Les patients coronariens stables ou stabilisés sont à haut risque d’évènements cardiovasculaires. Ils représentent une population hétérogène avec une présentation clinique, un terrain et un pronostic pouvant être extrêmement variables d’un patient à l’autre. Pourtant, d’après les recommandations internationales, tous doivent bénéficier d’une prise en charge relativement comparable basée sur des essais cliniques réalisés dans des sous-populations restreintes de patients stables et instables, pour la plupart anciens, et ne correspondant plus à la prise en charge actuelle des patients. Préciser les déterminants du pronostic de cette population, et notamment les stratégies thérapeutiques, est un enjeu majeur.Les antagonistes du système rénine-angiotensine (IEC/ARA2) font partie de l’arsenal médicamenteux de tout patient coronarien. Pourtant leur intérêt, en association aux antiagrégants plaquettaires et statines, est incertain chez les patients sans dysfonction ventriculaire gauche qui constituent un sous-groupe important parmi les patients stables.Le registre international REACH a évalué l’impact des IEC/ARA2 dans cette population avec 4 ans de suivi. La méthodologie statistique utilisée a été une analyse observationnelle avec ajustement ou avec appariement selon le score de propension. Il n’a pas été mis en évidence de bénéfice des IEC/ARA2 sur le critère de jugement principal composite associant décès cardiovasculaire – IDM – AVC, de même que sur le critère de jugement secondaire associant décès cardiovasculaire – IDM – AVC – Hospitalisation pour évènement athéro-thrombotique ou sur les critères tertiaires comprenant individuellement chacun des critères de jugement secondaire ainsi que sur la mortalité toute cause. Enfin il n’est pas ressorti non plus de bénéfice franc dans les sous-groupes d’analyse. Les résultats ont été concordants lorsque les analyses ont été réalisées pour les IEC seuls ou pour les ARA2 seuls, et ont été confortés par diverses analyses de sensibilité.Ces données méritent confirmation dans une cohorte indépendante. C’est l’un des objectifs du registre CLARIFY, registre de 32703 patients coronariens stables ou stabilisés, dont le suivi à 5 ans est terminé. Dans ce registre contemporain international, le taux global à 5 ans de mortalité toute cause a été de 7,9%, de mortalité non cardiovasculaire de 5% et de mortalité cardiovasculaire de 2,9%. Un évènement cardiovasculaire comprenant infarctus du myocarde (fatal ou non), angor instable, revascularisation coronaire par angioplastie ou pontage est survenu chez 15,9% des patients.Tout comme les IEC/ARA2, l’impact des bétabloquants dans la prise en charge du coronarien stable ou stabilisé, sans dysfonction ventriculaire est également controversé. Cette classe médicamenteuse est en cours d’évaluation dans CLARIFY. L’analyse tient compte du type de bétabloquant, de la dose prescrite, des éventuelles intolérances amenant à modifier leur utilisation, de la présence et de l’ancienneté d’un infarctus du myocarde et la fraction d’éjection ventriculaire gauche.CLARIFY a également pour objectif d’approfondir les déterminants du pronostic de la maladie coronarienne stable, avec une analyse spécifiquement focalisée sur la présence de symptômes angineux, d’ischémie myocardique et sur leur combinaison, en fonction de l’utilisation des méthodes de revascularisation myocardiques, pour mieux comprendre les mécanismes responsables des évènements cardiovasculaires et évoluer vers une prise en charge plus personnalisée. / Stable or stabilized coronary artery disease patients are at high risk for cardiovascular events. They represent a heterogeneous population. The clinical presentation, the context and the prognosis can be extremely variable from one patient to another. However, according to the international guidelines, those patients should be given a relatively comparable treatment based on clinical trials realized in restricted subpopulations of stable and unstable patients. Most of these trials are old, and no longer correspond to the current management. Specifying the determinants of the prognosis of this population, and in particular the therapeutic strategies, is a major challenge.The antagonist receptors of renin-angiotensin system (ACEI/ARB) are a part of the treatment of any coronary artery disease patient. Yet their interest in the prognosis of this population without left ventricular dysfunction in association with antiplatelet agents and statins is uncertain.The contemporary REACH registry has assessed the impact of ACEI/ARB in this population with a 4-year of follow-up. The statistical methodology used was based on the propensity score. After adjustment or matching with the propensity score, there was no benefit of ACEI/ARB on the primary endpoint of cardiovascular death - MI - stroke. No benefit was found on the secondary endpoint of cardiovascular death - MI - stroke - hospitalization for atherothrombotic events. No benefit was found on the tertiary criteria including individually each of the secondary endpoints and on any cause mortality. Finally,there was no clear benefit in the analyzes subgroups. These results were consistent when the analyzes were performed for ACEI alone or for ARB alone. They were also supported by sensitivity analyzes.These data should be confirmed or reversed in an independent cohort. This will be one of the many objectives of the CLARIFY registry, that enrolled 32,703 stable or stabilized coronary artery disease patients. The 5-year follow-up is complete. In this international contemporary registry, the overall 5-year rate of total mortality was 7.9%, non-cardiovascular mortality was 5% and cardiovascular mortality was 2.9%. A cardiovascular event including myocardial infarction (fatal or not), unstable angina, coronary revascularization by angioplasty or bypass surgery occured in 15.9% of patients.Like ACEI/ARB, the impact of betablockers on the management of stable or stabilized coronary artery disease without left ventricular dysfunction is also controversial. This drug class is being evaluated in CLARIFY. The analyzis takes into account the type of beta-blocker, the prescribed dose, any intolerance leading to changes in their use, the history of a myocardial infarction, and the left ventricular ejection fraction.CLARIFY will help to more define the determinants of the prognosis of stable coronary artery disease, with a more particular focus on symptomatic or not, ischemic or not, and revascularized or not, in order to better understand the mechanisms responsible for cardiovascular events, and evolve towards a more personalized and cost-effective care.

The purpose of this study was to determine the test-retest reliability of digitally recorded word recognition materials. Word recognition testing is included in a complete audiological evaluation to measure an individual's ability to discriminate what they hear. A phonetically balanced list of 50 monosyllabic words was presented to each participant at four different sensation levels (SL) using the American Speech Language Hearing Association recommended protocol for word recognition score testing. Each participant took a 10 minute break before the test was readministered. Participants included 40 subjects with varying levels of hearing loss, from normal hearing to severe hearing loss. The test and retest scores of all participants were analyzed to estimate the test-retest reliability to be .65 at 10 dB SL, .87 at 20 dB SL, .88 at 30 dB SL, and .95 at 40 dB SL. It was concluded that the word lists have strong test-retest reliability at 20, 30, and 40 dB SL and that the reliability increases as the presentation level increases.

Kaplan & Norton於1992年提出平衡計分卡做為績效評估工具後，已被許多國內外企業及政府部門陸續應用，並已產生提升績效的實際效果。臺北自來水事業處為提升機關績效，亦自2004年起應用平衡計分卡做為績效評估工具，其歷年來之推動成效與未來展望甚值探討，此為本文之研究動機與目的。 　　本文透過文獻研究法，廣泛蒐集各種文獻資料，以分析應用平衡計分卡做為績效評估工具之理論發展與運用趨勢，並以深度訪談法，瞭解研究個案機關各階層人員對平衡計分卡之認識與意見，進而提出更臻完善並具可行性的研究建議。 　　本研究主要建議有五項，機關策略地圖應適時修正、整合機關評估考核制度、強化機關績效管理能力、加強教育訓練與宣導平衡計分卡、儘速因應未來競爭環境。期待透過相關建議事項的採用，確立績效指標與績效考核標準，以建構出適用於個案機關自身環境的平衡計分卡績效評估模式，並藉由制度之推動，有助機關各單位績效目標更明確具體，在績效評估的衡量上產生良好效益，進而提升機關整體績效。 / Kaplan & Norton proposed the Balanced Score Card as a results assessment tool in 1992, there are many domestic and foreign enterprises and government departments apply the tool, and have produced practical results to enhance performance. Taipei Water Department in order to improve performance, use the Balanced Score Card as a performance assessment tool since 2004. The results of the effort and forecast over the years are very worth exploring. This is the motive and purpose of this study. The study collects all kinds of literature on the subject, and analyzes the development and application tendency of the Balanced Score Card as a performance evaluation tool. And by detailed interview method to realize the knowledge and opinions on the Balanced Scorecard of the study authorities at all levels of staff. Then we can propose more perfect and feasible research suggestion. There are five major recommendations of this study: authority strategy map should be duly amended; integration the assessment system of authority; strengthen the management capacity of agency performance; strengthen education, training and propaganda Balanced Score Card; in response to the future competitive environment as soon as possible. Look forward to adopt relevant recommendations of the matter, and establish performance indicators and performance assessment criteria. Construct a Balanced Score Card performance assessment mode to apply authority’s own environment. It’s helpful for various units of authority to more realize the performance goals by promoting the system. Produce good results on the performance evaluation, further improve the overall performance of organizations.

La simplification des algorithmes diagnostiques a entrainé une augmentation de la suspicion d'une embolie pulmonaire (EP). Sa prévalence est passée de 50% à moins de 20%. L'évocation du diagnostic peut être gênée par la coexistence d'une Broncho Pneumopathie Chronique Obstructive (BPCO). La 1ère étape de prise en charge d'un patient suspect d'EP est l'évaluation de la probabilité clinique, par exemple par le score de Genève. Nous montrons qu'en revenant au résultat de ce score, le clinicien prédit le risque de décès et de ré-hospitalisation dans les 3 mois que le patient ait - ou n'ait pas- d'EP. Ces résultats devraient permettre d'aider à décider d'un traitement ambulatoire ou d'une hospitalisation. De plus, nous montrons que l'existence d'une BPCO est associée à une modification de la présentation clinique de la Maladie Veineuse Thrombo-Embolique (MVTE): alors que ratio dans la population sans BPCO est de 2 Thromboses Veineuses Profondes (TVP) pour une 1 EP, ce rapport s'inverse dans la population de patients souffrant de BPCO. Ce point est critique car nous montrons par ailleurs que les patients BPCO avec MVTE présentent une moins bonne évolution que les patients sans BPCO, avec une augmentation du nombre de décès et de complication hémorragique pendant les 3 mois de suivi. En se concentrant sur les patients avec BPCO, il apparait que ceux se présentant initialement avec une EP sont plus à risque de mourir et de saigner dans les 3 mois de suivi par rapport aux patients BPCO avec TVP. Il est donc indispensable de trouver un traitement protégeant efficacement les patients BPCO avec EP d'une récidive embolique, mais sans augmenter le risque hémorragique

L'objectif de cette thèse est de conceptualiser, à partir de l'exploitation des données de remboursement de soins de l'Assurance Maladie, les différentes trajectoires de recours aux soins relatives à la prise en charge d'une pathologie chronique (asthme), et d'étudier les déterminants de ces trajectoires du point de vue du profil et du comportement subséquent du prescripteur de soins. L'étude de la relation entre le comportement prescriptif et la trajectoire de soins est appréhendée par des techniques de modélisation et d'analyses multivariées. L'objectif sous-jacent est d'évaluer, d'un point de vue médico-économique, l'impact de la typologie des prescripteurs (caractéristiques des offreurs de soins) sur les différentes trajectoires de soins suivies par les patients atteints de la pathologie définie supra. Les caractéristiques susceptibles d'identifier une typologie de prescripteur correspondent aux variables influant sur le comportement prescriptif, au sens large, du médecin (âge, sexe, durée d'exercice, type d'exercice, etc.). La question principale de la thèse est celle de l'effet régulateur de l'incitation économique, instaurée par le parcours de soins coordonnés (réforme de l'Assurance Maladie, août 2004), sur les trajectoires de soins, réellement observées, de patients atteints de pathologies chroniques. Les corollaires sont : Le déremboursement des actes hors parcours de soins coordonnés peut-il avoir un impact significatif sur la trajectoire empirique de prise en charge du patient ? Le profil du prescripteur d'actes médicaux a-t-il, toutes choses égales par ailleurs, un effet sur le respect ou non de la trajectoire de soins référentielle admise par le parcours de soins coordonnés ? Quels sont les déterminants principaux du non respect de cette trajectoire référentielle, du point de vue de l'analyse des caractéristiques des couples " médecin - patient" ?

<p>The problem of increasing eutrophication encouraged the Baltic States to implement new measures, which would help to decrease the nutrient load into the Baltic Sea. Constructed wetlands are considered as one of the possible solutions to the problem of nutrient leakage from agricultural areas in Sweden.</p><p>The aim of this study was to identify the best wetland locations in the Lake Ringsjön basin (in southern Sweden, Scania) using Land Score System (LSS) based on Geographic Information System (GIS). The required area of wetland was calculated on the base of average daily discharge in the whole basin. Next, the possible wetland sites were compared with the location of major nitrogen leakage sources (municipalities, and agriculture). The scenario, which came out from the implemented model (the wetland area required for each sub basin in the Lake Ringsjön basin), was compared to the two scenarios investigated by Swedish Meteorological and Hydrological Institute (SMHI), where wetlands covered 0,4 and 2% of the total cropland area in the Lake Ringsjön basin.</p><p>The result shows that the second SMHI’s scenario relates in some sub basins to the required wetland area calculated in my model. However, in some cases the wetland area seems to be underestimated.</p>

A “Value-Added” definition of school effectiveness calls for the evaluation of schools based on the unique contribution of schools to individual student academic growth. The estimates of value-added school effectiveness are usually used for ranking and classifying schools. The current simulation study examined and compared the validity of school effectiveness estimates in four statistical models for school ranking and classification. The simulation study was conducted under two sample size conditions and the situations typical in school effectiveness research. The Conditional Cross-Classified Model (CCCM) was used to simulate data. The findings indicated that the gain score model adjusting for students’ test scores at the end of kindergarten (i. e., prior entering to an elementary school) (Gain_kindergarten) could validly rank and classify schools. Other models, including the gain score model adjusting for students’ test scores at the end of Grade 4 (i. e., one year before estimating the school effectiveness in Grade 5) (Gain_grade4), the Unconditional Cross-Classified Model (UCCM), and the Layered Mixed Effect Model (LMEM), could not validly rank or classify schools. The failure of the UCCM model in school ranking and classification indicated that ignoring covariates would distort school rankings and classifications if no other analytical remedies were applied. The failure of the LMEM model in school ranking and classification indicated that estimation of correlations among repeated measures could not alleviate the damage caused by the omitted covariates. The failure of the Gain_grade4 model cautioned against adjustment using the test scores of the previous year. The success of the Gain_kindergarten model indicated that under some circumstances, it was possible to achieve valid school rankings and classifications with only two time points of data.

This thesis consists of three essays that examine issues on university attendance behavior, factorsof university completion, and the labor market value of a university diploma in Sweden. Essay [I] analyzes how the rapid expansion of higher education that increased the geographicalaccessibility to higher education in the 1990s affected university enrollment decisions amongvarious socioeconomic groups of young adults in Sweden. The empirical findings show that theprobability of enrollment in university education increases with accessibility to universityeducation. The results also indicate that accessibility adds to the likelihood of attending auniversity within the region of residence. Access to higher education more locally seems to havedecreased the social distance to higher education, meaning that the option of attending highereducation, as compared to entering the local labor market after upper secondary school, hasbecome a more common and a more natural alternative for more socioeconomic groups insociety. Essay [II] compares the performance of students in universities built before and after the largedecentralization and expansion of the higher educational system in Sweden, starting in the late1970s. Two outcome measures are used: (i) whether or not the student has obtained a degreewithin seven years after she initiated her studies; and (ii) whether or not she obtained 120 creditpoints (the requirement for most undergraduate degrees) within seven years. Controlling forseveral background variables as well as GPA scores in a binomial probit model, we show thatstudents at old universities are about 5 percentage points more likely to get a degree and about 9percentage points more likely to obtain 120 credit points. However, in an extended bivariatemodel where we consider selection on unobservables into university type, we cannot reject thepossibility of no difference in performance between the two university types. Essay [III] analyzes the labor market value of a university diploma (sheepskin) in Sweden. Incontrast to previous studies, this study only focuses on Swedish university students who havethree years of full time university education or more − where some have obtained a universitydegree, others not. The results show that for male students, the wage premium of possessing adegree, i.e. the sheepskin effect, is roughly 5-8 percent. For women, it is about 6-7 percent forthose who have completed four years of fulltime or more. For students who attended a moreprestigious university in the metropolitan areas in Sweden and majored in the natural sciences, asheepskin effect of roughly 13 percent for men and 22 percent for women is traced. However,this result did not hold among students who attended. Keywords: Higher education, university enrollment; university choice; accessibility; universitycompletion; selection bias; propensity score matching, sheepskin, human capital.

Questo lavoro analizza le determinanti dell’abbandono scolastico nel settore della Further Education in Inghilterra. In particolare, il primo capitolo descrive i modelli teorici per l’analisi dell’abbandono scolastico e fornisce una revisione della letteratura sulle principali determinanti dell’abbandono scolastico. Il secondo capitolo si concentra sugli effetti della dimensione delle scuole e delle aree di insegnamento sulla probabilita’ di abbandono parziale e totale. Introduce il concetto di abbandono parziale, dimostrando che gli studenti che hanno abbandonato lo studio di alcune ma non tutte le materie a cui si erano iscritti reagiscono a cambiamenti nella dimensione delle scuole e delle aree di insegnamento in maniera simile agli studenti che abbandonano completamente gli studi. Il terzo capitolo analizza l’effetto causale dell’iscrizione a istituzioni di Further Education che sono state recentemente fuse sulla probabilita’ di non completare gli studi. Utilizziamo la tecnica del propensity score matching e controlliamo la qualita’ del matching e la sensibilita’ delle stime al fallimento dell’assunzione di unconfoundedness. I nostri risultati dimostrano che iscriversi ad una scuola oggetto di fusione riduce la probabilita’ di abbandonale gli studi. / This work analyses the determinants of dropout behavior in the Further Education sector in England. More specifically, the first chapter describe the theoretical framework for the analysis of student withdrawal and provides a review of the literature on the main determinants of dropout behavior. The second chapter focuses on the effect of college and programme area size on the probability of dropping out both partially and completely. It introduces the concept of partial dropout showing that students that dropped out of some modules but not all the ones they were enrolled on react to changes in college and programme area size similarly to the ones that dropped out completely. The third chapter analyses the causal effect of enrolling in a recently merged Further Education college on the probability of dropping out. We employ the propensity score matching approach and check the quality of our matching and the sensitivity of the estimates to the failure of the unconfoundedness assumption. Our findings show that enrolling in a merged college reduces the probability of dropping out.

Rates of labor induction and augmentation have been increasing in recent decades (Glantz, 2005). According to the Listening to Mothers II survey, half of all labors in the U.S. are induced or augmented with Pitocin or other synthetic form of the hormone oxytocin (Declercq et al., 2006). Oxytocin, a naturally occurring hormone released in the pituitary gland, is involved in the stimulation of uterine contractions during labor and in the milk ejection reflex during breastfeeding, and research suggests it also has various effects on the brain, such as eliciting maternal behavior. However, studies have shown that exogenous oxytocin can interfere with the natural production and regulation of oxytocin and can have adverse effects on the fetus and mother. Therefore, I predict that the induction or augmentation of labor with Pitocin will negatively affect breastfeeding following birth. The proposed study will compare LATCH scores, used in hospitals to measure postpartum breastfeeding success, of dyads exposed to intravenous Pitocin prior to birth with control dyads that had no exposure to Pitocin during labor. It is hypothesized that dyads exposed to Pitocin will have significantly lower LATCH scores than controls. Given the countless health benefits of breastfeeding for both mother and infant, the results of this study will have important implications for the evaluation of common practices during labor and birth.