The coevolution of cooperation and dispersal in social groups and its implications for the emergence of multicellularity

Background Recent work on the complexity of life highlights the roles played by evolutionary forces at different levels of individuality. One of the central puzzles in explaining transitions in individuality for entities ranging from complex cells, to multicellular organisms and societies, is how different autonomous units relinquish control over their functions to others in the group. In addition to the necessity of reducing conflict over effecting specialized tasks, differentiating groups must control the exploitation of the commons, or else be out-competed by more fit groups. Results We propose that two forms of conflict – access to resources within groups and representation in germ line – may be resolved in tandem through individual and group-level selective effects. Specifically, we employ an optimization model to show the conditions under which different within-group social behaviors (cooperators producing a public good or cheaters exploiting the public good) may be selected to disperse, thereby not affecting the commons and functioning as germ line. We find that partial or complete dispersal specialization of cheaters is a general outcome. The propensity for cheaters to disperse is highest with intermediate benefit:cost ratios of cooperative acts and with high relatedness. An examination of a range of real biological systems tends to support our theory, although additional study is required to provide robust tests. Conclusion We suggest that trait linkage between dispersal and cheating should be operative regardless of whether groups ever achieve higher levels of individuality, because individual selection will always tend to increase exploitation, and stronger group structure will tend to increase overall cooperation through kin selected benefits. Cheater specialization as dispersers offers simultaneous solutions to the evolution of cooperation in social groups and the origin of specialization of germ and soma in multicellular organisms.

Treatment of acute renal failure in the intensive care unit: lower costs by intermittent dialysis than continuous venovenous hemodiafiltration

Intermittent and continuous renal replacement therapies (RRTs) are available for the treatment of acute renal failure (ARF) in the intensive care unit (ICU). Although at present there are no adequately powered survival studies, available data suggest that both methods are equal with respect to patient outcome. Therefore, cost comparison between techniques is important for selecting the modality. Expenditures were prospectively assessed as a secondary end point during a controlled, randomized trial comparing intermittent hemodialysis (IHD) with continuous venovenous hemodiafiltration (CVVHDF). The outcome of the primary end points of this trial, that is, ICU and in-hospital mortality, has been previously published. One hundred twenty-five patients from a Swiss university hospital ICU were randomized either to CVVHDF or IHD. Out of these, 42 (CVVHDF) and 34 (IHD) were available for cost analysis. Patients' characteristics, delivered dialysis dose, duration of stay in the ICU or hospital, mortality rates, and recovery of renal function were not different between the two groups. Detailed 24-h time and material consumption protocols were available for 369 (CVVHDF) and 195 (IHD) treatment days. The mean daily duration of CVVHDF was 19.5 +/- 3.2 h/day, resulting in total expenditures of Euro 436 +/- 21 (21% for human resources and 79% for technical devices). For IHD (mean 3.0 +/- 0.4 h/treatment), the costs were lower (Euro 268 +/- 26), with a larger proportion for human resources (45%). Nursing time spent for CVVHDF was 113 +/- 50 min, and 198 +/- 63 min per IHD treatment. Total costs for RRT in ICU patients with ARF were lower when treated with IHD than with CVVHDF, and have to be taken into account for the selection of the method of RRT in ARF on the ICU.

Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT

PURPOSE: To determine if multi–detector row computed tomography (CT) can replace conventional radiography and be performed alone in severe trauma patients for the depiction of thoracolumbar spine fractures. MATERIALS AND METHODS: One hundred consecutive severe trauma patients who underwent conventional radiography of the thoracolumbar spine as well as thoracoabdominal multi–detector row CT were prospectively identified. Conventional radiographs were reviewed independently by three radiologists and two orthopedic surgeons; CT images were reviewed by three radiologists. Reviewers were blinded both to one another’s reviews and to the results of initial evaluation. Presence, location, and stability of fractures, as well as quality of reviewed images, were assessed. Statistical analysis was performed to determine sensitivity and interobserver agreement for each procedure, with results of clinical and radiologic follow-up as the standard of reference. The time to perform each examination and the radiation dose involved were evaluated. A resource cost analysis was performed. RESULTS: Sixty-seven fractured vertebrae were diagnosed in 26 patients. Twelve patients had unstable spine fractures. Mean sensitivity and interobserver agreement, respectively, for detection of unstable fractures were 97.2% and 0.951 for multi–detector row CT and 33.3% and 0.368 for conventional radiography. The median times to perform a conventional radiographic and a multi–detector row CT examination, respectively, were 33 and 40 minutes. Effective radiation doses at conventional radiography of the spine and thoracoabdominal multi–detector row CT, respectively, were 6.36 mSv and 19.42 mSv. Multi–detector row CT enabled identification of 146 associated traumatic lesions. The costs of conventional radiography and multi–detector row CT, respectively, were $145 and $880 per patient. CONCLUSION: Multi–detector row CT is a better examination for depicting spine fractures than conventional radiography. It can replace conventional radiography and be performed alone in patients who have sustained severe trauma.

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

Long-term impact of a weight management summer camp on obese children

Background: interventions that focus on improving eating habits, increasing physical activity, and reducing sedentary behaviors on weight status and body mass index percentile and z-scores in youths have not been well documented. This study aimed to determine the short and long term effects of a 2-week residential weight management summer camp program for youths on weight, BMI, BMI percentile, and BMI z-score. ^ Methods: A sample of 73 obese multiethnic 10-14 years old youths (11.9 ± 1.4) attended a weight management camp called Kamp K'aana for two weeks and completed a 12-month follow-up on height and weight. As part of Kamp K'aana, participants received a series of nutrition, physical activity and behavioral lessons and were on an 1800 kcal per day meal plan. Anthropometric measurements of height and weight were taken to calculate participants' BMI percentiles and z-scores. Paired t-tests, chi square test and ANCOVA, adjusting for age, gender, and ethnicity were used to assess changes in body weight, BMI, BMI percentiles and BMI z-scores pre to two-weeks post-camp and 12 months post-camp. ^ Results: Significant reductions in body weight of 3.6 ± 1.4 (P = 0.0000), BMI of 1.4 ± 0.54 (P = 0.0000), BMI percentile of 0.45 ± 0.06 (P = 0.0000), and BMI z-score of 0.1 ± 0.06 (P = 0.0000) were observed at the end of the camp. Significant reductions in BMI z-scores (P < 0.001) and BMI percentile (P < 0.001) were observed at the 12-month reunion when compared to pre- and two-weeks post camp data. There was a significant increase in weight and BMI (P = 0.0000) at the 12-month reunion when compared to pre and post camp measurements. ^ Conclusion: Kamp K'aana has consistently shown short-term reductions in weight, BMI, BMI percentile, and BMI z-score. Results from analysis of long-term data suggest that this intervention had beneficial effects on body composition in an ethnically diverse population of obese children. Further research which includes a control group, larger sample size, and cost-analysis should be conducted.^

A simplified energy consumption model for fiber-based Next Generation Access Networks

ICTs account nowadays for 2% of total carbon emissions. However, in a time when strict measures to reduce energyconsumption in all the industrial and services sectors are required, the ICT sector faces an increase in services and bandwidth demand. The deployment of NextGenerationNetworks (NGN) will be the answer to this new demand and specifically, the NextGenerationAccessNetworks (NGANs) will provide higher bandwidth access to users. Several policy and cost analysis are being carried out to understand the risks and opportunities of new deployments, though the question of which is the role of energyconsumption in NGANs seems off the table. Thus, this paper proposes amodel to analyze the energyconsumption of the main fiber-based NGAN architectures, i.e. Fiber To The House (FTTH) in both Passive Optical Network (PON) and Point-to-Point (PtP) variations, and FTTx/VDSL. The aim of this analysis is to provide deeper insight on the impact of new deployments on the energyconsumption of the ICT sector and the effects of energyconsumption on the life-cycle cost of NGANs. The paper presents also an energyconsumption comparison of the presented architectures, particularized in the specific geographic and demographic distribution of users of Spain, but easily extendable to other countries.

Clean Coal Technologies Scenario and Evaluation of Present CO2 Dwindling Initiatives to Approach Zero Emission Power Stations By Coal Combustion. Deployment Situation and Evaluation Study

In the present uncertain global context of reaching an equal social stability and steady thriving economy, power demand expected to grow and global electricity generation could nearly double from 2005 to 2030. Fossil fuels will remain a significant contribution on this energy mix up to 2050, with an expected part of around 70% of global and ca. 60% of European electricity generation. Coal will remain a key player. Hence, a direct effect on the considered CO2 emissions business-as-usual scenario is expected, forecasting three times the present CO2 concentration values up to 1,200ppm by the end of this century. Kyoto protocol was the first approach to take global responsibility onto CO2 emissions monitoring and cap targets by 2012 with reference to 1990. Some of principal CO2emitters did not ratify the reduction targets. Although USA and China spur are taking its own actions and parallel reduction measures. More efficient combustion processes comprising less fuel consuming, a significant contribution from the electricity generation sector to a CO2 dwindling concentration levels, might not be sufficient. Carbon Capture and Storage (CCS) technologies have started to gain more importance from the beginning of the decade, with research and funds coming out to drive its come in useful. After first researching projects and initial scale testing, three principal capture processes came out available today with first figures showing up to 90% CO2 removal by its standard applications in coal fired power stations. Regarding last part of CO2 reduction chain, two options could be considered worthy, reusing (EOR & EGR) and storage. The study evaluates the state of the CO2 capture technology development, availability and investment cost of the different technologies, with few operation cost analysis possible at the time. Main findings and the abatement potential for coal applications are presented. DOE, NETL, MIT, European universities and research institutions, key technology enterprises and utilities, and key technology suppliers are the main sources of this study. A vision of the technology deployment is presented.

Parallelizing irregular and pointer-based computations automatically: perspectives from logic and constraint programming

Irregular computations pose sorne of the most interesting and challenging problems in automatic parallelization. Irregularity appears in certain kinds of numerical problems and is pervasive in symbolic applications. Such computations often use dynamic data structures, which make heavy use of pointers. This complicates all the steps of a parallelizing compiler, from independence detection to task partitioning and placement. Starting in the mid 80s there has been significant progress in the development of parallelizing compilers for logic pro­gramming (and more recently, constraint programming) resulting in quite capable paralle­lizers. The typical applications of these paradigms frequently involve irregular computations, and make heavy use of dynamic data structures with pointers, since logical variables represent in practice a well-behaved form of pointers. This arguably makes the techniques used in these compilers potentially interesting. In this paper, we introduce in a tutoríal way, sorne of the problems faced by parallelizing compilers for logic and constraint programs and provide pointers to sorne of the significant progress made in the area. In particular, this work has resulted in a series of achievements in the areas of inter-procedural pointer aliasing analysis for independence detection, cost models and cost analysis, cactus-stack memory management, techniques for managing speculative and irregular computations through task granularity control and dynamic task allocation such as work-stealing schedulers), etc.

Análisis de los mercados de gas mayoristas en Europa: Francia, Reino Unido, Bélgica y Holanda

Este proyecto consiste en una previa investigación descriptiva del mercado mayorista de gas en España. Para ello, se ha estudiado en profundidad el funcionamiento de los componentes que constituyen este sistema y las herramientas necesarias utilizadas para el sostenimiento del mismo. Se ha analizado las capacidades, peajes, etc. para poder extrapolar estos conocimientos al resto de los mercados europeos examinados. Una vez explorado el mercado español, se ha analizado el mercado belga, francés, inglés y holandés. En estos mercados se ha hecho un estudio de las bases necesarias que un comercializador necesita para poder introducirse en estos nuevos mercados. Por último, al tratarse de un proyecto de investigación, se ha realizado un estudio del coste económico que un estudio como este podría conllevar. 3 ABSTRACT This project is a descriptive pre-research study of the wholesale gas market in Spain. For that purpose, the system's structure, functioning and the strategies required for its sustainability have been studied extensively. Capacities, tolls, etc. have been analysed so that results can be then extrapolated to the other markets examined. Once the spanish market was explored; belgian, french, english and dutch markets were analysed. In these markets, the basis required for a potential marketer entering these markets, have been evaluated. At last, as a research study, it includes an economic cost analysis that a study like this would imply

On the economics of energy consumption in 4G networks: the case of Spain

Reducing energy consumption is one of the main challenges in most countries. For example, European Member States agreed to reduce greenhouse gas (GHG) emissions by 20% in 2020 compared to 1990 levels (EC 2008). Considering each sector separately, ICTs account nowadays for 2% of total carbon emissions. This percentage will increase as the demand of communication services and applications steps up. At the same time, the expected evolution of ICT-based developments - smart buildings, smart grids and smart transportation systems among others - could result in the creation of energy-saving opportunities leading to global emission reductions (Labouze et al. 2008), although the amount of these savings is under debate (Falch 2010). The main development required in telecommunication networks ?one of the three major blocks of energy consumption in ICTs together with data centers and consumer equipment (Sutherland 2009) ? is the evolution of existing infrastructures into ultra-broadband networks, the so-called Next Generation Networks (NGN). Fourth generation (4G) mobile communications are the technology of choice to complete -or supplement- the ubiquitous deployment of NGN. The risk and opportunities involved in NGN roll-out are currently in the forefront of the economic and policy debate. However, the issue of which is the role of energy consumption in 4G networks seems absent, despite the fact that the economic impact of energy consumption arises as a key element in the cost analysis of this type of networks. Precisely, the aim of this research is to provide deeper insight on the energy consumption involved in the usage of a 4G network, its relationship with network main design features, and the general economic impact this would have in the capital and operational expenditures related with network deployment and usage.

Morteros acumuladores con parafinas microencapsuladas para el aprovechamiento de la energía solar en suelos radiantes

Esta Tesis plantea la pregunta de si el uso de morteros con parafinas microencapsuladas combinado con colectores solares térmicos puede reducir el consumo de energías convencionales, en un sistema tradicional de suelo radiante. Se pretende contribuir al conocimiento acerca del efecto que produce en el edificio, el calor latente acumulado en suelos radiantes, utilizando morteros de cemento Portland con material de cambio de fase (PCM), en conjunto con la energía solar. Para cumplir con este propósito, la investigación se desarrolla considerando diversos aspectos. En primer lugar, se revisa y analiza la documentación disponible en la actualidad, de almacenamiento de energía mediante calor latente en la construcción, y en particular la aplicación de microcápsulas de PCM en morteros y suelos radiantes. También se revisa la documentación relacionada con la aplicación de la energía solar térmica y en suelo radiante. Se analiza la normativa vigente respecto al material, a los colectores solares y al suelo radiante. Se verifica que no hay normativa relacionada con mortero-PCM, debido a esto se aplica en la investigación una adaptación de la existente. La fase experimental desarrollada esta principalmente dirigida a la cuantificación, caracterización y evaluación de las propiedades físicas, mecánicas y térmicas del mortero de cemento Portland con parafinas microencapsuladas. Los resultados obtenidos y su análisis, permiten conocer el comportamiento de este tipo de morteros, con las diferentes variables aplicadas en la investigación. Además, permite disponer de la información necesaria, para crear una metodología para el diseño de morteros con parafina microencapsulada, tanto del punto de vista de su resistencia a la compresión y contenido de PCM, como de su comportamiento térmico como acumulador de calor. Esto se logra procesando la información obtenida y generando modelos matemáticos, para dosificar mezclas, y predecir la acumulación de calor en función de su composición. Se determinan los tipos y cantidades de PCM, y el cemento más adecuado. Se obtienen importantes conclusiones respecto a los aspectos constructivos a considerar en la aplicación de morteros con PCM, en suelo radiante. Se analiza y evalúa la demanda térmica que se puede cubrir con el suelo radiante, utilizando morteros con parafina microencapsulada, a través de la acumulación de energía solar producida por colectores solares, para condiciones climáticas, técnicas y tipologías constructivas específicas. Se determina que cuando los paneles cubren más de 60 % de la demanda por calefacción, se puede almacenar en los morteros con PCM, el excedente generado durante el día. Se puede cubrir la demanda de acumulación de energía con los morteros con PCM, en la mayoría de los casos analizados. Con esto, se determina que el uso de morteros con PCM, aporta a la eficiencia energética de los edificios, disminuyendo el consumo de energías convencionales, reemplazándola por energía solar térmica. En esta investigación, el énfasis está en las propiedades del material mortero de cemento-PCM y en poder generar metodologías que faciliten su uso. Se aborda el uso de la energía solar, para verificar que es posible su acumulación en morteros con PCM aplicados en suelo radiante, posibilitando el reemplazo de energías convencionales. Quedan algunos aspectos de la aplicación de energía solar a suelo radiante con morteros con PCM, que no han sido tratados con la profundidad que requieren, y que resultan interesantes de evaluar en este tipo de aplicaciones constructivas, como entre otros, los relacionados con la cuantificación de los ahorros de energía en las diferentes estaciones del año, de la estabilización de temperaturas internas, su análisis de costo y la optimización de este tipo de sistemas para utilización en verano, los que dan pie para otras Tesis o proyectos de investigación. ABSTRACT This Thesis proposes the question of whether the use of mortars with microencapsulated paraffin combined with solar thermal collectors can reduce conventional energy consumption in a traditional heating floor system. It aims to contribute to knowledge about the effect that it has on the building, the latent heat accumulated in heating floor, using Portland cement mortars with phase change material (PCM), in conjunction with solar energy. To fulfill this purpose, the research develops it considering various aspects. First, it reviews and analyzes the documentation available today, about energy storage by latent heat in the building, and in particular the application of PCM microcapsules in mortars and heating floors. It also reviews the documentation related to the application of solar thermal energy and heating floor. Additionally, it analyzes the current regulations regarding to material, solar collectors and heating floors. It verifies that there aren’t regulations related to PCM mortar, due to this, it applies an adaptation in the investigation. The experimental phase is aimed to the quantification, mainly, characterization and evaluation of physical, mechanical and thermal properties of Portland cement mortar with microencapsulated paraffin. The results and analysis, which allow us to know the behavior of this type of mortars with different variables applied in research. It also allows having the information necessary to create a methodology for designing mortars with microencapsulated paraffin, both from the standpoint of its resistance to compression and PCM content, and its thermal performance as a heat accumulator. This accomplishes by processing the information obtained, and generating mathematical models for dosing mixtures, and predicting heat accumulation depending on their composition. The research determines the kinds and amounts of PCM, and the most suitable cement. Relevant conclusions obtain it regarding constructive aspects to consider in the implementation of PCM mortars in heating floor. Also, it analyzes and evaluates the thermal demand that it can be covered in heating floor using microencapsulated paraffin mortars, through the accumulation of solar energy produced by solar collectors to weather conditions, technical and specific building typologies. It determines that if the panels cover more than 60% of the demand for heating, the surplus generated during the day can be stored in PCM mortars. It meets the demand of energy storage with PCM mortars, in most of the cases analyzed. With this, it determines that the use of PCM mortars contributes to building energy efficiency, reducing consumption of conventional energy, replacing it with solar thermal energy. In this research approaches the use of solar energy to determine that it’s possible to verify its accumulation in PCM mortars applied in heating floor, enabling the replacement of conventional energy. The emphasis is on material properties of PCM mortar and, in order to generate methodologies to facilitate their use. There are some aspects of solar energy application in PCM mortars in heating floor, which have not been discussed with the depth required, and that they are relevant to evaluate in this kind of construction applications, including among others: the applications related to the energy savings quantification in different seasons of the year, the stabilizing internal temperatures, its cost analysis and optimization of these systems for use in summer, which can give ideas for other thesis or research projects.

Consultoría en el marco económico-financiero de la empresa

Muchas de las grandes iniciativas empresariales, se ven truncadas por falta de un adecuado análisis económico-financiero. Incluso, muchas grandes ideas no son implantadas correctamente en el primer intento por este motivo, y son otras personas las que consiguen posteriormente el éxito de esas brillantes ideas gracias a una correcta aproximación financiera. Las empresas necesitan definir sus objetivos, establecer las para lograrlos, identificar las personas responsables de su ejecución (sus roles y funciones) y elaborar un plan económico-financiero que recoja el estudio de inversiones necesarias, el análisis de costes, la previsión de ingresos, así como la estrategia financiera más adecuada para la captación de los fondos necesarios para llevar a cabo las acciones programadas. Una vez iniciado el proyecto empresarial, será imprescindible realizar un seguimiento y control de la evolución (integración), tomando las medidas que se estimen oportunas para mantener el rumbo adecuado durante todo el tiempo de actividad. En este trabajo, aplicaremos las metodologías y buenas prácticas de la gestión de proyectos, como marco estructurado que nos permita abordar las principales cuestiones económico-financieras a tener en cuenta a la hora de enfrentarnos a un proyecto empresarial, para contribuir, en la medida de lo posible, a que los emprendedores tengan en cuenta estas cuestiones, facilitando así el desarrollo de negocios, en un difícil entorno económico de crisis como el que actualmente estamos viviendo en España, y animando de esta manera a optar por la iniciativa emprendedora, tratando de minimizar el riesgo en base al contenido. ---ABSTRACT---Lack of adequate economic and financial analysis truncates many of the entrepreneurship and innovation programs. Because of that reason, many great ideas are not even correctly implemented on the first attempt, and the person who finds the proper financial approach, succeed. All the enterprises have to establish clear objectives, actions to accomplish those objectives, assign roles, responsibilities and executive functions to specific people. Elaborate funding plan that contains surveys on necessary investments, cost analysis, estimate the income, liquid assets and also financial strategy suitable for fundraising to finance programmed actions. Once the project has been executed it is essential to monitor and control the development and integration adopting measures accordingly to the needs. This thesis applies methodology and best practice of project management as structured framework for the principal economic and financial issues facing business project. It is necessary contribution to entrepreneurs understanding of business, therefore facilitates business development in such rough environment as Spain is at this moment, and at the same time encourages adopting entrepreneur’s solution as less risky one. This document aims to explore all the economic and financial issues from methodological point of view based on my own professional experience, resulting in helping to understand the importance that economy and finances have in developing adequate corporate strategy. Crisis has highlighted inadequate functionality of many companies. Most popular first symptom is lack of cash flow that deteriorates the company, and results in suspension of payments followed by closing. In other cases, difficulties appear due to poor financial management of committed resources; to be observed in lack of prevision and planning or incorrect basic functionality and operational matters on daily basis. What would be your advice to someone who have magnificent business idea however no knowledge on how to handle finances in order to succeed in initiating and executing the project? Despite of the fact that the central nucleus of this paper is at economics and finances area, all the other concepts and topics given during master will be revived; for example business strategy, consultants abilities, organization and standard processes, among others, are impregnated with knowledge of project management.

Improving brain injury cognitive rehabilitation by personalized telerehabilitation services: Guttmann neuropersonal trainer

Cognitive rehabilitation aims to remediate or alleviate the cognitive deficits appearing after an episode of acquired brain injury (ABI). The purpose of this work is to describe the telerehabilitation platform called Guttmann Neuropersonal Trainer (GNPT) which provides new strategies for cognitive rehabilitation, improving efficiency and access to treatments, and to increase knowledge generation from the process. A cognitive rehabilitation process has been modeled to design and develop the system, which allows neuropsychologists to configure and schedule rehabilitation sessions, consisting of set of personalized computerized cognitive exercises grounded on neuroscience and plasticity principles. It provides remote continuous monitoring of patient's performance, by an asynchronous communication strategy. An automatic knowledge extraction method has been used to implement a decision support system, improving treatment customization. GNPT has been implemented in 27 rehabilitation centers and in 83 patients' homes, facilitating the access to the treatment. In total, 1660 patients have been treated. Usability and cost analysis methodologies have been applied to measure the efficiency in real clinical environments. The usability evaluation reveals a system usability score higher than 70 for all target users. The cost efficiency study results show a relation of 1-20 compared to face-to-face rehabilitation. GNPT enables brain-damaged patients to continue and further extend rehabilitation beyond the hospital, improving the efficiency of the rehabilitation process. It allows customized therapeutic plans, providing information to further development of clinical practice guidelines.

La reutilización de efluentes depurados en España: retrospectiva, desarrollo del marco normativo, estudio de las tecnologías de regeneración frente a los biorreactores de membrana y sus costes en función del uso

La reutilización de efluentes depurados siempre ha sido una opción en lugares con déficit coyuntural o estructural de recursos hídricos, se haya o no procedido a la regulación y planificación de esta práctica. La necesidad se crea a partir de las demandas de una zona, normalmente riego agrícola, que ven un mejor desarrollo de su actividad por contar con este recurso. España es el país de la UE que más caudal reutiliza, y está dentro de los diez primeros a nivel mundial. La regulación de esta práctica por el RD 1620/2007, ayudó a incorporar la reutilización de efluentes depurados a la planificación hidrológica como parte de los programas de medidas, con objeto de mitigar presiones, como son las extracciones de agua superficial y subterránea, o mejoras medioambientales evitando un vertido. El objeto de este trabajo es conocer la situación de la reutilización de efluentes depurados en España, los diferentes escenarios y planteamientos de esta actividad, el desarrollo del marco normativo y su aplicabilidad, junto a los tratamientos que permiten alcanzar los límites de calidad establecidos en la normativa vigente, en función de los distintos usos. Además, se aporta un análisis de costes de las distintas unidades de tratamiento y tipologías de líneas de regeneración, tanto de las utilizadas después de un tratamiento secundario como de otras opciones de depuración, como son los biorreactores de membrana (MBRs). Para el desarrollo de estos objetivos, en primer lugar, se aborda el conocimiento de la situación de la reutilización en España a través de una base de datos diseñada para cubrir todos los aspectos de esta actividad: datos de la estación depuradora de aguas residuales (EDAR), de la estación regeneradora (ERA), caudales depurados, reutilizados, volúmenes utilizados y ubicación de los distintos usos, tipos de líneas de tratamiento, calidades del agua reutilizada, etc. Las principales fuentes de información son las Confederaciones Hidrográficas (CCHH) a través de las concesiones de uso del agua depurada, las entidades de saneamiento y depuración de las distintas comunidades autónomas (CCAA), ayuntamientos, Planes Hidrológicos de Cuenca (PHC) y visitas a las zonas más emblemáticas. Además, se revisan planes y programas con el fin de realizar una retrospectiva de cómo se ha ido consolidando y desarrollando esta práctica en las distintas zonas de la geografía española. Se han inventariado 322 sistemas de reutilización y 216 tratamientos de regeneración siendo el más extendido la filtración mediante filtro arena seguido de una desinfección mediante hipoclorito, aunque este tratamiento se ha ido sustituyendo por un físico-químico con decantación lamelar, filtro de arena y radiación ultravioleta, tratamiento de regeneración convencional (TRC), y otros tratamientos que pueden incluir membranas, tratamientos de regeneración avanzados (TRA), con dosificación de hipoclorito como desinfección residual, para adaptarse al actual marco normativo. El uso más extendido es el agrícola con el 70% del caudal total reutilizado, estimado en 408 hm3, aunque la capacidad de los tratamientos de regeneración esperada para 2015, tras el Plan Nacional de Reutilización de Aguas (PNRA), es tres veces superior. Respecto al desarrollo normativo, en las zonas donde la reutilización ha sido pionera, las administraciones competentes han ido desarrollando diferentes recomendaciones de calidad y manejo de este tipo de agua. El uso agrícola, y en zonas turísticas, el riego de campos de golf, fueron los dos primeros usos que tuvieron algún tipo de recomendación incluso reglamentación. Esta situación inicial, sin una normativa a nivel estatal ni recomendaciones europeas, creó cierta incertidumbre en el avance de la reutilización tanto a nivel de concesiones como de planificación. En la actualidad sigue sin existir una normativa internacional para la reutilización y regeneración de efluentes depurados. Las recomendaciones de referencia a nivel mundial, y en concreto para el uso agrícola, son las de la OMS (Organización Mundial de la Salud) publicadas 1989, con sus posteriores revisiones y ampliaciones (OMS, 2006). Esta norma combina tratamientos básicos de depuración y unas buenas prácticas basadas en diferentes niveles de protección para evitar problemas sanitarios. Otra normativa que ha sido referencia en el desarrollo del marco normativo en países donde se realiza esta práctica, son las recomendaciones dadas por la Agencia Medioambiente Estadunidense (USEPA, 2012) o las publicadas por el Estado de California (Título 22, 2001). Estas normas establecen unos indicadores y valores máximos dónde el tratamiento de regeneración es el responsable de la calidad final en función del uso. Durante 2015, la ISO trabajaba en un documento para el uso urbano donde se muestra tanto los posibles parámetros que habría que controlar como la manera de actuar para evitar posibles riesgos. Por otro lado, la Comisión Europea (CE) viene impulsando desde el 2014 la reutilización de aguas depuradas dentro del marco de la Estrategia Común de Implantación de la Directiva Marco del Agua, y fundamentalmente a través del grupo de trabajo de “Programas de medidas”. Para el desarrollo de esta iniciativa se está planteando sacar para 2016 una guía de recomendaciones que podría venir a completar el marco normativo de los distintos Estados Miembros (EM). El Real Decreto 1620/2007, donde se establece el marco jurídico de la reutilización de efluentes depurados, tiende más a la filosofía implantada por la USEPA, aunque la UE parece más partidaria de una gestión del riesgo, donde se establecen unos niveles de tolerancia y unos puntos de control en función de las condiciones socioeconómicas de los distintos Estados, sin entrar a concretar indicadores, valores máximos o tratamientos. Sin embargo, en la normativa estadounidense se indican una serie de tratamientos de regeneración, mientras que, en la española, se hacen recomendaciones a este respecto en una Guía sin validez legal. Por tanto, queda sin regular los procesos para alcanzar estos estándares de calidad, pudiendo ser éstos no apropiados para esta práctica. Es el caso de la desinfección donde el uso de hipoclorito puede generar subproductos indeseables. En la Guía de recomendaciones para la aplicación del RD, publicada por el Ministerio de Agricultura y Medioambiente (MAGRAMA) en 2010, se aclaran cuestiones frecuentes sobre la aplicación del RD, prescripciones técnicas básicas para los sistemas de reutilización, y buenas prácticas en función del uso. Aun así, el RD sigue teniendo deficiencias en su aplicación siendo necesaria una revisión de la misma, como en las frecuencias de muestreo incluso la omisión de algunos parámetros como huevos de nematodos que se ha demostrado ser inexistentes tras un tratamiento de regeneración convencional. En este sentido, existe una tendencia a nivel mundial a reutilizar las aguas con fines de abastecimiento, incluir indicadores de presencia de virus o protozoos, o incluir ciertas tecnologías como las membranas u oxidaciones avanzadas para afrontar temas como los contaminantes emergentes. Otro de los objetivos de este trabajo es el estudio de tipologías de tratamiento en función de los usos establecidos en el RD 1620/2007 y sus costes asociados, siendo base de lo establecido a este respecto en la Guía y PNRA anteriormente indicados. Las tipologías de tratamiento propuestas se dividen en líneas con capacidad de desalar y las que no cuentan con una unidad de desalación de aguas salobres de ósmosis inversa o electrodiálisis reversible. Se realiza esta división al tener actuaciones en zonas costeras donde el agua de mar entra en los colectores, adquiriendo el agua residual un contenido en sales que es limitante en algunos usos. Para desarrollar este objetivo se han estudiado las unidades de tratamiento más implantadas en ERAs españolas en cuanto a fiabilidad para conseguir determinada calidad y coste, tanto de implantación como de explotación. El TRC, tiene un coste de implantación de 28 a 48 €.m-3.d y de explotación de 0,06 a 0,09 €. m-3, mientras que, si se precisara desalar, este coste se multiplica por diez en la implantación y por cinco en la explotación. En caso de los usos que requieren de TRA, como los domiciliarios o algunos industriales, los costes serían de 185 a 398 €.m-3.d en implantación y de 0,14 a 0,20 €.m-3 en explotación. En la selección de tecnologías de regeneración, la capacidad del tratamiento en relación al coste es un indicador fundamental. Este trabajo aporta curvas de tendencia coste-capacidad que sirven de herramienta de selección frente a otros tratamientos de regeneración de reciente implantación como son los MBR, u otros como la desalación de agua de mar o los trasvases entre cuencas dentro de la planificación hidrológica. En España, el aumento de las necesidades de agua de alta calidad en zonas con recursos escasos, aumento de zonas sensibles como puntos de captación para potables, zonas de baño o zonas de producción piscícola, y en ocasiones, el escaso terreno disponible para la implantación de nuevas plantas depuradoras (EDARs), han convertido a los MBRs, en una opción dentro del marco de la reutilización de aguas depuradas. En este trabajo, se estudia esta tecnología frente a los TRC y TRA, aportando igualmente curvas de tendencia coste-capacidad, e identificando cuando esta opción tecnológica puede ser más competitiva frente a los otros tratamientos de regeneración. Un MBR es un tratamiento de depuración de fangos activos donde el decantador secundario es sustituido por un sistema de membranas de UF o MF. La calidad del efluente, por tanto, es la misma que el de una EDAR seguida de un TRA. Los MBRs aseguran una calidad del efluente para todos los usos establecidos en el RD, incluso dan un efluente que permite ser directamente tratado por las unidades de desalación de OI o EDR. La implantación de esta tecnología en España ha tenido un crecimiento exponencial, pasando de 13 instalaciones de menos de 5.000 m3. d-1 en el 2006, a más de 55 instalaciones en operación o construcción a finales del 2014, seis de ellas con capacidades por encima de los 15.000 m3. d-1. Los sistemas de filtración en los MBR son los que marcan la operación y diseño de este tipo de instalaciones. El sistema más implantado en España es de membrana de fibra hueca (MFH), sobre todo para instalaciones de gran capacidad, destacando Zenon que cuenta con el 57% de la capacidad total instalada. La segunda casa comercial con mayor número de plantas es Kubota, con membranas de configuración placa plana (MPP), que cuenta con el 30 % de la capacidad total instalada. Existen otras casas comerciales implantadas en MBR españoles como son Toray, Huber, Koch o Microdym. En este documento se realiza la descripción de los sistemas de filtración de todas estas casas comerciales, aportando información de sus características, parámetros de diseño y operación más relevantes. El estudio de 14 MBRs ha posibilitado realizar otro de los objetivos de este trabajo, la estimación de los costes de explotación e implantación de este tipo de sistemas frente a otras alternativas de tratamiento de regeneración. En este estudio han participado activamente ACA y ESAMUR, entidades públicas de saneamiento y depuración de Cataluña y Murcia respectivamente, que cuentan con una amplia experiencia en la explotación de este tipo de sistemas. Este documento expone los problemas de operación encontrados y sus posibles soluciones, tanto en la explotación como en los futuros diseños de este tipo de plantas. El trabajo concluye que los MBRs son una opción más para la reutilización de efluentes depurados, siendo ventajosos en costes, tanto de implantación como de explotación, respecto a EDARs seguidas de TRA en capacidades por encima de los 10.000 m3.d-1. ABSTRACT The reuse of treated effluent has always been an option in places where a situational or structural water deficit exists, whether regulatory and/or planning efforts are completed or not. The need arises from the demand of a sector, commonly agricultural irrigation, which benefits of this new resource. Within the EU, Spain is ahead in the annual volume of reclaimed water, and is among the top ten countries at a global scale. The regulation of this practice through the Royal Decree 1620/2007 has helped to incorporate the water reuse to the hydrological plans as a part of the programme of measures to mitigate pressures such as surface or ground water extraction, or environmental improvements preventing discharges. The object of this study is to gain an overview of the state of the water reuse in Spain, the different scenarios and approaches to this activity, the development of the legal framework and its enforceability, together with the treatments that achieve the quality levels according to the current law, broken down by applications. Additionally, a cost analysis of technologies and regeneration treatment lines for water reclamation is performed, whereas the regeneration treatment is located after a wastewater treatment or other options such as membrane bioreactors (MBR). To develop the abovementioned objectives, the state of water reuse in Spain is studied by means of a database designed to encompass all aspects of the activity: data from the wastewater treatment plants (WWTP), from the water reclamation plants (WRP), the use of reclaimed water, treated water and reclaimed water annual volumes and qualities, facilities and applications, geographic references, technologies, regeneration treatment lines, etc. The main data providers are the River Basin authorities, through the concession or authorization for water reuse, (sanitary and wastewater treatment managers from the territorial governments, local governments, Hydrological Plans of the River Basins and field visits to the main water reuse systems. Additionally, a review of different plans and programmes on wastewater treatment or water reuse is done, aiming to put the development and consolidation process of this activity in the different regions of Spain in perspective. An inventory of 322 reuse systems and 216 regeneration treatments has been gathered on the database, where the most extended regeneration treatment line was sand filtration followed by hypochlorite disinfection, even though recently it is being replaced by physical–chemical treatment with a lamella settling system, depth sand filtration, and a disinfection with ultraviolet radiation and hypochlorite as residual disinfectant, named conventional regeneration treatment (CRT), and another treatment that may include a membrane process, named advanced regeneration treatment (ART), to adapt to legal requirements. Agricultural use is the most extended, accumulating 70% of the reclaimed demand, estimated at 408 hm3, even though the expected total capacity of WRPs for 2015, after the implementation of the National Water Reuse Plan (NWRP) is three times higher. According to the development of the water reuse legal framework, there were pioneer areas where competent authorities developed different quality and use recommendations for this new resource. Agricultural use and golf course irrigation in touristic areas were the first two uses with recommendations and even legislation. The initial lack of common legislation for water reuse at a national or European level created some doubts which affected the implementation of water reuse, both from a planning and a licensing point of view. Currently there is still a lack of common international legislation regarding water reuse, technologies and applications. Regarding agricultural use, the model recommendations at a global scale are those set by the World Health Organization published in 1989, and subsequent reviews and extensions about risk prevention (WHO, 2006). These documents combine wastewater treatments with basic regeneration treatments reinforced by good practices based on different levels of protection to avoid deleterious health effects. Another relevant legal reference for this practices has been the Environmental Protection Agency of the US (USEPA, 2012), or those published by the State of California (Title 22, 2001). These establish indicator targets and maximum thresholds where regeneration treatment lines are responsible for the final quality according to the different uses. During 2015, the ISO has worked on a document aimed at urban use, where the possible parameters to be monitored together with risk prevention have been studied. On the other hand, the European Commission has been promoting the reuse of treated effluents within the Common Implementation Strategy of the Water Framework Directive, mainly through the work of the Programme of Measures Working Group. Within this context, the publication of a recommendation guide during 2016 is intended, as a useful tool to fill in the legal gaps of different Member States on the matter. The Royal Decree 1620/2007, where the water reuse regulation is set, resembles the principles of the USEPA more closely, even though the EU shows a tendency to prioritize risk assessment by establishing tolerance levels and thresholds according to socioeconomic conditions of the different countries, without going into details of indicators, maximum thresholds or treatments. In contrast, in the US law, regeneration treatments are indicated, while in the Spanish legislation, the only recommendations to this respect are compiled in a non-compulsory guide. Therefore, there is no regulation on the different treatment lines used to achieve the required quality standards, giving room for inappropriate practices in this respect. This is the case of disinfection, where the use of hypochlorite may produce harmful byproducts. In the recommendation Guide for the application of the Royal Decree (RD), published by the Ministry of Agriculture and Environment (MAGRAMA) in 2010, clarifications of typical issues that may arise from the application of the RD are given, as well as basic technical parameters to consider in reuse setups, or good practices according to final use. Even so, the RD still presents difficulties in its application and requires a review on issues such as the sampling frequency of current quality parameters or even the omission of nematode eggs indicator, which have been shown to be absent after CRT. In this regard, there is a global tendency to employ water reuse for drinking water, including indicators for the presence of viruses and protozoans, or to include certain technologies such as membranes or advanced oxidation processes to tackle problems like emerging pollutants. Another of the objectives of this study is to provide different regeneration treatment lines to meet the quality requirements established in the RD 1620/2007 broken down by applications, and to estimate establishment and operational costs. This proposal has been based on what is established in the above mentioned Guide and NWRP. The proposed treatment typologies are divided in treatment trains with desalination, like reverse osmosis or reversible electrodialisis, and those that lack this treatment for brackish water. This separation is done due to coastal facilities, where sea water may permeate the collecting pipes, rising salt contents in the wastewater, hence limiting certain uses. To develop this objective a study of the most common treatment units set up in Spanish WRPs is conducted in terms of treatment train reliability to obtain an acceptable relationship between the required quality and the capital and operational costs. The CRT has an establishment cost of 28 to 48 €.m-3.d and an operation cost of 0.06 to 0.09 €.m-3, while, if desalination was required, these costs would increase tenfold for implementation and fivefold for operation. In the cases of uses that require ART, such as residential or certain industrial uses, the costs would be of 185 to 398 €.m-3.d for implementation and of 0.14 to 0.20 €.m-3 for operation. When selecting regeneration treatment lines, the relation between treatment capacity and cost is a paramount indicator. This project provides cost-capacity models for regeneration treatment trains. These may serve as a tool when selecting between different options to fulfill water demands with MBR facilities, or others such as sea water desalination plants or inter-basin water transfer into a water planning framework. In Spain, the requirement for high quality water in areas with low resource availability, the increasing number of sensitive zones, such as drinking water extraction, recreational bathing areas, fish protected areas and the lack of available land to set up new WWTPs, have turned MBRs into a suitable option for water reuse. In this work this technology is analyzed in contrast to CRT and ART, providing cost-capacity models, and identifying when and where this treatment option may outcompete other regeneration treatments. An MBR is an activated sludge treatment where the secondary settling is substituted by a membrane system of UF or MF. The quality of the effluent is, therefore, comparable to that of a WWTP followed by an ART. MBRs ensure a sufficient quality level for the requirements of the different uses established in the RD, even producing an effluent that can be directly treated in OI or EDR processes. The implementation of this technology in Spain has grown exponentially, growing from 13 facilities with less than 5000 m3.d-1 in 2006 to above 55 facilities operating by the end of 2014, 6 of them with capacities over 15000 m3.d-1. The membrane filtration systems for MBR are the ones that set the pace of operation and design of this type of facilities. The most widespread system in Spain is the hollow fiber membrane configuration, especially on high flow capacities, being Zenon commercial technology, which mounts up to 57% of the total installed capacity, the main contributor. The next commercial technology according to plant number is Kubota, which uses flat sheet membrane configuration, which mounts up to 30% of the total installed capacity. Other commercial technologies exist within the Spanish MBR context, such as Toray, Huber, Koch or Microdym. In this document an analysis of all of these membrane filtration systems is done, providing information about their characteristics and relevant design and operation parameters. The study of 14 full scale running MBRs has enabled to pursue another of the objectives of this work: the estimation of the implementation and operation costs of this type of systems in contrast to other regeneration alternatives. Active participation of ACA and ESAMUR, public wastewater treatment and reuse entities of Cataluña and Murcia respectively, has helped attaining this objective. A number of typical operative problems and their possible solutions are discussed, both for operation and plant design purposes. The conclusion of this study is that MBRs are another option to consider for water reuse, being advantageous in terms of both implementation and operational costs, when compared with WWTPs followed by ART, when considering flow capacities above 10000 m3.d-1.

Assistência de fisioterapia na UTI está relacionada a redução de custos de internação?

Introdução: A unidade de terapia intensiva (UTI) é conhecida por ser um setor de alta complexidade dos pacientes e por seu alto custo ao sistema hospitalar. A gravidade da doença, o tempo de internação na UTI e a necessidade de ventilação mecânica invasiva (VMI) são fatores conhecidos como influenciadores no custo destas unidades, sendo que aproximadamente 30% dos pacientes internados em UTI necessitam de VMI. Os objetivos deste estudo foram avaliar os custos de internação em UTI comparando unidades com assistência de fisioterapia 24 horas e unidades com assistência de fisioterapia 12 horas e analisar o impacto da fisioterapia nos referidos custos. Método: Este é um estudo observacional, prospectivo, realizado em um hospital geral, público e de grande porte, localizado na cidade de São Paulo. Foram incluídos pacientes clínicos e cirúrgicos com 18 anos de idade ou mais, que estiveram em VMI por um período >= 24 horas e que receberam alta da UTI para a enfermaria. A coleta de dados incluiu diagnóstico de internação hospitalar, diagnóstico de admissão na UTI, gravidade do paciente no momento da admissão na UTI através do Acute Physiology and Chronic Health Disease Classification (APACHE II), tempo de VMI e tempo de internação na UTI; para a análise de custos utilizamos a ferramenta Omega French Score. Um modelo de regressão linear múltipla foi construído para verificar a associação entre o custo de internação em UTI com o turno diário de assistência fisioterapêutica. Resultados: Foram incluídos na amostra 815 pacientes, distribuídos em dois grupos conforme o turno de fisioterapia existente na UTI: 332 pacientes em UTI\'s com 24 horas de assistência fisioterapêutica (PT-24) e 483 pacientes em UTI\'s com 12 horas de assistência fisioterapêutica (PT-12). Os grupos não apresentaram diferença quanto ao APACHE II (p=0,65); comparado ao grupo PT-12 o grupo PT-24 era mais velho (p < 0,001), apresentou menor tempo de VMI (p < 0,001) e de internação na UTI (p=0,013). Quanto a análise de custos o grupo PT-24 apresentou custos menores indicados pela menor pontuação no Omega 3 (p=0,005) e Omega Total (p=0,010), menor custo direto, custo com equipe médica e enfermagem (p=0,010). A análise de regressão linear múltipla indicou associação do custo da internação em UTI com as variáveis APACHE II (p < 0,001), tempo de internação da UTI (p < 0,001) e assistência fisioterapêutica em turnos de 24 horas (p=0,05). Conclusão: O grupo com assistência de fisioterapia em turnos de 24 horas apresentou custos menores sendo que a severidade da doença, o tempo de internação na UTI e a assistência de fisioterapia foram variáveis preditoras para redução de custo de internação na UTI