Disposição para pagar uma intervenção para melhorar o controlo da hipertensão em hipertensos não controlados : um estudo-piloto

RESUMO - A valorização económica de intervenções preventivas pode contribuir para melhorar a afetação de recursos em saúde. A hipertensão, primeira causa de morte em Portugal, é um grave problema de saúde Pública e o principal fator de risco para a ocorrência de Acidente Vascular Cerebral (AVC). O presente estudo é um primeiro ensaio para quantificar a disposição para pagar (DPP) da sociedade por uma intervenção de promoção da adesão à terapêutica em hipertensos não controlados. Foi aplicado um questionário presencial a uma amostra de conveniência (n=93), numa perspetiva ex post, sendo o questionário constituído por dois formatos de questões e dois cenários de diferentes reduções de pressão arterial sistólica (cenário 1 corresponde à redução de 10 mmHg e cenário 2 à redução de 20 mmHg). O risco de AVC a 10 anos foi adaptado à idade e ao sexo de cada participante. Relativamente ao cenário 1, a DPP média foi de €25,87 e €33,93, dependendo do formato da questão (resposta aberta ou bidding game, respetivamente). Na questão de resposta aberta, 78,3% dos participantes estavam dispostos para pagar pela intervenção, no bidding game 75,6% dos participantes referiram estar dispostos para pagar pelo menos €10. No cenário 2, a DPP média foi de €26,81 e €34,79, dependendo se o formato da questão era do tipo resposta aberta ou bidding game, respetivamente. Na questão de resposta aberta, 84,3% dos participantes estavam dispostos para pagar pela intervenção, no bidding game 76,1% dos participantes referiram estar dispostos para pagar pelo menos €10. Ao contrário do bidding game, nas questões de resposta aberta verificou-se 25,8% e 24,7% de respostas “não sei”, para o cenário 1 e cenário 2 respetivamente, diretamente relacionada com a baixa escolaridade dos participantes (p=0,004). Também se verificou uma maior tendência para respostas às questões de bidding game com valores mais elevados, comparativamente às questões de resposta aberta. Identificaram-se duas variáveis explicativas para os valores DPP: o rendimento e a ocupação principal. A sensibilidade dos respondentes à magnitude dos ganhos em saúde foi verificada internamente em cada questionário (os participantes referiram DPP mais elevadas no cenário 2 relativamente ao cenário 1), no entanto, os participantes que beneficiariam mais da intervenção não demonstraram DPP superiores aos restantes. Para confirmar os efeitos identificados neste estudo e extrapolá-los para a população portuguesa é necessário realizar um estudo representativo de população portuguesa.

Electron driven reactions in sulphur containing biological prototypes

The interaction of ionising radiation with living tissues may direct or indirectly generate several secondary species with relevant genotoxic potential. Due to recent findings that electrons with energies below the ionisation threshold can effectively damage DNA, radiation-induced damage to biological systems has increasingly come under scrutiny. The exact physico-chemical processes that occur in the first stages of electron induced damage remain to be explained. However, it is also known that free electrons have a short lifetime in the physiological medium. Hence, electron transfer processes studies represent an alternative approach through which the role of "bound" electrons as a source of damage to biological tissues can be further explored. The thesis work consists of studying dissociative electron attachment (DEA) and electron transfer to taurine and thiaproline. DEA measurements were executed in Siedlce University with Prof. Janina Kopyra under COST action MP1002 (Nanoscale insights in ion beam cancer therapy). The electron transfer experiments were conducted in a crossed atom(potassium)-molecule beam arrangement. In these studies the anionic fragmentation patterns were obtained. The results of both mechanisms are shown to be significantly different, unveiling that the damaging potential of secondary electrons can be underestimated. In addition, sulphur atoms appear to strongly influence the dissociation process, demonstrating that certain reactions can be controlled by substitution of sulphur at specific molecular sites.

Do Comandante Supremo das Forças Armadas

The President of the Portuguese Republic’s relation with the Armed Forces in the current political system is not confined to the vast legislative and constitutional set. As Chief of State and Supreme Commander of the Armed Forces, the President holds different powers. We develop an approach through the main concepts and themes that regulate the Armed Forces and National Defense, focusing the relations that involve the President directly. The attribution by inherence of the Supreme Command of the Armed Forces to the Chief of State, imposes a peculiar relation with the remainder sovereign institutions. The need to analyze the intermediate services as far as military and defense issues are concerned becomes necessary, in particular the role of the Military Cabinet – as a structure of direct support – and the High Council of National Defense – as an advisory body.

Estratégias de classificação dos arquivos familiares e pessoais contemporâneos: o exemplo do arquivo da família Benito Maçãs

A presente dissertação aborda a problemática teórica e metodológica da classificação de arquivos familiares e pessoais. Centrando-se no arquivo da família Benito Maçãs, produzido entre o final do século XVIII e o início do século XXI, são analisadas algumas das tendências recentes da classificação destes arquivos, sobretudo as que demonstram a sobrevalorização do enfoque orgânico e informativo. Através da caraterização das circunstâncias de produção e utilização do referido fundo, do aprofundamento dos principais conceitos operatórios subjacentes à classificação arquivística, bem como da análise de modelos classificativos teóricos e práticos, este estudo procura compreender as metodologias para a contextualização de arquivos familiares e pessoais. Os resultados demonstram a inexequibilidade da aplicação normalizada de modelos teóricos ou de critérios pré-definidos na contextualização de arquivos familiares e pessoais. Revelam, ainda, que as metodologias para a observação dos contextos não devem sobrepor-se à realidade documental, nem às especificidades da entidade produtora.

A relação entre família e escola e a perspectiva de minimização das dificuldades comportamentais e cognitivas apresentadas por adolescentes com Síndrome do Alcoolismo Fetal (SAF): estudos de casos na cidade de Manaus

Dissertação de mestrado em Educação Especial (área de especialização em Dificuldades de Aprendizagem Específicas)

Outcome of long-axis percutaneous sacroplasty as first-line treatment of sacral insufficiency fractures : P219

Purpose: To assess the clinical outcome of patients who were subjected to long-axis sacroplasty as first line treatment for sacral insufficiency fractures. Methods and materials: Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of PMMA was delivered along the path of each sacral fracture. For each individual patient, the VAS pain score before sacroplasty and at 1, 4, 24, and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/non-narcotic) along with the evolution of post interventional patient mobility before and after sacroplasty was also recorded. Results: The mean pre-procedure VAS score was 8 ± 1.9. This has rapidly declined in the first week after the procedure (mean 4 ± 1.5) followed by gradual decrease along the rest of follow-up period at 4 weeks (mean 3 ± 1.2), 24 weeks (mean 2 ± 1.3), and 48 weeks (mean 1.3 ± 1.4), respectively. Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas, 8 (42%) patients were using non-narcotics. Corresponding values after the procedure were 2/19 (10%) (narcotic) and 10/19 53% (non-narcotic). Seven (37%) patients did not address post-procedure analgesic use. The evolution of post interventional mobility was favourable in the study group since they revealed a significant improvement in their mobility point scale. Conclusion: Long-axis percutaneous sacroplasty is a suitable minimally invasive treatment option for patients who present with sacral insufficiency fractures. Future studies with larger patient number are warranted to grasp any potential limitations of this therapeutic approach.

Cos i espiritualitat : in-corporant rituals i creences en les noves formes de religiositat

El fenomen de les noves religions posa de relleu la importància del cos i les emocions com a elements constitutius de la subjectivitat. En aquest treball s'estudia el procés de construcció de la identitat espiritual, a través de la in-corporació de nous valors i creences, i de la corporeïtzació dels rituals. Es parteix d'una aproximació etnogràfica, a través d'un treball de camp al sí d'un grup d'orientació oriental. A partir de l'observació participant i la celebració d'entrevistes, es proposa analitzar com es forja l'espiritualitat. En tant que experiència corporal, es posa de manifest la rellevància de les emocions en els processos d'interacció i socialització de la persona en un grup donat.

Reporting intellectual capital in Spain

This study reports on the analysis of annual reports from 14- listed companies in Spainover a five-year period, from 1998 to 2002. Companies in the sample are selected on thebasis of their knowledge-based assets and incentives to report on Intellectual Capital.The empirical analysis is twofold:1) Firstly, we analyse the value of intellectual capital using a value-based approach,through the difference between market and book value over the period considered. Results show that there is a general decrease in the 'hidden value' of these companies, probably due to the general trend in stock markets.2) Secondly, we carry out a content-based analysis of the complete annual reports of the companies over the five year period. Preliminary findings seem to suggest that although the level of disclosure has increased over time, this is mainly in the form of narrative. Overall, the level of disclosure of intellectual capital remains low.

Avaliação Externa de Escolas: Estudo Comparativo entre Portugal e Cabo Verde

A avaliação externa de escolas assumiu, nos últimos anos, uma grande centralidade nas políticas educativas e apercebemos que cada vez mais, se tornou uma exigência nos estabelecimentos de ensino. É nesta perspetiva que levamos a cabo uma investigação cuja preocupação central assenta na avaliação externa de escolas como nosso objeto de estudo, uma vez que, devido à pertinência atribuída pelas políticas educativas e sustentada nas boas práticas internacionais é considerada um gerador de mudança que contribui para a melhoria da aprendizagem dos alunos e para o desenvolvimento das instituições. Assim, optamos por realizar o trabalho segundo uma abordagem predominantemente qualitativa, através de um inquérito por entrevistas, com o propósito de obter dados que permitissem compreender e conhecer o modelo da avaliação externa de escolas, que, enquanto área de avaliação e de melhorias é assumida como uma das prioridades na educação, que caminha para o progresso das escolas, qualificando-as, com o objetivo de gerar impacto na melhoria dos resultados dos alunos. De uma forma global constatamos que nas últimas décadas, particularmente em Portugal, varias foram as iniciativas de avaliação de escolas e que a lei nº 31/2002, de 20 de dezembro, veio dar continuidade aos programas antes implementados, atribuindo-lhe um caráter obrigatório. Entretanto, Cabo Verde não dispõe de nenhum regulamento que estabeleça a obrigatoriedade da mesma, mas tendo consciência do impacto que a avaliação externa de escolas tem suscitado em muitos países europeus, a inspeção - geral da educação iniciou-se uma experiência em março de 2012, mas falta ainda fazer a revisão dos normativos que permitam regularizar este fenómeno, de modo a que se torne seja uma prática regularizada e consistente. De acordo com os argumentos dos entrevistados, os dados revelam-se que, a avaliação externa de escolas têm como finalidade a melhoria do sistema educativo e os efeitos nomeadamente a este nível são o desenvolvimento a nível institucional e profissional dos professores, a boa gestão pedagógica e ainda o de produzir uma cultura de autoavaliação nas escolas.

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures.

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/non-narcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8 +/- 1.9 (range, 2 to 10). This rapidly and significantly (P < 0.001) declined in the first week after the procedure (mean 4 +/- 1.4; range, 1 to 7) followed by a gradual and significant (P < 0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3 +/- 1.1; range, 1 to 5), 24 weeks (mean 2.2 +/- 1.1; range, 1 to 5) and 48 weeks (mean 1.6 +/- 1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using non-narcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P < 0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach.

Chirurgie endoscopique endonasale des tumeurs de la base du crane : historique, état de l'art et perspectives d'avenir [Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches].

During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.

Infirmier en psychiatrie de liaison : développement de la supervision en milieu somatique [Liaison psychiatry nurse: The development of supervision in somatic medicine].

BACKGROUND: Over the years, somatic care has become increasingly specialized. Furthermore, a rising number of patients requiring somatic care also present with a psychiatric comorbidity. As a consequence, the time and resources needed to care for these patients can interfere with the course of somatic treatment and influence the patient-caregiver relationship. In the light of these observations, the Liaison Psychiatry Unit at the University Hospital in Lausanne (CHUV) has educated its nursing staff in order to strengthen its action within the general care hospital. What has been developed is a reflexive approach through supervision of somatic staff, in order to improve the efficiency of liaison psychiatry interventions with the caregivers in charge of patients. The kind of supervision we have developed is the result of a real partnership with somatic staff. Besides, in order to better understand the complexity of interactions between the two systems involved, the patient's and the caregivers', we use several theoretical references in an integrative manner. PSYCHOANALYTICAL REFERENCE: The psychoanalytical model allows us to better understand the dynamics between the supervisor and the supervised group in order to contain and give meaning to the affects arising in the supervision space. "Containing function" and "transitional phenomena" refer to the experience in which emotions can find a space where they can be taken in and processed in a secure and supportive manner. These concepts, along with that of the "psychic envelope", were initially developed to explain the psychological development of the baby in its early interactions with its mother or its surrogate. In the field of supervision, they allow us to be aware of these complex phenomena and the diverse qualities to which a supervisor needs to resort, such as attention, support and incentive, in order to offer a secure environment. SYSTEMIC REFERENCE: A new perspective of the patient's complexity is revealed by the group's dynamics. The supervisor's attention is mainly focused on the work of affects. However, these are often buried under a defensive shell, serving as a temporary protection, which prevents the caregiver from recognizing his or her own emotions, thereby enhancing the difficulties in the relationship with the patient. Whenever the work of putting emotions into words fail, we use "sculpting", a technique derived from the systemic model. Through the use of this type of analogical language, affects can emerge without constraint or feelings of danger. Through "playing" in that "transitional space", new exchanges appear between group members and allow new behaviors to be conceived. In practice, we ask the supervisee who is presenting a complex situation, to design a spatial representation of his or her understanding of the situation, through the display of characters significant to the situation: the patient, somatic staff members, relatives of the patient, etc. In silence, the supervisee shapes the characters into postures and arranges them in the room. Each sculpted character is identified, named, and positioned, with his or her gaze being set in a specific direction. Finally the sculptor shapes him or herself in his or her own role. When the sculpture is complete and after a few moments of fixation, we ask participants to express themselves about their experience. By means of this physical representation, participants to the sculpture discover perceptions and feelings that were unknown up to then. Hence from this analogical representation a reflection and hypotheses of understanding can arise and be developed within the group. CONCLUSION: Through the use of the concepts of "containing function" and "transitional space" we position ourselves in the scope of the encounter and the dialog. Through the use of the systemic technique of "sculpting" we promote the process of understanding, rather than that of explaining, which would place us in the position of experts. The experience of these encounters has shown us that what we need to focus on is indeed what happens in this transitional space in terms of dynamics and process. The encounter and the sharing of competencies both allow a new understanding of the situation at hand, which has, of course, to be verified in the reality of the patient-caregiver relationship. It is often a source of adjustment for interpersonal skills to recover its containing function in order to enable caregiver to better respond to the patient's needs.

Towards Machine Consciousness: Grounding Abstract Models as pi-Processes

We present a two-level model of concurrent communicating systems (CCS) to serve as a basis formachine consciousness. A language implementing threads within logic programming is ¯rstintroduced. This high-level framework allows for the de¯nition of abstract processes that can beexecuted on a virtual machine. We then look for a possible grounding of these processes into thebrain. Towards this end, we map abstract de¯nitions (including logical expressions representingcompiled knowledge) into a variant of the pi-calculus. We illustrate this approach through aseries of examples extending from a purely reactive behavior to patterns of consciousness.

Pharmacogenetics of Antiviral Treatment

RESUME - FRANÇAISRésuméDans ce travail de thèse, l'importance de la pharmacogénétique des traitements antiviraux a été évaluée en déterminant, au moyen de trois différentes approches, l'impact de variations génétiques sur la pharmacocinétique de deux traitements antirétroviraux (à savoir l'efavirenz et le lopinavir) ainsi que sur la capacité de pouvoir éliminer le virus de l'hépatite C de façon naturelle ou suite à un traitement médicamenteux.L'influence des variations génétiques sur les taux plasmatiques de l'efavirenz et de ses métabolites primaires a été évaluée par l'analyse d'un seul gène candidat : le cytochrome P450 (CYP) 2A6, impliqué dans une voie métabolique accessoire de l'efavirenz. Cette étude a permis de démontrer que le génotype du CYP2A6 devient cliniquement déterminant en l'absence de fonction du CYP2B6, impliqué dans la voie métabolique principale, et que la perte simultanée des voies métaboliques principales et accessoires entraine une augmen¬tation du risque d'interruption du traitement, soulignant la valeur prédictive du génotypage.L'influence de la génétique sur la clairance du lopinavir a été évaluée par l'analyse à grande échelle de gènes candidats, à savoir les gènes potentiellement impliqués dans l'absorption, le métabolisme, la distribution et l'élimination d'un médicament. Cette étude a permis l'identification de 4 polymorphismes, dans des transporteurs et des enzymes métaboliques, associés à la clairance du lopinavir et expliquant 5% de la variabilité inter¬individuelle de ce phénotype.L'influence de la génétique sur la capacité d'éliminer le virus de l'hépatite C, de façon naturelle ou à la suite d'un traitement, a été évaluée par l'analyse du génome entier. Cette étude a permis l'identification d'un polymorphisme situé à proximité de l'interféron-X3. Quatre variations génétiques potentiellement causales ont ensuite pu être identifiées par reséquencage. Finalement, la contribution nette de ce gène sur l'élimination du virus a pu être évaluée dans une cohorte infectée par une seule et même source, permettant ainsi de contrôler l'effet de la diversité virale, du genre et de la présence de co-infections.Cette thèse a permis de mettre en évidence les diverses méthodes disponibles pour la recherche en pharmacogénétique, ainsi que l'importance du reséquencage pour l'identification de variations génétiques causales.SUMMARY - ENGLISHSummaryIn this thesis work the relevance of pharmacogenetics of antiviral treatment has been assessed by investigating, through three different approaches, the impact of host genetic variation on antiretroviral drug disposition (namely efavirenz and lopinavir) and on natural or treatment-induced clearance of hepatitis C virus.The influence of host genetic variation on efavirenz and its primary metabolite plasma levels was assessed by single candidate gene approach, through comprehensive analysis of cytochrome P450 (CYP) 2A6 - involved in efavirenz accessory metabolic pathway. The study could demonstrate that CYP2A6 genotype became increasingly relevant in the setting of limited CYP2B6 function - involved in efavirenz main metabolic pathway - and that individuals with both main and accessory metabolic pathways impaired were at higher risk for treatment discontinuation, overall emphasizing the predictive power of genotyping.The influence of host genetic variation on lopinavir clearance was assessed by large scale candidate gene approach, through analysis of genes involved in the absorption, distribution, metabolism and elimination. The study identified four genetic variants in drug transporters and metabolizing enzymes that explained 5% of the interindividual variability in lopinavir clearance.The influence of host genetic variation on hepatitis C virus (HCV) natural or treatment- induced clearance was assessed through genome-wide association study approach. This study identified an intergenic polymorphism, part of a linkage disequilibrium block encompassing the interferon-3 gene, as highly associated with treatment-induced and spontaneous HCV clearance. Resequencing and recombinant mapping lead to the identification of four potentially causal genetic variants. Finally, we could assess the net contribution of genetic variants in interferon-3 to clearance by controlling for viral diversity, gender and co-infection status in a single source infected cohort.This thesis highlights the various genetic tools available to pharmacogenetic discovery (candidate gene, pathway or and genome-wide approaches), and the importance of resequencing for mapping of causal variants.

Sähköisen taloushallinnon vaikutus tilitoimistojen tuottavuuteen Case: Heeros Systems Oy

Tässä tutkimuksessa tarkasteltiin tuottavuuden käsitettä ja mittaamista palvelualoilla. Tutkielman tavoitteena oli kuvata ja ymmärtää sähköisen taloushallinnon vaikutusta tilitoimistojen tuottavuuteen. Aihetta lähestyttiin sähköisiä taloushallinto-ohjelmia valmistavan case-yhtiö Heeros Systems Oy:n avulla. Tutkimus on luonteeltaan laadullinen tutkimus, jonka tutkimusmenetelmä-nä käytettiin teemahaastatteluja. Tutkimusaineisto kerättiin haastattelemal-la yhteensä kymmentä tutkimuksen kohteena olevan tilitoimiston edusta-jaa. Tutkimuksen perusteella ei havaittu sähköisen taloushallinnon selkeästi vaikuttavan tilitoimistojen tuottavuuteen tässä vaiheessa, mutta toiminto-ympäristön sähköistyessä, esimerkiksi verkkolaskujen yleistyessä, tilan-teen uskotaan muuttuvan nopeasti. Tällöin tuottavuuden kasvu edellyttää työprosessin muuttamista ja huolellista suunnittelua.