A Directiva 2011-24-UE, relativa ao exercício dos direitos dos doentes em matéria de cuidados transfronteiriços : análise : potenciais repercussões no direito de acesso aos cuidados de saúde transfronteiriços em Portugal

RESUMO - 1. INTRODUÇÃO: Ao longo dos tempos, assistiu-se a um aumento da importância da Saúde Pública na Comunidade Europeia, mas só há relativamente pouco tempo teve o merecido lugar de destaque à luz da legislação comunitária. Neste contexto e com a adopção do Programa Europeu de Saúde Pública, surge a necessidade de actualizar o pensamento nesta área. Assim, é identificada uma oportunidade para formular uma estratégia, que seja passível de reduzir desigualdades e que também em compreenda as necessidades de saúde. Com o expandir da questão e com o propósito de reduzir as desigualdades, surge a Directiva 2011/24/UE, que visa regulamentar os direitos dos doentes em matéria de cuidados transfronteiriços. 2. OBJETIVO: Este trabalho apresenta como objetivo primordial analisar a Directiva 2011/24/UE, bem como a Lei n.º 52/2014, de 25 de Agosto, e identificar as principais barreiras, ao exercício do direito de acesso aos cuidados de saúde transfronteiriços, pelos beneficiários do SNS em Portugal, derivadas da aplicação de tais instrumentos legais. 3. METODOLOGIA: Foi utilizada uma abordagem analítica e documental, baseada na metodologia qualitativa. 4. CONCLUSÕES: As principais barreiras ao direito de acesso aos cuidados de saúde transfronteiriços, para os beneficiários do SNS em Portugal, são de ordem financeira, linguística e cultural, informacional, de mobilidade física, de proximidade geográfica, de carácter administrativo e de continuidade dos cuidados. A transposição da Directiva 2011/24/UE para o quadro jurídico português resulta essencialmente em iniquidades no âmbito do acesso aos cuidados de saúde transfronteiriços.

Concomitant involvement of the small intestine and the distal esophagus in an infant with massive necrotizing enterocolitis

Necrotizing enterocolitis is a disease of the newborn that may involve the small intestine and/or the colon, and the stomach. To our knowledge, massive necrosis of the small intestine with concomitant involvement of the esophagus has never been reported. A case of a 6-month-old boy with necrotizing enterocolitis and pan-necrosis of the small intestine, cecum, and the lower third of the esophagus is presented. After 70 days of treatment, intestinal transit was established by an anastomosis between the first centimeter of jejunum and the ascending colon. Finally, esophageal transit was established by a total gastric transposition with cervical esophagogastric anastomosis. The patient was maintained under total parenteral nutrition, and after 19 months he developed fulminant hepatic failure due to parenteral nutrition; he then underwent combined liver and small bowel transplantation. After 2 months, the patient died due to undefined neurologic complications, probably related to infection or immunosuppressive therapy.

Mark Rothko : Da origem mítica à refundação artística do mundo

Fenómeno assinalável no nosso século foi a emergência da chamada “arte global” (Belting), dando conta da crise do “mundo da arte” e a disseminação generalizada das práticas artísticas. Neste contexto a obra de Rothko ganha uma força inesperada. Sendo usualmente inscrito no “modernismo” com os seu valores de pureza e especificidade do meio, neste caso a pintura, a nossa investigação revela que o gesto Rothkoniano excede largamente esta representação, que levaria a distinguir radicalmente entre uma fase mítica e surrealista, uma fase abstracionista dos “colour field” e finalmente uma fase sublime das pinturas da Capela Ecuménica de Rothko. Existe uma continuidade evidente que remete para uma geoestética, onde a terra e a sua habitabilidade desempenham um papel crucial. Daí a necessidade de inscrever a obra de Rothko na geofilosofia contemporânea, tal com foi delineada por Gilles Deleuze e Félix Guattari. Procedeu-se, assim, a uma análise crítica da obra e da estética de Rothko, que profeticamente, mas inconscientemente, parece abrir o caminho para o pensamento de uma arte da terra. Trata-se de uma linha de continuidade que atravessa toda a obra de Rothko, refletindo uma picturação do mundo e a vontade de criar de um mundo pictórico e poético, reduzido a elementos mínimos, pós-figurativos mas onde se reconhece a incidência dos motivos como frame e abertura, linha de horizonte e pórticos e passagens. Num segundo momento, explora-se essa dimensão “inconsciente” num projeto artístico pessoal, que se desdobra em abordagens picturais, de pintura, de instalação e de vídeo, que denominamos por “A Terra como Acontecimento”. Este projeto prolonga o esforço Rothkoniano, ao mesmo tempo que o altera profundamente, nomeadamente pelo uso dos materiais, pela mutação no uso da cor, bem como pela maneira como os elementos figurativos são radicalmente alterados pela mera transposição da perspetiva usada. Se a ressonância rothkoniana está bem presente, não menos presente está a intenção de um confronto dialogante com a Obra de Mark Rothko. Aquilo que neste importante artista, era o inconsciente, marcado pelo mito e teologia, pela delimitação da linha de horizonte, bem clássica, e, acima de tudo, pela sua verticalidade marcadamente teológica, “A Terra como Acontecimento” é a matéria que é profundamente radicalizada, bem como a lógica concetual, a qual é preferentemente circular, sem orientação absoluta, e incompleta, o que implica uma outra visão da “abertura”/”fecho”, tão essencial na obra de Rothko. Desta investigação espera-se um contributo significativo para os debates atuais sobre a arte na contemporaneidade.

A liberalização do mercado energético e o papel das entidades reguladoras

The liberalisation of the energy market goes back to the 1990s, when it was impelled by the European legislator. Since then, three legislative packages, temporarily successive, were approved. Those packages contained the measures to be implemented in order to deepen the internal energy market. Besides the opening up of several national markets to competition, the European legislator aimed the creation of a real internal energy market within the European Union. The unbundling regime was one of the most important steps with respect to the liberalisation process. The introduction of these rules ensured independence to the various market operators. A real and effective right of choice was granted to the consumers so they may choose their electricity and natural gas supplier. Therefore, the activity of comercialisation is subject to competition. However, some activities of the electricity’s and natural gas’ chain of value, namely the activities of transportation and distribution, were kept under regulation rules. Even though it may seem odd, the assignment of important competences and strong powers to a regulatory authority was essential in order to achieve the liberalisation process’ goals. Electricity and natural gas are essential public goods; therefore the market operators are legally bound to public service obligations, such as the security, the universality and the continuity of the supply. The performance of these obligations may become, in some cases, unprofitable for those operators. For such reason, the protection of the consumers’ rights shall only be properly defended if there is a regulatory authority that monitors the behaviour of the operators and sanctions the failure to comply with the public service obligations. Portugal, as a Member State of the European Union, transposed into the national legal order the European directives concerning the liberalisation process. This transposition has caused radical changes to the electricity and natural gas’ national markets. The Entidade Reguladora dos Serviços Energéticos also suffered various mutations in order to keep up with the regulatory demands regarding the liberalisation process.

Os processos criativos na aprendizagem da técnica do violoncelo no ensino vocacional de música

Relatório de estágio de mestrado em Ensino de Música

As agências europeias no Direito Administrativo Europeu

Dissertação de mestrado em Direito Administrativo

A linear algebra approach to OLAP

Inspired by the relational algebra of data processing, this paper addresses the foundations of data analytical processing from a linear algebra perspective. The paper investigates, in particular, how aggregation operations such as cross tabulations and data cubes essential to quantitative analysis of data can be expressed solely in terms of matrix multiplication, transposition and the Khatri–Rao variant of the Kronecker product. The approach offers a basis for deriving an algebraic theory of data consolidation, handling the quantitative as well as qualitative sides of data science in a natural, elegant and typed way. It also shows potential for parallel analytical processing, as the parallelization theory of such matrix operations is well acknowledged.

Redefining the MED13L syndrome

Congenital cardiac and neurodevelopmental deficits have been recently linked to the mediator complex subunit 13-like protein MED13L, a subunit of the CDK8-associated mediator complex that functions in transcriptional regulation through DNA-binding transcription factors and RNA polymerase II. Heterozygous MED13L variants cause transposition of the great arteries and intellectual disability (ID). Here, we report eight patients with predominantly novel MED13L variants who lack such complex congenital heart malformations. Rather, they depict a syndromic form of ID characterized by facial dysmorphism, ID, speech impairment, motor developmental delay with muscular hypotonia and behavioral difficulties. We thereby define a novel syndrome and significantly broaden the clinical spectrum associated with MED13L variants. A prominent feature of the MED13L neurocognitive presentation is profound language impairment, often in combination with articulatory deficits.

Investigations on relational control of time perception

Tese de Doutoramento em Psicologia Básica

Dynamic three-dimensional reconstruction of the heart by transesophageal echocardiography

OBJECTIVE: To evaluate echocardiography accuracy in performing and obtaining images for dynamical three-dimensional (3D) reconstruction. METHODS: Three-dimensional (3D) image reconstruction was obtained in 20 consecutive patients who underwent transesophageal echocardiography. A multiplanar 5 MHz transducer was used for 3D reconstruction. RESULTS: Twenty patients were studied consecutively. The following cardiac diseases were present: valvar prostheses-6 (2 mitral, 2 aortic and 2 mitral and aortic); mitral valve prolapse- 3; mitral and aortic disease - 2; aortic valve disease- 5; congenital heart disease- 3 (2 atrial septal defect- ASD - and 1 transposition of the great arteries -TGA); arteriovenous fistula- 1. In 7 patients, color Doppler was also obtained and used for 3D flow reconstruction. Twenty five cardiac structures were acquired and 60 reconstructions generated (28 of mitral valves, 14 of aortic valves, 4 of mitral prostheses, 7 of aortic prostheses and 7 of the ASD). Fifty five of 60 (91.6%) reconstructions were considered of good quality by 2 independent observers. The 11 reconstructed mitral valves/prostheses and the 2 reconstructed ASDs provided more anatomical information than two dimensional echocardiography (2DE) alone. CONCLUSION: 3D echocardiography using a transesophageal transducer is a feasible technique, which improves detection of anatomical details of cardiac structures, particularly of the mitral valve and atrial septum.

Problemáticas de la interacción discursiva en la enseñanza y el aprendizaje de las Ciencias Naturales. Aportes didácticos. Interaction discoursive issues in teaching and learning Natural Sciences. Didactic contributions

Las didácticas específicas de las ciencias naturales revelan diferentes problemáticas en su enseñanza y aprendizaje en los diferentes niveles del sistema educativo. En particular, en las clases de ciencias la interacción discursiva docente alumnos adquiere relevancia, ya que el proceso de comunicación del conocimiento es uno de los pilares didácticos, junto a la trasposición del mismo. Especificamente, en este proyecto nos abocamos a aquellas intervenciones de docentes y alumnos que se relacionan con la construcción del conocimiento biológico y químico. El proyecto se enmarca en una actual linea de trabajo que indaga sobre las dificultades en los abordajes del conocimiento científico en las aulas, las características del discurso entre docentes y alumnos, las habilidades y dificultades en la comprensión de los enunciados de problemas y las características de los textos que se utilizan en las clases. Se focaliza este estudio en casos que intentan dar respuesta a tres temáticas, agrupadas en un conjunto de situaciones de investigación relacionadas con la interacción discursiva docente-alumno, retomando el rol del docente al hablar, guiar o diseñar las situaciones de referencia para el aprendizaje de los alumnos. Los casos son: 1- En cuanto a las concepciones sobre diversidad biológica en estudiantes de escuela secundaria y en textos académicos, atendemos a cómo la escuela presenta los contenidos ecológicos como un conjunto de dogmas y conceptos estáticos. Además suelen simplificarse conceptualmente y presentarse poco actualizados. Es por ello que se planea estudiar las concepciones y actitudes de los alumnos de secundaria sobre la biodiversidad, cómo estas dificultan su comprensión y los textos usados en relación a la promoción de la transposición didáctica. 2- En relación a cómo se elabora el patrón temático del tema célula en clases de Biología, se analizarán las diferentes estrategias de significados y de desarrollo temático, que se emplean en la comunicación aulica. Se intentará establecer si hay cambios en el desarrollo temático a medida que se avanza en la escolaridad. Esto es porque se puede apreciar que muchos de los problemas de aprendizaje del alumnado se deben a un desconocimiento tanto del patrón temático como del patrón estructural de la ciencia, siendo preciso evocar los patrones temáticos que se quieren utilizar, para construir un conocimiento compartido. 3-Finalmente, en los enunciados de problemas de Química, se analizarán las dificultades de comprensión lectora de alumnos de Ingeniería. Los docentes frecuentemente atribuyen los problemas a deficiencias en la instrucción recibida, sin considerarse los conocimientos previos del alumno, los obstáculos conceptuales originados en el tema, las deficiencias en la habilidad lectora, el tipo textual predominante en la consigna, el formato en el que se escribió la consigna y los factores personales, etc., siendo que la comprensión del enunciado de una consigna de trabajo condiciona fuertemente la posibilidad de su resolución. Los tres casos utilizarán metodologías cualitaritas que incluyan análisis de contenido en discursos orales y escritos. Los datos se registrarán desde observación no participante, registro etnográfico y con grabaciones de audio. Se espera contribuir al conocimiento, realizando aportes a la formación docente en tanto las estrategias discursivas que se emplean en el aula, en forma oral y en la escrita, conocer concepciones que dificultan o favoren la construcción del conocimiento científico, entre otras. Los productos de estos estudios estarán integrados por nuevos desarrollos para la formación docente, publicaciones científicas de impacto nacional e internacional, presentaciones a congresos, materiales didácticos y divulgativos, dictado de seminarios y/o cursos, redacción de informes a las escuelas intervinientes.. The specific Natural Sciences didactics show different problems in teaching and learning along the school system. In particular, the discourse used to communicate knowledge in Science lessons becomes important. With this project we will focus on the teachers and students actions regarding the construction of biological and chemical knowledge. This project attempts to answer these issues and brings together a range of research situations related to teacher-student interaction, through discourse, taking up the role of the teacher to speak, to plan and to guide student learning. We will study the ideas and attitudes of high school students about biodiversity that make difficult its understanding and the textbooks used in relation to promotion of the didactic transposition. In addition, regarding how the thematic pattern in biology classes is costructed, it will be analyzed the different meaning and thematic development strategies that are used in communication. We will attempt to establish whether there are any changes in the thematic development throughout high school education. Finally, we will analyze the reading comprehension problems in engineering students. Teachers frequently attribute these issues to deficiencies in prior education, without considering the students background, the conceptual obstacles arising in the field, the format in which the prompt is written, personal factors, etc., keeping in mind that the outcome of an activity is strictly dependant con the prompt understanding. We expect to make contributions to the teacher education in both the discourse strategies used in the classroom, orally and in writing, to learn about the conceptions that hinder or favor the knowledge construction, among others. The products of this study will be national and international impact scientific publications, conference presentations, popular science publications, seminars courses and reports to the schools involeved.

Palliative Senning in the Treatment of Congenital Heart Disease with Severe Pulmonary Hypertension

Background:Transposition of the great arteries (TGA) is the most common cyanotic cardiopathy, with an incidence ranging between 0.2 and 0.4 per 1000 live births. Many patients not treated in the first few months of life may progress with severe pulmonary vascular disease. Treatment of these patients may include palliative surgery to redirect the flow at the atrial level.Objective:Report our institutional experience with the palliative Senning procedure in children diagnosed with TGA and double outlet right ventricle with severe pulmonary vascular disease, and to evaluate the early and late clinical progression of the palliative Senning procedure.Methods:Retrospective study based on the evaluation of medical records in the period of 1991 to 2014. Only patients without an indication for definitive surgical treatment of the cardiopathy due to elevated pulmonary pressure were included.Results:After one year of follow-up there was a mean increase in arterial oxygen saturation from 62.1% to 92.5% and a mean decrease in hematocrit from 49.4% to 36.3%. Lung histological analysis was feasible in 16 patients. In 8 patients, pulmonary biopsy grades 3 and 4 were evidenced.Conclusion:The palliative Senning procedure improved arterial oxygen saturation, reduced polycythemia, and provided a better quality of life for patients with TGA with ventricular septal defect, severe pulmonary hypertension, and poor prognosis.

Hereditariedade da homeose

A preliminary account on the normal development of the imaginai discs in holometabolic Insects is made to serve as an introduction to the study of the hereditary homoeosis. Several facts and experimental data furnished specially by the students of Drosophila are brought here in searching for a more adequate explanation of this highly interesting phenomenon. The results obtained from the investigations of different homoeotic mutants are analysed in order to test Goldschmidt's theory of homoeosis. Critical examination of the basis on which this theory was elaborated are equally made. As a result from an extensive theoretical consideration of the matter and a long discussion of the most recent papers on this subject the present writer concludes that the Goldschmidt explanation of the homoeotic phenomena based on the action of diffusing substances produced by the genes, the "evocators", and on the alteration of the normal speed of maturation of the imaginai discs equally due to the activity of the genes, could not be proved and therefore should be abandoned. In the same situation is any other explanation like that of Waddington or Villee considered as fundamentally identical to that of Goldschmidt. In order to clear the problem of homoeosis in terms which seem to put the phenomenon in complete agreement with the known facts the present writer elaborated a theory first published a few years ago (1941) based entirely on the assumption that the imaginai discs are specifically determined by some kind of substances, probably of chemical nature, contained in the cytoplam of the cells entering in the consti- tution of each individual disc. These substances already present in the blastem of the egg in which they are distributed in a definite order, pass to different cells at the time the blastem is transformed into blastoderm. These substances according to their organogenic potentiality may be called antenal-substance, legsubstance, wing-substance, eye-substance, etc. The hipoderm of the embryo resulting from the multiplication of the blastoderm cells would be constituted by a series of cellular areas differing from each other in their particular organoformative capacity. Thus the hypoderm giving rise to the imaginai discs, it follows that each disc must have the same organogenic power of the hypodermal area it came from. Therefore the discs i*re determinated since their origin by substances enclosed in the cytoplasm of their cells and consequently can no longer alter their potentiality. When an antennal disc develops into a leg one can conclude that this disc in spite of its position in the body of the larva is not, properly speaking, an antennal disc but a true leg disc whose cells instead of having in their cytoplasm the antennal substance derived from the egg blastem have in its place the leg-substance. Now, if a disc produces a tarsus or an antenna or even a compound appendage partly tarsus-like, partly antenna-like, it follows tha,t both tarsal and antennal substances are present in it. The ultimate aspect of the compound structure depends upon the reaction of each kind of substance to the different causes influencing development. For instance, temperature may orient the direction of development either lowards arista or tarsus, stimulating, or opposing to the one or the other of these substances. Confering to the genes the faculty of altering the constitution of the substances containing in the cytoplasm forming the egg blastem or causing transposition of these substances from one area to another or promoting the substitution of a given substance by a different one, the hereditary homoeocis may be easily explained. However, in the opinion of the present writer cytoplasm takes the initiative in all developmental process, provoking the chromosomes to react specifically and proportionally. Accordingly, the mutations causing homoeotic phenomena may arise independently at different rime in the cytoplasm and in the chromosomes. To the part taken by the chromosomes in the manifestation of the homoeotic characters is due the mendalian ratio observed in homoeotic X normal crosses. Expression, in itself, is mainly due to the proportion of the different substances in the cells of the affected discs. Homoeotic phenomena not presenting mendelian ratio may appear as consequence of cytoplasmic mutation not accompanied by chromosomal mutation. The great variability in the morphology of the homoeotic characteres, some individual being changed towards an extreme expression of the mutant phenotype while others in spite of their homozigous constitution cannot be distinguished from the normal ones, strongly supports the interpretation based on the relative proportion of the determining substances in the discs. To the same interpretation point also asymetry and other particularities observed in the exteriorization of the phenomenon. In conformity with this new conception homoeosis should not prove homology of Insect appendages (Villee 1942) since a more replacement of substances may cause legs to develop in substitution of the wings, as it was already observed (requiring confirmation in the opinion of Bateson 1894, p. 184) and no one would conclude for the homology of these organs in the usual meaning of the term.

Prise en charge des troubles oculomoteurs après effraction iatrogène de l'orbite au cours d'interventions sinusiennes endoscopiques [Management of motility disorders secondary to iatrogenic orbital fracture during endoscopic sinus surgery.]

PURPOSE: Orbital wall fracture may occur during endoscopic sinus surgery, resulting in oculomotor disorders. We report the management of four cases presenting with this surgical complication. METHODS: A non-comparative observational retrospective study was carried out on four patients presenting with diplopia after endoscopic ethmoidal sinus surgery. All patients underwent full ophthalmologic and orthoptic examination as well as orbital imaging. RESULTS: All four patients presented with diplopia secondary to a medial rectus lesion confirmed by orbital imaging. A large horizontal deviation as well as limitation of adduction was present in all cases. Surgical management consisted of conventional recession-resection procedures in three cases and muscle transposition in one patient. A useful field of binocular single vision was restored in two of the four patients. CONCLUSION: Orbital injury may occur during endoscopic sinus surgery and cause diplopia, usually secondary to medial rectus involvement due to the proximity of this muscle to the lamina papyracea of the ethmoid bone. Surgical management is based on orbital imaging, duration of the lesion, evaluation of anterior segment vasculature, results of forced duction testing and intraoperative findings. In most cases, treatment is aimed at the symptoms rather than the cause, and the functional prognosis remains guarded.

Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and meta-analysis.

PURPOSE: Investigation of the incidence and distribution of congenital structural cardiac malformations among the offspring of mothers with diabetes type 1 and of the influence of periconceptional glycemic control. METHODS: Multicenter retrospective clinical study, literature review, and meta-analysis. The incidence and pattern of congenital heart disease in the own study population and in the literature on the offspring of type 1 diabetic mothers were compared with the incidence and spectrum of the various cardiovascular defects in the offspring of nondiabetic mothers as registered by EUROCAT Northern Netherlands. Medical records were, in addition, reviewed for HbA(1c) during the 1st trimester. RESULTS: The distribution of congenital heart anomalies in the own diabetic study population was in accordance with the distribution encountered in the literature. This distribution differed considerably from that in the nondiabetic population. Approximately half the cardiovascular defects were conotruncal anomalies. The authors' study demonstrated a remarkable increase in the likelihood of visceral heterotaxia and variants of single ventricle among these patients. As expected, elevated HbA(1c) values during the 1st trimester were associated with offspring fetal cardiovascular defects. CONCLUSION: This study shows an increased likelihood of specific heart anomalies, namely transposition of the great arteries, persistent truncus arteriosus, visceral heterotaxia and single ventricle, among offspring of diabetic mothers. This suggests a profound teratogenic effect at a very early stage in cardiogenesis. The study emphasizes the frequency with which the offspring of diabetes-complicated pregnancies suffer from complex forms of congenital heart disease. Pregnancies with poor 1st-trimester glycemic control are more prone to the presence of fetal heart disease.