The Population Cancer Registry of Cali (RPCC) has operated since 1962, disseminating high quality information to provide a framework to assess and control the burden of cancer in Cali. The collection of new cancer cases in permanent residents of Cali is done through active search in and notification from hospitals, and public and private laboratories. The Secretary of Municipal Public Health provides individual information on general mortality and death from cancer. Tumors are coded with ICDO-3 and mortality with ICD-10. Presented rates are standardized by age and trends are assessed by estimating the percentage annual change using the regression analysis in JoinPoint. The 5-year net survival was analyzed with the Pohar-Perme estimator. The 88.5% of the registered cancers had morphological verification (MV). The proportion of unknown primary site represented 5% and the death certificate only cases (DCO) varied between 0 to3% depending on the cancer site. All deaths were certified by a physician, 94.2% of cancer deaths were correctly certified. The ill-defined site proportion was 5.3% and that of uterine cancer not specified (C55) was 0.5%. For survival analysis, existing data collection procedure and infrastructure ensures assessment of the patient’s vital status and follow-up, with an average lost to follow-up of 13.2%. The information has been published in the eleven volumes of "Cancer Incidence in Five Continents" confirming high quality of the collected data. The RPCC PCRC has also participated in the Concord Study and is participating in SURVCAN-3. The Population Cancer Registry of Cali (RPCC) was started in 1962 as a research program of the Department of Pathology of the Universidad del Valle. It was initially funded by a donation from the Ana Fuller Fund. Later, La Universidad del Valle became the main source of both financial and scientific resources of the registry. The RPCC began at the same time as Pan American Health Organization (PAHO) conducted the Urban Mortality Study, which examined in detail all the death certificates of the city Cancer registries are systems that collect information in a continuous and systematic way about each new cancer case identified within a specific population in a given area and period The value of the modern cancer registry and its ability to carry out cancer control activities depend to a large extent on the underlying quality of its data and the established quality control procedures ,2. This area corresponds to 20% of the extension of the municipality of Cali (561.7 km2) 2. The rural land is approximately 424.4 km2 (divided into 15 corregimientos or designated areas) 2. In 2012, the municipality of Cali was defined as the cancer registry area. The geopolitical map is shown in Cali is the third largest city in Colombia, capital of the Province of Valle del Cauca, located by the Cauca river valley at coordinates 3°27'00" N 76°32'00" W. The western limit is the Farallones of Cali, which are part of the Western Cordillera of the Colombian Andes. According to both the 2005 census and National Administrative Department of Statistics of Colombia (DANE) projections, the estimated population for 2010 was 2.3 million inhabitants, 52% are women, and 26.2% self-identify as belonging to the black ethnic group in situ breast and cervical cancer. Excluded are benign tumors with uncertain behavior, malignant tumors of metastatic sites, and basal cell and epidermoid carcinoma of the skin (these were included until 1986). The cases that arrived in the city for treatment or diagnosis purposes are not considered residents of Cali.People of any age, residents in the urban area of Cali, with a diagnosis of invasive malignant tumor for the first time (incident), of any anatomical location, that has been confirmed or treated in partial or in total. The basis for diagnosis can be both microscopic ; and non-microscopic . The following cancers were included: single or multiple primary malignant tumors, all tumors of the Central Nervous System and In 2009, an information system was setup within the RPCC for the continuous monitoring of clinical outcomes of children with cancer treated in Cali (VIGICANCER). Details have been published earlier The basic information for the RPCC is collected in a pre-coded form that includes data of the person: name, sex, date of birth, age, and address. Neoplasms are described with anatomical location, morphology, behavior and, degree of differentiation, multiple primary tumors, the extent of disease (breast and cervix) and the most valid basis of cancer diagnosis. For the last 20 years, information on the outcomes has been collected: date of last contact, vital status, date of death, and cause of death. Neoplasms in adults are coded with ICDO-3 To calculate date of incidence we used the guidelines of the European Network of Cancer Registries (ENCR) The guidelines of the European Network of Cancer Registries (ENCR) A single person (administrator) makes initial matching between databases to detect new cases and update vital status information. A registration number is assigned to each case and the information that identifies a patient is deleted before the data is analyzed (name and other documents that can lead to identification of the patient).Universidad del Valle has been the main source of financial and technical resources. The research group at RPCC has a head quarter (287 m² area) with 15 employees working in the registry. The head of staff and his advisors are senior researchers and pathology professors at the School of Medicine. The coordinator is a business administrator with a master's degree in epidemiology and the information system is managed by an engineer with a master's degree in engineering with emphasis in systems engineering and computer science. There are three data collectors. The staff has job stability due to university affiliation that provided permanent contracts. The RPCC assures stability to the rest of the human resources using specific projects funds. The Information Technology network includes an intranet with Internet access supported by the Office of Information Technology and Telecommunications of Universidad del Valle. The local network includes a server, 11 computers and 5 laptops. Backup copies are made twice a day by means of an automatic daily script and a monthly external copy. The technical team of the RPCC meets weekly to resolve the problem cases. The software of the RPCC (Siscan) performs consistency checks when entering the data and the internal consistency is checked every six months with IarcTools The three-yearly survey of medical specialists in the city is a key activity in which several groups of students from the Faculty of Health of the Universidad del Valle have participated. This survey lasts for eight weeks and complements the continuous cancer data collection by the RPCC. As an initial step, the inventories of sites that have oncological services for the diagnosis and treatment of cancer that are not covered during routine collection activities are updated. The Faculty of Health of the Universidad del Valle is contacted, and the participating students are trained in biology, cancer nomenclature, and the methodology standardized to obtain cancer cases. Each participant is assigned a supervisor (member of the RPCC) and support materials are provided that include: 1) General recommendations; 2) minimum variables for collection; 3) list of malignant tumors; 4) manual for completing the form of the cancer morbidity survey; 5) list of assigned specialist physicians; 6) cover letters; and 7) collection forms. The supervisor has permanent contact to clarify doubts and concerns and receive weekly update of the information collected.This is done through active search and manually when the information is in physical format and structured and unstructured digital formats; or automatic to obtain structured and unstructured listings. Hospital expenditures are obtained periodically in a structured digital format. With an automatic process of data extraction, for each case a matching with the database of the Population Cancer Registry is done in two methods: Exact search  and SearWhen the cases already exist in the base of the RPCC , additional information is sought in the health insurance databases (public and private), general mortality in the city, and hospital discharges from clinics and hospitals in Cali. Information of identification, residence, date of last contact and vital state is recovered; these updated variables are marked as completed (Flag) and the case is excluded for future searches. The revised rules of the IARC 2004 In phase 3, cases that are not found in the main database of the cancer registry are processed. First, the three additional data sources are searched  to find It is used when there is no information on the personal identification document . The two,,The International Classification of Diseases (ICD-10) Individual data from 38,671 permanent residents of Cali during the period 1995-2009, aged between 15 and 99 years, with a diagnosis of a first invasive malignant tumor in one of the following fourteen locations defined by the ICD-10 were included for the analysis. : Stomach (C16), colorectal (C18-C20), liver (C22), lung (C34), melanoma (C43), breast (C50), cervix (C53), ovary (C56), prostate (C61), thyroid (C73), Hodgkin's lymphoma (C81), non-Hodgkin's lymphoma , multiple myeloma (C90), and leukemia (C91-C95). Following the Concord-2 study guidelines in situ, benign or of uncertain behavior, subjects with unknown ages, tumors detected during necropsy, cases diagnosed only through death certificate, and the syndromes myelodysplastic and myeloproliferative neoplasms such as chronic myeloid leukemia. Patients with synchronous bilateral breast cancer were included and treated as individual cases for the analysis.Excluded from the survival analysis are tumors identified as Death from any cause was considered an event in the survival analysis. The survival time of each case was determined by the difference in time (in days) between the date of diagnosis (index date) and the date of death, the date of last contact, or the date of the end of the study, which was defined as December 31, 2009. To compare the survival changes during the study period, the 15-year study period was divided into three: a first period between January 1, 1995 and December 31, 1999 that coincided with the implementation of the health reform in Colombia; and the other two periods; 2000-2004 and 2005-2009; after the implementation and consolidation of Law 100.Follow-up: To update the vital status and the date of last contact, links were established between the RPCC information system and the following databases: a) general mortality of the Municipal Public Health Secretariat of Cali; b) hospital discharges from Level III institutions; c) Identification System for Potential Beneficiaries of Social Programs ; and d) Private health insurance companies 2014). Process is described in . Processst, 2009. The response variable was the time between the diagnosis of cancer and the death of each individual. The maximum observation time for each subject for the failure to occur was five years. The censored variable was applied for patients who did not present the fault within the study period, and as a mechanism of censorship the loss was established during the follow-up and the end of the study. For the analysis, survival times greater than five years were censored, times after the loss to follow-up and / or as of December 31For the five-year periods 1995-1999 and 2000-2004, a cohort analysis was performed because all patients diagnosed with cancer during that period had at least five years of follow-up data until December 31, 2009. For the 2005-2009 period, survival analysis was carried using the period method For the 5-year net survival estimates, the Pohar-Perme estimator was used To verify the exhaustiveness, the death certificate method was used The main quality indicators for some selected cancer sites are presented in The percentage of cases with morphological verification (MV) -histology, cytology, bone marrow aspiration and flow cytometry-, for all cancer sites was 88.5% ranging between 85-100%, except in the liver (68.3%) and lung (66.4%). In patients with leukemia, Hodgkin's lymphoma and melanoma the MV was 100%.The percentage of cases with a death certificate only (DCO) varied between 0-3%, except in the liver (4.5%) and in the lung (6.0%). In general, for major cancer sites, they had a low percentage of cases obtained through death certificate only. Another indicator of quality that is also usually considered is the proportion of cancer cases that was coded as poorly defined site. Between the years 2008-2012 these tumors represented 4.6% of new cases of cancer in men and 5.4% in women.During the 1995-2009 period, 40,354 cases of the selected cancers were registered, 1.73% occurred in patients under 15 years. In 2.4% there was no age information and they were excluded from the analysis. All patients had follow-up and 13.2% of the observations were censored; this proportion was higher in brain, melanoma, colorectal and ovarian cancers. In cancers with poor survival: stomach, lung, liver and pancreas; the censored rate was less than 10%. In the most frequently diagnosed cancers the censored percentage was 10.1%, 11.5% and 16.4%; for breast, prostate and cervix, respectively. In 15.3% of the cases the date of death and the date of incidence were the same.Mortality due to cancer represented 18.0%  of the total deaths that occurred in the city during the period 2006-2015. 0.8% of the cases were not coded as cancer in the basic cause. All deaths were certified by a physician; the proportion of poorly defined site  was 5.3% and that of the uterine cancer not specified (C55) was 0.5%. Only 4 (0.02%) of the death certificate cases did not have age information. 94.2% of cancer deaths were well certified.All patients died from cancer during the 2008-2012 period were found in the cancer registry database. For recognized sites of metastasis; liver, lung, bone and brain; the ICD-10 (17) code of the death certificate was compared with the topographic code of the ICD-0-3 (11) assigned by the cancer registry. The 54% of people who died from cancer in Cali during the 2008-2012 period were already included in the RPCC database. The new cases notified by means of the death certificate (DCN) corresponded to 46% of the deaths of the period. The proportion was higher in cancers with high lethality as stomach (45%); and lower, in patients with breast cancer (12%), cervix (18%), prostate (14%) and childhood cancer (23%), The last survey conducted in 2014 costed US $ 23,300, where 19 students participated, each one received a bonus, transportation cost and one payment per survey. During the eight weeks, 107 oncological services were visited, located in medical centers (64), private clinics (36) and private offices (5). Information was obtained that identified 2,215 new cases of cancer (27.8%) and updated 5,750 cases (72.2%) that were already in the database of the RPCC.,-The Cali cancer registry is the only one registry in low and middle income countries that has accurately reported the cancer situation continuously over the last half century. The information is of high quality and has been included in all eleven volumes of Cancer Incidence in Five Continents (CI5) For forty years, RPC-Cali and was the only valid source of information on the incidence of cancer in Colombia Currently, the RPC-Cali participates in SURVCAN-3, an initiative of the IARC to produce reliable and comparable survival statistics for countries in transition. Due to the great strength of the Cancer Registry, Cali is the first city in the world to implement the initiative "C/Can 2025: Challenge of Cities Against Cancer"; an initiative of the International Union for Cancer Control (UICC) that seeks to increase the coverage and quality of oncological care in the cities of more than one million inhabitants of low and middle income countries.Several factors have contributed to the stability and continuity over time of the Cali Cancer Registry. The RPCC has standardized definitions and procedures for the collection, analysis, storage, validation and dissemination of information. Universidad del Valle has been the main source of financial and technical resources. The four directors that the RPCC has had in the 55 years of operation have been academics and researchers of the Department of Pathology, in charge of coordinating a trained human resource that belongs to the plant of the Universidad del Valle. The RPCC is constituted as a research group and ranked at the top of the Colombian research system. With specific projects, it provides solution to epidemiological problems and complements information gathering activities. The total cost per case in the RPCC was US $82, which included US $ 25 for fixed-cost activities, US $ 43 for central variable-cost activities, and US $ 14 for other activities The RPCC has social recognition in the city, thus facilitating the process of data collection that is made passively and actively from the various sources of data information. The oncological care facilities in Cali, include 165 oncology services enabled To estimate the rates and to construct the life tables for the survival study, reliable denominators based on population censuses and projections are required. The DANE facilitated the demographic structure of the population for the period 1962-2015.The Colombian government positioned cancer as a primary public health problem and established actions for comprehensive care to reduce morbidity and mortality due to this disease and improve the quality of life of cancer patients. Surveillance and control mechanisms were implemented, and the National Cancer Information System was organized. The model of care for these diseases was defined in the Ten-Year Plan for Cancer Control in Colombia 2012-2021 The value of a cancer registry depends greatly on the quality of the data and on the quality control procedures in force The RPCC uses standard methods to make the information comparable to other regions of the country and the world. The neoplasms are coded with the ICD-O-3 for adults The main and most reliable sources of data for the cancer registry are the histopathology reports; but they are not enough to guarantee clarity, such as poorly accessible tumors: those of the CNS, pancreas, lung, retroperitoneum and others; the basis of the diagnosis can be imaging studies, clinical examination and DCO.The percentage of RPC-Cali cases with a morphologically verified diagnosis (MV%) was 88.5%, similar to other RPC-Colombians and RPC-Latin American; and inferior to the majority of PRC-Europeans and North American RPCCs (90% -95%) In the RPC-Cali, the percentage of cases known only by death certificate (DCO%) was 1.7%; the lowest of all the RPC-Latin American; and like most RPC-North American and RPC-European The incidence rates have been stable over time and the expected values are comparable with those reported by cancer registries that serve similar populations such as Quito  and Costa Rica  The collaborative work with the SSPM of Cali facilitates access to information on general mortality and cancer; and allows us to have an independent source of verification of new cases of cancer. Cancer deaths were well certified at about 94.2%. The M:I ratio for all cancer sites during the period 2008-2012 was 51%; similar to that of other RPC-Latin American  The exhaustivity index was 87% (method of death certificates IE-CD) and in the cancers prioritized by the PNDC it was greater than 90%, except in cases of prostate cancer (72%). This RPC-Cali index is higher than that reported by other international cancer registers  The method depends on the availability of relatively good quality certificates, which mention the cause of death (completely and accurately) in the area covered by the cancer registry. This method has not been applied in other RPC-Latin American countries.The statistics of the cancer situation in Cali are public access after 36 months following the year of diagnosis. Data is also available on the RPPC portal http://rpcc.univalle.edu.co. This information describes 50 years of incidence (1962-2012), 30 years of mortality (1984-2014) and 15 years of survival (1995-2009).The data of each service in each institution are handled autonomously and independently. because the information is managed on different platforms, generating duplication of data, data transfer difficulties and a decrease in the quality and integrity of the information. The Colombian oncology services periodically notify to different dependencies of the ministry of health . These legacy systems are mostly local applications that lack interoperability for proper data management. Institutions begin to perceive notification as a burden and relegate them and deprioritize data transfer to the cancer registry. This complexity is a risk factor to guarantee completeness in the collection of information. Consequently, there are great possibilities of underestimating the cancer risk in the population. It is urgent to modify the current Ministry of Health regulations so that the RPC-Colombians are incorporated into the cancer information system with an adequate budget allocation.The implementation of standards and transfer mechanism, shared information flows and adoption of tools are priorities to communicate effectively with different information systems in the city of Cali. Also set public policies that facilitate the implementation of these solutions. And then, the creation of an interinstitutional data warehouse is essential to provide key support for making decisions both public at the population level and administrative at the clinical level. The main objective of this implementation is to guarantee quality information for knowledge management proposes. El Registro Poblacional de Cáncer de Cali (RPCC) se inició en 1962 como un programa de investigación del Departamento de Patología de la Universidad del Valle, fue inicialmente financiado por una donación del Fondo Ana Fuller, posteriormente, la Universidad del Valle ha sido la principal fuente de recursos financieros y de personal científico y técnico del registro. El RPCC comenzó al mismo tiempo que la Organización Panamericana de la Salud realizó el Estudio de Mortalidad Urbana, que examinó en detalle todos los certificados de defunción donde se incluyeron los de la ciudad Cali Los registros de cáncer son sistemas que recopilan información de manera continua y sistemática sobre cada caso nuevo de cáncer identificado dentro de una población específica en un periodo de tiempo determinado El valor del registro de cáncer moderno y su capacidad para llevar a cabo actividades de control del cáncer dependen en gran medida de la calidad subyacente de sus datos y los procedimientos de control de calidad establecidos ,2) Cali es la tercera ciudad de Colombia, capital del Departamento del Valle del Cauca, ubicada en el valle del rio Cauca en las coordenadas 3°27′00″N 76°32′00″O. El límite occidental son los Farallones de Cali, que hacen parte de la Cordillera Occidental de los Andes Colombianos. Según el censo del 2005 y de acuerdo con las proyecciones del DANE, la población estimada para el 2010 fue 2.3 millones de habitantes, 52% son mujeres, y 26.2% se auto reconocen como pertenecientes a la etnia negra 2. El suelo rural es de 424.4 km2 (dividido en 15 corregimientos) 2. En el 2012 se definió como área del registro de cáncer el municipio de Cali. El mapa geopolítico se muestra en la Desde su fundación, el área de registro ha sido la zona urbana de Cali, dividida administrativamente en 22 comunas, con una densidad bruta de 184.7 habitantes/kmin situ de mama y cérvix. Se excluyen tumores benignos y de comportamiento incierto, tumores malignos de sitio metastásico y carcinoma basocelular y epidermoide de piel (fueron incluidos hasta el año 1986). Los casos que han llegado a la ciudad para fines de tratamiento o diagnóstico no son considerados residentes de Cali. Hombres y mujeres de cualquier edad, residentes en el área urbana de Cali, con diagnóstico de tumor maligno invasivo por primera vez (incidente), de cualquier localización anatómica, independiente que haya sido confirmado o tratado en forma parcial o total. La base para el diagnóstico puede ser tanto microscópica ; como no microscópica . Se incluyen tumores malignos primarios únicos o múltiples, todos los tumores del Sistema Nervioso Central y cáncer En el 2009 se implementó dentro del RPCC un sistema de información para el monitoreo continuo de los resultados clínicos de niños con cáncer tratados en Cali (VIGICANCER), cuyos detalles ya han sido publicados European Network of Cancer Registries (ENCR)La información básica para el RPCC se recolecta en un formulario precodificado que incluye datos de la persona: nombre, sexo, fecha de nacimiento, edad, dirección. Las neoplasias se describen con la localización anatómica, la morfología, el comportamiento, el grado de diferenciación, los tumores múltiples primarios, la extensión de la enfermedad (mama y cérvix) y la base más valida del diagnóstico de cáncer. Desde hace 20 años se obtiene información del desenlace: fecha de último contacto, estado vital, fecha de defunción, causa de defunción. En los adultos las neoplasias se codifican con la CIEO-3 European Network of Cancer Registries (ENCR)Se siguen las guías de la La Universidad del Valle ha sido la principal fuente de recursos financieros y técnicos. Las oficinas del RPCC (área de 287 m²) alojan a 15 personas que trabajan en el registro. El director y el exdirector quien trabaja como asesor son investigadores senior y profesores de Patología en la Escuela de Medicina. La coordinadora es administradora de empresas con maestría en epidemiologia y el sistema de información lo administra una ingeniera con maestría en ingeniería con énfasis en ingeniería de sistemas y computación. Hay tres recolectores de planta. El personal tiene estabilidad laboral porque todos están vinculados a la universidad mediante contratos a término indefinido. El RPCC es un grupo de investigación y mediante proyectos específicos financia el resto del talento humano. La infraestructura de TI incluye una intranet con acceso a Internet respaldada por la Oficina de Tecnología de la Información y Telecomunicaciones de la Universidad del Valle. La infraestructura local incluye un servidor, 11 computadoras y 5 computadoras portátiles. Las copias de seguridad se realizan dos veces al día por medio de un guion diario automático y una copia externa mensual. El equipo técnico del RPCC se reúne semanalmente para resolver los casos problema. El software del RPCC (Siscan) efectúa controles de coherencia al ingresar los datos y semestralmente se verifica la consistencia interna con IarcTools La encuesta trienal a médicos especialistas de la ciudad es una actividad muy importante en la que han participado varias cohortes de estudiantes de la Facultad de Salud de la Universidad del Valle. Esta encuesta tiene una duración de ocho semanas y complementa la recolección continua que hace el RPCC. Como paso inicial se actualiza el censo de los sitios que tienen servicios oncológicos para el diagnóstico y tratamiento de cáncer que no son cubiertos durante las actividades de recolección rutinaria. Se convoca a la Facultad de Salud de la Universidad del Valle y a los estudiantes que acuden se capacitan sobre biología, nomenclatura del cáncer, y la metodología estandarizada por el registro de cáncer para la obtención de los casos de cáncer. A cada participante se le asigna un supervisor (integrante del RPCC) y se entrega material de apoyo que incluye: 1) Recomendaciones generales; 2) variables mínimas a recolectar; 3) listado de tumores malignos; 4) manual para el diligenciamiento del formulario de la encuesta de morbilidad de cáncer; 5) lista de médicos especialistas asignados; 6) cartas de presentación; 7) formularios de recolección. El supervisor tiene contacto permanente para aclarar las dudas e inquietudes y recibir semanalmente la información recolectada. La La Se hace mediante búsqueda activa y de manera manual cuando la información se encuentra en formato físico y formatos digitales estructurados y no estructurados; o automática para obtener listados estructurados y no estructurados. Los egresos hospitalarios se obtienen de manera periódica en formato digital estructurado. Con un proceso automático de extracción de datos, para cada caso se realiza un apareamiento con la base de datos del Registro Poblacional de Cáncer en dos métodos: Búsqueda exacta  y BúsqueCuando los casos ya existen en la base del RPCC , se busca información adicional en las bases de seguros de salud (públicas y privadas), mortalidad general de la ciudad; y egresos hospitalarios de clínicas y hospitales de Cali. Se recupera información de identificación, residencia, fecha de último contacto y estado vital; éstas variables actualizadas quedan señaladas como terminadas (Flag) y el caso se excluye para búsquedas futuras. La revisión de las reglas de la IARC 2004 En la fase 3 se procesan los casos que no se encuentran en la base principal del registro de cáncer. En primer lugar, se buscan en las tres fuentes auxiliares  para encSe utiliza cuando no hay información del documento de identificación personal, . Se prep,Age-standardised rate) mediante el método directo, utilizando como referencia la población estándar mundial ,Annual Percent Change), calculado por el método de mínimos cuadrados ponderados La Clasificación Internacional de Enfermedades (CIE-10) Se incluyeron para el análisis los datos individuales de 38,671 residentes permanentes de Cali durante el periodo 1995-2009, con edad entre 15 y 99 años, con diagnóstico de un primer tumor maligno invasivo en una de las siguientes catorce localizaciones definidas por la CIE-10 : Estómago (C16), colorectal (C18-C20), hígado (C22), pulmón (C34), melanoma (C43), mama (C50), cuello uterino (C53), ovario (C56), próstata (C61), tiroides (C73), linfoma Hodgkin (C81), linfoma no Hodgkin , mieloma múltiple (C90), leucemia (C91-C95). Siguiendo las guías del estudio Concord-2 in situ, benignos o de comportamiento incierto, sujetos con edades desconocidas, los tumores detectados durante la necropsia, los casos en los que la única evidencia de cáncer fue el certificado de defunción, los síndromes mielodisplásicos y las neoplasias mieloproliferativas como la leucemia mieloide crónica. Las personas con cáncer de mama bilateral sincrónico fueron incluidas y tratadas como casos individuales para el análisis.Se excluyeron del análisis de supervivencia: los tumores identificados como Definición de evento, fecha inicial y final La muerte por cualquier causa se consideró una falla. El tiempo de supervivencia de cada caso se determinó por la diferencia de tiempo (en días) entre la fecha de diagnóstico (fecha índice) y la fecha de la muerte, la fecha del último contacto, o la fecha de cierre del seguimiento, la cual fue definida como el 31 de diciembre de 2009. Para comparar el comportamiento de la supervivencia durante el tiempo analizado, el lapso de 15 años se dividió en tres: un primer periodo comprendido entre 1 de enero de 1995 y 31 de diciembre de 1999 que coincidió con la implementación de la reforma a la salud en Colombia; y los otros dos periodos; 2000-2004 y 2005-2009; después de la implementación y consolidación de la Ley 100. Para actualizar el estado vital y la fecha del último contacto, se establecieron enlaces entre el sistema de información del RPCC y las siguientes bases de datos: a) mortalidad general de la Secretaría de Salud Pública Municipal de Cali, b) egresos hospitalarios de instituciones de nivel III; c) Sistema de Identificación de Potenciales Beneficiarios de Programas Sociales  y d) Empresas aseguradoras de salud privadas 2014). Proceso descrito en las . ProcesoLa variable respuesta fue el tiempo transcurrido entre el diagnóstico de cáncer y la muerte de cada individuo. El tiempo máximo de observación para cada sujeto para que ocurra la falla fue cinco años. La variable de censura fue definida para las personas que no presentaron la falla dentro del periodo de estudio, y como mecanismos de censura se establecieron la pérdida durante el seguimiento y la finalización del estudio. Para el análisis fueron censuraron los tiempos de supervivencia mayores a cinco años, los tiempos posteriores a la pérdida durante el seguimiento y/o a 31-12-2009. Para los quinquenios 1995-1999 y 2000-2004 se realizó un análisis de cohorte porque todos los pacientes con diagnóstico de cáncer durante ese lapso tuvieron al menos cinco años de información disponible del seguimiento hasta el 31 diciembre 2009. Para el quinquenio 2005-2009, el monitoreo del análisis de supervivencia se llevó a cabo mediante un análisis de periodo Cancer, International Cancer Survival Standar ICSSPara las estimaciones de la supervivencia neta a 5 años se utilizó el estimador de Pohar-Perme Para comprobar la exhaustividad se utilizó el método del certificado de defunción La búsqueda activa y continua de los casos actualiza la base más válida para el diagnóstico y excluye algunos de los casos de mortalidad que no son cáncer (Rastreo no cáncer). El remante son los casos iniciados por el certificado de defunción (DCI por su sigla en inglés), que no habrían sido detectados por otra vía. Después de todas las maniobras de rastreo, queda un residuo de casos para los cuales la única evidencia de cáncer fue el certificado de defunción (DCO por su sigla en inglés).Los principales indicadores de calidad para algunas localizaciones seleccionadas de cáncer se presentan en la El porcentaje de casos con verificación morfológico (VM) -histología, citología, aspirado de médula ósea y citometría de flujo-, para todas las localizaciones de cáncer fue de 88.5% rango de 85-100%, excepto en hígado (68.3%) y pulmón (66.4%). En los pacientes con leucemia, linfoma de Hodgkin y melanoma la VM fue del 100%. El porcentaje de casos con certificado de defunción como única evidencia del diagnóstico de cáncer (DCO) varió entre 0-3%, excepto en hígado (4.5%) y en pulmón (6.0%). En general, las localizaciones más frecuentes presentan un bajo porcentaje de casos obtenidos solamente a través del certificado de defunción. Otro indicador de calidad que también suele considerarse es la proporción de los casos de cáncer que fue codificada como de sitio mal definido. Entre los años 2008-2012 estos tumores han representado el 4,6% de los casos nuevos de cáncer en los hombres y el 5.4% en las mujeres. Durante el periodo 1995-2009 se registraron 40,354 casos de los canceres seleccionados, 1.73% ocurrieron en pacientes menores de 15 años. En 2.4% no hubo información de edad y se excluyeron del análisis. Todos los pacientes tuvieron seguimiento y se censuraron el 13.2% de las observaciones; esta proporción fue mayor en cáncer de cerebro, melanoma, colorrectal y ovario. En los cánceres con pobre supervivencia: estómago, pulmón, hígado y páncreas; la proporción de censura fue menor al 10%. En los cánceres más frecuentes el porcentaje de censura fue 10.1%, 11.5% y 16.4%; para mama, próstata y cérvix, respectivamente. En 15.3% la fecha de muerte y la fecha de incidencia fue la misma. La mortalidad por cáncer representó el 18.0%  de la mortalidad general ocurrida en la ciudad durante el periodo 2006-2015. El 0.8% de los casos no fue codificado como cáncer en la causa básica. Todas las defunciones fueron certificadas por un médico; la proporción de sitio mal definido  fue 5.3% y la de cáncer de útero no especificado (C55) fue 0.5%. Solo 4(0.02%) de los certificados de defunción no tuvieron información de la edad. El 94.2% de las muertes por cáncer fueron bien certificadas. Todos los pacientes muertos por cáncer durante el periodo 2008-2012 se encontraron en la base de datos del registro de cáncer. Para los sitios reconocidos de metástasis; hígado, pulmón, hueso y cerebro; se comparó el código de la CIE-10 El 54% de las personas que murieron por cáncer en Cali durante el periodo 2008-2012 ya estaban incluidas en la base de datos del RPCC. Los casos nuevos notificados mediante el certificado de defunción (DCN) correspondieron al 46% de las defunciones del periodo. La proporción fue más alta en los canceres con alta letalidad como estómago (45%); y más baja, en los pacientes con cáncer de mama (12%), cuello uterino (18%), próstata (14%) y cáncer infantil (23%), La última encuesta realizada en 2,014 tuvo un costo de US$23,300, participaron 19 estudiantes, cada uno recibió una bonificación, subsidio de transporte y un pago por encuesta realizada. Durante las ocho semanas se visitaron 107 servicios oncológicos, ubicados en centros médicos (64), clínicas particulares (36) y consultorios particulares (5). Se obtuvo información que permitió identificar 2,215 casos nuevos de cáncer (27.8%) y actualizar 5,750 casos (72.2%) que ya estaban en la base de datos del RPCC.Cancer Incidence in Five Continents(CI5),-El registro de cáncer de Cali es el único entre los países de bajos y medianos ingresos que ha reportado con exactitud la situación del cáncer de forma continua durante el último medio siglo. La información es de alta calidad y ha sido incluida en todos los once volúmenes de Varios factores han contribuido a la permanencia y continuidad en el tiempo del Registro de Cáncer de Cali. El RPCC tiene definiciones y procedimientos estandarizados para la recolección, análisis, almacenamiento, validación y divulgación de la información. La Universidad del Valle ha sido la principal fuente de recursos financieros y técnicos. Los cuatro directores que ha tenido el RPCC en los 55 años de operación han sido académicos e investigadores del Departamento de Patología, encargados de coordinar un talento humano capacitado que pertenece a la planta de la Universidad del Valle. El RPCC está constituido como grupo de investigación y escalafonado en la cima del sistema de investigación colombiano. Con proyectos específicos resuelve los problemas epidemiológicos y complementa las actividades de recolección de información. El costo total por caso en el RPCC fue US$82, que incluyó US$25 para actividades de costos fijos, US$43 para actividades centrales de costo variable y US$14 para otras actividades  El RPCC tiene reconocimiento social en la ciudad, facilitando así el proceso de recopilación de datos que se hace de manera pasiva y activa en las diferentes fuentes de información. La infraestructura para la atención oncológica en Cali, cuenta con 165 servicios oncológicos habilitados El gobierno colombiano posicionó al cáncer como un problema de salud pública y estableció las acciones para la atención integral para reducir la morbimortalidad por este grupo de enfermedades y mejorar la calidad de vida de los pacientes oncológicos. Se implementaron los mecanismos de vigilancia y control y se organizó el Sistema Nacional de Información de Cáncer. El modelo de atención para estas enfermedades está definido en el Plan Decenal para el Control del Cáncer en Colombia 2012-2021 El valor de un registro de cáncer depende enormemente de la calidad de los datos y de los procedimientos de control de calidad vigentes El RPCC utiliza métodos estándar para que la información sea comparable con otras regiones del país y del mundo. En los adultos las neoplasias se codifican con la CIEO-3 Las principales y más confiables fuentes de datos para el registro de cáncer son los informes de histopatología; pero no son suficientes para garantizar la exhaustividad. En tumores poco accesibles tales como los del SNC, páncreas, pulmón, retroperitoneo y otros; la base del diagnóstico puede ser los estudios de imágenes, la exploración clínica y los DCO. El porcentaje de casos del RPC-Cali con un diagnostico morfológicamente verificado (MV%) fue 88.5%, similar a otros RPC-colombianos y RPC-Latinoamericanos; e inferior a la mayoría de RPC-europeos y RPCC-norteamericanos (90%-95%) En el RPC-Cali, el porcentaje de casos conocidos sólo por certificado de defunción (DCO%) fue 1.7%; el más bajo de todos los RPC-latinoamericanos; y similar a la mayoría de RPC-norteamericanos y RPC-europeos Surveillance, Epidemiology, and End Results Program). En muchos países de Latinoamérica la razón M:I es mayor a 1 en tumores con alta letalidad como páncreas, hígado, esófago, por falta de exhaustividad y/o falta de diagnóstico cuando el paciente estaba vivo. Las tasas de incidencia han sido estables en el tiempo y los valores esperados son comparables con los reportados por los registros de cáncer que atienden a poblaciones similares como Quito  y Costa Rica  El índice de exhaustividad mediante el método de los certificados de defunción (IE-CD) fue 87%; y en los canceres priorizados por el PNDC fue mayor a 90%, excepto en los casos de cáncer de próstata (72%). Este índice del RPC-Cali es más alto que el reportado por otros registros de cáncer internacionales  http://rpcc.univalle.edu.co. La información organizada en páginas web describe 50 años de incidencia (1962-2012), 30 años de mortalidad (1984-2014) y 15 años de supervivencia (1995-2009). Las estadísticas de la situación del cáncer en Cali son de acceso público en los 36 meses siguientes al año de diagnóstico y se encuentran disponibles en el portal del RPPC Los datos de cada servicio en cada institución se manejan de manera autónoma e independiente. La información cruza cada proceso fragmentada y en diferentes plataformas, generando la duplicación de datos, dificultades de transferencia y un decremento en la calidad e integridad de la información. Los servicios oncológicos colombianos hacen notificación periódica a diferentes dependencias del ministerio de salud . Estos sistemas heredados, en su mayoría son aplicaciones locales que carecen de interoperabilidad para una adecuada gestión de los datos. Las instituciones empiezan a percibir a la notificación como una carga y relegan a un segundo plano la transferencia de datos al registro de cáncer. Esta complejidad es un factor de riesgo para garantizar la exhaustividad en la recolección de información. En consecuencia, hay grandes posibilidades de subestimar el riesgo de cáncer en la población. Es urgente modificar la normatividad vigente del Ministerio de Salud debe modificarse para que los RPC-colombianos se incorporen al sistema de información de cáncer con una adecuada asignación presupuestal. Es prioritario la implementación de estándares y mecanismo de transferencia, flujos compartidos de información y adopción de herramientas que permitan comunicar lo diferentes sistemas de información en la ciudad de Cali. Así mismo fijar políticas públicas que faciliten la ejecución de estas soluciones y. Luego, es imprescindible la creación de una bodega de datos interinstitucional con el fin de proporcionar soportes claves para la toma de decisiones tanto públicas a nivel poblacional como administrativas a nivel clínico. El principal objetivo de esta implementación es garantizar información de calidad para la gestión del conocimiento.


Energía, la justa ” program, aimed at reducing energy poverty in the city of Barcelona, from the point of view of the target population and the workers involved in the intervention. To evaluate the “ Atlas-ti software . Interviews were conducted between October 2016 and March 2017. A qualitative, descriptive and exploratory pilot study was carried out, with a phenomenological approach. Twelve semi-structured interviews were conducted: to three users, three energy agents who performed interventions in the homes, and six professionals who participated in the program coordination. A thematic content analysis was carried out using  Trust in a contact person  facilitated the participation, although there were difficulties reaching people who had illegal energy supplies, immigrant women or immigrants who subrent properties. Regarding implementation, home visits, energy efficiency advice and the relationship with energy agents were the best assessed aspects. However, not being able to carry out reforms in deteriorated dwellings was considered a limitation. The program also contributed to raise awareness on energy rights, to save on utility bills and to generate tranquility and social support. Programs such as this one can promote energy empowerment and improve psychosocial status. However, strategies with a gender and equity perspective should be considered to reach other vulnerable groups. This situation is associated with a type of residential exclusion characterized by legal and economic problems3 . The intermediate determinants of EP are low household income, high prices of energy services and low energy efficiency of homes, all of which are conditioned, in turn, by structural factors such as socio-environmental policies4 .Energy poverty (EP) has been defined as not being able to pay for energy services to satisfy essential domestic needs or to allocate an excessive part of the income for the payment of energy bills5 . There is also an association between living with EP and the excess of winter mortality directly related to macroeconomic indicators6 . In fact, cold-related mortality is greater in regions with Mediterranean climatic conditions, which have poorer economic indicators than regions of central and northern Europe, with colder climates8 .Scientific literature has shown that EP can have health consequences, such as circulatory diseases, respiratory problems, as well as anxiety and depression1 . In 2014, it was estimated that 11% of households, that is, around 5.1 million people, were unable to maintain their homes at an adequate temperature in the cold months1 . The population most affected by EP comes from low-income households with some unemployed members9 . Likewise, the EP has been associated with single-parent, retired families and women who are engaged in domestic tasks11 .Between 2008 and 2014, Spain was the second country, after Greece, with the highest increase in the price of electricity in the European Union, which coincided with a period of strong economic recession in which unemployment increased and wages decreased12 . Likewise, it has been observed that carrying out reforms at the architectural level can significantly reduce winter mortality7 . However, evaluations of interventions on energy poverty are scarce. Therefore, the objective of this study was to know the valuations of an intervention aimed at reducing EP, incorporating both the perspective of the target persons and the workers involved in the program.Interventions carried out in other countries aimed at increasing energy efficiency in homes have been shown to improve thermal comfort, increase savings and, at the indirect benefits level, create a greater sense of security and well-being13 . This research is part of the evaluation of the “Energía, la justa” program, promoted by the Barcelona City Council during the first semester of 201614 . This program aimed to reduce EP in vulnerable populations through intervention in three areas. First, promoting energy efficiency habits to achieve savings; second, optimizing energy services such as discounting invoices through the processing of the social bonus; and third, installing micro-efficiency measures such as energy-saving light bulbs. On the other hand, the program included an employment insertion for long-term unemployed people, who were offered training to be “energy agents” (EA) and perform the intervention in the homes. The pilot study was conducted between October 2016 and March 2017.A qualitative, descriptive and exploratory pilot study was conducted from a phenomenological perspectiveThe qualitative evaluation was carried out through 12 semi-structured interviews with eight women and four men. The sample consisted of the following key agents: three people who were the recipients of the program, three EA and six people who worked on the coordination of the program, including a territory technique that carried out tasks of liaison between territorial agents, besides selecting the EA; a technical coordinator, responsible for training and advising the EAs; a program coordinator, responsible for the entities of the territory; and three social service social workers, who made contact with the candidate families to participate.A script of interviews was designed based on the assessment of the key agents on the implementation and coordination of the program, the implementation and impact of the intervention   . The se15 . The saturation of the discourse was used as closure criterion. The results were triangulated by different investigators who participated in the study.The interviews were recorded on audio and, once transcribed, a thematic content analysis was carried out using Atlas-ti software. The most relevant areas were identified according to the perspective of the key agents. Once the categories were identified, they were examined through a comparison process with the rest of the dataThe results are presented according to the perspective of the different key agents.Regarding the implementation and coordination of the intervention   , the reAccording to the AE, despite not always having the necessary materials to do the intervention generated frustration. On the other hand, among the contact barriers, there were people who distrusted the program, either because they had bad previous experiences with the energy companies or because they obtained the energy supplies illegally. In the immigrant population, there were cases with language barriers, such as women who did not speak Spanish and who, in addition, depended on the husband’s consent to participate. It was also commented that a part of the population was afraid to participate, especially immigrants who sublet rooms.According to the coordinators and the EAs, motivation and involvement were key factors, since, although sometimes they had to improvise, the conviction on the part of the agents facilitated their development. They also commented that the program did not manage to contact people who obtained their energy supplies illegally or had no connection with the social services of the neighborhood. On the other hand, it was pointed out that there was a clear gender inequality in the selection of the EA staff, with a male predominance associated with the construction profile of the workforce.Regarding the implementation of the intervention   , the foAccording to the EA, actions that favored saving and improvements in housing were implemented. However, in the floors with structural problems, as in the case of air leaks through windows or doors, the program could not obtain improvements due to not having the necessary resources to carry out reforms. The program was considered to be too short, and interventions were not completed. In addition, the lack of time limited the follow up.According to the coordinators, the home visits served to detect populations with significant personal and economic problems. Considering that the intervention was free and that the changes in the home were optional facilitated its implementation. On the other hand, the fact that the EAs had experienced EP situations facilitated the development of empathy and involvement in the intervention. Both the coordinators and the EAs identified the procedures that had to be carried out to change the tariffs with the energy companies as an obstacle, considered too bureaucratic and delaying the management.Regarding the impact of the intervention   , the reBoth from the perspective of the EAs and the coordinators, it was commented that the intervention fostered knowledge about more efficient energy consumption. This was seen as an empowerment strategy, especially for the youngest ones. According to the EA, making sure there would be no supply cuts reduced the concern and increased welfare. On the other hand, contacts with some people were beneficial from the social support point of view, especially in cases with few support networks.According to the coordinators, the training of the recipients contributed to saving and to experiencing a greater sense of comfort thanks to having, for example, the light on for a longer time. Also, the program had a possible impact on aspects of mental health such as stress, as well as on respiratory diseases. However, the impact was low when housing conditions were extremely deficient. In addition, due to the same circumstances of economic restriction of some families, the development of strategies to save on energy consumption was carried out in some cases before the intervention.in situ allowed to know more about people’s life conditions and establish a closer relationship with them.The main results of the study indicate that changes in the rates of energy supplies, receiving advice on energy efficiency, as well as carrying out the intervention within the homes were highly valued aspects. On the one hand, the program allowed some recipients to reduce their financial expenses, resulting in more tranquility. On the other hand, the fact of carrying out actions 16 . In addition, a sociocultural pattern related to gender inequalities was observed as immigrant women have fewer opportunities to learn the language of the country of destination and are more exposed to social problems17 . This situation placed them at a greater disadvantage to understand and participate in this program, highlighting the importance of developing effective strategies to contact socially excluded and difficult-to-reach sub-populations, especially considering the feminization of the EP10 .Regarding its implementation, the people who participated in the program assessed it as a positive municipal initiative and the professional contact as trustworthy. However, the program did not reach some of the most vulnerable populations. On the one hand, those people who were in a legal limbo with the energy companies showed greater distrust to perform any type of intervention in their homes. However, certain groups of immigrants sublet the housing, an illegality situation that generated greater resistance to participate. This social phenomenon, more frequent for immigrants than for Spaniards, shows social inequality related to the job insecurity, the difficulty of signing contracts with homeowners and the existence of a high-priced housing market with high rent prices1 . In addition, the lack of understanding about what is paid in an energy bill contributes to the figure of the “vulnerable consumer,” who sees limited ability to make decisions about the management of their economy20 .Regarding the implementation of the program, there was a good perception of the follow up made by the EAs to make the changes in the type of rate hired, which is especially relevant if one considers that one of the barriers was the bureaucratic procedures with the energy companies. In this sense, it has been observed that electricity and gas bills are seen as those that provide less information and less clear regarding the prices of their services, the conditions of supply and the type of contract22 .The fact that many of the EAs themselves had experienced EP facilitated the creation of a link with the target persons. In this way, the program not only provided energy support, but also offered social support to the extent that people noticed that an institution assessed as important was concerned about their living conditions. There is ample literature that shows the impact of having social support on people’s health, which translates into the need to understand energy vulnerability as a complex social system that should not only consider the energy field23 . However, in this program there were no improvements in people with very poor condition homes, since they required structural reforms. All this suggests the need to carry out actions that intervene on social and economic conditions to help alleviate the EP and its consequences.For the different key agents, the program had an economic impact and in the acquisition of knowledge about rights, which was considered a tool for the empowerment of the population. In general, the informants highlighted that saving contributed to the increase of well-being and less feelings of stress related to the non-payment of invoices. These results would be consistent with those found in another study, which showed that an intervention that improves energy efficiency in the home brings positive impact in the users, by experiencing fewer financial difficulties and by feeling healthierAmong the limitations of the study, it is noteworthy that we did not include a sample that could handle the experiences according to different characteristics of the target persons. However, having selected different agents allowed to provide a global vision of the program. In addition, this pilot study will lead to another qualitative evaluation that will allow us to analyze different types of people targeted by this intervention. Regarding the strengths, it should be noted that this is the first study at the Spanish state level that has made a qualitative assessment of different agents that have participated in a EP program. Thus, the results obtained will contribute to generate evidence on EP and health, an emerging and very relevant field in our context.In conclusion, the impact of the program was observed in terms of energy efficiency, at the economic level, and also improvements in the psychosocial health. In addition, the program fostered energy empowerment by increasing knowledge and the capacity to act for energy rights. It is worth noting the complexity that surrounds the population that lives in a EP situation, considering both the social determinants of health and the different axes of inequality such as gender, cultural diversity, migratory status and social class, among others. For this reason, this type of programs should be developed within the framework of agreements that are continued over time and associated with structural social policies that affect the multiple factors taking part on housing problems. 2 . Esta situación se asocia a un tipo de exclusión residencial caracterizada por problemas legales y económicos3 . Los determinantes intermedios de padecer PE son los bajos ingresos del hogar, los altos precios de los servicios de energía y la baja eficiencia energética de las viviendas, todo ello condicionado, a su vez, por factores estructurales como las políticas socioambientales4 .La pobreza energética (PE) ha sido definida como no poder pagar servicios energéticos para satisfacer necesidades domésticas esenciales o como destinar una parte excesiva de los ingresos para el pago de las facturas de energía5 . También, existe una asociación entre vivir con PE y el exceso de mortalidad invernal directamente relacionado con indicadores macroeconómicos6 . De hecho, la mortalidad relacionada con el frío es mayor en aquellas regiones con condiciones climáticas mediterráneas, que tienen peores indicadores económicos que las regiones de Europa central y del norte, con climas más fríos8 .La literatura científica ha mostrado que la PE puede tener consecuencias en la salud, como la aparición de enfermedades circulatorias, problemas respiratorios, además de ansiedad y depresión1 . En el año 2014 se estimó que el 11% de los hogares, es decir unos 5,1 millones de personas, no lograron mantener su vivienda a una temperatura adecuada en los meses fríos1 . La población más afectada por la PE procede de hogares con rentas bajas y con algún miembro desempleado9 . Asimismo, la PE se ha asociado a familias monomarentales, jubiladas y a mujeres que se dedican a las tareas domésticas11 .Durante los años 2008–2014, España fue el segundo país después de Grecia con el mayor incremento del precio de la electricidad de la Unión Europea, lo que coincidió con un período de fuerte recesión económica en el que aumentó el desempleo y hubo una caída de los salarios12 . Asimismo, se ha observado que realizar reformas a nivel arquitectónico puede llegar a reducir significativamente la mortalidad invernal7 . Sin embargo, las evaluaciones de intervenciones sobre la pobreza energética son escasas. Por ello, el objetivo del estudio fue conocer las valoraciones de una intervención orientada a reducir la PE, incoporando tanto la perspectiva de las personas destinatarias, como de las personas trabajadoras implicadas en el programa.Intervenciones realizadas en otros países orientadas a aumentar la eficiencia energética en los hogares han mostrado mejorar el confort térmico, aumentar el ahorro y, a nivel de beneficios indirectos, crear una mayor sensación de seguridad y de bienestar13 . Esta investigación forma parte de la evaluación del programa “Energía, la justa”, impulsado por el Ayuntamiento de Barcelona durante el primer semestre de 201614 . El objetivo de este programa fue reducir la PE en poblaciones vulnerables mediante una intervención en tres ámbitos. Primero, promoviendo hábitos de eficiencia energética para lograr ahorro; segundo, optimizando los servicios energéticos como el descuento en las facturas a través de la tramitación del bono social; y tercero, instalando medidas de microeficiencia como las bombillas de bajo consumo. Por otra parte, el programa incluyó un eje de inserción laboral para personas desempleadas de larga duración, a las cuales se les ofreció formación para ser “agentes energéticos” (AE) y realizar la intervención en los hogares. El estudio piloto se realizó entre octubre de 2016 y marzo de 2017.Se realizó un estudio piloto cualitativo, descriptivo y exploratorio, desde la perspectiva fenomenológicaLa evaluación cualitativa se realizó mediante 12 entrevistas semi-estructuradas, a ocho mujeres y cuatro hombres. La muestra estuvo compuesta por los siguientes agentes claves: tres personas destinatarias del programa, tres AE y seis personas que trabajaron en la coordinación del programa, entre las que se incluyeron a una técnica de territorio que realizó tareas de enlace entre los agentes del territorio, además de seleccionar a los AE; un coordinador técnico, responsable de la formación y el asesoramiento a los AE; una coordinadora de programa, responsable de las entidades del territorio; y tres trabajadoras sociales de servicios sociales que realizaron el contacto con las familias candidatas a participar.Se diseñó un guión de entrevistas en base a la valoración de los agentes clave sobre la puesta en marcha y coordinación del programa, la implementación e impacto de la intervención   . La selsoftware Atlas-ti. Se identificaron los ámbitos más relevantes según la perspectiva de los agentes clave. Una vez identificadas las categorías, se examinaron mediante un proceso de comparación con el resto de los datos15 . Como criterio de cierre se utilizó la saturación del discurso. Los resultados fueron triangulados por diferentes personas investigadoras que participaron en el estudio.Las entrevistas fueron grabadas en audio y, una vez transcritas, se realizó un análisis de contenido temático utilizando el Los resultados se presentan según la perspectiva de los diferentes agentes claves.Con respecto a la puesta en marcha y coordinación de la intervención   , las peSegún los AE, el hecho de no disponer siempre de los materiales necesarios para hacer la intervención generó sentimientos de frustración. Por otra parte, entre las barreras de contacto, hubo gente que desconfió del programa, bien por haber tenido malas experiencias previas con las compañías energéticas o porque obtenían los suministros de energía de forma ilegal. En la población inmigrante, hubo casos con barreras idiomáticas, como las mujeres que no hablaban castellano y que, además, dependían del consentimiento del marido para poder participar. También se comentó que una parte de la población tenía miedo a participar, sobre todo inmigrantes que subalquilaban habitaciones.Según las personas coordinadoras y los AE, la motivación y la implicación fueron factores claves, ya que, si bien a veces se tuvo que improvisar, la convicción por parte de los agentes facilitó su desarrollo. También, comentaron que el programa no logró contactar con personas que obtenían sus suministros de energía de forma ilegal o no tenían relación con los servicios sociales del barrio. Por otra parte, se señaló que hubo una clara desigualdad de género en la selección del personal de los AE, con un predominio masculino asociado al perfil laboral de la construcción.En cuanto a la implementación de la intervención   , el acoSegún los AE, se lograron implementar acciones que favorecieron el ahorro y mejoras en la vivienda. No obstante, se comentó que en los pisos con problemas estructurales, como en el caso de filtraciones de aire por ventanas o puertas, el programa no logró obtener mejoras al no contar con los recursos necesarios para realizar reformas. Con respecto a la duración del programa, se consideró que fue demasiado corto, con lo cual hubo intervenciones que no llegaron a finalizarse. Además, la falta de tiempo limitó realizar un seguimiento.Según las personas coordinadoras, las visitas domiciliarias sirvieron para detectar poblaciones con importantes problemas personales y económicos. La gratuidad de la intervención, y que los cambios en el hogar fueran opcionales, se valoraron como facilitadores para su implementación. Por otra parte, se señaló que el hecho de que los AE hubieran experimentado situaciones de PE facilitó que desarrollaran empatía e implicación en la intervención. Tanto los coordinadores como los AE, identificaron como barrera los trámites que se debían realizar para cambiar las tarifas con las compañías energéticas, considerados demasiado burocráticos y retardando la gestión.En cuanto al impacto de la intervención   , las peTanto desde la perspectiva de los AE como de los coordinadores, se comentó que la intervención fomentó el conocimiento sobre un consumo energético más eficiente. Esto se percibió como una estrategia de empoderamiento, sobre todo para los más jóvenes. Según los AE, ofrecer la seguridad de que no habría cortes de suministros disminuyó la preocupación y generó mayor bienestar. Por otra parte, se percibió que los contactos con algunas personas fueron beneficiosos desde el punto de vista del apoyo social, sobre todo en los casos que contaban con pocas redes de apoyo.Según las personas coordinadoras, la formación de las personas destinatarias contribuyó al ahorro y a experimentar mayor sensación de confort gracias a tener, por ejemplo, la luz encendida durante más tiempo. También, se señaló que el programa tuvo un posible impacto en aspectos de salud mental como el estrés, así como en enfermedades respiratorias. Sin embargo, el impacto fue percibido bajo cuando las condiciones de la vivienda eran extremadamente deficientes. Además, por las mismas circunstancias de restricción económica de algunas familias, el desarrollo de estrategias de ahorro en el consumo de energía se realizaba en algunos casos antes de la intervención.in situ , permitió tener un mayor conocimiento sobre las condiciones en las que viven las personas y establecer una relación más próxima con ellas.Los principales resultados del estudio señalan que los cambios en las tarifas de los suministros de energía, recibir asesoramiento en materia de eficiencia energética, así como realizar la intervención dentro de los hogares fueron aspectos muy bien valorados. Por un lado, el programa permitió que algunas personas destinatarias disminuyeran los gastos económicos, lo que generó mayor tranquilidad. Por otra parte, el hecho de haber realizado acciones 16 . Además, se observó un patrón sociocultural relacionado con las desigualdades de género en la medida que las mujeres inmigrantes tienen menos oportunidades de aprender la lengua del país de destino y están más expuestas a sufrir problemas sociales17 . Esta situación las posicionó en una mayor desventaja para comprender y participar en este programa, poniendo de relieve la importancia de desarrollar estrategias efectivas para contactar con sub-poblaciones socialmente excluidas y de difícil contacto, sobre todo considerando la feminización de la PE10 .En relación a su puesta en marcha, las personas que participaron en el programa valoraron positivamente que fuera una iniciativa municipal y que el profesional de contacto fuera de confianza. Sin embargo, el programa no logró llegar a determinadas poblaciones más vulnerables. Por un lado, aquellas personas que se encontraban en un limbo legal con las compañías de energía mostraron mayor desconfianza a realizar cualquier tipo de intervención en sus hogares. Por otra parte, se comentó que determinados colectivos de inmigrantes subalquilaban la vivienda, una situación de ilegalidad que generó mayor resistencia a participar. Este fenómeno social, más frecuente en el caso de población inmigrante que en el caso de población española, muestra la desigualdad social relacionada con la precarización laboral, la dificultad de firmar contratos con los propietarios de vivienda y la existencia de un mercado de vivienda con elevados precios del alquiler1 . Además, la falta de comprensión sobre qué es lo que se paga en un recibo de energía contribuye a la figura del “consumidor vulnerable”, que ve limitada su capacidad de tomar decisiones sobre la gestión de su economía20 .Con respecto a la implementación del programa, hubo una buena percepción sobre el acompañamiento que realizaron los AE para realizar los cambios en el tipo de tarifa contratada, lo que es especialmente relevante si se considera que una de las barreras fueron los trámites burocráticos con las compañías de energía. En este sentido, se ha observado que las facturas de electricidad y gas son percibidas como aquellas que aportan menos información y las menos claras con respecto a los precios de sus servicios, las condiciones de suministro y el tipo de contrato22 .El hecho de que muchos de los propios AE hubieran experimentado PE facilitó la creación de un vínculo con las personas destinatarias. De esta forma, el programa no solo proporcionó apoyo en materia energética, sino que también ofreció apoyo social en la medida que las personas percibieran que una institución valorada como importante se preocupaba por sus condiciones de vida. Existe amplia literatura que muestra el impacto de contar con apoyo social sobre la salud de las personas, lo que se traduce en la necesidad de entender la vulnerabilidad energética como un sistema social complejo que no solo debe considerar el ámbito de la energía23. Sin embargo, en este programa no se observaron mejoras en las personas con viviendas en muy mal estado, ya que requerían reformas de tipo estructural. Todo ello sugiere la necesidad de realizar acciones que intervengan sobre las condiciones sociales y económicas para ayudar a paliar la PE y sus consecuencias.Para los diferentes agentes clave, el programa tuvo un impacto a nivel económico y en la adquisición de conocimiento sobre derechos, lo que fue considerado una herramienta para el empoderamiento de la población. En general, los informantes destacaron que el ahorro contribuyó a tener mayor sensación de bienestar y menos sentimientos de estrés relacionado con el impago de las facturas. Estos resultados serían consistentes con los encontrados en otro estudio, que mostraba que una intervención que mejora la eficiencia energética en el hogar, genera un impacto positivo al experimentar en las personas usuarias menos dificultades financieras y sentirse más saludablesEntre las limitaciones del estudio destaca el no haber incluido una muestra que pudiera dar cuenta de las experiencias según diferentes características de las personas destinatarias. Sin embargo, el hecho de haber seleccionado a diferentes agentes permitió aportar una visión global del programa. Además, este estudio piloto derivará en otra evaluación cualitativa que permitirá analizar diferentes tipologías de personas destinatarias de esta intervención. En relación a las fortalezas, cabe destacar que este es el primer estudio a nivel del estado español que ha realizado una evaluación cualitativa a diferentes agentes que han participado en un programa en materia de PE. Así, los resultados obtenidos contribuirán a generar evidencia sobre la PE y la salud, un ámbito emergente y muy relevante en nuestro contexto.En conclusión, el impacto del programa se observó en términos de eficiencia energética, a nivel económico, y también de mejoras en la salud piscosocial. Asimismo, el programa fomentó el empoderamiento en materia energética al aumentar el conocimiento y la capacidad de actuar por los derechos energéticos. Cabe destacar la complejidad que envuelve a la población que vive en situación de PE, teniendo en cuenta tanto los determinantes sociales de la salud, como los diferentes ejes de desigualdad como el género, la diversidad cultural, el estatus migratorio y la clase social, entre otros. Por ello, este tipo de programas deberían desarrollarse en el marco de convenios continuados en el tiempo y asociados a políticas sociales de tipo estructural que incidan sobre los múltiples factores que intervienen en los problemas relacionados con la vivienda.


The perforating veins of the lower limbs (LL) have valves that enable the blood flow to be directed from the superficial vein system to the deep vein system and they may or may not be connected to the saphenous vein system.  To use vascular ultrasonography (VUS) to identify the frequency, location, caliber, and hemodynamic role of perforating veins that do not connect to saphenous veins, during preoperative mapping of LL varicose veins.  A cross-sectional study was conducted using VUS in women to study the frequency, location, distance from the sole of the foot, and hemodynamic role of perforating veins.  The frequencies of perforating veins independent of the saphenous veins were 92.6%, 5.1%, and 2.3%, in the leg, thigh, and knee, respectively, and 25.2% of them were incompetent while 72.3% were drainage veins. The mean diameters of perforating veins were 2.9 mm, 3.5 mm, and 3.7 mm, in the leg, thigh, and knee, respectively. Perforating veins were located at mean distances of 23.8 cm, 43.6 cm, and 59.4 cm above the sole of the foot in the leg, knee, and thigh, respectively. Perforating veins with reflux had a mean caliber of 3.5 mm, irrespective of location.  Perforating veins independent of the saphenous veins are most frequent in the leg, draining reflux from tributary veins. Irrespective of location, perforating veins with reflux had mean caliber of 3.5 mm.  The venous system of the lower limbs (LL) comprises the deep system, responsible for 85% of venous drainage, and the superficial system, responsible for the remaining 15%. Between these two systems there are an average of 64 perforating veins, between the foot and the groin, that communicate directly or indirectly, enabling flow to drain from superficial veins to deep veins.  There are four groups of perforating veins in the calf: the paratibial perforators, communicating between the great saphenous and posterior tibial veins; the perforators connecting the posterior accessory saphenous vein to the posterior tibial vein; and the lateral and anterior perforators of the leg. In the knee, the perforating veins are designated as lateral or medial, suprapatellar or infrapatellar, and popliteal fossa perforators. In the thigh, the perforators are medial, anterior, lateral, and posterior.  The perforating veins drain flow from the great and small saphenous veins to the deep veins or muscular veins or drain flow from tributary veins that are independent from the saphenous vein system, and which may play different hemodynamic roles.  Competent perforating veins drain flow to the deep system without interfering in the caliber of the saphenous or tributary veins. Incompetent perforating veins exhibit significant reflux and may transfer this reflux to saphenous or tributary veins, causing them to dilate. Drainage perforating veins drain reflux from saphenous or tributary veins.  During venous mapping with vascular ultrasonography (VUS), the medial, anterior, lateral, and posterior perforating veins of the thigh, knee, and leg should be examined. They can be identified in mode B by their course connecting superficial and deep veins and perforating the muscle fascia, thereby identifying their hemodynamic role in the venous system.  The objective of this study was to use VUS to identify the frequency, location, caliber, and hemodynamic role of perforating veins independent of the saphenous veins during preoperative mapping of LL varicose veins.  A cross-sectional study was conducted with women with signs or symptoms of chronic venous insufficiency (CVI) who had been referred to a vascular laboratory for venous mapping of the LL using VUS.  The study recruited women over the age of 18 with LL varicose veins of primary etiology and clinical classes C1 to C3 according to the clinical, etiology, anatomical and pathophysiology (CEAP) classification. The study excluded men; women with LL congenital varicose veins or varicose veins of secondary etiology or CEAP C4 to C6; and patients who had previously undergone surgical treatment for varicose veins.  The study was approved by the Research Ethics Commission at the Pontifícia Universidade Católica do Paraná (PUCPR), under CAAE nº 61368016.2.0000.0020 and certificate nº 111358/2016.  All patients included in the study were assessed using Siemens®Antares and Siemens®X 700 ultrasonography scanners with color Doppler .  Deep vein system flow was assessed to exclude recent or historic venous thrombosis, with the patient in decubitus dorsal, with transverse ultrasound sweeps in B mode and maneuvers to assess vein compressibility, using a low frequency transducer (5 Mhz).  The great and small saphenous veins were examined with the patient standing upright, using a high frequency transducer (7 Mhz) to obtain images of the veins with longitudinal ultrasound sweeps in mode B. With the aid of color flow mapping, valve function was assessed using a manual muscle compression maneuver distal to the position of the transducer, in order to produce and detect reflux in the superficial vein system and the perforating veins.  Perforating veins connected to or independent of the saphenous veins were located and assessed for reflux with the patient standing upright and reflux was quantified in terms of duration of reflux exceeding 0.35 seconds.  Evaluation of perforating veins independent of the saphenous veins considered location ; height in relation to the sole of the foot; and hemodynamic role .  Competent perforating veins with caliber less than 3 mm were not considered in the analysis, since they are not clinically relevant and are difficult to identify by clinical examination.  The results for quantitative variables were expressed as means, medians, minimum and maximum values, and standard deviations. Qualitative variables were expressed as frequencies and percentages.  Analysis of perforating veins, considering height from the sole of the foot, diameter, and hemodynamic role, was performed separately for each anatomic segment of thigh, knee, and leg, considering the total number of perforating veins per segment, including veins on the medial, lateral, and posterior aspects. Data were analyzed with IBM SPSS Statistics v.20.  A total of 361 LL were analyzed in 258 women with ages ranging from 18 to 88 years (mean of 48 years): 205 right limbs (56.8%) and 156 left limbs (43.2%).  Of the 361 limbs assessed, 155 (42.9%) had reflux in the great saphenous vein and 93 (25.7%) had reflux in the small saphenous vein.  A total of 475 perforating veins independent of the saphenous veins were identified in the 361 LL assessed: 24 (5.1%) perforators in the thigh, 11 (2.3%) in the knee, and 440 (92.6%) in the leg.  Eighty-three (23.0%) of the 361 LL had more than one perforating vein in the same segment, breaking down as one with two perforators in the thigh and 82 limbs with two or more perforators in the leg. Sixty-three (76.8%) of the limbs with two or more perforators in the leg had two perforators, 14 (17.1%) had three perforators, five (6.1%) had four perforators, and the majority (70%) had veins in more than one location .  In turn, 14 (58.4%) of the perforating veins in the thigh were identified in the lateral area, five (20.8%) in the medial area and five (20.8%) in the posterior area. Seventeen (70.8%) of the perforating veins in the thigh had reflux to tributary veins and seven (29.2%) drained reflux from tributary veins. All perforating veins in the thigh with diameters exceeding 3 mm were incompetent or provided drainage.  In relation to location and caliber   , perfor With regard to perforating veins in the knee, seven (63.6%) were identified in the posterior region of the knee, two (18.2%) in the medial region, and two (18.2%) in the lateral region. Six (54.5%) of the perforating veins in the knee had reflux into tributary veins and five (45.5%) drained reflux from tributary veins. All of the perforating veins in the knee larger than 3 mm were incompetent or provided drainage.  In terms of location and caliber   , the pe With regard to perforating veins in the leg, 289 (65.7%) were identified in the medial region of the leg, 90 (20.4%) in the lateral region and 61 (13.9%) in the posterior region. Ninety-seven (22.0%) of the perforating veins in the leg exhibited reflux flowing to tributary veins, 330 (75.0%) drained reflux from tributary veins, and 13 (3.0%) were competent and connected to tributary veins without reflux.  In terms of location and caliber   , the pe A total of 475 perforating veins were assessed for this study, 120 (25.2%) of which exhibited reflux in the thigh, knee, or leg, with a mean caliber of 3.5 mm, ranging from 2.0 to 6.3 mm.  Vascular ultrasound is the method of choice for detecting reflux of blood in specific veins, primarily using color flow mapping, which enables the extent and distribution of venous reflux to be identified with precision. , Depending on study population, the incidence of sources of superficial venous reflux unrelated to the saphenous trunk veins can range from 10 to 43%. ,- The most important sources of reflux that are not connected to saphenous veins and should be examined are the tributary veins of the posterior accessory saphenous vein, the accessory veins of the thigh, groin veins , perforating veins of the lateral and posterior surfaces of the thigh (veins of the sciatic nerve), and perforating veins of the medial, lateral, and posterior  aspects of the knee and leg.  Our study only focused on perforating veins that are independent of the saphenous veins and identified perforating veins in the thigh, knee, and leg in 5.1%, 2.3%, and 92.6% of the limbs assessed, respectively.  With relation to the perforating veins of the thigh, in our study the great majority (70.8%) were incompetent and 58.3% were located in the lateral thigh. Gianesini et al.  In our study, just 7 (1.4%) perforating veins were identified in the posterior knee. Similarly, Delis et al.  The majority (92.6%) of the perforating veins in our study were identified in the leg, 65% in the medial leg, with the primary function of draining reflux from tributary veins. Just 22% of perforating veins in the leg exhibited reflux flowing into tributary veins. It is important to highlight that competent perforating veins with calibers smaller than 3 mm were excluded from the study because they are not clinically relevant and are difficult to detect by physical examination.  Labropoulos et al.  Sandri et al.  In our study, considering only perforating veins with reflux at the thigh, knee, and leg (25%), mean calibers were 3.6 mm, 3.8 mm, and 2.9 mm, respectively. Irrespective of location, the caliber of perforating veins with reflux ranged from 2 to 6.3 mm, with mean caliber of 3.5 mm, which is similar to results from a study by Sandri et al.  The authors conclude that perforating veins independent of saphenous veins are more frequent in the leg, draining reflux from tributary veins. Irrespective of location, perforating veins with reflux had a mean caliber of 3.5 mm.   O sistema venoso dos membros inferiores (MMII) é composto pelo sistema profundo, responsável por 85% da drenagem venosa, e o superficial, responsável pelos 15% restantes. Entre esses dois sistemas, existem em média 64 veias perfurantes, entre o pé e a região inguinal, que fazem uma comunicação direta ou indireta, possibilitando a drenagem do fluxo das veias superficiais para as veias profundas  Na panturrilha são identificados quatro grupos de veias perfurantes: as perfurantes paratibiais, comunicando a safena magna e a veia tibial posterior; as perfurantes conectando o arco posterior da safena magna com a veia tibial posterior; e as perfurantes laterais e anteriores da perna. No joelho, as veias perfurantes são designadas como laterais ou mediais, supra ou infrapatelares e perfurantes da fossa poplítea. Na coxa, as perfurantes são mediais, anteriores, laterais e posteriores  As veias perfurantes drenam o fluxo das veias safenas magna e parva para as veias profundas ou musculares ou o fluxo de veias tributárias independentes do sistema das veias safenas, e podem desempenhar diferentes papéis hemodinâmicos. As veias perfurantes competentes drenam o fluxo para o sistema profundo sem interferir no calibre das veias safenas ou tributárias. As veias perfurantes incompetentes apresentam refluxo significativo e podem transferir esse refluxo para as veias safenas ou tributárias, causando a dilatação destas. As veias perfurantes de drenagem escoam refluxo das safenas ou tributárias  Durante o mapeamento venoso com ultrassonografia vascular (USV), devem ser pesquisadas as veias perfurantes mediais, anteriores, laterais e posteriores na coxa, joelho e perna, as quais são identificadas no modo B pelo seu trajeto de conexão entre as veias superficiais e profundas, perfurando a fáscia muscular, identificando o papel hemodinâmico no sistema venoso.  O objetivo deste trabalho foi identificar, pela USV, a frequência, localização, calibre e o papel hemodinâmico das veias perfurantes independentes das veias safenas no mapeamento pré-operatório das varizes dos MMII.  Foi realizado um estudo transversal em mulheres com sinais ou sintomas de insuficiência venosa crônica (IVC), encaminhadas ao laboratório vascular para realização de mapeamento venoso dos MMII utilizando USV.  Foram incluídas no estudo mulheres maiores de 18 anos com varizes em MMII de etiologia primária e pertencentes às classes clínicas C1 a C3 da classificação clínica, etiológica, anatômica e fisiopatológica (CEAP). Foram excluídos homens; mulheres com varizes em MMII de etiologia secundária ou congênita ou com CEAP C4 a C6; e pacientes que foram submetidas a tratamento cirúrgico das varizes.  O estudo foi aprovado pelo Comitê e Ética em Pesquisa da Pontifícia Universidade Católica do Paraná (PUCPR), com CAAE nº 61368016.2.0000.0020 e comprovante nº 111358/2016. ®Antares e Siemens® X 700 .  Todas as pacientes incluídas no estudo foram avaliadas em aparelhos de ultrassonografia com Doppler colorido Siemens Foi realizada avaliação do fluxo no sistema venoso profundo para a exclusão de trombose venosa recente ou antiga, com a paciente em decúbito dorsal, com cortes ultrassonográficos transversais em modo B e manobras de compressibilidade das veias, utilizando-se transdutores de baixa frequência (5 Mhz).  O estudo das veias safenas magna e parva foi realizado com a paciente em posição ortostática, utilizando transdutor de alta frequência (7 Mhz), para a obtenção das imagens das veias em cortes ultrassonográficos longitudinais em modo B. Com o auxílio do mapeamento do fluxo a cores, avaliou-se o funcionamento valvular pela manobra de compressão muscular manual distal ao posicionamento do transdutor, a fim de produzir e detectar refluxo no sistema venoso superficial e nas veias perfurantes.  Foi realizada a localização e pesquisa do refluxo nas veias perfurantes conectadas ou independentes das veias safenas, com a paciente também em posição ortostática, além da quantificação do refluxo considerando o tempo de duração do refluxo superior a 0,35 segundos  Para a avaliação das veias perfurantes independentes das veias safenas foi considerada a localização ; altura em relação à base do pé; e o papel hemodinâmico .  Para fins de análise, foram desconsideradas as veias perfurantes competentes com calibre inferior a 3 mm, por não apresentarem relevância clínica e serem de difícil identificação ao exame clínico.  Os resultados de variáveis quantitativas foram descritos por médias, medianas, valores mínimos, valores máximos e desvios padrões. Para variáveis qualitativas, foram apresentados frequências e percentuais.  A análise das veias perfurantes, considerando a altura em relação à base do pé, diâmetro e o papel hemodinâmico, foi realizada separadamente por segmento anatômico de coxa, joelho e perna, considerando a totalidade das veias perfurantes para cada segmento, incluindo as veias na face medial, lateral e posterior. Os dados foram analisados com o programa computacional IBM SPSS Statistics v.20.  Foram avaliados 361 MMII de 258 mulheres com idade variando entre 18 e 88 anos (média de 48 anos), sendo 205 membros direitos  e 156 membros esquerdos .  Dos 361 membros avaliados, 155  apresentaram refluxo na veia safena magna e 93  refluxo na veia safena parva.  Nos 361 MMII avaliados, foram identificadas 475 veias perfurantes independentes das veias safenas, sendo 24  perfurantes na coxa, 11  no joelho e 440 (92.6%) na perna.  Dos 361 MMII, 83 membros  apresentaram mais de uma veia perfurante no mesmo segmento, sendo um membro com duas perfurantes na coxa e 82 membros com duas ou mais perfurantes na perna. Dos membros com duas ou mais perfurantes na perna, 63  apresentaram duas perfurantes, 14  apresentaram três perfurantes, e cinco  apresentaram quatro perfurantes, sendo que a maioria (70%) apresentava veias em mais de uma localização .  Quanto às veias perfurantes na coxa, 14  foram identificadas na região lateral, cinco  na região medial e cinco  na região posterior. Do total de veias perfurantes na coxa, 17  apresentaram refluxo para veias tributárias, e sete  drenavam refluxo de veias tributárias. Todas as veias perfurantes maiores que 3 mm na coxa eram incompetentes ou de drenagem.  Em relação à localização e ao calibre   , as vei Quanto às veias perfurantes no joelho, sete  foram identificadas na região posterior do joelho, duas  na região medial e duas  na região lateral. Do total de veias perfurantes no joelho, seis  apresentaram refluxo para veias tributárias e cinco  drenavam refluxo de veias tributárias. Todas as veias perfurantes maiores que 3 mm no joelho eram incompetentes ou de drenagem.  Em relação à localização e calibre   , as vei Quanto às veias perfurantes na perna, 289  foram identificadas na região medial da perna, 90  na região lateral e 61  na região posterior. Do total de veias perfurantes na perna, 97  apresentaram refluxo para veias tributárias, 330  drenavam refluxo de veias tributárias, e 13  eram competentes e conectadas a veias tributárias sem refluxo.  Em relação à localização e calibre   , as vei Do total de 475 veias perfurantes avaliadas no estudo, 120 veias  apresentaram refluxo na coxa, joelho ou perna, com calibre médio de 3,5 mm, variando entre 2,0 e 6,3 mm.  A ecografia vascular é o método de escolha para detectar refluxo sanguíneo em veias específicas, principalmente com a utilização do mapeamento a cores do fluxo, sendo possível identificar com precisão a distribuição e a extensão do refluxo venoso , Dependendo da população estudada, a incidência de fontes de refluxo venoso superficial independentes do tronco das veias safenas pode variar de 10 a 43% ,- As principais fontes de refluxo independentes das veias safenas que devem ser pesquisadas são veias tributárias do arco posterior de perna, veias acessórias da coxa, veias da região inguinal (vulvares e glúteas), veias perfurantes na face lateral e posterior (veias do nervo ciático) de coxa e veias perfurantes na face medial, lateral e posterior (veia da fossa poplítea) do joelho e perna  O nosso estudo focou somente nas veias perfurantes independentes das veias safenas e identificou veias perfurantes na coxa, joelho e perna em 5,1%, 2,3% e 92,6% dos membros avaliados, respectivamente.  Com relação às veias perfurantes na coxa, no nosso estudo a grande maioria  era insuficiente e 58,3% localizadas na região lateral da coxa. Gianesini et al.  No nosso estudo, foram identificadas somente sete  veias perfurantes na região posterior do joelho. Da mesma forma, Delis et al.  A maioria  das veias perfurantes no nosso estudo foi identificada na perna, sendo 65% na região medial da perna, cuja função principal foi de drenar refluxo de veias tributárias. Somente 22% das veias perfurantes na perna apresentaram refluxo para veias tributárias. É importante destacar que veias perfurantes competentes com calibres inferiores a 3 mm foram excluídas do estudo por não apresentarem relevância clínica e serem de difícil detecção no exame físico.  Labropoulos et al.  Sandri et al.  No nosso estudo, considerando somente as veias perfurantes com refluxo na coxa, joelho e perna (25%) o calibre médio foi de 3,6 mm, 3,8 mm e 2,9 mm, respectivamente. Independentemente da localização, o calibre das veias perfurantes com refluxo variou entre 2 e 6,3 mm, com calibre médio de 3,5 mm, semelhante ao estudo de Sandri et al.  Os autores concluem que as veias perfurantes independentes das veias safenas são mais frequentes na perna, drenando refluxo de veias tributárias. Independentemente da localização, as veias perfurantes com refluxo apresentam calibre médio de 3,5 mm.