Generación de modelos físicos personalizados y segmentación de la pared arterial y el trombo intraluminal en imágenes de aneurismas aórticos abdominales

Esta tesis doctoral está encuadrada dentro del marco general de la ingeniería biomédica aplicada al tratamiento de las enfermedades cardiovasculares, enfermedades que provocan alrededor de 1.9 millones (40%) de muertes al año en la Unión Europea. En este contexto surge el proyecto europeo SCATh-Smart Catheterization, cuyo objetivo principal es mejorar los procedimientos de cateterismo aórtico introduciendo nuevas tecnologías de planificación y navegación quirúrgica y minimizando el uso de fluoroscopía. En particular, esta tesis aborda el modelado y diagnóstico de aneurismas aórticos abdominales (AAA) y del trombo intraluminal (TIL), allí donde esté presente, así como la segmentación de estas estructuras en imágenes preoperatorias de RM. Los modelos físicos específicos del paciente, construidos a partir de imágenes médicas preoperatorias, tienen múltiples usos, que van desde la evaluación preoperatoria de estructuras anatómicas a la planificación quirúrgica para el guiado de catéteres. En el diagnóstico y tratamiento de AAA, los modelos físicos son útiles a la hora de evaluar diversas variables biomecánicas y fisiológicas de las estructuras vasculares. Existen múltiples técnicas que requieren de la generación de modelos físicos que representen la anatomía vascular. Una de las principales aplicaciones de los modelos físicos es el análisis de elementos finitos (FE). Las simulaciones de FE para AAA pueden ser específicas para el paciente y permiten modelar estados de estrés complejos, incluyendo los efectos provocados por el TIL. La aplicación de métodos numéricos de análisis tiene como requisito previo la generación de una malla computacional que representa la geometría de interés mediante un conjunto de elementos poliédricos, siendo los hexaédricos los que presentan mejores resultados. En las estructuras vasculares, generar mallas hexaédricas es un proceso especialmente exigente debido a la compleja anatomía 3D ramificada. La mayoría de los AAA se encuentran situados en la bifurcación de la arteria aorta en las arterias iliacas y es necesario modelar de manera fiel dicha bifurcación. En el caso de que la sangre se estanque en el aneurisma provocando un TIL, éste forma una estructura adyacente a la pared aórtica. De este modo, el contorno externo del TIL es el mismo que el contorno interno de la pared, por lo que las mallas resultantes deben reflejar esta particularidad, lo que se denomina como "mallas conformadas". El fin último de este trabajo es modelar las estructuras vasculares de modo que proporcionen nuevas herramientas para un mejor diagnóstico clínico, facilitando medidas de riesgo de rotura de la arteria, presión sistólica o diastólica, etc. Por tanto, el primer objetivo de esta tesis es diseñar un método novedoso y robusto para generar mallas hexaédricas tanto de la pared aórtica como del trombo. Para la identificación de estas estructuras se utilizan imágenes de resonancia magnética (RM). Deben mantenerse sus propiedades de adyacencia utilizando elementos de alta calidad, prestando especial atención al modelado de la bifurcación y a que sean adecuadas para el análisis de FE. El método tiene en cuenta la evolución de la línea central del vaso en el espacio tridimensional y genera la malla directamente a partir de las imágenes segmentadas, sin necesidad de reconstruir superficies triangulares. Con el fin de reducir la intervención del usuario en el proceso de generación de las mallas, es también objetivo de esta tesis desarrollar un método de segmentación semiautomática de las distintas estructuras de interés. Las principales contribuciones de esta tesis doctoral son: 1. El diseño, implementación y evaluación de un algoritmo de generación de mallas hexaédricas conformadas de la pared y el TIL a partir de los contornos segmentados en imágenes de RM. Se ha llevado a cabo una evaluación de calidad que determine su aplicabilidad a métodos de FE. Los resultados demuestran que el algoritmo desarrollado genera mallas conformadas de alta calidad incluso en la región de la bifurcación, que son adecuadas para su uso en métodos de análisis de FE. 2. El diseño, implementación y evaluación de un método de segmentación automático de las estructuras de interés. La luz arterial se segmenta de manera semiautomática utilizando un software disponible a partir de imágenes de RM con contraste. Los resultados de este proceso sirven de inicialización para la segmentación automática de las caras interna y externa de la pared aórtica utilizando métodos basado en modelos de textura y forma a partir de imágenes de RM sin contraste. Los resultados demuestran que el algoritmo desarrollado proporciona segmentaciones fieles de las distintas estructuras de interés. En conclusión, el trabajo realizado en esta tesis doctoral corrobora las hipótesis de investigación postuladas, y pretende servir como aportación para futuros avances en la generación de modelos físicos de geometrías biológicas. ABSTRACT The frame of this PhD Thesis is the biomedical engineering applied to the treatment of cardiovascular diseases, which cause around 1.9 million deaths per year in the European Union and suppose about 40% of deaths per year. In this context appears the European project SCATh-Smart Catheterization. The main objective of this project is creating a platform which improves the navigation of catheters in aortic catheterization minimizing the use of fluoroscopy. In the framework of this project, the specific field of this PhD Thesis is the diagnosis and modeling of abdominal aortic aneurysm (AAAs) and the intraluminal thrombus (ILT) whenever it is present. Patient-specific physical models built from preoperative imaging are becoming increasingly important in the area of minimally invasive surgery. These models can be employed for different purposes, such as the preoperatory evaluation of anatomic structures or the surgical planning for catheter guidance. In the specific case of AAA diagnosis and treatment, physical models are especially useful for evaluating pressures over vascular structures. There are multiple techniques that require the generation of physical models which represent the target anatomy. Finite element (FE) analysis is one the principal applications for physical models. FE simulations for AAA may be patient-specific and allow modeling biomechanical and physiological variables including those produced by ILT, and also the segmentation of those anatomical structures in preoperative MR images. Applying numeric methods requires the generation of a proper computational mesh. These meshes represent the patient anatomy using a set of polyhedral elements, with hexahedral elements providing better results. In the specific case of vascular structures, generating hexahedral meshes is a challenging task due to the complex 3D branching anatomy. Each patient’s aneurysm is unique, characterized by its location and shape, and must be accurately represented for subsequent analyses to be meaningful. Most AAAs are located in the region where the aorta bifurcates into the iliac arteries and it is necessary to model this bifurcation precisely and reliably. If blood stagnates in the aneurysm and forms an ILT, it exists as a conforming structure with the aortic wall, i.e. the ILT’s outer contour is the same as the wall’s inner contour. Therefore, resulting meshes must also be conforming. The main objective of this PhD Thesis is designing a novel and robust method for generating conforming hexahedral meshes for the aortic wall and the thrombus. These meshes are built using largely high-quality elements, especially at the bifurcation, that are suitable for FE analysis of tissue stresses. The method accounts for the evolution of the vessel’s centerline which may develop outside a single plane, and generates the mesh directly from segmented images without the requirement to reconstruct triangular surfaces. In order to reduce the user intervention in the mesh generation process is also a goal of this PhD. Thesis to develop a semiautomatic segmentation method for the structures of interest. The segmentation is performed from magnetic resonance image (MRI) sequences that have tuned to provide high contrast for the arterial tissue against the surrounding soft tissue, so that we determine the required information reliably. The main contributions of this PhD Thesis are: 1. The design, implementation and evaluation of an algorithm for generating hexahedral conforming meshes of the arterial wall and the ILT from the segmented contours. A quality inspection has been applied to the meshes in order to determine their suitability for FE methods. Results show that the developed algorithm generates high quality conforming hexahedral meshes even at the bifurcation region. Thus, these meshes are suitable for FE analysis. 2. The design, implementation and evaluation of a semiautomatic segmentation method for the structures of interest. The lumen is segmented in a semiautomatic way from contrast filled MRI using an available software. The results obtained from this process are used to initialize the automatic segmentation of the internal and external faces of the aortic wall. These segmentations are performed by methods based on texture and shape models from MRI with no contrast. The results show that the algorithm provides faithful segmentations of the structures of interest requiring minimal user intervention. In conclusion, the work undertaken in this PhD. Thesis verifies the investigation hypotheses. It intends to serve as basis for future physical model generation of proper biological anatomies used by numerical methods.

Diseño arquitectónico y protección en caso de incendio: desarrollo normativo español en materia de evacuación en los siglos XIX y XX

Esta es la búsqueda de respuestas a esa duda constante: De dónde venimos y que hemos ido dejando por el camino. ¿Está todo claro en este recorrido o hemos actuado por acumulación de errores heredados de procesos anteriores? Es la investigación a través del descubrimiento de nuestro pasado, de nuestros orígenes en materia de seguridad de protección contra incendios, y sobre todo de ejecución de una arquitectura pensada para ser recorrida con mayor seguridad y ser evacuada en un tiempo razonable. El trabajo investiga, a nivel nacional, la evolución de la sociedad y sus efectos sobre la manera de interpretar el problema de la seguridad contra incendios en los edificios. El interés fundamentalmente es poner en claro todos aquellos aspectos que afectan a la evacuación de las personas. Para ello se han estudiado los principales hitos de actuación, las preocupaciones principales surgidas en cada momento y las soluciones adoptadas. Se ha comprobado su aplicación o su demora hasta que se ha producido el siguiente gran suceso que ha motivado una nueva revisión de los procedimientos de diseño y control. En primer lugar, tratando de relacionar los incendios fundamentales que han influido en nuestra forma de abordar el problema en distintos momentos de la historia de España. En segundo lugar, haciendo un recorrido sobre la figura del arquitecto y su participación en los medios de control y legislación sobre la manera de intervenir en el servicio de incendios o de resolver los edificios en materia de protección contra incendios o evacuación de sus ocupantes. En definitiva, descubriendo los escritos de algunos especialistas, fundamentales para entender nuestra manera de abordar el problema de la protección en los edificios, a lo largo de la historia. Se ha revisado como se han producido los siniestros más importantes en teatros y otros locales públicos .Analizando la forma en que los arquitectos implicados han tratado de resolver las posibles deficiencias ante el riesgo. Se trata de la tipología edificatoria donde, por primera vez, surge la preocupación por adoptar medidas y procedimientos de seguridad en caso de incendio. Resultan locales con una importante siniestralidad, donde se desarrolla la principal actividad lúdica del momento, y que por el importante número de personas que albergan, son fuente de preocupación entre el público y las autoridades. Otras cuestiones en un tema tan amplio, que quedan simplemente esbozadas en este trabajo de investigación, son los procedimientos de los sistemas de extinción, la estructura organizativa de la ciudad, las primeras sociedades de seguros de incendios, la aparición de patentes a partir del desarrollo industrial del siglo XIX. Todo ello, con el hilo conductor de la reglamentación que se ha ido elaborando al respecto. Al principio, sobre espectáculos públicos, acotando el punto de partida en la materia de nuestra reglamentación. Anticipando sistemas constructivos y datos dimensionales de la evacuación. Llegados a mediados del siglo XX, abordando otros usos. Haciendo seguimiento de la modernización de los procesos edificatorios y la reglamentación sectorial. Recabando información de las organizaciones profesionales que comienzan a reclamar una coordinación nacional de los sistemas preventivos y que desemboca en el Proyecto de Reglamento de prevención contra el fuego que nunca será publicado. Toda esta etapa, plagada de documentos de carácter voluntario u obligatorio, local y nacional, van definiendo los criterios dimensionales con los que debe resolverse los elementos arquitectónicos susceptibles de servir para la evacuación. Se trata de una etapa intensa en documentación, cambiante, sujeta a los criterios que establecen los países del entorno más avanzados en la materia. Las dos últimas décadas del siglo, acotadas por la transición política y varios siniestros de graves consecuencias, definen el proceso normativo que culmina con el código técnico de la edificación que hoy conocemos. Es un periodo de aprendizaje y asimilación del capítulo de la seguridad, donde los métodos son variados. Donde la intencionalidad última es trasladar un sistema prescriptivo a un modelo prestacional propio de la madurez en el análisis del tema y en las corrientes de los países del entorno. ABSTRACT This is the search for answers to that constant question: Where do we come from and what have left along the way? Has everything been clear on this journey, or have we acted as a result of a collection of errors learned from prior processes? This has been research through exploration of our past, of our origins regarding fire protection safety, and, above all, of the endeavour to utilize architecture aimed at offering the highest level of safety and evacuation in a reasonable time. This project has researched society’s change nationwide and its effects on how to interpret the difficulty of fire protection safety in buildings. Its focus has fundamentally been to clarify those aspects that affect the evacuation of people. To this end, the main milestones of action, the principal concerns that have arisen at each step, and the solutions taken have all been studied. A check was performed on their application; or their delay until a significant event occurred that prompted a new revision of design and control procedures. Firstly, this was done by attempting to connect the main fires that have influenced how we handle the problem at different times in Spain’s history. Secondly, an examination was done on the figure of the architect and his participation in the means of control and legislation on how to intercede in fire services, or how the architect finds solutions for buildings in terms of fire protection, or the evacuation of their occupants. In short, the written works of certain specialists, who are essential to our understanding of how to deal with the problem of protection in buildings, were explored throughout history. A study was done on the most significant disasters in theatres and other public establishments. This was done by analysing the way the architects involved have aimed to solve possible points liable to risk. It is a classification of building where, for the first time, the concern arose to adopt safety measures and procedures in the event of fires. Public establishments with considerable accident rates emerged. Here the main entertainment activities of the time took place. These spaces were a source of worry among the public and authorities due to the high number of persons they accommodated. Other issues in such an extensive subject, which are only outlined in this research study, are procedures in extinguishing systems, the organizational structure of cities, the first fire insurance companies, and the appearance of patents after the industrial development of the 19th century. All of these aspects are joined by the common thread of regulations that have been created in this matter. At the beginning, these regulations were for public shows, thus defining the starting point for our regulations. This was done in anticipation of structural systems and size data of evacuations. With the arrival of the mid-20th century, different uses were addressed. A modernization of construction processes and the industry regulations were tracked. Information was gathered from professional organizations that began to demand a national coordination of prevention systems which led to the Regulation Project on fire prevention which will never be published. Throughout this stage, replete with voluntary and compulsory documents, both on the local and national level, the dimensional criteria to be used in the resolution of architectural elements open to use in evacuation were defined. This was a period that was filled with documentation, change, and subject to the criteria that the most advanced countries in the field established in this regard. The final two decades of the century, marked by political transition and several accidents with grave consequences, defined the regulation process that culminated with the building technical code known today. This was a period of learning and understanding in the chapter of safety, where the methods are varied. In this chapter, the ultimate goal is to insert a prescriptive-based standard into a performance-based code suitable for cultivated experience in analysis of the subject and the tendencies in countries dealing with this field.

Dispositivo de fijación, cierre y acoplamiento para catéter de perfusión intravenosa

(SPA) Introducción: los medios de fijación a la piel de un catéter venoso periférico, de un catéter venoso central o de un catéter arterial central presentan los siguientes graves inconvenientes: ser la sede de infecciones a nivel del lugar de la punción, provocar una saturación de la zona anatómica, la cual resulta muy difícil de soportar e incómodo para el paciente portador, y suponer un riesgo para el personal de enfermería cuando se usan hilos de sutura para fijar el soporte del catéter. Objetivo: por lo anteriormente expuesto, se ha detecta- do la necesidad de diseñar un dispositivo que reduzca la complejidad y aparatosidad de los sistemas conocidos y empleados en la actualidad, favoreciendo la asepsia y la movilidad del paciente. Método: el desarrollo presentado en este artículo se refie- re a un sistema mecánico de fijación, cierre y acoplamiento para catéter de perfusión intravenosa. El sistema dispone de una pieza circular de pequeño espesor con al menos dos orificios para su fijación subcutánea, centralmente de uno o más conductos para acoplar lúmenes, y de una parte cilín- drica hueca que sobresale a uno de los lados, exteriormente roscada e interiormente lisa con un tetón de posición. Para uso domiciliario se dispone de un tapón de estanqueidad con uno o más tubos de pequeño diámetro que se acoplan en los orificios para lúmenes, una ranura de posición, un tirador y un tapón roscado ciego para el cierre hermético con la parte roscada. Para uso hospitalario se dispone de un tapón intermedio con una o más entradas para lúmenes, así como de un tapón roscado hueco que permite su acopla- miento hermético con la parte roscada. Resultados: el desarrollo descrito en este artículo va a ser utilizado en dos ambientes: ambiente domiciliario y ambiente hospitalario. Además, reduce el riesgo de infec- ción y saturación de la zona anatómica de los pacientes en los que se realiza la punción cutánea en la que se fijan catéteres venosos periféricos, catéteres venosos centrales o catéteres arteriales centrales. (ENG) Introduction: skin fixing devices in peripheral, central or arterial catheters have several important drawbacks: site infection, stacking of material in the anatomical area which is very annoying for the patient and medical staff risk when fixating stitches are used. Objective: to develop a fixing device that simplifies presently used systems, favoring asepsis and motility. Methods: the device herein described is composed by a mechanical fixation, a closing system and coupling for intravenous catheters. The system has a thin circular pie- ce with at least two holes for subcutaneous fixation, one or several conducts for lumina and a hollow cylindrical part in one side, screwed exteriorly and flat inside, with an oriented protuberance. A watertight plug with one or several thin tubes that adapt to the lumina, a positional slot, a handle and a solid screwed tap for perfect closure are available for at home use. An intermediate plug with one or several lumina and a screwed hollow plug are pro- vided for in hospital use. Results: the above described device is intended to be used in two settings: in hospital and at home. It is su- pposed to reduce the risk of infection and stacking of the anatomical site where cutaneo us puncture with fixation of peripheral, central or arterial catheters is performed.

Mecánica de las bóvedas de fábrica: el enfoque del equilibrio

El padre Vicente tosca, arquitecto, filósofo, matemático, y astrónomo, Y comienza su Tratado de Arquitectura (que forma parte de su Compendio matemático, 9 vols. 1701-1715) abordando el tema de la traza o proyecto de bóvedas: Lo más sutil y primoroso de la Arquitectura... es la construcción de todo género de arcos y bóvedas, cortando sus piedras, y ajustándolas con tal artificio, que la misma gravedad y peso que las había de precipitar hácia la tierra, las mantenga constantes en el ayre, sustentándose las unas á las otras en virtud de la mutua complicación que las enlaza, con lo que cierran por arriba las fábricas con toda seguridad y firmeza. El equilibrio se alcanza a través de la geometría y, de este modo es posible la construcción de edificios de fábrica seguros. Las antiguas reglas tradicionales para el proyecto de bóvedas y estribos de fábrica tienen un carácter geométrico, ya que establecen ciertas relaciones entre las dimensiones de los elementos estructurales. Regulan, por ejemplo, que el grosor de un estribo debe ser una cierta fracción entera de la luz de las bóvedas. De hecho en la afirmación del padre Tosca encontramos la esencia misma del proyecto de estructuras de fábrica (Huerta 2004). Sin embargo para nosotros, arquitectos e ingenieros del siglo XXI, todo esto nos parece demasiado ingenuo, la demostración de la ignorancia de los antiguos maestros; de hecho, hasta el siglo XVIII no se desarrolló una teoría científica de las estructuras, basada en la Resistencia de Materiales y las leyes de la Mecánica (Huerta 1996). De cualquier forma estos *ignorantes+ maestros constructores levantaron el Pantheon de Roma, Santa Sofía y las catedrales góticas. Por tanto, puede que, después de todo, el enfoque geométrico tradicional no esté demasiado equivocado. Es posible que los antiguos maestros tuvieran una teoría, distinta de nuestra teoría científica, pero basada en un profundo conocimiento de la naturaleza y comportamiento de las estructuras de fábrica. Si fuera así, sería interesante conocer algo sobre esta teoría, la cual, si juzgamos por los resultados, era extraordinaria. Sin embargo, aunque podemos ampliar nuestros conocimientos, no podemos sustraernos a los que ya tenemos. Estamos forzados a abordar el tema del análisis de arcos y bóvedas desde un enfoque científico, dentro del marco de la teoría de estructuras actual. Antes de proseguir se deben hacer dos observaciones. La primera se refiere al objetivo de la Teoría de Estructuras. El objetivo de la teoría estructural es el proyecto de construcciones seguras o el análisis de la seguridad de las que ya existen. Es una ciencia aplicada no una ciencia pura. Como Rankine (1858) señaló, si la pregunta que se hace el científico es *qué quiero saber+, la del arquitecto o ingeniero es *qué quiero hacer+. Todas las consideraciones teóricas están condicionadas por la necesidad de una respuesta a un problema sin demora. La segunda observación hace referencia a nuestra propia ignorancia respecto al tema. Ya no se construyen bóvedas y toda la tradición de la construcción en fábrica se ha perdido en el mundo occidental. Esta parte de la arquitectura, que fue considerada *lo más sutil y primoroso+, nos es ajena. La mayor parte de los arquitectos e ingenieros nunca han visto construir una sencilla bóveda. Carecemos del oficio y experiencia del antiguo constructor, que seleccionaba la piedra, dibujaba las plantillas para cortarla, trazaba la cimbra, dirigía el proceso de construcción y, finalmente, supervisaba el descimbrado. Rodrigo Gil de Hontañón (Tratado de arquitectura, ca. 1540, copiado en García, 1681) después de describir la construcción de una bóveda gótica de crucería advierte que: . . . estas cosas, podran ser difiçiles de comprehender faltando en quien las procura la experiencia, la practi¬ca, la profesion de la canteria, y la execuçion, o el aberse allado presente a algunos çierres de cruçeria, para haçerse capaz en el asiento de ella. Esta es precisamente la situación de cualquier arquitecto o ingeniero de la actualidad. A partir de aquí trataremos de mostrar que los enfoques tradicional y moderno del cálculo de estructuras de fábrica llevan a la misma conclusión fundamental: la absoluta importancia de la geometría. Se demostrará que la moderna teoría del Análisis Límite de las estructuras de Fábrica, que ha sido desarrollada por el profesor Heyman, es la herramienta más apropiada para comprender y analizar las construcciones de fábrica. Esta teoría conduce al *enfoque del equilibrio+; el calculista necesita sólo estudiar posible estados de equilibrio con la fábrica trabajando a compresión. La existencia de estos posibles estados de equilibrio depende de la geometría. Una construcción segura es una construcción en equilibrio: la teoría moderna conduce a las mismas disposiciones geométricas que la tradicional. No podía ser de otro modo, los espectaculares logros de los antiguos arquitectos no pudieron ser fruto de la casualidad. Se harán numerosas referencias históricas con la intención de dejar claro que existe una antigua tradición en el cálculo científico de las estructuras de fábrica según el enfoque del equilibrio. Tenemos mucho que aprender de los arquitectos e ingenieros de la antigüedad. Pudieron no tener una profunda comprensión de la teoría, pero poseían los conocimientos esenciales, ésos que proporciona la reflexión sobre la práctica. Ars sine scientia nihil est, la práctica no es nada sin la teoría, pero la teoría sin la práctica es simplemente peligrosa. La experiencia, en nuestro caso, debemos buscarla en los edificios construidos y en lo que podemos extraer de la lectura crítica de los antiguos tratados de arquitectura e ingeniería.

Potencialidades e alcances do monitoramento como ferramenta de gestão da saúde

No Brasil, a construção bem como as mudanças nos mais de vinte anos do Sistema Único de Saúde (SUS) tem demandado um crescente interesse em estratégias que valorizem o uso da informação em saúde. Cada vez mais as incertezas entre a complexidade deste sistema e as intervenções necessárias para atender os seus preceitos e as necessidades da população precisam de respostas ágeis e efetivas. A efetividade dos serviços e a equidade em sua prestação são cruciais na atenção à saúde e mostram-se como desafio frente à dificuldade de avaliação dos resultados das ações pela demora no impacto nos indicadores epidemiológicos clássicos. O monitoramento é uma prática que pode ser destacada pela agilidade nas respostas, porém é nítido o quanto a discussão sobre o assunto é pouco estabelecida na literatura disponível. Se apresenta como uma prática interativa e proativa que utiliza informações disponíveis com o potencial de organizar e divulgar rapidamente as descobertas feitas, gerar um aprendizado organizacional e apoiar o processo decisório. A proposta deste estudo considerou o Painel de Monitoramento da Secretaria Municipal da Saúde de São Paulo como ponto de partida para pesquisar sobre as potencialidades do monitoramento na gestão. Uma pesquisa de métodos mistos foi a opção metodológica para este trabalho que buscou aprofundar o marco referencial teórico sobre monitoramento, descrever e analisar criticamente as referências técnicas utilizadas para a construção da proposta e realizar um estudo de caso único em território descentralizado do município de São Paulo sobre a rotina local na sua utilização e com isso analisar as potencialidades e os alcances desta experiência na gestão municipal. Concluiu-se que o monitoramento por meio de indicadores selecionados a partir de dados secundários é uma estratégia oportuna de acompanhar a tendência de determinadas ações possibilitando assim a emissão de juízo de valor e tomada de decisão com rapidez. O aplicativo propicia aos gestores e técnicos informações relevantes que apoiam o processo decisório, além de possibilitar a sua utilização em diferentes contextos da gestão e portes territoriais. Por outro lado, a prática cotidiana é pautada por prioridades normativas, onde a precisão do registro, a coerência das fontes e a quantidade apontada sobrepõem-se à informação em si, o seu significado e as ações necessárias para o enfrentamento dos problemas. O uso da informação é cultura em construção e o Painel de Monitoramento traz a possibilidade de organizar, qualificar e difundir dados secundários dos diferentes sistemas de informação do Sistema Único de Saúde (SUS). Além disso, tem contribuído também no papel de fomentar as discussões sobre os diferentes temas que envolvem as prioridades de uma gestão em todos os níveis do sistema de saúde do município de São Paulo.

Proteção diferencial de transformadores de potência utilizando a transformada Wavelet

About 10% of faults involving the electrical system occurs in power transformers. Therefore, the protection applied to the power transformers is essential to ensure the continuous operation of this device and the efficiency of the electrical system. Among the protection functions applied to power transformers, the differential protection appears as one of the main schemes, presenting reliable discrimination between internal faults and external faults or inrush currents. However, when using the low frequency components of the differential currents flowing through the transformer, the main difficulty of the conventional methods of differential protection is the delay for detection of the events. However, internal faults, external faults and other disturbances related to the transformer operation present transient and can be appropriately detected by the wavelet transform. In this paper is proposed the development of a wavelet-based differential protection for detection and identification of external faults to the transformer, internal faults, and transformer energizing by using the wavelet coefficient energy of the differential currents. The obtained results reveal the advantages of using of the wavelet transform in the differential protection compared to conventional protection, since it provides reliability and speed in detection of these events.

Acompanhamento do crescimento e desenvolvimento da criança: a participação das mães da área rural

The accompaniment of growth and development is the central thrust of child care in primary health care in order to contribute to the reduction of infant morbidity and mortality and promote healthy development. Despite its importance, the family health unit located in rural Parazinhocounty experiences the problem of frequent absences of children to follow-up consultations. Thus, this study aims to analyze the participation of mothers in the accompaniment of growth and development of children in the Family Health Strategy. This is an exploratory, descriptive study with a qualitative approach with the method action research, developed with mothers who are part of the monitoring of the growth and development of children in the rural area of the municipality of Parazinho/RN from May to October 2014. Data collection was performed using the focus group techniques, participant observation and individual interviews. Data were analyzed using thematic analysis of categorization. The study was approved by the Research Ethics Committee, under the opinion embodied 617,559 and CAAE 28598014.7.0000.5537. In step situation analysis, were conducted two focus groups, attended by a total of 14 mothers of different rural locations. From the speeches, one realizes that they have a satisfactory understanding of the monitoring of the growth and development of the childwas a learning moment. The nurse was mentioned as key professional that actionof accompaniment. The main reason that mothers to abandon consultations is access to health services, due to the distance from their homes to the basic unit, the shortage of public transport for the movement of users and delay between the service and the back home. As a strategy to try to tackle these problems, at the suggestion of their mothers was created Monitoring of Growth and Development Itinerant, where the FHS team moved to rural locations, performing activities related to children's health. Mothers who participated in the action approved the initiative as improving access and care of health needs, despite indicate dissatisfaction as the poor infrastructure and little privacy in consultations. Therefore, it is concluded that, despite the difficulties encountered often for lack of management support and involvement of some professionals, the monitoring of growth and development itinerant proved to be an important tool in solving the problem of access to services oriented to the health of child, in addition to functioning as a space for the realization of health education, becoming, since then, an activity inherent in family health team schedule.

Avaliação do acesso aos serviços de reabilitação física para vítimas de acidentes de trânsito: caminhos para melhoria da qualidade do sistema de saúde

The Physical Rehabilitation services (PR) are of fundamental importance in combating the global epidemic of Traffic Accidents (TA). Considering the numerous physical and social consequences of the survivors, quality problems in access to PR are a hazard to recovery of victims. It is necessary to improve the management of quality of services, assessing priority dimensions and intervening in their causes, to ensure rehabilitation available in time and suitable conditions. This study aimed to identify barriers to access to rehabilitation considering the perception of TA victims and professionals. The aim is also to estimate the access to rehabilitation and their associated factors. This is a qualitative and quantitative study of exploratory nature developed in Natal / RN with semi-structured interviews with 19 health professionals and telephone survey to 155 victims of traffic accidents. To explore barriers to access the speeches were transcribed and analyzed using the Alceste software (version 4.9). During the interviews used the following guiding question: “What barriers hinder or prevent access to physical rehabilitation for victims of traffic accidents?”. The names of classes and axes resulting from Alceste was performed by ad hoc query to three external researchers with subsequent consensus of the most representative name of analysis. We conducted multivariate analysis of the influence of the variables of the accident, sociodemographic, clinical and assistance on access to rehabilitation. Associations with p <0.20 in the bivariate analysis were submitted to logistic regression, step by step, with p <0.05 and confidence interval (CI) of 95%. The main barriers identified were: “Bureaucratic regulation”, “Long time to start rehabilitation”, “No post-surgery referral” and “inefficiency of public services”. These barriers were divided into a theoretical model built from the cause-effect diagram, in which we observed that insufficient access to rehabilitation is the product of causes related to organizational structure, work processes, professional and patients. Was constructed two logistic regression models: “General access to rehabilitation” and “Access to rehabilitation to public service”. 51.6% of patients had access to rehabilitation, and 32.9% in public and 17.9% in the private sector. The regression model “General access to rehabilitation” included the variables Income (OR:3.7), Informal Employment (OR:0.11), Unemployment (OR:0.15), Perceived Need for PR (OR:10) and Referral (OR: 27.5). The model “Access to rehabilitation in the public service” was represented by the “Referral to Public Service” (OR: 23.0) and “Private Health Plan” (OR: 0.07). Despite the known influence of social determinants on access to health services, a situation difficult to control by the public administration, this study found that the organizational and bureaucratic procedures established in health care greatly determine access to rehabilitation. Access difficulties show the seriousness of the problem and the factors suggest the need for improvements in comprehensive care for TA survivors and avoid unnecessary prolongation of the suffering of the victims of this epidemic.

Estudo da Acessibilidade Organizacional aos Serviços de Saúde Bucal de um Município de Pequeno Porte do Nordeste Brasileiro

Objective: This study aimed to evaluate the accessibility to oral health services in Santa Cruz (RN), focusing on the organizational aspect which is characterized by variables like delay in getting consultation, waiting lines, difficulty scheduling appointments, lack of material, among others. Material and Methods: For such purpose, questionnaires were addressed to 194 users’ houses based on census tract. Results: It has been found that 12.9% of the population has never gone to the dentist’s office, and that the service demand has not been affected by users’ individual and socioeconomic characteristics, except for gender. Data have revealed that 36.1% of users went to the dentist’s in less than a year. In addition, the youngest users are among those who seek the dentist’s office more frequently (p<0.05). 63.3% of the interviewees have reported they find some kind of difficulty when seek for dental care, and 43.2% of users have waited three weeks or more for assistance. It is also noteworthy that 7.4% of the interviewees have been finding difficulties in getting access to urgency care, and that long wait for the consultation is the most frequently cited matter. Conclusion: It could be verified that accessibility to oral health services in the municipality of Santa Cruz (RN) has been hampered by factors related to public policies organization, especially with regards to the work process.

Estudo da Acessibilidade Organizacional aos Serviços de Saúde Bucal de um Município de Pequeno Porte do Nordeste Brasileiro

Objective: This study aimed to evaluate the accessibility to oral health services in Santa Cruz (RN), focusing on the organizational aspect which is characterized by variables like delay in getting consultation, waiting lines, difficulty scheduling appointments, lack of material, among others. Material and Methods: For such purpose, questionnaires were addressed to 194 users’ houses based on census tract. Results: It has been found that 12.9% of the population has never gone to the dentist’s office, and that the service demand has not been affected by users’ individual and socioeconomic characteristics, except for gender. Data have revealed that 36.1% of users went to the dentist’s in less than a year. In addition, the youngest users are among those who seek the dentist’s office more frequently (p<0.05). 63.3% of the interviewees have reported they find some kind of difficulty when seek for dental care, and 43.2% of users have waited three weeks or more for assistance. It is also noteworthy that 7.4% of the interviewees have been finding difficulties in getting access to urgency care, and that long wait for the consultation is the most frequently cited matter. Conclusion: It could be verified that accessibility to oral health services in the municipality of Santa Cruz (RN) has been hampered by factors related to public policies organization, especially with regards to the work process.

Efeitos da internacionalização no desvio da estrutura de capital alvo e na velocidade de ajuste

This dissertation investigates the effects of internationalization in two gaps related to the capital structure that have not been discussed by the Brazilian literature yet. To this, were developed two independent sections. The first examined what the effects of internationalization on the deviation from the target capital structure. The second examined what the effects of internationalization on speed of adjustment (SOA) of the capital structure. It used data from Brazil, multinational and domestic companies, from 2006 to 2014. The results of the first analysis indicate that internationalization helps reduce the difference between the target and the current debt. That is, to the extent that the level of internationalization increases; whether only export or a combination of export, assets and employees abroad, the gap between the current structure and the target structure decreases. This reduction is given as a function of internationalization as a consequence of the upstream effect of the upstream-downstream hypothesis. Thus, as the Market Timing theory, it can be seen as an opportunity for adjustment of the capital structure, and with the reduction of deviation, there is also a reduction in the cost of capital of the firm. The result of the second analysis indicates that internationalization is able to significantly increase the speed adjustment, ensuring for the multinational a faster adjustment of its capital structure. Exports increase the SOA in 9 to 23%. And when also kept active assets and employees abroad the increase is 8 to 20%. In terms of time, while domestic company takes more than three years to reduce half of the deviation that has, while multinacional companies take on average one and a half year to reduce the same proportion of the deviation. The validity of the upstream-downstream hypothesis for the effect of internationalization in SOA was confirmed by comparing the results for US companies. Thus, the phenomenon of internationalization increases SOA when companies are from less stable markets, such as Brazil; and it has a less significcative effect when companies are derived from more stable markets, because they already have a high speed of adjustmennt. In addition, the adequacy analysis of the estimators also showed the model pooled OLS (Ordinary Least Squares) presents the highest quality in predicting the SOA than the system GMM (Generalized Method of Moments). For future studies it is suggested to analyze the effect of international event, by itself, and to validate the hypothesis using samples of different markets and the use of other estimators.

Adherencia al tratamiento con antineoplásicos orales

En los últimos años, la investigación del tratamiento del cáncer ha tenido como resultado el desarrollo de un gran número de medicamentos con el fin de curar la patología, prolongar la supervivencia de los pacientes o mejorar su calidad de vida. Entre estos fármacos se encuentran los antineoplásicos de administración por vía oral (ANEO). Las ventajas que la vía oral ofrece sobre la parenteral son múltiples: mayor autonomía para el paciente, posología más cómoda y minimización de los riesgos derivados del uso de catéteres periféricos o de reservorios en vías centrales (Consejería de Salud de La Rioja, 2010; Verbrugghe et al., 2013; Anderson et al., 2014; Trivedi et al., 2014). Los ANEO plantean también nuevos retos para los profesionales sanitarios, ya que precisan de una alta adherencia terapéutica y la realización de frecuentes ajustes posológicos en función de la eficacia conseguida y de la tolerancia al tratamiento (Consejería de Salud de La Rioja, 2010). La adherencia terapéutica es un fenómeno complejo, que está condicionado por múltiples factores. Los términos adherencia y cumplimiento se emplean, con frecuencia, de forma indistinta. En un principio, solamente se utilizaba el término cumplimiento para definir la toma correcta de los medicamentos, mientras que hoy día está completamente consensuado el uso del término adherencia, entendida como una actitud del paciente que implica su compromiso respecto a la medicación prescrita por el médico, con una participación activa en la elección y el mantenimiento del régimen terapéutico (OMS, 2004; Fontanals Martínez et al., 2011). Por tanto, es un comportamiento humano, modulado por componentes subjetivos, y en esta dimensión debe ser esencialmente comprendido, abordado e investigado. Se puede considerar que la adherencia engloba dos conceptos: cumplimiento de dosis y forma de administración, y persistencia en la duración del tratamiento prescrito (Nogués Solán et al., 2007)...

Atuação das equipes da atenção primária na identificação precoce do câncer infanto-juvenil

Identificar o conhecimento de profissionais da atenção primária sobre a identificação precoce do câncer infanto-juvenil e descrever o desempenho das equipes de saúde antes da realização de treinamentos para identificação precoce do câncer infanto-juvenil. Método: Os dados foram obtidos por um questionário e grupo focal com 30 profissionais de uma Unidade de Saúde da Família, e analisados por temas geradores. Resultados: Os profissionais possuem conhecimentos sobre a identificação do câncer infanto-juvenil, e, demandam conhecer mais sobre os sinais e sintomas para identificação precoce, e a prestação de uma assistência sistematizada. Conclusão: Torna-se fundamental estimular a qualificação dos profissionais da atenção primária para a identificação precoce e o fortalecimento de uma rede de assistência que proporcione atendimento integral e a redução no retardo do diagnóstico de câncer infanto-juvenil

Sistema de notificação e monitorização de acidentes para motociclos

A percentagem de utilização de motociclos tem vindo a crescer relativamente à utilização de veículos automóveis. Provavelmente, este número continuará a aumentar anualmente devido a diversos fatores: a mobilidade, a flexibilidade de circulação e o menor gasto de combustível. No entanto, um dos principais problemas da condução de motociclos é o elevado risco de acidente, comparativamente com os veículos automóveis. A segurança do condutor e passageiros, quando sujeitos a um acidente, merece total atenção. Convém, pois, encontrar soluções com capacidade de prevenir ou ajudar a minimizar o número de mortalidade que possam ocorrer diariamente. Uma maior atenção às medidas de segurança rodoviária veio diminuir o número de acidentes, no entanto, quando estes acontecem, a ajuda das unidades médicas demora algum tempo a chegar. Sabe-se que nestas situações, qualquer segundo pode fazer a diferença. Este é o problema que o autor deseja resolver. Na presente dissertação, o autor pretende demonstrar como desenvolveu um sistema para motociclos com a capacidade de reconhecer um acidente, enviando um alerta (SMS) com a informação do local da ocorrência (GPS). Este sistema foi preparado para operar em locais isolados com pouco ou nenhum tráfego rodoviário. Implementou-se no referido sistema uma tecnologia sem fios e fiabilizou-se um método capaz de ser utilizado em diversos modelos de motociclos. Procedeu-se à realização de interfaces que permitem monitorizar e possibilitar o reconhecimento da informação sobre o condutor e sobre o acidente, em tempo real.

Sistemas de gerenciamento de bibliotecas: riscos decorrentes do processo de migração de dados

This work aims to analyze risks related to information technology (IT) in procedures related to data migration. This is done considering ALEPH, Integrated Libray System (ILS) that migrated data to the Library Module present in the software called Sistema Integrado de Gestão de Atividades Acadêmicas (SIGAA) at the Zila Mamede Central Library at the Federal University of Rio Grande do Norte (UFRN) in Natal/Brazil. The methodological procedure used was of a qualitative exploratory research with the realization of case study at the referred library in order to better understand this phenomenon. Data collection was able once there was use of a semi-structured interview that was applied with (11) subjects that are employed at the library as well as in the Technology Superintendence at UFRN. In order to examine data Content analysis as well as thematic review process was performed. After data migration the results of the interview were then linked to both analysis units and their system register with category correspondence. The main risks detected were: data destruction; data loss; data bank communication failure; user response delay; data inconsistency and duplicity. These elements point out implication and generate disorders that affect external and internal system users and lead to stress, work duplicity and hassles. Thus, some measures were taken related to risk management such as adequate planning, central management support, and pilot test simulations. For the advantages it has reduced of: risk, occurrence of problems and possible unforeseen costs, and allows achieving organizational objectives, among other. It is inferred therefore that the risks present in data bank conversion in libraries exist and some are predictable, however, it is seen that librarians do not know or ignore and are not very worried in the identification risks in data bank conversion, their acknowledge would minimize or even extinguish them. Another important aspect to consider is the existence of few empirical research that deal specifically with this subject and thus presenting the new of new approaches in order to promote better understanding of the matter in the corporate environment of the information units