Cuidado Paliativo é cuidado ativo total de pacientes cuja doença não é mais passível de responder a tratamento curativo. Almeja-se controlar a dor e outros sintomas e tratar de problemas de ordem psicológica, social e espiritual. O objetivo é melhorar a qualidade de vida do paciente e de seus familiares, de acordo com a definição da Organização Mundial de Saúde. Esta abordagem, portanto, é de responsabilidade de uma equipe multidisciplinar que enfoca a pessoa doente e o alívio integral do sofrimento. A vida é afirmada, e a morte é encarada como natural, não sendo antecipada nem postergada. Dada a importância desta difícil tarefa, é crucial que o atendimento seja de boa qualidade, e para tanto é necessário utilizar indicadores de qualidade do Cuidado Paliativo. No caso do câncer incurável, os indicadores de qualidade do Cuidado Paliativo incluem a avaliação da qualidade de vida, do controle dos sintomas e da satisfação do paciente e da família com o cuidado. Além desses indicadores, fundamentais, porém de difícil obtenção, existem aqueles obtidos com base em dados administrativos. Dentre estes, os mais frequentes são a fração de pacientes encaminhados ao Cuidado Paliativo, a porcentagem de pacientes que receberam quimioterapia no final da vida e fração de óbitos ocorridos na unidade de cuidados paliativos ou no domicílio. Numa situação ideal, espera-se que a grande maioria dos pacientes seja encaminhada à unidade de cuidados paliativos e que o óbito ocorra na própria unidade ou na residência do paciente, e não em unidades de emergência, na terapia intensiva ou em enfermarias gerais. Quanto à quimioterapia no final da vida, pode ser um indicador de tratamento inapropriadamente agressivo. Cabe ressaltar, contudo, que estes indicadores não estão universalmente validados. Levando-se em consideração esta limitação, estudos em outros países concluem que o Cuidado Paliativo é subutilizado e introduzido tardiamente no curso da doença. Este cenário negativo inclui o uso agressivo da quimioterapia no final da vida. Um diagnóstico de câncer de pulmão metastático geralmente implica em um curto tempo de vida com uma carga elevada de sintomas. Nesta situação, a quimioterapia parece ser vantajosa, prolongando a vida e melhorando a sua qualidade, quando se avalia esse grupo de pacientes de uma forma global. Em um paciente individual, porém, há de ser levar em conta seu estado funcional, bem como as comorbidades e a toxicidade do tratamento. Também são importantes aspectos da comunicação médico-paciente quanto ao prognóstico e os benefícios esperados da quimioterapia. Neste contexto, a necessidade da visão global do paciente e do controle de sintomas implica no Cuidado Paliativo, isoladamente ou associado ao tratamento oncológico específico. Resolvemos, portanto investigar, retrospectivamente, indicadores de qualidade, com base em dados administrativos, do Cuidado Paliativo em pacientes portadores de câncer de pulmão não pequenas células (CPNPC) metastático atendidos na Fundação Pio XII, Hospital de Câncer de Barretos, cujo óbito tenha ocorrido entre Janeiro de 2003 e Janeiro de 2005. Os indicadores escolhidos foram a porcentagem de pacientes encaminhados à unidade de Cuidados Paliativos, o local do óbito e a porcentagem de pacientes que receberam quimioterapia no último mês de vida.No total foram revisados 275 prontuários, destes 36 estavam incompletos, sendo elegíveis 239 pacientes para as análises. A data do óbito foi detectada em 218 pacientes, sendo o atestado de óbito disponível em 166 pacientes. A maioria dos pacientes (75,3%) tinha baixa escolaridade, analfabetos ou com o ensino fundamental incompleto. A cor era branca em 78,6% dos casos e a idade mediana era de 64 anos (intervalo 31-90 anos). O hábito do tabagismo foi detectado em 77,4% dos pacientes. Quanto às características clínicas, notamos que o escore de estado funcional Karnofsky (KPS) não foi registrado em aproximadamente metade dos pacientes. Naqueles em que havia registro, 58,8% apresentavam estado funcional preservado (KPS >70%). Os sítios de metástase mais frequentes foram o fígado (39,3%), ossos (22,6%) e cérebro (19,7%). Em relação aos sintomas, os mais frequentes foram dor (47,6%) e dispnéia (34,3%), sendo os opiódes usados por 36,8% dos pacientes. O tratamento oncológico consistiu em cirurgias (6,5%), radioterapia (61,9%) e quimioterapia (44,7%). Os esquemas mais utilizados (85,9%) em primeira linha foram as combinações baseadas em platina, com uma mediana de três ciclos administrados por paciente. A quimioterapia de segunda linha foi aplicada em 9,0% dos pacientes.Quanto aos indicadores de qualidade do Cuidado Paliativo, somente 104/239 (43,5%) dos pacientes foram encaminhados à unidade de cuidados paliativos. Nestes o óbito ocorreu em 38 ± 58 (media ± desvio padrão) dias, sendo uma fração importante destes, 20/104 (19,2%), em menos de quatro dias. Num modelo por análise de regressão logística, o sexo feminino, a menor escolaridade, a realização de radioterapia, a ausência de dor, e a ausência do uso de quimioterapia foram preditivos do encaminhamento à unidade (p=0,04; 0,03; 0,01; 0,03; 0,05), respectivamente. A quimioterapia foi aplicada em 46 dos 239 pacientes (19,2%) no último mês de vida, sendo a ausência de realização de radioterapia (p= 0,02) o único fator preditivo, pela análise de regressão logística. Em relação ao local do óbito, este ocorreu no domicílio ou na unidade de cuidados paliativos em somente 119/218 (55,5%) dos casos, sendo os restantes em enfermarias clínicas, na emergência ou em unidades de terapia intensiva. A sobrevida global foi de 4,4 ± 0,3 (media ± desvio padrão) meses após o diagnóstico da metástase, pela análise de Kaplan-Meier.Em conclusão, este grupo de pacientes portadores de CPNPC metastático não se beneficiou plenamente do Cuidado Paliativo e uma fração significativa destes foi submetida a tratamento agressivo no final da vida. A dificuldade em estimar-se o prognóstico e fatores culturais ligados a negação da finitude humana e exaltação da tecnologia, além de barreiras na comunicação médico-paciente precisam ser melhor estudados / Palliative Care is the total active care of patients whose disease is no longer amenable to curative measures. Control of pain and other symptoms is a priority, and psychological, social and spiritual issues are taken into consideration. The goal is to improve the quality of life of patients and of their families, according to the World Health Organization definition. Thus a team approach is necessary, with focus on the individual as a whole and aiming to ease suffering. Life is affirmed and death is seen as natural and neither hastened nor postponed. Given the importance of this hard task, quality of care should be optimal. In relation to incurable cancer, Palliative Care quality measures include the evaluation of the quality of life, of symptom control and of patient´s and family satisfaction with care. In addition to these measures, which are fundamental but difficult to obtain, there are those obtained from administrative data. Among these, the most frequent are the percentage of patients who were referred to the palliative care unit, the percentage of patients who were treated with chemotherapy near the end of life and the fraction of patients who died in their homes or in the palliative care unit. In an ideal setting, the great majority of these patients should be referred to Palliative Care, the place of death should be the Palliative Care unit or the patients´ homes. Death should not occur in emergency rooms, intensive care units or acute care inpatient units. Regarding chemotherapy administration near the end of life, that may imply in an inappropriately aggressive treatment. However, these quality measures lack universal validation. With this caveat in mind, studies conducted in other countries concluded that Palliative Care is underutilized and introduced late in the disease course. This negative scenario includes the aggressive use of chemotherapy near the end of life.A diagnosis of metastatic lung cancer usually implies in a short survival and a heavy symptom burden. Chemotherapy may prolong survival and improve the quality of life, when this population is analyzed as a whole. In the individual patient, however, performance status, comorbidities and treatment toxicity must be taken into consideration. Patient-doctor communication issues that deal with prognosis and the expected benefits of chemotherapy are also critical. In this context, to see the patient as a whole and symptom control demands Palliative Care, alone or in addition to specific anti-cancer treatment.Thus, we decided to retrospectively investigate administrative based quality measures of Palliative Care in metastatic non small cell lung cancer patients (NSCLC), who were managed at Fundação Pio XII, Hospital de Câncer de Barretos, and who died from January 2003 to January 2005. The measures that were chosen were the percentage of patients who were referred to the palliative care unit, the place of death and the percentage of patients who were treated with chemotherapy in the last month of life. A total of 275 patient charts were reviewed, 36 were incomplete, thus 239 patients were eligible for the analysis of clinical and treatment characteristics. The time of death was available for 218 patients, and the death certificate was available for 166 patients. Most (75,3%) patients had a low educational level, being illiterate or with incomplete elementary school. Patients were white (78,6%) with median age of 64 years (range 31-90 years). Smoking history was positive in 77,4% patients. In relation to the clinical characteristics, Karnofsky (KPS) performance status score was not recorded in approximately half of the patient group. In those that it was available, 58,8% presented with preserved functional status do (KPS>70). The most frequent metastatic sites were liver (39,3%), bones (22,6%) and brain (19,7%). The most frequent symptoms were pain (47,6%) and shortness of breath (34,3%); opioids were used by 36,8% dos patients. Cancer treatment was surgery (6,5%), radiotherapy (61,9%) and chemotherapy (44,7%). The most commonly used protocols in first line (85,9%) were platinun based combination chemotherapy, with a median of three cycles per patient. Second line chemotherapy was administered to 9,0% of patients.In relation to the Palliative Care quality measures, only 104/239 (43,5%) patients were referred to the unit, 38±58 days before death, being a significant minority, 20/104 (19,2%) referred late, four or less days before death. In a logistic regression model, female gender, low educational level, radiotherapy, lack of pain and lack of chemotherapy administration were predictive of referral to the unit (p=0,04; 0,03; 0,01; 0,03; 0,05), respectively. Chemotherapy was administered to a significant minority 46/239 (19,2%) of patients in the last month of life. In this case, the lack of radiotherapy was the only predictive variable by logistic regression analysis (p= 0,02). The place of death was in the patients´ homes or in the Palliative Care unit in only 119/218 (55,5%) cases, being the rest in acute care beds, emergency rooms or intensive care units. The overall survival after the diagnosis of metastatic disease was 4,4 ± 0,3 months, by Kaplan-Meier analysis.In conclusion, our NSCLC patients did not fully benefit from Palliative Care and a significant fraction of these patients were submitted to aggressive care near the end of their lives. The difficulty in estimating patients´ prognosis and cultural factors linked to the denial of human finitude and technicism, as well as patient- doctor communication barriers should be explored in future studies

Orientador: Lee Luan Ling / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia Eletrica e de Computação / Made available in DSpace on 2018-08-03T21:35:27Z (GMT). No. of bitstreams: 1 Hwang_Fernando_M.pdf: 5466957 bytes, checksum: 06a2e1e62bae4e53bd64a55d9d64c0f5 (MD5) Previous issue date: 2004 / Mestrado

Denna uppsats syfte och mål har varit att undersöka distribution och funktion för den i dellboska partikeln e. Undersökningen utgår från material transkriberat dels från egna inspelningar, dels inspelningar från Swedia2000projektet. Analysen uppdelas sedan på två delar; en första grammatisk undersökning för att fastställa regler för distributionen, somgenomförs utifrån skribentens och informanters språkkänsla samt konkordansundersökningar. Dessa resultat ligger sedan till grund för undersökningen av partikelns funktion i diskursen utifrån definitioner av diskursmarkörer. Slutligen har undersökningen visat att partikelntroligtvis kan införas under begreppet final dubblering av negation, samt också kan definieras som en diskurspartkel med funktionen att signalera övertygelse om att det som sägs är riktigt, och något som inte bör ifrågasättas.

This dissertation investigates the role of grammatical versus methodological influences in the production and perception of final devoicing in experimentally-elicited speech from Russian. It addresses the question of how the partial preservation of the phonological voicing contrast in word-final obstruents is affected by (i) task-independent factors that reflect phonological and lexical properties of stimuli words (underlying voicing, word length, lexical competition) and (ii) task-dependent biases that arise due to the nature of the experimental task performed by the speaker (availability of orthographic inputs, presence of minimal pairs among the stimuli). Results of a series of acoustic production and perceptual identification tasks reveal that task-dependent factors account for the presence of robust and perceptually salient differences in the parameter of phonetic voicing. Several types of stimuli items also show limited but statistically significant differences in closure/frication duration and release duration that are independent of the presence of orthography or inclusion of full minimal pairs among test items. Taken together, these findings indicate that non-grammatical factors can play a prominent biasing role in both production and perception of the voicing contrast in experimentally-elicited speech, such that certain voicing-dependent cues are maintained only in the presence of task-dependent pressures. However, not all incompletely neutralized differences between phonologically voiced versus voiceless final obstruents can be attributed to the effects of orthography or inclusion of minimal pairs among the stimuli. In the theoretical domain, these results are argued to favour a less restrictive definition of neutralization and a model of phonology that views devoicing as a loss of the primary acoustic cue to the underlying voicing contrast rather than complete identity of the [voiced] feature.

This thesis project examined both schwa insertion and simplification following word-final consonant clusters in a large corpus of spoken French. Two main research questions were addressed. Can a system of forced alignment reliably reproduce pronunciation judgements that closely match those of a human researcher? How do variables, such as speech style, following context, motivation for simplification and speech rate, affect the variable pronunciations of word-final consonant clusters? This project describes the creation and testing of a novel system of forced alignment capable of segmenting recorded French speech. The results of comparing the pronunciation judgements between automatic and manual methods of recognition suggest that a system of forced alignment using speaker adapted acoustic models performed better than other acoustic models; produced results that are likely to be similar to the results produced by manual identification; and that the results of forced alignment are not likely to be affected by changes in speech style or speech rate. This project also described the application of forced alignment on a corpus of natural language spoken French. The results presented in this large sample corpus analysis suggest that the dialectal differences between Québec and France are not as simple as ``simplification in Québec, schwa insertion in France". While the results presented here suggest that the process of simplification following a word-final consonant cluster is similar in both dialects, the process of schwa insertion is likely to be different in each dialect. In both dialects, word-final consonant cluster simplification is more frequent in a preconsonantal context; is most likely in a spontaneous or less formal speech style and in that speech style is positively associated with higher speaking rates. Schwa insertion following a word-final consonant cluster displays much stronger dialectal differences. Schwa insertion in the dialect from France is strongly affected by following context and possibly speech style. Schwa insertion in the dialect from Québec is not affected by following context and is strongly predicted by a lack of consonant cluster simplification.

This thesis provides a look on the issue of logistics on the present. The main objectives of the thesis are representation of the logistic flow of final products of the company Opavia-LU, s r.o. to the final client to maximize his needs and to focus on the certain problem and find his solution. The thesis is divided into theoretical and practical part. The theoretical part is dedicated to analysis of the basic theoretical points of logistics and the assumptions of its efficiency. In the practical part there is the description and the analysis of the logistic flow of final products and the solution of the concrete problem.

The aim of this diploma work is the examination of using the public financial statements as a basis for extern financial analysis. The work consists of three parts. The first part concerns the final accounts set up according to the Czech accounting rules. It describes the legal regulation of this domain, basic requirements on public information, individual elements of final accounts and further obligations associated with it. Second part of the work is aimed at the financial analysis and gives an overview of information sources and basic techniques of financial analysis. It is mainly focused on the horizontal and vertical analysis of financial statements and analysis of ratio indicators. In the third part, obtained theoretical knowledge in the field of financial analysis is used for examination of financial health of particular company DOPRAVA ZARUBA M&K, s.r.o..

My final thesis concerns Employee Research which has been done in Siemens company.

This diploma work deals with the manner in which the internal auditor should communicate the results of their engagement findings to other departments within the organization. This diploma work deals with to whom the internal auditor should disclose certain facts and how to choose the appropriate form of audit reports in order to give their addressees best possibility to point to these audit findings and create follow-up with an effective remedy for the irregularities found.

This thesis is focused on the impact of the events that are connected with the Palestinian-Israeli conflict. The main focus is on the socioeconomic impact those events had on the Gaza Strip and West Bank. Therefore, the first chapter of this thesis summarizes the development in the area of today's Israel, Gaza Strip and West Bank territories in the period before the formation of the state of Israel to today. The second chapter continues with the socioeconomic description of those territories since the year 1967 until today. This chapter shows the influence of the occupation on the socioeconomic situation in the areas mentioned above and describes the socioeconomic changes that appeared in connection with the peace process in the nineties and also explains the influence of the current events on the socioeconomic situation in both areas. The thesis ends with a chapter that is focused on the main problems that appear when negotiating about the final status of the Palestinian territories, including the economic issues, and it outlines a possible solution of those problems in the case of a hypothetical decision for the existence of two independent states -- Palestine and Israel.