Enjeux de l'introduction du parcours de soins coordonné en France par la Loi du 13 août 2004

Pour répondre à ces questions sur les enjeux du parcours de soins, nous allons estimer les recours aux médecins ambulatoires en 2003 à partir de l'enquête Santé Insee. Nous nous attacherons plus particulièrement à l'étude de la demande de consultations hors parcours de soins en fonction des déterminants sociodémographiques, économiques et éducatifs. L'objectif est d'évaluer si le cadre de la loi à la potentialité de bouleverser les pratiques de recours aux médecins ambulatoires, et d'évaluer les personnes qui ne s'inscrivent pas dans le schéma du parcours de soins coordonné et d'estimer les impacts possibles des incitations financières mises en place. Nous essayerons ensuite, au regard de nos résultats, de comprendre les objectifs de politique publique de cette réforme. [P. 15]

Estimation de l'impact économique de l'introduction d'un test diagnostique rapide pour le dépistage des MRSA au CHUV

Contexte : Parmi les infections nosocomiales, le Staphylocoque méticilline résistant (MRSA) est le germe pathogène le plus couramment identifié dans les hôpitaux du monde entier. La stratégie de contrôle des MRSA au CHUV implique le dépistage des patients à risque. Avec la méthode de dépistage par culture, le temps d'attente est de plusieurs jours. Ceci occasionne des problèmes dans la gestion des flux des patients, principalement à cause des mesures d'isolement. Pour réduire le temps d'attente, l'hôpital envisage d'utiliser une méthode de diagnostic rapide par "polymerase chain reaction" (PCR). Méthodologie : Les données concernant les dépistages réalisés, dans trois services durant l'année 2007, ont été utilisées. Le nombre de jours d'isolement a d'abord été déterminé par patient et par service. Ensuite une analyse des coûts a été effectuée afin d'évaluer la différence des coûts entre les deux méthodes pour chaque service. Résultats : Le principal impact économique de la méthode par PCR dépend principalement du nombre de jours d'isolements évités par rapport à la méthode de culture. Aux services de soins, l'analyse a été menée sur 192 dépistages. Quand la différence de jours d'isolement est de deux jours, le coût des dépistages diminue de plus de 12kCHF et le nombre de jours d'isolement diminue de 384 jours. Au centre interdisciplinaire des urgences, sur 96 dépistages, le gain potentiel avec la méthode PCR est de 6kCHF avec une diminution de 192 jours d'isolement. Aux soins intensifs adultes, la méthode de dépistage par PCR est la méthode la plus rentable avec une diminution des coûts entre 4KCHF et 20K CHF et une diminution des jours d'isolement entre 170 et 310. Pour les trois services analysés, les résultats montrent un rapport coût-efficacité favorable pour la méthode PCR lorsque la diminution des jours d'isolement est supérieure à 1.3 jour. Quand la différence de jours d'isolement est inférieure à 1.3, il faut tenir compte d'autres paramètres, comme le coût de matériel qui doit être supérieur à 45.5 CHF, et du nombre d'analyses par dépistage, qui doit être inférieur à 3, pour que la PCR reste l'alternative la plus intéressante. Conclusions : La méthode par PCR montre des avantages potentiels importants, tant économiques qu'organisationnels qui limitent ou diminuent les contraintes liées à la stratégie de contrôle des MRSA au CHUV. [Auteure, p. 3]

Analysis of space-time environmental data in complex regions

This thesis develops a comprehensive and a flexible statistical framework for the analysis and detection of space, time and space-time clusters of environmental point data. The developed clustering methods were applied in both simulated datasets and real-world environmental phenomena; however, only the cases of forest fires in Canton of Ticino (Switzerland) and in Portugal are expounded in this document. Normally, environmental phenomena can be modelled as stochastic point processes where each event, e.g. the forest fire ignition point, is characterised by its spatial location and occurrence in time. Additionally, information such as burned area, ignition causes, landuse, topographic, climatic and meteorological features, etc., can also be used to characterise the studied phenomenon. Thereby, the space-time pattern characterisa- tion represents a powerful tool to understand the distribution and behaviour of the events and their correlation with underlying processes, for instance, socio-economic, environmental and meteorological factors. Consequently, we propose a methodology based on the adaptation and application of statistical and fractal point process measures for both global (e.g. the Morisita Index, the Box-counting fractal method, the multifractal formalism and the Ripley's K-function) and local (e.g. Scan Statistics) analysis. Many measures describing the space-time distribution of environmental phenomena have been proposed in a wide variety of disciplines; nevertheless, most of these measures are of global character and do not consider complex spatial constraints, high variability and multivariate nature of the events. Therefore, we proposed an statistical framework that takes into account the complexities of the geographical space, where phenomena take place, by introducing the Validity Domain concept and carrying out clustering analyses in data with different constrained geographical spaces, hence, assessing the relative degree of clustering of the real distribution. Moreover, exclusively to the forest fire case, this research proposes two new methodologies to defining and mapping both the Wildland-Urban Interface (WUI) described as the interaction zone between burnable vegetation and anthropogenic infrastructures, and the prediction of fire ignition susceptibility. In this regard, the main objective of this Thesis was to carry out a basic statistical/- geospatial research with a strong application part to analyse and to describe complex phenomena as well as to overcome unsolved methodological problems in the characterisation of space-time patterns, in particular, the forest fire occurrences. Thus, this Thesis provides a response to the increasing demand for both environmental monitoring and management tools for the assessment of natural and anthropogenic hazards and risks, sustainable development, retrospective success analysis, etc. The major contributions of this work were presented at national and international conferences and published in 5 scientific journals. National and international collaborations were also established and successfully accomplished. -- Cette thèse développe une méthodologie statistique complète et flexible pour l'analyse et la détection des structures spatiales, temporelles et spatio-temporelles de données environnementales représentées comme de semis de points. Les méthodes ici développées ont été appliquées aux jeux de données simulées autant qu'A des phénomènes environnementaux réels; nonobstant, seulement le cas des feux forestiers dans le Canton du Tessin (la Suisse) et celui de Portugal sont expliqués dans ce document. Normalement, les phénomènes environnementaux peuvent être modélisés comme des processus ponctuels stochastiques ou chaque événement, par ex. les point d'ignition des feux forestiers, est déterminé par son emplacement spatial et son occurrence dans le temps. De plus, des informations tels que la surface bru^lée, les causes d'ignition, l'utilisation du sol, les caractéristiques topographiques, climatiques et météorologiques, etc., peuvent aussi être utilisées pour caractériser le phénomène étudié. Par conséquent, la définition de la structure spatio-temporelle représente un outil puissant pour compren- dre la distribution du phénomène et sa corrélation avec des processus sous-jacents tels que les facteurs socio-économiques, environnementaux et météorologiques. De ce fait, nous proposons une méthodologie basée sur l'adaptation et l'application de mesures statistiques et fractales des processus ponctuels d'analyse global (par ex. l'indice de Morisita, la dimension fractale par comptage de boîtes, le formalisme multifractal et la fonction K de Ripley) et local (par ex. la statistique de scan). Des nombreuses mesures décrivant les structures spatio-temporelles de phénomènes environnementaux peuvent être trouvées dans la littérature. Néanmoins, la plupart de ces mesures sont de caractère global et ne considèrent pas de contraintes spatiales com- plexes, ainsi que la haute variabilité et la nature multivariée des événements. A cet effet, la méthodologie ici proposée prend en compte les complexités de l'espace géographique ou le phénomène a lieu, à travers de l'introduction du concept de Domaine de Validité et l'application des mesures d'analyse spatiale dans des données en présentant différentes contraintes géographiques. Cela permet l'évaluation du degré relatif d'agrégation spatiale/temporelle des structures du phénomène observé. En plus, exclusif au cas de feux forestiers, cette recherche propose aussi deux nouvelles méthodologies pour la définition et la cartographie des zones périurbaines, décrites comme des espaces anthropogéniques à proximité de la végétation sauvage ou de la forêt, et de la prédiction de la susceptibilité à l'ignition de feu. A cet égard, l'objectif principal de cette Thèse a été d'effectuer une recherche statistique/géospatiale avec une forte application dans des cas réels, pour analyser et décrire des phénomènes environnementaux complexes aussi bien que surmonter des problèmes méthodologiques non résolus relatifs à la caractérisation des structures spatio-temporelles, particulièrement, celles des occurrences de feux forestières. Ainsi, cette Thèse fournit une réponse à la demande croissante de la gestion et du monitoring environnemental pour le déploiement d'outils d'évaluation des risques et des dangers naturels et anthro- pogéniques. Les majeures contributions de ce travail ont été présentées aux conférences nationales et internationales, et ont été aussi publiées dans 5 revues internationales avec comité de lecture. Des collaborations nationales et internationales ont été aussi établies et accomplies avec succès.

Ferro zero: uma nova abordagem para o tratamento de águas contaminadas com compostos orgânicos poluentes

Anthropogenic pollution of groundwater and surface water has become a very serious environmental problem around the world. A wide range of toxic pollutants is recalcitrant to the conventional treatment methods, thus there is much interest in the development of more efficient remediation processes. Degradation of organic pollutants by zero-valent iron is one of the most promising approaches for water treatment, mainly because it is of low cost, easy to obtain and effective. After a general introduction to water pollution and current treatments, this work highlights the advances, applications and future trends of water remediation by zero-valent iron. Special attention is given to degradation of organochloride and nitroaromatic compounds, which are commonly found in textile and paper mill effluents.

Homogenization Dynamics and Introduction Routes of Invasive Freshwater Fish in the Iberian Peninsula

Nonnative invasive species are one of the main global threats to biodiversity. The understanding of the traits characterizing successful invaders and invasion-prone ecosystems is increasing, but our predictive ability is still limited. Quantitative information on biotic homogenization and particularly its temporal dynamics is even scarcer. We used freshwater fish distribution data in the Iberian Peninsula in four periods (before human intervention, 1991, 1995, and 2001) to assess the temporal dynamics of biotic homogenization among river basins. The percentage of introduced species among fish faunas has increased in recent times (from 41.8% in 1991 to 52.5% in 2001), leading to a clear increase in the similarity of community composition among basins. The mean Jaccard's index increase (a measure of biotic homogenization) from the pristine situation to the present (17.1%) was similar to that for Californian fish but higher than for other studies. However, biotic homogenization was found to be a temporally dynamic process, with finer temporal grain analyses detecting transient stages of biotic differentiation. Introduced species assemblages were spatially structured along a latitudinal gradient in the Iberian Peninsula, with species related to sport fishing being characteristic of northern basins. Although the comparison of fish distributions in the Iberian Peninsula and France showed significant and generalized biotic homogenization, nonnative assemblages of northeastern Iberian basins were more similar to those of France than to those of the rest of the Iberian Peninsula, indicating a main introduction route. Species introduced to the Iberian Peninsula tended to be mainly piscivores or widely introduced species that previously had been introduced to France. Our results indicate that the simultaneous analysis of the spatial distribution of introduced assemblages (excluding native species that reflect other biogeographical patterns) and their specific traits can be an effective tool to detect introduction and invasion routes and to predict future invaders from donor regions

A brief introduction to molecular orbital theory of simple polyatomic molecules for undergraduate chemistry students

A simple, four-step method for better introducing undergraduate students to the fundamentals of molecular orbital (MO) theory of the polyatomic molecules H2O, NH3, BH3 and SiH4 using group theory is reported. These molecules serve to illustrate the concept of ligand group orbitals (LGOs) and subsequent construction of MO energy diagrams on the basis of molecular symmetry requirements.

The introduction of Mormonism to Finnish society, 1840-1900

This study examines the place of The Church of Jesus Christ of Latter-day Saints (commonly known as the Mormon church) in the Russian Grand Duchy of Finland between the years 1840 and 1900. Attention is put on both the internal workings of the movement and the reactions of society. Theoretical insight is gained through the concepts of social construction and religious economies. Mormon image formation in Finland began by 1840 through newspaper reports on activities abroad and through essays on the faith’s history and doctrine. Mormons are mentioned almost 3,500 times in Finnish newspapers between 1840 and 1900, and at least twelve unique book titles sold in the country were explicitly devoted to discussing Mormonism. Most of the publicity was derived from foreign sources. Discourse analysis of this textual corpus shows a hegemonic discourse that combined themes such as fraud, deception, and theocracy in explaining the Mormon movement. Accompanied by plural marriage, these themes contributed to the construction of a strongly negative image of Mormonism already before the first missionaries arrived in 1875. In a society with a stringently regulated religious economy, this image contributed to a high level of resistance by civil authorities and Lutheran clergy. Twenty-five Mormon missionaries worked in Finland between 1875 and 1900, with a concentrated effort taking place between 1875 and 1889. At least 78 persons converted, mostly in the coastal areas among the Swedish-speaking minority population. Nine percent emigrated to Utah, 36% were excommunicated, others fell into oblivion, while still others clung to their new faith. The work was led from Sweden, with no stable church organization emerging among the isolated pockets of converts. Mormonism’s presence was thus characterized by private or small-group religiosity rather than a vibrant movement. The lack of religious community, conversation, and secondary socialization eventually caused the nineteenth-century manifestation of Finnish Mormonism to die out. Only one group of converts was perpetuated past World War II, after which large-scale proselytizing began.

Tree structure and richness in an Atlantic Forest fragment: distance from anthropogenic and natural edges

Approximately 7.2% of the Atlantic rainforest remains in Brazil, with only 16% of this forest remaining in the State of Rio de Janeiro, all of it distributed in fragments. This forest fragmentation can produce biotic and abiotic differences between edges and the fragment interior. In this study, we compared the structure and richness of tree communities in three habitats - an anthropogenic edge (AE), a natural edge (NE) and the fragment interior (FI) - of a fragment of Atlantic forest in the State of Rio de Janeiro, Brazil (22°50'S and 42°28'W). One thousand and seventy-six trees with a diameter at breast height > 4.8 cm, belonging to 132 morphospecies and 39 families, were sampled in a total study area of 0.75 ha. NE had the greatest basal area and the trees in this habitat had the greatest diameter:height allometric coefficient, whereas AE had a lower richness and greater variation in the height of the first tree branch. Tree density, diameter, height and the proportion of standing dead trees did not differ among the habitats. There was marked heterogeneity among replicates within each habitat. These results indicate that the forest interior and the fragment edges (natural or anthropogenic) do not differ markedly considering the studied parameters. Other factors, such as the age from the edge, type of matrix and proximity of gaps, may play a more important role in plant community structure than the proximity from edges.

The introduction of navigation in liver surgery in Brazil

The authors thoroughly report the development, the technical aspects and the performance of the first navigated liver resections, by laparotomy and laparoscopy, in Brazil, done at the National Cancer Institute, Ministry of Health, using a surgical navigator.

Introduction of the T-10 static line parachuting capability to the NH90 helicopter

The purpose of this study was to investigate the suitability of the Finnish Defence Forces’ NH90 helicopter for parachuting operations with the T-10 static line parachute system. The work was based on the Army Command’s need to compensate for the reduction in the outsourced flight hours for the military static line parachuting training. The aim of the research was to find out the procedures and limitations with which the NH90 IOC+ or FOC version helicopter could be used for static line parachutist training with the T-10B/MC1-1C parachutes. The research area was highly complicated and non-linear. Thus analytical methods could not be applied with sufficient confidence, even with present-day computing power. Therefore an empirical research method was selected, concentrating on flight testing supported with literature study and some calculated estimations. During three flights and 4.5 flight hours in Utti, Finland on 1720 September 2012, a total of 44 parachute drops were made. These consisted of 16 dummy drops and 28 paratrooper jumps. The test results showed that when equipped with the floor mounted PASI-1 anchor line, the deflector bar of the NHIndustries’ Parachuting Kit and Patria’s floor protection panels the Finnish NH90 variant could be safely used for T-10B/MC1-1C static line parachuting operations from the right cabin door at airspeed range of 5080 KIAS (90–150 km/h). The ceiling mounted anchor lines of the NHI’s Parachuting Kit were not usable with the T-10 system. This was due to the static lines’ unsafe behaviour in slipstream when connected to the cabin ceiling level. In conclusion, the NH90 helicopter can be used to meet the Army Command’s requirement for an additional platform for T-10 static line parachutist training. Material dropping, the effect of additional equipment and jumping from the rear ramp should be further studied.

Scaling up stepwise feature introduction to construction of large software systems

Developing software is a difficult and error-prone activity. Furthermore, the complexity of modern computer applications is significant. Hence,an organised approach to software construction is crucial. Stepwise Feature Introduction – created by R.-J. Back – is a development paradigm, in which software is constructed by adding functionality in small increments. The resulting code has an organised, layered structure and can be easily reused. Moreover, the interaction with the users of the software and the correctness concerns are essential elements of the development process, contributing to high quality and functionality of the final product. The paradigm of Stepwise Feature Introduction has been successfully applied in an academic environment, to a number of small-scale developments. The thesis examines the paradigm and its suitability to construction of large and complex software systems by focusing on the development of two software systems of significant complexity. Throughout the thesis we propose a number of improvements and modifications that should be applied to the paradigm when developing or reengineering large and complex software systems. The discussion in the thesis covers various aspects of software development that relate to Stepwise Feature Introduction. More specifically, we evaluate the paradigm based on the common practices of object-oriented programming and design and agile development methodologies. We also outline the strategy to testing systems built with the paradigm of Stepwise Feature Introduction.