Managing diabetes in Switzerland : a systemic approach

Executive summaryThe increasing prevalence of chronic diseases is one of the major causes of rising health expenditure, as stated by the WHO. Not only chronic diseases are very costly, but they are by far the leading cause of mortality in the world, representing 60% of all deaths. Diabetes in particular is becoming a major burden of disease. In Switzerland around 5% of the population suffer of type 2 diabetes and 5 to 10% of the annual health care budget is attributable to diabetes. If the predictions of WHO do realise, the prevalence of diabetes will double until 2030 and so is expected the attributable health expenditure.The objective of this thesis is to provide policy recommendations as to slow down the disease progression and its costly complication. We study the factors that influence diabetes dynamics and the interventions that improve health outcomes while decreasing costs according to different time horizon and use systems thinking and system dynamic.Our results show that managing diabetes requires using integrated care interventions that are effective on three fronts: (1) delaying the onset of complications, (2) slowing down the disease progression and (3) accelerating the time to diagnosis of diabetes and its complications. We recommend firstly the implementation of those interventions targeted at changing patients' behaviour which are also less expensive, but require a change in the delivery of care and medical practices. Then policies targeted at an earlier diagnosis of diabetes, its prevention and the diagnosis of complications are to be considered. This sequence of interventions allows saving money, as total costs decrease, even including the costs of interventions and result in longer life expectancy of diabetics in the long term.In diabetes management there is therefore a trade-off between medical costs and patients' benefits on the one hand and between the objectives of obtaining results in the short or long term on the other hand. Decision makers need to deliver acceptable outcomes in the short term. Considering this criterion, the preferred policy may be to focus only on diagnosed diabetics, thus attempting to slow down the progression of their disease, compared to an integrated care approach addressing all the aspects of the disease. Such a policy also yields desirable results in terms of costs and patients' benefits.

CAV2 vector gene transfer into central nervious System

Estudi realitzat a partir d’una estada al Institut de Génétique Moléculaire de Montpellier, França, entre 2010 i 2012. En aquest projecte s’ha avaluat les avantatges dels vectors adenovirals canins tipus 2 (CAV2) com a vectors de transferència gènica al sistema nerviós central (SNC) en un model primat no-humà i en un model caní del síndrome de Sly (mucopolisacaridosis tipus 7, MPS VII), malaltia monogènica que cursa amb neurodegeneració. En una primera part del projecte s’ha avaluat la biodistribució, l’eficàcia i la durada de l’expressió del transgen en un model primat no humà, (Microcebus murinus). Com ha vector s’ha utilitzat un CAV2 de primera generació que expressa la proteïna verda fluorescent (CAVGFP). Els resultats aportats en aquesta memòria demostren que en primats no humans, com en d’altres espècies testades anteriorment per l’equip de l’EJ Kremer, la injecció intracerebral de CAV2 resulta en una extensa transducció del SNC, siguent les neurones i els precursors neuronals les cèl•lules preferencialment transduïdes. Els vectors canins, servint-se de vesícules intracel•lulars són transportats, majoritàriament, des de les sinapsis cap al soma neuronal, aquest transport intracel•lular permet una extensa transducció del SNC a partir d’una única injecció intracerebral dels vectors virals. En una segona part d’aquest projecte s’ha avaluat l’ús terapèutic dels CAV2. S’ha injectat un vector helper-dependent que expressa el gen la b-glucuronidasa i el gen de la proteïna verda fluorescent (HD-RIGIE), en el SNC del model caní del síndrome de Sly (MPS VII). La biodistribució i la eficàcia terapèutica han estat avaluades. Els nivells d’activitat enzimàtica en animals malalts injectats amb el vector terapèutic va arribar a valors similars als dels animals no afectes. A més a més s’ha observat una reducció en la quantitat dels GAGs acumulats en les cèl•lules dels animals malalts tractats amb el vector terapèutic, demostrant la potencialitat terapèutica dels CAV2 per a malalties que afecten al SNC. Els resultats aportats en aquest treball ens permeten dir que els CAV2 són unes bones eines terapèutiques per al tractament de malalties que afecten al SNC.

Guidelines for the Conversion of Urban Four-Lane Undivided Roadways to Three-Lane Two-Way Left-turn Lane Facilities, April 2001

Four-lane undivided roadways in urban areas can experience a degradation of service and/or safety as traffic volumes increase. In fact, the existence of turning vehicles on this type of roadway has a dramatic effect on both of these factors. The solution identified for these problems is typically the addition of a raised median or two-way left-turn lane (TWLTL). The mobility and safety benefits of these actions have been proven and are discussed in the “Past Research” chapter of this report along with some general cross section selection guidelines. The cost and right-of-way impacts of these actions are widely accepted. These guidelines focus on the evaluation and analysis of an alternative to the typical four-lane undivided cross section improvement approach described above. It has been found that the conversion of a four-lane undivided cross section to three lanes (i.e., one lane in each direction and a TWLTL) can improve safety and maintain an acceptable level of service. These guidelines summarize the results of past research in this area (which is almost nonexistent) and qualitative/quantitative before-and-after safety and operational impacts of case study conversions located throughout the United States and Iowa. Past research confirms that this type of conversion is acceptable or feasible in some situations but for the most part fails to specifically identify those situations. In general, the reviewed case study conversions resulted in a reduction of average or 85th percentile speeds (typically less than five miles per hour) and a relatively dramatic reduction in excessive speeding (a 60 to 70 percent reduction in the number of vehicles traveling five miles per hour faster than the posted speed limit was measured in two cases) and total crashes (reductions between 17 to 62 percent were measured). The 13 roadway conversions considered had average daily traffic volumes of 8,400 to 14,000 vehicles per day (vpd) in Iowa and 9,200 to 24,000 vehicles per day elsewhere. In addition to past research and case study results, a simulation sensitivity analysis was completed to investigate and/or confirm the operational impacts of a four-lane undivided to three-lane conversion. First, the advantages and disadvantages of different corridor simulation packages were identified for this type of analysis. Then, the CORridor SIMulation (CORSIM) software was used x to investigate and evaluate several characteristics related to the operational feasibility of a four-lane undivided to three-lane conversion. Simulated speed and level of service results for both cross sections were documented for different total peak-hour traffic, access densities, and access-point left-turn volumes (for a case study corridor defined by the researchers). These analyses assisted with the identification of the considerations for the operational feasibility determination of a four -lane to three-lane conversion. The results of the simulation analyses primarily confirmed the case study impacts. The CORSIM results indicated only a slight decrease in average arterial speed for through vehicles can be expected for a large range of peak-hour volumes, access densities, and access-point left-turn volumes (given the assumptions and design of the corridor case study evaluated). Typically, the reduction in the simulated average arterial speed (which includes both segment and signal delay) was between zero and four miles per hour when a roadway was converted from a four-lane undivided to a three-lane cross section. The simulated arterial level of service for a converted roadway, however, showed a decrease when the bi-directional peak-hour volume was about 1,750 vehicles per hour (or 17,500 vehicles per day if 10 percent of the daily volume is assumed to occur in the peak hour). Past research by others, however, indicates that 12,000 vehicles per day may be the operational capacity (i.e., level of service E) of a three-lane roadway due to vehicle platooning. The simulation results, along with past research and case study results, appear to support following volume-related feasibility suggestions for four-lane undivided to three-lane cross section conversions. It is recommended that a four-lane undivided to three-lane conversion be considered as a feasible (with respect to volume only) option when bi-directional peak-hour volumes are less than 1,500 vehicles per hour, but that some caution begin to be exercised when the roadway has a bi-directional peak-hour volume between 1,500 and 1,750 vehicles per hour. At and above 1,750 vehicles per hour, the simulation indicated a reduction in arterial level of service. Therefore, at least in Iowa, the feasibility of a four-lane undivided to three-lane conversion should be questioned and/or considered much more closely when a roadway has (or is expected to have) a peak-hour volume of more than 1,750 vehicles. Assuming that 10 percent of the daily traffic occurs during the peak-hour, these volume recommendations would correspond to 15,000 and 17,500 vehicles per day, respectively. These suggestions, however, are based on the results from one idealized case xi study corridor analysis. Individual operational analysis and/or simulations should be completed in detail once a four-lane undivided to three-lane cross section conversion is considered feasible (based on the general suggestions above) for a particular corridor. All of the simulations completed as part of this project also incorporated the optimization of signal timing to minimize vehicle delay along the corridor. A number of determination feasibility factors were identified from a review of the past research, before-and-after case study results, and the simulation sensitivity analysis. The existing and expected (i.e., design period) statuses of these factors are described and should be considered. The characteristics of these factors should be compared to each other, the impacts of other potentially feasible cross section improvements, and the goals/objectives of the community. The factors discussed in these guidelines include • roadway function and environment • overall traffic volume and level of service • turning volumes and patterns • frequent-stop and slow-moving vehicles • weaving, speed, and queues • crash type and patterns • pedestrian and bike activity • right-of-way availability, cost, and acquisition impacts • general characteristics, including - parallel roadways - offset minor street intersections - parallel parking - corner radii - at-grade railroad crossings xii The characteristics of these factors are documented in these guidelines, and their relationship to four-lane undivided to three-lane cross section conversion feasibility identified. This information is summarized along with some evaluative questions in this executive summary and Appendix C. In summary, the results of past research, numerous case studies, and the simulation analyses done as part of this project support the conclusion that in certain circumstances a four-lane undivided to three-lane conversion can be a feasible alternative for the mitigation of operational and/or safety concerns. This feasibility, however, must be determined by an evaluation of the factors identified in these guidelines (along with any others that may be relevant for a individual corridor). The expected benefits, costs, and overall impacts of a four-lane undivided to three-lane conversion should then be compared to the impacts of other feasible alternatives (e.g., adding a raised median) at a particular location.

Factors associated with beliefs about adherence to non-pharmacological treatment of patients with heart failure

This study aimed at assessing beliefs about the benefits and barriers to adherence to daily self-monitoring of weight/edema in patients with heart failure, and the influence of demographic and clinical variables on those beliefs. 105 patients were interviewed. The mean of the subscales Benefits and Barriers were 20.2 (± 5.7) and 30.1 (±7.1), respectively. Patients perceived that adherence to daily self-monitoring of weight/edema could keep them healthy, improve their quality of life and decrease the chances of readmission. Approximately half of patients (46.7%) reported forgetting this measure. Those who controlled weight once a month were more likely to have barriers to adherence (OR= 6.6; IC 95% 1.9-13.8; p=0.01), showing this measure to be the main factor related to perceived barriers. Education in health can contribute with the development of strategies aimed at lowering barriers and increasing benefits of this control.

Health-related quality of life among patients with advanced cancer: an integrative review

This integrative literature review aimed to characterize scientific articles on health-related quality of life – HRQoL – among patients with advanced cancer from national and international literature, and summarize those factors evidenced in the literature that contributed to the improvement or worsening of HRQoL among patients with advanced cancer. The search for materials was conducted in the following databases: CINAHL, EMBASE, PubMed, SciELO and LILACS. Among the 21 articles in the sample, 13 showed an improvement of HRQoL among patients with advanced cancer related to the development of physical, emotional and spiritual interventions. In eight studies, we identified predictive symptoms of low HRQoL, such as pain, fatigue, sleep disorders, depression, nutritional changes, and others. The results showed that clinical manifestations, which many times were inherent in cancer, such as factors that can lower patients’ HRQoL, while physical, psychological and spiritual benefits resulting from therapeutic interventions may promote its improvement.


Análise da performance organizacional: Proposta de um modelo do balanced scorecard para a avaliação do desempenho do comando da 1ª região militar

Esta pesquisa gira à volta da avaliação do desempenho organizacional com enfoque no sistema denominado Balanced Scorecard. Esta ferramenta, criada no início da década de noventa, por David Norton e Robert Kaplan, tem vindo a contagiar os gestores, e nos dias de hoje várias são as organizações que beneficiam dela para obter excelência. A primeira metodologia foi apresentada em mil novecentos e noventa e três (1993), constituída por oito etapas. No ano de mil novecentos e noventa e seis (1996), os autores desenvolveram uma nova metodologia, melhorada, composta por dez etapas. Começámos por fazer um levantamento teórico dos conceitos ligados a esta ferramenta, as suas vantagens e desvantagens, as fases da sua execução, os possíveis obstáculos ao seu sucesso e os frutos que poderão ser colhidos com a sua implementação. Através de uma proposta de implementação, escolhemos o Comando da 1ª Região Militar, para verificar quais serão os impactos na gestão desta organização. Do diagnóstico situacional efectuado com base em entrevistas, análise documental e observação, verificámos que a organização possui algumas insuficiências ao nível do desempenho de gestão, derivadas sobretudo da situação logística e financeira. Na construção do mapa estratégico, principal componente do Balanced scorecard, vimo-nos na necessidade de deslocar a perspectiva do cliente ou de mercado para o topo de configuração, devido à natureza do objecto negocial da organização em estudo. O modelo de avaliação de desempenho desenvolvido evidenciou a importância que a utilização deste sistema poderá ter na melhoria das actividades castrenses, sobretudo pelo aumento do nível de comunicação entre os subgrupos e a gestão de topo, neste caso, o Pessoal de Comando e as Pequenas Unidades, devido à natureza e qualidade das informações fornecidas pelo mapa estratégico. The aim of this study is to look at the organizational performance measurement system, with a special emphasis upon the so called Balanced Scorecard System. This tool, created at the beginning of the 1990’s by David Norton and Robert Kaplan, has been gaining the enthusiasm of administrator, and at the present time, several organizations are using it in the search for excellence. The first methodology was presented in 1993 and was formed by eight steps. In 1996, however, its creators developed an improved version of this methodology, now composed by ten steps. We start by doing a research of the theoretical concepts related to this tool, its advantages and disadvantages, the stages of its implementation, possible obstacles to its success, and the benefits that can come from its use. Based on an implementation proposal, we chose the First Military Command Region of Cape Verde to study the possible impacts of this system on the management of that Institution. From an investigation on the existent situation, based on interviews, analysis of documents and “in locus” observation, we realised that the institution shows some administrative insufficiencies, mainly due to its logistics and financial situation. In the building of the strategic map, the main component of the Balanced Scorecard System, we were obliged to move the perspective of the client or the market to the top of the configuration, because of the nature of the trading object of the institution being studied. The performance measurement model developed, clearly showed the importance that the implementation of this system might have on the improvement of the Military activities, mainly because of the improvement on the type of communication that can be established between the subgroups and the higher hierarchical levels, in this case, the Commander Staff and the lower Units, due to the type and quality of the information provided by the strategic map.

Use of high-frequency jet ventilation for percutaneous tumor ablation.

PURPOSE: To report feasibility and potential benefits of high-frequency jet ventilation (HFJV) in tumor ablations techniques in liver, kidney, and lung lesions. METHODS: This prospective study included 51 patients (14 women, mean age 66 years) bearing 66 tumors (56 hepatic, 5 pulmonary, 5 renal tumors) with a median size of 16 ± 8.7 mm, referred for tumor ablation in an intention-to-treat fashion before preoperative anesthesiology visit. Cancellation and complications of HFJV were prospectively recorded. Anesthesia and procedure duration, as well as mean CO2 capnea, were recorded. When computed tomography guidance was used, 3D spacial coordinates of an anatomical target <2 mm in diameter on 8 slabs of 4 slices of 3.75-mm slice thickness were registered. RESULTS: HFJV was used in 41 of 51 patients. Of the ten patients who were not candidate for HFJV, two patients had contraindication to HFJV (severe COPD), three had lesions invisible under HFJV requiring deep inspiration apnea for tumor targeting, and five patients could not have HFJV because of unavailability of a trained anesthetic team. No specific complication or hypercapnia related to HFJV were observed despite a mean anesthetic duration of 2 h and ventilation performed in procubitus (n = 4) or lateral decubitus (n = 6). Measured internal target movement was 0.3 mm in x- and y-axis and below the slice thickness of 3.75 mm in the z-axis in 11 patients. CONCLUSIONS: HFJV is feasible in 80 % of patients allowing for near immobility of internal organs during liver, kidney, and lung tumor ablation.

A Contabilidade de Gestão nas Empresas de Grande Dimensão de Cabo Verde

O presente estudo é uma abordagem das empresas cabo-verdianas para a compreensão da situação da contabilidade de gestão, evidenciando os sistemas de custeio utilizados, a adequação das informações obtidas e os benefícios da sua utilização. Deste modo, para atingirmos os objectivos foi formulada uma questão de investigação e respectivas hipóteses de investigação. Verificou-se pela literatura que no mundo a contabilidade de gestão tem sofrido várias alterações de forma a responder as mudanças do meio envolvente onde as empresas estão inseridas. No entanto, as técnicas contemporâneas têm sido adoptadas de uma forma muito lenta. A metodologia utilizada foi quantitativa, onde aplicamos um questionário para a recolha de dados, enviado por correio electrónico e respondido presencialmente, à amostra constituida por 164 empresas consideradas de grande dimensão, pertencentes aos três grandes sectores de actividade, tendo recebido em tempo útil, 54 respostas (32,9%). Contudo, destas 54 empresas que responderam apenas 14 possuem contabilidade de gestão. De acordo com os resultados obtidos, concluímos que as técnicas tradicionais de contabilidade de gestão são as mais utilizadas nas empresas estudadas, como por exemplo, o orçamento e a análise de desvios. No entanto, algumas empresas já utilizam técnicas contemporâneas, mas em simultâneo com as tradicionais.The main objective of this study is to analyze the situation of management accounting in Capeverdean companies. To characterize the situation of management accounting we formulated a research question and hypothesis in order to: analyze the cost system used, the quality of the information and the benefits of adopting a management accounting system. The literature shows that management accounting has been through many modifications and has steadily evolved so that it fits the environment where companies are implanted. However, the adoption of contemporary management accounting techniques has proven to be a slow process. The methodology used to gather data was through a survey. Some questionnaires were answered at the companies and the others were sent through e-mail to the sample of 164 large companies, belonging to the three main sectors. The response rate was of 18, 94% (54 companies). However, from those 54 companies just 14 have management accounting. According to the results, we have concluded that the companies we study have a management accounting system that relies on the use of the traditional techniques, like budget and budget control. Yet, some of those already use contemporary techniques, alongside the traditional techniques.

Les influències dels factors socials en l'ús de serveis formals

Objectiu: Aquest estudi pretén aportar coneixement sobre el model d’atenció que reben les persones de més de 79 anys dependents del municipi de Vic. Analitzar en quina mesura es fa ús dels serveis formals i quines variables influeixen en la utilització d’aquest. Mètode: Estudi retrospectiu, descriptiu i transversal. De metodologia quantitativa. La població d’estudi són aquelles persones de 80 i més anys de Vic que van sol·licitar la valoració de dependència entre els anys 2007-2010, amb un grau II o III de dependència reconegut i un Pla Individual d’Atenció validat i concedit per la Generalitat de Catalunya (n=453). Les dades provenen de registres de la Generalitat de Catalunya i de l’Àrea d’Afers Socials i Ciutadania de l’Ajuntament de Vic. Les variables dependents són la utilització de recursos formals (teleassitència, servei d’atenció domiciliària –públic i privat- , centre de dia, residència i prestacions econòmiques derivades de la llei de la dependència). El grau de dependència, el gènere, l’edat, l’estat civil, la convivència, el cuidador principal i el nivell de renda es van considerar variables independents. Resultats: El model d’atenció majoritari és el que complementa el suport informal amb el formal (62.3%). L’ús de recursos formals té un paper subsidiari (37.7%). La variable convivència influeix de forma significativa amb l’ús de serveis formals (p&0.001 en l’ús de TAS, el SAD públic i el SAD privat) . Conclusió: Els disseny de programes i criteris de provisió de serveis haurien de contemplar no només el grau de dependència sinó també variables més d’entorn com la convivència. No obstant, existeix encara poca evidència científica en aquesta línia, per això s’hauria de potenciar l’ investigació que permetés analitzar les variables de la funció social de forma més acurada. Paraules clau: Dependència, suport formal, suport informal.

Business Sphere, Vol. 17, no.3

Through networking, Iowa’s manufacturers share expertise in lean manufacturing, supply chain efficiency and rapid prototyping, strengthening the powerful environment for success. The Iowa Department of Economic Development builds on these strengths with a focus on advanced manufacturing, extending financial and tax benefits to companies making substantial investments and creating higher skill, higher paying jobs. Many companies these days are finding that it pays to explore options in Iowa as they plan manufacturing expansions. You can get in touch with us at www.iowalifechanging.com.

Business Sphere, Vol. 20, no.3

When selecting sites for the industry’s leading data centers, experts and IT leaders such as Google and Microsoft, are increasingly choosing Iowa They’re doing so because they understand that Iowa is a safe zone for data and information storage — tucked away from the major threats and terrorist targets in the U.S. What’s more, there are many infrastructural and financial benefits that only Iowa offers. With all this activity, available research and Iowa’s inherent advantages, it seems the question isn't so much why Iowa, but why not?

Implementing an interfaculty series of courses on interprofessional collaboration in prelicensure health science curriculums.

Introduction: Interprofessional collaborative practices are increasingly recognized as an effective way to deal with complex health problems. However, health sciences students continue to be trained in specialized programs and have little occasion for learning in interdisciplinary contexts. Program Development: The project's purpose was to develop content and an educational design for new prelicensure interfaculty courses on interprofessional collaboration in patient and family-centered care which embedded interprofessional education principles where participants learn with, from and about each other. Implementation: Intensive training was part of a 45-hour program, offered each semester, which was divided into three 15-hour courses given on weekends, to enhance accessibility. Evaluation: A total of 215 students completed questionnaires following the courses, to assess their satisfaction with the educational content. Pre/post measures assessed perception of skills acquisition and perceived benefits of interprofessional collaboration training. Results showed a significant increase from the students' point of view in the knowledge and benefits to be gained from interprofessional collaboration training.

Iowa Public Employees' Retirement System Member Handbook, September 2011

The IPERS Member Handbook summarizes the retirement plan that is provided for most employees of Iowa’s schools, cities, counties, townships, state agencies, and other governmental units. This publication explains the rights and benefits of IPERS membership in as clear and useful a manner as possible; however, it is not intended to be a complete presentation of the IPERS law and policies. Benefits provided under IPERS differ for Special service members—sheriffs, deputy sheriffs, and those working in other protection occupations, such as firefighters, police, correctional officers, and conservation officers. This publication explains what these differences are. To help you find information that applies only to you, IPERS also publishes a variety of booklets and brochures to guide you through IPERS benefits at specific stages of your career, from membership enrollment to retirement. These educational resources are available for viewing or printing from our website at www.ipers.org. You may also contact IPERS and request a free printed copy. Alternative formats containing the information in this publication are available upon request. Note: This publication reflects the law as of July 2011. Some provisions will become effective at later dates, as noted. Any inconsistencies or inadvertent omissions will be resolved in favor of the law.

FY2008 Annual Summary July 1, 2007 - June 30, 2008

It’s really quite simple. IPERS is a sure thing. IPERS benefits carry a lifetime guarantee. A bad economy and declining stock market do not decrease your benefits. Instead, your benefit amount is determined by a pre-established formula that replaces a percentage of your pre-retirement wages. How close your benefits get to the maximum of the IPERS plan—replacing 65 percent of pre-retirement wages or 72 percent for public safety personnel—is mostly up to you. Current employees don’t have to worry about where to invest or what to do when there is a slump in the stock market. Retirees don’t have to worry that a down market will reduce their monthly payments, and they never have to worry about outliving their IPERS benefits. Disability payments and death benefits act as a safety net for members and their families.

Board examination for anatomical pathology in Switzerland: two intense days to verify professional competence.

About 15 years ago, the Swiss Society of Pathology has developed and implemented a board examination in anatomical pathology. We describe herein the contents covered by this 2-day exam (autopsy pathology, cytology, histopathology, molecular pathology, and basic knowledge about mechanisms of disease) and its exact modalities, sketch a brief history of the exam, and finish with a concise discussion about the possible objectives and putative benefits weighed against the hardship that it imposes on the candidates.