Evaluation of Medical Students’ Attitudes and Performance of Basic Surgery Skills in a Training Program Using Fresh Human skin, Excised During Body Contouring Surgeries

BACKGROUND: Learning surgical skills in the operating room may be a challenge for medical students. Therefore, more approaches using simulation to enable students to develop their practical skills are required. OBJECTIVES: We hypothesized that (1) there would be a need for additional surgical training for medical students in the pre-final year, and (2) our basic surgery skills training program using fresh human skin would improve medical students' surgical skills. DESIGN: We conducted a preliminary survey of medical students to clarify the need for further training in basic surgery procedures. A new approach using simulation to teach surgical skills on human skin was set up. The procedural skills of 15 randomly selected students were assessed in the operating room before and after participation in the simulation, using Objective Structured Assessment of Technical Skills. Furthermore, subjective assessment was performed based on students' self-evaluation. The data were analyzed using SPSS, version 21 (SPSS, Inc., Chicago, IL). SETTING: The study took place at the Inselspital, Bern University Hospital. PARTICIPANTS: A total of 186 pre-final-year medical students were enrolled into the preliminary survey; 15 randomly selected medical students participated in the basic surgical skills training course on the fresh human skin operating room. RESULTS: The preliminary survey revealed the need for a surgical skills curriculum. The simulation approach we developed showed significant (p < 0.001) improvement for all 12 surgical skills, with mean cumulative precourse and postcourse values of 31.25 ± 5.013 and 45.38 ± 3.557, respectively. The self-evaluation contained positive feedback as well. CONCLUSION: Simulation of surgery using human tissue samples could help medical students become more proficient in handling surgical instruments before stepping into a real surgical situation. We suggest further studies evaluating our proposed teaching method and the possibility of integrating this simulation approach into the medical school curriculum.

Federally regulated institutional review boards: The aspects of a "model" IRB---Is the current system in need of a tune up or complete overhaul?

Institutional Review Boards (IRBs) are the primary gatekeepers for the protection of ethical standards of federally regulated research on human subjects in this country. This paper focuses on what general, broad measures that may be instituted or enhanced to exemplify a "model IRB". This is done by examining the current regulatory standards of federally regulated IRBs, not private or commercial boards, and how many of those standards have been found either inadequate or not generally understood or followed. The analysis includes suggestions on how to bring about changes in order to make the IRB process more efficient, less subject to litigation, and create standardized educational protocols for members. The paper also considers how to include better oversight for multi-center research, increased centralization of IRBs, utilization of Data Safety Monitoring Boards when necessary, payment for research protocol review, voluntary accreditation, and the institution of evaluation/quality assurance programs. ^ This is a policy study utilizing secondary analysis of publicly available data. Therefore, the research for this paper focuses on scholarly medical/legal journals, web information from the Department of Health and Human Services, Federal Drug Administration, and the Office of the Inspector General, Accreditation Programs, law review articles, and current regulations applicable to the relevant portions of the paper. ^ Two issues are found to be consistently cited by the literature as major concerns. One is a need for basic, standardized educational requirements across all IRBs and its members, and secondly, much stricter and more informed management of continuing research. There is no federally regulated formal education system currently in place for IRB members, except for certain NIH-based trials. Also, IRBs are not keeping up with research once a study has begun, and although regulated to do so, it does not appear to be a great priority. This is the area most in danger of increased litigation. Other issues such as voluntary accreditation and outcomes evaluation are slowing gaining steam as the processes are becoming more available and more sought after, such as JCAHO accrediting of hospitals. ^ Adopting the principles discussed in this paper should promote better use of a local IRBs time, money, and expertise for protecting the vulnerable population in their care. Without further improvements to the system, there is concern that private and commercial IRBs will attempt to create a monopoly on much of the clinical research in the future as they are not as heavily regulated and can therefore offer companies quicker and more convenient reviews. IRBs need to consider the advantages of charging for their unique and important services as a cost of doing business. More importantly, there must be a minimum standard of education for all IRB members in the area of the ethical standards of human research and a greater emphasis placed on the follow-up of ongoing research as this is the most critical time for study participants and may soon lead to the largest area for litigation. Additionally, there should be a centralized IRB for multi-site trials or a study website with important information affecting the trial in real time. There needs to be development of standards and metrics to assess the performance of the IRBs for quality assurance and outcome evaluations. The boards should not be content to run the business of human subjects' research without determining how well that function is actually being carried out. It is important that federally regulated IRBs provide excellence in human research and promote those values most important to the public at large.^

Auxiliary material and basic geochemical and benthic foraminiferal stable isotope data for the interval bracketing Eocene Thermal Maximum 2 (ETM2) at DSDP Sites 401 and 550 in the northeastern Atlantic Ocean

Ever since its discovery, Eocene Thermal Maximum 2 (ETM2; ~53.7 Ma) has been considered as one of the "little brothers" of the Paleocene-Eocene Thermal Maximum (PETM; ~56 Ma) as it displays similar characteristics including abrupt warming, ocean acidification, and biotic shifts. One of the remaining key questions is what effect these lesser climate perturbations had on ocean circulation and ventilation and, ultimately, biotic disruptions. Here we characterize ETM2 sections of the NE Atlantic (Deep Sea Drilling Project Sites 401 and 550) using multispecies benthic foraminiferal stable isotopes, grain size analysis, XRF core scanning, and carbonate content. The magnitude of the carbon isotope excursion (0.85-1.10 per mil) and bottom water warming (2-2.5°C) during ETM2 seems slightly smaller than in South Atlantic records. The comparison of the lateral d13C gradient between the North and South Atlantic reveals that a transient circulation switch took place during ETM2, a similar pattern as observed for the PETM. New grain size and published faunal data support this hypothesis by indicating a reduction in deepwater current velocity. Following ETM2, we record a distinct intensification of bottom water currents influencing Atlantic carbonate accumulation and biotic communities, while a dramatic and persistent clay reduction hints at a weakening of the regional hydrological cycle. Our findings highlight the similarities and differences between the PETM and ETM2. Moreover, the heterogeneity of hyperthermal expression emphasizes the need to specifically characterize each hyperthermal event and its background conditions to minimalize artifacts in global climate and carbonate burial models for the early Paleogene.

User-centric need-driven affect modeling for spoken conversational agents: design and evaluation

It is easy to get frustrated at spoken conversational agents (SCAs), perhaps because they seem to be callous. By and large, the quality of human-computer interaction is affected due to the inability of the SCAs to recognise and adapt to user emotional state. Now with the mass appeal of artificially-mediated communication, there has been an increasing need for SCAs to be socially and emotionally intelligent, that is, to infer and adapt to their human interlocutors’ emotions on the fly, in order to ascertain an affective, empathetic and naturalistic interaction. An enhanced quality of interaction would reduce users’ frustrations and consequently increase their satisfactions. These reasons have motivated the development of SCAs towards including socio-emotional elements, turning them into affective and socially-sensitive interfaces. One barrier to the creation of such interfaces has been the lack of methods for modelling emotions in a task-independent environment. Most emotion models for spoken dialog systems are task-dependent and thus cannot be used “as-is” in different applications. This Thesis focuses on improving this, in which it concerns computational modeling of emotion, personality and their interrelationship for task-independent autonomous SCAs. The generation of emotion is driven by needs, inspired by human’s motivational systems. The work in this Thesis is organised in three stages, each one with its own contribution. The first stage involved defining, integrating and quantifying the psychological-based motivational and emotional models sourced from. Later these were transformed into a computational model by implementing them into software entities. The computational model was then incorporated and put to test with an existing SCA host, a HiFi-control agent. The second stage concerned automatic prediction of affect, which has been the main challenge towards the greater aim of infusing social intelligence into the HiFi agent. In recent years, studies on affect detection from voice have moved on to using realistic, non-acted data, which is subtler. However, it is more challenging to perceive subtler emotions and this is demonstrated in tasks such as labelling and machine prediction. In this stage, we attempted to address part of this challenge by considering the roles of user satisfaction ratings and conversational/dialog features as the respective target and predictors in discriminating contentment and frustration, two types of emotions that are known to be prevalent within spoken human-computer interaction. The final stage concerned the evaluation of the emotional model through the HiFi agent. A series of user studies with 70 subjects were conducted in a real-time environment, each in a different phase and with its own conditions. All the studies involved the comparisons between the baseline non-modified and the modified agent. The findings have gone some way towards enhancing our understanding of the utility of emotion in spoken dialog systems in several ways; first, an SCA should not express its emotions blindly, albeit positive. Rather, it should adapt its emotions to user states. Second, low performance in an SCA may be compensated by the exploitation of emotion. Third, the expression of emotion through the exploitation of prosody could better improve users’ perceptions of an SCA compared to exploiting emotions through just lexical contents. Taken together, these findings not only support the success of the emotional model, but also provide substantial evidences with respect to the benefits of adding emotion in an SCA, especially in mitigating users’ frustrations and ultimately improving their satisfactions. Resumen Es relativamente fácil experimentar cierta frustración al interaccionar con agentes conversacionales (Spoken Conversational Agents, SCA), a menudo porque parecen ser un poco insensibles. En general, la calidad de la interacción persona-agente se ve en cierto modo afectada por la incapacidad de los SCAs para identificar y adaptarse al estado emocional de sus usuarios. Actualmente, y debido al creciente atractivo e interés de dichos agentes, surge la necesidad de hacer de los SCAs unos seres cada vez más sociales y emocionalmente inteligentes, es decir, con capacidad para inferir y adaptarse a las emociones de sus interlocutores humanos sobre la marcha, de modo que la interacción resulte más afectiva, empática y, en definitiva, natural. Una interacción mejorada en este sentido permitiría reducir la posible frustración de los usuarios y, en consecuencia, mejorar el nivel de satisfacción alcanzado por los mismos. Estos argumentos justifican y motivan el desarrollo de nuevos SCAs con capacidades socio-emocionales, dotados de interfaces afectivas y socialmente sensibles. Una de las barreras para la creación de tales interfaces ha sido la falta de métodos de modelado de emociones en entornos independientes de tarea. La mayoría de los modelos emocionales empleados por los sistemas de diálogo hablado actuales son dependientes de tarea y, por tanto, no pueden utilizarse "tal cual" en diferentes dominios o aplicaciones. Esta tesis se centra precisamente en la mejora de este aspecto, la definición de modelos computacionales de las emociones, la personalidad y su interrelación para SCAs autónomos e independientes de tarea. Inspirada en los sistemas motivacionales humanos en el ámbito de la psicología, la tesis propone un modelo de generación/producción de la emoción basado en necesidades. El trabajo realizado en la presente tesis está organizado en tres etapas diferenciadas, cada una con su propia contribución. La primera etapa incluyó la definición, integración y cuantificación de los modelos motivacionales de partida y de los modelos emocionales derivados a partir de éstos. Posteriormente, dichos modelos emocionales fueron plasmados en un modelo computacional mediante su implementación software. Este modelo computacional fue incorporado y probado en un SCA anfitrión ya existente, un agente con capacidad para controlar un equipo HiFi, de alta fidelidad. La segunda etapa se orientó hacia el reconocimiento automático de la emoción, aspecto que ha constituido el principal desafío en relación al objetivo mayor de infundir inteligencia social en el agente HiFi. En los últimos años, los estudios sobre reconocimiento de emociones a partir de la voz han pasado de emplear datos actuados a usar datos reales en los que la presencia u observación de emociones se produce de una manera mucho más sutil. El reconocimiento de emociones bajo estas condiciones resulta mucho más complicado y esta dificultad se pone de manifiesto en tareas tales como el etiquetado y el aprendizaje automático. En esta etapa, se abordó el problema del reconocimiento de las emociones del usuario a partir de características o métricas derivadas del propio diálogo usuario-agente. Gracias a dichas métricas, empleadas como predictores o indicadores del grado o nivel de satisfacción alcanzado por el usuario, fue posible discriminar entre satisfacción y frustración, las dos emociones prevalentes durante la interacción usuario-agente. La etapa final corresponde fundamentalmente a la evaluación del modelo emocional por medio del agente Hifi. Con ese propósito se llevó a cabo una serie de estudios con usuarios reales, 70 sujetos, interaccionando con diferentes versiones del agente Hifi en tiempo real, cada uno en una fase diferente y con sus propias características o capacidades emocionales. En particular, todos los estudios realizados han profundizado en la comparación entre una versión de referencia del agente no dotada de ningún comportamiento o característica emocional, y una versión del agente modificada convenientemente con el modelo emocional propuesto. Los resultados obtenidos nos han permitido comprender y valorar mejor la utilidad de las emociones en los sistemas de diálogo hablado. Dicha utilidad depende de varios aspectos. En primer lugar, un SCA no debe expresar sus emociones a ciegas o arbitrariamente, incluso aunque éstas sean positivas. Más bien, debe adaptar sus emociones a los diferentes estados de los usuarios. En segundo lugar, un funcionamiento relativamente pobre por parte de un SCA podría compensarse, en cierto modo, dotando al SCA de comportamiento y capacidades emocionales. En tercer lugar, aprovechar la prosodia como vehículo para expresar las emociones, de manera complementaria al empleo de mensajes con un contenido emocional específico tanto desde el punto de vista léxico como semántico, ayuda a mejorar la percepción por parte de los usuarios de un SCA. Tomados en conjunto, los resultados alcanzados no sólo confirman el éxito del modelo emocional, sino xv que constituyen además una evidencia decisiva con respecto a los beneficios de incorporar emociones en un SCA, especialmente en cuanto a reducir el nivel de frustración de los usuarios y, en última instancia, mejorar su satisfacción.

Self Learning and self evaluation exercises database in basic mechanics: a theoretical-practical approach

In the School of Mines of the Technical University of Madrid (UPM) the first course of different degrees has been implemented and adapted to the European Higher Educational Area (EHEA). In all of the degrees there is a first semester course which gathers all the contents of basic mechanics: from the first kinematics concepts to the rigid solid plane motion Before the Bologna process took place, the authors had established the final assessment of the theoretical contents through open questions of theoretical-practical character In the present work, the elaboration of a wide database containing theoretical-practical questions that students can access on line is presented. The questions are divided in thirteen different questionnaires composed of a number of questions randomly chosen from a certain group in the database. Each group corresponds to a certain learning objective that the student knows. After answering the questionnaire and checking the grade assigned according to the performance of the student, the pupils can see the correct response displayed on the screen and widely explained by the professors. This represents a 10% of the final grade. As the student can access the questionnaires as many times as they want, the main goal is the self-assessment of each learning objective and therefore, getting the students involved in their own learning process so they can decide how much time they need to acquire the required level.

Architectural guidelines for the Curricula: 3 Layers, 3 New Dimensions, 2 Basic Orientations, Different levels in the Topics

Today, designing informatics curricula is a major problem. As a technology, informatics is experiencing a dramatic evolution, with its rapidly expanding areas of application and everincreasing impact on society. At first glance, it seems that if we might need several different curricula for facing very different practical educational situations, and not just one or two curricula. The current deep discrepancies among some of our more prestigious computer scientists in relation to the focus of informatics education are in fact a form of recognition of this necessity and at the same time, proof we are at a turning point.

Optically programmable logic cells as basic units for transmission and synchronization of chaotic signals

We proposed an optical communications system, based on a digital chaotic signal where the synchronization of chaos was the main objective, in some previous papers. In this paper we will extend this work. A way to add the digital data signal to be transmitted onto the chaotic signal and its correct reception, is the main objective. We report some methods to study the main characteristics of the resulting signal. The main problem with any real system is the presence of some retard between the times than the signal is generated at the emitter at the time when this signal is received. Any system using chaotic signals as a method to encrypt need to have the same characteristics in emitter and receiver. It is because that, this control of time is needed. A method to control, in real time the chaotic signals, is reported.

La identificaciónde de los daños estructurales, herramienta de la nueva atribución de responsabilidades : análisis crítico de la transición del art. 1591 cc al art. 17 LOE

RESUMEN Su objetivo esencial: Regular el proceso de la edificación, está basado en 3 grandes pilares: 1.- Completar la configuración legal de los agentes que intervienen en el mismo, fijando sus obligaciones para así establecer las responsabilidades. 2.- Fomentar la calidad de los edificios. 3.- Fijar las garantías a los usuarios frente a los posibles daños. Estos tres fundamentos están intensamente relacionados, ya que, las obligaciones y responsabilidades de los agentes son la base de la constitución de las garantías a los usuarios, definidas mediante los requisitos básicos que deben satisfacer los edificios. Partiendo del análisis cualitativo y cuantitativo del grado de cumplimiento del objetivo de la nueva Ley, elaborado a través del estudio de sus tres pilares fundamentales, proponemos medidas tendentes a la plena entrada en vigor de la misma. Para ello se deberá desarrollar el Real Decreto previsto en la Disposición Adicional 2ª, una vez conseguido el grado de madurez de los sectores de la edificación y del seguro. En todo este proceso de estudio hemos podido apreciar que la objetiva identificación de los daños y en especial los que afectan la estabilidad del edificio, constituye una herramienta fundamental para la correcta atribución de responsabilidades a los agentes, basada en la aplicación de los tres grados de responsabilidad “ex lege” por daños materiales y sus plazos de prescripción surgidos del nuevo régimen impuesto por el art. 17 LOE Para avalar esta propuesta hemos analizado: 1.- El entorno económico, general y pormenorizado al sector de la edificación, en Europa y España durante el período comprendido entre los años 1990 y 2013, años previos y posteriores a la entrada en vigor de la Ley, dada la influencia de los ciclos de actividad producidos en la regulación del sector, las responsabilidades atribuidas a los agentes, el fomento de la calidad y las garantías ofrecidas a los adquirentes. 2.- Las diversas legislaciones sobre responsabilidades y garantías de los agentes de la edificación en los países de nuestro entorno económico. 3.- La gestación de la LOE, incidiendo en la evolución de los últimos borradores y su tramitación parlamentaria. 4.- El desarrollo doctrinal de la Transición desde el régimen de responsabilidades, fijado por el art. 1591 de Código Civil, y su Jurisprudencia, hacia el nuevo régimen de responsabilidades establecido por el art. 17 LOE. En esta tarea además de apreciar la asimilación, por parte de los Jueces y Magistrados, de los principios doctrinales de la LOE, hemos observado la labor de los peritos, de cuya experta identificación de las causas de los daños depende la justa y eficaz atribución de responsabilidades. 5 -. El grado de eficacia de la LOE a la vista de la estadística siniestral, de la que ya hay datos consolidados, tras la cancelación de casi 15.000 expedientes de reclamación a Arquitectos. 6 -. También hemos estudiado el grado de cumplimiento con el usuario y propietario de las garantías previstas en el art. 19 de la Ley y en la D.A. 1ª, los efectos reales alcanzados y las tareas pendientes por delante. Analizando la atribución de responsabilidades a los agentes de la edificación, dentro del primer pilar fundamental de la LOE, hemos estudiado las actuaciones de los peritos expertos y su incidencia en este objetivo, previa selección de casos de gran interés y dificultad. Fruto de ello se han formulado propuestas tendentes a la especialización de este colectivo, evitando conductas “irregulares” que tanto daño provocan a los agentes reclamados como a los propietarios afectados. Este daño es evidente pudiendo ocasionar condenas injustas, enriquecimientos ilícitos o bien falsas expectativas de satisfacción de daños mal dictaminados y costosas e ineficaces reparaciones. De cara a la consecución del pilar de la calidad de la edificación, mediante los requisitos básicos planteados por la LOE y desarrollados por el Código Técnico de la Edificación (Real Decreto 314/2006, de 17 de marzo), hemos procesado datos de expedientes de reclamaciones por daños que afectan a edificios ejecutados bajo el nuevo régimen LOE. Con esta base se han analizado las causas generadoras de las diversas lesiones y su frecuencia para que de este análisis puedan establecerse pautas de actuación para su prevención. Finalmente, tras demostrar que las garantías obligatorias impuestas por la LOE sólo abarcan un pequeño porcentaje de los posibles daños a la edificación, insistimos en la necesidad de la plena eficacia de la Ley mediante la aprobación de todas las garantías previstas y para todo tipo de edificaciones. En suma, se ha diseñado la tesis como una matriz abierta en la que podremos continuar incorporando datos de la evolución de la doctrina, la jurisprudencia y la estadística de los daños en la edificación. ABSTRACT The approval of Law 38/1999 on November 5, 1999, (Official Gazette BOE 266/1999 of 11.6.1999, p. 38925), was the culmination of a long period of over 20 years of gestation for which deep agreements were needed between all stakeholders affected. Although several parliamentary groups denounced its incomplete approval, regarding mandatory guarantees to the purchaser, its enactment caused general satisfaction among most of the the building agents. This assessment remains after fourteen years since its partial enactment. Its essential purpose, “to regulate the building process”, is based on 3 pillars: 1.- To complete the legal configuration of the agents involved in it, setting their obligations in order to establish their responsibilities. 2.- To promote the buildings quality. 3.- To specify users´guarantees against possible buildings damage. These three issues are strongly related, since the obligations and responsibilities of the actors are the basis of the users’guarantees constitution, defined by the basic performance required by buildings. Based on the qualitative and quantitative analysis of the fulfillment of the new law’s objectives, made by monitoring the three pillars, we propose measures to the full enactment of this Directive, by the development of the Royal Decree, provided in its Second Additional Provision, once maturity in the sectors of the building and insurance is achieved. Throughout this process of study we have seen that the skill identification of damage, particularly those affecting the stability of the building, is an essential tool for the proper allocation of responsibilities of the new regime installed by the art. 17 LOE, based on the application of the three degrees of responsibility "ex lege" for property damage and limitation periods. To support this proposal, we have analyzed: 1.- The evolution of the building sector in Europe and Spain during the years before and after the enactment of the Law, due to the influence of cycles of activity produced in industry regulation, the responsibilities attributed to agents, promotion of the quality and the assurances given to acquirers. 2.- The scope of various laws on liability and building agents warranties in the countries of our economic environment. 3.- The long period of LOE generation, focusing on the developments in recent drafts and parliamentary procedure. 4.- The doctrinal development in the Transition from the regime of responsibilities, set by art. 1591 of the Civil Code, and its Jurisprudence, to the new liability regime established by art. 17 LOE. In this task, while we have noted assimilation by the Judges and Magistrates of the doctrinal principles of the LOE, we have also analyzed the work of experts, whose skilled identification of the damage causes helps the fair and efficient allocation of responsibilities. 5 - The effectiveness of the LOE based on knowledge of the siniestral statistics, which are already consolidated data, after the cancellation of nearly 15,000 claims to Architects. 6.- We have also studied the degree of compliance with the user and owner guarantees, established in art. 19 and the D.A. 1th of the LOE, exposing the real effects achieved and the pending tasks ahead. Analyzing the allocation of the building agents´ responsibilities, within the first cornerstone of the LOE, we have studied the expert witnesses actions and their impact on this duty, selecting cases of great interest and difficulty in this aim. The result of this enterprise has been to propose the specialization of this group, avoiding "irregular" behaviors that create as much damage as the agents claimed to affected owners. This damage is evident and can cause wrong convictions, illicit enrichment, false expectations and inefficient and costly damage repairs. In order to achieve the pillar of building quality through the basic requirements set by the LOE and developed by the Technical Building Code (Royal Decree 314/ 2006 of 17 March), we have analyzed records of damage claims involving buildings executed under the new regime LOE. On this basis we have analyzed the root causes of various damages and their frequency, from these data it will be easy to propose lines of action for prevention. Finally, after demonstrating that mandatory warranties imposed by LOE cover only a small percentage of the potential building damage, we emphasize the need for the full effectiveness of the Law by the obligation all the guarantees provided in the art. 19 LOE, and for all types of buildings. In conclusion, this thesis is designed as an open matrix in which we will continue including data on the evolution of the doctrine, jurisprudence and the statistics of the damage to the building.

Assessment methodology to make urban transport interchanges attractive for users

En las ciudades europeas, los patrones de movilidad son cada vez más complejos debido fundamentalmente a un crecimiento sostenido de la población así como a la tendencia de dispersión de los núcleos urbanos. En consecuencia, muchos de los usuarios del transporte público se ven obligados a combinar varios modos o servicios de transporte para completar sus viajes diarios. Por tanto, el mayor reto de las ciudades es conseguir una mejora e incremento en la movilidad mientras que al mismo tiempo se reducen problemas como la congestión, los accidentes y la contaminación (COM, 2006). Un principio básico para lograr una movilidad sostenible es reducir los inconvenientes y molestias derivados de la transferencia o ruptura del viaje. En este sentido, los intercambiadores de transporte público juegan un papel fundamental como nodos de la red urbana de transporte y la calidad del servicio prestado en ellos tiene una influencia directa sobre la experiencia diaria de los viajeros. Como señaló Terzis and Last (2002), un intercambiador de transportes urbano eficiente debe ser competitivo y al mismo tiempo, debe ser atractivo para los usuarios dado que sus experiencias físicas y sus reacciones psicológicas se ven influenciadas de manera significativa por el diseño y operación del intercambiador. Sin embargo, todavía no existen standards o normativas a nivel europeo que especifiquen como deberían ser estos intercambiadores. Esta tesis doctoral proporciona conocimientos y herramientas de análisis dirigidas a planificadores y gestores de los propios intercambiadores con el fin de entender mejor el funcionamiento de los intercambiadores y gestionar así los recursos disponibles. Así mismo, esta tesis identifica los factores clave en el diseño y operación de intercambiadores urbanos de transporte y proporciona algunas guías generales de planificación en base a ellos. Dado que las percepciones de los usuarios son particularmente importantes para definir políticas adecuadas para intercambiadores, se diseñó y se llevó a cabo en 2013 una encuesta de satisfacción al viajero en tres intercambiadores de transporte urbano europeos: Moncloa (Madrid, España), Kamppi (Helsinki, Finlandia) e Ilford Railway Station ( Londres, Reino Unido). En resumen, esta tesis pone de relieve la naturaleza ambivalente de los intercambiadores urbanos de transporte, es decir, como nodos de la red de transporte y como lugares en sí mismos donde los usuarios pasan tiempo dentro de ellos y propone algunas recomendaciones para hacer más atractivos los intercambiadores a los usuarios. Travel patterns in European urban areas are becoming increasingly complex due to a sustained increase in the urban population and the trend towards urban sprawl. Consequently, many public transport users need to combine several modes or transport services to complete their daily trips. Therefore, the challenge facing all major cities is how to increase mobility while at the same time reducing congestion, accididents and pollution (COM, 2006). Reducing the inconvenience inherent in transferring between modes is a basic principle for achieving sustainable mobility. In this regard, transport interchanges play a key role as urban transport network nodes, and the quality of the service provided in them has a direct influence on travellers' daily experience. As noted by Terzis and Last (2000), an efficient urban transport interchange must be competitive and, at the same time, be attractive for users given that their physical experiences and psychological reactions are significantly influenced by the design and operation of the interchange. However, yet there are no standards or regulations specifying the form these interchanges should take in Europe. This doctoral thesis provides knowledge and analysis tools addressed to developers and managers in order to understand better the performance of an urban transport interchange and manage the available resources properly. Likewise, key factors of the design and operation of urban transport interchanges are identified and some 'Planning guidelines' are proposed on the basis on them. Since the users' perceptions of their experience are particularly important for achieving the most appropriate policy measures for interchanges, an ad‐hoc travellers' satisfaction survey was designed and carried out in 2013 at three European transport interchanges: Moncloa (Madrid, Spain), Kamppi (Helsinki, Finland) and Ilford Railway Station (London, United Kingdom) In summary, this thesis highlights the ambivalent nature of the urban transport interchanges, i.e. as nodes within the transport network and as places where users spending time and proposes some policy recommendations in order to make urban transport interchanges attractive for users.

Rede e apoio social entre idosos atendidos em um ambulatório de Geriatria

O objetivo geral deste estudo foi analisar a relação entre a rede e apoio social, satisfação com o apoio social recebido e as variáveis sociodemográficas, de saúde física e mental, dos idosos atendidos em um Ambulatório de Geriatria de um Hospital Geral Terciário do interior paulista. Trata-se de um estudo descritivo, transversal e exploratório, realizado com 98 idosos atendidos no referido ambulatório. Para a coleta de dados, utilizaram-se o Mini Exame do Estado Mental, um questionário de caracterização sociodemográfica e de saúde, a Escala de Depressão Geriátrica (EDG-15), o Índice de Katz, a Escala de Lawton e Brody, a Escala de medida da rede e apoio social do Medical Outcomes Study e a Escala de Satisfação com o Suporte Social. Os aspectos éticos foram respeitados conforme a Resolução 466/2012 do Conselho Nacional de Saúde. A média de idade dos idosos foi de 80,1 anos, 70,4% eram mulheres, 49,0% viúvos; a média de anos de estudo foi 2,3; 24,5% dos idosos residiam com o cônjuge e filhos ou somente com os filhos; a renda familiar média foi de R$1.773,70. Quanto à capacidade funcional, 80,6% eram independentes para as atividades básicas da vida diária e 88,8% eram parcialmente dependentes para as instrumentais. Os idosos possuíam, em média, 5,3 diagnósticos médicos e os sintomas depressivos estiveram presentes para 61,2% deles. Quanto à rede social, o escore total médio foi de 6,4 pessoas para contato na rede, sendo que 36,7% apresentavam médio contato e participação em atividades sociais. Em relação ao apoio social, o maior escore médio foi para a dimensão material (90,2) e o menor para a interação social positiva (81,8); já para a satisfação com o suporte social, 36,7% e 32,7% apresentaram alta e média satisfação, respectivamente. Foi encontrada correlação inversa entre os escores de todas as dimensões da escala de apoio social e os escores da EDG-15, indicando que quanto maior o apoio social em todas as dimensões, menor é a presença de sintomas depressivos e houve diferenças estatisticamente significativas para todas as dimensões, material (p=0,014), afetiva (p=0,026), interação (p=0,011), emocional (p=0,001) e informação (p=0,005); já a correlação entre os escores das dimensões da escala de apoio social e os escores na escala de Lawton e Brody, foi inversa e fraca para as dimensões material (r=-0,157) e informação (r=-0,027), sugerindo que quanto menor a independência para as AIVDs, maior o apoio social nas referidas dimensões, porém, não houve diferença estatisticamente significativa, material (p=0,121) e informação (p=0,789). A correlação entre os escores da EDG-15 e os escores da escala de satisfação com o apoio social, foi inversa e moderada (r=- 0,467), indicando que quanto maior a satisfação com o apoio social, menor a presença de sintomas depressivos, sendo estatisticamente significativa (p=0,000). Evidencia-se a importância de conhecer se os idosos estão inseridos em rede social e se percebem o apoio social para um melhor direcionamento da assistência prestada ao idoso e para o planejamento e formulação de políticas públicas, programas e projetos voltados a essa população

Interpersonal relations and nurses' job satisfaction through knowledge and usage of relational skills

Background/rationale: Many interpersonal labor disputes stem from the lack of communication skills and the relational problems in the interactions between health professionals. Aims/methods: A qualitative study was conducted in a Spanish hospital in order to get to know how the communicative interaction between hospital nurses is like in relation to the nurses' interpersonal interaction and communication skills developed in their working relationships. Twenty-one hospital nurses between 29 and 55 years old, working in different wards, were interviewed. Open-ended interview discourses were transcribed verbatim and analyzed using qualitative content analysis. Results: The following four key themes were analyzed: communication and sender; communication and awareness of who has the problem; non-verbal communication; communication and recipient. Conclusion: The results of this study highlight the need to broaden nurses' relational–communication skills in order to increase job satisfaction.

Outcomes after stroke: Basic and instrumental activities of daily living, community reintegration and generic health status

This study describes the discharge destination, basic and instrumental activities of daily living (ADL), community reintegration and generic health status of people after stroke, and explored whether sociodemographic and clinical characteristics were associated with these outcomes. Participants were 51 people, with an initial stroke, admitted to an acute hospital and discharged to the community. Admission and discharge data were obtained by chart review. Follow-up status was determined by telephone interview using the Modified Barthel Index, the Assessment of Living Skills and Resources, the Reintegration to Normal Living Index, and the Short-Form Health Survey (SF-36). At follow up, 57% of participants were independent in basic ADL, 84% had a low risk of experiencing instrumental ADL difficulties, most had few concerns with community reintegration, and SF-36 physical functioning and vitality scores were lower than normative values. At follow up, poorer discharge basic ADL status was associated with poorer instrumental ADL and community reintegration status, and older participants had poorer instrumental ADL, community reintegration and physical functioning. Occupational therapists need to consider these outcomes when planning inpatient and post-discharge intervention for people after stroke.

Adolescents' reactions to universal and indicated prevention programs for depression: Perceived stigma and consumer satisfaction

There is a common view that one of the major considerations in selecting between universal and indicated interventions is the marked stigma produced by the latter. However, to date there has been no empirical examination of this assumption. The current study examined reported stigma and program satisfaction following two school-based interventions aimed at preventing depression in 532 middle adolescents. The interventions were conducted either across entire classes by classroom teachers (universal delivery) or in small high risk groups by mental health professionals (indicated delivery). The indicated delivery was associated with significantly greater levels of perceived stigma, but effect sizes were small and neither program was associated with marked stigma in absolute terms. Perceived stigma was more strongly associated with aspects of the individual including being male and showing greater externalizing symptomatology. In contrast, the indicated program was evaluated more positively by both participants and program leaders and effect sizes for these measures of satisfaction were moderate to large. The results point to the need for further empirical evaluation of both perceived stigma and program satisfaction in providing balanced considerations of the value of indicated and universal programs.

Need for systematic synthetic phonics teaching within the early reading curriculum

Both the New Zealand Ministry of Education's Literacy Experts Group and the Australian National Inquiry into the Teaching of Literacy have recently acknowledged the centrality of systematic instruction in synthetic phonics to early reading instruction, but this conclusion remains contentious in some circles. This paper briefly summarises empirical research in basic psychology and evidence-based evaluation studies supporting the inclusion of systematic synthetic phonics instruction within the early reading curriculum, allowing practising psychologists to develop an informed opinion on this issue.