Дисертації з теми "Trauma systems"

Flood literature presents an inconsistent account of post-disaster distress; debating whether distress is pathological or normal and attempting to understand distress in terms of disaster variables. The literature therefore provides little guidance as to how to formulate difficulties in a clinically meaningful way reflective of individual’s experiences. The SPAARS model is presented as a model by which to reconcile these differences and quantitative support for its concepts were studied within two flooded samples. Participants who were flooded in Carlisle in 2005 (n=32) and participants flooded in Morpeth in 2008 (n=29) provided two samples at different stages in flood recovery and facilitated a quasi-longitudinal sample for comparison of flood-related distress over time. Participants were asked to complete a survey pertaining to: basic emotions experienced during the flood event, basic emotions experienced after the flood, Impact of Events Scale-Revised (IES-R), Regulation of Emotions Questionnaire (REQ) and the Trauma Symptom Inventory (TSI). Findings suggest that a third of participants who were flooded experienced clinically significant levels of distress, even after four years. Both samples showed higher levels of impact symptoms on the IES compared to symptoms on the TSI. Anxiety and anger were significant in reported flood experiences both during and after the flooding. Flood-related variables and previous experiences had no effect on increased distress but greater use of internal-dysfunctional emotion regulation strategies was related to increased impact and distress symptoms. Study findings and the SPAARS model are discussed in relation to previous flooding and PTSD literature, as well as clinical implications for the treatment of post-disaster distress and for the future management of flood-affected populations.

Rehabilitation outcomes are an important measurement of trauma system effectiveness. However, currently there is no clinically applicable trauma rehabilitation score or framework available to evaluate health and rehabilitation needs after trauma. The World report on Disability (2011) recommended the application of the World Health Organisation International Classification of Function, Disability and Health (ICF) as a framework for all aspects of rehabilitation. A standardised language, based on coded categories would aid in international efforts to evaluate health and disability globally. The ICF framework has not been applied in trauma rehabilitation or trauma systems to date. The objectives were to investigate rehabilitation needs of trauma patients and evaluate to what extent the ICF can be used as a framework to capture and assess health and rehabilitation outcome of patients following traumatic injuries. Two cohort studies with 103 and 308 patients respectively demonstrated the utility of the Rehabilitation Complexity Scale (RCS) in an acute trauma setting. The RCS outperformed other acute measures and rehabilitation complexity correlated with length of stay and discharge destination. A systematic review of 34 articles confirmed that outcome measures frequently used in trauma outcome studies represent only six percent of health concepts contained in the ICF. A quantitative international on-line questionnaire with expert clinicians working in trauma (n=217), identified 121 ICF categories pertinent to rehabilitation and health outcome of trauma patients. Qualitative patient interviews (n=32) identified nearly double the amount of ICF categories (n=234) compared to clinicians. Combined analysis of qualitative and quantitative data presents 109 ICF categories important for rehabilitation and health outcome assessment of trauma patients, using the ICF as a framework. This thesis describes the need for improved outcome evaluation of trauma patients. It demonstrates the acceptability of the ICF language and framework amongst clinicians and suggests the application of the ICF as a framework for trauma service delivery and outcome assessment.

The work presented in this thesis focuses on the design and testing of a casualty extraction robot intended to stabilize the head and neck of an unresponsive person. The employment of robots in dangerous locales such as combat zones or the site of a natural disaster has the potential to help keep first responders out of harm's way as well as to improve the efficiency of search and rescue teams. After a review of robotic search and rescue platforms the Semi-Autonomous Victim Extraction Robot(SAVER) is introduced. The necessity of a device intended to support the head and cervical spine during transport on a rescue robot is then discussed. The kinematic and dynamic analyses of various candidate differential mechanisms intended for the head stabilization device are described, and the chosen mechanism is demonstrated in a proof-of-concept device. Following testing with a simple PID controller, it was determined an advanced feedback controller with disturbance rejection capabilities was required. Linear Active Disturbance Rejection Control (LADRC) was chosen for its effectiveness in rejecting perturbations and handling modeling uncertainties. The performance the proposed LADRC control scheme was compared with PID in simulation and the results are presented. Finally, a prototype of the device was designed and built to validate the functionality of the subsystem, and the results of the corresponding experimentation are discussed.
M. S.

Background: Trauma is a significant public health problem both in the UK and beyond. It can have a devastating impact on individuals, their family and society. The care of injured patients has long been thought to be sub-standard in the UK and patient outcomes were noted to be worse than other developed countries. Between 2010-12 regional trauma systems were introduced in England, with the aim of improving survival and long-term outcomes of injured patients. The aim of this study was to critically assess the implementation of these trauma systems on processes and outcomes of care in two regions of England. Methods: A systematic review was undertaken to identify studies evaluating the association between an inclusive trauma system and patient outcome. A mixed-methods approach was used for the study. Data on trauma deaths were obtained from the UK Office for National Statistics (ONS). The Trauma Audit and Research Network (TARN) database was interrogated to provide data on all patients who presented to hospital within two years before and two years after trauma system implementation. A time-series analysis and a before and after study, using a comparator region to control for temporal trends, was undertaken for each region. Twenty semi-structured interviews with Emergency Department (ED) staff were conducted to gain a broader understanding of the effect of this change. Data were then merged and areas of convergence and discrepancy highlighted. Results: The systematic review identified eight observational studies that all demonstrated a significant fall in the odds of death when patients presenting with traumatic injuries were treated within such a system. However, they were deemed to represent a very low-quality body of evidence. ONS data demonstrated that whilst trauma mortality rates were stable, between 30- 50% die outside of hospital. Analysis of TARN data demonstrated that, following system implementation, a greater proportion of injured patients were seen at Major Trauma Centres (MTCs), quality of care indices such as time to CT scan improved and mortality fell. Analysis of the interviews revealed seven main themes and whilst all staff welcomed the commitment to improve trauma care, some, especially outside of the MTCs, expressed concerns about disengagement and being unable to provide the level of care expected. Conclusions: This study adds to the body of evidence supporting the role of inclusive trauma systems in improving quality of care indices and patient outcomes. Contrary to some other studies, this study has shown improvements within two years, particularly at MTCs. Whilst most ED staff interviewed corroborated this view, some barriers to delivering high quality trauma care were felt to remain. Whilst trauma was once seen as a disease of young men and motor vehicle collisions, it is now dominated by falls in the elderly population and trauma systems must be able to meet their needs. Further research is warranted to learn more about the large population of trauma patients that do not survive to reach hospital. Perhaps some of the greatest future improvements of trauma systems are to be found here.

This master’s thesis proposed an integrative group counseling intervention utilizing trauma-focused cognitive behavioral therapy (TF-CBT), attachment theory, and mindfulness for youth who have experienced Adverse Childhood Experiences (ACEs). The proposed group is intended as a Tier 2 support in a trauma-informed multi-tiered system of supports on a school campus; however, the group can be offered in mental health treatment settings. Synopses of the research described the symptomology of trauma, detailing the adverse consequences for youth who have experienced trauma, including the neurobiological impairments, mental health challenges, social limitations, maladaptive behavioral outcomes, harmful academic impact, and negative health outcomes. The literature review substantiated the probable benefits of the use each component of this integrative group counseling intervention to support youth with post-trauma difficulties. The integrative intervention is designed to reduce trauma symptomology, improve attachment patterns, and increase mindfulness in youth who have ACEs. Limitations, implications and recommended future research are discussed.

As healthcare and health systems become increasingly complex, expectations of what constitutes high quality care continue to evolve. Stakeholders now require contemporary and meaningful measures of system performance. As such, valid healthcare quality metrics are rapidly becoming essential for those providing and receiving healthcare to assess performance and motivate change. This thesis investigates the utility of quality indicators in trauma care. Multiple in-hospital indicators have been promulgated by various bodies for assessing quality of trauma care. The properties of ideal indicators have been widely documented however few published data have reported these properties for many trauma measures. The emphasis on trauma process measures (eg. time to interventions) highlights the need for indicators with known links to patient outcomes. This process-outcome link may be viewed as a measure of an indicator’s construct validity. As this property is unknown for many trauma indicators, this thesis focuses on the construct validity of a number of routinely utilised trauma indicators. In this thesis, the available in-hospital indicators proposed by The American College of Surgeons Committee on Trauma and additional indicators used in the Victorian State Trauma System were investigated for their relationships with patient outcomes. A small number of indicators were found to have statistically significant relationships with patient outcomes, however many indicators demonstrated counter-intuitive relationships, whereby high quality care was linked with poorer patient outcomes. These results suggested that links between indicators and outcomes may not be best measured using individual indicators for individual patients. Rather, a strategy for measuring patient outcomes at the hospital level may be needed. To combine multiple indicators into a single measure of hospital level performance, a number of composite methods were explored using two trauma registries. Three composite weighting schemes were employed. As composite measures are often used for provider ranking or benchmarking, the stability of hospital ranks between providers and over time was investigated. The composites were found to have moderate to strong correlations (0.76-0.99) however variability in composite hospital rankings existed, particularly for middle ranking facilities. The construct validity of each available indicator and composite score was investigated through the relationship with hospital level risk-adjusted mortality using Poisson regression models, risk adjusting for expected deaths using the TRISS formulation. Each composite measure demonstrated a significant association with mortality, with the mortality decrease across the middle 50% of each composite score ranging from 12.06% – 16.13%. These findings suggest that complex measures such as trauma composite indices may be better able to measure the interactions between processes within complex systems that influence quality of care. This thesis adds valuable insight into the use of indicators for assessing quality of care in trauma systems. The combination of individual indicators into composite forms appears to strengthen the construct validity of these measures. By demonstrating the process-outcome link for trauma composite indices, this thesis has identified a means of utilising process measures to assess hospital level performance that may become important for future public reporting and hospital funding schemes.

This doctoral study examines the aspects of psychological trauma and investigates why singular explanatory models fail compared with a holistic approach. Part of this integrated approach includes the development of a benchmarked psychometric test, the Sherry Trauma Assessment Test [STAT]) (Copyrighted © Richard Sherry 2011). The test’s reliability was evaluated using Chronbach’s alpha (p< 0.001 levels of significance), which these findings were crosschecked with the findings from eleven other psychometric tests to standardise the results. In comparing the data sets, the STAT test project data was used to both answer fundamental questions within the field of clinical trauma psychology and confirm the reliability of the newly developed psychometric test. Furthermore, the information was collected and used to derive a principle component analysis (PCA) to help in developing a model to support current thinking within the social neuro-scientific arenas as well as to better organize clinical psychology assessment and treatment approaches. These findings have important implications on how trauma, in particular, the human neuropsychological learning process, is addressed. This psychometric foundation was then used to develop this newer model and adaptive tele-medicine platform (Zielinski et al., 2006). This multidisciplinary integration of information, expertise and models, has served to clarify the effects of maturation in relationship to traumatic response and helped to refine the understanding of how traumatic phenomena serves to fragment the integration of embedded systems, and what can be done to reverse these problematic processes in order to replace them with positive cycles of development. The STAT test findings have shown statistically significant results (p< 0.001 level), which provide quantitatively grounded evidence in support of this psychometric measure and improve clinical assessment and treatment approaches. The theoretical model of the STAT test is included in the concept of Integrated Systems Healing, which was developed independently, but has similar theoretical roots in Goetz and Caron’s (2005) bio-psychosocial model of the Systemic Healing used in the treatment of sick children. The author describes further conceptual developments within the concept of Integrated Systems Healing (Copyrighted © Richard Sherry 2011) to include the holistic systems approach, which could be used for a large-scale treatment with specific interacting components of Integration, Compassion, Developmentally scaled interventions, and Sustainability or the ICDS Model (Copyrighted © Richard Sherry 2011). This project has evolved improved strategies for integrative assessment, feedback, and holistic approaches for learning and programme development to improve people’s lives. These foundations of improved internal and external dynamic assessment connect to flexible tele-health approaches, using defined cut-off scores, elearning modules, and strategies for checking and reassessment. Further work links and integrates processes to identify and reduce vulnerability and strengthen resiliency and support.

This thesis investigates perinatal trauma and perinatal mental health, including obsessive compulsive, post-traumatic stress, panic, social phobia, agoraphobia, general anxiety, major depression and postnatal depression symptoms within attachment theory's perspective. It aims to give insight into both caregiving and caretaking experiences of mothers in the pursuit of understanding the aftermath of perinatal trauma Thus it aims to understand first of all, interrelated factors like attachment styles, social support and parental rearing experience in predicting perinatal mental health including anxiety specific symptoms. Then it examines the mediational relationship between support and attachment styles and draws attention to understanding the importance of this relationship in relation to practical implications. This thesis also aims to understand the differences and similarities in various trauma experiences. The final aim of this thesis focuses on the experience of perinatal trauma and the relationship between mothers who experienced previous perinatal trauma and the subsequent infant. The thesis employs both qualitative and quantitative design and analysis techniques.

Leaders play a crucial role in mitigating organizational trauma. Perverse and toxic leaders can disrupt the operating system, including initiating such rupturing events as closing programs or budget cuts. Other times, the disruptions are external and caused by socio-political changes, competitions, and lack of public acceptance. Behavioral health organizations by the nature of their work and the position they occupy in society are at risk of receiving the traumatizing events that change the culture and the operating systems. Leaders are responsible for managing the culture of an organization and mitigating the traumatic events that can result in mediocre services and organizational peril. Transformational leaders possess a great deal of emotional intelligence and believe in their abilities to lead in difficult times. They acknowledge the trauma or traumatizing events, and labor in transforming culture as leaders, employees, and the organization transcends through the events. A Delphi study allowed 18 experts in behavioral health organizations, to share their personal and professional experiences and to arrive at a consensus about leadership roles relating to the phenomenon of organizational trauma. Consequently, the role of leaders in preventing, mitigating, and healing organizational trauma was recognized as an essential role. Last, the experts agreed that transformational leadership styles, as well as emotional intelligence, are necessary interpersonal and professional skills to consider in training and development programs for leaders. The findings were congruent with the knowledge found in the literature review which indicates a need for ongoing study and research.

The current experiment aims to integrate the neuropsychological and physiological consequences of rape trauma and physical restraint. Given the preponderance of rape on college campuses, it is important for continued research efforts to provide insight into the impact that this traumatic experience may have on the victim. Moreover, it is expected that an improved understanding of these consequences and mechanisms will provide a foundation for prevention and treatment efforts. Within this context, capacity theory provides a basis for appreciating that extreme stress may alter and/or damage neural systems principally associated with the regulatory control or inhibition over brain regions directly involved in the experiential processing and/or comprehension of the traumatic event. The aim of the present experiment was to explore how the experience of rape trauma may alter or diminish this capacity, resulting in deregulation, heightened reactivity, and sensitivity to decomposition from subsequent exposure to these events. It was hypothesized that individuals with resultant capacity limitations would differ in the regulatory control of cynical hostility or denial and sympathetic advances of the autonomic nervous system. Results demonstrated that women who have experienced rape showed decreased frontal regulatory control capacity compared to women who have not experienced rape as evidenced in sympathetic reactivity (heart rate, electrodermal activity, and systolic blood pressure) to frontal lobe stressors. Results are discussed in terms of the extant neuropsychological literature and the implications of observed differences for women who have experienced rape type trauma.
Doctor of Philosophy

BACKGROUND. Across Canada there are substantial differences in the organization and evaluation of regional trauma systems. The design, evaluation and improvement of trauma care is frustrated by variable definitions of trauma systems, their primary objectives, and preferred performance measures. Tools that support decision makers in design and policy development are needed 2, 3. OBJECTIVE. This research aimed to 1) describe decision makers’ perceptions of the scope and objectives of ideally organized regional systems of trauma care and injury control in Canada, and 2) identify decision makers’ informational needs, specifically with regard to performance measures meaningful as actionable guidance for the design and policy development of regional systems of trauma care and injury control. METHODS. Based on a literature review of commonly used trauma system performance measures, a 35-question structured electronic survey was constructed, vetted by a reference group of experts, tested, and circulated over a 3-week period. The framing sample was 342 health administrators and trauma directors self-reported to be involved in decision making for organized injury management and control from all health regions of Canada. Survey responses were collated and descriptive statistics generated. RESULTS. There were 82 complete responses for a response rate of 24.0%. There was strong support for a broadly inclusive definition of a trauma system and for government oversight using standard performance indicators. Among responders there was near equal support, 41.2% and 31.7% respectively, for ensuring delivery of rapid and appropriate care (processes of care) and minimizing individual and societal burden of injury (outcomes of care) as the overarching drivers of system design. Of 24 listed performance indicators, measures of timeliness of care, preventable deaths, severity-adjusted hospital mortality, safety, satisfaction and access to care were preferred. CONCLUSION. This study showed that decision makers responsible for regional trauma systems in Canada believe that the ideal trauma system should coordinate multiple agencies influential in injury management around clear system objectives that address both major and minor trauma, and that government endorsed national standards are needed to ensure efficient and effective processes that reduce the individual and societal burden of injury.

This complex practice as research project was designed to interrogate the potential of 'Traumaturgy', an emergent dramaturgical methodology, in addressing the many challenges of writing, staging, and performing, autobiographical trauma narratives and to understand the impact of this process on the psychic, and somatic memories, of the autobiographical performer. The methodology was designed to motivate complex reflections on personal and cultural traumata as critical provocations for the re-writing and performing of the memory-scripts associated with the autobiographical traumatic life events such as adoption, which are explored through the traumaturgical performance process. Rather than distracting the psyche from the autobiographical traumatic experience, the traumaturgy model functions by seeking to establish new internal cognitive networks: positive associations that might facilitate an empowering, liberating transition, initiated through the act of traumaturgically framed narrative performance. Models of trauma intervention locate narrative reconstructions of the traumatic experience as a central focus for the process of recovery (Eagle., 2000; Herman, 1992; Schwartz & Prout, 1991) etc, however, unlike expressive therapies (see Glading, 1991; Moreno, 1975) which exist within the relative safety of the applied theatre space, key to this methodology is the achievement of strategic closure, by returning the performance to the traditional theatre environment and inviting an audience to play the role of witness. This creative synthesis between trauma theory and dramaturgical responses to the staging, and performing of post-traumatic memory based materials, forms the axis of this methodological approach. The research-sharing event In Search of Duende, which represented the performative articulation of this thesis, culminated in the performance of the play Dancing For Franco, which sought to re-write, and re process the researcher’s autobiographical trauma-based memory scripts through its witnessed performance. The play takes the somatic language of flamenco intertwoven with the adoption narratives of the researcher, and individuals affected by the Francoist system of illegal baby theft which are collectively known as the Niños Robados (Spain’s Stolen Children), and the fictional narratives of created characters, to understand how the traumaturgy model might instigate transformational processes within the autobiographical performer.

This qualitative research explored the impact that art therapy and attachment focused treatment may have on a child or adolescent with complex trauma. Literature was reviewed to explore complex trauma in children and adolescents, as well as explore treatment models that include but are not exclusive to art therapy and attachment focused treatment. The current study utilized interviews, as subjects were invited to engage in the art process and discussion with the intent to discover new, in-depth meaning about treating complex trauma in children in adolescents. Data collected from interviews revealed gaps in the mental health system and how art therapy assisted in providing a bridge for the clients to improve their ability to navigate a complex system. Art therapy was found to assist in forming secure attachment for the client, a primary function in the treatment process. Findings also suggested that art therapy provided clients with tools for communication to explore and express their external and internal experiences in a safe environment. Findings further demonstrated the importance of establishing a therapeutic relationship with children and adolescents with complex trauma as essential for maintenance of progress in treatment.

This study explored the process of negotiating music therapy in a community based setting known as The Potter’s House. The Potter’s House was established fourteen years ago as the first non-racial shelter for battered and destitute women and their children in the city of Pretoria. Furthermore, the study considers Community Music Therapy as a possible frame for music therapy practice in South Africa. The study was conducted according to a qualitative research paradigm. Three data collection sources were used to gather information about the way in which music therapy was negotiated at The Potter’s House. Data collection was in the form of interviews (conducted with the manager of The Potter’s House and the music therapy participants) as well as clinical session notes. The aim of the interviews was to explore members’ experiences and views of the music therapy process. The clinical session notes include significant information that relates to my own reflections and experiences of the music therapy process. This study seems to highlight certain factors that appear prominent in the process of negotiating music therapy in this specific shelter for battered women and their children. These factors and how they were negotiated seem to emphasize the value of a Community Music Therapy framework in the shelter context. The study further suggests that Community Music Therapy could be utilized more broadly in the South African context.
Mini Dissertation (MMus)--University of Pretoria, 2007.
Music
MMus
Unrestricted

Magister Artium - MA (Psychology)
Post-apartheid South Africa has been marked by high levels of trauma resulting from exposure to violence. Many South Africans are therefore at risk for developing Posttraumatic Stress Disorder (PTSD). Despite a large body of research identifying various protective factors which may influence an individual's response to a traumatic event, a gap in South African research on the relationship between exposure to multiple traumatic experiences, protective factors and the development of PTSD was identified. Therefore, located within the systems theory framework, the aim of this study was to investigate the relationship between demographic characteristics, types of exposure to trauma and resilience associated with the development of posttraumatic stress (PTS) when there are multiple exposures to trauma. A quantitative, cross-sectional, exploratory study on 158 psychology students at the University of the Western Cape was undertaken. Using a non-random, convenience sampling method, data were collected by means of four self-report questionnaires namely; a biographical questionnaire, the Life Events Checklist for DSM-5 (LEC-5), the Resilience Scale for Adults (RSA), and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5).

Traumatic brain injury (TBI) affects 1.4 million people a year in the United States alone and despite the fact that 96% of people survive a TBI, the health and socioeconomic consequences can be grave, partially due to the fact that very few clinical treatments are available to reduce the damage and subsequent dysfunction following TBI. To better understand the various mechanical, electrical, and chemical events during neural injury, and to elucidate specific cellular events and mechanisms that result in cell dysfunction and death, new high-throughput models are needed to recreate the environmental conditions during injury. This thesis project focuses on the creation of a novel and clinically relevant single-cell injury model of traumatic brain injury (TBI). The implementation of the model requires the development of a novel injury device that allows specialized micro-interfacing functionality with neural micro environments, which includes the induction of prescribed strains and strain rates onto neural tissue, such as groups of cells, individual cells, and cell processes. The device consists of a high-resolution micro-electro-mechanical-system (MEMS) microtweezer microactuator tool that is introducible into both biological and aqueous environments and can be proximally positioned to specific targets in neural tissue and neural culture systems. This microtweezer, which is constructed using traditional photolithography and micromachining processes, is controllable by a custom developed software-automated controller that incorporates a high precision linear actuator and utilizes a luer-based microtool docking interface. The injury studies will include examination of intracellular calcium concentration over the injury time course to evaluate neuronal plasma membrane permeability, which is a significant contributor to secondary injury cascades following initial mechanical insult. Mechanical strain and strain rate input tolerance criteria will also be used to determined thresholds for cellular dysfunction and death.

O trauma é uma das principais causas de morte no mundo. Estima-se que mais de cinco milhões de pessoas morrem anualmente por algum tipo de trauma e que outras milhões que sobrevivem aos ferimentos ficam com sequelas temporárias ou permanentes, o que implica em custos diretos e indiretos de bilhões de reais. Desta forma, o problema do trauma envolve questões de ordem epidemiológica, social, assistencial, financeira e de gestão. Uma das maneiras de minimizar este problema é avaliar as fases do atendimento por meio de programas de melhoria de qualidade. O Comitê de Trauma do Colégio Americano de Cirurgiões criou uma base de dados única de registros de traumas de diversos centros nos Estados Unidos e Canadá na base de dados única do National Trauma Data Bank (NTDB). Após coletados, os dados são processados e transformados em relatórios anuais com indicadores que fornecem uma visão da situação geral do atendimento ao trauma em todo o país. Muitos países investem recursos para construir registros de trauma ou base de dados regionais, que são importantes fontes de dados para construção de indicadores de qualidade. No Brasil não existe a notificação sistemática dos pacientes traumatizados nos serviços de saúde. O presente estudo tem por finalidade desenvolver um software com módulo de notificação e vigilância epidemiológica dos traumas associado à monitorização e análise dos dados consolidados utilizando indicadores de qualidade. Para teste do software foi utilizado o banco de dados de pacientes traumatizados atendidos na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (UE-HCFMRP/USP) no período de 2006 a 2014. No software desenvolvido há duas maneiras de inserir dados de trauma: manualmente por meio do preenchimento do formulário eletrônico de notificação ou por meio da importação direta de arquivo Excel com a mesma sequência de dados. Desta forma, os indicadores são gerados automaticamente e podem ser visualizados em gráficos e tabelas. Os resultados obtidos através do uso da ferramenta foram utilizados para analisar a situação da assistência ao trauma na região de Ribeirão Preto. A análise destes resultados também foi essencial para verificar a capacidade da ferramenta em prover informações relevantes para a gestão hospitalar. A partir da análise dos resultados obtidos, concluímos que a ferramenta pode auxiliar a avaliação da qualidade do atendimento ao trauma. Uma possibilidade de expansão do sistema é incluir novos indicadores e coletar dados de outras instituições para permitir benchmarking externo.
Trauma is a leading cause of death worldwide. It is estimated that more than five million people die annually from some sort of trauma and millions more who survive their injuries are left with temporary or permanent sequelae, which leads to billions of Reais in direct and indirect costs. Thus, the question of trauma involves epidemiological, social, healthcare, financial and management issues. One way to lessen such problems is to evaluate the phases of medical care through quality improvement programs. The American College of Surgeons Committee on Trauma has created a unique aggregation of trauma registry data from several centers in the United States and Canada in a single database, the National Trauma Data Bank (NTDB). After collected, the data are processed into annual reports with indicators that provide a view of the overall situation of trauma care nationwide. Many countries invest resources on gathering trauma registries or building regional databases, which are important sources of data for generating care quality indicators. In Brazil there is no systematic notification of trauma patients in health services. The present study aims to develop a software with a trauma notification and epidemiological surveillance module associated with the monitoring and analysis of the consolidated data using care quality indicators. To test the software we used the database of trauma patients treated at the Emergency Unit of the Clinics Hospital at the Ribeirão Preto Medical School - University of São Paulo (UE HCFMRP/USP) from 2006 to 2014. There are two ways to feed the software with the trauma data: manually, by completing an electronic notification form or by directly importing an Excel file with the same data stream. The indicators are then generated automatically and can be viewed in charts and tables. The results yielded from the software were used to assess the situation of trauma healthcare in the Ribeirão Preto region. The analysis of such results was also crucial to determine the software capacity to provide relevant information for hospital management. The results analysis led us to conclude that the software can help assess the quality of trauma healthcare. A possibility of system expansion is to include new indicators and collect data from other institutions to allow external benchmarking.

As lesões por esforços repetitivos/distúrbios osteomusculares relacionados ao trabalho (LER/DORT) afetam os trabalhadores em todo o mundo, uma vez que causam sofrimento e limitação tanto em atividades cotidianas como no trabalho. Este agravo ainda tem como principais consequências a incapacidade temporária ou permanente para as atividades laborais, o afastamento do trabalho, por conseguinte, os prejuízos socioeconômicos gerados à sociedade pela redução da produtividade. Há, ainda, a necessidade de avaliar a ocorrência, as associações e o afastamento do trabalho por LER/DORT nos mais diversos grupos ocupacionais. Considerando as possíveis diferenças entre os sexos para LER/DORT, deve-se considerar a estratificação das análises por sexo. No capítulo I, foi realizado um estudo com dados retrospectivos de LER/DORT do Sinan e dos microdados do Censo de 2010 do IBGE. Foram analisadas variáveis sociodemográficas, trabalhistas, das cargas e ambiente de trabalho e os desfechos de interesse, com frequências absolutas e relativas, medidas de tendências centrais e dispersão, taxas do agravo, testes de hipóteses e modelos de regressão. Foram estimadas como medidas de efeitos a razão de prevalência e a razão de taxas. Para as ocorrências, o absenteísmo e os fatores associados a LER/DORT, destacaram-se idade a partir dos 30 anos, ocupações braçais, ambiente estressante e transtornos mentais. Quanto à tendência, trabalhadores a partir de 50 anos de idade e trabalhadores industriais e químicos foram fortemente associados de forma crescente na série temporal. O sítio anatômico de maior ocorrência foram os ombros. No capítulo II, foi feita uma revisão sistemática (RS) sobre distúrbios musculoesqueléticos (DME) de ombros em trabalhadores, para descrever a prevalência do agravo neste sítio anatômico. Foram incluídos 10 estudos de base populacional; a prevalência de DME de ombros variou de 7,1% a 29,3%, no sexo feminino de 6% a 31,1%, no sexo masculino de 9% a 14,4%, trabalhadores \"braçais\" e com idade a partir de 50 anos foram mais acometidos. Por fim, houve comparação entre os dois capítulos desta tese e os resultados assemelharam-se. Sugere-se, a partir destes achados, a reavaliação do processo de trabalho para indivíduos de idade intermediária a avançada, aqueles com transtornos mentais e no que tange o estresse laboral. Ainda sugere-se um sistema de notificação digital para melhoria e otimização dos sistemas de informação em agravos ocupacionais.
Repetitive strain injuries/work-related musculoskeletal disorders (RSI/WRMD) affect workers around the world as they cause suffering and limitation both in daily activities and at work. This aggravation still has as main consequences the temporary or permanent incapacity for the labor activities, the work retirement and, consequently, the socioeconomic damages generated to the society mostly by the reduction of the productivity. There is also a need to assess the occurrence, associations and withdrawal of work by RSI in the most diverse occupational groups. Considering the possible differences between the genders for RSI, the stratification of analyzes by sex must be considered. In chapter I, a retrospective data study of SINAN of RSI and the microdata of the IBGE\'s 2010 Census was carried out. Sociodemographic, labor, workload and work environment variables were analyzed, with absolute and relative frequencies, measures of central tendencies and dispersion, injury rates, hypothesis tests and regression models. The prevalence ratio and the rate ratio were estimated as measures of effects. For the occurrences, absenteeism and the factors associated with RSI were more prominent in age from 30 years on, manual occupations, work stress and mental disorders. As for the trend, 50 years-old workers and industrial and chemical workers were strongly associated with increasing time series. The most common anatomical site was the shoulders. In Chapter II a systematic review (RS) was performed on musculoskeletal disorders of shoulders (MDS) in workers, to describe the prevalence of the disease in this anatomical site. Ten population-based studies were included, the prevalence of MDS of the shoulders ranged from 7,1% to 29,3%, in the female sex from 6% to 31,1%, in the male sex from 9% to 14,4% workers aged 50 and over were more affected. Finally, there was a comparison between the two chapters of this thesis and the results resembled. These findings suggest the reassessment of the work process for individuals from intermediate to advanced age, those with mental disorders and with regard to work stress, and also a digital notification system for improvement and information optimization systems in occupational diseases.

Hypotheses. The severity and specific anatomical location of an initial traumatic injury are important in determining the level of risk of subsequent post traumatic respiratory compromise. An immediate post-traumatic stress response can be identified, and the subsequent activation of the inflammatory and coagulation cascades can be related to the degree of injury sustained and the subsequent development of complications. Results. Regression analysis of possible epidemiological factors determining the risk of ARDS demonstrated that the Injury Severity Score (ISS), the presence of a femoral fracture, the combination of long bone and abdominal injuries and unstable physiological observations on admission were each independently associated with ARDS. In the prospective clinical cohort study, the serum concentrations of a number of mediators, particularly interleukin-6, was shown to correlate with the severity of injury. However, no marker was found to be a useful indicator of the later development of respiratory insufficiency. In the laboratory study, an immediate depressant response of the cardiovascular system to injury was identified, the components of the stress response were observed to evolve in a reproducible manner, and the additional surgical treatment of the injury was not found to make a significant difference to this response. Conclusion. Several epidemiological, clinical and laboratory factors contributing to the development of the post-traumatic stress response are measurable. A group of patients at increased risk of respiratory insufficiency can be identified by their epidemiological features, but the role of measurements of inflammatory and coagulation activation remains to be defined.

The overarching thesis under investigation is that the endogenous opioid system plays a key role in depression subsequent to traumatic childhood social experiences. This is suggested by the fact that animal work indicates that mu-opioids robustly mediate separation-distress, and that early social stressors lead to long term dysregulation in key related circuitries and neuroanatomical structures.

Contexto: A morbimortalidade por causas externas constitui um dos mais graves problemas de saúde pública global. Dentre as estratégias preventivas primárias, a educação para a segurança é uma das áreas em que é mais nítida a influência das concepções das pessoas sobre as atitudes e determinantes de vulnerabilidades e resiliências. Especialistas da disciplina do controle de injúrias físicas, no âmbito da língua inglesa, hegemônica, advogam pela proscrição do termo acidente, pelo menos do léxico acadêmico, mas também evitando o seu emprego na promoção da saúde, por conta de um potencial efeito negativo de suas alegadas acepções pré-científicas de imprevenibilidade nas ações educativas. Essa questão, ainda polêmica entre os pesquisadores de língua inglesa, nunca foi estudada na língua portuguesa. Seu estudo tem grande relevância para a inserção da pesquisa brasileira nas iniciativas em andamento, no âmbito mundial, para a normalização terminológica nesse campo de conhecimento. Observa-se uma tendência crescente na utilização do termo injúria, nos textos acadêmicos originais em português, com definição equivalente à dos textos em inglês, fenômeno que merece um olhar mais atento. Objetivos: Promover a inserção da discussão terminológica no campo das ciências médicas, por meio do olhar crítico sobre o impacto da passagem de falantes do português por cursos de graduação selecionados sobre suas concepções dos vocábulos acidente e injúria, principalmente quanto à associação com noções de causalidade, intencionalidade, previsibilidade e prevenibilidade. Métodos: Estudo observacional, transversal, com coleta de informações quantitativas por meio de enquete autoadministrada realizada integralmente pela internet. A amostra alvo compreendeu estudantes de primeiro e último ano de medicina, direito, comunicação e educação de todas as escolas da cidade de Porto Alegre, Brasil. Desenvolvemos um aplicativo original, capaz de recrutar respondentes, enviar convites pessoais por e-mail, armazenar as respostas e exportar os dados. O software e os dados foram hospedados em um site específico do projeto, com acesso permanente pela internet. As variáveis preditoras foram os seguintes atributos dos sujeitos: idade, sexo, estágio do curso, curso, inclinação política, espiritualidade, arrojo, hábito de ler instruções sobre produto de limpeza, fonte de orientação sobre segurança, uso do cinto de segurança, uso de assento infantil de segurança, uso de capacete de ciclista, modo de armazenar arma de fogo, experiência com perda de ente querido por causas externas, experiência de hospitalização por causas externas e conhecimento de causas de morte de crianças e de adolescentes. As variáveis de desfecho foram as seguintes concepções dos sujeitos acerca dos termos acidente, injúria e lesão: tipo de dano; associações de ideias com as três palavras; noções de fatalidade, intencionalidade, previsibilidade e prevenibilidade associadas à palavra acidente; associação de traumatismo cranioencefálico com injúria, acidente ou lesão; grau de prevenibilidade atribuído a cada uma das três palavras e culpabilidade da vítima num caso definido de acidente com criança. Para investigar a associação entre atributos e concepções submetemos os dados à análise de correspondência simples e ao teste qui-quadrado com análise de resíduos. Resultados: A taxa de resposta à enquete foi de 34,5%. Metade dos sujeitos responderam até o segundo dia, 66,3% durante a primeira semana. 4,2% dos sujeitos se recusaram a revelar sua religião e 19,2% se recusaram a revelar sua inclinação política, enquanto apenas 2,8% se recusaram a responder questões sobre concepções e atitudes. Não houve diferença significativa entre os que responderam cedo ou tarde, quanto a atributos e concepções selecionados. Estudantes de medicina se distinguiram dos demais pelas associações com a arreligiosidade, com o conhecimento de que a mortalidade de crianças e jovens se dá principalmente por causas externas e com o hábito de buscar orientação sobre segurança em fontes especializadas. Os sujeitos revelaram percepção preponderante de que os chamados acidentes são preveníveis e tal percepção não mudou se a palavra usada na pergunta foi injúria ou lesão. A palavra acidente evocou noções de prevenibilidade em 85,1% dos sujeitos, previsibilidade em 50,3%, fatalidade em 15,1%, e intencionalidade em 2,3%. Religiosidade apresentou correspondência com noções de não previsibilidade e fatalidade atribuídas à palavra acidente. Calouros associaram a palavra acidente a noções de não previsibilidade, enquanto formandos foram significativamente distintos em considerar que acidentes podem ser previstos. Os sujeitos associaram injúria com dano moral, de modo quase unânime e, em menor grau, com noções de calúnia e difamação; uma porção limitada associou injúria com dano físico e ferimento. Associaram mais a palavra lesão com dano físico, mas também revelaram concepções igualitárias de dano físico, moral e material. Estudantes de cursos e estágios diferentes variaram significativamente em suas concepções de acidente e injúria. Estudantes de medicina se colocaram em franca oposição aos de todos os demais cursos no tangente à associação de injúria com danos físicos. Estudantes de direito associaram acidente com noções de negligência, dano moral e difamação. Estudantes de educação associaram acidente com noções de não prevenibilidade e fatalidade. Conclusões: A enquete online para investigar concepções de estudantes universitários acerca de injúrias físicas é factível e produz taxas de resposta similares às da literatura. Um período de acompanhamento superior a três semanas não é recomendável; limitar os esforços de recrutamento de respondentes a esse tempo restrito permite uma concentração mais racional de recursos. A enquete online é efetiva na abordagem de questões sensíveis, como atitudes em segurança, inclinação religiosa e política. A análise geométrica de dados é eficaz em evidenciar correspondências entre um grande número de modalidades de variáveis categóricas e denota de modo apropriado as suas associações estatisticamente significativas. A análise de resíduos ajustados mais ratifica do que enfraquece a análise geométrica. O currículo médico promove a terminologização da palavra injúria. Um modelo conceptual da injúria como entidade nosológica tem que respeitar o fato da terminologização da palavra injúria no âmbito médico, assim como conceder que a significação leiga da palavra acidente é um evento antecedente não intencional e prevenível, potencialmente gerador de injúria. No âmbito da linguagem médica, há uma definição de espaços semânticos específicos para os termos lesão (com acepção de dano anatomopatológico sem causação externa) e injúria (com acepção de dano físico, com ou sem lesão). Noções populares vinculadas à palavra acidente têm mais sutilezas do que sustentam os que propugnam pelo seu banimento do léxico acadêmico.
Background: Morbidity and mortality due to external causes constitute one of the most serious public health problems worldwide. Among primary preventive strategies, safety education is one of the areas in which people's conceptions are more likely to influence both attitudes and determinants of vulnerability and resilience. Injury control experts, within the hegemonic English language, advocate for proscribing the term accident at least from the academic vocabulary, but also for avoiding its use in health promotion, due to a potential deleterious effect of its alleged pre-scientific notion of nonpreventability upon educative actions. Such issue, which is an ongoing controversy among English speaking researchers, has never been studied within the Portuguese realm. Its study bears great relevance towards introducing Brazilian research into the current worldwide initiatives pursuing terminology normalization within this field of knowledge. There is a growing trend of original academic texts written in Portuguese to use the term injury with an equivalent meaning to that used in English; this phenomenon deserves a harder look. Objectives: To promote the introduction of terminology discussion in the field of medical sciences, by means of a critical gaze upon how the passage of Portuguese speakers through selected undergraduate university courses may have an impact on their conceptions of the words accident and injury, mainly as to associations with notions of causality, intent, foreseeability and preventability. Methods: A cross-sectional observational study, which collected quantitative information by means of a self-administered web-based questionnaire. The target sample comprised first-year and last-year students of medical, law, communication and education schools in Porto Alegre, Brazil. We devised an original software application, which was capable of organizing the recruited information concerning prospective respondents, sending out customized e-mail invitations, gathering and housing response data in an online database, and exporting data to statistical softwares. All softwares and data were hosted in a project specific site with continuous Internet access. Predictor variables were the following subjects' attributes: age, sex, course stage, political and religious persuasion, risk-taking proclivity, habit of reading cleaning products' package insert instructions, source of safety orientation, safety belt wearing habits, use of child safety seat, cycling helmet wearing habits, gun storing, personal (or close relation) injury history, and knowledge about child and adolescent causes of death. Outcome variables were the following conceptions of the terms accident, injury and lesion: type of damage; associations of some ideas with the three words; notions of fatality, intent, foreseeability and preventability associated with the word accident; association of head trauma with accident, injury and lesion; degree of preventability attributed to each of the three words; and victim culpability in a case of child accident. We investigated associations between attributes and conceptions by means of simple correspondence analysis and chi-square test with residual analysis. Results: The response rate was 34.5%. Half of the subjects responded by the second day, 66.3% during the first week. 4.2% subjects refused to disclose religious persuasion, and 19.2% refused to disclose political persuasion, whereas only 2.8%, on average, refused to answer questions on conceptions and attitudes. There was no significant difference between early and late respondents in respect to selected attributes and conceptions. Medical students were distinguished from the rest due to their associations with nonreligiosity, knowledge that most child and youth deaths have external causes, and searching safety orientation in specialized sources. Subjects showed preponderant perception that so-called accidents are preventable, and such perception did not change whether the question used the word injury or lesion. The word accident evoked the notion of preventability to 85.1% of the subjects, foreseeability to 50.3%, fatality to 15.1%, and intentionality to 2.3%. Religiosity showed correspondence with notions of nonprevisibility and fatality being attributed to the word accident. First-year students associated the word accident with notions of nonprevisibility, while last-year students were significantly distinct as they considered that accidents can be foreseen. Subjects unanimously associated injury with moral damage, and to a lesser degree with notions of calumny and defamation; a limited portion associated injury with physical damage and wound. They mainly associated the word lesion with physical damage, but also revealed equivalent conceptions of physical, moral, and material damage. Students from different courses and stages significantly varied in their conceptions of accident and injury. Medical students were in stark opposition to those from the other courses as to their association of injury with physical damage. Law students associated accident with notions of negligence, moral damage, and defamation. Education students associated accident with notions of nonpreventability and fatality. Conclusions: Web surveying university students' conceptions about injuries is feasible and yields response rates similar to those found in the literature. A follow-up period longer than three weeks is not warranted; restricting recruiting efforts to such period of time allows a more rational allocation of resources. A web survey is effective in tackling sensitive issues, such as safety attitudes, religious and political persuasion. Geometric data analysis is efficacious in evincing correspondences among a great number of categorical variable modalities, and appropriately denotes their statistically significant associations. The adjusted standardized residual analysis ratifies more than weakens the geometric analysis. Medical curriculum promotes the terminologization of the word injury. A conceptual framework of injury as a nosologic entity must acknowledge the fact of terminologization of the word injury in the medical realm, as well as concede the lay signification of the word accident as an anteceding, unintentional, and preventable event, which potentially causes injury. Within the realm of medical language, there is a definition of specific semantic spaces for the terms lesion (with the acception of anatomopathological damage without external causation) and injury (with the acception of physical damage, with or without lesion). Lay notions of the word accident carry more subtleties than those who advocate for banning it from the academic lexicon maintain.

The purpose of this thesis is to evaluate a new paediatric trauma victim bank for the simulation tool Emergo Train System® (ETS). The area of child trauma care is rather small and there is limited knowledge about potential emergency events. The emergency care for children should not be considering the same as for adults. Relevant personnel should, therefore, be to able train and prepare for potential crisis. Hence, a suitable victim bank within ETS exercises is needed. In order to develop a suitable victim bank, this thesis have tested and evaluated a new paediatric trauma victim bank. The test was conducted through an ETS exercise with a subsequent evaluation questionnaire. With the help of the exercise the paediatric victim bank was evaluated. The result of exercise was compiled through mean and standard deviation of the questions within the questionnaire and potential correlation between the questions. The result showed that the participants thought that knowledge and information they gained during the exercise would help them in further real-life situations and that the victim trauma bank were relevant for training paediatric trauma care personnel. The results also showed further recommendations that could improve the validation process of ETS exercises.

Adoption-focused psychoeducation is deemed essential in maintaining the permanency of traumatized children within a new family unit. However, adoptive parents of traumatized children struggle to find training to address their unique concerns. Guided by the lens of psychodynamic theory, the purpose of this study was to investigate the challenges faced by adoptive families of traumatized children. Special focus was placed on the social and emotional relationships of the adoptive parents of traumatized children, to identify the realistic expectations towards attachment from the families' perspectives. Fifteen families were randomly selected to participate in this study from a group of 30 parents who adopted traumatized children in Arizona. A phenomenological approach was utilized to gather information from face-to-face and telephone interviews. The data analysis utilized the horizontalization approach which highlighted significant statements that were classified into codes. Thematic categories were drawn and summarized. Textual descriptions evolved from the thematic groups acknowledging their experiences and how these lived experiences guided their decision to adopt a traumatized child. Verification techniques, data mining, journaling, clustering, brainstorming, and peer reviews were used to ensure the quality of data. Emergent themes emphasized the need for adoption-focused training specific to traumatized children. Further research on this phenomenon should determine the significance of specialized psychoeducational training versus general foster care training, before and after adoption. Positive social change may result in tailoring existing training programs to meet the needs of families who adopt traumatized children.

[EN] Over the last years, multiagent systems have been proven to be a powerful and versatile paradigm, with a big potential when it comes to solving complex problems in dynamic and distributed environments, due to their flexible and adaptive behavior. This potential does not only come from the individual features of agents (such as autonomy, reactivity or reasoning power), but also to their capability to communicate, cooperate and coordinate in order to fulfill their goals. In fact, it is this social behavior what makes multiagent systems so powerful, much more than the individual capabilities of agents. The social behavior of multiagent systems is usually developed by means of high level abstractions, protocols and languages, which normally rely on (or at least, benefit from) agents being able to communicate and interact indirectly. However, in the development process, such high level concepts habitually become weakly supported, with mechanisms such as traditional messaging, massive broadcasting, blackboard systems or ad hoc solutions. This lack of an appropriate way to support indirect communication in actual multiagent systems compromises their potential. This PhD thesis proposes the use of event tracing as a flexible, effective and efficient support for indirect interaction and communication in multiagent systems. The main contribution of this thesis is TRAMMAS, a generic, abstract model for event tracing support in multiagent systems. The model allows all entities in the system to share their information as trace events, so that any other entity which require this information is able to receive it. Along with the model, the thesis also presents an abstract architecture, which redefines the model in terms of a set of tracing facilities that can be then easily incorporated to an actual multiagent platform. This architecture follows a service-oriented approach, so that the tracing facilities are provided in the same way than other traditional services offered by the platform. In this way, event tracing can be considered as an additional information provider for entities in the multiagent system, and as such, it can be integrated from the earliest stages of the development process.
[ES] A lo largo de los últimos años, los sistemas multiagente han demostrado ser un paradigma potente y versátil, con un gran potencial a la hora de resolver problemas complejos en entornos dinámicos y distribuidos, gracias a su comportamiento flexible y adaptativo. Este potencial no es debido únicamente a las características individuales de los agentes (como son su autonomía, y su capacidades de reacción y de razonamiento), sino que también se debe a su capacidad de comunicación y cooperación a la hora de conseguir sus objetivos. De hecho, por encima de la capacidad individual de los agentes, es este comportamiento social el que dota de potencial a los sistemas multiagente. El comportamiento social de los sistemas multiagente suele desarrollarse empleando abstracciones, protocolos y lenguajes de alto nivel, los cuales, a su vez, se basan normalmente en la capacidad para comunicarse e interactuar de manera indirecta de los agentes (o como mínimo, se benefician en gran medida de dicha capacidad). Sin embargo, en el proceso de desarrollo software, estos conceptos de alto nivel son soportados habitualmente de manera débil, mediante mecanismos como la mensajería tradicional, la difusión masiva, o el uso de pizarras, o mediante soluciones totalmente ad hoc. Esta carencia de un soporte genérico y apropiado para la comunicación indirecta en los sistemas multiagente reales compromete su potencial. Esta tesis doctoral propone el uso del trazado de eventos como un soporte flexible, efectivo y eficiente para la comunicación indirecta en sistemas multiagente. La principal contribución de esta tesis es TRAMMAS, un modelo genérico y abstracto para dar soporte al trazado de eventos en sistemas multiagente. El modelo permite a cualquier entidad del sistema compartir su información en forma de eventos de traza, de tal manera que cualquier otra entidad que requiera esta información sea capaz de recibirla. Junto con el modelo, la tesis también presenta una arquitectura {abs}{trac}{ta}, que redefine el modelo como un conjunto de funcionalidades que pueden ser fácilmente incorporadas a una plataforma multiagente real. Esta arquitectura sigue un enfoque orientado a servicios, de modo que las funcionalidades de traza son ofrecidas por parte de la plataforma de manera similar a los servicios tradicionales. De esta forma, el trazado de eventos puede ser considerado como una fuente adicional de información para las entidades del sistema multiagente y, como tal, puede integrarse en el proceso de desarrollo software desde sus primeras etapas.
[CAT] Al llarg dels últims anys, els sistemes multiagent han demostrat ser un paradigma potent i versàtil, amb un gran potencial a l'hora de resoldre problemes complexes a entorns dinàmics i distribuïts, gràcies al seu comportament flexible i adaptatiu. Aquest potencial no és només degut a les característiques individuals dels agents (com són la seua autonomia, i les capacitats de reacció i raonament), sinó també a la seua capacitat de comunicació i cooperació a l'hora d'aconseguir els seus objectius. De fet, per damunt de la capacitat individual dels agents, es aquest comportament social el que dóna potencial als sistemes multiagent. El comportament social dels sistemes multiagent solen desenvolupar-se utilitzant abstraccions, protocols i llenguatges d'alt nivell, els quals, al seu torn, es basen normalment a la capacitat dels agents de comunicar-se i interactuar de manera indirecta (o com a mínim, es beneficien en gran mesura d'aquesta capacitat). Tanmateix, al procés de desenvolupament software, aquests conceptes d'alt nivell son suportats habitualment d'una manera dèbil, mitjançant mecanismes com la missatgeria tradicional, la difusió massiva o l'ús de pissarres, o mitjançant solucions totalment ad hoc. Aquesta carència d'un suport genèric i apropiat per a la comunicació indirecta als sistemes multiagent reals compromet el seu potencial. Aquesta tesi doctoral proposa l'ús del traçat d'esdeveniments com un suport flexible, efectiu i eficient per a la comunicació indirecta a sistemes multiagent. La principal contribució d'aquesta tesi és TRAMMAS, un model genèric i abstracte per a donar suport al traçat d'esdeveniments a sistemes multiagent. El model permet a qualsevol entitat del sistema compartir la seua informació amb la forma d'esdeveniments de traça, de tal forma que qualsevol altra entitat que necessite aquesta informació siga capaç de rebre-la. Junt amb el model, la tesi també presenta una arquitectura abstracta, que redefineix el model com un conjunt de funcionalitats que poden ser fàcilment incorporades a una plataforma multiagent real. Aquesta arquitectura segueix un enfoc orientat a serveis, de manera que les funcionalitats de traça són oferides per part de la plataforma de manera similar als serveis tradicionals. D'aquesta manera, el traçat d'esdeveniments pot ser considerat com una font addicional d'informació per a les entitats del sistema multiagent, i com a tal, pot integrar-se al procés de desenvolupament software des de les seues primeres etapes.
Búrdalo Rapa, LA. (2016). TRAMMAS: Enhancing Communication in Multiagent Systems [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/61765
TESIS

Bone healing following trauma is known to be associated with an early increase in serum concentrations of several pro-inflammatory and angiogenic growth factors. However, the temporal pattern of growth factors (GFs) involved in bone formation and their relationship with trauma severity has not been explored. Furthermore, to what extent osteogenic progenitors, including mesenchymal stem cells (MSCs) are ‘mobilized’ following trauma is unknown. This study investigated the systemic levels of four GFs (PDGF-AA, TGF-β2, follistatin and angiogenin) over the first two weeks following trauma in three groups of patients with increasing severity (Isolated trauma (n=15), Polytrauma (n=15), and Head injury (n=14)) and compared to Healthy Controls (n=9). The dynamics of GF release measured by ELISA was correlated with clinical and biochemical inflammatory parameters and the healing outcome assessed by clinical and radiological parameters as well as requirement of surgical re-interventions. Potential MSC mobilization from their iliac crest bone marrow (ICBMA) niches into peripheral circulation was measured by standard colony-forming assay-fibroblast, at least twice following trauma. Further correlations were sought with circulating levels of platelets, PDFG-BB and PDGF-AA. Growth factors described as anabolic for bone (PDGF-AA and angiogenin) had an initial suppression following trauma (50% and 80% by day 1, respectively), whereas inhibitory GF follistatin was upregulated compared to control (1.5-fold by day 1). This effect was more pronounced with increasing trauma severity. The variability of TGF-β2 was too high to allow differences between trauma groups to be detected. The dynamics of all GFs were not correlated with the inflammatory state of the patients, assessed both clinically (Systemic Inflammatory Response Syndrome score) and biochemically (total white cell count, C-reactive protein and platelet levels). However, there was a significant correlation between levels of time-matched PDGF-AA and platelets (p<0.01, r=+0.61), independent of trauma severity. A marked suppression of TGF-β2 throughout the time course which reached statistical significance in the first week following trauma (5-fold, p<0.05) was observed in patients identified as ‘poor healers’; the same group additionally displayed an altered dynamics of follistatin release compared to patients who healed normally. The numbers of ICBMA MSCs were dynamic over time in the same patient, but did not correlate with trauma severity or patients’ inflammatory state. Instead, significant correlations were observed between the changes in ICBMA MSC numbers and changes the levels of PDGF-AA (p<0.01, r=+0.55), and PDGF-BB (p=0.03, r=+0.38) and circulating platelets (p=0.02, r=+0.44). No MSCs were found in patients’ peripheral blood at any time point studied. These data indicated that measuring GFs implicated in BMP signalling pathway may lead to the discovery of novel biomarkers of fracture non union. Measuring patient’s inflammatory response following fracture did not correlate with the release of growth factors studied suggesting that these phenomena were independent. Limited MSC mobilization in the bone marrow (but not into PB) did take place but appeared to be related to platelet counts and a possible release of PDGF-AA and PDGF-BB GFs, which are known to be mitogenic for MSCs. It was not linked to trauma severity or predictive of the healing outcome. Further research is needed to investigate the predictive value of TGF-β2 and follistatin in a larger cohort of patients. Whilst this is the first study showing a ‘dynamic’ nature of the MSC pool in human BM, further work should determine whether the influence of platelets is due to enhanced MSC migration or their proliferation in situ.

Severe extremity trauma often involves significant damage to multiple tissue types, including bones, skeletal muscles, peripheral nerves, and blood vessels. Such injuries present unique challenges for reconstruction, and improving structural and functional outcomes of intervention remains a pressing, unmet clinical need. While tissue engineering/regenerative medicine (TE/RM) therapeutics offer promising potential to overcome the status quo limitations of surgical reconstruction, very few products have transitioned to clinical practice. Improving treatment options will likely require advancing our understanding of the biological interactions occurring in the repair of damaged tissues. Bone tissue is known to be innervated and highly vascularized, and both tissue types are involved in normal bone physiology. However, the degree to which these tissue relationships influence the repair of large, multi-tissue defects remains unknown. Accordingly, the goal of this thesis was to investigate tissue regeneration in two novel composite injury models. First, we characterized interactions in a composite bone and nerve injury model where a segmental bone defect was combined with a peripheral nerve gap. Our results indicated that although tissue regeneration was not impaired, the composite injury group experienced a marked functional deficit in the operated limb compared to single-tissue injury. Second, we developed a model of composite bone and vascular extremity trauma by combining a critically-sized segmental bone defect with surgically-induced hind limb ischemia to evaluate the effects on BMP-2-mediated bone repair. Interestingly, our results demonstrated a stimulatory effect of the recovery response to ischemia on bone regeneration. Finally, we investigated early vascular growth and gene expression as potential mechanisms coupling the response to ischemia with bone defect repair. Although the response to ischemia promoted robust vascular growth in the thigh, it did not directly augment vascularization at the site of bone regeneration. In addition, the stimulatory effects of ischemia on bone regeneration could not be explained by gene expression alone based on the genes and time points investigated. Taken together, this thesis presents pioneering work on a new thrust of TE/RM research – tissue regeneration in models of composite injury. This work has provided new insights on the complexity of composite tissue repair, specifically in regard to the relationship between vascular tissue growth and bone healing. Going forward, successful leverage of models of composite tissue injuries will provide valuable test beds for screening new technologies, advance the understanding of tissue repair biology, and ultimately, may produce new therapeutic interventions for limb salvage and reconstruction that improve outcomes for extremity trauma patients.

Ultrasound is an effective imaging modality because it is safe, unobtrusive and portable. However, it is also very operator-dependent and significant skill is required to capture quality images and properly detect abnormalities. Training is an important part of ultrasound, but the limited availability of training courses presents a significant hindrance to the use of ultrasound being used in additional settings. The goal of this work was to design and implement an interactive training system to help train and evaluate sonographers. The Interactive Training System for Medical Ultrasound is an inexpensive, software-based training system in which the trainee scans a lifelike manikin with a sham transducer containing a 6 degree of freedom tracking sensor. The observed ultrasound image is generated from a pre-stored 3D image volume and is controlled interactively by the sham transducer's position and orientation. Based on the selected 3D volume, the manikin may represent normal anatomy, exhibit a specific trauma or present a given physical condition. The training system provides a realistic scanning experience by providing an interactive real-time display with adjustable image parameters such as scan depth, gain, and time gain compensation. A representative hardware interface has been developed including a lifelike manikin and convincing sham transducers, along with a touch screen user interface. Methods of capturing 3D ultrasound image volumes and stitching together multiple volumes have been evaluated. System performance was analyzed and an initial clinical evaluation was performed. This thesis presents a complete prototype training system with advanced simulation and learning assessment features. The ultrasound training system can provide cost-effective and convenient training of physicians and sonographers. This system is an innovative approach to training and is a powerful tool for training sonographers in recognizing a wide variety of medical conditions.

Desde 1980 observa-se um crescente registro de ocorrências de causas externas no Brasil, que passaram a ocupar o segundo lugar dentre as causas de morte em grandes centros urbanos, superando as neoplasias. Foram analisados os dados de pacientes vítimas de trauma com internação na Unidade de Emergência do HCFMRP, em Ribeirão Preto (SP) entre 2006 e 2009. Foi realizada uma análise descritiva, envolvendo informações sobre o evento traumático, índices de gravidade RTS, ISS e TRISS, provenientes do software IntegraVep, de uso do Núcleo Hospitalar de Epidemiologia do HCFMRP, além de quantificações de exames laboratoriais e radiológicos demandados aos referidos pacientes, com o intuito de analisar as características e evolução dos pacientes. Foi possível observar a alta quantia de exames radiológicos e laboratoriais solicitados para pacientes com lesões leves além da distribuição dos pacientes quanto a faixa etária, sexo, mecanismos de trauma e gravidade de lesão. A utilização de um software específico para análise dos dados existentes no banco de dados do HCRP se mostrou adequada ao ser usado para os pacientes vítimas de trauma, podendo ser expandido para os demais setores do hospital.
Since 1980 there has been a growing record of occurrences of external causes in Brazil, which now occupy the second place among the causes of death in large urban centers, beating cancer. We analyzed the data of trauma patients with admission to the Emergency Unit of HCFMRP in Ribeirão Preto (SP) between 2006 and 2009. We performed a descriptive analysis, involving information about the traumatic event, severity indices RTS, ISS and TRISS, from the IntegraVep software, use of the Center for Hospital Epidemiology of HCFMRP, and quantitions of laboratory and radiological defendants to those patients with the aim of analyzing the characteristics and outcomes of patients. It was possible to observe the high amount of radiological and laboratory-only bid for patients with minor injuries and the distribution of patients by age, sex, mechanism of trauma and injury severity. The use of specific software for the analysis of existing data in the database of the HCRP was adequate to be used for trauma patients and can be expanded to other hospital departments.

Neste estudo investigamos os mecanismos reguladores associados à indução da inflamação pulmonar decorrente da /IR intestinal. A hipótese é que mediadores inflamatórios gerados no intestino, drenados pelo sistema linfático medeiam as repercussões pulmonares observadas na SDRA. Grupos de ratos foram submetidos à isquemia intestinal por meio da oclusão da artéria mesentérica superior (45 min) seguida da reperfusão intestinal por 2h. Grupos de ratos foram submetidos à obstrução do fluxo linfático (canulação do dueto torácico linfático, ou sua secção) previamente à indução da I/R intestinal. Os dados indicaram que a secção do dueto linfático torácico reduziu a atividade pulmonar de MPO (índice indireto de presença de neutrófilos), bem como a permeabilidade vascular (extravasamento do corante Azul de Evans) pulmonar e intestinal e aumento da atividade de LDH intestinal (índice de lesão tecidual). Sistemicamente, a ligação do dueto linfático antes da indução de l/R intestinal reduziu os níveis séricos de TNF-a, IL- 1b e elevou aqueles de IL-10, LTB4e TXB2. Ainda, observamos que a linfa coletada nesses animais é rica em TNF-a, IL-1b, IL-10, LTB4 e TXB2. O tratamento dos animais previamente à l/R intestinal com o inibidor de síntese de TNF-a, pentoxifilina (PTX), reduziu a atividade de MPO pulmonar nos animais submetidos a l/R intestinal com o dueto linfático intaeto e a potencializou naqueles onde o dueto torácico linfático foi seccionado. A PTX reduziu o aumento de permeabilidade vascular pulmonar e intestinal em condições onde dueto linfático torácico foi mantido intacto. Por outro lado em animais l/R intestinal com o dueto linfático seccionado, a PTX não causou redução adicional da permeabilidade vascular, mas reduziu os níveis séricos de IL-1b e aumentou os de LTB4, enquanto na linfa, o tratamento com PTX aumentou a concentração de IL-10 e LTB4 e reduziu a de IL-1b e TXB2. A inibição não seletiva das NOS com o composto L-NAME causou aumento dos níveis séricos de TNF-a, os quais foram reduzidos pela secção do dueto linfático. O bloqueio da geração do NO nos animais com dueto seccionado não alterou o perfil no soro de IL-10, mas elevou a concentração de IL-1b. Ainda, na linfa dos animais tratados com L-NAME, houve aumento de IL-1b, IL-10, LTB4 e TXB2 e redução de TNF-a. Nossos dados ainda revelaram que o pulmão dos animais I/R intestinal gerou IL1b e IL-10 quando o dueto linfático estava intacto, e que sua secção reduziu os níveis gerados dessas citocinas. A PTX reduziu a geração de IL-1b e aumentou a IL-10 no pulmão.O L-NAME aumentou a IL-1b e IL-10 nos animais com o dueto intacto e interrupção do fluxo linfático aumentou os níveis de IL-1b. A I/R intestinal, em animais com o dueto intacto, aumentou, enquanto na vigência da obstrução do fluxo linfático, houve redução da expressão de ICAM-1, Mac-1 e E-selectina no pulmão. Finalmente, os dados apresentados neste estudo sugerem que eventos isquêmicos intestinais seguidos de sua reperfusão, induzem a geração de mediadores inflamatórios locais (intestino) os quais uma vez drenados pelo sistema linfático mesentérico são transportados pela linfa e atingem o pulmão. Nessas condições observa-se inflamação pulmonar e geração adicional de mediadores inflamatÓrios os quais são lançadas à circulação e concorrem para o desenvolvimento da inflamação sistêmica e eventualmente para a falência múltipla dos órgãos.
In this study we investigated the role of lymphatic system on the mechanisms associated to the induction of lung inflammation afier intestinal I/R in rats. The hypothesis ofthe study was that upon intestinal I/R, inflammatory mediators are generated in the intestine and once drained by mesenteric lyrnphatic system interfere with the lung homeostasis contributing to lung dysfunction observed in ARDS. To these purposes groups of rats were submitted to occlusion of superior mesenteric artery (45 min) followed by intestinal reperfusion during 2h when the rats were killed. Groups of rats were subjected to thoracic lymphatic duct ligation previously to induction of the intestinal I/R. The data showed that the thoracic duct ligation significantly reduced the increased pulmonary MPO activity and the augrnented vascular perrneability (extravasation of the Evans blue dye) in lung and intestine. In addition, thoracic duct ligation increased the intestinal activity of LDH. Systemically, the obstruction of lymph flow, leaded to reduction of TNF in serum of rats upon intestinal I/R and increased the levels of IL-1O, LTB4 and TXB2. Elevated levels of TNF-a, IL-lb), IL-1O, LTB4 and TXB2 were also found in lymph ofrats upon intestinal I/R. The treatment of the animals previously to the intestinal I/R induction with inhibitor of TNF-a synthesis, pentoxyfilline (PTX), reduced the lung MPO activity upon lymphatic duct intact that was exacerbated by thoracic duct ligation. PTX treatment reduced the increased vascular permeability of the lung and intestine conditions in rats with lymphatic duct intact. On the other hand, when the thoracic duct was ligated, the PTX did not cause additional reduction of vascular permeability in both tissues , but reduced the serum levels of IL-1b) and increased those of LTB4. Lymph of rats treated with PTX revealed an increased leveI of IL-10 and LTB4 and a reduced leveI of IL-b) and TXB2. L-NAME treatment increased the serum levels of TNF-a, which were reduced by the thoracic lymphatic duct ligation. The blockade of NO synthesis in rats with lymphatic duct ligation did not modify the IL-10 serum levels, but increased those of IL-1b). Lymph of rats upon L-NAME treatment, an increased level of IL-1b), IL-1O, LTB4 and TXB2 and a reduction of TNF-a levels were detected. Pulmonary tissue of Iymphatic duct intact rats after intestinal I/R were increased the release of IL-1b) and IL-10 whereas the thoracic duct ligation reduced the release of these cytokines. PTX treatment reduced the levels of IL-1b) and increased the IL-10 in the lung. L-NAME treatment increased the IL-1b) and IL-10 in lung of intact duct rats but the obstruction of lymph flow caused an increase release of IL-1b levels. Intestinal I/R in intact duct rats, increased whereas the thoracic duct ligation reduced the pulmonary expression of ICAM-1, Mac-1 and E-selectin. In conclusion, our data suggest that intestinal I/R, induces the generation of local inflammatory mediators (intestine) which drained by the mesenteric lymphatic system are carried by the lymph and reach the lung. ln these conditions we observed pulmonary inflammation and additional generation of inflammatory mediators and eventually the development of the systemic inflammation. Our data support the view that lymphatic system play a role a path underlying the spread oflung and gut injury after intestinal I/R.