national planning" competence. However, the subsequent issued legal framework - which gives the central state competences over land planning, using the "National Spatial Strategy" - fails to effectively regulate this exercise of jurisdiction, including in this condition the technical guidelines dictated by the national planning agency; thus becoming urgent to put in force a law that assume it, which demands the previous design of a management model of these competences, which is the aim that seeks to contribute the present work. Its structure is as follows: Chapter 1: "The problem, objectives and background" that includes the study of the legal and technical framework in force in relation to land planning, starts with a brief overview of previous efforts to adopt it in Ecuador. The chapter is complemented with a preliminary assessment of the experience of the autonomous governments to formulate and manage their early development plans and land planning, in compliance with the constitutional mandate. Subsequently the overall objective of the work and a coherent set of objectives are defined. This chapter concludes with an analysis of the state of art: the history of land use planning in Latin America in the context of their historical predecessors. Chapter 2, "Design of a management model", which begins with the methodological approach to follow, conditioned by the constitutional texts linking the relationship of "correspondence" land planning with development planning and with the exercise of the sectorial competences assigned by itself to different levels of government. Indeed, such a relationship basically means that development planning should acquire a global, comprehensive, complete, total, character in the sense that it also provides for their territorial dimensions and that their planning is integrated to social, economic, political, cultural and environmental factors, so that in each of the levels, development planning is a unique process and a whole. For these conditions, the design in question demands pretreatment of the aspects covered by the methodology in relation to the conceptualization and management of the planning and management of human development model envisaged by the Constitution to the various territorial levels, followed by analysis and evaluation of the distribution of powers. In this framework a management model is designed into seven specific components that define the overall strategic objectives which aim to land planning, structure plans, and an integrated nationwide system, that understand the territory under a systemic vision and propose a general methodological framework to draft these instruments. Then a key issue is addressed, the coordination with development planning, the establishment of sectorial and regional and global dimensions of management at each territorial level, which in turn allows the formulation of the contents of the plans determinations and defining a set of management guidelines. Chapter 3, "Verification", It has traduced into asking for the revision of the proposed model by a select group of national experts in spatial planning by following recommended procedures for such queries. Chapter 4, "General Conclusions", a coherent set of propositions that summarize the results obtained in the different preceding chapters, which demonstrates the validity of the proposed model.