Determinantes sociais condicionantes das altas clínicas dos utentes da rede nas UCCI: um estudo de caso

Introdução: O adiamento das altas clínicas nas Unidades de Cuidados Continuados Integrados (UCCI) por motivos sociais é actualmente considerado um dos principais motivos que impedem a integração atempada de novos clientes na Rede Nacional de Cuidados Continuados, RNCC, daqui em diante designada como a REDE. Este atraso tem impacto ao nível da recuperação e estabilização dos utentes, bem como ao nível de eficiência e eficácia da UCCI, não podendo deixar de se considerarem os aspectos sociais e económicos. Objectivo Geral: Identificar os determinantes que influenciam as altas clínicas em UCCI. Métodos e População do Estudo: Este é um estudo de caso colectivo, em que os dados observacionais, transversais, são recolhidos por meio de questionário de auto-relato (por cada área de intervenção directa) e por análise dos processos de consulta de pacientes. O objecto desta pesquisa abrange dois grupos: o grupo de amostra composto por 70 profissionais de saúde que lidam directamente com os utentes e o grupo amostra composto de utentes internados na UCCI L Nostrum, com alta clínica entre 1/1/2011 e 31/12/2012, e que foram integrados através da REDE. Foram recolhidos os dados de 293 utentes sendo objecto de estudo os casos de 83 utentes integrados através da REDE e com prolongamento de internamento por motivos sociais. Resultados: Na percepção dos profissionais de saúde, as respostas institucionais apresentam-se como a condicionante mais indicada, tanto para os utentes em geral, com 22 indicações (88%) como para os utentes da REDE, com 10 indicações (40%). Relativamente aos motivos familiares há referência de 76% para os utentes em geral e de 36% para os utentes da REDE. Os motivos económicos também apresentam, para os profissionais inquiridos, um valor expressivo (68%) nos utentes em geral, estando nos da REDE este factor condicionante a par com os motivos familiares (36%). Os motivos estruturais têm menor expressão tanto nos utentes em geral (32%) como nos utentes da REDE (16%). “Outros” para os utentes em geral, refere-se a dependência funcional (4%). Nos motivos familiares, para os utentes em geral, 23 (92%) foi mais vezes indicada a insuficiência de suporte familiar, para os utentes da REDE, 13 (52%). A ausência de suporte familiar, para os utentes em geral, representa 48% das respostas, seguindo-se o suporte inadequado (28%) e a ausência de cuidadores (24%). Para os utentes da REDE, o suporte inadequado apresenta-se como segundo motivo (7%), seguindo-se a ausência de suporte familiar (16%). Na percepção dos profissionais, os utentes da REDE estão também condicionados pela distância geográfica (8%) da sua área residencial. Em termos estruturais, os motivos mais assinalados pelos profissionais para a generalidade dos utentes foram as barreiras físicas à mobilidade (80%) e a habitação sem condições básicas de habitabilidade (78%). Os mesmos motivos foram assinalados para os utentes da REDE, barreiras físicas à mobilidade (40%) e habitação sem condições de habitabilidade (28%). No entanto, relativamente aos utentes em geral, a ausência de habitação (29%) e a distância geográfica (4%) também foram motivos assinalados. Dos motivos económicos percebidos pelos profissionais, a insuficiência de rendimentos é o factor mais assinalado pela generalidade dos utentes (84%) e pelos da REDE (68%), seguida da percepção da capacidade de reposta limitada das instituições, 64% para a generalidade dos utentes e 28% para os da REDE e por fim os tipos de respostas insuficientes para as necessidades individuais dos utentes (20% dos utentes em geral e 12% da REDE). No total dos dois anos, 2011 e 2012, verificaram-se na UCCI L Nostrum 293 prorrogações (100%) das quais 210 (71,6%) foram consideradas dentro do prazo e justificadas com motivos clínicos, enquanto 83 (28,3%) foram efectivamente protelamentos por motivos sociais, tendo em conta que nestes casos os utentes já não tinham critérios clínicos que justificassem a sua permanência na UCCI. Das 210 prorrogações consideradas dentro do prazo e justificadas com motivos clínicos, 93 (44,3%) foram-no por tempo de espera para transferência de UCCI. Em 2011, dos 146 utentes com alta protelada (100%), 50 utentes (34,2%) permaneceram na UCCI por motivos sociais, enquanto em 2012 houve registo de 33 casos de protelamento (22,4%) em 147 (100%) altas prorrogadas. Conclusões: Dos factores identificados como motivo de protelamento nos 83 utentes, estritamente por motivos sociais, destaca-se o protelamento de alta por espera de integração em equipamento/resposta adequada, nomeadamente lar ou serviços de apoio domiciliário (79,5%), seguindo-se a insuficiência de rendimentos do utente/familiares para contratação de serviços ou resposta institucional (74,7%), a inexistência de condições habitacionais para regresso ao domicílio (63,9%) e a insuficiência de suporte familiar (54,2%). Regista-se também a inadequação do suporte familiar (31,3%), a inexistência de suporte familiar (28,9%) e, em menor percentagem, a ausência de condições estruturais (13,3%). A ausência de domicílio (sem abrigo) (8,4%) e a ausência de rendimentos (4,8%) também foram factores inibidores da alta clínica. Dos 293 utentes identificados que tiveram protelamento da alta por motivos sociais verificou-se que 144 (49,1%) dos utentes permaneceram unicamente pela existência de condicionantes institucionais e familiares/estruturais. Aspectos éticos: ao longo deste estudo, foram assegurados e respeitados, todos os procedimentos de garantia da confidencialidade e rigor na recolha dos dados, e a não interferência nas dinâmicas da instituição, dos utentes e dos profissionais.

The diabatic contour advective semi-Lagrangian model

This article describes a novel algorithmic development extending the contour advective semi-Lagrangian model to include nonconservative effects. The Lagrangian contour representation of finescale tracer fields, such as potential vorticity, allows for conservative, nondiffusive treatment of sharp gradients allowing very high numerical Reynolds numbers. It has been widely employed in accurate geostrophic turbulence and tracer advection simulations. In the present, diabatic version of the model the constraint of conservative dynamics is overcome by including a parallel Eulerian field that absorbs the nonconservative ( diabatic) tendencies. The diabatic buildup in this Eulerian field is limited through regular, controlled transfers of this field to the contour representation. This transfer is done with a fast newly developed contouring algorithm. This model has been implemented for several idealized geometries. In this paper a single-layer doubly periodic geometry is used to demonstrate the validity of the model. The present model converges faster than the analogous semi-Lagrangian models at increased resolutions. At the same nominal spatial resolution the new model is 40 times faster than the analogous semi-Lagrangian model. Results of an orographically forced idealized storm track show nontrivial dependency of storm-track statistics on resolution and on the numerical model employed. If this result is more generally applicable, this may have important consequences for future high-resolution climate modeling.

A regime-dependent balanced control variable based on potential vorticity

In this paper it is argued that rotational wind is not the best choice of leading control variable for variational data assimilation, and an alternative is suggested and tested. A rotational wind parameter is used in most global variational assimilation systems as a pragmatic way of approximately representing the balanced component of the assimilation increments. In effect, rotational wind is treated as a proxy for potential vorticity, but one that it is potentially not a good choice in flow regimes characterised by small Burger number. This paper reports on an alternative set of control variables which are based around potential vorticity. This gives rise to a new formulation of the background error covariances for the Met Office's variational assimilation system, which leads to flow dependency. It uses similar balance relationships to traditional schemes, but recognises the existence of unbalanced rotational wind which is used with a new anti-balance relationship. The new scheme is described and its performance is evaluated and compared to a traditional scheme using a sample of diagnostics.

The relationship between diffuse spectral reflectance of the soil and its cation exchange capacity is scale-dependent

Diffuse reflectance spectroscopy (DRS) is increasingly being used to predict numerous soil physical, chemical and biochemical properties. However, soil properties and processes vary at different scales and, as a result, relationships between soil properties often depend on scale. In this paper we report on how the relationship between one such property, cation exchange capacity (CEC), and the DRS of the soil depends on spatial scale. We show this by means of a nested analysis of covariance of soils sampled on a balanced nested design in a 16 km × 16 km area in eastern England. We used principal components analysis on the DRS to obtain a reduced number of variables while retaining key variation. The first principal component accounted for 99.8% of the total variance, the second for 0.14%. Nested analysis of the variation in the CEC and the two principal components showed that the substantial variance components are at the > 2000-m scale. This is probably the result of differences in soil composition due to parent material. We then developed a model to predict CEC from the DRS and used partial least squares (PLS) regression do to so. Leave-one-out cross-validation results suggested a reasonable predictive capability (R2 = 0.71 and RMSE = 0.048 molc kg− 1). However, the results from the independent validation were not as good, with R2 = 0.27, RMSE = 0.056 molc kg− 1 and an overall correlation of 0.52. This would indicate that DRS may not be useful for predictions of CEC. When we applied the analysis of covariance between predicted and observed we found significant scale-dependent correlations at scales of 50 and 500 m (0.82 and 0.73 respectively). DRS measurements can therefore be useful to predict CEC if predictions are required, for example, at the field scale (50 m). This study illustrates that the relationship between DRS and soil properties is scale-dependent and that this scale dependency has important consequences for prediction of soil properties from DRS data

Measuring and modelling mixture toxicity of imidacloprid and thiacloprid on Caenorhabditis elegans and Eisenia fetida

While the standard models of concentration addition and independent action predict overall toxicity of multicomponent mixtures reasonably, interactions may limit the predictive capability when a few compounds dominate a mixture. This study was conducted to test if statistically significant systematic deviations from concentration addition (i.e. synergism/antagonism, dose ratio- or dose level-dependency) occur when two taxonomically unrelated species, the earthworm Eisenia fetida and the nematode Caenorhabditis elegans were exposed to a full range of mixtures of the similar acting neonicotinoid pesticides imidacloprid and thiacloprid. The effect of the mixtures on C. elegans was described significantly better (p<0.01) by a dose level-dependent deviation from the concentration addition model than by the reference model alone, while the reference model description of the effects on E. fetida could not be significantly improved. These results highlight that deviations from concentration addition are possible even with similar acting compounds, but that the nature of such deviations are species dependent. For improving ecological risk assessment of simple mixtures, this implies that the concentration addition model may need to be used in a probabilistic context, rather than in its traditional deterministic manner. Crown Copyright (C) 2008 Published by Elsevier Inc. All rights reserved.

Causes of the apparent scale independence of fractal indices associated with forest fragmentation in Bolivia

In a recent investigation, Landsat TM and ETM+ data were used to simulate different resolutions of remotely-sensed images (from 30 to 1100 m) and to analyze the effect of resolution on a range of landscape metrics associated with spatial patterns of forest fragmentation in Chapare, Bolivia since the mid-1980s. Whereas most metrics were found to be highly dependent on pixel size, several fractal metrics (DLFD, MPFD, and AWMPFD) were apparently independent of image resolution, in contradiction with a sizeable body of literature indicating that fractal dimensions of natural objects depend strongly on image characteristics. The present re-analysis of the Chapare images, using two alternative algorithms routinely used for the evaluation of fractal dimensions, shows that the values of the box-counting and information fractal dimensions are systematically larger, sometimes by as much as 85%, than the "fractal" indices DLFD, MPFD, and AWMFD for the same images. In addition, the geometrical fractal features of the forest and non-forest patches in the Chapare region strongly depend on the resolution of images used in the analysis. The largest dependency on resolution occurs for the box-counting fractal dimension in the case of the non-forest patches in 1993, where the difference between the 30 and I 100 m-resolution images corresponds to 24% of the full theoretical range (1.0 to 2.0) of the mass fractal dimension. The observation that the indices DLFD, MPFD, and AWMPFD, unlike the classical fractal dimensions, appear relatively unaffected by resolution in the case of the Chapare images seems due essentially to the fact that these indices are based on a heuristic, "non-geometric" approach to fractals. Because of their lack of a foundation in fractal geometry, nothing guarantees that these indices will be resolution-independent in general. (C) 2006 International Society for Photogrammetry and Remote Sensing, Inc. (ISPRS). Published by Elsevier B.V. All rights reserved.

The geography of tyranny and despair: development indicators and the hypothesis of genetic inevitability of national inequality

Development geography has long sought to understand why inequalities exist and the best ways to address them. Dependency theory sets out an historical rationale for under development based on colonialism and a legacy of developed core and under-developed periphery. Race is relevant in this theory only insofar that Europeans are white and the places they colonised were occupied by people with darker skin colour. There are no innate biological reasons why it happened in that order. However, a new theory for national inequalities proposed by Lynn and Vanhanen in a series of publications makes the case that poorer countries have that status because of a poorer genetic stock rather than an accident of history. They argue that IQ has a genetic basis and IQ is linked to ability. Thus races with a poorer IQ have less ability, and thus national IQ can be positively correlated with performance as measured by an indicator like GDP/capita. Their thesis is one of despair, as little can be done to improve genetic stock significantly other than a programme of eugenics. This paper summarises and critiques the Lynn and Vanhanen hypothesis and the assumptions upon which it is based, and uses this analysis to show how a human desire to simplify in order to manage can be dangerous in development geography. While the attention may naturally be focused on the 'national IQ' variables as a proxy measure of 'innate ability', the assumption of GDP per capita as an indicator of 'success' and 'achievement' is far more readily accepted without criticism. The paper makes the case that the current vogue for indicators, indices and cause-effect can be tyrannical.

Calibrating flood inundation models: identifying and addressing uncertainty in satellite observed flood extents

Improvements in the resolution of satellite imagery have enabled extraction of water surface elevations at the margins of the flood. Comparison between modelled and observed water surface elevations provides a new means for calibrating and validating flood inundation models, however the uncertainty in this observed data has yet to be addressed. Here a flood inundation model is calibrated using a probabilistic treatment of the observed data. A LiDAR guided snake algorithm is used to determine an outline of a flood event in 2006 on the River Dee, North Wales, UK, using a 12.5m ERS-1 image. Points at approximately 100m intervals along this outline are selected, and the water surface elevation recorded as the LiDAR DEM elevation at each point. With a planar water surface from the gauged upstream to downstream water elevations as an approximation, the water surface elevations at points along this flooded extent are compared to their ‘expected’ value. The pattern of errors between the two show a roughly normal distribution, however when plotted against coordinates there is obvious spatial autocorrelation. The source of this spatial dependency is investigated by comparing errors to the slope gradient and aspect of the LiDAR DEM. A LISFLOOD-FP model of the flood event is set-up to investigate the effect of observed data uncertainty on the calibration of flood inundation models. Multiple simulations are run using different combinations of friction parameters, from which the optimum parameter set will be selected. For each simulation a T-test is used to quantify the fit between modelled and observed water surface elevations. The points chosen for use in this T-test are selected based on their error. The criteria for selection enables evaluation of the sensitivity of the choice of optimum parameter set to uncertainty in the observed data. This work explores the observed data in detail and highlights possible causes of error. The identification of significant error (RMSE = 0.8m) between approximate expected and actual observed elevations from the remotely sensed data emphasises the limitations of using this data in a deterministic manner within the calibration process. These limitations are addressed by developing a new probabilistic approach to using the observed data.

Ranking efficiency units in DEA using bootstrapping an applied analysis for Slovenian farm data

This article explores how data envelopment analysis (DEA), along with a smoothed bootstrap method, can be used in applied analysis to obtain more reliable efficiency rankings for farms. The main focus is the smoothed homogeneous bootstrap procedure introduced by Simar and Wilson (1998) to implement statistical inference for the original efficiency point estimates. Two main model specifications, constant and variable returns to scale, are investigated along with various choices regarding data aggregation. The coefficient of separation (CoS), a statistic that indicates the degree of statistical differentiation within the sample, is used to demonstrate the findings. The CoS suggests a substantive dependency of the results on the methodology and assumptions employed. Accordingly, some observations are made on how to conduct DEA in order to get more reliable efficiency rankings, depending on the purpose for which they are to be used. In addition, attention is drawn to the ability of the SLICE MODEL, implemented in GAMS, to enable researchers to overcome the computational burdens of conducting DEA (with bootstrapping).

Mercury: An agent of poverty in Ghana's small-scale gold-mining sector?

There is consensus worldwide that the artisanal and small-scale mining (ASM) sector is comprised of individuals who are trapped in a vicious cycle of poverty, lacking the necessary financial and technological means to improve their standards of living. Minimal work, however, has been undertaken to identify the very factors behind miners' plight, which inevitably vary from country to country. This paper uses a case study of Ghana to argue that an increased dependence upon mercury for amalgamation In artisanal gold-mining communities is one such-albeit overlooked-"agent of poverty". There is mounting empirical evidence which suggests that dealings with the monoponistic middlemen who supply mercury, purchases of costly medicines to remedy ailments caused by mercury poisoning, and a lack of appropriate safeguards and alternatives to amalgamation, are preventing gold miners from improving their practices and livelihoods. The solution to the problem lies in breaking this cycle of dependency, which can be achieved by providing miners with robust support services, mercury-free technologies and education. (c) 2006 Elsevier Ltd. All rights reserved.

A mathematical model of the in vitro keratinocyte response to chromium and nickel exposure

A mathematical model describing the main mechanistic processes involved in keratinocyte response to chromium and nickel has been developed and compared to experimental in vitro data. Accounting for the interactions between the metal ions and the keratinocytes, the law of mass action was used to generate ordinary differential equations which predict the time evolution and ion concentration dependency of keratinocyte viability, the amount of metal associated with the keratinocytes and the release of cytokines by the keratinocytes. Good agreement between model predictions and existing experimental data of these endpoints was observed, supporting the use of this model to explore physiochemical parameters that influence the toxicological response of keratinocytes to these two metals.

Analysis of creep strain during tensile fatigue of cortical bone

During fatigue tests of cortical bone specimens, at the unload portion of the cycle (zero stress) non-zero strains occur and progressively accumulate as the test progresses. This non-zero strain is hypothesised to be mostly, if not entirely, describable as creep. This work examines the rate of accumulation of this strain and quantifies its stress dependency. A published relationship determined from creep tests of cortical bone (Journal of Biomechanics 21 (1988) 623) is combined with knowledge of the stress history during fatigue testing to derive an expression for the amount of creep strain in fatigue tests. Fatigue tests on 31 bone samples from four individuals showed strong correlations between creep strain rate and both stress and “normalised stress” (σ/E) during tensile fatigue testing (0–T). Combined results were good (r2=0.78) and differences between the various individuals, in particular, vanished when effects were examined against normalised stress values. Constants of the regression showed equivalence to constants derived in creep tests. The universality of the results, with respect to four different individuals of both sexes, shows great promise for use in computational models of fatigue in bone structures.

Competitive strategy revisited: contested concepts and dynamic capabilities

Strategy is a contested concept. The generic literature is characterized by a diverse range of competing theories and alternative perspectives. Traditional models of the competitive strategy of construction firms have tended to focus on exogenous factors. In contrast, the resource-based view of strategic management emphasizes the importance of endogenous factors. The more recently espoused concept of dynamic capabilities extends consideration beyond static resources to focus on the ability of firms to reconfigure their operating routines to enable responses to changing environments. The relevance of the dynamics capabilities framework to the construction sector is investigated through an exploratory case study of a regional contractor. The focus on how firms continuously adapt to changing environments provides new insights into competitive strategy in the construction sector. Strong support is found for the importance of path dependency in shaping strategic choice. The case study further suggests that strategy is a collective endeavour enacted by a loosely defined group of individual actors. Dynamic capabilities are characterized by an empirical elusiveness and as such are best construed as situated practices embedded within a social and physical context.

An investigation of the existing situation and trends in building energy efficiency management in China

According to the Chinese State Council's "Building Energy Efficiency Management Ordinance", a large-scale investigation of energy efficiency (EE) in buildings in contemporary China has been carried out in 22 provincial capitals and major cities in China. The aim of this project is to provide reliable information for drawing up the "Decision on reinforcing building energy efficiency" by the Ministry of Construction of China. The surveyed organizations include government departments, research institutions, property developers, design institutions, construction companies, construction consultancy services companies, facility management departments, financial institutions and those which relate to the business of building energy efficiency. In addition, representatives of the media and residents were also involved. A detailed analysis of the results of the investigation concerning aspects of the cur-rent situation and trends in building energy consumption, energy efficiency strategy and the implementation of energy efficiency measures has been conducted. The investigation supplies essential information to formulate the market entrance policy for new buildings and the refurbishment policy for existing buildings to encourage the development of energy efficient technology.

The challenges facing privatization of infrastructure projects in Libya

Libya with its strategic location and natural resources stands as a crucial link between the Arab world, Europe, and Africa. The people of Libya have an optimistic outlook with regard to the Libyan economy after the suspension of the United Nations sanctions in 1999 that had been imposed on Libya in 1992, as well as the recent emphasis on privatization from the government. Since then, local and foreign investors have been encouraged to take a more prominent role in order to help privatize some of the state run-industries; the attention to privatization is aimed to help Libya’s economic growth and reduce its heavy dependency on oil revenues. Considering the economic situation, Libya is a rich country. However, it needs to modernize, it needs more and better infrastructure, it needs non-oil based financing, furthermore, it needs to develop a financial model for development and investment from the private sector. Although the Libyan government is working on the improvement of the business environment to make it more attractive for foreign investors in a way to move towards privatization, they have ignored some of the challenges that privatization will be facing in Libya. Privatization can not be implemented overnight. They have taken this for granted without careful consideration of its challenges. This paper attempts to investigate and discuss the challenges that need to be taken into account before privatization of infrastructure projects can be introduced in Libya. This paper is based on interviews with senior technical officials in the government.