Of missing fathers and Big Fish: reconstructive tendencies after postmodernism

Many things have been said about literature after postmodernism, but one point there seems to be some agreement on is that it does not turn its back radically on its postmodernist forerunner, but rather generally continues to heed and value their insights. There seems to be something strikingly non-oedipal about the recent aesthetic shift. It is a project of reconstruction that remains deeply rooted in postmodernist tenets. Such an essentially non-oedipal attitude, I would argue, is central to the nature of the reconstructive shift. This, however, also raises questions about the wider cultural context from which such an aesthetic stance arises. If postmodernism was nurtured by the revolutionary spirits of the late 1960s, reconstruction faces a different world with different strategies. Instead of the postmodernist urge to subvert, expose and undermine, reconstruction yearns towards tentative and fragile intersubjective understanding, towards responsibility and community. Instead of revolt and rebellion it explores reconciliation and compromise. One instance in which this becomes visible in reconstructive narratives is the recurring figure of the lost father. Missing father figures abound in recent novels by authors like Mark Z. Danielewski, Dave Eggers, Yann Mantel, David Mitchell etc. It almost seems like a younger generation is yearning for the fathers which postmodernism has struggled hard to do away with. My paper will focus on one particularly striking example to explore the implications of this development: Daniel Wallace’s novel Big Fish and Tim Burton’s well-known film adaptation of the same. In their negotiation of fact and fiction, of doubt and belief, of freedom and responsibility, all of which converge in a father-son relationship, they serve well to illustrate central characteristics and concerns of recent attempts to leave postmodernism behind.

MARITAL STATUS AND CARDIOVASCULAR RISK (SERUM, CHOLESTEROL, CIGARETTE, SMOKING, BLOOD, PRESSURE, SYSTOLIC)

There were three purposes of this study. The first was to describe the association between stable marital status and serum cholesterol, systolic blood pressure and cigarette smoking. The second purpose was to determine whether individuals who were married at one point and became widowed or divorced/separated had higher serum cholesterol, higher systolic blood pressure or were more likely to smoke prior to the change in marital status compared with individuals who did not change marital status. The third purpose was to determine whether the changes in marital status described above were related to increases in serum cholesterol or in cigarette smoking behavior. The rationale for the study was to determine whether previously reported associations between marital status categories and cardiovascular mortality may be mediated through higher values of risk correlates for cardiovascular disease among unmarried individuals.^ The study group selected for this dissertation was a sample from the Hypertension Detection and Follow-up Program (HDFP) population. The HDFP population was aged 30-69 years at the initial visit and included blacks and whites, males and females. The population was followed five years after the initial visit and periodic measurements of serum cholesterol, blood pressure and cigarette smoking behavior were obtained.^ Serum cholesterol was not associated with stable marital status category or with marital status prior to change. Changes in serum cholesterol were associated with marital status categories after change but the serum cholesterol values deceased rather than increased. Married individuals were shown to have higher serum cholesterol values compared with unmarried. Selection of the HDFP population may have influenced an ability to detect a significant association between marital status and serum cholesterol but it is doubtful that use of a general population would alter the direction of the association.^ Systolic blood pressure was significantly higher at the initial visit among unmarried white males and females compared with their married counterparts. No association between systolic blood pressure was found among black males or females. Those individuals who were married at the initial visit who experienced a change in marital status were found to have higher systolic blood pressure prior to the change in marital status. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of author.) UMI ^

Rabies control in the developing world: Results of a cross-sectional study in Bohol, Philippines

Rabies remains a significant problem in much of the developed world, where canine rabies is not well controlled, and the bite of an infected dog is the most common means of transmission. The Philippines continues to report several hundred cases of human rabies every year, and many more cases go undetected. In recent years, the province of Bohol has been targeted by the Philippine government and the World Health Organization for a rabies eradication program. ^ The primary objective of this dissertation research was to describe factors associated with dog vaccination coverage and knowledge, attitudes, and practices regarding rabies among households in Bohol, Philippines. Utilizing a cross-sectional cluster survey design, we sampled 460 households and 541 dogs residing within dog-owning households. ^ Multivariate linear regression was used to examine potential associations between knowledge, attitudes, and practices (KAPs) and variables of interest. Forty-six percent of households knew that rabies was spread through the bite of an infected dog. The mean knowledge score was 8.36 (SD: ± 3.4; range: 1–24). We found that having known someone with rabies was significantly associated with an almost one point increase in the knowledge score (β = 0.88; p = 0.02). The mean attitudes score was 5.65 (SD: ± 0.63; range: 2–6), and the mean practices score was 7.07 (SD: ± 1.7; range: 2–9). Both the attitudes score and the practices score were positively and significantly associated with only the knowledge score and no other covariates. ^ Multivariate logistic regression was used to examine associations between dog vaccination coverage and variables of interest. Approximately 71% of owned dogs in Bohol were reported as vaccinated at some time during their lives. We found that a dog's age was significantly associated with vaccination, and the odds of vaccination increased in a linear fashion with age. We also found that dogs had approximately twice the odds of being vaccinated if they were confined both day and night to the household premises or if the owner was employed; however, these results were only marginally significant (p = 0.07) in the multivariate model. ^ Finally, a systematic review was conducted on canine rabies vaccination and dog population demographics in the developing world. We found few studies on this topic, especially in countries where the burden of rabies is greatest. Overall, dog ownership is high. Dogs are quite young and do not live very long due to disease and accidents. The biggest deterrent to vaccination is the rapid dog population turnover. ^ It is our hope that this work will be used to improve dog rabies vaccination programs around the world and save lives, both human and canine.^

Ensayo, viaje y memoria : lectura de El destino de un continente (1923) de Manuel Ugarte

Dentro del corpus ensayístico de Manuel Ugarte figura una obra titulada El destino de un continente (1923) que da cuenta de su gira por el continente americano. El propósito de este largo viaje que emprende Ugarte es de carácter propagandístico, pues sostiene públicamente —a través de conferencias, mítines— la tesis de la unidad continental como estrategia defensiva contra la política intervencionista norteamericana. Pareciera, inicialmente, que el texto en cuestión merecería un abordaje desde los estudios de la literatura de viaje, lo que es en sí mismo correcto aunque, a nuestro entender, insuficiente. De manera que tenemos un problema de orden genérico que bien vale la pena plantear a fin de ajustar nuestra lectura. Es cierto que se trata de un viaje, pero no de un viaje cualquiera, en términos de un sujeto que se traslada de un sitio a otro con propósitos meramente turísticos, sino que la motivación central del desplazamiento ugarteano se sitúa en una acción catequística, si se quiere, de prédica que pretende mover a la acción.

High reynolds numbers turbulent boundary layers

Esta tesis estudia las similitudes y diferencias entre los flujos turbulentos de pared de tipo externo e interno, en régimen incompresible, y a números de Reynolds moderada¬mente altos. Para ello consideramos tanto simulaciones numéricas como experimentos de capas límites con gradiente de presiones nulo y de flujos de canal, ambos a números de Reynolds en el rango δ+ ~ 500 - 2000. Estos flujos de cortadura son objeto de numerosas investigaciones debido a la gran importancia que tienen tanto a nivel tecnológico como a nivel de física fundamental. No obstante, todavía existen muchos interrogantes sobre aspectos básicos tales como la universalidad de los perfiles medios y de fluctuación de las velocidades o de la presión, tanto en la zona cercana a la pared como en la zona logarítmica, el escalado y el efecto del número de Reynolds, o las diferencias entre los flujos internos y externos en la zona exterior. En éste estudio hemos utilizado simulaciones numéricas ya existentes de canales y capas límites a números de Reynolds δ+ ~ 2000 y δ+ ~ 700, respectivamente. Para poder comparar ambos flujos a igual número de Reynolds hemos realizado una nueva simulación directa de capa límite en el rango δ+ ~ 1000-2000. Los resultados de la misma son presentados y analizados en detalle. Los datos sin postprocesar y las estadísticas ya postprocesadas están públicamente disponibles en nuestro sitio web.162 El análisis de las estadísticas usando un único punto confirma la existencia de perfiles logarítmicos para las fluctuaciones de la velocidad transversal w'2+ y de la presión p'2+ en ambos tipos de flujos, pero no para la velocidad normal v'2+ o la velocidad longitudinal u'2+. Para aceptar o rechazar la existencia de un rango logarítmico en u'2+ se requieren números de Reynolds más altos que los considerados en éste trabajo. Una de las conse¬cuencias más importantes de poseer tales perfiles es que el valor máximo de la intensidad, que se alcanza cerca de la pared, depende explícitamente del número de Reynolds. Esto ha sido confirmado tras analizar un gran número de datos experimentales y numéricos, cor¬roborando que el máximo de u'2+, p/2+, y w'2+ aumenta proporcionalmente con el log(δ+). Por otro lado, éste máximo es más intenso en los flujos externos que en los internos. La máxima diferencia ocurre en torno a y/δ ~ 0.3-0.5, siendo esta altura prácticamente independiente del número de Reynolds considerado. Estas diferencias se originan como consecuencia del carácter intermitente de las capas límites, que es inexistente en los flujos internos. La estructura de las fluctuaciones de velocidad y de presión, junto con la de los esfuer¬zos de Reynolds, se han investigado por medio de correlaciones espaciales tridimensionales considerando dos puntos de medida. Hemos obtenido que el tamaño de las mismas es gen¬eralmente mayor en canales que en capas límites, especialmente en el caso de la correlación longitudinal Cuu en la dirección del flujo. Para esta correlación se demuestra que las es¬tructuras débilmente correladas presentan longitudes de hasta 0(75), en el caso de capas límites, y de hasta 0(185) en el caso de canales. Estas longitudes se obtienen respecti-vamente en la zona logarítmica y en la zona exterior. Las longitudes correspondientes en la dirección transversal son significativamente menores en ambos flujos, 0(5 — 25). La organización espacial de las correlaciones es compatible con la de una pareja de rollos casi paralelos con dimensiones que escalan en unidades exteriores. Esta organización se mantiene al menos hasta y ~ 0.65, altura a la cual las capas límites comienzan a organi¬zarse en rollos transversales. Este comportamiento es sin embargo más débil en canales, pudiéndose observar parcialmente a partir de y ~ 0.85. Para estudiar si estas estructuras están onduladas a lo largo de la dirección transver¬sal, hemos calculado las correlaciones condicionadas a eventos intensos de la velocidad transversal w'. Estas correlaciones revelan que la ondulación de la velocidad longitudinal aumenta conforme nos alejamos de la pared, sugiriendo que las estructuras están más alineadas en la zona cercana a la pared que en la zona lejana a ella. El por qué de esta ondulación se encuentra posiblemente en la configuración a lo largo de diagonales que presenta w'. Estas estructuras no sólo están onduladas, sino que también están inclinadas respecto a la pared con ángulos que dependen de la variable considerada, de la altura, y de el contorno de correlación seleccionado. Por encima de la zona tampón e independien¬temente del número de Reynolds y tipo de flujo, Cuu presenta una inclinación máxima de unos 10°, las correlaciones Cvv y Cm son esencialmente verticales, y Cww está inclinada a unos 35°. Summary This thesis studies the similitudes and differences between external and internal in¬compressible wall-bounded turbulent flows at moderately-high Reynolds numbers. We consider numerical and experimental zero-pressure-gradient boundary layers and chan¬nels in the range of δ+ ~ 500 — 2000. These shear flows are subjects of intensive research because of their technological importance and fundamental physical interest. However, there are still open questions regarding basic aspects such as the universality of the mean and fluctuating velocity and pressure profiles at the near-wall and logarithmic regions, their scaling and the effect of the Reynolds numbers, or the differences between internal and external flows at the outer layer, to name but a few. For this study, we made use of available direct numerical simulations of channel and boundary layers reaching δ+ ~ 2000 and δ+ ~ 700, respectively. To fill the gap in the Reynolds number, a new boundary layer simulation in the range δ+ ~ 1000-2000 is presented and discussed. The original raw data and the post-processed statistics are publicly available on our website.162 The analysis of the one-point statistic confirms the existence of logarithmic profiles for the spanwise w'2+ and pressure p'2+ fluctuations for both type of flows, but not for the wall-normal v'2+ or the streamwise u'2+ velocities. To accept or reject the existence of a logarithmic range in u'2+ requires higher Reynolds numbers than the ones considered in this work. An important consequence of having such profiles is that the maximum value of the intensities, reached near the wall, depends on the Reynolds number. This was confirmed after surveying a wide number of experimental and numerical datasets, corrob¬orating that the maximum of ul2+, p'2+, and w'2+ increases proportionally to log(δ+). On the other hand, that maximum is more intense in external flows than in internal ones, differing the most around y/δ ~ 0.3-0.5, and essentially independent of the Reynolds number. We discuss that those differences are originated as a consequence of the inter¬mittent character of boundary layers that is absent in internal flows. The structure of the velocity and pressure fluctuations, together with those of the Reynolds shear stress, were investigated using three-dimensional two-point spatial correlations. We find that the correlations extend over longer distances in channels than in boundary layers, especially in the case of the streamwise correlation Cuu in the flow direc-tion. For weakly correlated structures, the maximum streamwise length of Cuu is O(78) for boundary layers and O(188) for channels, attained at the logarithmic and outer regions respectively. The corresponding lengths for the transverse velocities and for the pressure are shorter, 0(8 — 28), and of the same order for both flows. The spatial organization of the velocity correlations is shown to be consistent with a pair of quasi-streamwise rollers that scales in outer units. That organization is observed until y ~ 0.68, from which boundary layers start to organize into spanwise rollers. This effect is weaker in channels, and it appears at y ~ 0.88. We present correlations conditioned to intense events of the transversal velocity, w', to study if these structures meander along the spanwise direction. The results indicate that the streamwise velocity streaks increase their meandering proportionally to the distance to the wall, suggesting that the structures are more aligned close to the wall than far from it. The reason behind this meandering is probably due to the characteristic organization along diagonals of w'. These structures not only meander along the spanwise direction, but they are also inclined to the wall at angles that depend on the distance from the wall, on the variable being considered, and on the correlation level used to define them. Above the buffer layer and independent of the Reynolds numbers and type of flow, the maximum inclination of Cuu is about 10°, Cvv and Cpp are roughly vertical, and Cww is inclined by 35°.

Time-resolved evolution of coherent structures in turbulent channels

El objetivo de esta tesis es estudiar la dinámica de la capa logarítmica de flujos turbulentos de pared. En concreto, proponemos un nuevo modelo estructural utilizando diferentes tipos de estructuras coherentes: sweeps, eyecciones, grupos de vorticidad y streaks. La herramienta utilizada es la simulación numérica directa de canales turbulentos. Desde los primeros trabajos de Theodorsen (1952), las estructuras coherentes han jugado un papel fundamental para entender la organización y dinámica de los flujos turbulentos. A día de hoy, datos procedentes de simulaciones numéricas directas obtenidas en instantes no contiguos permiten estudiar las propiedades fundamentales de las estructuras coherentes tridimensionales desde un punto de vista estadístico. Sin embargo, la dinámica no puede ser entendida en detalle utilizando sólo instantes aislados en el tiempo, sino que es necesario seguir de forma continua las estructuras. Aunque existen algunos estudios sobre la evolución temporal de las estructuras más pequeñas a números de Reynolds moderados, por ejemplo Robinson (1991), todavía no se ha realizado un estudio completo a altos números de Reynolds y para todas las escalas presentes de la capa logarítmica. El objetivo de esta tesis es llevar a cabo dicho análisis. Los problemas más interesantes los encontramos en la región logarítmica, donde residen las cascadas de vorticidad, energía y momento. Existen varios modelos que intentan explicar la organización de los flujos turbulentos en dicha región. Uno de los más extendidos fue propuesto por Adrian et al. (2000) a través de observaciones experimentales y considerando como elemento fundamental paquetes de vórtices con forma de horquilla que actúan de forma cooperativa para generar rampas de bajo momento. Un modelo alternativo fué ideado por del Álamo & Jiménez (2006) utilizando datos numéricos. Basado también en grupos de vorticidad, planteaba un escenario mucho más desorganizado y con estructuras sin forma de horquilla. Aunque los dos modelos son cinemáticamente similares, no lo son desde el punto de vista dinámico, en concreto en lo que se refiere a la importancia que juega la pared en la creación y vida de las estructuras. Otro punto importante aún sin resolver se refiere al modelo de cascada turbulenta propuesto por Kolmogorov (1941b), y su relación con estructuras coherentes medibles en el flujo. Para dar respuesta a las preguntas anteriores, hemos desarrollado un nuevo método que permite seguir estructuras coherentes en el tiempo y lo hemos aplicado a simulaciones numéricas de canales turbulentos con números de Reynolds lo suficientemente altos como para tener un rango de escalas no trivial y con dominios computacionales lo suficientemente grandes como para representar de forma correcta la dinámica de la capa logarítmica. Nuestros esfuerzos se han desarrollado en cuatro pasos. En primer lugar, hemos realizado una campaña de simulaciones numéricas directas a diferentes números de Reynolds y tamaños de cajas para evaluar el efecto del dominio computacional en las estadísticas de primer orden y el espectro. A partir de los resultados obtenidos, hemos concluido que simulaciones con cajas de longitud 2vr y ancho vr veces la semi-altura del canal son lo suficientemente grandes para reproducir correctamente las interacciones entre estructuras coherentes de la capa logarítmica y el resto de escalas. Estas simulaciones son utilizadas como punto de partida en los siguientes análisis. En segundo lugar, las estructuras coherentes correspondientes a regiones con esfuerzos de Reynolds tangenciales intensos (Qs) en un canal turbulento han sido estudiadas extendiendo a tres dimensiones el análisis de cuadrantes, con especial énfasis en la capa logarítmica y la región exterior. Las estructuras coherentes han sido identificadas como regiones contiguas del espacio donde los esfuerzos de Reynolds tangenciales son más intensos que un cierto nivel. Los resultados muestran que los Qs separados de la pared están orientados de forma isótropa y su contribución neta al esfuerzo de Reynolds medio es nula. La mayor contribución la realiza una familia de estructuras de mayor tamaño y autosemejantes cuya parte inferior está muy cerca de la pared (ligada a la pared), con una geometría compleja y dimensión fractal « 2. Estas estructuras tienen una forma similar a una ‘esponja de placas’, en comparación con los grupos de vorticidad que tienen forma de ‘esponja de cuerdas’. Aunque el número de objetos decae al alejarnos de la pared, la fracción de esfuerzos de Reynolds que contienen es independiente de su altura, y gran parte reside en unas pocas estructuras que se extienden más allá del centro del canal, como en las grandes estructuras propuestas por otros autores. Las estructuras dominantes en la capa logarítmica son parejas de sweeps y eyecciones uno al lado del otro y con grupos de vorticidad asociados que comparten las dimensiones y esfuerzos con los remolinos ligados a la pared propuestos por Townsend. En tercer lugar, hemos estudiado la evolución temporal de Qs y grupos de vorticidad usando las simulaciones numéricas directas presentadas anteriormente hasta números de Reynolds ReT = 4200 (Reynolds de fricción). Las estructuras fueron identificadas siguiendo el proceso descrito en el párrafo anterior y después seguidas en el tiempo. A través de la interseción geométrica de estructuras pertenecientes a instantes de tiempo contiguos, hemos creado gratos de conexiones temporales entre todos los objetos y, a partir de ahí, definido ramas primarias y secundarias, de tal forma que cada rama representa la evolución temporal de una estructura coherente. Una vez que las evoluciones están adecuadamente organizadas, proporcionan toda la información necesaria para caracterizar la historia de las estructuras desde su nacimiento hasta su muerte. Los resultados muestran que las estructuras nacen a todas las distancias de la pared, pero con mayor probabilidad cerca de ella, donde la cortadura es más intensa. La mayoría mantienen tamaños pequeños y no viven mucho tiempo, sin embargo, existe una familia de estructuras que crecen lo suficiente como para ligarse a la pared y extenderse a lo largo de la capa logarítmica convirtiéndose en las estructuras observas anteriormente y descritas por Townsend. Estas estructuras son geométricamente autosemejantes con tiempos de vida proporcionales a su tamaño. La mayoría alcanzan tamaños por encima de la escala de Corrsin, y por ello, su dinámica está controlada por la cortadura media. Los resultados también muestran que las eyecciones se alejan de la pared con velocidad media uT (velocidad de fricción) y su base se liga a la pared muy rápidamente al inicio de sus vidas. Por el contrario, los sweeps se mueven hacia la pared con velocidad -uT y se ligan a ella más tarde. En ambos casos, los objetos permanecen ligados a la pared durante 2/3 de sus vidas. En la dirección de la corriente, las estructuras se desplazan a velocidades cercanas a la convección media del flujo y son deformadas por la cortadura. Finalmente, hemos interpretado la cascada turbulenta, no sólo como una forma conceptual de organizar el flujo, sino como un proceso físico en el cual las estructuras coherentes se unen y se rompen. El volumen de una estructura cambia de forma suave, cuando no se une ni rompe, o lo hace de forma repentina en caso contrario. Los procesos de unión y rotura pueden entenderse como una cascada directa (roturas) o inversa (uniones), siguiendo el concepto de cascada de remolinos ideado por Richardson (1920) y Obukhov (1941). El análisis de los datos muestra que las estructuras con tamaños menores a 30η (unidades de Kolmogorov) nunca se unen ni rompen, es decir, no experimentan el proceso de cascada. Por el contrario, aquellas mayores a 100η siempre se rompen o unen al menos una vez en su vida. En estos casos, el volumen total ganado y perdido es una fracción importante del volumen medio de la estructura implicada, con una tendencia ligeramente mayor a romperse (cascada directa) que a unirse (cascade inversa). La mayor parte de interacciones entre ramas se debe a roturas o uniones de fragmentos muy pequeños en la escala de Kolmogorov con estructuras más grandes, aunque el efecto de fragmentos de mayor tamaño no es despreciable. También hemos encontrado que las roturas tienen a ocurrir al final de la vida de la estructura y las uniones al principio. Aunque los resultados para la cascada directa e inversa no son idénticos, son muy simétricos, lo que sugiere un alto grado de reversibilidad en el proceso de cascada. ABSTRACT The purpose of the present thesis is to study the dynamics of the logarithmic layer of wall-bounded turbulent flows. Specifically, to propose a new structural model based on four different coherent structures: sweeps, ejections, clusters of vortices and velocity streaks. The tool used is the direct numerical simulation of time-resolved turbulent channels. Since the first work by Theodorsen (1952), coherent structures have played an important role in the understanding of turbulence organization and its dynamics. Nowadays, data from individual snapshots of direct numerical simulations allow to study the threedimensional statistical properties of those objects, but their dynamics can only be fully understood by tracking them in time. Although the temporal evolution has already been studied for small structures at moderate Reynolds numbers, e.g., Robinson (1991), a temporal analysis of three-dimensional structures spanning from the smallest to the largest scales across the logarithmic layer has yet to be performed and is the goal of the present thesis. The most interesting problems lie in the logarithmic region, which is the seat of cascades of vorticity, energy, and momentum. Different models involving coherent structures have been proposed to represent the organization of wall-bounded turbulent flows in the logarithmic layer. One of the most extended ones was conceived by Adrian et al. (2000) and built on packets of hairpins that grow from the wall and work cooperatively to gen- ´ erate low-momentum ramps. A different view was presented by del Alamo & Jim´enez (2006), who extracted coherent vortical structures from DNSs and proposed a less organized scenario. Although the two models are kinematically fairly similar, they have important dynamical differences, mostly regarding the relevance of the wall. Another open question is whether such a model can be used to explain the cascade process proposed by Kolmogorov (1941b) in terms of coherent structures. The challenge would be to identify coherent structures undergoing a turbulent cascade that can be quantified. To gain a better insight into the previous questions, we have developed a novel method to track coherent structures in time, and used it to characterize the temporal evolutions of eddies in turbulent channels with Reynolds numbers high enough to include a non-trivial range of length scales, and computational domains sufficiently long and wide to reproduce correctly the dynamics of the logarithmic layer. Our efforts have followed four steps. First, we have conducted a campaign of direct numerical simulations of turbulent channels at different Reynolds numbers and box sizes, and assessed the effect of the computational domain in the one-point statistics and spectra. From the results, we have concluded that computational domains with streamwise and spanwise sizes 2vr and vr times the half-height of the channel, respectively, are large enough to accurately capture the dynamical interactions between structures in the logarithmic layer and the rest of the scales. These simulations are used in the subsequent chapters. Second, the three-dimensional structures of intense tangential Reynolds stress in plane turbulent channels (Qs) have been studied by extending the classical quadrant analysis to three dimensions, with emphasis on the logarithmic and outer layers. The eddies are identified as connected regions of intense tangential Reynolds stress. Qs are then classified according to their streamwise and wall-normal fluctuating velocities as inward interactions, outward interactions, sweeps and ejections. It is found that wall-detached Qs are isotropically oriented background stress fluctuations, common to most turbulent flows, and do not contribute to the mean stress. Most of the stress is carried by a selfsimilar family of larger wall-attached Qs, increasingly complex away from the wall, with fractal dimensions « 2. They have shapes similar to ‘sponges of flakes’, while vortex clusters resemble ‘sponges of strings’. Although their number decays away from the wall, the fraction of the stress that they carry is independent of their heights, and a substantial part resides in a few objects extending beyond the centerline, reminiscent of the very large scale motions of several authors. The predominant logarithmic-layer structures are sideby- side pairs of sweeps and ejections, with an associated vortex cluster, and dimensions and stresses similar to Townsend’s conjectured wall-attached eddies. Third, the temporal evolution of Qs and vortex clusters are studied using time-resolved DNS data up to ReT = 4200 (friction Reynolds number). The eddies are identified following the procedure presented above, and then tracked in time. From the geometric intersection of structures in consecutive fields, we have built temporal connection graphs of all the objects, and defined main and secondary branches in a way that each branch represents the temporal evolution of one coherent structure. Once these evolutions are properly organized, they provide the necessary information to characterize eddies from birth to death. The results show that the eddies are born at all distances from the wall, although with higher probability near it, where the shear is strongest. Most of them stay small and do not last for long times. However, there is a family of eddies that become large enough to attach to the wall while they reach into the logarithmic layer, and become the wall-attached structures previously observed in instantaneous flow fields. They are geometrically self-similar, with sizes and lifetimes proportional to their distance from the wall. Most of them achieve lengths well above the Corrsin’ scale, and hence, their dynamics are controlled by the mean shear. Eddies associated with ejections move away from the wall with an average velocity uT (friction velocity), and their base attaches very fast at the beginning of their lives. Conversely, sweeps move towards the wall at -uT, and attach later. In both cases, they remain attached for 2/3 of their lives. In the streamwise direction, eddies are advected and deformed by the local mean velocity. Finally, we interpret the turbulent cascade not only as a way to conceptualize the flow, but as an actual physical process in which coherent structures merge and split. The volume of an eddy can change either smoothly, when they are not merging or splitting, or through sudden changes. The processes of merging and splitting can be thought of as a direct (when splitting) or an inverse (when merging) cascade, following the ideas envisioned by Richardson (1920) and Obukhov (1941). It is observed that there is a minimum length of 30η (Kolmogorov units) above which mergers and splits begin to be important. Moreover, all eddies above 100η split and merge at least once in their lives. In those cases, the total volume gained and lost is a substantial fraction of the average volume of the structure involved, with slightly more splits (direct cascade) than mergers. Most branch interactions are found to be the shedding or absorption of Kolmogorov-scale fragments by larger structures, but more balanced splits or mergers spanning a wide range of scales are also found to be important. The results show that splits are more probable at the end of the life of the eddy, while mergers take place at the beginning of the life. Although the results for the direct and the inverse cascades are not identical, they are found to be very symmetric, which suggests a high degree of reversibility of the cascade process.

Entrainment Effects in Turbulent Boundary Layers

Esta tesis estudia el comportamiento de la región exterior de una capa límite turbulenta sin gradientes de presiones. Se ponen a prueba dos teorías relativamente bien establecidas. La teoría de semejanza para la pared supone que en el caso de haber una pared rugosa, el fluido sólo percibe el cambio en la fricción superficial que causa, y otros efectos secundarios quedarán confinados a una zona pegada a la pared. El consenso actual es que dicha teoría es aproximadamente cierta. En el extremo exterior de la capa límite existe una región producida por la interacción entre las estructuras turbulentas y el flujo irrotacional de la corriente libre llamada interfaz turbulenta/no turbulenta. La mayoría de los resultados al respecto sugieren la presencia de fuerzas de cortadura ligeramente más intensa, lo que la hace distinta al resto del flujo turbulento. Las propiedades de esa región probablemente cambien si la velocidad de crecimiento de la capa límite aumenta, algo que puede conseguirse aumentando la fricción en la pared. La rugosidad y la ingestión de masa están entonces relacionadas, y el comportamiento local de la interfaz turbulenta/no turbulenta puede explicar el motivo por el que las capas límite sobre paredes rugosas no se comportan como en el caso de tener paredes lisas precisamente en la zona exterior. Para estudiar las capas límite a números de Reynolds lo suficientemente elevados, se ha desarrollado un nuevo código de alta resolución para la simulación numérica directa de capas límite turbulentas sin gradiente de presión. Dicho código es capaz de simular capas límite en un intervalo de números de Reynolds entre ReT = 100 — 2000 manteniendo una buena escalabilidad hasta los dos millones de hilos en superordenadores de tipo Blue Gene/Q. Se ha guardado especial atención a la generación de condiciones de contorno a la entrada correctas. Los resultados obtenidos están en concordancia con los resultados previos, tanto en el caso de simulaciones como de experimentos. La interfaz turbulenta/no turbulenta de una capa límite se ha analizado usando un valor umbral del módulo de la vorticidad. Dicho umbral se considera un parámetro para analizar cada superficie obtenida de un contorno del módulo de la vorticidad. Se han encontrado dos regímenes distintos en función del umbral escogido con propiedades opuestas, separados por una transición topológica gradual. Las características geométricas de la zona escalan con o99 cuando u^/isdgg es la unidad de vorticidad. Las propiedades del íluido relativas a la posición del contorno de vorticidad han sido analizados para una serie de umbrales utilizando el campo de distancias esféricas, que puede obtenerse con independencia de la complejidad de la superficie de referencia. Las propiedades del fluido a una distancia dada del inerfaz también dependen del umbral de vorticidad, pero tienen características parecidas con independencia del número de Reynolds. La interacción entre la turbulencia y el flujo no turbulento se restringe a una zona muy fina con un espesor del orden de la escala de Kolmogorov local. Hacia el interior del flujo turbulento las propiedades son indistinguibles del resto de la capa límite. Se ha simulado una capa límite sin gradiente de presiones con una fuerza volumétrica cerca de la pared. La el forzado ha sido diseñado para aumentar la fricción en la pared sin introducir ningún efecto geométrico obvio. La simulación consta de dos dominios, un primer dominio más pequeño y a baja resolución que se encarga de generar condiciones de contorno correctas, y un segundo dominio mayor y a alta resolución donde se aplica el forzado. El estudio de los perfiles y los coeficientes de autocorrelación sugieren que los dos casos, el liso y el forzado, no colapsan más allá de la capa logarítmica por la complejidad geométrica de la zona intermitente, y por el hecho que la distancia a la pared no es una longitud característica. Los efectos causados por la geometría de la zona intermitente pueden evitarse utilizando el interfaz como referencia, y la distancia esférica para el análisis de sus propiedades. Las propiedades condicionadas del flujo escalan con 5QQ y u/uT, las dos únicas escalas contenidas en el modelo de semejanza de pared de Townsend, consistente con estos resultados. ABSTRACT This thesis studies the characteristics of the outer region of zero-pressure-gradient turbulent boundary layers at moderate Reynolds numbers. Two relatively established theories are put to test. The wall similarity theory states that with the presence of roughness, turbulent motion is mostly affected by the additional drag caused by the roughness, and that other secondary effects are restricted to a region very close to the wall. The consensus is that this theory is valid, but only as a first approximation. At the edge of the boundary layer there is a thin layer caused by the interaction between the turbulent eddies and the irroational fluid of the free stream, called turbulent/non-turbulent interface. The bulk of results about this layer suggest the presence of some localized shear, with properties that make it distinguishable from the rest of the turbulent flow. The properties of the interface are likely to change if the rate of spread of the turbulent boundary layer is amplified, an effect that is usually achieved by increasing the drag. Roughness and entrainment are therefore linked, and the local features of the turbulent/non-turbulent interface may explain the reason why rough-wall boundary layers deviate from the wall similarity theory precisely far from the wall. To study boundary layers at a higher Reynolds number, a new high-resolution code for the direct numerical simulation of a zero pressure gradient turbulent boundary layers over a flat plate has been developed. This code is able to simulate a wide range of Reynolds numbers from ReT =100 to 2000 while showing a linear weak scaling up to around two million threads in the BG/Q architecture. Special attention has been paid to the generation of proper inflow boundary conditions. The results are in good agreement with existing numerical and experimental data sets. The turbulent/non-turbulent interface of a boundary layer is analyzed by thresholding the vorticity magnitude field. The value of the threshold is considered a parameter in the analysis of the surfaces obtained from isocontours of the vorticity magnitude. Two different regimes for the surface can be distinguished depending on the threshold, with a gradual topological transition across which its geometrical properties change significantly. The width of the transition scales well with oQg when u^/udgg is used as a unit of vorticity. The properties of the flow relative to the position of the vorticity magnitude isocontour are analyzed within the same range of thresholds, using the ball distance field, which can be obtained regardless of the size of the domain and complexity of the interface. The properties of the flow at a given distance to the interface also depend on the threshold, but they are similar regardless of the Reynolds number. The interaction between the turbulent and the non-turbulent flow occurs in a thin layer with a thickness that scales with the Kolmogorov length. Deeper into the turbulent side, the properties are undistinguishable from the rest of the turbulent flow. A zero-pressure-gradient turbulent boundary layer with a volumetric near-wall forcing has been simulated. The forcing has been designed to increase the wall friction without introducing any obvious geometrical effect. The actual simulation is split in two domains, a smaller one in charge of the generation of correct inflow boundary conditions, and a second and larger one where the forcing is applied. The study of the one-point and twopoint statistics suggest that the forced and the smooth cases do not collapse beyond the logarithmic layer may be caused by the geometrical complexity of the intermittent region, and by the fact that the scaling with the wall-normal coordinate is no longer present. The geometrical effects can be avoided using the turbulent/non-turbulent interface as a reference frame, and the minimum distance respect to it. The conditional analysis of the vorticity field with the alternative reference frame recovers the scaling with 5QQ and v¡uT already present in the logarithmic layer, the only two length-scales allowed if Townsend’s wall similarity hypothesis is valid.

El proyecto de vivienda como laboratorio de estrategias para Sejima y Nishizawa de 1987 a 2010

Como indica el título, esta tesis plantea el estudio de la arquitectura doméstica elaborada por los arquitectos japoneses Kazuyo Sejima y Ryue Nishizawa. Más concretamente, la investigación se ciñe a un conjunto integrado por veinticinco casas que los arquitectos proyectaron entre 1987, momento en el que Sejima establece su propia oficina, y 2010, fecha en la que el reconocimiento del trabajo que ambos venían desarrollando queda certificado a nivel internacional, ya que ese año son galardonados con el premio Pritzker y comisarían la Bienal deVenecia. Del estudio conjunto y sistemático de estos proyectos, y de sus distintas versiones se espera poder obtener una serie de criterios exegéticos que permitan comprenderlos y explicarlos mejor, relacionándolos entre sí de manera coherente. A estos criterios es a lo que hemos denominado estrategias. En el momento en el que se inicia esta investigación se detectó un vacío editorial respecto al tema tratado, apenas había textos, propios o ajenos que abordaran esta faceta de la obra de Sejima y Nishizawa en profundidad. No en vano, algunos críticos han acuñado el apelativo de "arquitectos sin palabras" para referirse, tanto a ellos como a la generación de arquitectos que la pareja encabeza, dando a entender que se trata de una arquitectura carente de explicación.1 Sin embargo, esta investigación sostiene que el hecho de que los arquitectos no hablen en exceso de su obra y mantengan una actitud centrada en desarrollar de forma práctica su trabajo no quiere decir que prescindan de realizar operaciones compositivas altamente idealizadas y abstractas, refrendadas por un marco cultural y teórico que se pueda describir. Tras recopilar, ordenar y analizar un número lo suficientemente amplio como para ser significativo de las manifestaciones verbales que los arquitectos han realizado a lo largo del periodo estudiado, se ha observado que de entre todos los términos que los dos socios que integran SANAA emplean para describir sus proyectos, uno de los más relevantes y quizás también el más general resulta la palabra “sistema”.2 El modo en el que ambos describen los principios de su arquitectura, diferenciando entre los componentes del programa, y las relaciones que se establecen entre éstos, y entre ellos y el exterior permiten sostener que no se trata de un uso accidental término. Paralelamente, al mismo tiempo que se indaga sobre el corpus intelectual de esta teoría se intenta detallar las circunstancias que favorecieron tal trasvase de ideas entre Occidente y Japón y como acabaron llegando al ámbito de estos arquitectos. Al amparo de este marco teórico y tras redibujar las viviendas documentadas, se intentará describir los rasgos de la estructura material de las viviendas analizadas, así como cartografiar los patrones organizativos que las caracterizan. Para ello se empleará el rigor instrumental que aporta la teoría de grafos como método habitual para la representación, estudio y caracterización de sistemas. Los resultados de la investigación evidencian que hay una serie de estrategias — tanto materiales como organizativas— que enunciadas en sus primeros proyectos se van desarrollando en obras posteriores, conformado sistemas que están paulatinamente más organizados. Y que llegado un punto en la trayectoria de estos arquitectos, se observa que tales estrategias, se van superponiendo de distinta forma en diversos proyectos, por lo que es posible agruparlos y hablar de ellos atendiendo a características comunes. Finalmente, el estudio concluye que tanto a nivel material como reladonal, bien podría decirse que en el periodo estudiado, las estrategias empleadas por Sejima y Nishizawa para elaborar su arquitectura doméstica persiguen un objetivo común que se fundamenta en la elaboración de planteamientos sintéticos que les permiten explorar y responder creativamente ante las disyuntivas previamente establecidas, precisamente explotando el potencial de las paradojas que las originan. ABSTRACT As the title suggest itself, this thesis deals about the study of domestic architecture developed by Japanese architects Kazuyo Sejima and Ryue Nishizawa. More specifically, research focus its attention on a group of twenty five houses that both architects projected from 1987, when Sejima establishes her own practice, and 2010, as the moment in which their work obtains international acknowledgment, since this year they are awarded the Pritzker prize and cúrate the Venice Biennale. From the combined and systematic study of all these projects, and their different versions are expected to obtain a series of exegetical criteria to relate to each other, understand and explain better. These criteria are what we cali strategies. By the time when this research began, an editorial emptiness about the treaty issue was detected; there were barely texts that addressed this aspect of the work of Sejima and Nishizawa in depth, neither the ones written by the architects themselves ñor by other authors. Some critics have coined the ñame "wordless generation" to refer to both them as to the generation of architects that the couple leads, implying that it is an architecture devoid of explanation.3 However, this study argües that the fact that architects do not speak too much about his work and keep themselves focused on developing practical work attitude does not mean that dispense perform highly idealized and abstract compositional operations, fueled by a frame cultural and theoretical that can be described. After collect, sort and analyze a large enough number of verbal statements done by the architects about their work as to be meaningful, it was observed that of all the terms that the two partners that intégrate SANAA used to describe their projects, one of the most important and, perhaps one of the most general, is the word "system".4 The way in which both describe the principies of their architecture distinguishing between program components and the relationships established between them, and between them and the outside allow us the view that it is not accidental use of a term. Similarly, while it investigates the intellectual corpus of this theory it attempts to explain some of the circumstances that favored such transfer of ideas between the West and Japan and how eventually reaching the scope of these architects. Under this framework and after redraw the documented houses we attempt to describe the characteristics of the material structure of the projects tested, as well as mapping the organizational patterns that characterize them. For this, we use the instrumental rigor that brings graph theory, as a regular method of representation, study and characterization of systems used. The research results show that there are a number of strategies -both material and organizational level- that once they are set out in its first projects are developed in later works. Bringing up systems that are gradually more and more organized. And at one point in the career of these architects, such strategies are observed, they are superimposed differently on various projects, making it possible to group them and discuss them according to common characteristics. Finally, the study condueles that both materially and organizational it could be said that in the period studied, the strategies employed by Sejima and Nishizawa to develop its domestic architecture pursue a common goal, which is based on the development of synthetic approaches that allow them explore and respond creatively to the previously established dilemmas precisely exploiting the paradoxical potential that originates them.

Fragilidade e qualidade de vida de idosos com doença renal crônica

Introdução: A expectativa de vida dos brasileiros cresce a cada ano; com isso, os idosos vivem mais, e fatores como, Hipertensão Arterial Sistêmica, Diabetes mellitus e o próprio processo de envelhecimento os tornam suscetíveis à doença renal crônica (DRC). Com a DRC, esses idosos têm maiores chances de desenvolverem a fragilidade e terem consequências desfavoráveis na Qualidade de Vida (QV). Objetivo geral: Analisar a relação entre as variáveis independentes (fragilidade, características sociodemográficas e clínicas) e a variável desfecho (QV) de idosos com DRC em tratamento conservador, hemodiálise (HD) e diálise peritoneal (DP). Material e método: Trata-se de uma pesquisa quantitativa, descritiva e transversal. Participaram idosos com 60 anos ou mais, com DRC em tratamento conservador, HD ou DP, que estavam, no mínimo, há seis meses em tratamento e em acompanhamento em um hospital público de Ribeirão Preto-SP. A coleta de dados ocorreu de outubro/14 a março/15, utilizando-se os seguintes instrumentos: de caracterização sociodemográfica, econômica e clínica adaptado; para avaliar a fragilidade, a Edmonton Frail Scale (EFS); para avaliar a QV, o WHOQOL-BREF e WHOQOL-OLD; para avaliar a cognição, o Mini-Exame do Estado Mental (MEEM). Foram realizadas análises estatísticas descritivas, teste de correlação de Spearman e análise de variância multivariada (MANOVA) para as variáveis de interesse. O nível de significância adotado foi de 5%. O projeto foi aprovado por um Comitê de Ética em Pesquisa com seres humanos com CAAE número 34923214.0.0000.5393; seguiu-se as recomendações da Resolução CNS 466/2012. Resultados: Participaram 77 idosos, sendo 35 em tratamento conservador, 14 em DP e 28 em HD. A maioria era homem (41; 53,2%) e tinha companheiro(a) (51; 66,2%). A média dos escores de fragilidade entre os tratamentos foi: tratamento conservador (7,71±3,10); DP (6,79±2,72) e HD (7,36±2,92). No WHOQOL-BREF, os domínios relações sociais e físico obtiveram maior e menor escores médios, respectivamente, (68,93±17,48) e (55,44±14,11). O WHOQOL-OLD apresentou a maior média na faceta Intimidade (68,67±16,45) e menor média na faceta Morte e morrer (37,66±22,76). Foram encontradas correlações inversas entre a idade e o escore do MEEM (p=0,001) e entre anos de estudo e fragilidade (p=0,016); por outro lado, houve correlações positivas entre os escores do MEEM e anos de estudo (p<0,001), entre número de complicações da DRC e fragilidade (p<0,001) e número de comorbidades e fragilidade (p<0,001). Em relação à QV, houve correlação positiva entre o escore global do WHOQOL-BREF e o escore da faceta global do WHOQOL-OLD, bem como correlação inversa entre os escores globais desses instrumentos com os escores de fragilidade (p<0,00; p=0,023). Na MANOVA, o tipo de tratamento e o número de complicações não influenciaram a QV, porém a fragilidade apresentou relação com o constructo, sendo que, para o aumento de um ponto na escala da fragilidade, a QV apresentou redução média de 1,38 no escore global do WHOQOL-BREF e 0,82 no escore global do WHOQOL-OLD, considerando pertencer ao mesmo tipo de tratamento. Conclusão: os pacientes com DRC apresentaram piores escores médios de QV mediante a maiores escores de fragilidade, independentemente do tipo de tratamento e considerando-se a mesma média de complicações

Double Reasonableness and the Fourth Amendment

Recently the Supreme Court has placed new limits on both the substance of the Fourth Amendment and the exclusionary that serves as the principal remedy for Fourth Amendment violations. In this Article we briefly summarize these limitations and then argue that the curtailment of the exclusionary rule has the potential to ameliorate substantive Fourth Amendment doctrine. The limited reach of the modern exclusionary rule provides the Court with license to develop an expansive new substantive framework free of the specter of a correspondingly expansive remedial framework. One point on which nearly all jurists and commentators agree is that current Fourth Amendment doctrine is a mess. We argue that the Court’s exclusionary rule cases, while frustrating and ill-conceived if viewed in isolation, provide the Court with an opportunity to revisit problematic Fourth Amendment doctrine that was born under a very different remedial regime. Such an approach would allow the Court to adhere to its current view of the exclusionary rule as a remedy of last resort while creating a Fourth Amendment with teeth. The goal is a Fourth Amendment right that is more substantial and clearly defined, but a remedy that remains limited to egregious violations of clear substantive rules. The time is now to lift the Fourth Amendment fog.

Propagation, structural similarity and image quality

Póster presentado en SPIE Photonics Europe, Brussels, 16-19 April 2012.

Profiling in sport using momentum and perturbations

Examining a team’s performance from a physical point of view their momentum might indicate unexpected turning points in defeat or success. Physicists describe this value as to require some effort to be started, but also that it is relatively easy to keep it going once a sufficient level is reached (Reed and Hughes, 2006). Unlike football, rugby, handball and many more sports, a regular volleyball match is not limited by time but by points that need to be gathered. Every minute more than one point is won by either one team or the other. That means a series of successive points enlarges the gap between the teams making it more and more difficult to catch up with the leading one. This concept of gathering momentum, or the reverse in a performance, can give the coaches, athletes and sports scientists further insights into winning and losing performances. Momentum investigations also contain dependencies between performances or questions if future performances are reliant upon past streaks. Squash and volleyball share the characteristic of being played up to a certain amount of points. Squash was examined according to the momentum of players by Hughes et al. (2006). The initial aim was to expand normative profiles of elite squash players using momentum graphs of winners and errors to explore ‘turning points’ in a performance. Dynamic systems theory has enabled the definition of perturbations in sports exhibiting rhythms (Hughes et al., 2000; McGarry et al., 2002; Murray et al., 2008), and how players and teams cause these disruptions of rhythm can inform on the way they play, these techniques also contribute to profiling methods. Together with the analysis of one’s own performance it is essential to have an understanding of your oppositions’ tactical strengths and weaknesses. By modelling the oppositions’ performance it is possible to predict certain outcomes and patterns, and therefore intervene or change tactics before the critical incident occurs. The modelling of competitive sport is an informative analytic technique as it directs the attention of the modeller to the critical aspects of data that delineate successful performance (McGarry & Franks, 1996). Using tactical performance profiles to pull out and visualise these critical aspects of performance, players can build justified and sophisticated tactical plans. The area is discussed and reviewed, critically appraising the research completed in this element of Performance Analysis.

La historia de enfermería: trascendencia del fenómeno cuidado y su relación con el tiempo

La historia es una disciplina que contribuye a la enfermería para dejar huella de la trascendencia de su quehacer profesional, el cuidado. La estrecha vinculación con el tiempo nos remite a Martin Heidegger como el filósofo que plantea una articulación inseparable entre el tiempo y el ser a través del cuidado. Por lo que se reflexiona sobre el contexto filosófico del cuidado y su relación con el tiempo, que permite identificar una paradoja en el quehacer profesional de enfermería, quienes se encuentran cumpliendo horarios, rutinas y actividades fuera de la cuestión ética de otorgar un momento para cada cosa, afectado por aceleradas dinámicas, sobrepoblación de pacientes en las instituciones de salud, haciendo imposible proporcionar el cuidado como tal, ya que su temporalidad consiste en satisfacer las necesidades para la existencia de la persona a partir de cuidados que permitan conceptualizarlo como un ser completo y en ese sentido, contar con los tiempos necesarios para poder realizar de manera satisfactoria un cuidado con calidad y fomentar el proceso de la construcción de la disciplina.

Patients' and professionals' views on managing fibromyalgia

BACKGROUND: Managing fibromyalgia is a challenge for both health care systems and the professionals caring for these patients, due, in part, to the fact that the etiology of this disease is unknown, its symptoms are not specific and there is no standardized treatment. OBJECTIVE: The present study examines three aspects of fibromyalgia management, namely diagnostic approach, therapeutic management and the health professional-patient relationship, to explore specific areas of the health care process that professionals and patients may consider unsatisfactory. METHODS: A qualitative study involving semistructured interviews with 12 fibromyalgia patients and nine health professionals was performed. RESULTS: The most commonly recurring theme was the dissatisfaction of both patients and professionals with the management process as a whole. Both groups expressed dissatisfaction with the delay in reaching a diagnosis and obtaining effective treatment. Patients reported the need for greater moral support from professionals, whereas the latter often felt frustrated and of little help to patients. Patients and professionals agreed on one point: the uncertainty surrounding the management of fibromyalgia and, especially, its etiology. CONCLUSION: The present study contributes to a better understanding regarding why current management of fibromyalgia is neither effective nor satisfactory. It also provides insight into how health professionals can support fibromyalgia patients to achieve beneficial results. Health care services should offer greater support for these patients in the form of specific resources such as fibromyalgia clinics and health professionals with increased awareness of the disease.

Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA

Aims: This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients' perspective during the first year post-surgery. Methods: Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year. Results: Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males. Conclusion: Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly 'out-of-pocket' for the experience. (C) 2004 OsteoArthritis Research Society International. Published by Elsevier Ltd. All rights reserved.