Effectiveness and Cost-effectiveness of Outpatient Physiotherapy After Knee Replacement for Osteoarthritis: Study Protocol for a Randomised Controlled Trial

Background: Primary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement. Methods/design: Two hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises. The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective. Discussion: This research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency.

The Broader Impact of Disability Research: Aligning Public Policy with the Experiences of People with Disabilities and Healthcare Providers

Thesis (Ph.D.)--University of Washington, 2016-07

Evaluation of a versatile energy auditing tool

Energy auditing can be an important contribution for identification and assessment of energy conservation measures (ECMs) in buildings. Numerous tools and software have been developed, with varying degree of precision and complexity and different areas of use.   This paper evaluates PHPP as a versatile, easy-to-use energy auditing tool and gives examples of how it has been compared to a dynamic simulation tool, within the EU-project iNSPiRe. PHPP is a monthly balance energy calculation tool based on EN13790. It is intended for assisting the design of Passive Houses and energy renovation projects and as guidance in the choice of appropriate ECMs.   PHPP was compared against the transient simulation software TRNSYS for a single family house and a multi-family house. It should be mentioned that dynamic building simulations might strongly depend on the model assumptions and simplifications compared to reality, such as ideal heating or real heat emission system. Setting common boundary conditions for both PHPP and TRNSYS, the ideal heating and cooling loads and demands were compared on monthly and annual basis for seven European locations and buildings with different floor area, S/V ratio, U-values and glazed area of the external walls.   The results show that PHPP can be used to assess the heating demand of single-zone buildings and the reduction of heating demand with ECMs with good precision. The estimation of cooling demand is also acceptable if an appropriate shading factor is applied in PHPP. In general, PHPP intentionally overestimates heating and cooling loads, to be on the safe side for system sizing. Overall, the agreement with TRNSYS is better in cases with higher quality of the envelope as in cold climates and for good energy standards. As an energy auditing tool intended for pre-design it is a good, versatile and easy-to-use alternative to more complex simulation tools.

Os efeitos das reclamações online na lealdade dos consumidores: um estudo experimental

In an environment of constant change, technological developments, market competition and more informed consumers, the search for a lasting relationship through the conquest of loyalty has become the objective of companies. However, several authors suggest that this loyalty can be affected by negative comments available on the internet. Therefore, this dissertation has as objective to examine if the complaints are available on the internet impact the loyalty to a brand of mobile phone. The research used as the basis the Expanded NCSB model suggest by Johnson et al. (2001), studying five prominent drives of loyalty: image/brand reputation, affective commitment, calculative commitment, perceived value and trust, beyond the satisfaction construct as moderator variable. The research method adopted was the experimental design which included 285 undergraduate students, with the trial which included 285 undergraduate students, with the field study of the mobile industry, specifically, the brands of cell phones. The research approach was quantitative and methods were descriptive statistics, factor analysis, cluster analysis, linear regression and non-parametric test of Wilcoxon for data analysis. Of the 16 hypothesis stemmed from the research model proposed, 12 were confirmed. The results showed that the complaint available on the internet, here represented by the available on the site Reclame Aqui, may impact consumer perceptions about brand loyalty, as well as its antecedents, being that these complaints can affect all the consumers, regardless of historical satisfaction with the brand. It also noted the positive relationship between the independent variables trust, image/brand reputation, perceived value, affective commitment and calculative commitment and the dependent variable - loyalty, even when considering the data obtained after exposure to the complaint. However, no unanimous conclusion that the relationship between these variables was strongest in the group with satisfactory experience. At the first moment of the research, the trust was the most important variable for the formation of loyalty. However, after exposure to treatment, the image/brand reputation, was more relevant. Contributions of the study, limitations and recommendations for future researches are approached in the present investigation

Balanceamento de linhas de montagem e aplicação de ferramentas Lean no contexto da Polisport

Cada vez mais, nos dias que correm, está presente em todas as organizações a metodologia lean, que assenta numa base de melhoria contínua, de forma a responder às necessidades do mercado e à satisfação do cliente, tendo como principal finalidade a criação de valor para o produto e a eliminação de desperdícios inerente aos processos de produção do mesmo. Um elemento essencial na gestão de qualquer organização com ênfase nos resultados é o uso de indicadores de desempenho no processo de tomada de decisão. Este projeto teve como objetivo principal a identificação e eliminação de desperdícios, melhorando os processos de montagem, através do estudo dos tempos de ciclo dos centros de trabalhos/produtos mais críticos, procedendo a um balanceamento adequado e posterior simulação dos resultados através do software Arena. Posteriormente foram analisados os resultados assim como o impacto que essas mudanças causaram na empresa, com base na implementação de ferramentas de melhoria, nomeadamente ferramentas lean. Essas mudanças tiveram um impacto positivo na produção final das cadeiras e dos porta-bebés, no que diz respeito à diminuição de filas de espera entre postos, diminuição dos tempos de processamento e aumento da produção para alguns dos modelos em estudo.

The efficiency of four transtibial suspension systems: a malformation case study

This work was developed in the form of a case study to measure the efficiency of gait and conclude if the tested suspension systems differ in the efficiency in a various tested transtibial prostheses,based on the data provided by radiologic images, indirect calorimetry and perception of the patient. Introduction - The suspension system and the stump adjustment to the socket plays an important role in the functionality of the prosthesis, the mobility of the amputee and overall satisfaction with the device. The comfort and functional effectiveness of the prosthesis are closely related. The harmony between the residual limb and prosthesis is crucial to that this meets its function and enable effective March and allow the amputated the continuity of their Daily day activities, keeping the stump functional. Comfort and functional effectiveness of the prosthesis are closely related, suspension systems should prevent excessive longitudinal and rotational transverse displacement of the stump within the socket, these systems should help stabilize and enhance the connection of the prosthesis to the residual limb, reducing the pistonning, increased proprioception and providing a more natural gait.

A Stationless Bikeshare Proof of Concept for College Campuses

Bikeshares promote healthy lifestyles and sustainability among commuters, casual riders, and tourists. However, the central pillar of modern systems, the bike station, cannot be easily integrated into a compact college campus. Fixed stations lack the flexibility to meet the needs of college students who make quick, short-distance trips. Additionally, the necessary cost of implementing and maintaining each station prohibits increasing the number of stations for user convenience. Therefore, the team developed a stationless bikeshare based on a smartlock permanently attached to bicycles in the system. The smartlock system design incorporates several innovative approaches to provide usability, security, and reliability that overcome the limitations of a station centered design. A focus group discussion allowed the team to receive feedback on the early lock, system, and website designs, identify improvements and craft a pleasant user experience. The team designed a unique, two-step lock system that is intuitive to operate while mitigating user error. To ensure security, user access is limited through near field ii communications (NFC) technology connected to a mechatronic release system. The said system relied on a NFC module and a servo working through an Arduino microcontroller coded in the Arduino IDE. To track rentals and maintain the system, each bike is fitted with an XBee module to communicate with a scalable ZigBee mesh network. The network allows for bidirectional, real-time communication with a Meteor.js web application, which enables user and administrator functions through an intuitive user interface available on mobile and desktop. The development of an independent smartlock to replace bike stations is essential to meet the needs of the modern college student. With the goal of creating a bikeshare that better serves college students, Team BIKES has laid the framework for a system that is affordable, easily adaptable, and implementable on any university expressing an interest in bringing a bikeshare to its campus.

Spatiotemporal control over the co-conformational switching in pH-responsive flavylium-based multistate pseudorotaxanes

A multistate molecular dyad containing flavylium and viologen units was synthesized and the pH dependent thermodynamics of the network completely characterized by a variety of spectroscopic techniques such as NMR, UV-vis and stopped-flow. The flavylium cation is only stable at acidic pH values. Above pH ≈ 5 the hydration of the flavylium leads to the formation of the hemiketal followed by ring-opening tautomerization to give the cis-chalcone. Finally, this last species isomerizes to give the trans-chalcone. For the present system only the flavylium cation and the trans-chalcone species could be detected as being thermodynamically stable. The hemiketal and the cis-chalcone are kinetic intermediates with negligible concentrations at the equilibrium. All stable species of the network were found to form 1 : 1 and 2 : 1 host : guest complexes with cucurbit[7]uril (CB7) with association constants in the ranges 10(5)-10(8) M(-1) and 10(3)-10(4) M(-1), respectively. The 1 : 1 complexes were particularly interesting to devise pH responsive bistable pseudorotaxanes: at basic pH values (≈12) the flavylium cation interconverts into the deprotonated trans-chalcone in a few minutes and under these conditions the CB7 wheel was found to be located around the viologen unit. A decrease in pH to values around 1 regenerates the flavylium cation in seconds and the macrocycle is translocated to the middle of the axle. On the other hand, if the pH is decreased to 6, the deprotonated trans-chalcone is neutralized to give a metastable species that evolves to the thermodynamically stable flavylium cation in ca. 20 hours. By taking advantage of the pH-dependent kinetics of the trans-chalcone/flavylium interconversion, spatiotemporal control of the molecular organization in pseudorotaxane systems can be achieved.

Patients' satisfaction and quality of life in coronary artery disease

OBJECTIVES: To assess satisfaction of survivors of coronary artery diseases (CAD) with healthcare services and to determine whether specific components of standard health-related quality of life (HRQL) assessment tools might identify areas of satisfaction and dissatisfaction. METHOD: A specific tool developed to provide a comprehensive assessment of healthcare needs was administered concomitantly with generic and specific HRQL instruments, on 242 patients with CAD, admitted to an acute coronary unit during a single year. RESULTS: 92.5% of patients confirmed their trust in and satisfaction with the care given by their General Practitioner; even so, one third experienced difficulty getting an appointment and a quarter wanted more time for each consultation or prompt referral to a specialist when needed. Around a third expressed dissatisfaction with advice from the practice nurse or hospital consultant. Overall 54% were highly satisfied with services, 33% moderately satisfied and 13% dissatisfied.Cronbach's alpha was 0.87; the corrected total-item correlation ranged between 0.55-0.75, with trivial 'floor' score and low 'ceiling' effect. Several domains in all three HRQL tools correlated with items relating to satisfaction. The Seattle Angina Questionnaire Treatment Score correlated significantly with all satisfaction items and with the global satisfaction score. CONCLUSION: Cardiac patients' demanded better services and advice from, and more time with, health professionals and easier surgery access. The satisfaction tool showed acceptable psychometric properties. In this patient group, disease-specific HRQL tools seem more appropriate than generic tools for surveys of patient satisfaction

Aprendizaje basado en problemas, ABP : una propuesta para transformar la enseñanza-aprendizaje de las aplicaciones de la trigonometría en la solución de triángulos en el grado 10º

El estudio tuvo como propósito determinar la efectividad relativa del ABP, comparado con el método tradicional para desarrollar habilidades de resolución de problemas en el aprendizaje de las aplicaciones de la solución de triángulos en el grado 10º de la Institución Educativa El Progreso, de El Carmen de Viboral, Antioquia. La enseñanza-aprendizaje de las matemáticas sustentadas con la estrategia didáctica Aprendizaje Basado en Problemas permite a los estudiantes y docentes aproximarse al conocimiento de una manera similar a como lo hacen los científicos; el primer paso es una situación de duda, perplejidad del estudiante provocada por la Situación Problema planteada por el docente, el segundo un momento de “sugerencias” en las que la mente salta hacia adelante en busca de una posible solución (Dewey, 1933, p. 102). El tercer paso “intelectualización” de la dificultad que se ha percibido para convertirlo en un problema que debe solucionarse (Dewey, 1933, p. 103). La cuarta es “la idea conductora o hipótesis”, las cuales se basan en la formulación de explicaciones sugeridas o soluciones posibles (Dewey, 1933, p. 104). El quinto paso sería el “razonamiento”, consiste en la elaboración racional de una idea que se va desarrollando de acuerdo a las habilidades de cada persona (Dewey, 1933, p. 105). El paso final es la “comprobación de hipótesis” en situaciones reales. Este proceso se evidenció a través de cuatro Situaciones-Problema enfocadas desde un contexto auténtico “la remodelación del parque principal de El Carmen de Viboral” con el objetivo de motivar a los estudiantes para el aprendizaje de algunos conceptos matemáticos y el desarrollo de habilidades de resolución de problemas. La metodología de la investigación fue un diseño cuasi-experimental con grupo experimental compuesto por 38 estudiantes del grado 10º2 y grupo control con 37 estudiantes del grado 10º1. Se empleó como técnica de recolección de la información una prueba pre-test antes del tratamiento y una prueba post-test que se aplicó después del tratamiento a ambos grupos; se aplicó también una escala de satisfacción de los estudiantes con la metodología tradicional en ambos grupos y una escala de satisfacción con la estrategia didáctica ABP sólo al grupo experimental; la observación directa, y el portafolio que evidenciaba todas las construcciones de los estudiantes. La aplicación de la estrategia didáctica experimental se aplicó durante 4 meses, con una intensidad horaria de cuatro horas semanales, tiempo durante el cual se implementaron las cuatro Situaciones-Problema. Se concluyó entre otros aspectos que el 86,5% de los estudiantes encuentran las clases de matemáticas como interesantes, contextualizadas, aplicables y significativas, mientras que antes del tratamiento sólo el 44,4% se encontraba satisfecho con las clases de matemáticas, con una diferencia en cambio de actitud de 42,1% frente a las clases de matemáticas con la metodología tradicional. En el análisis comparativo de adquisición de competencias específicas se demuestra que el grupo experimental demostró ser matemáticamente más competente con respecto al grupo control en todas las competencias evaluadas: capacidad de modelación, inductiva, comunicativa y habilidad procedimental. Además, el proyecto de investigación tuvo un valor agregado: 10 estudiantes tuvieron la oportunidad de conocer más sobre su cultura ceramista mediante el diseño y construcción de mosaicos que los ofreció la casa de la cultura en forma gratuita.

The Southern Ischia canyon system: examples of deep sea depositional systems on the continental slope off Campania (Italy)

The Southern Ischia canyon system has been investigated in detail through Multibeam bathymetry and Sparker seismic data and has been put in the geological framework of the deep sea depositional systems off the Campania region. The geological and geomorphological characteristics of the canyon system have been also compared with the characters of the Mediterranean submarine canyons and with the deep sea depositional systems of the Tyrrhenian sea. The Southern Ischia canyon system engraves a narrow continental shelf from Punta Imperatore to Punta San Pancrazio, being limited southwestwards from the relict volcanic edifice of the Ischia Bank. It consists of twenty-two drainage axes, whose planimetric trending has been reconstructed in a sketch morphological map realized through the geological interpretation of Multibeam bathymetry. While the eastern boundary of the canyon system is controlled by extensional tectonics, being limited by a NE-SW trending (anti-Apenninic) normal fault, its western boundary is controlled by volcanism, due to the growth of the Ischia volcanic bank. Submarine gravitational instabilities also acted in relationships to the canyon system, allowing for the individuation of large-scale creeping at the sea bottom and hummocky deposits already interpreted as debris avalanche deposits. Quaternary marine seismic sequences have been reconstructed through a densely spaced seismic grid recorded through a Sparker multitip seismic source, allowing for a detailed observation of steep erosional slopes occurring on the southern flank of the island and related deep sea depositional systems. Important implications of this study will regard the coastal monitoring and beach nourishment of the southern flank of the island, being involved by a strong erosion of marine and coastal systems.

'Immune System Approaches to Intrusion Detection - A Review'

Abstract. The use of artificial immune systems in intrusion detection is an appealing concept for two reasons. Firstly, the human immune system provides the human body with a high level of protection from invading pathogens, in a robust, self-organised and distributed manner. Secondly, current techniques used in computer security are not able to cope with the dynamic and increasingly complex nature of computer systems and their security. It is hoped that biologically inspired approaches in this area, including the use of immune-based systems will be able to meet this challenge. Here we collate the algorithms used, the development of the systems and the outcome of their implementation. It provides an introduction and review of the key developments within this field, in addition to making suggestions for future research.

Avaliação de desempenho e o compromisso face ao superior hierárquico

Mestrado em Contabilidade e Gestão das Instituições Financeiras

Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

Importance: critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. Objective: to evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post–intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. Design, Setting, and Participants: a parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. Interventions: during the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. Main Outcomes and Measures: the Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). Results: median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, −0.2 [95% CI, −1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, −0.1 [95% CI, −3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, −3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. Conclusions and Relevance: post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery.

Formalização e Implementação de um Sistema de Gestão Ambiental Segundo a Norma ISO 14001:2004 numa empresa de Construção Civil

Dissertação de Mestrado em Gestão Integrada da Qualidade, Ambiente e Segurança