Naval architecture as a subject for the proposed marine engineering course at the University of Moratuwa

Orientador: Prof. Dr. Fabian Calixto FraizDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Odontologia. Defesa : Curitiba, 30/09/2019Inclui referênciasResumo: Os SIGs (sistemas de informação geográfica) são ferramentas que permitem analisar as mudanças na organização espacial seja interligando informações populacionais com seu contexto social ou examinando a sua relação com o acesso à serviços de saúde. Apesar da prevalência de cárie dentária na infância ter diminuído ao longo dos anos, ainda se apresenta como um desafio para a saúde, já que pode causar grande impacto na qualidade de vida de crianças. Este estudo transversal de análise espacial avaliou a relação da experiência de cárie dentária com a acessibilidade geográfica entre a residência da criança e os serviços odontológicos. Realizado com amostra representativa e aleatória de pré-escolares dos Centros Municipais de Educação Infantil de São José dos Pinhais/PR envolvendo 526 crianças. Foi utilizada a prevalência de 50% para cárie dentária, adotou-se nível de confiança (1-?) de 95% e precisão requerida para estimativa de 5%. O cálculo amostral foi realizado a partir da fórmula de estimativa com proporção para a população finita que resultou em uma amostra mínima de 306 crianças que multiplicada por 1,2 para efeito do desenho e acrescida em 30% devido a estimativa de perda, resultou em uma amostra total de 526 crianças. Foram obtidos dados completos de 405 crianças de 18 a 36 meses de idade, independente do sexo, matriculadas nos CMEIS e examinadas para cárie dentária (ceo-d modificado). Os pontos georreferenciados das unidades básicas de saúde (US), clínicas particulares (CP) e residências (R) foram incluídos em dois sistemas de informação geográfica (SIG), o software ArcGIS e o aplicativo Distancetoclosest, criado especificamente para este estudo. Foram determinados o tempo para percorrer e as menores distância euclidiana, rota de carro e rota caminhando entre a residência e os serviços. As distâncias médias (em km) foram: euclidiana R-US de 1,31 (DP=0,70) e R-CP de 0,57 (DP=0,55), rota de carro R-US de 1,95 (DP=1,11) e R-CP de 0,90 (DP=0,96), rota caminhando R-US 1,80 (DP=1,06) e R-CP de 0,85 (DP=0,96). Os tempos médios (em minutos) foram: para rota de carro R-US 4,88 (DP=2,12) e R-CP 2,50 (DP=1,80) e caminhando R-US 22,49 (DP=13,18) e R-CP 10,62 (DP=11,78). A prevalência de cárie foi de 23% (IC95%: 19-27). As associações entre a experiência de cárie (ceo-d modificado ? 1) e as variáveis socioeconômicas foram analisadas através do Teste Qui-Quadrado de tendência linear (?=0,05). Todas as variáveis de acessibilidade geográfica foram categorizadas em tercil para a análise de associação com a experiência de cárie (ceo-d modificado ? 1) através de regressão de Poisson univariada com variância robusta. Para as variáveis de acessibilidade geográfica que na análise univariada apresentaram p<0,20 foram construídos modelos de regressão de Poisson mutivariado com variância robusta para a experiência de cárie dentária. Todos os modelos multivariados foram ajustados para escolaridade do responsável (escolaridade superior: sim e não) e renda familiar em salários mínimos (categorizada pelo tercil). A associação entre a acessibilidade geográfica e a experiência de cárie dentária foi observada apenas com relação aos serviços públicos. As crianças que residiam em locais com maior tempo caminhando até a US (p=0,03, RP:1,65; IC95%:1,04-2,64), maior distância caminhando entre a R-US (p=0,03, RP:1,64; IC95%:1,03-2,59) e maior distância euclidiana entre a R-US (p=0,04, RP:1,65; IC95%:1,01-2,69) apresentavam maior prevalência de cárie dentária. Conclui-se que acessibilidade geográfica aos serviços odontológicos públicos apresentou uma influência determinante na experiência de cárie na primeira infância independente dos fatores socioeconômicos. Palavras-chave: Sistemas de Informação Geográfica; Cárie Dentária; Saúde Pública; Criança; Acesso aos Serviços de Saúde.Abstract: GIS (Geographic Information Systems) is a tool for analyzing changes in spatial organization, either by linking population information with its social context or by examining its relationship with access to health services. Although the prevalence of childhood dental caries has decreased over the years, it is still a health challenge, as it can have a major impact on children's quality of life. This cross-sectional spatial analysis study evaluated the relationship between dental caries experience and geographical accessibility between the child's residence and dental services. Performed with a representative and random sample of preschool children from the Municipal Centers of Early Childhood Education of São José dos Pinhais / PR involving 526 children. A prevalence of 50% for dental caries was used, a confidence level (1-?) of 95% and precision required to estimate 5%. The sample size calculation was performed using the finite population proportion estimation formula that resulted in a minimum sample of 306 children that multiplied by 1.2 for the design effect and increased by 30% due to the loss estimate, resulting in a total sample of 526 children. Complete data were obtained from 405 children, aged 18 to 36 months, regardless of gender, enrolled in CMEIS and examined for dental caries (modified dmft). The georeferenced points of the basic health units (US), private clinics (CP) and residences (R) were included in two geographic information systems (GIS), the ArcGIS software and the Distancetoclosest application, created specifically for this study. The time to travel and the shortest Euclidean distance, car route and walking route between residence and services were determined. The average distances (in km) were: Euclidean R-US of 1.31 (SD = 0.70) and R-CP of 0.57 (SD = 0.55), R-US car route of 1.95 (SD = 1.11) and R-CP of 0.90 (SD = 0.96), walking route R-US 1.80 (SD = 1.06) and R-CP of 0.85 (SD = 0,96). The average times (in minutes) were: for driving route R-US 4.88 (SD = 2.12) and R-CP 2.50 (SD = 1.80) and walking R-US 22.49 (SD = 13.18) and R-CP 10.62 (SD = 11.78). The prevalence of caries was 23% (95% CI: 19-27). The associations between the caries experience (modified dmft ? 1) and the socioeconomic variables were analyzed using the chi-square linear trend test (? = 0.05). All geographic accessibility variables were categorized into tertile for the analysis of association with caries experience (modified ceo-d ? 1) by univariate Poisson regression with robust variance. For the geographical accessibility variables that presented p <0.20 in the univariate analysis, robust variance Poisson regression models were constructed for the dental caries experience. All multivariate models were adjusted for guardian's education (higher education: yes and no) and family income in minimum wages (categorized by tertile). The association between geographical accessibility and dental caries experience was observed only in relation to public services. Children who lived in places with longer time walking to US (p = 0.03, PR: 1.65; 95% IC: 1.04-2.64), longer walking distance between US (p = 0.03, RP: 1.64; 95% IC: 1.03-2.59) and greater Euclidean distance between US-R (p = 0.04, RP: 1.65; 95% IC: 1.01-2.69) had a higher prevalence of dental caries. It is concluded that geographical accessibility to public dental services had a determining influence on the experience of early childhood caries regardless of socioeconomic factors. Keywords: Geographic Information Systems; Dental Caries; Public Health; Child; Health Services Accessibilit

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research