Fatalidade ou missão:estudo exploratório sobre as estratégias utilizadas pelas Ajudantes de Lar, para fazer face às exigências da sua profissão

Dissertação de Mestrado em Políticas de Desenvolvimento de Recursos Humanos

Nouvelles directives assécurologiques pour la prise en charge de la chirurgie bariatrique: conséquences pratiques [New guidelines for bariatric surgery care: practical implications].

From the 1st of January 2011, new conditions have been validated in which surgery for weight loss is borne by the basic insurance. These are very significant changes compared to the old criteria. Indeed, on one hand, patients with BMI > or = 35 kg/m2 may, without age limit and in the absence of comorbidities benefit from surgery without prior request to the medical council health insurance company concerned. On the other hand, the notion of a minimum casuistry is for the first time introduced in centers performing this type of intervention. In addition, certified centers are required to follow standard procedures for the patients' teaching and follow up.

Development and current use of parenteral nutrition in critical care - an opinion paper.

Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

Distribution channel plan for wound care products: Case 3M Finland Ltd.

The aim of this master’s thesis was to make a qualitative marketing research and on the basis of this to develop a distribution plan for the case company Finnish 3M Ltd.’s wound care products. The literature review includes three important parts: distribution channel planning, the buying behavior of seniors, and special characteristics of health care products’ marketing. The empirical part of this thesis comprises two different parts. The first part is a marketing research, in which the buying behavior of wound care products is studied in Espoo. The research aim was to examine, in which distribution channels the wound care patients under home care would most preferably buy wound care products during the time period, when municipalities will not yet provide the products for free. The data was collected through semi-structured phone interviews and regular interviews, and was treated qualitatively and anonymously. The study revealed that the recommendations of nurses and doctors influenced most the buying behavior of wound care customers. In the second part of the thesis a distribution channel plan for wound care products was made for the case company 3M Finland Ltd. based on the results. 3M Finland Ltd. should focus on pharmacies, online-stores and municipal health centers as their main distributors.

Academics as parents--parents as academics : a study of the integration of intellectual and child-care labours /

Discussions concerning the challenges of combining work and family are certainly not new, and still actively continue. There is, however, a silence in the related literature regarding a comprehensive description of integrating specifically university academic ~. work and family responsibilities. This silence is especially evident for men who are parents as well as academics. With the participation of 4 key informants, this qualitative research study gave voice to men and women who participate in the academic labour of a Canadian university as professors, and as graduate students, along with the parenting labour of at least 1 child under the age of7. Methodology was developed to reveal in-depth perspectives regarding the work practices employed by 4 key informants as they combined intellectual and child-care responsibilities. Multiple data collection methods included journal reflections, day time observation sessions, a focus group, and a final evaluation questionnaire. Using research findings, together with information extrapolated from Three Models of the Family (Eichler, 1997), this study also took steps toward developing a Proposed "Three Models of the University," to offer explanation for the work practices of the key informants as academics/parents, and also for future consideration in university policy formation.

Évaluation de l’effet clinique de la durée d’entreposage des culots érythrocytaires chez les enfants admis aux soins intensifs

Les transfusions de culots érythrocytaires (CE) sont un traitement fréquent en soins intensifs pédiatriques. Des études chez l’adulte suggèrent qu’une durée prolongée d’entreposage des CE est associée à une mauvaise évolution clinique. Aucune étude prospective n’a été conduite en pédiatrie. Notre objectif était d’évaluer l’effet clinique de la durée d’entreposage des CE chez des patients de soins intensifs pédiatriques. Nous avons donc conduit une étude observationnelle prospective dans 30 centres de soins intensifs pédiatriques en Amérique du Nord, chez tous les patients consécutifs de moins de 18 ans, séjournant aux soins intensifs pendant plus de 48 heures. Le critère de jugement primaire était l’incidence de cas de syndrome de défaillance multiviscérale après transfusion. Les critères de jugement secondaire étaient la mortalité à 28 jours et la durée d’hospitalisation aux soins intensifs. En utilisant un modèle de régression logistique, les risques relatifs furent ajustés pour le sexe, l’âge, la sévérité de la maladie à l’admission, le nombre total de transfusions et la dose totale de transfusion. L’étude a montré que les patients recevant des CE entreposés pendant 14 jours ou plus avaient un risque relatif ajusté de 1.87 (IC 95% 1.04 :3.27, p=0.03) de contracter ou de détériorer un syndrome de défaillance multiviscérale après transfusion. Ces mêmes patients avaient une durée d’hospitalisation aux soins intensifs prolongée (+3.7 jours, p<0.001), mais pas de risque augmenté de mortalité. En conclusion, chez les patients de soins intensifs pédiatriques, la transfusion de CE entreposés 14 jours ou plus est associée avec une augmentation de l’incidence de syndrome de défaillance multiviscérale et une durée d’hospitalisation prolongée aux soins intensifs.

Caractérisation des unités de soins aigus chirurgicaux au sein des départements de chirurgie générale au Canada

Introduction : The acute care surgery (ACS) units are dedicated to the prompt management of surgical emergencies. It is a systemic way of organizing on-call services to diminish conflict between urgent care and elective obligations. The aim of this study was to define the characteristics of an ACS unit and to find common criteria in units with reported good functioning. Methods : As of July 1st 2014, 22 Canadian hospitals reported having an ACS unit. A survey with questions about the organization of the ACS units, the population it serves, the number of emergencies and trauma cases treated per year, and the satisfaction about the implementation of this ACS unit was sent to those hospitals. Results : The survey’s response rate was 73%. The majority of hospitals were tertiary or quaternary centers, served a population of more than 200 000 and had their ACS unit for more than three years. The median number of surgeons participating in an ACS unit was 8.5 and the majority were doing seven day rotations. The median number of operating room days was 2.5 per week. Most ACS units (85%) had an estimated annual volume of more than 2500 emergency consultations (including both trauma and non-trauma) and 80% operated over 1000 cases per year. Nearly all the respondents (94%) were satisfied with the implementation of the ACS unit in their hospital. Conclusion : Most surgeons felt that the implementation of an ACS unit resulted in positive outcomes. However, there should be a sizeable catchment population and number of surgical emergencies to justify the resulting financial and human resources.

An evaluation of Primary health care system in Kerala

The thesis entitled An Evaluation of Primary Health Care System in Kerala. The present study is intended to examine the working of primary health care system and its impact on the health status of people. The hypothesis tested in the thesis includes, a. The changes in the health profile require reallocation of resources of primary health care system, b. Rate of utilization depends on the quality of services provided by primary health centers, and c. There is a significant decline in the operational efficiency of the primary health care system. The major elements of primary health care stated in the report of AlmaAta International Conference on Primary Health Care (WHO, 1994)” is studied on the basis of the classification of the elements in to three: Preventive, Promotive, and Curative measures. Preventive measures include Maternal and Child Health Care including family Planning. Provision of water and sanitation is reviewed under promotive measures. Curative measures are studied using the disease profile of the study area. Collection of primary data was done through a sample survey, using pre-tested interview schedule of households of the study area. Multi stage random sampling design was used for selecting the sample. The design of the present study is both descriptive and analytical in nature. As far as the analytical tools are concerned, growth index, percentages, ratios, rates, time series analysis, analysis of variance, chi square test, Z test were used for analyzing the data. Present study revealed that no one in these areas was covered under any type of health insurance. Conclusion states that considering the present changes in the health profile, traditional pattern of resource allocation should be altered to meet the urgent health care needs of the people. Preventive and promotive measures like health education for giving awareness among people to change health habits, diet pattern, life style etc. are to be developed. Proper diagnosis and treatment of the disease at the beginning of the stage itself may help to cure majority of disease. For that, Public health policy must ensure the primary health care as enunciated at Alma- Ata international Conference. At the same time Public health is not to be treated as the sole responsibility of the government. Active community participation is an essential means to attain the goals.

Effect of management strategies on the performance of ruminant livestock production systems and the safety of plant and animal products in the city of Sikasso, Mali

The regional population growth in West Africa, and especially its urban centers, will bring about new and critical challenges for urban development policy, especially in terms of ensuring food security and providing employment for the growing population. (Peri-) urban livestock and vegetable production systems, which can contribute significantly to these endeavours, are limited by various constraints, amongst them limited access to expensive production factors and their (in)efficient use. To achieve sustainable production systems with low consumer health risks, that can meet the urban increased demand, this doctoral thesis determined nutrient use efficiencies in representative (peri-) urban livestock production systems in three West African cities, and investigated potential health risks for consumers ensuing from there. The field study, which was conducted during July 2007 to December 2009, undertook a comparative analysis of (peri-) urban livestock production strategies across 210 livestock keeping households (HH) in the three West African cities of Kano/Nigeria (84 HH), Bobo Dioulasso/Burkina Faso (63 HH) and Sikasso/Mali (63 HH). These livestock enterprises were belonging to the following three farm types: commercial gardening plus field crops and livestock (cGCL; 88 HH), commercial livestock plus subsistence field cropping (cLsC; 109 HH) and commercial gardening plus semi-commercial livestock (cGscL; 13 HH) which had been classified in a preceding study; they represented the diversity of (peri-) urban livestock production systems in West Africa. In the study on the efficiency of ruminant livestock production, lactating cowsand sheep herd units were differentiated based on whether feed supplements were offered to the animals at the homestead (Go: grazing only; Gsf: mainly grazing plus some supplement feeding). Inflows and outflows of nutrients were quantified in these herds during 18 months, and the effects of seasonal variations in nutrient availability on animals’ productivity and reproductive performance was determined in Sikasso. To assess the safety of animal products and vegetables, contamination sources of irrigated lettuce and milk with microbiological contaminants, and of tomato and cabbage with pesticide residues in (peri-) urban agriculture systems of Bobo Dioulasso and Sikasso were characterized at three occasions in 2009. Samples of irrigation water, organic fertilizer and ix lettuce were collected in 6 gardens, and samples of cabbage and tomato in 12 gardens; raw and curdled milk were sampled in 6 dairy herds. Information on health risks for consumers of such foodstuffs was obtained from 11 health centers in Sikasso. In (peri-) urban livestock production systems, sheep and goats dominated (P<0.001) in Kano compared to Bobo Dioulasso and Sikasso, while cattle and poultry were more frequent (P<0.001) in Bobo Dioulasso and Sikasso than in Kano. Across cities, ruminant feeding relied on grazing and homestead supplementation with fresh grasses, crop residues, cereal brans and cotton seed cake; cereal grains and brans were the major ingredients of poultry feeds. There was little association of gardens and livestock; likewise field cropping and livestock were rarely integrated. No relation existed between the education of the HH head and the adoption of improved management practices (P>0.05), but the proportion of HH heads with a long-term experience in (peri-) urban agriculture was higher in Kano and in Bobo Dioulasso than in Sikasso (P<0.001). Cattle and sheep fetched highest market prices in Kano; unit prices for goats and chicken were highest in Sikasso. Animal inflow, outflow and dairy herd growth rates were significantly higher (P<0.05) in the Gsf than in the Go cattle herds. Maize bran and cottonseed expeller were the main feeds offered to Gsf cows as dry-season supplement, while Gsf sheep received maize bran, fresh grasses and cowpea pods. The short periodic transhumance of Go dairy cows help them maintaining their live weight, whereas Gsf cows lost weight during the dry season despite supplement feeding at a rate of 1506 g dry matter per cow and day, resulting in low productivity and reproductive performance. The daily live weight gains of calves and lambs, respectively, were low and not significantly different between the Go and the Gsf system. However, the average live weight gains of lambs were significantly higher in the dry season (P<0.05) than in the rainy season because of the high pressure of gastrointestinal parasites and of Trypanosoma sp. In consequence, 47% of the sheep leaving the Go and Gsf herds died due to diseases during the study period. Thermo-tolerant coliforms and Escherichia coli contamination levels of irrigation water significantly exceeded WHO recommendations for the unrestricted irrigation of vegetables consumed raw. Microbial contamination levels of lettuce at the farm gate and the market place in Bobo Dioulasso and at the farm gate in Sikasso were higher than at the market place in Sikasso (P<0.05). Pesticide residues were detected in only one cabbage and one tomato sample and were below the maximum residue limit for consumption. Counts of thermo-tolerant coliforms and Escherichia coli were higher in curdled than in raw milk (P<0.05). From 2006 to x 2009, cases of diarrhea/vomiting and typhoid fever had increased by 11% and 48%, respectively, in Sikasso. For ensuring economically successful and ecologically viable (peri-) urban livestock husbandry and food safety of (peri-) urban foodstuffs of animal and plant origin, the dissemination and adoption of improved feeding practices, livestock healthcare and dung management are key. In addition, measures fostering the safety of animal products and vegetables including the appropriate use of wastewater in (peri-) urban agriculture, restriction to approve vegetable pesticides and the respect of their latency periods, and passing and enforcement of safety laws is required. Finally, the incorporation of environmentally sound (peri-) urban agriculture in urban planning by policy makers, public and private extension agencies and the urban farmers themselves is of utmost importance. To enable an efficient (peri-) urban livestock production in the future, research should concentrate on cost-effective feeding systems that allow meeting the animals’ requirement for production and reproduction. Thereby focus should be laid on the use of crop-residues and leguminous forages. The improvement of the milk production potential through crossbreeding of local cattle breeds with exotic breeds known for their high milk yield might be an accompanying option, but it needs careful supervision to prevent the loss of the local trypanotolerant purebreds.

‘Boots for my Sancho’: structural vulnerability among Latin American day labourers in Berkeley, California

This paper addresses the structural vulnerability of Latin American undocumented day labourers in Northern California, as it is expressed in conversations on street corners where they wait for work. The intimate aspects of migrant experience become exemplified in jokes about the Sancho – a hypothetical character who has moved in on a day labourer's family and who enjoys the money he sends home. Joking turns to more serious topics of nostalgia and tensions with family far away, elements that come together with the fears and threats of labour on the corner and affect the way day labourers see themselves. Sexuality is rearticulated in the absence of women and masculinity becomes enmeshed in the contingencies of unregulated work and long-term separation from the people the men support. Together, these elements result in the articulation of threat to the immigrant body itself, which is exemplified by anxieties over homosexual propositions on the corner. Cet article aborde la vulnérabilité structurelle des travailleurs journaliers latino-américains sans papiers dans le Nord de la Californie, telle qu'ils l'expriment dans leurs conversations en attendant du travail aux coins des rues. Les aspects intimes de l'expérience de la migration sont exemplifiés à travers des blagues sur le Sancho – un personnage hypothétique qui, au pays natal, s'est installé dans la famille d'un journalier pour profiter de l'argent qu'elle reçoit de ce dernier. Les blagues deviennent alors des sujets de conversation plus sérieux, sur un fond de nostalgie et de tensions qui résulte de l'éloignement vis-à-vis de la famille – des éléments qui accompagnent les peurs et les menaces liées aux embauches des coins de rue et ont un impact sur la manière dont les journaliers se perçoivent. La sexualité est articulée par rapport à l'absence des femmes et la virilité s'empêtre dans les contingences du travail illégal et de la séparation sur le long terme d'avec les êtres que ces hommes soutiennent financièrement. Ensemble, tous ces éléments ont pour résultat une articulation de la menace vis-à-vis du corps de l'immigré lui-même, qui est exemplifiée par les angoisses dues aux propositions d'homosexuels aux coins des rues.

Psychological intervention in an only multifamily session at an Acute Care Unit of a psychiatric clinic

This article provides an overview of the psychological intervention in a Unit Care of Mental Health. The objectives and therapeutic actions to follow are defined through the participation of an interdisciplinary team and networking; it includes support groups and, especially, the families of patients that suffer a severe mental disorder. The materials and resources used were weekly sessions of one hour and forty minutes, for two years of monitoring (2005-2007). The study population consists of families of patients with different pathologies, which are in the Intensive Care Unit. In terms of design, it is made a qualitativeanalysis of 100 field day formats, and fills a matrix of content analysis. It is reviewed the objectives, the approach Multi-Focus, methodology, used techniques, the procedures developed and the feedback given at each session. The findings from this study show that mental disorders are related to the environment in which the patient is developed and complex social process. They also suggest a greater need for psychiatric patient care and its networks, timely and relevantly. By the other hand, it shows the importance of increasing efforts to make available in the field of mental health brief strategic interventions in interdisciplinary teams, it is appropriate a psycho educational and therapeutic approach in which the actions are coordinated at different levels.

Eficacia y seguridad de la melatonina para el manejo de los trastornos del sueño en el autismo: meta-análisis

INTRODUCCIÓN: El 80% de los niños y adolescentes con trastornos del espectro autista (TEA) presenta algún trastorno del sueño, en cuya génesis al parecer intervienen alteraciones en la regulación de la melatonina. El objetivo de este metaanálisis fue determinar la eficacia y seguridad de la melatonina para el manejo de ciertos trastornos del sueño en niños con TEA. MÉTODOS: Tres revisores extrajeron los datos relevantes de los ensayos clínicos aleatorizados doble ciego de alta calidad publicados en bases de datos primarias, de ensayos clínicos, de revisiones sistemáticas y de literatura gris; además se realizó búsqueda en bola de nieve. Se analizaron los datos con RevMan 5.3. Se realizó un análisis del inverso de la varianza por un modelo de efectos aleatorios para las diferencias de medias de los desenlaces propuestos: duración del tiempo total, latencia de sueño y número de despertares nocturnos. Se evaluó la heterogeneidad interestudios con el parámetro I2 RESULTADOS: La búsqueda inicial arrojó 355 resultados, de los cuales tres cumplieron los criterios de selección. La melatonina resultó ser un medicamento seguro y eficaz para aumentar la duración total del sueño y disminuir la latencia de sueño en niños y adolescentes con TEA; hasta el momento la evidencia sobre el número de despertares nocturnos no es estadísticamente significativa. DISCUSIÓN: A la luz de la evidencia disponible, la melatonina es una elección segura y eficaz para el manejo de ciertos problemas del sueño en niños y adolescentes con TEA. Es necesario realizar estudios con mayores tamaños muestrales y comparados con otros medicamentos disponibles en el mercado.

Equity and Efficiency in Education: motivations and targets

The recently released "Educational PAC" attempts to place basic education at the center of the social debate. We have subsidized this debate, offering a diagnosis of how different education levels can impact individuals' lives through broad and easily interpreted indicators. Initially, we analyze how much each educational level reaches the poorest population. For example, how are those in the bottom strata of income distribution benefited by childcare centers, private secondary education, public university or adult education. The next step is to quantify the return of educational actions, such as their effects on employability and an individual's wages, and even health as perceived by the individual, be that individual poor, middle class or elite. The next part of the research presents evidence of how the main characters in education, aka mothers, fathers and children, regard education. The site available with the research presents a broad, user-friendly database, which will allow interested parties to answer their own questions relative to why people do not attend school, the time spent in the educational system and returns to education, which can all be cross-sectioned with a wide array of socio-demographic attributes (gender, income, etc.) and school characteristics (is it public, are school meals offered, etc.) to find answers to: why do young adults of a certain age not attend school? Why do they miss classes? How long is the school day? Aside from the whys and hows of teaching, the research calculates the amount of time spent in school, resulting from a combination between absence rates, evasion raters and length of the school day. The study presents ranks of indicators referring to objective and subjective aspects of education, such as the discussion of the advantages and care in establishing performance based incentives that aim at guiding the states in the race for better educational indicators.

The variability and predictors of quality of AIDS care services in Brazil

Background: Since establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery.Methods: The survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality.Results: The questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities.Conclusion: The survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Care and Cleaning of Maxillofacial Prostheses

Both the cleaning and care of the prosthesis are fundamental for maintaining its quality. Therefore, the aim of this study was to show the methods of cleaning and care the patient needs to take as regards the prosthesis and adjacent tissue, starting with correct instruction and training by the professional. It has been verified that among the materials for fabricating maxillofacial prostheses, silicone was considered the major retainer of microorganisms on its surface. Therefore, for cleaning prostheses, the use of water and neutral soap, as well as chlorhexidine, is recommended. As regards care of the adjacent tissues, it is recommended to remove the prosthesis before going to sleep, in addition to washing the prosthesis receptor tissues with water and neutral soap or with a mixture of hydrogen peroxide and water. Whereas for the mucosal surfaces of the ophthalmic cavity, cleaning with filtered and boiled water or physiological solution at least 3 times a day is recommended.