[pt] A relação médico-paciente consiste numa díade que é hierarquicamente assimétrica. Uma parte cuida e a outra recebe cuidado, análogo ao que ocorre nas relações de apego. O médico teria o papel de figura de apego, possibilitando ativar o seu sistema de cuidado. O objetivo deste estudo é analisar como o sistema de cuidado está inserido na relação médico-paciente, analisando o estilo de apego do médico, além de relacioná-lo à capacidade de cuidado que o médico tem com seu paciente. Foram entrevistados onze hematologistas do Rio de Janeiro e São Paulo com experiência no SUS utilizando um roteiro de entrevista semiestruturado e foi aplicado o instrumento de autorrelato EVA (Escala de Vinculação do Adulto). Após análise de conteúdo das entrevistas e análise por clusters do EVA, os médicos entrevistados apresentaram apego seguro, com aspectos defensivos evitativos e amedrontados. Quatro categorias também foram estabelecidas: experiências pessoais com medicina e/ou hematologia; especificidade da hematologia; como lidar com as questões sobre perdas; e cuidado com o outro. Conclui-se que o presente trabalho prioriza o lado do médico nesta relação, e a importância do atendimento às suas necessidades psicológicas e relacionais. Com isso, intervenções podem ser propostas à equipe de saúde, de forma a cuidar de maneira consistente destes profissionais e aprimorar sua relação com o paciente e seus familiares. / [en] The doctor-patient relationship consists of a hierarchically asymmetrical dyad. One side cares and the other receives care, analogous to the attachment relationship. The doctor would have the attachment figure s role, being able to activate his or her caregiving system. The purpose of this study is to analyze how the care system is inserted in the doctor-patient relationship, analyzing the attachment style of the physician in addition to relating it to the care ability that the doctor has with his/her patient. Eleven hematologists from Rio de Janeiro and São Paulo with experience in SUS were interviewed using a semi-structured interview script and the self-report instrument AAS-R (Adult Attachment Scale-Revised) was applied. After content analysis of the interview and a cluster analysis of the AAS-R, all the doctors presented secure attachment, with avoidant-dismissing and avoidant-fearful defensive aspects. Four categories were also analyzed: personal experiences with medicine and/or hematology; hematology s specificity; how to deal with loss; and caring towards other. We concluded that the present it is important to prioritize the doctor s stance in the relationship, and to attend their psychological and relational needs. In that manner, interventions in the healthcare team can be proposed, providing the proper care to the healthcare professional, and, hence, improve their relationship with patients and their family members.

Dissertação (Mestrado) - Universidade Federal de Santa Catarina, Centro Sócio-Econômico. / Made available in DSpace on 2012-10-19T01:36:34Z (GMT). No. of bitstreams: 0Bitstream added on 2016-01-09T04:23:54Z : No. of bitstreams: 1 152810.pdf: 4552473 bytes, checksum: 8a554b51434e929b8fe24bf829ff8568 (MD5) / Configura-se nas três esferas governamentais (federal, estadual e municipal), o desempenho organizacional e o desempenho pessoal nos Serviços de Prevenção e Assistência da Aids do Sistema de Saúde Pública em Florianópolis, na percepção de seus profissionais. O modo de investigação adotado foi o estudo de caso, do tipo descritivo-exploratório, em uma abordagem qualitativa. A população deste estudo foi constituída de profissionais da saúde. A entrevista semi-estruturada foi o principal instrumento de coleta de dados e para a interpretação dos relatos utilizou-se a técnica de análise de conteúdo. Alguns dos aspectos que configuram o D.O. abordados neste estudo foram: a falta de integração destas, tanto em nível interno como externo. Sugerindo um certo isolamento nas ações dos setores de saúde pública que lidam com a Aids em Florianópolis. Desta forma, há indícios de pouca eficácia no desempenho destas unidades pela ausência de ações congruentes capazes de enfrentar a epidemia da Aids. Alguns dos elementos que configuram o D.P., revelam equipes reduzidas de pessoas; a contratação de algumas chefias com competência técnica inadequada para gerir os serviços de prevenção e assistência da Aids. Tais elementos, encontram-se mais ou menos acentuados nestas unidades, o que pode refletir no desempenho pessoal daqueles que ali atuam.

Orientador: Maria de Lurdes Zanolli / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-11T22:21:26Z (GMT). No. of bitstreams: 1 Almeida_PauloVicenteBonilha_M.pdf: 1942924 bytes, checksum: 72e963c2634b2130650bc6e202056123 (MD5) Previous issue date: 2008 / Resumo: Os sistemas de saúde orientados pelos princípios da Atenção Primária à Saúde alcançam melhores indicadores de saúde, têm menores custos e maior satisfação dos usuários. Entretanto há muitas divergências sobre as formas de estruturá-los, para obtenção destes princípios. Em muitos países a Atenção Primária é prestada por médicos de família, que funcionam como porta de entrada do sistema de saúde, acompanhados ou não por outros profissionais de saúde. Médicos de outras especialidades também podem estar disponíveis, como pediatra, ginecologista, clínico geral, e outros. No Brasil, desde 1994, o Ministério da Saúde vem implantando o Programa de Saúde da Família (PSF), como estratégia central da Atenção Primária do Sistema Único de Saúde. O PSF baseia-se no trabalho de uma equipe composta por um médico de família generalista, uma enfermeira, um ou mais auxiliares de enfermagem e de quatro a seis agentes comunitários de saúde. Esta composição das equipes de saúde da família tem sido criticada como insuficiente, principalmente nos grandes centros urbanos, para dar conta das diversas e complexas realidades de saúde do país. Uma das críticas é em relação à ausência do médico pediatra na equipe. Este trabalho analisou parte da experiência do programa no município de Campinas (SP-Brasil), denominado de PSF-Paidéia e implantado com adaptações à realidade local, entre as quais a existência de pediatra em cerca de 140 equipes. O objetivo foi conhecer a visão de pediatras e médicos de família sobre a atenção à saúde da criança por eles praticada, os limites e avanços deste modelo tecno-assistencial, o papel de cada um neste trabalho e como pensam idealmente a existência do pediatra no programa. Para tanto, foi utilizada metodologia qualitativa e, como técnica de coleta de dados, entrevistas semi-estruturadas. Trabalhou-se com uma amostra intencional, selecionando para entrevistas pediatras e médicos de família de 10 equipes, indicadas pelos distritos de saúde do município, como as melhores segundo a adesão às diretrizes do PSF-Paidéia. A técnica de tratamento dos dados colhidos foi a da Análise de Conteúdo, na modalidade Análise Temática. Os avanços mais valorizados são o trabalho em equipe e as reuniões de equipe, para elaboração de projetos terapêuticos singulares. Já como limites: o volume de pronto-atendimento e o excesso de famílias cadastradas por equipe. A atenção à criança é realizada basicamente pelo pediatra e somente na ausência deste o médico generalista a atende. A melhoria da capacitação do médico de família para o cuidado à criança é vista como fundamental. Houve uma quase unanimidade de reconhecimento da importância do pediatra na atenção básica e não como referência à distância, pela ampliação da resolutividade que traria para a equipe in loco. Entretanto, foram apontadas críticas à sua atuação, muito focada no referencial biomédico e no consultório médico, havendo necessidade de maior envolvimento com o trabalho em equipe, os aspectos psicossociais, a família e o território, para que ele possa se legitimar plenamente como necessário nas equipes de saúde da família. Para dar conta do complexo perfil de morbidade das crianças e adolescentes do século XXI o pediatra geral da atenção primária precisaria de uma nova formação. Também parece importante uma melhor definição, pelos órgãos gestores, do papel do pediatra nas equipes do PSF-Paidéia, bem como na atenção primária à criança no SUS / Abstract: The primary-care-oriented health systems get better health indicators, have low costs and better users satisfaction. Though, there is great divergence about how to structure them to obtain the principles of primary health care. In a lot of countries the primary care is provided by general practitioners, working as the health system "gatekeepers", sometimes with other health professionals. Specialists, like pediatricians, gynecologists and internists may be present too. In Brazil, since 1994, the health ministry is developing the Family Health Program (FHP) as the central strategy of the Primary Health Care. The Family Health Program is based in a team's work of a general practitioner, a nurse, one or more auxiliary nurses and four or six community health agents. This composition has been criticized as insufficient to attend to the very different and complex health realities of the country, especially in big cities. One of the criticisms has been against the absence of the pediatrician. This study analyzed the city of Campinas's experience, called FHP-Paidéia that implemented this health program with adaptations to the local reality, especially the existence of the pediatrician in its 140 teams. The objective was to know the vision of general practitioners and pediatricians about their practice with child health care, the health model advances and limitations, the role of each one in this work, and how they ideally think about the pediatrician's presence in the FHP. It was used qualitative methodology and semi-structured interviews. Working with an intentional sample, pediatricians and general practitioners of ten teams were indicated to this research by the health districts of the city as the best developing the FHP-Paidéia's principles. The analysis method was based on the content analysis, in its thematic analysis version. The most considered advances were the team's work and the team's reunions to discuss the patients health projects. The limitations were the excess of families listed by each team. The child health care is basically provided by the pediatrician and is done by the general practitioner only if the pediatrician is not present. The improvement of the general practitioner's training for providing the child health care is seen as very important. There was almost unanimity about the importance of the pediatrician participation in the Primary Health Care and not as a specialty, because of the improvement of the team's resolubility with this presence. There were criticisms to the pediatrician's work, considered too focused in the biomedical paradigm and in the office. In conclusion, there is need for the pediatrician to have more engagement with the team's work, the psychological and social aspects, and with the family and territory in order for the pediatrician to gain acceptance as truly essential to the health teams. To be efficient against this complex new morbidity of children and teenagers the pediatrician needs a new specialization. It seems also important a better definition about the pediatrician's role in FHP-Paidéia's teams and in the child primary health care in the Unified Health System, the brazilian health system / Mestrado / Pediatria / Mestre em Saude da Criança e do Adolescente

Bien que devenu un événement rare dans les pays riches, la mortalité maternelle est toujours considéré comme un marqueur du dysfonctionnement du système de soins d'un pays. Le premier travail de cette thèse avait pour objectif d'étudier l'évolution du profil de la mortalité maternelle en France entre 1998 et 2007 à partir des données de l'Enquête Nationale Confidentielle sur les Morts Maternelles (ENCMM). Le ratio de mortalité maternelle (RMM) est resté stable, avec 9 décès pour 100 000 naissances vivantes. Il se situe dans la moyenne basse des pays européens ayant un système renforcé de mesure, ce qui est relativement satisfaisant compte-tenu de l'évolution du profil des femmes et de l'augmentation observée ailleurs. La principale cause de décès était l'hémorragie obstétricale. La proportion des morts maternelles évitables n'a pas évolué et est restée au tour de 50%. Ces résultats soulignent qu'une réduction du RMM est envisageable. Pour cela, une meilleure compréhension de ses déterminants est essentielle. Le deuxième travail a abordé la question des disparités régionales. Cette analyse a montré que le risque de mort maternelle en postpartum, après prise en compte des certaines caractéristiques individuelles des femmes, était supérieur dans les DOM et en Ile-de-France, comparé au reste de la France métropolitaine, et que des facteurs liés au contenu et à l'organisation des soins pourraient être impliqués. La pertinence des leçons tirées de l’étude de la mortalité maternelle dépend de la validité de sa mesure. Le dernier travail avait pour objectif d’évaluer les écueils des statistiques de routine de mortalité pour étudier la fréquence et les causes de mortalité maternelle. La sous-estimation du RMM dans les statistiques de mortalité a diminué significativement au cours du temps. Cependant, les inexactitudes sont plus importantes que le RMM ne le montre ; en effet, pour 2007-2009 une mort maternelle sur trois de l’ENCMM n’est pas repérée dans les statistiques de mortalité et le profil de causes diffère de celui issu de l’ENCMM. / While maternal mortality has become a very rare event in developed countries, it remains a marker of the performance of a country’s health system. The first work of this thesis was to study the evolution of maternal mortality profile in France between 1998 and 2007 using data from the Confidential enquiry into maternal deaths (ENCMM). The maternal mortality ratio (MMR) remained stable, with 9 deaths per 100,000 live births, it is in the low average of other European countries that also have enhanced measurement systems, which is consider satisfactory in view of the evolution of profile of women and the rise of MMR observed elsewhere. The main cause of death was obstetric hemorrhage. The proportion of avoidable maternal deaths has not changed and remained around 50%. These results emphasize that reducing the MMR is possible, for this, a better understanding of its determinants is essential. The second work explored regional disparities of maternal mortality. The results showed that the risk of postpartum maternal death was higher, after taking women's individual characteristics into account, in the overseas districts (DOM) but also in Ile-de-France, compared with the rest of metropolitan France; we thus deduce that factors related to care may be involved.The relevance of lessons learned from the study of maternal mortality depends on the validity of the data used. The last work assessed the pitfalls of routine mortality statistics to study the frequency and profile of maternal mortality. The underestimation of MMR in mortality statistics has decreased significantly over time. However, inaccuracies are greater than suggested by the MMR; the routine statistics failed to identify one third of the maternal deaths identified by the ENCMM and the causes profile differs from that resulting from the ENCMM.

L’accident vasculaire cérébral (AVC) est une maladie avec des taux de morbidité et de mortalité élevés, il est classé parmi les causes les plus fréquentes de décès et d’invalidité acquise dans le monde entier. Ainsi, évaluer son épidémiologie peut jouer un rôle crucial dans la réduction de son impact sur la population et la société. Le fardeau de l’AVC est attribué principalement aux pays en voie de développement, puisque les gens dans les pays développés ont une meilleure prise en charge et une sensibilisation accrue sur les symptômes et les facteurs de risque de l’AVC. Toutefois, dans les pays moins développés, où la population confronte l’énorme impact de l’urbanisation et de la mondialisation avec une augmentation accrue de la prévalence des facteurs de risque cardiovasculaire, l’incidence des AVC reste élevée. Peu de données épidémiologiques existent sur les AVC au Liban. Par conséquent, il était nécessaire de mener cette étude.Nous avons effectué une étude de cohorte multicentrique, prospective, basé sur l’incidence. Nous avons inclus 203 participants âgés de 18 ans et plus de 8 hôpitaux à Beyrouth entre Août 2015 et Août 2016 avec un diagnostic d’AVC confirmé. Les patients ont été suivis pendant une période d’un an (à l’admission à l’hôpital, à la sortie de l’hôpital et à 3, 6 et 12 mois par des visites à domicile).L’hypertension est le facteur de risque le plus puissant et le plus fréquent de l’AVC. Seulement 2,5 % des AVC ischémiques ont subi une thrombolyse. Le taux de mortalité cumulé était 13,3% à 1 mois et 21,2% à 1 an. Les complications et la gravité de l’AVC étaient des prédicteurs de décès à 1 mois et 1 an. Le niveau socio-économique bas, la dépendance dans les activités quotidiennes et les comorbidités étaient prédicteurs de mortalité supplémentaire à 1 an. La qualité de vie est relativement faible chez les patients atteints d’AVC et plus de 15 % d'entre eux étaient déprimés. Les principaux déterminants de la qualité de vie étaient: l’état fonctionnel, la dépendance dans les activités de la vie quotidienne, l’âge et la dépression. Les principaux déterminants de la dépression étaient l’état fonctionnel et la qualité de vie. Le coût direct hospitalier de tous les cas d’AVC était US$ 1,413,069 pour 2626 jours (538 US$ par jour à l’hôpital). Le coût moyen hospitalier par patient était US$ 6961±15, 663. Les AVC hémorragiques ont été les plus coûteux, l'accident ischémique transitoire étant le moins coûteux. Les prédicteurs de coûts étaient : la longueur du séjour hospitalier et dans l'unité de soins intensifs, le type d’AVC, la gravité de l’AVC, l'échelle de Rankin modifiée, les tiers payeurs, la chirurgie et les complications infectieuses.La prévention primaire est d’une importance primordiale dans la réduction de la charge de l’AVC. Les campagnes de sensibilisation sur les symptômes de cette maladie surtout pour la population hypertendue contribueront à limiter l’incidence de la maladie et donc à diminuer le fardeau financier et social élevé de l’AVC (le coût de la maladie et la qualité de vie). La mise en place d’unités spécialisées pour les AVC et l’augmentation du pourcentage de patients thrombolysés peuvent réduire la mortalité à court terme et les incapacités de longue durée et donc améliorer la qualité de vie des patients atteints d’AVC. / Stroke is a disease with high morbidity and mortality rates, classified among the most common causes of death and acquired disability worldwide. Thus, assessing its epidemiology may play a crucial role in reducing its impact on the population and the society. Stroke late burden is attributable to developing countries mainly, as people in developed countries have a better access to optimal care and an increased awareness on stroke symptoms and risk factors. However, in less developed countries, where population confronts the huge impact of urbanization and globalization with a great increase in the prevalence of cardiovascular risk factors, the incidence of stroke remains high. Lebanon is lacking data on the epidemiology of stroke. Therefore, it was necessary to conduct this study and highlight some features of the disease epidemiology.We carried out a multicenter prospective incidence-based cohort study. We included 203 participants aged 18 years and more from 8 hospitals in Beirut between August 2015 and August 2016 with confirmed diagnosis of stroke. Patients were followed for a 1-year period (at hospital admission and discharge, and by home visits at 3, 6 and 12 months).Hypertension was the most powerful and prevalent risk factor for stroke. Only 2.5% of ischemic strokes received thrombolytic therapy. Cumulative mortality rates were 13.3% at 1-month and 21.2% at 1-year. Stroke severity and complications were predictors of death at 1-month and 1-year. Low socioeconomic status, dependency in daily living activities, and co-morbidities were additional 1-year mortality predictors. The quality of life was relatively low in stroke patients and more than 15% of them were depressed. The main determinants of quality of life were functional status, dependency in daily living activities, age, and depression. The main determinants of depression were functional status and quality of life. The direct in-hospital cost for all cases was US$1,413,069 for 2626 days (US$538 per in-hospital day). The average in-hospital cost per stroke patient was US$6961±15,663. Hemorrhagic strokes were the most costly, transient ischemic attack being the least costly. Cost drivers were hospital and intensive care unit length of stay, type of stroke, stroke severity, modified Rankin Scale, third party payer, surgery and infectious complications.Primary prevention is of paramount importance in reducing the burden of stroke. Awareness campaigns on stroke symptoms especially among hypertensive population would help limit the incidence of the disease and therefore decrease the high financial and social burden of stroke (cost of illness and quality of life). The establishment of stroke units and increasing the percentage of thrombolysis may reduce short-term mortality and long term disabilities and therefore improve the quality of life of stroke patients.

Contexte : Le délai d’accès au traitement pour cancer est un aspect important de la qualité des soins. Compte tenu de l’augmentation du nombre de cancers, les établissements de soins seront amenés à traiter un nombre élevé de patients atteints de cancers. Notre objectif était d’étudier le délai d’accès au traitement après le diagnostic de cancer chez les patients atteints de cancers du côlon (CC), du rectum-anus (RC) ou du poumon (CP) ainsi que les facteurs associés et l’impact des inégalités sociales.Méthode : A l’aide de codes diagnostiques de la classification internationale des maladies et de codes de la classification commune des actes médicaux, nous avons sélectionné dans la base du programme de médicalisation des systèmes d’information de nouveaux patients diagnostiqués pour CC, RC et CP en 2009-2010 et traités. Les informations sur ces patients ont été croisées avec celles des bénéficiaires d’affection longue durée pour ces cancers et avec celles de l’indice de désavantage social.Résultats : Nous avons inclus 15 694, 6 623 et 14 596 patients atteints et traités respectivement pour CC, CR et CP. Les délais médians entre l’endoscopie et l’accès à : 1) la chirurgie chez les patients avec un parcours chirurgical pour CC, CR et CP étaient respectivement de 22 (Q25 = 14; Q75 = 34), 97 (Q25 = 34; Q75 = 141), et 44 (Q25 = 26; Q75 = 82) jours ; 2) la chimiothérapie chez les patients avec un parcours non-chirurgical pour CC, CR et CP étaient respectivement de 36 (Q25 = 21; Q75 = 59), 40 (Q25 = 27; Q75 = 59) et 33 (Q25 = 22; Q75 = 49) jours; 3) la radiothérapie chez les patients avec un parcours non-chirurgical chez les patients avec CR et CP étaient respectivement de 53 (Q25 = 39; Q75 = 78) et 88 (Q25 = 46; Q75 = 162) jours; 4) au premier traitement, quel que soit le parcours, était de 23 (Q25 = 14; Q75 = 35), 43 (Q25 = 27; Q75 = 74) et 34 (Q25 = 22; Q75 = 50) jours respectivement pour CC, CR et CP. Le délai d’accès au premier traitement variait selon les régions. Il était long dans la plupart des régions du nord et dans les départements d’Outre-mer, court dans les régions d’Île-de-France, du sud, de l’est et parfois de l’ouest pour les trois cancers. En analyse multiniveau, l’âge et le statut de l’établissement du premier traitement étaient significativement associés au délai d’accès au premier traitement pour CC. Ces facteurs, y compris l’indice de désavantage social étaient significativement associés au délai d’accès au premier traitement pour le CR et le CP. Le délai d’accès au premier traitement augmentait avec l’âge. Il était plus élevé dans les hôpitaux publics comparés aux hôpitaux privés et faible chez les patients des communes les moins défavorisées comparés aux patients des communes les plus défavorisées. Conclusion : A notre connaissance, cette étude est la première à décrire les délais d’accès au traitement après endoscopie chez les patients atteints de cancer à partir des bases médico-administratives en France. Les résultats, qui compléteront ceux issus des données registres de cancers et des réseaux régionaux de cancérologie, pourront être utiles aux décideurs politiques dans la mise en place de recommandations de prise en charge des cancers. / Background: timeliness of cancer treatment is an important aspect of health quality. Care centers are expected to treat a growing number of patients with cancer. Our objectives were to examine treatment times from diagnosis to first-course therapy for patients with colon (CC), rectum-anus (RC), and lung (LC) cancers and assess factors associated with time to-treatment and the impact of deprivation index.Methods: using the international classification of diseases and medical procedures codes, from national hospital discharge database which has been crossed with long term illness data and French deprivation Index information, we selected patients newly diagnosed for CC, RC or LC in 2009-2010 who had undergone treatment.Results: We included 15,694, 6,623 and 14,596 patients diagnosed and treated for CC, RC and LC respectively. Median times from endoscopy to: 1) surgery in patients with a surgical treatment pathway for CC, RC, and LC were 22 (Q25 = 14; Q75 = 34), 97 (Q25 = 34; Q75 = 141), and 44 (Q25 = 26; Q75 = 82) days, respectively; 2) to chemotherapy for patients with a non-surgical treatment pathway, for CC, RC, and LC were 36 (Q25 = 21; Q75 = 59), 40 (Q25 = 27; Q75 = 59), and 33 (Q25 = 22; Q75 = 49) days respectively; 3) to radiotherapy in RC and LC patients were 53 (Q25 = 39; Q75 = 78) and 88 (Q25 = 46; Q75 = 162) days respectively; 4) to first treatment, irrespective of pathway and treatment combination for CC, RC and LC were 23 (Q25 = 14; Q75 = 35), 43 (Q25 = 27; Q75 = 74), and 34 (Q25 = 22; Q75 = 50) days respectively.Time to first treatment vary across regions. It was longer in most northern regions and in overseas districts and shorter in Île-de-France, southern, eastern and sometimes in western regions for the three cancers. In multilevel analysis, Age and status of the first care center were significantly associated to time to first treatment in CC patients. Similar factors, including Deprivation index, were significantly associated to time to first treatment in RC and LC patients. The time to first treatment increased with age. It was higher in public hospitals compared to private hospitals and low in patients with low deprivation index compared to patients with high deprivation index. Conclusion: To our knowledge, this is the first study based on medico-administrative database describing time to first treatment after endoscopy in patients suffering from cancers in France. The results, which will complement those from cancer registry data and regional networks of cancerology, could inform decision-making policies on the implementation of guidelines on timeframes for cancer treatment access.

[pt] Os procedimentos atuais de localização de corpos estranhos ferromagnéticos utilizados na prática clínica envolvem as técnicas de imageamento de radioscopia e radiografia, que apresentam diversas limitações e riscos. Assim, técnicas de localização baseadas em magnetômetros como SQUID, GMI e GMR têm sido desenvolvidas, com variados graus de complexidade e sucesso. Uma das principais dificuldades de ordem prática, além do custo e das dimensões do sistema de medição no caso do SQUID, que opera a temperaturas criogênicas, é a necessidade de o paciente estar posicionado em uma estrutura móvel de grandes dimensões que permita a determinação das coordenadas da posição bidimensional do mapeamento magnético. Por outro lado, as pequenas dimensões dos sensores GMR ou GMI possibilitam o desenvolvimento de um sistema de medição portátil que poderia integrar outros sensores que em conjunto viabilizem a determinação da posição espacial do sensor magnético em relação ao paciente. Esta dissertação de mestrado investiga técnicas de determinação da posição espacial de um dispositivo portátil, baseado em uma plataforma Raspberry Pi, integrando sensor GMR, câmera, sensores inerciais e um sensor de distância, visando ao futuro desenvolvimento de um protótipo de dispositivo médico portátil para localização de corpos estranhos ferromagnéticos. A pesquisa também investiga técnicas de resolução do problema inverso magnético em tempo real baseadas em filtros de Kalman e ajuste por mínimos quadrados, de modo a acelerar o procedimento diagnóstico na futura aplicação clínica do dispositivo. / [en] The current procedures for locating ferromagnetic foreign bodies used in the clinic involve radioscopy and radiography image techniques, which presents several limitations and risks. Thus, localization techniques based on magnetometers were developed as SQUID, GMI and GMR, with varying degrees of complexity and success. One of the main difficulties, in addition to the cost and dimensions of the system, in the case of the SQUID, which operates at cryogenic temperatures, is the need for the patient to be positioned in a large structure that allows flexibility in the configurations of the two-dimensional position of the magnetic mapping. On the other hand, the small dimensions of the GMR or GMI sensors allow the development of a portable measurement system that could integrate other sensors that together make it possible to determine the spatial position of the magnetic sensor in relation to the patient. This master s dissertation investigates techniques for determining the spatial position of a portable device, based on a Raspberry Pi platform, integrating GMR sensor, camera, inertial sensors and a distance sensor, aiming at the future development of a prototype of a portable medical device for localization of ferromagnetic foreign bodies. The research also investigates real-time inverse magnetic problem solving techniques based on Kalman filters and least squares adjustment, in order to accelerate the diagnostic procedure in the future clinical application of the device.

[pt] Esta dissertação apresenta um projeto de sistema portátil de localização de corpos estranhos metálicos não ferromagnéticos por meio de mapeamento magnético. O sistema baseia-se na indução de correntes parasitas no corpo estranho por um estágio de excitação e na medição por um magnetômetro GMI comercial de elevada resolução (25 pT). A topologia do instrumento é baseada no desacoplamento dos estágios de excitação e medição, com uma configuração que produz linhas de campo magnético primário elevadas na região do corpo estranho e tênues na região do sensor. Esta característica supera as limitações de um instrumento previamente desenvolvido, permitindo aumentar o campo magnético primário de excitação sem saturar o magnetômetro. O projeto é baseado em simulações computacionais, considerando dois tipos de excitação e duas orientações para o eixo de sensibilidade do magnetômetro. Diretrizes internacionais para os limites de exposição à radiação não-ionizante, aspectos biometrológicos, construtivos e elétricos também foram levados em consideração no projeto. A análise de desempenho das configurações mais promissoras confirmou a viabilidade do instrumento de medição proposto, otimizando a operação linear do magnetômetro durante o procedimento de medição e contribuindo para a futura construção de um protótipo de sistema de medição completo, com características de desempenho e segurança asseguradas para a aplicação biomédica pretendida. / [en] This dissertation presents a portable system for the localization of nonferromagnetic foreign metal bodies by magnetic mapping. The system is based on the induction of eddy currents in the foreign body by an excitation stage and the measurement by a high resolution commercial GMI magnetometer (25 pT). The instrument topology is based on the decoupling of the stages of excitation and measurement, with a configuration that produces a high primary magnetic field in the foreign body region and a weak one in the sensor region. This feature surpasses the limitations of a previously developed instrument, allowing to increase the primary excitation magnetic field without saturating the magnetometer. The project is based on computational simulations, considering two types of excitation and two orientations for the magnetometer sensitivity axis. International guidelines for exposure limits to non-ionizing radiation, biometrological, constructive and electrical aspects were also taken into consideration in the project. The performance analysis of the most promising settings confirmed the viability of the proposed measurement instrument, optimizing the linear operation of the magnetometer during the measurement procedure and contributing to the future construction of a complete measurement system prototype, with performance and safety characteristics ensured for the intended biomedical application.

[pt] Nesta tese, abordamos o escalonamento de profissionais de saúde para propor um uso mais eficiente da capacidade existente e fornecer acesso oportuno em diferentes serviços de saúde. Apresentamos um conjunto de problemas relacionados à programação de equipes de saúde. O primeiro problema procura reduzir o tempo de porta-médico em uma unidade de pronto atendimento; o segundo problema visa reduzir o tempo de espera total de tratamento também em uma unidade de pronto atendimento; o terceiro problema visa fornecer acesso oportuno à consulta clínica e à cirurgia em uma unidade cirúrgica especializada. Foram propostos e resolvidos modelos de programação estocástica de dois estágios que procuram representar com precisão as características particulares inerentes a cada problema. Um aspecto importante em problemas de saúde é o grande número de incertezas envolvidas nos processos. A incorporação da incerteza aumenta a complexidade do problema e, portanto, torna-se impossível computacionalmente considerar todos os cenários possíveis. Essa dificuldade é contornada usando a Aproximação por Média Amostral (SAA) para representar a incerteza na demanda. Modelo de simulação de eventos discretos (DES) é usado para representar os problemas. Por fim, as soluções foram aplicadas a estudos de caso reais, mostrando que os modelos propostos são adaptáveis a diferentes prestadores de serviços de saúde. Ao longo da tese, resolvemos com eficiência os modelos utilizando casos reais de hospitais no Brasil e nos EUA. / [en] In this thesis, we approach the problem of healthcare staff scheduling to propose a more efficient use of existing capacity to provide timely access in different health services. We present a set of problems related to healthcare staff scheduling. The first problem seeks to reduce the door-to-doctor time in an Emergency Department; the second problem aims to reduce the waiting time of the overall treatment also in an Emergency Department; the third problem aims to provide timely access to both clinic and surgery in a specialized surgical unit. We formulate and solve two-stage stochastic programming models that seek to accurately represent the particular features that are inherent of each problem. An important aspect in healthcare problems is a large number of uncertainties involved in the processes. The incorporation of the uncertainty increases the complexity of the problem, and it, therefore, becomes computationally infeasible to consider all of the possible scenarios. We circumvent this difficulty by relying on Sample Average Approximation (SAA) to address the demand uncertainty. We also use a discrete-event simulation (DES) model to represent the problems. Finally, we apply the framework to real case studies showing that the proposed models are adaptable to different healthcare providers. Throughout the thesis, we efficiently solve the models using real cases of Brazil and USA hospitals.

This review examines the factors that can influence an investigation into the unexpected death of a child before considering if using imaging techniques could be of benefit. Method A systematic search strategy was adopted to search databases using keywords, these results were then subjected to inclusion and exclusion criteria to filter and refine the evidence base further. Discussion More research is published on the use of MRI in comparison with other modalities. There is evidence in the case of MRI in particular that its use could be of benefit in identifying and ruling out potential causes of death in children. Conclusion More research is needed on the use of CT but the routine use of MRI in child death investigation could now be considered. Ethical considerations appear to be a barrier to research in this area and discussions as to how such considerations can be overcome is necessary.