No / This paper aims to estimate the patterns of care and related resource use attributable to managing acute and chronic wounds among a catchment population of a typical clinical commissioning group (CCG)/ health board and corresponding National Health Service (NHS) costs in the UK. This was a sub-analysis of a retrospective cohort analysis of the records of 2000 patients in The Health Improvement Network (THIN) database. Patients’ characteristics, wound-related health outcomes and health-care resource use were quanti ed for an average CCG/health board with a catchment population of 250,000 adults ≥18 years of age, and the corresponding NHS cost of patient management was estimated at 2013/2014 prices. An average CCG/health board was estimated to be managing 11,200 wounds in 2012/2013. Of these, 40% were considered to be acute wounds, 48% chronic and 12% lacking any speci c diagnosis. The prevalence of acute, chronic and unspeci ed wounds was estimated to be growing at the rate of 9%, 12% and 13% per annum respectively. Our analysis indicated that the current rate of wound healing must increase by an average of at least 1% per annum across all wound types in order to slow down the increasing prevalence. Otherwise, an average CCG/health board is predicted to manage ~23,200 wounds per annum by 2019/2020 and is predicted to spend a discounted (the process of determining the present value of a payment that is to be received in the future) £50 million on managing these wounds and associated comorbidities. Real-world evidence highlights the substantial burden that acute and chronic wounds impose on an average CCG/health board. Strategies are required to improve the accuracy of diagnosis and healing rates. Declaration of interest: The study’s sponsors had no involvement in the study design, the collection, analysis and interpretation of the data, the writing of this manuscript and the decision to submit this article for publication. The views expressed in this article are those of the authors and not necessarily those of the NHS, the National Institute for Health Research (NIHR), the Department of Health, or any of the other sponsors. / NIHR Wound Prevention and Treatment Healthcare Technology Co-operative (National Institute for Health Research WoundTec HTC), Bradford Institute For Health Research, Bradford, West Yorkshire, UK, following an open tendering process. Additional funding was provided by: 3M Health Care Limited, Loughborough, Leicestershire, UK; Activa Healthcare Limited, Burton On Trent, Staffordshire, UK; Brightwake Limited, Kirkby In Ashfield, Nottinghamshire, UK; KCI Medical Limited, Crawley, West Sussex, UK; Longhand Data, Welburn, North Yorkshire, UK; Medira Limited, Cambridge, Cambridgeshire, UK; Mölnlycke Health Care Limited, Dunstable, Bedfordshire, UK; Park House Healthcare Limited, Elland, West Yorkshire, UK; Perfectus Biomed Limited, Daresbury, Warrington, UK; Pulsecare Medical LLC, North Andover, Massachusets, US; Smith & Nephew Medical Limited, Hull, East Riding Of Yorkshire, UK; Sozo Woundcare Limited, Harrogate, North Yorkshire, UK; Systagenix Wound Management Limited, Gatwick Airport, West Sussex, UK; Trio Healthcare, Great Missenden, Buckinghamshire, UK; Urgo Limited, Loughborough, Leicestershire, UK; Willingsford Limited, Southampton, Hampshire, UK.

nÃo hà / The reduction of the tax burden has been one of the main tools used by the Brazilian states in order to benefit companies established in their territories, with the objective of protecting the local market and especially the generation of employment. The Government of CearÃ, imbued with this purpose, promoted the reduction of the tax burden applied to the segments of Wholesale and Retail Footwear, using the systematic replacement tax with a aggregate of 55%, which is on average 24% lower that the rate of Additives practiced by such segments. In this work, through empirical tests, we will attest if the benefit granted promoted the extension of the tax base as a way to compensate the reduction of the tax burden. / A reduÃÃo da carga tributÃria tem sido um dos principais instrumentos utilizados pelos Estados brasileiros como forma de beneficiar empresas estabelecidas em seus territÃrios, tendo como objetivo proteger o mercado local e principalmente a geraÃÃo de emprego. O Governo Cearense, imbuÃdo desse propÃsito, promoveu a reduÃÃo da carga tributÃria aplicada aos segmentos de ComÃrcio Atacadista e Varejista de CalÃados, utilizando para tanto a sistemÃtica da substituiÃÃo tributÃria com uma agregaÃÃo de 55%, que à em mÃdia 24% menor que a Taxa de Adicionamento mÃdia praticada por tais segmentos. Nesse trabalho, atravÃs de testes empÃricos, iremos atestar se o benefÃcio concedido promoveu o alargamento da base tributÃria como forma de compensar a reduÃÃo da carga tributÃria.

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This diploma thesis focuses on free time activities of elementary school teachers in relation with their perception of workload. In the theoretical part the teacher's characteristics are mentioned, but it primarily focuses on workload and teachers' free time activities. The topics are seen through multiple points of view. Different segments of workload and types of free time are presented. Empirical part is elaborated using in-depth interview with chosen elementary school teachers. The main goal of this research was to uncover, how much the workload influences teachers' spending of their free time and how are they coping with the workload. Participants of this research are coping with the workload well and they are spending their free doing activities completely different from their profession. Most mentioned activities were physical activities, manual labor and sport.

Technological advances during the past 30 years have dramatically improved survival rates for children with life-threatening conditions (preterm births, congenital anomalies, disease, or injury) resulting in children with special health care needs (CSHCN), children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and related services beyond that required by children generally. There are approximately 10.2 million of these children in the United States or one in five households with a child with special health care needs. Care for these children is limited to home care, medical day care (Prescribed Pediatric Extended Care; P-PEC) or a long term care (LTC) facility. There is very limited research examining health outcomes of CSHCN and their families. The purpose of this research was to compare the effects of home care settings, P-PEC settings, and LTC settings on child health and functioning, family health and function, and health care service use of families with CSHCN. Eighty four CSHCN ages 2 to 21 years having a medically fragile or complex medical condition that required continual monitoring were enrolled with their parents/guardians. Interviews were conducted monthly for five months using the PedsQL TM Generic Core Module for child health and functioning, PedsQL TM Family Impact Module for family health and functioning, and Access to Care from the NS-CSHCN survey for health care services. Descriptive statistics, chi square, and ANCOVA were conducted to determine differences across care settings. Children in the P-PEC settings had a highest health care quality of life (HRQL) overall including physical and psychosocial functioning. Parents/guardians with CSHCN in LTC had the highest HRQL including having time and energy for a social life and employment. Parents/guardians with CSHCN in home care settings had the poorest HRQL including physical and psychosocial functioning with cognitive difficulties, difficulties with worry, communication, and daily activities. They had the fewest hours of employment and the most hours providing direct care for their children. Overall health care service use was the same across the care settings.

Based on the view of an agent as an information processing system, and the premise that for such a system it is evolutionary advantageous to be parsimonious with respect to informational burden, an information-theoretical framework is set up to study behaviour under information minimisation pressures. This framework is based on the existing method of relevant information, which is adopted and adapted to the study of a range of cognitive aspects. Firstly, the model of a simple reactive actor is extended to include layered decision making and a minimal memory, in which it is shown that these aspects can decrease some form of bandwidth requirements in an agent, but at the cost of an increase at a different stage or moment in time, or for the system as a whole. However, when combined, they do make it possible to operate with smaller bandwidths at each part of the cognitive system, without increasing the bandwidth of the whole or lowering performance. These results motivate the development of the concept of look-ahead information, which extends the relevant information method to include time, and future informational effects of immediate actions in a more principled way. It is shown that this concept can give rise to intrinsic drives to avoid uncertainty, simplify the environment, and develop a predictive memory. Next, the framework is extended to incorporate a set of goals, rather than deal with just a single task. This introduces the task description as a new source of relevant information, and with that the concept of relevant goal information. Studying this quantity results in several observations: minimising goal information bandwidth results in ritualised behaviour; relevant goal and state information may to some point be exchanged for one another without affecting the agent’s performance; the dynamics of goal information give rise to a natural notion of sub-goals; bottlenecks on goal memory, and a measure of efficiency on the use of these bottlenecks, provide natural abstractions of the environment, and a global reference frame that supersedes local features of the environment. Finally, it is shown how an agent or species could actually arrive at having a large repertoire of goals and accompanying optimal sensors and behaviour, while under a strong information-minimisation pressure. This is done by introducing an informational model of sensory evolution, which indicates that a fundamental information-theoretical law may underpin an important evolutionary catalyst; namely, even a fully minimal sensor can carry additional information, dubbed here concomitant information, that is required to unlock the actual relevant information, which enables a minimal agent to still explore, enter and acquire different niches, accelerating a possible evolution to higher acuity and behavioural abilities.

Background: Rectal cancer 5-year survival has increased from 58% of those diagnosed in 1987-1989 to 68% of those diagnosed in 2003-2009. Rectal cancer patients commonly receive one of two surgical treatments: permanent ostomy (a resection of tumor following by a stoma) or anastomosis (a resection followed by a reconnection with or without a prior temporary ostomy). The multifaceted consequences of both types of surgery potentially can affect both long-term psychological well-being and financial concerns of patients and their families. The overall goal of this dissertation is to increase the understanding of the impact of depression on the quality of life of rectal cancer survivors. Methods: The research data were based on a quality of life survey conducted in 2010-2011 among long-term survivors (≥ 5 years post-diagnosis) of rectal cancer. Participants were identified through the Kaiser Permanente (KP) health systems in Northern California and Southwest Washington/Oregon. Data included both the 2010/2011 survey data and KP electronic medical records (EMRs). Results: 1) The 24.7% prevalence of self-reported current depression among long-term rectal survivors was observed with a higher prevalence of 31% among those with permanent ostomies. Although average perceived financial burden level was low in this population of insured cancer survivors, 20% still reported moderate-to-high burden. Perceived financial burden was especially high among those who recalled having depression immediately after surgery and reported depression at the time of survey.2) All self-reported measures showed low sensitivity varying from 26% to 56% and high specificity from 77% to 82.7% against either diagnostic scheme from EMRs. Using either diagnostic scheme, the MCS-12 measure, a Mental Composite Summary (MCS) score from the 12-item Short-Form Health Survey with a cut-off point of≤45.6 for a self-reported depression, performed better as compared to the other two self-reported measures. 3) Approximately one in six rectal cancer survivors experienced depression after their surgery of sufficient severity to result in a depression diagnosis. Among survivors with recurrent depression diagnoses, those with a permanent ostomy reported significantly lower psychological well-being than those with an anastomosis. Conclusions: Depression burden is elevated after receiving surgery and remains a problem long after cancer diagnosis and treatment. Types of rectal cancer surgery received and gender of survivors may complicate the extent of depression burden. Among long-term rectal cancer survivors, having depression is associated with higher perceived financial burden. Chronic or recurrent course of depression may exist in this group of rectal cancer survivors and has significant impact on long-term psychological well-being. Self-reported measures for depression, such as MCS-12 measure with a cutoff point≤45.6, have the potential to be utilized for epidemiological studies when common screening instruments, electronic medical records, or administrative databases are not available. Implications: These findings underline the significance of depression assessments after surgery for this population of rectal cancer survivors and the importance of symptoms monitoring throughout the cancer survivorship continuum. Depressive symptoms should be monitored and managed as early as after cancer diagnosis and surgery to optimize survivors' long-term emotional well-being. In addition, depression screening and treatment as well as discussion of financial issues may have important roles in long-term survivorship care planning, particularly for those with permanent ostomies.

Water, sediments, floodplain soils, and fish from Big and Little Bayou creeks were assessed for polychlorinated biphenyls (PCBs) and metals in 1987-2005. The streams were impacted by effluents from the Paducah Gaseous Diffusion Plant (PGDP). PCBs were rarely detected in water samples. Aroclor 1248 detections in sediments and floodplains were sporadic, but 1254 and 1260 were consistent. Seasonal variations were only observed for Aroclor 1248. Detection of PCBs in floodplains indicated recent influx of contaminated sediments. Species-specific PCB residues patterns were studied for Lepomis cyanellus, L. megalotis, L. macrochirus, and Campostoma anomalum. Highest PCB concentrations were found in stoneroller minnows. PCBs decreased over time in sunfish species, but retained a baseline level. No relationships were found between sunfish age and PCB concentrations. At low PCB levels, green sunfish body burden (BB) did not correlate with lipid content. A certain PCB concentration must be exceeded before PCB BB correlates with lipid content. Stream flows differed by season, and fish PCB BB differed by season, but stream flow did not correlate with fish BB. Congener groups corresponded to Aroclor concentrations. Higher chlorinated biphenyls peaked in the spring for sport fish. PCBs remobilized in the spring resulted in higher summer BB for the stoneroller minnows, whereas sunfish eliminated PCBs by summer. This variability was due to the sunfishs ability to regulate PCBs. Metal concentrations did not display the seasonal variability evident in the PCB data. Water metals may have peaked during storm events and decreased rapidly. Water Pb increased with time, but the source could not determined. Zinc in Little Bayou creek likely originated from the PGDP. Except for Cu and Zn, stoneroller minnow metal BB decreased with time. Metal BB were used to determine bioavailable fractions. Less than half of the water column Cd, Cr, Fe, and Pb in impacted areas were bioavailable to stoneroller minnows, whereas 59% of Ag, 73% of Cu, and 64% of Zn were bioavailable. Cumulative criterion units were calculated to determine additive metal impacts, and proved useful in locating sectors with possible ecological impact. In-situ monitors proved valuable in studying PCB and metal behavior under real-world conditions.

The introduction of the polymerase chain reaction (PCR) into the diagnostic setting has provided unprecedented opportunities in the field of respiratory medicine, not only because pathogens need no longer be cultivable for detection but also through improved sensitivity, specificity and turnaround time compared with traditional methods. The recent discovery of several novel respiratory viruses, such as human metapneumovirus (HMPV), human bocavirus and human coronaviruses (HCoVs) NL63 and HKU1 has nevertheless created significant challenges in respiratory diagnostics, as identification of which pathogens should be tested for is increasingly difficult. The recent discovery of two novel respiratory coronaviruses (HCoV-HKU1 and HCoV-NL63) presented the opportunity to undertake large scale clinical and epidemiologic study of these alongside two previously known respiratory coronaviruses, HCoV-229E and HCoV-OC43. Over 12,000 samples collected over three years were screened using a novel four-way multiplex real-time reverse transcription-PCR (RTPCR). Clinically, coronaviruses were similar to viruses currently included in routine diagnostics, with the exception of HCoV-229E which was identified as an opportunistic pathogen in immunocompromised hosts. Variability in detection frequencies of HCoVHKU1 and HCoV-OC43 was evident. The low detection frequencies of HCoVs, comparable to those of parainfluenza viruses 1 and 2 (which are included in the routine diagnostic screening panel) indicate a borderline case for inclusion of these pathogens in routine respiratory diagnostics. To investigate the epidemiology and clinical correlates of HMPV in Edinburgh, large scale retrospective screening of over 7000 respiratory samples collected over two years was conducted. Nucleotide sequencing of HMPV-positive samples was undertaken to determine phylogenetic relationships of circulating HMPV strains. HMPV comprises two genotypes, A and B. Comparisons of the clinical presentations of the two genotypes revealed little difference, with only the observation that sub-genotype B2 was more frequently associated with infection of immunocompromised patients. Detection frequencies and symptomatology associated with HMPV infections were comparable to respiratory viruses currently included in the routine diagnostic panel, mandating its inclusion in future diagnostic screening. A switch of the predominantly circulating genotype of HMPV was observed between respiratory seasons. This is a phenomenon more widely reported for the closely related respiratory syncytial virus (HRSV), which also comprises two circulating groups. To further investigate subtype (HRSV)/ genotype (HMPV) switching, evolutionary analyses of nucleotide sequence data generated from isolates collected from geographically disparate referral centres was undertaken. The fusion and attachment (G) genes were targeted, as these encode major surface proteins and are immunogenic. Analyses were by MCMC analyses using Bayesian Evolutionary Analyses of Sampling Trees (BEAST) software. Identification of positively selected sites was performed using Phylogenetic Analysis Maximum Likelihood (PAML). Switching of the predominantly circulating lineage does not arise for either virus due to emergence of novel strains, but through fluctuating circulation frequencies of pre-existing lineages which have been circulating for several decades, indicated by the time since the most recent common ancestor. Two HRSV-A lineages comprising genotypes undergoing turnover and replacement were identified. This finding is agreeable with serologic studies of the 1970s which reported three HRSV serogroups, two within HRSV-A and one within HRSV-B. HMPV and HRSV have similar mutation rates. Positively selected sites identified within the HRSV G gene were incongruent with those identified in a previous study, generating the hypothesis that immune evasion occurs within linear epitopes rather than at specific sites. A great deal of clinical and epidemiologic data was generated through this work, parallel studies of other respiratory viruses and through diagnostic screening results. To provide a robust indication of where resources should be diverted in terms of diagnostics, therapeutics and vaccine development, and to inform infection control measures and public health policy planning, quantification of the relative disease burden attributable to the most commonly detected respiratory viruses was calculated using the World Health Organization- endorsed Disability Adjusted Life Year (DALY) model. Relative disease burden was calculated in an age stratified manner to reflect the differences in sampling in different age groups. HRSV and influenza A were consistently one of the greatest causes of disease regardless of sampled population, although HRSV caused more disease in children under 5 than influenza A and B combined. Rhinoviruses and PIV-3 were significant pathogens in all groups except those aged 16-64 years; rhinoviruses were the leading cause of disease in the immunocompromised patient group. The potential for patient-specific diagnostic screening and guidance of interventions such as patient cohorting were clear.

This thesis explores treatment satisfaction and dissatisfaction in patients with chronic low back pain (CLBP). Chapters 1 and 2 provide background on CLBP, and treatment satisfaction and dissatisfaction. Chapter 3 presents study 1, the systematic review which identified research concerning treatment satisfaction and dissatisfaction in patients with CLBP. Findings indicated a need to define the concept, and establish appropriate measurement based on patient input and evidence to support the reliability and validity of items. Chapter 4 presents study 2, a qualitative study. Ten patients with CLBP taking medication and/or receiving physiotherapy were interviewed. A conceptual model of CLBP and a thematic map of treatment satisfaction and dissatisfaction were developed. Satisfaction was related to being 'happy' or 'pleased', and maintaining normal functioning. Treatment not working, causing discomfort, or negatively affecting health-related quality of life, as well as inconvenience of medication, lack of information, not feeling involved in treatment decisions, lack of trust and confidence in healthcare professionals, and being misdiagnosed or undiagnosed, were associated with dissatisfaction. Chapter 5 documents the development of the CLBP Treatment Satisfaction Questionnaire, based on patient input from study 2. Cognitive debriefing showed items were relevant and understood by patients. Chapter 6, study 3, explored the psychometric properties of the questionnaire. The longitudinal design involved data collection from 249 patients, some of whom participated in follow-ups. Results indicated that treatment satisfaction/dissatisfaction involves an appraisal of the following seven domains: 'Information Provided about Back Pain and Treatment', 'Burden of Back Pain', 'Impact of Back Pain and Treatment on Relationships', 'Satisfaction with the Treatment Process', 'Problems with Side Effects of Medication', 'Adherence to Physiotherapy', and 'Medication Acceptability'. Some evidence of reliability and validity are presented. This thesis concludes with Chapter 7, a discussion of the main findings of the studies, strengths and limitations, and recommendations for future research.