Patterns of care in recurrent glioblastoma in Switzerland: a multicentre national approach based on diagnostic nodes

Despite moderate improvements in outcome of glioblastoma after first-line treatment with chemoradiation recent clinical trials failed to improve the prognosis of recurrent glioblastoma. In the absence of a standard of care we aimed to investigate institutional treatment strategies to identify similarities and differences in the pattern of care for recurrent glioblastoma. We investigated re-treatment criteria and therapeutic pathways for recurrent glioblastoma of eight neuro-oncology centres in Switzerland having an established multidisciplinary tumour-board conference. Decision algorithms, differences and consensus were analysed using the objective consensus methodology. A total of 16 different treatment recommendations were identified based on combinations of eight different decision criteria. The set of criteria implemented as well as the set of treatments offered was different in each centre. For specific situations, up to 6 different treatment recommendations were provided by the eight centres. The only wide-range consensus identified was to offer best supportive care to unfit patients. A majority recommendation was identified for non-operable large early recurrence with unmethylated MGMT promoter status in the fit patients: here bevacizumab was offered. In fit patients with late recurrent non-operable MGMT promoter methylated glioblastoma temozolomide was recommended by most. No other majority recommendations were present. In the absence of strong evidence we identified few consensus recommendations in the treatment of recurrent glioblastoma. This contrasts the limited availability of single drugs and treatment modalities. Clinical situations of greatest heterogeneity may be suitable to be addressed in clinical trials and second opinion referrals are likely to yield diverging recommendations.

A New Multidisciplinary Home Care Telemedicine System to Monitor Stable Chronic Human Immunodeficiency Virus-Infected Patients: A Randomized Study

BACKGROUND: Antiretroviral therapy has changed the natural history of human immunodeficiency virus (HIV) infection in developed countries, where it has become a chronic disease. This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals. METHODOLOGY: We developed a new internet-based home care model covering the entire management of chronic HIV-infected patients. This was called Virtual Hospital. We report the results of a prospective randomised study performed over two years, comparing standard care received by HIV-infected patients with Virtual Hospital care. HIV-infected patients with access to a computer and broadband were randomised to be monitored either through Virtual Hospital (Arm I) or through standard care at the day hospital (Arm II). After one year of follow up, patients switched their care to the other arm. Virtual Hospital offered four main services: Virtual Consultations, Telepharmacy, Virtual Library and Virtual Community. A technical and clinical evaluation of Virtual Hospital was carried out. FINDINGS: Of the 83 randomised patients, 42 were monitored during the first year through Virtual Hospital (Arm I) and 41 through standard care (Arm II). Baseline characteristics of patients were similar in the two arms. The level of technical satisfaction with the virtual system was high: 85% of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system. Neither clinical parameters [level of CD4+ T lymphocytes, proportion of patients with an undetectable level of viral load (p = 0.21) and compliance levels >90% (p = 0.58)] nor the evaluation of quality of life or psychological questionnaires changed significantly between the two types of care. CONCLUSIONS: Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients. Telemedicine should be considered as an appropriate support service for the management of chronic HIV infection. TRIAL REGISTRATION: Clinical-Trials.gov: NCT01117675.

Assessing agriculture-water relationships: a Pan-European multidimensional modelling approach.

This paper aims at developing a simulation framework to jointly assess agricultural and water issues. While the strong linkages between water, food, and the environment call for an integrated and multidisciplinary modelling approach, a complete and consistent modelling system to evaluate food-water relationships in Europe was missing so far. The spatial economic simulation model for agriculture CAPRI, which comprises a set of environmental indicators to assess food-environment interrelations within European regions, has been extended to account for food-water links. This modelling framework enables simulating the potential impact of climate change and water availability on agricultural production at the EU regional level, as well as looking at the sustainable use of water, the implementation of water policies or the integration of water issues in the Common Agricultural Policy

Multidisciplinary Design Optimization Application to Conceptual Design of University-class Microsatellite Projects

Esta tesis se ha realizado en el contexto del proyecto UPMSat-2, que es un microsatélite diseñado, construido y operado por el Instituto Universitario de Microgravedad "Ignacio Da Riva" (IDR / UPM) de la Universidad Politécnica de Madrid. Aplicación de la metodología Ingeniería Concurrente (Concurrent Engineering: CE) en el marco de la aplicación de diseño multidisciplinar (Multidisciplinary Design Optimization: MDO) es uno de los principales objetivos del presente trabajo. En los últimos años, ha habido un interés continuo en la participación de los grupos de investigación de las universidades en los estudios de la tecnología espacial a través de sus propios microsatélites. La participación en este tipo de proyectos tiene algunos desafíos inherentes, tales como presupuestos y servicios limitados. Además, debido al hecho de que el objetivo principal de estos proyectos es fundamentalmente educativo, por lo general hay incertidumbres en cuanto a su misión en órbita y cargas útiles en las primeras fases del proyecto. Por otro lado, existen limitaciones predeterminadas para sus presupuestos de masa, volumen y energía, debido al hecho de que la mayoría de ellos están considerados como una carga útil auxiliar para el lanzamiento. De este modo, el costo de lanzamiento se reduce considerablemente. En este contexto, el subsistema estructural del satélite es uno de los más afectados por las restricciones que impone el lanzador. Esto puede afectar a diferentes aspectos, incluyendo las dimensiones, la resistencia y los requisitos de frecuencia. En la primera parte de esta tesis, la atención se centra en el desarrollo de una herramienta de diseño del subsistema estructural que evalúa, no sólo las propiedades de la estructura primaria como variables, sino también algunas variables de nivel de sistema del satélite, como la masa de la carga útil y la masa y las dimensiones extremas de satélite. Este enfoque permite que el equipo de diseño obtenga una mejor visión del diseño en un espacio de diseño extendido. La herramienta de diseño estructural se basa en las fórmulas y los supuestos apropiados, incluyendo los modelos estáticos y dinámicos del satélite. Un algoritmo genético (Genetic Algorithm: GA) se aplica al espacio de diseño para optimizaciones de objetivo único y también multiobjetivo. El resultado de la optimización multiobjetivo es un Pareto-optimal basado en dos objetivo, la masa total de satélites mínimo y el máximo presupuesto de masa de carga útil. Por otro lado, la aplicación de los microsatélites en misiones espaciales es de interés por su menor coste y tiempo de desarrollo. La gran necesidad de las aplicaciones de teledetección es un fuerte impulsor de su popularidad en este tipo de misiones espaciales. Las misiones de tele-observación por satélite son esenciales para la investigación de los recursos de la tierra y el medio ambiente. En estas misiones existen interrelaciones estrechas entre diferentes requisitos como la altitud orbital, tiempo de revisita, el ciclo de vida y la resolución. Además, todos estos requisitos puede afectar a toda las características de diseño. Durante los últimos años la aplicación de CE en las misiones espaciales ha demostrado una gran ventaja para llegar al diseño óptimo, teniendo en cuenta tanto el rendimiento y el costo del proyecto. Un ejemplo bien conocido de la aplicación de CE es la CDF (Facilidad Diseño Concurrente) de la ESA (Agencia Espacial Europea). Está claro que para los proyectos de microsatélites universitarios tener o desarrollar una instalación de este tipo parece estar más allá de las capacidades del proyecto. Sin embargo, la práctica de la CE a cualquier escala puede ser beneficiosa para los microsatélites universitarios también. En la segunda parte de esta tesis, la atención se centra en el desarrollo de una estructura de optimización de diseño multidisciplinar (Multidisciplinary Design Optimization: MDO) aplicable a la fase de diseño conceptual de microsatélites de teledetección. Este enfoque permite que el equipo de diseño conozca la interacción entre las diferentes variables de diseño. El esquema MDO presentado no sólo incluye variables de nivel de sistema, tales como la masa total del satélite y la potencia total, sino también los requisitos de la misión como la resolución y tiempo de revisita. El proceso de diseño de microsatélites se divide en tres disciplinas; a) diseño de órbita, b) diseño de carga útil y c) diseño de plataforma. En primer lugar, se calculan diferentes parámetros de misión para un rango práctico de órbitas helio-síncronas (sun-synchronous orbits: SS-Os). Luego, según los parámetros orbitales y los datos de un instrumento como referencia, se calcula la masa y la potencia de la carga útil. El diseño de la plataforma del satélite se estima a partir de los datos de la masa y potencia de los diferentes subsistemas utilizando relaciones empíricas de diseño. El diseño del subsistema de potencia se realiza teniendo en cuenta variables de diseño más detalladas, como el escenario de la misión y diferentes tipos de células solares y baterías. El escenario se selecciona, de modo de obtener una banda de cobertura sobre la superficie terrestre paralelo al Ecuador después de cada intervalo de revisita. Con el objetivo de evaluar las interrelaciones entre las diferentes variables en el espacio de diseño, todas las disciplinas de diseño mencionados se combinan en un código unificado. Por último, una forma básica de MDO se ajusta a la herramienta de diseño de sistema de satélite. La optimización del diseño se realiza por medio de un GA con el único objetivo de minimizar la masa total de microsatélite. Según los resultados obtenidos de la aplicación del MDO, existen diferentes puntos de diseños óptimos, pero con diferentes variables de misión. Este análisis demuestra la aplicabilidad de MDO para los estudios de ingeniería de sistema en la fase de diseño conceptual en este tipo de proyectos. La principal conclusión de esta tesis, es que el diseño clásico de los satélites que por lo general comienza con la definición de la misión y la carga útil no es necesariamente la mejor metodología para todos los proyectos de satélites. Un microsatélite universitario, es un ejemplo de este tipo de proyectos. Por eso, se han desarrollado un conjunto de herramientas de diseño para encarar los estudios de la fase inicial de diseño. Este conjunto de herramientas incluye diferentes disciplinas de diseño centrados en el subsistema estructural y teniendo en cuenta una carga útil desconocida a priori. Los resultados demuestran que la mínima masa total del satélite y la máxima masa disponible para una carga útil desconocida a priori, son objetivos conflictivos. En este contexto para encontrar un Pareto-optimal se ha aplicado una optimización multiobjetivo. Según los resultados se concluye que la selección de la masa total por satélite en el rango de 40-60 kg puede considerarse como óptima para un proyecto de microsatélites universitario con carga útil desconocida a priori. También la metodología CE se ha aplicado al proceso de diseño conceptual de microsatélites de teledetección. Los resultados de la aplicación del CE proporcionan una clara comprensión de la interacción entre los requisitos de diseño de sistemas de satélites, tales como la masa total del microsatélite y la potencia y los requisitos de la misión como la resolución y el tiempo de revisita. La aplicación de MDO se hace con la minimización de la masa total de microsatélite. Los resultados de la aplicación de MDO aclaran la relación clara entre los diferentes requisitos de diseño del sistema y de misión, así como que permiten seleccionar las líneas de base para el diseño óptimo con el objetivo seleccionado en las primeras fase de diseño. ABSTRACT This thesis is done in the context of UPMSat-2 project, which is a microsatellite under design and manufacturing at the Instituto Universitario de Microgravedad “Ignacio Da Riva” (IDR/UPM) of the Universidad Politécnica de Madrid. Application of Concurrent Engineering (CE) methodology in the framework of Multidisciplinary Design application (MDO) is one of the main objectives of the present work. In recent years, there has been continuing interest in the participation of university research groups in space technology studies by means of their own microsatellites. The involvement in such projects has some inherent challenges, such as limited budget and facilities. Also, due to the fact that the main objective of these projects is for educational purposes, usually there are uncertainties regarding their in orbit mission and scientific payloads at the early phases of the project. On the other hand, there are predetermined limitations for their mass and volume budgets owing to the fact that most of them are launched as an auxiliary payload in which the launch cost is reduced considerably. The satellite structure subsystem is the one which is most affected by the launcher constraints. This can affect different aspects, including dimensions, strength and frequency requirements. In the first part of this thesis, the main focus is on developing a structural design sizing tool containing not only the primary structures properties as variables but also the satellite system level variables such as payload mass budget and satellite total mass and dimensions. This approach enables the design team to obtain better insight into the design in an extended design envelope. The structural design sizing tool is based on the analytical structural design formulas and appropriate assumptions including both static and dynamic models of the satellite. A Genetic Algorithm (GA) is applied to the design space for both single and multiobejective optimizations. The result of the multiobjective optimization is a Pareto-optimal based on two objectives, minimum satellite total mass and maximum payload mass budget. On the other hand, the application of the microsatellites is of interest for their less cost and response time. The high need for the remote sensing applications is a strong driver of their popularity in space missions. The satellite remote sensing missions are essential for long term research around the condition of the earth resources and environment. In remote sensing missions there are tight interrelations between different requirements such as orbital altitude, revisit time, mission cycle life and spatial resolution. Also, all of these requirements can affect the whole design characteristics. During the last years application of the CE in the space missions has demonstrated a great advantage to reach the optimum design base lines considering both the performance and the cost of the project. A well-known example of CE application is ESA (European Space Agency) CDF (Concurrent Design Facility). It is clear that for the university-class microsatellite projects having or developing such a facility seems beyond the project capabilities. Nevertheless practicing CE at any scale can be beneficiary for the university-class microsatellite projects. In the second part of this thesis, the main focus is on developing a MDO framework applicable to the conceptual design phase of the remote sensing microsatellites. This approach enables the design team to evaluate the interaction between the different system design variables. The presented MDO framework contains not only the system level variables such as the satellite total mass and total power, but also the mission requirements like the spatial resolution and the revisit time. The microsatellite sizing process is divided into the three major design disciplines; a) orbit design, b) payload sizing and c) bus sizing. First, different mission parameters for a practical range of sun-synchronous orbits (SS-Os) are calculated. Then, according to the orbital parameters and a reference remote sensing instrument, mass and power of the payload are calculated. Satellite bus sizing is done based on mass and power calculation of the different subsystems using design estimation relationships. In the satellite bus sizing, the power subsystem design is realized by considering more detailed design variables including a mission scenario and different types of solar cells and batteries. The mission scenario is selected in order to obtain a coverage belt on the earth surface parallel to the earth equatorial after each revisit time. In order to evaluate the interrelations between the different variables inside the design space all the mentioned design disciplines are combined in a unified code. The integrated satellite system sizing tool developed in this section is considered as an application of the CE to the conceptual design of the remote sensing microsatellite projects. Finally, in order to apply the MDO methodology to the design problem, a basic MDO framework is adjusted to the developed satellite system design tool. Design optimization is done by means of a GA single objective algorithm with the objective function as minimizing the microsatellite total mass. According to the results of MDO application, there exist different optimum design points all with the minimum satellite total mass but with different mission variables. This output demonstrates the successful applicability of MDO approach for system engineering trade-off studies at the conceptual design phase of the design in such projects. The main conclusion of this thesis is that the classical design approach for the satellite design which usually starts with the mission and payload definition is not necessarily the best approach for all of the satellite projects. The university-class microsatellite is an example for such projects. Due to this fact an integrated satellite sizing tool including different design disciplines focusing on the structural subsystem and considering unknown payload is developed. According to the results the satellite total mass and available mass for the unknown payload are conflictive objectives. In order to find the Pareto-optimal a multiobjective GA optimization is conducted. Based on the optimization results it is concluded that selecting the satellite total mass in the range of 40-60 kg can be considered as an optimum approach for a university-class microsatellite project with unknown payload(s). Also, the CE methodology is applied to the remote sensing microsatellites conceptual design process. The results of CE application provide a clear understanding of the interaction between satellite system design requirements such as satellite total mass and power and the satellite mission variables such as revisit time and spatial resolution. The MDO application is done with the total mass minimization of a remote sensing satellite. The results from the MDO application clarify the unclear relationship between different system and mission design variables as well as the optimum design base lines according to the selected objective during the initial design phases.

A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Impact assessment of an integrated approach for thermal power generation plants asset management in the current energy market

El sector energético, en España en particular, y de forma similar en los principales países de Europa, cuenta con una significativa sobrecapacidad de generación, debido al rápido y significativo crecimiento de las energías renovables en los últimos diez años y la reducción de la demanda energética, como consecuencia de la crisis económica. Esta situación ha hecho que las centrales térmicas de generación de electricidad, y en concreto los ciclos combinados de gas, operen con un factor de utilización extremadamente bajo, del orden del 10%. Además de la reducción de ingresos, esto supone para las plantas trabajar continuamente fuera del punto de diseño, provocando una significativa pérdida de rendimiento y mayores costes de explotación. En este escenario, cualquier contribución que ayude a mejorar la eficiencia y la condición de los equipos, es positivamente considerada. La gestión de activos está ganando relevancia como un proceso multidisciplinar e integrado, tal y como refleja la reciente publicación de las normas ISO 55000:2014. Como proceso global e integrado, la gestión de activos requiere el manejo de diversos procesos y grandes volúmenes de información, incluso en tiempo real. Para ello es necesario utilizar tecnologías de la información y aplicaciones de software. Esta tesis desarrolla un concepto integrado de gestión de activos (Integrated Plant Management – IPM) aplicado a centrales de ciclo combinado y una metodología para estimar el beneficio aportado por el mismo. Debido a las incertidumbres asociadas a la estimación del beneficio, se ha optado por un análisis probabilístico coste-beneficio. Así mismo, el análisis cuantitativo se ha completado con una validación cualitativa del beneficio aportado por las tecnologías incorporadas al concepto de gestión integrada de activos, mediante una entrevista realizada a expertos del sector de generación de energía. Los resultados del análisis coste-beneficio son positivos, incluso en el desfavorable escenario con un factor de utilización de sólo el 10% y muy prometedores para factores de utilización por encima del 30%. ABSTRACT The energy sector particularly in Spain, and in a similar way in Europe, has a significant overcapacity due to the big growth of the renewable energies in the last ten years, and it is seriously affected by the demand decrease due to the economic crisis. That situation has forced the thermal plants and in particular, the combined cycles to operate with extremely low annual average capacity factors, very close to 10%. Apart from the incomes reduction, working in out-of-design conditions, means getting a worse performance and higher costs than expected. In this scenario, anything that can be done to improve the efficiency and the equipment condition is positively received. Asset Management, as a multidisciplinary and integrated process, is gaining prominence, reflected in the recent publication of the ISO 55000 series in 2014. Dealing Asset Management as a global, integrated process needs to manage several processes and significant volumes of information, also in real time, that requires information technologies and software applications to support it. This thesis proposes an integrated asset management concept (Integrated Plant Management-IPM) applied to combined cycle power plants and develops a methodology to assess the benefit that it can provide. Due to the difficulties in getting deterministic benefit estimation, a statistical approach has been adopted for the cot-benefit analysis. As well, the quantitative analysis has been completed with a qualitative validation of the technologies included in the IPM and their contribution to key power plant challenges by power generation sector experts. The cost- benefit analysis provides positive results even in the negative scenario of annual average capacity factor close to 10% and is promising for capacity factors over 30%.

A stress and coping approach to organisational change: Evidence from three field studies

In this paper, a stress and coping perspective is used to outline the processes that determine employee adaptation to organisational change. A theoretical framework that simultaneously considers the effects of event characteristics, situational appraisals, coping strategies, and coping resources is reviewed, Three empirical investigations of organisational change that have tested various components of the model are then presented. In the first study, there was evidence linking event characteristics, situational appraisals, coping strategies and coping resources to levels of employee adjustment in a sample of pilots employed in a newly merged airline company. In a more focused test of the model with a sample of employees experiencing a restructuring process in their Organisation it was found that the provision of change-related information enhanced levels of efficacy to deal with the change process which, in turn, predicted psychological wellbeing, client engagement, and job satisfaction. In a study of managers affected by a new remuneration scheme, there was evidence to suggest that managers who received change-specific information and opportunities to participate in the change process reported higher levels of change readiness. Managers who reported higher levels of readiness for change also reported higher levels of psychological wellbeing and job satisfaction. These studies highlight ways in which managers and change agents can help employees to cope during times of organisational change.

Martensite Crystallography - the apparent controversy between the infinitesimal deformation approach and the phenomenological theory of martensitic transformations

The aim of this article is to demonstrate that the apparent controversy between the infinitesimal deformation (ID) approach and the phenomenological theory of martensitic transformations (PTMTs) in predicting the crystallographic characteristics of a martensitic transformation is entirely based on unjustified approximations associated with the way in which the ID calculations are performed. When applied correctly, the ID approach is shown to be absolutely identical to the PTMT. Nevertheless, there may be some advantages in using the ID approach. In particular, it is somewhat simpler than the PTMT; it is based on a physical concept that is easier to understand and, most important, it may provide a tool for investigating some of the features of martensitic transformations that have eluded explanation via the PTMT.

A statistical approach to predict the effect of confinement on the detonation velocity of commercial explosives

Commercial explosives behave non-ideally in rock blasting. A direct and convenient measure of non-ideality is the detonation velocity. In this study, an alternative model fitted to experimental unconfined detonation velocity data is proposed and the effect of confinement on the detonation velocity is modelled. Unconfined data of several explosives showing various levels of nonideality were successfully modelled. The effect of confinement on detonation velocity was modelled empirically based on field detonation velocity measurements. Confined detonation velocity is a function of the ideal detonation velocity, unconfined detonation velocity at a given blasthole diameter and rock stiffness. For a given explosive and charge diameter, as confinement increases detonation velocity increases. The confinement model is implemented in a simple engineering based non-ideal detonation model. A number of simulations are carried out and analysed to predict the explosive performance parameters for the adopted blasting conditions.

Random error in willingness to pay measurement: A multiple indicators, latent variable approach to the reliability of contingent values

The reliability of measurement refers to unsystematic error in observed responses. Investigations of the prevalence of random error in stated estimates of willingness to pay (WTP) are important to an understanding of why tests of validity in CV can fail. However, published reliability studies have tended to adopt empirical methods that have practical and conceptual limitations when applied to WTP responses. This contention is supported in a review of contingent valuation reliability studies that demonstrate important limitations of existing approaches to WTP reliability. It is argued that empirical assessments of the reliability of contingent values may be better dealt with by using multiple indicators to measure the latent WTP distribution. This latent variable approach is demonstrated with data obtained from a WTP study for stormwater pollution abatement. Attitude variables were employed as a way of assessing the reliability of open-ended WTP (with benchmarked payment cards) for stormwater pollution abatement. The results indicated that participants' decisions to pay were reliably measured, but not the magnitude of the WTP bids. This finding highlights the need to better discern what is actually being measured in VVTP studies, (C) 2003 Elsevier B.V. All rights reserved.

Participatory approach for the identification of dairy industry needs in the design of research, development and extension actions: Australian and Brazilian case studies

In both Australia and Brazil there are rapid changes occurring in the macroenvironment of the dairy industry. These changes are sometimes not noticed in the microenvironment of the farm, due to the labour-intensive nature of family farms, and the traditionally weak links between production and marketing. Trends in the external environment need to be discussed in a cooperative framework, to plan integrated actions for the dairy community as a whole and to demand actions from research, development and extension (R, D & E). This paper reviews the evolution of R, D & E in terms of paradigms and approaches, the present strategies used to identify dairy industry needs in Australia and Brazil, and presents a participatory strategy to design R, D & E actions for both countries. The strategy incorporates an integration of the opinions of key industry actors ( defined as members of the dairy and associated communities), especially farm suppliers ( input market), farmers, R, D & E people, milk processors and credit providers. The strategy also uses case studies with farm stays, purposive sampling, snowball interviewing techniques, semi-structured interviews, content analysis, focus group meetings, and feedback analysis, to refine the priorities for R, D & E actions in the region.

A new approach to the synthesis of nanocrystal conjugated polymer composites

A novel one pot process has been developed for the preparation of PbS nanocrystals in the conjugated polymer poly 2-methoxy,5-(2 ethyl-hexyloxy-p-phenylenevinylene) (MEH-PPV). Current techniques for making such composite materials rely upon synthesizing the nanocrystals and conducting polymer separately, and subsequently mixing them. This multi-step technique has two serious drawbacks: templating surfactant must be removed before mixing, and co-solvent incompatibility causes aggregation. In our method, we eliminate the need for an initial surfactant by using the conducting polymer to terminate and template nanocrystal growth. Additionally, the final product is soluble in a single solvent. We present materials analysis which shows PbS nanocrystals can be grown directly in a conducting polymer, the resulting composite is highly ordered and nanocrystal size can be controlled.

The Bazhanov-Stroganov model from 3D approach

We apply a three-dimensional approach to describe a new parametrization of the L-operators for the two-dimensional Bazhanov-Stroganov (BS) integrable spin model related to the chiral Potts model. This parametrization is based on the solution of the associated classical discrete integrable system. Using a three-dimensional vertex satisfying a modified tetrahedron equation, we construct an operator which generalizes the BS quantum intertwining matrix S. This operator describes the isospectral deformations of the integrable BS model.

A versatile synthetic approach to peptidyl privileged structures using a "safety-catch" linker

Peptidyl privileged structures have been widely used by many groups to discover biologically active molecules. In this context, privileged substructures are used as hydrophobic anchors, to which peptide functionality is appended to gain specificity. Utilization of this concept has led to the discovery of many different active compounds at a wide range of biological receptors. A synthetic approach to these compounds has been developed on a safety-catch linker that allows rapid preparation of large libraries of these molecules. Importantly, amide bond formation/cleavage through treatment with amines is the final step; it is a linker strategy that allows significant diversification to be easily incorporated, and it only requires the inclusion of an amide bond. In addition, chemistry has been developed that permits the urea moiety to be inserted at the N-terminus of the peptide, allowing the same set of amines (either privileged substructures or amino acid analogues) to be used at both the N- and C-termini of the molecule. To show the robustness of this approach, a small library of peptidyl privileged structures were synthesized, illustrating that large combinatorial libraries can be synthesized using these technologies.

Learning with other health professions in the United Kingdom MPharm degree:Multidisciplinary and placement education

This paper reviews the approach to multidisciplinary and placement education in UK schools of pharmacy. The methodology involved triangulation of course documentation, staff interviews and a final year student survey. Staff members were supportive of multidisciplinary learning. The advantages were development of a wider appreciation of the students? future professional role and better understanding of the roles of other professional groups. The barriers were logistics (student numbers; multiple sites; different timetables), the achievement of balanced numbers between disciplines and engagement of students from all participating disciplines. Placement education was offered by all schools, predominantly in hospital settings. Key problems were funding and the lack of staff resources. Currently, multidisciplinary learning within the UK for pharmacy students is inadequate and is coupled with relatively low levels of placement education. In order for things to change, there should be a review of funding and support from government and the private sector employers.