Avaliação do potencial da Telemedicina em Cuidados Paliativos no câncer avançado

Este estudo avaliou o potencial da Telemedicina como suporte complementar a assistência ambulatorial na monitoração de sintomas em pacientes com câncer avançado. Foram acompanhados 12 pacientes do ambulatório do Núcleo de Cuidados Paliativos do Hospital Universitário Pedro Ernesto (NCP-HUPE) de janeiro de 2011 a agosto de 2013. Mensalmente foram feitas consultas ambulatoriais pela médica e equipe multidisciplinar. Neste intervalo, os pacientes do domicilio, através de seus computadores pessoais se conectaram ao Laboratório de TeleSSaúde UERJ pelo serviço de webconferências interagindo com a mesma médica assistente do ambulatório. Os pacientes também tiveram acesso à médica por celular e email. A cada entrevista (presencial e remota) foi aplicada a Escala de Avaliação de Sintomas de Edmonton [Edmonton Symptom Assessment System (ESAS)], e coletado outros dados quanto a outras queixas biopsicossociais e espirituais, agravos à saúde, qualidade de áudio e vídeo da conexão, avaliação dos familiares com a Telemedicina e interferência da Telemedicina quanto ao local do óbito do paciente. Houve dificuldade na seleção dos pacientes, pois o HUPE é um hospital público cuja população assistida tem, caracteristicamente, baixa escolaridade, nível socioeconômico restrito e pouca habilidade com informática. O tempo médio de acompanhamento foi de 195 dias (DP 175,11; range: 11-553 dias). Todos receberam diagnóstico de câncer avançado e tinham dificuldades com locomoção. Sem dúvidas, a ESAS favoreceu a comunicação dos sintomas com os profissionais de saúde; porém, condições clínicas e controle dos sintomas singulares, avaliados em momentos distintos e sujeitos a influências diversas, impedem conclusões em relação às pretensas vantagens. Acompanhamento clínico, detecção de agravos à saúde e de sintomas físicos, psicossociais e espirituais foram possíveis de ser observados pela Telemedicina, confirmados e medicados nas consultas presenciais. A conexão para webconferência foi estabelecida por familiares, pois nenhum paciente operava computadores. O óbito domiciliar ocorreu em 41,67% e todos, mesmo os óbitos hospitalares, receberam suporte à distância do NCP. Durante o estudo foram feitos 305 contatos: 110 consultas presenciais a pacientes e familiares e 195 por Telemedicina (77 webconferências, 38 telefonemas e 80 emails). Todos os familiares referiram satisfação com o suporte oferecido. A Telemedicina permitiu maior acesso ao sistema de saúde (maior número de contatos), reduziu a busca por serviços de emergência, ajudou o controle dos sintomas e proporcionou orientações e segurança aos familiares. Este suporte favoreceu intervenções precoces e proativas e assistência continuada até o óbito. A Telemedicina demonstrou ser um bom adjuvante na monitoração e gerenciamento de sintomas de pacientes em cuidados paliativos em domicílio, não substituindo, mas complementando a assistência presencial.

Anomalies in North American climate: the South Asian-tropical west Pacific connection

How do tropical heating fluctuations create North American climate anomalies? We propose some answers using the results from a simplified global atmospheric model. We find that the South Asian-tropical west Pacific area is especially effective at stimulating North American responses. The relatively strong tropical/extratropical interaction between these two areas is the result of two major processes acting on the Rossby wave signal induced by the tropical heating fluctuations. These factors are: 1) Wave guiding by the Asian-north Pacific subtropical jet; and 2) Wave amplification within unstable regions of the jet flank. These factors allow relatively small, remote, and short-term tropical fluctuations to have relatively large impacts on North American climate.

Near and distant connection of atmospheric systems to ocean temperature change in the coastal California Current region

In studying hydrosphere, atmosphere, and biosphere interactions, it is useful to focus on specific subsystem processes and energy exchanges (forcing). Since subsystem scales range over ten orders of magnitude, it may be difficult to focus research on scales that will yield useful results in terms of establishing causal and predictive connections between more easily and less easily observed subsystems. In an effort to find pertinent scales, we have begun empirical investigations into relationships between atmospheric, oceanic, and biological systems having spatial scales exceeding 10^3 kilometers and temporal scales of six months or more.

Active Voltage Control on series connection of IGBTs and diode recovery optimization

In this paper an Active Voltage Control (AVC) technique is presented, for series connection of insulated-gate-bipolar-transistors (IGBT) and control of diode recovery. The AVC technique can control the switching trajectory of an IGBT according to a pre-set reference signal. In series connections, every series connected IGBT follows the reference and so that the dynamic voltage sharing is achieved. Another key advantage for AVC is that by changing the reference signal at turn-on, the diode recovery can be optimised. © 2010 IEEE.

IGBT series connection under active voltage control

In this paper an Active Voltage Control (AVC) technique is presented, for series connection of insulated-gate-bipolar-transistors (IGBT) and control of diode recovery. The AVC technique can control the switching trajectory of an IGBT according to a pre-set reference signal. In series connections, every series connected IGBT follows the reference and so that the dynamic voltage sharing is achieved. For the static voltage balancing, the AVC technique can clamp the highest collector-to-emitter voltage to a pre-set clamping voltage level. By selecting the value of the clamping voltage, the difference among series connected IGBTs can be controlled in an accepted range. Another key advantage for AVC is that by changing the reference signal at turn-on, the diode recovery can be optimized. © 2011 EPE Association - European Power Electr.

Managing water resources and their connection to land and energy

Effective management is a key to ensuring the current and future sustainability of land, water and energy resources. Identifying the complexities of such management is not an easy task, especially since past studies have focussed on studying these resources in isolation from one another. However, with rapid population growth and an increase in the awareness of a potential change in climatic conditions that may affect the demand for and supply of food, water and energy, there has been a growing need to integrate the planning decisions relating to these three resources. The paper shows the visualisation of linked resources by drawing a set of interconnected Sankey diagrams for energy, water and land. These track the changes from basic resource (e.g. coal, surface water, groundwater and cropland) through transformations (e.g. fuel refining and desalination) to final services (e.g. sustenance, hygiene and transportation). The focus here is on the water analysis aspects of the tool, which uses California as a detailed case study. The movement of water in California is traced from its source to its services by mapping the different transformations of water from when it becomes available, through its use, to further treatment, to final sinks (including recycling and reuse of that resource). The connections that water has with energy and land resources for the state of California are highlighted. This includes the amount of energy used to pump and treat water, and the amount of water used for energy production and the land resources which create a water demand to produce crops for food. By mapping water in this way, policy-makers and resource managers can more easily understand the competing uses of water (environment, agriculture and urban use) through the identification of the services it delivers (e.g. sanitation, agriculture, landscaping), the potential opportunities for improving the management of the resource (e.g. building new desalination plants, reducing the demand for services), and the connections with other resources which are often overlooked in a traditional sector-based management strategy.

IGBT series connection under Active Voltage Control with temporary clamp

This paper presents the use of an Active Voltage Control (AVC) technique for balancing the voltages in a series connection of Insulated Gate Bipolar Transistors (IGBTs). The AVC technique can control the switching trajectory of an IGBT according to a pre-set reference signal. In series connections, every series connected IGBT follows the reference and so that the dynamic voltage sharing is achieved. For the static voltage balancing, a temporary clamp technique is introduced. The temporary clamp technique clamps the collector-emitter voltage of all the series connected IGBTs at the ideal voltage so that the IGBTs will share the voltage evenly. © 2012 IEEE.