An assessment of the economic and social impacts of climate change on the health sector in the Caribbean

Climate change affects the fundamental bases of good human health, which are clean air, safe drinking water, sufficient food, and secure shelter. Climate change is known to impact health through three climate dimensions: extreme heat, natural disasters, and infections and diseases. The temporal and spatial climatic changes that will affect the biology and ecology of vectors and intermediate hosts are likely to increase the risks of disease transmission. The greatest effect of climate change on disease transmission is likely to be observed at the extremes of the range of temperatures at which transmission typically occurs. Caribbean countries are marked by unique geographical and geological features. When combined with their physical, infrastructural development, these features make them relatively more prone to negative impacts from changes in climatic conditions. The increased variability of climate associated with slow-moving tropical depressions has implications for water quality through flooding as well as hurricanes. Caribbean countries often have problems with water and sanitation. These problems are exacerbated whenever there is excess rainfall, or no rainfall. The current report aims to prepare the Caribbean to respond better to the anticipated impact of climate change on the health sector, while fostering a subregional Caribbean approach to reducing carbon emissions by 2050. It provides a major advance on the analytical and contextual issues surrounding the impact of climate change on health in the Caribbean by focusing on the vector-borne and waterborne diseases that are anticipated to be impacted directly by climate change. The ultimate goal is to quantify both the direct and indirect costs associated with each disease, and to present adaptation strategies that can address these health concerns effectively to benefit the populations of the Caribbean.

Análise econômica de sistema de abastecimento de água público fechado: estudo de caso da Cidade Universitária Professor José da Silveira Netto - Belém (PA)

O abastecimento de água é de suma importância não só para a sobrevivência humana, como também para o desenvolvimento de atividades econômicas e institucionais, ou seja, para vida orgânica/biótica e para a vida social. Com relação à disponibilidade desse recurso, o Brasil é um país com enormes reservas potencias para atender a esse fim. A Cidade Universitária Professor José da Silveira Netto, Campus da UFPA, atualmente produz sua água, com a captação através de aquifero subterrâneo, e, em pequena quantidade, também compra da Concessionária Local. Contudo, em relação à produção na Universidade Federal do Pará não há conhecimento quanto aos custos de manutenção da linha de produção, da mão-deobra envolvida, etc. A falta desse conhecimento não permite que o Gestor possa agir de forma estratégica, com relação a essa situação. Este trabalho visa levantar os custos diretos e indiretos da produção de 1m³ de água tratada na Cidade Universitária Professor José da Silveira Netto, comparando-o com os valores cobrados pela Concessionária Local, a fim de demonstrar ao gestor qual a situação mais vantajosa à Administração com relação ao assunto a ser abordado. Ademais, foram criados cenários futuros, tendo em vista que a atividade universitária é dinâmica e crescente, além do que se incorporaram condições como custo de energia e valor da outorga para captação de água, ainda não integrados nos custo atuais de produção. Os resultados demonstram claramente que a opção de produzir água para consumo é a mais vantajosa em termos econômicos para a Instituição, em qualquer cenário proposto. Ressalta-se que o custo por m³ da água produzida varia de R$ 0,31 a R$ 0,45, enquanto que a compra através da Concessionária Local, em torno de R$ 4,30/m³ para o ano de 2011, só se mostrará viável se esse preço for de no máximo de R$ 0,50/m³. Com essas informações e análises devidamente apresentadas de forma clara e tecnicamente consideradas, este trabalho poderá ser utilizado como instrumento de gestão pública capaz de permitir o melhor ou mais adequado sistema de Abastecimento de Água na Cidade Universitária Professor José da Silveira Netto.

Decisão making or buying: uma aplicação em células de manufatura de uma indústria de produção mecânica

In order to maintain the competitiveness the companies seek for cost reduction and resource optimization. A product or service price is calculated considering direct and indirect costs involved in its fabrication, which means that if an intern indirect process is optimized, the final price of the product is also reduced and becomes more interesting to the final costumer. Considering this reasoning, the companies must evaluate each of their processes and optimize them. It is common to outsource intern products manufacturing as a cost reduction strategy, nevertheless when there are already resources and capability to produce the own goods, it becomes necessary to evaluate the economic gain that each strategy - make or buy - generates. This paper aims to evaluate the necessary support to take a decision regarding making or buying in a production cell of hoses based in the value of economic cost, system cost and decision process

Neural models for predicting hole diameters in drilling processes

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Neural models for predicting hole diameters in drilling processes

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Mental Disorders of Aging: An Emerging Public Health Crisis?

Focuses on the emergence of public health crisis in the U.S. in connection with the projected increase in the number of older adults with mental disorders. Disorders which are commonly associated with older adults; Sources of mental health services for older adults; Factors that contribute to high levels of psychopathology; Impact of the economic costs of mental disorders on direct and indirect costs for healthcare; Recommendations for the expected crisis in geriatric mental health.

Three-year cost analysis of function-centred versus pain-centred inpatient rehabilitation in patients with chronic non-specific low back pain

OBJECTIVE: To compare costs of function- and pain-centred inpatient treatment in patients with chronic low back pain over 3 years of follow-up. DESIGN: Cost analysis of a randomized controlled trial. PATIENTS: A total of 174 patients with chronic low back pain were randomized to function- or pain-centred inpatient treatment. METHODS: Data on direct and indirect costs were gathered by questionnaires sent to patients, health insurance providers, employers, and the Swiss Disability Insurance Company. RESULTS: There was a non-significant difference in total medical costs after 3 years' follow-up. Total costs were 77,305 Euros in the function-centred inpatient treatment group and 83,085 Euros in the pain-centred inpatient treatment group. Likewise, indirect costs after 3 years from lost work days were non-significantly lower in the function-centred in-patient treatment group (6354 Euros; 95% confidence interval -20,892, 8392) and direct medical costs were non-significantly higher in the function-centred inpatient treatment group (574 Euros; 95% confidence interval -862, 2011). CONCLUSION: The total costs of function-centred and pain-centred inpatient treatment were similar over the whole 3-year follow-up.

Waking Up to Sleep Medicine Education

Background: Sleep disorders are an important cause of morbidity among our population with billions of dollars spent on direct and indirect costs attributed to sleep disorders. In spite of raising prevalence and morbidity, surveys have shown inadequate education in sleep medicine at all levels at medical school. According to national sleep disorders research plan data, in 1990 about 37 % of medical schools did not offer any sleep education and of the schools which offered it, the average time devoted to sleep medicine was about 2 hours. Sleep disorders have found to be uniformly under diagnosed in primary care settings. [See PDF for complete abstract]

Minimally invasive surgery when treating endometriosis has a positive effect on health and on quality of work life of affected women

STUDY QUESTION: What is the effect of the minimally invasive surgical treatment of endometriosis on health and on quality of work life (e.g. working performance) of affected women? SUMMARY ANSWER: Absence from work, performance loss and the general negative impact of endometriosis on the job are reduced significantly by the laparoscopic surgery. WHAT IS KNOWN ALREADY: The benefits of surgery overall and of the laparoscopic method in particular for treating endometriosis have been described before. However, previous studies focus on medical benchmarks without including the patient's perspective in a quantitative manner. STUDY DESIGN, SIZE, DURATION: A retrospective questionnaire-based survey covering 211 women with endometriosis and a history of specific laparoscopic surgery in a Swiss university hospital, tertiary care center. Data were returned anonymously and were collected from the beginning of 2012 until March 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women diagnosed with endometriosis and with at least one specific laparoscopic surgery in the past were enrolled in the study. The study investigated the effect of the minimally invasive surgery on health and on quality of work life of affected women. Questions used were obtained from the World Endometriosis Research Foundation (WERF) Global Study on Women's Health (GSWH) instrument. The questionnaire was shortened and adapted for the purpose of the present study. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 587 women invited to participate in the study, 232 (232/587 = 40%) returned the questionnaires. Twenty-one questionnaires were excluded due to incomplete data and 211 sets (211/587 = 36%) were included in the study. Our data show that 62% (n = 130) of the study population declared endometriosis as influencing the job during the period prior to surgery, compared with 28% after surgery (P < 0.001). The mean (maximal) absence from work due to endometriosis was reduced from 2.0 (4.9) to 0.5 (1.4) hours per week (P < 0.001). The mean (maximal) loss in working performance after the surgery averaged out at 5.7% (12.6%) compared with 17.5% (30.5%) before this treatment (P < 0.001). LIMITATIONS, REASONS FOR CAUTION: The mediocre response rate of the study weakens the representativeness of the investigated population. Considering the anonymous setting a non-responder investigation was not performed. A bias due to selection, information and negativity effects within a retrospective survey cannot be excluded, although study-sensitive questions were provided in multiple ways. The absence of a control group (sham group; e.g. patients undergoing specific diagnostic laparoscopy without treatment) is a further limitation of the study. WIDER IMPLICATIONS OF THE FINDINGS: Our study shows that indicated minimally invasive surgery has a clear positive effect on the wellbeing and working performance of women suffering from moderate to severe endometriosis. Furthermore, national net savings in indirect costs with the present number of surgeries is estimated to be €10.7 million per year. In an idealized setting (i.e. without any diagnosis delay) this figure could be more than doubled. STUDY FUNDING/COMPETING INTERESTS: The study was performed on behalf of the University Hospital of Bern (Inselspital) as one of the leading Swiss tertiary care centers. The authors do not declare any competing interests.

Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians

Background. Diabetes places a significant burden on the health care system. Reduction in blood glucose levels (HbA1c) reduces the risk of complications; however, little is known about the impact of disease management programs on medical costs for patients with diabetes. In 2001, economic costs associated with diabetes totaled $100 billion, and indirect costs totaled $54 billion. ^ Objective. To compare outcomes of nurse case management by treatment algorithms with conventional primary care for glycemic control and cardiovascular risk factors in type 2 diabetic patients in a low-income Mexican American community-based setting, and to compare the cost effectiveness of the two programs. Patient compliance was also assessed. ^ Research design and methods. An observational group-comparison to evaluate a treatment intervention for type 2 diabetes management was implemented at three out-patient health facilities in San Antonio, Texas. All eligible type 2 diabetic patients attending the clinics during 1994–1996 became part of the study. Data were obtained from the study database, medical records, hospital accounting, and pharmacy cost lists, and entered into a computerized database. Three groups were compared: a Community Clinic Nurse Case Manager (CC-TA) following treatment algorithms, a University Clinic Nurse Case Manager (UC-TA) following treatment algorithms, and Primary Care Physicians (PCP) following conventional care practices at a Family Practice Clinic. The algorithms provided a disease management model specifically for hyperglycemia, dyslipidemia, hypertension, and microalbuminuria that progressively moved the patient toward ideal goals through adjustments in medication, self-monitoring of blood glucose, meal planning, and reinforcement of diet and exercise. Cost effectiveness of hemoglobin AI, final endpoints was compared. ^ Results. There were 358 patients analyzed: 106 patients in CC-TA, 170 patients in UC-TA, and 82 patients in PCP groups. Change in hemoglobin A1c (HbA1c) was the primary outcome measured. HbA1c results were presented at baseline, 6 and 12 months for CC-TA (10.4%, 7.1%, 7.3%), UC-TA (10.5%, 7.1%, 7.2%), and PCP (10.0%, 8.5%, 8.7%). Mean patient compliance was 81%. Levels of cost effectiveness were significantly different between clinics. ^ Conclusion. Nurse case management with treatment algorithms significantly improved glycemic control in patients with type 2 diabetes, and was more cost effective. ^

The high cost of inappropriate empiric treatment of presumed Clostridium difficile-associated diarrhea

The Center for Disease Control and Prevention (CDC) estimates that more than 2 million patients annually acquire an infection while hospitalized in U.S. hospitals for other health problems, and that 88,000 die as a direct or indirect result of these infections. Infection with Clostridium difficile is the most important common cause of health care associated infectious diarrhea in industrialized countries. The purpose of this study was to explore the cost of current treatment practice of beginning empiric metronidazole treatment for hospitalized patients with diarrhea prior to identification of an infectious agent. The records of 70 hospitalized patients were retrospectively analyzed to determine the pharmacologic treatment, laboratory testing, and radiographic studies ordered and the median cost for each of these was determined. All patients in the study were tested for C. difficile and concurrently started on empiric metronidazole. The median direct cost for metronidazole was $7.25 per patient (95% CI 5.00, 12.721). The median direct cost for laboratory charges was $468.00 (95% CI 339.26, 552.58) and for radiology the median direct cost was $970.00 (95% CI 738.00, 3406.91). Indirect costs, which are far greater than direct costs, were not studied. At St. Luke's, if every hospitalized patient with diarrhea was empirically treated with metronidazole at a median cost of $7.25, the annual direct cost is estimated to be over $9,000.00 plus uncalculated indirect costs. In the U.S., the estimated annual direct cost may be as much as $21,750,000.00, plus indirect costs. ^ An unexpected and significant finding of this study was the inconsistency in testing and treatment of patients with health care associated diarrhea. A best-practice model for C. difficile testing and treatment was not found in the literature review. In addition to the cost savings gained by not routinely beginning empiric treatment with metronidazole, significant savings and improvement in patient care may result from a more consistent approach to the diagnosis and treatment of all patients with health care associated diarrhea. A decision tree model for C. difficile testing and treatment is proposed, but further research is needed to evaluate the decision arms before a validated best practice model can be proposed. ^

Optimización multiobjetivo inteligente del dimensionamiento energético en sistemas ferroviarios señalizados y en plataformas software de tiempo real

La capacidad de transporte es uno de los baremos fundamentales para evaluar la progresión que puede llegar a tener un área económica y social. Es un sector de elevada importancia para la sociedad actual. Englobado en los distintos tipos de transporte, uno de los medios de transporte que se encuentra más en alza en la actualidad, es el ferroviario. Tanto para movilidad de pasajeros como para mercancías, el tren se ha convertido en un medio de transporte muy útil. Se encuentra dentro de las ciudades, entre ciudades con un radio pequeño entre ellas e incluso cada vez más, gracias a la alta velocidad, entre ciudades con gran distancia entre ellas. Esta Tesis pretende ayudar en el diseño de una de las etapas más importantes de los Proyectos de instalación de un sistema ferroviario: el sistema eléctrico de tracción. La fase de diseño de un sistema eléctrico de tracción ferroviaria se enfrenta a muchas dudas que deben ser resueltas con precisión. Del éxito de esta fase dependerá la capacidad de afrontar las demandas de energía de la explotación ferroviaria. También se debe atender a los costes de instalación y de operación, tanto costes directos como indirectos. Con la Metodología que se presenta en esta Tesis se ofrecerá al diseñador la opción de manejar un sistema experto que como soluciones le plantee un conjunto de escenarios de sistemas eléctricos correctos, comprobados por resolución de modelos de ecuaciones. Correctos desde el punto de vista de validez de distintos parámetros eléctrico, como de costes presupuestarios e impacto de costes indirectos. Por tanto, el diseñador al haber hecho uso de esta Metodología, tendría en un espacio de tiempo relativamente corto, un conjunto de soluciones factibles con las que poder elegir cuál convendría más según sus intereses finales. Esta Tesis se ha desarrollado en una vía de investigación integrada dentro del Centro de Investigaciones Ferroviarias CITEF-UPM. Entre otros proyectos y vías de investigación, en CITEF se ha venido trabajando en estudios de validación y dimensionamiento de sistemas eléctricos ferroviarios con diversos y variados clientes y sistemas ferroviarios. A lo largo de los proyectos realizados, el interés siempre ha girado mayoritariamente sobre los siguientes parámetros del sistema eléctrico: - Calcular número y posición de subestaciones de tracción. Potencia de cada subestación. - Tipo de catenaria a lo largo del recorrido. Conductores que componen la catenaria. Características. - Calcular número y posición de autotransformadores para sistemas funcionando en alterna bitensión o 2x25kV. - Posición Zonas Neutras. - Validación según normativa de: o Caídas de tensión en la línea o Tensiones máximas en el retorno de la línea o Sobrecalentamiento de conductores o Sobrecalentamiento de los transformadores de las subestaciones de tracción La idea es que las soluciones aportadas por la Metodología sugieran escenarios donde de estos parámetros estén dentro de los límites que marca la normativa. Tener la posibilidad de tener un repositorio de posibles escenarios donde los parámetros y elementos eléctricos estén calculados como correctos, aporta un avance en tiempos y en pruebas, que mejoraría ostensiblemente el proceso habitual de diseño para los sistemas eléctricos ferroviarios. Los costes directos referidos a elementos como subestaciones de tracción, autotransformadores, zonas neutras, ocupan un gran volumen dentro del presupuesto de un sistema ferroviario. En esta Tesis se ha querido profundizar también en el efecto de los costes indirectos provocados en la instalación y operación de sistemas eléctricos. Aquellos derivados del impacto medioambiental, los costes que se generan al mantener los equipos eléctricos y la instalación de la catenaria, los costes que implican la conexión entre las subestaciones de tracción con la red general o de distribución y por último, los costes de instalación propios de cada elemento compondrían los costes indirectos que, según experiencia, se han pensado relevantes para ejercer un cierto control sobre ellos. La Metodología cubrirá la posibilidad de que los diseños eléctricos propuestos tengan en cuenta variaciones de coste inasumibles o directamente, proponer en igualdad de condiciones de parámetros eléctricos, los más baratos en función de los costes comentados. Analizando los costes directos e indirectos, se ha pensado dividir su impacto entre los que se computan en la instalación y los que suceden posteriormente, durante la operación de la línea ferroviaria. Estos costes normalmente suelen ser contrapuestos, cuánto mejor es uno peor suele ser el otro y viceversa, por lo que hace falta un sistema que trate ambos objetivos por separado. Para conseguir los objetivos comentados, se ha construido la Metodología sobre tres pilares básicos: - Simulador ferroviario Hamlet: Este simulador integra módulos para construir esquemas de vías ferroviarios completos; módulo de simulación mecánica y de la tracción de material rodante; módulo de señalización ferroviaria; módulo de sistema eléctrico. Software realizado en C++ y Matlab. - Análisis y estudio de cómo focalizar los distintos posibles escenarios eléctricos, para que puedan ser examinados rápidamente. Pico de demanda máxima de potencia por el tráfico ferroviario. - Algoritmos de optimización: A partir de un estudio de los posibles algoritmos adaptables a un sistema tan complejo como el que se plantea, se decidió que los algoritmos genéticos serían los elegidos. Se han escogido 3 algoritmos genéticos, permitiendo recabar información acerca del comportamiento y resultados de cada uno de ellos. Los elegidos por motivos de tiempos de respuesta, multiobjetividad, facilidad de adaptación y buena y amplia aplicación en proyectos de ingeniería fueron: NSGA-II, AMGA-II y ɛ-MOEA. - Diseño de funciones y modelo preparado para trabajar con los costes directos e indirectos y las restricciones básicas que los escenarios eléctricos no deberían violar. Estas restricciones vigilan el comportamiento eléctrico y la estabilidad presupuestaria. Las pruebas realizadas utilizando el sistema han tratado o bien de copiar situaciones que se puedan dar en la realidad o directamente sistemas y problemas reales. Esto ha proporcionado además de la posibilidad de validar la Metodología, también se ha posibilitado la comparación entre los algoritmos genéticos, comparar sistemas eléctricos escogidos con los reales y llegar a conclusiones muy satisfactorias. La Metodología sugiere una vía de trabajo muy interesante, tanto por los resultados ya obtenidos como por las oportunidades que puede llegar a crear con la evolución de la misma. Esta Tesis se ha desarrollado con esta idea, por lo que se espera pueda servir como otro factor para trabajar con la validación y diseño de sistemas eléctricos ferroviarios. ABSTRACT Transport capacity is one of the critical points to evaluate the progress than a specific social and economical area is able to reach. This is a sector of high significance for the actual society. Included inside the most common types of transport, one of the means of transport which is elevating its use nowadays is the railway. Such as for passenger transport of weight movements, the train is being consolidated like a very useful mean of transport. Railways are installed in many geography areas. Everyone know train in cities, or connecting cities inside a surrounding area or even more often, taking into account the high-speed, there are railways infrastructure between cities separated with a long distance. This Ph.D work aims to help in the process to design one of the most essential steps in Installation Projects belonging to a railway system: Power Supply System. Design step of the railway power supply, usually confronts to several doubts and uncertainties, which must be solved with high accuracy. Capacity to supply power to the railway traffic depends on the success of this step. On the other hand is very important to manage the direct and indirect costs derived from Installation and Operation. With the Methodology is presented in this Thesis, it will be offered to the designer the possibility to handle an expert system that finally will fill a set of possible solutions. These solutions must be ready to work properly in the railway system, and they were tested using complex equation models. This Thesis has been developed through a research way, integrated inside Citef (Railway Research Centre of Technical University of Madrid). Among other projects and research ways, in Citef has been working in several validation studies and dimensioning of railway power supplies. It is been working by a large range of clients and railways systems. Along the accomplished Projects, the main goal has been rounded mostly about the next list of parameters of the electrical system: - Calculating number and location of traction substations. Power of each substation. - Type of Overhead contact line or catenary through the railway line. The wires which set up the catenary. Main Characteristics. - Calculating number and position of autotransformers for systems working in alternating current bi-voltage of called 2x25 kV. - Location of Neutral Zones. - Validating upon regulation of: o Drop voltages along the line o Maximum return voltages in the line o Overheating/overcurrent of the wires of the catenary o Avoiding overheating in the transformers of the traction substations. Main objective is that the solutions given by the Methodology, could be suggest scenarios where all of these parameters from above, would be between the limits established in the regulation. Having the choice to achieve a repository of possible good scenarios, where the parameters and electrical elements will be assigned like ready to work, that gives a great advance in terms of times and avoiding several tests. All of this would improve evidently the regular railway electrical systems process design. Direct costs referred to elements like traction substations, autotransformers, neutral zones, usually take up a great volume inside the general budget in railway systems. In this Thesis has been thought to bear in mind another kind of costs related to railway systems, also called indirect costs. These could be enveloped by those enmarked during installation and operation of electrical systems. Those derived from environmental impact; costs generated during the maintenance of the electrical elements and catenary; costs involved in the connection between traction substations and general electric grid; finally costs linked with the own installation of the whole electrical elements needed for the correct performance of the railway system. These are integrated inside the set has been collected taking into account own experience and research works. They are relevant to be controlled for our Methodology, just in case for the designers of this type of systems. The Methodology will cover the possibility that the final proposed power supply systems will be hold non-acceptable variations of costs, comparing with initial expected budgets, or directly assuming a threshold of budget for electrical elements in actual scenario, and achieving the cheapest in terms of commented costs from above. Analyzing direct and indirect costs, has been thought to divide their impact between two main categories. First one will be inside the Installation and the other category will comply with the costs often happens during Railway Operation time. These costs normally are opposed, that means when one is better the other turn into worse, in costs meaning. For this reason is necessary treating both objectives separately, in order to evaluate correctly the impact of each one into the final system. The objectives detailed before build the Methodology under three basic pillars: - Railway simulator Hamlet: This software has modules to configure many railway type of lines; mechanical and traction module to simulate the movement of rolling stock; signaling module; power supply module. This software has been developed using C++ and Matlab R13a - Previously has been mandatory to study how would be possible to work properly with a great number of feasible electrical systems. The target comprised the quick examination of these set of scenarios in terms of time. This point is talking about Maximum power demand peaks by railway operation plans. - Optimization algorithms. A railway infrastructure is a very complex system. At the beginning it was necessary to search about techniques and optimization algorithms, which could be adaptable to this complex system. Finally three genetic multiobjective algorithms were the chosen. Final decision was taken attending to reasons such as time complexity, able to multiobjective, easy to integrate in our problem and with a large application in engineering tasks. They are: NSGA-II, AMGA-II and ɛ-MOEA. - Designing objectives functions and equation model ready to work with the direct and indirect costs. The basic restrictions are not able to avoid, like budgetary or electrical, connected hardly with the recommended performance of elements, catenary and safety in a electrical railway systems. The battery of tests launched to the Methodology has been designed to be as real as possible. In fact, due to our work in Citef and with real Projects, has been integrated and configured three real railway lines, in order to evaluate correctly the final results collected by the Methodology. Another topic of our tests has been the comparison between the performances of the three algorithms chosen. Final step has been the comparison again with different possible good solutions, it means power supply system designs, provided by the Methodology, testing the validity of them. Once this work has been finished, the conclusions have been very satisfactory. Therefore this Thesis suggest a very interesting way of research and work, in terms of the results obtained and for the future opportunities can be created with the evolution of this. This Thesis has been developed with this idea in mind, so is expected this work could adhere another factor to work in the difficult task of validation and design of railway power supply systems.

Investigação da eficácia da teleconsulta na programação do implante coclear

A demanda crescente de usuários de implante coclear (IC) e a distribuição irregular de profissionais especializados no país, tornam necessário o deslocamento de pacientes por longas distâncias para os atendimentos, com consequente aumento dos custos diretos e indiretos do tratamento. A teleconsulta pode ser vista como uma alternativa em potencial para o acesso desta população a estes serviços. O presente ensaio clínico, randomizado, controlado, avaliou a eficácia da teleconsulta síncrona na programação dos sistemas de IC em usuários acompanhados em um Programa de Implante Coclear credenciado pelo Sistema Único de Saúde. Participaram do estudo 79 indivíduos com idades entre nove e 68 anos (média de 21,6), 41 do sexo masculino e 38 do sexo feminino, usuários de IC por um período de 0,58 a 24,75 anos. Estes indivíduos foram divididos em dois grupos, de acordo com o modo de programação do IC: controle (n=40), que realizou o procedimento face a face e experimental (n=39) que realizou a teleconsulta síncrona. Treze fonoaudiólogos sem experiência na programação do dispositivo atuaram como facilitadores das teleconsultas. Os procedimentos de programação do IC englobaram a telemetria de impedância, definição dos níveis de estimulação elétrica, varredura e balanceamento dos eletrodos e ajuste fino da programação. Como medidas de avaliação de resultados foram utilizados o tempo dispendido na consulta, a audiometria em campo livre, o percentual de reconhecimento de sentenças no silêncio e no ruído, o limiar de reconhecimento de sentenças no silêncio e ruído (HINT-Brasil), a avaliação da satisfação com a consulta (escala MISS-21) e de aspectos pertinentes à teleconsulta. Os facilitadores responderam as questões abertas referentes à suas impressões dos atendimentos. Os dados foram analisados por meio de estatística inferencial (testes t de Student, Wilcoxon, Mann-Whitney e correlação de Spearman). Os resultados mostraram que após a programação do IC, em média, os participantes apresentaram limiares audiométricos abaixo de 30 dB NA. O reconhecimento da fala pós atendimento, respectivamente para os grupos experimental e controle, foram de 81,3% e 83,8% (silêncio) e 57,9% e 58,1% (ruído). No HINT-Brasil os resultados foram, respectivamente, para os grupos experimental e controle 61,4 dB NA e 61,8 dB NA (silêncio) e relação S/R de 9,5 dB NA e 10,4 dB NA (ruído). Os participantes estiveram satisfeitos com a consulta. Não houve diferença estatisticamente significativa entre os grupos em nenhuma das medidas de resultado. Todos os participantes relataram que teleconsulta pode ser vista como uma alternativa viável ao atendimento face a face e sua aplicação clínica facilitaria a rotina de pacientes usuários de IC. Os facilitadores destacaram a sua importância para o aprendizado e como ferramenta de formação continuada. A teleconsulta síncrona foi eficaz na programação dos sistemas de IC e amplamente aceita pelos usuários e profissionais.

The 2014 chikungunya virus outbreak in the U.S. Virgin Islands: epidemiology, long-term health outcomes, and economic burden

Thesis (Ph.D.)--University of Washington, 2016-06

Modeling the fiscal impacts caused by climate change

Aim of the paper: The purpose is to gather the practices and to model the impacts of climate change on fiscal spending and revenues, responsibilities and opportunities, balance and debt related to climate change (CC). Methodology of the paper: The methodology will distinguish fiscal cost of mitigation and adaptation, besides direct and indirect costs. It will also introduce cost benefit analyses to evaluate the propensity of policy makers for action or passivity. Several scenarios will be drafted to see the different outcomes. The scenarios shall contain the possible losses in the natural and artificial environment and resources. Impacts on public budget are based on damage of income opportunities and capital/wealth/natural assets. There will be a list of actions when the fiscal correction of market failures will be necessary. Findings: There will be a summary and synthesis of estimation models on CC impacts on public finances, and morals of existing/existed budgeting practices on mitigation. The model will be based on damages (and maybe benefits) from CC, adjusted with probabilities of scenarios and policy making propensity for action. Findings will cover the way of funding of fiscal costs. Practical use, value added: From the synthesis of model, the fiscal cost of mitigation and adaptation can be estimated for any developed, emerging and developing countries. The paper will try to reply, also, for the challenge how to harmonize fiscal and developmental sustainability.