The Primary Care Internal Medicine Continuity of Care Unit (PCIM CCU) was established to address gaps identified in the care provided for complex chronic patients.The PCIM CCU was set up in June 2006 from the Department of Internal Medicine at the University Hospital of Guadalajara, reaching out to primary care (PC), with the aim of achieving collaboration and coordination between the two levels of care and avoiding the sense of imposition that can be felt in primary care with regards all that comes from the hospital. To this end, several meetings were held between the medical management for primary care, the coordinators of the various primary care teams and the internists responsible for the PCIM CCU prior to the launch of this pilot project.Unidades de Pacientes Pluripatológicos: Estándares y recomendaciones” [The objective of the project was to facilitate continuity of care for patients with complex chronic conditions and those with multiple diseases as well as cases in which diagnosis must not be delayed. The methodology for the project see  was simiaciones”  publisheMedical staff involved: one internist until February 2010, and subsequently three.Infrastructure: the intention was to use already existing personnel (nursing and administrative staff) and facilities; for this, a hospital ward was restructured, being used jointly with the medical and surgical short stay unit (SSU), with the following facilities: a consultation room, day hospital area and conventional inpatient beds.The initial catchment population of the PCIM CCU, when there was only one internist, was 58,479 people under the care of three health centres . In February 2010, the project was extended to seven health centres, increasing the catchment population to 134,613 and involving three internists.The data on the activity of the PCIM CCU in its five-years of operation are reported below in relation to the various areas of the unit’s work.A total of 1892 telephone calls were made to the internists, of which only 762 resulted in new patient referrals to the PCIM CCU; the remaining calls were queries that were resolved at the time.A total of 1989 patients were seen. The ratio of follow-up to first appointments ranged from 0.81 to 1.95; that is, there were fewer than two check-ups for every new patient seen.The characteristics of patients seen in consultations were as follows : patientIt has four arm chairs for diagnostic and therapeutic procedures. During the study period a total of 676 procedures were carried out, of which the most common were: blood sample collection and parenteral treatments, in particular iron infusion. Other procedures included: paracentesis, thoracocentesis, and lumbar punctures.The ward being shared with the SSU, eight beds were assigned to the PCIM CCU. Patients could be admitted either directly from specialist appointments or the Day Hospital, or from the hospital emergency department, provided that they were from the catchment area of the health centres participating in the PCIM CCU programme.The care indices in 2010 were better that those generated by conventional hospitalisation under the care of the Department of Internal Medicine. In particular, the risk-adjusted average length of stay index was 0.93, that is, lower than the overall value for the Health Service of 1 and that of the Department of Internal Medicine itself, which was 1.01. Further, the impact of the care provided to patients managed by the PCIM CCU is -171, that is, we have saved 171 hospital bed stays, while traditional healthcare under the Department of Internal Medicine used, for the same year, 156 more hospital bed days (impact of +156). Put another way, if we estimate the impact as a function of the standard average length of stay by diagnostic related group (DRG) in the Spanish National Health System, in 2010, the PCIM CCU managed to reduce hospitalisation, saving 171 hospital bed days, while the Department of Internal Medicine oversaw the use of 156 bed days that could have been avoided.The good outcomes reported are the result of a relatively new approach to care that requires changes in the way of working in both the hospital and primary care. This study demonstrates that the optimisation of hospital resources is feasible through real, effective and personalized coordination between primary care and internal medicine specialists. Despite the fact that healthcare indices generated already indicate benefits of this way of working, further research should be conducted to assess whether it has an impact on the mortality or the readmission rate of patients with multiple chronic diseases.La Unidad de Continuidad Asistencial Primaria-Interna (UCAPI) se crea por los vacíos existentes en el proceso asistencial a pacientes crónicos complejos.La UCAPI nace en junio de 2006 desde el Servicio de Medicina Interna del Hospital Universitario de Guadalajara, extendiéndose hacia Atención Primaria (AP) siempre con la filosofía de colaboración y coordinación entre ambos niveles asistenciales, evitando la sensación de imposición que puede generar en Atención Primaria todo aquello que venga del hospital; para ello, se mantuvieron varias sesiones conjuntas con la Dirección Médica de Primaria, los coordinadores de los distintos Equipos de Atención Primaria y los internistas responsables de la UCAPI antes de la puesta en marcha de este proyecto. Su objetivo es facilitar la continuidad asistencial de los pacientes crónicos complejos, de pacientes con pluripatología y de pacientes en fase diagnóstica no demorable.La metodología de trabajo ver  es similPersonal facultativo: un internista hasta febrero de 2010, cuando ya se amplía con tres.Infraestructura: era deseable emplear personal (de enfermería y administrativo) y material ya existentes; para ello, se reconvierte una planta hospitalaria que se comparte con la Unidad de Corta Estancia (UCE) médica y quirúrgica, donde se ubicará: consulta, hospital de día y hospitalización convencional.El área que se cubre con la UCAPI constaba inicialmente, cuando estaba sólo un internista, de 3 Centros de Salud que atienden a 58.479 tarjetas sanitarias . En febrero de 2010 se amplía a 7 Centros, lo que hace un total de 134.613 tarjetas y 3 internistas.Los datos de la actividad realizada en este tiempo, 5 años, se divide entre los distintos dispositivos con los que cuenta la UCAPI, a saber:se reciben 1892 llamadas a los móviles de los internistas, de las cuales únicamente 762 son nuevas derivaciones de pacientes para ser atendidos en la UCAPI; el resto son dudas que se resuelven sobre la marcha.se han atendido un total de 1989 pacientes. El índice de consultas sucesivas /primeras es de 0,81 a 1,95; es decir, apenas se generan 2 revisiones por cada paciente nuevo que se atiende.Descripción de los pacientes atendidos en la consulta : critericonsta de 4 sillones para procedimientos diagnóstico-terapéuticos. Se realizan en este tiempo 676 procedimientos; los más numerosos: extracciones de analíticas y tratamientos parenterales, concretamente el hierro. Otros procesos realizados son: paracentesis, toracocentesis y punciones lumbares.al ser una planta compartida con la UCE, se han asignado 8 camas. El origen de los pacientes que ingresan puede ser bien directamente de la consulta u Hospital de Día, bien de la Urgencia hospitalaria siempre que los pacientes pertenezcan a los Centros de Salud adscritos al programa de la UCAPI. Los índices asistenciales generados en el año 2010 resultaron más favorables que los generados por la hospitalización convencional en Medicina Interna con un índice de Estancia Media Ajustado en 2010 de 0,93, es decir, inferior a la norma del Servicio de Salud, que es 1, y del propio Servicio de Medicina Interna, que es de 1,01. Además, el impacto que tiene la asistencia a los pacientes ingresados en la UCAPI es de -171, es decir, se han ahorrado 171 estancias hospitalarias, mientras que la asistencia tradicional de Medicina Interna empleó, para el mismo año, 156 estancias hospitalarias más (Impacto de + 156). Esto es, si se calcula el impacto en función del estándar de estancia media por GRD (grupo relacionado de diagnósticos) del Sistema Nacional de Salud, la UCAPI logra ahorrar en su asistencia 171 estancias hospitalarias, mientras que Medicina Interna podría haber evitado 156 estancias en el año 2010.Los datos asistenciales pertenecen a una forma asistencial reciente que obliga a cambiar mentalidades de trabajo en hospital y en Atención Primaria. Este trabajo demuestra la posible optimización de recursos hospitalarios a través de una coordinación real, efectiva y personalizada entre Atención Primaria y Medicina Interna. A pesar de que los índices asistenciales generados son favorables a esta nueva forma de trabajar, todavía queda por conocer si esto incidirá en la tasa de mortalidad o de reingresos de los pacientes con patologías múltiples y crónicas.


The potential for conservation of individual species has been greatly advanced by the International Union for Conservation of Nature's (IUCN) development of objective, repeatable, and transparent criteria for assessing extinction risk that explicitly separate risk assessment from priority setting. At the IV World Conservation Congress in 2008, the process began to develop and implement comparable global standards for ecosystems. A working group established by the IUCN has begun formulating a system of quantitative categories and criteria, analogous to those used for species, for assigning levels of threat to ecosystems at local, regional, and global levels. A final system will require definitions of ecosystems; quantification of ecosystem status; identification of the stages of degradation and loss of ecosystems; proxy measures of risk (criteria); classification thresholds for these criteria; and standardized methods for performing assessments. The system will need to reflect the degree and rate of change in an ecosystem's extent, composition, structure, and function, and have its conceptual roots in ecological theory and empirical research. On the basis of these requirements and the hypothesis that ecosystem risk is a function of the risk of its component species, we propose a set of four criteria: recent declines in distribution or ecological function, historical total loss in distribution or ecological function, small distribution combined with decline, or very small distribution. Most work has focused on terrestrial ecosystems, but comparable thresholds and criteria for freshwater and marine ecosystems are also needed. These are the first steps in an international consultation process that will lead to a unified proposal to be presented at the next World Conservation Congress in 2012.Establecimiento de Criterios para la Lista Roja de UICN de Ecosistemas AmenazadosEl potencial para la conservación de muchas especies ha avanzado enormemente porque la Unión Internacional para la Conservación de la Naturaleza (UICN) ha desarrollado criterios objetivos, repetibles y transparentes para evaluar el riesgo de extinción que explícitamente separa la evaluación de riesgo de la definición de prioridades. En el IV Congreso Mundial de Conservación en 2008, el proceso comenzó a desarrollar e implementar estándares globales comparables para ecosistemas. Un grupo de trabajo establecido por la UICN ha formulado un sistema inicial de categorías y criterios cuantitativos, análogos a los utilizados para especies, para asignar niveles de amenaza a ecosistemas a niveles local, regional y global. Un sistema final requerirá de definiciones de ecosistemas; cuantificación del estatus de ecosistemas; identificación de las etapas de degradación y pérdida de los ecosistemas; medidas de riesgo (criterios) alternativas; umbrales de clasificación para esos criterios y métodos estandarizados para la realización de evaluaciones. El sistema deberá reflejar el nivel y tasa de cambio en la extensión, composición, estructura y funcionamiento de un ecosistema, y tener sus raíces conceptuales en la teoría ecológica y la investigación empírica. Sobre la base de esos requerimientos y la hipótesis de que el riesgo del ecosistema es una función del riesgo de las especies que lo componen, proponemos un conjunto de 4 criterios: declinaciones recientes en la distribución o funcionamiento ecológica, pérdida total histórica en la distribución o funcionamiento ecológico, distribución pequeña combinada con declinación, o distribución muy pequeña. La mayor parte del trabajo se ha concentrado en ecosistemas terrestres, pero también se requieren umbrales y criterios comparables para ecosistemas dulceacuícolas y marinos. Estos son los primeros pasos de un proceso de consulta internacional que llevará a una propuesta unificada que será presentada en el próximo Congreso Mundial de Conservación en 2012. Like the IUCN Red List criteria for species, a global set of criteria for ecosystems must be easily understood by policy makers and the public. Additionally it should be made explicit that risk assessments are just one component of conservation priority setting and thus should be consistent with the species-based approach for red lists.ecosystem  is lost or, at the other extreme, when the last biotic element is lost. We believe the scientific community needs to focus on developing a pragmatic, standardized approach intermediate between these extremes i.e., . EliminaBecause direct measurement of the level of threat to ecosystems and species is costly and difficult, assessments need to use surrogate measures of risk, or “criteria” , that arIn the case of species, assessment criteria are derived from estimates of geographical distribution, abundance, and their temporal trends . Thus, tNevertheless, the abundance and trend-based criteria used presently for species assessments may lose meaning in the context of ecosystems  because in ecosystems changes in spatial extent represent the endpoint of processes such as structural conversion and functional decline. Therefore, additional criteria are needed to standardize reliable measures of ecological function  for whicIn this context, indicators of functional loss may include specific measures of threat , measures of structure , or measures of function  . For exaIntegrating the challenges and existing research outlined above, then, our proposed system combines measures of geographical distribution, ecological function, and their temporal trends over short and long periods in a manner analogous to the assessment of species for the IUCN Red List and results in four criteria : rate ofOnce criteria have been resolved, a further task will be quantifying thresholds for each criterion that reflect different levels of risk (i.e., vulnerable, endangered, critically endangered; By presenting preliminary, relatively simple criteria and thresholds ; Fig. 1,Nearly 15 years passed between the initial development of criteria for the IUCN Red List of Threatened Species and their official adoption . To miniIt is important to differentiate ecosystem risk assessment—a scientific, technical activity—from priority setting, a fundamentally societal, value-laden activity . As specAlthough the scientific and logistical challenges to developing criteria for an ecosystem red list are substantial, we believe the time is right to do so. Current opportunities include ongoing assessments at local and global scales, a strong IUCN mandate from governments and the conservation community, public concern worldwide about ecosystems and human dependence on them, a rich experience with the species red-listing process, and continuing and massive improvements in data collection and computing power. What remains is to engage the world's conservation and ecosystem scientists in this task.


Healthcare models are evolving from healthcare fragmented across centres and levels of care, towards an increasing integration of services. This new model makes it necessary to identify the specific needs of target populations and, based on this, diversify the services provided to better meet the requirements of various population groups and even specific individuals .In recent years, several centres of excellence working in the field of integrated care  have been dedicating considerable and growing efforts to the identification of the most complex segment of the population by analysing already existing data and the introduction of proactive care models , 3.Serveis de Salut Integrats Baix Empordà) is an integrated health organisation, responsible for the public healthcare services for a catchment population of 125,000. It has a single healthcare structure and also a single electronic medical record database, both of which are clear facilitators for the integration of healthcare [The Baix Empordà Integrated Health Service , geographical zones for the administration of health in our region, with a total catchment population of 93,233 (16.3% >65 years of age). Two workshops have been held with the key stakeholders involved: primary care doctors, internists, nurses, geriatricians, emergency doctors, and social workers. These workshops were aimed and structured to promote discussion and reach conclusions by consensus. On the basis of these sessions, the interventions to be carried out and corresponding lines of action were established .We built a predictive model for high-cost patients on the basis of age, sex and morbidity according to the CRGs, expenditure on medications >p95, use of hospital drugs in outpatient settings, and hospitalisation. The intervention project was then tested in one of the HAs and its usefulness was assessed.These are obtained from three phases:Identification of 4833 high-risk, high-cost patients; 80% being in CRGs 5, 6 and 7 . Their previous use of resources compared to other patients is reported in Setting up of an alert identifying complex chronic patients in the shared electronic medical records and distribution of these patients by primary care doctor.Specification of the interventions to be carried out and their validation using a pilot, carried out in one of the HAs with the involvement of nine healthcare units and a group of 94 patients. The common actions that should be carried out included reviewing and updating of: prescriptions, and assessment of the level of adherence to medications, attendance to primary care/hospital appointments and more specific issues . We set aside time in the working day of the professionals for them to carry out these interventions. The programmed interventions included: appointments, home visits and/or telephone consultations. Outcomes can be seen in We set up an overall strategy using a predictive model to identify high-risk, high-cost patients. This identification of such patients facilitates the task of care of primary care doctors/nurses and continuity with the other levels of care. The relatively small number of patients selected and assigned to each primary care doctors/nurses enables personalised analysis and intervention. The intervention defined has been found to be feasible and has made it possible to identify areas of improvement in the monitoring and control of chronic patients by primary care professionals.In order to act proactively, it is now necessary to define specific interventions. We aim to evaluate the results one year after the introduction of the programme. For this purpose, we plan to carry out a study with the design of a clinical trial to control for the variable “intervention” and quantify its effect.It is already clear, however, that this strategy must be complemented by other strategies in the areas of the emergency services, hospitalisation and social care, in order to adapt care to meet needs of this type of patient.Los modelos de atención sanitaria están evolucionando de una asistencia fragmentada en los centros y niveles, a una integración de servicios. Este nuevo modelo requiere identificar las necesidades específicas de la población asignada y diversificar en consecuencia la oferta de servicios, para adecuarla a las características de los diferentes grupos de población, e incluso individuos concretos .En los últimos años muchas organizaciones excelentes que trabajan en entornos de atención integrada  están destinando muchos y crecientes esfuerzos a identificar el segmento de población de mayor complejidad clínica mediante el análisis de información ya existente y la introducción de modelos de atención proactiva , 3.Serveis de Integrats Baix Empordà (SSIBE) es una Organización Sanitaria Integrada, responsable de los servicios sanitarios públicos en una comarca de 125.000 habitantes, de la provincia de Gerona . Dispone de una única estructura asistencial, así como una única historia clínica electrónica, hechos claramente facilitadores para la integración asistencial .Desde el año 2001, SSIBE tiene abierta una línea de investigación y desarrollo sobre el análisis de la morbilidad y el gasto a nivel individual. Categorizamos de forma continuada la morbilidad de nuestra población mediante los Clinical Risk Groups (CRGs), y analizamos su relación con la utilización de recursos. Un 1% de los usuarios consumen el 22% del presupuesto .Nos planteamos el reto de priorizar la atención y los recursos al servicio de los pacientes crónicos complejos. En este marco hemos desarrollado un modelo predictivo para la identificación de la población diana, basado en la morbilidad atendida y en que la variable dependiente es el gasto sanitario total elevado. Esta experiencia nos permite identificar los factores asociados a un mayor consumo de recursos en relación a la cronicidad .Nuestro objetivo es poder definir una estrategia asistencial proactiva sobre pacientes en riesgo de alto coste identificados mediante un modelo predictivo. Esta estrategia definida nos debe permitir orientar los recursos y adecuar las intervenciones a este grupo de pacientes; así mismo evaluar si las intervenciones permiten modificar su morbilidad esperada.Esta estrategia se divide en dos partes: una primera para definir el proyecto de intervención, el modelo predictivo y su validación, y una segunda para diseñar una intervención que nos posibilite evaluar los resultados mediante un ensayo clínico. El trabajo descrito a continuación se centra en la primera parte del proyecto.El proyecto se desarrolla en 4 Áreas Básicas de Salud (ABS), con una población de 93.233 personas . Se han realizado dos seminarios de trabajo con los principales agentes implicados: médicos de primaria, internistas, enfermeras, geriatras, médicos de urgencias y asistentes sociales. Los seminarios fueron dirigidos y estructurados para facilitar la discusión y consensuar las conclusiones. De los seminarios se concretaron diferentes ejes de actuación con las intervenciones a realizar .Se ha construido un modelo predictivo de pacientes de alto coste en base a edad, sexo, morbilidad según CRG, coste de recetas de farmacia >p95, uso de medicación hospitalaria de dispensación ambulatoria (MHDA) y uso de hospitalización.Se ha validado el proyecto de intervención en un ABS y se ha valorado su adecuación.Se distribuyen en tres fases:Identificación de 4.833 pacientes en riesgo de alto coste, el 80% de los cuales pertenecen a los Status de CRG 5-6-7 (“enfermedad crónica dominante única o múltiple”). La utilización previa de recursos que realizan respecto a los otros pacientes se puede ver en la Implementación en la historia clínica electrónica compartida de una alerta que identifica a los pacientes crónicos complejos. Distribución de los listados de pacientes predichos por médico de primaria.Definición de las intervenciones a realizar y validación de las misma en una prueba piloto, efectuada en 1 ABS con 9 unidades asistenciales y 94 pacientes incluidos. Las acciones comunes realizadas son revisión y actualización de: pauta de medicación, cumplimiento de la prescripción, adherencia a las visitas primaria-hospital, y acciones más específicas . Definimos un espacio en la agenda de trabajo del profesional para llevar a cabo las intervenciones. Se programan diferentes intervenciones: visita, atención domiciliaria y/o atención telefónica. Los resultados se pueden ver en la Disponemos de una estrategia global basada en un modelo de predicción del riesgo de pacientes de alto coste. La identificación de los pacientes facilita la intervención del médico/enfermera de primaria y la continuidad de atención con los otros ámbitos asistenciales. El número de pacientes seleccionados y distribuidos por médico/enfermera de primaria hace factible realizar el análisis e intervención personalizada.La intervención definida ha sido factible y permite identificar aspectos de mejora en el seguimiento y control de los pacientes crónicos por parte de los profesionales de atención primaria.Es necesaria la definición de intervenciones concretas para actuar de forma proactiva. Se prevé la evaluación de resultados al año de la implementación del programa. Para ello nos planteamos una implementación bajo un diseño de ensayo clínico para controlar la variable intervención y cuantificar su efecto.Esta estrategia debe ser complementada por otras estrategias en el ámbito de urgencias, hospitalización y sociosanitario que permitan adecuar la atención de estos pacientes.


In the Acknowledgments section, the affiliation of Xavier Rodó is listed incorrectly. The correct affiliation is: ICREA and Institut Català de Ciències del Clima.


Bidasoa integrated health organisation (IHO) was established in January 2011, bringing together the hospital and the three health centres of the Bidasoa health region. A new organisational model was introduced to integrate the resources of the region in order to facilitate:A change in the model for the relationships between professionals; andA change in the model for the provision of care.To improve collaboration we have focused on the following areas:Design and communication of the Strategic PlanCommunication between units and professionalsCreation of a joint technical committee as a body for clinician participationCreation of clinical and health care joint committees : patient safety, pharmacy, clinical records, etc.Setting up of a shared IntranetCreation of culture-cultural change:Progress towards the introduction of a shared medical recordDevelopment of integrated care pathways (ICPs): care pathways that specify the relationships between professionals participating in the provision of care related to a specific health problem. In 2011, the ICPs for atrial fibrillation, heart failure (HF) and chronic obstructive pulmonary disease (COPD) were designed.Development of clinical guidelinesEstablishment of a continuity of care unit (CCU) composed of an internist, a liaison nurse and a social worker.Integration of the clinical system:to support primary care (PC), providing one-stop appointmentsto provide a health care unit for patients with multiple conditions as described below.The aims of the CCU are:The referral internist  is responsible for the admission of patients with complex or multiple conditions in the event that they require admission to hospital. The mission of the CCU is to stabilise patients and facilitate continuity of care by the PC doctor and nurse. These patients have in place a continuity of care plan (CCP) between levels of care. The role of the liaison nurse is to support the patient in his/her transition from hospital to home, where they are followed up by PC.The referral internist visits the health centre every other week to undertake clinical sessions with the PC professionals, and is available to general practitioners at any time for any queries they may have.Development of shared leadership with the setting up of clinical management units in the three health centresEstablishment of a transparency information system.Management and leadership:Bidasoa IHO has adopted a healthcare strategy in line with the Kaiser Permanente model, defining actions for the various levels of the care pyramid:For complex cases, we have started to identify patients with high levels of comorbidityFor patients with a lower level of complexity (middle level of the Kaiser pyramid), continuity of care is provided with PC through the work of the liaison nurse and the ICPs for HF and COPDWith regards to the lower level of the Kaiser pyramid, Bidasoa IHO involves an intervention for patients with recent-onset diabetes, as identified using the adjusted clinical group (ACG) system.We describe the activity of the CCU in more detail below.In th first five months of operation of the CCU, we identified 57 complex patients, according to the definition of Ollero et al. , with anThe data collected on the first 30 patients cared for under the CCP are the following:70 admissions in 2010 (2.3 admissions per patient)39 admissions in the first 9 months of 2011That is, so far there has been a 25% decrease in the number of admissions. In this sample of patients, we also found that there were 112 attendances to Emergency Department in 2010, while in the first 9 months of 2011 there have been just 35 (a 58% decrease).Nine months after the setting up of the CCU, 115 patients had been allocated to CCPs. The average age of patients was 79.5 years, they were on multiple medications (an average of 8 drugs), attended an average of 9 consultations with specialists and were classified as at high social risk (41%).For the identification of complex patients, other sources of information have also been used:We used the Ambulatory Care Sensitive Conditions classification. A total of 73 patients were admitted to Bidasoa Hospital due to COPD. They had an average of 7 diagnoses at discharge from hospital, 23 of them having high blood pressure (HBP) and 11 diabetes mellitus (DM).Further, 135 patients were admitted due to heart failure in 2010. These patients had an average of 8.9 diagnoses at discharge, 63 patients having HBP and 43 DM.Finally, we analysed information from the ACGs. We identified 414 people aged 65 or below with a high level of comorbidity. Only 27% of these individuals were admitted to Bidasoa Hospital in 2010, which may suggest that they were seen at the tertiary level hospital. Further, we identified 53 people above 65 years of age with a high level of comorbidity of whom 45% were admitted to Bidasoa Hospital.The have modified the focus of the models for care and for the relationship between professionals. The creation of the CCU has resulted in a decrease in hospital admissions and in attendances to the Emergency Department by patients with multiple conditions.Nearly half the patients that were admitted for HF and/or COPD are candidates for care under a CCP and the remaining are less complex chronic patients.La Organización Sanitaria Integrada (OSI) Bidasoa se crea en enero de 2011 integrando los tres centros de salud de la comarca Bidasoa con el Hospital. Se estructura un modelo de organización diferente, para integrar los recursos de la región con el objetivo de facilitar:Un cambio en el modelo de relación entre profesionales yUn cambio en el modelo asistencial.Para avanzar en la colaboración se ha trabajado alrededor de:Elaboración y comunicación del Plan EstratégicoComunicación entre unidades y entre profesionalesConsejo Técnico mixto como órgano de participación asistencial.Comités mixtos  clínico asistenciales: seguridad de pacientes, farmacia, documentación clínica, …Intranet común …Creación de cultura – cambio cultural:Avance hacia la historia clínica compartidaDesarrollo de GPSs: rutas asistenciales que delimitan las relaciones entre los profesionales que participan en el proceso asistencial relacionado con un problema de salud concreto. En 2011, se han diseñado los GPS de fibrilación auricular, Insuficiencia Cardiaca y EPOC.Desarrollo de vías clínicasCreación de una Unidad de Continuidad Asistencial (UCA), que integra a tres internistas, una enfermera de enlace y una trabajadora social.Integración del sistema clínico: servir de apoyo al médico de atención primaria (AP), actuando como consulta de alta resolución.servir de unidad asistencial a los pacientes pluripatológicos como se describe más adelante.La UCA tiene como objetivos:El internista de referencia , es responsable de los ingresos de los pacientes complejos/pluripatológicos cuando ingresan en el hospital. La misión de la UCA es estabilizar a estos pacientes y facilitar la continuidad asistencial por parte del médico y enfermera de AP. Estos pacientes tienen activado un Plan de Continuidad (PAC) entre los dos niveles. La enfermera de enlace tiene un papel conductor del paciente hacia su domicilio en donde es seguido por AP.El internista de referencia se desplaza al centro de salud con periodicidad quincenal para sesiones clínicas con los profesionales de AP y mantiene una accesibilidad permanente para los médicos de familia.Desarrollo del liderazgo compartido con el desarrollo de Unidades de Gestión Clínica en los tres centros de saludSistema de información transparenteGobierno y liderazgo:OSI Bidasoa adopta una estrategia asistencial en línea con el modelo de Kaiser, definiendo actuaciones para los diferentes estratos del complejo asistencial:Para casos complejos se ha iniciado la identificación de pacientes con comorbilidad elevada.Para pacientes con menor nivel de complejidad (parte media de la pirámide de Kaiser), se facilita su continuidad asistencial hacia AP por medio de la enfermera de enlace y seguimiento de los GPS de Insuficiencia cardiaca y EPOC.En cuanto a la parte baja de la pirámide Kaiser, OSI Bidasoa interviene en la población de diabéticos poco evolucionados, identificados por ACGs .A continuación se describe en más detalle la actividad de la UCA.En los 5 primeros meses de funcionamiento de la UCA se identificaron, siguiendo la definición de Ollero et al. , 57 paciPara los 30 primeros pacientes incluidos en el PAC, se aprecian los siguientes datos:70 ingresos es el año 2010 39 ingresos en los primeros 9 meses de 2011Es decir, una disminución de un 25% en el número de ingresos.En estos pacientes se observa además que si en 2010 tuvieron 112 visitas por urgencias, en los nueve primeros meses de 2011 han necesitado acudir a urgencias en 35 ocasiones (disminución del 58%).Nueve meses después del inicio de actividad de la UCA se han incluido en PACs a 115 pacientes. Pacientes que tienen una edad media de 79,5 años, polimedicados (8 fármacos de promedio), con 9 consultas de promedio con las especialidades. Riesgo social elevado (41%).En el proceso de identificación de pacientes complejos, se han explorado también otras fuentes de información.Uso de los Ambulatory Care Sensivity Conditions: En el Hospital Bidasoa ingresaron 73 pacientes por EPOC. Estos pacientes tienen 7 Diagnósticos al alta, 23 tienen además Hipertensión Arterial (HTA) y 11 Diabetes Mellitus (DM). Ingresaron también 135 pacientes por Insuficiencia Cardiaca (IC) en 2010. Estos pacientes tienen 8,9 Diagnósticos al alta, 63 tienen además HTA y 43 DM.Finalmente, se ha explorado la información a partir de los ACGs. Se han identificado 414 personas menores de 65 años con elevado nivel de comorbilidad. Sólo el 27% ingresaron en el Hospital Bidasoa en 2010, lo que probablemente indica que son pacientes atendidos en el nivel terciario. También se han identificado 53 personas mayores de 65 años con elevado nivel de comorbilidad de las cuales ingresaron en el Hospital Bidasoa el 45%.Se ha modificado el enfoque del modelo asistencial y el modelo de relación entre profesionales. La creación de la UCA ha resultado en una disminución de los ingresos hospitalarios y las visitas a urgencias de pacientes pluripatológicos.La mitad de los pacientes que ingresan por IC y/o EPOC son susceptibles de ser incluidos en un PAC y la otra mitad aproximadamente pertenecerían a otro estrato menos complejo de la población de pacientes crónicos.


To evaluate factors associated with neonatal death within 24 hours after birth in very low birth weight preterm newborns.0/7–316/7 weeks, birth weight of 500–1499g without malformations, in 19 public maternity hospitals in nine capitals in northeastern Brazil from July to December 2007. The 19 hospitals were assessed in relation to physical resources, equipment, human resources and aiming at quality in care initiatives. Hospital, maternal and neonatal characteristics, neonatal morbidity, neonatal procedures and interventions were compared between preterm newborns that died or survived up to 24 hours of life. The variables associated with death within 24 hours after birth were determined by logistic regression.Prospective cohort of live births with gestational age of 23Of the 627 newborns enrolled in the study, 179 (29%) died within 168 hours after birth, of which 59 (33%) up to 24 hours and 97 (54%) up to 48 hours after birth. The variables associated with death <24h were: weight <1000g , 5th minute Apgar <7 , male gender . A better hospital structure was a protective factor for early neonatal death .The high neonatal mortality on the first day of life in capital cities of Northeast Brazil is associated with biological variables such as weight and gender of the newborn, as well as low vitality at birth and a worse infrastructure of the hospital where the birth occurred. Neonatal mortality has acquired increasing importance as the most significant cause of infant mortality. Of all neonatal deaths, 3/4 happen in the first week of life. The first day of life has the highest risk of death and accounts for 25–45% of all deaths.The neonatal mortality rate remains high in Brazil; it was of 10:1000 live births in 2011, which is 2.5 times higher than that in the United States and Canada and about 10 times higher than that of Japan in the same year.In recent years, the prevalence of preterm births in Brazil is growing, first due to the increased use of assisted reproduction techniques, and second due to the quality of prenatal care and significant increase in the frequency of early terminations of pregnancy by surgical deliveries.In addition to the inequalities in the international and regional scenario, there are differences in neonatal mortality in different health institutions. The causes of the differences are not clear, even after adjusting for patient characteristics. Hospital care plays a key role in mortality variation found between the various centers. This fact is of importance, as the majority of deliveries in Brazil take place in health institutions.In this context, the aim of this study was to evaluate factors associated with neonatal death in the first 24 h of very low birth weight preterm infants born in public hospitals of capital cities of Northeast Brazil.0/7 to 316/7 weeks and weighing ≥500 and <1500g, born in 19 public reference hospitals in the capitals of the nine Northeastern states from July to December of 2007. Patients with major congenital malformations, transferred from other institutions, and those who died in the delivery room were excluded. The study used the database of the North-Northeast Perinatal Health Network (RENOSPE), an initiative of the Ministry of Health through the Technical Department of Child Health. The project was approved by the Ethics Committee of the Maternity School Assis Chateaubriand and UNIFESP and the Data Custodian was obtained from RENOSP 2007.Hospital-based prospective cohort of live births with gestational age of 23The research developed by RENOSPE with data collected from the Neonatal Intensive Care Unit evaluated 36 hospitals in the Northeast states. In this study, we included only hospitals located in the capital cities (29). Of those, two were excluded for not having maternity and eight for having less than 20 patients during the collection period. Therefore, 19 hospitals were included in nine capitals of the Brazilian Northeast.The selected hospitals were serving only patients of the Unified Health System (SUS). Data collection was performed prospectively in the chart of the newborn, from admission to discharge or death, by a field investigator trained by RENOSPE. Data collected included hospital characteristics, maternal and neonatal demographics, and clinical evolution of the evaluated newborns.The 19 maternity hospitals were evaluated using a questionnaire filled out by health professionals with respect to physical resources, equipment, human resources, and initiatives in search of quality of care, according to the previously published methodology,Data of variables related to maternal demographic characteristics, complications during pregnancy, and use of antenatal corticosteroids were collect—considered present if at least one dose of corticosteroids was given before delivery—and type of delivery. The evaluated neonatal data were related to patient characteristics, procedures in the delivery room, and the use of positive pressure ventilation (PPV) was defined when delivered with bag-mask or tracheal tube, and the presence of advanced resuscitation if PPV with heart massage and/or medications. Information concerning the newborn's temperature on admission to the ICU were collected, considering hypothermia <36 °C,t test for quantitative variables and chi-square or Fisher's exact test for qualitative variables. To identify factors associated with death within 24 h after birth, logistic regression was performed with the backward stepwise method. The independent factors introduced in the initial model were those with p-value <0.20 in the univariate analysis and maintenance at p<0.05 to remain in the model. The association between the independent variables and the response variables was expressed as Odds Ratio (OR) and 95% confidence intervals (95%CI). The final model adjustment was evaluated using the Hosmer–Lemeshow test. Statistical analysis was performed using SPSS 17.0 software  and p<0.05 was considered significant.Statistical analysis initially compared the variables according to the presence or absence of outcome using the Mann–Whitney or 0/7 and 316/7, weighing between 500 and 1499 g, without congenital malformations  died before 168 h of life; of which, 59 (33%) within 24 h. The following distribution of deaths according to gestational age was observed: 216 infants with 23–27 weeks, of which 38 (18%) died within 24 h and 411 neonates with 28–31 weeks, of which 21 (5%) died within 24 h.p=0.712.This multicenter study shows that neonatal mortality in the first 24 h of life is high in very low birth weight preterm infants in the capital cities of northeastern Brazil, compared with the more developed regions of Brazil and developed countries. Of the 627 studied neonates, 59 (9.4%) died in the first 24 h. In the study of university public maternities in the South and Southeast performed by the Brazilian Neonatal Research Network in 2004, of 560 newborns evaluated, excluding deaths in the delivery room, 25 (4.5%) died within 24 h. It is noteworthy that patients weighing between 400 and 1499 g were included in the study, which may have contributed to increase this percentage.Among the factors associated with neonatal death on the first day of life there are three groups of variables: those related to the quality of perinatal care , those related to neonatal biological variables , and those reflecting care during labor and delivery (Apgar score at 5 min).,,Regarding hospital structure, all hospitals in the study belonged to the Unified Health System (SUS) and several authors reported high rates of neonatal mortality in SUS public hospitals.Regarding the biological factors related to neonatal death within 24 h after birth, we highlight the extremely low birth weight and male. Among the 287 infants <1000g analyzed in this study, 45 (15.7%) died within 24 h, accounting for 76% of neonates who died during this period. Birth weight <1000g increased three times the risk of death within 24 h, compared to the weight of 1000–1499g. In the American Neonatal Network, among the 6780 extreme low birth weight preterm infants born between 1998 and 2003, mortality was 14.3% in the first 24 h.,The male gender is strongly associated with death in the first 24 h of life, with a risk of death three times higher compared to women. The same finding was seen in-hospital mortality in other studies.Among the factors related to care in childbirth associated with mortality within the first 24h after birth, the Apgar score <7 at 5 min is highlighted. In a population-based research in the United States performed between 2001 and 2002, Lee et al.It is important to emphasize that the use of secondary data has limitations and difficulties inherent in the methodology and favors failures in completing the forms. Thus, eight hospitals were excluded from the study for presenting non-representative sample of its institutions. Furthermore, the interval of seven years between data collection and its analysis shows the difficulties for consolidating information in units where there is no training for research. Nevertheless, this is the first study with prospective collection of reference maternities data in the Northeast region that helps outline a picture of the service to labor and delivery of very low birth weight preterm infants, which contribute significantly to neonatal children mortality and influence human development index of these places. In this context, the results indicate that early neonatal mortality especially in the first 24 h is high in very low birth weight preterm patients in the city capitals of the Northeast region compared to the more developed regions of Brazil and in developed countries. Our findings reveal the existence of failures in the intensive care units assessed, with poor hospital infrastructure and high contribution of extremely low birth weight and perinatal asphyxia for mortality within the first 24 h of life. Overcoming these data requires a government policy that clearly assigns responsibilities for actions aimed at improving the quality, with priority settings, selection and definitions of interventions and constant evaluation. A mortalidade neonatal vem assumindo importância crescente como componente mais expressivo da mortalidade infantil. De todos os óbitos neonatais, 3/4 ocorrem na primeira semana de vida. O primeiro dia de vida apresenta o maior risco de morte e representa 25-45% de todas as mortes.No Brasil, a taxa de mortalidade neonatal persiste elevada, é de 10/1.000 nascidos vivos em 2011, 2,5 vezes superior à dos Estados Unidos e do Canadá e cerca de dez vezes maior do que a do Japão no mesmo ano.A prevalência da prematuridade vem crescendo nos últimos anos no Brasil, decorrente, por um lado, da disseminação de técnicas de reprodução assistida e, de outro, da qualidade da assistência no pré-natal e do aumento significativo da frequência de interrupções antecipadas da gravidez por partos cirúrgicos.Além de desigualdades no cenário internacional e regional, existem diferenças na mortalidade neonatal em diferentes instituições de saúde. Não são claras as causas dessas diferenças, mesmo após ajuste para diversas características dos pacientes. Os cuidados hospitalares desempenham papel fundamental na variação de mortalidade encontrada entre os diversos centros. Tal fato se reveste de importância, uma vez que a maioria dos partos no Brasil ocorre em instituições de saúde.Nesse contexto, a presente pesquisa tem por objetivo avaliar os fatores associados ao óbito neonatal até 24 horas após o nascimento de neonato pré-termo de muito baixo peso, nascidos em hospitais públicos nas capitais da Região Nordeste.0/7 a 316/7 semanas e peso ≥500g e <1.500g, nascidos em 19 maternidades públicas de referência nas capitais dos nove estados da Região Nordeste, de julho a dezembro de 2007. Foram excluídos os pacientes portadores de malformações congênitas maiores, aqueles transferidos de outras instituições e os que morreram em sala de parto. A pesquisa usou o banco de dados da Rede Norte-Nordeste de Saúde Perinatal (Renospe), uma iniciativa do Ministério da Saúde por intermédio da Área Técnica de Saúde da Criança. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da Maternidade Escola Assis Chateaubriand e Unifesp e obtido o Termo de Fiel Depositário para uso dos dados da Renospe 2007.Coorte prospectiva de base hospitalar dos nascidos vivos com idade gestacional de 23A pesquisa desenvolvida pela Renospe, com dados coletados das Unidades de Terapia Intensiva Neonatal, avaliou 36 hospitais nos estados do Nordeste. No presente estudo, foram incluídos somente os hospitais localizados nas capitais de estado (29). Desses, foram excluídos dois por não terem maternidade e oito com número de pacientes inferior a 20 no período da coleta. Foram, portanto, incluídos 19 em nove capitais do Nordeste brasileiro.Os hospitais selecionados atendiam exclusivamente pacientes do Sistema Único de Saúde. A coleta dos dados foi feita desde o momento da internação até a ocasião da alta ou óbito, a partir do prontuário do recém-nascido, de forma prospectiva por um pesquisador de campo treinado pela Renospe. Foram incluídas nessa coleta as características hospitalares, as características demográficas maternas e neonatais e a evolução clínica dos recém-nascidos avaliados.Os 19 hospitais-maternidades foram avaliados por meio de formulário preenchido por profissionais de saúde, com relação aos recursos físicos, equipamentos, recursos humanos e iniciativas de busca de qualidade no atendimento, de acordo com metodologia publicada anteriormente,Foram coletadas variáveis relacionadas às características demográficas maternas, intercorrências na gestação e uso do corticoide antenatal, considerado presente se pelo menos uma dose de corticoide foi aplicada antes do parto; e tipo de parto. Os dados neonatais avaliados relacionaram-se às características dos pacientes, aos procedimentos em sala de parto, e foi definido o uso de ventilação com pressão positiva (VPP) quando aplicada com balão e máscara ou cânula traqueal e a presença de reanimação avançada, se VPP com massagem cardíaca e/ou medicações. Foram coletadas informações relativas à temperatura do recém-nascido na admissão à UTI, considerada hipotermia <36°C,t ou de Mann-Whitney para as variáveis quantitativas e por qui-quadrado ou teste exato de Fisher para as variáveis qualitativas. Para verificar os fatores associados ao óbito até 24 horas após o nascimento, efetuou-se a regressão logística com a estratégia passo a passo, com o método backward. Os fatores independentes introduzidos no modelo inicial foram todos aqueles que apresentaram valor de p<0,20 à análise univariada e se devia manter p<0,05 para permanecer no modelo. A associação entre as variáveis independentes e as variáveis-resposta foi expressa em razão de chances (OR) e intervalo de confiança de 95% (IC95%). O ajuste do modelo final foi avaliado pelo teste de Hosmer-Lemeshow. Em toda a análise estatística, o software usado foi o SPSS 17.0  e foi significativo p<0,05.Na análise estatística, inicialmente compararam-se as variáveis de acordo com a presença ou ausência do desfecho por meio do teste 0/7 e 316/7, peso entre 500 e 1.499g e sem malformações congênitas  morreram antes de 168 horas de vida, dos quais 59 (33%) antes de 24 horas. Observa-se a seguinte distribuição dos óbitos de acordo com a idade gestacional: 216 pacientes com 23-27 semanas, dos quais 38 (18%) faleceram até 24 horas, e 411 neonatos com 28-31 semanas, dos quais 21 (5%) faleceram até 24 horas.A distribuição das características maternas de acordo com a presença do óbito do recém-nascido até 24 horas de vida é mostrada na p=0,712.A Este estudo multicêntrico revela que a mortalidade neonatal nas primeiras 24 horas de vida é elevada nos recém-nascidos pré-termo de muito baixo peso nas capitais da região Nordeste, se comparada com a de regiões mais desenvolvidas do Brasil e com países desenvolvidos: dos 627 neonatos estudados, 59  morreram nas primeiras 24 horas. No estudo da Rede Brasileira de Pesquisas Neonatais, em 2004, com maternidades públicas universitárias do Sul e Sudeste, dos 560 neonatos avaliados, excluídos os óbitos em sala de parto, 25  morreram nas primeiras 24 horas. Salienta-se que foram incluídos no estudo citado pacientes com peso entre 400 e 1.499g, o que pode ter contribuído para elevar tal percentual.Dentre os fatores associados ao óbito neonatal no primeiro dia de vida, ressaltam-se três grupos de variáveis: as ligadas à qualidade do atendimento perinatal , aquelas relacionadas às variáveis biológicas neonatais (peso ao nascer e sexo masculino) e as que refletem o atendimento ao trabalho de parto e ao parto (Apgar de 5 minutos).,,No que diz respeito à estrutura hospitalar, todos os hospitais do estudo pertenciam ao Sistema Único de Saúde (SUS) e vários autores indicam taxas de mortalidade neonatal elevadas em hospitais públicos do SUS.No que concerne aos fatores biológicos ligados ao óbito neonatal até 24 horas após o nascimento, destacam-se o extremo baixo peso ao nascer e o sexo masculino. Dentre os 287 recém-nascidos <1.000g analisados no presente estudo, 45  morreram até 24 horas, perfizeram 76% dos neonatos que morreram nesse período. O peso ao nascer <1.000g aumentou em três vezes o risco de morte nas primeiras 24 horas, comparado com o peso de 1.000-1.499g. Na rede americana Neonatal Network, dentre os 6.780 neonatos pré-termo de extremo baixo peso nascidos entre 1998 e 2003, a mortalidade foi de 14,3% nas primeiras 24 horas.,O sexo masculino apresentou forte associação com o óbito nas primeiras 24 horas de vida, com risco três vezes maior de morte comparado com o feminino. O mesmo achado foi evidenciado na mortalidade intra-hospitalar em outros estudos. Dentre os fatores relacionados à atenção ao parto que se associaram à mortalidade nas primeiras 24 horas após o nascimento, destaca-se o Escore de Apgar com 5 minutos <7. Em uma investigação de base populacional nos Estados Unidos, entre 2001-2002, Lee et al.É importante enfatizar que o uso de dados secundários apresenta limitações e dificuldades inerentes à própria metodologia e favorece falhas no preenchimento dos formulários. Assim, oito hospitais foram excluídos da pesquisa por apresentar amostra não representativa de suas instituições. Além do mais, o lapso de sete anos entre coleta de dados e sua análise mostra as dificuldades para a consolidação de informações em unidades em que não há capacitação para a pesquisa. Apesar disso, trata-se do primeiro estudo com coleta prospectiva de dados de maternidades de referência da Região Nordeste que permite delinear um retrato do atendimento ao nascimento e parto de neonatos pré-termo de muito baixo peso, que contribuem substancialmente para a mortalidade neonatal e infantil e influenciam o índice de desenvolvimento humano desses locais. Nesse contexto, os resultados permitem concluir que a mortalidade neonatal precoce especialmente nas primeiras 24 horas é elevada nos pacientes pré-termo de muito baixo peso nas capitais da Região Nordeste se comparada com a de regiões mais desenvolvidas do Brasil e a de países desenvolvidos. Os achados revelam a existência de falhas nas unidades de terapia intensiva avaliadas, com infraestrutura hospitalar deficiente e elevada contribuição do extremo baixo peso e da asfixia perinatal para a mortalidade nas primeiras 24 horas de vida. A superação desses dados requer uma política governamental que, de forma clara, atribua responsabilidades para ações direcionadas à melhoria de qualidade, com definições de prioridades, seleção e definições de intervenções e avaliação constantes.


The following information is missing from the Funding section: Additionally, this work was supported by Fondation ICM, “Investissements d’avenir” ANR-10-IAIHU-06. The complete, correct funding information is as follows: This work was supported by grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES-COFECUB 681–10), Programa de Apoio aos Núcleos de Excelência (PRONEX—Project NENASC), Fundação de Apoio à Pesquisa do Estado de Santa Catarina (FAPESC), QREN (CENTRO-07-ST24-FEDER-002006). Additionally, this work was supported by Fondation ICM, “Investissements d’avenir” ANR-10-IAIHU-06. DR and AAC received scholarships from CNPq. RDP is supported by a research fellowship from CNPq. RRV and RAC are supported by Visitant Research fellowships from CNPq (Ciência sem Fronteiras). The authors have no financial or personal conflicts of interest related to this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


To develop an equation to estimate the breast reference temperature according to the variation of room and core body temperatures. Four asymptomatic women were evaluated for three consecutive menstrual cycles. Using thermography, the temperature of breasts and eyes was measured as indirect reference of core body and room temperatures. To analyze the thermal behavior of the breasts during the cycle, the core body and room temperatures were normalized by means of a mathematical equation. We performed 180 observations and the core temperature had the highest correlation with the breast temperature, followed by room temperature. The proposed prediction model could explain 45.3% of the breast temperature variation, with variable room temperature variable; it can be accepted as a way to estimate the reference breast temperature at different room temperatures. The average breast temperature in healthy women had a direct relation with the core and room temperature and can be estimated mathematically. It is suggested that an equation could be used in clinical practice to estimate the normal breast reference temperature in young women, regardless of the day of the cycle, therefore assisting in evaluation of anatomical studies. Compared with some anatomical tests, such as mammography and ultrasound, thermograms were shown to be more relevant for investigation of breast diseases.-3 However, in the 21st century, with deeper understanding of neuroendocrine and immunobiological phenomena, the importance of functional studies gave rise to a new approach in breast thermography publications. First of all, the method is not comparable to mammography, since it is a dynamic evaluation of the functional behavior of the skin covering the breast.,5Since the 20,7 Thermal hyperemia, occurring over a few hundredths of a degree, is a new expanded workup approach to traditional clinical inspection that cannot be perceived by the human eye, and produces characteristic images on the skin surface that cannot be accurately quantified as objective temperature data, e.g.The breast is a gland attached to the dermis and its biological functions, such as microcirculation, perfusion, vascular and inflammatory activity, change constantly and can be documented and quantified by high-resolution thermal imaging. However, the skin temperature may vary with the room temperature, as well as with the metabolic activity of tissues and, especially, with the core body temperature.Unlike anatomical tests, such as mammography, thermography is a physiological measure that cannot be analyzed in the same context. This is particularly important because, for diagnostic support, not only a qualitative study of thermal distribution is required, but also a quantitative analysis of skin temperature values resulting from the balance between heat transfer from the tissues to the skin surface and from the skin to the environment. Thermography can only be used to validate studies of certain diseases if the results published in the literature are comparable, i.e., if they apply the same methodology. But there are no internationally standardized temperature values for diagnostic thermographic evaluation of a given disease, and there is no normal reference range for the breasts, due to major variation in two factors: individual metabolism and room temperature. Each body depending on its size, age, sex, height, weight, body composition, level of physical activity, fasting, hydration and circadian rhythm, has a different core temperature and metabolism, and therefore skin temperature differs by region.-14 The literature frequently indicates analysis by thermal gradients, comparing equivalent opposing regions.Infrared thermal imaging can only produce reliable and valid results if the technique is compliant with established standards. In medical applications, these standards are based on the physics of heat radiation and thermoregulation of the human body.,14 However, although the temperature is kept stable during image acquisition, the room temperature in most published studies varies between 18°C and 26°C.Skin temperature may vary 0.5°C for each 1°C increase or decrease in room temperature; the literature recommends that the room temperature be stable with variation of ±1.0°C, preferably ±0.5°C, during the acquisition of thermal images. This also explains the room temperature variation between medical thermography studies of populations from different locations, with adjustment of the temperature based on the patients’ thermal comfort. Colder countries with cooler rooms, and tropical countries with warmer rooms. Individual and environmental variables can influence the thermal comfort of patients. The most important characteristics include metabolism, sex, age, ethnicity, activity level and eating habits.In clinical practice, it is difficult to establish a testing environment with strict temperature control and consistency every day of the year. The impacting factors are mostly humidity, number and movement of people during the evaluation, room lighting, nearby equipment and heat sources, ventilation, doors opening between examinations, and wall insulation. They all prevent consistent control of room temperature during the examination. Depending on the geographical area and time of year, each location has its own climate changes determining different thermal comfort ranges. When we compare patients from tropical countries and colder places, there is an obvious difference in thermal comfort between different populations. The conditions for thermal comfort depend on the activities developed by individuals, their garments, and environmental variables that allow for heat exchange between body and environment.We need to develop an application for thermography in research and clinical practice at different locations that can be validated for investigating diseases by comparison, without the need for rigorous acclimatization to maintain the same consistent temperature during the whole year. That is why it is so important to have the possibility of interpreting these images over a broader room temperature range, respecting the thermal comfort of each patient, and then mathematically correct the temperature to compare with normal parameters and also between the published studies. It is necessary, therefore, to obtain reliable and independent analyzes of the patients’ environmental and metabolic conditions in different data acquisition scenarios.To develop a prediction equation for the thermal behavior of breasts, regardless of room and core body temperature variations.Hospital de Clínicas da Universidade Federal do Paraná, under number CAAE: 17984413.8.0000.0096 and opinion number 339 545. The healthy volunteers were subjected to daily breast temperature monitoring for 3 months, with a thermographic device , in the same room located at the Núcleo de Pesquisa e Desenvolvimento de Energia Autossustentável da Universidade Federal do Paraná, at intentionally uncontrolled room temperature.Four volunteers with normal breast health were evaluated for 3 consecutive months in search of scientific evidence of temperature changes in the breasts during the monthly menstrual period. The study enrolled four young female volunteers of childbearing age, between 12 and 26 years (16.9±4.7), with no complaints related to the breasts or any other underlying disease, from August 2013 to January 2014. All subjects signed the Informed Consent Form, and the study was conducted according to Resolution 466/2012 of the National Health Council and the recommendations of the Declaration of Helsinki, revised in 2008. The work was approved by the Research Ethics Committee of the The device provides images with resolution of 76,800 pixels and sensitivity of 0.05°C, and calculates the skin temperature of the breasts with no need for contact, using the Stephen-Boltzmann equation (Equation 1)where The intensity of the thermal radiation emitted by a body depends on its temperature and ability to emit radiation, which is given by the emissivity of the body. The emissivity is calculated as the relationship between the energy radiated by the body and the energy radiated from a black body at the same temperature, and is 0.98 for the human skin.For measuring the skin temperature of the breasts, the patients previously stood shirtless for 10 minutes in a room without temperature control, according to the local climate (Curitiba (PR), Brazil), always in the morning between 8:00 and 10:00 am, in a closed environment without any airflow and without sweating or shivering.Anterior views were taken with the arms lifted over the head to expose the entire axillary region, as shown in ,20 The MET was measured as an indirect value closest to the core body temperature . The same device was used to record the breast and eye temperatures, which simplifies the methodology using one single measuring instrument and avoiding the standard error between different devices. The core body temperature was indirectly obtained by measuring the MET, more specifically at the medial corner of the eye. This is the warmest area of the face, where supraorbital and suprathroclear arteries emerge to the forehead, as well as direct branches of the ophthalmic artery and the internal carotid, bringing warm blood from the inside , according to research conducted by Dr. Marc Abreu, a Brazilian working at Yale University. This area is also known as the brain temperature tunnel (BTT).perature .The room temperature was also indirectly obtained using the value of the thermal image background as reference. The walls of the room where the images were taken was made of cement, and the emissivity used in the formula was corrected to 0.96.t” test, Pearson´s correlation coefficient, standard error of estimate, total error and constant error, as well as linear regression analysis applied to the dataset. The level of statistical significance established was 5% (p<0.05). Statistical analysis was performed with the software Statistical Package for Social Sciences (SPSS) version 21.For statistical analysis in this study, we used the paired Student’s “oC (34.6±0.7°C), with a thermal gradient of 3.7oC  and the eye temperature ranged between 34°C and 38°C (36.4±0.8°C), with a respective thermal gradient of 12.1°C and 4°C .There was a high correlation between the average temperature of the right and left breasts  , that isThe scatter plot showed there was greater correlation of the average breast temperature with the MET (core), followed by the room temperature (p<0.01) .2=0.46)  .Based on est: estimated average temperature of the breast; CT: maximum eye temperature (core); RT: room temperature.Where ATEquation 2 can also be used to correct the breast temperature to a reference temperature when thermograms are acquired at different temperatures. To do so, simply replace the RT with the desired reference temperature. In this study, the room temperature was indirectly measured based on the background temperature of the thermal image. This may suggest that the breasts have a higher correlation with the core body temperature than with the forehead temperature.The MET had good and significant correlation with the breast temperature (r=0.605). We did not find any studies investigating the correlation between eye or room temperature and the breast temperature. However, correlations of about 0.49 have been published for the maximum and 0.12 for the minimum forehead temperature in relation to the breast temperature.In respect to breast and room temperatures, the correlation observed (r=0.368) was regular, but significant. A study investigating the skin temperature variation in unstable environments showed graphic results suggestive of a good correlation between these variables, without specifying the correlation coefficients.Many of the normally inactive veins of the superficial plexus of the breasts becomes active when metabolic activity increases, and the temperature of the avascular part of the skin also increases. This metabolic increase can be indirectly detected based on the core body temperature. To ensure proper functioning of internal organs and the brain, the core temperature and the skin surface temperature should be kept within normal ranges and approximately constant, due to the biochemical reactions necessary for life. The reactions only occur at temperatures close to the optimum value for enzyme activity. Thus, the core body temperature influences the skin temperature by the dynamics of superficial vessels.Under normal conditions, there is a consistent thermal flow from the inside to the outside of the body. The heat passes on to the environment through the skin. In the trunk, the skin covers a large area of metabolically active muscle and glandular tissue, which continuously produces lots of heat. The temperature in this region is typically determined by the core body temperature through heat transport by conduction.Although no significant difference was found within a specific phase of the menstrual cycle, the breast temperature had high correlation with the core body temperature at the time of acquisition. In other words, images acquired at the beginning, middle or end of the cycle (month) did not show any specific thermal pattern characterizing higher or lower metabolic activity of the breasts in young women during the menstrual cycle, despite the variation in core temperature. The core body temperature and the room temperature may be masking the effect of hormones on the average breast temperature. However, this study did not identify any changes in the average breast temperature relative to the menstrual cycle, i.e., the temperatures measured from day 1 of the menstrual period until the day before the next period. Also, there was no increase in the maximum eye temperature during the estimated luteal phase, indicating that the average breast temperature is more closely related to the core MET than to hormonal activity in the breasts. However, this study was not designed to evaluate ovulation in young women, but how the thermal behavior of the breasts varies during the cycles.Some studies reported that certain physiological processes in women are related to the different phases of the ovulatory cycle. The most important include changes in gonadotropin, estrogens and progesterone levels in the blood. The diversity of the fluid balances and fluctuations in the core body temperature , which is approximately 0.4°C, is higher in the luteal phase than in the follicular phase of the cycle. Therefore, the temperature of the skin, including the breasts, is directly affected by the room temperature.The blood palys a role in normalizing the temperature of the organs and muscles, where metabolic heat is generated to be later dissipated to the outside through capillary vessels on the skin. In warm weather, blood converges to the body surface, increasing the temperature. The body starts sweating to cool down the skin and then proceeds to cool down the blood. The opposite happens when the weather is cold. In this case, the blood accumulates heat in the central part of the body, distant from the skin to prevent heat loss. without any air flow exceeding 0.2m/s, which can cause heat loss by forced convection. Nevertheless, a lot of variability was observed in room and core body temperatures measured in a city like Curitiba (PR), with an average daily temperature variation range of 12°C to 13°C. Curitiba (PR) is the coldest capital city in Brazil. The annual average is 16.5 °C (8.4°C to 26.2°C), and it is coldest in July and warmest in February. Therefore, it is not always possible to keep a constant and uniform temperature in a closed environment, pointing to the relevance of finding ways to correct the temperature measured, such as the equation proposed in this study.This is why the literature recommends maintaining the temperature of the examination room as constant and uniform as possible,2) of the breast temperature variation at variable room temperature, and may be accepted as a way to estimate the reference breast temperature at different room temperatures.The proposed prediction model can explain 45.3%  na mesma sala, situada no Núcleo de Pesquisa e Desenvolvimento de Energia Autossustentável da Universidade Federal do Paraná, porém intencionalmente sem controle da temperatura ambiente.Foram avaliadas quatro voluntárias com a saúde das mamas normal, durante 3 meses consecutivos, para identificar evidências cientificas das alteraçãoes de temperaturas nas mamas durante todo o período mensal da mulher. Participaram do estudo quatro voluntárias jovens do sexo feminino, em idade fértil, entre 12 a 26 anos , sem queixas em relação às mamas ou qualquer outra doença de base, no período de agosto de 2013 a janeiro de 2014. Todas as participantes do estudo assinaram o Termo de Consentimento Livre e Esclarecido, e a pesquisa foi conduzida de acordo com a resolução 466/2012 do Conselho Nacional de Saúde e as recomendações da Declaração de Helsinque, revisada em 2008. O trabalho foi aprovado pelo Comitê de Ética em Pesquisa sob o número CAAE: 17984413.8.0000.0096 do Hospital de Clínicas da Universidade Federal do Paraná, com número de parecer 339.545. As voluntárias saudáveis foram submetidas a um acompanhamento diário da temperatura das mamas durante 3 meses, com um aparelho termográfico O equipamento permite capturar imagens de 76.800 onde A intensidade de radiação térmica emitida por um corpo depende da temperatura e da capacidade deste em emitir radiação, que é dada pela emissividade do corpo. O cálculo da emissividade de um corpo é obtido a partir da relação entre a energia irradiada do corpo e a energia irradiada de um corpo negro na mesma temperatura, e corresponde a 0,98 para pele humana.Para aquisição da temperatura cutânea das mamas, a paciente permaneceu previamente em posição ortostática por 10 minutos, com a parte superior despida, em ambiente sem controle de temperatura, conforme clima local  sempre pela manhã, entre 8 e 10 horas, em um ambiente fechado, sem corrente de ar e sem que apresentasse sudorese ou tremor.Foi realizada incidência anterior, com os braços apoiados sobre a cabeça expondo amplamente a região axilar, como demonstrada na ,20 Verificou-se então a TMO para obter um valor indireto mais próximo ao da temperatura central do corpo . Utilizou-se o mesmo equipamento para registro da temperatura das mamas e olhos, facilitando a metodologia por meio de um único instrumento de registro, bem como do erro padrão entre equipamentos para medida de temperatura. Assim, a temperatura central foi obtida indiretamente, mensurando-se a TMO, mais especificamente canto medial dos olhos. Esta é a área mais aquecida da face, da qual emergem para a fronte as artérias supraorbitais e supratrocleares, ramos diretos da artéria oftálmica e carótida interna que trazem sangue aquecido da parte interna (hipotálamo), segundo pesquisa desenvolvida pelo brasileiro Dr. Marc Abreu na Universidade de Yale, denominado também de túnel de temperatura cerebral (BTT).do corpo .A temperatura ambiente também foi obtida indiretamente utilizando-se o valor térmico do fundo da imagem do termograma como referência. A parede da sala onde foram captadas as imagens era composta de cimento, cuja emissividade utilizada na fórmula foi corrigida para 0,96.t de Student pareado, coeficiente de correlação de Pearson, erro padrão de estimativa, erro total e erro constante, além de análise de regressão linear aplicada ao conjunto de dados. O nível de significância estabelecido foi de 5% . A análise estatística dos dados foi executada com o software Statistical Package for Social Science (SPSS), versão 21.Nesse estudo, utilizaram-se, para análise estatística, o teste Foram realizadas 180 observações ao todo, sendo eliminadas 13 imagens por não apresentarem foco perfeito. A média de dias do ciclo foi de 25,4±3,9. A temperatura média das mamas variou de 32,7 a 36,4°C , com um gradiente térmico de 3,7°C .A temperatura ambiente, neste estudo, variou de 15,5 a 27,6°C  e a temperatura ocular variou de 34°C a 38°C , respectivamente 12,1°C e 4°C de gradiente térmico .Houve elevada correlação entre a temperatura média das mamas direita com esquerda  , isto é,O gráfico de dispersão mostrou que houve correlação maior da temperatura média das mamas com a TMO , seguida da temperatura ambiente  .2=0,46)  .A partir da est: temperatura média estimada da mama; TC: temperatura máxima ocular ; TA: temperatura ambiente.Onde TMA equação 2 pode também ser utilizada para a correção da temperatura das mamas para uma temperatura de referência quando da aquisição dos termogramas em temperaturas diferentes. Para tanto, basta substituir TA pela temperatura de referência desejada. Neste estudo, foi utilizada uma temperatura ambiente indireta a partir da temperatura do fundo da imagem térmica. Assim, pode-se inferir que as mamas apresentam correlação mais elevada com a temperatura central do que com a região frontal.A TMO apresentou boa e significativa correlação com a temperatura das mamas . Não foram encontrados estudos que avaliassem a correlação entre a temperatura ocular ou central e a temperatura das mamas. Porém já foram publicadas correlações na ordem de 0,49 para a temperatura máxima da região frontal e 0,12 para a mínima em relação à temperatura das mamas.Em relação à temperatura das mamas com o ambiente, foi observada uma correlação regular , porém significativa. Estudo que investigou a variação da temperatura da pele em ambientes instáveis apresentou resultados gráficos sugerindo boa correlação entre essas variáveis, mas não apresentaram valores exatos dos coeficientes de correlação. Muitas das veias normais inativas do plexo superficial das mamas se tornam ativas com o aumento da atividade metabólica, assim como há aumento da temperatura cutânea da parte avascular. Esse aumento metabólico pode ser avaliado indiretamente pela temperatura central. Para que os órgãos internos e cérebro funcionem corretamente, a temperatura central e a da superfície da pele devem ser mantidas dentro de faixas normais e aproximadamente constantes, em razão das reações bioquímicas necessárias à vida. Estas ocorrem, portanto, próximas a um valor ótimo de temperatura para a atividade das enzimas. Desse modo, a temperatura central influi na temperatura da pele por meio da dinâmica dos vasos superficiais.Em condições normais, há um fluxo térmico uniforme do interior do corpo para o exterior. A pele é o órgão pelo qual o calor passa para o ambiente. No tronco, a pele cobre uma grande área de massa metabolicamente ativa muscular e glandular, que continuamente produz grande quantidade de calor. A temperatura dessa região é normalmente determinada pela temperatura central por meio do transporte térmico, por condução.Apesar de não ter sido constatada uma diferença significativa com um período específico do ciclo menstrual, a temperatura das mamas teve alta correlação com a temperatura central no momento da captura, ou seja, as imagens adquiridas no início, meio ou fim do ciclo (mês) não tiveram um padrão térmico específico suficiente para caracterizar maior ou menor atividade metabólica das mamas em mulheres jovens durante ciclo menstrual, apesar da variação da temperatura central. A temperatura central, bem como a temperatura ambiente, pode ter influenciado, encobrindo o efeito hormonal sobre a temperatura média da mama. No entanto, não foi identificada, neste estudo, variação de temperaturas média das mamas em relação ao período do ciclo menstrual, ou seja, das temperaturas verificadas a partir do primeiro dia da menstruação até o dia que antecedeu a próxima menorreia. Também não foi observada elevação da temperatura máxima ocular na provável fase lútea, o que denota que a temperatura média das mamas tem maior relação com a TMO central do que com a atividade hormonal das mamas. Embora não tenha sido objetivo desta pesquisa avaliar a ovulação de mulheres jovens, e sim a variação do comportamento térmico da mama ao longo dos ciclos.Estudos relatam que certo número de processos fisiológicos no corpo de uma mulher está relacionado com as diferentes fases do ciclo ovulatório. O mais importante destes inclui alterações nos níveis de gonadotropinas, estrogênios e progesterona no sangue. A diversidade dos balanços de água e as flutuações na temperatura central , que é de aproximadamente 0,4°C, são mais elevadas na fase lútea do que na fase folicular do ciclo. Portanto, a temperatura da pele, incluindo das mamas, é diretamente afetada pela temperatura ambiente.O sangue exerce a função de normalizador da temperatura dos órgãos e músculos, onde é gerado calor metabólico, que é dissipado nos capilares da pele para o ambiente exterior. Num clima quente, o sangue converge para a superfície do corpo, aumentando a temperatura. O corpo começa a suar para esfriar a pele e inicia-se um processo de esfriamento do sangue. O contrário acontece quando o clima é frio. Neste caso, o sangue acumula calor na parte central do corpo ficando distante da pele e evitando a saída de calor. sem correntes de ar e com velocidade não superior a 0,2m/s, que possam provocar perda térmica por convecção forçada. Porém, observou-se grande variabilidade das temperaturas central e ambiente obtidos na prática clínica em uma cidade como Curitiba (PR), que apresenta amplitude térmica média anual que varia entre 12°C e 13°C. Curitiba (PR), é a capital mais fria do Brasil. A média anual é 16,5°C , mais fria no mês de julho e mais quente em fevereiro. Portanto, nem sempre é possível manter temperatura constante e uniforme, mesmo em um ambiente fechado, o que torna interessantes os meios de correção da temperatura obtida, como, por exemplo, pela equação proposta neste estudo.Neste sentido, é que a literatura recomenda manter a temperatura da sala de exames o mais constante e uniforme possível,2 ajustado) da variação da temperatura das mamas com temperatura ambiente variável e pode ser aceito como uma forma de estimar a temperatura de referência das mesmas em diferentes temperaturas ambientais.O modelo de predição proposto consegue explicar 45,3% (R quimioterápicos, acompanhamento evolutivo de doenças inflamatórias, e apoio a triagem de anormalidades, e poderia ser utilizada em conjunto com a avaliação clínica e exames anatômicos. Alterações fisiológicas, anomalias térmicas e vasculares são detectadas por meio da termografia, comprovadamente um método de análise fisiológica.Ferramentas como mamografia, ultrassonografia e ressonância magnética, são importantes recursos para avaliação das diversas enfermidades da mama, pois permitem avaliação morfológica. A termografia de mamas é um método de análise funcional, que tem sido proposto como auxiliar no estudo de novas medicações,Pode-se citar como uma limitação importante deste estudo a não utilização de técnicas de radioimunoensaio de hormônios ou imagens ultrasonográficas de acompanhamento de cistos foliculares maduros e de corpo lúteo, para a determinação da ovulação. Ainda assim, esses resultados podem servir de base para estudos futuros correlacionando com ovulação documentada pelos métodos anteriores.A temperatura média das mamas em mulheres jovens saudáveis teve relação direta com a temperatura central e do ambiente, e pôde ser estimada matematicamente. Este estudo sugeriu a viabilidade do uso da termografia na prática clínica, por meio de uma equação, para estimativa da temperatura de referência da mama normal em mulheres jovens, independente da temperatura ambiente e dia do ciclo da paciente, auxiliando na avaliação semiológica médica e complementar de estudos anatômicos. Dessa forma, os médicos poderiam registrar as temperaturas das mamas e, por meio de programa de computador, corrigir a variação das temperaturas ambiente e central, normalizando tais temperaturas sem a dependência de um ambiente com temperatura fixa ou um período de aclimatização prolongado. Ainda assim, sugere-se a realização de novos estudos para confirmação e validação das relações matemáticas apresentadas neste trabalho.