O exercício eficaz da liderança significa um recurso de grande importância para o desenvolvimento do trabalho do enfermeiro. O presente estudo investigou a liderança deste profissional que atua em centro cirúrgico de instituições hospitalares na cidade de Londrina (Paraná). Selecionamos como referencial teórico o modelo de liderança proposto por Hersey e Blanchard, denominado Liderança Situacional. Os objetivos consistiram em identificar a correspondência de opinião entre o enfermeiro de centro cirúrgico e o pessoal auxiliar de enfermagem em relação ao estilo de liderança exercido pelo enfermeiro e o estilo de liderança que este profissional deveria adotar em relação ao nível de maturidade do pessoal auxiliar de enfermagem frente as atividades desenvolvidas na sala de operação. Para o alcance dos objetivos propostos, elaboramos instrumentos, os quais foram submetidos a validação aparente e de conteúdo, bem como realizamos um teste piloto. Os instrumentos foram aplicados em quinze enfermeiros, dois técnicos e treze auxiliares de enfermagem. Os resultados demonstraram que o estilo de liderança mais exercido pelo enfermeiro, apontado pelos participantes do estudo, foi o E3 (compartilhar). Quanto ao estilo de liderança que o enfermeiro deveria adotar em relação ao nível de maturidade do pessoal auxiliar frente as atividades desenvolvidas na sala de operação, houve predomínio do estilo E4 (delegar), sugerindo que os liderados pesquisados apresentavam nível de maturidade alto (M4). Entendemos que a Liderança Situacional pode ser utilizada como referencial teórico para fundamentar o exercício da liderança do enfermeiro de centro cirúrgico com vistas a melhoria da assistência prestada ao cliente e o desenvolvimento do potencial da equipe de enfermagem. / The effective exercise of the leadership means a resource of great importance for the development of the male nurse work. This study investigated this professional’s leadership that acts in surgical center at hospitals in Londrina (Paraná). It was chosen as theoretical background a model of leadership proposed by Hersey and Blanchard called Situational Leadership. Our purposes were to identify the correspondence of opinion between the nurse from the surgical center and the nursing assistants concerning the nurse’s leadership style and the leadership style that this professional should adopt in relation to the nursing assistants’ level of maturity in face of the activities developed at the surgical room. As for the accomplishment of the proposed objectives, some instruments were designed and submitted to apparent and content validation, as well as we accomplished a pilot test. The instruments were applied to fifteen nurses, two nursing technicians and thirteen nursing assistants. The results showed that the most performed leadership style among nurses, pointed for the participants of the study, was the E3 (sharing). As for the leadership style that the nurse should adopt in relation of the maturity level of the assistants from the activities developed in the surgery room, there was prevalence of the style E4 (delegating), suggesting that led researched they presented level of maturity high (M4). It is understood that the Situational Leadership can be used as theoretical background to establish the leadership of the nurse from the surgical center aiming at the improvement of the assistance given to the customer as well as development of the potential of the nursing team.

O presente trabalho constitui uma avaliação prospectiva da utilização do método de esterilização feminina não-cirúrgica com quinacrina. O grupo em estudo é formado por dez mulheres, atendidas no período de abril a setembro de 1990, no Ambulatório de Planejamento Familiar do Hospital Sotero del Rio, Santiago, Chile. O perfil reprodutivo das mulheres, revela que o inicio da vida fértil foi, em media, aos 12.1 anos e aproximadamente quatro anos depois (16.4 anos), iniciaram a atividade sexual sem uso de métodos anticoncepcionais. Em consequência, verifica-se que a primeira gravidez ocorreu, em média, aos 19.1 anos, ou seja, ainda dentro do período que compreende a adolescência. Após este evento obstétrico - gravidez - a maioria iniciou o uso de métodos de planejamento familiar por volta dos 21 anos, tendo como resultado, uma variada e não muito bem sucedida história anticoncepcional. A decisão de encerrar a vida reprodutiva com medidas definitivas foi tomada pelo casal, baseado em informações fornecidas pelos profissionais de saúde e referindo razões de planejamento familiar, história anticoncepcional e obstétrica negativa. No momento de concretizar esta decisão, as mulheres faziam em média, 34.8 anos e parte de uma família legalmente constituída com 3.2 filhos vivos. Destas mulheres, 40 por cento ainda tinham a opção de utilizar métodos reversíveis modernos, no momento de submeter-se a este método definitivo. O seguimento prospectivo do método não-cirúrgico mostra que os efeitos colaterais, como os maiores níveis de quinacrina plasmática e urinária apresentam-se no período das primeiras 48 horas, após inserção intrauterina da primeira e segunda doses de \"pellets\" de quinacrina. / This paper consists of an evaluation on the use of quinacrine as a non-surgical irreversible method for female sterilization. The study group is made up of ten women, seen at the Sotero del Rio Hospital outpatient clinic in Santiago, Chile, from april to september 1990. This study reveals that the women\'s reproductive life began on average at the age of 12.1 years and approximately four years later they began their sexual activity without the use of contraceptive methods. Consequently their first pregnancy occurred at the age of 19.1 years, during late adolescent years. Two years after pregnancy many of these women began to use contraceptive methods (at the age of 21, on average). As a result their obstetric history shows a non well succeeded and varied response to anticonceptional methods. The decision to close reprodutive life taking permanent steps was made by the couples based on information furnished by health professionals. The reasons given were related to family planning, anticonceptional and negative obstetric history. On implementing their decision, the group averaged 34.8 years and averaged 3.2 a lived children per subject. A total of 40 per cent of these women could still use other modern reversible methods before being submited to this permanent one. The follow-up of this non-surgical procedure shows that side effects such as higher levels of quinacrine in the blood and urine ocurred in the first 48 hours after the first and second intrauterine insertion of quinacrine pellets.

Resumo: Propósito: Investigar a efetividade da descompressão no tratamento inicial de ameloblastomas e os efeitos desse tipo de tratamento conservador nas características histopatológicas e de proliferação celular do tumor. Materiais e Métodos: Foram estudados retrospectivamente 8 pacientes portadores de ameloblastoma de mandíbula procedentes da Faculdade de Odontologia de Araçatuba-UNESP e do Hospital das Clínicas da FMUSP, sendo 4 ameloblastomas unicísticos e 4 multicísticos que tiveram como tratamento inicial pré-cirúrgico a descompressão. Foram avaliados o dados clínicos e imaginológicos antes e depois da descompressão. Foram definidos critérios para a indicação da descompressão. Fez-se também o estudo comparativo histopatológico antes e depois da descompressão. Os efeitos da descompressão sobre a proliferação celular do tumor foram investigados por meio da contagem de AgNORs e avaliação da expressão de PCNA e Ki-67. Resultados: Em todos os casos a descompressão foi efetiva promovendo considerável redução do tumor. O caráter cístico do tumor foi comprovado por punção aspirativa prévia em todos os pacientes. Aspecto radiográfico unilocular foi visto em 5 casos e multilocular com grande loja radiolúcida em 2. O período de descompressão foi de 5 a 12 meses e a técnica mostrou ser bem aceita pelo paciente, de baixo custo e de fácil execução. A avaliação comparativa histopatológica revelou que em alguns casos a descompresssão pode modificar o clássico padrão do epitélio odontogênico do ameloblastoma para um epitélio do tipo ameloblastomatoso com abrandamento dos critérios de Vickers & Gorlin. Não observamos significativa diferença na contagem do AgNOR e na expressão do PCNA e do Ki-67 do epitélio tumoral antes e depois da descompressão. Conclusão: Nossos resultados indicam que a descompressão é um valioso método no tratamento inicial de... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Purpose: To investigate the effectiveness of decompression in ameloblastoma initial treatment and its action on histopathologic characteristics and cellular proliferation of the tumor. Materials e Methods: A retrospective study of 4 unicystic and 4 multicystic mandible ameloblastoma submitted to decompression was realized with. Clinical and radiologic informations before and after decompression were obtained from the records of the Faculty of Dentistry of Araçatuba, UNESP and of the Hospital das Clínicas of the School of Medicine, USP. Criterions for decompression indication were determined and a histopathologic comparative study before and after decompression was realized. The effect of decompression on cellular proliferation was investigated by AgNOR count and expression of PCNA and Ki-67 evaluation. Results: Decompression was effective in all the studied cases presenting a considerable decrease of the tumor. The cystic aspect was confirmed by previous aspirate punction. Unilocular radiologic aspect was observed in 5 cases and multilocular with great radiolucent region in 2 cases. The decompression period lasted from 5 to 12 months and the technique was well accepted by the patients, with low cost and easy accomplishment. In some cases the histopathological comparative evaluation showed an alteration of the classical odontogenic epithelium pattern of the ameloblastoma to an ameloblastomatous epithelium with lightening of Vickers & Gorlin criterions. Significative difference in the cellular proliferation to the tumoral epithelium was not observed between before and after the decompression. Conclusion: Our results consider decompression as a valuable method for initial treatment of unicystic and multicystic ameloblastoma with great cystic degeneration. It decreases the tumor size and increases the bone support reducing the necessity of mandibulectomy... (Complete abstract, click electronic address below) / Orientador: Norberto Perri Moraes / Coorientador: Marcelo Macedo Crivelini / Banca: Idelmo Rangel Garcia Júnior / Banca: Antônio Francisco Durighetto Júnior / Banca: Norberto Perri Moraes / Mestre

Since the first robotic surgical intervention was performed in 1985 using a PUMA industrial manipulator, development in the field of surgical robotics has been relatively fast paced, despite the tremendous costs involved in developing new robotic interventional devices. This is due to the clear advantages to augmented a clinicians skill and dexterity with the precision and reliability of computer controlled motion. A natural extension of robotic surgical intervention is the integration of image guided interventions, which give the promise of reduced trauma, procedure time and inaccuracies. Despite magnetic resonance imaging (MRI) being one of the most effective imaging modalities for visualizing soft tissue structures within the body, MRI guided surgical robotics has been frustrated by the high magnetic field in the MRI image space and the extreme sensitivity to electromagnetic interference. The primary contributions of this dissertation relate to enabling the use of direct, live MR imaging to guide and assist interventional procedures. These are the two focus areas: creation both of an integrated MRI-guided development platform and of a stereotactic neural intervention system. The integrated series of modules of the development platform represent a significant advancement in the practice of creating MRI guided mechatronic devices, as well as an understanding of design requirements for creating actuated devices to operate within a diagnostic MRI. This knowledge was gained through a systematic approach to understanding, isolating, characterizing, and circumventing difficulties associated with developing MRI-guided interventional systems. These contributions have been validated on the levels of the individual modules, the total development system, and several deployed interventional devices. An overview of this work is presented with a summary of contributions and lessons learned along the way.

During a laparoscopic surgery, an endoscopic camera is used to provide visual feedback of the surgery to the surgeon and is controlled by a skilled assisting surgeon or a nurse. However, in robot-assisted teleoperated systems such as the daVinci surgical system, the same control lies with the operating surgeons. This results in an added task of constantly changing view point of the endoscope which can be disruptive and also increase the cognitive load on the surgeons. The work presented in this thesis aims to provide an approach that results in an intelligent camera control for such systems using machine learning algorithms. A particular task of pick and place was selected to demonstrate this approach. To add a layer of intelligence to the endoscope, the task was classified into subtasks representing the intent of the user. Neural networks with long short term memory cells (LSTMs) were trained to classify the motion of the instruments in the subtasks and a policy was calculated for each subtask using inverse reinforcement learning (IRL). Since current surgical robots do not enable the movement of the camera and instruments simultaneously, an expert data set was unavailable that could be used to train the models. Hence, a user study was conducted in which the participants were asked to complete the task of picking and placing a ring on a peg in a 3-D immersive simulation environment created using CHAI libraries. A virtual reality headset, Oculus Rift, was used during the study to track the head movements of the users to obtain their view points while they performed the task. This was considered to be expert data and was used to train the algorithm to automate the endoscope motion. A 71.3% accuracy was obtained for the classification of the task into 4 subtasks and the inverse reinforcement learning resulted in an automated trajectory of the endoscope which was 94.7% similar to the human trajectories collected demonstrating that the approach provided in thesis can be used to automate endoscopic motion similar to a skilled assisting surgeon.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Objective The objective of this study was to investigate the effect of preoperative diastolic dysfunction on postoperative mortality and morbidity after cardiovascular surgery. Methods We systematically searched for articles that assessed the prognostic role of diastolic dysfunction on cardiovascular surgery in PubMed, Cochrane Library, Web of Science, Embase and Scopus until February 2016. Twelve studies (n=8224) met our inclusion criteria. Due to scarcity of outcome events, fixed-effects meta-analysis was performed using the Mantel-Haenszel method. Results Preoperative diagnosis of diastolic dysfunction was associated with higher postoperative mortality (OR 2.41, 95% CI 1.54-3.71; p<0.0001), major adverse cardiac events (MACE) (OR 2.07, 95% CI 1.55-2.78; p <=0.0001) and prolonged mechanical ventilation (OR 2.08, 95% CI 1.04-4.16; p=0.04) in comparison to patients without diastolic dysfunction among patients who underwent cardiovascular surgery. The odds of postoperative myocardial infarction (OR: 1.29, 95% CI 0.82, 2.05; p=0.28) and atrial fibrillation (OR: 2.67; 95% CI 0.49-14.43; p=0.25) did not significantly differ between the two groups. Severity of preoperative diastolic dysfunction was associated with increased postoperative mortality (OR 21.22, 95% CI 3.74 -120.33; p=0.0006) for Grade 3 diastolic dysfunction compared with patients with normal diastolic function. Inclusion of left ventricular ejection fraction (LVEF) <40% accompanying diastolic dysfunction, did not further impact postoperative mortality (p=0.27; I2 =18%) when compared with patients with normal LVEF and diastolic dysfunction. Conclusions Presence of preoperative diastolic dysfunction was associated with higher postoperative mortality and MACE, regardless of LVEF. Mortality was significantly higher in grade III diastolic dysfunction. Keywords Diastolic dysfunction; cardiovascular surgical procedures; mortality; meta-analysis / Revisión por pares

Surgical robotic systems and computer assisted surgery have revolutionized the delivery of surgical care by providing precision, accuracy and miniaturization of instrumentation unachievable with manual equipment and techniques. Despite advancements generated by these technologies, unmet challenges exist when working in the unstructured flexible environment of a surgical site. Current surgical robots are limited to preoperative surgical plans and minimal intraoperative sensory information due to inherent design limitations of these systems and lack of frameworks for utilization of real-time data. These limitations place restrictive burdens on surgeons for control with incomplete information on the robot, the surgical environment and their interaction. Acquisition and intelligent use of real-time intraoperative sensory information to augment current systems will result in a new generation of ``smart'' surgical robots that will enable surgeons to make strides in the complexity of techniques, precision, and overall capabilities of surgical procedures. These improvements will be made by adapting to the environment during teleoperation in order to make surgical slaves behave more reliably and safely. Improved intraoperative data integration will also allow autonomous performance of low level tasks, such as retraction, exploration of tissue margins, biopsy and suturing. This doctoral study seeks to advance methods and systems for addressing fundamental limitations of existing surgical robots by adding intraoperative intelligence based on mechanical sensory information. Interaction force data on the surgical slave unit can be acquired either through direct measurement by a dedicated force/torque sensor at the interaction site or indirect measurement of robot actuation forces. With interaction data, models of the environmental interaction can be constructed and novel control laws applied to modify the behavior of a robotic system to improve safety and surgical performance. In the first section of this dissertation, general algorithms for exploration and control in flexible environments are investigated for surgical robots with force sensing capabilities. Hybrid force-motion control and redundant coverage paths are described for exploration of the shape of a flexible environment. Based on localized excitation of tissue coupled with simultaneous force measurements, an algorithm for discrete tissue impedance estimates is presented and evaluated for adaptive exploration and segmentation of embedded features. The application of these algorithms for autonomous exploration and estimation are shown in flexible tissue models. In the second section of the dissertation, a framework for compliant motion control is presented for continuum surgical robots subject to unknown interactions with the environment. Through a mapping of unknown environmental interaction forces to a generalized description, joint level actuation force measurements serve as an input to a compliant motion controller that allows surgical slaves to actively comply with environmental forces. Un-modeled effects on the joint level forces are corrected via a feed-forward online estimate. Linear and non-linear regression techniques are evaluated for estimation and compensation of these model uncertainties. Conditions for the stability of the controller are defined and experimentally validated for complex multi-point robot-environmental interaction. Finally, the design and analysis of a novel telerobotic system is presented for minimally invasive surgery in deep surgical sites. The clinical requirements for a benchmark application in transurethral resection of bladder tumor and the design considerations for this system are described. Kinematic analysis of the dexterity at the surgical site and experimental evaluation of the manipulation capabilities of the system are presented in the context of representative clinical tasks. In summary, the algorithms and analysis presented in this dissertation constitute a methodology for collection and integration of sensory information toward the development and deployment of surgical robots with improved capabilities. The fundamental discoveries introduced will contribute to the development of a next generation of smart surgical robots that intelligently interact with the surgical environment leading to safer, faster, less invasive procedures with improved surgical outcomes.

Yang Qin. / "June 2003." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2003. / Includes bibliographical references (p. 168-207). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

O presente trabalho constitui uma avaliação prospectiva da utilização do método de esterilização feminina não-cirúrgica com quinacrina. O grupo em estudo é formado por dez mulheres, atendidas no período de abril a setembro de 1990, no Ambulatório de Planejamento Familiar do Hospital Sotero del Rio, Santiago, Chile. O perfil reprodutivo das mulheres, revela que o inicio da vida fértil foi, em media, aos 12.1 anos e aproximadamente quatro anos depois (16.4 anos), iniciaram a atividade sexual sem uso de métodos anticoncepcionais. Em consequência, verifica-se que a primeira gravidez ocorreu, em média, aos 19.1 anos, ou seja, ainda dentro do período que compreende a adolescência. Após este evento obstétrico - gravidez - a maioria iniciou o uso de métodos de planejamento familiar por volta dos 21 anos, tendo como resultado, uma variada e não muito bem sucedida história anticoncepcional. A decisão de encerrar a vida reprodutiva com medidas definitivas foi tomada pelo casal, baseado em informações fornecidas pelos profissionais de saúde e referindo razões de planejamento familiar, história anticoncepcional e obstétrica negativa. No momento de concretizar esta decisão, as mulheres faziam em média, 34.8 anos e parte de uma família legalmente constituída com 3.2 filhos vivos. Destas mulheres, 40 por cento ainda tinham a opção de utilizar métodos reversíveis modernos, no momento de submeter-se a este método definitivo. O seguimento prospectivo do método não-cirúrgico mostra que os efeitos colaterais, como os maiores níveis de quinacrina plasmática e urinária apresentam-se no período das primeiras 48 horas, após inserção intrauterina da primeira e segunda doses de \"pellets\" de quinacrina. / This paper consists of an evaluation on the use of quinacrine as a non-surgical irreversible method for female sterilization. The study group is made up of ten women, seen at the Sotero del Rio Hospital outpatient clinic in Santiago, Chile, from april to september 1990. This study reveals that the women\'s reproductive life began on average at the age of 12.1 years and approximately four years later they began their sexual activity without the use of contraceptive methods. Consequently their first pregnancy occurred at the age of 19.1 years, during late adolescent years. Two years after pregnancy many of these women began to use contraceptive methods (at the age of 21, on average). As a result their obstetric history shows a non well succeeded and varied response to anticonceptional methods. The decision to close reprodutive life taking permanent steps was made by the couples based on information furnished by health professionals. The reasons given were related to family planning, anticonceptional and negative obstetric history. On implementing their decision, the group averaged 34.8 years and averaged 3.2 a lived children per subject. A total of 40 per cent of these women could still use other modern reversible methods before being submited to this permanent one. The follow-up of this non-surgical procedure shows that side effects such as higher levels of quinacrine in the blood and urine ocurred in the first 48 hours after the first and second intrauterine insertion of quinacrine pellets.

Orientador: Gilson Helio Toniollo / Banca: André Lacerda de Oliveira Abreu / Banca: Juan Carlos Duque Moreno / Banca: Bruno Watanabe Minto / Banca: Andrigo Barboza de Nardi / Resumo: Os procedimentos cirúrgicos contraceptivos possuem como finalidades evitar ou tratar enfermidades do trato reprodutor e promover controle populacional de animais de companhia. Contudo, são traumáticos e implicam em dor pós-operatória, fazendo-se necessário o desenvolvimento de técnicas menos invasivas. O presente estudo objetivou desenvolver e descrever a técnica de ovário-histerectomia (OHE) laparoscópica total transvaginal (total-NOTES) em cadelas e compará-la quanto à dor e o estresse pós-operatórios, parâmetros intra-operatórios e complicações às abordagens vídeo-assistida com único portal (grupo SPVA) e convencional (grupo OPEN). A técnica de OHE por total-NOTES demonstrou-se factível em cadelas. Os grupos NOTES e SPVA apresentaram menores tempo cirúrgico total (25,7 ± 6,8 e 23,1 ± 4,0 minutos, respectivamente) em comparação ao grupo OPEN (34,0 ± 6,4 minutos e 5,3 ± 1,3, respectivamente). As cadelas submetidas a OHE pelas técnicas de total- NOTES e vídeo-assistida com único portal apresentaram menores, dor pós-operatória pela técnica de escala numérica visual (NRS) em todos os momentos de avaliação e cortisol sérico em dois momentos de avaliação em relação aos animais operados pela técnica convencional. Concluiu-se que OHE por total-NOTES é factível em cadelas, tendo apresentado resultados semelhantes à técnica vídeo-assistida com único portal e melhor tempo cirúrgico e menores, dor e estresse pós-operatório em comparação com a abordagem convencional. A técnica de total-NOTES apresentou a vantagem de não requerer cuidados especiais com a ferida cirúrgica / Abstract: The contraceptive surgical procedures aim to avoid or treat reproductive tract disorders and to control the populations of companion animals. However, surgery may lead to surgical trauma and postoperative pain. Thus, the development of new less invasive techniques of surgical contraception is desired. The current study aimed to develop and compare the technique of total transvaginal laparoscopic (total-NOTES) ovariohysterectomy (OHE) to the single-port video-assisted (SPVA group) and conventional (OPEN group) techniques in bitches for postsurgical pain and stress, intra-surgical parameters and complications of ovariohysterectomy performed by the pure-NOTES (NOTES group). The pure-NOTES OHE technique was feasible in bitches. The groups NOTES and SPVA presented shorter overall surgical time (25,7 ± 6,8 and 23,1 ± 4,0 minutes, respectively) and less intra-operative hemorrhage score (1,9 ± 1,8 and 1,1 ± 0,9, respectively) in comparison to the OPEN group (34,0 ± 6,4 minutes and 5,3 ± 1,3, respectively). Bitches submitted to pure- NOTES and single-port video-assisted techniques of OHE presented less pain numerical rating score (NRS) in all time points and less surgical stress by serum cortisol measurement in two moments of evaluation than the animals spayed using the conventional technique. In conclusion, the total-NOTES OHE is feasible in bitches. Both total-NOTEs and single-port video-assisted techniques required lower surgical time and resulted in less postoperative pain and stress in comparison to the conventional approach. The total-NOTES technique required no special care of the surgical wound / Doutor