Dissertations / Theses on the topic 'Modern trends in logistics'
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Kosek, Martin. "Uplatnění logistiky v mezinárodním obchodě." Master's thesis, Vysoká škola ekonomická v Praze, 2012. http://www.nusl.cz/ntk/nusl-162278.
Full textGoeke, Dominik [Verfasser], and Oliver [Akademischer Betreuer] Wendt. "Emerging Trends in Logistics: New Models and Algorithms for Vehicle Routing / Dominik Goeke ; Betreuer: Oliver Wendt." Kaiserslautern : Technische Universität Kaiserslautern, 2018. http://d-nb.info/116822943X/34.
Full textBraganca, Paulo. "Fouth-Party Logistics : A study on modern logistics." Thesis, Umeå University, Umeå School of Business, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-20918.
Full textThe business environment has changed tremendously in the last two decades. Corporations have been forced to realign their global strategies and in order to cut costs, they started to transfer activities which were previously performed in-house to the market (e.g. IT, manufacturing or logistics) focusing instead on their core competencies. Nowadays companies outsource several of their logistics activities to so-called third-party logistics (3PL) companies and thus from being centralized, vertically integrated and with single-sited manufacturing facilities, enterprises have their network of resources globally dispersed.
As a result corporate management has realized that the competitive vehicle is no longer the individual firm, with its own resources and competencies. Instead, in order to cope with shorter product life cycles and ever more demanding customers, both on industrial and consumer markets, individual firms need to strategically become part of ‘extended enterprises’; that is, networks of specialist providers of resources and competencies.
However, because the capabilities to manage the entire network do not exist in any one organization, a new business organization was needed to provide the strategic knowledge and competence that will enable the complete integration of the supply chain. This new sort of firm, with core competencies on logistics processes and supply chain IT integration, besides offering consulting services on implementation and development of logistics and supply chain solutions, manages through the use of logistics control towers “the best of breed” 3PL specialists, integrating the end-to-end supply chain so that superior customer value is delivered in the most cost effective way. But how does the use of a supply chain integrator help the supply chain as a whole to achieve competitive advantages that enhance end-customer service? This paper aims to answer the above question. I felt that in order to be able to do that the most appropriate research strategy would be a qualitative study. Hence, a multi-case study was performed on three Swedish companies which differentiate themselves from the more traditional third-party logistics providers. The study was conducted by performing a set of semi-structured interviews with these companies. In order to give the study some sort of structure, I used an interview guide which was divided into three different themes; a) Organizational Design, b) Enterprise Logistics Integration and c) Logistics and Competitive advantages.
Once the interviews were transcribed and summarized, the empirical findings were then analyzed in light of a theoretical framework chosen previously. These theories, which in general terms relate to organizational design, supply chain management and finance, were also divided in the same themes as above. Finally, conclusions were drawn by linking the results of the interviews with the theoretical framework. It became evident that the supply chain integrator can help the supply chain as a whole not only to reduce costs related to inventory holding but also to help its client to improve end-customer service.
Nicolosi, Danielle. "Modern Trends in Resort Architecture." Thesis, The University of Arizona, 1999. http://hdl.handle.net/10150/559314.
Full textNikitina, Tatjana, and Anna Repeta. "Modern trends in the institutional investing in Russia." Universität Potsdam, 2011. http://opus.kobv.de/ubp/volltexte/2012/5846/.
Full textMohanka, Rachna 1972. "Third party logistics service providers : current trends in acquiring information systems capabilities." Thesis, Massachusetts Institute of Technology, 1999. http://hdl.handle.net/1721.1/80153.
Full textBastian, Anne. "Explaining Trends in Car Use." Doctoral thesis, KTH, Transportvetenskap, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:kth:diva-214558.
Full textQC 20170918
Li, Yu 1976. "Impact of modern logistics on industrial location choice and property markets." Thesis, Massachusetts Institute of Technology, 2007. http://hdl.handle.net/1721.1/42259.
Full textIncludes bibliographical references (p. 147-152).
The debate on the impact of modern logistics on industrial location choice and property markets focuses on (1) whether modern inventory control and supply- chain configuration consolidate manufacturing and distribution locations and (2) whether modern logistics have reduced the demand for industrial real estate. In this research, I test the hypothesis that modern logistics have been restructuring industrial manufacturing and distribution networks, dispersing firms into certain regions to achieve the economies of dispersion, and reducing the demand for industrial space per unit of industrial output. The methodology used includes (a) theoretical analysis, (b) statistical and econometric analysis, (c) case studies, and (d) comparative analysis. Because the theoretical analysis does not provide a clear conclusion, I rely on empirical analyses to derive the actual impact or implications. Principle findings from the U.S. empirical study include (1) the changes in the distribution sector have a more significant impact on industrial location choice and property markets than the changes in the manufacturing sector; (2) both manufacturing and distribution industries have been dispersed in the past two decades; (3) improvement of inventory control is almost ubiquitous and, within a supply chain, certain players' gains are not necessarily at the cost of their suppliers' or customers' losses; (4) the traditional partial stock-adjustment model using yearly data does not explain the industrial property market well.
(cont.) Major findings from the China case studies include (1) modern logistics enable manufacturers to achieve cost reductions and service-level improvements simultaneously, and the impacts on their industrial location choice and space demand are consistent with the empirical findings of their U.S. counterparts; (2) with the expansion of globalization, advances in information technology, development of efficient markets, and increased demand from sophisticated customers, location choice and demand for industrial space will continue to be determined by the requirements of efficient supply chains.
by Yu Li.
Ph.D.
Truong, Alfred Kar Yin. "Fast growing and interpretable oblique trees via logistic regression models." Thesis, University of Oxford, 2009. http://ora.ox.ac.uk/objects/uuid:e0de0156-da01-4781-85c5-8213f5004f10.
Full textWooders, Jameson D. "Local economies and material culture : trends on early modern Berkshire, 1650-1750." Thesis, University of Reading, 2011. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.552986.
Full textRoss, Jason W. "Shaping the Chinese People's Liberation Army's image : historical roots to modern trends /." Connect to title online (Scholars' Bank), 2008. http://hdl.handle.net/1794/8688.
Full textAbu, El-Shaer Yardy Afaf Mizel. "Trends and developments in the poetic language of Bilād al-Shām, 1967 -1987." Thesis, Durham University, 1995. http://etheses.dur.ac.uk/5117/.
Full textBozkurt, Melda. "The Effects Of Natural Disaster Trends On The Pre-positioning Implementation In Humanitarian Logistics Networks." Master's thesis, METU, 2011. http://etd.lib.metu.edu.tr/upload/12613198/index.pdf.
Full textdata is used to designate the disaster trends
EM-DAT database is used to acquire the necessary data which includes the disaster locations, type of disasters and number of people affected. Also the most recent four years&rsquo
data is used for verification of the results. Locations of the optimal warehouses for pre-positioning are determined considering the generated emergency response scenarios. When we pursue this exploration, besides determining the optimal pre-positioning locations given by CARE International, we also determined where the natural disaster trend drifts towards.Therefore, this research tries to find an answer whether the disaster trends should be considered to determine the location of the pre-positioned items or not.
Hope, Jacquie. "Green trends in East Germany : critiques of modern industrial society in GDR literature." Thesis, University of Oxford, 1992. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.357351.
Full textOcasio, Tracy L. "An investigation of the current trends in the modern day child welfare system." Instructions for remote access. Click here to access this electronic resource. Access available to Kutztown University faculty, staff, and students only, 2002. http://www.kutztown.edu/library/services/remote_access.asp.
Full textSource: Masters Abstracts International, Volume: 45-06, page: 2955. Typescript. Abstract precedes thesis as 1 preliminary leaf. Includes bibliographical references (leaves ).
Ross, Jason W. 1983. "Shaping the Chinese People's Liberation Army's Image: Historical Roots to Modern 11 Trends." Thesis, University of Oregon, 2008. http://hdl.handle.net/1794/8688.
Full textTraditional Chinese society did much to devalue and stigmatize soldiers. During the Chinese civil war the Chinese Communist Party's military campaign had to recruit large numbers of soldiers. This began a long struggle to undo traditional stereotypes held against soldiers. Later, peacetime saw the PLA at the forefront of massive propaganda campaigns, which eventually led to a zenith in popular imagery. Modem observers of China are noting how fast, far and widespread efforts are to modernize the massive PLA. This new PLA requires a new kind of soldier, one who is comfortable with a computer. Ironically, the technology that makes modernization of the PLA possible also strengthens the civilian economy, creating a strong disincentive for highly educated youths to join the anny. As a result, the modem Chinese government has once again embarked on a massive campaign to strengthen the prestige of the PLA in China.
Adviser: Ina Asim
Smith, Conrad E. "Spiritual warfare an analysis of modern trends based on historical research and biblical exegesis /." Theological Research Exchange Network (TREN), 1994. http://www.tren.com.
Full textPiecyk, Maja Izabela. "Analysis of long-term freight transport, logistics and related CO2 trends on a business-as-usual basis." Thesis, Heriot-Watt University, 2010. http://hdl.handle.net/10399/2326.
Full textNover, Scott. "Netflix vs. the World| A Study of Competitive Trends in the Modern American TV Industry." Thesis, The George Washington University, 2018. http://pqdtopen.proquest.com/#viewpdf?dispub=10823909.
Full textThe TV industry is a competitive marketplace with rapidly realigning powers and players, fueled by an environment of intense conglomeration and consolidation. The present study focuses on three facets of this industry that are inextricably related to competition: (1) government rules, regulations, and policies; (2) the role of TV content production; and, (3) the role of consumer behavior and preference. Further, it explores the technology behind TV, as television distribution is intrinsic to the future of the industry.
Wood, Samantha (Soprano). "Distance Learning in Singing Education: An Overview of Historical and Modern Approaches and Future Trends." Thesis, University of North Texas, 2019. https://digital.library.unt.edu/ark:/67531/metadc1505254/.
Full textKarlsson, Jacob, and Peter Reumark. "Future drivers and trends influencing the outbound logistics development : A cross-sectional study focusing on the industrial aftermarket." Thesis, Linköping University, Department of Management and Engineering, 2007. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-9232.
Full textThe main purpose of this thesis has been to explore and evaluate future drivers and trends within outbound logistics. In addition to this it was said that Syncron International AB, which assigned the study, should be able to use the findings to develop their products and services in a way that would satisfy future customer demand.
The thesis was mainly carried out in three steps. Firstly, an extensive theoretical framework was constructed which formed the base for the continuing study. The theoretical framework contributed to both opinions in the studied areas, which were further processed later on in the study, as well as it formed the interview material. Secondly, interviews were held with a selection of Syncron’s customers which had experience from the studied areas. The results from the empirical study were then evaluated and summarized. Thirdly, the empirical and the theoretical results were analyzed and compared to form conclusions regarding the future of outbound logistics. These conclusions included recommendations for how Syncron and similar companies should adjust and prepare for this development.
The future of outbound logistics will be more complex in many aspects due to various reasons. The customers are expected to demand more customized product and service offerings as well as they will demand suppliers to take over responsibility for service and maintenance. Distribution strategies like direct deliveries, cross-docking and transport consolidation are expected to be used to a greater extent in the future, as one method to deal with challenging future demands.
The above mentioned issues, in combination with increased environmental pressures, will demand more from planning and management activities. This will in turn require further developed tools for planning and management, which are expected to be one of the main enablers for the future logistical development. These tools should also be able to increase the visibility throughout the entire supply chain, which is considered to become a crucial prerequisite in planning and forecasting processes in the future. It is important that companies like Syncron are aware of the expected enablers of the future logistical development, since it is within this area their customers will need assistance.
Reinitz, Kortney. "Trends in media coverage of the issues of the '80s and '90s." Virtual Press, 2000. http://liblink.bsu.edu/uhtbin/catkey/1191717.
Full textDepartment of Journalism
Barbosa, Fernando Ferreira da Luz. "Investor disagreement: the modern approach." reponame:Repositório Institucional do FGV, 2015. http://hdl.handle.net/10438/13872.
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Disagreement between economists is a well know fact. However, it took a long time for this concept to be incorporated in economic models. In this survey, we review the consequences and insights provided by recent models. Since disagreement between market agents can be generated through different hypotheses, the main differences between them are highlighted. Finally, this work concludes with a short review of nowcasting using google trends, emphasizing advances connecting both literatures.
Saint, Marie Katina. "The Changing Face of Property: Land and Bodies in Early Modern English Literature and Contemporary Legal Trends." Thesis, University of Oregon, 2015. http://hdl.handle.net/1794/19326.
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Schoergendorfer, Angela. "BAYESIAN SEMIPARAMETRIC GENERALIZATIONS OF LINEAR MODELS USING POLYA TREES." UKnowledge, 2011. http://uknowledge.uky.edu/gradschool_diss/214.
Full textHanžl, Václav. "Význam námořní dopravy ve světové ekonomice: současné trendy." Master's thesis, Vysoká škola ekonomická v Praze, 2009. http://www.nusl.cz/ntk/nusl-11020.
Full textKellogg, Andrew. "Closeted Channels: Trends of Sexual-Minority Characters on Primetime Television." Ohio University Honors Tutorial College / OhioLINK, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=ouhonors1399889530.
Full textReis, Dinis Alexandre da Silva. "A Evolução da Distribuição Moderna em Portugal no Ramo Alimentar: a opção da subcontratação logística." Master's thesis, Instituto Politécnico de Setúbal. Escola Superior de Ciências Empresariais, 2014. http://hdl.handle.net/10400.26/7716.
Full textNos últimos trinta anos têm sido significativas as alterações verificados no Comércio. As realidades existentes anteriormente são completamente distintas das atuais. O aumento do poder de compra, as expetativas e exigências dos consumidores, a realidade social, a disponibilidade de tempo, a inserção da mulher no mercado de trabalho, a melhoria das infraestruturas e os avanços tecnológicos são alguns dos inúmeros fatores que levaram a que o Comércio sofresse significativas alterações e em que as realidades existentes anteriormente sejam completamente distintas das atuais. A presente dissertação analisa como estas alterações levaram a um crescimento da distribuição moderna em relação às relações de comércio tradicional existentes em décadas atrás. Pretende-se estudar como a distribuição moderna alimentar em Portugal agiu face à opção de contratação de operadores logísticos e influenciou o seu desenvolvimento. O desenvolvimento desta temática é deveras interessante uma vez que procura não só perceber como cresceu a distribuição moderna como também perceber porquê, e aqui o binómio alteração da procura versus oferta tem um papel fundamental. Através de dados fornecidos por especialistas no ramo da Distribuição moderna e através de um enquadramento do tema na bibliografia já existente e de dados estatísticos, nomeadamente no que concerne ao volume de faturação da Distribuição moderna e ao volume de faturação de operadores logísticos em Portugal, pretende-se verificar se há uma relação direta entre a estratégia logística da distribuição moderna e crescimento de operadores logísticos. A subcontratação logística é então vetor fundamental na análise efetuada sendo que as opiniões a recolher devem levar a concluir ou não que os operadores logísticos estão capacitados e têm as competências suficientes ou podem melhorar a oferta até aqui prestada. Procurar-se-á perceber como as tendências para o futuro da distribuição moderna são vistas pelas organizações em estudo nomeadamente no que concerne a processos a implementar, performance para melhorar, desafios ao nível do e-commerce e das relações com fornecedores.
Abstract: the last thirty years have been significant changes recorded in the Trade. The previously existing realities are quite different from today. The increase in purchasing power , the expectations and demands of consumers , the social reality , the availability of the time , the inclusion of women in the labour market , improving infrastructure and technological advances are some of the many factors that lead to Trade suffered significant changes and the previously existing realities are completely different from today. This dissertation analyzes how these changes have led to a growth of modern distribution in relation to traditional trade relations existing in decades ago. The aim is to study how the modern food distribution in Portugal acted face the option of hiring logistics operators and influenced its development. The development of this theme is very interesting as it seeks not only to see how grown modern distribution but also to see why, and here the binomial change in the demand versus supply plays a key role. Through data provided by experts in the field of modern distribution and through a theme framework in existing literature and statistical data, particularly with regard to the volume of turnover of modern distribution and volume of billing logistics operators in Portugal, want to check if there is a direct relationship between the strategy of modern logistics distribution and growth of logistics operators. Logistics outsourcing is so fundamental vector in the analysis carried out and that the views collected must lead to the conclusion or not that logistics operators are trained and have sufficient skills or can improve the offer so far provided. Search will be to see how the trends for the future of modern distribution are seen by the organizations under study in particular concerning the processes to implement, to improve performance, the challenges of e-commerce level and relations with suppliers. Search will be to see how the trends for the future of modern distribution are seen by the organizations under study in particular concerning the processes to implement, to improve performance, the challenges of e-commerce level and relations with suppliers.
Leijonhufvud, Lotta. "Grain tithes and manorial yields in early modern Sweden : trends and patterns of production and productivity c. 1540-1680 /." Uppsala : Swedish Univ. of Agricultural Sciences (Sveriges lantbruksuniv.), 2001. http://epsilon.slu.se/avh/2001/91-576-5829-3.pdf.
Full textSmiljanić, Dušan. "NEW TRENDS IN DEVELOPING MANAGERIAL COMPETENCIES FOR MODERN COMPANIES: APPLICABILITY OF MUSIC IN IMPROVING BUSINESS EFFICIENCY AND WORKING ENVIRONMENT." Doctoral thesis, Vysoká škola ekonomická v Praze, 2009. http://www.nusl.cz/ntk/nusl-165967.
Full textMokhlesi, Javad, and Saman Lohrasebi. "The Current State and Future Trends in The Use of Pallets in Distribution Systems." Thesis, Högskolan i Borås, Institutionen Ingenjörshögskolan, 2010. http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-19689.
Full textSchwartz, Brian Matthew. "Evaluation of the genetic gain in upland cotton during the twentieth century." Thesis, Texas A&M University, 2005. http://hdl.handle.net/1969.1/4906.
Full textSlepička, Jiří. "Analýza a návrh optimalizace internetového obchodního modelu společnosti NS Svoboda s.r.o." Master's thesis, Vysoká škola ekonomická v Praze, 2012. http://www.nusl.cz/ntk/nusl-124554.
Full textBropleh, Minger. "Incongruent Premodern and Modern Beauty Ideals: A Case Study of South Korea and India's Reconciliation of Current Beauty Trends With Foundational Religious Ideals." Scholarship @ Claremont, 2014. http://scholarship.claremont.edu/cmc_theses/810.
Full textHamnebo, Karl, and Oscar Askfelt. "Information flows in Demand Responsive Public Transport : Interactivity, information, and flexibility in a modern ridesharing service." Thesis, Malmö universitet, Fakulteten för teknik och samhälle (TS), 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-43270.
Full textKrálíková, Jitka. "Moderní nástroje marketingové komunikace." Master's thesis, Vysoká škola ekonomická v Praze, 2011. http://www.nusl.cz/ntk/nusl-86048.
Full textDžurňáková, Mária. "Rozvoj logistiky v České republice." Master's thesis, Vysoká škola ekonomická v Praze, 2008. http://www.nusl.cz/ntk/nusl-4399.
Full textConceição, Carlos Augusto Ribeiro da. "Koonsland-comércio de duplos." Master's thesis, Instituições portuguesas -- UNL-Universidade Nova de Lisboa -- FCSH-Faculdade de Ciências Sociais e Humanas -- -Departamento de Ciências da Comunicação, 1997. http://dited.bn.pt:80/29838.
Full textDias, Fernando Paulo Leitão Simões Rosa. "Ecos expressionistas na pintura portuguesa (1910-1940)." Master's thesis, Instituições portuguesas -- UNL-Universidade Nova de Lisboa -- FCSH-Faculdade de Ciências Sociais e Humanas -- -Departamento de História da Arte, 1996. http://dited.bn.pt:80/29877.
Full textPereira, Teresa Matos. "A primitividade do ver ou a renúncia da razão na arte do primeiro modernismo em Portugal." Master's thesis, Instituições portuguesas -- UL-Universidade de Lisboa -- -Faculdade de Belas Artes, 2001. http://dited.bn.pt:80/30084.
Full textPtáčníková, Jarmila. "Moderní metody v retail businessu." Master's thesis, Vysoká škola ekonomická v Praze, 2008. http://www.nusl.cz/ntk/nusl-4855.
Full textEkros, Axel, and Gustaf Utbult. "Nya försäljningskanalers framväxt inom klädhandeln : En utforskande studie inom klädhandeln." Thesis, Jönköping University, JTH, Logistik och verksamhetsledning, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:hj:diva-51937.
Full textPurpose – The purpose of the study is “Study the current buying channels to meet coming trends within retailing” Three questions have been formulated to answer the purpose of this study. 1. What are the current buying behaviours today? 2. What is today’s buying channels within the clothing retail market? 3. What type of buying behaviour corresponds to today's buying channels? Method – To answer the purpose of the study, a literature study and interviews were conducted. The literature study was conducted to analyse and gather information from previously known empirical studies, research overviews which relate to the relevant research area. Five interviews were conducted with experts with different perspective of clothing retail market, to create a broader understanding of the topic. The collected data has been systematically analysed using thematic analysis. Theories surrounding the study's three research questions have been developed along the course of the study. Findings – The study have identified the major buying behaviours and buying channels in society given the study's delimitations. The major buying behaviours which have been identified are Showrooming, webrooming and purchases made through single channel. Identified buying channels are brick-and-mortar, direct channel, e-tailer and dual channel. Channel strategies used are Omnichannel, Multi-channel and cross-channel. Trends which may continue are the continued adaptation and integration of omnichannel and cross-channel systems among retail companies. Additional trend of importance is the continued work from retail firms with seamless interaction between multiple channels. Information retrieval will be done more online, and customers are looking for an experience when they visit a store, akin to showrooms. Omnichannel integration where the customer experiences a seamless experience between the different channels have become crucial. Clothing companies focus on the experience at the store and choose to invest in fewer stores of higher quality. Implications – The study identifies relations within buying behaviours and buying channels which may gain create a deeper understanding within the retail market. Trends which have been identified may aid retail firms understanding for consumer different behaviour. The study contributes with an understanding how consumers effect the development of buying channels, through their confirmatory role. Further research in this area can be to conduct a quantitative study to catch the trend, the strength and therefore its impact on the overall market. Limitations – The study is limited to interviews conducted only with people located in Sweden. To gain a broader understanding, interviews can be conducted all over the world. The study is limited to five interviews. Given the limitation, more interviews of people in additional sectors may be of interest for further research.
Antonucci, Ryan J. "Changing Perceptions of il DuceTracing Political Trends in the Italian-American Media during the Early Years of Fascism." Youngstown State University / OhioLINK, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=ysu1379111698.
Full textNascimento, Paulo Victor Fernandes Souza 1964. "Desenvolvimento de um modelo de predição clínica para infecção-colonização por bactérias multidroga resistentes em um hospital geral." [s.n.], 2013. http://repositorio.unicamp.br/jspui/handle/REPOSIP/309458.
Full textTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: As infecções relacionadas à assistência à saúde são responsáveis pela elevação do custo assistencial, aumento da morbimortalidade hospitalar e aumento do tempo de internação. Uma característica peculiar dessas infecções diz respeito à resistência dos microrganismos envolvidos. Protocolos de tratamento de infecções graves, como pneumonia e sepse, indicam o uso inicial de associações antimicrobianas de largo espectro, caso o paciente apresente fatores de risco para resistência. Posteriormente, com o resultado das culturas, o esquema terapêutico inicial seria readequado. Entretanto, esse processo conhecido como "descalonamento" ocorre de forma infrequente. Assim, no momento da escolha inicial dos antimicrobianos para o tratamento de síndromes infecciosas graves, os profissionais se deparam com um dilema: Utilizar um esquema de amplo espectro para a maior proteção do paciente, mas que raramente será revisto e contribuir para o aumento da resistência da microbiota hospitalar, ou tentar o uso de esquemas menos abrangentes? Com o objetivo de auxiliar o médico nesse momento da prescrição, procurou-se identificar possíveis características dos pacientes que pudessem servir como fatores preditores para infecção ou colonização para microrganismos multirresistentes. Em um hospital geral de 90 leitos, na cidade de São José dos Campos, no Estado de São Paulo, Brasil, foi conduzido um estudo de caso-coorte, entre junho de 2009 e junho de 2011, em que todos os pacientes que realizaram pelo menos um exame de cultura foram incluídos (753 pacientes). Os casos foram definidos como todos os pacientes que apresentaram culturas clínicas com o isolamento de pelo menos um microrganismo multirresistente (146 pacientes). A multirresistência foi definida conforme o consenso do Centro de Controle de Infecções e Doenças dos Estados Unidos da América em associação com o Centro Europeu para Prevenção e Controle de Doenças. Os controles foram todos os pacientes que se submeteram a culturas as quais não demonstraram crescimento de um agente multirresistente. Foram avaliadas quatorze variáveis demográficas e clínicas, comumente identificadas como fatores de risco. Foram construídos três modelos de predição clínica: regressão logística, árvore de classificação e floresta aleatória. No modelo de regressão logística, em função de intensa colinearidade, optou-se pela eliminação das variáveis pelo método backward. Na validação interna deste modelo, foi utilizada a técnica de reamostragem por bootstrap. O novo modelo foi calibrado com um fator de shrinkage de 0,91. Os modelos de árvore de classificação e floresta aleatória identificaram, de maneira semelhante, as variáveis mais importantes para predição que foram: história de internação nos últimos 180 dias, tempo de internação até a realização da cultura, Índice de comorbidades de Charlson, presença de cateter nasoentérico, traqueostomia e cateter venoso central. Foi realizada a validação externa temporal com uma nova amostra coletada entre julho e dezembro de 2011, num total de 342 pacientes. As acurácias dos modelos de regressão logística, árvore de classificação e floresta aleatória foram avaliadas por curvas ROC (Receiver operating characteristic). As áreas sobre a curva foram respectivamente: 72,4%, 66,2% e 69,2%. O modelo final da regressão logística com o total de pacientes estudados (1092) apresentou uma área sob a curva ROC corrigida do otimismo de 77,1%
Abstract: Healthcare-associated infections are responsible for rising health care costs, increasing morbidity, mortality, and longer hospital stays. A peculiar characteristic of such infections is the resistance of the involved microorganisms. The presence of infectious agents resistant to multiple classes of antimicrobials is increasing in such infections. Thus, multidrug resistance brings a real challenge to everyday clinical practice. Protocols for treatment of severe infections such as pneumonia and sepsis indicate the use of broad-spectrum antimicrobial associations as the initial therapy if the patient has a risk factor for resistance. Later, with the result of cultures, an adjustment of the initial therapeutic regimen would be expected. However, this process, known as de-escalation, occurs infrequently. Thus, at the moment of choosing the initial antibiotics for treating serious infectious syndromes, physicians are challenged with a dilemma: either to prescribe broad-spectrum antibiotics and contribute to increasing antibiotic resistance or to use a narrow spectrum of antimicrobials and put patients' prognosis at risk. The aim of this study was to identify potential predictors for the harboring of multidrug-resistant bacteria and to build a clinical prediction model that could help physicians to recognize patients with different risks for infection or colonization by these microorganisms. We conducted a case-cohort study in a 90-bed general hospital, at São José dos Campos, São Paulo State, Brazil, with all patients that performed at least one culture (753 patients). Cases were defined as patients that had had a culture demonstrating a multi-resistant agent (146 patients). Controls were all other patients that had had at least one culture. The consensus definition from the Center for Disease Control and the European Centre for Disease Prevention and Control was used to describe antibiotic multi-resistance. Fourteen traditional risk factors were evaluated as predictors. We constructed three clinical prediction models: logistical regression, classification tree, and random forest. In the logistical regression model, due to severe collinearity, we chose to eliminate variables by the backward method. In this model, for internal validation, we used the bootstrap resampling procedure. The new model was calibrated with the use of a shrinkage factor of 0.91. Similarly, the classification tree and random forest models identified that the most important variables for prediction were: admission history of 180 days, tube feeding, and length of hospital stay before culture, Charlson comorbidity index, central venous catheter, and tracheostomy. A temporal external validation was performed with a new sample collected between July and December 2011, with 342 patients. The accuracies of logistic regression, classification tree and random forest models were evaluated by ROC (Receiver operating characteristic) curves. The areas under the curve were 72.4%, 66.2% and 69.2%, respectively. The final logistical regression model with the overall study population (1092 patients) is described and shows an optimism-corrected area under the ROC curve of 77.1%
Doutorado
Epidemiologia
Doutor em Saude Coletiva
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