L'utilizzo dei casi di studio per favorire l'apprendimento di metodologie e strumenti per lo sviluppo organizzativo o di percorsi di cura nelle aziende sanitarie

La formazione, in ambito sanitario, è considerata una grande leva di orientamento dei comportamenti, ma la metodologia tradizionale di formazione frontale non è la più efficace, in particolare nella formazione continua o “long-life education”. L’obiettivo primario della tesi è verificare se l’utilizzo della metodologia dello “studio di caso”, di norma utilizzata nella ricerca empirica, può favorire, nel personale sanitario, l’apprendimento di metodi e strumenti di tipo organizzativo-gestionale, partendo dalla descrizione di processi, decisioni, risultati conseguiti in contesti reali. Sono stati progettati e realizzati 4 studi di caso con metodologia descrittiva, tre nell’Azienda USL di Piacenza e uno nell’Azienda USL di Bologna, con oggetti di studio differenti: la continuità di cura in una coorte di pazienti con stroke e l’utilizzo di strumenti di monitoraggio delle condizioni di autonomia; l’adozione di un approccio “patient-centred” nella presa in carico domiciliare di una persona con BPCO e il suo caregiver; la percezione che caregiver e Medici di Medicina Generale o altri professionisti hanno della rete aziendale Demenze e Alzheimer; la ricaduta della formazione di Pediatri di Libera Scelta sull’attività clinica. I casi di studio sono stati corredati da note di indirizzo per i docenti e sono stati sottoposti a quattro referee per la valutazione dei contenuti e della metodologia. Il secondo caso è stato somministrato a 130 professionisti sanitari all’interno di percorso di valutazione delle competenze e dei potenziali realizzato nell’AUSL di Bologna. I referee hanno commentato i casi e gli strumenti di lettura organizzativa, sottolineando la fruibilità, approvando la metodologia utilizzata, la coniugazione tra ambiti clinico-assistenziali e organizzativi, e le teaching note. Alla fine di ogni caso è presente la valutazione di ogni referee.

Le cure oncologiche e la prospettiva del paziente. Revisione di letteratura e un caso di studio

Numerose ricerche indicano i modelli di cure integrate come la migliore soluzione per costruire un sistema più efficace ed efficiente nella risposta ai bisogni del paziente con tumore, spesso, però, l’integrazione è considerata da una prospettiva principalmente clinica, come l’adozione di linee guida nei percorsi della diagnosi e del trattamento assistenziale o la promozione di gruppi di lavoro per specifiche patologie, trascurando la prospettiva del paziente e la valutazione della sua esperienza nei servizi. Il presente lavoro si propone di esaminare la relazione tra l’integrazione delle cure oncologiche e l’esperienza del paziente; com'è rappresentato il suo coinvolgimento e quali siano i campi di partecipazione nel percorso oncologico, infine se sia possibile misurare l’esperienza vissuta. L’indagine è stata svolta sia attraverso la revisione e l’analisi della letteratura sia attraverso un caso di studio, condotto all'interno della Rete Oncologica di Area Vasta Romagna, tramite la somministrazione di un questionario a 310 pazienti con neoplasia al colon retto o alla mammella. Dai risultati, emerge un quadro generale positivo della relazione tra l’organizzazione a rete dei servizi oncologici e l’esperienza del paziente. In particolare, è stato possibile evidenziare quattro principali nodi organizzativi che introducono la prospettiva del paziente: “individual care provider”,“team care provider”,“mixed approach”,“continuity and quality of care”. Inoltre, è stato possibile delineare un campo semantico coerente del concetto di coinvolgimento del paziente in oncologia e individuare quattro campi di applicazione, lungo tutte le fasi del percorso: “prevenzione”, “trattamento”,“cura”,“ricerca”. Infine, è stato possibile identificare nel concetto di continuità di cura il modo in cui i singoli pazienti sperimentano l’integrazione o il coordinamento delle cure e analizzare differenti aspetti del vissuto della persona e dell’organizzazione.

Willem Marinus Dudok. Progetti urbani per la citta' di Hilversum

Il tema principale affrontato dalla presente ricerca è quello dell’architettura della città; attraverso lo studio dei progetti urbani redatti dall’architetto Willem Marinus Dudok per la città di Hilversum, la tesi vuole confermare l’ipotesi che la costruzione dei “luoghi urbani” collettivi è il fulcro dell’idea di architettura che porta alla costruzione della città. La ricerca si propone di studiare il contributo dato da Dudok al progetto dello sviluppo urbano della città olandese, considerando un arco temporale che va dal 1915, anno in cui l’architetto viene designato a ricoprire la carica di direttore del locale ufficio Lavori Pubblici, al 1954, anno simbolico della sua nomina a cittadino onorario di Hilversum. Il lavoro di ricerca vuole individuare quelle caratteristiche formali e tipologiche, insite nei quartieri progettati dall’architetto olandese, in grado di definire una struttura urbana capace di sostenere un ragionamento architettonico indipendente dal luogo e dal tempo, un ragionamento impostato sulla definizione della forma urbis. Non desidera certo delineare un modello, vista la consapevolezza che ogni progetto ha un proprio luogo e un proprio tempo, cerca di tratteggiare, piuttosto, uno scenario possibile per il progetto urbano, capace di assurgere ad exemplum per la costruzione della città. I progetti analizzati riguardano edifici residenziali e spazi urbani per la collettività; questi rappresentano veri e propri nuclei aggregativi per la costruzione dei complessi di alloggi popolari, dei quali definiscono la scena fissa delle vicende umane. Lo studio di questi quartieri rappresenta, pertanto, il tentativo di decodificare un “modo” di comporre la città dal quale sia possibile estrapolare temi validi e di carattere generale che permettano di formalizzare una serie di utili insegnamenti, tramite i quali poter pensare alla realizzazione della stessa, nella convinzione che “la qualità del progetto consiste nella qualità dei caratteri del tema e nel loro riconoscimento nelle forme dell’architettura”.

Populationsgenetik eisenzeitlicher Reiternomaden der Eurasischen Steppe

Vorliegende Dissertation beschäftigt sich mit der Populationsgenetik eisenzeitlicher Bevölkerungen der Eurasischen Steppe, die mit der skythischen Kultur assoziiert werden. Für die Analysen wurden 30 Fragmente der kodierenden Region und die HVR1 (16040–16400) des mitochondrialen Genoms, sowie 20 phänotypische Marker untersucht. Die Marker wurden durch Multiplex-PCRs angereichert, mit einem probenspezifischen barcode versehen und einer parallelen Sequenzanalyse mit dem 454 GS FLX Sequenzierer unterzogen. 97 Individuen wurden erfolgreich analysiert, von denen 19 aus dem Westen der Eurasischen Steppe und 78 aus dem Bereich des Altai-Gebirges stammen. Die populationsgenetischen Analysen ergaben geringe genetische Distanzen zwischen den skythischen Populationen aus dem Bereich des Altai-Gebirges, die sich vom 9. bis zum 3. Jahrhundert vor Christus erstrecken, was für eine kontinuierliche Bevölkerungsentwicklung sprechen könnte. Weiterhin finden sich geringe genetische Distanzen zwischen den Gruppen im Osten und Westen der Eurasischen Steppe, was auf eine gemeinsame Ursprungspopulation, oder zumindest Genfluss hinweisen kann. Die Ergebnisse aus dem Vergleich mit neolithischen und bronzezeitlichen Referenzpopulationen aus Zentralasien und den angrenzenden Gebieten weisen auf die Möglichkeit eines gemeinsamen zentral-asiatischen Ursprungs hin, zeigen aber auch, dass die östlichen und westlichen Gruppen der Eisenzeit jeweils zusätzlich lokalem Genfluss ausgesetzt waren. Die Allelfrequenzen der phänotypischen Marker deuten auf einen größeren europäischen Einfluss auf das östliche Zentralasien in der Eisenzeit hin, oder ansteigenden Genfluss aus Ostasien nach der Eisenzeit.

Orbits design for Leo space based solar power satellite system

Space Based Solar Power satellites use solar arrays to generate clean, green, and renewable electricity in space and transmit it to earth via microwave, radiowave or laser beams to corresponding receivers (ground stations). These traditionally are large structures orbiting around earth at the geo-synchronous altitude. This thesis introduces a new architecture for a Space Based Solar Power satellite constellation. The proposed concept reduces the high cost involved in the construction of the space satellite and in the multiple launches to the geo-synchronous altitude. The proposed concept is a constellation of Low Earth Orbit satellites that are smaller in size than the conventional system. For this application a Repeated Sun-Synchronous Track Circular Orbit is considered (RSSTO). In these orbits, the spacecraft re-visits the same locations on earth periodically every given desired number of days with the line of nodes of the spacecraft’s orbit fixed relative to the Sun. A wide range of solutions are studied, and, in this thesis, a two-orbit constellation design is chosen and simulated. The number of satellites is chosen based on the electric power demands in a given set of global cities. The orbits of the satellites are designed such that their ground tracks visit a maximum number of ground stations during the revisit period. In the simulation, the locations of the ground stations are chosen close to big cities, in USA and worldwide, so that the space power constellation beams down power directly to locations of high electric power demands. The j2 perturbations are included in the mathematical model used in orbit design. The Coverage time of each spacecraft over a ground site and the gap time between two consecutive spacecrafts visiting a ground site are simulated in order to evaluate the coverage continuity of the proposed solar power constellation. It has been observed from simulations that there always periods in which s spacecraft does not communicate with any ground station. For this reason, it is suggested that each satellite in the constellation be equipped with power storage components so that it can store power for later transmission. This thesis presents a method for designing the solar power constellation orbits such that the number of ground stations visited during the given revisit period is maximized. This leads to maximizing the power transmission to ground stations.

Transformer modeling ATP : internal faults & high-frequency discretization

Power transformers are key components of the power grid and are also one of the most subjected to a variety of power system transients. The failure of a large transformer can cause severe monetary losses to a utility, thus adequate protection schemes are of great importance to avoid transformer damage and maximize the continuity of service. Computer modeling can be used as an efficient tool to improve the reliability of a transformer protective relay application. Unfortunately, transformer models presently available in commercial software lack completeness in the representation of several aspects such as internal winding faults, which is a common cause of transformer failure. It is also important to adequately represent the transformer at frequencies higher than the power frequency for a more accurate simulation of switching transients since these are a well known cause for the unwanted tripping of protective relays. This work develops new capabilities for the Hybrid Transformer Model (XFMR) implemented in ATPDraw to allow the representation of internal winding faults and slow-front transients up to 10 kHz. The new model can be developed using any of two sources of information: 1) test report data and 2) design data. When only test-report data is available, a higher-order leakage inductance matrix is created from standard measurements. If design information is available, a Finite Element Model is created to calculate the leakage parameters for the higher-order model. An analytical model is also implemented as an alternative to FEM modeling. Measurements on 15-kVA 240?/208Y V and 500-kVA 11430Y/235Y V distribution transformers were performed to validate the model. A transformer model that is valid for simulations for frequencies above the power frequency was developed after continuing the division of windings into multiple sections and including a higher-order capacitance matrix. Frequency-scan laboratory measurements were used to benchmark the simulations. Finally, a stability analysis of the higher-order model was made by analyzing the trapezoidal rule for numerical integration as used in ATP. Numerical damping was also added to suppress oscillations locally when discontinuities occurred in the solution. A maximum error magnitude of 7.84% was encountered in the simulated currents for different turn-to-ground and turn-to-turn faults. The FEM approach provided the most accurate means to determine the leakage parameters for the ATP model. The higher-order model was found to reproduce the short-circuit impedance acceptably up to about 10 kHz and the behavior at the first anti-resonant frequency was better matched with the measurements.

Space trajectories optimization using variable-chromosome-length genetic algorithms

The problem of optimal design of a multi-gravity-assist space trajectories, with free number of deep space maneuvers (MGADSM) poses multi-modal cost functions. In the general form of the problem, the number of design variables is solution dependent. To handle global optimization problems where the number of design variables varies from one solution to another, two novel genetic-based techniques are introduced: hidden genes genetic algorithm (HGGA) and dynamic-size multiple population genetic algorithm (DSMPGA). In HGGA, a fixed length for the design variables is assigned for all solutions. Independent variables of each solution are divided into effective and ineffective (hidden) genes. Hidden genes are excluded in cost function evaluations. Full-length solutions undergo standard genetic operations. In DSMPGA, sub-populations of fixed size design spaces are randomly initialized. Standard genetic operations are carried out for a stage of generations. A new population is then created by reproduction from all members based on their relative fitness. The resulting sub-populations have different sizes from their initial sizes. The process repeats, leading to increasing the size of sub-populations of more fit solutions. Both techniques are applied to several MGADSM problems. They have the capability to determine the number of swing-bys, the planets to swing by, launch and arrival dates, and the number of deep space maneuvers as well as their locations, magnitudes, and directions in an optimal sense. The results show that solutions obtained using the developed tools match known solutions for complex case studies. The HGGA is also used to obtain the asteroids sequence and the mission structure in the global trajectory optimization competition (GTOC) problem. As an application of GA optimization to Earth orbits, the problem of visiting a set of ground sites within a constrained time frame is solved. The J2 perturbation and zonal coverage are considered to design repeated Sun-synchronous orbits. Finally, a new set of orbits, the repeated shadow track orbits (RSTO), is introduced. The orbit parameters are optimized such that the shadow of a spacecraft on the Earth visits the same locations periodically every desired number of days.

Multiscale methods for shape constraints in deconvolution: Confidence statements for qualitative features

We derive multiscale statistics for deconvolution in order to detect qualitative features of the unknown density. An important example covered within this framework is to test for local monotonicity on all scales simultaneously. We investigate the moderately ill-posed setting, where the Fourier transform of the error density in the deconvolution model is of polynomial decay. For multiscale testing, we consider a calibration, motivated by the modulus of continuity of Brownian motion. We investigate the performance of our results from both the theoretical and simulation based point of view. A major consequence of our work is that the detection of qualitative features of a density in a deconvolution problem is a doable task, although the minimax rates for pointwise estimation are very slow.

New Product Portfolio Performance in Family Firms

This study investigates the relationship between top management team (TMT) innovation orientation and new product portfolio performance in small and medium-sized family firms by exploring two family firm-specific sources of TMT diversity as moderators: the number of generations involved in the TMT and the ratio of family members in the TMT. Results indicate that family-induced diversity in the TMT has opposing moderating effects. Although a positive relationship exists between TMT innovation orientation and new product portfolio performance when multiple generations are involved in the TMT, TMT innovation orientation and new product portfolio performance experience a negative relationship when the ratio of family members in the TMT is high. The study discusses theoretical and managerial implications of the findings and develops avenues for future research.

CHARACTERIZING, ASSESSING AND IMPROVING HEALTHCARE REFERRAL COMMUNICATION

Similar to other health care processes, referrals are susceptible to breakdowns. These breakdowns in the referral process can lead to poor continuity of care, slow diagnostic processes, delays and repetition of tests, patient and provider dissatisfaction, and can lead to a loss of confidence in providers. These facts and the necessity for a deeper understanding of referrals in healthcare served as the motivation to conduct a comprehensive study of referrals. The research began with the real problem and need to understand referral communication as a mean to improve patient care. Despite previous efforts to explain referrals and the dynamics and interrelations of the variables that influence referrals there is not a common, contemporary, and accepted definition of what a referral is in the health care context. The research agenda was guided by the need to explore referrals as an abstract concept by: 1) developing a conceptual definition of referrals, and 2) developing a model of referrals, to finally propose a 3) comprehensive research framework. This dissertation has resulted in a standard conceptual definition of referrals and a model of referrals. In addition a mixed-method framework to evaluate referrals was proposed, and finally a data driven model was developed to predict whether a referral would be approved or denied by a specialty service. The three manuscripts included in this dissertation present the basis for studying and assessing referrals using a common framework that should allow an easier comparative research agenda to improve referrals taking into account the context where referrals occur.

Volume and shape in feature space on adaptive FCM in MRI segmentation.

Intensity non-uniformity (bias field) correction, contextual constraints over spatial intensity distribution and non-spherical cluster's shape in the feature space are incorporated into the fuzzy c-means (FCM) for segmentation of three-dimensional multi-spectral MR images. The bias field is modeled by a linear combination of smooth polynomial basis functions for fast computation in the clustering iterations. Regularization terms for the neighborhood continuity of either intensity or membership are added into the FCM cost functions. Since the feature space is not isotropic, distance measures, other than the Euclidean distance, are used to account for the shape and volumetric effects of clusters in the feature space. The performance of segmentation is improved by combining the adaptive FCM scheme with the criteria used in Gustafson-Kessel (G-K) and Gath-Geva (G-G) algorithms through the inclusion of the cluster scatter measure. The performance of this integrated approach is quantitatively evaluated on normal MR brain images using the similarity measures. The improvement in the quality of segmentation obtained with our method is also demonstrated by comparing our results with those produced by FSL (FMRIB Software Library), a software package that is commonly used for tissue classification.

Dental fear and satisfaction with dental services in Switzerland.

OBJECTIVES Dental satisfaction is associated with continuity of dental care, compliance with dentist advice, and positive health outcomes. It is expected that people with higher dental fear might have less dental satisfaction because of more negative dental experiences. The objective of this study was to examine satisfaction and reasons for satisfaction with dental practitioners in Switzerland and variations by dental fear. METHODS A national sample of 1,129 Swiss residents aged 15-74 (mean = 43.2 years) completed a personal interview at their home with questions assessing dental fear, dental service use, general satisfaction with their dentist, and reasons for satisfaction or dissatisfaction. RESULTS Overall, 47.9 percent of participants responded that they were satisfied with their dentist and 47.6 percent that they were very satisfied. Satisfaction differed significantly by gender, language spoken, region of residence, and educational attainment. Greater dental fear was significantly associated with greater dissatisfaction with the dentist. The percentage of people who were very satisfied with the dentist ranged from 56.0 percent among people with no fear to 30.5 percent for participants with "quite a lot" of fear but was higher (44.4 percent) for people who stated that they were "very much" afraid of the dentist. The most common reasons attributed for satisfaction with dentists were interpersonal characteristics of the dentist and staff. People with "quite a lot" of fear were found to endorse these sentiments least. CONCLUSIONS Although higher dental fear was associated with more dissatisfaction with the dentist, the level of satisfaction among fearful individuals in Switzerland is still high.

Dynamic intraligamentary stabilization: novel technique for preserving the ruptured ACL

PURPOSE Replacement of the torn anterior cruciate ligament (ACL) with a transplant is today`s gold standard. A new technique for preserving and healing the torn ACL is presented. HYPOTHESIS a dynamic intraligamentary stabilization (DIS) that provides continuous postinjury stability of the knee and ACL in combination with biological improvement of the healing environment [leucocyte- and platelet-rich fibrin (L-PRF) and microfracturing] should enable biomechanically stable ACL self-healing. METHODS Ten sportive patients were treated by DIS employing an internal stabilizer to keep the unstable knee in a posterior translation, combined with microfracturing and platelet-rich fibrin induction at the rupture site to promote self-healing. Postoperative clinical [Tegner, Lysholm, International Knee Documentation Committee (IKDC), visual analogue scale patient satisfaction score] and radiological evaluation, as well as assessment of knee laxity was performed at 6 weeks, 3, 6, 12, and 24 months. RESULTS One patient had a re-rupture 5 months postoperative and was hence excluded from further follow-ups. The other nine patients presented the following outcomes at 24 months: median Lysholm score of 100; IKDC score of 98 (97-100); median Tegner score of 6 (range 9-5); anterior translation difference of 1.4 mm (-1 to 3 mm); median satisfaction score of 9.8 (9-10). MRI showed scarring and continuity of the ligament in all patients. CONCLUSIONS DIS combined with microfracturing and L-PRF resulted in stable clinical and radiological healing of the torn ACL in all but one patient of this first series. They attained normal knee scores, reported excellent satisfaction and could return to their previous levels of sporting activity. LEVEL OF EVIDENCE Case series with no comparison group, Level IV.

Las etapas de la valorización financiera y el rol del sindicalismo argentino

El golpe de Estado de 1976 interrumpió el modelo sustitutivo de importaciones y transformó el comportamiento económico y social del último cuarto de siglo. Este escenario de predominio de la espectulación sobre la producción –profundizado en democracia- potenció la concentración del capital, y trajo aparejado un alto nivel de exclusión social. La continuidad de este modelo en democracia, exigió una articulación entre sistema político y valorización financiera. La situación del sindicalismo y el rol que jugó su principal Confederación, muestran las formas de disciplinamiento o cooptación que sufrió el movimiento obrero argentino y las estrategias elegidas por sus dirigentes.