Propuesta de algoritmos de predicción de glucosa en pacientes diabéticos

La diabetes mellitus es el conjunto de alteraciones provocadas por un defecto en la cantidad de insulina secretada o por un aprovechamiento deficiente de la misma. Es causa directa de complicaciones a corto, medio y largo plazo que disminuyen la calidad y las expectativas de vida de las personas con diabetes. La diabetes mellitus es en la actualidad uno de los problemas más importantes de salud. Ha triplicado su prevalencia en los últimos 20 anos y para el año 2025 se espera que existan casi 300 millones de personas con diabetes. Este aumento de la prevalencia junto con la morbi-mortalidad asociada a sus complicaciones micro y macro-vasculares convierten la diabetes en una carga para los sistemas sanitarios, sus recursos económicos y sus profesionales, haciendo de la enfermedad un problema individual y de salud pública de enormes proporciones. De momento no existe cura a esta enfermedad, de modo que el objetivo terapéutico del tratamiento de la diabetes se centra en la normalización de la glucemia intentando minimizar los eventos de hiper e hipoglucemia y evitando la aparición o al menos retrasando la evolución de las complicaciones vasculares, que constituyen la principal causa de morbi-mortalidad de las personas con diabetes. Un adecuado control diabetológico implica un tratamiento individualizado que considere multitud de factores para cada paciente (edad, actividad física, hábitos alimentarios, presencia de complicaciones asociadas o no a la diabetes, factores culturales, etc.). Sin embargo, a corto plazo, las dos variables más influyentes que el paciente ha de manejar para intervenir sobre su nivel glucémico son la insulina administrada y la dieta. Ambas presentan un retardo entre el momento de su aplicación y el comienzo de su acción, asociado a la absorción de los mismos. Por este motivo la capacidad de predecir la evolución del perfil glucémico en un futuro cercano, ayudara al paciente a tomar las decisiones adecuadas para mantener un buen control de su enfermedad y evitar situaciones de riesgo. Este es el objetivo de la predicción en diabetes: adelantar la evolución del perfil glucémico en un futuro cercano para ayudar al paciente a adaptar su estilo de vida y sus acciones correctoras, con el propósito de que sus niveles de glucemia se aproximen a los de una persona sana, evitando así los síntomas y complicaciones de un mal control. La aparición reciente de los sistemas de monitorización continua de glucosa ha proporcionado nuevas alternativas. La disponibilidad de un registro exhaustivo de las variaciones del perfil glucémico, con un periodo de muestreo de entre uno y cinco minutos, ha favorecido el planteamiento de nuevos modelos que tratan de predecir la glucemia utilizando tan solo las medidas anteriores de glucemia o al menos reduciendo significativamente la información de entrada a los algoritmos. El hecho de requerir menor intervención por parte del paciente, abre nuevas posibilidades de aplicación de los predictores de glucemia, haciéndose viable su uso en tiempo real, como sistemas de ayuda a la decisión, como detectores de situaciones de riesgo o integrados en algoritmos automáticos de control. En esta tesis doctoral se proponen diferentes algoritmos de predicción de glucemia para pacientes con diabetes, basados en la información registrada por un sistema de monitorización continua de glucosa así como incorporando la información de la insulina administrada y la ingesta de carbohidratos. Los algoritmos propuestos han sido evaluados en simulación y utilizando datos de pacientes registrados en diferentes estudios clínicos. Para ello se ha desarrollado una amplia metodología, que trata de caracterizar las prestaciones de los modelos de predicción desde todos los puntos de vista: precisión, retardo, ruido y capacidad de detección de situaciones de riesgo. Se han desarrollado las herramientas de simulación necesarias y se han analizado y preparado las bases de datos de pacientes. También se ha probado uno de los algoritmos propuestos para comprobar la validez de la predicción en tiempo real en un escenario clínico. Se han desarrollado las herramientas que han permitido llevar a cabo el protocolo experimental definido, en el que el paciente consulta la predicción bajo demanda y tiene el control sobre las variables metabólicas. Este experimento ha permitido valorar el impacto sobre el control glucémico del uso de la predicción de glucosa. ABSTRACT Diabetes mellitus is the set of alterations caused by a defect in the amount of secreted insulin or a suboptimal use of insulin. It causes complications in the short, medium and long term that affect the quality of life and reduce the life expectancy of people with diabetes. Diabetes mellitus is currently one of the most important health problems. Prevalence has tripled in the past 20 years and estimations point out that it will affect almost 300 million people by 2025. Due to this increased prevalence, as well as to morbidity and mortality associated with micro- and macrovascular complications, diabetes has become a burden on health systems, their financial resources and their professionals, thus making the disease a major individual and a public health problem. There is currently no cure for this disease, so that the therapeutic goal of diabetes treatment focuses on normalizing blood glucose events. The aim is to minimize hyper- and hypoglycemia and to avoid, or at least to delay, the appearance and development of vascular complications, which are the main cause of morbidity and mortality among people with diabetes. A suitable, individualized and controlled treatment for diabetes involves many factors that need to be considered for each patient: age, physical activity, eating habits, presence of complications related or unrelated to diabetes, cultural factors, etc. However, in the short term, the two most influential variables that the patient has available in order to manage his/her glycemic levels are administered insulin doses and diet. Both suffer from a delay between their time of application and the onset of the action associated with their absorption. Therefore, the ability to predict the evolution of the glycemic profile in the near future could help the patient to make appropriate decisions on how to maintain good control of his/her disease and to avoid risky situations. Hence, the main goal of glucose prediction in diabetes consists of advancing the evolution of glycemic profiles in the near future. This would assist the patient in adapting his/her lifestyle and in taking corrective actions in a way that blood glucose levels approach those of a healthy person, consequently avoiding the symptoms and complications of a poor glucose control. The recent emergence of continuous glucose monitoring systems has provided new alternatives in this field. The availability of continuous records of changes in glycemic profiles (with a sampling period of one or five minutes) has enabled the design of new models which seek to predict blood glucose by using automatically read glucose measurements only (or at least, reducing significantly the data input manually to the algorithms). By requiring less intervention by the patient, new possibilities are open for the application of glucose predictors, making its use feasible in real-time applications, such as: decision support systems, hypo- and hyperglycemia detectors, integration into automated control algorithms, etc. In this thesis, different glucose prediction algorithms are proposed for patients with diabetes. These are based on information recorded by a continuous glucose monitoring system and incorporate information of the administered insulin and carbohydrate intakes. The proposed algorithms have been evaluated in-silico and using patients’ data recorded in different clinical trials. A complete methodology has been developed to characterize the performance of predictive models from all points of view: accuracy, delay, noise and ability to detect hypo- and hyperglycemia. In addition, simulation tools and patient databases have been deployed. One of the proposed algorithms has additionally been evaluated in terms of real-time prediction performance in a clinical scenario in which the patient checked his/her glucose predictions on demand and he/she had control on his/her metabolic variables. This has allowed assessing the impact of using glucose prediction on glycemic control. The tools to carry out the defined experimental protocols were also developed in this thesis.

Caracterização dos processos de manutenção em equipamentos eletromédicos hospitalares

Atualmente existe uma gama considerável de procedimentos assistenciais de saúde os quais, seja por cultura, ou por exigências legais, só podem ser realizados com aporte tecnológico. Logo reduzir o tempo de parada de um equipamento médico está diretamente associado à viabilização da assistência necessária ao paciente. Em outras palavras, prestar uma manutenção otimizada representa qualidade na prestação de serviço da unidade assistencial de saúde, podendo em alguns casos, até, evitar a morte do paciente. Para isso é muito importante que os defeitos sejam reconhecidos e tratados adequadamente, não se esquecendo da otimização dos recursos financeiros. Com base nesta premissa, este trabalho propõe estabelecer uma relação dos tipos de defeitos apresentados pelos equipamentos com sua ocorrência, utilizando para tal o método de Pareto, fornecendo uma ferramenta de análise de grande utilidade na estruturação de grupos de manutenção corretiva de um serviço de engenharia clínica. Assim foram tomados como amostra quatro tipos de equipamentos que são eletrocardiógrafos, monitores cardíacos, unidades eletrocirúrgicas e incubadoras neonatais; caracterizando a existência de defeitos que podem ser classificados em baixa, média e alta complexidade de resolução, o que reflete na necessidade de ferramentas gerais ou específicas ao reparo e do nível de qualificação da equipe técnica, além do universo de componentes, partes e peças envolvidas com cada etapa de manutenção. Foram qualificados e quantificados defeitos para cada tipo de equipamentos acima, onde se constatou que nos equipamentos médico-hospitalares estudados, a maioria das paradas requisitou intervenções simples, de baixa complexidade. Ou seja, poucos defeitos foram responsáveis por muitas ordens de serviço e que o corpo técnico de manutenção pode esperar e se programar para atuar em cada um deles de acordo com o gráfico de Pareto. Desta forma o serviço de engenharia clínica pode ser direcionado para as necessidades prioritárias do estabelecimento assistencial de saúde, sendo capaz de produzir resultados com melhor custo-benefício.

Determinants of Financial Development across the Mediterranean. MEDPRO Technical Report No. 29/February 2013

Casual observation shows that that the financial systems in the southern and eastern Mediterranean are unable (or unwilling) to divert the financial resources that are available to them as funding opportunities to private enterprises. Using a sample of both northern and southern Mediterranean countries for the years 1985 to 2009, this study empirically assesses the reasons underlying such conditions. The results show that strong legal institutions, good democratic governance and adequate implementation of financial reforms can have a substantial positive impact on financial development only when they are present collectively. Moreover, inflation appears to undermine banking development, but less so when the capital account is open. Government debt growth appears to weaken credit growth, which confirms that public debt ‘crowds out’ private debt. Lastly, capital inflows appear to primarily have an income effect, increasing income and thereby national savings, and thus increasing the availability of credit.

Core competencies in financial management for information technology personnel implementing financial systems in the federal government.

A joint project of the Chief Financial Officers Council and the Joint Financial Management Improvement Program.

Financial statistics of cities having a population of over 100,000.

Title varies slightly.

Nutritional issues in adolescent health.

Mode of access: Internet.

Predictors of first semester attrition and their relation to retention of generic associate degree nursing students

In community college nursing programs the high rate of attrition was a major concern to faculty and administrators. Since first semester attrition could lead to permanent loss of students and low retention in nursing programs, it was important to identify at-risk students early and develop proactive approaches to assist them to be successful. The goal of nursing programs was to graduate students who were eligible to take the national council licensing examination (RN). This was especially important during a time of critical shortage in the nursing workforce. ^ This study took place at a large, multi-campus community college, and used Tinto's (1975) Student Integration Model of persistence as the framework. A correlational study was conducted to determine whether the independent variables, past academic achievement, English proficiency, achievement tendency, weekly hours of employment and financial resources, could discriminate between the two grade groups, pass and not pass. Establishing the relationship between the selected variables and successful course completion might be used to reduce attrition and improve retention. Three research instruments were used to collect data. A Demographic Information form developed by the researcher was used to obtain academic data, the research questionnaire Measure of Achieving Tendency measured achievement motivation, and the Test of Adult Basic Education (TABE), Form 8, Level A, Tests 1, 4, and 5 measured the level of English proficiency. The Department of Nursing academic policy, requiring a minimum course grade of “C” or better was used to determine the final course outcome. A stepwise discriminant analysis procedure indicated that college language level and pre-semester grade point average were significant predictors of final course outcome. ^ Based on the findings of the study recommendations focused on assessing students' English proficiency prior to admission into the nursing program, an intensive remediation plan in language comprehension for at-risk students, and the selection of alternate textbooks and readings that more closely matched the English proficiency level of the students. A pilot study should be conducted to investigate the benefit of raising the admission grade point average. ^

Water Governance in Haiti: An Assessment of Laws and Institutional Capacities

The Republic of Haiti struggles to sustainably manage its water resources. Public health is compromised by low levels of water supply, sanitation, and hygiene, and water resources are often contaminated and unsustainably allocated. While poor governance is often blamed for these shortcomings, the laws and institutions regulating water resources in Haiti are poorly understood, especially by the international community. This study brings together and analyzes Haitian water laws, assesses institutional capacities, and provides a case study of water management in northern Haiti in order to provide a more complete picture of the sector. Funded by the Inter-American Development Bank as part of the Water Availability, Quality and Integrated Water Resources Management in Northern Haiti (HA-T1179) Project, this study took place from January-July 2015, with the help of local experts and participating stakeholders. The results indicate that Haiti’s water law framework is highly fragmented, with overlapping mandates and little coordination between ministries at the national level, and ambiguous but unrealistic roles for subnational governments. A capacity assessment of institutions in northern Haiti illustrates that while local stakeholders are engaged, human and financial resources are insufficient to carry out statutory responsibilities. The findings suggest that water resources management planning should engage local governments and community fixtures while supplementing capacities with national or international support.

Deliberação e participação: dinâmica e efetividade do conselho de saúde de Mossoró/RN – 2009/2012

The social participation in Brazil takes a new impetus with the (re)democratization process of the Brazilian society and is strengthened by the resurgence of the civil society and the 1988 Constitution. In this context, the study is conducted with the scope to verify the effectiveness of deliberative Municipal Health Council of Mossoro (CMSM), with theoretical and methodological support based on the following models: the participatory normativity, which measures the degree of institutionalization, democratization and council representation; and the effectiveness of deliberative that, from the calling capacity and agenda of the participants, from the kinds of manifestation, from the decisions and the council’s office, that measures the degree of effectiveness of the deliberative council. It appears, thus, that the council has an average degree of effectiveness deliberative, standing out as means an institution that practice, despite the existence of obstacles and challenges, the role of control over municipal health policies, due, among other factors, the conservative political context, the asymmetry of resources between the counselors, the little substantive participation of the actors who attend its meetings, either counselor or not, and in particular, the reduced influence of the members in its decision-making process. In public management of Mossoro, social participation, especially social control over public actions, face, today, great number of difficulties to be held. The study recognizes that, in such circumstances, the council partially fulfills the role for which it was created, what does not impede, however, be characterized as an important deliberative space, since it allows the participation of representatives of the various segments of the state, society, their demands and intentions. Overcoming such obstacles moves through the interest of civil society to wake up and fight for the spaces in these institutions.

Gestão e gerenciamento de resíduos sólidos: diretrizes jurídico-ambientais para a sustentabilidade

rates in the Brazilian cities, which time there is an inexistent theoretical reflection about public policy statement adding the way of Urban Solid Waste (USW) and tailing integrated management plans in the majorly Brazilian cities. The unappropriated solid waste disposal and final pollution result in a strong socioenvironmental problems and material extravagancies that should be used to recycling and reusing waste material, besides bringing immense challenges for the thematic Strategy Urban and Environmental Management it considers the Sustainable City Model. Moreover, this labor projects a discussion about USW problematic through legally and environmentally point of view, including the public environmental policy and the social technologies as resolution tactics. At that time, it reports rights, scientific articles, documents and Environmental Law Doctrine on findings thematic studies, also the propose displays an interdisciplinary research methodology which combines bibliographic method - focusing theory aspects of the legally environmentally guiding principle, public policy and social technologies. Those are theorist features very important to create a Municipal Integrated Solid Waste Management Plan (PMGIRS) - modus operandi of the Federal Law n. 12.305/2010 (National Solid Waste Policy - PNRS). That policy is interesting to receive financial resources from federal government (Cities Ministry; idem, Federal Decree n. 7.404/2010 and Federal Law n. 10.257/2001) helping the preservation of the environment, regional development, generation of jobs and income (art. 6º), in addition broadening spreading’s private companies dedicated to waste management. Consequently, the PNRS contains a set of guidelines and general procedures; it should be an operation of this legal policy contextualized by Social Technologies theory (TS) into social issues, legal, economic and environmental aspects. Therefore, this research notes the possibility of public policy statement implementation over and done with the PNRS by the terms of development and sustainability in the urban space.

Party rules, party resources and the politics of parliamentary democracies How parties organize in the 21st century

This article introduces the first findings of the Political Party Database Project, a major survey of party organizations in parliamentary and semi-presidential democracies. The project’s first round of data covers 122 parties in 19 countries. In this article, we describe the scope of the database, then investigate what it tells us about contemporary party organization in these countries, focusing on parties’ resources, structures and internal decision-making. We examine organizational patterns by country and party family, and where possible we make temporal comparisons with older data sets. Our analyses suggest a remarkable coexistence of uniformity and diversity. In terms of the major organizational resources on which parties can draw, such as members, staff and finance, the new evidence largely confirms the continuation of trends identified in previous research: that is, declining membership, but enhanced financial resources and more paid staff. We also find remarkable uniformity regarding the core architecture of party organizations. At the same time, however, we find substantial variation between countries and party families in terms of their internal processes, with particular regard to how internally democratic they are, and the forms that this democratization takes.

Living conditions in old age: Coexisting disadvantages across life domains

The aim of this thesis was to analyse coexisting disadvantages in the older Swedish population. Coexisting disadvantages are those that occur simultaneously in various life domains. A person who simultaneously experiences several disadvantages may be particularly vulnerable and less well-equipped to manage daily life and may also need support from several different welfare service providers. Concerted actions may be needed for older people who experience not only physical health problems and functional limitations, but also other problems. Research that encompasses a wide range of living conditions provides a basis for setting political priorities and making political decisions. The studies in this thesis used data from two Swedish nationally representative surveys: the Level of Living Survey, which includes people aged 18 through 75, and the Swedish Panel Study of Living Conditions of the Oldest Old, which includes people aged 77 and older. Study I showed that the probability of experiencing coexisting disadvantages was higher in people 77 and older than in those aged 18 through 76. These age differences were partly driven by a high prevalence of physical health problems in older people. In all age groups, coexisting disadvantages were more common in women than men. The longitudinal analyses in Study II indicated that coexisting disadvantages in old age persist in some people but are temporary in others. Moreover, the results suggested a pattern of accumulating disadvantages: reporting one disadvantage in young old age (in particular, psychological health problems) increased the probability of reporting coexisting disadvantages in late old age.   Study III showed that physical health problems were a central component of coexisting disadvantages. The results also showed that being older; female; previously employed as a manual labourer; and divorced/separated, widowed or never married were associated with an increased probability of experiencing coexisting disadvantages. However, the experience of coexisting disadvantages differed: the groups associated with coexisting disadvantages tended to report different combinations of disadvantage. Study IV showed that the prevalence of coexisting disadvantages in those 77 and older increased slightly between 1992 and 2011. Physical health problems became more common over time, whereas limited ability to manage daily activities (ADL limitations), limited financial resources and limited political resources became less common. Associations between different disadvantages were found in all survey years, but certain associations changed over time. The results suggest that in general, the composition of coexisting disadvantages in the older population may have altered over time. In sum, results showed that coexisting disadvantages were associated with specific demographic and socio-economic groups. Physical health problems and psychological health problems were of particular importance to the accumulation and coexistence of disadvantages in old age.

A descentralização das políticas de desenvolvimento rural: uma análise da experiência do Rio Grande do Norte

MATOS FILHO, João. A descentralização das Políticas de desenvolvimento rural - uma análise da experiência do Rio Grande do Norte. 2002. 259f. Tese (Doutorado em Ciências Econômicas)– Instituto de Economia da Universidade Estadual de Campinas, Campinas, 2002.

Conselho Municipal de Saúde de Pedras de Fogo - PB: um estudo sobre participação

The present study aims to understand the process of Participation of the Health Council- CMS in the formularization, implementation and control of the Municipal health plan of Pedras de Fogo, through four criteria of quality of participation considered by Demo (1993): representation, legitimacy, base participation, and self-responsibility. The criteria of representation is related to the quality of politics of the representative over the representings. Legitimacy is related to the politics` quality of the process of participation based on norms and rules that stipulate the participation, the base participation is a necessary political support so that the power authorization directed to the representings can be effective and the self-responsibility refers to the capacity of being responsible when it concerns to the public service or property. Through the descriptive and exploratory study a qualitative method was adopted to consider the conditions of the participation of the twelve council members of the City council of Health of Pedras de Fogo, through a formulated Instrument based on the criteria of DEMO (1993). It was concluded that the quality of the participation of the council members of the CMS of Pedras de Fogo understands essential aspects of the criteria of quality considered by Demo (1993) but it shows fragilities as unfamiliarity with the norms that legitimize the performance of the council; unfamiliarity of its condition of being an agent and the importance of the participation of the base for the reinforcement of its participation, as well as inertia related to the check and rendering of accounts on its performance. This way it makes sense that the participation of the council in the four criteria of quality of politics considered in this paper needs to improve

A descentralização das políticas de desenvolvimento rural: uma análise da experiência do Rio Grande do Norte

MATOS FILHO, João. A descentralização das Políticas de desenvolvimento rural - uma análise da experiência do Rio Grande do Norte. 2002. 259f. Tese (Doutorado em Ciências Econômicas)– Instituto de Economia da Universidade Estadual de Campinas, Campinas, 2002.