Projeto de reforço de um edifício de habitação

Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia Civil na Área de Especialização de Estruturas

Compression stockings and the prevention of symptomatic venous thromboembolism: data from the Tinzaparin in Acute Ischaemic Stroke Trial

Background: Venous thromboembolism (VTE) is a well recognised and preventable complication of acute stroke. While graduated compression stockings reduce the risk of VTE in surgical patients their benefit in acute stroke remains uncertain. Methods: The relationship between symptomatic VTE and use of stockings using observational data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’, which compared 10 days of treatment with tinzaparin (175 IU.kg-1 or 100 IU.kg-1) with, aspirin (300 mg od), was assessed using logistic regression adjusted for known VTE risk factors and treatment. Results: Symptomatic VTE occurred in 28 patients (1.9%, DVT 18, PE 13) within 15 days of enrolment in 1,479 patients. Patients wearing one or two stockings for any period of time during the first 10 days (n=803) had a non-significant increase (odds ratio, OR 2.45, 95% confidence interval, CI 0.95 - 6.32) in the risk of symptomatic VTE. In contrast, those wearing bilateral stockings for 10 days (n=374) had a non-significant reduction in the odds of symptomatic VTE as compared to those who wore no stockings or wore them for less than 10 days (OR 0.65, 95% CI 0.26-1.65). Mild stroke and treatment with tinzaparin were associated with a reduced risk of VTE. Conclusions: Bilateral graduated compression stockings may reduce the incidence of VTE by one-third in patients with acute ischaemic stroke. However, the uncertainty in this finding, low frequency of symptomatic VTE, potential for stockings to cause harm, and cost of stockings highlight the need for a large randomised-controlled trial to examine the safety and efficacy of stockings in acute stroke.

Projeto de uma ferramenta específica para cravação de terminais elétricos

A necessidade contínua de incrementar a produtividade em todos os sectores leva a que sejam utilizados equipamentos cada vez mais sofisticados, permitindo novas técnicas de abordagem dos processos de fabrico, velocidades mais elevadas e maior precisão no produto final. No entanto, quase todos os equipamentos necessitam de ferramentas adequadas, que tirem partido efetivamente das potencialidades dos equipamentos disponíveis. A Engenharia tem aqui um papel extremamente importante, já que terá de conceber as ferramentas atendendo à satisfação de um elevado número de requisitos, que passam genericamente por tirar o máximo partido dos fatores tecnológicos proporcionados pelos equipamentos, cumprir com a cadência de produção necessária, assegurar a qualidade estipulada, garantir a segurança dos colaboradores que com ela trabalham e permitir uma fácil montagem e afinação, reduzindo assim os tempos de preparação e as possibilidades de fabrico de peças fora das especificações. Este trabalho foi desenvolvido em torno de uma necessidade real, tendo sido estipulados os requisitos necessários pelo cliente e tendo sido elaborado todo o projeto da ferramenta em torno desses mesmos requisitos. Foi efetuada uma otimização da ferramenta ainda na fase de anteprojeto, permitindo minimizar o seu custo e maximizar o seu rendimento e aptidão para o fim em vista. Os materiais foram cuidadosamente selecionados, tendo em vista a utilização de cada componente e a relação custo‐benefício. Foi ainda efetuada uma orçamentação da mesma, assim como um plano de instruções para a operação e manutenção da ferramenta. Deste modo, este trabalho é o resumo de grande parte do conhecimento adquirido, quer ao longo da vida académica, quer ao longo da experiência profissional.

Medication adherence and direct treatment cost among diabetes patients attending a tertiary healthcare facility in Ogbomosho, Nigeria

Background Diabetes mellitus (DM) is now prevalent in many countries in sub- Saharan Africa, with associated health and socioeconomic consequences. Adherence to antidiabetic medications has been shown to improve glycaemic control, which subsequently improves both the short- and longterm prognosis of the disease. The main objective of this study was to assess the level of adherence to antidiabetic drugs among outpatients in a teaching hospital in southwestern Nigeria. Methods A cross-sectional study was carried out using the eight-item Morisky Medication Adherence Scale (MMAS-8) among diabetic patients attending the medical outpatients’ diabetes clinic of Ladoke Akintola University Teaching Hospital, in Ogbomosho, Oyo State in southwestern Nigeria, during a three-month period (October to December 2013). Results A total of 129 patients participated in the study with a male-to-female ratio of 1:1.5. Seventy-eight (60.5%) patients had systemic hypertension as a comorbid condition while the remaining were being managed for diabetes mellitus alone. Only 6 (4.7%) of the patients had type 1 DM while the remaining 123 (95.3%) were diagnosed with type 2 DM. Metformin was the most prescribed oral hypoglycaemic agent (n = 111, 58.7%) followed by glibenclamide (n = 49, 25.9%). Medication adherence was classified as good, medium, and poor for 52 (40.6%), 42 (32.8%), and 34 (26.6%) patients, respectively. Medication costs accounted for 72.3% of the total direct cost of DM in this study, followed by the cost of laboratory investigations (17.6%). Conclusion Adherence of diabetes patients in the study sample to their medications was satisfactory. There is a need for the integration of generic medicines into routine care as a way of further reducing the burden of healthcare expenditure on the patients.

Obtenção e caracterização de dióxido de estanho nanoestruturado pelo método de síntese contínua por combustão em solução

Continuous Synthesis by Solution Combustion was employed in this work aiming to obtain tin dioxide nanostructured. Basically, a precursor solution is prepared and then be atomized and sprayed into the flame, where its combustion occurs, leading to the formation of particles. This is a recent technique that shows an enormous potential in oxides deposition, mainly by the low cost of equipment and precursors employed. The tin dioxide (SnO2) nanostructured has been widely used in various applications, especially as gas sensors and varistors. In the case of sensors based on semiconducting ceramics, where surface reactions are responsible for the detection of gases, the importance of surface area and particle size is even greater. The preference for a nanostructured material is based on its significant increase in surface area compared to conventional microcrystalline powders and small particle size, which may benefit certain properties such as high electrical conductivity, high thermal stability, mechanical and chemical. In this work, were employed as precursor solution tin chloride dehydrate diluted in anhydrous ethyl alcohol. Were utilized molar ratio chloride/solvent of 0,75 with the purpose of investigate its influence in the microstructure of produced powder. The solution precursor flux was 3 mL/min. Analysis with X-ray diffraction appointed that a solution precursor with molar ratio chloride/solvent of 0,75 leads to crystalline powder with single phase and all peaks are attributed to phase SnO2. Parameters as distance from the flame with atomizer distance from the capture system with the pilot, molar ratio and solution flux doesn t affect the presence of tin dioxide in the produced powder. In the characterization of the obtained powder techniques were used as thermogravimetric (TGA) and thermodiferential analysis (DTA), particle size by laser diffraction (GDL), crystallographic analysis by X-ray diffraction (XRD), morphology by scanning electron microscopy (SEM), transmission electron microscopy (TEM), specific surface area (BET) and electrical conductivity analysis. The techniques used revealed that the SnO2 exhibits behavior of a semiconductor material, and a potentially promising material for application as varistor and sensor systems for gas

High On/Off ratio memristive switching of manganite/cuprate bilayer by interfacial magnetoelectricity

Memristive switching serves as the basis for a new generation of electronic devices. Memristors are two-terminal devices in which the current is turned on and off by redistributing point defects, e.g., vacancies, which is difficult to control. Memristors based on alternative mechanisms have been explored, but achieving both the high On/Off ratio and the low switching energy desirable for use in electronics remains a challenge. Here we report memristive switching in a La_(0.7)Ca_(0.3)MnO_(3)/PrBa_(2)Cu_(3)O_(7) bilayer with an On/Off ratio greater than 103 and demonstrate that the phenomenon originates from a new type of interfacial magnetoelectricity. Using results from firstprinciples calculations, we show that an external electric-field induces subtle displacements of the interfacial Mn ions, which switches on/off an interfacial magnetic “dead” layer, resulting in memristive behavior for spin-polarized electron transport across the bilayer. The interfacial nature of the switching entails low energy cost about of a tenth of atto Joule for write/erase a “bit”. Our results indicate new opportunities for manganite/cuprate systems and other transition-metal-oxide junctions in memristive applications.

Cost-Effectiveness of Rotavirus Vaccination for Under-Five Children in Iran

Background: Rotavirus diarrhea is one of the most important causes of death among under-five children. Anti-rotavirus vaccination of these children may have a reducing effect on the disease. Objectives: this study is intended to contribute to health policy-makers of the country about the optimal decision and policy development in this area, by performing cost-effectiveness and cost-utility analysis on anti-rotavirus vaccination for under-5 children. Patients and Methods: A cost-effectiveness analysis was performed using a decision tree model to analyze rotavirus vaccination, which was compared with no vaccination with Iran’s ministry of health perspective in a 5-year time horizon. Epidemiological data were collected from published and unpublished sources. Four different assumptions were considered to the extent of the disease episode. To analyze costs, the costs of implementing the vaccination program were calculated with 98% coverage and the cost of USD 7 per dose. Medical and social costs of the disease were evaluated by sampling patients with rotavirus diarrhea, and sensitivity analysis was also performed for different episode rates and vaccine price per dose. Results: For the most optimistic assumption for the episode of illness (10.2 per year), the cost per DALY averted is 12,760 and 7,404 for RotaTeq and Rotarix vaccines, respectively, while assuming the episode of illness is 300%, they will be equal to 2,395 and 354, respectively, which will be highly cost-effective. Number of life-years gained is equal to 3,533 years. Conclusions: Assuming that the illness episodes are 100% and 300% for Rotarix and 300% for Rota Teq, the ratio of cost per DALY averted is highly cost-effective, based on the threshold of the world health organization (< 1 GDP per capita = 4526 USD). The implementation of a national rotavirus vaccination program is suggested.

Internationalization process of TUBOFURO

The central objective of this case study was to formulate the strategy of internationalization of Tubofuro®, discriminating relevant points from its design to its implementation. This is a company located in Leiria, Ortigosa parish, which operates, among others, in the Portuguese PVC pipes industry for which currently the domestic market is clearly insufficient, given the oversupply compared to demand. Being Tubofuro® an exporting company since 2004, the work here developed specifically intended to increase sales to the foreign market, with this representing 45% of total company's business in 2018 increasing of the number of markets through new partners to enable the positioning of Tubofuro® among the main players in each market, particularly in South American markets, North African and European. To achieve the above objectives presented a case study was applied, centred on Tubofuro® company, target of the internationalization strategy. The search carried out for the formulation of the strategy has been supported on a thorough analysis of the external environment and internal characteristics of the company, for which were crossed different types of data, quantitative, qualitative, secondary data and primary data. From this work resulted the development of internationalization and international marketing plan for the next three years, whose objectives are based on entrance and consequent growth in new markets, including the market Chilean, Peruvian, Mexican, Argentine, Algerian and German, as well growth in the presence and turnover in the markets for which Tubofuro® already exports regularly, for example Spain, France, Tunisia and Morocco. Based on the production capacity of Tubofuro® company, which will not suffer any kind of investment for incrementing but only to update, it is expected that the appropriate response capacity for the company is 8 regular markets, and could eventually arise sporadic exports to other markets not interfering with the normal production capacity of the company. The suggestion of the presented markets resulted from the study of the final price based on the one that local customers purchase a product equal or similar to Tubofuro® and the number of potential existing customers in each market. The internationalization model known as Uppsala Model corresponds to the strategy adopted by the company to its internationalization process, taking into account the philosophy of senior management and the risk aversion of them. The sales team Tubofuro® demand for each market, export a full container registering customer feedback, including quality and flow capacity in the market in order to seek a partnership agreement with a local distributor, which allows the Tubofuro® go to step two above mentioned model. The partnership agreement is based on mutual commitment to technical cooperation and trade between the Tubofuro® and partner, in order to increase the performance capacity among local customers. Only if the market presents a greater demand to our supply capacity and be justified by cost / benefit ratio, the entry into this market through a joint venture or subsidiary is that the decision will be taken. Although this is a case study, which means that is adjusted to the concrete case Tubofuro® preventing generalization of findings, we believe that this work can be a useful example for other companies in the internationalization process or the methodology adopted in formulating strategy or the outputs and conclusions drawn.

Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: Results from the Metocard-CNIC trial (Effect of Metoprolol in Cardioprotection during an Acute Myocardial Infarction)

The goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events. Early IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI). The METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up. Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046). In patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions.

The role of heart rate as a risk marker for predicting adverse outcomes

Cardiovascular disease is one of the leading causes of death around the world. Resting heart rate has been shown to be a strong and independent risk marker for adverse cardiovascular events and mortality, and yet its role as a predictor of risk is somewhat overlooked in clinical practice. With the aim of highlighting its prognostic value, the role of resting heart rate as a risk marker for death and other adverse outcomes was further examined in a number of different patient populations. A systematic review of studies that previously assessed the prognostic value of resting heart rate for mortality and other adverse cardiovascular outcomes was presented. New analyses of nine clinical trials were carried out. Both the original and extended Cox model that allows for analysis of time-dependent covariates were used to evaluate and compare the predictive value of baseline and time-updated heart rate measurements for adverse outcomes in the CAPRICORN, EUROPA, PROSPER, PERFORM, BEAUTIFUL and SHIFT populations. Pooled individual patient meta-analyses of the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials, and the BEAUTIFUL and SHIFT trials, were also performed. The discrimination and calibration of the models applied were evaluated using Harrell’s C-statistic and likelihood ratio tests, respectively. Finally, following on from the systematic review, meta-analyses of the relation between baseline and time-updated heart rate, and the risk of death from any cause and from cardiovascular causes, were conducted. Both elevated baseline and time-updated resting heart rates were found to be associated with an increase in the risk of mortality and other adverse cardiovascular events in all of the populations analysed. In some cases, elevated time-updated heart rate was associated with risk of events where baseline heart rate was not. Time-updated heart rate also contributed additional information about the risk of certain events despite knowledge of baseline heart rate or previous heart rate measurements. The addition of resting heart rate to the models where resting heart rate was found to be associated with risk of outcome improved both discrimination and calibration, and in general, the models including time-updated heart rate along with baseline or the previous heart rate measurement had the highest and similar C-statistics, and thus the greatest discriminative ability. The meta-analyses demonstrated that a 5bpm higher baseline heart rate was associated with a 7.9% and an 8.0% increase in the risk of all-cause and cardiovascular death, respectively (both p less than 0.001). Additionally, a 5bpm higher time-updated heart rate (adjusted for baseline heart rate in eight of the ten studies included in the analyses) was associated with a 12.8% (p less than 0.001) and a 10.9% (p less than 0.001) increase in the risk of all-cause and cardiovascular death, respectively. These findings may motivate health care professionals to routinely assess resting heart rate in order to identify individuals at a higher risk of adverse events. The fact that the addition of time-updated resting heart rate improved the discrimination and calibration of models for certain outcomes, even if only modestly, strengthens the case that it be added to traditional risk models. The findings, however, are of particular importance, and have greater implications for the clinical management of patients with pre-existing disease. An elevated, or increasing heart rate over time could be used as a tool, potentially alongside other established risk scores, to help doctors identify patient deterioration or those at higher risk, who might benefit from more intensive monitoring or treatment re-evaluation. Further exploration of the role of continuous recording of resting heart rate, say, when patients are at home, would be informative. In addition, investigation into the cost-effectiveness and optimal frequency of resting heart rate measurement is required. One of the most vital areas for future research is the definition of an objective cut-off value for the definition of a high resting heart rate.

Plan de medios y posicionamiento digital

El principal objetivo de este trabajo de grado ha sido diseñar un plan estratégico de medios digitales para el lanzamiento de un nuevo producto para una compañía. En este trabajo, se han establecido parámetros como presupuesto, qué tipos de medios digitales serán usados y el porqué de ellos, se estableció las actividades por cada red social a usar y se muestra la relación costo – beneficio de realizar pauta publicitaria en redes sociales.

Estimated Disability-adjusted Life Years Averted By Long-term Provision Of Long Acting Contraceptive Methods In A Brazilian Clinic.

What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago. Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted. LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce. We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012. Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted. We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted. The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world. LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population. This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

Waist-to-height Ratio Percentiles And Cutoffs For Obesity: A Cross-sectional Study In Brazilian Adolescents.

This study aimed to describe the distribution of waist-to-height ratio (WHtR) percentiles and cutoffs for obesity in Brazilian adolescents. A cross-sectional study including adolescents aged 10 to 15 years was conducted in the city of São Paulo, Brazil; anthropometric measurements (weight, height, and waist-circumference) were taken, and WHtRs were calculated and then divided into percentiles derived by using Least Median of Squares (LMS) regression. The receiver operating characteristic (ROC) curve was used in determining cutoffs for obesity (BMI ≥ 97th percentile) and Mann-Whitney and Kruskal-Wallis tests were used for comparing variables. The study included 8,019 adolescents from 43 schools, of whom 54.5% were female, and 74.8% attended public schools. Boys had higher mean WHtR than girls (0.45 ± 0.06 vs 0.44 ± 0.05; p=0.002) and higher WHtR at the 95th percentile (0.56 vs 0.54; p<0.05). The WHtR cutoffs according to the WHO criteria ranged from 0.467 to 0.506 and 0.463 to 0.496 among girls and boys respectively, with high sensitivity (82.8-95%) and specificity (84-95.5%). The WHtR was significantly associated with body adiposity measured by BMI. Its age-specific percentiles and cutoffs may be used as additional surrogate markers of central obesity and its co-morbidities.

Evaluation Of Characteristic-to-total Spectrum Ratio: Comparison Between Experimental And A Semi-empirical Model.

Primary X-ray spectra were measured in the range of 80-150kV in order to validate a computer program based on a semiempirical model. The ratio between the characteristic and total air Kerma was considered to compare computed results and experimental data. Results show that the experimental spectra have higher first HVL and mean energy than the calculated ones. The ratios between the characteristic and total air Kerma for calculated spectra are in good agreement with experimental results for all filtrations used.