Administração em saúde : da prestação à avaliação de resultados

A área da “política e administração da saúde”, tem merecido um interesse crescente nas últimas décadas. Provavelmente em consequência do substancial aumento das despesas de saúde que tem ocorrido em todo o mundo mas, também porque se tem verificado uma sensível melhoria da situação de saúde das populações, o que faz com que, “policy makers”, académicos, analistas do setor e “media” tragam as questões de saúde para as primeiras páginas, valorizando-as e tentando melhorar a compreensão sobre o muito complexo processo de prestação em saúde.Não se trata no entanto de uma melhoria que usualmente seja quantificada, ocorrendo até que, se são frequentes, as tentativas de medir os custos e a produção da saúde, setor que tem uma importante dimensão económica, o mesmo não se verifica em relação aos seus resultados (o impacto que os cuidados tiveram na saúde das populações) e ainda menos em relação aos chamados “ganhos em saúde”, afinal o objectivo maior dos sistemas de saúde.Assim, entre a subida das despesas e a melhoria dos resultados, há uma falta de relacionamento que torna difícil fazer um balanço, pelo que é urgente adotar modelos de avaliação da prestação e dos seus resultados que sejam explícitos e ajudem a validar a efetividade da prestação e dos resultados obtidos. O presente trabalho pretende ser um contributo para clarificar esta questão e procurar um indicador corrente que possa ser utilizado para objetivar os “ganhos em saúde” e que, por ser quantificável, possa permitir a definição de medidas de efetividade dos resultados obtidos e de avaliação da performance dos sistemas de saúde.Não será mais uma medida de medição da produção (outputs) mas que pode resolver muitos problemas de há longos anos, e dar suporte ao confronto recursos/resultados e permitindo avaliar a performance de sistemas de saúde, com consistência face aos seus objectivos e fiabilidade, sendo capaz de detetar as mudanças e de mostrar as diferenças.

Avaliação dos JDC em Educação Física : Estudo de Caso

Este estudo teve como questão de pesquisa verificar se há evidência de progressão na avaliação final dos Jogos Desportivos Colectivos de invasão, mantendo o protocolo de avaliação inicial, utilizando as Provas de Avaliação Aferida, aplicadas na Escola Secundária Dona Luísa de Gusmão (ESDLG). Como contributo à aplicação e sustentabilidade das Provas apresentamos um levantamento dos níveis introdução e elementar do Programa, em que destacamos princípios comuns que possam beneficiar a clarificação do currículo para os professores avaliadores e contribuir para o ensino dos jogos desportivos. O presente trabalho assume-se como um estudo exploratório de caso, em que se escolheu uma turma específica de oitavo ano da ESDLG, com vinte e seis sujeitos envolvidos no caso. Isto para estudar a filosofia de aplicação das Provas de Avaliação, em que a sua operacionalização é da responsabilidade do Grupo de Educação Física. Os resultados apontam para a progressão do nível de desempenho dos alunos nas matérias de Andebol, Basquetebol e Futebol. A avaliação nos jogos desportivos colectivos da ESDLG está de acordo com as orientações dos PNEF. O estudo é válido pela representação que as Provas têm nos objectivos definidos nos Programas Nacionais de Educação Física e obedece a níveis de fidelidade pela constância apresentada nas observações realizadas pelos professores nos dois momentos de avaliação. Importa também referir que as Provas de Avaliação alicerçam a aferição de critérios, moderam a avaliação dos alunos e permitem ao Agrupamento de Educação Física tomar decisões mediante os resultados e tendências das Provas. Para que a avaliação possa ser ainda mais objectiva será importante associar às Provas de Avaliação um ensino contextualizado dos jogos desportivos, de modo a que se avalie o aluno nas mesmas condições em que se ensina.

Slopes of Avian Species-Area Relationships, Human Population Density, and Environmental Factors

There is increasing interest in how humans influence spatial patterns in biodiversity. One of the most frequently noted and marked of these patterns is the increase in species richness with area, the species–area relationship (SAR). SARs are used for a number of conservation purposes, including predicting extinction rates, setting conservation targets, and identifying biodiversity hotspots. Such applications can be improved by a detailed understanding of the factors promoting spatial variation in the slope of SARs, which is currently the subject of a vigorous debate. Moreover, very few studies have considered the anthropogenic influences on the slopes of SARs; this is particularly surprising given that in much of the world areas with high human population density are typically those with a high number of species, which generates conservation conflicts. Here we determine correlates of spatial variation in the slopes of species–area relationships, using the British avifauna as a case study. Whilst we focus on human population density, a widely used index of human activities, we also take into account (1) the rate of increase in habitat heterogeneity with increasing area, which is frequently proposed to drive SARs, (2) environmental energy availability, which may influence SARs by affecting species occupancy patterns, and (3) species richness. We consider environmental variables measured at both local (10 km × 10 km) and regional (290 km × 290 km) spatial grains, but find that the former consistently provides a better fit to the data. In our case study, the effect of species richness on the slope SARs appears to be scale dependent, being negative at local scales but positive at regional scales. In univariate tests, the slope of the SAR correlates negatively with human population density and environmental energy availability, and positively with the rate of increase in habitat heterogeneity. We conducted two sets of multiple regression analyses, with and without species richness as a predictor. When species richness is included it exerts a dominant effect, but when it is excluded temperature has the dominant effect on the slope of the SAR, and the effects of other predictors are marginal.

Quantification of the probability of containment failure caused by an in-vessel steam explosion for the Sizewell B PWR

AEA Technology has provided an assessment of the probability of α-mode containment failure for the Sizewell B PWR. After a preliminary review of the methodologies available it was decided to use the probabilistic approach described in the paper, based on an extension of the methodology developed by Theofanous et al. (Nucl. Sci. Eng. 97 (1987) 259–325). The input to the assessment is 12 probability distributions; the bases for the quantification of these distributions are discussed. The α-mode assessment performed for the Sizewell B PWR has demonstrated the practicality of the event-tree method with input data represented by probability distributions. The assessment itself has drawn attention to a number of topics, which may be plant and sequence dependent, and has indicated the importance of melt relocation scenarios. The α-mode failure probability following an accident that leads to core melt relocation to the lower head for the Sizewell B PWR has been assessed as a few parts in 10 000, on the basis of current information. This assessment has been the first to consider elevated pressures (6 MPa and 15 MPa) besides atmospheric pressure, but the results suggest only a modest sensitivity to system pressure.

Potential impacts of climate change on water quality and ecology in six UK rivers

A modelling study has been undertaken to assess the likely impacts of climate change on water quality across the UK. A range of climate change scenarios have been used to generate future precipitation, evaporation and temperature time series at a range of catchments across the UK. These time series have then been used to drive the Integrated Catchment (INCA) suite of flow, water quality and ecological models to simulate flow, nitrate, ammonia, total and soluble reactive phosphorus, sediments, macrophytes and epiphytes in the Rivers Tamar, Lugg, Tame, Kennet, Tweed and Lambourn. A wide range of responses have been obtained with impacts varying depending on river character, catchment location, flow regime, type of scenario and the time into the future. Essentially upland reaches of river will respond differently to lowland reaches of river, and the responses will vary depending on the water quality parameter of interest.

Examining the interaction of growing crops with local climate using a coupled crop-climate model

This paper examines to what extent crops and their environment should be viewed as a coupled system. Crop impact assessments currently use climate model output offline to drive process-based crop models. However, in regions where local climate is sensitive to land surface conditions more consistent assessments may be produced with the crop model embedded within the land surface scheme of the climate model. Using a recently developed coupled crop–climate model, the sensitivity of local climate, in particular climate variability, to climatically forced variations in crop growth throughout the tropics is examined by comparing climates simulated with dynamic and prescribed seasonal growth of croplands. Interannual variations in land surface properties associated with variations in crop growth and development were found to have significant impacts on near-surface fluxes and climate; for example, growing season temperature variability was increased by up to 40% by the inclusion of dynamic crops. The impact was greatest in dry years where the response of crop growth to soil moisture deficits enhanced the associated warming via a reduction in evaporation. Parts of the Sahel, India, Brazil, and southern Africa were identified where local climate variability is sensitive to variations in crop growth, and where crop yield is sensitive to variations in surface temperature. Therefore, offline seasonal forecasting methodologies in these regions may underestimate crop yield variability. The inclusion of dynamic crops also altered the mean climate of the humid tropics, highlighting the importance of including dynamical vegetation within climate models.

Modelling European winter wind storm losses in current and future climate

Severe wind storms are one of the major natural hazards in the extratropics and inflict substantial economic damages and even casualties. Insured storm-related losses depend on (i) the frequency, nature and dynamics of storms, (ii) the vulnerability of the values at risk, (iii) the geographical distribution of these values, and (iv) the particular conditions of the risk transfer. It is thus of great importance to assess the impact of climate change on future storm losses. To this end, the current study employs—to our knowledge for the first time—a coupled approach, using output from high-resolution regional climate model scenarios for the European sector to drive an operational insurance loss model. An ensemble of coupled climate-damage scenarios is used to provide an estimate of the inherent uncertainties. Output of two state-of-the-art global climate models (HadAM3, ECHAM5) is used for present (1961–1990) and future climates (2071–2100, SRES A2 scenario). These serve as boundary data for two nested regional climate models with a sophisticated gust parametrizations (CLM, CHRM). For validation and calibration purposes, an additional simulation is undertaken with the CHRM driven by the ERA40 reanalysis. The operational insurance model (Swiss Re) uses a European-wide damage function, an average vulnerability curve for all risk types, and contains the actual value distribution of a complete European market portfolio. The coupling between climate and damage models is based on daily maxima of 10 m gust winds, and the strategy adopted consists of three main steps: (i) development and application of a pragmatic selection criterion to retrieve significant storm events, (ii) generation of a probabilistic event set using a Monte-Carlo approach in the hazard module of the insurance model, and (iii) calibration of the simulated annual expected losses with a historic loss data base. The climate models considered agree regarding an increase in the intensity of extreme storms in a band across central Europe (stretching from southern UK and northern France to Denmark, northern Germany into eastern Europe). This effect increases with event strength, and rare storms show the largest climate change sensitivity, but are also beset with the largest uncertainties. Wind gusts decrease over northern Scandinavia and Southern Europe. Highest intra-ensemble variability is simulated for Ireland, the UK, the Mediterranean, and parts of Eastern Europe. The resulting changes on European-wide losses over the 110-year period are positive for all layers and all model runs considered and amount to 44% (annual expected loss), 23% (10 years loss), 50% (30 years loss), and 104% (100 years loss). There is a disproportionate increase in losses for rare high-impact events. The changes result from increases in both severity and frequency of wind gusts. Considerable geographical variability of the expected losses exists, with Denmark and Germany experiencing the largest loss increases (116% and 114%, respectively). All countries considered except for Ireland (−22%) experience some loss increases. Some ramifications of these results for the socio-economic sector are discussed, and future avenues for research are highlighted. The technique introduced in this study and its application to realistic market portfolios offer exciting prospects for future research on the impact of climate change that is relevant for policy makers, scientists and economists.

Terrestrial implications for the maritime geoarchaeological resource: A view from the Lower Palaeolithic

Stone tools and faunal remains have been recovered from the English Channel and the North Sea through trawling, dredging for aggregates, channel clearance, and coring. These finds highlight the potential for a maritime Lower Palaeolithic archaeological resource. It is proposed here that any Lower Palaeolithic artefacts, faunal remains, and sediments deposited in the maritime zone during dry, low-stand phases were once (and may still be) contextually similar to their counterparts in the terrestrial Lower Palaeolithic records of north-western Europe. Given these similarities, can interpretive models and analytical frameworks developed for terrestrial archaeology be profitably applied to an assessment of the potential value of any maritime resource? The terrestrial geoarchaeological resource for the Lower Palaeolithic is dominated by artefacts and ecofacts that have been fluvially reworked. The spatio-temporal resolution of these data varies from entire river valleys and marine isotope stages to river channel gravel bar surfaces and decadal timescales, thus supporting a variety of questions and approaches. However, the structure of the terrestrial resource also highlights two fundamental limitations in current maritime knowledge that can restrict the application of terrestrial approaches to any potential maritime resource: (i) how have the repetitive transgressions and regressions of the Middle and Late Pleistocene modified the terrace landforms and sediments associated with the river systems of the English Channel and southern North Sea basins?; and (ii) do the surviving submerged terrace landforms and fluvial sedimentary deposits support robust geochronological models, as is the case with the classical terrestrial terrace sequences? This paper highlights potential approaches to these questions, and concludes that the fluvial palaeogeography, Pleistocene fossils, and potential Lower Palaeolithic artefacts of the maritime geoarchaeological resource can be profitably investigated in future as derived, low-resolution data sets, facilitating questions of colonisation, occupation, demography, and material culture.

Annular variability and eddy-zonal flow interactions in a simplified atmospheric GCM. Part 1: Characterization of high and low frequency behaviour

Experiments have been performed using a simplified, Newtonian forced, global circulation model to investigate how variability of the tropospheric jet can be characterized by examining the combined fluctuations of the two leading modes of annular variability. Eddy forcing of this variability is analyzed in the phase space of the leading modes using the vertically integrated momentum budget. The nature of the annular variability and eddy forcing depends on the time scale. At low frequencies the zonal flow and baroclinic eddies are in quasi equilibrium and anomalies propagate poleward. The eddies are shown primarily to reinforce the anomalous state and are closely balanced by the linear damping, leaving slow evolution as a residual. At high frequencies the flow is strongly evolving and anomalies are initiated on the poleward side of the tropospheric jet and propagate equatorward. The eddies are shown to drive this evolution strongly: eddy location and amplitude reflect the past baroclinicity, while eddy feedback on the zonal flow may be interpreted in terms of wave breaking associated with baroclinic life cycles in lateral shear.

Optimal inverter design for an induction machine using resonant frequency matching

The frequency responses of two 50 Hz and one 400 Hz induction machines have been measured experimentally over a frequency range of 1 kHz to 400 kHz. This study has shown that the stator impedances of the machines behave in a similar manner to a parallel resonant circuit, and hence have a resonant point at which the Input impedance of the machine is at a maximum. This maximum impedance point was found experimentally to be as low as 33 kHz, which is well within the switching frequency ranges of modern inverter drives. This paper investigates the possibility of exploiting the maximum impedance point of the machine, by taking it into consideration when designing an inverter, in order to minimize ripple currents due to the switching frequency. Minimization of the ripple currents would reduce torque pulsation and losses, increasing overall performance. A modified machine model was developed to take into account the resonant point, and this model was then simulated with an inverter to demonstrate the possible advantages of matching the inverter switching frequency to the resonant point. Finally, in order to experimentally verify the simulated results, a real inverter with a variable switching frequency was used to drive an induction machine. Experimental results are presented.

Methodology for assessing the appropriateness of Continuing Professional Development for pharmacy professionals’ revalidation

From April 2010, the General Pharmaceutical Council (GPhC) will be responsible for the statutory regulation of pharmacists and pharmacy technicians in Great Britain (GB).[1] All statutorily regulated health professionals will need to periodically demonstrate their fitness-to-practise through a process of revalidation.[2] One option being considered in GB is that continuing professional development (CPD) records will form a part of the evidence submitted for revalidation, similar to the system in New Zealand.[3] At present, pharmacy professionals must make a minimum of nine CPD entries per annum from 1 March 2009 using the Royal Pharmaceutical Society of Great Britain (RPSGB) CPD framework. Our aim was to explore the applicability of new revalidation standards within the current CPD framework. We also wanted to review the content of CPD portfolios to assess strengths and qualities and identify any information gaps for the purpose of revalidation.

Modelling the lava dome extruded at Soufrière Hills Volcano, Montserrat, August 2005–May 2006. Part II: Rockfall activity and talus deformation

During many lava dome-forming eruptions, persistent rockfalls and the concurrent development of a substantial talus apron around the foot of the dome are important aspects of the observed activity. An improved understanding of internal dome structure, including the shape and internal boundaries of the talus apron, is critical for determining when a lava dome is poised for a major collapse and how this collapse might ensue. We consider a period of lava dome growth at the Soufrière Hills Volcano, Montserrat, from August 2005 to May 2006, during which a 100 × 106 m3 lava dome developed that culminated in a major dome-collapse event on 20 May 2006. We use an axi-symmetrical Finite Element Method model to simulate the growth and evolution of the lava dome, including the development of the talus apron. We first test the generic behaviour of this continuum model, which has core lava and carapace/talus components. Our model describes the generation rate of talus, including its spatial and temporal variation, as well as its post-generation deformation, which is important for an improved understanding of the internal configuration and structure of the dome. We then use our model to simulate the 2005 to 2006 Soufrière Hills dome growth using measured dome volumes and extrusion rates to drive the model and generate the evolving configuration of the dome core and carapace/talus domains. The evolution of the model is compared with the observed rockfall seismicity using event counts and seismic energy parameters, which are used here as a measure of rockfall intensity and hence a first-order proxy for volumes. The range of model-derived volume increments of talus aggraded to the talus slope per recorded rockfall event, approximately 3 × 103–13 × 103 m3 per rockfall, is high with respect to estimates based on observed events. From this, it is inferred that some of the volumetric growth of the talus apron (perhaps up to 60–70%) might have occurred in the form of aseismic deformation of the talus, forced by an internal, laterally spreading core. Talus apron growth by this mechanism has not previously been identified, and this suggests that the core, hosting hot gas-rich lava, could have a greater lateral extent than previously considered.

Evaluating the role of environmental quality in the sustainable rural economic development of England

The issue of the sustainable development of rural economies in England has recently received considerable attention. This is because many of the poorest areas in the country are rural, often of high environmental quality, but suffering from high unemployment and a lack of services and facilities. The rapid decline in agricultural incomes and in-migration of affluent urban workers since 1990 has exacerbated economic inequality in such areas. A number of factors have the potential to drive rural development and this paper applies, and considers, the feasibility of a method from the USA for combining economic and environmental variables in a regional growth model to examine the hypothesis that environmental quality is an important determinant of sustainable rural development in England. The model output suggests that, although environmental quality does play a role in sustainable rural development in England there are other, more important, factors driving development. These include business and communications infra-structure, the degree and opportunities for commuting and underlying employment prospects. The robustness and limitations of the method for combining economic and environmental variables is discussed in relation to the spatial interrelatedness of Local Authority Districts in England, and conclusions are drawn about areas for refinement and improvement of the method.

Longevity, early emergence and body size in a pollinating fig wasp - implications for stability in a fig-pollinator mutualism

1. Fig trees (Ficus) are pollinated only by agaonid wasps, whose larvae also gall fig ovules. Each ovule develops into either a seed (when pollinated) or a wasp (when an egg is also laid inside) but not both. 2. Ovipositing wasps (foundresses) favour ovules near the centre of the enclosed inflorescence (syconium or 'fig'), leaving ovules near the outer wall to develop into seeds. This spatial stratification of wasps and seeds ensures reproduction in both partners, and thereby enables mutualism persistence. However, the mechanism(s) responsible remain(s) unknown. 3. Theory shows that foundresses will search for increasingly rare inner ovules and ignore outer ovules, as long as ovipositing in outer ovules is sufficiently slow and/or if inner ovules confer greater fitness to wasps. The fig-pollinator mutualism can therefore be stabilized by strong time constraints on foundresses and by offspring fitness gradients over variation in ovule position. 4. Female fig wasps cannot leave their galls without male assistance. We found that females in outer ovules were unlikely to be released. Inner ovules thus have added value to foundresses, because their female offspring are more likely to mate and disperse. 5. For those offspring that did emerge, gall position (inner/outer) and body size did not influence the order in which female pollinators exited syconia, nor did early emerging wasps enjoy increased life spans. 6. We also found that the life spans of female wasps nearly doubled when given access to moisture. We suggest that conflict resolution in the fig-pollinator mutualism may thus be influenced by tropical seasonality, because wasps may be less able to over-exploit ovules in dry periods due to time constraints.

Resolving the energy paradox of chaperone/usher-mediated fibre assembly

Periplasmic chaperone/usher machineries are used for assembly of filamentous adhesion organelles of Gram-negative pathogens in a process that has been suggested to be driven by folding energy. Structures of mutant chaperone-subunit complexes revealed a final folding transition (condensation of the subunit hydrophobic core) on the release of organelle subunit from the chaperone-subunit pre-assembly complex and incorporation into the final fibre structure. However, in view of the large interface between chaperone and subunit in the pre-assembly complex and the reported stability of this complex, it is difficult to understand how final folding could release sufficient energy to drive assembly. In the present paper, we show the X-ray structure for a native chaperone-fibre complex that, together with thermodynamic data, shows that the final folding step is indeed an essential component of the assembly process. We show that completion of the hydrophobic core and incorporation into the fibre results in an exceptionally stable module, whereas the chaperone-subunit preassembly complex is greatly destabilized by the high-energy conformation of the bound subunit. This difference in stabilities creates a free energy potential that drives fibre formation.