Дисертації з теми "Service du cure"

Thesis (M.S. in Management) Naval Postgraduate School, June 2000.
Thesis advisor(s): Lewis, Ira A.; Liao, Shu S. "June 2000." Includes bibliographical references (p. 63-64). Also available in print.

This thesis is about the Tukula Fenna Project (TFP) that was set up at the Home Care Department of St. Raphael of St Francis Hospital (Nsambya Hospital) in Kampala, Uganda. In 2003, Associazione Casa Accoglienza alla vita “Padre Angelo” (ACAVPA) or “HOUSE FOR LIFE, Father Angelo” and other Italian partners; in particular, PENTA Foundation and University of Padova, Department of paediatrics collectively signed a memorandum of understanding (MoU) with Nsambya Hospital. The aim of the MoU was to collaborate with the hospital in the fight against HIV particularly in children and adolescents, orphans and vulnerable children (OVC) and their families in Kampala and three surrounding districts (Mukono, Wakiso and Mpigi). Thus, the MoU officially established the children’s HIV programme at Nsambya Hospital, Home Care Department in 2003. The programme was then called the “PCP Project” because the initial intervention was among other things, providing Cotrimoxazole prophylaxis against Pneumocystis Carinii pneumonia (PCP, also known as Jiroveci Pneumonia). As more resources including provision of antiretroviral drugs (ARVs) from external sources and expertise became available over the years, the project evolved into a full-blown HIV programme for infants, children and adolescents as well as their families and caretakers. Additionally, the name “PCP”, was replaced by “Tukula Fenna”, which means “growing up together” in the local language (Luganda). The project was implemented at the Home Care Department within an existing community home-based care (CHBC) model that evolved in response to the HIV epidemic in Uganda, and other high-burden resource-limited settings. The TFP provides comprehensive HIV care, treatment and psychosocial support services (PSS) and apart from operating at the Home Care department of Nsambya Hospital, it also operates at Ggaba Parish Outreach Clinic and 3 other outreach clinics in and around Kampala. This thesis describes the research outcomes of the project that was managed by Dr. Massavon from 2008 to 2013. It reviews the published literature from the key milestones of the HIV epidemic to the post-conflict health reforms in Uganda and their relevance to current health outcomes, the national AIDS response and health systems strengthening. The literature review also examines the human resources for health (HRH) crisis and task shifting in the scaling up of ART in high-burden resource-limited settings. In addition, the review looks at the evolution of complementary HIV service delivery models like community and home-based care as a spontaneous response to the HIV epidemic in many resource-limited settings including Uganda. Finally, the literature documents that, there are relatively few paediatric HIV services in the country, leading to poor geographical access and a low antiretroviral therapy (ART) coverage for children and that, HIV-infected children and in particular, AIDS orphans are an underserved and an understudied population. At the time of this thesis, approximately 2,100 infants, children and adolescents had been enrolled into care in the TFP; about 1140 were active in care, and about 60% were on ART. Approximately, 47% of children and adolescents in the project are orphans. This thesis therefore aims at contributing to improving paediatric HIV management through operational research in the context of a CHBC model in Kampala, Uganda. The findings cover key outcomes such as retention in care, attrition and loss to follow up (LTFU), treatment failure, mortality on antiretroviral therapy (ART) and operationalization of dried blood spots (DBS) for viral load testing among HIV-infected children. The thesis also included a specific study on HIV-Epstein-Barr Virus (EBV) co infections in children and adolescents, considered relevant to the project setting. Except for study 5 (EBV study) which was a cross-sectional study, the studies were generally retrospective cohort studies conducted at the Home Care Department of Nsambya Hospital in Kampala, Uganda. The methodology of the operational research was based on an implementation schema derived from the ART guidelines of the WHO and Uganda (Figure 17). The selection of the outcomes for the operational research was based on the rationale that, they have direct bearings on implementation and potentially could improve the same. The findings and implications from the six studies that constitute the chapters of the thesis are summarized as follows: Study 1: This retrospective observational study compared HIV and TB outcomes from adults and children in the Nsambya CHBC with national averages from 2007-2011. The core findings show that Nsambya CHBC activities enhance and complement national HIV and TB management, and resulted in better outcomes when compared to the national averages. This approach may hold the potential for chronic disease management in resource-limited settings. Scaling up CHBC could have wider positive impacts on the management of not only HIV and TB, but also other chronic diseases as well as the general health system. A long-standing “faith-based solidarity” among international donors and partners has been pivotal to the survival and evolution of the Nsambya CHBC. Study 2: This is a retrospective cohort analysis of attrition and LTFU and their predictors among children and adolescents aged 0-20 years. Over the study period, 5.34% (62) of patients died, 37.61% (437) were LTFU, and thus overall attrition was 42.94% (499). Generally, attrition and LTFU were relatively high among children and adolescents in the TFP. Not receiving ART was the single factor significantly associated with attrition in the cohort, while both baseline BMI z-scores and receipt of ART were protective against LTFU among HIV positive children and adolescents. Efforts should be made to initiate ART among all paediatric patients as soon as possible, and to provide aggressive follow-up for those not yet receiving ART. Orphans need more nutritional support to reduce the burden of malnutrition and improved access to early ART, which could also promote growth responses in this vulnerable and understudied group. Study 3: This retrospective cohort study reviewed records from HIV positive children age 0 to 18 years engaged in a CHBC and a Facility-based, family-centred approach (FBFCA) from 2003 to 2010 focussing on retention in care, loss to follow-up, mortality, use of ART, and clinical characteristics. Irrespective of model of care, children receiving ART had better retention in care and therefore long-term survival. Encouragingly, if children were on ART, then their survival was as good, if not slightly better, in the CHBC compared to the FBFCA. Based on our observations, substantial improvement in child survival can be achieved in either a community-based or a family-care model as long as HIV- infected children are identified early and begun on ART. To ensure this occurs, early identification of HIV infected children requires strong linkages of pregnant HIV- infected women to prevention of mother to child transmission (PMTCT) services; active tracking to ensure all HIV exposed infants receive Polymerase Chain Reaction-based early infant diagnosis. Additionally, rapid early initiation of ART among HIV infected infants and children are essential. Study 4: This is an observational study that included HIV-infected children attending the Beira Central Hospital (Mozambique) and the Nsambya Hospital, Home Care Department (Uganda), and evaluated clinical and immunological failure according to the WHO 2006 guidelines. Two hundred and eighteen of 740 children with at least 24 weeks follow-up experienced treatment failure ((29% 95%CI (26-33)), with crude incidence of 20.0 events per 100 person-years (95%CI 17.5-22.9). Having tuberculosis co-infection or WHO stage 4, or starting a non-triple cART significantly increased the risk of failure. Drug toxicity (18.3%), drug availability (17.3%) and anti-tuberculosis drug interactions (52, 25.7%) were the main reported reasons while only 9 (4%) patients switched cART for clinical or immunological failure. Considerable delay in switching to second line cART may occur despite an observed high rate of treatment failure. Our findings reinforce the need for simplification of more effective clinical and immunological criteria for prompt recognition of cART treatment failure. Children presenting with advanced disease and TB co-infection should be targeted for closer and more sensitive monitoring of treatment response. This should be matched with a constant provision of appropriate antiretroviral drugs with optimization of first line drugs and treatment sequencing. Supply of new paediatric formulations for second line regimens and drug optimization should be considered as critical milestones to allow scaling up of early cART and reduction of treatment failure in children. Study 5: In this cross-sectional study, dried blood spot (DBS) samples from 213 HIV-1 infected children were collected and EBV DNA was extracted and analysed for quantification of EBV types 1 and 2 and for quantification of 16S ribosomial DNA (16S rDNA), a marker of microbial translocation. Ninety-two of 140(66%) children on ART and 57 of 73(78%) ART-naive children had detectable EBV levels. Co-infection with both EBV types was significantly less frequent in ART-treated than in ART-naïve children (OR=0.54, 95%CI 0.30;0.98, p=0.042). HIV-1 inducing microbial translocation and a state of persistent immune activation, may lead to EBV replication and expansion of EBV-infected B-cells, thus increasing the EBV-DNA load. Super-infection by both types of EBV in HIV-1 infected subjects may represent an additional risk for the onset of EBV-related malignancies. ART, by limiting HIV-1 replication, microbial translocation and related immune activation, may prevent super-infection by both EBV types and keep EBV viremia down, thus reducing the risk of EBV-associated lymphomas. Study 6: This was a retrospective study to evaluate viral load (VL) using DBS and to explore the accuracy of clinical and immunological criteria for treatment failure (TF) in a cohort of HIV-1-infected children. In this cohort, immunological and clinical criteria as per WHO 2010 guidelines poorly predicted the presence of a viral load greater than either 1000 cp/ml or 5000 cp/ml (whole blood) from DBS. The low sensitivity and positive predictive values for immunological and/or clinical failure confirm those reported by the literature. This finding further supports the WHO recommendations that VL monitoring should be implemented and used to identify cases of treatment failure earlier. Policy implications of key findings of thesis Scaling up CHBC could have wider positive impacts on the management of not only HIV and TB, but also other chronic diseases as well as the general health system. In this thesis, and in line with the literature, Early ART initiation was associated with improved survival and retention in both community-based and facility-based approaches. ART is potentially protective against EBV-related lymphoproliferative disorders in HIV-EBV co infected children. This calls for early ART initiation and close monitoring in such children. Operationalization of the use of DBS in viral load monitoring in HIV-infected children in low and middle-income countries is feasible and should be encouraged to improve the quality of paediatric HIV management in such settings. The low ART coverage among children calls for urgent, greater and more effective decentralization of paediatric ART services within primary health care services at the district and sub-district levels in the general health system in Uganda. Children presenting with advanced HIV disease and TB co-infection should be targeted for closer and more sensitive monitoring of treatment response. Orphans need more nutritional support to reduce the burden of malnutrition and improved access to early ART, which in turn could promote growth responses in this vulnerable and understudied group
Questa tesi descrive il Progetto Fenna Tukula (TFP) in corso presso il Home Care Department dell'Ospedale St. Raphael e St. Francis (Nsambya Hospital) a Kampala (Uganda). Nel 2003, l'Associazione Casa Accoglienza alla Vita "Padre Angelo" (ACAVPA) insieme ad altri Partner (in particolare la Fondazione PENTA e l'Università di Padova), hanno firmato una lettera di intenti con il Nsambya Hospital. L'obiettivo di questo documento era di collaborare con l'ospedale nella lotta all'AIDS nei bambini ed adolescenti, orfani (OVC) e le loro famiglie a Kampala e nei distretti circostanti di Mukono, Wakiso e Mpigi. Il progetto è stato chiamato inizialmente "PCP project" in quanto l'intervento consisteva essenzialmente nella profilassi con il Cotrimoxazole per la prevenzione della polmonite da Pneumocystis Carinii (conosciuta anche come Jiroveci Pneumonia). Dopo due anni dall’inizio del progetto grazie ad una aumentata disponibilita’ di risorse e’ stato possibile fornire ai bambini che ne avevano necessita’ la terapia con farmaci antiretrovirali (ARVs) da e quindi il progetto si e’ inidirizzato verso un programma 'tout-court' di lotta all'AIDS pediatrico con un approccio globale, che includeva anche le famiglie e non solamente i bambini. Di conseguenza, il nome "PCP" è stato rimpiazzato da "Tukula Fenna", che significa "crescere insieme" nella lingua locale (luganda). Il progetto si e’ caratterizzato con l’implementazione di un modello di cure domiciliari (CHBC) adattato alla realta’ dell’ Uganda andando quindi oltre i confini dello NHC fino a comprendere delle strutture periferiche tra cui la Clinica della Parrocchia di Ggaba ed altre 3 cliniche nei dintorni di Kampala. Questa tesi descrive i risultati dell’ attivita’ di ricerca svolta nell’ ambito del progetto che è stato coordinato dal Dr. Massavon tra il 2008 e il 2013. La tesi si articola in una prima parte di revisione della letteratura con particolare riferimento alla realta’ ugandese sia da un punto di vista dell’ epidemiologia dell’ HIV che dell’ organizzazione sanitaria nel paese con particolare riferimento all'evoluzione dei modelli sanitari finalizzati alla lotta all'AIDS, come modelli di cura comunitaria o domiciliari. L’ analisi della letteratura ha documentato che, in Uganda vi sono relativamente pochi servizi specialistici sull’ HIV pediatrico. Tale aspetto ha come conseguenza una disparita’ tra le varie regioni del paese e un limitato accesso alla terapia antiretrovirale per i bambini soprattutto coloro che sono senza genitori naturali. A dicembre 2013 circa 2.100 bambini ed adolescenti sono stati arruolati nel TFP. 1.140 sono seguiti regolarmente e il 60% di loro sono in terapia con ART. Il 47% dei bambini è orfano. La finalita’ ultima della tesi e’ quello di contribuire al miglioramento delle cure nei bambini HIV positivi in Uganda attraverso la valutazione di un modello di assistenza domiciliare. In quest’ ottica l’ attivita’ di ricerca si e’ articolata nella valutazione delle caratteristiche dei pazienti persi al follow-up, dell’ outcome della terapia antiretrovirale e, in un ambito piu’ prettamente clinico, nello studio dell’ impatto della infezione da EBV sulla progressione della malattia da HIV. L’ attivita’ si e’ sviluppata attorno diverse linee di ricerca i cui risultati sono stati pubblicati (o in corso di pubblicazione) nei lavori i cui elementi fondamentali sono riassunti di seguito: Studio 1: Studio osservazionale retrospettivo che analizza i risultati del follow-up dei pazienti con HIV e TB (adulti e bambini) seguiti presso lo Nsambya Hospital confrontandoli con i dati nazionali tra il 2007 e il 2011. I risultati mostrano che il modello seguito allo Nsambya ha prodotto migliori risultati in termini di morbilita’ e mortalita’ rispetto alle medie nazionali. Il modello descritto basato sull’ assistenza domiciliare potrebbe essere utilizzato anche in altri contesti nei paesi in via di sviluppo. Studio 2: Analisi di coorte retrospettiva per la valutazione delle caratteristiche dei pazienti persi al follow up (LTFU) e dei fattori di rischio associati, nei bambini ed adolescenti tra 0 e 20 anni. Nel corso del periodo di follow up considerato, il 5,3% dei pazienti è deceduto, il 37,6% e’ stato perso al follow-up con un “attritio” globale del 42,9%. In generale, LTFU sono stati relativamente alti tra i bambini e gli adolescenti nel TFP. La terapia con ARV e la crescita regolare sono stati fattori associati con la permanenza in follow up e con la sopravvivenza. Tali osservazioni suggeriscono come gli sforzi dovrebbero essere indirizzati ad iniziare la ART nei pazienti pediatrici il prima possibile, e a fornire un follow-up regolare a coloro che non sono ancora in terapia. Particolare attenzione va data agli orfani che necessitano di un supporto alimentare particolarmente attento e di un follow up regolare per definire il momento migliore quando iniziare la ART. Studio 3: Studio di coorte retrospettivo che ha studiato i bambini HIV positivi tra 0 e 18 anni inseriti in un programma di assistenza domiciliare con un approccio centrato sulla famiglia (FBFCA) dal 2003 al 2010, focalizzandosi sulla perdita al follow-up, la mortalità, l'uso di ART e le caratteristiche cliniche. A prescindere dal modello di cura, i bambini che ricevevano l'ART sono seguiti piu’ regolarmente e di conseguenza hanno una sopravvivenza a lungo termine maggiore. Basandosi sulle nostre osservazioni, un miglioramento sostanziale nella sopravvivenza dei bambini può essere raggiunto sia con un modello basato sulla assistenza domiciliare che sul coinvolgimento attivo della comunita’. Studio 4: Studio osservazionale prospettico che ha incluso bambini HIV positivi assistiti presso il Beira Central Hospital, in Mozambico e lo Nsambya Hospital, che ha valutato il rischio di fallimento immunologico e clinico secondo le linee guida del WHO del 2006. 218 su 740 bambini con almeno 24 settimane di follow-up ha avuto un fallimento della terapia ((29% 95% CI (26-33)), con una incidenza di 20.0 eventi su 100 anni-persona (95%CI 17.5-22.9). La coinfezione con la TB, la presenza di AIDS (WHO stadio 4), o l’inizio della ART con uno o due farmaci aumenta significativamente il rischio di fallimento terapeutico. Un ritardo considerevole nel passaggio alla seconda linea di cART si e’ osservato nonostante un alto tasso di fallimento terapeutico. Tali osservazioni sottolineano ancora una volta l’importanza di garantire un efficace monitoraggio clinico e immunolgico per poter modificare la terapia prima che insorgano ceppi virali resistenti. Insieme alla necessita’ di un corretto monitoraggio va sottolineata l’importanza di garantire una fornitura di farmaco regolare senza interruzioni e le formulazioni pediatriche per i bambini piu’ piccoli Studio 5: Studio trasversale, effettuato su campioni raccolti in cartoncini assorbenti (DBS) prelevati da 243 bambini affetti da HIV-1 da cui e’ stato estratto il DNA del EBV per analisi e quantificazione dei tipi 1 e 2, e per la quantificazione di 16s DNA ribosomiale (16S rDNA), un marker di traslocazione microbica. 92 su 140 (66%) dei bambini in terapia con ART e 57 su 73 (78%) di bambini non trattati sono risultati positivi all’ EBV. La coinfezione con entrambi i tipi di EBV è stata significativamente meno frequente in coloro in terapia con ART (OR=0.54, 95%CI 0.30; 0.98, p=0.042). Tale osservazione e’ compatibile con il fatto che ' HIV-1, che induce una traslocazione microbica e uno stato di persistente attivazione immunitaria, può portare a una replicazione di EBV ed ad una espansione di cellule B infette, aumentando di conseguenza il DNA dell'EBV. La co-infezione da EBV in soggetti affetti da HIV-1 può rappresentare un rischio addizionale per lo scatenarsi di tumori (linfomi) associati al EBV. Il trattamento con ART, riducendo la replicazione dell’ HIV-1, la traslocazione microbica e la relativa attivazione immunitaria, può prevenire la super infezione da EBV e mantenere la viremia EBV bassa, riducendo il rischio di linfomi ad esso associata. Studio 6: Studio retrospettivo per valutare la carica virale dell’HIV (VL) su campioni raccolti in DBS e per esplorare l'accuratezza dei criteri clinici ed immunologici per la definizione del fallimento terapeutico. La bassa sensibilità e valore predittivo del fallimento clinico e/o immunologico, da noi osservate, confermano quanto riportato in letteratura. Questa osservazione supporta ulteriormente la raccomandazione del WHO che il monitoraggio della carica virale debba essere implementato ed utilizzato per identificare precocemente casi di fallimento del trattamento. Implicazioni dei risultati della tesi e messaggi chiave Il modello assistenziale centrato sull’ assistenza domiciliare e’ risultato molto efficace per ridurre il rischio di perdita al follow up. Tale modello potrebbe quindi essere considerato anche per l’assistenza dei malati di TB o con altre malattie croniche. Le nostre osservazioni supportano quanto gia’ riportato in letteratura che l’inizio precoce dell’ ART e’ era associato non solo aduna migliore sopravvivenza ma anche ad un minor rischio di perdita al follow up. Il trattamento ART è potenzialmente protettivo contro patologie linfoproliferative correlate al EBV nei bambini con coinfezione da HIV ed EBV. L’uso del DBS per il monitoraggio della carica virale nei bambini HIV positivi si e’ rivelato fattibile sia da un punto di vista organizzativo che della qualita’ dei campioni da testare. Tale metodica dovrebbe quindi essere incoraggiata per migliorare la qualità della gestione pediatrica dell'HIV soprattutto nei paesi in via di sviluppo La bassa copertura di ART tra i bambini richiede un urgente, maggiore e più efficace decentramento dei servizi pediatrici centrali e la loro integrazione con i servizi sanitari di base a livello distrettuale e sub-distrettuale in Uganda. I bambini che presentino uno stadio avanzato di infezione HIV e coinfezione da TB dovrebbero essere sottoposti a monitoraggio più serrato per iniziare il trattamento ART appena cio’ si renda necessario. Gli orfani necessitano un particolare attenzione sia per quanto riguarda il supporto nutrizionale che il monitoraggio clinico e immunologico necessario per iniziare correttamente la ART.

Objetivou-se com o presente trabalho investigar as relações existentes entre dois espaços de \"cura\": o serviço local de saúde e a instituição religiosa, representada pelas várias Igrejas Pentecostais. A investigação, de corte qualitativo, baseou-se em depoimentos colhidos de sujeitos que frequentavam simultaneamente estes dois espaços de \"cura\". Concluiu-se que os dois espaços são usados conjuntamente e percebidos como nítidamente distintos. Através da análise dos depoimentos foi possível estabelecer uma série de categorias distintivas que permitem especificar as particularidades e diferenças entre o espaço racionalcientífico e o espaço religioso, quando se trata de \"cura\". Concluiu-se também que os sistemas oficiais tem muito a aprender dos \"sistemas religiosos\", notadamente no que diz respeito ao caráter \"acolhedor\" destes últimos.
The objective of this work is to investigate the relationships between two \"cure\" spaces: the local health service and the religious institution represented here by several Pentecostal Churches. The qualitative section investigation was based on statements taken from people who attended the two \"cure\" spaces simultarieously. We concluded that the two spaces are used concurrently and understood as clearly distinct. Through the analysis of the statements it was possible to establish a series of different categories permitting to specifY peculiarities and dissimilarities between the -rational - scientific and the religious spaces when we refer to \"cure\". We have also concluded that the official systems have much to leam from \"religious systems\" especially when considering the \"welcoming\" character of the latter ones.

Objetivou-se com o presente trabalho investigar as relações existentes entre dois espaços de \"cura\": o serviço local de saúde e a instituição religiosa, representada pelas várias Igrejas Pentecostais. A investigação, de corte qualitativo, baseou-se em depoimentos colhidos de sujeitos que frequentavam simultaneamente estes dois espaços de \"cura\". Concluiu-se que os dois espaços são usados conjuntamente e percebidos como nitidamente distintos. Através da análise dos depoimentos foi possível estabelecer uma série de categorias distintivas que permitem especificar as particularidades e diferenças entre o espaço racional científico e o espaço religioso, quando se trata de \"cura\". Concluiu-se também que os sistemas oficiais tem muito a aprender dos \"sistemas religiosos\" notadamente no que diz respeito ao caráter \"acolhedor\" destes últimos.
The objective of this work is to investigate the relationships between two \"cure\" spaces: the local health service and the religious institution represented here by several Pentecostal Churches. The qualitative section investigation was bas.ed on statements taken from people who attended the two \"cure\" spaces simultarieously. We concluded that the two spaces are used concurrently and understood as clearly distinct. Through the analysis of the statements it was possible to establish a series of different categories permitting to specify peculiarities and dissimilarities bet\\veen the -rational - scientific and the religious spaces when we refer to cure\". We have also concluded that the official systems have much to leam from \"religious systems\" especially when considering the \"welcoming\" character o f the latter ones.

Research is needed that examines the effects of kiosk technology on restaurant operational performance measures, such as total sales. The study employs a 2X2 between-subjects field experimental design to empirically test the hypothesized relationships proposed in the research model. The data collection site was Burger King located in the student union of a large Tier 1 research university in southwest USA. The independent variables included ordering method (kiosk vs. cashier) and operational volume (peak vs. off-peak). The dependent variables were cognitive and affective attitudes, behavioral intention, satisfaction, sales per person, and order time. Consumers at Burger King were approached before they started ordering their meal to ask for voluntary participation. If they agreed to participate, they were randomly assigned into two test groups. Participants in one test group used kiosk technology to order their meals, while those in the other test groups spoke with a cashier to order their meals. The same number of participants were recruited from peak and non-peak volumes. The seconds used to order was observed and recorded after consumer engagement with the ordering method. After participants ordered, they completed a paper survey that measured their behaviors while ordering with each method and asked participants to indicate total purchase amount. Results of 192 surveys indicated to different extents that consumer behaviors were more positive with kiosk technology. Affective attitude results, however, were insignificant. On average, kiosk technology was found to be a faster method of ordering in quick-service restaurants, but it yielded less sales than when the consumer ordered from a cashier.

L’objectiu principal d’aquesta tesi és l’anàlisi dels treballs de cura remunerats a persones en situació de dependència a Catalunya. A partir d’una perspectiva qualitativa, s’analitzen les representacions socials i de gènere associades a aquests treballs, realitzats en els serveis d’atenció a la dependència (domiciliaris i institucionals), i s’aporten dades empíriques entorn aquest sector ocupacional, caracteritzat per la feminització i la precarietat laboral. També es formula una proposta d'aplicabilitat de la investigació a fi d’afavorir la igualtat de gènere i el reconeixement social de l’activitat. A nivell metodològic s’han seguit dues estratègies d’investigació: en primer lloc s’han escollit els Serveis d’Ajuda a Domicili com a casos etnogràfics per incidir en la observació i l’anàlisi de les relacions de gènere, les característiques del treball de cura remunerat en aquests serveis i la relació de les organitzacions prestadores del servei amb l'administració municipal; en segon lloc s’han escollit diversos serveis de cura per incidir en les barreres i oportunitats de la implicació de homes en aquest sector ocupacional. S’han realitzat entrevistes en profunditat a les persones que participen en la gestió del servei i en la prestació de cura directa; i observació participant en diversos serveis de cura. La metodologia qualitativa ha permès reconstruir les experiències i percepcions de les persones que es dediquen en aquest sector ocupacional, a fi de conèixer l'impacte de les condicions laborals i de les representacions socials i culturals entorn aquesta activitat. Les dades empíriques treballades s’han abordat principalment des de les aportacions teòriques de l’economia de la cura, del social care, de les aproximacions performatives del gènere i adoptant una perspectiva interseccional. Amb aquesta tesi es confirma que, tot i que la cura continua estant principalment abordada per la família, el creixement de les necessitats d’atenció a causa de l’envelliment de la població comporta que aquest sector ocupacional es trobi actualment en expansió. Es tracta d'un sector fortament feminitzat que s’ha configurat com un nínxol ocupacional tant per a dones autòctones amb poca formació, com per a persones immigrants procedents de l’estranger. Amb el procés d’externalització dels serveis públics, les organitzacions privades s’han convertit en les principals ocupadores del sector, fet que no ha favorit a la qualitat del servei i a les condicions laborals. S’ha pogut demostrar també la desigualtat d'oportunitats dels homes per accedir en aquests treballs, tot i que la seva implicació (minoritària) comporta models emergents d’homes dedicats a aquest tipus de treballs i per tant canvis en els sistemes i relacions de gènere. Aquesta tesi aporta un coneixement en profunditat d’aquest sector ocupacional necessari per orientar propostes de canvi que afavoreixin al reconeixement social d’aquest treball, la seva redistribució i la millora de l'atenció a les persones en situació de dependència. La tesi acaba amb una sèrie de recomanacions a partir de les quals es podria treballar per avançar cap a la dignificació del treball de cura remunerat i la seva professionalització, a fi de garantir un sistema de cura sustentable i de qualitat. D’aquesta forma, els resultats que es presenten tenen un alt grau d'aplicabilitat, especialment en la intervenció social i en el disseny de polítiques socials.
The main goal of this thesis is to analyse paid caregiving occupations providing care to individuals living in situations of dependency in Catalonia. The social and gender representations associated with these occupations, performed in the dependent care services (both at home and in institutions), will be analysed from a qualitative perspective, and empirical data will be provided about this occupational sector, characterised by feminisation and job instability. A proposal to apply the research will also be formulated with a view to fostering gender equality and the social recognition of the activity. The research methodology involved two research strategies: firstly, Home-Help Services were selected as ethnographic cases to highlight the observation and analysis of gender relations, the characteristics of the paid care work in these services and the relation between the service providers and the municipal administration. Secondly, various caregiving services were selected to highlight the barriers and opportunities of the involvement of men in this occupational sector. In-depth interviews were conducted with those individuals who participate in the management of the service and in directly providing the care; as well as the observation of different caregiving services. The qualitative methodology served to reconstruct the experiences and perceptions of people working in this occupational sector, with a view to determining the impact of the working conditions and the social and cultural representations related to this activity. The empirical data worked on were mainly examined from the theoretical contributions of the economy of care, social care, performative gender approaches and through the adoption of an intersectional perspective. This thesis confirms that, although care continues to be mainly provided by the family, the growth in the need for care as a result of the ageing of the population means that this occupational sector is currently expanding. It is a strongly feminised sector which has become established as an occupational niche both for native women with a low educational level and immigrants. With the externalisation process of public services, private organisations have become the main service providers of the sector, something which has not improved the quality of the service or the working conditions. The thesis has also demonstrated the unequal opportunities for men when accessing these jobs, although their (minor) involvement entails emerging models of men devoted to these types of jobs and therefore, changes in the gender systems and relations. This thesis provides in-depth knowledge of this occupational sector which is essential to guide proposals for change that promote the social recognition of this job, its redistribution and the improvement in the care of persons in situations of dependency. The thesis concludes with a series of recommendations which could be used to move towards conferring dignity and professionalization on paid caregiving work, in order to guarantee a sustainable and quality caregiving system. In this way, the results presented herein are highly applicable, especially in social intervention and in the design of social policies.

For hydrology, the watershed its the primary unit of study, which dynamics its influenced by various elements. The effort of science to place these elements in interaction originated hydrological models. These models aim to simulate parts of the hydrologic cycle, for, between other objectives, dimension drainage structures. This study highlights the model developed by the Soil Conservation Service, known as Curve Number, which considers the physical parameters of the watershed to estimate the maximum runoff for a given rainfall event. In this regard, GIS techniques were applied in obtaining these parameters in order to compare the final results with those obtained by hydrological studies conducted without the application of such techniques. The physical characteristics that compose the model were obtained from a digital elevation model hydrologically consistent generated from cartographic data available. Subsequently, by specific computational algorithms, was generated a map of the direction of water flow and, from this, the definition of the contributing area of watershed. The lenght of river was interpreted based on the topographical data at a 1:50,000 scale, and, thereafter, effectively slope calculations was performed. Remote sensing techniques were performed to obtain the classification of Landsat 7 satellite images, with reference to the soil uses predefined by SCSCN. This classification was crossed with the soil map of the region, obtaining the value of the parameter Curve Number. Precipitation was calculated according to the rainfall equation for the representative pluviometric post of the region. Thereafter, the modeling was performed to compare the use of GIS techniques with conventional methods applied. The results showed that the techniques applied returned values closer to the true about the parameters, area and length of river. The effective slope calculated in a distributed manner showed a lower value than that used in the conventional method, which greatly influenced in the calculation of time of concentration and peak. The parameter CN has been shown numerically close, however, this parameter is very sensitive to the model, contributing to the discrepancy in the comparison of the final results. Finally, it is concluded that the increase in accuracy of the parameters did not result in increased accuracy of the model, however, in front of the adjustments aplied to the conventional method, it does not represent the inapplicability of these techniques. Was diagnosed that the model needs to be adapted.
A hidrologia tem a bacia hidrográfica como sua principal unidade de estudo, que por sua vez tem a dinâmica influenciada por diversos elementos. O esforço da ciência em colocar estes elementos em interação originou os modelos hidrológicos. Estes modelos visam simular partes do ciclo hidrológico, para, dentre outros objetivos, dimensionar estruturas de drenagem. O presente estudo destaca o modelo desenvolvido pelo Soil Conservation Service, conhecido como Curve Number, que considera parâmetros físicos da bacia hidrográfica para estimar a vazão máxima durante determinado evento pluviométrico. Neste sentido, foram aplicadas técnicas de geoprocessamento na obtenção destes parâmetros, visando comparar os resultados finais com os obtidos por meio de estudo hidrológico realizado sem a aplicação de tais técnicas. As características físicas que alimentaram o modelo foram obtidas através de modelo digital de elevação hidrologicamente consistente gerado a partir dos dados cartográficos disponíveis. Posteriormente, por meio de algoritmos computacionais específicos, foi gerado o mapa de direção do fluxo d´água no relevo e, a partir deste, a definição da área contribuinte da bacia hidrográfica. A extensão do talvegue foi interpretada com base nos dados das cartas topográficas na escala de 1:50.000 da região, sendo, a partir daí, realizados os cálculos de declividade efetiva. Técnicas de sensoriamento remoto foram realizadas para obter a classificação de imagens do satélite Landsat 7, tendo como referência as tipologias pré-definidas pelo SCS-CN. Esta classificação foi cruzada com o mapa de solos da região, obtendo o valor do parâmetro Curve Number. A precipitação foi calculada de acordo com a equação de chuvas intensas para o posto pluviográfico representativo da região. A partir daí, a modelagem foi realizada, visando comparar a utilização das técnicas de geoprocessamento com os métodos convencionais aplicados. Os resultados demonstraram que as técnicas aplicadas retornaram valores mais próximos da realidade no que diz respeito aos parâmetros, área da bacia e comprimento do talvegue. A declividade efetiva calculada de forma distribuída demonstrou um valor menor do que o utilizado no método convencional, o que influenciou bastante no cálculo dos tempos de concentração e pico. O valor do parâmetro CN demonstrou-se numericamente próximo, porém, este parâmetro é muito sensível no modelo, contribuindo para a discrepância na comparação dos resultados finais. Por fim, conclui-se que o aumento na precisão dos parâmetros não ocasionou aumento de precisão do modelo, porém, diante dos ajustes realizados na aplicação do método convencional, isto não representou a inaplicabilidade destas técnicas, sendo diagnosticado que o modelo necessita de adaptações.

For many years trans people have been treated as suffering from some pathology, proposing various curative treatments as a solution to their alleged health problem. However, recent studies show that gender identity of people is a very personal and diverse characteristic so must be protected. In this article, the author explains how an understanding of gender identity that is respectful of human rights involves rethinking the State’s view of transgender people. This change of perspective requires discarding the pathological vision and opting for a system that will equip them with the necessary tools to develop their identity and avoid discrimination.
Durante muchos años se ha tratado a las personas trans como si sufriesen de alguna patología, proponiéndose diversos tratamientos curativos como solución a su supuesto problema de salud. Sin embargo, recientes estudios muestran que la identidad de género de las personas es una característica personalísima y diversa por lo cual debe ser protegida.En el presente artículo, el autor explica como una compresión de la identidad de género que sea respetuosa de los derechos humanos implica replantear la visión del Estado sobre las personas trans. Dicho cambio de perspectiva requiere descartar la visión patológica y optar por un sistema que otorgue las herramientas necesarias para expresar su identidad y evitar situaciones de discriminación.

Dans la tendance d'Internet, nous commençons à compter nos activités quotidiennes sur les systèmes de base en nuage pour stocker nos données et pour suivre tout notre état et comportement lors de l'utilisation de services Web. Par conséquent, nos données ne sont plus sécurisées comme auparavant, car nous avons délégué la responsabilité de les protéger, de les sécuriser et de les stocker à des tiers. Ces dernières années, de grandes entreprises telles que Yahoo, Facebook ou LinkedIn ont été victimes de plusieurs fuites, ce qui montre à quel point nous sommes vulnérables. Nous disposons aujourd'hui d'appareils mobiles plus puissants que jamais. Cependant, nous n'explorons pas leurs capacités en matière de traitement, de stockage et de mesures de sécurité pour utiliser les services Web localement. De plus, nos appareils sont fondamentalement divisés en deux mondes différents, ceux avec Android et ceux avec un système d'exploitation iOS. Néanmoins, avec la popularité de la technologie mobile, notre comportement a changé. Aujourd'hui, il est courant de trouver un utilisateur utilisant deux ou trois appareils mobiles en même temps, souvent avec un système d'exploitation différent. Par conséquent, nous sommes simultanément confrontés à un environnement à plusieurs périphériques avec le même système d'exploitation ou des systèmes d'exploitation différents, dans lequel la plupart des technologies et des services Web nécessitent le recours à un fournisseur tiers pour la synchronisation et le maintien de l'état de nos tâches quotidiennes. Bien que ce scénario chaotique concerne plusieurs appareils et systèmes d'exploitation, il existe une technologie mentionnée précédemment à la fin des années 90, appelée Liquid Software, qui pourrait être une solution pour harmoniser ce scénario. Le Liquid Software vise à permettre une migration fluide vers différents appareils avec ou sans le même système d'exploitation, tout en préservant l'expérience utilisateur d'une application ou d'un service donné. Dans cette thèse, basée sur les principes de Liquid Software, nous nous concentrons sur un environnement multi-périphériques capable de synchroniser le service Web côté client sans dépendre d'un système de base Cloud. Nous avons proposé une architecture basée sur des modèles, appelée Le CUBE, qui utilise des principes centrés sur l'utilisateur combinés à différentes technologies, telles que les principes REST et RESTful. Le CUBE propose également un modèle à quatre couches dans lequel REST et RESTful fonctionnent indépendamment l'un de l'autre mais en coopération. Un autre élément critique du CUBE est la couche de conversation (CC), modélisée dans le but de permettre la modification des données / états à partir des services Web. La CC utilise des techniques de traitement du langage naturel pour trouver et définir des services Web adaptés à l'utilisateur. Une autre contribution du CUBE est la création d'une sorte de réseau d'utilisateurs appelé INNER CUBE, avec tous les appareils mobiles appartenant à un seul utilisateur. Le but de la combinaison de ces éléments au sein d'une seule unité, le CUBE, est de permettre le transfert fluide de services/données et de sessions d'appareils (ordinateurs de bureau, ordinateurs portables et téléphones mobiles) vers d'autres appareils, quel que soit leur système d'exploitation, et au même temps, entièrement transparent pour l'utilisateur final, tout en réduisant la dépendance du fournisseur tiers. Nous avons également proposé deux tests pour valider le modèle CUBE
Within the trend of the Internet, we start to rely our daily activities on Cloud Base Systems to store our data and keep tracking all our state and behavior while using Web Services. Therefore, our data are no longer safe as before since we have delegated the responsibility to keep them safe, secure, and stored by third-party providers. In the last few years, big companies such as Yahoo, Facebook, or LinkedIn were victims of several leaks, which demonstrates how vulnerable we are. We have nowadays more powerful mobile devices than ever before. However, we do not explore their capacities regarding processing, storage, and security measures to using Web Services locally. Moreover, our devices are basically divided into two different worlds, those with Android, and those with an iOS operating system. Nevertheless, with the popularity of mobile technology, our behavior has changed. Today it is common to find a user using two or three mobile devices at the same time, and often they have a different operating system. Therefore, we are facing simultaneously a multiple-device environment with the same or different operating systems, where most of the technology and Web Services requiring a third-party provider to synchronizing and keep the state of our daily tasks. Although of this chaotic scenario regarding multiples devices and operating systems, there is a technology earlier mentioned at the end of 90's called Liquid Software that may be a solution to bring harmony to this scenario. The Liquid Software aims to allow for fluently migrate towards different devices with or without the same operating system, and at the same time keep the user-experience of a given application or service. In this thesis, based on Liquid Software principles, we focus on multiple devices environment able to synchronize Web Service at the client-side without depending on a Cloud Base System. We proposed the model-based architecture, called the CUBE, that makes use of User-Centric principles combined with different technologies, such as REST and RESTful principles. The CUBE also proposes a four layers model where REST and RESTful work independently from each other but in cooperation. Another critical element of the CUBE is the Conversation Layer (CL), modeled with the purpose to allow change data/state from Web Services. The CL makes use of techniques of Natural Language Processing to find and defining suitable Web Services to the user. Another contribution of the CUBE is creating a kind of user-network called INNER CUBE with all mobile devices that belong to a single user. The aim of combining these elements inside a single unit, the CUBE, is to allow for fluently move services/data and sessions from devices (desktops, laptops, and mobiles phones) to other ones regardless of their operating system, and at the same time, entirely transparent for the final user, and also reducing the dependency of the third-party provider. We have also proposed two tests to validate the CUBE model

In molti paesi come la Colombia, l’inserimento delle donne nel mercato del lavoro ha avuto progressi importanti, tuttavia questo inserimento accade in condizioni di svantaggio. Svantaggi che si esprimono in una maggiore disoccupazione, informalità e segregazione delle donne in determinate tipologie di occupazioni nonché nei rami più bassi delle strutture gerarchiche. Questa ricerca vuole individuare e analizzare le dinamiche che inducono le donne in Colombia e in particolar modo a Bogotà, a rimanere segregate nel mercato del lavoro e in molti casi addirittura fuori dalla formalità. Inoltre si vuole indagare il valore che l’intraprendenza e l’imprenditoria formale possono avere nella ricerca dell’indipendenza economica delle donne che si ritrovano in situazioni di svantaggio. Il tema centrale dunque è quello dell’empowerment femminile e la gender equality analizzati e rielaborati in un’ottica sistemica, ovvero cercando di coinvolgere diversi attori nella ricerca e valutando l’importanza che possono avere le comunità locali in questi processi. Sotto questo punto di vista diventano ancora più rilevanti le opportunità di ascolto e dialogo tra i diversi attori locali (singoli, pubblici, privati, ecc) e la promozione di strategie collaborative e di corresponsabilità cittadina. Infine, questa tesi ha come obiettivo il proporre processi che portino alla progettazione di servizi attraverso i quali le donne di Bogotá possano avere l’opportunità di sviluppare la propria intraprendenza e agentività nella ricerca della propria indipendenza economica.

Dissertation (Ph.D.)--University of Toledo, 2005.
Typescript. "A dissertation [submitted] as partial fulfillment of the requirements of the Doctor of Philosophy degree in Engineering." Bibliography: leaves 69-74.

The International Space Station provides a high-quality of microgravity and extended exposure time which makes it a platform of choice for microgravity research. In order to increase accessibility of onboard experimentation, Space Applications Services will soon launch the ICE Cubes facility as part of its ICE Cubes Service. The facility is foreseen to host standardized plug-and-play payload cubes to reduce overall cost and procedure time required to install payloads on the station. To remotely support the facility it is decided to develop a utility cube named Cube-Zero that will be launched and installed with the facility on the station. This thesis work included the complete design, development and documentation of the cube. The thesis started by conducting a preliminary needs and market study from which two specific purposes were defined for the cube. In addition to its original function of support-utility, the cube is tasked to be a technical commercial demonstrator for the service. This led to the conceptual design of the cube as a multidisciplinary framework able to host two user-defined experiment modules. The preliminary concept was further refined in this paper and with support of prototypes, simulations and analyses led to a final functional design for the Cube-Zero. The work is concluded with the manufacturing of an engineering model of the cube. The model is fully operational, can support the test of the facility before launch and can demonstrate to users its versatility and ease of use in operating any kind of experiment module. Eventually, the information gathered in this thesis report will support future users into developing their own Cube-Zero payload module and guide Space Applications Services into manufacturing, testing and operating the Cube-Zero protoflight model.
ICE Cubes

We are at the dawn of the next chapter of manned space flight, and space travel will soon be within reach for the majority of the humanity, not just the elite. The imminent launch of Virgin Galactic's first commercial service this year, soon to be followed by companies such as SpaceX and Blue Origin, means that space tourism will quickly go from one individual every few years to dozens, perhaps hundreds of new space tourists annually. Everyday civilians going to space for the purpose of tourism will have fundamentally different needs than professional astronauts going up to space for days or month at a times for work and research. To make space travel within reach of the masses, space tourist will need a different and simplified process compared to traditional astronauts. This thesis created a user-centered service that allows companies to handle the increasing number of private individuals going to space. The service not only prepares the customer for the space flight, but also provides an experience that will last a lifetime, that will be shared with others, and in the process perhaps inspire a new generation of human progress and collaboration. The result is a snapshot of the overall service, illustrate the user experience in an immersive, virtual environment. As part of the exploration, an immersive and very effective new method of user experience testing is developed as contribution to the field of Interaction Design.

Cette thèse étudie comment des infirmier.es de nuit prennent la décision de recourir ou non à l'hôpital en cas d'urgence gériatrique en EHPAD. Le raisonnement clinique et la prise de décision chez des infirmiers sont rarement documentés. L'expérimentation « IDE de nuit » des projets paerpa offrait l'occasion de les étudier au prisme de l'âge et de l'incertitude dans un contexte d'urgence. Elle a aussi permis d'étudier l'épreuve organisationnelle que constitue une telle innovation. En mobilisant une approche interactionniste et sociocognitive et en nous fondant sur une enquête ethnographique trois années durant, nous avons saisi in situ le raisonnement et le jugement infirmiers à l'épreuve de l'urgence et du contexte expérimental. Cette recherche éclaire plusieurs aspects : comment le care est mobilisé au service du cure ; comment l'urgence constitue une construction, qui est influencée par le rôle joué par le patient âgé et ses aides-soignantes ; comment les compétences qui font l'innovation s'élaborent à l'épreuve de l'irréversibilité des actions et des résultats ; comment et quand commence et se termine une innovation organisationnelle dans un contexte expérimental ; enfin, comment tous ces éléments participent à définir l'économie morale qui s'est mise en place autour des personnes âgées vivant en EHPAD, cibles de cette innovation.Mot clés : urgence gériatrique, prise de décision, innovation organisationnelle, IDE de nuit, expérimentation, paerpa, le 15, recours à l'hôpital, aides-soignantes, EHPAD
This thesis studies how night-shift nurses decide whether or not to resort to the hospital to deal with geriatric emergency cases in a nursing home. Clinical reasoning and decision-making among nurses are rarely documented. The “IDE de nuit” experimentation of Paerpa's projects offered the opportunity to study them through the prism of age and uncertainty in the context of an emergency. It also made it possible to study the organizational test that such an innovation constitutes. Through an interactionist and socio-cognitive approach and based on an ethnographic investigation lasting three years, we captured in situ nurses' reasoning and judgment while dealing with emergency cases in an experimental context. This research sheds light on several aspects: how care is mobilized in the service of the cure; how the emergency constitutes a social construction, which is influenced by the role played by the elderly patient and his caregivers; how the skills that drive innovation are developed and conditioned by the irreversibility of the actions and their results; how and when an organizational innovation begins and ends in an experimental context; finally, how all these elements contribute to defining the moral economy that has been made up and created around elderly people living in EHPADs, targets of this innovation.Keywords: geriatric emergency, decision-making, organizational innovation, IDE de nuit, experimentation, paerpa, le 15, SAMU, hospital, nursing assistants, EHPAD

Managed care became the dominant model for moderating healthcare costs in the 1990's. The later half of this past decade witnessed early signs of a return to escalating premiums. Providers and consumers have reacted negatively to perceptions of health plan micro-management and restriction of choice.

Durante il periodo di tirocinio svolto presso la Fondazione Piemontese per la Ricerca sul Cancro, una delle ONLUS di Torino che opera in ambito oncologico con sede presso l’Istituto Candiolo, sono emerse una serie di necessità e di temi che la Fondazione avrebbe voluto approfondire. Tra i vari progetti per il futuro è emersa la volontà di attivare un punto fisico nel cuore della città di Torino, un “recreational hub”, che potesse offrire servizi legati all’accoglienza e all’accompagnamento di pazienti e familiari fornendo loro informazioni, distribuendo materiali, mostrando filmati e ospitando, ad esempio, corsi e attività formative rivolte ai pazienti (ad es. sull’estetica in campo oncologico o l’alimentazione per la prevenzione). Inoltre l’hub avrebbe consentito di offrire servizi dedicati alla promozione della prevenzione, con una sezione dedicata anche alla raccolta fondi e il merchandising. Il progetto di tesi intende approfondire queste tematiche soprattutto legate al supporto della persona durante il percorso di cura e alla sensibilizzazione come strumento di prevenzione della malattia. Da qui è nato "Get Well", un servizio di supporto itinerante, aperto alla cittadinanza, per i malati di Cancro non ospedalizzati e i loro familiari, per divulgare uno stile di vita sano, prevenire la malattia e supportare nel percorso di cura.

Driving under distraction may lead drivers to wrong actions that can result in serious accidents. The objective of this thesis was to apply a driving simulator to verify variations in drivers\' behavior while driving. Behavior to drive on a curve was measured by variation in drivers\' speed profile in a virtualized highway. The comparison was performed between two identical simulations, one involving drivers distracted with a mental workload, and other in which they were full aware of driving task. 54 volunteer drivers took part in this study, which was divided into 4 stages. 17 drivers performed the distraction test known as PASAT, and results showed that distracted drivers did not recognize the beginning of the curve and drove through it at speeds higher than those when they were fully aware. Moreover, driving performance was increased when drivers were aware of driving, thereby hitting high speeds in tangents, but perceiving curves in advance to reduce acceleration. This study confirms that driving simulators are beneficial in discovering drivers\' behavior exposed to activities that could be highly risky if driving in real situations.
A distração durante a atividade de direção pode levar o condutor de veículos automotores a cometer falhas, que podem ocasionar até mesmo acidentes graves. Este estudo aborda a utilização de simuladores de direção para verificar variações no comportamento de motoristas ao realizar a atividade de direção, distraídos ou com plena atenção na condução do veículo. O comportamento é medido pela variação no perfil de velocidade dos condutores para desenvolver uma curva considerada perigosa em uma rodovia simulada em ambiente virtual. A variação de velocidade deste perfil é comparada entre duas simulações idênticas, onde em uma delas os condutores estão distraídos com um teste que proporciona estresse mental e, na outra, estão com plena atenção à direção. 54 condutores fizeram parte deste estudo dividido em 3 etapas. 17 participantes realizaram o teste de distração conhecido como PASAT, e a análise dos resultados mostram que, distraídos, os condutores não perceberam o início da curva e desenvolveram velocidades maiores durante seu trajeto. Além disso, quando estavam com plena atenção à atividade de direção, o desempenho dos condutores foi melhor, atingindo velocidades maiores nas tangentes, mas percebendo as curvas antecipadamente e reduzindo suas velocidades antes de iniciar esses trechos.

Datum: 2010-03-22

Nivå: Kandidatuppsats i företagsekonomi, 15 hp

Författare: Kristina Flintull, Malin Severin

Handledare: Nazeem Seyed-Mohamed

Titel: Katt och hund ska bli vår kund! En studie om Cura apotekets ambition att bli husdjursägarnas favoritapotek.

Syfte: Med Cura apoteket som uppdragsgivare syftar studien till att undersöka vilka kvaliteter företaget bör framhäva i sin marknadsföring för att bearbeta och bli ICA Maxi:s kundsegment husdjursägares favoritapotek. Studien utreder även huruvida åsikterna om kvaliteter skiljer sig inom segmentet; mellan katt- och hundägare samt mellan män och kvinnor.

Metod: Utifrån en kvalitativ intervju med Cura apotekets chef för inköp och sortiment presenteras teorier kring The Services Marketing Mix samt kundlojalitet. Med denna bakgrund genomfördes en kvantitativ enkätundersökning med 208 ICA Maxikunder med hund- eller katt. Telefonintervjuer med åtta deltagare från enkätundersökningen utfördes för att erhålla ett ytterligare kvalitativt perspektiv.

Slutsats: Inga betydande skillnader mellan män och kvinnors åsikter inom segmentet husdjursägare kan utläsas. Olika åsikter förekommer däremot mellan hund- och kattägare inom kundsegmentet, där hundägare är mest positiva till de kvaliteter Cura apoteket kommer att kunna erbjuda. Cura apoteket bör därför rikta sin marknadsföring främst mot ICA Maxi:s hundägare och framhäva personalens kunskap, ett brett produktsortiment, lönsamma kunderbjudanden samt utökad tillgänglighet genom lojalitetsskapande aktiviteter.

Date: 2010-03-22

Level: Bachelor Thesis in Business Administration, 15 credits

Authors: Kristina Flintull, Malin Severin

Advisor: Nazeem Seyed-Mohamed

Title: We aim higher with your pet as our buyer! A study about the Cura pharmacy’s ambition to be pet owners’ favourite pharmacy.

Purpose: The aim of this thesis is to study what qualities the Cura pharmacy should focus on in its marketing to become ICA Maxi’s segment pet owners’ favourite pharmacy. The study analyses differences in opinions about qualities within the segment; between cat- and dog owners as well as men and women.

Methodology: Based on a qualitative interview with the Cura pharmacy’s head of purchase and assortment, the theories of The Services Marketing Mix and Customer Loyalty are presented. A quantitative survey was conducted with 208 cat or dog owners who do their shopping at ICA Maxi. Phone interviews were then made with eight participants from the survey to obtain further qualitative perspectives.

Conclusion: No differences regarding opinions between men and women can be observed. Cat and dog owners have different views though, where dog owners are more positive to the qualities the Cura pharmacy will be able to offer. Therefore, the Cura pharmacy should focus their marketing mostly on ICA Maxi’s dog owners. The company should bring forward the knowledge of their pharmacists, their wide range of products, beneficial customer offers and extended availability, all through loyalty creating activities.

The diploma thesis focuses on the analysis of the current state of reporting and data analysis of the ALVAO Service Desk system in the company's internal operation. Based on the findings of deficiencies, a new method of reporting and data analysis on the Microsoft Power BI platform is proposed. The proposal includes the entire Power BI feature cycle from data accessing to sharing.

The computer and microelectronics technologies are developing very quickly nowadays. In the mean time, the modern integrated avionics systems are burgeoning unceasingly. The modern integrated modular architecture more and more requires the low-latency and reliable communication databus with the high bandwidth. The traditional avionics databus technology, such as ARINC429, can not provide enough high speed and size for data communication, and it is a problem to achieve transmission mission successfully between the advanced avionic devices with the sufficient bandwidth. AFDX(Avionics Full Duplex Switched Ethernet) is a good solution for this problem, which is the high-speed full duplex switched avionic databus, on the basis of the Ethernet technology. AFDX can not only avoid Ethernet conflicts and collisions, but also increase transmission rate with a lower weigh of the databus. AFDX is now adopted by A380,B787 aircraft successfully. The avionics data must be delivered punctualy and reliablely, so it is very essential to validate the real-time performance of AFDX during the design process. The simulation is a good method to acquire the network performance, but it only happends in some given set of scenarios, and it is impossible to consider every case. So a sophisticatd network performance method for the worst-case scenario with the pessimistic upper bound requires to be deduced. The avionic design engineers have launched many researches in the AFDX simulation and methods study. That is the goal that this thesis is aimming for. The development of this project can been planned in the following two steps. In the first step, a communication platform plans to be implemented to simulate the AFDX network in two versions – the RTAI realtime framework and Linux user space framework. Ultimately, these frameworks need to be integrated into net-ASS, which is an integrated simulation and assessment platform in the cranfield’s lab.The second step deduces an effective method to evaluate network performance, including three bounds(delay,backlog and output flow), based on the NC. It is called Network Calculus. It is an internet theory keeping the network system in determistic way. It is also used in communication queue management. This mathematics method is planed to be verified with simulation results from the AFDX simuation communication platform, in order to assure its validity and applicability. All in all, the project aims to assess the performance of different network topologies in different avionic architectures, through the simulation and the mathematical assessment. The technologies used in this thesis benefit to find problems and faults in the beginning stage of the avionics architecture design in the industrial project, especially, in terms of guarantee the lossless service in avionics databus.

The Patient Protection and Affordable Care Act of 2010 expanded rural Medicaid and Medicare coverage. However, different vehicles of delivering care (e.g., hospitals, health clinics, etc.) have differing organizational capacity that may or may not enable them to overcome the challenges of expanded provision. Consequently, this research employed structural contingency and organizational performance models to investigate the impact of organizational factors on productivity growth, while recognizing that contextual factors also affect the delivery of care. Latent growth curve modeling was used to study a national panel of 708 U.S. hospital-based Rural Health Clinics for the years 2005 to 2008. Productivity was measured through dynamic slacks-based data envelopment analyses. Unconditional and conditional linear growth curve models were fitted to data. Findings revealed that 1) hospital-based clinics with higher baseline levels of productivity in 2005 had a slower rate of growth in productivity for the years 2006 to 2008, 2) hospital-based clinics with physicians had significantly higher productivity, 3) hospital-based clinics in urban focused areas had significantly higher productivity, 4) newer hospital-based clinics had significantly higher productivity, and 5) prospective payment system was negatively related to the rate of change in productivity growth. Organizational and contextual factors included in this study significantly explained initial differences in productivity but were unable to explain productivity growth. Future research could improve the study by 1) including additional explanatory variables, such as the use of technology and disease management programs, 2) adjusting productivity measures by case mix measures, and 3) conducting truncated panel data regression with Monte Carlo simulation.
ID: 030422818; System requirements: World Wide Web browser and PDF reader.; Mode of access: World Wide Web.; Thesis (Ph.D.)--University of Central Florida, 2011.; Includes bibliographical references (p. 154-165).
Ph.D.
Doctorate
Public Affairs
Health and Public Affairs

With recognition of turnover as a financial issue increasing, companies are searching for strategies to confront the problem in ways that generate a good return on investment. Successfully managing turnover is a matter of understanding its costs, causes and cures. In service–oriented industries such as banking, people are considered among the most important assets of a firm. Forward–thinking banks are looking for ways to leverage people, along with processes and technology, to achieve their objectives. Employee expectations are changing, too, forcing organisations to place a greater emphasis on talent management strategies and practices. Employees rarely quit on the spot. Generally, an employee becomes dissatisfied and stays disengaged for quite a while before leaving. However, from the moment of disengagement, most employees are no longer as dedicated or productive as they once were. Nearly all the real reasons why employees quit, fall into four basic categories of human needs: the need for trust, the need for hope, the need to feel competent, and the need to feel valued and trustworthy (Branham, 2005). Thirteen possible reasons for resignations were identified within the banking sector, namely: desire to take on a new challenge, bad relationship with management, bad relationship with colleagues, lack of opportunity for advancement, lack of appreciation (perception of recognition), better compensation and benefits elsewhere, long working hours, lack of control over work or working environment, travelling distance to work, personal satiation at home, lack of training and support to reach potential, the department is conducive to black advancement, the bank embraces diversity for all. Most of the employees that resigned voluntary did so because of lack of opportunity for advancement, a desire to take on a new challenge and a lack of appreciation. The statistical analysis revealed that amongst position title, there is a statistical significance for the bank embraces diversity for all as a reason for resignation and that the effect between junior managers and team leaders has a large effect. Analysis by gender differences shows that there is a statistical significance for personal situation at home as a reason for resignation and that females feels stronger about this than males. When looked at the difference between ethnic group, there are two reasons that are statistical significant namely, better compensation elsewhere and long working hours. Africans, coloureds and white‘s size effect is large, meaning that Africans and coloureds feel stronger about leaving for better compensation elseware than whites.
Thesis (M.B.A.)--North-West University, Potchefstroom Campus, 2012.

Hardmetal industry is continuously seeking for high-performance products at reduced costs. In addition, it is strongly struggled by the high and volatile prices of raw materials. At this juncture, producers and end-users are deeply concerned in increasing the performance and enhancing service-life and reliability of engineering products, and replacing current constituents by alternative and less critical materials. Premature and unexpected fracture, together with wear, is the main damage phenomenon limiting the life in most cemented carbide applications. In the vast majority of cases such ruptures stem from the combination of high monotonic and cyclic stresses, together with different damage-related features associated with harsh service conditions, such as corrosion, and thermal shock. Therefore, relevant consideration of fracture toughness and fatigue resistance is required if reliability and lifetime of hardmetals applications is to be increased. Following the above ideas, the purpose of this thesis is to improve the performance and increase the reliability of cemented carbides in rupture-limited applications on the basis of enhanced damage tolerance and reduced fatigue sensitivity through an optimal microstructural design. Within this framework, this investigation is composed of three main subjects covering different aspects related to the performance of hardmetals under service-like conditions. The first two sections are devoted to conduct a comprehensive study on the influence of the microstructure on fracture and fatigue behaviour of hardmetals. The aim of the third section is to evaluate microstructural effects on the tolerance of cemented carbides to service-like damage, induced either by localised corrosion or thermal shock. Main contribution to toughness in cemented carbides derives from plastic stretching of crack-bridging ductile enclaves at the crack wake, referred to as the multiligament zone. Hence, the development of a multiligament zone implies the existence of a rising crack growth resistance (R-curve) behaviour in cemented carbides. This effectiveness of this toughening mechanism is intimately related to the microstructural characteristics. Within this context, the first section of this thesis is dedicated to carry out a detailed investigation of fracture mechanics and mechanisms in cemented carbides, and to propose a relation to capture microstructural effects on the R-curve characteristics of these materials. Strength reduction of hardmetals under the application of cyclic stresses is related to the inhibition of the crack-tip bridging mechanism. For WC¿Co cemented carbides, the degradation of bridging ligaments is mainly associated with an accumulation of the fcc to hcp phase transformation. However, this mechanism does not apply for Ni binders; therefore, it remains unclear if effective fatigue susceptibility of Co-base hardmetals is comparable to that of cemented carbides consisting of alternative binders. Moreover, hardmetals exhibit crack-deflection as an additional toughening mechanism, but contrary to the case of crack-bridging, it is immune to fatigue loads. The effective action of this toughening mechanism is speculated to increase with rising carbide mean grain size. Hence, the second part of this thesis is devoted to study and understand the fatigue sensitivity of cemented carbides consisting of binders with deformation mechanisms beyond phase transformation as well as medium/coarse microstructures. Finally, the third section of this thesis consists of a systematic study on the influence of the microstructure on damage-related features induced by either thermal shock or corrosion, in order to set out guidelines for optimal microstructural design. In doing so, the structural integrity of damaged cemented carbides is assessed on the basis of residual strength, and microstructural effects on damage tolerance are captured by means of considering induced damage level as a critical parameter.
Por un lado, la industria del metal duro está sumergida en una búsqueda constante de materiales de altas prestaciones a un coste reducido. Por el otro lado, las materias primas tienen precios altos y volátiles, que comprometen la estabilidad del mercado. En esta coyuntura, los productores y los usuarios finales están muy interesados, tanto en aumentar el rendimiento, incrementar la vida útil y mejorar la fiabilidad de estos productos, como en su sustitución por materiales alternativos y considerados menos críticos. En este contexto, el desgaste y la ruptura prematura son los dos principales mecanismos que limitan la vida útil de las aplicaciones de metal duro. En la gran mayoría de los casos las rupturas prematuras derivan de la combinación de altas tensiones, tanto monótonas como cíclicas, con el daño inducido durante la vida en servicio, como la corrosión, y el choque térmico. Por lo tanto, con el fin de aumentar fiabilidad en estas aplicaciones, es necesario entender los mecanismos de daño y fallo en estos materiales. Así, el propósito de esta tesis es mejorar el rendimiento y aumentar la fiabilidad de los carburos cementados a partir del desarrollo de materiales con una mayor tolerancia al daño y una menor sensibilidad a fatiga, a través de un óptimo diseño microestructural. La presente investigación se compone de tres partes que abarcan diferentes aspectos relacionados con el desempeño de los metales duros en condiciones de servicio. Las dos primeras secciones están dedicadas a realizar un estudio general sobre la influencia de la microestructura en el comportamiento a fractura y fatiga del metal duro. El objetivo de la tercera sección es evaluar los efectos microestructurales en la tolerancia al daño de los carburos cementados, ya sea inducido por corrosión o por choque térmico. El principal mecanismo de tenacidad en los carburos cementados reside en el estiramiento plástico de ligamentos metálicos de puenteo que se forman detrás de la punta de la grieta, llamada la zona de multiligamentos. El desarrollo del mecanismo de puenteo implica un incremento de la resistencia a fractura a medida que aumenta la longitud de la grieta. Este mecanismo es conocido como curva-R y su eficacia está íntimamente relacionada con las características microestructurales del material. Así, la primera parte de esta tesis doctoral está dedicada a llevar a cabo una investigación detallada de los mecanismos de fractura en los carburos cementados, y a proponer una relación que permita captar los efectos microestructurales en las características de curva-R de estos materiales. Por otro lado, la segunda parte de la tesis está dedicada a estudiar la influencia de la microestructura, incluyendo tanto el tamaño de grano de la fase carburo como el contenido de la fase ligante y su naturaleza química, en la sensibilidad a fatiga de los carburos cementados. Así, se ha prestado una atención particular en estudiar el comportamiento a fatiga de los carburos cementados con base níquel y en su comparación con los de base cobalto. Por otro lado, también se ha estudiado la influencia del tamaño de grano en la deflexión de grieta como un mecanismo adicional de aumento de tenacidad, inmune a las solicitaciones cíclicas. Por último, la tercera sección de esta tesis consiste en un estudio sistemático de la influencia de la microestructura de los carburos cementados en su tolerancia al daño, inducido tanto por corrosión como por choque térmico, con el fin de establecer las directrices para un diseño microestructural óptimo. De este modo, la integridad estructural de carburos cementados se evalúa sobre la base de su resistencia residual a flexión después de la inducción de daño

W rozprawie zostały rozpatrzone możliwości wykorzystania stochastycznej krzywej, opartej na pomiarach, do oszacowania niezajętego pasma w sieci telekomunikacyjnej. W badaniach wykorzystano realny ruch internetowy, pochodzący z sieci operatora telekomunikacyjnego

Le système de santé béninois est composé du secteur public et du secteur privé. Le rôle principal dans l'administration du système de santé revient en effet à l'Etat, garant de l'intérêt public et de l'amélioration de l'état sanitaire de la population. L'Etat intervient parfois directement dans la production ou le financement des soins. Il exerce un contrôle sur les relations entre institutions de financement, professionnels et malades au nom des impératifs sanitaires et économiques généraux. Nos recherches portent sur l’hospitalisation privée au Bénin. Nous avons essayé de montrer en quoi le droit de la santé pouvait contribuer à améliorer l’accès aux soins des populations béninoises. Dans une première partie, nous avons essayé de mettre en relief les éléments qui ont conduit à la déliquescence du secteur privé de la santé au Bénin et en faisant un état des lieux du secteur privé de santé béninois suite à la crise qu’à traversé le Bénin dans les années 80. Le mimétisme institutionnel y a joué un rôle important dans la déliquescence du système de santé béninois. Dans une seconde partie, il s’est agit de montrer la place qu’occupe l’usager, le patient et le malade dans le système de santé en général et dans le secteur privé en particulier. Nous avons pu montrer que le droit de la santé au Bénin est à un statut embryonnaire et il devenait nécessaire de mettre en route un processus qui favorisera la prise en compte du droit des usagers du système de santé béninois en général et du secteur privé en particulier. La bonne qualité des soins dans un pays comme le Bénin dépendant en grande partie des différentes composantes du système et des personnes qui font ce système, il importe aujourd’hui de repenser le système de santé béninois en général en prenant en compte la notion de droit de la santé, sans négliger les ressources dont dispose le pays en matière sanitaire, notons ici que nous évoquons la médecine traditionnelle. Le droit de la santé pourra être perçu ici comme un élément d’équilibre et de justice dans l’accès aux soins. Pour une médecine équitable et de qualité, il devient primordial que l’Afrique en général et le Bénin en particulier prennent en compte la notion de droit de la santé afin de garantir aux usagers un accès sécurisé aux structures de soins
The Benin health system is composed of public sector and private sector. The primary role in administering the health system goes to the government as guarantor of public interest and improving the health of the population. The state sometimes intervenes directly in the production or financing of care. It exercises control over the relationship between financial institutions, professionals and patients on behalf of the general health and economic imperatives. Our research focuses on the private hospital in Benin. We have tried to show how law could help improve health care access for people of Benin. In the first part, we tried to highlight the elements that led to the failed private sector health care in Benin and to make an inventory of private health sector in Benin following the crisis that crossed the Benin in the 80s. Institutional mimicry played an important role in the decay of the health system in Benin. In a second part, he acts to show the place of the user, the patient and the patient in the health system in general and in the private sector in particular. We have shown that the right to health in Benin is an embryonic status and it became necessary to initiate a process that will take account the rights of users of the health system in general and the Beninese private sector in particular. Good quality care in a country like Benin depend largely on different components of the system and people who do this system, it is now important to rethink the Benin health system in general, taking into account the concept of law health, without neglecting the resources of the country in health, we note here that evoke traditional medicine. The right to health can be seen here as an element of balance and fairness in access to care. For a fair and quality medicine, it becomes imperative that Africa in general and Benin in particular take into account the concept of health law to ensure users secure access to health facilities

Ce travail aborde la question des interventions sanitaires dans les espaces urbains dits « campi nomadi », où vivent les communautés roms, dans la ville de Rome.Dans la première partie, les données de type démographique sont abordées sous l’angle d’une problématisation de leurs formes de collecte des données et des enjeux politiques qui les déterminent. Leur analyse est mise en relation avec le constat que la majorité des études de type médical sur les Roms concernent des questions génétiques, comme c’est aussi le cas des nouvelles formes de fichage et d’identification. Dans la deuxième et troisième partie, l’attention se concentre sur l’ethnographie qui a été menée dans les « campi nomadi » de Rome, en suivant l’activité quotidienne d’une unité médicale mobile (dite « Camper sanitario ») dédiée au soin dans ces espaces urbains. La rencontre médicale dans les espaces d’exception où ces patients résident devient l’occasion d’observer les dynamiques de leurs relations avec la société majoritaire et les institutions qui la réglementent. L’enquête vise à identifier les éléments de l’économie morale des gestes des interventions médicales. Le but est de les restituer à leur dimension biopolitique de pacification de sujets qui font l’objet de strictes politiques de sécurité et de rejet de la part du gouvernement soit national soit local
This work deals with the sanitary interventions in the urban spaces called “campi nomadi” that can be found around the city of Rome, where Roma communities live. The first part of this research deals with the demographic data, from the point of view of the problematization of the ways it had been collected and the political stakes which determine it. Its analysis is related to the acknowledgement of the fact that the grand majority of the medical studies on Roma population engage on genetic data, in the same way the new forms of profiling and identification. The second and third part of this work concentrate on the ethnographic research pursued in the nomad camps of Rome, following the daily activity of a mobile medical unit (also called “sanitary camper”) who’s main activity was offering medical support in this urban spaces. The medical encounter that takes place in this spaces of exception, where the patients live, becomes the occasion for observing the dynamics of their relations with the dominant society and the institutions which rule it. This research aims to identify those elements which relate to the moral economy of the acts of medical intervention by underlying their bio-political dimension related to the pacification of the subjects which are otherwise object of strict security policies and of rejection from local and national administrations

The Master's Thesis is divided into three parts. In first part it is dealing with particularities of marketing of services and specifically with marketing of language schools. In practical part it is analysing language schools in Prague and Brno by marketing research It compares and evaluates marketing mix of language schools and shows common and different points of the biggest players and defines their market position by value curves. The third part is about concrete language school from the environment of a smaller city in Slovakia. It describes its marketing mix, analyses competition and shows its strong and weak points in market position by value curves.

Internet ha supuesto el despegue de las redes de conmutación de paquetes, las ha convertido en un medio al que todo el mundo quiere acceder, y ha obligado a replantear todas las previsiones que manejaban los operadores sobre el tráfico que iban a soportar sus redes en cada una de sus partes: el acceso, la agregación y la dorsal. Precisamente, la evaluación de estas y otras situaciones deben estar incluidas en el proceso de diseño y planificación de cualquier red, en lo que se ha denominado planificación estratégica. La estimación de la demanda de tráfico resulta especialmente importante porque permite al operador anticiparse a situaciones de congestión y bloqueo de la red. Utiliza herramientas de modelado del tráfico, bien para su cálculo analítico o para su estudio mediante simulación, y al ser una herramienta fundamental, existe un extenso catálogo de modelos de tráfico: genéricos y particularizados, de fuentes individuales y de redes completas, de elementos de interconexión y de enlaces. En esta Tesis, se han analizado los diferentes modelos existentes y se ha desarrollado un nuevo modelo que tiene en cuenta el comportamiento del tráfico desde su preparación por parte de la capa de aplicación, hasta su inserción en la capa física. El modelo propuesto parte de la solución ON-OFF tradicional, aunque aplicado a tres niveles diferentes (conexión, sesión y ráfaga), de forma que cada estado ON se encuentra modulado por el modelo correspondiente a la capa inferior. Como alternativa más simple, surgen los modelos multifuente, que intentan introducir el efecto de la interacción entre las diferentes fuentes, también conocido como agregación. Para considerar este caso, se ha realizado un estudio de modelos específicos para su aplicación a puntos de agregación, especialmente los situados en la red de acceso, al ser ésta la parte de la red que más alto coste presenta en su implementación. Partiendo del modelo ON-OFF para una sola fuente, se ha propuesto una variante multifuente, que aprovecha las propiedades de la función de distribución binomial para realizar el cálculo del tráfico agregado por un número determinado de fuentes. El resultado ha sido comparado mediante la observación de flujos reales, tal como propone la teoría del Network Calculus, y que ha sido evaluada y aplicada en este trabajo con ejemplos prácticos que se han incluido en el documento. El estudio realizado en esta Tesis concluye que el tráfico de fuente está condicionado a tres premisas fundamentales: el usuario, el servicio y la tecnología de acceso, de donde surge un nuevo concepto que especifica de forma sistemática y ordenada todas las variaciones, denominada CASUAL (Cubo de Acceso/Servicios/Usuarios de Asignación Libre) y ha sido aplicada en una herramienta realizada a su efecto, junto con los modelos de tráfico de fuente propuestos.
Internet has been the catalyst of the development of packet switched networks, which have become the resource which everyone wants to access. As a consequence, the operators need to recalculate all their forecasts about the traffic to be transported by their networks. In fact, the evaluation of these and other situations should be included within the design and planning phases of any network, in the so called strategic planning overall process.Traffic demand estimation is particularly interesting, since it allows the operator to anticipate bottlenecks and blocking situations of the network. It uses traffic modelling tools, either for their analytical or simulation-based study. Since they have become an essential tool, there is a wide range of traffic models: generic and particularized, for individual sources and complete networks, for interconnection elements and links.In this thesis, we have analyzed the different models and have developed a new model that takes into account traffic patterns from preparation by the application layer to its insertion into the physical layer. The proposed model is based on the traditional on-off solution, but applied to three different levels (connection, session and burst), so that each ON state is modulated by the model corresponding to the bottom layer. As a simpler alternative, multisource models emerge, seeking to introduce the effect of the interaction between different sources, also known as aggregation. To consider this case, it has made a study of specific models for application to aggregation points, especially those located in the access network, as this is the part of the network that has higher cost in implementation. Based on the ON-OFF model for a single source, is a proposed multi-source variant, which exploits the properties of the binomial distribution function for the calculation of the aggregate traffic for a specified number of sources. The result has been compared by observation of actual flows, as proposed by the theory of Network Calculus, and has been evaluated and implemented in this work with practical examples that are included in the document.The study in this thesis concludes that the traffic source is conditioned on three fundamental premises: the user, service and technology access, where there was a new concept that specifies a systematic and orderly all the variations, called CASUAL (Cube of Access / Services / Users with Free Allocation) and has been implemented in a tool made of its effect, along with the traffic source models proposed.

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Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior
This study examines peasant family farming from an agroecological perspective. It intends to analyze the changes resulting from the transition from conventional to agro-ecological agriculture in the daily practices of farmers articulated associated with the Network of Agroecological and Solidarity Farmers of the Curu and Aracatia?u Valleys Territory, the locus of this empirical research, and a space which has highlighted the social dynamics of agroecological innovation, as well as articulating environmental exchanges and knowledge development. As a way to further that goal, we seek to identify the forms of social organization previously present in the daily lives of these subjects, in addition to grasping the determinants that lead or led them to adopt agroecology, noting the need to verify the forms of resistance, and the strategies adopted by farmers and how they articulate collectively. Through the historical and dialectical methods, we seek to take the implications of technical modernization of agriculture under the conditions of production and reproduction of peasants and thus situate the emergence of agroecology, a focus that is born as a counterpoint to conventional patterns of agricultural development based on the paradigm of the Green Revolution. We structured this study around the trajectory of agroecological farmers that developed and internalized agroecological practices, processes, and organizational forms. For the analysis, we used theoretical and methodological frameworks from literature related to field research. The systematization and analysis of experiments revealed that agroecological transition is a broad process of change, not restricted to technical matters. We observed changes in production practices, diversification of production and feeding practices, ecological awareness, production autonomy, and organizations formed to face the challenges resulting from the imposition of the dominant agricultural development model that combines environmental degradation, land ownership concentration, and wealth concentration
Esse estudo tem como universo tem?tico a agricultura familiar camponesa na perspectiva agroecol?gica. Pretende analisar as mudan?as decorrentes do processo de transi??o da agricultura convencional para agricultura agroecol?gica no cotidiano dos agricultores e agricultoras articulados ? Rede de Agricultores Agroecol?gicos e Solid?rios do Territ?rio dos Vales do Curu e Aracatia?u, l?cus da pesquisa emp?rica. Como caminho para o aprofundamento desse objetivo, procuramos identificar as formas de organiza??o social anteriormente presentes no cotidiano desses sujeitos, al?m de apreender os determinantes que os levam ou os levaram a adotar a agroecologia, atentando para a necessidade de verificar as formas de resist?ncia e, por fim, as estrat?gias constru?das pelos agricultores e como estas se articulam coletivamente. A tematiza??o da agroecologia coloca-se como uma problem?tica complexa, o que implica em articular a dimens?o sociot?cnica com as lutas sociais e ecol?gicas em resposta ? marginaliza??o e degrada??o impostas pelo modelo de desenvolvimento agr?cola dominante. A partir do m?todo hist?rico e dial?tico, buscamos apanhar as implica??es da moderniza??o t?cnica da agricultura sob as condi??es de produ??o e reprodu??o dos camponeses e, assim, situar a emerg?ncia da agroecologia, enfoque que nasce como contraponto ao padr?o convencional de desenvolvimento agr?cola baseado no paradigma da Revolu??o Verde. Estruturamos o presente estudo em torno das pr?ticas, processos e formas de organiza??o desenvolvidas e internalizadas ao longo da trajet?ria dos agricultores que enveredaram por essa pr?tica. Devido ? especificidade de nosso objeto, optamos pela pesquisa qualitativa e observa??o sistem?tica. Para as an?lises, utilizamos a pesquisa bibliogr?fica e documental - referencial te?rico-metodol?gico associadas ? pesquisa de campo. As an?lises das experi?ncias revelaram que a transi??o agroecol?gica ? um processo amplo de mudan?as. Assim, tais mudan?as revelaram-se nas pr?ticas produtivas, na diversifica??o da produ??o e pr?ticas alimentares, na consci?ncia ecol?gica e nas formas de organiza??o constru?das pelos agricultores para enfrentar as dificuldades trazidas pela imposi??o do modelo de desenvolvimento agr?cola dominante que combina degrada??o ambiental, concentra??o fundi?ria e concentra??o de riquezas

Developing countries are increasing their adoption of information systems at the country level now. One important aspect distinguishing the implementation of information systems in developing countries from that in developed countries is that developing countries usually lack the resources and capability for training and support, and the workers need to learn to use the system from their own experience. Thus, a better understanding of the workers’ learning-by-doing after the implementation of an information system in developing countries may have important theoretical and practical implications, but empirical evidence on this issue remains limited. This dissertation seeks to fill in the gap by investigating workers’ learning-by-doing after the implementation of an information system at two levels. First, it studies how an individual customs agent’ experience preparing and submitting customs documents influences her performance in document preparation and submission tasks. Second, it also examines how an agent-inspector dyad’s experience working together affects the performance of customs inspection tasks completed through the cooperation of the dyad. The first chapter provides an overview of the dissertation. The second chapter examines how the relatedness of workers’ prior experience affects their learning-by-doing and operational performance in service work. Prior research has viewed relatedness along a single dimension. However, tasks and the underlying knowledge required for task performance can vary along multiple attributes. This chapter extends prior conceptualizations of relatedness by defining it as a multi-dimensional construct and also accounting for the level of task relatedness between different categories in each task dimension. It separates the level of workers’ experience from the relatedness of their experience, and then link the two constructs to workers’ task performance, including their efficiency and quality. Analyzing data on the processing of 998,258 import customs declarations in Costa Rica from 2006-2010, the second chapter finds that customs agents, the major workers processing the customs declarations, learn from their experience to improve their time to complete the task but not their quality of completion. Moreover, it finds that the relatedness of customs agents’ experience to their current task is positively related to the quality of task completion but has a U-shape relationship with completion time, such that the completion time first decreases with and then increases with an increase in customs agents' experience relatedness. The chapter also finds that the impact of customs agents’ experience relatedness is enhanced when the agents have more experience. Overall, the results highlight the role of experience relatedness in workers’ performance in learning-by-doing service work, and help to identify ways for managers to improve different operational performance measures. Many service tasks are completed by dyads rather than by an individual worker. In this setting, the individuals in the dyad not only need to acquire knowledge about the task, but also have to learn to work with each other. Thus, individuals’ experience working together may have significant performance implications for dyads. However, this effect remains largely unexamined, especially when there are conflicts within the dyad. In the third chapter, it theorizes how a dyad’s experience working together influences the dyad’s task performance, and label it as a learning-by-working-together effect. The chapter further proposes that the impact of dyad experience can vary across tasks with different levels of complexity, goal conflict, and combinations of the two. It examines learning-by-working-together in a setting where there is goal conflict, but the dyad must work together to complete the task: customs inspections. Based on a field study on data of 323,520 customs inspections in Costa Rica, the third chapter shows that the number of prior interactions between a customs agent and a customs inspector is positively associated with the agent-inspector dyad’s efficiency in customs inspection. In addition, it demonstrates that the impact of an agent-inspector dyad’s experience working together is greater for high-complexity tasks than for low-complexity tasks, and weaker for high-conflict tasks than for low-conflict tasks. It also shows that due to a joint effect of task complexity and task-level goal conflict, dyad experience exhibits the largest impact on the performance of high-complexity, high-conflict tasks. The chapter discusses the implications of our results for the study of learning curves and for the practice.

RESUMEN Objetivo: Comparar los sistemas de puntaje MEDS (Mortality in Emergency Department Sepsis), SOFA (Sepsis-related Organ Failure Assessment), APACHE II (Acute Physiology and Cronic Health Evaluation) y CURB-65 (Confusion, Urea, nitrogen, Respiratory rate, Blood pressure, 65 years of age and older) para pronóstico de mortalidad y complicaciones en pacientes sépticos. Materiales y métodos: Se realizó un estudio de evaluación prospectiva de prueba diagnóstica. Se evaluaron un total de 308 pacientes que ingresaron al servicio de emergencia de un hospital peruano de los cuales 265 pacientes cumplieron con los criterios de inclusión y exclusión. Para el análisis estadístico se utilizó el programa STATA versión 11. Se realizaron la comparación de los puntajes, análisis de la curva ROC (receiver operating characteristic) y la comparación de áreas bajo la curva ROC para cada puntaje. Resultados: Se incluyeron 265 pacientes con una media de edad de 63 (±20) años. 44.5% presentó sepsis severa y 21.5% shock séptico. 155 (58.4%) pacientes fallecieron y/o presentaron complicaciones. En el análisis multivariado se encontró como variables asociadas significativamente a mortalidad y complicaciones a la edad, oliguria, alteración del estado mental, injuria pulmonar aguda y el uso de inotrópicos. Con respecto al análisis de las curvas ROC, el área bajo la curva ROC fue 0.74 para SOFA, 0.73 para MEDS, 0.73 para APACHE II y 0.67 para CURB 65 siendo este último significativamente inferior a las tres primeras. Conclusión: Los scores MEDS, SOFA y APACHE II son scores adecuados para predecir mortalidad y complicaciones en pacientes sépticos. En contraparte, el score CURB 65 es menos apropiado y no debe ser usado rutinariamente para evaluar el pronóstico de pacientes sépticos.

La mejora en la atención y el cuidado del paciente crítico es un tema que al médico intensivista preocupa, con el objetivo de aumentar la efectividad y eficacia en el manejo de estos pacientes han surgido distintos programas de actuación que proponen una atención y un cuidado continuado a lo largo de todo su proceso asistencial. La UCI sin paredes es la base de todas estas iniciativas. El concepto de UCI extendida se inicia en la detección y atención del paciente crítico fuera de la UCI, lo más precoz posible para mejorar su pronóstico, así como continuar con los cuidados durante su estancia en UCI, optimizando los mismos para disminuir las secuelas inherentes a los tratamientos que la UCI comporta. El proceso de Continuidad Asistencial continúa tras el alta de UCI, con el apoyo y soporte que el paciente requiera, para minimizar el salto cualitativo que a veces puede suponer el paso a la Unidad de Hospitalización convencional. La hipótesis de esta Tesis Doctoral ha sido que la aplicación de un programa de seguimiento activo de los pacientes dados de alta de UCI tiene un efecto beneficioso en su evolución intrahospitalaria. Para demostrar dicha hipótesis se ha diseñado un estudio longitudinal, prospectivo, intervencionista, aplicado a la UCI del Hospital del Mar, en el que se han incluido todos los pacientes dados de alta del Servicio de Medicina Intensiva durante un periodo de 3 años. Se han recogido variables referentes a la situación basal del paciente previas al ingreso en UCI, durante el ingreso en UCI y al alta de UCI. Se realizó el seguimiento de estos pacientes, tras el alta de UCI, realizando distintas intervenciones según necesidades de cada paciente y los requerimientos del equipo asistencial de la Unidad de Hospitalización convencional. Se registraron las complicaciones en cuanto a la necesidad de reingreso y mortalidad. De los resultados recabados se han obtenido las siguientes conclusiones: el programa de seguimiento activo del paciente crítico al alta de UCI disminuye el número de reingresos en el Servicio de Medicina Intensiva y reduce la mortalidad. La tasa de reingresos en UCI es del 8,3%. Los factores de riesgo que se relacionan con mayor riesgo de reingreso son: la edad, los índices de gravedad al ingreso y al alta, determinadas comorbilidades, el ingreso procedente desde la Unidad de Hospitalización convencional, determinados tratamientos durante el ingreso, determinados dispositivos al alta, las altas no programadas, determinados parámetros clínicos y analíticos. Los pacientes que reingresan tienen 5 veces más probabilidades de morir respecto a los que no reingresan. La tasa de mortalidad global al alta de UCI es del 9,2% y la tasa de mortalidad no esperada es del 1,8%. Los factores de riesgo que aumentan la probabilidad de fallecer tras el alta de UCI son: la edad, los días de estancia en UCI, los índices de gravedad al ingreso y al alta, determinadas comorbilidades, el ingreso procedente desde la Unidad de Hospitalización convencional, determinados tratamientos durante el ingreso, determinados dispositivos al alta, determinados parámetros clínicos y analíticos y el reingreso. Se cumplen los estándares de calidad de la SEMICYUC referentes al alta no programada, tasa de reingreso y razón estandarizada de mortalidad. El programa de seguimiento activo se ha consolidado a lo largo de los 3 años aumentando su efectividad y eficacia disminuyendo la tasa de reingresos, la tasa de mortalidad en UCI entre los pacientes que han requerido reingreso y mostrando una tendencia en la disminución de la mortalidad global hospitalaria.
Better care after ICU admission is nowadays a challenge for intensive care physicians.The design of new programs and the offer of new ICU services reflect the intention to increase the effectivity and the efficiency of the treatment we give to the patient after an ICU admission and during their hospital admission. Critical care specialists have acquired new roles even out the walls of their ICU. “ICU without walls” is a concept designed to detect critical illness early, and to give a rapid response to resuscitate patients wherever the area they are in the hospital, with the intention to prevent, to improve the treatment and to give a continuation in the treatments received in the ICU previous to the discharge. All these strategies are implemented to improve de prognostic and to reduce the morbimorbidity associated to the critic patient. The existence of a follow-up program after the ICU discharge represents a strategy to give support to the patient and to the give support to the team that will receive the patient in the normal ward. This strategy is a way to reduce the difference in patient assistance between the ICU and the hospitalization ward. The hypothesis of this doctoral thesis is that the implementation of a Post-ICU follow-up program represents a significant benefit in the evolution of the patients during the hospital stay. To prove our hypothesis we designed a prospective, longitudinal and interventionist study that was applied in Hospital del Mar ICU. We included all the patients that were discharge alive from the ICU during three consecutive years. We collected demographic and clinical data from the period before ICU, during ICU stay and at the moment of ICU discharge. We performed a follow-up after patient discharge from the ICU. During the follow-up we could collaborate with the patient, the family and physicians to give support to the consolidation of the treatment that was started in the ICU and to improve the transmission between the ICU and the Hospitalization ward. Mortality and readmission were registered. From the study, we can say that the implementation of the follow-up program produced a decrease in the number of adverse effects after an ICU discharge. The number of readmission and the mortality after ICU admission decreased after de implementation of the program. The number of readmissions in ICU is 8.3% in the literature. The risks factors that can increase the risk of readmission are: age, severity index, organ dysfunction in the admissions and in the moment of discharge, some comorbidity, admission from the hospitalization ward, renal replacement therapy during the ICU stay, non-programed ICU discharge, ICU long admission. The global mortality rate in ICU is around 9.2% and the unexpected death is 1.8%. The risk factors that can contribute to die after ICU admission are: age, severity index at the admission and at the discharge, organ dysfunction at admission and discharge, comorbidities, ICU stay, admission from hospitalization ward, renal substitutive therapy, more than 10 days in mechanical ventilation, long ICU stay a readmission. During these period we could accomplish all the SEMICYUC parameters of quality: non programmed discharge from the ICU, the early readmission rate and the standardized Mortality Ratio. The follow-up program has been consolidated over 3 years, increasing its effectiveness by decreasing the rate of readmissions, reducing the mortality rate in the ICU among patients who have required readmission and showing a trend in the decrease in overall mortality.

Aquesta tesi analitza l’impacte de la crisi econòmica en els principals Estats de Benestar Europeus i els canvis introduïts en els sistemes de cures de llarga durada —CLD— d’Anglaterra, Alemanya, Suècia i Espanya. Alhora, aborda les tendències lligades als canvis identificats en cada país entre 2008-2017 en relació a: la contracció-expansió dels sistemes; els processos de reestructuració —remercantilització, contenció de costos i recalibració— i la refamiliarització dels sistemes. L’estratègia metodològica utilitzada és el cross-national i l’estudi de cas dins de la variant casos diferents. S’ha considerat als països triats tipus ideals de Benestar: el Continental; el Liberal; l'Universal i el Mediterrani, segons la classificació d'Esping-Andersen (1990) o autors com Moreno (2001) i Ferrera (1996). L'estudi combina tècniques quantitatives i qualitatives, utilitza bases de dades estadístiques i dades qualitatives primàries i secundàries. Una part important de les dades estadístiques s'han obtingut de les bases de dades estandarditzades de l'OCDE i, en menor mesura, de les bases de dades dels serveis nacionals estadístics dels països estudiats. Per a obtenir les dades qualitatives primàries s’han dut a terme entrevistes semiestructurades a informants clau. Hi ha tres nivells d’anàlisi: el primer explora els canvis en la provisió de servei de CLD; el segon revisa les reformes legislatives i el tercer nivell recull la percepció dels entrevistats quant als canvis i els factors explicatius.
This thesis analyses the impact of the economic crisis in the Welfare Stats across Europe and the changes caused within the long-term care systems of England, Germany, Sweden and Spain. Furthermore, this scrutinises the ensuing tendencies linked to the identified changes in each country within the analysis’ timespan regarding: the system’s contraction-expansion; the restructuring mechanisms (re-commodification, costs’ containment and re-calibration) and the re-familiarisation process. The methodological strategy used in the study is cross-national and the case’s study method within the variant of different cases¨. The chosen countries are considered to be ideal types of each Welfare State: the continental; the liberal; the universal and the Mediterranean, according to the classic categorisation of Esping-Andersen (1990) and other authors like Moreno (2001) and Ferrera (1996). The study combines quantitative and qualitative techniques and uses statistical data as well as primary and secondary qualitative data. A major part of the used statistical data has been obtained by turning to the standardised databases of the OECD and in a minor way, the databases of the statistic national services of the studied countries. In order to obtain the primary qualitative data, the technique of semi-structured interviewing for the key informants has been used. There are also three analysis levels: the first explores the changes within the LTC service provision; the second reviews the legislation modifications within the LTC systems and the third level compiles the perception of these interviewees in terms of these changes and the explaining factors.

Introducción: La comunicación entre profesionales de la salud, niños y familiares en un servicio de urgencias pediátrico (SUP) es clave para un buen cuidado del niño en el domicilio, una buena adherencia al tratamiento y una buena satisfacción del servicio de los familiares. Para alcanzar estos indicadores, podría ser útil la utilización del modelo de cuidado centrado en la familia (MCCF), que se caracteriza por reconocer y respetar el rol de la familia en el que el profesional empodera, apoya y anima a tomar decisiones. Objetivo: Analizar desde la perspectiva del MCCF, el proceso comunicativo, la adherencia al tratamiento y la satisfacción de las familias que, por un problema de salud banal de sus hijos, acuden a un SUP. Método: Diseño mixto con dos estudios realizados en un SUP catalán. 1) Diseño cuantitativo compuesto de dos fases. Fase I: evaluó la relación entre las percepciones de atención recibida y la satisfacción, mediante cuestionarios con 385 familias. Fase II: consistió en obtener indicadores cuantitativos de la utilidad de la información recibida y la adherencia terapéutica mediante un seguimiento en el domicilio durante 6 días con 37 familias. 2) Diseño de aproximación cualitativa, para profundizar la comprensión del tipo de atención y roles percibidos en un SUP, mediante grabaciones de audio de las visitas con las mismas 37 familias. Resultados: Se evidenció una relación estadísticamente significativa entre percepción del MCCF y satisfacción (B=0.25; IC95% [0.20-0.29]; p<.001). En cambio, en el análisis cualitativo se apreció una falta de información por parte de los diferentes profesionales, con falta de feed-back y cesión de espacio para preguntas, dando información de cuidados y tratamientos banales por entendidos con uso de tecnicismos. Un 45,7% de los familiares no siguieron la prescripción médica. Conclusiones: Existe una relación positiva entre la percepción del MCCF y la satisfacción. La satisfacción mejoró al sexto día de la visita a urgencias. Se observaron diferencias entre la percepción de sentirse informados durante la visita y la observación donde existe una falta de ésta en diferentes aspectos. Aparece una baja adherencia al tratamiento delante de patologías banales.
Introduction: Communication between health professionals, children and family members in a pediatric emergency department (PED) is key to good home care, good adherence to treatment and family members’ satisfaction. In order to reach an adequate level of satisfaction, the use of the family-centered care (FCC) may be helpful because it recognizes and respects the role of the family and the professional empowers, supports and encourages decision-making. Objective: To analyze, from the perspective of the FCC, the communicative process, the adherence to treatment and the satisfaction of families who go to a PED because of a banal health problem of their children. Method: Mixed design with two studies carried out in a Catalan PED. 1) Quantitative design composed of two phases. Phase I evaluated the relationship between the perceptions of care received and satisfaction, through questionnaires given to 385 families. Phase II consisted of obtaining quantitative indicators of the usefulness of the information received and therapeutic adherence through a 6-day follow-up with 37 families. 2) Qualitative design, to deepen the understanding of the type of attention and roles perceived in a PED, through audio recordings of the visits with the same families. Results: A statistically significant relationship was found between FCC perception and satisfaction (B=0.20; IC95% [0.20-0.29]; p<.001). Nevertheless, the qualitative analysis showed a lack of information provided by the different professionals, an apparent lack of feed-back and time availability for questions. The professionals considered the information given about care and treatments with the use of technical terms to be understood. 45.7% of the families did not follow the medical prescription. Conclusions: There is a positive relationship between FCC perception and satisfaction and results improved on the sixth day after the visit. There were differences between the subjective perception of being informed during the visit and the objective observation where there was a lack of information in different aspects. There is low adherence to treatment for banal pathologies.

La definición de neumonía adquirida en la comunidad (NAC) tiene diferentes conceptos y criterios de inclusión; sin embargo se requiere una combinación de signos, síntomas y características radiológicas. La BTS (British Thoracic Society) la define como una enfermedad aguda más imágenes radiográficas las cuales se encuentran en al menos un segmento o un lóbulo y no se encontraban previamente o debido a otras causas.

Aim of the proper track design is build track, which enable smooth run of the vehicle as much as is possible complying with the safety rules and reasonable level of comfort for passengers. However, this track has to be maintainable and the vehicle shouldn’t face unacceptable amount of wear. On the other hand it is clear that it is impossible to build ideal (straight) track because of many environmental and morphological conditions. So the rules for track designing have to be set carefully in order to produce a good track design which meets the conditions mentioned above. The principles for track designing are evaluated with using the results of track test running dynamic behavior of the vehicles in this study. These tests were made for couple vehicles on several track sections. The influence of design parameters on the dynamic behavior are evaluated based on these results. That’s defining one of the basic part interactions between vehicle and track. Evaluation of the quality of track geometry in service has the same or may be higher importance. Limit values as defined in standard ČSN 73 6360-2 was set partially in consideration results of scientific studies, but partially in consideration of as common practice. So that part of this work is verification of the influence of tolerance in each parameter and their combinations in order to allow reasonable establishment of their limit values for track maintenance and for preventing of train derailment.

Dans le contexte du changement climatique, la transition écologique repose en partie sur l'adoption d'une consommation durable, en accord avec les Objectifs de Développement Durable des Nations-Unies (2015). La pluralité de définitions associées à la consommation durable entraîne l'absence d'un consensus en matières de classification et de délimitation du périmètre de la consommation durable. En conséquence, les données et les mesures relatives à la consommation durable sont limitées, ce qui restreint la réalisation d'études empiriques à ce sujet. La thèse s'emploie à résoudre ces contraintes à travers trois chapitres, en proposant une méthodologie et des résultats originaux.Le premier chapitre propose une méthodologie pour mesurer de la consommation durable des ménages dans 150 pays, sur la période 1995-2015. Cette mesure est construite à partir des biens et services environnementaux dont les classifications, CLEG et APEC, sont identifiées dans la demande finale des ménages des tables Input-Output Exiobase3rx.Le deuxième chapitre étudie la relation entre le revenu disponible et la consommation durable au niveau macro-économique, en retenant le cadre de la Courbe Environnementale d'Engel. Cette analyse empirique estime l'effet du revenu disponible sur la consommation durable des ménages, ainsi que les élasticités d'Engel qui, en fonction de leurs valeurs, déterminent si cette consommation est assimilée à une consommation de luxe ou de nécessité. Par ailleurs, notre estimation économétrique introduit un instrument à la Bartik qui suggère un effet significatif des politiques fiscales vertes sur la consommation durable des ménages. À partir d'une simulation, nous soulignons l'importance de prendre en compte la vraie valeur des élasticités d'Engel dans le cadre de politiques de redistribution globale, telles que le Fonds Climat.Le troisième chapitre évalue l'effet des inégalités de revenus sur ce type de consommation, contribuant ainsi au débat sur l'arbitrage entre qualité environnementale et inégalités. En utilisant trois indicateurs d'inégalités, nos résultats suggèrent que l'impact des inégalités sur la consommation durable peut varier en fonction du niveau de revenu et de la mesure d'inégalités considérée. En proposant un polynôme de degré supérieur, nous explorons la sensibilité de cette consommation à une variation du niveau d'inégalités et déterminons un niveau optimal d'inégalités qui maximise la consommation durable des ménages.Dans l'ensemble, cette thèse contribue à mesurer la consommation durable des ménages par pays et à en explorer ses déterminants, tout en offrant des perspectives pour l'élaboration de politiques environnementales et redistributives
In the context of climate change, ecological transition relies in part on the adoption of sustainable consumption, in line with the United Nations' Sustainable Development Goals (2015). The diversity of definitions associated with sustainable consumption leads to a lack of consensus related to the classifications and scope of sustainable consumption. Consequently, data and measures related to sustainable consumption are limited, thereby restricting empirical studies on this subject. The thesis addresses these constraints through three chapters, offering the original methodology and results.Chapter 1 presents a methodology for measuring household sustainable consumption in 150 countries over the period 1995-2015. This measure is constructed using environmental goods and services, classified as CLEG and APEC, identified in the final demand of households from the Input-Output Tables Exiobase3rx.Chapter 2 explores the relationship between disposable income and sustainable consumption at the macroeconomic level, referring to the Environmental Engel Curve framework. The empirical analysis estimates the effect of disposable income on household sustainable consumption and determines Engelian elasticities which, depending on their values, categorize this consumption as either a luxury or a necessity consumption. Furthermore, our econometric estimation introduces a Bartik instrument, suggesting a significant impact of green fiscal policies on household sustainable consumption. Performing a simulation exercise, we emphasize the importance of considering the «true value» of Engelian elasticities in the context of global redistribution policies, such as the Climate Fund.Chapter 3 evaluates the effect of income inequality on this type of consumption, thereby contributing to the debate on the trade-off between environmental quality and inequalities. Using three inequality indicators, our results suggest that the impacts of inequalities on sustainable consumption depend on the income level and the measure of inequalities considered. By introducing a higher-order polynomial, we analyse the sensitivity of this consumption to changes in the level of inequalities and determine an optimal level of inequalities that maximizes household sustainable consumption.Overall, this thesis contributes to the measurement of household sustainable consumption by country and explores its determinants, while also providing insights for environmental and redistributive policies

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This paper presents a model based on Markov Chains and enhanced with the use of Kernel Density Estimation and of MMFM (Markov Modulated Fluid Model) in order to evaluate the performance of the transmission link in OFDMTDMA systems. For that purpose, traffic models based on the Kernel method and the MMFM with adjusted autocorrelation function are proposed. From the model implemented for the OFDM-TDMA system, it was derived equations for estimation of QoS parameters such as delay and average queue size in the buffer. The obtained results confirm that the proposed model is efficient in describing the link performance indicators. The use of MMFM to model the arrival process improves the QoS parameter estimates of the queueing model making their values very close to those of the simulation results. It was also developed an equation to the OFDMTDMA system’s service curve. Through this equation and the concept of Envelope Process, it was proposed an equation to estimate the probability of buffer overflow in OFDM-TDMA systems. The results show that the estimates of the overflow probability based on the system’s service curve are very close to the ones obtained by simulations and that the computational complexity to obtain them is significantly reduced compared to the model based on Markov Chains due to the absence of matrix computation.
Este trabalho apresenta um modelo baseado em Cadeias de Markov e aprimorado com o uso do método de Kernel de estimação não-paramétrica e de MMFM (Markov Modulated Fluid Model) com o objetivo de avaliar e descrever o desempenho do enlace de transmissão em sistemas OFDM-TDMA. Para tal, modelos de tráfego baseados no Método de Kernel e em MMFM com ajuste da função de autocorrelação são propostos. A partir do modelo implementado para o sistema OFDM-TDMA, foram obtidas equações para estimação de parâmetros de QoS como retardo e tamanho médio da fila no buffer. Os resultados obtidos confirmam que o modelo proposto é bastante eficiente ao descrever os indicadores de desempenho do sistema. O uso de MMFM para modelar o processo de chegada de pacotes aprimora os estimadores de parâmetros de QoS tornando as estimativas bem próximas dos valores obtidos com as simulações. Também deduziu-se uma equação para a curva de serviço de Sistemas OFDM-TDMA. Em seguida, utilizando-se desta curva de serviço e do conceito de Processo Envelope foi proposta uma equação para estimação de probabilidade de transbordo do buffer em sistemas OFDM-TDMA. Os resultados obtidos mostram que as estimativas de probabilidade de transbordo baseadas na curva de serviço do sistema se aproximam bem dos resultados da simulação e a complexidade computacional do cálculo necessário para obtê-los é significativamente reduzida em relação ao modelo definido utilizando Cadeias de Markov.

The IDSA Community-Acquired Pneumonia (CAP) Guideline recommends ceftriaxone in combination with doxycycline as an alternative to combination therapy with ceftriaxone and azithromycin for non-intensive care unit (ICU) patients hospitalized with CAP. This is an attractive alternative regimen due to recent concerns of increased cardiovascular risk associated with azithromycin. The objective of this study was to compare the clinical outcomes of azithromycin and doxycycline each in combination with ceftriaxone for non-ICU Veterans hospitalized with CAP.