Objetivos: Avaliar a eficácia da injeção intraoperatória para identificação do linfonodo sentinela (LS) em câncer de mama com o uso do Dextran 500-99m-Tecnécio (Tc) e azul patente. Analisar se as doses do radiofármaco, o IMC (índice de massa corporal) e o volume da mama influenciam no tempo para migração ao LS. Metodologia: Estudo prospectivo, realizado entre abril de 2008 e junho de 2009, que incluiu 74 biópsias de LS em pacientes com câncer de mama em estádios T1N0 e T2N0. Injetou-se, após indução anestésica, de 0,5 a 1,5 mCi de Dextran 500-99m-Tc filtrado 0,22 μm na região subareolar num volume de 5 ml e 2 ml de azul patente. Resultados: Identificou-se o LS em 100% dos casos. Um LS (1,35%) estava marcado apenas com o azul patente. A taxa de identificação com o “probe” foi de 98% (73/74 casos). A dose média de radiofármaco aplicada foi 0,97 mCi + 0,22. O tempo médio para marcação do LS foi de 10,7 minutos (+ 5,7min). Identificamos em média 1,66 LS com o radioisótopo. A dose aplicada não apresentou relação com o tempo para captação (p=0,73). Quanto maior o volume da mama e IMC, maior o tempo para captação na região axilar (Pearson Correlation r=0,393 p<0,01; r=0,469 p<0,01 - respectivamente). Conclusão: A injeção intraoperatória do radiofármaco é eficaz para identificação do LS em câncer de mama. O tempo para marcação do LS é maior em pacientes com IMC elevado e mamas volumosas. Doses maiores de radiofármaco não diminuem o tempo de migração. / Objectives: To determine the identification of sentinel lymph node (SLN) in breast cancer after intraoperative injection of Dextran 500‐99mTechnetium (Tc) and blue dye. To analyze if the doses of the radioisotope, body mass index (BMI) and breast volume influence the migration time of the SLN. Methodology: Prospective study between april 2008 and june 2009, which included 74 biopsies of SLN in patients with breast cancer in stages T1N0 and T2N0. Intraoperative injection after induction of general anesthesia, 0.5 to 1.5 mCi of dextran 500‐99m‐Tc filtered 0.22 μm in the subareolar region in a volume of 5 ml and 2 ml of blue dye. Results: We identified the SLN in 100% of cases. In one case (1.35%) the SLN was marked only with the blue dye. The SLN identification rate with the probe was 98% (73/74 cases). The mean dose of radioisotope injected was 0.97 + 0.22 mCi. The average time to mark the SLN was 10.7 minutes (+ 5.7 min). We identified an average 1.66 SLN with the radioisotope. The dose had no effect on the time to capture (p = 0.73). The larger breast volume and BMI, the greater the capture time in the axillary region (Pearson Correlation r=0.393 p <0.01, r=0.469 p <0.01 - respectively). Conclusion: Intraoperative injection of the radioisotope is effective for the identification the SLN in breast cancer. Time to mark the SLN is higher in patients with high BMI and large breasts. Higher doses of radioisotope do not decrease the migration time.

Eventos de inundação são fenômenos geralmente associados a eventos de chuvas intensas. Nesses eventos a cobertura de nuvens, normalmente, prejudica o mapeamento com uso de imagens ópticas. Assim, este trabalho tem como objetivo avaliar os resultados de mapeamento de áreas de inundação utilizando imagens SAR e SRTM. Para aplicação dos métodos foram analisadas as áreas de inundação nas cidades de Santa Fe e Parana, na Argentina. Embora a maior inundação registrada tenha sido no ano de 2003, registros de inundação são frequentemente observados nas províncias de Santa Fé e Entre Ríos. Foi utilizado imagens do satélite Sentinel-1, equipado com sensor C-SAR com dupla polarização (VV/VH). As imagens obtidas são do tipo Interferométrico (IW) Ground Range Detected (GRDH) com resolução espacial de 10 m. Foram utilizadas imagens em períodos com e sem eventos de inundação entre 2016 e 2017, calibradas e coregistradas. Sobre as imagens foram aplicadas técnicas de limiarização e de análise temporal para mapear a mancha de inundação. Também foi elaborado mapa a partir do Modelo Digital de Elevação (MDE) utilizando como referência estações de medição de nível da água dos rios. A validação de todos os métodos foi totalmente remota, baseando-se em um mapeamento da inundação de abril de 2003 na cidade de Santa Fe. Além disso, imagens publicadas de eventos de inundação complementaram a validação e foi possível comparar os resultados com uma imagem óptica Landsat – 8 com resolução de 15 m do dia 22 de fevereiro de 2016, quando o nível do rio Paraná estava acima do nível de alerta Os resultados dos três mapeamentos foram somados para formar uma única imagem com a mancha de inundação em comum. Entre as melhores acurácias, o método de análise do MDE atingiu o melhor resultado, 82% da área de inundação, no entanto, considerando os três métodos, a acurácia atinge mais de 91% de precisão. A técnica de limiarização foi mais eficiente em áreas sem alvos verticais, como áreas urbanas por exemplo. O MDE foi eficiente para simular a inundação em todos os alvos, no entanto em modelos de elevação com melhor resolução, o resultado final do mapeamento será mais preciso. A análise temporal mostrou ser uma técnica promissora para mapeamentos de inundação, no entanto um mapa detalhado de uso de solo é fundamental para aprimorar o resultado desta análise. Todos os processos foram feitos remotamente, possibilitando o desenvolvimento no futuro de um sistema automático para detecção de evento de inundação que pode ser aplicado em áreas com características similares. / Flood events usually go hand in hand with intensive rainfall during which clouds compromise any mapping attempts with optical imagery. Thus, this thesis aims at evaluate the results of mapping flood areas using SAR and SRTM images. For this purpose, flood areas in the cities Santa Fe and Parana in Argentina were analyzed. While the worst flood was registered in 2003, flood events frequently occur in both provinces Santa Fé and Entre Ríos. The employed Sentinel-1 satellite carrying a C-SAR sensor with dual polarization (VV/VH) provided interferometric (IW) Ground Range Detected (GRDH) imagery with a spatial resolution of 10 meters. Images from periods with and without flood events between 2016 and 2017 were calibrated and co-registered. Subsequently on the images were applied threshold and time analysis techniques, as well as a Digital Elevation Model (DEM) analysis with data from stations which measure the rivers’ water levels. The validation of all methods was totally remote, based on a flood mapping of April 2003 in the city of Santa Fe. In addition, published images of flood events complemented the validation and it was possible to compare the results with an optical image Landsat - 8 with 15 m resolution of February 22, 2016, when the level of the Paraná River was above the alert level The three maps were summed to form a single image with the flood spot in common. Among the best accuracy, the MDE analysis method achieved the best result, 82% of the flood area, however, considering all three methods, the accuracy reaches more than 91% accuracy. The thresholding technique was more efficient in areas with no vertical targets, such as urban areas. The DEM was efficient to simulate flooding on all targets, however using elevation models with better resolution, the final result of the mapping will be more accurate. The temporal analysis showed to be a promising technique for flood mapping, however a detailed map of land use is fundamental to improve the results of this analysis. All processes were done remotely, allowing the future development of an automatic flood event detection system that can be applied in areas with similar characteristics.

A linfocintilografia tem contribuído muito para a visualização da drenagem linfática e linfonodo sentinela (LNS) acometido e o estado patológico do LNS é considerado o fator prognóstico mais importante do melanoma. Os objetivos deste trabalho foram descrever os padrões de drenagem linfática em pacientes operados por melanoma, avaliar as características clínicas, demográficas e cirúrgicas destes pacientes, assim como a contribuição da Linfocintilografia na localização dos LNS com vistas à biópsia do mesmo. Foram avaliados 29 pacientes com melanoma operados, e a Linfocintilografia pré-operatória foi realizada após 60 minutos da injeção de Fitato marcado com Tecnécio 99m (99mTc), em 4 pontos cardeais a 1,0 cm da lesão. Encontramos maior acometimento por melanoma na população feminina e idosa, maioria em região de tronco posterior. A maioria (37,04%) drenou para 2 LNS/LNNS, 88,89% dos pacientes drenaram apenas para região ipsilateral à lesão, e 88,89% também drenaram apenas para um único território de drenagem. Encontramos padrões de drenagem linfática inesperados em melanoma localizados nas regiões de cabeça e pescoço, tronco anterior e tronco posterior. A técnica de linfocintilografia foi eficaz para evidenciar LNS/LNNS em 93,10% dos pacientes e dos 23 exames anatomopatológicos realizados, 6 (26,09%) apresentaram comprometimento metastático nos LNS. / Lymphoscintigraphy has contributed much to the visualization of lymphatic drainage and sentinel lymph node (SLN) and involved SLN pathological state is considered the most important prognostic factor of melanoma. Our objectives were to describe the lymphatic drainage patterns, to evaluate the clinical, demographic, and surgical data, as well as assessing the contribution of lymphoscintigraphy for SLN localization in a sample of patients operated for melanoma. We evaluated 29 patients operate with melanoma, and the Preoperative lymphoscintigraphy was performed after 60 minutes of injection of phytate labeled with Technetium 99m (99mTc) in 4 cardinal points to 1,0 cm of the lesion. We found greater involvement by melanoma in the elderly female population and, most located in the posterior trunk region. The majority (37.04%) drained for 2 SLN/ SLNN, 88.89% of the patients drained only to the ipsilateral region, and also 88,89% had lymphatic drainage to only a single drainage area. We found unexpected lymphatic drainage patterns in melanoma localized in head and neck, trunk, anterior and posterior trunk. The technique of lymphoscintigraphy was effective to show SLN/SLNN in 93.10% of patients, and from 23 pathological examinations performed, 6 (26.09%) exhibited metastatic involvement in the SLN.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Este trabalho aborda a influÃncia da incisÃo para-areolar no quadrante superior externo da mama, na localizaÃÃo do linfonodo sentinela em modelo canino. A BiÃpsia do linfonodo sentinela (BLS) à um mÃtodo de amostragem seletiva, minimamente invasivo, altamente sensÃvel em predizer o estado axilar, podendo evitar o esvaziamento ganglionar em pacientes sem comprometimento metastÃtico. Mulheres, com cirurgias mamÃrias previas, foram excluÃdas da realizaÃÃo da BLS por muitos cirurgiÃes por acreditar que teriam um Ãndice de falso negativo elevado, inviabilizando o mÃtodo. Outros mastologistas passaram a empregar, empiricamente, a injeÃÃo do marcador corante ou radioativo acima da borda da incisÃo prÃvia, porÃm fica a dÃvida se o gÃnglio identificado à realmente o Linfonodo Sentinela (LS). Este trabalho experimental, em modelo canino, tem como objetivo identificar a influÃncia das incisÃes para-areolares prÃvias, no quadrante superior externo (QSE) da mama na identificaÃÃo do linfonodo sentinela. à utilizado o radiocolÃide TecnÃcio99 injetado na derme sub-areolar das mamas torÃcicas craniais, para marcar o LS. Esperado o tempo de migraÃÃo do radiofÃrmaco para axila e identificado o local de marcaÃÃo com probe. Procede-se incisÃo arciforme para- areolar no QSE, entre 9 e 12h à direita e 12 e 3 h à esquerda, a 2cm do mamilo. O corante azul patente Ã, entÃo, injetado na borda superior destas incisÃes. No ponto marcado com o gama-probe à realizada a incisÃo axilar mÃnima, onde o LS à identificado com auxÃlio do probe, que capta a radiaÃÃo do gÃnglio, eou pela visualizaÃÃo direta do linfonodo impregnado com o corante. SÃo comparadas duas tÃcnicas de local de injeÃÃo e a concordÃncia entre os mÃtodos de identificaÃÃo do LS. Os experimentos da pesquisa ocorreram entre Janeiro 2008 e Maio 2009. A amostra à composta de 40 mamas torÃcicas craniais, oriundas de 23 cadelas adultas, sem raÃa definida, da espÃcie Canis familiaris. A anÃlise estatÃstica foi realizada com o auxÃlio do programa Graphpad e utilizados o Teste de McNemar e Coeficiente de ConcordÃncia de Kappa. Os resultados demonstram que em 95% das mamas estudadas (3840) obtiveram o LS identificado na axila apÃs a injeÃÃo de tecnÃcio na regiÃo subareolar e em 82% dos casos (33/40) coraram com azul patente injetado no bordo superior da incisÃo padronizada. Os resultados obtidos indicam a concordÃncia entre os mÃtodos em 82% dos casos na identificaÃÃo do LS (3340). As incisÃes para-areolares prÃvias, nos quadrantes superiores externos, das mamas torÃcicas craniais da cadela, nÃo demonstram interferir, de maneira significante, na BLS quando o corante à injetado na borda superior da incisÃo. O linfonodo encontrado a partir de injeÃÃo na borda superior da incisÃo previa, corresponde ao linfonodo sentinela da mama da cadela, em 95% dos casos (3233). / This paper discusses the influence of para-areolar incision in the upper outer quadrant of the breast for the location of the sentinel lymph node in canine model. Sentinel lymph node biopsy (SLNB)&#8213;a minimally invasive selective sampling technique highly predictive of the condition of the armpit&#8213;can spare metastasis-free patients from unnecessary axillary dissection. The high incidence of false-negative results has led many surgeons to no longer indicate SLNB to women with previous breast surgery. Some mastologists prefer to empirically inject a dye or radio-labelled marker above the border of the previous incision, though it is not always clear if the identified ganglion is in fact the sentinel lymph node. The objective of the present study was to evaluate the influence of previous para-areolar incisions in the upper outer quadrant (UOQ) of the breast upon the identification of the sentinel lymph node (SLN) in a canine model. The SLN was marked with Technetium-99m (99mTc) injected into the subareolar skin of the cranial breast. Once the marker had migrated to the axilla and the marked site had been identified with a gamma probe, an arcuate para-areolar incision was performed 2 cm from the nipple in the UOQ (between the 9 and 12 oâclock position on the right side, and between the 12 and 3 oâclock position on the left side). Patent blue dye was then injected above the upper border of the incision. At the marked site a minimal axillary incision was made and the SLN was identified by gamma probe and/or by direct visualization of the dye. The agreement between the two injection sites and the two SLN identification methods was determined. The experiments were carried out between January 2008 and May 2009 on a sample of 40 cranial breasts of 23 adult females of the species Canis familiaris. Using the statistics software Graphpad, the data were submitted to the McNemar test and the Kappa agreement coefficient was calculated. Our findings show that in 95% (38/40) of the breasts the SLN was identified by injection of 99mTc in the subareolar region, and that in 82% (33/40) of cases the SLN was identified by injection of patent blue dye above the upper border of the incision. Thus, the methods agreed in 82% (33/40) of cases. Previous para-areolar incisions in the UOQ of the cranial breasts did not interfere significantly with the biopsy when the dye was injected above the upper border of the incision. The lymph node identified by injection above the upper border of the previous incision corresponded to the SLN in 95% (32/33) of cases.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / A gastrectomia com linfadenectomia ampliada ainda à o padrÃo ouro para o tratamento curativo do cÃncer de estÃmago (CaE), embora este procedimento possa levar a alto Ãndice de morbidade ou mortalidade, principalmente nos pacientes que nÃo apresentem disseminaÃÃo linfÃtica da doenÃa. A pesquisa do linfonodo sentinela (LS), jà consagrada nos tumores iniciais de mama e nos melanomas, apresenta-se cada vez mais freqÃente no trato digestÃrio, em especial no CaE com resultados animadores. Estudos iniciados nos meados do ano 2000 retratam busca crescente e bastante prÃspera para esclarecimento desta questÃo. O objetivo deste trabalho à elaborar um modelo experimental que possa demonstrar tecnicamente, em laboratÃrio, a viabilidade da pesquisa do LS no antro gÃstrico da cadela. Foram estudadas 25 cadelas com peso aproximado de 11 Kg e idade de 01 a 02 anos, sem raÃa definida (SRD), clinicamente saudÃveis, proveniente do Centro de Controle de Zoonoses do MunicÃpio de Fortaleza (CCZ) que tinham programaÃÃo para eutanÃsia. Com escolha aleatÃria, estes animais foram estudados individualmente e semanalmente. Utilizou-se, separadamente, TecnÃcio (99mTc) com traÃador/colÃide Fitato e corante vital azul patente V Guerbert 2,5 % (AP) injetados a 01 cm do piloro, na pequena curvatura no antro gÃstrico da cadela e analisados nos tempos zero, 05, 10, 15 e 20 minutos. ApÃs este perÃodo realizou-se pesquisa âin vivoâ do local de injeÃÃo do marcador e linfonodos encontrados e âex-vivoâ destes linfonodos. Para o estudo com o 99mTc utilizou-se o aparelho Gamma Probe modelo Nuclearlab DGC-II - detector para cirurgia radioguiada e sonda captadora de irradiaÃÃo acoplada com unidade de contagem e rastreamento sonoro e para o AP, visÃo direta. Para a anÃlise estatÃstica utilizou-se o teste de McNemar e o Coeficiente de ConcordÃncia de Kappa. Foi estabelecido em 5% o nÃvel de significÃncia (p&#8804;0,05). Com o uso do 99mTc isolado foi identificado a presenÃa do LS em 20 animais (80%). Quando se utilizou o corante AP isolado a presenÃa do LS foi identificada em 24 animais (96 %). NÃo houve significÃncia estatÃstica quanto ao uso destes marcadores para a pesquisa do LS no antro gÃstrico da cadela. Concluiu-se que (1) O estÃmago da cadela à adequado para modelo experimental de pesquisa âin vivoâ do linfonodo sentinela e (2) O tecnÃcio (99mTc) e corante vital â azul patente V Guerbert 2,5 % (AP) sÃo eficientes como marcadores de linfonodo sentinela do antro gÃstrico da cadela. / The gastrectomy with extensive lymphadenectomy still is the gold standard for the dressing treatment of the gastric cancer (GC), even so these procedures can take high index of morbidity or mortality, mainly in the patients who do not present lymphatic dissemination of the illness. The research of sentinel lymph node (SLN), already consecrated in the initial tumors of breast and the melanomas, presents each time more frequent for upper gastrointestinal cancers, specially in GC with encouraging results. Studies initiated in the middles of 2000 portray increasing and sufficiently prosperous search for clarification of this question. The objective of this work is to elaborate an experimental model that can demonstrate technically, in laboratory, the research viability of SLN in gastric antrum of the dog. 25 female dogs had been studied with approach weight of 11 kg and age of 01/02 years, without definite race (WDR), healthful clinically, proceeding from the Control Center of Zoonosis of Fortaleza City with programming for euthanasia. With random choice, these animals had been studied individually and weekly. It was used, separately, radioisotopic 99mtechnetium labeled phytate and patent blue dye (V Guerbert 2.5%) injected at 01 cm above the piloro, on the small bending in the antrum gastric of the dog and analyzed in the times zero, 05, 10, 15 and 20 minutes. After this period, the injection place of the markers and gastric lymph nodes were appraised âin vivoâ (in the animal) and the gastric lymph nodes âex vivoâ (out of the animal). For the study with the 99mtechnetium it was used the device Gamma Probe model Nuclearlab DGC-II (radioguiada surgery with sounding lead of irradiation connected to unit of counting and sonorous tracking) and for the patent blue dye, direct vision. For the analysis statistics were used the test of McNemar and the Quantify agreement with Kappa. The level of significance was established in 5% (p&#8804;0,05). When the radioisotopic 99mtechnetium labeled phytate was used single, the LS was identified in 20 animals (80%). With the patent blue dye single, in 24 animals (96%). There is no statistic significance with the use of those markers for the LS research in the gastric antrum of the dog. The conclusions are (1) The stomach of the dog is adjusted for experimental model in alive research of the sentinel lymph node (2) The radioisotopic 99mtechnetium labeled phytate and patent blue dye (V Guerbert 2.5%) are efficients as markers of sentinel lymph node of the dogâs gastric antrum.

CoordenaÃÃo de AperfeiÃoamento de NÃvel Superior / O cÃncer de vulva corresponde a aproximadamente 1% das neoplasias malignas da mulher e de 3% a 5% de tumores genitais femininos. 90% destes sÃo carcinomas espino-celulares, curÃveis quando diagnosticado precocemente. O tratamento radical inclui o esvaziamento inguinal bilateral na maioria dos casos. Aproximadamente 30% das pacientes operÃveis tÃm disseminaÃÃo linfonodal, as 70% restantes tÃm mutilaÃÃo desnecessÃria. A possibilidade de aplicar o conceito de linfonodo sentinela, na conservaÃÃo dos linfonodos regionais da vulva, ainda nÃo à consenso. O modelo experimental na vulva da cadela à um passo importante no reconhecimento das peculiaridades da drenagem linfÃtica deste ÃrgÃo pela similaridade com a drenagem em humanos. Este trabalho experimental, em modelo canino tem como objetivo apresentar o modelo para a pesquisa do linfonodo sentinela na vulva da cadela usando o Azul Patente e Fitato de TecnÃcio; avaliar o Azul Patente como marcador do linfonodo sentinela da vulva da cadela; avaliar o Fitato de TecnÃcio como marcador do linfonodo sentinela na vulva da cadela, comparar os mÃtodos obtidos pelas duas tÃcnicas. Foram utilizados nos procedimentos 25 cadelas, adultas, sadias, com peso variando entre 10 e 12kg. InjeÃÃo de 5ÂCI de TecnÃcio na regiÃo vulvar, com espera de 30â. Rastreamento com probe das regiÃes de drenagem vulvar, injeÃÃo de 0,5mL de azul patente na regiÃo vulvar, com espera de 15â. Definidos os pontos âquentesâ com o probe, por incisÃes inguinais abordou-se o linfonodo, avaliando-se com o probe o linfonodo sentinela in-vivo e ex-vivo, anotando-se os valores; registrados os linfonodos corados e nÃo corados com azul patente; comparados os dois mÃtodos. Em 88% dos linfonodos houve presenÃa da lateralidade, tal diferenÃa foi significante (&#61539; = 28.88 e p<0,0001). NÃo houve diferenÃa significante (p>0,05) entre os lados direito e esquerdo, quanto à intercessÃo dos dois mÃtodos. Os nÃveis de radiaÃÃo detectados foram idÃnticos em ambos os lados (p>0,05), tambÃm nÃo foi verificada diferenÃa significante (p>0,05) em ambos os lados, nas contagens in vivo e ex vivo, e no nÃmero de linfonodo corado com azul patente. O modelo experimental apresentado foi capaz de definir o linfonodo sentinela utilizando o Azul Patente e TecnÃcio(99mTc). A identificaÃÃo do linfonodo sentinela à exequÃvel com Azul Patente no mapeamento da cadeia linfÃtica; o mapeamento linfÃtico com TecnÃcio(99mTc), permite identificar com detalhes o sistema de drenagem linfÃtica; nÃo houve diferenÃa significante entre os dois mÃtodos (p=1,0), Azul Patente e TecnÃcio(99mTc).

Both literature and practice have looked at different strategies to diminish healthcare associated costs. As an extension to this stream of research, the present three paper dissertation addresses the issue of reducing elevated healthcare costs using analytics. The first paper looks at extending the benefits of auditing algorithms from mere detection of fraudulent providers to maximizing the deterrence from inappropriate behavior. Using the structure of the physicians' network, a new auditing algorithm is developed. Evaluation of the algorithm is performed using an agent-based simulation and an analytical model. A case study is also included to illustrate the application of the algorithm in the warranty domain. The second paper relies on experimental data to build a personalized medical recommender system geared towards re-enforcing price-sensitive prescription behavior. The study analyzes the impact of time pressure, and procedure cost and prescription prevalence/popularity on the physicians' use of the system's recommendations. The third paper investigates the relationship between patients' compliance and healthcare costs. The study includes a survey of the literature along with a longitudinal analysis of patients' data to determine factors leading to patients' non-compliance, and ways to alleviate it.

Using of Sentinel-1 data for radar interferometry Abstract The diploma thesis deals with extraction of a digital surface model (DSM) using synthetic aperture radar interferometry (InSAR) and Sentinel-1 data in selected locations of the Czech Republic. The InSAR technique, the Sentinel-1 data, their parameters and possibilities of their usage are described in the theoretical part of the thesis. The specification of the model areas and used data follows. The practical part is focused on creating a methodology of deriving a digital surface model and its extracting in the three tested locations. These locations differ from each other in their geomorphological features and land cover. At the end of this part the comparison of the extracted model with the reference model DMP 1G using statistical methods is carried out. At the end of this thesis the results are evaluated and discussed. Key words: InSAR, Sentinel-1, SAR, DSM

Various biotic and abiotic agents are changing forests. Prolonged human activities substantially could cause not only different changes in forests but also could accelerate natural hazards in the Anthropocene. Despite several remote sensing-based research in forest changes, there is a need for a holistic study that could visualize different dimensions of anthropogenic-induced forest changes such as forest loss, forest fragmentation, and forest degradation. Besides, the effects of these changes require to be investigated in the natural hazards’ studies in forest regions. This research was accomplished for holistic assessing of long-term forest loss, forest fragmentation, and forest degradation induced by human activities such as sprawling residential areas and expanding road networks in northeast Iran. Moreover, it has investigated the significance of forest dynamics in analyzing of landslide susceptibility in the forest regions. The time series of Landsat data with the contribution of aerial photos were employed to investigate long-term forest changes in three spans from 1966 to 2016. The expansion of forest roads was extracted from a combination of satellite images and topographic maps. Both pixel– and object-based approaches were used for analyzing forest changes. The spatial autocorrelation indicators and spatial regression models were applied for visualizing patterns of forest changes and possible relationships between forest changes and the expansion of residential areas and road networks. Furthermore, the detection of old and new landslide events was accomplished through Sentinel-1 and -2 images and DEM derivatives using object-oriented random forest method. The significance of conditioning and triggering factors that control the susceptibility of protected and non-protected forests to landslides was explored using the object-based random forest approach as well. Key findings revealed that the expansion of residential areas and rural roads have increasingly heightened the rates of forest loss before 2000. However, the spatial patterns of forest dynamics were changed from forest loss to forest fragmentation and forest degradation– along with the expansion of forest and mine roads– since the 1980s. Although the topographic and hydrologic features were the top influential predictors that control the susceptibility of protected forests to landslides, the natural and anthropogenic triggers have obtained significant values in non-protected forests to the landslides as well; forest fragmentation and logging were the top features of anthropogenic triggers. This research verifies that influential variables are different either for detecting landslides or for assessing landslide susceptibility in different forest regions. The spatial-based regression models showed higher efficiency than the traditional regression model for modelling relationships between forest changes and anthropogenic- induced drivers; however, there was no priority between spatial models. Random forest algorithm demonstrated satisfactory accuracy for mapping of both old and new landslides and landslide susceptibility with higher accuracy in the protected forests. This research has investigated human-induced forest changes; however, other abiotic and biotic agents may cause these changes such as climate hazards, forest fires, insect outbreaks, pathogens, and other natural hazards that need to be explored in the future studies. / Verschiedene biotische und abiotische Faktoren verursachen Veränderungen im Wald. Dauerhafte menschliche Eingriffe im Anthropozän könnten nicht nur zu unterschiedlichen Typen von Veränderungen im Wald selbst führen, sondern auch bestehende Naturgefahren verstärken. Trotz verschiedener fernerkundungsgestützter Forschungsarbeiten zu Waldveränderungen besteht Bedarf an einer holistischen Studie, welche verschiedene Dimensionen anthropogen verursachter Waldveränderungen wie Waldverlust, Waldfragmentierung und Waldschädigung aufzeigen kann. Außerdem ist es notwendig, die Auswirkungen derartiger Veränderungen in Naturgefahrenstudien für Waldgebiete zu untersuchen. Ziel dieser Forschung war es, eine holistische Bewertung von langfristigem Waldverlust, Waldfragmentierung und Waldschädigung durchzuführen, die durch menschliche Aktivitäten wie Ausbreitung von Siedlungsgebieten und Ausbau von Straßennetzen im Nordosten des Iran verursacht werden. Darüber hinaus hat diese Forschungsarbeit die Bedeutung der Walddynamik in der Analyse von Rutschungsneigung innerhalb von Waldgebieten untersucht. Um langfristige Waldveränderungen in drei Intervallen zwischen 1966 und 2016 zu untersuchen, wurden Zeitreihen von Landsat-Daten und zusätzlich von Luftbildern verwendet. Die Erweiterung der Waldwege wurde aus einer Kombination von Satellitenbildern und topographischen Karten extrahiert. Für die Analyse von Waldveränderungen wurden sowohl pixel- als auch objektbasierte Ansätze verwendet. Räumliche Autokorrelationsindikatoren und räumliche Regressionsmodelle wurden eingesetzt, um Muster von Waldveränderungen und Zusammenhänge zwischen Waldveränderungen und der Erweiterung von Wohngebieten und Straßennetzen zu visualisieren. Darüber hinaus wurde die Erkennung alter und neuer Erdrutsche aus Sentinel-1 und -2 Bildern und DEM-Derivaten unter Verwendung der objektorientierten „Random Forest “-Methode durchgeführt. Ebenfalls mit dem objektbasierten „Random Forest “-Ansatz wurde die Bedeutung von Konditionierungs- und Auslösefaktoren untersucht, welche die Suszeptibilität einer Fläche für Erdrutsche in geschützten und nicht geschützten Wäldern kontrollieren. Die zentralen Erkenntnisse sind, dass die Ausbreitung von Siedlungsflächen und der Ausbau von Landstraßen die Waldverluste vor dem Jahr 2000 zunehmend erhöht haben. Mit dem Ausbau von Wald- und Bergbaustraßen änderten sich jedoch seit den 1980er Jahren die räumlichen Muster der Walddynamik von Waldverlust hin zu Waldfragmentierung und Walddegradierung. Obwohl die orographischen und hydrologischen Merkmale die wichtigsten Einflussfaktoren hinsichtlich Suszeptibilität für das Auftreten von Erdrutschen in Schutzwäldern waren, haben weitere natürliche und anthropogene Auslöser Signifikanz erreicht innerhalb der nicht geschützten Waldflächen: Holzeinschlag und Waldfragmentierung waren dabei die dominierenden anthropogenen Auslöser. Die Studie bestätigt zudem, dass die Parameter für die Erkennung von Erdrutschen und für die Beurteilung der Rutschungs-Suszeptibilität an die verschiedenen Waldgebiete anzupassen sind. In der Modellierung der Beziehung zwischen Waldveränderungen und anthropogenen Einflüssen zeigten räumlich basierte Regressionsmodelle eine höhere Effizienz als das traditionelle Regressionsmodell; allerdings gab es keine klare Priorität innerhalb der räumlichen Modelle. Der „Random Forest “-Ansatz zeigte eine zufriedenstellende Genauigkeit sowohl bei der Kartierung historischer Erdrutsche als auch in der Bestimmung der Rutschungs-Suszeptibilität. Dabei lag die erreichte Genauigkeit in den geschützten Waldgebieten höher. Diese Forschungsarbeit hat vom Menschen verursachte Waldveränderungen untersucht. Da jedoch auch andere abiotische und biotische Faktoren die geschilderten Veränderungen verursachen können, sind weitere Studien notwendig. Diese könnten z. B. Klimaparameter, Waldbrände, Insektenschädigung und andere Naturgefahren einschließen.

This thesis is devoted to general practice (GP) networks in Belgium, their development and their activities within the Belgian health system context. These networks are specific research tools for the repeated or continuous collection and analysis of data related to diseases and other health events observed in general practice, including interventions of general practitioners. The thesis focuses on three not-for-profit general practice research networks which are operational today: (1) the national Network of Sentinel General Practices (SGP), coordinated by the Federal research institute Sciensano; (2) the Flemish Intego network, coordinated by the Academic Center for General Practice of Catholic University Leuven; (3) the network of the Fédération des maisons médicales et des collectifs de santé francophones (FMM) with its Monitoring Chart (Tableau de bord), which collects data from Wallonia and the Brussels-Capital Region. The thesis is divided into a general introduction, three main parts and a final discussion with concluding remarks. The general introduction outlines the importance of data from general practice and the contribution of GP networks to research. Furthermore, it points out the importance of general practice for the control of sexually transmitted infections (STIs), a specific field of action. The first main part of the thesis investigates the research question of how the three GP research networks developed within the specific context of the Belgian health system. It is based on the interpretation of written sources such as project reports, annual network reports, research publications, parliamentary documents, relevant websites and the existing research literature. The context analysis included a comparison with the Netherlands since the latter have strong traditions with regard to the position of the general practitioner in the health system (gatekeeper to secondary care, whereas in Belgium the patient generally chooses his/her health provider, and a Global Medical File administered by the general practitioner is not mandatory in Belgium), to general practice research networks and computerisation. It could be shown (1) that Belgium has held a middle position in the European Union regarding GP computerisation; (2) that, contrary to the Netherlands, an operational national GP network based on data from electronic health records (EHRs) could not be established; and (3) that Belgian health system computerisation, which advanced substantially in the last decade, put the issue of health data collection and storage by a new digital service on the agenda. Subsequently, three sub-chapters focus on the development of the three GP networks from their foundation until today. They demonstrate that the SGP and Intego were founded as innovative tools originating from Flemish general practice research, whereas the Monitoring Chart originated from the dynamism of Integrated Primary Health Care Centres (IPHCCs, Maisons médicales) in French-speaking Belgium. Acting as health observatories was both part of the mission of the IPHCCs and the demand of the Regional governments. With time, the research designs of the three GP networks became more sophisticated. Furthermore, European cooperation of the SGP with other GP networks since the late 1980s stands out, since the vision to establish a European sentinel general practice network led to joint influenza surveillance as one of its lasting achievements. In continuation of the developments described above, the second main part of the thesis addresses the missions and the organisation of the three GP networks today as well as their respective strengths and limitations in comparative perspective. It is based on network publications and reports, relevant websites and informal information from the networks themselves. The comparison shows that there is little overlap between the activities of the three GP networks, given the different areas of investigation and the complementarity of supplementary information collected by the SGP versus routine data extraction from EHRs in the other two networks. Furthermore, Intego and the Monitoring Chart essentially cover different parts of the country. The prospective research design of the SGP allows formulating hypotheses and designing research questionnaires with precise definitions of diagnoses before the start of a new research topic in order to minimise inter-observer variability, whereas the diagnosis in the other two networks is the result of the general practitioner's clinical judgement. The Intego network disposes of a substantial number of routine parameters collected over more than two decades by now. With these data, the researchers can design retrospective cohort studies without recording or recall bias by the GP who does not know during his/her daily routine for which research questions his/her data may be used later. The Monitoring Chart stands out by its comparatively strong presence in the Brussels-Capital Region and its data from the less well-to-do part of the population. The third main part of the thesis focuses on STIs which provided a research opportunity, given that Belgian public health efforts to control them have increased in recent years and that the three GP networks engaged in research activities in this regard. The first sub-chapter addresses challenges for the surveillance and monitoring of STIs due to the nature of the pathogens, followed by a sub-chapter about characteristics of STI surveillance and monitoring in Belgium. Afterwards, a sub-chapter describes health policy efforts in order to establish the Belgian HIV Plan 2014-2019. The development of the HIV Plan was analysed by applying the policy streams model of John Kingdon. The analysis was based on published government statements, parliamentary documents, and websites of stakeholders, and showed that the Federal Ministry of Health initiative to achieve the HIV Plan was characterised by a coordinating role with a participatory approach towards the other Belgian governments and stakeholders. The 2013 protocol agreement of the Belgian governments committed them to principles, actions, and cooperation regarding HIV prevention, testing, treatment of persons living with HIV and care for their quality of life, but not to budgets, priorities or target figures. The implementation of the plan, highlighting aspects relating to general practice, is addressed in the subsequent sub-chapter. Two further sub-chapters are based on the analysis of retrospective cohort studies with Intego data from 2009 to 2013, based on EHR routine registration by over 90 general practitioners in Flanders. In the first sub-chapter, the frequencies of gonorrhoea and syphilis diagnoses were investigated. Case definitions were applied. Due to small case numbers obtained, cases were pooled and averaged over the observation period. Frequencies were compared with those calculated from mandatory notification. A total of 91 gonorrhoea and 23 syphilis cases were registered. The average Intego annual frequency of gonorrhoea cases obtained was 11.9 (95% Poisson confidence interval (CI) 9.6; 14.7) per 100,000 population, and for syphilis 3.0 (CI 1.9; 4.5), respectively, while mandatory notification was calculated at 14.0 (CI: 13.6, 14.4) and 7.0 (CI: 6.7, 7.3), respectively. In spite of limitations such as small numbers and different case definitions, the data suggests that the general practitioner was involved in the large majority of gonorrhoea cases, while the majority of new syphilis cases did not come to the knowledge of the general practitioner. The second sub-chapter deals with the prescription of antibiotics to treat gonorrhoea in general practice in Flanders 2009-2013. Belgian guidelines recommended ceftriaxone or alternatively spectinomycin from 2008 onwards and azithromycin combination therapy since 2012. The study investigated to which extent contemporary gonorrhoea treatment guidelines were followed. Ninety-one gonorrhoea cases with ten chlamydia and one genital trichomonas coinfections in 90 patients were registered between 2009 and 2013. The proportion of cases with ceftriaxone and/or spectinomycin prescriptions rose from 13% (two of 15 cases) in 2009 to 56% (nine of 16 cases) in 2013. Combination therapy of ceftriaxone and/or spectinomycin together with azithromycin rose from 0 of 15 cases (0%) in 2009 to 7 of 16 cases (44%) in 2013. Although numbers are small, the results suggest that gonorrhoea therapy guideline adherence improved between 2009 and 2013. Future opportunities, recommended in the final discussion, include (1) extending provider-led STI testing in Belgium, with a prominent role for general practitioners; (2) investigating barriers and facilitators for the achievement of the Global Medical File, notably if sensitive and potentially stigmatising issues such as STIs or mental health are involved; (3) making task delegation by the general practitioner towards other primary health care providers more attractive; (4) facilitating general practitioners' tasks by the introduction of support features into the EHR in order to improve registration and quality of care in general; (5) eliciting Regional government support in order to investigate the diagnostic profiles of the patient population of IPHCCs; and (6) establishing an extended network for the collection and analysis of "production data" (such as the number of contacts, interventions, referrals, prescriptions and diagnostic requests) from general practitioners and other primary health care providers, proceeding from the know-how and the experience of the three investigated GP networks. / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished