Children are the cornerstone of the community as well as the future of society. Child abuse and suicide among the young population is a serious and prevalent problem. Through a number of survey studies undertaken in other countries including Canada, United States, and Australia, researchers demonstrated that child abuse was related to suicidal behavior. However, this association had not been examined in Hong Kong. However, the number of hospital admissions for child abuse in Hong Kong had increased from 15.6 to 61.9 per 100,000 between 1995 and 2015 and 3.7% of child abuse cases had previously recorded suicide attempts. This study aimed to identify the association between child abuse and suicide attempts compared with influenza infection using electronic hospital admission records. From January 1, 1995 to July 31, 2016, patients with admission age < 18 years with the diagnosis of child abuse or influenza infection were included in this study (n = 54,256). The study also retrieved data on suicide attempt hospital admissions after the first hospital admission from the database. The study results demonstrate that the adjusted hazard ratio indicated that at any given point of time, child abuse subjects had 4.79 times higher risk (95% CI 3.88 to 5.92) of attempting suicide compared with influenza infected subjects. The hazard ratio for sexual abuse and physical abuse compared with the influenza infected group was 6.48 (95% CI 4.56 to 9.19) and 4.83 (95% CI 3.67 to 6.34). Study results indicated that there was a significant association between child abuse and suicide attempts in Hong Kong. If confirmed, the study results may inform policy and interventions to reduce child abuse and consequently child suicide attempts.

Made available in DSpace on 2014-06-11T19:28:04Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-01-22Bitstream added on 2014-06-13T20:36:55Z : No. of bitstreams: 1 varallo_fr_me_arafcf.pdf: 2844690 bytes, checksum: 3c22713b3171e234e431e8c9717a455d (MD5) / Reações Adversas a Medicamentos (RAM) são um importante problema de saúde pública, pois reduzem a qualidade de vida do paciente e geram gastos desnecessários aos hospitais. Por isso, o presente estudo estimou a prevalência de internações hospitalares por possível RAM, identificou o perfil demográfico dos pacientes acometidos, bem como os fármacos e as possíveis RAM mais frequentemente relacionadas com as internações hospitalares. Para tanto, realizou-se um estudo observacional e transversal na clínica médica de um hospital de ensino, entre os meses de agosto a dezembro de 2008. Os pacientes foram entrevistados sobre os sintomas/queixas/motivos de internação que os levaram ao hospital e quais medicamentos utilizaram nos 15 dias prévios à internação. Durante o período do estudo, observou-se que a internação hospitalar estava relacionada com possível RAM em 115 pacientes (46,4%), sendo a maioria mulheres e não-idosos. Os fármacos mais frequentemente relacionados com a internação foram os que atuam nos sistemas: cardiovascular (48,7%), digestório (22,9%) e nervoso central (14,1%). Quanto ao tipo de receituário dos medicamentos responsáveis por RAM, 90,9% eram sob prescrição, sendo que 9,4% eram sujeitos a controle especial e 9,1% eram isentos de prescrição. Dos medicamentos responsáveis pelas internações, 58% pertenciam à lista RENAME. Em relação aos idosos, 43,9% utilizaram medicamentos impróprios, os quais foram possivelmente responsáveis pela internação de 29,2% pacientes. As manifestações clínicas das RAM mais comuns foram: do aparelho digestório (23,0%), dos aparelhos respiratório (20,2%) e circulatório (14,6%), além de sintomas, sinais e achados anormais de exames clínicos e laboratoriais (20,2%). Apenas a polimedicação foi detectada como fator de risco para internações por possível RAM. Estudos farmacoepidemiológicos como este... / Adverse Drug Reaction (ADR) is an important public health concern, because they decrease the patient’s quality of life and raise the unnecessary expenditure for the hospital. The purpose of this study was to: 1) assess the prevalence of ADR-related admission; 2) identify the demographic characteristics of the patients with ADR; 3) identify the main drugs and the ADR more often associated with hospitalization. A cross-sectional observational study was performed. It was conducted in an internal medicine ward in a teaching hospital and the data was collected from August 2008 to December 2008. The patients were interviewed about their symptoms, complaints, and causes of hospitalization, which were responsible to the hospital admission and what were the drugs used 15 days prior the hospitalization. During the period of the study, it was observed ADR-related admission in 115 (46.4%) patients; the majority was woman and no-elderly. Medications that were commonly involved in these cases were those acting on the cardiovascular (48.7%), gastrointestinal (22.9%) and nervous system (14.1%). Regarding the type of prescription medicines, 90.6% were under prescription, of these 9.4% still were subjected to special control, and 9.1% were non-prescription drugs. 58.0% medicines ADR-related admission belonged to RENAME’s list. Considering the elderly people, 43.9% of them used inappropriate drugs, which were possibly responsible for hospitalization in 29.2% patients. The clinical manifestations of RAM most commonly associated with the hospitalization were: gastrointestinal system (23.0%), abnormal findings in clinical and laboratory tests (20.2%), respiratory system (20.2%) and circulatory system (14.6%). Only polipharmacy was detected as a risk factor for ADR-related admission. The present pharmacoepidemiological study shows the need of patient’s therapeutic monitoring in the first... (Complete abstract click electronic access below)

Each year, hospitalizations from long-term care (LTC) settings occur, in part, due to underdeveloped nursing assessment skills, ineffective communication with primary care providers (PCPs), and delayed intervention. Through staff development nursing education, the quality and timeliness of care can be improved. The practice question that guided this doctoral project focused on whether evidence-based research information would assist in decreasing LTC-to-hospital admission rates through improved nursing assessment skills and better communication with PCPs. Using the logic model, the effectiveness of a program was evaluated and the impact of interventions on a predicted outcome was determined. Sources of evidence included obtaining best practice research information from scholarly nursing journals and official nursing websites. Analytical strategies included a review of the literature to examine data from nursing journals, websites, and other publication sources in addition to the use of a synthesis matrix that classified different ideas rated by the Cochrane Consumer Network. The findings of this project might contribute to positive social change by fostering improved patient assessments, enhanced communication with PCPs, early intervention, and decreased LTC-to-hospital admission rates through the improvement of nursing practice policy.

Resumo: Reações Adversas a Medicamentos (RAM) são um importante problema de saúde pública, pois reduzem a qualidade de vida do paciente e geram gastos desnecessários aos hospitais. Por isso, o presente estudo estimou a prevalência de internações hospitalares por possível RAM, identificou o perfil demográfico dos pacientes acometidos, bem como os fármacos e as possíveis RAM mais frequentemente relacionadas com as internações hospitalares. Para tanto, realizou-se um estudo observacional e transversal na clínica médica de um hospital de ensino, entre os meses de agosto a dezembro de 2008. Os pacientes foram entrevistados sobre os sintomas/queixas/motivos de internação que os levaram ao hospital e quais medicamentos utilizaram nos 15 dias prévios à internação. Durante o período do estudo, observou-se que a internação hospitalar estava relacionada com possível RAM em 115 pacientes (46,4%), sendo a maioria mulheres e não-idosos. Os fármacos mais frequentemente relacionados com a internação foram os que atuam nos sistemas: cardiovascular (48,7%), digestório (22,9%) e nervoso central (14,1%). Quanto ao tipo de receituário dos medicamentos responsáveis por RAM, 90,9% eram sob prescrição, sendo que 9,4% eram sujeitos a controle especial e 9,1% eram isentos de prescrição. Dos medicamentos responsáveis pelas internações, 58% pertenciam à lista RENAME. Em relação aos idosos, 43,9% utilizaram medicamentos impróprios, os quais foram possivelmente responsáveis pela internação de 29,2% pacientes. As manifestações clínicas das RAM mais comuns foram: do aparelho digestório (23,0%), dos aparelhos respiratório (20,2%) e circulatório (14,6%), além de sintomas, sinais e achados anormais de exames clínicos e laboratoriais (20,2%). Apenas a polimedicação foi detectada como fator de risco para internações por possível RAM. Estudos farmacoepidemiológicos como este... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract : Adverse Drug Reaction (ADR) is an important public health concern, because they decrease the patient's quality of life and raise the unnecessary expenditure for the hospital. The purpose of this study was to: 1) assess the prevalence of ADR-related admission; 2) identify the demographic characteristics of the patients with ADR; 3) identify the main drugs and the ADR more often associated with hospitalization. A cross-sectional observational study was performed. It was conducted in an internal medicine ward in a teaching hospital and the data was collected from August 2008 to December 2008. The patients were interviewed about their symptoms, complaints, and causes of hospitalization, which were responsible to the hospital admission and what were the drugs used 15 days prior the hospitalization. During the period of the study, it was observed ADR-related admission in 115 (46.4%) patients; the majority was woman and no-elderly. Medications that were commonly involved in these cases were those acting on the cardiovascular (48.7%), gastrointestinal (22.9%) and nervous system (14.1%). Regarding the type of prescription medicines, 90.6% were under prescription, of these 9.4% still were subjected to special control, and 9.1% were non-prescription drugs. 58.0% medicines ADR-related admission belonged to RENAME's list. Considering the elderly people, 43.9% of them used inappropriate drugs, which were possibly responsible for hospitalization in 29.2% patients. The clinical manifestations of RAM most commonly associated with the hospitalization were: gastrointestinal system (23.0%), abnormal findings in clinical and laboratory tests (20.2%), respiratory system (20.2%) and circulatory system (14.6%). Only polipharmacy was detected as a risk factor for ADR-related admission. The present pharmacoepidemiological study shows the need of patient's therapeutic monitoring in the first... (Complete abstract click electronic access below) / Orientador: Cleópatra da Silva Planeta / Coorientador: Patrícia de Carvalho Mastroianni / Banca: Cleópatra da Silva Planeta / Banca: Regina Célia Garcia de Andrade / Banca: Leonor de Castro Monteiro Loffredo / Mestre

Symptom control may become challenging for terminally ill patients as they near the end of life. Patients often seek hospital admission to address symptoms, such as pain, nausea, vomiting, and restlessness. Alternatively, palliative medicine focuses on the control and mitigation of symptoms, while allowing patients to maintain their quality of life, whether in an outpatient or inpatient setting. Hospice care provides, in addition to inpatient care at a hospice facility or in a hospital, the option for patients to receive symptom management at home. This option for symptom control in the outpatient setting is essential to preventing repeated and expensive hospital readmissions. This article discusses the impact of hospice care on hospital readmission rates.

Por existirem poucos estudos sobre o momento da internação hospitalar para a realização da cirurgia por câncer de mama, decidiu-se melhor compreender este momento a partir do referencial da teoria das representações sociais e da teoria do enfrentamento, buscando-se em um grupo de mulheres a identificação do significado da admissão hospitalar necessária para a realização da cirurgia, bem como as estratégias de enfrentamento por elas utilizadas nesse momento. A coleta de dados foi realizada numa amostra composta por 10 mulheres e pelos principais profissionais envolvidos em suas admissões. Com as mulheres foram realizadas observações participantes com a utilização do diário de campo e entrevistas semi-estruturadas, analisadas qualitativamente; e os profissionais foram observados com a utilização de um instrumento aberto-fechado, analisado qualitativa e quantitativamente. Em relação às mulheres, foram identificadas as seguintes categorias: perda da mama, medo da morte, cura, cuidado enquanto estratégia de retorno à saúde e dia normal. As estratégias de enfrentamento identificadas foram: médicos, Deus, ela própria, crenças próprias, família, namorado, outros que passaram pela mesma experiência, coragem, confiança, força de vontade, oração, não pensar e convivência com pessoas brincalhonas capazes de passar energia boa. A análise conjunta das representações sociais com as estratégias de enfrentamento evidenciou que em 70% das participantes houve relação entre o significado atribuído à admissão hospitalar e as estratégias de enfrentamento utilizadas. A relação entre as representações sociais e as estratégias de enfrentamento mostrou que as categorias: cura, cuidado enquanto estratégia de retorno à saúde e dia normal foram as mais eficazes no enfrentamento da admissão hospitalar. O instrumento utilizado com os principais profissionais que realizaram as admissões hospitalares mostrou que 100% dos principais responsáveis pelas admissões hospitalares foram enfermeiras; 100% delas tentaram estabelecer um vínculo positivo com as mulheres no momento do chamamento; 80% não se apresentaram às mulheres que receberam; 90% utilizaram preferencialmente o termo senhora no período em que permaneceram com as mulheres; 100% demonstraram preocupação com o ambiente físico relacionado à admissão hospitalar; 70% mostraram-se dispostas a ouvir as mulheres recebidas; 80% receberam as mulheres na posição ereta e, 60% das admissões hospitalares ocorreram com a presença de uma enfermeira e uma auxiliar de enfermagem. Alguns desses dados permitiram verificar que esses profissionais forneceram suporte às mulheres, mas ao mesmo tempo outros dados mostraram que estes mesmos profissionais se distanciaram de um cuidado capaz de contemplar os aspectos físicos, mentais e espirituais dessas mulheres. Pontua-se, a partir desta análise, a necessidade do estabelecimento da subjetividade no momento da internação como forma de identificação das necessidades das mulheres com câncer de mama. Para tanto, sugere-se a construção de um complemento para o protocolo de admissão hospitalar atualmente utilizado na enfermaria, onde os dados deste estudo foram coletados. / For existing few studies on the moment of the hospital internment for the accomplishment of the surgery for breast cancer, it was more good decided to understand this moment from the referencial of the theory of the social representations and the theory of coping, searching in a group of women the identification of the meaning of the necessary hospital admission for the accomplishment of the surgery. The collect of data was carried through in a composed sample for 10 women and the main involved professionals in its admissions. With the women were done participant observations with utilization of field notes and semi-structured interviews that were qualitative analyzed, and the professionals were observed with utilization of open-closed instrument, that was analyzed in a qualitative and quantitative way. In relation to the women, were identified these categories: loss of the breast, fear of the death, cure, care while return strategy the health and normal day. The strategies of coping identified were: physicians, God, herself, own believes, family, boyfriend, others that had passed for the same experience, courage, confidence, will-power, prayer, don’t think and stay together of joking people that are capable to pass good energy. The analyze of social representations and strategies of coping together showed that in 70% of participants were relation between the meaning attributed to he hospital admission and the strategies of coping used. The relation between social representations and strategies of coping showed that the categories: cure, holistic care and normal day were the most effective in the coping of hospital admission. The instrument used with the main professionals who had carried through the hospital admissions showed that 100% of these professionals were nurse; 90% had used the term preferential lady in the period where they had remained with the women; 100% had demonstrated concern with the related physical environment to the hospital admission; 70% had revealed made use to hear the received women; 80% had received the women in erect position e, 60% of the hospital admissions had occurred with the presence of a nurse and one nurse aid. Some of these data had allowed to verify that these professionals had supplied support to the women, but at the same time other data had shown that these same professionals were distant of a care capable to contemplate the physical aspects, mental and spirituals of these women. From this analyze the necessity of the establishment of subjectivity in the moment of admission is emphasized as form of identification of the necessities of the women with breast cancer. For this, it is suggested construction of a complement for the protocol of hospital admission currently used in the infirmary, where the data of this study had been collected.

Introdução: A internação psiquiátrica pode ser: voluntária; involuntária; compulsória. Esta última é determinada pela autoridade judicial não podendo ser questionada em seu aspecto legal, entretanto cabem questionamentos quanto aos aspectos técnicos e éticos. Objetivo: Discutir como a Equipe Multiprofissional de uma enfermaria psiquiátrica que vivencia o cuidado ao paciente em internação compulsória. Método: estudo de caso descritivo, compreensivo, por meio de pesquisa quantiqualitativa, no Serviço de Internação Psiquiátrica do Hospital de Clínicas Dr. Alberto Lima, no município de Macapá- AP. Participaram os servidores maiores de 18 anos, de ambos os sexos, de locais e níveis socioeconômicos variados e que assinaram o Termo de Consentimento Livre e Esclarecido. Coleta de dados: utilizou-se o questionário sociodemográfico e econômico e foram feitas entrevistas semiestruturadas. Foi realizado Grupo Focal (GF), em que se apresentaram os discursos elaborados, a fim de que, diante dos diferentes entendimentos, os discursos espontâneos analisados fossem apresentados aos entrevistados da equipe multiprofissional e, para isso, foi estabelecida uma conversa sobre a realidade vivenciada. Para o tratamento dos dados qualitativos, aplicou-se a técnica do Discurso do Sujeito Coletivo (DSC); os dados quantitativos foram expressos pelo pacote Excel e analisados por meio do software Bioestat 5.3. Resultados: Destacaram-se características da Enfermaria Psiquiátrica e a caracterização sociodemográfica e clínica das internações. A equipe é predominantemente do sexo feminino, a maior parte trabalha em outros serviços e possui nível de escolaridade superior completo. A partir das entrevistas, emergiram os DSCs, apresentados por categoria, as ancoragens, vistas como desafios éticos identificados sob a ótica da vivência do cuidado. O estudo mostrou que há empatia dos profissionais com o sofrimento das mães e familiares das pessoas com transtornos mentais e que precisam internação compulsória e consideram que a internação compulsória é uma forma de tratamento, desde que bem indicada. Os participantes destacaram que a ordem médica deveria valer mais que a ordem judicial na determinação da internação compulsória. O Grupo Focal fez emergir as categorias: A difícil experiência do cuidar em internação involuntária/ compulsória; Incipiência da RAPS; Obstáculos para o cuidar de qualidade na internação compulsória e involuntária. Os desafios éticos de cuidar dos pacientes psiquiátricos internados contra a vontade foram revelados pelas ancoragens isoladas nos DSCs: os apenados são pessoas com comportamento inadequado; autoritarismo e paternalismo no tratamento da pessoa com transtorno mental; empatia com o sofrimento familiar; internação psiquiátrica compulsória amparada em sólida avaliação e indicação técnicas; judicialização da saúde e as questões éticas e técnicas desta prática; internação psiquiátrica é necessária, mas somente por avaliação da equipe técnica; justiça não tem poder para avaliar a pessoa se tem ou não indicação para a internação psiquiátrica. Considerações Finais: os profissionais, diante de fatos impositivos pela justiça nas internações psiquiátricas involuntárias/ compulsórias, elegem como prioridade o diálogo entre o Judiciário e os profissionais de saúde como caminho para um possível consenso entre esses segmentos, sem minimizar a responsabilidade de cada um, com o intuito único de prestar atenção adequada e com qualidade à pessoa envolvida no processo de internação compulsória. / Introduction: Psychiatric hospital admission can be: voluntary; involuntary; compulsory. The last one is legally enforced, it cannot be questioned in its legal aspect, however there can be questioning on technical and ethical issues. Objective: To discuss how the Multiprofessional Team of a Psychiatric Ward to experience a patients health care in compulsory hospitalization. Method: descriptive, comprehensive case study by means of quanti-qualitative research at the Psychiatric Admission Service of Hospital de Clínicas Dr. Alberto Lima in the municipality of Macapá Amapá State, Brazil. Male and female healthcare professionals over 18 years of age from varied places and socioeconomic status participated in the study, who signed the Free Informed Consent Form. Data collection: the questionnaire on economic and sociodemographic status was used, as well as semi-structured interviews were carried out. The Focus Group (FG) was held and the elaborated discourses were presented so that the analyzed spontaneous accounts, due to their different understandings, were presented to the participants of the multiprofessional team. Thus, a conversation on the experienced reality was established. The technique of the Discourse of the Collective Subject (DCS) was applied to analyze the qualitative data; quantitative data were expressed by the Excel package and analyzed by means of the Bioestat 5.3 software. Results: Psychiatric Nursing characteristics as well as the sociodemographic and clinical profile of the hospital admissions stood out. Females prevail in the team, most of them work in other services and have complete Higher Education level. From the interviews, the DCSs emerged, presented by category, the anchorages viewed as ethical challenges and identified in the light of lived caring. The study showed the empathy between the professionals and the suffering of mothers and family members of the mentally-ill who need compulsory hospital admission, and they consider it a way of treatment as long as it is well referred. The participants pointed out that a medical order should outstand a legal order in order to determine compulsory admission. The following categories emerged from the Focus Group: The hard experience of caring for the involuntary/compulsory admitted ones; The incipience of the Psychosocial Care Network; Obstacles for the quality care of those undergoing involuntary and compulsory hospital admission. The ethical challenges to care for psychiatric patients hospitalized against their will were unfolded by the isolated anchorages in the DCSs: the convicts are improperly behaved people; authoritarianism and patronizing in the treatment of people with mental disorders; empathy towards family suffering; compulsory psychiatric admission grounded in sound assessment and technical referral; healthcare judicialization and ethical and technical issues in this practice; psychiatric admission is necessary, but only if assessed by a technical team; justice has no power to assess whether a person can be referred to a psychiatric hospital admission or not. Final considerations: due to court orders for involuntary/compulsory hospital admissions, professionals find dialogue as the priority between judicial officers and healthcare professionals as a way for them to come to an agreement, without minimizing the responsibility of any parties, aiming at delivering proper and quality care to the person involved in the process of compulsory hospital admission.

Context: As one of the major causes of death and disability in Canada, research into the treatment and prevention of acute cerebrovascular syndrome (ACVS) remains a priority for clinicians, researchers and the general public. Understanding the relationship between current treatment practices of a rapid stroke clinic and patient outcomes is an essential part of measuring success and considering opportunities for quality improvement. Objective: This study compared the 90-day and 1-year hospital admission and mortality outcomes of patients who were referred to and seen in a rapid stroke clinic (the shows) following an initial transient neurological event (TNE) with those who were referred to but not seen in the same clinic (the no-shows). The specific outcomes examined were stroke events, cardiovascular events and all other hospital events. Methods: In this post-test only non-equivalent group design, data on patient outcomes was collected in the Victoria-based Stroke Rapid Assessment Unit (SRAU) between 2007 and 2013. Analysis included an assessment of group equivalency for possible confounders (age, sex and severity score) and two sets of multivariate logistic regressions were conducted on nine outcomes. Results: An independent t-test revealed there was a statistically significant difference between the mean age of the shows (mean= 68.26) and no-shows (mean= 69.90) (p<0.01). While the proportion of males and females in each of the groups was similar (Fisher’s Exact test, p = 0.831, ns), the severity score of the treatment group (mean= 3.64) was statistically more severe in the show group than the no-show group (mean= 3.50; t = 2.137, p<0.05). Controlling for age, sex and severity score, the odds ratios (ORs) were calculated to compare the odds of various outcomes in the treated (shows) versus the untreated (no-shows) patients groups. ORs for the 90-day and 1-year hospital admissions for stroke-related events were 0.071 (p<0.01) and 0.091 (p<0.01), respectively; the OR for 1-year stroke deaths was 0.167 (p<0.01), indicating a strong protective factor related to attending the clinic appointment. For the cardiovascular outcomes, the ORs for hospitalizations were 0.967 (ns) at 90-days and 0.978 (ns) within 1-year and the OR for the 1-year cardiac-related deaths was 0.391 (ns). For all other outcomes, the ORs were 0.525 (p<0.01) for hospitalizations within 90-days, 0.579 (p<0.01) for hospitalizations within 1-year and 0.299 (p<0.01) for deaths within 1-year. These findings remained consistent with re-analysis excluding subjects who had an event within 5.4 days of their initial TNE. These latter finding largely rules out the possibility that the primary reason the no-shows did not make their clinic appointment, was due to a subsequent hospital event. Conclusion: The ORs for the outcomes show a protective effect of stroke and all other hospital outcomes (but not cardiac events) for patients treated in the rapid assessment clinic. The exclusion of patients who experienced an outcome while waiting for a clinic appointment, lowered the protective effect of the treatment and emphasized the need for rapid assessment but did not alter the main study conclusions. Future research that explores factors influencing appointment adherence and patient attitudes towards acute treatment of TNEs might reveal strategies that could help to reduce the number of patients that remain untreated and at a higher risk for poor outcomes. / Graduate

Recurrent data are widely encountered in many applications. This thesis work focuses on how the recurrent hospital admissions relate to the air pollutants. In particular, we consider the data for two major cities in Saskatchewan. The study period ranges from January 1, 2005 to December 30, 2011 and involves 20,284 patients aged 40 years and older. The hospital admission data is from the Canadian Institute for Health Information (CIHI). The air pollutants data is from the National Air Pollution Surveillance Program (NAPS) from Environment Canada. The data set has been approved by the Biomedical Research Ethics Board, University of Saskatchewan. The gaseous pollutants included in this study are carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), as well as particulate matter PM2:5 (tiny particles in the air that are 2:5 microns in width). In the data analysis, we applied three different existing models to all respiratory diseases and asthma, respectively. The three models are the Poisson process model (also called Andersen-Gill model), the Poisson process model with the number of previous events as a covariate and the Poisson process model with shared gamma distributed frailties (random effects). For all respiratory diseases, the Poisson process model with random effects provides the best t in comparison to the other two models. The model output suggests that the increased risk of hospital readmission is significantly associated with increased CO and O3. For asthma, the Poisson process model provides the best t in comparison to the other two models. We found that only CO and O3 have significant effects on recurrent hospital admissions due to asthma. We concluded this thesis with the discussion on the current and potential future work.

This thesis aims to make contributions at substantive, methodological and theoretical levels. First, the findings from three observational studies are combined to identify obstacles to the use of shared decision-making in modern psychiatric practice. Particular attention is paid to how patients' choices about their treatment are facilitated or constrained by the actions of mental health professionals. A typology of pressure is constructed, based on detailed analyses of how pressure is applied and resisted in routine encounters (outpatient consultations) and "crisis' situations (assessments for compulsory admission to hospital, and ward rounds in acute inpatient care). Findings from two ethnographies and one conversation analysis (CA) study are presented. 'Meaning' is central to the write-up of each set of findings, however while the analytic focus of the ethnographies is 'insider' knowledge and meanings, in the CA study it is gn the activities that make those meanings possible in the first place. The methodological contribution of the thesis stems from its demonstration of how to produce a coherent, unified research account from two very different versions of qualitative inquiry. Despite the potential for analytic inconsistency, the thesis arguably has far greater force and persuasiveness as a result of the attempt to combine, compare and contrast findings from three studies. It is contended that a sound theoretical base for sociological research may be created by combining Goffman's micro-sociology with Foucault's analyses of disciplinary power/knowledge in one of a number of ways. A Goffmanian 'home base' is adopted for this thesis, with Foucauldian thinking applied to add a historical, 'macro' dimension to the analysis that Goffman's work so conspicuously lacks. Foucault's work also provides the conceptual tools for examining the more subtle form of control through expertise that would be missed in a purely Goffmanian study.