The "help" question doesn't help when screening for major depression: external validation of the three-question screening test for primary care patients managed for physical complaints.

BACKGROUND: Major depression, although frequent in primary care, is commonly hidden behind multiple physical complaints that are often the first and only reason for patient consultation. Major depression can be screened by two validated questions that are easier to use in primary care than the full DSM-IV criteria. A third question, called the "help" question, improves the specificity without apparently decreasing the sensitivity of this screening procedure. We validated the abbreviated screening procedure for major depression with and without the "help" question in primary care patients managed for a physical complaint. METHODS: This diagnostic accuracy study used data from a cohort study called SODA (for SOmatisation Depression Anxiety ) conducted by 24 general practitioners (GPs) in western Switzerland that included patients over 18 years of age with at least one physical complaint at index consultation. Major depression was identified with the full Patient Health Questionnaire. GPs were asked to screen patients for major depression with the three screening questions one year after inclusion. RESULTS: Out of 937 patients with at least one physical complaint, 751 were eligible one year after index consultation. Major depression was diagnosed in 69/724 (9.5%) patients. The sensitivity and specificity of the two-question method alone were 91.3% (95% confidence interval 81.4-96.4%) and 65.0% (95% confidence interval 61.2-68.6%), respectively. Adding the "help" question decreased the sensitivity (59.4% ; 95% confidence interval 47.0-70.9%) but improved the specificity (88.2% ; 95% confidence interval 85.4-90.5%) of the three-question method. CONCLUSIONS: The use of two screening questions for major depression was associated with high sensitivity and low specificity in primary care patients presenting a physical complaint. Adding the "help" question improved the specificity but clearly decreased the sensitivity; when using the "help" question; four out of ten patients with depression will be missed, compared to only one out of ten with the two-question method. Therefore, the "help" question is not useful as a screening question, but may help discussing management strategies.

Estrategias comerciales en la gestión de proyectos

El objetivo del presente Trabajo Final de Carrera ha consistido en realizar un estudio de investigación sobre estrategias comerciales aplicables en la gestión de proyectos, con el fin de identificar y proponer estrategias de gestión para el desarrollo e implementación de estrategias comerciales que posibiliten la reducción de costes y creación de nuevos modelos comerciales que permitan maximizar el retorno de inversión en proyectos de índole tecnológica. El estudio ha tratado las diversas áreas funcionales y de conocimiento que convergen en la gestión económica y financiera de un proyecto: (1) El área de Marketing y la concepción del plan estratégico. (2) La gestión y control de costes. (3) La gestión del suministro y compras. (4) El plan comercial de ventas. (5) La estrategia y gestión de un proyecto. En definitiva el presente proyecto representa un estudio de rigor de las áreas funcionales y del conocimiento que aquí se citan, así como sus implicaciones a lo largo del ciclo de vida de un proyecto.

The central role of mosquito cytochrome P450 CYP6Zs in insecticide detoxification revealed by functional expression and structural modelling.

The resistance of mosquitoes to chemical insecticides is threatening vector control programmes worldwide. Cytochrome P450 monooxygenases (CYPs) are known to play a major role in insecticide resistance, allowing resistant insects to metabolize insecticides at a higher rate. Among them, members of the mosquito CYP6Z subfamily, like Aedes aegypti CYP6Z8 and its Anopheles gambiae orthologue CYP6Z2, have been frequently associated with pyrethroid resistance. However, their role in the pyrethroid degradation pathway remains unclear. In the present study, we created a genetically modified yeast strain overexpressing Ae. aegypti cytochrome P450 reductase and CYP6Z8, thereby producing the first mosquito P450-CPR (NADPH-cytochrome P450-reductase) complex in a yeast recombinant system. The results of the present study show that: (i) CYP6Z8 metabolizes PBAlc (3-phenoxybenzoic alcohol) and PBAld (3-phenoxybenzaldehyde), common pyrethroid metabolites produced by carboxylesterases, producing PBA (3-phenoxybenzoic acid); (ii) CYP6Z8 transcription is induced by PBAlc, PBAld and PBA; (iii) An. gambiae CYP6Z2 metabolizes PBAlc and PBAld in the same way; (iv) PBA is the major metabolite produced in vivo and is excreted without further modification; and (v) in silico modelling of substrate-enzyme interactions supports a similar role of other mosquito CYP6Zs in pyrethroid degradation. By playing a pivotal role in the degradation of pyrethroid insecticides, mosquito CYP6Zs thus represent good targets for mosquito-resistance management strategies.

Appropriateness of therapy for active Crohn's disease: results of a multidisciplinary international Expert Panel (EPACT II)

INTRODUCTION: The development of novel therapies and the increasing number of trials testing management strategies for luminal Crohn's disease (CD) have not filled all the gaps in our knowledge. Thus, in clinical practice, many decisions for CD patients need to be taken without high quality evidence. For this reason, a multidisciplinary European expert panel followed the RAND method to develop explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD. AIMS & METHODS: Twelve international experts convened in Geneva, Switzerland in December 2007, to rate explicit clinical scenarios, corresponding to real daily practice, on a 9-point scale according to the literature evidence and their own expertise. Median ratings were stratified into three categories: appropriate (7-9), uncertain (4-6) and inappropriate (1-3). RESULTS: Overall, panelists rated 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD. In anti-TNF naïve patients, budesonide and prednisone were found appropriate for mild-moderate CD, and infliximab (IFX) when those had previously failed or had not been tolerated. In patients with prior success with IFX, this drug with or without co-administration of a thiopurine analog was favored. Other anti-TNFs were appropriate in case of intolerance or resistance to IFX. High doses steroids, IFX or adalimumab were appropriate in severe active CD. Among 105 indications for ST-D or ST-R disease, the panel considered appropriate the thiopurine analogs, methotrexate, IFX, adalimumab and surgery for limited resection, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R. CONCLUSION: Steroids, including budesonide for mild-to-moderate CD, remain first-line therapies in active luminal CD. Anti-TNFs, in particular IFX with respect to the amount of available evidence, remain second-line for most indications. Thiopurine analogs are preferred to anti-TNFs when steroids are not appropriate, except when anti-TNFs were previously successful. These recommendations are available online (www.epact.ch). A prospective evaluation of these criteria in a large database in Switzerland in underway to validate these criteria.

Behavioral aspects of investment fund's markets: are good managers lucky or skilled?

It is generally accepted that financial markets are efficient in the long run a lthough there may be some deviations in the short run. It is also accepted that a good portfolio manager is the one who beats the market persistently along time, this type of manager could not exist if markets were perfectly efficient According to this in a pure efficient market we should find that managers know that they can not beat the market so they would undertake only pure passive management strategies. Assuming a certain degree of inefficiency in the short run, a market may show some managers who tr y to beat the market by undertaking active strategies. From Fama’s efficient markets theory we can state that these active managers may beat the market occasionally although they will not be able to enhance significantly their performance in the long run. On the other hand, in an inefficient market it would be expected to find a higher level of activity related with the higher probability of beating the market. In this paper we follow two objectives: first, we set a basis to analyse the level of efficiency in an asset invest- ment funds market by measuring performance, strategies activity and it’s persistence for a certain group of funds during the period of study. Second, we analyse individual performance persistence in order to determine the existence of skilled managers. The CAPM model is taken as theoretical background and the use of the Sharpe’s ratio as a suitable performance measure in a limited information environment leads to a group performance measurement proposal. The empiri- cal study takes quarterly data from 1999-2007 period, for the whole population of the Spanish asset investment funds market, provided by the CNMV (Comisión Nacional del Mercado de Valores). This period of study has been chosen to ensure a wide enough range of efficient market observation so it would allow us to set a proper basis to compare with the following period. As a result we develop a model that allows us to measure efficiency in a given asset mutual funds market, based on the level of strategy’s activity undertaken by managers. We also observe persistence in individual performance for a certain group of funds

From Support to Control : A Configurational Perspective on Conjugal Quality

The topic of conjugal quality provides an empirical illustration of the relevance of the configurational perspective on families. Based on a longitudinal sample of 1,534 couples living in Switzerland drawn from the study "Social Stratification, Cohesion and Conflict in Contemporary Families", we show that various types of interdependencies with relatives and friends promote distinct conflict management strategies for couples as well as unequal levels of conjugal quality. We find that configurations characterized by supportive and non-interfering relationships with relatives and friends for both partners are associated with higher conjugal quality, while configurations characterized by interference are associated with lower conjugal quality.

Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system.

OBJECTIVES: The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system. METHODS: This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined. RESULTS: A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6). CONCLUSIONS: Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts.

Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.

Population-level changes to promote cardiovascular health.

BACKGROUND: Cardiovascular diseases (CVD) cause 1.8 million premature (<75 years) death annually in Europe. The majority of these deaths are preventable with the most efficient and cost-effective approach being on the population level. The aim of this position paper is to assist authorities in selecting the most adequate management strategies to prevent CVD. DESIGN AND METHODS: Experts reviewed and summarized the published evidence on the major modifiable CVD risk factors: food, physical inactivity, smoking, and alcohol. Population-based preventive strategies focus on fiscal measures (e.g. taxation), national and regional policies (e.g. smoke-free legislation), and environmental changes (e.g. availability of alcohol). RESULTS: Food is a complex area, but several strategies can be effective in increasing fruit and vegetables and lowering intake of salt, saturated fat, trans-fats, and free sugars. Tobacco and alcohol can be regulated mainly by fiscal measures and national policies, but local availability also plays a role. Changes in national policies and the built environment will integrate physical activity into daily life. CONCLUSION: Societal changes and commercial influences have led to the present unhealthy environment, in which default option in life style increases CVD risk. A challenge for both central and local authorities is, therefore, to ensure healthier defaults. This position paper summarizes the evidence and recommends a number of structural strategies at international, national, and regional levels that in combination can substantially reduce CVD.

Secondary Accident Data Fusion for Assessing Long-Term Performance of Transportation Systems, 2007

Secondary accident statistics can be useful for studying the impact of traffic incident management strategies. An easy-to-implement methodology is presented for classifying secondary accidents using data fusion of a police accident database with intranet incident reports. A current method for classifying secondary accidents uses a static threshold that represents the spatial and temporal region of influence of the primary accident, such as two miles and one hour. An accident is considered secondary if it occurs upstream from the primary accident and is within the duration and queue of the primary accident. However, using the static threshold may result in both false positives and negatives because accident queues are constantly varying. The methodology presented in this report seeks to improve upon this existing method by making the threshold dynamic. An incident progression curve is used to mark the end of the queue throughout the entire incident. Four steps in the development of incident progression curves are described. Step one is the processing of intranet incident reports. Step two is the filling in of incomplete incident reports. Step three is the nonlinear regression of incident progression curves. Step four is the merging of individual incident progression curves into one master curve. To illustrate this methodology, 5,514 accidents from Missouri freeways were analyzed. The results show that secondary accidents identified by dynamic versus static thresholds can differ by more than 30%.

Controlo Interno como factor de melhoria empresarial - estudo de caso prático Centro de Emprego e Formação Profissonal Santa Cruz

A problemática do controlo interno como factor de melhoria empresarial, foi a que orientou esta pesquisa realizada no CEFPSC (Centro de Emprego e Formação Profissional de Santa Cruz). É que, segundo Morais & Martins (2007, pág. 27) existe controlo adequado quando a gestão planeou e organizou, isto é, concebeu, de tal modo que foi assegurado uma garantia razoável que os riscos da organização foram adequadamente geridos e de que os objectivos e metas da organização serão alcançados de forma eficiente e económica. Sendo assim, é de notar a importância desta ferramenta em traçar estratégias de gestão no processo decisório, servindo assim de uma mais-valia à entidade com vista a permitir responder à questão: Em que medida o controlo interno tem sido utilizado como método de apoio à gestão do Centro de Emprego e Formação Profissional de Santa Cruz? Este trabalho tem como objectivo compreender a actuação e a contribuição do Controlo Interno na gestão eficiente do CEFPSC. As informações foram recolhidas mediante a aplicação de um questionário de controlo interno e entrevistas ao Responsável do CEFPSC, bem como ao Presidente do IEFP, enquanto órgão central. O tratamento dos dados foi realizado com auxílio informático, utilizando, para tal, o programa Excel.

Pertenças identitárias de jovens do Casal da Boba

Resumo - O trabalho que aqui se apresenta centra-se numa reflexão sobre as pertenças identitárias de jovens descendentes de imigrantes cabo-verdianos. O objectivo principal do estudo é o de contribuir para compreender como é que estes jovens definem e afirmam as suas pertenças identitárias. Os jovens em estudo estabelecem relações com dois códigos culturais, um transmitido no seio familiar e outro pelo contacto com a sociedade portuguesa e nessa medida a sua gestão identitária é complexa. Os descendentes de imigrantes cabo-verdianos ou novos portugueses têm múltiplas referências e pertenças identitárias e representam parte da juventude portuguesa de hoje.

Spatial variability of soil chemical properties after coffee tree removal

Assessing the spatial variability of soil chemical properties has become an important aspect of soil management strategies with a view to higher crop yields with minimal environmental degradation. This study was carried out at the Centro Experimental of the Instituto Agronomico, in Campinas, São Paulo, Brazil. The aim was to characterize the spatial variability of chemical properties of a Rhodic Hapludox on a recently bulldozer-cleaned area after over 30 years of coffee cultivation. Soil samples were collected in a 20 x 20 m grid with 36 sampling points across a 1 ha area in the layers 0.0-0.2 and 0.2-0.4 m to measure the following chemical properties: pH, organic matter, K+, P, Ca2+, Mg2+, potential acidity, NH4-N, and NO3-N. Descriptive statistics were applied to assess the central tendency and dispersion moments. Geostatistical methods were applied to evaluate and to model the spatial variability of variables by calculating semivariograms and kriging interpolation. Spatial dependence patterns defined by spherical model adjusted semivariograms were made for all cited soil properties. Moderate to strong degrees of spatial dependence were found between 31 and 60 m. It was still possible to map soil spatial variability properties in the layers 0-20 cm and 20-40 cm after plant removal with bulldozers.

Mitigation of methane and nitrous oxide emissions from flood-irrigated rice by no incorporation of winter crop residues into the soil

Winter cover crops are sources of C and N in flooded rice production systems, but very little is known about the effect of crop residue management and quality on soil methane (CH4) and nitrous oxide (N2O) emissions. This study was conducted in pots in a greenhouse to evaluate the influence of crop residue management (incorporated into the soil or left on the soil surface) and the type of cover-crop residues (ryegrass and serradella) on CH4 and N2O emissions from a flooded Albaqualf soil cultivated with rice (Oryza sativa L.). The closed chamber technique was used for air sampling and the CH4 and N2O concentrations were analyzed by gas chromatography. Soil solution was sampled at two soil depths (2 and 20 cm), simultaneously to air sampling, and the contents of dissolved organic C (DOC), NO3-, NH4+, Mn2+, and Fe2+ were analyzed. Methane and N2O emissions from the soil where crop residues had been left on the surface were lower than from soil with incorporated residues. The type of crop residue had no effect on the CH4 emissions, while higher N2O emissions were observed from serradella (leguminous) than from ryegrass, but only when the residues were left on the soil surface. The more intense soil reduction verified in the deeper soil layer (20 cm), as evidenced by higher contents of reduced metal species (Mn2+ and Fe2+), and the close relationship between CH4 emission and the DOC contents in the deeper layer indicated that the sub-surface layer was the main CH4 source of the flooded soil with incorporated crop residues. The adoption of management strategies in which crop residues are left on the soil surface is crucial to minimize soil CH4 and N2O emissions from irrigated rice fields. In these production systems, CH4 accounts for more than 90 % of the partial global warming potential (CH4+N2O) and, thus, should be the main focus of research.

Heavy metals in soils and plants in mango orchards in Petrolina, Pernambuco, Brazil

The monitoring of heavy metal concentrations in areas under intensive agriculture is essential for the agricultural sustainability and food safety. This paper evaluates the total contents of heavy metals in soils and mango trees in orchards of different ages (6, 7, 8, 9, 10, 11, 14, 16, 17, 19, and 26 years) in Petrolina, Pernambuco, Brazil. Soil samples were taken from the layers 0-20 cm and 20-40 cm, and mango leaves were collected in the growth stage. Areas of native vegetation (Caatinga) adjacent to the cultivated areas were used for comparison. The total concentrations of heavy metals (Cu, Cr, Fe, Zn, Mn, Ni, and Pb) were determined in soils and leaves. In general, mango cultivation led to Cu and Zn accumulation in the soil surface and to a reduction in the contents of Ni, Pb, Mn, and Fe in surface and subsurface. Since contamination by Cu, Zn, and Cr was detected, these areas must be monitored to prevent negative environmental impacts. For instance, the presence of Cr in mango tree leaves indicates the need to investigate the source of the element in these orchards. The management strategies of the different companies led to deficiency or excess of some metals in the evaluated areas. However, the Fe and Mn levels were adequate for the mineral nutrition of mango in all areas.