Unfulfilled rehabilitation needs and dissatisfaction with care 12 months after a stroke : an explorative observational study

BACKGROUND: People who have suffered a stroke commonly report unfulfilled need for rehabilitation. Using a model of patient satisfaction, we examined characteristics in individuals that at 3 months after stroke predicted, or at 12 months were associated with unmet need for rehabilitation or dissatisfaction with health care services at 12 months after stroke. METHODS: The participants (n = 175) received care at the stroke units at the Karolinska University Hospital, Sweden. The dependent variables "unfulfilled needs for rehabilitation" and "dissatisfaction with care" were collected using a questionnaire. Stroke severity, domains of the Stroke Impact Scale (SIS), the Sense of Coherence scale (SOC) and socio demographic factors were used as independent variables in four logistic regression analyses. RESULTS: Unfulfilled needs for rehabilitation at 12 months were predicted by strength (SIS) (odds ratio (OR) 7.05) at three months, and associated with hand function (SIS) (OR 4.38) and poor self-rated recovery (SIS) (OR 2.46) at 12 months. Dissatisfaction with care was predicted by SOC (OR 4.18) and participation (SIS) (OR 3.78), and associated with SOC (OR 3.63) and strength (SIS) (OR 3.08). CONCLUSIONS: Thirty-three percent of the participants reported unmet needs for rehabilitation and fourteen percent were dissatisfied with the care received. In order to attend to rehabilitation needs when they arise, rehabilitation services may need to be more flexible in terms of when rehabilitation is provided. Long term services with scheduled re-assessments and with more emphasis on understanding the experiences of both the patients and their social networks might better be able to provide services that attend to patients' needs and aid peoples' reorientation; this would apply particularly to those with poor coping capacity.

Usual clinical practice for early supported discharge after stroke with continued rehabilitation at home : an observational comparative study

Introduction: Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke. Material and methods: This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke. Results: At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs. Conclusions: ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Principles of High Quality Documentation for Provenance: A Philosophical Discussion

Computer technology enables the creation of detailed documentation about the processes that create or affect entities (data, objects, etc.). Such documentation of the past can be used to answer various kinds of questions regarding the processes that led to the creation or modification of a particular entity. The answer to such questions is known as an entity's provenance. In this paper, we derive a number of principles for documenting the past, grounded in work from philosophy and history, which allow for provenance questions to be answered within a computational context. These principles lead us to argue that an interaction-based model is particularly suited for representing high quality documentation of the past.

Principles of Personalisation of Service Discovery

We define personalisation as the set of capabilities that enables a user or an organisation to customise their working environment to suit their specific needs, preferences and circumstances. In the context of service discovery on the Grid, the demand for personalisation comes from individual users, who want their preferences to be taken into account during the search and selection of suitable services. These preferences can express, for example, the reliability of a service, quality of results, functionality, and so on. In this paper, we identify the problems related to personalising service discovery and present our solution: a personalised service registry or View. We describe scenarios in which personsalised service discovery would be useful and describe how our technology achieves them.

Optimal Rehabilitation Strategy In Water Distribution Systems Considering Reduction In Greenhouse Gas Emissions

Most of water distribution systems (WDS) need rehabilitation due to aging infrastructure leading to decreasing capacity, increasing leakage and consequently low performance of the WDS. However an appropriate strategy including location and time of pipeline rehabilitation in a WDS with respect to a limited budget is the main challenge which has been addressed frequently by researchers and practitioners. On the other hand, selection of appropriate rehabilitation technique and material types is another main issue which has yet to address properly. The latter can affect the environmental impacts of a rehabilitation strategy meeting the challenges of global warming mitigation and consequent climate change. This paper presents a multi-objective optimization model for rehabilitation strategy in WDS addressing the abovementioned criteria mainly focused on greenhouse gas (GHG) emissions either directly from fossil fuel and electricity or indirectly from embodied energy of materials. Thus, the objective functions are to minimise: (1) the total cost of rehabilitation including capital and operational costs; (2) the leakage amount; (3) GHG emissions. The Pareto optimal front containing optimal solutions is determined using Non-dominated Sorting Genetic Algorithm NSGA-II. Decision variables in this optimisation problem are classified into a number of groups as: (1) percentage proportion of each rehabilitation technique each year; (2) material types of new pipeline for rehabilitation each year. Rehabilitation techniques used here includes replacement, rehabilitation and lining, cleaning, pipe duplication. The developed model is demonstrated through its application to a Mahalat WDS located in central part of Iran. The rehabilitation strategy is analysed for a 40 year planning horizon. A number of conventional techniques for selecting pipes for rehabilitation are analysed in this study. The results show that the optimal rehabilitation strategy considering GHG emissions is able to successfully save the total expenses, efficiently decrease the leakage amount from the WDS whilst meeting environmental criteria.

Three principles of competitive nonlinear pricing

We make three contributions to the theory of contracting under asymmetric information. First, we establish a competitive analog to the revelation principIe which we call the implementation principIe. This principIe provides a complete characterization of all incentive compatible, indirect contracting mechanisms in terms of contract catalogs (or menus), and allows us to conclude that in competi tive contracting situations, firms in choosing their contracting strategies can restrict attention, without loss of generality, to contract catalogs. Second, we establish a competi tive taxation principIe. This principIe, a refinement of the implementation principIe, provides a complete characterization of all implementable nonlinear pricing schedules in terms of product-price catalogs and allows us to reduce any game played over nonlinear pricing schedules to a strategically equivalent game played over product-price catalogs. Third, using the competitive taxation principIe and a recent result due to Reny (1999) on the existence of Nash equilibria in discontinuous games, we demonstrate the existence of a N ash equilibrium for the mixed extension of the nonlinear pricing game.

Enforcing international financial standards in Brazil: limits and possibilities for adoption of IOSCO principles

Foreign capital and institutional investors play a key role in the Brazilian capital and financial markets. Internationally promoted regulatory patterns, especially IOSCO principles, have been increasingly influencing administrative rule making by the Brazilian Securities and Exchange Commission (CVM) as well as the adoption of transnational rules in Brazil by means of self-regulatory activity. Even though there is a certain level of convergence of market regulatory standards at the transnational level, implementation and enforcement of rules remains essentially domestic. We analyze two case studies regarding the transposition of international standards into the Brazilian legal system, which illustrate this tension between the transnational and domestic dimensions of financial markets regulation. The first case concerns a CVM rule on disclosure of executive compensation and the its interpretation by local courts. The second case refers to the adoption of suitability rules.

Integrating eye tracking in virtual reality for stroke rehabilitation

This thesis reports on research done for the integration of eye tracking technology into virtual reality environments, with the goal of using it in rehabilitation of patients who suffered from stroke. For the last few years, eye tracking has been a focus on medical research, used as an assistive tool  to help people with disabilities interact with new technologies  and as an assessment tool  to track the eye gaze during computer interactions. However, tracking more complex gaze behaviors and relating them to motor deficits in people with disabilities is an area that has not been fully explored, therefore it became the focal point of this research. During the research, two exploratory studies were performed in which eye tracking technology was integrated in the context of a newly created virtual reality task to assess the impact of stroke. Using an eye tracking device and a custom virtual task, the system developed is able to monitor the eye gaze pattern changes over time in patients with stroke, as well as allowing their eye gaze to function as an input for the task. Based on neuroscientific hypotheses of upper limb motor control, the studies aimed at verifying the differences in gaze patterns during the observation and execution of the virtual goal-oriented task in stroke patients (N=10), and also to assess normal gaze behavior in healthy participants (N=20). Results were found consistent and supported the hypotheses formulated, showing that eye gaze could be used as a valid assessment tool on these patients. However, the findings of this first exploratory approach are limited in order to fully understand the effect of stroke on eye gaze behavior. Therefore, a novel model-driven paradigm is proposed to further understand the relation between the neuronal mechanisms underlying goal-oriented actions and eye gaze behavior.

Influence of door handles design in effort perception: accessibility and usability

The application of ergonomics in product design is essential to its accessibility and usability. The development of manual devices should be based on ergonomic principles. Effort perception analysis is an essential approach to understand the physical and subjective aspects of the interface. The objective of the present study was to analyze the effort perception during a simulated task with different door handles by Portuguese subjects of both genders and different ages. This transversal study agreed with ethical aspects. 180 subjects of both genders pertaining to three age groups have participated. Five door handles with different shapes were evaluated. A subjective numeric rating scale of 5 levels was used to evaluate the effort. For statistical analysis it was applied the Friedman non-parametric test. The results have showed no significant differences of effort perception in door handles "A" and "B"; "A" and "D"; and "D" and "C". Door handle "E" presented the lowest values of all. In general, there's an inverse relationship between the results of biomechanical studies and the effort perception of the same task activity. This shows that door handles design influence directly these two variables and can interfere in the accessibility and usability of these kinds of products.

O direito à saúde e a política nacional de atenção oncológica: uma análise a partir da crescente judicialização dos medicamentos antineoplásicos

The 1988 Federal Constitution of Brazil by presenting the catalog of fundamental rights and guarantees (Title II) provides expressly that such rights reach the social, economic and cultural rights (art. 6 of CF/88) as a means not only to ratify the civil and political rights, but also to make them effective and practical in the life of the Brazilian people, particularly in the prediction of immediate application of those rights and guarantees. In this sense, health goes through condition of universal right and duty of the State, which should be guaranteed by social and economic policies aimed at reducing the risk of disease and other hazards, in addition to ensuring universal and equal access to actions and services for its promotion, protection and recovery (Article 196 by CF/88). Achieving the purposes aimed by the constituent to the area of health is the great challenge that requires the Health System and its managers. To this end, several policies have been structured in an attempt to establish actions and services for the promotion, protection and rehabilitation of diseases and disorders to health. In the mid-90s, in order to meet the guidelines and principles established by the SUS, it was established the Política Nacional de Atenção Oncológica PNAO, in an attempt to sketch out a public policy that sought to achieve maximum efficiency and to be able to give answers integral to effective care for patients with cancer, with emphasis on prevention, early detection, diagnosis, treatment, rehabilitation and palliative care. However, many lawsuits have been proposed with applications for anticancer drugs. These actions have become very complex, both in the procedural aspects and in all material ones, especially due to the highcost drugs more requested these demands, as well as need to be buoyed by the scientific evidence of these drugs in relation to proposed treatments. The jurisprudence in this area, although the orientations as outlined by the Parliament of Supreme Court is still in the process of construction, this study is thus placed in the perspective of contributing to the effective and efficient adjudication in these actions, with focus on achieving the fundamental social rights. Given this scenario and using research explanatory literature and documents were examined 108 lawsuits pending in the Federal Court in Rio Grande do Norte, trying to identify the organs of the Judiciary behave in the face of lawsuits that seeking oncology drugs (or antineoplastic), seeking to reconcile the principles and constitutional laws and infra constitutional involving the theme in an attempt to contribute to a rationalization of this judicial practice. Finally, considering the Rational Use of health demands and the idea of belonging to the Brazilian people SUS, it is concluded that the judicial power requires ballast parameters of their decisions on evidence-based medicine, aligning these decisions housing constitutional principles that the right to health and the scientific conclusions of efficacy, effectiveness and efficiency in oncology drugs, when compared to the treatments offered by SUS

Characterization of the motor performance in infants with a diagnosis of Cerebral Palsy in process of rehabilitation: the importance of the proactivity of caregivers

Introduction: The progress in technology, associated to the high survival rate in premature newborn infants in neonatal intensive care units, causes an increase in morbidity. Individuals with CP present complex motor alterations, with primary deficits of abnormal muscle tone affecting posture and voluntary movement, alteration of balance and coordination, decrease of force, and loss of selective motor control with secondary problems of contractures and bone deformities.Objective: The aim of this work is to describe the spontaneous movement and strategies that lead infants with cerebral palsy to move.Methods: Seven infants used to receive assistance at the Essential Stimulation Center of CIAM (Israeli Center for Multidisciplinary Support - Philanthropic Institution), with ages ranging between six and 18 months with diagnosis of Cerebral Palsy (CP) were assessed.Results: The results show the difficulty presented by the infants with respect to the spontaneous motor functions and the necessity of help from the caregiver in order to perform the functional activity (mobility). Prematurity prevails as the major risk factor among the complications.Conclusion: The child development can be understood as a product of the dynamic interactions involving the infant, the family, and the context. Thus, the social interactions and family environment in which the infant live may encourage or limit both the acquisition of skills and the functional independence.

Clinical Viability for Immediate Loading of Dental Implants: Part II-Treatment Alternatives

The treatment with implants aims to obtain a direct interface between bone and implant. The implant is kept load-free during 4 to 6 months in the 2-stage procedure, which is considered a requisite for osseointegration. However, this period is based on empirical principles and uncomfortable for patient. So, the immediate loading protocol was Suggested to submit implants to occlusal function after placement. This protocol has been applied for several conditions of edentulism. The aim of this study was to evaluate the treatment alternatives for immediate loading of complete and partial edentulous patients. In general, the studies have demonstrated high previsibility for rehabilitation of complete edentulous arches with full-arch, implant-supported prosthesis. The rehabilitation with immediate loading for maxillary overdenture is questionable because there is no longitudinal study in literature. The studies with partial edentulous arches have demonstrated high success rates for implants placed in the mandibular and maxillary anterior region. Additional care is recommended for posterior region mainly in the maxillary arch, and further studies are suggested to corroborate this treatment.