Le syndrome confusionnel postopératoire (SCPO) chez la personne âgée (PA) est une complication fréquente et potentiellement grave. Sa prévention constitue donc un axe de travail essentiel dans une démarche globale et multidisciplinaire d’amélioration de la prise en soin des PA en chirurgie. Après une revue de la littérature, nous avons élaboré un programme multidisciplinaire de prévention du SCPO et sa méthodologie d’évaluation. Ce programme est actuellement en cours d’évaluation grâce à une étude interventionnelle, contrôlée, randomisée en stepped wedge (étude CONFUCIUS, financée par le Programme de Recherche en Qualité Hospitalière) au sein de trois services de chirurgie (orthopédie, digestif, urologie). À ce jour, 51 patients (âge moyen = 81,6 ans et 45% de femmes) ont été inclus. Le programme de prévention sera déployé à partir de novembre 2012 dans le service de chirurgie orthopédique en collaboration avec l’équipe mobile de gériatrie de l’établissement. Préalablement, nous avons évalué les connaissances et la perception des soignants relatives au SCPO grâce à une approche quantitative et qualitative. Celles-ci sont insuffisantes, tout particulièrement concernant les signes cliniques et le diagnostic. En effet, seuls 4% des soignants connaissaient la forme hypoactive et aucun l’outil diagnostique de référence, la Confusion Assessment Method. Une banalisation du SCPO a été mise en évidence, des croyances et des représentations persistent. Cela montre qu’il est nécessaire de lutter contre les idées reçues avant d’engager toute action de prévention. Nos travaux s’inscrivent dans une démarche globale et multidisciplinaire d’amélioration de la qualité et de la sécurité des soins en chirurgie et seront poursuivis, notamment par une étude permettant de déterminer le rôle prédictif des biomarqueurs du liquide céphalo-rachidien dans la survenue de SCPO et d’une démence 12 mois après l’intervention chirurgicale chez la PA / Postoperative delirium is common in elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology bases on randomized study design. After a review of literature, a multifaceted program of delirium prevention coordinated by a mobile geriatric team (MGT) was created. This program is currently being evaluated in a randomized, controlled, interventional, stepped wedge study (the CONFUCIUS study funding by the National French Program of Hospital Quality Research) within three surgical departments (orthopedics, gastroenterology, and urology). To date, 51 patients (mean age of 81.6 years; 45% female) have been included. The program will be rolled out from November 2012 in the department of orthopedic surgery in collaboration with the hospital’s MGT. Prior to the implementation of the prevention program, the knowledge base in older postoperative delirium. Only 4% of nursing staff knew the hypoactive form and none of nursing staff knew the Confusion Assessment Method. In addition, some stereotypes persist. This work is part of a comprehensive and multidisciplinary approach to improving quality and safety in surgical care. It will be followed by a study aiming to determine the capacity of cerebrospinal fluid biomarkers in predicting the onset of POD and dementia 12 months after surgery

Cylindrical shells are widely used in civil engineering. Examples include cooling towers, pipelines, nuclear containment vessels, steel silos and tanks for storage of bulk solids and liquids, and pressure vessels. The loading condition for these shells is quite varied depending on the function of the shell. Axial compression, global bending, external or internal pressure and wind loading are some of the most common loading forms for realistic structures. The failure of these cylindrical shell structures is often controlled by elastic or elastic-plastic buckling failure. Yield failure may occur in thick cylinders in some situations. A cylindrical shell under different loading conditions may display quite different buckling behaviour. The objective of this thesis is to investigate the characteristics of different buckling behaviours of cylindrical shell structures under axial compression, global bending, uniform external pressure and wind pressure. Some challenging practical problems in the design of these shell structures are explored. This thesis is expected to have some far-reaching impacts in defining how to design cylindrical shell structures to give them adequate strength to resist extreme events. Many aspects will be based on the latest Eurocode (EN 1993-1-6, 2007) and Recommendations (ECCS EDR5, 2008). The results show both some strength and some weaknesses in the Eurocode in design of shell structures. New methods are proposed for some practical problems. Some new conclusions and suggestions are derived and are expected to provide some useful knowledge for the improvement of the Eurocode in cylindrical shell design in general.

Sleep is essential for survival but a significant minority of the adult population are dissatisfied with their sleep, and 6-10% meet the criteria for insomnia disorder, characterised by difficulties falling asleep at bedtime, waking up in the middle of the night or too early in the morning, and daytime symptoms. Cognitive behavioural therapy for insomnia (CBT-I), an evidence-based sleep-focused intervention, has been suggested as the treatment of choice for chronic insomnia. However, access to specialised sleep therapists is sparse, and a service delivery model based on the principles of ‘stepped care’ has been proposed. Even though CBT-I is shown to be effective, there is a need to continue the development of cognitive behavioural treatments for insomnia. As a complement to traditional interventions, the potential value of acceptance, that is, to make an active choice of openness towards psychological experiences, has been recognized. However, it has not yet been systematically investigated, and specific instruments for studying acceptance in insomnia are lacking. The present thesis is based on three studies: Study I showed that manual-guided CBT for insomnia delivered by ordinary primary care personnel has a significant effect on perceived insomnia severity, sleep onset latency and wake time after sleep onset. Study II demonstrated that non-responders in Study I reported shorter sleep time at baseline than did responders, a notion that may help select patients for this type of low-end intervention in a stepped care treatment approach. Study III aimed to develop a new assessment instrument for studying acceptance of insomnia, the Sleep Problem Acceptance Questionnaire (SPAQ), resulting in an eight-item questionnaire with two factors; the first being Activity Engagement, persisting with normal activities even when sleep is unsatisfactory, and the second involving Willingness, avoiding fighting and trying to control sleep problems. In conclusion, the present thesis demonstrates that it is feasible to treat patients with insomnia using CBT-I administrated by ordinary primary care personnel in general practice, and that those with relatively longer initial sleep duration benefit most from treatment, enabling allocation to relevant treatment intensity. In addition, acceptance of sleep difficulties may be quantified using the SPAQ.

Background: Although physical inactivity has been linked with numerous chronic health conditions and overall mortality, the majority of English adults report insufficient physical activity. To increase population physical activity levels, researchers have called for more community-level interventions. To evaluate these complex public health interventions, innovative study designs are required. The aim of this thesis was to evaluate whether a community-level physical activity intervention—‘Devon Active Villages’—increased the activity levels of rural communities. Methods: The Devon Active Villages intervention provided villages with 12 weeks of physical activity opportunities for all age groups. Community engagement helped tailor activity programmes for each village; communities were then supported for a further 12 months. 128 rural villages from south-west England were randomised to receive the intervention in one of four time periods, as part of a stepped wedge cluster randomised controlled trial. Data collection consisted of a postal survey of a random sample of adults (≥18 years), at baseline, and after each of the four intervention periods. The primary outcome of interest was the proportion of adults who reported sufficient physical activity to meet the current guidelines (≥150mins of moderate-and-vigorous, or ≥75mins of vigorous-intensity activity per week). The number of minutes spent in moderate-and-vigorous activity per week was analysed as a secondary outcome. Using data from all five periods, a comparison of study outcomes between intervention and control arms was performed, allowing for time period (as a fixed effect), and the random effect induced by correlation of outcomes (clustering) within villages. Additionally, the baseline data were analysed separately using logistic and linear regression models to examine the correlates of physical activity behaviour in rural adults. Results: Baseline study: 2415 adults completed the postal survey (response rate 37.7%). The following factors both increased the odds of meeting the recommended activity guidelines and were associated with more leisure-time physical activity: being male, in good health, greater commitment to being more active, favourable activity social norms, greater physical activity habit, and recent use of recreational facilities. In addition, there was evidence that younger age, lower body mass index, having a physical occupation, dog ownership, inconvenience of public transport, and using recreational facilities outside the local village were associated with greater reported leisure-time physical activity. Main study: 10,412 adults (4693 intervention, 5719 control) completed the postal survey (response rate 32.2%). The intervention did not increase the odds of adults meeting the physical activity guideline, although there was weak evidence of an increase in the minutes of moderate-and-vigorous-intensity activity per week. The ineffectiveness of the intervention may have been due to its low penetration—only 16% of intervention participants reported being aware of the intervention, and just 4% reported participating in intervention events. Conclusions: Baseline study: This study highlights potentially important correlates of physical activity that could be the focus of interventions targeting rural populations, and demonstrates the need to examine rural adults separately from their urban counterparts. Main study: A community-level physical activity intervention providing tailored physical activity opportunities to rural villages did not improve physical activity levels in adults. Greater penetration of such interventions needs to be achieved for them to have any chance of increasing the prevalence of physical activity at the community level.

Neste trabalho apresenta-se uma avaliação do estado da arte de aspectos hidráulicos relacionados aos vertedores em degraus submetidos aos diferentes regimes de escoamento. Em uma segunda parte, é sugerida uma metodologia adimensional e simplificada para o pré-dimensionamento do comprimento de bacias de dissipação por ressalto hidráulico, além de uma abordagem conceitual voltada ao escoamento sobre um degrau. Entre os tópicos tratados na avaliação do estado da arte, pode-se citar, por exemplo, a dissipação de energia promovida pelos degraus, o risco de cavitação, a aeração do escoamento, o uso de aeradores de fundo e geometrias não convencionais. Quanto à metodologia desenvolvida, fundamentada na segunda lei do movimento de Newton associada à equação de Darcy-Weisbach, apresenta-se algumas comparações com dados experimentais de diferentes pesquisadores, além de exemplos de aplicação. Foi possível concluir, com a avaliação do estado da arte, que há um interesse crescente pelo conhecimento das características hidráulicas de vertedores em degraus. Através da metodologia desenvolvida, graças às comparações com dados experimentais de diferentes pesquisadores, foi possível concluir que não há um consenso absoluto sobre a magnitude do fator de resistência de Darcy-Weisbach. Com os exemplos de aplicação apresentados, notou-se que para um mesmo problema, o uso de diferentes métodos pode conduzir a projetos significativamente diferentes. / This work presents a state-of-the-art evaluation of aspects related hydraulic to stepped spillways submitted to the different flow regimes. In a second part, it is suggested a dimensionless and simplified methodology for preliminary design of the stilling basin length, besides a conceptual approach related to the free fall hydraulics. Among topics treaties in the state-of-the-art evaluation, it can cite, for example, the energy dissipation promoted by the steps, incipient cavitation, the air entrainment, the use of bottom aerator and unconventional geometries. Regarding the developed methodology, based in the Newton\'s law of motion associate to Darcy-Weisbach equation, it presents some comparisons with experimental data of different researchers, besides application examples. It was possible to conclude, with the state-of-the-art evaluation, that there is an increasing interest for hydraulics characteristic of stepped spillways knowledge. Through the developed methodology, after comparisons with experimental data of different researchers, was possible to conclude that there is not an absolute consensus about the Darcy-Weisbach friction factor magnitude. With the application examples, it noticed that for a same problem, the different methods use can lead for significantly different designs.

Este trabalho traz contribuições experimentais, numéricas e teóricas acerca dos escoamentos turbulentos em canais e vertedores em degraus. Com a exposição de resultados de diferentes autores, procurou-se apresentar uma visão histórica sobre a evolução do conhecimento ligado ao tema, bem como o seu estado-da-arte. Os resultados experimentais foram obtidos em um canal em degraus com 1V:1H. Procurou-se investigar o comportamento da superfície livre com o uso de um medidor ultrassônico de deslocamentos. Foi possível obter perfis médios bem definidos, compostos por um trecho inicial com a forma S2 e S3 e um trecho ondulado a partir do início da aeração superficial. Esses perfis formados por valores médios levaram à definição de profundidades características que compõem a onda e de um comprimento de transição ao escoamento bifásico entre o final do perfil S2 e o primeiro pico da onda. As comparações dos dados experimentais deste trabalho e dos resultados experimentais e numéricos de outros autores, referentes à posição de início da aeração e à altura de escoamento nesta posição, indicaram haver excelente concordância entre as diferentes propostas. Foram fornecidas expressões empíricas para a maior parte das quantidades medidas. Além dos valores médios, os sinais instantâneos obtidos com o ultrassom foram também analisados, tendo sido possível extrair informações sobre a distribuição da intensidade turbulenta, energia cinética turbulenta, número de Strouhal e coeficientes de assimetria e curtose. Estas quantidades estatísticas revelaram diferentes regiões ao longo do canal em degraus, incluindo a região de decaimento das mesmas, com posição final coincidente. Como resultado foi proposta uma expressão para calcular a posição vertical do início do escoamento uniforme. A segunda parte desta tese contém uma revisão sobre as equações e princípios básicos de mecânica dos fluidos e sobre aspectos essenciais relacionados a soluções numéricas. Ao comparar os resultados experimentais com soluções numéricas das equações de Navier-Stokes médias de Reynolds, conservação de massa e diferentes modelos de turbulência, concluiu-se haver excelente sobreposição das soluções aos experimentos. Isto foi possível com o uso do modelo não homogêneo para o escoamento com superfície livre e com os modelos de turbulência k-&#949, RNG k-&#949, SSG e zero-equação. Em seguida, utilizando-se o modelo k-&#949, foram realizadas simulações numéricas em domínios que correspondem a vertedores sem comportas e com dimensões de protótipo. Explorou-se também o uso do referido conjunto de equações na obtenção de informações sobre escoamentos em quedas sucessivas. Neste caso a análise dos resultados se concentrou nas profundidades ao longo do canal e da energia residual. A terceira parte da tese contém proposições e considerações teóricas e semi-empíricas. Entre elas, pode-se mencionar que foram apresentadas equações para previsão de perfis da superfície livre, fator de resistência, comprimento de transição, desenvolvimento da camada limite e coeficiente de reoxigenação. Finalmente, o último capítulo antes das conclusões traz discussões acerca dos três pontos de vista: experimental, numérico e teórico. / This work includes contributions from experimental, numerical and theoretical studies about turbulent flows in stepped chutes and spillways. Initially, previous results and proposals of different authors are presented, intending to furnish an overview of the historical evolution of the knowledge in this theme and its state-of-the-art. The experimental results were obtained in a stepped channel with step ratio 1V:1H. The behavior of the free surface was investigated using an ultrasonic displacement meter. It was possible to obtain well-defined time-averaged profiles, comprising a first stretch with the S2 and S3 forms, and a second wavy stretch, which was produced by the surface aeration. These profiles consist of average depths, and led to the definition of characteristics depths for the first \"wave\" and to a transition length between the end of the S2 profile and the first peak of the wavy region. Comparisons between the experimental data obtained in this study and experimental and numerical results of other authors, regarding the inception point and the water depth at this position, indicated excellent agreement between the different proposals. Empirical expressions are proposed here for most of the measured parameters. In addition to the analysis of the average values, also the instantaneous signals obtained with the ultrasound sensor were analyzed; allowing to obtain information about the distribution of the turbulent intensity, the turbulent kinetic energy, the Strouhal number, and the coefficients of skewness and kurtosis. The behavior of these statistical quantities revealed different regions along the stepped chute, and a final region of decay coincident for all quantities. As a result, an expression was proposed to calculate the vertical position of the beginning of the uniform flow. The second part of this thesis contains a review of the basic principles and equations of fluid mechanics and some key aspects related to numerical solutions. By comparing the experimental results with the numerical solutions of the Reynolds Averaged Navier-Stokes equations, the conservation of mass, and different turbulence models, it was concluded that there exist an excellent superposition between the numerical predictions and the experiments. This was made possible using an inhomogeneous model for the free surface flow and the turbulence models k-&#949, RNG k-&#949, SSG and zero-equation. Further, using the k-&#949 model, numerical simulations were carried out for uncontrolled spillways (without gates), considering prototype dimensions. The same set of equations was used for skimming flows and nappe flows. In the second case, the analysis focused on the water depths along the channel and on the residual energy. The third part of the thesis contains theoretical and semi-empirical formulations based on fluid mechanics\' principles. The presented equations are for predictions of free surface profiles, resistance factors, transition lengths, development of boundary layer and reaeration. Finally, the last chapter before the conclusions presents discussions about the three points of view: experimental, numerical and theoretical.

Postpartum Depression (PPD) occurs in 10-20% of new mothers. PPD can lead to serious health risks to both the mother and infant, increase the risk of complications during birth, and cause lasting effects on the development and wellbeing of the child. Many mothers suffering from PPD do not receive treatment due to fear of being stigmatized, lack of education, or not being able to access mental health services. High prevalence of PPD, along with the negative and lasting effects it can cause point to the importance of developing an effective and feasible method of assessing and treating this disorder. A pediatric primary care office may be an opportune setting to screen for PPD since mothers often accompany their children to regularly scheduled well child visits. While some studies have examined PPD screening within the pediatric primary care setting, few have explored the addition of an on-site Behavioral Health Consultant to provide brief interventions for depressed mothers as part of a stepped care model. The primary aim of the current study is assess the feasibility of implementing a stepped care protocol that assesses PPD and provides brief interventions and referrals for depressed mothers within a pediatric primary care clinic. The protocol consists of several phases including: 1) distribution of the Edinburgh Postpartum Depression Screener to every mother arriving for a well child visit during the first six months of their child’s life; 2) appropriate documentation in the clinic’s electronic health record (EHR) of the Edinburgh score and resulting plan of action; 3) a brief same day intervention by the on-site Behavioral Health Consultant and referral to outside provider, if applicable; and 4) phone call follow up with the mother and referred provider, if applicable. Research assistants will monitor the EHR to determine the clinic’s fidelity to the protocol (e.g., if the Edinburgh is being administered properly). Data will also be collected from the EHR to determine if a correlation exists between Edinburgh scores and number of Emergency Room visits made by the child, immunizations administered to the child, and number of well child checks the child attended. Data collected throughout the month of March showing the Edinburgh uptake, consistency with protocol, and any correlation between Edinburgh scores and other variables will be presented.

<p>Egentlig depression är en folksjukdom, men i dagsläget är kognitiv beteendeterapi, som fått mest stöd i depressionsforskning, en bristvara. Därav finns ett behov av att med begränsade resurser kunna hjälpa så många patienter som möjligt och då är Internetbaserad självhjälpsbehandling i ett alternativ vid mild till måttlig depression. Denna behandlingsform kan dock inte hjälpa alla, varför de som inte svarat på den inledande behandlingen som ett andra steg bör erbjudas mer intensiv och individualiserad vård; så kallad. stepped care. Vid depression uppvisar vissa patienter sudden gains, det vill säga relativt stora, snabba och stabila minskningar av symptom, som ofta bibehålls på lång sikt.</p><p>Syftet med studien var att undersöka effekten av stepped care vid mild till måttlig depression, vinna ökade kunskaper om sudden gains samt se om överlappningar mellan sudden gains och stepped care fanns.</p><p>85 deltagare inkluderades i studien, varav 69 randomiserades till Internetbaserad självhjälpsbehandling eller live gruppbehandling. Övriga deltagare utgjorde en preferensgrupp där de själva valt Internetbehandling. Båda behandlingsalternativen utgick från samma KBT-baserade behandlingsmoduler, som administrerades under åtta veckor samtidigt som veckovisa självskattningar med MADRS-S hämtades in. Efter avslutad behandling bedömdes vilka deltagare, bland dem som fått Internetbehandling, som var i behov av fortsatt vård och därmed skulle erbjudas ytterligare åtta sessioner med telefonterapi.</p><p>Efter de första åtta veckorna var 70 % av samtliga deltagare utan diagnos och 40 % av deltagarna hade uppvisat sudden gains. Endast 22 % visade sig vid eftermätningen behöva gå vidare till telefonterapi, varav 60 % tackade ja och 40 % fullföljde. Efter avslutad telefonterapi var 75 % av dessa deltagare utan diagnos. En begränsning med studien är att den endast är partiellt randomiserad. Slutsatsen är att den Internetbaserade självhjälpsbehandlingen var så effektiv att få deltagare behövde ytterligare vård i stepped care. De deltagare som uppvisade sudden gains mådde bättre än övriga vid behandlingens slut och fortsatte att må bättre vid enmånadsuppföljning.</p>

Egentlig depression är en folksjukdom, men i dagsläget är kognitiv beteendeterapi, som fått mest stöd i depressionsforskning, en bristvara. Därav finns ett behov av att med begränsade resurser kunna hjälpa så många patienter som möjligt och då är Internetbaserad självhjälpsbehandling i ett alternativ vid mild till måttlig depression. Denna behandlingsform kan dock inte hjälpa alla, varför de som inte svarat på den inledande behandlingen som ett andra steg bör erbjudas mer intensiv och individualiserad vård; så kallad. stepped care. Vid depression uppvisar vissa patienter sudden gains, det vill säga relativt stora, snabba och stabila minskningar av symptom, som ofta bibehålls på lång sikt. Syftet med studien var att undersöka effekten av stepped care vid mild till måttlig depression, vinna ökade kunskaper om sudden gains samt se om överlappningar mellan sudden gains och stepped care fanns. 85 deltagare inkluderades i studien, varav 69 randomiserades till Internetbaserad självhjälpsbehandling eller live gruppbehandling. Övriga deltagare utgjorde en preferensgrupp där de själva valt Internetbehandling. Båda behandlingsalternativen utgick från samma KBT-baserade behandlingsmoduler, som administrerades under åtta veckor samtidigt som veckovisa självskattningar med MADRS-S hämtades in. Efter avslutad behandling bedömdes vilka deltagare, bland dem som fått Internetbehandling, som var i behov av fortsatt vård och därmed skulle erbjudas ytterligare åtta sessioner med telefonterapi. Efter de första åtta veckorna var 70 % av samtliga deltagare utan diagnos och 40 % av deltagarna hade uppvisat sudden gains. Endast 22 % visade sig vid eftermätningen behöva gå vidare till telefonterapi, varav 60 % tackade ja och 40 % fullföljde. Efter avslutad telefonterapi var 75 % av dessa deltagare utan diagnos. En begränsning med studien är att den endast är partiellt randomiserad. Slutsatsen är att den Internetbaserade självhjälpsbehandlingen var så effektiv att få deltagare behövde ytterligare vård i stepped care. De deltagare som uppvisade sudden gains mådde bättre än övriga vid behandlingens slut och fortsatte att må bättre vid enmånadsuppföljning.

This dissertation divides into three parts: (a) design and research of asymmetric stepped impedance resonator (SIR); (b) design and fabrication of dual-band and ultra-wide band (UWB) bandpass filters (BPFs) and (c) design and fabrication of millimeter wave filters. (a)design and research of asymmetric stepped impedance resonator. In the first part of the dissertation, we propose an asymmetric SIR, and the effect of electrical length ratio and impedance ratio on the performance of frequency has been discussed in detail. The insertion loss and spurious can be controlled by the structural parameters of asymmetric SIR which decreases the length of resonator effectively and achieves the reduction of whole size. Additionally, this characterization of the asymmetric SIR can be extensively applied on the interconnection of RFIC. (b) design and fabrication of dual-band and ultra-wide band (UWB) filters. In the second part of the dissertation, we propose dual-band and UWB BPFs by using asymmetric SIRs. The designed dual-band BPF is conformed to the standard of wireless local area network (WLAN), and the designed UWB BPF is conformed to the standard that Federal Communications Commission (FCC) defined. The structural parameters of asymmetric SIR can be adjusted accurately by the theoretical equations we calculated. Then, the ideal performance can be achieved. (c) design and fabrication of millimeter wave filters. In the third part of the dissertation, we propose the design of millimeter wave filters fabricated by the standard of complementary metal-oxide semiconductor (CMOS). Asymmetric SIRs are used to design the microwave filter to estimate that the feasibility of system on chip (SoC). Finally, some suggestions are made in the future work on technology for system on chip (SoC).