Twins prematurity--the influence of prenatal surveillance

OBJECTIVE: To evaluate the influence of the local prenatal surveillance of twin pregnancies in the obstetrical results. METHODS: A prospective cohort study of multiple pregnancies delivered over a period of 16 years in a tertiary centre was conducted. In this study 861 twin pregnancies were included. They were compared for obstetric complications, gestational age at delivery, mode of delivery and birthweight, according to the place of the surveillance. RESULTS: Of the 861 cases examined, the following obstetric complications were significantly different: metrorrhagia (p = 0.039), infections (p < 0.001), HELLP (p = 0.007), PROMPT (p < 0.001) and fetal death (p = 0.024). The mode of delivery was similar but occurred mostly ≤32 weeks (p < 0.001), the birthweight was mostly <2000 g and occurred more NICU admission (p < 0.001) when surveillance was outside the MPC-MDM. CONCLUSION: Our results demonstrate the crucial importance of prenatal surveillance be carried in a differentiated referral centers with specific/strict protocols or the urgent implementation of same protocols in all other places of surveillance, since this straight surveillance greatly reduces the occurrence of prenatal complications, mainly PROMPT, PTD.

Microstructure and tensile properties of carbon-epoxy laminates produced by automated fibre placement: Influence of a caul plate on the effects of gap and overlap embedded defects

Automated fibre placement (AFP) enables the trajectory of unidirectional composite tape to be optimized, but laying down complex shapes with this technology can result in the introduction of defects. The aim of this experimental study is to investigate the influence of gaps and overlaps on the microstructure and tensile properties of carbon-epoxy laminates. First, a comparison between a hand-layup and AFP layup, draped and cured under the same conditions, shows equivalent microstructures and tensile properties. This provides the reference values for the study. Then, gap and overlap embedded defects (more or less severe) are introduced during manufacturing, on two cross-ply layups [(0°/(90°)5/0°] and [(90°/0°)2/90°]. Autoclave cure without a caul plate results in local thickness variation and microstructural changes which depend on the defect type. This has a strong influence on mechanical performance. Use of a caul plate avoids these variations and in this case embedded defects hardly affect tensile properties.

Relações interorganizacionais e eficiência coletiva: um estudo de caso no arranjo produtivo local de confecções do Agreste de Pernambuco

This work is a study in the Local Productive Arrangement of confections from Agreste of Pernambuco, as a relevant sector in economic and social aspect. This research has as central aim to understand how the inter-organizational relations influence the collective efficiency of arrangement. The theoretical framework employed highlights the approaches that deal with the benefits of business agglomeration for the develop­ment of firms and regions. It has discussed the approach of small and medium enter­ prises and industrial districts (SCHMITZ, 1997), which introduce the concept of col­ lective efficiency, explaining that only those externalities explained by Marshall (1996) are not sufficient to explain the competitive advantage of enterprises, expand­ing the idea that organizations achieve competitive advantage not acting alone. To examine the influences of relations in the collective efficiency, it has been taken as analytical perspective theory of social networks (GRANOVETTER, 1973, 1985; BURT, 1992; UZZI, 1997) because it has believe that this approach provides subsi­ dies for a structural analysis of social relationships in face the behavior of human ac­tion. By examining the organizations in a social network, you should understand the reason of this establishment of the relationship, their benefits, and as the information flow takes place and density of links between the actors (Powell; SMITH-DOERR, 1994). As for the methods, this study is characterized as a case study, in according to the purposed objectives, in addition to qualitative method. Also, due to recovering of the historical milestones of the arrangement, it is used a sectional approach with longitudinal perspective (VIEIRA, 2004). The primary and secondary data were used in order to understand the evolutionary process of the sector and their inter-actors re­ lationships in the arrangement for the promotion of development, for both, was used the contend and documentary analysis technique, respectively (DELLAGNELO ; SIL­VA, 2005). The approach of social networks has permitted understand that social re­lationships may extend the collective efficiency of the arrangement, and therefore need to develop policies that encourage the legalization of informal companies in ar­rangement, by showing up themselves representative. Thus, the relations estab­ lished in LPA of confections from Agreste of Pernambuco need for more effective mechanisms to broaden the collective efficiency. Therefore, this way as take place has directly benefited only a group of companies that are linked in some way the sup­portive institutions. So we can conclude that the inter-actor relations have limited the collective efficiency of LPA, being stimulated by the institutions in support only to groups of entrepreneurs, even those that produce external relations for all clustered companies

Encapsulation of Local Anesthetic Bupivacaine in Biodegradable Poly(DL-lactide-co-glycolide) Nanospheres: Factorial Design, Characterization and Cytotoxicity Studies

Local anesthetic agents cause temporary blockade of nerve impulses productiong insensitivity to painful stimuli in the area supplied by that nerve. Bupivacaine (BVC) is an amide-type local anesthetic widely used in surgery and obstetrics for sustained peripheral and central nerve blockade. in this study, we prepared and characterized nanosphere formulations containing BVC. To achieve these goals, BVC loaded poly(DL-lactide-co-glycolide) (PLGA) nanospheres (NS) were prepared by nanopreciptation and characterized with regard to size distribution, drug loading and cytotoxicity assays. The 2(3-1) factorial experimental design was used to study the influence of three different independent variables on nanoparticle drug loading. BVC was assayed by HPLC, the particle size and zeta potential were determined by dynamic light scattering. BVC was determined using a combined ultrafiltration-centrifugation technique. The results of optimized formulations showed a narrow size distribution with a polydispersivity of 0.05%, an average diameter of 236.7 +/- 2.6 nm and the zeta potential -2.93 +/- 1,10 mV. In toxicity studies with fibroblast 3T3 cells, BVC loaded-PLGA-NS increased cell viability, in comparison with the effect produced by free BVC. In this way, BVC-loaded PLGA-NS decreased BVC toxicity. The development of BVC formulations in carriers such as nanospheres could offer the possibility of controlling drug delivery in biological systems, prolonging the anesthetic effect and reducing toxicity.

Poly(Lactide-co-Glycolide) Nanocapsules Containing Benzocaine: Influence of the Composition of the Oily Nucleus on Physico-Chemical Properties and Anesthetic Activity

The aim of this work was to investigate the influence of the oily nucleus composition on physico-chemical properties and anesthetic activity of poly (lactide-co-glycolide) nanocapsules with benzocaine.Nanocapsules containing benzocaine were prepared with three different oily nucleus composition and characterized by mean diameter, polydispersivity, zeta potential, pH and stability were investigated as a function of time. In vitro release kinetics were performed in a system with two compartments separated by a cellulose membrane. Intensity and duration of analgesia were evaluated in rats by sciatic nerve blockade.The greatest stability, slower release profile and improvement in the local anesthetic activity of BZC were obtained with the formulation using USP mineral oil as component.Results from our study provide useful perspectives on selection of the primary materials needed to produce suspensions of polymeric nanocapsules able to act as carriers of BZC, with potential future application in the treatment of pain.

Influence des conditions hydrométéorologiques sur les flux et bilans sédimentaires en estuaire de Seine

La dynamique sédimentaire à l’embouchure de l’estuaire de Seine est principalement contrôlée par les forçages hydrométéorologiques (débit, vent, vagues, marée) et les fortes pressions anthropiques (endiguement, dragage, clapage). La compréhension et la quantification de la dynamique des flux sédimentaires en suspension (sable/vase) est un enjeu majeur, autant d’un point vu écologique (ex. turbidité, envasement) que financier (ex. gestion des chenaux de navigation). La mise en place de réseaux de mesure in situ permet une meilleure compréhension de la dynamique sédimentaire de l’estuaire, mais leur caractère local rend difficile toute estimation des flux et bilans sédimentaires. Pour répondre à ces questions, cette étude s’appuie sur la modélisation numérique, validée par de nombreuses séries de mesures in situ, afin de quantifier les flux et bilans sédimentaires à différentes échelles caractéristiques de temps et d'espace. Les concentrations simulées dans la zone d'extension du bouchon vaseux sont du même ordre que les observations et leur dynamique associée aux différentes phases et cycles de la marée, ainsi qu'au cycle hydrologique, est satisfaisante. L’analyse des flux résiduels et bilans sédimentaires aux échelles annuelle et trimestrielle a permis d’identifier un schéma de circulation à l’embouchure de l’estuaire et de quantifier l’importance du forçage hydrologique (crue/étiage) sur les échanges sédimentaires. Enfin, ce travail se poursuivra par l’étude de ces flux et bilans pour différents scénarios hydrométéorologiques contrastés.

THERE GOES THE ELECTORAL NEIGHBORHOOD: LOCAL NETWORKS, ATTRIBUTION OF RESPONSIBILITY, AND THE (UN) FAIRNESS OF ELECTIONS

During the last two decades there have been but a handful of recorded cases of electoral fraud in Latin America. However, survey research consistently shows that often citizens do not trust the integrity of the electoral process. This dissertation addresses the puzzle by explaining the mismatch between how elections are conducted and how the process is perceived. My theoretical contribution provides a double-folded argument. First, voters’ trust in their community members (“the local experience”) impacts their level of confidence in the electoral process. Since voters often find their peers working at polling stations, negative opinions about them translate into negative opinions about the election. Second, perceptions of unfairness of the system (“the global effect”) negatively impact the way people perceive the transparency of the electoral process. When the political system fails to account for social injustice, citizens lose faith in the mechanism designed to elect representatives -and ultimately a set of policies. The fact that certain groups are systematically disregarded by the system triggers the notion that the electoral process is flawed. This is motivated by either egotropic or sociotropic considerations. To test these hypotheses, I employ a survey conducted in Costa Rica, El Salvador, Honduras, and Guatemala during May/June 2014, which includes a population-based experiment. I show that Voters who trust their peers consistently have higher confidence in the electoral process. Whereas respondents who were primed about social unfairness (treatment) expressed less confidence in the quality of the election. Finally, I find that the local experience is predominant over the global effect. The treatment has a statistically significant effect only for respondents who trust their community. Attribution of responsibility for voters who are skeptics of their peers is clear and simple, leaving no room for a more diffuse mechanism, the unfairness of the political system. Finally, now I extend analysis to the Latin America region. Using data from LAPOP that comprises four waves of surveys in 22 countries, I confirm the influence of the “local experience” and the “global effect” as determinants of the level of confidence in the electoral process.

THE INFLUENCE OF URBAN FORM AT DIFFERENT GEOGRAPHICAL SCALES ON TRAVEL BEHAVIOR; EVIDENCE FROM U.S. CITIES

Suburban lifestyle is popular among American families, although it has been criticized for encouraging automobile use through longer commutes, causing heavy traffic congestion, and destroying open spaces (Handy, 2005). It is a serious concern that people living in low-density suburban areas suffer from high automobile dependency and lower rates of daily physical activity, both of which result in social, environmental and health-related costs. In response to such concerns, researchers have investigated the inter-relationships between urban land-use pattern and travel behavior within the last few decades and suggested that land-use planning can play a significant role in changing travel behavior in the long-term. However, debates regarding the magnitude and efficiency of the effects of land-use on travel patterns have been contentious over the years. Changes in built-environment patterns is potentially considered a long-term panacea for automobile dependency and traffic congestion, despite some researchers arguing that the effects of land-use on travel behavior are minor, if any. It is still not clear why the estimated impact is different in urban areas and how effective a proposed land-use change/policy is in changing certain travel behavior. This knowledge gap has made it difficult for decision-makers to evaluate land-use plans and policies. In addition, little is known about the influence of the large-scale built environment. In the present dissertation, advanced spatial-statistical tools have been employed to better understand and analyze these impacts at different scales, along with analyzing transit-oriented development policy at both small and large scales. The objective of this research is to: (1) develop scalable and consistent measures of the overall physical form of metropolitan areas; (2) re-examine the effects of built-environment factors at different hierarchical scales on travel behavior, and, in particular, on vehicle miles traveled (VMT) and car ownership; and (3) investigate the effects of transit-oriented development on travel behavior. The findings show that changes in built-environment at both local and regional levels could be very influential in changing travel behavior. Specifically, the promotion of compact, mixed-use built environment with well-connected street networks reduces VMT and car ownership, resulting in less traffic congestion, air pollution, and energy consumption.

Multi-level, Multi-stage and Stochastic Optimization Models for Energy Conservation in Buildings for Federal, State and Local Agencies

Energy Conservation Measure (ECM) project selection is made difficult given real-world constraints, limited resources to implement savings retrofits, various suppliers in the market and project financing alternatives. Many of these energy efficient retrofit projects should be viewed as a series of investments with annual returns for these traditionally risk-averse agencies. Given a list of ECMs available, federal, state and local agencies must determine how to implement projects at lowest costs. The most common methods of implementation planning are suboptimal relative to cost. Federal, state and local agencies can obtain greater returns on their energy conservation investment over traditional methods, regardless of the implementing organization. This dissertation outlines several approaches to improve the traditional energy conservations models. Any public buildings in regions with similar energy conservation goals in the United States or internationally can also benefit greatly from this research. Additionally, many private owners of buildings are under mandates to conserve energy e.g., Local Law 85 of the New York City Energy Conservation Code requires any building, public or private, to meet the most current energy code for any alteration or renovation. Thus, both public and private stakeholders can benefit from this research. The research in this dissertation advances and presents models that decision-makers can use to optimize the selection of ECM projects with respect to the total cost of implementation. A practical application of a two-level mathematical program with equilibrium constraints (MPEC) improves the current best practice for agencies concerned with making the most cost-effective selection leveraging energy services companies or utilities. The two-level model maximizes savings to the agency and profit to the energy services companies (Chapter 2). An additional model presented leverages a single congressional appropriation to implement ECM projects (Chapter 3). Returns from implemented ECM projects are used to fund additional ECM projects. In these cases, fluctuations in energy costs and uncertainty in the estimated savings severely influence ECM project selection and the amount of the appropriation requested. A risk aversion method proposed imposes a minimum on the number of “of projects completed in each stage. A comparative method using Conditional Value at Risk is analyzed. Time consistency was addressed in this chapter. This work demonstrates how a risk-based, stochastic, multi-stage model with binary decision variables at each stage provides a much more accurate estimate for planning than the agency’s traditional approach and deterministic models. Finally, in Chapter 4, a rolling-horizon model allows for subadditivity and superadditivity of the energy savings to simulate interactive effects between ECM projects. The approach makes use of inequalities (McCormick, 1976) to re-express constraints that involve the product of binary variables with an exact linearization (related to the convex hull of those constraints). This model additionally shows the benefits of learning between stages while remaining consistent with the single congressional appropriations framework.

Influência das áreas verdes no microclima local: um estudo do conjunto habitacional Ponta Negra, Natal/RN

Owing to na intense process of urban development, urban uneasiness and discomfort in the daily life of populations have nowadays, especially in the big cities, become increasingly ordinary issues. Population density, degeneration of central areas and pollution are some of the environmental stressors the urban man is subjected to. The existence of open areas in the urban network contributes to a better movement of the air and transforms salubrity conditions. Yet, it has been noticed that parks and squares are disappearing from the heart of the city districts. In their place there are either unused plots of land where garbage has been dumped or nearly all-paved squares with meager or no vegetation at all. Such areas, when handled properly, play an important role in the city because in addition to being zones for rendering a mild climate they perform social, cultural and hygienic functions. Aiming at demonstrating that proper handling of green areas can favorably influence the local microclimate, we have attempted to develop analysis from the point of view of bioclimatizing attributes of urban form and their relationship to the local microclimate found in the eight open areas located in the Ponta Negra Housing Complex in the city of Natal/RN

Avaliação ecológico-econômica do manguezal de Macau/RN e a importância da aplicação de práticas preservacionistas pela indústria petrolífera local

This work presents the results of a survey in oil-producing region of the Macau City, northern coast of Rio Grande do Norte. All work was performed under the Project for Monitoring Environmental Change and the Influence of Hydrodynamic forcing on Morphology Beach Grass Fields, Serra Potiguar in Macau, with the support of the Laboratory of Geoprocessing, linked to PRH22 - Training Program in Geology Geophysics and Information Technology Oil and Gas - Department of Geology/CCET/UFRN and the Post-Graduation in Science and Engineering Oil/PPGCEP/UFRN. Within the economic-ecological context, this paper assesses the importance of mangrove ecosystem in the region of Macau and its surroundings as well as in the following investigative exploration of potential areas for projects involving reforestation and / or Environmental Restoration. At first it was confirmed the ecological potential of mangrove forests, with primary functions: (i) protection and stabilization of the shoreline, (ii) nursery of marine life, and (iii) source of organic matter to aquatic ecosystems, (iv) refuge of species, among others. In the second phase, using Landsat imagery and techniques of Digital Image Processing (DIP), I came across about 18,000 acres of land that can be worked on environmental projects, being inserted in the rules signed the Kyoto Protocol to the market carbon. The results also revealed a total area of 14,723.75 hectares of activity of shrimp production and salting that can be harnessed for the social, economic and environmental potential of the region, considering that over 60% of this area, ie, 8,800 acres, may be used in the planting of the genus Avicennia considered by the literature that the species best sequesters atmospheric carbon, reaching a mean value of 59.79 tons / ha of mangrove

GENETIC VARIATION, LOCAL ADAPTATION AND POPULATION STRUCTURE IN NORTH AMERICAN RED OAK SPECIES, QUERCUS RUBRA L. AND Q. ELLIPSOIDALIS E. J. HILL

Forest trees, like oaks, rely on high levels of genetic variation to adapt to varying environmental conditions. Thus, genetic variation and its distribution are important for the long-term survival and adaptability of oak populations. Climate change is projected to lead to increased drought and fire events as well as a northward migration of tree species, including oaks. Additionally, decline in oak regeneration has become increasingly concerning since it may lead to decreased gene flow and increased inbreeding levels. This will in turn lead to lowered levels of genetic diversity, negatively affecting the growth and survival of populations. At the same time, populations at the species’ distribution edge, like those in this study, could possess important stores of genetic diversity and adaptive potential, while also being vulnerable to climatic or anthropogenic changes. A survey of the level and distribution of genetic variation and identification of potentially adaptive genes is needed since adaptive genetic variation is essential for their long-term survival. Oaks possess a remarkable characteristic in that they maintain their species identity and specific environmental adaptations despite their propensity to hybridize. Thus, in the face of interspecific gene flow, some areas of the genome remain differentiated due to selection. This characteristic allows the study of local environmental adaptation through genetic variation analyses. Furthermore, using genic markers with known putative functions makes it possible to link those differentiated markers to potential adaptive traits (e.g., flowering time, drought stress tolerance). Demographic processes like gene flow and genetic drift also play an important role in how genes (including adaptive genes) are maintained or spread. These processes are influenced by disturbances, both natural and anthropogenic. An examination of how genetic variation is geographically distributed can display how these genetic processes and geographical disturbances influence genetic variation patterns. For example, the spatial clustering of closely related trees could promote inbreeding with associated negative effects (inbreeding depression), if gene flow is limited. In turn this can have negative consequences for a species’ ability to adapt to changing environmental conditions. In contrast, interspecific hybridization may also allow the transfer of genes between species that increase their adaptive potential in a changing environment. I have studied the ecologically divergent, interfertile red oaks, Quercus rubra and Q. ellipsoidalis, to identify genes with potential roles in adaptation to abiotic stress through traits such as drought tolerance and flowering time, and to assess the level and distribution of genetic variation. I found evidence for moderate gene flow between the two species and low interspecific genetic differences at most genetic markers (Lind and Gailing 2013). However, the screening of genic markers with potential roles in phenology and drought tolerance led to the identification of a CONSTANS-like (COL) gene, a candidate gene for flowering time and growth. This marker, located in the coding region of the gene, was highly differentiated between the two species in multiple geographical areas, despite interspecific gene flow, and may play a role in reproductive isolation and adaptive divergence between the two species (Lind-Riehl et al. 2014). Since climate change could result in a northward migration of trees species like oaks, this gene could be important in maintaining species identity despite increased contact zones between species (e.g., increased gene flow). Finally I examined differences in spatial genetic structure (SGS) and genetic variation between species and populations subjected to different management strategies and natural disturbances. Diverse management activities combined with various natural disturbances as well as species specific life history traits influenced SGS patterns and inbreeding levels (Lind-Riehl and Gailing submitted).

An Analysis of the Factors that Influence Regional Economic Development Cooperation

This dissertation is a comparative case study of regional cooperation in the field of economic development. In the 21st century global economy, proponents of regionalism have put forth fresh arguments for collective action. A regional approach to economic development activity presents a classic social dilemma: How can local officials collectively improve the economic prospects of a region, and remain autonomous to act in the best interest of the local community? This research examines the role of social capital in overcoming this social dilemma. Three (3) comparable Metropolitan Statistical Areas (MSAs) form the empirical basis of this research. The Houston MSA, the Atlanta MSA and the Miami MSA present distinct variations of regionalized economic development activity. This dissertation seeks to explain this disparity in the dependent variable. The hypothesis is that accrued social capital is crucial to obtaining economic development cooperative agreements. This qualitative research utilized secondary demographic and economic databases, survey instruments, interviews, field observations, and a review of legislative and administrative decisions to formulate a clear understanding of the factors influencing the current state of regional economic development cooperation within each region. The study concludes that the legislative and executive decisions of state government exert inordinate influence on the capacity of local officials to cooperate regionally for economic development purposes.

The Influence of HOPE VI Public Housing on Public Schools

In the United States, public school enrollment is typically organized by neighborhood boundaries. This dissertation examines whether the federally funded HOPE VI program influenced performance in neighborhood public schools. In effect since 1992, HOPE VI has sought to revitalize distressed public housing using the New Urbanism model of mixed income communities. There are 165 such HOPE VI projects nationwide. Despite nearly two decades of the program’s implementation, the literature on its connection to public school performance is thin. My dissertation aims to narrow this research gap. There are three principal research questions: (1) Following HOPE VI, was there a change in socioeconomic status (SES) in the neighborhood public school? The hypothesis is that low SES (measured as the proportion of students qualifying for the Free and Reduced Lunch Program) would reduce. (2) Following HOPE VI, did the performance of neighborhood public schools change? The hypothesis is that the school performance, measured by the proportion of 5th grade students proficient in state wide math and reading tests, would increase. (3) What factors relate to the performance of public schools in HOPE VI communities? The focus is on non-school, neighborhood factors that influence the public school performance. For answering the first two questions, I used t-tests and regression models to test the hypotheses. The analysis shows that there is no statistically significant change in SES following HOPE VI. However, there are statistically significant increases in performance for reading and math proficiency. The results are interesting in indicating that HOPE VI neighborhood improvement may have some relationship with improving school performance. To answer the third question, I conducted a case study analysis of two HOPE VI neighborhood public schools, one which improved significantly (in Philadelphia) and one which declined the most (in Washington DC). The analysis revealed three insights into neighborhood factors for improved school performance: (i) a strong local community organization; (ii) local community’s commitment (including the middle income families) to send children to the public school; and (iii) ties between housing and education officials to implement the federal housing program. In essence, the study reveals how housing policy is de facto education policy.

Preferência do local de cuidados dos doentes em fim de vida: revisão sistemática da literatura

PROBLEMÁTICA: Com o aumento da população e comummente com o aumento de doenças crónicas, leva a um crescimento de doentes que necessitam de cuidados paliativos. A intervenção em cuidados paliativos visa o alívio do sofrimento e melhorar a qualidade de vida do doente e sua família, respeitando as suas preferências e desejos. Os profissionais de saúde necessitam de formação em Cuidados Paliativos, respeitando as expetativas dos doentes e permitir que a pessoa seja cuidada no seu local preferido de cuidados e não recorrer consecutivamente a urgências e internamentos de agudos. OBJETIVOS: Demonstrar a importância da identificação da preferência do local de cuidados dos doentes em fim-de-vida, compreender a importância do planeamento de cuidados e Diretivas antecipadas de vontade (DAV), relacionar a escolha do local de cuidados com o local de morte, identificar os fatores que influenciam e condicionam a escolha do local de cuidados dos doentes em fim-de-vida e por fim, perceber a organização e qualidade dos serviços. DESENHO: Revisão sistemática da literatura que inclui estudos de natureza qualitativa. METODOLOGIA: Foram incluídos oito estudos, publicados entre 1 de Janeiro de 2016 e 31 de Agosto 2016, pesquisados em bases de dados de referência e com acesso ao texto integral. RESULTADOS: Este estudo demonstra a importância das preferências dos doentes e serem registadas, a importância das Diretivas Antecipadas de Vontade, bem como o planeamento do cuidado de forma antecipada. É fundamental ter em conta os fatores que influenciam e condicionam a escolha do local de cuidados. CONCLUSÃO: Deve dar-se importância às preferências do local de cuidado dos doentes em fim-de-vida. Os doentes em fim-de-vida na sua globalidade preferem ser cuidados e morrerem em casa. As equipas multidisciplinares desenvolvem um papel preponderante no cuidado aos doentes em fim-de-vida. Quando os cuidados prestados são de alta qualidade, permite ao doente ser cuidado e morrer no seu local preferido.