Curso de investigación en Atención Primaria de la Salud: experiencia sobre módulo de búsqueda bibliográfica y gestores de citas / Research course in Primary Health Care: experience with the bibliographic search module and citation managers

La Federación Argentina de Medicina Familiar y General apoyó el desarrollo, la difusión y la implementación de una propuesta educativa sobre investigación en atención primaria. Consiste en 4 módulos independientes, destinado para miembros interesados/as, con 2 encuentros virtuales teórico-prácticos, que favorecieran el intercambio de opiniones y experiencias entre colegas. El objetivo del primer módulo fue proporcionar conocimiento, brindar pautas y ofrecer herramientas para la búsqueda bibliográfica y el uso de gestores de citas. Se realizó difusión mediante sociedades y redes sociales. Se incluyó una evaluación individual, que diera cuenta de lectura complementaria y la aplicación práctica de los contenidos. Se llevó a cabo en Junio, con 39 preinscripto/as, mayoritariamente residentes. Hubo 24 participantes efectivos (61%), asistieron 17 y 20 personas respectivamente, y 11 (46%) obtuvieron el certificado de aprobación por responder la consigna en tiempo y forma. En cuanto a los/as asistentes, hubo predominio de mujeres (79%), provenientes de Asociación Metropolitana de Medicina Familiar (25%), Asociación Cordobesa de Medicina Familiar y Comunitaria (16%), Asociación Misionera de Medicina General/Familiar y del Equipo de Salud (16%), Asociación Tucumana de Medicina Familiar, General y Comunitaria (12%), y otras minorías. Expresaron satisfacción, agradecimiento y reconocimiento por la actividad, destacando la buena predisposición de organizadores y equipo docente, la utilidad práctica de la temática, la evidente planificación, y el apoyo político-económico. Esta valiosa experiencia educativa (planteada como necesidad pendiente) resultó exitosa, ya que los/as participantes demostraron un alto nivel de interés, de asistencia de diferentes provincias, y de compromiso. Los certificados emitidos otorgan créditos educativos válidos para la recertificación (AU)

The Federación Argentina de Medicina Familiar y General supported the development, dissemination and implementation of an educational proposal on research in primary care. It consists of 4 independent modules, intended for interested members, with 2 virtual theoretical-practical meetings, which favored the exchange of opinions and experiences among colleagues. The objective of the first module was to provide knowledge, guidelines and tools for bibliographic search and the use of citation managers. Dissemination was carried out through societies and social networks. An individual evaluation was included, to account for complementary reading and the practical application of the contents. It was carried out in June, with 39 pre-registered participants, mostly residents. There were 24 effective participants (61%), 17 and 20 people attended respectively, and 11 (46%) obtained the certificate of approval for answering the instructions in due time and form. As for the attendees, there was a predominance of women (79%), coming from Asociación Metropolitana de Medicina Familiar (25%), Asociación Cordobesa de Medicina Familiar y Comunitaria (16%), Asociación Misionera de Medicina General/Familiar y del Equipo de Salud (16%), Asociación Tucumana de Medicina Familiar, General y Comunitaria (12%), and other minorities. They expressed satisfaction, gratitude, and recognition for the activity, highlighting the good predisposition of the organizers and teaching team, the practical usefulness of the subject matter, the evident planning, and the political-economic support. This valuable educational experience (raised as a pending need) was successful since the participants showed a high level of interest, attendance from different provinces, and commitment. The certificates issued grant educational credits valid for recertification (AU)

Teoría de la complejidad y los sistemas de salud / Complexity theory and health systems

En la investigación en salud es todavía poco frecuente el uso de la Teoría de la Complejidad y de la Fractalidad (más aún en tópicos no relacionados directamente con la biología molecular o con la clínica). La complejidad nos propone complementar con propuestas desde nuevas perspectivas el pensamiento lineal y cuantitativo predominante todavía en la metodología de producción del conocimiento científico. El estudio de los sistemas de salud necesita un enfoque que se aparte de la linealidad, lo rígido y lo direccional, dado que los mismos son sistemas complejos en los que el todo es más que la simple suma de sus partes. La crisis global generada ante la pandemia por COVID-19 nos puso frente a la oportunidad (y a la obligación) de repensar tanto nuestra praxis cotidiana como nuestra forma de producir conocimiento (AU)

In health research, the use of the Complexity and Fractality Theory is still infrequent (even more so in topics not directly related to molecular or clinical biology). The complexity proposes us to complement with proposals from new perspectives the linear and quantitative thinking still predominant in the methodology of production of scientific knowledge. The study of health systems needs an approach that moves away from linearity, rigidity and direction, since they are complex systems in which the whole is more than the simple sum of its parts. The global crisis generated by the COVID-19 pandemic presented us with the opportunity (and the obligation) to rethink both our daily praxis and our way of producing knowledge (AU)

Design and implementation of a modular pulse wave preprocessing and analysis system based on a new detection algorithm / 生物医学工程学杂志

As one of the standard electrophysiological signals in the human body, the photoplethysmography contains detailed information about the blood microcirculation and has been commonly used in various medical scenarios, where the accurate detection of the pulse waveform and quantification of its morphological characteristics are essential steps. In this paper, a modular pulse wave preprocessing and analysis system is developed based on the principles of design patterns. The system designs each part of the preprocessing and analysis process as independent functional modules to be compatible and reusable. In addition, the detection process of the pulse waveform is improved, and a new waveform detection algorithm composed of screening-checking-deciding is proposed. It is verified that the algorithm has a practical design for each module, high accuracy of waveform recognition and high anti-interference capability. The modular pulse wave preprocessing and analysis software system developed in this paper can meet the individual preprocessing requirements for various pulse wave application studies under different platforms. The proposed novel algorithm with high accuracy also provides a new idea for the pulse wave analysis process.

20 anos da comissão consultiva em avaliação psicológica: desafios da ADI 3481 / 20 years of the advisory committee on psychological assessment: challenges of ADI 3481 / 20 años de la comisión consultiva en evaluación psicológica: desafíos de la ADI 3481

A Comissão Consultiva em Avaliação Psicológica (CCAP) do Conselho Federal de Psicologia (CFP), em seu 20º aniversário, vem discutir os possíveis efeitos, ainda efetivamente desconhecidos, da Ação Direta de Inconstitucionalidade (ADI) 3481, instruída no Supremo Tribunal Federal (STF), a qual desestruturou o modo como os testes psicológicos eram comercializados no Brasil. A livre comercialização de testes psicológicos coloca em risco a segurança de avaliações psicológicas e cabe à categoria profissional pensar estratégias de enfrentamento desses riscos. Neste artigo, são discutidos possíveis efeitos da ADI 3481 para a categoria profissional da psicologia, bem como para a sociedade em geral, e são também elencadas possíveis estratégias de enfrentamento desses riscos, sem desconsiderar aspectos éticos relacionados a eles. Dessa forma, busca-se neste manuscrito, além da problematização dos efeitos derivados da ADI 3481, pensar soluções ou alternativas que venham a redirecionar a trajetória da área da avaliação psicológica no Brasil. Com isso, abre-se um espaço de discussão e encaminhamentos que a categoria profissional precisará tomar nos próximos anos.(AU)

The Advisory Commission for Psychological Assessment of the Federal Council of Psychology discusses, on its 20th anniversary, the possible and still effectively unknown effects of the Direct Action of Unconstitutionality (DAU) 3481, following the Supreme Federal Court, which interrupted how psychological tests were marketed in Brazil. The free trade of psychological tests puts the safety of psychological assessments at risk, and this professional category must think of strategies to face these risks. This study discusses the possible effects of DAU 3481 for professional psychology and for society in general, listing possible strategies for coping with these risks without disregarding its ethical aspects. Thus, this study seeks to problematize the effects derived from DAU 3481 and think of solutions or alternatives that may redirect the trajectory of the field of psychological assessment in Brazil, thus opening a space for discussion and referrals professional psychology will require in the coming years.(AU)

La Comisión Consultiva en Evaluación Psicológica (CCEP) del Consejo Federal de Psicología (CFP), en su 20.º aniversario, propone discutir los posibles efectos aún efectivamente desconocidos de la Acción Directa de Inconstitucionalidad (ADI) 3481, determinada por el Supremo Tribunal Federal (STF), por la cual trastornó la forma de comercializar las pruebas psicológicas en Brasil. La comercialización sin restricciones de las pruebas psicológicas pone en riesgo la seguridad de las evaluaciones psicológicas, y le corresponde a la categoría profesional pensar estrategias para enfrentar estos riesgos. En este artículo se discuten los posibles efectos de la ADI 3481 para la categoría profesional de la Psicología, así como para la sociedad en general, pero también se enumeran posibles estrategias para el enfrentamiento de estos riesgos, sin descuidar los aspectos éticos relacionados con ellos. Así, este manuscrito busca, además de problematizar los efectos derivados de la ADI 3481, pensar en soluciones o alternativas que puedan reconducir la trayectoria del campo de la evaluación psicológica en Brasil. Esto abre un espacio de discusión y derivaciones que la categoría profesional deberá tomar en los próximos años.(AU)

Teoría de la complejidad en la atención del paciente con dolor musculoesquelético / Complexity theory in the management of patients with musculoskeletal pain

Los sistemas no lineales no son susceptibles de ser investigados con métodos reduccionistas. En este sentido, la teoría de la complejidad ofrece un enfoque alternativo para cuantificar la importancia de los factores contextuales en el paciente con dolor musculoesquelético. El resultado del uso positivo (placebo) o negativo (nocebo) de factores contextuales en el entorno terapéutico, podría ser responsable de gran parte de un componente inespecífico en la eficacia del tratamiento, afectando directamente la calidad de los resultados relacionados con la salud del paciente (por ejemplo, dolor, funcionalidad o satisfacción). En los últimos años, se ha incrementado la comprensión del valor de estos efectos. A pesar del creciente interés, el conocimiento y el reconocimiento de los efectos terapéuticos, continúan siendo limitados y heterogéneos entre los fisioterapeutas, lo cual reduce su valor traslacional en el campo de la fisioterapia. El propósito de este estudio es presentar el abordaje el paciente con dolor musculoesquelético desde la perspectiva la teoría de la complejidad.

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients' health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Normalization by second order graphs: A visual alternative to simplify systems / Normalización mediante grafos de Segundo orden: una alternativa visual para simplificar sistemas

Abstract This issue stems from the need for tools to analyze and make decisions around complex systems, where they apply the rules for linearly dependent sets, with the purpose of providing a visual tool, which serves to support complexity reduction processes. Two great precedents are Armstrong's Axioms, which has been applied from its publication to the present for database normalization, the other is set theory, a fundamental pillar of the Structured Query Language; based on them, together with the second-order logic, which adds qualifiers for subsets or properties, this work has been prepared, with an explanatory metrology with a qualitative approach, in an axiomatic system. As a result, a support tool has been provided to analyze complex systems naturally, by breaking cycles and detecting patterns, without interfering with existing models; however, for large systems it can be difficult to address it in its entirety, so it is recommended to divide by subsystems. With this work a technique has been accomplished, repeatable by anyone, but with a strong theoretical foundation. This work has great utility for the normalization of relational databases and an enormous potential for application in the design of systems beyond computational systems, it is also useful for understanding dependencies by their axiomatic nature.

Resumen Este tema nace de la necesidad de herramientas para analizar y tomar decisiones en torno a sistemas complejos, donde apliquen las reglas para conjuntos linealmente dependientes, con el fin de proporcionar una herramienta visual, que sirva de apoyo a procesos de reducción de la complejidad. Dos grandes precedentes son los Axiomas de W. Armstrong, el cual se ha aplicado desde su publicación hasta la actualidad para la normalización de bases de datos, el otro es la teoría de conjuntos, pilar fundamental del Lenguaje de Consultas Estructurado; en base a ellos, junto con la lógica de segundo orden, la cual añade cualificadores para subconjuntos o propiedades se ha elaborado este trabajo, con una metrología explicativa con enfoque cualitativo, en un sistema axiomático. Como resultado se ha proporciona una herramienta de soporte para analizar sistemas complejos de forma natural, rompiendo ciclos y detectando patrones, sin interferir con los modelos existentes; sin embargo, para sistemas de gran tamaño puede ser difícil abordarlo en su totalidad, por lo que se recomienda dividir por subsistemas. Con este trabajo se ha consumado una técnica, repetible por cualquiera, pero con fuerte fundamento teórico. Este trabajo tiene gran utilidad para la normalización de bases de datos relacionales y un enorme potencial de aplicación en el diseño de sistemas más allá de los sistemas computacionales, también resulta útil para la comprensión de dependencias por su naturaleza axiomática.

Death and Complexity / Muerte y complejidad / Morte e complexidade

Abstract: There is no such thing as a science of death, although there is a science of life, as it happens. Death is not so much the subject matter of science but an experience, and death experiences we find abundantly in the literature. Now, experience is told not so much in a scientific tenure but as a narrative. Within the framework of bioethics, death comes closer, particularly what is usually known as end-of-life dilemmas, i.e., palliative care, a most sensitive arena, if there is any at all. This paper argues about the interplay or dialogue between death and complexity science. It claims that the knowledge of death is truly the knowledge of life and provides three arguments that lead to the central claim. The first argument is very much close to a kind of heuristic for knowing about death, while the second shows the challenge of knowing death. The third one consists of a reappraisal of death within an extensive cultural or civilizing framework. Lastly, some open-ended conclusions are drawn.

Resumen: No existe cosa tal como una ciencia de la muerte, sin embargo si existe una ciencia de la vida, por suerte. La muerte no se trata de un asunto de ciencia sino de una experiencia, y experiencias de muerte abundan en la literatura. De hecho, la experiencia se cuenta no tanto en un tono científico sino más bien como una narrativa. Dentro del marco de la bioética, la muerte se aborda de una manera más cercana, particularmente en los que se conocen como dilemas del fin de la vida, por ejemplo, el cuidado paliativo, una arena muy sensible, si es que la hay. Este artículo discute sobre la interacción o el diálogo entre la muerte y la ciencia de la complejidad. Afirma que el conocimiento de la muerte en verdad es el conocimiento de la vida y da tres argumentos que llevan a esta afirmación central. El primer argumento es muy cercano a un tipo de heurística por conocer acerca de la muerte, mientras que el segundo expone el reto de conocer la muerte. El tercero consiste en una revaluación de la muerte dentro de un amplio marco cultural o civilizador. Por último, se esbozan algunas conclusiones abiertas.

Resumo: Não existe uma ciência da morte como tal, contudo sim existe uma ciência da vida. A morte não se trata de um assunto de ciência, mas sim de uma experiência, e experiências de morte abundam na literatura. De fato, a experiência se conta não tanto em um tom científico, mas sim como uma narrativa. No âmbito da bioética, a morte é abordada de uma maneira mais íntima, particularmente no que se conhece como "dilemas do fim da vida", por exemplo, no cuidado paliativo, uma arena muito sensível, sim é que a há. Neste artigo, discute-se sobre a interação ou o diálogo entre a morte e a ciência da complexidade. Afirma-se que o conhecimento da morte em verdade é o conhecimento da vida e são apresentados três argumentos que levam a essa afirmação central. O primeiro argumento é muito próximo de um tipo de heurística por conhecer sobre a morte, enquanto o segundo expõe o desafio de conhecer a morte. O terceiro consiste em uma reavaliação da morte dentro de um amplo referencial cultural ou civilizador. Por último, são esboçadas algumas conclusões abertas.

Insights into vaccine hesitancy from systems thinking, Rwanda

Objective To investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors. Methods Local immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff ); interviews with 161 children's caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed. Findings/ A comparison of service providers' and caregivers' perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake. Conclusion The application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers' vaccination behaviour. Confidencebuilding social structures and context-dependent challenges that affect vaccine uptake were also identified.

Complexity, Basis of the Epistemological and Ontological Approach for the Development of General Job Competences / La complejidad: base del enfoque epistemológico y ontológico para el desarrollo de competencias laborales generales

RESUMEN Las competencias laborales generales (CLG) como aspectos asociados a la productividad y la competitividad buscan la formación de personas que emprendan proyectos de vida que les posibilite desempeñarse con éxito en su quehacer laboral, por ello estas competencias preparan a los jóvenes en la responsabilidad de ser productivos para sí mismos y para los demás, en atención a los retos sociales, económicos, culturales y tecnológicos. Lo anterior exige el reconocimiento de bases epistémicas y ontológicas para la generación y el desarrollo de esa competencia. Este artículo realiza un acercamiento a estas bases y explica las relaciones ante el nuevo paradigma de la complejidad, brinda cuatro postulados en los que se explica por qué la formación en CLG exige una mirada no mecanicista, ni reduccionista, ni fragmentada, que permita comprender la formación y dar nuevas pistas ante las reducidas miradas de educación en los territorios.

ABSTRACT The General Job Competencies (GJC), as aspects associated with productivity and competitiveness, seek to train people to undertake life projects that enable them to perform successfully in their work tasks. For this reason, these competencies prepare young people in the responsibility of being productive for themselves and for others; taking into account social, economic, cultural, and technological challenges. This requires the recognition of epistemic and ontological bases for the generation and development of these competencies. This article makes an approach to these bases, explaining the relationships in the face of the new paradigm of complexity, and provides four postulates where it is explained why training at GJC requires a non-mechanistic, reductionist, or fragmented view that allows for an understanding of the training, and for giving new clues to the reduced views of education in the territories.

Indicadores estratégicos em saúde pública / Strategic indicators in public health

O Relatório anual da Organização Mundial de Saúde (OMS) teve como foco, no ano de 2000, a discussão de modelos de análise de sistemas de saúde ao redor do mundo. O documento propõe que todo sistema de saúde deve ter como objetivo fundamental a promoção da melhoria da saúde das pessoas, mas ao mesmo tempo ser justo nos gastos orçamentários e responsivo às demandas da população (WHO, 2020). Para atingir estes objetivos, torna-se crucial o conceito de performance, ou seja, como executar essas ações com os recursos disponíveis com o máximo desempenho, também entendido como eficiência, ou seja, a relação entre o produto da intervenção de saúde e os recursos utilizados (ALBUQUERQUE et al, 2017).

The Annual Report of the World Health Organization (WHO) focused, in 2000, on the discussion of models of analysis of health systems around the world. The document proposes that every health system should have as its fundamental objective the promotion of improving people's health, but at the same time be fair in budget expenditures and responsive to the demands of the population (WHO, 2020). To achieve these objectives, the concept of performance becomes crucial, that is, how to perform these actions with the available resources with maximum performance, also understood as efficiency, that is, the relationship between the product of the health intervention and the resources used (ALBUQUERQUE et al, 2017)

System dynamics modeling for tooth decay treatment in Brazilian children

Abstract Prevention and health promotion are considered important strategies to control oral diseases. Dental caries is preventable disease and remains the most common chronic disease that affects mainly low income children and still considered the main cause of tooth loss in adulthood in Brazil. The aim of this study is to present a System Dynamics model (SDM) specifically developed with the Stella Architect software to estimate the cost and clinical hours required to control the evolution of dental caries in preschool children in Maringá, Brazil. Two main strategies to control caries were considered in the model: the application of fluoride varnish on teeth presenting white spots, and the use of Atraumatic Restorative Treatment (ART) in cavitated carious lesions without pulp involvement. The parameters used in the model were: number of people covered by a local oral health team = 4,000; number of children up to 5 years = 7% of the population; children's decayed, missing, filled teeth (dmft) index = 2.4; time/cost of 4 applications of fluoride varnish = 5 minutes/US$ 0.716; and time/cost of each ART restoration = 15 minutes/US$ 1.475. The SDM generated an estimated total cost of US$698.00, and a total of 112 clinical hours to treat the population in question. The use of the SDM presented here has the potential to assist decision making by measuring the material and human resources required to prevent and control dental caries at an early age.

Elucidation of the pathophysiology of intradialytic muscle cramps: pharmacokinetics applied to translational research

In the conventional concept of translational research, investigations flow from the laboratory bench to the bedside. However, clinical research can also serve as the starting point for subsequent laboratory investigations that then lead back to the bedside. This article chronicles the evolution of a series of studies in which a detailed analysis of pharmacokinetics in hemodialysis patients revealed new physiological insight that, through a systems approach incorporating kinetic, physicochemical, physiologic, and clinical trial results, led to an elucidation of the pathophysiology of intradialytic skeletal muscle cramps. Based on this understanding, a therapeutic path forward is proposed.

Notas sobre redes, Estado e políticas públicas / Notes on networks, the State, and public policies / Notas sobre redes, Estado y políticas públicas

Resumo: Esse artigo apresenta sucintamente e problematiza a utilização da análise de redes sociais como método para a investigação de políticas públicas. Amplamente disseminada a partir dos anos 1970, a análise de redes permite o estudo das políticas com a consideração simultânea dos vários atores que influenciam a produção de políticas. A matriz pluralista da literatura de policy networks, entretanto, a distancia das premissas da sociologia relacional e dificulta a utilização da perspectiva para casos como o brasileiro, marcado pela multiplicidade de atores estatais e societais conectados por diversos tipos de vínculo, com destaque para os informais. Essas particularidades podem ser solucionadas com a articulação de categorias desenvolvidas recentemente como tecido relacional do Estado e governança, desde que devidamente integradas à análise. O quadro conceitual resultante representa uma ferramenta poderosa para a compreensão da influência de padrões relacionais sobre a produção de políticas públicas.

Abstract: This article briefly presents and analyzes the use of social network analysis as a method for studying public policies. Widely disseminated since the 1970s, network analysis allows the study of policies with simultaneous consideration for the various stakeholders that influence policymaking. The pluralistic matrix of the policy networks literature and the difference with the premises of relational sociology hinder the use of the approach for cases like Brazil, marked by the multiplicity of state and civil society actors with various types of links, especially informal ones. These specificities can be solved by linking the categories developed recently as the relational fabric for the state and governance, as long as properly integrated into the analysis. The resulting conceptual framework is a powerful tool for understanding the influence of relational patterns on the production of public policies.

Resumen: Este artículo presenta sucintamente y problematiza la utilización del análisis de redes sociales como método para la investigación de políticas públicas. Ampliamente difundido a partir de los años 1970, el análisis de redes permite el estudio de políticas con la consideración simultánea de los varios actores que influencian la producción de políticas. La matriz pluralista de la literatura sobre policy networks, no obstante, la aleja de las premisas de la sociología relacional y dificulta su utilización para casos como el brasileño, marcado por la multiplicidad de actores estatales y societarios interrelacionados por diversos tipos de vínculos, destacando los informales. Estas particularidades se pueden solucionar con la coordinación de categorías desarrolladas recientemente como el tejido relacional del estado y su gobernanza, siempre que estén debidamente integrados en el análisis. El marco conceptual resultante representa una poderosa herramienta para la comprensión de la influencia de patrones relacionales en la generación de políticas públicas.

Complejidad y bioética: complejidad como marco de la bioética global / Complexity and Bioethics: Complexity as a Framework for Global Bioethics / Complexidade e bioética: complexidade como referencial da bioética global

Resumen El propósito de este trabajo es revisar las limitaciones que existen en la visión actual de la bioética para enfrentar los desafíos que plantea la sociedad del riesgo tecnocientífico frente a la vida. En este sentido, se elaboró un estudio de tipo exploratorio cuya perspectiva de abordaje del problema de estudio se sustenta en la complejidad, y cuya metodología se corresponde con una revisión narrativa acerca de los temas señalados. Para esto se realiza una revisión general de los conceptos relacionados con bioética global y complejidad a la luz de los textos analizados, se muestran las restricciones de la perspectiva actual, se establecen los criterios esenciales para el desarrollo de una perspectiva compleja de los fenómenos y, bajo estas condiciones, se propone trabajar la complejidad como un elemento central para fundamentar la bioética global. En el texto se presentan varias reflexiones en relación con la pertinencia de esta visión de la bioética global a fin de aproximarse al fenómeno de la vida.

Abstract The purpose of this paper is to review the limitations in the current view of bioethics to face the challenges posed by the techno-scientific risk society to life. We conducted an exploratory study whose approach to the research problem is supported by complexity and whose methodology is a narrative review of such topics. For this purpose, an overview of the concepts related to global bioethics and complexity is made in light of the texts analyzed, the restrictions of the current perspective are shown, and the essential criteria to develop a complex perspective of phenomena are determined. Under these conditions, we propose to treat complexity as a central element to substantiate global bioethics. The article presents several reflections on the relevance of this view of global bioethics to tackle the phenomenon of life.

Resumo O propósito deste trabalho é revisar as limitações existentes na visão atual da bioética para enfrentar os desafios que a sociedade do risco tecnocientífico propõe ante a vida. Nesse sentido, elaborou-se um estudo de tipo exploratório, cuja perspectiva de abordagem do problema de estudo está sustentada nas ciências da complexidade e cuja metodologia utilizada é uma revisão narrativa a respeito dos temas assinalados. Para isso, faz-se uma revisão geral dos conceitos relacionados com a bioética global e com a complexidade à luz dos textos analisados; apresentam-se as restrições da perspectiva atual, estabelecem-se os critérios essenciais para o desenvolvimento de uma perspectiva complexa dos fenômenos e, com essas condições, propõe-se trabalhar a complexidade como um elemento central para fundamentar a bioética global. O texto apresenta várias reflexões sobre a relevância dessa visão da bioética global para aproximar-se do fenômeno da vida.

Aplicación de algunos conceptos de la teoría de la complejidad a los procesos de salud-enfermedad en atención primaria / Applicability of some concepts of complexity theory to health-disease processes in primary care

El proceso de atención de un paciente y/o de su familia puede implicar una única consulta o bien una prolongada interac-ción entre dicho usuario ­y/o sistema de usuarios- y al menos, algún profesional de la salud. Podemos pensar a una persona, su familia, su entorno ampliado y su interacción con el sistema de salud, como un sis-tema complejo en un punto de su trayectoria.El autor de este ensayo reflexiona sobre la potencial aplicabilidad de algunos conceptos de la teoría de la complejidad a la comprensión de los procesos de salud-enfermedad en atención primaria y las limitaciones actuales para el desarrollo y la aplicación de las tecnologías que pudieran derivarse de este cuerpo teórico. (AU)

The process of patient and/or family care may involve a single consultation or a prolonged interaction between the user -and/or system of users -and at least one health professional.We can think of a person, his family, his extended context and his interaction with the health system, as a complex system at a point in his trajectory.The author of this essay reflects on the potential applicability of some concepts of complexity theory to the understanding of health-disease processes in primary care and the current limitations for the development and application of technologies that may arise from this theoretical body. (AU)

Diagnostic methodology of cardiac dynamics based on the Zipf-Mandelbrot law: evaluation with 50 patients / Metodología diagnóstica de la dinámica cardiaca basada en ley de Zipf-Mandelbrot: evaluación con 50 pacientes

Abstract: Objective: Zipf-Mandelbrot law has been used to assess the complexity of cardiac systems. The objective of this work is to corroborate the clinical applicability of a diagnostic methodology developed from Zipf-Mandelbrot law, in the differentiation of normality and acute cardiac disease. Material and methods: there were taken 50 continuous electrocardiographic Holter monitoring records, 20 normal and 30 with acute alterations of the cardiac dynamics. The frequencies of occurrence of heart rates in ranges of 15 lat/min were organized hierarchically to demonstrate the hyperbolic behavior of dynamics and to apply the Zipf-Mandelbrot law. A linearization was performed and the statistical fractal dimension of each dynamic was obtained, giving rise to the mathematical diagnosis. Sensitivity, specificity and Kappa coefficient were calculated. Results: The values of the statistical fractal dimension of the acute cardiac dynamics were between 0.7123 and 0.9327, whereas for the normal dynamics were found between 0.4253 and 0.6698, evidencing quantitative differences between states of normality and disease. Sensitivity and specificity values of 100% were found and the kappa coefficient was 1. Conclusions: The clinical and diagnostic utility of the mathematical methodology based on Zipf-Mandelbrot law was verified, observing a decrease of dynamics complexity in cases of acute heart disease.(AU)

Resumen: Objetivo: La ley de Zipf-Mandelbrot ha sido utilizada con el fin de evaluar la complejidad de los sistemas cardiacos. El objetivo de este trabajo es corroborar la aplicabilidad clínica de una metodología diagnóstica desarrollada a partir de la ley de Zipf-Mandelbrot, en la diferenciación de normalidad y enfermedad cardiaca aguda. Material y métodos: Se tomaron 50 Holter cardiacos (monitoreo electrocardiográfico continuo ambulatorio), 20 normales y 30 con alteraciones agudas de la dinámica cardiaca. Se organizaron jerárquicamente las frecuencias de aparición de frecuencias cardiacas en rangos de a 15 lat/min, para evidenciar el comportamiento hiperbólico de las dinámicas y aplicar la ley de Zipf-Mandelbrot. Se realizó una linealización y se obtuvo la dimensión fractal estadística de cada dinámica, dando lugar al diagnóstico matemático. Fueron calculadas la sensibilidad, especificidad y el coeficiente Kappa. Resultados: Los valores de la dimensión fractal estadística de las dinámicas cardiacas agudas se encontraron entre 0.7123 y 0.9327, mientras que para las dinámicas normales se hallaron entre 0.4253 y 0.6698, evidenciando diferencias cuantitativas entre estados de normalidad y enfermedad. Se encontraron valores de sensibilidad y especificidad del 100% y el coeficiente kappa fue de 1. Conclusiones: Fue comprobada la utilidad clínica y diagnóstica de la metodología matemática basada en la ley de Zipf-Mandelbrot, observando un decremento de la complejidad de la dinámica en casos de enfermedad cardiaca aguda.(AU)

La eutanasia y la medicalización de la muerte desde una perspectiva jurídica compleja / Euthanasia and the medicalization of death from a complex juridical perspective / A eutanásia e a medicalização da morte a partir de uma perspectiva jurídica complexa

Resumen Este trabajo trata el fenómeno de la medicalización de la vida relacionado con el fin de esta; esboza, además, vínculos con el derecho a través de la juridización de la salud, y así incorpora como resultado este término. Se hace hincapié en un caso actual sobre retiro del soporte vital y se relaciona con la ley de derechos del paciente, fallos, legislación extranjera y doctrina médica, bioética y jurídica. El marco teórico es el del pensamiento complejo de Edgar Morin y la teoría trialista del mundo jurídico. El aporte se centra en el tratamiento complejo y trialista del fenómeno de la medicalización de la muerte. En cuanto a la metodología, se plantea la cualitativa, estudiando casos reflejados en fallos, y analizando su discurso. El tema permite tratar problemas de teoría general del derecho como el vacío legislativo y el papel del juez. Se concluye provisoriamente que Argentina tiene una cultura juridizadora, a pesar de la ley que contempla la llamada muerte digna.

Abstract The paper deals with the phenomenon of the medicalization of life, related to the end of it, outlining links with the law through the legalization of health, and thus incorporates this term as a result. It focuses on a current case of withdrawal of life support and it's related to the patient's rights law, judgments, international legislation, and medical, bioethical and legal doctrine. The theoretical framework is the complex thought of Edgar Morin and the trialist theory of the legal world. The contribution focuses on the complex and trialist treatment of the phenomenon of the medicalization of death. As for the methodology, the qualitative one is raised, studying cases reflected in failures, and analyzing its speech. The subject allows dealing with problems of general theory of law such as the legislative vacuum and the role of the judge. It is provisionally concluded that Argentina has a legal culture, despite the law that includes for the so-called dignified death.

Resumo Este trabalho trata o fenómeno da medicalização da vida relacionado com o fim dela; ele também descreve os laços com o direito através da juridicização da saúde, e assim incorpora esse termo como resultado. Faz-se ênfase em um caso atual sobre a retirada do suporte vital e está relacionado com a lei dos direitos do paciente, falhas, legislação estrangeira e doutrina médica, bioética e jurídica. O quadro teórico é o do pensamento complexo de Edgar Morin e a teoria trialista do mundo jurídico. A contribuição centra-se no tratamento complexo e trialista do fenómeno da medicalização da morte. Quanto à metodologia, apresenta-se a qualitativa, estudando casos refletidos em falhos e analisando seu discurso. O tema permite lidar com problemas de teoria geral do direito, como o vácuo legislativo e o papel do juiz. Conclui-se provisoriamente que a Argentina tem uma cultura juridicizadora, apesar da lei que prevê a chamada morte digna.

Saturación en los servicios de urgencias: Análisis de cuatro hospitales de Medellín y simulación de estrategias / Emergency Department Overcrowding: A Four-Hospital Analysis in Medellín and a Strategy Simulation / Saturação nos serviços de urgência: Análise de quatro hospitais de Medellín e simulação de estratégias

Resumen Las urgencias médicas pueden saturarse debido a factores externos e internos al servicio. Esto se refleja en congestión, tiempos de espera elevados e insatisfacción de los usuarios. Identificar y simular estrategias para gestionar las urgencias médicas, procurando atenuar la saturación. Investigación exploratoria y analítica, con trabajo de campo en cuatro unidades de urgencias de Medellín y simulación de estrategias contra la saturación mediante dinámica de sistemas. Las estrategias utilizadas son: reorganizar el registro, remitir los pacientes que no requieren atención urgente, implementar consultorio fast-track e incrementar el traslado a pisos. Esta última es la estrategia más efectiva en la simulación. Aunque las estrategias de flujo pueden ayudar a resolver la saturación a partir de sus causas internas, como lo sugiere la literatura, su alcance es limitado. Se requieren estrategias de entrada, que no están al alcance del servicio, y estrategias de salida del sistema hospitalario. Es posible disminuir la saturación, concibiendo las urgencias y el hospital como dos elementos de un mismo sistema, de modo que se agilice el flujo de pacientes y se cuente con oferta adecuada de camas hospitalarias sin sobredimensionar la capacidad instalada.

Abstract Medical emergency services can be overcrowded due to both external and internal service factors. This is evinced in the congestion, longer waits, and dissatisfaction by the users. To identify and simulate strategies for processing medical emergency requests in order to mitigate the overcrowding. An exploratory and analytical research was conducted based on the field work at four emergency rooms in hospitals of Medellín; simulation strategies were then proposed against the overcrowded service with system dynamics. The strategies included: to reorganize the sign-in, refer to other places those patient not requiring emergency services, implement fast-track services, and increase the inpatient capacity. The last one becomes the most effective strategy in the simulation. While the flow strategies can help to solve the service overcrowding due to internal causes as suggested in the literature, these strategies are limited in their scope. The required patient sign-in strategies as well as the patient discharge strategies are not easy-to-do in these emergency rooms. Overcrowding can be reduced by thinking of the hospital and the emergency room as two elements in a single system, so that the patient flow can be speeded up; the bed number for inpatients must be improved without overflowing the hospital capacity.

Resumo As urgências médicas podem se saturar devido a fatores externos e internos ao serviço. Isso se reflete em congestão, tempos de espera elevados e insatisfação dos usuários. Identificar e simular estratégias para gerir as urgências médicas, procurando atenuar a saturação. Pesquisa exploratória e analítica, com trabalho de campo em quatro unidades de urgências de Medellín e simulação de estratégias contra a saturação mediante dinâmica de sistemas. As estratégias utilizadas são: reorganizar o cadastro, reencaminhar os pacientes que não precisam atendimento urgente, implementar clínica ambulatória fast-track e facilitar o traslado aos quartos. Esta última é a estratégia mais efetiva na simulação. Ainda que as estratégias de fluxo possam ajudar a resolver a saturação a partir de suas causas internas, como sugere a literatura, seu escopo é limitado. Precisam-se estratégias de entrada, que no estão dentro do escopo do serviço e estratégias de saída do sistema hospitalar. Conclusões: é possível diminuir a saturação, concebendo as urgências e o hospital como dois elementos de um mesmo sistema, de jeito de agilitar o fluxo de pacientes e contar com oferta adequada de leitos hospitalares sem superdimensionar a capacidade instalada.