Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents

Objective: To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to 'current practice'. Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria ('equity'; 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6-17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios. Results: Compared to current practice, CBT by public psychologists is the most cost-effective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders. Conclusions: Cognitive behavioural therapy provided by a public psychologist is the most effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require 'start-up' costs and attention to ensuring an adequate workforce.

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

Objective: To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice. Method: Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental cost-effectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted. Results: The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient. Conclusions: MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

Objective: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filters ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs). Results: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater. Conclusions: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

Self-Esteem, Confidence, and Relationships in Brazilian Men with Erectile Dysfunction Receiving Sildenafil Citrate: A Randomized, Parallel-Group, Double-Blind, Placebo-Controlled Study in Brazil

Psychosocial manifestations of erectile dysfunction (ED) differ across cultures. Understanding the treatment response to ED medications within cultural groups can aid in resource allocation and in developing treatment strategies. Evaluate the effect of sildenafil treatment on self-esteem, confidence, and sexual relationship satisfaction in Brazilian men with ED. The Self-Esteem and Relationship (SEAR) questionnaire, a validated, 14-question instrument developed to specifically address self-esteem and relationship issues within the context of ED. Men aged 18 years or older with a clinical diagnosis of ED (<= 21 on the Sexual Health Inventory for Men) and in a stable relationship with a partner during the study were eligible. The primary end point was a change from baseline in the self-esteem subscale of the SEAR questionnaire. Thirteen Brazilian sites participated in a randomized, double-blind, placebo-controlled trial of sildenafil treatment for ED. Patients were randomized to receive either 50 mg of sildenafil (adjustable to 25 mg or 100 mg based on patient response) or matching placebo approximately 1 hour before anticipated sexual activity but not more than once a day. At the end of double-blind treatment, 63 and 66 patients in the placebo and sildenafil groups, respectively, from 13 Brazilian sites were assessed for efficacy. Brazilian patients receiving sildenafil had significantly greater improvements in their scores on the SEAR self-esteem subscale (42.9 [95% confidence interval 35.7-50.0]) compared with placebo (21.1 [95% confidence interval 13.7-28.6]; P < 0.0001). Effect sizes ranged from 0.91 to 1.25 for individual SEAR components. The psychosocial parameters in Brazilian men with ED assessed by the SEAR questionnaire showed significant improvements in self-esteem, confidence, and relationships after treatment with sildenafil. Glina S, Damiao R, Abdo C, Afif-Abdo J, Tseng L-J, and Stecher V. Self-esteem, confidence, and relationships in Brazilian men with erectile dysfunction receiving sildenafil citrate: A randomized, parallel-group, double-blind, placebo-controlled study in Brazil. J Sex Med 2009;6:268-275.

Predicting plant leaf area production: shoot assimilate accumulation and partitioning, and leaf area ratio, are stable for a wide range of sorghum population densities

Predicting plant leaf area production is required for modelling carbon balance and tiller dynamics in plant canopies. Plant leaf area production can be studied using a framework based on radiation intercepted, radiation use efficiency (RUE) and leaf area ratio (LAR) (ratio of leaf area to net above-ground biomass). The objective of this study was to test this framework for predicting leaf area production of sorghum during vegetative development by examining the stability of the contributing components over a large range of plant density. Four densities, varying from 2 to 16 plants m(-2), were implemented in a field experiment. Plants were either allowed to tiller or were maintained as uniculm by systematic tiller removal. In all cases, intercepted radiation was recorded daily and leaf area and shoot dry matter partitioning were quantified weekly at individual culm level. Up to anthesis, a unique relationship applied between fraction of intercepted radiation and leaf area index, and between shoot dry weight accumulation and amount of intercepted radiation, regardless of plant density. Partitioning of shoot assimilate between leaf, stem and head was also common across treatments up to anthesis, at both plant and culm levels. The relationship with thermal time (TT) from emergence of specific leaf area (SLA) and LAR of tillering plants did not change with plant density. In contrast, SLA of uniculm plants was appreciably lower under low-density conditions at any given TT from emergence. This was interpreted as a consequence of assimilate surplus arising from the inability of the plant to compensate by increasing the leaf area a culm could produce. It is argued that the stability of the extinction coefficient, RUE and plant LAR of tillering plants observed in these conditions provides a reliable way to predict leaf area production regardless of plant density. Crown Copyright (C) 2002 Published by Elsevier Science B.V. All rights reserved.

Agronomic performance of 27 cocoa progenies and plant selection based on productivity, self-compatibility and disease resistance

The objective of the present work was to evaluate 27 progenies of cocoa crosses considering the agronomic traits and select F1 plants within superior crosses. The experiment was installed in March 2005, in the Experimental Station Joaquim Bahiana (ESJOB), in Itajuipe, Bahia. The area of the experiment is of approximately 3 ha, with a total of 3240 plants. Thirteen evaluations of vegetative brooms, five of cushion brooms and 15 of number of pods per plant were accomplished. Thirty pollinations were made for each selected plant to test for self-compatibility. The production, based on the number of pods per plant, and resistance to witches´ broom indicated CEPEC 94 x CCN 10, RB 39 x CCN 51 and CCN 10 x VB 1151 as superior progenies. All selections tested were self-compatible. The analyses of progenies and individual tree data, associated to visual field observations, allowed the selection of 17 plants which were included in a network of regional tests to determine the phenotypic stability.

Cost of schizophrenia: direct costs and use of resources in the State of São Paulo

OBJECTIVE: To estimate the direct costs of schizophrenia for the public sector. METHODS: A study was carried out in the state of São Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. RESULTS: Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US$191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. CONCLUSIONS: Most schizophrenia patients in the state of São Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.

Water quality issues in rivers, lakes and reservoirs in Asian countries: an approach to the problems and the methodologies

Water covers over 70% of the Earth's surface, and is vital for all known forms of life. But only 3% of the Earth's water is fresh water, and less than 0.3% of all freshwater is in rivers, lakes, reservoirs and the atmosphere. However, rivers and lakes are an important part of fresh surface water, amounting to about 89%. In this Master Thesis dissertation, the focus is on three types of water bodies – rivers, lakes and reservoirs, and their water quality issues in Asian countries. The surface water quality in a region is largely determined both by the natural processes such as climate or geographic conditions, and the anthropogenic influences such as industrial and agricultural activities or land use conversion. The quality of the water can be affected by pollutants discharge from a specific point through a sewer pipe and also by extensive drainage from agriculture/urban areas and within basin. Hence, water pollutant sources can be divided into two categories: Point source pollution and Non-point source (NPS) pollution. Seasonal variations in precipitation and surface run-off have a strong effect on river discharge and the concentration of pollutants in water bodies. For example, in the rainy season, heavy and persistent rain wash off the ground, the runoff flow increases and may contain various kinds of pollutants and, eventually, enters the water bodies. In some cases, especially in confined water bodies, the quality may be positive related with rainfall in the wet season, because this confined type of fresh water systems allows high dilution of pollutants, decreasing their possible impacts. During the dry season, the quality of water is largely related to industrialization and urbanization pollution. The aim of this study is to identify the most common water quality problems in Asian countries and to enumerate and analyze the methodologies used for assessment of water quality conditions of both rivers and confined water bodies (lakes and reservoirs). Based on the evaluation of a sample of 57 papers, dated between 2000 and 2012, it was found that over the past decade, the water quality of rivers, lakes, and reservoirs in developing countries is being degraded. Water pollution and destruction of aquatic ecosystems have caused massive damage to the functions and integrity of water resources. The most widespread NPS in Asian countries and those which have the greatest spatial impacts are urban runoff and agriculture. Locally, mine waste runoff and rice paddy are serious NPS problems. The most relevant point pollution sources are the effluents from factories, sewage treatment plant, and public or household facilities. It was found that the most used methodology was unquestionably the monitoring activity, used in 49 of analyzed studies, accounting for 86%. Sometimes, data from historical databases were used as well. It can be seen that taking samples from the water body and then carry on laboratory work (chemical analyses) is important because it can give an understanding of the water quality. 6 papers (11%) used a method that combined monitoring data and modeling. 6 papers (11%) just applied a model to estimate the quality of water. Modeling is a useful resource when there is limited budget since some models are of free download and use. In particular, several of used models come from the U.S.A, but they have their own purposes and features, meaning that a careful application of the models to other countries and a critical discussion of the results are crucial. 5 papers (9%) focus on a method combining monitoring data and statistical analysis. When there is a huge data matrix, the researchers need an efficient way of interpretation of the information which is provided by statistics. 3 papers (5%) used a method combining monitoring data, statistical analysis and modeling. These different methods are all valuable to evaluate the water quality. It was also found that the evaluation of water quality was made as well by using other types of sampling different than water itself, and they also provide useful information to understand the condition of the water body. These additional monitoring activities are: Air sampling, sediment sampling, phytoplankton sampling and aquatic animal tissues sampling. Despite considerable progress in developing and applying control regulations to point and NPS pollution, the pollution status of rivers, lakes, and reservoirs in Asian countries is not improving. In fact, this reflects the slow pace of investment in new infrastructure for pollution control and growing population pressures. Water laws or regulations and public involvement in enforcement can play a constructive and indispensable role in environmental protection. In the near future, in order to protect water from further contamination, rapid action is highly needed to control the various kinds of effluents in one region. Environmental remediation and treatment of industrial effluent and municipal wastewaters is essential. It is also important to prevent the direct input of agricultural and mine site runoff. Finally, stricter environmental regulation for water quality is required to support protection and management strategies. It would have been possible to get further information based in the 57 sample of papers. For instance, it would have been interesting to compare the level of concentrations of some pollutants in the diferente Asian countries. However the limit of three months duration for this study prevented further work to take place. In spite of this, the study objectives were achieved: the work provided an overview of the most relevant water quality problems in rivers, lakes and reservoirs in Asian countries, and also listed and analyzed the most common methodologies.

Real-time tracking and reporting of dynamic events in hierarchical wireless sensor networks

Wireless Sensor Networks (WSNs) are highly distributed systems in which resource allocation (bandwidth, memory) must be performed efficiently to provide a minimum acceptable Quality of Service (QoS) to the regions where critical events occur. In fact, if resources are statically assigned independently from the location and instant of the events, these resources will definitely be misused. In other words, it is more efficient to dynamically grant more resources to sensor nodes affected by critical events, thus providing better network resource management and reducing endto- end delays of event notification and tracking. In this paper, we discuss the use of a WSN management architecture based on the active network management paradigm to provide the real-time tracking and reporting of dynamic events while ensuring efficient resource utilization. The active network management paradigm allows packets to transport not only data, but also program scripts that will be executed in the nodes to dynamically modify the operation of the network. This presumes the use of a runtime execution environment (middleware) in each node to interpret the script. We consider hierarchical (e.g. cluster-tree, two-tiered architecture) WSN topologies since they have been used to improve the timing performance of WSNs as they support deterministic medium access control protocols.

Reliability and availability in reconfigurable computing: a basis for a common solution

Dynamically reconfigurable SRAM-based field-programmable gate arrays (FPGAs) enable the implementation of reconfigurable computing systems where several applications may be run simultaneously, sharing the available resources according to their own immediate functional requirements. To exclude malfunctioning due to faulty elements, the reliability of all FPGA resources must be guaranteed. Since resource allocation takes place asynchronously, an online structural test scheme is the only way of ensuring reliable system operation. On the other hand, this test scheme should not disturb the operation of the circuit, otherwise availability would be compromised. System performance is also influenced by the efficiency of the management strategies that must be able to dynamically allocate enough resources when requested by each application. As those resources are allocated and later released, many small free resource blocks are created, which are left unused due to performance and routing restrictions. To avoid wasting logic resources, the FPGA logic space must be defragmented regularly. This paper presents a non-intrusive active replication procedure that supports the proposed test methodology and the implementation of defragmentation strategies, assuring both the availability of resources and their perfect working condition, without disturbing system operation.

Radiation dose rates and exposure associated to Technologically Enhanced Naturally Occurring Radioactive Materials (TENORM) at locations of a Portuguese coal-fired power plant

Coal contains trace quantities of natural radionuclides such as Th-232, U-235, U-238, as well as their radioactive decay products and 40K. These radionuclides can be released as fly ash in atmospheric emissions from coal-fired power plants, dispersed into the environment and deposited on the surrounding top soils. Therefore, the natural radiation background level is enhanced and consequently increase the total dose for the nearby population. A radiation monitoring programme was used to assess the external dose contribution to the natural radiation background, potentially resulting from the dispersion of coal ash in past atmospheric emissions. Radiation measurements were carried out by gamma spectrometry in the vicinity of a Portuguese coal-fired power plant. The radiation monitoring was achieved both on and off site, being the boundary delimited by a 20 km circle centered in the stacks of the coal plant. The measured radionuclides concentrations for the uranium and thorium series ranged from 7.7 to 41.3 Bq/kg for Ra-226 and from 4.7 to 71.6 Bq/kg for Th-232, while K-40 concentrations ranged from 62.3 to 795.1 Bq/kg. The highest values were registered near the power plant and at distances between 6 and 20 km from the stacks, mainly in the prevailing wind direction. The absorbed dose rates were calculated for each sampling location: 13.97-84.00 ηGy/h, while measurements from previous studies carried out in 1993 registered values in the range of 16.6-77.6 ηGy/h. The highest values were registered at locations in the prevailing wind direction (NW-SE). This study has been primarily done to assess the radiation dose rates and exposure to the nearby population in the surroundings of a coal-fired power plant. The results suggest an enhancement or at least an influence in the background radiation due to the coal plant past activities.

Radioactivity levels of 238U and 232Th decay series and related dose rates in the surroundings of a coal power plant using high resolution g-spectrometry

Gamma radiations measurements were carried out in the vicinity of a coal-fired power plant located in the southwest coastline of Portugal. Two different gamma detectors were used to assess the environmental radiation within a circular area of 20 km centred in the coal plant: a scintillometer (SPP2 NF, Saphymo) and a high purity germanium detector (HPGe, Canberra). Fifty urban and suburban measurements locations were established within the defined area and two measurements campaigns were carried out. The results of the total gamma radiation ranged from 20.83 to 98.33 counts per second (c.p.s.) for both measurement campaigns and outdoor doses rates ranged from 77.65 to 366.51 Gy/h. Natural emitting nuclides from the U-238 and Th-232 decay series were identified as well as the natural emitting nuclide K-40. The radionuclide concentration from the uranium and thorium series determined by gamma spectrometry ranged from 0.93 to 73.68 Bq/kg, while for K-40 the concentration ranged from 84.14 to 904.38 Bq/kg. The obtained results were used primarily to define the variability in measured environmental radiation and to determine the coal plant’s influence in the measured radiation levels. The highest values were measured at two locations near the power plant and at locations between the distance of 6 and 20 km away from the stacks, mainly in the prevailing wind direction. The results showed an increase or at least an influence from the coal-fired plant operations, both qualitatively and quantitatively.

Avaliação e Otimização do Consumo de Água no Processo e do Sistema de Tratamento de Efluentes

O elevado consumo de água associado à escassez deste recurso contribuiu para que alternativas de reutilização/reciclagem de água fossem estudadas que permitam diminuir o seu consumo e minimizar a dependência das indústrias. Monitorizar e avaliar os consumos de água, a nível industrial, é imprescindível para assegurar uma gestão sustentável dos recursos hídricos, sendo este o objetivo da presente dissertação. As alternativas encontradas na unidade industrial em estudo foram a substituição do equipamento sanitário e o aproveitamento do efluente tratado para operações de lavagem e/ou arrefecimento por contacto direto. A maioria do equipamento sanitário não é eficiente, tendo-se proposto a substituição desse sistema por um de menor consumo que permitirá uma poupança de 30 % no consumo de água, que corresponderá a 12 149,37 €/ano, sendo o retorno do investimento estimado em 3 meses. O efluente industrial na entrada da ETAR e nas diferentes etapas - tratamento primário de coagulação/floculação; tratamento secundário ou biológico em SBR; tratamento terciário de coagulação/floculação - foi caracterizado através da medição da temperatura, pH, oxigénio dissolvido e pela determinação da cor, turvação, sólidos suspensos totais (SST), azoto total, carência química de oxigénio (CQO), Carência Bioquímica de Oxigénio ao fim de 5 dias (CBO5) e razão CBO5/CQO. Esta caracterização permitiu avaliar o efluente industrial bruto que se caracteriza por um pH alcalino (8,3 ± 1,7); condutividade baixa (451 ± 200,2 μS/cm); elevada turvação (11 255 ± 8812,8 FTU); cor aparente (63 670 ± 42293,4 PtCo) e cor verdadeira (33 621 ± 19547,9 PtCo) elevadas; teores elevados de CQO (24 753 ± 11806,7 mg/L O2) SST (5 164 ± 3845,5 mg/L) e azoto total (718 mg/L) e um índice de biodegradabilidade baixo (razão CBO5/CQO de 1,4). Este estudo permitiu verificar que a eficiência global do tratamento do efluente foi 82 % na remoção da turvação, 83 % na remoção da cor aparente, 96 % na remoção da cor verdadeira, 85 % na remoção da CQO e 30 % na remoção dos SST. Quanto às eficiências de remoção associadas ao tratamento primário no que diz respeito à turvação, cor aparente, CQO e SST, apresentam valores inferiores aos referidos na literatura para o mesmo tipo de tratamento em efluentes similares. As eficiências de remoção obtidas no tratamento secundário são inferiores às do tratamento primário: turvação, cor aparente, CQO e SST, pelo que procurou-se otimizar a primeira etapa do processo de tratamento Neste estudo de otimização estudou-se a influência de cinco coagulantes – Sulfato de Alumínio, PAX XL – 10, PAX 18, cloreto de ferro e a conjugação de PAX 18 com sulfato de ferro - e seis floculantes – Superfloc A 150, Superfloc A 130, PA 1020, Ambifloc 560, Ambifloc C58 e Rifloc 54 - no tratamento físico-químico do efluente. O PAX 18 e o Ambifloc 560 UUJ foram os que apresentaram as mais elevadas eficiências de remoção (99,85 % na cor, 99,87 % na turvação, 90,12 % na CQO e 99,87 % nos SST). O custo associado a este tratamento é de 1,03 €/m3. Pela comparação com os critérios de qualidade no guia técnico ERSAR, apenas o parâmetro da CQO excede o valor, contudo o valor obtido permite diminuir os custos associados a um tratamento posterior para remoção da CQO remanescente no efluente residual tratado.

Factors that determine the level of care children and adolescents experiencing mental disorders receive

RESUMO: Resumo Uma prestação de serviços de saúde mental para crianças e adolescentes (CAMHS) oportuna, eficaz e baseada na evidência pode evitar incapacidade a longo prazo. No entanto, estes serviços são criticamente sub-financiados em todo o mundo. É um imperativo garantir que este precioso recurso não seja desperdiçado. Os governos e outras partes interessadas relevantes na área da saúde mental precisam de conhecer o estado de saúde mental da população, quais os recursos disponíveis e como melhor utilizar os recursos disponíveis para orientar uma política e decisões efectivas sobre os níveis de serviços. Objetivo: O objetivo deste artigo é explorar o papel da acuidade, gravidade e complexidade na determinação dos cuidados em saúde mental especializados recebidos por crianças e adolescentes que sofrem perturbações mentais. Métodos: Este estudo é exploratório envolvendo uma revisão sistemática da literatura. Foi realizada uma pesquisa com palavras-chave utilizando bases de dados PsychINFO, EMBASE, PubMed e MEDLINE. A literatura cinzenta também foi investigada com um enfoque nas abordagens sistémicas, organizacionais e políticas para a organização e comissionamento de CAMHS. Foram selecionados apenas documentos escritos em Inglês. Três países, Bélgica, Reino Unido e Estados Unidos, todos eles com modelos muito diferentes de organização de CAMHS, foram revistos para investigar de que forma os conceitos de acuidade, gravidade e complexidade foram utilizados na sua concepção de serviços para determinar o nível da assistência prestada. Resultados: Nem a Bélgica, nem o modelo norte-americano de CAMHS organização de serviço parecem estar alinhados com os principais conceitos na determinação do nível de prestação de serviços. O sistema de serviços do Reino Unido de CAMHS está mais estreitamente alinhado com esses conceitos e tem uma alocação de recursos mais equilibrada entre o hospital e a comunidade. O seu ponto fraco está na falta de flexibilidade entre os níveis de serviço e na falta de apoio para com o sector dos cuidados de saúde primários. Conclusões: A variabilidade na alocação de recursos a diferentes níveis especializados de CAMHS (em regime de internamento, ambulatório, e na comunidade) e o modelo diferente de estrutura de serviços entre os países estudados indica uma inconsistência na forma como as crianças e adolescentes que apresentam aos CAMHS são referenciados para os cuidados que recebem. Isto põe em questão se as crianças e adolescentes com perturbações mentais estão a receber o nível e tipo de cuidados concordantes com as suas necessidades. A concepção e o comissionamento de sistemas de CAMHS levam-nos à discussão de uma série de princípios fundamentais que devem ser considerados. O sistema perfeito no entanto, ainda está para ser encontrado. -------------------------------- ABSTRACT: Provision of timely, effective, evidence based mental health services to children and adolescents can prevent long term impairment, but they are critically underfunded across the globe. There is an imperative to ensure this precious resource is not wasted. Governments and other relevant mental health stakeholders need to know the mental health status of the population, what resources are available and how best to use the resources available to guide effective policy and decisions about service levels. Aim: The aim of this paper is to explore the role of acuity, severity and complexity in determining the specialist mental health care that children and adolescents experiencing mental disorders receive. Methods: This study is exploratory involving a systematic scan of the literature. A key word search was conducted using databases PSYCHINFO, EMBASE, PUBMED and MEDLINE. Grey literature was also searched to focus on systemic, organisational and policy approaches to the organisation and commissioning of CAMHS. Only documents written in English were selected. Three countries Belgium, UK and the US all with very different models of service organisation for CAMHS were reviewed to investigate how well the concepts of acuity, severity and complexity were used to determine the level of care delivered in their service design. Findings: Neither the Belgium nor the US model of CAMHS service organisation appear to align with the key concepts driving intensity of level of service provision. The UK CAMHS service system most closely aligns with the concepts. It has a more balanced resource allocation between hospital and community. Its downfall is in its lack of flexibility between service levels and its lack of support for the primary care sector. Conclusions: The variability in resource allocation to different service levels (inpatient, outpatient, community) within specialist CAMHS and the differing model of service structure across countries indicates an inconsistency in how children and adolescents presenting to CAMHS are allocated to the care they receive. This puts into question whether children and adolescent with mental disorders are receiving a level and type of care commensurate with their needs. In commissioning and designing CAMHS systems a number of key principles that should be considered are discussed. The perfect system however, is yet to be found.

Comparison of single and multi-objective evolutionary algorithms for robust link-state routing

Traffic Engineering (TE) approaches are increasingly impor- tant in network management to allow an optimized configuration and resource allocation. In link-state routing, the task of setting appropriate weights to the links is both an important and a challenging optimization task. A number of different approaches has been put forward towards this aim, including the successful use of Evolutionary Algorithms (EAs). In this context, this work addresses the evaluation of three distinct EAs, a single and two multi-objective EAs, in two tasks related to weight setting optimization towards optimal intra-domain routing, knowing the network topology and aggregated traffic demands and seeking to mini- mize network congestion. In both tasks, the optimization considers sce- narios where there is a dynamic alteration in the state of the system, in the first considering changes in the traffic demand matrices and in the latter considering the possibility of link failures. The methods will, thus, need to simultaneously optimize for both conditions, the normal and the altered one, following a preventive TE approach towards robust configurations. Since this can be formulated as a bi-objective function, the use of multi-objective EAs, such as SPEA2 and NSGA-II, came nat- urally, being those compared to a single-objective EA. The results show a remarkable behavior of NSGA-II in all proposed tasks scaling well for harder instances, and thus presenting itself as the most promising option for TE in these scenarios.