Patience, Persistence and Pragmatism: Experiences and Lessons Learnt from the Implementation of Clinically Integrated Teaching and Learning of Evidence-Based Health Care - A Qualitative Study

Background

Clinically integrated teaching and learning are regarded as the best options for improving evidence-based healthcare (EBHC) knowledge, skills and attitudes. To inform implementation of such strategies, we assessed experiences and opinions on lessons learnt of those involved in such programmes.

Methods and Findings

We conducted semi-structured interviews with 24 EBHC programme coordinators from around the world, selected through purposive sampling. Following data transcription, a multidisciplinary group of investigators carried out analysis and data interpretation, using thematic content analysis. Successful implementation of clinically integrated teaching and learning of EBHC takes much time. Student learning needs to start in pre-clinical years with consolidation, application and assessment following in clinical years. Learning is supported through partnerships between various types of staff including the core EBHC team, clinical lecturers and clinicians working in the clinical setting. While full integration of EBHC learning into all clinical rotations is considered necessary, this was not always achieved. Critical success factors were pragmatism and readiness to use opportunities for engagement and including EBHC learning in the curriculum; patience; and a critical mass of the right teachers who have EBHC knowledge and skills and are confident in facilitating learning. Role modelling of EBHC within the clinical setting emerged as an important facilitator. The institutional context exerts an important influence; with faculty buy-in, endorsement by institutional leaders, and an EBHC-friendly culture, together with a supportive community of practice, all acting as key enablers. The most common challenges identified were lack of teaching time within the clinical curriculum, misconceptions about EBHC, resistance of staff, lack of confidence of tutors, lack of time, and negative role modelling.

Conclusions

Implementing clinically integrated EBHC curricula requires institutional support, a critical mass of the right teachers and role models in the clinical setting combined with patience, persistence and pragmatism on the part of teachers.

The Brut Tradition

This article tracks the development of the Brut tradition, from its inception in the ninth century text the Historia Brittonum, via Geoffrey of Monmouth’s twelfth century Historia Regum Britannaie, Wace’s Roman de Brut and Layamon’s Brut (both twelfth century), to the myriad Prose Bruts, in Anglo-Norman, Latin and Middle English, from the thirteenth to the sixteenth centuries. It argues that the Brut is best understood both as a distinctive literary tradition and as a well-spring of mythography from which a range of late medieval, and post-medieval, writers drew. The article indicates the utility of the Brut tradition to emergent notions of English identity and the role the narratives recorded by the Brut tradition played in orchestrating English colonial attitudes to its insular and continental neighbours. The article concludes by assessing the importance of the Brut tradition for book culture and emergent models of literary taste in the later Middle Ages

Reliability of reports of childhood trauma in bipolar disorder: A test–retest study over 18 months

This study aimed to explore the reliability of self-reported trauma histories in a population with a diagnosis of Bipolar Disorder using the Childhood Trauma Questionnaire. Previous studies in other populations suggest high reliability of trauma histories over time and it was postulated that a similar high reliability would be demonstrated in this population. Thirty-nine patients with a confirmed diagnosis (DSM-IV criteria) were followed-up and re-administered the Childhood Trauma Questionnaire after 18 months. Cohen's kappa scores and intraclass correlations suggest reasonable test-retest reliability over the 18-month time period of the study for all types of childhood abuse, namely emotional, physical, sexual, and physical abuse and emotional neglect. Intraclass correlations ranged from r = .50 to (sexual abuse) to r = .96 (physical abuse). Cohen's kappas ranged from .44 (sexual abuse) to .76 (physical abuse). Retrospective reports of childhood trauma can be seen as reliable and are in keeping with results found with other mental health populations.

Effects of a book gifting programme on literacy outcomes for foster children: A randomised controlled trial evaluation of the Letterbox Club in Northern Ireland

The poor educational outcomes of children in care is a significant concern internationally. Whilst there have been many interventions developed to address this problem, very few of these have been rigorously evaluated. This article presents the findings of a randomised controlled trial that sought to measure the effectiveness of a book gifting programme (the Letterbox Club) that aims to improve literacy skills amongst children aged 7-11 years in foster care. The programme involves children receiving six parcels of books sent through the post over a six-month period. The trial, which ran between April 2013 and June 2014, involved a sample of 116 children in Northern Ireland (56 randomly allocated to the intervention group and 60 to a waiting list control group). Outcome measures focused on reading skills (reading accuracy, comprehension and rate) and attitudes to reading and school. The trial found no evidence that the book-gifting programme had any effect on any of the outcomes measured. Drawing upon some of the emergent themes from the accompanying qualitative process evaluation that sought to determine foster carer/child attitude towards and engagement with the parcels, it is suggested that one plausible reason for the ineffectiveness of the Letterbox Club, as intimated by carers and children (rather than explicitly explored with them), is the lack of support provided to the carers/children in relation to the packs received. Reflective of an ecological model of children’s development, it is recommended that for book-gifting programmes to be effective they need to include a focus on encouraging the direct involvement of foster carers in shared literacy activities with the children using the books that are gifted.

Undergraduate interprofessional education using high-fidelity paediatric simulation

BACKGROUND: High-fidelity simulation is becoming increasingly important in the delivery of teaching and learning to health care professionals within a safe environment. Its use in an interprofessional context and at undergraduate level has the potential to facilitate the learning of good communication and teamworking, in addition to clinical knowledge and skills.

METHODS: Interprofessional teaching and learning workshops using high-fidelity paediatric simulation were developed and delivered to undergraduate medical and nursing students at Queen's University Belfast. Learning outcomes common to both professions, and essential in the clinical management of sick children, included basic competencies, communication and teamworking skills. Quantitative and qualitative evaluation was undertaken using published questionnaires.

RESULTS: Quantitative results - the 32-item questionnaire was analysed for reliability using spss. Responses were positive for both groups of students across four domains - acquisition of knowledge and skills, communication and teamworking, professional identity and role awareness, and attitudes to shared learning. Qualitative results - thematic content analysis was used to analyse open-ended responses. Students from both groups commented that an interprofessional education (IPE) approach to paediatric simulation improved clinical and practice-based skills, and provided a safe learning environment. Students commented that there should be more interprofessional and simulation learning opportunities.

DISCUSSION: High-fidelity paediatric simulation, used in an interprofessional context, has the potential to meet the requirements of undergraduate medical and nursing curricula. Further research is needed into the long-term benefits for patient care, and its generalisability to other areas within health care teaching and learning.

Ciências no primeiro ciclo do ensino básico : um programa para educação para desenvolvimento sustentável

Num planeta finito, a impossibilidade de um crescimento contínuo e a necessidade de preservar os seus recursos naturais e ambientais, tendo em vista assegurar opções de qualidade de vida e bem-estar das gerações futuras, fez emergir e estruturar o conceito de Desenvolvimento Sustentável. Perante os múltiplos desafios que o futuro coloca, a educação constitui-se como uma via para alcançar um desenvolvimento mais harmonioso das relações entre os seres humanos e entre estes e a natureza, indispensável à humanidade na persecução dos seus legítimos anseios de paz, liberdade e justiça social. A importância atribuída à educação no sentido de uma adequada perceção da situação do planeta levou as Nações Unidas a proclamarem, no início deste século (dezembro de 2002), a Década da Educação para o Desenvolvimento Sustentável (2005-2014): um desafio internacional lançado aos países para que recorram à educação como ferramenta essencial na promoção de Desenvolvimento Sustentável. A vida nas sociedades contemporâneas é, como nunca antes, influenciada por desenvolvimentos científicos e tecnológicos e dependente dos respetivos progressos. Assim, a Educação Científica assume um papel fundamental na compreensão das problemáticas que enfrentamos e na consciencialização da responsabilidade do ser humano na situação planetária atual, devendo promover o desenvolvimento de cidadanias proativas, fundamentadas e responsáveis, no sentido da mudança, numa perspetiva crítica global que garanta a sustentabilidade do planeta. Estas finalidades são alvo de reflexão por parte de diversas instâncias da sociedade – nas quais se incluem organismos como a UNESCO, comunidades nacionais e internacionais de investigação em Educação Científica, e o poder político – e espelham-se em propostas de reforma e de revisão curricular em diversos países. Ora, sem ser exclusiva, a educação formal nos primeiros anos de escolaridade tem um papel fundamental, por ter caráter obrigatório na maioria dos países. Paralelamente existe um crescente reconhecimento a nível internacional em torno da importância de se iniciar precocemente a Educação Científica com vista a alcançar esses propósitos. Resultados alcançados em diversas investigações evidenciam que a Educação Científica nos primeiros anos de escolaridade tem impacte positivo relevante no desenvolvimento de literacia científica e no desenvolvimento de atitudes positivas face à Ciência e a aprendizagens de Ciências. A presente investigação pretende ser um contributo para a Década da Educação para o Desenvolvimento Sustentável no Primeiro Ciclo do Ensino Básico. O percurso de investigação, de natureza qualitativa, foi desenvolvido em três fases distintas mas articuladas entre si: a fase I integrou processos interpretativos de investigação documental e teve como principais objetivos o estabelecimento do quadro teórico de suporte à problemática de Educação para Desenvolvimento Sustentável e a caraterização de perspetivas de Educação Científica decorrentes de política educativa em Portugal; na fase II caraterizou-se a importância atribuída por professores do Primeiro Ciclo do Ensino Básico à Educação Científica e respetiva componente experimental, bem como as suas conceções acerca de Literacia Científica, orientações Ciência-Tecnologia-Sociedade no ensino das Ciências, Desenvolvimento Sustentável e o modo como dizem articular as referidas conceções com as suas práticas de sala de aula; na fase III apresentou-se um Programa de Ciências, concebido segundo os referenciais atrás definidos e avaliado por um painel de peritos, para Educação para Desenvolvimento Sustentável, “A Terra e os seres vivos: conhecer para valorizar e proteger”, para implementação em cada um dos quatro anos de escolaridade do Primeiro Ciclo do Ensino Básico. O presente estudo assume-se como um contributo para a inovação na Educação Científica no Primeiro Ciclo do Ensino Básico e fundamenta a necessidade de a reorientar, tendo em vista a resposta a compromissos internacionais assumidos por Portugal no âmbito da Década da Educação para o Desenvolvimento Sustentável, bem como a importância de acompanhar orientações e políticas recomendadas a nível internacional, numa perspetiva de educação num contexto de globalização.

O expansionismo europeu : os Descobrimentos e a nova visão do mundo nos séculos XV e XVI : uma experiência de ensino

Relatório da Prática de Ensino Supervisionada, Ensino de História e Geografia no 3.º Ciclo do Ensino Básico e Ensino Secundário, Universidade de Lisboa, 2013

Avaliação do estatuto de conservação da flora endémica de Cabo Verde

Tese de mestrado. Biologia (Ecologia e Gestão Ambiental). Universidade de Lisboa, Faculdade de Ciências, 2014

FITS into Practice: Translating Research into Practice in Reducing the Use of Anti-psychotic Medication for People with Dementia Living in Care Homes

Objectives: This paper reports on the acceptability and effectiveness of the FITS (Focussed Intervention Training and Support) into Practice Programme. This intervention was scaled up from an earlier cluster randomised-controlled trial that had proven successful in significantly decreasing antipsychotic prescribing in care homes. Method: An in depth 10-day education course in person-centred care was delivered over a three-month period, followed by six supervision sessions. Participants were care-home staff designated as Dementia Care Coaches (DCCs) responsible for implementing interventions in 1 or 2 care homes. The course and supervision was provided by educators called Dementia Practice Development Coaches (DPDCs). Effectiveness data included monitoring antipsychotic prescriptions, goal attainment, knowledge, attitudes and implementation questionnaires. Qualitative data included case studies and reflective journals to elucidate issues of implementation. Results: Of the 100 DCCs recruited, 66 DCCs completed the programme. Pre-post questionnaires demonstrated increased knowledge and confidence and improved attitudes to dementia. Twenty per cent of residents were prescribed antipsychotics at baseline which reduced to 14% (31% reduction) with additional dose reductions being reported alongside improved personalised goal attainment. Crucial for FITS into Practice to succeed was the allocation and protection of time for the DCC to attend training and supervision and to carry out implementation tasks in addition to their existing job role. Evaluation data showed that this was a substantial barrier to implementation in a small number of homes. Discussion and conclusions: The FITS into practice programme was well evaluated and resulted in reduction in inappropriate anti-psychotic prescribing. Revisions to the intervention are suggested to maximise successful implementation.

Presidential power and congressional acquiescence in the "war" on terrorism: a new constitutional equilibrium?

US presidents have expanded executive power in times of war and emergency,sometimes aggressively so. This article builds on the application of punctuated equilibria theory by Burnham (1999 and Ackerman (1999). Underpinning this theory is the notion that rapid changes in - or external shocks to - domestic and international society impose new and insistent demands on the state. In so doing, they produce important and decisive moments of institutional mobilization and creativity, disrupt a pre-existing, relatively stable, equilibrium between the Congress and the president, and precipitate decisions or nondecisions by the electorate and political leaders that define the contours for action when the next crisis or external shock occurs. The article suggests that the combination of President George W. Bush's presidentialist doctrine, 9/11 and the 'war' on terror has consolidated a new, constitutional equilibrium. While some members of Congress contest the new order, the Congress collectively has acquiesced in its own marginalization. The article surveys a wide range of executive power assertions and legislative retreats. It argues that power assertions generally draw on precedent: on, for example, a tradition of wartime presidential extraconstitutional leadership extending to presidents, such as John Adams and Abraham Lincoln,as well as to Cold War and post-Cold War presidentialism.

Labour and the free churches 1918-1939: radicalism, righteousness and religion

It is a commonplace that the labour movement was somehow nurtured within the witness for liberty of the Free Churches. Exploring this at a range of levels - including organisation, rhetoric, policies, electoral politics and people - this book demonstrates the extent to which this remained a reality into the inter-war years. The distinctive religious setting in which it emerged indeed helps to explain the differences between Labour and more Marxist counterparts on the Continent. It is shown here that this setting continued to influence Labour approaches towards welfare, nationalisation and industrial relations between the wars. In the process Labour also adopted some of the righteousness of tone of the Free Churches. This setting was, however, changing. Dropping their traditional suspicion of the State, Nonconformists instead increasingly invested it with religious values, turning it through its growing welfare functions into the provider of practical Christianity. This nationalisation of religion continues to shape British attitudes to the welfare state as well as imposing narrowly utilitarian and material tests of relevance upon the churches and other social institutions. The elevation of the State was not, however, intended as an end in itself. What mattered were the social and individual outcomes. Socialism, for those Free Churchmen and women who helped to shape Labour in the early twentieth century, was about improving society as much as systems.

Construction of womanhood in the bengali language of Bangladesh

The subject-matter of this essay is gender justice in language which, as I argue, may be achieved through the development of a gender-related approach to linguistic human rights. The last decades of the 20th century, globally marked by a “gender shift” in attitudes to language policy, gave impetus to the social movement for promoting linguistic gender equality. It was initiated in Western Europe and nowadays is moving eastwards, as ideas of gender democracy progress into developing countries. But, while in western societies gender discrimination through language, or linguistic sexism, was an issue of concern for over three decades, in developing countries efforts to promote gender justice in language are only in their infancy. My argument is that to promote gender justice in language internationally it is necessary to acknowledge the rights of women and men to equal representation of their gender in language and speech and, therefore, raise a question of linguistic rights of the sexes. My understanding is that the adoption of the Universal Declaration of Linguistic Rights in 1996 provided this opportunity to address the problem of gender justice in language as a human rights issue, specifically as a gender dimension of linguistic human rights.

Damage evaluation of drilled carbon/epoxy laminates based on area assessment methods

The characteristics of carbon fibre reinforced laminates had widened their use, from aerospace to domestic appliances. A common characteristic is the need of drilling for assembly purposes. It is known that a drilling process that reduces the drill thrust force can decrease the risk of delamination. In this work, delamination assessment methods based on radiographic data are compared and correlated with mechanical test results (bearing test).

Exposição profissional a chumbo : utilização da protoporfirina-zinco (PPZ) na vigilância de saúde de trabalhadores ex

Resumo Uma estratégia de avaliação e prevenção de riscos na exposição a agentes químicos deve ter sempre em conta que a vigilância do ambiente de trabalho e a da saúde dos trabalhadores são aspectos complementares de uma mesma realidade – os riscos resultantes da interacção entre um agente químico e os trabalhadores a ele expostos. Se à Vigilância Ambiental compete apreciar o risco, pela caracterização do agente no ambiente de trabalho, a Vigilância Biológica pronuncia-se sobre a interacção entre o tóxico e o organismo, avaliando a resposta à agressão química e a evolução das reacções de adaptação ou de desajuste face à absorção do tóxico. Os Indicadores Biológicos, deste modo, assumem um estatuto de instrumento privilegiado na vigilância da saúde dos trabalhadores expostos, na medida em que medem a quantidade de tóxico que efectivamente penetrou e foi absorvido, ou o resultado (efeito) determinado por essa mesma dose. O presente estudo procura contribuir para a definição de um quadro metodológico de utilização dos Indicadores Biológicos na avaliação/gestão da exposição profissional ao chumbo, designadamente apreciando a variação da protoporfirina-zinco (PPZ), indicador até ao presente ainda não utilizado em Portugal. O chumbo é um metal de ocorrência natural, cujos níveis nos diversos ecossistemas resultam, principalmente, das actividades antropogénicas de natureza doméstica e industrial. A sua capacidade poluente é assinalável, representando uma fonte de exposição permanente para o homem, demonstrável pela sua constante presença no organismo apesar de não desempenhar qualquer tipo de função fisiológica. São actualmente inúmeras as suas aplicações, tornando a exposição profissional ao chumbo uma realidade vasta: indústrias de acumuladores eléctricos, de vidros, de plásticos e de munições, construção civil, manutenção e reparação automóvel e de navios, fabrico de tintas, indústrias electrónicas, fundições e actividades de soldadura são, entre outras, situações onde é uma realidade a ter em conta. A penetração dos compostos inorgânicos de chumbo no organismo efectua-se principalmente por via respiratória, não sendo, no entanto, desprezável, a sua penetração por via digestiva. As partículas absorvidas são transportadas pelo sangue principalmente ligadas aos eritrocitos (95%), distribuem-se pelos tecidos moles e depositam-se essencialmente no tecido ósseo, onde representam mais de 90% da carga corporal do total absorvido e tendo aí um elevado tempo de semi-vida (mais de 20 anos). Não é metabolizado no organismo e a sua eliminação efectua-se essencialmente por via renal,sendo igualmente excretado, em menor escala, através das fezes, do suor, da saliva, das faneras e do leite materno. O conhecimento científico evidencia que concentrações sanguíneas de chumbo entre 20 e 50 mg/dL são susceptíveis de determinar efeitos adversos no homem, podendo ser afectados o sistema hematopoiético, o sistema nervoso, o sistema cardiovascular, o sistema reprodutor e o sistema imunitário. Contudo, ainda muito há a clarificar no âmbito da toxicidade do chumbo. Os níveis de exposição a que correspondem as alterações nos diversos órgãos e sistemas continuam a ser motivo de alguma controvérsia. As características carcinogénicas e mutagénicas do chumbo são, ainda, um campo de vasta exigência de investigação. A intoxicação por chumbo e seus sais (Saturnismo) de origem ocupacional é reconhecida em Portugal como doença profissional (grupo 1 - Doenças Provocadas por Agentes Químicos, da Lista das Doenças Profissionais). É uma intoxicação do tipo crónico, fruto da absorção contínua de doses relativamente pequenas durante longo período, evidenciando-se no seu início por sinais e sintomas vagos e difusos de grande inespecificidade, que podem incluir, nomeadamente, perda de apetite, sabor metálico na boca, palidez, mal-estar e fadiga, cefaleias, mialgias e artralgias, irritabilidade, tremores finos, obstipação, cólicas abdominais, insónias, déficit da memória de curto prazo e da capacidade de concentração. Um importante conjunto de indicadores biológicos pode ser utilizado na vigilância periódica da saúde de trabalhadores nestas condições de exposição. Tais indicadores (de dose ou de efeito), encerram diferentes significados e comportam distintas exigências, competindo ao Médico do Trabalho, no âmbito dos programas de prevenção dos efeitos adversos relacionados com a exposição profissional a chumbo, seleccionar a sua utilização e interpretar a sua informação, de modo a avaliar a interacção do tóxico com o organismo numa fase de reversibilidade. O presente estudo envolveu 180 trabalhadores dos quais 110 apresentavam plumbémias (Pb-S) iguais ou superiores a 40 mg/dL. Além da Pb-S, a todos foi doseada a protoporfirina-zinco (PPZ) e efectuado o Hemograma e a cerca de 25% foi determinada a concentração do ácido d-aminolevulínico urinário (ALA-U). Os doseamentos da PPZ efectuados em amostra de sangue capilar através de um hematofluorímetro portátil revelaram-se de total fiabilidade, dando significado a uma técnica de fácil execução e baixo custo. A avaliação do tipo de colheita urinária para doseamento do ALA-U concluiu pela necessidade de recurso a urinas de 24 horas.Os resultados do estudo evidenciaram uma elevada associação entre a PPZ e a Pb-S, com uma maior magnitude e de início mais precoce do que o que registado na associação da Pb-S com o ALA-U. Revelaram, ainda, fracos níveis de associação da hemoglobina (e outros parâmetros hematológicos) com a Pb-S. E demonstraram para um cut-off de 100 mg/ dL de PPZ, taxa de falsos negativos e falsos positivos, para plumbémias a partir de 70 mg/dL, inferiores a 20%. Assim, concluiu-se que, nos protocolos de vigilância de saúde de trabalhadores expostos a chumbo, o doseamento da PPZ por hematofluorímetro, em sangue de colheita capilar, é adequado, fiável e de realização preferencial em relação ao do ALA-U. Concluiu-se, também, que a realização do hemograma apenas se justifica em situações individuais que clinicamente o tornem aconselhável. E que estes protocolos devem incluir a realização da Pb-S e da PPZ, podendo, em situações de controlo rigoroso (ambiental, biológico e clínico), basear-se apenas na determinação da PPZ reservando os outros indicadores para aprofundar a investigação médica nos casos de taxas elevadas desta ou de situações limitantes. ■ Résumée Une stratégie d’évaluation et de prévention des risques d’exposition aux agents chimiques doit toujours tenir en considération que la vigilance du lieu de travail et de la santé des travailleurs sont des aspects complémentaires d’une même réalité – les risques résultant d’une interaction entre l’agent chimique et les travailleurs exposés. Si c’est à la Vigilance Ambiantale de juger le risque, par la caractérisation de l’agent dans le lieu de travail, la Vigilance Biologique, elle, se prononce sur l’interaction entre le toxique et l’organisme, évaluant la réponse à l’agression chimique et l’évolution des réactions d’adaptation ou de rupture face à l’absorption du toxique. Les Indicateurs Biologiques assument ainsi un statut d’instrument privilégié de vigilance de la santé des travailleurs exposés, dans la mesure où ils déterminent la quantité de toxique qui a effectivement été pénétré et absorbé, ou le résultat (effet) déterminé par cette dose. Cette étude-ci cherche à contribuer à la définition d’un cadre méthodologique d’utilisation des Indicateurs Biologiques dans l’évaluation/ gestion de l’exposition professionnelle au plomb inorganique, évaluant spécialement le comportement de la protoporphirine-zinc (PPZ), indicateur pas encore utilisé au Portugal.Le plomb est un métal d’occurrence naturelle dont les niveaux dans les différents écosystèmes en résultent, principalement, des activités anthropogéniques de nature domestique et industrielle. Sa capacité polluante peut être signalée, représentant une source d’exposition permanente pour l’homme, celle-ci démontrable par sa présence continue dans l’organisme, même si elle n’y accomplit aucune fonction physiologique. Actuellement ses applications sont innombrables, faisant de l’exposition professionnelle au plomb une réalité de grande ampleur : industries d’accumulateurs électriques, de verre, de plastique et de munitions, bâtiments, manutention et réparation automobile et navale, fabrication d’encres, industries électroniques, fontes et activités de soudure sont, entre autres, des situations réelles a en tenir compte. La pénétration du plomb inorganique dans l’organisme se fait principalement par voie respiratoire, pouvant se faire également par voie digestive. Les particules absorbées sont transportées par le sang, surtout liées aux érythrocytes (95%), se repartent à travers les tissus mous et se déposent essentiellement dans le tissu osseux, où elles représentent plus de 90% de la charge corporelle de ce qui a été absorbé et ont un temps de demi-vie élevé (plus de 20 ans). Le plomb n’est pas métabolisé dans l’organisme et son élimination se fait essentiellement par voie rénale, pouvant tout de même, à une moindre échelle, être excrété dans les fèces, de la sueur, de la salive, des ongles, des cheveux et du lait maternel. La connaissance scientifique met en évidence que des concentrations sanguines de plomb entre 20 et 50 mg/dL sont susceptibles de déterminer des effets adverses dans l’homme, pouvant les systèmes hématopoïétique, nerveux, cardiovasculaire, reproducteur et immunitaire en être affectés. Cependant, il en reste beaucoup à éclaircir dans le domaine de la toxicité du plomb. Les niveaux d’exposition auxquels correspondent les modifications des divers organes et systèmes, demeurent toujours sujet de quelque controverse. Les caractéristiques carcinogèniques et mutagèniques du plomb restent toujours un champ d’investigation d’une grande exigence. L’intoxication par le plomb et ses sels (Saturnisme) d’origine occupationnelle est reconnue, au Portugal, comme une maladie professionnelle (groupe 1- Maladies Provoquées par des Agents Chimiques, de la Liste des Maladies Professionnelles). C’est une intoxication du tipe chronique, due à l’absorption continue de doses relativement petites pendant une longue période, mise en évidence à travers des signes et des symptômes vagues et diffus sans grande spécificité, lesquels peuvent inclure, particulièrement, le manque d’appétit, goût métallique dans la bouche, pâleur, malaise et fatigue, céphalées, myalgies et arthralgies, irritabilité, tremblements fins, constipation, coliques abdominales, insomnies, déficit de la mémoire à court terme et de la capacité de concentration.Un ensemble important d’indicateurs biologiques peut être employé dans la vigilance périodique de la santé des travailleurs dans ces conditions d’exposition. Ces indicateurs (de dose ou d’effet) renferment différentes significations et comportent diverses exigences, devant le Médecin de Travail, dans le domaine des programmes de prévention des effets adverses qui sont en relation avec l’exposition professionnelle au plomb, sélectionner son utilisation et interpréter son information de façon à évaluer l’interaction de l’élément toxique avec l’organisme à un stade de réversibilité. L’étude ci-présent engloba 180 travailleurs desquels 110 présentaient des plombémies (Pb-S) égales ou supérieures à 40 mg/dL. À part la Pb-S, la protoporphyrine-zinc (PPZ) leur a été prise en dosage et un Hémogramme fut effectué et fut déterminé l’acide d- aminolévulinique urinaire (ALA-U) sur environ 25% des travailleurs. Le dosage de la PPZ efectué en échantillon de sang capillaire par un fluorimètre portable, s’est accomplit d’une fiabilité total, donnant du sgnificat à une téchnique de facile execution et bas prix. L’évaluation de la prise urinaire par dosage du ALA-U conclut au besoin d’un recours aux urines de 24 heures Les résultats de l’étude ont mis en évidence une association élevée entre la PPZ et la Pb- S, avec une intensité majeure et de début plus précoce par rapport à celui qui fut registré lors de l’association de la Pb-S avec la ALA-U. Ces résultats ont également montré de faibles niveaux d’association entre l’hémoglobine (et autres paramètres hématologiques) et la Pb-S. Ils ont démontré aussi, une valeur de cut-off de 100 mg/dL de PPZ, des taux de faux négatifs et faux positifs, pour des plombémies de 70 mg/dL, inférieurs à 20%. On peut donc conclure que dans les protocoles de vigilance de la santé des travailleurs exposés au plomb, le dosage de la PPZ par fluorimetrie dans le sang capillaire est adéquat, fiable et de réalisation préférentielle par rapport à celui du ALA-U. On peut également conclure que la réalisation de l’hémogramme ne se justifie que dans les cas individuels où, cliniquement, celui-ci est conseillé. De plus, ces protocoles doivent inclure la réalisation de la Pb-S et de la PPZ, pouvant, en cas de contrôle rigoureux (ambiantal, biologique et clinique), s’appuyer que dans la détermination de la PPZ réservant les autres indicateurs pour approfondir l’investigation médicale dans les cas où les taux de celle-ci sont élevés ou dans les cas de situations limitantes. ■ Summary Any strategy to evaluate and prevent the risks of chemical agents exposure must always regard the work environment and workers health as complementary aspects of one reality - the resulting risks from the interaction between the chemical agent and the exposed workers. It is the responsibility of Environmental Monitoring to evaluate the risks of exposure by the characterization of the chemical agent in the work environment. Biological Monitoring, on the other hand, pronounces itself over the toxin and body interaction, evaluating human response to the chemical aggression and the body adaptations to the toxic absorption. Biological Exposure Indices (BEI) assume, therefore, a privileged status among exposed workers' health monitoring instruments, as they measure the actual penetrated and absorbed toxic quantity and the effect it produces. This research study aims to contribute to the definition of a methodological strategy on the utilization of BEI’s in evaluating inorganic lead's occupational exposure, more specifically appreciating the zinc protoporphyrin (ZPP) variation, an index that has never been taken under consideration in Portugal until now. Lead is a natural metal whose ecosystem’s levels are mainly due to domestic and industrial anthropogenic activities. Its pollutant capacity is notable, representing a permanent exposure risk shown by its constant presence in the human body, although it has no physiologic function. Nowadays, lead's applications are countless, turning its professional exposure a huge reality: storage batteries industries, glass industries, plasterers and munitions industries, building construction, ships and motor car maintenance and repairing, ink manufacture, electronics industries, foundries and other soldering activities are, among so many other, realities to attend to. Respiration is the main cause of human body's inorganic lead absorption, although digestive pathway must not to be ignored. The absorbed particles are transported by blood, essentially bounded to erythrocytes (95%). It is distributed by soft tissues and settled mainly on bone tissues, where it represents approximately 90% of the total body charge and has a high half-life time (more than 20 years). It is not metabolized by the organism, its elimination being effectuated by renal activity and, in smaller scale, through lees, sweat, saliva, nails, hair and maternal milk.Scientific knowledge shows that concentrations of lead in blood between 20 e 50 mg/dL are susceptible to determine adverse effects in man and able to affect the hematopoietic system, the nervous system, the cardiovascular system, the reproductive system and the immunological system. Nevertheless, there's still much to be learned and clarified about lead's toxicity. The correlation between exposure levels and human's systems and organs alteration levels continues to be a centre of controversies. Still, lead's carcinogenic and mutagenic characteristics continue to be a high demanding research field. Intoxication by lead and its compounds (saturnism), from occupational origin, is recognized in Portugal as an occupational disease, included in Group 1 - Chemical Agents Caused Diseases, on the Occupational Diseases List. It is a chronic intoxication caused by a continuous absorption of small doses, throughout a long period of time. Its signs and symptoms are diffuse and imprecise, of great unspecificity, such as loss of appetite, metallic flavor in the mouth, paleness, ailment and fatigue, headaches, myalgia and arthralgia, irritability, thin tremors, constipation, abdominal pain, insomnias, short memory loses and inability to concentrate. A considered number of BEI’s can be used in Periodic Health Monitoring of workers in such exposure conditions. Such BEI (dose indices or effect indices) provide different meanings and imply different procedures, being Occupational Doctors responsibility, in the context of lead related adverse effects preventive programmes, to select and interpret its information, in order to evaluate the interaction between toxic and organism in a reversible phase of the toxic action. The present research study involved 180 workers, 110 of which presented blood lead levels (PbB) above or equal to 40 mg/dL. Besides PbB, all workers has been evaluated for zinc protoporphyrin levels (PPZ) and submitted to a haemogram. About 25% of the workers were selected for d-aminolevulinic urinary acid (ALA-U) determination. The evaluation of PPZ, by a portable hematofluorometer using capillary blood samples, turned out to be an easy procedure with low costs and total warrantability. As in regard for ALA- U procedure, it was concluded the necessity of 24 hours urine samples. This research results underlined a strong connection between ZPP and PbB, which was found to to be stringer and to begin earlier than it was registered for PbB and ALA-U association. The same study also revealed a low association level between PbB and hemoglobin or other hematological indices. It was also verified less than 20% of false negatives and false positives cases when admitted a ZPP 100 mg/dL cut off value for PbB³ 70 mg/dL. As in result it was concluded that in Health Monit

Health problems among detainees in Switzerland: a study using the ICPC-2 classification.

BACKGROUND: Little is known about the health status of prisoners in Switzerland. The aim of this study was to provide a detailed description of the health problems presented by detainees in Switzerland's largest remand prison. METHODS: In this retrospective cross-sectional study we reviewed the health records of all detainees leaving Switzerland's largest remand prison in 2007. The health problems were coded using the International Classification for Primary Care (ICPC-2). Analyses were descriptive, stratified by gender. RESULTS: A total of 2195 health records were reviewed. Mean age was 29.5 years (SD 9.5); 95% were male; 87.8% were migrants. Mean length of stay was 80 days (SD 160). Illicit drug use (40.2%) and mental health problems (32.6%) were frequent, but most of these detainees (57.6%) had more generic primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Furthermore, 7.9% reported exposure to violence during arrest by the police. CONCLUSION: Morbidity is high in this young, predominantly male population of detainees, in particular in relation to substance abuse. Other health problems more commonly seen in general practice are also frequent. These findings support the further development of coordinated primary care and mental health services within detention centers.