Submitted by Setor de Tratamento da Informa??o - BC/PUCRS (tede2@pucrs.br) on 2016-06-14T13:02:45Z No. of bitstreams: 1 DIS_ANA_PAULA_PEREIRA_FLORES_COMPLETO.pdf: 1719590 bytes, checksum: 3662dfc224e6bcf55c88ceed101e0dcb (MD5) / Made available in DSpace on 2016-06-14T13:02:46Z (GMT). No. of bitstreams: 1 DIS_ANA_PAULA_PEREIRA_FLORES_COMPLETO.pdf: 1719590 bytes, checksum: 3662dfc224e6bcf55c88ceed101e0dcb (MD5) Previous issue date: 2016-01-28 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / The following study demonstrates the results of the research developed during the realization of a master's thesis in Social Services in the Postgraduate Program of the School of Humanities of PUCRS, who had as a primary focus to identify how, and if, the social participation, primarily through the Conferences of Social Assistance, can materialize itself and exert influence in the management and execution of the Social Assistance Politics, especially as a parameter in the elaboration of the main instrument of planning of this public politic, independent of which is the Plan of Social Assistance. In the definition of the counties that would participate in the research, there was an effort to include initially 5 counties of different population densities, in accordance with the classification through the size of the population by the Nacional Politic of Social Assistance (BRASIL, 2004). In this sense, an endeavor was made in the search of information on the counties management, with the objective to verify if the social participation, mainly through the Conferences of Social Assistance, can exercise influence in the process of planning this public politic, as an expression of the public will and the forums of deliberation and social participation. To attain the objectives of this study, the critical dialectical method was chosen. The data was analyzed through the categories of the method: historicity, contradiction and totality. Also used as explanatory categories of the reality: Social Participation, the Social Assistance Politic, the Unified System of Social Assistance (SUAS), the Public Conferences, the Counties Plan of Social Assistance and the Access to Information. The study is descriptive and of qualitative nature. For the research procedures the used technique was documentary analysis. However, in the investigation process, there was a great difficulty of access of the documents to be researched, in this case, the Counties Plan of Social Assistance (PMAS), which demonstrated a fragility in the social control of the researched counties, as well as difficulties in dealing with the transparency of public data, by the counties management of the Social Assistance Politic. In this way, there were already preliminary difficulties to the exercise of social participation through the citizens, and yet, an evident incoherence as regards to the transparency of public information of this politic, taking into account the recommendations of SUAS and the Federal Law n? 12.527, of November 18, 2011 ? Law of Information Access (LAI) (BRASIL, 2011), which regulates the constitutional access of information, to be observed by the public agencies of direct and indirect management of all powers of the Union, the States, the DF and the Counties. In this manner, a debate is necessary to be made about how the social participation is being outlined and materialized as a main instrument of local planning of the Social Assistance Politic, as well as the public transparency of information inherent to it, considering that this issues are in a determinate and undeniable moment of construction and fortification in Brazil. / O estudo a seguir apresentado demonstra os resultados da pesquisa desenvolvida durante a realiza??o do Mestrado em Servi?o Social no Programa de P?s-Gradua??o da Escola de Humanidades da PUCRS, que teve por escopo principal identificar como, e, se, a participa??o social, principalmente por meio das Confer?ncias de Assist?ncia Social, consegue se materializar e exercer influ?ncias na gest?o e execu??o da Pol?tica de Assist?ncia Social, especialmente, enquanto par?metro na elabora??o do principal instrumento de planejamento dessa pol?tica p?blica, qual seja o Plano de Assist?ncia Social. Na defini??o dos munic?pios para a pesquisa, buscou-se contemplar inicialmente 05 munic?pios de portes diferentes, conforme a classifica??o segundo o n?mero total de habitantes, constante na Pol?tica Nacional de Assist?ncia Social (BRASIL, 2004). Nesse sentido, foram investidos esfor?os na busca de informa??es nas gest?es municipais no intuito de verificar se a participa??o social, principalmente por meio das Confer?ncias de Assist?ncia Social, consegue exercer influ?ncia no processo de planejamento dessa pol?tica p?blica, enquanto express?o da vontade popular e dos f?runs m?ximos de delibera??o e participa??o social. Para a consecu??o dos objetivos desse estudo optou-se pelo m?todo dial?tico cr?tico. Os dados foram analisados a partir das categorias do m?todo: historicidade, contradi??o e totalidade. Tamb?m foram observadas como categorias explicativas da realidade: Participa??o Social, a Pol?tica de Assist?ncia Social, o Sistema ?nico de Assist?ncia Social (SUAS), as Confer?ncias P?blicas, os Planos de Assist?ncia Social e o Acesso ? Informa??o.O estudo ? do tipo descritivo e de natureza qualitativa. Quanto ao procedimento de pesquisa utilizou-se a t?cnica de an?lise documental. Contudo, no processo de investiga??o, foi constatada uma grande dificuldade de acesso aos documentos a serem pesquisados, no caso, os Planos Municipais de Assist?ncia Social (PMAS), o que demonstrou uma fragilidade do controle social dos munic?pios pesquisados, bem como dificuldades no trato com a transpar?ncia dos dados p?blicos, por parte das gest?es municipais da Pol?tica de Assist?ncia Social. Dessa forma, j? foram evidenciadas dificuldades preliminares para o exerc?cio da participa??o social por parte dos cidad?os e cidad?s, e ainda, uma evidente incoer?ncia, no que se refere ? transpar?ncia das informa??es p?blicas dessa pol?tica, com as recomenda??es do SUAS e da Lei Federal n? 12.527, de 18 de novembro de 2011- Lei de Acesso ? Informa??o (LAI) (BRASIL, 2011), que regula as previs?es constitucionais do acesso ? informa??o, a serem observados pela ?rg?os p?blicos da administra??o direta e indireta de todos os poderes da Uni?o, dos Estados, do DF e dos Munic?pios. Nesse sentido, faz-se necess?rio um debate sobre como est? se delineando e materializando a participa??o social, no principal instrumento de planejamento local da Pol?tica de Assist?ncia Social, bem como a transpar?ncia p?blica das informa??es a ela inerentes, temas estes em determinante e ineg?vel momento de constru??o e fortalecimento no Brasil

Made available in DSpace on 2014-12-17T15:39:05Z (GMT). No. of bitstreams: 1 AnaIOL_DISSERT.pdf: 3163839 bytes, checksum: 5153814b36c4bfcc26c77240b0c38fd8 (MD5) Previous issue date: 2014-04-11 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / National surveys indicate that 6.8 % of the brazilian population is dependent on alcohol and 1 % dependent on illicit drugs, representing a significant portion of the population affected by this issue . Primary Care becomes instrumental in expanding the coverage of this demand and in reducing unnecessary referrals for specialized care. This study aimed to investigate the responsiveness and institutional support of Primary Care Teams in relation to the demands of alcohol and drugs users. The research was conducted in a Family Health Unit in West Sanitary District of Natal City. With quantitative and qualitative nature, our study consisted of two stages. At first, we performed a mapping of alcohol and other drugs abusive use in a sample of the population assisted by Family Heath Teams, using sociodemographic questionnaire and ASSIST (Alcohol, Smoking and Substance Involvement Screening Test). 406 questionnaires were completed. Of these questionnaires, 27.8% are men and 72.2% women, of which 56% are between 20 and 39 years-old, they are housewives, have a stable relationship and are consumers of tobacco (37.6%), marijuana (13%) and especially alcohol (57%). In second stage, two Conversation Circles with Family Health Teams and the referential Family Health Support Center were formed to discuss the data of the mapping realized in the previous phase. The circles, which had participation of 20 of the 37 professional teams from Family Health and 2 from Family Health Support Center, showed a lack of professional training in the subject; inability of the healthcare network in the user embracement; belief of professionals that nothing can be done when matter is alcohol and drugs; and referencing as the only care action performed by teams. Thus we point out the need to support an approach on issues of alcohol and drugs which consider gender issues, investing in Harm Reduction Policy as a possibility of working in this context for recognizing each user in their uniqueness and strategizing with them to promote health in a broad and contextualized way / Pesquisas nacionais indicam que 6,8% da popula??o brasileira ? dependente de ?lcool e 1% dependente de drogas il?citas, representando uma parcela significativa da popula??o atingida por esta problem?tica. A Aten??o Prim?ria torna-se fundamental na amplia??o da cobertura dessa demanda e na diminui??o dos encaminhamentos desnecess?rios para a aten??o especializada. Este estudo objetivou investigar a capacidade de resposta e suporte institucional de equipes de Aten??o Prim?ria em rela??o ?s demandas de usu?rios de ?lcool e drogas. A pesquisa foi desenvolvida em uma Unidade de Sa?de da Fam?lia no Distrito Sanit?rio Oeste de Natal. De natureza quantitativa e qualitativa, nosso estudo foi composto de duas etapas. Na primeira, foi realizado um mapeamento do uso abusivo de ?lcool e outras drogas em uma amostra da popula??o adscrita das equipes de SF, utilizando question?rio sociodemogr?fico e o ASSIST (Alcohol, Smoking and Substance Involvement ScreeningTest). Foram aplicados 406 question?rios. Desses, 27,8% s?o homens e 72,2% mulheres, das quais 56% t?m entre 20 e 39 anos, s?o donas de casa, t?m relacionamento est?vel e consumidoras de tabaco (37,6%), maconha (13%) e principalmente ?lcool (57%). Na segunda etapa foram formadas duas Rodas de Conversa com as equipes de Sa?de Fam?lia e NASF de refer?ncia para a discuss?o dos dados do mapeamento realizado na fase anterior. As rodas, que contaram com a participa??o de 20 dos 37 profissionais das equipes de SF e 2 do NASF, evidenciaram a falta de capacita??o dos profissionais na tem?tica; incapacidade da rede em acolher o usu?rio; cren?a dos profissionais de que nada pode ser feito quando o assunto ? ?lcool e drogas e o encaminhamento como ?nica a??o de cuidado realizada pelas equipes. Diante disso, indicamos a necessidade de fundamentar de forma consistente uma abordagem nas quest?es de uso de ?lcool e drogas que leve em considera??o as quest?es de g?nero, investindo na pol?tica de Redu??o de Danos como uma possibilidade de atua??o nesse ?mbito por reconhecer cada usu?rio em sua singularidade e tra?ar com estrat?gias de promo??o a sa?de de forma ampla e contextualizada

Made available in DSpace on 2015-04-14T13:22:26Z (GMT). No. of bitstreams: 1 462499.pdf: 88854 bytes, checksum: 50bd2d6bb05d85e1007f9f491b40980d (MD5) Previous issue date: 2014-03-10 / Since the publication of Constitution of 1988, Brazil started to implement series of public policy aiming to develop the Welfare State, wherefore guarantee the population s wellness. The important conquest happened in 2004 when was formulated the Pol?tica Nacional de Assist?ncia Social (PNAS), that policy regulates the framing of Sistema ?nico de Sa?de (SUS), that organize the actions whit the objective of to attempt individuals and families with risk and social vulnerability. In the organization of SUAS, Servi?o de Prote??o e Atendimento Integral ? Fam?lia (PAIF), one of the services offered by Centro de Refer?ncia da Assist?ncia Social (CRAS), acts preventively in order to strengthen the family and communitarian ties, besides to promote and guarantee of social rights of families and individuals in social vulnerability. Among the professionals who started to work in Social Assistance are the psychologists, the Community Social Psychology, knowledge area of Psychology, is composed by different theoretical and practical repertoires to comprehend how the psychosocial phenomena interact in between individuals and society. In this way, the Social Support emerges as an important research issue and intervention of Psychology in a public policy area. Therefore, was proposed the study in order to identify the structural and functional configuration of Social Support in different families accompanied by PAIF de Porto Alegre. The research was composed by a sequential mixed design, contemplating, initially, a quantitative study and a qualitative study posterior. In the first state were exerted questionnaires to identify the perception of social support and family support in 91 individuals accompanied by PAIF. The results of first study indicate a relation between family autonomy and follow-up period in CRAS, about scholarship and family adaptation and between scholarship and perception of family support. It was indicated the difference between support network of women and men, a relation between communitarian participation and financial income, communitarian integration and age, time tracking and financial value of social benefit. Besides, there was a relation between the dimensions of Social Communitarian and Family Support. After the quantitative stage, it was started the qualitative study in wich the objective is to identifying how the resources and stressors of Social Support influenced the development of families supported by PAIF. Four participants were selected, withal extreme levels of Social Support and Family Support in quantitative study. Biographical interviews of narrative character and analyzed by the perspective of Content Analysis. The results of the content of narratives were organized in two central axes: the vital stressors happenings and the different psychosocial resources. In this way, it was identify the importance of neighbors, religious institutions and public services in communitarian support, and family has not a major role as requester or provider of support. / A partir da promulga??o da Constitui??o de 1988, o Brasil implementou uma s?rie de pol?ticas p?blicas que visam a constru??o da Seguridade Social na perspectiva de garantir o bem estar da popula??o. Uma importante conquista ocorre em 2004 quando fora formulada a Pol?tica Nacional de Assist?ncia Social (PNAS) que regulamenta a constru??o do Sistema ?nico da Assist?ncia Social (SUAS), que por sua vez, organiza as a??es na busca em atender indiv?duos e fam?lias em situa??o de risco e vulnerabilidade social. Dentro da organiza??o do SUAS, o Servi?o de Prote??o e Atendimento Integral a Fam?lia (PAIF), um dos servi?os ofertados pelo Centro de Referencia da Assist?ncia Social (CRAS), atua de maneira preventiva com o intuito de fortalecer os v?nculos familiares e comunit?rios, al?m de promover a garantia de direitos sociais de fam?lias e indiv?duos em situa??o de vulnerabilidade. Entre os profissionais que passam a atuar no campo socioassistencial encontram-se os psic?logos. A Psicologia ? composta por m?ltiplos e diferentes repert?rios te?ricos e pr?ticos, por sua vez, a Psicologia Social busca compreender como os fen?menos psicossociais interagem nos indiv?duos e na sociedade. Neste sentido, o Apoio Social, ou Suporte Social, surge como um importante tema de pesquisa e interven??o da psicologia no campo das pol?ticas p?blicas. Neste sentido, foi proposto o presente estudo cujo objetivo foi identificar a configura??o estrutural e funcional de Apoio Social em algumas fam?lias acompanhadas pelo Servi?o PAIF de Porto Alegre. A pesquisa foi composta por um delineamento misto sequencial, contemplando inicialmente um estudo quantitativo e posteriormente um estudo qualitativo. Na primeira etapa foram utilizados question?rios para identificar a percep??o do apoio social e do suporte familiar com 91 pessoas acompanhadas pelo Servi?o PAIF. Os resultados do primeiro estudo indicam a rela??o entre maior Percep??o de Suporte Familiar e maior Escolaridade, maior Adapta??o Familiar e maior Escolaridade, maior Autonomia Familiar e maior Tempo de Acompanhamento no CRAS. Identificou-se tamb?m, diferen?a entre uma maior Rede de Apoio das mulheres em compara??o com a dos homens, rela??o entre maior Participa??o Comunit?ria e menor Renda, maior Integra??o Comunit?ria e maior Idade da Pessoa, maior Tempo de Acompanhamento no CRAS e maior Valor do Beneficio Social. Al?m disso, houve correla??o entre as dimens?es do Apoio Social Comunit?rio e do Suporte Familiar. Ap?s a etapa quantitativa, iniciou-se o estudo qualitativo que buscou identificar como os recursos e estressores de Apoio Social influenciam no desenvolvimento das fam?lias acompanhadas pelo Servi?o PAIF. Foram selecionados quatro participantes, com n?veis extremos de Apoio Social e Suporte Familiar do estudo quantitativo. Foram realizadas entrevistas biogr?ficas de car?ter narrativo e analisadas sob a perspectiva da An?lise de Conte?do. Os resultados a partir dos conte?dos das narrativas foram organizados em dois eixos centrais: Acontecimentos Vitais Estressantes e os diferentes Recursos Psicossociais. Assim, a partir das narrativas pode-se identificar m?ltiplos e cont?nuos eventos vitais estressantes, a import?ncia dos vizinhos, das institui??es religiosas e dos servi?os p?blicos no apoio comunit?rio. Quanto ao apoio familiar, a fam?lia n?o teve maior papel como requisitante ou provedora de suporte.

Future heavy duty vehicles will be designed and manufactured with improved Advanced Driver Assistance Systems, ADAS. When developing ADAS, an accurate model of the vehicle dynamics greatly simplifies the development process. One element integral to the vehicle lateral dynamics and development of ADAS is the steering system. This thesis aims to develop an accurate model of a heavy duty vehicle steering system suitable for simulations. The input to the system is an input torque at the steering wheel and the output is the wheel angle. Physical models of the system components are developed using bond graphs and known relations. Some components are modelled with non-linear inefficiencies and friction of different complexity. Unknown parameters and functions are identified from measurement data using system identification tools such as, for example, linear regression and non-linear grid search. The different subsystems are identified separately to the extent deemed possible. Different model designs are considered, validated, and compared. The advantages and disadvantages of different model choices are discussed. Finally, a non-linear state space model is selected for its high accuracy and efficiency. As this final model can be used to simulate a heavy duty vehicle steering system on a desktop computer faster than real time, it fulfills its purpose.

Submitted by PPG Servi?o Social (servico-social-pg@pucrs.br) on 2019-03-12T14:24:56Z No. of bitstreams: 1 Disserta??o - Karen L?gia Le?o.pdf: 1096450 bytes, checksum: 7ad99419b218c039c16fbd554e2dc608 (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2019-03-21T12:17:09Z (GMT) No. of bitstreams: 1 Disserta??o - Karen L?gia Le?o.pdf: 1096450 bytes, checksum: 7ad99419b218c039c16fbd554e2dc608 (MD5) / Made available in DSpace on 2019-03-21T12:40:17Z (GMT). No. of bitstreams: 1 Disserta??o - Karen L?gia Le?o.pdf: 1096450 bytes, checksum: 7ad99419b218c039c16fbd554e2dc608 (MD5) Previous issue date: 2019-01-16 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / The present dissertation systematizes the results of the research developed during the Master's Degree in Social Work in the Postgraduate Program of the Humanities School of PUCRS, whose main purpose was to analyze how the intersectoriality in the Social Assistance Policy in the Region of the Vale do Ca?, in order to contribute with subsidies for its improvement. To carry out the study, a qualitative, mixed-focus research based on the dialectical-critical method was undertaken, having as sample three municipalities of the Ca? Valley Region that is composed of twenty municipalities. The data collection was carried out through interviews with three managers and three social workers from each municipality, as well as the documents related to the social assistance policy in them. The main results of the study are the incipience of intersectoral practice in the municipalities / locus of the research. Thus, even with the notes made by managers and social workers on the relevance of intersectoral praxis, there is a vast path to be followed, full of contradictions and challenges. Thus, it is concluded that the intersectoriality must be understood as a management model that has as fundamental value the totality of the subjects and the families, in order to have effective access to the offer of public services and to legally guaranteed social rights. / A presente disserta??o sistematiza os resultados da pesquisa desenvolvida durante o Curso de Mestrado em Servi?o Social no Programa de P?s-Gradua??o da Escola de Humanidades da PUCRS, que teve por intuito principal analisar como vem se materializando a intersetorialidade na Pol?tica de Assist?ncia Social na Regi?o do Vale do Ca?, com vistas a contribuir com subs?dios para seu aprimoramento. Para realiza??o do estudo, empreendeu-se uma pesquisa qualitativa, de enfoque misto, alicer?ada no m?todo dial?tico-cr?tico, tendo como amostra tr?s munic?pios da Regi?o do Vale do Ca? que ? composta por vinte munic?pios. A coleta de dados realizou-se atrav?s da realiza??o de entrevistas com tr?s gestores e tr?s assistentes sociais de cada munic?pio, bem como foram analisados os documentos relacionados ? pol?tica de assist?ncia social nos mesmos. Como principais resultados do estudo, se destaca a incipi?ncia da pr?tica intersetorial nos munic?pios/l?cus da pesquisa realizada. Destarte, mesmo com os apontamentos feitos pelos gestores e assistentes sociais sobre a relev?ncia da pr?xis intersetorial, se evidencia um vasto caminho a ser trilhado, repleto de contradi??es e desafios. Assim, se conclui que a intersetorialidade deve ser compreendida como um modelo de gest?o que tem como valor fundamental a totalidade dos sujeitos e das fam?lias, para que se tenha acesso efetivo quanto ? oferta dos servi?os p?blicos e aos direitos sociais garantidos legalmente.

Submitted by Setor de Tratamento da Informa??o - BC/PUCRS (tede2@pucrs.br) on 2015-11-24T11:21:49Z No. of bitstreams: 1 476411 - Texto Parcial.pdf: 722906 bytes, checksum: 986b895e283eb864bc2aa49dbaf05144 (MD5) / Made available in DSpace on 2015-11-24T11:21:49Z (GMT). No. of bitstreams: 1 476411 - Texto Parcial.pdf: 722906 bytes, checksum: 986b895e283eb864bc2aa49dbaf05144 (MD5) Previous issue date: 2015-10-19 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / This thesis brings up the insertion of Psychology in the public social assistance politics, particularly in Social Work, and more specifically, in the process of building the processes of the job that affects directly on the daily routine of the psychologists who work at SUAS (Social Assistance Care System), especially those who work at the CRASs (Social Assistance Reference Centers) connected to the FASC (Social Assistance and Citizenship Foundation) of Porto Alegre, Rio Grande do Sul, Brazil. This thesis is organized in three sections. The first section consists of a study about published academic production about Psychology in the Social Work in Brazil, with emphasis in its relationship with the CRASs. This draws a possibility to analyze the historical evolution of the researcher?s preoccupation regarding this issue, as well as observation of some basic characteristics of the productions. For this, a study took place inspired on a narrative review proposal with consultation of the electronic databases. In the second section, there is an attempt to characterize and discuss the work of the psychologists within the SUAS, more specifically of those working at the CRASs.This study parts from the premise that the psychologists are employed in the Social Assistance System, essential to the engineering and weaving of the politics, as well as being necessary to the users to warrant access to their social rights. The third and last section debates about the work processes and the practices of the psychologists. These last two studies are based on research analysys done with 27 professionals connected to CRASs, where data was collected through interviews and analysed with the help of Fundametal Theory (FT). The results obtained indicate that in the last years there has been an important involvement and investment in the Social Assistance area. Moreover, Social Assistance has been helping in the expansion and interiorization of the profession and in the development of practices different from the traditional. It is identified that the workers are working under adverse conditions that can be made explicit in the areas of formation and work relations, showing itself from the ways of hiring up to the development of routine activities in the SUAS.It is also highlighted, due to the field being new and in expansion, that its materialization as a source of reference of help to the social needs of the population still needs mediations for it to take place. The characterization of the psychologists workers of SUAS in Porto Alegre shows there are countless challenges in order to build a professional make that is commited with social rights. At last, even with the advances, implementation and regulation of SUAS is still not a complete reality in the daily work of professionals at CRASs. It is pointed out, especially, the challenge of the formation that, according to the interviewees, is still poor when it comes to prepare for working in the social sphere, lacking both references and techniques to complement the knowledge already instilled in the profession. / A presente Tese aborda a inser??o da Psicologia nas Pol?ticas Sociais P?blicas, particularmente a Assist?ncia Social, mais especificamente, o processo de constru??o dos processos de trabalho que repercutem diretamente no cotidiano das (os) psic?logas (os) que atuam no Sistema ?nico de Assist?ncia Social (SUAS) e, especialmente, nos Centros de Refer?ncia da Assist?ncia Social (CRASs), vinculados ? Funda??o de Assist?ncia Social e Cidadania (FASC), da cidade de Porto Alegre, estado do Rio Grande do Sul, Brasil. Esta Tese est? organizada em tr?s se??es. A primeira se??o consiste num estudo sobre a produ??o acad?mica publicada da Psicologia na Assist?ncia Social brasileira, com especial ?nfase na sua rela??o com os CRASs. Tal desenho possibilita a an?lise da evolu??o hist?rica da preocupa??o das (os) pesquisadoras (es) a respeito deste tema, assim como a observa??o de algumas das caracter?sticas fundamentais desta produ??o. Para tanto, foi realizado um estudo inspirado em uma proposta de revis?o narrativa com consulta ?s bases de dados eletr?nicas. Na segunda se??o procura-se caracterizar e discutir o trabalho da (o) psic?loga (o) no ?mbito do SUAS, especificamente das (os) trabalhadoras (es) que atuam nos CRASs.Tal estudo parte da premissa de que a (o) profissional da Psicologia ? uma (um) trabalhadora (or) da Assist?ncia Social, fundamental para a engrenagem e a tecelagem da pol?tica, assim como necess?ria (o) para a garantia do acesso das (os) usu?rias (os) ao direito social. A terceira e ?ltima se??o debate os processos de trabalho e as pr?ticas das (os) psic?logas (os). Estes dois ?ltimos estudos est?o alicer?ados em an?lise de pesquisa realizada com 27 profissionais vinculadas (os) aos CRASs, sendo que os dados foram obtidos por meio de entrevistas e analisados com o apoio na Teoria Fundamentada (TF). Os resultados alcan?ados indicaram que nos ?ltimos anos h? um envolvimento e um investimento importantes da ?rea em rela??o ? Assist?ncia Social. Al?m disso, a Assist?ncia Social tem colaborado para a expans?o e interioriza??o da profiss?o e para o desenvolvimento de pr?ticas diferentes das tradicionais.Identifica-se, que as (os) trabalhadoras (es) est?o submetidas a condi??es adversas que podem ser explicitadas no campo da forma??o e das rela??es de trabalho, aparecendo desde o modo de contrata??o at? o desenvolvimento das atividades rotineiras do trabalho no SUAS.Destaca-se ainda que, por ser este um campo novo e em expans?o, sua materializa??o como atendimento ?s necessidades sociais da popula??o ainda carece da constru??o de media??es para a sua realiza??o. A caracteriza??o das (os) trabalhadoras (es) psic?logas (os) do SUAS em Porto Alegre aponta in?meros desafios para a constru??o de um fazer profissional comprometido com os direitos sociais. Por fim, apesar dos avan?os, a regula??o e a implementa??o do SUAS ainda n?o s?o uma completa realidade no cotidiano de trabalho das (os) profissionais nos CRASs. Ressalta-se, especialmente, o desafio da forma??o que, conforme apontam as (os) entrevistadas (os), ainda ? prec?ria no que tange ao preparo para a atua??o no ?mbito social, carecendo tanto de referenciais como de t?cnicas que complementem os fazeres e saberes j? institu?dos na profiss?o.

Submitted by M?rden L?les (marden.inacio@ufvjm.edu.br) on 2016-07-07T23:47:14Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) paulo_henrique_cruz_ferreira.pdf: 2821217 bytes, checksum: 329372ee7884d45a7ca335ae5f127b1b (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2016-07-11T19:39:24Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) paulo_henrique_cruz_ferreira.pdf: 2821217 bytes, checksum: 329372ee7884d45a7ca335ae5f127b1b (MD5) / Made available in DSpace on 2016-07-11T19:39:24Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) paulo_henrique_cruz_ferreira.pdf: 2821217 bytes, checksum: 329372ee7884d45a7ca335ae5f127b1b (MD5) Previous issue date: 2015 / RESUMO Estudo de car?ter quantitativo e descritivo, que objetivou avaliar a qualidade da assist?ncia de enfermagem e a satisfa??o do cliente externo de um hospital p?lo, refer?ncia para a regi?o ampliada de sa?de. Para coleta de dados utilizou-se o instrumento adaptado e validado no Brasil, intitulado de Instrumento de Satisfa??o do Paciente (ISP). An?lises descritiva e univariada foram conduzidas. Dentre os clientes 53,4% era do sexo masculino, 43% com ensino fundamental incompleto, 52,9% casados, m?dia de idade de 53,3 anos, m?dia de interna??o hospitalar de 6,4 dias, 51,1% era a primeira interna??o na institui??o. Os resultados apontaram que na avalia??o dos tr?s dom?nios, percebemos que os clientes externos relataram satisfa??o com o cuidado de enfermagem recebido uma vez que obtivemos uma m?dia total de 3,7%, sendo que o dom?nio profissional foi o melhor avaliado seguido respectivamente pelos dom?nios de confian?a e educacional. Esperamos que tais resultados forne?am ferramentas para subsidiar a gest?o do servi?o de enfermagem da institui??o e forne?a subs?dios para a melhoria no processo de trabalho. / Disserta??o (Mestrado) ? Programa de P?s-gradua??o em Ensino em Sa?de, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2015. / ABSTRACT Study of exploratory and descriptive character, which aimed to evaluate the quality of nursing care and outpatient satisfaction of a pole hospital, a reference to the expanded health region. For data collection we used the adapted and validated instrument in Brazil, entitled Patient Satisfaction Instrument (PSI). Descriptive and univariate analyzes were conducted. Among the customers 53.4% were male, 43% had not completed elementary school, 52.9% married, average age 53.3 years, mean hospital stay of 6.4 days, 51.1% was the first hospitalization at the institution. The results show that the assessment of the three domains, we realize that external clients reported satisfaction with nursing care received since obtained an overall average of 3.7%, and the professional domain was the best evaluated followed respectively by domain confidence and educational. We hope that these results provide tools to subsidize the management of the institution's nursing service and provide subsidies to improve the work process.

Die vorliegende Untersuchung stellt sich die folgenden Fragen: Welchen Stand hat die Entwicklung von mechanischen Kreislaufunterstützungssystemen für Kinder, worin unterscheiden sich die eingesetzten Verfahren? Wie beeinflusst der Blutkontakt mit Fremdmaterial das Kapillarleck beim Kind? Welche Erfahrungen gibt es mit dem pulsatilen Ventrikelunterstützungssystem Berlin Heart beim Kind, welche Schwierigkeiten und Nebenwirkungen sind für das Kindesalter spezifisch? Wann profitieren Kinder von einer mechanischen Kreislaufunterstützung? Die bei Kindern am häufigsten eingesetzten Verfahren, Herzlungenmaschine (HLM), extrakorporale Membranoxygenierung (ECMO) und pneumatisch pulsatiles ventrikuläres Assist device (VAD) unterscheiden sich in Technik, Indikation, Nebenwirkung und möglicher Einsatzdauer erheblich. Die HLM dient der intraoperativen Kreislaufunterstützung. ECMO haben wir seit 1990 zur mittelfristigen Kreislaufunterstützung bei mehr als 70 Kindern für eine Dauer von ein bis zwei, selten bis zu drei Wochen eingesetzt. Mit VAD''s haben wir seit 1990 bei 56 Kindern die Herzfunktion teils monatelang ersetzt. Es bestehen multiple Unterschiede bei dem Einsatz von VAD zwischen Säuglingen, Kindern und Erwachsenen sowohl in der Indikation, Physiologie, Technik, Antikoagulation, der Familienbetreuung und hinsichtlich der Komplikationen. Bei jeder mechanischen Kreislaufunterstützung aktiviert der Fremdflächenkontakt des Blutes das Kontaktsystem, zu dem Gerinnungs- und Komplementsystem gehören. Klinische Äquivalente sind Thrombosen, Thrombozytenverlust und Kapillarleck. Insbesondere Säuglinge neigen zu diesen Komplikationen, weil das Verhältnis von Blutvolumen zu Fremdfläche ungünstig ist und der kontaktabhängige alternative Weg der Komplementaktivierung im jungen Alter vorherrscht. - Wir untersuchten prospektiv den prä- und postoperativen Verlauf von Kontakt- und Komplementsystem (C1q, C3, C4, C1-Inhibitor, Faktor B, Faktor XIIa) bei 11 herzoperierten Säuglingen ohne und 24 Säuglingen mit HLM. Es konnte nachgewiesen werden, dass obwohl bei allen Kindern eine Komplementaktivierung vorhanden war, diese signifikant ausgeprägter in der HLM-Gruppe stattfand. Die Kontaktaktivierung (Faktor XIIa, Präkallikrein) ließ sich nur in der HLM-Gruppe nachweisen, so dass belegt war, dass es nicht die Anästhesie oder die Operation an sich, sondern die HLM ist, die die inflammatorische Reaktion hervorruft. - Bei 27 mit HLM operierten Säuglingen untersuchten wir prospektiv die CLS-Entstehung und die Komplement- und Kontaktaktivierung. Bei den 10 Kindern, die im späteren Verlauf ein Kapillarlecksyndrom (CLS) entwickelten, waren bereits 30 Minuten nach HLM-Beginn die C1-INH-Konzentration und -Aktivität niedriger und Faktor XIIa, C3a und C5a höher als bei den 17 Kindern, die später kein CLS entwickelten. Die Aktivierung korrelierte mit dem Alter der Kinder und der HLM-Zeit, nicht mit der Tiefe der Hypothermie. - Retrospektiv untersuchten wir 28 Kinder (6 Tage - 16 Jahre alt), bei denen im terminalen Herzversagen nach Reanimation die Herzfunktion mit dem parakorporalen pneumatischen VAD Berlin Heart 1-98 Tage lang unterstützt wurde. Zwölf dieser Kinder wurden unter laufender Reanimation mit Herzdruckmassage in den Operationssaal gebracht. 13 Patienten erreichten eine Herztransplantation, 3 Kinder wurden mit dem eigenen Herzen vom System entwöhnt. 12 Kinder starben am System, Todesursachen waren Schock, Multiorganversagen, Sepsis und Blutungen. - Bei 95 herztransplantierten Kindern untersuchten wir retrospektiv die Verläufe in Abhängigkeit davon, ob die Kinder (I) vor der Transplantation in relativ stabilem Zustand zuhause waren (n=33), ob sie (II) kritisch krank hospitalisiert waren (n= 44), oder ob sie (III) nach Reanimation mit einem VAD kreislaufunterstützt wurden (n=18, Dauer 4-111 Tage). Die Überlebensraten nach 1Mo/1J/5J betrugen in Gruppe I 88/88/80 %, Gruppe II 88/82/79 %, Gruppe III 72/72/72 %. Der frühpostoperative Verlauf nach Transplantation war bei Gruppe III nur wenig komplizierter, was den Erfolg der Transplantation nicht minderte. - Retrospektiv untersuchten wir den Verlauf von 4 Kindern mit schwerer Myokarditis, die bei kardiogenem Schock mit biventrikulärem VAD kreislaufunterstützt wurden. Das schockbedingte Multiorganversagen und die Thrombozytopenie bildete sich während der Unterstützung mit dem VAD zurück. Drei Kinder konnten nach Erholung des Myokards vom VAD entwöhnt werden, eines wurde erfolgreich transplantiert. - Ausserdem untersuchten wir den Verlauf von 84 Kindern, die wegen Kardiomyopathie auf der Intensivstation behandelt wurden. Von den 69 (= 82 %), bei denen eine kreislaufstützende medikamentöse Therapie ausreichend war, konnten 32 herztransplantiert werden, 36 besserten sich und wurden nach Hause entlassen und ein Kind verstarb akut. Fünfzehn der 84 Kinder (= 18 %) ließen sich nicht stabilisieren und erhielten nach Reanimation eine mechanische Kreislaufunterstützung mit VAD (Dauer 1 – 98 Tage). Von diesen konnten 12 transplantiert werden. Die in dieser Habilitationsschrift ausgeführten Arbeiten haben weiterführende Fragestellungen und Grenzbereiche des mechanischen Kreislaufersatzes im Kindesalter aufgezeigt und neue Therapiestrategien dargestellt. Dadurch ist es möglich, die Überlebenschancen von Kindern mit terminalem Herzversagen erheblich zu verbessern. Sei es durch Zeitgewinn bis zur Erholung des Myokards oder zum Organangebot auf der HTx-Warteliste. Durch den Zeitgewinn, den die VAD`s den zur HTx gelisteten Kindern bieten, brauchen zur Transplantation freigegebene Kinderherzen seltener verworfen werden, mehr Kinder können überleben und die Ausnutzung der angebotenen Organe gelingt besser. / This scientific work addresses the following questions: what is the state of the art in mechanical circulatory support (MCS) in infants and children? How do the different techniques differ? How does mechanical circulatory support influence the systemic inflammatory response after cardiac surgery? What are the indications for use of the pneumatic pulsatile ventricular support system Berlin Heart in children and what do our experience and the results of its use show? The MCS systems most often used for children of all ages are cardiopulmonary bypass (CPB), extracorporeal membrane oxygenation (ECMO), centrifugal pumps and the pneumatic pulsatile ventricular assist device (VAD). These systems vary in indications, results, side effects and potential supporting time. CPB is used to replace the circulation during cardiac surgery. ECMO has been used in our hospital since 1990 for circulatory support in cases of cardiac failure and of pulmonary failure and has been applied in more than 70 children over a period of 1 to 3 weeks. The VAD (Berlin Heart) has been used since 1990 in 56 children for long-term support, when the heart function had to be supported for up to several months. In VAD use there are multiple differences in indication, physiology, underlying disease, technique, anticoagulation and complications between infants, children and adults. In every case of MCS there is contact and complement activation as a reaction of the blood to foreign surfaces, resulting in capillary leak and activation of coagulation and anticoagulation systems with the risk of thrombosis or bleeding. In particular, young infants are prone to systemic inflammatory response in the form of capillary leak. In a prospective study we compared the complement activation after cardiac operations with or without CPB in 35 infants and measured serially the complement function and concentrations or activity of C1q, C3, C4, C1 esterase inhibitor, factor B, the activated split product C3a, prekallikrein and factor XIIa of the contact system. We found that complement activation occurs in all infants but is significantly higher in the group with CPB. Contact activation occurred only in patients who undergo CPB. Thus, the inflammatory response is caused by the use of a CPB circuit and to a lesser degree by surgical procedures and anesthesia. In 27 infants with CPB surgery we prospectively investigated the early clinical parameters that predict the development of capillary leak syndrome (CLS) and examined the relationship between CLS and complement and contact activation and C1 esterase inhibitor during and after bypass. We found that contact and complement activation occurs during CPB and contributes to CLS more frequently in infants of a younger age and with a prolonged bypass time. This activation and decrease in C1 esterase inhibitor was strongly expressed in the CLS group. Although MCS in intractable heart failure in children has normally been limited to centrifugal pumps and ECMO, we implanted 28 children with the pediatric sized pulsatile air-driven Berlin Heart VAD. Our aim was to keep the children alive and allow recovery from shock sequeale until later transplantation or myocardial recovery. Twelve children were brought to the operating room under cardiac massage. In total 12 children died on the system, but thirteen children were transplanted and three were sucessfully weaned from the system. Acute myocarditis appears to be a promising precondition for complete recovery during VAD support and in patients with cardiomyopathy support until transplantation is the goal for the future. We reviewed the course of 95 children who had undergone heart transplantation in our center to investigate whether previous VAD support has an impact on long-term outcome after transplantation. Three groups were compared and we found that bridging to transplantation with a pulsatile pneumatic VAD is a safe procedure in pediatric patients. After transplantation the overall survival rate is 86 % at 1 month, 82 % at 1 year and 75 % at 5 years. The survival of children previously supported with a VAD is similar to that of patients who were bridged with inotropes or who awaited heart transplantation electively. In 4 children with fulminant myocarditis and cardiogenic shock in whom all aggressive medical treatment failed we found that artificial replacement of the heart with complete unloading was followed by total recovery; 3 patients were successfully weaned from the device. No patient died and heart transplantation was necessary in only one child. Retrospectively we examined the course of 84 children who were treated at the ICU, presenting severe cardiac failure due to cardiomyopathy. In 15 of them medical treatment failed and the disease progressed so rapidly that they would have died during the waiting period before a suitable donor organ was found. After resuscitation these 15 children were supported with a VAD. Only 3 died during the waiting period and 12 (80%) underwent later heart transplantation. Progress has been rapid towards individualized choice of mechanical circulatory support systems for children of different ages and with different indications. With the Berlin Heart VAD prolonged circulatory support until myocardial recovery or until heart transplantation is effective in children and infants. It offers time to restore organ function, allows extubation, mobilization and neurological examination and increases the chances for successful transplantation. It can be used with low device-related morbidity and satisfactory results especially in the myocarditis and the cardiomyopathy groups. Complete recovery from secondary organ dysfunction should be achieved before heart transplantation is considered. We expect not only that children with end-stage heart failure will benefit from long-term VAD support, but also that fewer organs from young donors will be lost. Of particular importance is our experience with myocardial recovery in children with acute myocarditis in whom the devices could be explanted.

Ziel dieser Arbeit war es, neue Therapieprinzipien zu entwickeln und zu überprüfen, ob diese geeignet sind, ein Rechtsherzversagen nach Implantation eines LVAD bei Patienten mit terminaler Herzinsuffizienz zu verhindern. Bei Patienten mit chronischem Linksherzversagen erhöht sich der pulmonalvaskuläre Widerstand. Als Ursache wird eine Dysregulation des pulmonalen Gefäßendothels verstanden, die mit einer gestörten Freisetzung von NO und einer erhöhten Expression von Endothelin einhergeht und die bei längerem Bestehen auch strukturelle Veränderungen der Lungenstrombahn nach sich zieht. Bei Patienten mit chronischem Linksherzversagen führt dies zu einer sekundären pulmonalen Hypertonie, die direkt die rechtsventrikuläre Funktion beeinträchtigt und durch eine Vasodilatantientherapie zunächst noch reversibel ist. Nach LVAD-Implantation bei terminaler Herzinsuffizienz steigt häufig der pulmonalvaskuläre Widerstand unter anderem infolge der extrakorporalen Zirkulation weiter an, so daß bei vielen Patienten ein Rechtsherzversagen aufgund der sekundären pulmonalen Hypertonie mit hoher Morbidität und Mortalität auftritt. Weder positiv inotrope Pharmaka noch systemische Vasodilatantien oder gar die sekundäre Implantation eines RVAD konnten das Problem bisher lösen. Einen völlig neuen Therapieansatz stellt die inhalative Verabreichung von NO dar, welches durch die direkte Wirkung auf die glatte Gefäßmuskulatur eine selektive Vasodilatation in der pulmonalen Zirkulation bewirkt und somit konsekutiv die rechtsventrikuläre Nachlast senkt, ohne dabei den systemischen Widerstand zu beeinflussen. Zunächst wurden die klinischen Effekte einer inhalativen NO-Therapie bei Patienten untersucht, die nach Implantation eines LVAD aufgrund einer rechtsventrikulären Dysfunktion bei sekundärer pulmonaler Hypertonie ein postoperatives low-cardiac-output-Syndrom entwickelt hatten. Im ersten Teil der Untersuchungen konnte gezeigt werden, daß die ausgeprägtesten hämodynamischen Wirkungen bei einer individuellen NO-Dosis zwischen 25 und 40 ppm NO erreicht werden. Bis zu 40 ppm nahmen der pulmonalvaskuläre Widerstand und der pulmonalarterielle Mitteldruck progredient ab, während der Cardiac Index dosisabhängig signifikant stieg, ohne daß dabei eine Änderung der systemischen Druck- und Widerstandsverhältnisse zu bemerken war. Die pulmonalvaskuläre Selektivität der inhaltiven NO-Therapie sowie die teils dramatische hämodynamische Verbesserung waren somit bestätigt. Auch unter Dauerapplikation der jeweils individuell ausgetesteten optimalen NO-Dosierung zeigte sich über den gesamten Behandlungszeitraum die oben beschriebene signifikante hämodynamische Verbesserung mit Abnahme der rechtsventrikulären Nachlast bei gleichzeitiger Zunahme des Cardiac Index. Zusätzlich wurde mittels TEE ein stetiger Anstieg der RVEF und ein Abfall des RVEDV dokumentiert. Somit konnte bei den Patienten unter NO-Therapie zunächst die Katecholamingabe deutlich reduziert und die NO-Behandlung ausgeschlichen werden. Im Verlauf der Therapie kam es weder durch eine abrupte Unterbrechung der NO-Zufuhr bei täglich durchgeführten NO-Auslassversuchen noch bei Beendigung der Therapie zu einer hämodynamischen Verschlechterung, was indirekt die Erholung des rechten Ventrikels belegt. Trotz der insgesamt eindrucksvollen hämodynamischen Verbesserung unter Beatmung mit NO gab es einige Patienten, bei denen trotz hochdosierter Katecholamintherapie und adäquatem Volumenersatz die rechtsventrikuläre Dysfunktion persistierte. Dies wurde darauf zurückgeführt, daß durch Zunahme des Cardiac Index und somit des venösen Rückstromes nach LVAD-Implantation eine Erholung der Rechtsherzfunktion nicht möglich war. Um die Erholung der Rechtsherzfunktion über eine Minimierung der rechtsventrikulären Schlagarbeit zu ermöglichen, wurde ein zu sämtlichen anderen Therapiestrategien kontroverses Konzept entwickelt, das sowohl der rechtsventrikulären Vorlast und Nachlast als auch der inotropen Therapie Rechnung trägt. Statt wie bisher einen hohen Cardiac Index anzustreben wurde jetzt untersucht, ob nicht bei einem postoperativ recht niedrigen Cardiac Index von 2.5 L/min/m2 (( 2.3 L/min/m2 und ( 2.8 L/min/m2) mit daraus folgender Verminderung der Schlagarbeit eine Erholung des rechten Ventrikel möglich ist, ohne dabei jedoch die Organperfusion zu gefährden. Dies beinhaltete neben einer frühzeitig eingeleiteten NO-Beatmung eine minimale Katecholamintherapie und einen restriktiven Volumenersatz. Deshalb wurde mit der NO-Beatmung bereits intraoperativ bei Abgang vom kardiopulmonalen Bypass begonnen. Ein Cardiac Index von circa2.5 L/min/m2 erwies sich bei den analgosedierten und beatmeten Patienten für eine adäquate Organperfusion als ausreichend und zeigte sich darüber hinaus als geeignet, ein Rechtsherzversagen zu verhindern und eine Restitution der rechtsventrikulären Funktion sicherzustellen. Die inhalative NO-Therapie wurde auch hier bei allen Patienten ohne Auftreten eines Rebound-Phänomen beendet. Bekannt ist, daß Endothelin-1 als potenter endogener Vasokonstriktor (Produktion als auch Elimination hauptsächlich in der Lunge) eine pulmonale Hypertonie auslösen kann und damit als Antagonist zum wichtigsten endothelialen Mediator der pulmonalen Vasodilatation, dem NO, betrachtet wird. Zur Klärung weiterer pathophysiologischer Grundlagen wurden die Plasmaspiegel von ET-1 und Big ET-1 unter NO-Therapie nach LVAD-Implantation gemessen. Die präoperativen ET-1- und Big ET-1-Plasmaspiegel waren, wie bei terminaler Herzinsuffizienz zu erwarten, deutlich erhöht und korrelierten mit dem pulmonalvaskulären Widerstand. Dass die höchsten Plasmakonzentrationen von ET-1 intraoperativ gemessen wurden steht in Einklang mit anderen Untersuchungen und wurde mit einer durch den kardiopulmonalen Bypass ausgelösten endothelialen Dysfunktion erklärt. Unter inhalativer NO-Therapie fielen die Plasmaspiegel von ET-1 und Big ET-1 signifikant ab und waren nach Beendigung der Therapie am niedrigsten. Es bestand eine signifikante, inverse Korrelation zwischen der mittleren inhalativen NO-Dosis und den Plasmaspiegeln von ET-1 und Big ET-1. Simultan mit dem Abfall der Plasmaspiegel der Endotheline verbesserte sich die Hämodynamik. Der Abfall des pulmonalarteriellen Druckes korrelierte mit dem Abfall der ET-1-Plasmaspiegel. Die Ergebnisse lassen darauf schließen, daß eine inhalative NO-Therapie, welche die bei sekundärer pulmonaler Hypertonie pathophysiologisch defiziente endogene NO-Produktion ausgleicht, neben einer pulmonalselektiven Vasodilatation auch zu einer NO-vermittelten Inhibition der Endotheline ET-1 und Big-ET-1 führt. Da auch die Linksherzinsuffizienz durch die mechanische Entlastung mit einem LVAD suffizient behandelt ist, kann sich erneut ein physiologisches Gleichgewicht zwischen den Antagonisten NO und Endothelin in der Lungenstrombahn einstellen, das eine Dysfunktion des pulmonalen Gefäßendothels behebt. Dies erklärt, dass eine NO-Beatmung nur vorübergehend erforderlich ist und nach Beendigung der NO-Inhalation ein Rebound-Phänomen mit Wiederanstieg des pulmonalvaskulären Widerstands und konsekutiver Rechtsherzbelastung ausbleibt. Zur Unterstützung der rechtsventrikulären Funktion nach Implantation eines LVAD wurden folgende Therapieprinzipien etabliert: - Eine inhalative NO-Therapie sollte frühzeitig bereits zum Abgang vom kardiopulmonalen Bypass eingesetzt werden. - Eine intraindividuelle Dosistitration von NO ist sinnvoll um einen optimalen Behandlungseffekt mit der geringst möglichen Dosis zu erzielen. - Die inhalative NO-Therapie senkt selektiv den pulmonalvaskulären Widerstand und verursacht keine systemische Hypotension. Die rechtsventrikuläre Nachlast fällt ab, ohne dass die linksventrikulären Füllungsdrucke pathologisch ansteigen, da der linke Ventrikel durch das LVAD entlastet ist. - Tritt trotz NO-Beatmung eine rechtsventrikuläre Dysfunktion auf, so ist zur weiteren Entlastung des rechten Ventrikels ein niedriger Cardiac Index von circa 2.5 L/min/m2 angezeigt, um den venösen Rückstrom gering zu halten. - Dies ist durch eine minimale Katecholamintherapie und einen restriktiven Volumenersatz zu erzielen. Die Reduktion der rechtsventrikulären Schlagarbeit erlaubt eine Erholung der rechtsventrikulären Funktion. - Die ET-1- und Big-ET-1-Plasmaspiegel fallen um so rascher ab, je langsamer die NO-Dosis reduziert wird, da zwischen den Plasmaspiegeln der Endotheline und der mittleren inhalativen NO-Dosis eine inverse Korrelation gefunden wurde. Daher ist eine schrittweise Entwöhnung der inhalativen NO-Therapie erforderlich, um ein Rebound-Phänomen zu verhindern. - NO-Auslaßversuche sind geeignet, um in kritischen Fällen die Abhängigkeit von einer NO-Beatmung in der Entwöhnungsphase zu überprüfen. - Da eine Dysfunktion des pulmonalen Gefäßendothels nach Beendigung der inhalativen NO-Therapie offensichtlich nicht mehr fortbesteht, ist im weiteren klinischen Verlauf in der Regel nicht mit einer erneuten Rechtsherzbelastung durch einen Anstieg des pulmonalvaskulären Widerstands zu rechnen. / This thesis aimed to develop and evaluate new therapeutic principles to prevent right ventricular failure following LVAD implantation in patients with end-stage heart failure. Pulmonary vascular resistance increases in patients with chronic left ventricular failure. The mechanism is thought to be a dysregulation of the pulmonary vascular endothelium with an impaired release of NO and increased expression of endothelin, which in the long term leads to structural changes in the pulmonary circulation. In patients with chronic left ventricular failure this causes secondary pulmonary hypertension, directly compromising right ventricular function, but initially this is not fixed and is still reversible by vasodilator therapy. Following LVAD implantation in end-stage heart failure, pulmonary vascular resistance may further increase, partially due to cardiopulmonary bypass, and many patients develop frank right ventricular failure due to aggravation of secondary pulmonary hypertension, which is associated with a high morbidity and mortality. Neither positive inotropic drugs nor systemic vasodilators or even the secondary implantation of a RVAD were able to solve the problem. A novel therapeutic approach is the administration of inhaled NO, which directly acts on vascular smooth muscle cells causing selective pulmonary vasodilation and therefore decreases right ventricular afterload without altering systemic vascular resistance. The clinical effects of NO inhalation therapy were first studied in patients presenting with postoperative low cardiac output syndrome after LVAD implantation due to secondary pulmonary hypertension and right ventricular dysfunction. In this first study the greatest hemodynamic effects were demonstrated at individually titrated doses of 25 to 40 ppm NO. The pulmonary vascular resistance and the mean pulmonary artery pressure progressively decreased with increasing doses up to 40 ppm NO, as the cardiac index significantly increased dependent on dosage and without any noticeable change of the systemic arterial pressure or systemic vascular resistance. Thus a selective pulmonary vasodilating effect of inhaled nitric oxide along with a hemodynamic improvement, which in some patients was dramatic, was demonstrated. During continuous administration with the individually titrated optimal dose significant beneficial effects were shown during the entire treatment period with a decrease of the right ventricular afterload and a consequent increase of the cardiac index. In addition, a steady increase of the RVEF and a decrease of the RVEDV were demonstrated by TEE. This permitted us to first lower the catecholamine dose in these patients and then to wean them of the NO therapy. In the course of NO therapy hemodynamic deterioration was provoked neither by acute interruption of NO administration at daily performed "NO-off-trials", nor after weaning of NO therapy, which indirectly proved regeneration of the right ventricle. Although an overall impressive hemodynamic improvement was demonstrated with NO inhalation there were some patients in whom right ventricular dysfunction persisted despite maximal inotropic support and adequate volume replacement. This was thought to be due to the increase in cardiac index and thereby venous return after LVAD implantation preventing restoration of right ventricular function. To permit improvement of right ventricular function by minimizing right ventricular stroke work, a comprehensive concept contradictory to all other treatment strategies was developed, taking right ventricular preload, afterload and inotropic therapy into account. Instead of the intention being to generate a high cardiac index, it was studied whether a relatively low postoperative cardiac index of 2.5 L/min/m2 (= 2.3 L/min/m2 and = 2.8 L/min/m2) which decreases stroke work, enables the right ventricle to regenerate without compromising perfusion to vital organs. This meant early administration of inhaled NO, minimal catecholamine support and restrictive volume replacement. NO inhalation was initiated intraoperatively as soon as weaning from cardiopulmonary bypass had taken place. A cardiac index of 2.5 L/min/m2 proved to be sufficient in the analgosedated and ventilated patients to ensure sufficient organ perfusion and in addition proved to be successful in preventing right ventricular failure and permitting restitution of right ventricular function. Inhaled NO therapy was weaned successfully without rebound phenomena. The potent endogenous vasoconstrictor endothelin-1 (produced and eliminated primarily in the lungs) has been shown to cause pulmonary hypertension and is an antagonist of the most important endothelial mediator of pulmonary vasodilation, NO. To further elucidate the pathophysiology, plasma levels of ET-1 and big ET-1 were measured during NO therapy following LVAD implantation. As expected in end-stage heart failure, the preoperative ET-1 and big ET-1 plasma levels were considerably increased and correlated with the pulmonary vascular resistance. The highest plasma concentrations of ET-1 were measured intraoperatively, which is in keeping with other studies and has been explained by an endothelial dysfunction triggered by cardiopulmonary bypass. Plasma levels of ET-1 and big ET-1 fell significantly during NO therapy and were lowest after termination of inhaled NO. A significant inverse correlation was found between the mean inhaled NO dose and the ET-1 and big ET-1 plasma levels. Hemodynamics improved simultaneously with the drop in plasma levels of the endothelins. The decrease of the pulmonary artery pressures correlated with the decrease of the ET-1 plasma levels. It can be derived from the results that inhaled NO not only induces pulmonary selective vasodilation by replacing a deficient endogenous NO production in secondary pulmonary hypertension, but inhaled NO also inhibits the endothelins ET-1 and big ET-1. In addition, left ventricular failure is effectively treated by mechanical unloading through the LVAD, thus permitting a new physiologic balance to develop between the antagonists NO and endothelin in the pulmonary circulation and ameliorating dysfunction of the pulmonary vascular endothelium. This explains why NO inhalation is needed only as an intermediate therapy and the fact that a rebound phenomenon with increases in pulmonary vascular resistance and consecutive right ventricular constraint does not occur. To support right ventricular function after LVAD implantation, the following therapeutic principles have been established: - Inhaled NO therapy should be started early on weaning from cardiopulmonary bypass. - Intraindividual dose titration is useful to ensure maximal effects with minimal doses. - Inhaled NO selectively decreases pulmonary vascular resistance without inducing systemic hypotension. Right ventricular afterload decreases without pathologically increased left ventricular filling pressures, as the left ventricle is unloaded by the LVAD. - If right ventricular dysfunction presents despite NO inhalation, venous return should be lowered to relieve the right ventricle, by keeping the cardiac index low at around 2.5 L/min/m2. - This is accomplished by minimal inotropic support and restrictive volume replacement. Regeneration of right ventricular function is made possible by a reduction of right ventricular stroke work. - The slower the inhaled NO dose was lowered, the faster the ET-1 and big ET-1 plasma levels fell, as an inverse correlation was found between the plasma levels of the endothelins and the mean inhaled NO dose. Therefore stepwise weaning of inhaled NO therapy is essential in preventing rebound phenomena. - "NO-off-trials" are useful to monitor inhaled NO dependency during weaning from NO therapy in critical cases. - As dysfunction of the pulmonary vascular endothelium obviously does not persist after cessation of inhaled NO therapy, as a rule right ventricular compromise due to an increase in pulmonary vascular resistance does not occur during the further clinical course.

Submitted by Caroline Xavier (caroline.xavier@pucrs.br) on 2017-05-08T19:24:04Z No. of bitstreams: 1 TES_GEOVANA_PRANTE_GASPAROTTO_COMPLETO.pdf: 5179336 bytes, checksum: 82676a5264b71c1f4313edac5ff5177a (MD5) / Approved for entry into archive by Caroline Xavier (caroline.xavier@pucrs.br) on 2017-05-08T19:24:18Z (GMT) No. of bitstreams: 1 TES_GEOVANA_PRANTE_GASPAROTTO_COMPLETO.pdf: 5179336 bytes, checksum: 82676a5264b71c1f4313edac5ff5177a (MD5) / Made available in DSpace on 2017-05-08T19:24:27Z (GMT). No. of bitstreams: 1 TES_GEOVANA_PRANTE_GASPAROTTO_COMPLETO.pdf: 5179336 bytes, checksum: 82676a5264b71c1f4313edac5ff5177a (MD5) Previous issue date: 2017-01-24 / La presente tesis tiene como tema central la perspectiva de g?nero en el Sistema ?nico de Asistencia Social ? SUAS ? a partir de la Seguridad Social garantizada por la protecci?n social de la Asistencia Social. La investigaci?n que origina este estudio propone analizar las seguridades previstas en el SUAS, revelando las cuestiones de g?nero presentes en esta pol?tica p?blica, buscando contribuir con subsidios para implantaci?n e implementaci?n de la universalidad de la protecci?n social del SUAS. En esta direcci?n, el estudio se caracteriza como una investigaci?n social de nivel explicativo, de enfoque cualitativo, con utilizaci?n de datos cuantitativos. La investigaci?n abarc? el territorio del Estado de R?o Grande del Sur. Participaron de la investigaci?n un total de 117 trabajadores/as del SUAS, 97 de ellos vinculados/as a las unidades de ejecuci?n de los servicios socioasistenciales implantados en los municipios del Estado y 20 trabajadoras vinculadas al ?rgano gestor Estadual del SUAS. Como procedimientos y t?cnicas para la recolecci?n de datos, se realizaron entrevistas con las trabajadoras vinculadas al Estado, con base en un plan semiestructurado, y una encuesta en l?nea enviada a los equipos de referencia de los servicios socioasistenciales de los municipios. Los datos recolectados fueron sometidos a an?lisis de contenido, basada en Bardin (1997). Todo el proceso de investigaci?n y producci?n de la tesis se orienta por el m?todo dial?ctico-cr?tico, fundamentado en la teor?a social de Marx. De este modo, adem?s del recorrido metodol?gico de la investigaci?n, esta tesis pone en evidencia el m?todo de an?lisis de la realidad como base sobre la que se fundamenta la concepci?n de mundo y de humanidad que orienta todo el estudio. Totalidad, contradicci?n e historicidad se destacan como categor?as del m?todo que son transversales a todo el estudio. En la perspectiva de atender a los objetivos propuestos, se definen como categor?as te?ricas explicativas de la realidad: seguridad social del SUAS, matricialidad sociofamiliar y g?nero. A partir de los an?lisis realizados acerca de los fen?menos y procesos sociales que inciden en la perspectiva de g?nero y en la garant?a de las seguridades sociales del SUAS, se hace evidente el impacto negativo de las estructuras todav?a precarias que se han puesto a disposici?n de los servicios socioasistenciales y, principalmente, de la prevalencia de concepciones y pr?cticas tradicionales y conservadoras, tanto en lo que se refiere a la perspectiva de g?nero como en la propia Pol?tica de Asistencia Social, lo que implica la fragilidad o hasta la ausencia del enfrentamiento de las desigualdades de g?nero por los servicios y seguridad social del SUAS y, tambi?n, su reproducci?n. Se se?ala que la proposici?n del presente estudio se plantea en la perspectiva de la superaci?n de los l?mites y retos a?n existentes para la materializaci?n del SUAS en la direcci?n de la lucha por la igualdad entre mujeres y hombres, buscando la garant?a de derechos a la poblaci?n usuaria de este Sistema. / A presente tese possui como tema central a perspectiva de g?nero no Sistema ?nico de Assist?ncia Social ? SUAS ? a partir das Seguran?as Sociais afian?adas pela prote??o social da Assist?ncia Social. A pesquisa que origina este estudo prop?e como objetivo de investiga??o analisar as seguran?as previstas no SUAS, desvendando as quest?es de g?nero presentes nesta pol?tica p?blica, visando a contribuir com subs?dios para implanta??o e implementa??o da universalidade da prote??o social do SUAS. Nessa dire??o, o estudo caracteriza-se como uma pesquisa social de n?vel explicativo, de abordagem qualitativa, com utiliza??o de dados quantitativos. A pesquisa abrangeu o territ?rio do Estado do Rio Grande do Sul. Participaram da pesquisa o total de 117 trabalhadores/as do SUAS, sendo 97 vinculados/as ?s unidades de execu??o dos servi?os socioassistencias implantados nos munic?pios do Estado e 20 trabalhadoras vinculadas ao ?rg?o gestor Estadual do SUAS. Como procedimentos e t?cnicas para coleta de dados, realizaram-se entrevistas com as trabalhadoras vinculadas ao Estado, com base em roteiro semi-estruturado, e question?rio on line enviado ?s equipes de refer?ncia dos servi?os socioassistenciais dos munic?pios. Os dados coletados foram submetidos ? an?lise de conte?do, baseada em Bardin (1997). Todo o processo de pesquisa e produ??o da tese ? orientado pelo m?todo dial?tico-cr?tico, fundamentado na teoria social de Marx. Assim sendo, al?m do percurso metodol?gico da pesquisa, esta tese evidencia o m?todo de an?lise da realidade, enquanto base sobre a qual se fundamenta a concep??o de mundo e de humanidade que orienta todo o estudo. Totalidade, contradi??o e historicidade destacam-se como categorias do m?todo que s?o transversais a todo o estudo. Na perspectiva de atender aos objetivos propostos, definem-se como categorias te?ricas explicativas da realidade: seguran?as sociais do SUAS, matricialidade sociofamiliar e g?nero. A partir das an?lises realizadas acerca dos fen?menos e processos sociais que incidem na perspectiva de g?nero e na garantia das seguran?as sociais do SUAS, fica evidente o impacto negativo das estruturas ainda prec?rias que t?m sido disponibilizadas aos servi?os socioassistenciais e, principalmente, da preval?ncia de concep??es e pr?ticas tradicionais e conservadoras, tanto no que se refere ? perspectiva de g?nero quanto na pr?pria Pol?tica de Assist?ncia Social, o que implica a fragilidade ou mesmo a aus?ncia do enfrentamento das desigualdades de g?nero pelos servi?os e seguran?as sociais do SUAS e, tamb?m, sua reprodu??o. Ressalta-se que a proposi??o do presente estudo se d? na perspectiva da supera??o dos limites e desafios ainda existentes para a materializa??o do SUAS na dire??o da luta pela igualdade entre mulheres e homens, visando ? garantia de direitos ? popula??o usu?ria deste Sistema.