Accesos vasculares para hemodiálisis, cuál es el más costo efectivo?

Marco conceptual: La enfermedad renal crónica es un serio problema de salud pública en nuestro país por la gran cantidad de recursos económicos que requiere su atención. La hemodiálisis es el tratamiento más usado en nuestro medio; el acceso vascular y sus complicaciones derivadas son el principal aspecto que incrementa los costos de atención en éstos pacientes. Materiales y métodos: Se realizó un estudio económico de los accesos vasculares en pacientes incidentes de hemodiálisis en el año 2012 en la agencia RTS-Fundación Cardio Infantil. Se estableció el costo de creación y mantenimiento del acceso con catéter central, fístula arteriovenosa nativa, fístula arteriovenosa con injerto; y el costo de atención de las complicaciones para cada acceso. Se determinó la probabilidad de ocurrencia de complicaciones. Mediante un árbol de decisiones se trazó el comportamiento de cada acceso en un período de 5 años. Se establecieron los años de vida ajustados por calidad (QALY) en cada acceso y el costo para cada uno de éstos QALY. Resultados: de 36 pacientes incidentes de hemodiálisis en 2012 el 100% inició con catéter central, 16 pacientes cambiaron a fístula arteriovenosa nativa, 1 a fístula arteriovenosa con injerto que posteriormente pasó a CAPD, 15 continuaron su acceso con catéter y 4 pacientes fallecieron. En 5 años se obtuvieron 2,36 QALY para los pacientes con catéter central que costarían $ 24.813.036,39/QALY y 2,535 QALY para los pacientes con fístula nativa que costarían $ 6.634.870,64/QALY. Conclusiones: el presente estudio muestra que el acceso vascular mediante fístula arteriovenosa nativa es el más costo-efectivo que mediante catéter

Incidencia del gasto en educación sobre los hogares en Bogotá en 2003

Se evalúa el impacto redistributivo de las políticas educativas en Bogotá mediante el Análisis de Incidencia del Beneficio. A pesar que los hogares son autónomos con respecto a la elección entre la educación oficial y no oficial, la provisión pública de la educación genera fuertes impactos progresivos en el ingreso que se explayan hacia reducciones de pobreza y desigualdad, sin importar el cálculo del subsidio que se impute al ingreso.

Modelo anisotrópico de cálculo de rutas de coste mínimo con gvSIG y SEXTANTE

La Vía Augusta era una vía romana que iba desde Cádiz hasta Roma. Estaba compuesta de un ramal principal y de diversos ramales secundarios que en su mayoría, constituyen el sustrato de la actual red principal de carreteras del Mediterráneo en la Península Ibérica. A pesar de ello, no se conoce la localización exacta de muchos de esos ramales. El presente artículo muestra un estudio de por dónde deberían atravesar, posiblemente, las rutas romanas el Pirineo Oriental. Para el cálculo de estas rutas se aplica un algoritmo de mínimo coste que incorpora diversas variables y que tiene en cuenta que el desplazamiento se lleva a cabo a pie, y siguiendo la orografía del terreno. Se utilizan en el proceso las herramientas de análisis de costes y el cálculo de rutas óptimas que incorpora SEXTANTE. En particular se estudia y se modela la ruta de mínimo coste anisotrópica, es decir aquella en la que es importante la dirección del movimiento. El proceso consiste en analizar diversas rutas de mínimo coste, entendiendo como coste el esfuerzo en recorrerla. Se busca, por tanto, el camino que sea más sencillo de recorrer teniendo en cuenta principalmente la orografía del terreno (MDT), la pendiente y su orientación. Además, en el estudio se tienen en cuenta otras variables como los usos de suelo, la red hidrográfica, la red de comunicaciones romana conocida, así como la ubicación de puentes y asentamientos romanos entre otros. Las diferentes rutas obtenidas se contrastan con las rutas propuestas por los historiadores y arqueólogos

Terrestrial carnivores and human food production: impact and management

1. The production of food for human consumption has led to an historical and global conflict with terrestrial carnivores, which in turn has resulted in the extinction or extirpation of many species, although some have benefited. At present, carnivores affect food production by: (i) killing human producers; killing and/or eating (ii) fish/shellfish; (iii) game/wildfowl; (iv) livestock; (v) damaging crops; (vi) transmitting diseases; and (vii) through trophic interactions with other species in agricultural landscapes. Conversely, carnivores can themselves be a source of dietary protein (bushmeat). 2. Globally, the major areas of conflict are predation on livestock and the transmission of rabies. At a broad scale, livestock predation is a customary problem where predators are present and has been quantified for a broad range of carnivore species, although the veracity of these estimates is equivocal. Typically, but not always, losses are small relative to the numbers held, but can be a significant proportion of total livestock mortality. Losses experienced by producers are often highly variable, indicating that factors such as husbandry practices and predator behaviour may significantly affect the relative vulnerability of properties in the wider landscape. Within livestock herds, juvenile animals are particularly vulnerable. 3. Proactive and reactive culling are widely practised as a means to limit predation on livestock and game. Historic changes in species' distributions and abundance illustrate that culling programmes can be very effective at reducing predator density, although such substantive impacts are generally considered undesirable for native predators. However, despite their prevalence, the effectiveness, efficiency and the benefit:cost ratio of culling programmes have been poorly studied. 4. A wide range of non-lethal methods to limit predation has been studied. However, many of these have their practical limitations and are unlikely to be widely applicable. 5. Lethal approaches are likely to dominate the management of terrestrial carnivores for the foreseeable future, but animal welfare considerations are increasingly likely to influence management strategies. The adoption of non-lethal approaches will depend upon proof of their effectiveness and the willingness of stakeholders to implement them, and, in some cases, appropriate licensing and legislation. 6. Overall, it is apparent that we still understand relatively little about the importance of factors affecting predation on livestock and how to manage this conflict effectively. We consider the following avenues of research to be essential: (i) quantified assessments of the loss of viable livestock; (ii) landscape-level studies of contiguous properties to quantify losses associated with variables such as different husbandry practices; (iii) replicated experimental manipulations to identify the relative benefit of particular management practices, incorporating (iv) techniques to identify individual predators killing stock; and (v) economic analyses of different management approaches to quantify optimal production strategies.

Decision making for HVAC&R system selection for a typical office building in the UK

Demands for thermal comfort, better indoor air quality together with lower environmental impacts have had ascending trends in the last decade. In many circumstances, these demands could not be fully covered through the soft approach of bioclimatic design like optimisation of the building orientation and internal layout. This is mostly because of the dense urban environment and building internal energy loads. In such cases, heating, ventilation, air-conditioning and refrigeration (HVAC&R) systems make a key role to fulfill the requirements of indoor environment. Therefore, it is required to select the most proper HVAC&R system. In this study, a robust decision making approach for HVAC&R system selection is proposed. Technical performance, economic aspect and environmental impacts of 36 permutations of primary and secondary systems are taken into account to choose the most proper HVAC&R system for a case study office building. The building is a representative for the dominant form of office buildings in the UK. Dynamic performance evaluation of HVAC&R alternatives using TRNSYS package together with life cycle energy cost analysis provides a reliable basis for decision making. Six scenarios broadly cover the decision makers' attitudes on HVAC&R system selection which are analysed through Analytical Hierarchy Process (AHP). One of the significant outcomes reveals that, despite both the higher energy demand and more investment requirements associated with compound heating, cooling and power system (CCHP); this system is one of the top ranked alternatives due to the lower energy cost and C02 emissions. The sensitivity analysis reveals that in all six scenarios, the first five top ranked alternatives are not changed. Finally, the proposed approach and the results could be used by researchers and designers especially in the early stages of a design process in which all involved bodies face the lack of time, information and tools for evaluation of a variety of systems.

Enhanced three-factor security protocol for consumer USB mass storage devices

The Universal Serial Bus (USB) is an extremely popular interface standard for computer peripheral connections and is widely used in consumer Mass Storage Devices (MSDs). While current consumer USB MSDs provide relatively high transmission speed and are convenient to carry, the use of USB MSDs has been prohibited in many commercial and everyday environments primarily due to security concerns. Security protocols have been previously proposed and a recent approach for the USB MSDs is to utilize multi-factor authentication. This paper proposes significant enhancements to the three-factor control protocol that now makes it secure under many types of attacks including the password guessing attack, the denial-of-service attack, and the replay attack. The proposed solution is presented with a rigorous security analysis and practical computational cost analysis to demonstrate the usefulness of this new security protocol for consumer USB MSDs.

Economic Impact of a Rotavirus Vaccine in Brazil

The study was done to evaluate the cost-effectiveness of a national rotavirus vaccination programme in Brazilian children from the healthcare system perspective. A hypothetical annual birth-cohort was followed for a five-year period. Published and national administrative data were incorporated into a model to quantify the consequences of vaccination versus no vaccination. Main outcome measures included the reduction in disease burden, lives saved, and disability-adjusted life-years (DALYs) averted. A rotavirus vaccination programme in Brazil would prevent an estimated 1,804 deaths associated with gastroenteritis due to rotavirus, 91,127 hospitalizations, and 550,198 outpatient visits. Vaccination is likely to reduce 76% of the overall healthcare burden of rotavirus-associated gastroenteritis in Brazil. At a vaccine price of US$ 7-8 per dose, the cost-effectiveness ratio would be US$ 643 per DALY averted. Rotavirus vaccination can reduce the burden of gastroenteritis due to rotavirus at a reasonable cost-effectiveness ratio.

Remoção de óleos emulsificados por flotação por ar dissolvido

Neste trabalho estuda-se o processo de flotação por ar dissolvido (FAD) como método de remoção de óleos emulsificados. Realizou-se uma revisão bibliográfica tanto do processo de flotação como dos fundamentos físico-químicos envolvidos na estabilidade e flotação de emulsões. Foram realizados testes de estabilidade de emulsões, de FAD descontínuos e contínuos, utilizando-se emulsões de 1000 mg/l de Óleo diesel e heptano. Verificou-se a eficiência do sulfato de alumínio e de compostos poliméricos como agentes desestabilizantes. Estudou-se a influência do tipo e concentração dos agentes desestabilizantes, pH da emulsão, do tipo de água e agitação nos testes de estabilidade como também na flotação por ar dissolvido. Os resultados obtidos indicaram a viabilidade técnica da aplicação do processo para a clarificação de efluentes oleosos atingindo valores de turbidez residual satisfatórios (menores que 5 UNT). O sulfato de alumínio mostrou-se mais eficiente como agente desestabilizante de ambas emulsões nos estudos de estabilidade e testes de PAD descontínuos, mas o polímero catiônico C-505 apresentou melhores resultados nos testes de flotação contínuos. O presente trabalho ainda apresenta um estudo de dimensionamento e do custo da unidade de FAD para remoção de óleos emulsificados que leva em consideração os custos de investimentos e de operação da unidade. Verifica-se que o custo total da unidade depende da vazão de alimentação, taxa de recirculação, taxa ar/sólido em massa e concentração inicial de óleos. Conclui-se que para as taxas de ar/sólido usados na indústria (geralmente menores que 0,1) o custo operacional do reagente é o parâmetro determinante do custo total atualizado da unidade. Isto faz com que o custo total atualizado seja essencialmente independente da relação taxa de aplicação - taxa ar/sólido.

Estilo e agrupamento de fundos : um estudo aplicado aos fundos multimercados brasileiros

Uma classificação adequada de fundos é importante para que o investidor possa organizar a informação disponível de tal modo que possa tomar decisões de aplicação de seus recursos de forma eficiente. No Brasil, existem dois sistemas de classificação amplamente utilizados, o CVM e o ANBIMA, porem ambos possuem categorias com fronteiras subjetivas, isto é, possuem um elevado grau de arbitrariedade na definição de suas categorias, este fato prejudica uma alocação eficiente por parte do investidor. Fundos multimercado são fundos que possuem política de investimento que envolvem vários fatores de risco sem concentração em nenhum fator especial, diferentemente das outras classes de fundos do mercado brasileiro. Sob este aspecto, uma categorização adequada dos fundos multimercados traria inúmeros benefícios tais como a redução do custo de análise, a maior facilidade no processo de tomada de decisão de investimento, uma diversificação mais eficiente, clareza na comparação de desempenho e o melhor entendimento dos riscos incorridos dentre outros benefícios. O presente trabalho tem como objetivo, utilizando-se da já consagrada técnica de análise de estilo de Sharpe (1992), decompor a exposição de cada fundo em seus principais fatores de risco, após isto, utilizar-se da análise de cluster para agrupar os fundos de forma coerente a suas exposições, tentando assim fazer um classificação mais eficiente; isto seria um contraponto a classificação mais utilizada pelo mercado brasileiro, a classificação Anbima, que se baseia no regulamento do fundo, isto é, no que o fundo “pode” investir, e não no que o fundo efetivamente investe.

Satisfação da equipe de enfermagem do serviço de atendimento móvel às urgências (SAMU) no ambiente de trabalho

Descriptive exploratory study, prospective with quantitative approach, performed on the Medical Regulation Central of SAMU/Natal, aiming to identify the level of professional satisfaction of the members of the nursing team working at SAMU/Natal; and verify the degree of importance attributed by the professionals to each of the components Professional Satisfaction: autonomy, interaction, professional status , work requirements, organizational rules and remuneration. The population was of 60 professionals, with data collected from january to february 2005. We used an instrument translated and validated by Lino (1999) to the portuguese language, the Professional Satisfaction Rate (PSR). The results demonstrate that there was a slight predominance of the female gender (54,9%); aged between 36 and 45 years old (60,8%); married (58,8%), 82,4% with children, 30,8% aged between 05 and 09. Regarding formation, we observed that 78,4% were nursing technicians and 21,6% nurses, formed for 11 to 15 years (17,5%). From the 11 nurses, 09 (81,8%) informed they have specialization, 29,4% of the team has been working for 11 to 15 years on the urgency area, 58.8% works for more than 02 years on SAMU, 72,6% of the team members have fixed work schedules. There was homogeneity on the work shifts: 41,2% on the day shift and 53% on the night shift. Regarding the reason to be working on SAMU, 64% chose to work in the service, and among these 76,3% predominantly perform direct care to the patients, 96,1% like and are satisfied to work in the service. Regarding the remuneration, 90,9% informed they receive 05 to 10 minimum wages; 70% of the technicians informed they receive -2 to 05 minumum wages, 50,1% informed they receive no additional benefit. The analysis of PSR through Cronbach s Alpha Coeficient resulted on the value of 0,94 and through Kendall s Tau Coeficient on 0,87, demonstrating to be a trustworthy instrument to measure the level of professional satisfaction of the SAMU nursing team, in our environment. As for the level of importance attributed to the components of professional satisfaction, we indentified that the nursing team considered the Autonomy component as the most important, followed by the component Remuneration, Interaction, Work Requirements, Work Requirements, Organizational Rules and Professional Status . Regarding the current level of professional satisfaction, we identified they were most satisfied with the Professional Status , Autonomy, Interaction, Remuneration, Work Requirements and Organizational Rules. The real professional satisfaction level, calculated through statistics, however, tells these professionals are more satisfied with Autonomy, Remuneration, Interaction, Work Requirements, professional Status and Organizational Rules. The PSR in our work was of 8,6, indicating the SAMU Natal nursing team has little satisfaction on their work environment

Controlador adaptativo por posicionamento de pólos e estrutura variável aplicado ao controle de geradores eólicos baseados em máquina de indução duplamente alimentada

In the last decade, the renewable energy sources have present a major propulsion in the world due to several factors: political, environmental, financial and others. Within this context, we have in particular the energy obtained through wind, wind energy - that has highlighted with rapid growth in recent years, including in Brazil, mostly in the Northeast, due to it s benefit-cost between the clean energies. In this context, we propose to compare the variable structure adaptive pole placement control (VS-APPC) with a traditional control technique proportional integral controller (PI), applied to set the control of machine side in a conversion system using a wind generator based on Double-Fed Induction Generator (DFIG). Robustness and performance tests were carried out to the uncertainties of the internal parameters of the machine and variations of speed reference.

Avaliação econômica de sistemas agroflorestais implantados para recuperação de reserva legal no Pontal do Paranapanema, São Paulo

O Pontal do Paranapanema, extremo oeste do Estado de São Paulo, é conhecido em todo o Brasil devido aos conflitos pela posse da terra, protagonizados pelo Movimento dos Trabalhadores Rurais Sem Terra (MST), que transformou significativamente a paisagem da região, onde atualmente se observam pequenas ilhas de assentamentos rurais imersos numa matriz de grandes pastagens. O Código Florestal prevê que esses assentamentos, assim como qualquer propriedade rural, deve manter 20% de sua área com cobertura vegetal arbórea. Essa área, conhecida como Reserva Florestal Legal, deve ser restaurada, caso não exista. Assim, esta pesquisa se desenvolveu no assentamento Santa Zélia, Município de Teodoro Sampaio, São Paulo, numa área de 15 ha de Reserva Legal. Seis famílias desse assentamento foram responsáveis pela restauração da área, através de módulos agroflorestais (Taungya) temporários. Dois indicadores foram utilizados para avaliação econômica da produção agrícola na área: Valor Presente Líquido (VLP) e Relação Benefício-Custo (RB/C). Os resultados indicaram valores positivos em todas as famílias analisadas, levando à conclusão de que sistemas agroflorestais podem ser adotados na recuperação de áreas de reserva legal em propriedades rurais. Sua maior ou menor viabilidade econômica irá depender de um manejo mais intenso na área para produção agrícola e de preços satisfatórios para venda no mercado.

Transverse cylindrical grinding of a eutectic alloy

We report herein on a comparison of the performance of two different grinding wheels (conventional and CBN) in the transverse cylindrical grinding of a eutectic alloy. Three cutting conditions were tested: rough, semi-finishing and finishing. The parameters of evaluation were the cutting force, roughness and wheel wear. The optimal cutting force and roughness values were obtained when grinding with the conventional wheel, due to the superior dressing operation performed under every cutting condition tested. Although the CBN wheel presented the best G ratio values, they were lower than expected owing to the inappropriate dressing operation applied. Excessive wheel corner wear was detected in both wheels, caused by the grinding kinematics (transverse grinding) employed. In terms of cutting force and roughness, the conventional wheel proved to be the better choice under the conditions tested. However, in terms of the G ratio, a cost analysis is crucial to determine whether the differences between the wheels justify the use of the CBN wheel, in which case the dressing operation requires improvement.

Tamanho de amostra e estimativa de custo em levantamento epidemiológico de cárie dentária

This study aimed to analyze how the prevalence and the distribution of dental caries influence the sample size in epidemiological surveys, and how much are the costs. Secondary data of oral health surveys in 12-year-old schoolchildren from Bauru in 1976, 1984, 1990, 1994, and 2001, and from Piracicaba in 2001 and 2005 were studied. Sample sizes were estimated taking into account the mean DMFT and standard deviation of each survey, establishing sampling errors of 1%, 2%, 5%, and 10%. Costs were estimated considering permanent material, consumption material and human resources. The sample size in both towns needed to be increased, ranging from 119 in 1976 to 1,118 in 2001 in Bauru, and from 954 in 2001 to 1,252 in 2005 in Piracicaba, when a sampling error of 10% was considered. The cost of dental caries surveys was verified considering different sampling errors. This cost depends on how acceptable is the margin of difference between the true mean and the one found in the survey. In conclusion, the reduction in the prevalence of dental caries has determined the need for increase in sample size and in costs for conducting the surveys.