Lógicas de acção na gestão intermédia das escolas : o caso do departamento curricular das expressões

O tema da investigação prende-se com a gestão intermédia das escolas, especificamente, o departamento curricular de expressões (DCEXP). Este estudo analisa as mudanças provocadas pelo novo modelo de estrutura intermédia estabelecido pelo DL nº 75/2008, de 22 de Abril, tendo em conta os vários modelos de agrupamento de escolas vigentes no actual sistema educativo. Procurou-se conhecer a perspectiva de directores, coordenadores de departamento de expressões e professores do mesmo departamento sobre os processos organizacionais e as lógicas de acção desenvolvidas. Para consolidar as múltiplas interrogações e o trajecto final assentar numa reflexão solidamente construída, o corpus teórico envolveu duas grandes temáticas: abordagem da escola como organização e o seu desenvolvimento no sistema educativo português. Em termos metodológicos, optou-se por um estudo qualitativo, com características exploratórias e descritivas. Para a recolha de dados, seleccionámos três agrupamentos de escolas de três concelhos limítrofes ao distrito de Lisboa (um agrupamento vertical, um agrupamento horizontal e um mega agrupamento). Os sujeitos participantes de cada agrupamento foram os directores, os coordenadores do departamento curricular de expressões, um professor do mesmo departamento com muita experiência profissional e um com menos experiência. Realizaram-se doze entrevistas semi-estruturadas, constituídas por um conjunto de questões formuladas a partir dos objectivos e organizadas em temas. Para analisar os dados, utilizámos a técnica de análise de conteúdo. A análise das representações dos diversos grupos de entrevistados permitiu vislumbrar que, apesar da aceitação das mudanças estabelecidas pelos normativos vigentes, as lógicas de acção mantêm-se centradas nas disciplinas de forma fragmentada, dificultando processos colaborativos interdisciplinares. A insatisfação em relação ao actual modelo é consensual em todos os grupos de entrevistados tendo presente a sua complexidade que resulta de aspectos relacionados com a sua dimensão e multidisciplinaridade. No entanto, também vislumbrámos aspectos potenciadores do DCEXP que o valorizam na organização escolar e no processo educativo dos alunos.

Contributos para uma prospectiva da implementação de um centro de responsabilidade de radiologia numa Unidade Local de Saúde: o caso da Unidade Local de Saúde do Norte Alentejano

Mestrado em Intervenção Sócio-Organizacional na Saúde - Área de especialização: Políticas de Administração e Gestão de Serviços de Saúde.

A supervisão nas estruturas intermédias do 1º ciclo: as coordenações de ano

Dissertação apresentada à Escola Superior de Educação de Lisboa para obtenção do grau de mestre em Ciências da Educação, especialidade em Supervisão em Educação

O director de turma como mediador entre o concelho de turma, os alunos, e os encarregados de educação: Contributos para a avaliação da direcção de turma

O presente estudo tem como objectivo investigar o reconhecimento e a relevância do papel do Director de Turma enquanto gestor intermédio para os alunos, os encarregados de educação e para os próprios, tendo em conta a interface inter-relacionai em que a função se desenvolve. Este trabalho teve como pressupostos de base a convicção de que a Educação é um fenómeno complexo que, para além de outras, mobiliza dimensões sociológicas, psicológicas e epistemológicas, além de necessitar, constantemente, de reflexão sobre as suas práticas. Assim, conscientes de que o papel do Director de Turma é de grande importância nas organizações escolares, foi nosso objectivo estudá-lo sob o ponto de vista teórico a partir de uma reflexão na prática e efectuar um estudo empírico do modo como a função é percepcionada como elo de ligação entre os Alunos, os Encarregados de Educação e a Escola. Aborda-se a figura do Director de Turma, enquanto gestor pedagógico intermédio da organização escolar, tendo em conta as atribuições que lhe são consagradas na lei e a forma como os demais parceiros vêm a sua função, em especial numa Escola do 2º e 3° ciclos do Ensino Básico, de acordo com as perspectivas/representações dos próprios actores educativos. O estudo visou em concreto, proporcionar uma análise sustentada do reconhecimento e valorização da figura do Director de Turma enquanto mediador entre o aluno, os encarregados de educação e a Escola. Pretendeu-se, nomeadamente, questionar teórica e empiricamente, a interacção e a articulação entre a formação pessoal, a actuação e as representações dos Directores de Turma. Assim, investigou-se de que modo o Director de Turma, considerado como um agente de mediação, é ou não reconhecido e valorizado enquanto figura responsável pela ligação do aluno e do seu encarregado de educação à Escola. Como opção metodológica optou-se por um estudo de caso, recorrendo à complementaridade entre os procedimentos quantitativos e qualitativos, de acordo com os objectivos visados. Assim, as técnicas de recolha de dados utilizados neste estudo foram o inquérito, por questionário, e a entrevista. Estes instrumentos foram sendo sucessivamente aperfeiçoados. Participaram, a nível do inquérito por questionário, duas turmas, uma do 2° ciclo e outra do 3° ciclo (num total de 45 alunos e respectivos encarregados de educação) e a nível da entrevista, os dois Directores de Turma das turmas envolvidas. Procurou-se, deste modo, contribuir para elucidar em que medida a figura do Director de Turma é reconhecida e valorizada como elo de ligação entre os Alunos, os Encarregados de Educação e a Escola enquanto gestor intermédio. Nas Conclusões após o confronto entre as questões de partida, o quadro teórico e os resultados do estudo empírico, discutem-se as dificuldades e limitações que um estudo desta natureza envolve. Avança-se, por fim, com algumas sugestões que a investigação realizada permite, no sentido de utilizar o conhecimento produzido para melhorar o relacionamento entre o Aluno, os Encarregados de Educação e a Escola e, consequentemente, o processo ensino-aprendizagem. ABSTRACT; The purpose of this study is to investigate the recognition and relevance of the role of the classroom director as an intermediate supervisor to the students, the parents and the classroom director himself, having in mind the inner- relation interface the function takes place. This work was conceived on the basic notion that Education is a complex-phenomenon, setting in motion, among other things, sociological, psychological and epistemological dimensions, as well as requiring, frequently, reflection about its practices. Therefore, conscious of the fact that the role of the class director is of enormous importance within a school environment, our aim was to study it from the theoretical point of view by a reflection in practice and performing an empirical analysis on the way it is understood as a link among the students, parents and the school. The role of classroom director is thus analysed as a pedagogical director in a school setting. Taking into consideration the rights conferred to him/her by law and the way all the other partners assign to the class director, particularly in a 2nd and 3rd cycle of the Elementary School system, in accordance with the perspectives/representations of the education actors. More specifically, this study is an in-depth analysis of the recognition and the valuation of the class director figure as a mediator among the pupils, the parents and the school. ln other words, the interaction between theory and practice in the daily performance of the classroom director were questioned and studied for further analysis. Hence, questioned the way in which the classroom director, seen as a mediation agent, could be considered as a coordinator, recognized and valorized as the responsible figure by the linking among the pupil and his/her parents to the school. The case was realized in the 2nd and 3rd cycle of an elementary school in the Alentejo. As a methodological option, quantitative and qualitative processes were both employed, thus keeping in line with the main objective of this work. Therefore, the data collected and herein utilized were the result of queries, i.e., questionnaires and personal interviews. The former were addressed at the pupils of two classes, one of the 2nd cycle and another of the 3rd cycle of the school and their parents (45 pupils and the same number of parents in total), and the two classroom directors of the classes implicated in the study. ln the Conclusion, a balance of the study is presented, comparing the initial research questions, the theoretical framework, and the results of the empirical analysis developed. A few suggestions are presented from the experience gained in this investigation, i.e., using the knowledge acquired in order to improve and enrich the relationship among the pupils, the parents, the school, and the teaching learning process.

Improving interMediAte Risk management. MARK study

Background: Cardiovascular risk functions fail to identify more than 50% of patients who develop cardiovascular disease. This is especially evident in the intermediate-risk patients in which clinical management becomes difficult. Our purpose is to analyze if ankle-brachial index (ABI), measures of arterial stiffness, postprandial glucose, glycosylated hemoglobin, self-measured blood pressure and presence of comorbidity are independently associated to incidence of vascular events and whether they can improve the predictive capacity of current risk equations in the intermediate-risk population. Methods/Design: This project involves 3 groups belonging to REDIAPP (RETICS RD06/0018) from 3 Spanish regions. We will recruit a multicenter cohort of 2688 patients at intermediate risk (coronary risk between 5 and 15% or vascular death risk between 3-5% over 10 years) and no history of atherosclerotic disease, selected at random. We will record socio-demographic data, information on diet, physical activity, comorbidity and intermittent claudication. We will measure ABI, pulse wave velocity and cardio ankle vascular index at rest and after a light intensity exercise. Blood pressure and anthropometric data will be also recorded. We will also quantify lipids, glucose and glycosylated hemoglobin in a fasting blood sample and postprandial capillary glucose. Eighteen months after the recruitment, patients will be followed up to determine the incidence of vascular events (later follow-ups are planned at 5 and 10 years). We will analyze whether the new proposed risk factors contribute to improve the risk functions based on classic risk factors. Discussion: Primary prevention of cardiovascular diseases is a priority in public health policy of developed and developing countries. The fundamental strategy consists in identifying people in a high risk situation in which preventive measures are effective and efficient. Improvement of these predictions in our country will have an immediate, clinical and welfare impact and a short term public health effect

Risk management measures for REACH registered intermediate substances in pulp mill

Tämän työn tavoitteena on antaa kuvaus riskinhallintamenetelmistä viidelle välituotekemikaalille, joita käytetään Stora Enson Imatran tehtailla. Välituotekemikaalit ovat mustalipeä, viherlipeä, valkolipeä, natriumbisulfiitti ja natriumsulfiitti. Nämä kemikaalit ovat jo rekisteröityjä ECHA:an ja rekisteröintiin liittyen ECHA:an on toimitettava myös kuvaus riskinhallintamenetelmistä. Työn alussa kuvaillaan työn kannalta olennaiset säädökset ja viranomaiset, jotka valvovat kemikaalien käyttöä ja valmistusta Euroopan Unionin alueella. Tämän jälkeen kerrotaan yleisesti välituotekemikaalien rekisteröintikriteereistä. Työn loppuosa käsittää kuvauksen riskinhallintamenetelmistä jokaiselle kemikaalille. Riskinhallintamenetelmät sisältävät eristyksen teknisin keinoin, menettelytapa- ja valvontatekniikat, johtamistavat ja henkilökunnan koulutuksen ja välituotekemikaalien kuljetuksen. Myös jokaisen kemikaalin ominaisuudet on kuvattu ja lyhyt prosessikuvaus kemikaalien valmistuksesta ja käytöstä on esitetty helpottamaan ymmärtämistä.

Photon Management Structures for Absorption Enhancement in Intermediate Band Solar Cells and Crystalline Silicon Solar Cells

El objetivo de la tesis es investigar los beneficios que el atrapamiento de la luz mediante fenómenos difractivos puede suponer para las células solares de silicio cristalino y las de banda intermedia. Ambos tipos de células adolecen de una insuficiente absorción de fotones en alguna región del espectro solar. Las células solares de banda intermedia son teóricamente capaces de alcanzar eficiencias mucho mayores que los dispositivos convencionales (con una sola banda energética prohibida), pero los prototipos actuales se resienten de una absorción muy débil de los fotones con energías menores que la banda prohibida. Del mismo modo, las células solares de silicio cristalino absorben débilmente en el infrarrojo cercano debido al carácter indirecto de su banda prohibida. Se ha prestado mucha atención a este problema durante las últimas décadas, de modo que todas las células solares de silicio cristalino comerciales incorporan alguna forma de atrapamiento de luz. Por razones de economía, en la industria se persigue el uso de obleas cada vez más delgadas, con lo que el atrapamiento de la luz adquiere más importancia. Por tanto aumenta el interés en las estructuras difractivas, ya que podrían suponer una mejora sobre el estado del arte. Se comienza desarrollando un método de cálculo con el que simular células solares equipadas con redes de difracción. En este método, la red de difracción se analiza en el ámbito de la óptica física, mediante análisis riguroso con ondas acopladas (rigorous coupled wave analysis), y el sustrato de la célula solar, ópticamente grueso, se analiza en los términos de la óptica geométrica. El método se ha implementado en ordenador y se ha visto que es eficiente y da resultados en buen acuerdo con métodos diferentes descritos por otros autores. Utilizando el formalismo matricial así derivado, se calcula el límite teórico superior para el aumento de la absorción en células solares mediante el uso de redes de difracción. Este límite se compara con el llamado límite lambertiano del atrapamiento de la luz y con el límite absoluto en sustratos gruesos. Se encuentra que las redes biperiódicas (con geometría hexagonal o rectangular) pueden producir un atrapamiento mucho mejor que las redes uniperiódicas. El límite superior depende mucho del periodo de la red. Para periodos grandes, las redes son en teoría capaces de alcanzar el máximo atrapamiento, pero sólo si las eficiencias de difracción tienen una forma peculiar que parece inalcanzable con las herramientas actuales de diseño. Para periodos similares a la longitud de onda de la luz incidente, las redes de difracción pueden proporcionar atrapamiento por debajo del máximo teórico pero por encima del límite Lambertiano, sin imponer requisitos irrealizables a la forma de las eficiencias de difracción y en un margen de longitudes de onda razonablemente amplio. El método de cálculo desarrollado se usa también para diseñar y optimizar redes de difracción para el atrapamiento de la luz en células solares. La red propuesta consiste en un red hexagonal de pozos cilíndricos excavados en la cara posterior del sustrato absorbente de la célula solar. La red se encapsula en una capa dieléctrica y se cubre con un espejo posterior. Se simula esta estructura para una célula solar de silicio y para una de banda intermedia y puntos cuánticos. Numéricamente, se determinan los valores óptimos del periodo de la red y de la profundidad y las dimensiones laterales de los pozos para ambos tipos de células. Los valores se explican utilizando conceptos físicos sencillos, lo que nos permite extraer conclusiones generales que se pueden aplicar a células de otras tecnologías. Las texturas con redes de difracción se fabrican en sustratos de silicio cristalino mediante litografía por nanoimpresión y ataque con iones reactivos. De los cálculos precedentes, se conoce el periodo óptimo de la red que se toma como una constante de diseño. Los sustratos se procesan para obtener estructuras precursoras de células solares sobre las que se realizan medidas ópticas. Las medidas de reflexión en función de la longitud de onda confirman que las redes cuadradas biperiódicas consiguen mejor atrapamiento que las uniperiódicas. Las estructuras fabricadas se simulan con la herramienta de cálculo descrita en los párrafos precedentes y se obtiene un buen acuerdo entre la medida y los resultados de la simulación. Ésta revela que una fracción significativa de los fotones incidentes son absorbidos en el reflector posterior de aluminio, y por tanto desaprovechados, y que este efecto empeora por la rugosidad del espejo. Se desarrolla un método alternativo para crear la capa dieléctrica que consigue que el reflector se deposite sobre una superficie plana, encontrándose que en las muestras preparadas de esta manera la absorción parásita en el espejo es menor. La siguiente tarea descrita en la tesis es el estudio de la absorción de fotones en puntos cuánticos semiconductores. Con la aproximación de masa efectiva, se calculan los niveles de energía de los estados confinados en puntos cuánticos de InAs/GaAs. Se emplea un método de una y de cuatro bandas para el cálculo de la función de onda de electrones y huecos, respectivamente; en el último caso se utiliza un hamiltoniano empírico. La regla de oro de Fermi permite obtener la intensidad de las transiciones ópticas entre los estados confinados. Se investiga el efecto de las dimensiones del punto cuántico en los niveles de energía y la intensidad de las transiciones y se obtiene que, al disminuir la anchura del punto cuántico respecto a su valor en los prototipos actuales, se puede conseguir una transición más intensa entre el nivel intermedio fundamental y la banda de conducción. Tomando como datos de partida los niveles de energía y las intensidades de las transiciones calculados como se ha explicado, se desarrolla un modelo de equilibrio o balance detallado realista para células solares de puntos cuánticos. Con el modelo se calculan las diferentes corrientes debidas a transiciones ópticas entre los numerosos niveles intermedios y las bandas de conducción y de valencia bajo ciertas condiciones. Se distingue de modelos de equilibrio detallado previos, usados para calcular límites de eficiencia, en que se adoptan suposiciones realistas sobre la absorción de fotones para cada transición. Con este modelo se reproducen datos publicados de eficiencias cuánticas experimentales a diferentes temperaturas con un acuerdo muy bueno. Se muestra que el conocido fenómeno del escape térmico de los puntos cuánticos es de naturaleza fotónica; se debe a los fotones térmicos, que inducen transiciones entre los estados excitados que se encuentran escalonados en energía entre el estado intermedio fundamental y la banda de conducción. En el capítulo final, este modelo realista de equilibrio detallado se combina con el método de simulación de redes de difracción para predecir el efecto que tendría incorporar una red de difracción en una célula solar de banda intermedia y puntos cuánticos. Se ha de optimizar cuidadosamente el periodo de la red para equilibrar el aumento de las diferentes transiciones intermedias, que tienen lugar en serie. Debido a que la absorción en los puntos cuánticos es extremadamente débil, se deduce que el atrapamiento de la luz, por sí solo, no es suficiente para conseguir corrientes apreciables a partir de fotones con energía menor que la banda prohibida en las células con puntos cuánticos. Se requiere una combinación del atrapamiento de la luz con un incremento de la densidad de puntos cuánticos. En el límite radiativo y sin atrapamiento de la luz, se necesitaría que el número de puntos cuánticos de una célula solar se multiplicara por 1000 para superar la eficiencia de una célula de referencia con una sola banda prohibida. En cambio, una célula con red de difracción precisaría un incremento del número de puntos en un factor 10 a 100, dependiendo del nivel de la absorción parásita en el reflector posterior. Abstract The purpose of this thesis is to investigate the benefits that diffractive light trapping can offer to quantum dot intermediate band solar cells and crystalline silicon solar cells. Both solar cell technologies suffer from incomplete photon absorption in some part of the solar spectrum. Quantum dot intermediate band solar cells are theoretically capable of achieving much higher efficiencies than conventional single-gap devices. Present prototypes suffer from extremely weak absorption of subbandgap photons in the quantum dots. This problem has received little attention so far, yet it is a serious barrier to the technology approaching its theoretical efficiency limit. Crystalline silicon solar cells absorb weakly in the near infrared due to their indirect bandgap. This problem has received much attention over recent decades, and all commercial crystalline silicon solar cells employ some form of light trapping. With the industry moving toward thinner and thinner wafers, light trapping is becoming of greater importance and diffractive structures may offer an improvement over the state-of-the-art. We begin by constructing a computational method with which to simulate solar cells equipped with diffraction grating textures. The method employs a wave-optical treatment of the diffraction grating, via rigorous coupled wave analysis, with a geometric-optical treatment of the thick solar cell bulk. These are combined using a steady-state matrix formalism. The method has been implemented computationally, and is found to be efficient and to give results in good agreement with alternative methods from other authors. The theoretical upper limit to absorption enhancement in solar cells using diffractions gratings is calculated using the matrix formalism derived in the previous task. This limit is compared to the so-called Lambertian limit for light trapping with isotropic scatterers, and to the absolute upper limit to light trapping in bulk absorbers. It is found that bi-periodic gratings (square or hexagonal geometry) are capable of offering much better light trapping than uni-periodic line gratings. The upper limit depends strongly on the grating period. For large periods, diffraction gratings are theoretically able to offer light trapping at the absolute upper limit, but only if the scattering efficiencies have a particular form, which is deemed to be beyond present design capabilities. For periods similar to the incident wavelength, diffraction gratings can offer light trapping below the absolute limit but above the Lambertian limit without placing unrealistic demands on the exact form of the scattering efficiencies. This is possible for a reasonably broad wavelength range. The computational method is used to design and optimise diffraction gratings for light trapping in solar cells. The proposed diffraction grating consists of a hexagonal lattice of cylindrical wells etched into the rear of the bulk solar cell absorber. This is encapsulated in a dielectric buffer layer, and capped with a rear reflector. Simulations are made of this grating profile applied to a crystalline silicon solar cell and to a quantum dot intermediate band solar cell. The grating period, well depth, and lateral well dimensions are optimised numerically for both solar cell types. This yields the optimum parameters to be used in fabrication of grating equipped solar cells. The optimum parameters are explained using simple physical concepts, allowing us to make more general statements that can be applied to other solar cell technologies. Diffraction grating textures are fabricated on crystalline silicon substrates using nano-imprint lithography and reactive ion etching. The optimum grating period from the previous task has been used as a design parameter. The substrates have been processed into solar cell precursors for optical measurements. Reflection spectroscopy measurements confirm that bi-periodic square gratings offer better absorption enhancement than uni-periodic line gratings. The fabricated structures have been simulated with the previously developed computation tool, with good agreement between measurement and simulation results. The simulations reveal that a significant amount of the incident photons are absorbed parasitically in the rear reflector, and that this is exacerbated by the non-planarity of the rear reflector. An alternative method of depositing the dielectric buffer layer was developed, which leaves a planar surface onto which the reflector is deposited. It was found that samples prepared in this way suffered less from parasitic reflector absorption. The next task described in the thesis is the study of photon absorption in semiconductor quantum dots. The bound-state energy levels of in InAs/GaAs quantum dots is calculated using the effective mass approximation. A one- and four- band method is applied to the calculation of electron and hole wavefunctions respectively, with an empirical Hamiltonian being employed in the latter case. The strength of optical transitions between the bound states is calculated using the Fermi golden rule. The effect of the quantum dot dimensions on the energy levels and transition strengths is investigated. It is found that a strong direct transition between the ground intermediate state and the conduction band can be promoted by decreasing the quantum dot width from its value in present prototypes. This has the added benefit of reducing the ladder of excited states between the ground state and the conduction band, which may help to reduce thermal escape of electrons from quantum dots: an undesirable phenomenon from the point of view of the open circuit voltage of an intermediate band solar cell. A realistic detailed balance model is developed for quantum dot solar cells, which uses as input the energy levels and transition strengths calculated in the previous task. The model calculates the transition currents between the many intermediate levels and the valence and conduction bands under a given set of conditions. It is distinct from previous idealised detailed balance models, which are used to calculate limiting efficiencies, since it makes realistic assumptions about photon absorption by each transition. The model is used to reproduce published experimental quantum efficiency results at different temperatures, with quite good agreement. The much-studied phenomenon of thermal escape from quantum dots is found to be photonic; it is due to thermal photons, which induce transitions between the ladder of excited states between the ground intermediate state and the conduction band. In the final chapter, the realistic detailed balance model is combined with the diffraction grating simulation method to predict the effect of incorporating a diffraction grating into a quantum dot intermediate band solar cell. Careful optimisation of the grating period is made to balance the enhancement given to the different intermediate transitions, which occur in series. Due to the extremely weak absorption in the quantum dots, it is found that light trapping alone is not sufficient to achieve high subbandgap currents in quantum dot solar cells. Instead, a combination of light trapping and increased quantum dot density is required. Within the radiative limit, a quantum dot solar cell with no light trapping requires a 1000 fold increase in the number of quantum dots to supersede the efficiency of a single-gap reference cell. A quantum dot solar cell equipped with a diffraction grating requires between a 10 and 100 fold increase in the number of quantum dots, depending on the level of parasitic absorption in the rear reflector.

A cross-sectional evaluation of community pharmacists’ perceptions of intermediate care and medicines management across the healthcare interface

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists’ (CPs) involvement. 
Objective To determine CPs’ awareness of and involvement with IC services, perceptions of the transfer of patients’ medication information between healthcare settings and views of the development of a CP–IC service. 
Setting Community pharmacies in Northern Ireland. 
Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. 
Main outcome measure CPs’ awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs ‘agreed/strongly agreed’ that they understood the term ‘intermediate care’. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings ‘all of the time’. Only 9.5 and 0.5 % of respondents ‘strongly agreed’ that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. ‘Current workload’ was ranked as the most important barrier to service development.
Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients’ medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings.

Use of an accelerated chest pain assessment protocol in patients at intermediate risk of adverse cardiac events

Objective: To determine the feasibility, safety and effectiveness of a structured clinical pathway for stratification and management of patients presenting with chest pain and classified as having intermediate risk of adverse cardiac outcomes in the subsequent six months. Design: Prospective clinical audit. Participants and setting: 630 consecutive patients who presented to the emergency department of a metropolitan tertiary care hospital between January 2000 and June 2001 with chest pain and intermediate-risk features. Intervention: Use of the Accelerated Chest Pain Assessment Protocol (ACPAP), as advocated by the Management of unstable angina guidelines - 2000 from the National Heart Foundation and the Cardiac Society of Australia and New Zealand. Main outcome measure: Adverse cardiac events during six-month follow-up. Results: 409 patients (65%) were reclassified as low risk and discharged at a mean of 14 hours after assessment in the chest pain unit. None had missed myocardial infarctions, while three (1%) had cardiac events at six months (all elective revascularisation procedures, with no readmissions with acute coronary syndromes). Another 110 patients (17%) were reclassified as high risk, and 21 (19%) of these had cardiac events (mainly revascularisations) by six months. Patients who were unable to exercise or had non-diagnostic exercise stress test results (equivocal risk) had an intermediate cardiac event rate (8%). Conclusions: This study validates use of ACPAP. The protocol eliminated missed myocardial infarction; allowed early, safe discharge of low-risk patients; and led to early identification and management of high-risk patients.

Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes.METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

Multi-agent management system for electric vehicle charging

This paper proposes an implementation, based on a multi-agent system, of a management system for automated negotiation of electricity allocation for charging electric vehicles (EVs) and simulates its performance. The widespread existence of charging infrastructures capable of autonomous operation is recognised as a major driver towards the mass adoption of EVs by mobility consumers. Eventually, conflicting requirements from both power grid and EV owners require automated middleman aggregator agents to intermediate all operations, for example, bidding and negotiation, between these parts. Multi-agent systems are designed to provide distributed, modular, coordinated and collaborative management systems; therefore, they seem suitable to address the management of such complex charging infrastructures. Our solution consists in the implementation of virtual agents to be integrated into the management software of a charging infrastructure. We start by modelling the multi-agent architecture using a federated, hierarchical layers setup and as well as the agents' behaviours and interactions. Each of these layers comprises several components, for example, data bases, decision-making and auction mechanisms. The implementation of multi-agent platform and auctions rules, and of models for battery dynamics, is also addressed. Four scenarios were predefined to assess the management system performance under real usage conditions, considering different types of profiles for EVs owners', different infrastructure configurations and usage and different loads on the utility grid (where real data from the concession holder of the Portuguese electricity transmission grid is used). Simulations carried with the four scenarios validate the performance of the modelled system while complying with all the requirements. Although all of these have been performed for one charging station alone, a multi-agent design may in the future be used for the higher level problem of distributing energy among charging stations. Copyright (c) 2014 John Wiley & Sons, Ltd.

Standard commercial education robotic platform: intermediate solution to teaching robotics

Teaching robotics to students at the beginning of their studies has become a huge challenge. Simulation environments can be an effective solution to that challenge where students can interact with simulated robots and have the first contact with robotic constraints. From our previous experience with simulation environments it was possible to observe that students with lower background knowledge in robotics where able to deal with a limited number of constraints, implement a simulated robotic platform and study several sensors. The question is: after this first phase what should be the best approach? Should the student start developing their own hardware? Hardware development is a very important part of an engineer's education but it can also be a difficult phase that could lead to discouragement and loss of motivation in some students. Considering the previous constraints and first year engineering students’ high abandonment rate it is important to develop teaching strategies to deal with this problem in a feasible way. The solution that we propose is the integration of a low-cost standard robotic platform WowWee Rovio as an intermediate solution between the simulation phase and the stage where the students can develop their own robots. This approach will allow the students to keep working in robotic areas such as: cooperative behaviour, perception, navigation and data fusion. The propose approach proved to be a motivation step not only for the students but also for the teachers. Students and teachers were able to reach an agreement between the level of demand imposed by the teachers and satisfaction/motivation of the students.

The Hybrid Approach for Palliation of Hypoplastic Left Heart Syndrome: Intermediate Results of a Single-Center Experience

INTRODUCTION: Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS: We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS: Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS: In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.

Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study.

PURPOSE: To evaluate a diagnostic strategy for pulmonary embolism that combined clinical assessment, plasma D-dimer measurement, lower limb venous ultrasonography, and helical computed tomography (CT). METHODS: A cohort of 965 consecutive patients presenting to the emergency departments of three general and teaching hospitals with clinically suspected pulmonary embolism underwent sequential noninvasive testing. Clinical probability was assessed by a prediction rule combined with implicit judgment. All patients were followed for 3 months. RESULTS: A normal D-dimer level (<500 microg/L by a rapid enzyme-linked immunosorbent assay) ruled out venous thromboembolism in 280 patients (29%), and finding a deep vein thrombosis by ultrasonography established the diagnosis in 92 patients (9.5%). Helical CT was required in only 593 patients (61%) and showed pulmonary embolism in 124 patients (12.8%). Pulmonary embolism was considered ruled out in the 450 patients (46.6%) with a negative ultrasound and CT scan and a low-to-intermediate clinical probability. The 8 patients with a negative ultrasound and CT scan despite a high clinical probability proceeded to pulmonary angiography (positive: 2; negative: 6). Helical CT was inconclusive in 11 patients (pulmonary embolism: 4; no pulmonary embolism: 7). The overall prevalence of pulmonary embolism was 23%. Patients classified as not having pulmonary embolism were not anticoagulated during follow-up and had a 3-month thromboembolic risk of 1.0% (95% confidence interval: 0.5% to 2.1%). CONCLUSION: A noninvasive diagnostic strategy combining clinical assessment, D-dimer measurement, ultrasonography, and helical CT yielded a diagnosis in 99% of outpatients suspected of pulmonary embolism, and appeared to be safe, provided that CT was combined with ultrasonography to rule out the disease.

Thermal modeling and management in ultrathin chip stack technology

This paper presents a thermal modeling for power management of a new three-dimensional (3-D) thinned dies stacking process. Besides the high concentration of power dissipating sources, which is the direct consequence of the very interesting integration efficiency increase, this new ultra-compact packaging technology can suffer of the poor thermal conductivity (about 700 times smaller than silicon one) of the benzocyclobutene (BCB) used as both adhesive and planarization layers in each level of the stack. Thermal simulation was conducted using three-dimensional (3-D) FEM tool to analyze the specific behaviors in such stacked structure and to optimize the design rules. This study first describes the heat transfer limitation through the vertical path by examining particularly the case of the high dissipating sources under small area. First results of characterization in transient regime by means of dedicated test device mounted in single level structure are presented. For the design optimization, the thermal draining capabilities of a copper grid or full copper plate embedded in the intermediate layer of stacked structure are evaluated as a function of the technological parameters and the physical properties. It is shown an interest for the transverse heat extraction under the buffer devices dissipating most the power and generally localized in the peripheral zone, and for the temperature uniformization, by heat spreading mechanism, in the localized regions where the attachment of the thin die is altered. Finally, all conclusions of this analysis are used for the quantitative projections of the thermal performance of a first demonstrator based on a three-levels stacking structure for space application.