Family Practitioner Committees and their customers

This paper illustrates some of the ways in which the Family Practitioner Committee will have to change in order to being about their transformation from the ‘passive paying agency’ into the ‘active manager of customer interests’ when the proposals from the recent White Paper, ‘Working for Patients’, became law. We were asked to examine what was happening in the area of ‘consumer relations’ within the National Health Service by the Department of Health. Part of this work has involved our surveying all of the Family Practitioner Committees in England and Wales. This paper presents the results of our survey, examining some of the pioneering work carried out by a handful of FPCs to enhance consumer relations and highlighting the enormous amount of work that has yet to be done to ensure that providers and financiers really know what customers want from their local Health Service. All 98 FPCs were written to for information about customer relations’ initiatives and 60 replies were received. Of these only nine FPCs had carried out work in the area of customer relations, ten planned to do so and one had work in progress. The number of active FPCs varied notably by region. There was evidence of more work being done in the northern part of the country than in the south. The responses indicated that very little work was being undertaken to test the quality of the service provided by contractors (e.g. GPs) to FPCs. Most of the work was either a public relations exercise or surveys of accessibility. The results appeared to have little or no impact upon the policy of the FPCs. If FPCs are to become active managers of primary care services, radical changes in their practices with regard to customer relations are essential and long overdue.

Estudio ergonómico y elaboración de un manual de buenas prácticas ergonómicas de las normativas española y colombiana, mediante el método ROSA para asistentes administrativos de la ESPOCH

El presente trabajo de titulación busca realizar un manual de buenas prácticas ergonómicas en base a un estudio ergonómico fundamentado en normativas NTP y NTC de los asistentes administrativos de la ESCUELA SUPERIOR POLITECNICA DE CHIMBORAZO. En el desarrollo del proyecto se realiza una inspección mediante el método para la evaluación del trabajo con PDV para obtener la problemática inicial, donde se determinó que 31 personas presentaban inconvenientes ergonómicos relacionados con el ordenador, 23 con las sillas, 17 con el escritorio y 28 personas con los accesorios de su puesto de trabajo. Después se efectuaron las evaluaciones mediante el método ROSA, el cual permitió obtener el nivel de riesgo asociado a la persona, detectando que en un total de 32 asistentes, el 50% obtuvo un riesgo alto, 34% muy alto, 3% como extremadamente alto y 13% como mejorable; también se realizó un contraste de los resultados de la evaluación mediante el método ROSA aplicando las normativas NTC y NTP, obteniendo resultados de 19% riesgo alto, 9% muy alto, 3% como extremadamente alto y 69% como mejorable aplicando la NTC 1440; en comparación de la NTP 242 se obtuvieron resultados de 44% alto, 12% muy alto, 3% como extremadamente alto y 41% como mejorable. Finalmente se determinó que las NTC reducen los niveles de riesgos ergonómicos y se obtuvo un manual de buenas prácticas ergonómicas indicando posturas adecuadas del personal para su jornada laboral. Se recomienda hacer el cambio de las sillas de trabajo, así como achaflanar las esquinas de los escritorios e implementar reguladores de altura y dirección para monitores junto con ciclos de capacitaciones continuas acerca de las posturas de trabajo en la oficina.This degree Project is intended to create a manual of good ergonomic practices based on an ergonomic study based on NTP and NTC regulations of the administrative assistants of ESCUELA SUPERIOR POLITECNICA DE CHIMBORAZO. During the development of the project, an inspection was performed using the method for the evaluation of the work whit PDV to obtain the first problem, where it was determined that 31 people had ergonomic problems related to the use of computer, 23 with the chairs position, 17 with the desk and 28 people with the accessories of their workstation. Afterwards, the evaluations were carried out using ROSA method, which made it possible to obtain the level of risk associated whit the person, identifying that in a total of 32 assistants, 50% obtained a high risk, 34% very high, 3% as extremely high and 13% as improvable; a contrasting of the results of the evaluation by means of ROSA method applying the NTC and NTP standards was also developed, obtaining results of 19% high risk, 9% very high, 3% as extremely high and 69% as improvable applying the NTC 1440; in comparison with the NTP 242, results of 44% high, 12% very high, 3% as extremely high and 41% as improvable were obtained. Finally, it was determined that the NTCs reduce the levels of ergonomic risk and a manual of good ergonomic practices was produced, indicating appropriate postures for the personnel for their workday. It is recommended to change the work chairs, as well as chamfer the corners of the desks and implement height and direction regulators for monitors along with continuous training cycles about workings postures in the office

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Indonesia’s national mobilisation strategy : growing deeper roots?

Indonesia’s latest efforts to build up a national reserve system and cultivate awareness of the state ideology at the societal level has defence implications, but they are actually more about responding to internal security concerns than the needs of external defence.Published versio

SUPRESSIVIDADE NATURAL DE SOLOS DA REGIÃO CENTRO-OESTE A Rhizoctonia solani KÜHN NATURAL SUPPRESSIVENESS OF SOILS FROM WEST CENTRAL BRAZIL TO Rhizoctonia solani Kühn

<!-- @page { margin: 2cm } --> <p class="western" align="justify"><em>Rhizoctonia</em> <em>solani</em> é um fungo cosmopolita que habita o solo, com vasto número de hospedeiros, e causa importantes doenças na maioria das plantas cultivadas em todo o mundo. É uma espécie complexa, com muitos biotipos que diferem quanto à patogenicidade, aos hospedeiros, à distribuição na natureza e à aparência em meio de cultura. O feijoeiro comum é suscetível a este patógeno e a sua suscetibilidade é inversamente proporcional ao desenvolvimento da planta. A atividade microbiana de alguns solos pode prevenir o estabelecimento de fungos fitopatogênicos. Solos com esta propriedade são denominados antagônicos, de longa vida, resistentes ou supressivos. O objetivo deste trabalho foi avaliar os níveis de supressividade natural a <em>R.</em> <em>solani</em> de alguns solos classificados como latossolo roxo, latossolo vermelho-escuro, areia quartzoza e latossolo roxo, respectivamente, coletados nos municípios de Itumbiara, Silvânia, Jussara e Santa Helena de Goiás, no Estado de Goiás, em três áreas contíguas com os seguintes históricos de uso: a) solo cultivado com feijão irrigado via pivô central por mais de quatro anos consecutivos; b) solo sob vegetação nativa; e c) solo sob pastagem de <em>Brachiaria</em> <em>decubens</em>. Os solos foram coletados na camada de 0-20 cm e armazenados em casa de vegetação. Para a inoculação dos solos foram utilizados grãos de sorgo, inoculados com <em>Rhizoctonia</em> <em>solani</em>, em seis densidades – 0, 100, 500, 1.000, 5.000 e 10.000 propágulos/g de solo – e triturados. O experimento foi conduzido sob condições de casa de vegetação, em um delineamento de blocos completos casualizados e esquema fatorial 6 x 4 x 3. A unidade experimental foi constituída de bandejas plásticas com 4 kg de solo e 40 plantas. Quinze dias após a emergência, as plantas foram arrancadas e avaliadas. Posteriormente, foi calculado o índice de McKinney. A análise de variância apresentou interação tripla significativa, e os graus de liberdade foram desdobrados em análises de regressão entre as doses de inóculo e o índice de doença em porcentagem, numa equação exponencial do tipo: ID = A x e (-B/dose do inóculo + 1). Nas regiões de Itumbiara e Silvânia, o índice de doença progrediu como aumento do número de propágulos por grama de solo, atingindo valores superiores a 70%. Porém, para ambas as regiões, não houve diferenças significativas entre os solos de mata, pastagem e feijão com relação ao índice de doença. Por outro lado, nos solos de Jussara e Santa Helena, foi observado um incremento do índice da doença com o aumento da dose de inóculo para todos os históricos, e os solos de mata e de pastagem apresentaram índice de doença semelhante em todas as doses de inóculo utilizadas. Em solos provenientes de área de feijão irrigado, da região de Santa Helena, os incrementos no índice de doença foram menores, não ultrapassando a 60%.</p> <p class="western" align="justify">PALAVRAS-CHAVE: Podridão radicular de <em>Rhizoctonia</em>; controle biológico; população microbiana do solo.</p> <!-- @page { margin: 2cm } --> <p class="western" align="justify">Rhizoctonia solani is a highly destructive world wide soil fungus, with a large host-range, that causes important diseases in a great number of the crops. It is a complex specie whichpossesses many biotypes, differing in their pathogenicity, hosts,distribution in the nature and cultural appearance in solid media.Dry beans are susceptible to this pathogen and the susceptibility is inversely proportional to the host development. The microbial activity of some soils can prevent the establishment of phytopathogenic fungi. Soils with this property are named antagonistic, long life, resistant or supressive. The objective of this work was to evaluate the levels of natural supressiveness to R. solani of some soils previously submitted to different managements from West Central Brazil. Soil samples were collected in Itumbiara, Silvânia, Jussara and Santa Helena de Goiás counties of Goiás State, and classified as: Purple Latosol, Dark-Red Latosol, Sandy Soil and Purple Latosol, respectively. Each soil sample was collected in the layer of 0-20 cm, in contiguous areas with the following characteristics: a) soil cultivated with beans irrigated with central pivot, for more than four consecutive years; b) soil under native vegetation, and c) soil under Brachiaria decubens pasture. Sorghum grains colonized by Rhizoctonia solani, were ground and mixed to the soil samples. Six inoculum densities were used: 0, 100, 500, 1000, 5000 and 10000 propagules per gram of soil. The experiment was conducted under greenhouse conditions, using a randomized complete block design, in a factorial scheme 6 x 4 x 3, with four replications. The experimental unit was a plastic tray with 4 kg of soil and 40 plants. Fifteen days after the emergence symptoms severity were evaluated and the McKinney index estimated. The analysis of variance revealed significance of triple interaction and the degrees of freedom were unfolded in regression analyses among the inoculum doses and the disease index in percentage, in the following exponential equation: ID = A x e (-B/dose do inóculo + 1). In the soil samples from Itumbiara and Silvânia the disease index increased with the increment of the number of propagules for gram of soil, reaching values larger than 70%. However, for both soils, there were no significant differences among the natural vegetation, pasture and bean cultivated soils. On the other hand, in soils from Jussara and Santa Helena, in spite of the disease index increment with the increase of the inoculum doses, the natural and pasture soils showed similar disease indexes for all the inoculum doses used. In soil from irrigated beans, the increment in the diseases index was smaller, not surpassing 60%.</p> <p class="western">KEY-WORDS: Rhizoctonia root rot; biological control; soil microbial population.</p&gt

Mechanical resistance of the modified stabilization method for the tibial tuberosity advancement technique: ex vivo experimental study in dogs Resistência mecânica da técnica de avanço da tuberosidade tibial modificada: estudo experimental ex vivo em cães

The present study aimed to evaluate a modification of the stabilization method of the tibial tuberosity advancement technique (TTA), originally described for stabilization of the cranial cruciate deficient stifle. Ten adult mongrel dogs with weights ranging from 25 to 30kg were used. After euthanasia, the hind-limbs were divided into two groups: G1 - test (n=10), and G2 - control (n=10) represented by the contra lateral limb. The test group was submitted to the modified TTA technique, stabilized by one shaft screw in craniocaudal position and a titanium cage inserted at the osteotomy site. The position of the patellar tendon, 90° in relation to the tibial plateau, and the correct position of all implants were confirmed radiographically after surgery. Posteriorly, in both groups, limbs were harvested and tibias collected with their respectively patellar tendon insertion preserved for the mechanical resistance test. The fixation of the tibial tuberosity with a shaft screw and titanium cage resulted in resistance compatible with the normal physiological forces transferred to the hind-limbs during locomotion. The biomechanical tests confirmed the viability of the method performed for the tibial tuberosity fixation and support future clinical trials to validate the technique.<br>O presente estudo teve por objetivo avaliar a resistência mecânica do método de estabilização da técnica de avanço da tuberosidade tibial (TTA), originalmente descrita para tratamento da ruptura do ligamento cruzado cranial. Foram avaliados 10 cães, sem raça definida e com massa corporal entre 25 e 30kg. Após a eutanásia, os membros pélvicos foram divididos em dois grupos, sendo que G1 era o grupo teste (n=10) e G2 o controle (n=10), representado pelo membro contralateral. O grupo operado foi submetido à técnica de avanço da tuberosidade tibial (TTA) modificada, com emprego de um parafuso especial em posição craniocaudal e um espaçador de titânio inserido no local de osteotomia. O posicionamento do tendão patelar perpendicularmente ao platô tibial e o correto posicionamento dos implantes foi confirmado radiograficamente em todos os espécimes. Posteriormente, em ambos os grupos foram coletadas as tíbias, com preservação da inserção dos seus respectivos tendões patelares, para realização dos testes de resistência mecânica. A estabilização da tuberosidade tibial por parafuso especial em sentido craniocaudal e espaçador de titânio demonstrou resistência compatível com as forças fisiológicas tradicionalmente impostas ao membro pélvico durante a locomoção. Os testes biomecânicos confirmam a viabilidade do método de estabilização e sustentam estudos clínicos futuros para validação da técnica cirúrgica