Método experimental para la caracterización de las diferentes tecnologías de integración arquitectónica de la energía fotovoltaica en condiciones de funcionamiento real = Experimental method for characterization of several building integrated photovoltaic technologies under real working conditions

Hoy en día, el proceso de un proyecto sostenible persigue realizar edificios de elevadas prestaciones que son, energéticamente eficientes, saludables y económicamente viables utilizando sabiamente recursos renovables para minimizar el impacto sobre el medio ambiente reduciendo, en lo posible, la demanda de energía, lo que se ha convertido, en la última década, en una prioridad. La Directiva 2002/91/CE "Eficiencia Energética de los Edificios" (y actualizaciones posteriores) ha establecido el marco regulatorio general para el cálculo de los requerimientos energéticos mínimos. Desde esa fecha, el objetivo de cumplir con las nuevas directivas y protocolos ha conducido las políticas energéticas de los distintos países en la misma dirección, centrándose en la necesidad de aumentar la eficiencia energética en los edificios, la adopción de medidas para reducir el consumo, y el fomento de la generación de energía a través de fuentes renovables. Los edificios de energía nula o casi nula (ZEB, Zero Energy Buildings ó NZEB, Net Zero Energy Buildings) deberán convertirse en un estándar de la construcción en Europa y con el fin de equilibrar el consumo de energía, además de reducirlo al mínimo, los edificios necesariamente deberán ser autoproductores de energía. Por esta razón, la envolvente del edifico y en particular las fachadas son importantes para el logro de estos objetivos y la tecnología fotovoltaica puede tener un papel preponderante en este reto. Para promover el uso de la tecnología fotovoltaica, diferentes programas de investigación internacionales fomentan y apoyan soluciones para favorecer la integración completa de éstos sistemas como elementos arquitectónicos y constructivos, los sistemas BIPV (Building Integrated Photovoltaic), sobre todo considerando el próximo futuro hacia edificios NZEB. Se ha constatado en este estudio que todavía hay una falta de información útil disponible sobre los sistemas BIPV, a pesar de que el mercado ofrece una interesante gama de soluciones, en algunos aspectos comparables a los sistemas tradicionales de construcción. Pero por el momento, la falta estandarización y de una regulación armonizada, además de la falta de información en las hojas de datos técnicos (todavía no comparables con las mismas que están disponibles para los materiales de construcción), hacen difícil evaluar adecuadamente la conveniencia y factibilidad de utilizar los componentes BIPV como parte integrante de la envolvente del edificio. Organizaciones internacionales están trabajando para establecer las normas adecuadas y procedimientos de prueba y ensayo para comprobar la seguridad, viabilidad y fiabilidad estos sistemas. Sin embargo, hoy en día, no hay reglas específicas para la evaluación y caracterización completa de un componente fotovoltaico de integración arquitectónica de acuerdo con el Reglamento Europeo de Productos de la Construcción, CPR 305/2011. Los productos BIPV, como elementos de construcción, deben cumplir con diferentes aspectos prácticos como resistencia mecánica y la estabilidad; integridad estructural; seguridad de utilización; protección contra el clima (lluvia, nieve, viento, granizo), el fuego y el ruido, aspectos que se han convertido en requisitos esenciales, en la perspectiva de obtener productos ambientalmente sostenibles, saludables, eficientes energéticamente y económicamente asequibles. Por lo tanto, el módulo / sistema BIPV se convierte en una parte multifuncional del edificio no sólo para ser física y técnicamente "integrado", además de ser una oportunidad innovadora del diseño. Las normas IEC, de uso común en Europa para certificar módulos fotovoltaicos -IEC 61215 e IEC 61646 cualificación de diseño y homologación del tipo para módulos fotovoltaicos de uso terrestre, respectivamente para módulos fotovoltaicos de silicio cristalino y de lámina delgada- atestan únicamente la potencia del módulo fotovoltaico y dan fe de su fiabilidad por un período de tiempo definido, certificando una disminución de potencia dentro de unos límites. Existe también un estándar, en parte en desarrollo, el IEC 61853 (“Ensayos de rendimiento de módulos fotovoltaicos y evaluación energética") cuyo objetivo es la búsqueda de procedimientos y metodologías de prueba apropiados para calcular el rendimiento energético de los módulos fotovoltaicos en diferentes condiciones climáticas. Sin embargo, no existen ensayos normalizados en las condiciones específicas de la instalación (p. ej. sistemas BIPV de fachada). Eso significa que es imposible conocer las efectivas prestaciones de estos sistemas y las condiciones ambientales que se generan en el interior del edificio. La potencia nominal de pico Wp, de un módulo fotovoltaico identifica la máxima potencia eléctrica que éste puede generar bajo condiciones estándares de medida (STC: irradición 1000 W/m2, 25 °C de temperatura del módulo y distribución espectral, AM 1,5) caracterizando eléctricamente el módulo PV en condiciones específicas con el fin de poder comparar los diferentes módulos y tecnologías. El vatio pico (Wp por su abreviatura en inglés) es la medida de la potencia nominal del módulo PV y no es suficiente para evaluar el comportamiento y producción del panel en términos de vatios hora en las diferentes condiciones de operación, y tampoco permite predecir con convicción la eficiencia y el comportamiento energético de un determinado módulo en condiciones ambientales y de instalación reales. Un adecuado elemento de integración arquitectónica de fachada, por ejemplo, debería tener en cuenta propiedades térmicas y de aislamiento, factores como la transparencia para permitir ganancias solares o un buen control solar si es necesario, aspectos vinculados y dependientes en gran medida de las condiciones climáticas y del nivel de confort requerido en el edificio, lo que implica una necesidad de adaptación a cada contexto específico para obtener el mejor resultado. Sin embargo, la influencia en condiciones reales de operación de las diferentes soluciones fotovoltaicas de integración, en el consumo de energía del edificio no es fácil de evaluar. Los aspectos térmicos del interior del ambiente o de iluminación, al utilizar módulos BIPV semitransparentes por ejemplo, son aún desconocidos. Como se dijo antes, la utilización de componentes de integración arquitectónica fotovoltaicos y el uso de energía renovable ya es un hecho para producir energía limpia, pero también sería importante conocer su posible contribución para mejorar el confort y la salud de los ocupantes del edificio. Aspectos como el confort, la protección o transmisión de luz natural, el aislamiento térmico, el consumo energético o la generación de energía son aspectos que suelen considerarse independientemente, mientras que todos juntos contribuyen, sin embargo, al balance energético global del edificio. Además, la necesidad de dar prioridad a una orientación determinada del edificio, para alcanzar el mayor beneficio de la producción de energía eléctrica o térmica, en el caso de sistemas activos y pasivos, respectivamente, podría hacer estos últimos incompatibles, pero no necesariamente. Se necesita un enfoque holístico que permita arquitectos e ingenieros implementar sistemas tecnológicos que trabajen en sinergia. Se ha planteado por ello un nuevo concepto: "C-BIPV, elemento fotovoltaico consciente integrado", esto significa necesariamente conocer los efectos positivos o negativos (en términos de confort y de energía) en condiciones reales de funcionamiento e instalación. Propósito de la tesis, método y resultados Los sistemas fotovoltaicos integrados en fachada son a menudo soluciones de vidrio fácilmente integrables, ya que por lo general están hechos a medida. Estos componentes BIPV semitransparentes, integrados en el cerramiento proporcionan iluminación natural y también sombra, lo que evita el sobrecalentamiento en los momentos de excesivo calor, aunque como componente estático, asimismo evitan las posibles contribuciones pasivas de ganancias solares en los meses fríos. Además, la temperatura del módulo varía considerablemente en ciertas circunstancias influenciada por la tecnología fotovoltaica instalada, la radiación solar, el sistema de montaje, la tipología de instalación, falta de ventilación, etc. Este factor, puede suponer un aumento adicional de la carga térmica en el edificio, altamente variable y difícil de cuantificar. Se necesitan, en relación con esto, más conocimientos sobre el confort ambiental interior en los edificios que utilizan tecnologías fotovoltaicas integradas, para abrir de ese modo, una nueva perspectiva de la investigación. Con este fin, se ha diseñado, proyectado y construido una instalación de pruebas al aire libre, el BIPV Env-lab "BIPV Test Laboratory", para la caracterización integral de los diferentes módulos semitransparentes BIPV. Se han definido también el método y el protocolo de ensayos de caracterización en el contexto de un edificio y en condiciones climáticas y de funcionamiento reales. Esto ha sido posible una vez evaluado el estado de la técnica y la investigación, los aspectos que influyen en la integración arquitectónica y los diferentes tipos de integración, después de haber examinado los métodos de ensayo para los componentes de construcción y fotovoltaicos, en condiciones de operación utilizadas hasta ahora. El laboratorio de pruebas experimentales, que consiste en dos habitaciones idénticas a escala real, 1:1, ha sido equipado con sensores y todos los sistemas de monitorización gracias a los cuales es posible obtener datos fiables para evaluar las prestaciones térmicas, de iluminación y el rendimiento eléctrico de los módulos fotovoltaicos. Este laboratorio permite el estudio de tres diferentes aspectos que influencian el confort y consumo de energía del edificio: el confort térmico, lumínico, y el rendimiento energético global (demanda/producción de energía) de los módulos BIPV. Conociendo el balance de energía para cada tecnología solar fotovoltaica experimentada, es posible determinar cuál funciona mejor en cada caso específico. Se ha propuesto una metodología teórica para la evaluación de estos parámetros, definidos en esta tesis como índices o indicadores que consideran cuestiones relacionados con el bienestar, la energía y el rendimiento energético global de los componentes BIPV. Esta metodología considera y tiene en cuenta las normas reglamentarias y estándares existentes para cada aspecto, relacionándolos entre sí. Diferentes módulos BIPV de doble vidrio aislante, semitransparentes, representativos de diferentes tecnologías fotovoltaicas (tecnología de silicio monocristalino, m-Si; de capa fina en silicio amorfo unión simple, a-Si y de capa fina en diseleniuro de cobre e indio, CIS) fueron seleccionados para llevar a cabo una serie de pruebas experimentales al objeto de demostrar la validez del método de caracterización propuesto. Como resultado final, se ha desarrollado y generado el Diagrama Caracterización Integral DCI, un sistema gráfico y visual para representar los resultados y gestionar la información, una herramienta operativa útil para la toma de decisiones con respecto a las instalaciones fotovoltaicas. Este diagrama muestra todos los conceptos y parámetros estudiados en relación con los demás y ofrece visualmente toda la información cualitativa y cuantitativa sobre la eficiencia energética de los componentes BIPV, por caracterizarlos de manera integral. ABSTRACT A sustainable design process today is intended to produce high-performance buildings that are energy-efficient, healthy and economically feasible, by wisely using renewable resources to minimize the impact on the environment and to reduce, as much as possible, the energy demand. In the last decade, the reduction of energy needs in buildings has become a top priority. The Directive 2002/91/EC “Energy Performance of Buildings” (and its subsequent updates) established a general regulatory framework’s methodology for calculation of minimum energy requirements. Since then, the aim of fulfilling new directives and protocols has led the energy policies in several countries in a similar direction that is, focusing on the need of increasing energy efficiency in buildings, taking measures to reduce energy consumption, and fostering the use of renewable sources. Zero Energy Buildings or Net Zero Energy Buildings will become a standard in the European building industry and in order to balance energy consumption, buildings, in addition to reduce the end-use consumption should necessarily become selfenergy producers. For this reason, the façade system plays an important role for achieving these energy and environmental goals and Photovoltaic can play a leading role in this challenge. To promote the use of photovoltaic technology in buildings, international research programs encourage and support solutions, which favors the complete integration of photovoltaic devices as an architectural element, the so-called BIPV (Building Integrated Photovoltaic), furthermore facing to next future towards net-zero energy buildings. Therefore, the BIPV module/system becomes a multifunctional building layer, not only physically and functionally “integrated” in the building, but also used as an innovative chance for the building envelope design. It has been found in this study that there is still a lack of useful information about BIPV for architects and designers even though the market is providing more and more interesting solutions, sometimes comparable to the existing traditional building systems. However at the moment, the lack of an harmonized regulation and standardization besides to the non-accuracy in the technical BIPV datasheets (not yet comparable with the same ones available for building materials), makes difficult for a designer to properly evaluate the fesibility of this BIPV components when used as a technological system of the building skin. International organizations are working to establish the most suitable standards and test procedures to check the safety, feasibility and reliability of BIPV systems. Anyway, nowadays, there are no specific rules for a complete characterization and evaluation of a BIPV component according to the European Construction Product Regulation, CPR 305/2011. BIPV products, as building components, must comply with different practical aspects such as mechanical resistance and stability; structural integrity; safety in use; protection against weather (rain, snow, wind, hail); fire and noise: aspects that have become essential requirements in the perspective of more and more environmentally sustainable, healthy, energy efficient and economically affordable products. IEC standards, commonly used in Europe to certify PV modules (IEC 61215 and IEC 61646 respectively crystalline and thin-film ‘Terrestrial PV Modules-Design Qualification and Type Approval’), attest the feasibility and reliability of PV modules for a defined period of time with a limited power decrease. There is also a standard (IEC 61853, ‘Performance Testing and Energy Rating of Terrestrial PV Modules’) still under preparation, whose aim is finding appropriate test procedures and methodologies to calculate the energy yield of PV modules under different climate conditions. Furthermore, the lack of tests in specific conditions of installation (e.g. façade BIPV devices) means that it is difficult knowing the exact effective performance of these systems and the environmental conditions in which the building will operate. The nominal PV power at Standard Test Conditions, STC (1.000 W/m2, 25 °C temperature and AM 1.5) is usually measured in indoor laboratories, and it characterizes the PV module at specific conditions in order to be able to compare different modules and technologies on a first step. The “Watt-peak” is not enough to evaluate the panel performance in terms of Watt-hours of various modules under different operating conditions, and it gives no assurance of being able to predict the energy performance of a certain module at given environmental conditions. A proper BIPV element for façade should take into account thermal and insulation properties, factors as transparency to allow solar gains if possible or a good solar control if necessary, aspects that are linked and high dependent on climate conditions and on the level of comfort to be reached. However, the influence of different façade integrated photovoltaic solutions on the building energy consumption is not easy to assess under real operating conditions. Thermal aspects, indoor temperatures or luminance level that can be expected using building integrated PV (BIPV) modules are not well known. As said before, integrated photovoltaic BIPV components and the use of renewable energy is already a standard for green energy production, but would also be important to know the possible contribution to improve the comfort and health of building occupants. Comfort, light transmission or protection, thermal insulation or thermal/electricity power production are aspects that are usually considered alone, while all together contribute to the building global energy balance. Besides, the need to prioritize a particular building envelope orientation to harvest the most benefit from the electrical or thermal energy production, in the case of active and passive systems respectively might be not compatible, but also not necessary. A holistic approach is needed to enable architects and engineers implementing technological systems working in synergy. A new concept have been suggested: “C-BIPV, conscious integrated BIPV”. BIPV systems have to be “consciously integrated” which means that it is essential to know the positive and negative effects in terms of comfort and energy under real operating conditions. Purpose of the work, method and results The façade-integrated photovoltaic systems are often glass solutions easily integrable, as they usually are custommade. These BIPV semi-transparent components integrated as a window element provides natural lighting and shade that prevents overheating at times of excessive heat, but as static component, likewise avoid the possible solar gains contributions in the cold months. In addition, the temperature of the module varies considerably in certain circumstances influenced by the PV technology installed, solar radiation, mounting system, lack of ventilation, etc. This factor may result in additional heat input in the building highly variable and difficult to quantify. In addition, further insights into the indoor environmental comfort in buildings using integrated photovoltaic technologies are needed to open up thereby, a new research perspective. This research aims to study their behaviour through a series of experiments in order to define the real influence on comfort aspects and on global energy building consumption, as well as, electrical and thermal characteristics of these devices. The final objective was to analyze a whole set of issues that influence the global energy consumption/production in a building using BIPV modules by quantifying the global energy balance and the BIPV system real performances. Other qualitative issues to be studied were comfort aspect (thermal and lighting aspects) and the electrical behaviour of different BIPV technologies for vertical integration, aspects that influence both energy consumption and electricity production. Thus, it will be possible to obtain a comprehensive global characterization of BIPV systems. A specific design of an outdoor test facility, the BIPV Env-lab “BIPV Test Laboratory”, for the integral characterization of different BIPV semi-transparent modules was developed and built. The method and test protocol for the BIPV characterization was also defined in a real building context and weather conditions. This has been possible once assessed the state of the art and research, the aspects that influence the architectural integration and the different possibilities and types of integration for PV and after having examined the test methods for building and photovoltaic components, under operation conditions heretofore used. The test laboratory that consists in two equivalent test rooms (1:1) has a monitoring system in which reliable data of thermal, daylighting and electrical performances can be obtained for the evaluation of PV modules. The experimental set-up facility (testing room) allows studying three different aspects that affect building energy consumption and comfort issues: the thermal indoor comfort, the lighting comfort and the energy performance of BIPV modules tested under real environmental conditions. Knowing the energy balance for each experimented solar technology, it is possible to determine which one performs best. A theoretical methodology has been proposed for evaluating these parameters, as defined in this thesis as indices or indicators, which regard comfort issues, energy and the overall performance of BIPV components. This methodology considers the existing regulatory standards for each aspect, relating them to one another. A set of insulated glass BIPV modules see-through and light-through, representative of different PV technologies (mono-crystalline silicon technology, mc-Si, amorphous silicon thin film single junction, a-Si and copper indium selenide thin film technology CIS) were selected for a series of experimental tests in order to demonstrate the validity of the proposed characterization method. As result, it has been developed and generated the ICD Integral Characterization Diagram, a graphic and visual system to represent the results and manage information, a useful operational tool for decision-making regarding to photovoltaic installations. This diagram shows all concepts and parameters studied in relation to each other and visually provides access to all the results obtained during the experimental phase to make available all the qualitative and quantitative information on the energy performance of the BIPV components by characterizing them in a comprehensive way.

Pré-condicionamento isquêmico remoto em portadores de claudicação intermitente de membros inferiores

INTRODUÇÃO: Pré-condicionamento isquêmico remoto (PCIR) é o fenômeno pelo qual curtos períodos de isquemia sub-letal sobre um órgão ou tecido, intercalados com reperfusão do mesmo, conferem a outros órgãos ou tecidos distantes deste, um aumento na capacidade da resistir a episódios subsequentes de isquemia, a qual os mesmos possam ser expostos. Com base nesse fato, testamos a hipótese de que o pré-condicionamento isquêmico remoto em pacientes portadores de claudicação intermitente de membros inferiores poderia aumentar a capacidade de deambulação desses pacientes, extrapolando o conceito do PCIR de aumento da capacidade de preservação da integridade celular frente à isquemia, para a manutenção da função celular, tornando a célula mais apta ao trabalho em situações de privação de oxigênio, geradas pela restrição do fluxo sanguíneo, como ocorre nos pacientes com claudicação intermitente de membros inferiores, durante o exercício. OBJETIVOS: Avaliar se o PCIR aumenta a distância de início de claudicação e/ou a distância total de claudicação em pacientes com doença arterial obstrutiva periférica. MÉTODOS: Foram estudados 52 pacientes ambulatoriais que apresentavam queixa de claudicação intermitente dos membros inferiores, associada a um pulso arterial ausente ou reduzido no membro sintomático e/ou um índice tornozelo-braço <0,90. Estes pacientes foram randomizados em três grupos (A, B e C). Todos os pacientes foram submetidos a dois testes de caminhada em esteira de acordo com o protocolo de Gardner. O grupo A fez o primeiro teste de esteira sem o pré-condicionamento isquêmico remoto e, após 7 dias, foi submetido a um novo teste de esteira, agora precedido pelo pré-condicionamento isquêmico remoto. O grupo B foi submetido ao pré-condicionamento isquêmico remoto antes do primeiro teste de esteira e, após 7 dias, realizou novo teste de esteira, agora sem o pré-condicionamento isquêmico remoto. Já no Grupo C (grupo controle), ambos os testes de esteira foram realizados sem pré-condicionamento isquêmico remoto, também com 7 dias de intervalo. RESULTADOS: Os grupos A e C mostraram um aumento na distância de início de claudicação, no segundo teste, em comparação com o primeiro teste. O grupo A teve um aumento estatisticamente significativo, em relação ao grupo C (grupo controle). Com relação à distância total de claudicação, todos os grupos (A, B e C), mostraram um aumento estatisticamente significativo a favor do segundo teste, porém não foi observada diferença entre os grupos (A, B e C). CONCLUSÕES: O pré-condicionamento isquêmico remoto aumentou a distância inicial de claudicação em pacientes com claudicação intermitente, no entanto, ele não afetou a distância total de claudicação dos pacientes portadores de claudicação intermitente de membros inferiores

La cooperación sur-sur como nueva dimensión de la política exterior brasileña en el gobierno de Lula: una aproximación constructiva

Over the last decade, we have witnessed a growing number of academic researches that have Brazil and its position in the international system as an object of study, which debate is open, because there is no consensus of its role and intentions: if it is to promote the development and cooperation, or, after all, if it also has international political interests, like greater weight in the international system, greater decision capability, and others typically economics like how to gain market for its companies. Because of its geographical size, its growing economic importance, its visibility for the Brazil 2014 World Cup and the Rio 2016 Olympics, and the political demonstrations in the streets, it is hard to deny the attraction that Brazil is gaining every day. This work was created with several objectives that are tried to be answered along the writing of this thesis: a general objective that generates secondary ones and, at the same time, subsequent collateral objectives. Among the general objectives, we have the purpose of understanding and analyzing how the South-South Cooperation (SSC) is in the wider debate of the International Cooperation for Development (ICD). In this sense, it is necessary to point out the difficulty to trace clear lines of differentiation between the traditional North-South Cooperation (NSC) and the latest SSC. This is because, among other questions, there is not a definition until this moment shared by all the countries participating in it, as well as the lack of database that indicates precisely which are all the 'development partners' emerging. This thesis introduces the debate about international cooperation analyzing the challenges that it faces, the global changes that have come to transform the 'new architecture to development' and to analyze the gaps that Brazil can take with other emerging powers to improve the current and weakened assistance system...

Diseño y análisis comparativo de un inventario de indicadores de mortalidad evitable adaptado a las condiciones sanitarias de Colombia

Objetivos. Elaborar un inventario de indicadores de mortalidad evitable (INIME) que permita analizar las fallas en el control de los riesgos de mortalidad predominantes en Colombia y comparar los resultados de su aplicación con los obtenidos mediante dos enfoques ampliamente utilizados. Métodos. Se revisaron los registros oficiales de mortalidad de Colombia de 1985 a 2001; las causas básicas de muerte se clasificaron según la CIE-9. Se seleccionaron los indicadores de mortalidad evitable (ME) mediante un algoritmo que combinó las listas de Holland y de Taucher, la definición de Rutstein y colaboradores y el principio de Uemura. Se compararon las proporciones de muertes evitables resultantes de aplicar el INIME y las dos listas de ME a una base de datos con los registros oficiales de defunciones de Colombia de 1993 a 1996. Resultados. De las 680 617 defunciones registradas en el período de estudio, se clasificaron como evitables 18,2% según la lista de Holland y 51,3% según la lista de Taucher. La ME según el INIME ascendió a 76,7%. Este patrón se mantuvo relativamente estable entre 1993 y 1996. Las diferencias observadas en la proporción de muertes evitables según el INIME y las dos listas de ME se relacionaron con el perfil epidemiológico local y el enfoque conceptual de cada lista. Conclusiones. Las diferencias entre el INIME y las listas de ME de Holland y de Taucher muestran las consecuencias de usar una u otra clasificación en el contexto colombiano. El INIME puede constituir un recurso valioso para fundamentar y evaluar políticas sanitarias, pero debe ajustarse a la situación específica en que se aplique.

Variabilidad de la estancia media en pacientes hospitalizados en un hospital de Traumatología durante el año 2010

Objetivos: El objetivo principal del estudio es conocer la estancia media hospitalaria y su variabilidad en relación con el motivo de ingreso, en una unidad de hospitalización de un hospital monográfico de Traumatología. (Unión de Mutuas. Castellón) Metodología: Estudio transversal, descriptivo, basado en datos administrativos, cuya población estuvo formada por todos los individuos que tuvieron algún episodio de hospitalización durante el año 2010, siendo este el criterio de inclusión, por orden cronológico de aparición. Resultados: Se identificaron un total de 736 episodios asistenciales y 133 códigos CIE-9CM. La edad media fue 44 (+/-10) años. El 83,25% de los pacientes fueron varones. El código 836.0 (Desgarro de cartílago o menisco interno de la rodilla-actual) fue el diagnóstico más habitual (12,25%) y la artroscopia la técnica quirúrgica mayoritaria. “Fractura de pelvis” (CIE-9CM 808) resultó el código diagnóstico que presentó mayor estancia media con 25 (+/-9.84) estancias y mayor variabilidad de la misma, seguido de los diagnósticos “Fractura de diáfisis de tibia-cerrada”, “Fractura de diáfisis de tibia/peronéabierta”, “Contusión de múltiples sitios, ncoc” y “Fractura de tibia y peroné”. Conclusiones: Se observa poca variabilidad en la estancia media excepto en los procesos diagnosticados como fractura de pelvis y en los relacionados con fracturas de los miembros inferiores.

Fitting of a New Design of Full Scleral Contact Lens in Advanced Keratoconus with Previous Implantation of Intracorneal Ring Segments

This case report reports the visual rehabilitation obtained with the fitting of a new design of full scleral contact lens (ICD 16.5 contact lens, Paragon Vision Sciences, distributed by Lenticon, Madrid, Spain) in a cornea with advanced keratoconus and previous implantation of intracorneal ring segment with a very limited effect. This eye had a refraction of –3.00 × 55° cylinder, providing a visual acuity of 0.5 LogMAR. The topographic pattern was very irregular with the presence of a significant central protrusion and a significant central corneal thinning. Some previous unsuccessful fittings have been performed with corneal and corneal-scleral lenses. A comfortable wearing was achieved with a fully scleral contact lens of 4600 μm of sagittal height, optical power of –11.25 D, and providing an apical clearance of 196 μm. A visual acuity of 0.0 LogMAR combined with a relevant aberrometric improvement was achieved with this contact lens. The patient was completely satisfied with the fitting. The result was maintained during 1 year after the fitting. Full scleral lenses are then able to provide comfortable wear and a significant increase in visual acuity combined with a significant improvement in the visual quality in eyes with advanced keratoconus.

Proton pump inhibitors and the risk of fractures in older adults: a population-based retrospective cohort study

Thesis (Master's)--University of Washington, 2016-06

Age-at-first-registration and heterogeneity in affective psychoses

Background: Previous research into age of onset in affective disorders has produced conflicting results. This paper examines the influence of heterogeneity on the age-at-first-registration distribution for the ICD-9 diagnostic group 'affective psychosis'. Method: For 1979-1991, data for age-at-first-registration for 4985 individuals diagnosed with affective psychosis (ICD-9 296.x) were extracted from a name-linked mental health register. These data were divided into (i) '296.1 only', a category used to code unipolar depression (males = 700; females = 1321); and (ii) '296 other', all 296 cases other than 296.1 (males = 1280; females = 1684). Inception rates for each 5-year age division were adjusted for the background population age-structure as a rate per 100 000 population. Results: The age-at-first-registration distribution for affective psychosis has a wide age range, with women outnumbering men. There is a near-linear increase in inception rates for both men and women with 296.1 only, while the bulk of those with affective psychoses (296 other) have an inverted U-shaped age distribution. Males have an earlier modal age-at-first-registration for 296 other compared to females. Conclusion: The heterogeneity in terms of subtypes and sex in affective psychosis clouds the interpretation of age-at-first-registration. Separating those with unipolar psychotic depression from other subclassifications and differentiating by sex may provide clues to factors that precipitate the onset of affective psychosis.

A comparison of competing methods for the detection of surgical-site infections in patients undergoing total arthroplasty of the knee, partial and total arthroplasty of hip and femoral or similar vascular bypass

Recent research suggests that the retrospective review of the International Classification of Disease (ICD-9-CM) codes assigned to a patient episode will identify a similar number of healthcare-acquired surgical-site infections as compared with prospective surveillance by infection control practitioners (ICP). We tested this finding by replicating the methods for 380 surgical procedures. The sensitivity and specificity of the ICP undertaking prospective surveillance was 80% and 100%, and the sensitivity and specificity of the review of ICD-10-AM codes was 60% and 98.9%. Based on these results we do not support retrospective review of ICD-10-AM codes in preference prospective surveillance for SSI. (C) 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Co-existing conditions for deaths from infectious and parasitic diseases in Australia

Objective: To examine the frequency distribution of co-existing conditions for deaths where the underlying cause was infectious and parasitic diseases. Materials and methods: Besides the underlying cause of death, the distributions of co-existing conditions for deaths from infectious and parasitic diseases were examined in total and by various age and sex groups, at individual and chapter levels, using 1998 Australian mortality data. Results: In addition to the underlying cause of death, the average number of reported co-existing conditions for a single infectious and parasitic death was 1.62. The most common co-existing conditions were respiratory failure, acute renal failure non-specific causes, ischaemic heart disease, pneumonia and diabetes. When studying the distribution of co-existing conditions at the ICD-9 chapter level, it was found that the circulatory system diseases were the most important. There was an increasing trend in the number of reported co-existing conditions from 60 years of age upwards. Gender differences existed in the frequency of some reported co-existing conditions. The most common organism types of co-existing conditions were other bacterial infection and other viruses. Conclusions: The study indicated that the quality of death certificates is less than satisfactory for the 1998 Australian mortality data. The findings may be helpful in clarifying the ICD coding rules and the development of disease prevention strategies. (C) 2003 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Personality disorders in the community: Results from the Australian National Survey of Mental Health and Well-Being Part III - Relationships between specific type of personality disorder, Axis 1 mental disorders and physical conditions with disability and health consultations

Background The aims of this study were threefold. First, to ascertain whether personality disorder (PD) was a significant predictor of disability (as measured in a variety of ways) over and above that contributed by Axis I mental disorders and physical conditions. Second, whether the number of PD diagnoses given to an individual resulted in increasing severity of disability, and third, whether PD was a significant predictor of health and mental health consultations with GPs, psychiatrists, and psychologists, respectively, over the last 12 months. Method Data were obtained from the National Survey of Mental Health and Wellbeing, conducted between May and August 1997. A stratified random sample of households was generated, from which all those aged 18 and over were considered potential interviewees. There were 10 641 respondents to the survey, and this represented a response rate of 78%. Each interviewee was asked questions indexing specific ICD-10 PD criteria. Results Five measures of disability were examined. It was found that PD was a significant predictor of disability once Axis I and physical conditions were taken into account for four of the five disability measures. For three of the dichotomously-scored disability measures, odds ratios ranged from 1.88 to 6.32 for PD, whilst for the dimensionally-scored Mental Summary Subscale of the SF-12, a beta weight of -0.17 was recorded for PD. As regards number of PDs having a quasi-linear relationship to disability, there was some indication of this on the SF-12 Mental Summary Subscale and the two role functioning measures, and less so on the other two measures. As regards mental consultations, PD was a predictor of visits to GPs, psychiatrists and psychologists, over and above Axis I disorders and physical conditions. Conclusion The study reports findings from a nationwide survey conducted within Australia and as such the data are less influenced by the selection and setting bias inherent in other germane studies. However, it does support previous findings that PD is a significant predictor of disability and mental health consultations independent of Axis I disorders and physical conditions.

Differences in prevalence of pre-existing morbility between injured and non-injured populations

Objectives To identify and examine differences in pre-existing morbidity between injured and non-injured population-based cohorts. Methods Administrative health data from Manitoba, Canada, were used to select a population-based cohort of injured people and a sample of non-injured people matched on age, gender, aboriginal status and geographical location of residence at the date of injury. All individuals aged 18-64 years who had been hospitalized between 1988 and 1991 for injury (International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code 800-995) (n = 21032), were identified from the Manitoba discharge database. The matched non-injured comparison group comprised individuals randomly selected 1: 1 from the Manitoba population registry. Morbidity data for the 12 months prior to the date of the injury were obtained by linking the two cohorts with all hospital discharge records and physician claims. Results Compared to the non-injured group, injured people had higher Charlson Comorbidity Index scores, 1.9 times higher rates of hospital admissions and 1.7 times higher rates of physician claims in the year prior to the injury. Injured people had a rate of admissions to hospital for a mental health disorder 9.3 times higher, and physician claims for a mental health disorder 3.5 times higher, than that of non-injured people. These differences were all statistically significant (P < 0.001). Conclusion Injured people were shown to differ from the general non-injured population in terms of pre-existing morbidity. Existing population estimates of the attributable burden of injury that are obtained by extrapolating from observed outcomes in samples of injured cases may overestimate the magnitude of the problem.

The empirical basis of substance use disorders diagnosis: research recommendations for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V)

Aims This paper presents the recommendations, developed from a 3-year consultation process, for a program of research to underpin the development of diagnostic concepts and criteria in the Substance Use Disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and potentially the relevant section of the next revision of the International Classification of Diseases (ICD). Methods A preliminary list of research topics was developed at the DSM-V Launch Conference in 2004. This led to the presentation of articles on these topics at a specific Substance Use Disorders Conference in February 2005, at the end of which a preliminary list of research questions was developed. This was further refined through an iterative process involving conference participants over the following year. Results Research questions have been placed into four categories: (1) questions that could be addressed immediately through secondary analyses of existing data sets; (2) items likely to require position papers to propose criteria or more focused questions with a view to subsequent analyses of existing data sets; (3) issues that could be proposed for literature reviews, but with a lower probability that these might progress to a data analytic phase; and (4) suggestions or comments that might not require immediate action, but that could be considered by the DSM-V and ICD 11 revision committees as part of their deliberations. Conclusions A broadly based research agenda for the development of diagnostic concepts and criteria for substance use disorders is presented.

Enhancing employment services for people with severe mental illness: the challenge of the Australian service environment

Objectives: Comparatively few people with severe mental illness are employed despite evidence that many people within this group wish to obtain, can obtain and sustain employment, and that employment can contribute to recovery. This investigation aimed to: (i) describe the current policy and service environment within which people with severe mental illness receive employment services; (ii) identify evidence-based practices that improve employment outcomes for people with severe mental illness; (iii) determine the extent to which the current Australian policy environment is consistent with the implementation of evidence-based employment services for people with severe mental illness; and (iv) identify methods and priorities for enhancing employment services for Australians with severe mental illness through implementation of evidence-based practices. Method: Current Australian practices were identified, having reference to policy and legal documents, funding body requirements and anecdotal reports. Evidence-based employment services for people with severe mental illness were identified through examination of published reviews and the results of recent controlled trials. Results: Current policy settings support the provision of employment services for people with severe mental illness separate from clinical services. Recent studies have identified integration of clinical and employment services as a major factor in the effectiveness of employment services. This is usually achieved through co-location of employment and mental health services. Conclusions: Optimal evidence-based employment services are needed by Australians with severe mental illness. Providing optimal services is a challenge in the current policy environment. Service integration may be achieved through enhanced intersectoral links between employment and mental health service providers as well as by co-locating employment specialists within a mental health care setting.

The development of a research agenda for substance use disorders diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V)

Aims paper describes the background to the establishment of the Substance Use Disorders Workgroup, which was charged with developing the research agenda for the development of the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It summarizes 18 articles that were commissioned to inform that process. Methods A preliminary list of research topics, developed at the DSM-V Launch Conference in 2004, led to the identification of subjects that were subject to formal presentations and detailed discussion at the Substance Use Disorders Conference in February 2005. Results The 18 articles presented in this supplement examine: (1) categorical versus dimensional diagnoses; (2) the neurobiological basis of substance use disorders; (3) social and cultural perspectives; (4) the crosswalk between DSM-IV and the International Classification of Diseases Tenth Revision (ICD-10); (5) comorbidity of substance use disorders and mental health disorders; (6) subtypes of disorders; (7) issues in adolescence; (8) substance-specific criteria; (9) the place of non-substance addictive disorders; and (10) the available research resources. Conclusions In the final paper a broadly based research agenda for the development of diagnostic concepts and criteria for substance use disorders is presented.