External validation of Villalta score in high-middle income country patients with deep vein thrombosis.

ABSTRACT: Post-thrombotic syndrome (PTS) is a late complication that does not have a cure yet, with a prevalence estimated between 20 to 75%, associated with previous deep vein thrombosis event. Although the Villalta score (VS) is the gold-standard clinical tool for diagnostic and prognostic evaluation of PTS, there are currently no VS intra-rater agreement established and no validation studies for VS' application into Brazilian Portuguese. We sought to translate and validate VS reliability systematically; and, secondarily, to compare the ultrasound findings with the severity of PTS.We systematically translated the original VS into Brazilian Portuguese (BP). Fifty participants who underwent two outpatient visits were evaluated using the translated VS. We assessed its intra-rater and inter-rater agreement and compared BP VS versus CEAP clinical component (CEAP C), and the clinical PTS severity versus the duplex ultrasound (DUS) findings. The study and its report followed the Guidelines for Reporting Reliability and Agreement Studies.The intra-rater evaluation of VS grades had a simple Kappa coefficient of 0.73, and the simple Kappa coefficient inter-rater for VS grades was 0.67. When VS was compared to CEAP C, it established a remarkably high correlation over 0.9. There was difference among VS values compared to DUS initial deep vein thrombosis territory, with femoropopliteal showing higher values than distal veins. Higher VS values were correlated to DUS venous recanalization and reflux.There was a substantial inter-rater and intra-rater agreement when the BP VS was applied; and when compared to CEAP C, VS showed a high correlation. When VS grading was compared to DUS characteristics, there were significant statistical and clinical correlation, with presence of reflux and recanalization showing higher VS values. This external VS validation also changes the clinical practice allowing the VS use in a different population and establishes the VS intra-rater agreement.

Primer estudio epidemiológico de injuria renal aguda con requerimiento de terapia de reemplazo renal en argentina. sobrevida general y renal a mediano plazo / First epidemiological study of acute kidney injury with requirement of renal replacement therapy in argentina. intermediate general and renal survival

Resumen Introducción: La injuria renal aguda es un trastorno complejo, multicausal, asociado con alta mortalidad y ocasional dependencia de diálisis crónica. Se desconoce la evolución de los pacientes que requieren terapia de reemplazo renal por injuria renal aguda en Argentina. Material y métodos: Estudio prospectivo, observacional, longitudinal y multicéntrico, en mayores de 14 años, ingresados en hospitales públicos de la provincia de Santa Fe, con diagnóstico de injuria renal aguda y necesidad de terapia de reemplazo renal, durante dos años (2017 y 2018). Resultados: Total 255 pacientes. Frecuencia 164 ppm/año, 1.85/1000 internaciones por año, varones 70,98%, edad 46-66 años, comorbilidades en 71,37%, internación en unidad de cuidados críticos 89.02%, compromiso extrarrenal 82.52%. Causas más frecuentes: hipotensión arterial 62.35%, infecciones 52.73%, nefrotóxicos 17.65%. Terapia de reemplazo renal: hemodiálisis intermitente 74.51%, diálisis lenta 11.76%, terapia continua 13.73%. Evolución: vivos a 30 días 116 (45.49%), dependencia de diálisis crónica 12 (10.34%). Mortalidad: 54.51% a 30 días, progresando al 65.88% a los 420 días. Sin diferencia significativa en mortalidad a 30 días según edad, sexo, terapia de reemplazo renal, comorbilidades ni creatininemia en primera diálisis. Hubo diferencia significativa (p <0.05) en mortalidad en injuria renal aguda aislada versus compromiso extrarrenal (RR: 1.55), Unidad de Cuidados Críticos versus Sala (RR: 3.31) e hipotensión arterial (RR: 1.79) como causa. Los pacientes con dependencia de diálisis crónica presentaron mayor mortalidad a 420 días que aquellos que recuperaron función renal (50% vs 22%, RR: 2.26). Conclusiones: Este es el primer estudio epidemiológico de injuria renal aguda, con seguimiento de la población que requirió terapia de reemplazo renal en Argentina. Está compuesto por pacientes jóvenes, graves y con alta proporción de compromiso de órganos extrarrenales. La mortalidad es elevada y se prolonga más allá del inicio de la terapia de reemplazo renal, la dependencia de diálisis crónica conlleva un peor pronóstico vital.

Abstract Introduction: Acute kidney injury is a complex, multicausal disorder associated with high mortality and chronic dialysis dependence. The evolution of patients who required renal replacement therapy due to acute kidney injury in Argentina is unknown. Methods: Prospective, observational, longitudinal, multicentric study in individuals over 14 years of age admitted to public hospitals (Province of Santa Fe) with a diagnosis of acute kidney injury and need for renal replacement therapy; study duration: two years (2017 and 2018). Results: Total 255 patients. Frequency 164 ppm/year, 1.85/1000 hospitalizations/year, males 70.98%, age 46.66 years, comorbidities present in 71.37%, hospitalization in critical care 89.02%, extra renal involvement 82.52%. Most frequent causes: arterial hypotension 62.35%, infections 52.73%, nephrotoxic 17.65%. Renal replacement therapy: intermittent hemodialysis 74.51%, sustained low-efficiency dialysis 11.76%, continuous: 13.73%. Evolution: alive at 30 days 116 (45.49%), chronic dialysis dependence 12 (10.34%). Mortality: at 30 days 54.51%, progressing to 65.88% at 420 days. No significant difference in mortality at 30 days according to age, sex, renal replacement therapy, comorbidities or creatinine in first dialysis. There was a significant difference (p <0.05) in mortality in isolated acute renal injury extra renal involvement (RR: 1.55), Critical Care Unit vs Ward (RR: 3.31) and arterial hypotension as cause (RR: 1.79). Patients with chronic dialysis dependence presented higher mortality than those who recovered renal function (50% vs 22%, RR: 2.26). Conclusions: This is the first epidemiological study with follow-up of the population that required renal replacement therapy in Argentina. It is composed of young, severe patients with a high proportion of extra renal organ involvement. Mortality is high and continues beyond the onset of renal replacement therapy, chronic dialysis dependence leads to a worse vital prognosis.

Peripherally inserted central catheter versus central venous catheter for intravenous access: A protocol for systematic review and meta-analysis.

BACKGROUND: Since the first description of the central venous catheter (CVC) in 1952, it has been used for the rapid administration of drugs, chemotherapy, as a route for nutritional support, blood components, monitoring patients, or combinations of these. When CVC is used in the traditional routes (eg, subclavian, jugular, and femoral veins), the complication rates range up to 15% and are mainly due to mechanical dysfunction, infection, and thrombosis. The peripherally inserted central catheter (PICC) is an alternative option for CVC access. However, the clinical evidence for PICC compared to CVC is still under discussion. In this setting, this systematic review (SR) aims to assess the effects of PICC compared to CVC for intravenous access. METHODS: We will perform a comprehensive search for randomised controlled trials (RCTs), which compare PICC and traditional CVC for intravenous access. The search strategy will consider free text terms and controlled vocabulary (eg, MeSH and Entree) related to "peripherally inserted central venous catheter," "central venous access," "central venous catheter," "catheterisation, peripheral," "vascular access devices," "infusions, intravenous," "administration, intravenous," and "injections, intravenous." Searches will be carried out in these databases: MEDLINE (via PubMed), EMBASE (via Elsevier), Cochrane CENTRAL (via Wiley), IBECS, and LILACS (both via Virtual Health Library). We will consider catheter-related deep venous thrombosis and overall successful insertion rates as primary outcomes and haematoma, venous thromboembolism, reintervention derived from catheter dysfunction, catheter-related infections, and quality of life as secondary outcomes. Where results are not appropriate for a meta-analysis using RevMan 5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. RESULTS: Our SR will be conducted according to the Cochrane Handbook of Systematic Reviews of Interventions and the findings will be reported in compliance with PRISMA. CONCLUSION: Our study will provide evidence for the effects of PICC versus CVC for venous access. ETHICS AND DISSEMINATION: This SR has obtained formal ethical approval and was prospectively registered in Open Science Framework. The findings of this SR will be disseminated through peer-reviewed publications or conference presentations. REGISTRATION:: osf.io/xvhzf. ETHICAL APPROVAL: 69003717.2.0000.5505.

Early mobilization for children in intensive therapy: A protocol for systematic review and meta-analysis.

INTRODUCTION: Intensive care units focus primarily on life support and treatment of critically ill patients, but there are many survivors with complications, such as generalized muscle disorders, functional disability and reduced quality of life after hospital discharge, resulting from prolonged stays in these units. The current evidence suggests that early mobilization-based rehabilitation (exercise initiated immediately after the patient's significant physiological changes have stabilized) in critically ill adults can alleviate these complications from immobility and critical illness. However, there are a lack of practice guidelines, conflicting perceptions about safety, and knowledge gaps about benefits in the critically ill paediatric population. Therefore, we aim to assess the effects of early mobilization for children in intensive therapy. METHODS AND ANALYSIS: Systematic searches will be carried out in Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Centre on Health Sciences Information, Cumulative Index to Nursing & Allied Health Literature and physiotherapy evidence database databases at a minimum without date or language restrictions for relevant individual parallel, cross-over and cluster randomized controlled trials. In addition, a search will also be carried out in the World Health Organization International Clinical Trials Registry Platform, and in the clinical trial registries of ClinicalTrials.gov, looking for any on-going randomised controlled trials that compare early mobilization with any other type of intervention. Two review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion or by arbitration. The primary outcomes will be mortality and adverse events. Secondary outcomes will include duration of critical care (days), duration of mechanical ventilation support, muscle strength, pain and neuropsychomotor development. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevMan 5 software (e.g., if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. ETHICS AND DISSEMINATION: This protocol was prospectively registered at Open Science Framework and approved by the Ethics and Research Committee of the Federal University of Sao Paulo (8543210519). We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal. REGISTRATION:: osf.io/ebju9.

Effect of 7 Months of Physical Training and Military Routine on the Bone Mass of Young Adults.

INTRODUCTION: Physical activity (PA) has a great influence on bone mineral density (BMD) and bone mineral content (BMC), however longitudinal studies that seek to relate bone mass to physical activity are scarce and have a small sample size. The aim of this study was to evaluate and compare the effect of 7 months of military physical training (MPT), impact sports (IS), and swimming in the bone mass of young military adults. MATERIALS AND METHODS: A prospective study was conducted with 213 military school students (male and aged 19.2 ± 1.2 years) divided into three groups: MPT (n = 144), IS (n = 56), and Swimming (n = 13). Dual-energy X-ray absorptiometry was used to determine body composition (percentage of fat, fat mass, and fat-free mass) and bone mass (BMD, BMD Z-Score, total BMC, arm BMC, leg BMC, and trunk BMC), at the beginning of the military service and after 7 months of training. RESULTS: It was observed a significant increase in BMD, BMD Z-Score, total BMC and BMC of all segments analyzed for all groups (p < 0.01). There was a significantly greater variation in BMD of the IS group in relation to the MPT group (p < 0.01), and in the arm BMC of the MPT group in relation to the IS group (p < 0.05). CONCLUSION: After 7 months of training, there were significant increases in BMC and BMD of all the groups evaluated. The bone response was associated with the muscular group used in the physical exercise and the IS group showed greater gain in BMD.

O índice de diluição de esgoto e o estudo de caso da região metropolitana de São Paulo / The sewage dilution index and the case study of São Paulo's metropolitan area

A implantação e a ampliação dos sistemas de esgotamento sanitário devem contemplar não só aspectos políticos, técnicos e econômicos, mas também sociais, ambientais e de sustentabilidade. Para subsidiar a tomada de decisão com base neste paradigma, e auxiliar na definição das prioridades de intervenções, propõe-se aqui um novo indicador de sustentabilidade, que aqui foi denominado de Índice de Diluição de Esgoto - IDE. Este índice correlaciona a vazão de esgoto sanitário não tratado com a vazão dos corpos d'água e permite efetuar a avaliar o sistema de esgotamento sob a ótica da capacidade suporte do ambiente. A revisão bibliográfica abordou quatro temas: os esgotos sanitários, os recursos hídricos superficiais, a poluição dos corpos d'água por esgoto sanitário e os indicadores de sustentabilidade. Com base nos parâmetros de qualidade padrões dos esgotos sanitários e dos corpos d'água limpos, bem como na legislação ambiental, foram identificadas quatro faixas de risco associadas aos valores do IDE: acima de 0,1% há o risco à saúde e à eutrofização de represas, acima de 5% à comunidade aquática, acima de 10% à harmonia paisagística e acima de 15% à harmonia odorífera. Com o IDE desenvolvido, foi estudado o caso da Região Metropolitana de São Paulo - RMSP: o valor do índice foi calculado para as suas diversas sub-bacias de esgotamento. As bacias com os maiores valores de IDE situam-se em um anel que circunda a RMSP, enquanto que aquelas com os menores valores, nas porções interna e externa deste anel. Poucas sub-bacias apresentaram valores inferior a 0,1% e muitas apresentaram valores acima de 15%, que extrapola os 200% em alguns casos. O estudo da RMSP foi realizado à luz de variáveis territoriais e socioeconômicas, o que propiciou uma discussão do diagnóstico e do planejamento do sistema de esgotamento sob a ótica da sustentabilidade e dos riscos associados

The implementation and expansion of sewage systems should include not only political, technical and economic aspects, but also social, environmental and sustainability aspects. In order to support decision-making based on this paradigm and to endorse the interventions's priorities selection, a new sustainability indicator is proposed here, which has been called Sewage Dilution Index - SDI. This index correlates untreated sanitary sewage flow with the water bodies flow and allows the evaluation of the sewage system from the perspective of environmental support capacity. The literature review addressed four themes: sanitary sewage, surface water resources, pollution of water bodies by sanitary sewage and sustainability indicators. Based on the sanitary sewers and clean water bodies quality parameters standard, as well as environmental legislation, four risk ranges were identified associated with SDI values: above 0.1% a health and reservoir eutrophication risk was identified, above 5% an aquatic community risk, above 10% a landscape harmony risk and above 15% an odoriferous harmony risk. After the SDI was developed, it was accomplished the São Paulo's Metropolitan Area - SPRA case study: the sewage's índex values was calculated for it's sewage's sub-basins. The sub-basins with the highest values of SDI are located in a ring that surrounds the SPRA, whereas those with the lowest values are located inside and outside of this ring. Few sub-basins presented values below 0,1% and many showed values above 15%, which exceeds 200% in some cases. The SPRA case study was accomplished associated with territorial and socioeconomic variables, which allowed a discussion of the diagnosis and planning of the sewage system from the sustainability and associated risks point of view

Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as important health care-associated pathogens. Colonization precedes infection but the risk of developing infection amongst those colonized with CRE is not clear. METHODS: We searched multiple databases for studies reporting rates of CRE-colonized patients subsequently developing infection. RESULTS: Ten studies fulfilled our inclusion criteria, including 1,806 patients used in our analysis. All studies were observational and conducted among adult inpatients. The cumulative rate of infection was 16.5% in our study. The most common site of infection was the lung, identified in half of patients, followed in decreasing frequency by urinary tract; primary bloodstream; and skin and soft tissue, including surgical sites. Colonization or infection by CRE prolonged stay and was associated with a 10% overall mortality in our analysis. CONCLUSION: Our study results suggest an overall 16.5% risk of infection with CRE amongst patients colonized with CRE. Given the high mortality rate observed with CRE infection and the difficulty in treating these infections, research to investigate and develop strategies to eliminate the colonization state are needed.

Registro prospectivo de estrategias diagnósticas implementadas para tromboembolia venosa en servicios de medicina intensiva de Santa Fe / Prospective Registry of Diagnostic Strategies Applied on Venous Thromboembolism in Intensive Care Units of Santa Fe

Introducción La tromboembolia venosa es una enfermedad frecuente con una morbimortalidad elevada, que puede reducirse en forma drástica cuando la condición se reconoce y trata precozmente. Su diagnóstico tropieza con dos dificultades: la baja sospecha clínica y la complejidad de los recursos técnicos requeridos no siempre disponibles, lo que dificulta la aplicación de los algoritmos propuestos en las guías. Objetivos Evaluar las estrategias diagnósticas en los servicios de cuidados intensivos de la ciudad de Santa Fe ante la sospecha de tromboembolia venosa, identificar si se utiliza algún algoritmo diagnóstico y el grado de incertidumbre diagnóstica final. Material y métodos Se convocó a todos los servicios de cuidados intensivos para adultos de la ciudad de Santa Fe para la elaboración de un registro prospectivo, multicéntrico y observacional con el reclutamiento de los pacientes internados con sospecha de tromboembolia venosa [(trombosis venosa profunda (TVP) y/o tromboembolia pulmonar (TEP)]. Resultados En un período de 3 meses y medio se internaron 3.042 pacientes en los 19 servicios de cuidados intensivos de la ciudad. Se sospechó tromboembolia venosa en 83 pacientes (50 TEP, 10 TVP y 23 TEP + TVP). El diagnóstico se confirmó en 25 (30,1%), se descartó en 33 (39,8%) y permaneció incierto en 25 (30,1%). La incertidumbre diagnóstica final fue del 25,7% en los servicios privados y del 66,6% en los públicos. La tasa de sospecha fue del 2,7% (rango 0,9% a 8,8%). No hubo empleo sistemático de guías clínicas ni de consensos conocidos. Conclusiones Este registro mostró un índice de sospecha global bajo para tromboembolia venosa, no se utilizaron los algoritmos diagnósticos propuestos en guías y consensos y el diagnóstico per­maneció incierto en el 30,1%.

Introduction Venous thromboembolism is a common disease with high morbidity and mortality which can be reduced drastically with early diagnosis and treatment. The diagnosis of venous thromboembolism faces two difficulties: the low clinical suspicion and the complexity of the technical resources required which are not always available, making it difficult to apply the algorithms recommended by the guidelines. Objectives The evaluate the diagnostic strategies used by the intensive care units in the city of Santa Fe when venous thromboembolism suspected, and to identify if any diagnostic algorithm is applied and the degree of final uncertain diagnosis. Methods A prospective multicenter and observational registry of patients hospitalized with suspicion of venous thromboembolism [(deep venous thrombosis (DVT) and/or pulmonary embolism (PE)] was elaborated by all the adult intensive care units. Results Over a three and a half-month period, 3042 patients were hospitalized in the 19 intensive care units of the city. Venous thromboembolism was suspected in 83 patients (50 PE, 10 DVT and 23 PE + DVT). The diagnosis was confirmed in 25 (30.1%), was ruled out in 33 (39.8%) and remained uncertain in 25 (30.1%). The final uncertain diagnosis was 25.7% in private centers and 66.6% in public hospitals. The index of suspicion was 2.7% (range 0.9% to 8.8%). The algorithms recommended by guidelines were not systematically used. Conclusions This registry showed a low global index of suspicion for venous thromboembolism, the algorithms recommended by guidelines were not used and the final uncertain diagnosis was 30.1%.

Registro prospectivo de estrategias diagnósticas implementadas para tromboembolia venosa en servicios de medicina intensiva de Santa Fe / Prospective Registry of Diagnostic Strategies Applied on Venous Thromboembolism in Intensive Care Units of Santa Fe

Introducción La tromboembolia venosa es una enfermedad frecuente con una morbimortalidad elevada, que puede reducirse en forma drástica cuando la condición se reconoce y trata precozmente. Su diagnóstico tropieza con dos dificultades: la baja sospecha clínica y la complejidad de los recursos técnicos requeridos no siempre disponibles, lo que dificulta la aplicación de los algoritmos propuestos en las guías. Objetivos Evaluar las estrategias diagnósticas en los servicios de cuidados intensivos de la ciudad de Santa Fe ante la sospecha de tromboembolia venosa, identificar si se utiliza algún algoritmo diagnóstico y el grado de incertidumbre diagnóstica final. Material y métodos Se convocó a todos los servicios de cuidados intensivos para adultos de la ciudad de Santa Fe para la elaboración de un registro prospectivo, multicéntrico y observacional con el reclutamiento de los pacientes internados con sospecha de tromboembolia venosa [(trombosis venosa profunda (TVP) y/o tromboembolia pulmonar (TEP)]. Resultados En un período de 3 meses y medio se internaron 3.042 pacientes en los 19 servicios de cuidados intensivos de la ciudad. Se sospechó tromboembolia venosa en 83 pacientes (50 TEP, 10 TVP y 23 TEP + TVP). El diagnóstico se confirmó en 25 (30,1%), se descartó en 33 (39,8%) y permaneció incierto en 25 (30,1%). La incertidumbre diagnóstica final fue del 25,7% en los servicios privados y del 66,6% en los públicos. La tasa de sospecha fue del 2,7% (rango 0,9% a 8,8%). No hubo empleo sistemático de guías clínicas ni de consensos conocidos. Conclusiones Este registro mostró un índice de sospecha global bajo para tromboembolia venosa, no se utilizaron los algoritmos diagnósticos propuestos en guías y consensos y el diagnóstico per¡maneció incierto en el 30,1%.(AU)

Introduction Venous thromboembolism is a common disease with high morbidity and mortality which can be reduced drastically with early diagnosis and treatment. The diagnosis of venous thromboembolism faces two difficulties: the low clinical suspicion and the complexity of the technical resources required which are not always available, making it difficult to apply the algorithms recommended by the guidelines. Objectives The evaluate the diagnostic strategies used by the intensive care units in the city of Santa Fe when venous thromboembolism suspected, and to identify if any diagnostic algorithm is applied and the degree of final uncertain diagnosis. Methods A prospective multicenter and observational registry of patients hospitalized with suspicion of venous thromboembolism [(deep venous thrombosis (DVT) and/or pulmonary embolism (PE)] was elaborated by all the adult intensive care units. Results Over a three and a half-month period, 3042 patients were hospitalized in the 19 intensive care units of the city. Venous thromboembolism was suspected in 83 patients (50 PE, 10 DVT and 23 PE + DVT). The diagnosis was confirmed in 25 (30.1%), was ruled out in 33 (39.8%) and remained uncertain in 25 (30.1%). The final uncertain diagnosis was 25.7% in private centers and 66.6% in public hospitals. The index of suspicion was 2.7% (range 0.9% to 8.8%). The algorithms recommended by guidelines were not systematically used. Conclusions This registry showed a low global index of suspicion for venous thromboembolism, the algorithms recommended by guidelines were not used and the final uncertain diagnosis was 30.1%.(AU)

O sistema municipal de meio ambiente no Brasil: avanços e desafios / Environmental municipal system: advances and challenges

O papel dos governos locais, antes vistos como mero prestadores de serviços, vem evoluindo, pós-Constituição de 1988, para o de agentes do desenvolvimento local. Neste contexto, eles devem assumir o seu papel constitucional de zelar pelo meio ambiente, tomando a decisão de envolver-se com o tema e capacitando-se através da instituição de um Sistema Municipal de Meio Ambiente - SISMUMA. O SISMUMA é um conjunto de órgãos e entidades do Município que são responsáveis pela preservação, conservação, proteção, defesa, melhoria, recuperação e controle do meio ambiente e uso adequado dos recursos ambientais do Município. Este Sistema é uma estrutura político-administrativa que em última instância visa a inserção do componente ambiental no processo de tomada de decisão local, por meio da formulação, implementação e avaliação de políticas ambientais e integração com outras políticas, considerando a realidade e potencialidade de cada região, em conformidade com os princípios de desenvolvimento sustentável. Este artigo visa caracterizar e contextualizar o SISMUMA no Brasil, discutindo o seu papel estratégico na governança para a sustentabilidade municipal, entendida como processo de articulação e negociação que potencializa a integração do componente ambiental no processo de tomada de decisão local, e consequentemente, no processo de desenvolvimento local.

After Brazilian 1988 Federal Constitution, the role of local governments is evolving from being seen as mere provider of services to being the local development agents. In this context, they must assume their constitutional role of looking after the environment, taking the decision of becoming involved in this matter and to qualify themselves by establishing a Environment Municipal System – SISMUMA. The SISMUMA is a group of municipal agencies and entities responsible for the preservation, conservation, protection, defense, improvement, restoration and control of the environment and appropriate use of the environmental resources of the municipality. This system is a political-administrative structure that ultimately aims at the integration of the environmental component in the local decision-making process, through the formulation, implementation and evaluation of environmental policies and integration with other policies. This is done considering the reality and potentiality of each region, in accordance with the principles of sustainable development. This article aims to characterize and contextualize the SISMUMA in Brazil, discussing its strategic role in municipal governance for the sustainability, role known as an articulation and negotiation process which reinforces the environmental integration component in the local decision-making , and consequently in the local development process.

O sistema municipal de meio ambiente no Brasil: avanços e desafios / Environmental municipal system: advances and challenges

O papel dos governos locais, antes vistos como mero prestadores de serviços, vem evoluindo, pós-Constituição de 1988, para o de agentes do desenvolvimento local. Neste contexto, eles devem assumir o seu papel constitucional de zelar pelo meio ambiente, tomando a decisão de envolver-se com o tema e capacitando-se através da instituição de um Sistema Municipal de Meio Ambiente - SISMUMA. O SISMUMA é um conjunto de órgãos e entidades do Município que são responsáveis pela preservação, conservação, proteção, defesa, melhoria, recuperação e controle do meio ambiente e uso adequado dos recursos ambientais do Município. Este Sistema é uma estrutura político-administrativa que em última instância visa a inserção do componente ambiental no processo de tomada de decisão local, por meio da formulação, implementação e avaliação de políticas ambientais e integração com outras políticas, considerando a realidade e potencialidade de cada região, em conformidade com os princípios de desenvolvimento sustentável. Este artigo visa caracterizar e contextualizar o SISMUMA no Brasil, discutindo o seu papel estratégico na governança para a sustentabilidade municipal, entendida como processo de articulação e negociação que potencializa a integração do componente ambiental no processo de tomada de decisão local, e consequentemente, no processo de desenvolvimento local.(AU)

Riesgo relativo, sensibilidad y especificidad: un enfoque desde el análisis matemático y el álgebra lineal / Relative risk, sensitivity, specificity: an approach from mathematical analysis and linear algebra

El riesgo relativo (RR), la razón de productos cruzados (OR), la especificidad (E) y la sensibilidad (S) constituyen medidas de resumen para variables cualitativas de interés en Medicina. Se presenta el RR como una función continua de dos variables y se analiza la condición para la cual este se aproxima a la OR a partir de su desarrollo en serie de potencias. La sensibilidad, la especificidad y los valores predictivos (VPP y VPN) se analizan como funciones continuas de una variable en todo su dominio, con un comportamiento asintótico característico. A partir del estudio de un sistema de ecuaciones lineales homogéneo se deduce una ecuación general que vincula S, E, VPP y VPN y se discuten diferentes casos de interés(AU)

The relative risk (RR), the odds ratio (OR), the specificity (E) and the sensitivity (S) are measures for qualitative variables of medical interest in Medicine. It is analysed the RR as a continue function of two variables as well as the conditions by which it is approximated to the OR by means of a power series expansion. It is analysed too the sensitivity, the specificity and the predictive values as continue functions of one variable in all its domains of definition as well as the asymptotic behaviour of these functions. It is discussed different interesting cases by means of a system of linear equations in S, E, VPP, VPN(AU)

Procesamiento de las observaciones satelitales gps para el estudio de variaciones del nivel medio del mar en Venezuela / Processing of gps satellite observations for studying mean sea level variations in Venezuela / Processamento das observações satelitais gps para o estudo de variações do nível medio do mar na Venezuela

La determinación del nivel medio de mar (NMM) es una de las tareas de mayor importancia para la Geodesia, debido a su coincidencia con el geoide. En una primera aproximación, el NMM define el sistema de referencia vertical de cada país. En Venezuela, el NMM ha sido estimado a partir de registros realizados en estaciones mareográficas distribuidas a lo largo de la costa, durante largos periodos de tiempo. Los posibles cambios de esta superficie han sido determinados a partir de un análisis de dichos registros sin tomar en cuenta fuentes de movimiento terrestre y la interconexión de los mareógrafos, generando una representación aproximada de las variaciones del NMM. Ello ha motivado el desarrollo de una metodología que permita monitorizar y registrar los cambios en el NMM mediante técnicas geodésicas espaciales como de altimetría satelital y GPS. Se planificó y ejecutó la primera campaña de mediciones GPS en los mareógrafos de la red nacional. La naturaleza y exactitud requerida en la determinación de posiciones ameritó el desarrollo de una metodología de procesamiento adecuada. Se utilizó el Bernese GPS Software V 5.0 como plataforma para el diseño de dos estrategias de procesamiento y se utilizaron los servicios de procesamiento online CSRS-PPP y SCOUT con fines comparativos. Se describen las metodologías utilizadas y los criterios para la selección de la mejor opción de procesamiento.

Due to its coincidence with the geoid, the definition tool for most national vertical reference systems, the mean sea level (MSL) is considered as one of the most important tasks in Geodesy. The Venezuelan MSL has been established by long time records at various tide gauging stations alongside the coastline. These original registrations have been analyzed without consideration of possible landslides or ground movements at the stations, nor the interconnection of gauging stations, leading to an approximate image of MSL variations. Thus, a methodology has been developed to monitor and register MSL changes using spatial geodetic techniques such as GPS and satellite altimetry. A first simultaneous GPS observation campaign on all tide gauging stations in the country was planned and carried out. An adequate processing method was developed for obtaining high accuracy position results. Using the Bernese GPS Software Version 5.0 as a processing tool, two different strategies were applied and compared with the results from CSRS and SCOUT Precise Point Processing techniques. The methodologies applied and decision making critera for the best processing option are described.

A determinação do nível médio do mar (NMM) é uma das tarefas de maior importância para a Geodésia, devido à sua coincidência com o geóide. Em uma primeira aproximação, o NMM define o sistema de referencia vertical de cada país. Na Venezuela, o NMM tem sido estimado a partir de registros realizados em estações maregráficas distribuídas ao longo da costa, durante longos períodos de tempo. As possíveis mudanças desta superfície têm sido determinadas a partir de uma análise de ditos registros sem levar em consideração fontes de movimento terrestre e a interconexão dos marégrafos, gerando uma representação aproximada das variações do NMM. Isto tem motivado o desenvolvimento de uma metodologia que permita monitorar e registrar as mudanças no NMM mediante técnicas geodésicas espaciais de altimetria satelital e GPS. Planificou-se e executou-se a primeira campanha de medições GPS nos marégrafos da rede nacional. A natureza e exatidão requerida na determinação de posições exigiram o desenvolvimento de uma metodologia de processamento. Utilizou-se o Bernese GPS Software V 5.0 como plataforma para o desenho de duas estratégias de processamento e se utilizou os serviços de processamento on-line CSRS-PPP e SCOUT com fins comparativos. Descrevem-se as metodologias utilizadas e os critérios para a seleção da melhor opção de processamento.

Aplicaciones de la inteligencia artificial en la Medicina: perspectivas y problemas / Artificial intelligence applied to medicine: prospects and problems

Los avances experimentados en el campo de la informática médica en Cuba comprenden la investigación, la docencia, la asistencia secundaria y primaria; así como la gerencia de las instituciones de salud. En este campo, las aplicaciones pertenecientes a la denominada área de la inteligencia artificial despiertan un gran interés, debido a sus posibilidades para involucrarse en situaciones donde se requiere un gran acervo de conocimientos médicos, el veloz procesamiento de los datos y la toma efectiva de decisiones. Se valoran las perspectivas de uso de sistemas con comportamiento inteligente en el ámbito médico cubano, un objetivo básico en el sector de la salud, debido a la prioridad concedida a las investigaciones fundamentales y aplicadas en ciencias médicas en función de los programas dirigidos al mejoramiento de la salud de nuestro pueblo. Se plantean algunos problemas relevantes de cuya solución dependerá la implementación de ingenios que simulen el intelecto del médico en toda su dimensión. La aplicación de la inteligencia artificial en la Medicina, además de requerir de una adecuada delimitación de sus metas y tareas, plantea serias dificultades en los planos científicos, tecnológicos, filosóficos y éticos. A pesar de los esfuerzos, su concepto se utiliza todavía en no pocos casos para referirse a ciertas simulaciones por computadoras de operaciones consideradas antes inherentes al hombre mientras que las computadoras con atributos de inteligencia artificial son aún muy limitados, no perciben la semántica de la información y exhiben posibilidades lógicas muy modestas comparadas con las mostradas por los médicos.

The advances attained in Medical Informatics in Cuba include research, teaching, primary and secondary health care, as well as the management of health institutions. In this field, the applications in the area called Artificial Intelligence arouse great interest because of their possibilities to be involved in situations where it is required a wealth of medical knowledge, the rapid data processing and the effective decision making. The prospects for using systems with intelligent behaviour in the Cuban medical area, a basic objective in the health sector due to the priority given to the fundamental and applied research in the medical sciences in function of the programs aimed at improving the health of our people, are assessed. The implementation of devices simulating the intellect of the doctor in all its dimension will depend on the solution of some significant problems that are exposed. The application of Artificial Intelligence in medicine, in addition to require an adequate delimitation of tasks and goals, poses serious difficulties at the scientific, technological, philosophical and ethic spheres. Despite the efforts, its concept is yet used in many cases to refer to certain computer simulations of operations that before were considered inherent to man while the computers with attributes of Artificial Intelligence are still very limited, do not perceive the semantics of the information and show very modest logical possibilities in comparison with those of the physicians.

Aplicaciones de la inteligencia artificial en la Medicina: perspectivas y problemas / Artificial intelligence applied to medicine: prospects and problems

Los avances experimentados en el campo de la informática médica en Cuba comprenden la investigación, la docencia, la asistencia secundaria y primaria; así como la gerencia de las instituciones de salud. En este campo, las aplicaciones pertenecientes a la denominada área de la inteligencia artificial despiertan un gran interés, debido a sus posibilidades para involucrarse en situaciones donde se requiere un gran acervo de conocimientos médicos, el veloz procesamiento de los datos y la toma efectiva de decisiones. Se valoran las perspectivas de uso de sistemas con comportamiento inteligente en el ámbito médico cubano, un objetivo básico en el sector de la salud, debido a la prioridad concedida a las investigaciones fundamentales y aplicadas en ciencias médicas en función de los programas dirigidos al mejoramiento de la salud de nuestro pueblo. Se plantean algunos problemas relevantes de cuya solución dependerá la implementación de ingenios que simulen el intelecto del médico en toda su dimensión. La aplicación de la inteligencia artificial en la Medicina, además de requerir de una adecuada delimitación de sus metas y tareas, plantea serias dificultades en los planos científicos, tecnológicos, filosóficos y éticos. A pesar de los esfuerzos, su concepto se utiliza todavía en no pocos casos para referirse a ciertas simulaciones por computadoras de operaciones consideradas antes inherentes al hombre mientras que las computadoras con atributos de inteligencia artificial son aún muy limitados, no perciben la semántica de la información y exhiben posibilidades lógicas muy modestas comparadas con las mostradas por los médicos(AU)

The advances attained in Medical Informatics in Cuba include research, teaching, primary and secondary health care, as well as the management of health institutions. In this field, the applications in the area called Artificial Intelligence arouse great interest because of their possibilities to be involved in situations where it is required a wealth of medical knowledge, the rapid data processing and the effective decision making. The prospects for using systems with intelligent behaviour in the Cuban medical area, a basic objective in the health sector due to the priority given to the fundamental and applied research in the medical sciences in function of the programs aimed at improving the health of our people, are assessed. The implementation of devices simulating the intellect of the doctor in all its dimension will depend on the solution of some significant problems that are exposed. The application of Artificial Intelligence in medicine, in addition to require an adequate delimitation of tasks and goals, poses serious difficulties at the scientific, technological, philosophical and ethic spheres. Despite the efforts, its concept is yet used in many cases to refer to certain computer simulations of operations that before were considered inherent to man while the computers with attributes of Artificial Intelligence are still very limited, do not perceive the semantics of the information and show very modest logical possibilities in comparison with those of the physicians(AU)

Evaluation of abdominal wall strength after TRAM flap surgery.

Evaluation of abdominal wall function after transverse rectus abdominis musculocutaneous (TRAM) flap surgery has been mostly subjective. The purpose of this study was to measure abdominal wall strength objectively and to compare the results with the patient's performance of daily activities. Abdominal wall strength was objectively measured with the B200 IsoStation machine preoperatively and 1 year after TRAM flap breast reconstruction. These data were compared with the results of a questionnaire evaluating the patient's performance of daily activities. The results of this testing in 21 patients demonstrated the following: (1) a decrease in abdominal wall strength after bilateral pedicled TRAM flap surgery, which was significant in trunk flexion (34.2 +/- 16.9 ft-lbs to 20.6 +/- 15.2 ft-lbs); (2) compensation by other truncal musculature, with an increase in the strength of trunk rotation (18.8 +/- 13.5 ft-lbs to 28.6 +/- 17.7 ft-lbs) seen after unilateral pedicled TRAM flap surgery; (3) minimal interference with the patient's daily activities; and (4) no effect of mesh on strength. A relationship was demonstrated between the degree of loss of strength in trunk flexion and the patient's difficulty in performing certain activities. The patients who had the greatest loss in trunk flexion following the use of both pedicles also had the most difficulty in performing some daily activities. The patients were satisfied with their reconstructive procedure, with an average score of 8.3 (on a scale of 1 to 10), and reported an improvement in the appearance of their abdomen, with an average increase of 5.1 to 6.8 (on a scale of 1 to 10).