Orientador: Simone Biagio Chiacchio / Coorientador: Maria Lucia Gomes Lourenço / Banca: Wilson Roberto Fernandes / Banca: Roberto Calderon Gonçalves / Resumo: A avaliação clínica dos recém-nascidos, bem como a definição da conduta terapêutica adotada, representam expressivos desafios ao Médico Veterinário. O objetivo deste estudo foi descrever os padrões de vitalidade e bioquímica neonatal em equinos da raça Paint Horse nascidos em eutocia nas primeiras 48 horas de vida. Foram avaliados 20 neonatos, ao nascimento e 10 minutos após o parto pelo escore de Apgar modificado. As avaliações laboratoriais (hemogasometria, eletrólitos, lactato, glicemia e cortisol) e eletrocardiográficas foram realizadas imediatamente após o parto (M0) e as quatro (M1), oito (M2), 12 (M3), 16 (M4), 20 (M5), 24 (M6), 36 (M7) e 48 horas (M8) após o nascimento. No escore de Apgar, observou-se diferença estatística entre os momentos analisados (p< 0,001), sendo a média ao nascimento, 7,80 ± 0,89 e 10 minutos após, 8,35 ± 0,99. Durante as 48 horas pós-parto, a temperatura corporal apresentou elevação progressiva. Os parâmetros laboratoriais como o lactato, sódio, potássio, glicose, ânion gap e cortisol alteraram-se significativamente nos momentos analisados. Não foram encontradas diferenças estatísticas entre as variáveis hemogasométricas. No traçado eletrocardiográfico, notou-se diminuição progressiva da duração do intervalo QT e da amplitude e duração da onda T. Em conclusão, potros neonatos apresentaram alterações eletrolíticas, bioquímicas e eletrocardiográficas significativas durante as primeiras 48 horas de vida, sendo os parâmetros propostos adequados para a avaliação da vitalidade neonatal. A ocorrência comum de anormalidades clínicas e laboratoriais em potros recém-nascidos aparentemente saudáveis sublinha a necessidade da realização de exames clínicos regulares e valores laboratoriais de referência, em diferentes idades. Os dados encontrados subsidiam os aspectos fundamentais sobre a fisiologia neonatal e a variabilidade dos parâmetros clínicos, em potros em ... / Abstract: Clinical evaluations of newborns, as well as defining the therapeutic decision, represent significant challenges to the veterinarian. The aim of this study was to describe the patterns of neonatal vitality and biochemistry in horses breed Paint Horse eutocia born in the first 48 hours of life. 20 neonates at birth and were evaluated 10 minutes after delivery with Apgar modified. Laboratory (blood gas, electrolytes, lactate, glucose and cortisol) and electrocardiographic evaluations were performed immediately after birth (M0) and four (M1), eight (M2), 12 (M3), 16 (M4), 20 (M5 ), 24 (M6) 36 (M7) and 48 hours (M8) after birth. At Apgar score, there was statistical difference between the analyzed time points (p <0.001), with an average at birth, 7.80 ± 0.89, and 10 minutes, 8.35 ± 0.99. During the 48 hours postpartum, body temperature showed a progressive increase. Laboratory parameters such as lactate, sodium, potassium, glucose, anion gap and cortisol changed significantly in the time points analyzed. No statistical differences were found between blood gas parameters. In the electrocardiogram, there was progressive decrease in QT interval duration and the amplitude and duration of the T wave In conclusion, neonatal foals showed significant electrolyte, biochemical and electrocardiographic changes during the first 48 hours of life, with the appropriate parameters for proposed assessment of neonatal vitality. The common occurrence of clinical and laboratory abnormalities in apparently healthy newborn foals emphasizes the need to conduct regular clinical examinations and laboratory reference values at different ages. The data found subsidize the fundamental aspects of neonatal physiology and the variability of the clinical parameters in foals eutocia and serve as a basis for clinical decision making in cases of dystocia / Mestre

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Pesquisa sobre as caracterÃsticas da comunicaÃÃo nÃo-verbal entre o enfermeiro e o cego, cujos objetivos sÃo os seguintes: analisar a comunicaÃÃo nÃo-verbal do enfermeiro com o cego durante a consulta de enfermagem; testar o Ãndice de confiabilidade entre os juÃzes da anÃlise da comunicaÃÃo nÃo-verbal; classificar os sinais nÃo-verbais, segundo o referencial de Hall (1986); verificar a associaÃÃo entre as filmagens e os fatores de comunicaÃÃo nÃo-verbal; e identificar as barreiras da comunicaÃÃo nÃo-verbal entre a enfermeira e o cego. Adotou-se uma abordagem exploratÃria, descritiva, quantitativa, com vistas a fornecer subsÃdios para a intervenÃÃo e, portanto, melhoria na qualidade do atendimento a esta clientela. O estudo foi desenvolvido no perÃodo de fevereiro a abril de 2005, em uma unidade de saÃde de referÃncia, de nÃvel secundÃrio, na cidade de Fortaleza-CE, com enfermeiras que atendiam a diabÃticos, haja vista que a diabetes pode causar vÃrias doenÃas oculares, como catarata, glaucoma e retinopatia diabÃtica. Previamente, foram contatadas as quatorze enfermeiras da instituiÃÃo que realizavam consultas de enfermagem a diabÃticos. Destas, sete concordaram em participar da pesquisa, mas apenas quatro fizeram parte da amostra. Quanto à seleÃÃo dos pacientes diabÃticos cegos, foi feita de forma aleatÃria, respeitando-se os princÃpios Ãticos de pesquisa com seres humanos. Constituiu-se, portanto, de pessoas que adquiriram a cegueira em decorrÃncia da diabetes e que iriam ser atendidas pelas enfermeiras que concordaram em participar da pesquisa. Cinco cegos compuseram a amostra. Para a coleta de dados utilizou-se uma cÃmera filmadora que registrou toda a consulta de enfermagem entre a enfermeira, o cego e o acompanhante. O instrumento de anÃlise dos dados para avaliar a comunicaÃÃo nÃo-verbal da enfermeira com o cego foi elaborado conforme o referencial teÃrico de Hall (1986), com Ãnfase na Teoria ProxÃmica, e recebeu a denominaÃÃo de ComunicaÃÃo NÃo-Verbal Enfermeira â Cego (CONVENCE). Concomitantemente à coleta de dados, o CONVENCE foi enviado a trÃs juÃzes para ser analisado. Para a anÃlise das filmagens escolheram-se outros trÃs juÃzes que concordaram em participar da pesquisa a que foram treinados segundo o referencial proposto. A partir do CONVENCE foram elaboradas cinco categorias, com suas respectivas subcategorias. Categoria 1 - DistÃncia Espacial, com as subcategorias 1.1 - distÃncia, 1.2 - postura, 1.3- eixo, 1.4 - contato. Categoria 2 - Comportamento Social, com as subcategorias: 2.1 - gestos emblemÃticos, 2.2 - gestos ilustradores, 2.3 - gestos reguladores. Categoria 3 - Comportamento Facial. Categoria 4 - CÃdigo Visual, com as subcategorias: 4.1 - abertura ocular, 4.2 - direÃÃo do olhar. Categoria 5 - Volume da Voz. As sessÃes de treinamento e anÃlise dos dados foram realizadas com todos os juÃzes presentes na mesma sala e no mesmo horÃrio predeterminado no inÃcio da capacitaÃÃo. As filmagens foram analisadas a cada quinze segundos, totalizando 1.131 anÃlises de comunicaÃÃo nÃo-verbal. Ao analisar as categorias e subcategorias, os principais resultados observados foram os seguintes. Na categoria 1, a subcategoria distÃncia Ãntima prevaleceu com 1.030 (91,0%), pelo fato do ambiente onde aconteciam as consultas favorecer, tanto ao profissional quanto ao paciente, adotar quase unicamente esta distÃncia. Nesta categoria, a subcategoria 2 mostrou que a postura sentada, 1.112, (98,3%) obteve quase unanimidade nas imagens analisadas. Quando emissor e receptor mantÃm a mesma postura significa que ambos estÃo em sintonia, partilhando do mesmo ritmo, grau de interesse e movimento. TambÃm nesta categoria, a subcategoria 4, denominada contato, demonstrou que em 943 (83,3%) interaÃÃes nÃo houve contato. O gesto mais observado na subcategoria gestos emblemÃticos foi mover as mÃos, com 762 (67,4%). A direÃÃo do olhar, subcategoria 4.2, desviado do interlocutor, contabilizou 597 (52,8%) e centrado no interlocutor, 502 (44,4%). Em todas as filmagens, houve interferÃncias considerÃveis no momento da interaÃÃo enfermeiro-paciente. Tal fato foi considerado como barreira à comunicaÃÃo. O enfermeiro deve-se mostrar interessado durante a interaÃÃo, e à o olhar sobre o paciente que favorecerà esta atenÃÃo na consulta de enfermagem. Conclui-se, de acordo com os dados, que o enfermeiro precisa conhecer e aprofundar os estudos em comunicaÃÃo nÃo-verbal e adequar o seu uso ao tipo de pacientes assistidos durante as consultas. / Study on the characteristics of non-verbal communication between the nurse and the blind patient, whose objectives are the following: analyzing the nurseâs non-verbal communication with the blind patient during the nursing attendance; testing the reliability index among the referees of non-verbal communication analysis; classifying the non-verbal signs, according to Hallâs referential (1986); verifying the association between the video recordings and the non-verbal communication factors; and identifying the barriers to non-verbal communication between the nurse and the blind patient. The approach adopted is exploratory, descriptive, and quantitative, aiming at gathering information for intervention and, therefore, for improvement in the quality of assistance to this clientele. The study has been developed during the period of February to April of 2005, in a reference healthcare unit, of secondary level, in the city of Fortaleza-Ce, with nurses that attended to diabetic patients, as diabetes may cause several ocular disorders, such as cataract and diabetic retinopathy. Previously, the fourteen nurses who attended to diabetic patients at the institution had been contacted. Of those, seven agreed in participating of the study, but only four made part of the study group. In what regards the selection of blind diabetic patients, it was performed at random, considering the ethical principles that govern studies with human beings. The group has been constituted, therefore, by people who went blind as a consequence of diabetes, and who were going to be attended by the nurses who were part of the study group. Five blind people integrated the study group. To the data collection, a video camera was employed, which recorded the entire nursing attendance between the nurse, the blind person and his/her companion. The instrument for data analysis to evaluate the non-verbal communication between the nurse and the blind person was elaborated according to Hallâs theoretical referential (1986), with emphasis on the proxemic theory, and received the designation Nurse - Blind Patient Non-Verbal Communication (CONVENCE). Simultaneously to the data analysis, CONVENCE was sent to three referees in order to be analyzed. To the analysis of the video recordings, three other referees were chosen, who agreed in participating in the study and that were trained according to the proposed referential. From CONVENCE, five categories were elaborated, with their respective sub-categories. Category 1: Spatial distance, with the sub-categories 1.1- distance, 1.2- posture, 1.3- axis, 1.4-contact. Category 2 â Social behavior, with the subcategories: 2.1-emblematic gestures, 2.2 illustrating gestures, 2.3 âregulating gestures. Category 3 â Facial behavior. Category 4 â Visual Code, with the subcategories: 4.1 â ocular opening, 4.2 looking direction. Category 5 â Voice volume. The training sessions and the data analysis were carried out with all the referees present in the same room and at the same time that had been preset in the beginning of the training. The video recordings were analyzed each fifteen seconds, summing up 1.131 non-verbal communication analyses. When analyzing the categories and subcategories, the main results that were observed are the following: In category 1, the subcategory minimal distance prevailed with 1.030 (91%), due to the fact that the environment were the attendance took place favored the adoption of almost exclusively that distance, either by the professional or by the patient. In this category, the subcategory 2 has shown that the sitting posture (98.3 %) almost obtained unanimity in the images that were analyzed. When addresser and addressee maintain the same posture, it means that they are attuned, sharing the same rhythm, degree of interest, and movement. Also, in this category, the subcategory 4, denominated contact, demonstrated that in 943 (83.3 %) interactions there was no contact. The most observed gesture in the subcategory âemblematic gesturesâ was the moving of hands (762 or 67.4%). The looking direction, subcategory 4.2, deviated from the interlocutor added up 597 (52.8%) and centered in the interlocutor, 502 (44.4%). In all the video recordings, there were considerable interferences in the moment of the interaction nurse-patient. Such fact was considered a hindrance to communication. The nurse has to demonstrate interest during the interaction, and it is the look towards the patient that will favor this attention during the nursing attendance. It can be concluded, according to the data, that the nurse needs to know and to intensify the studies in non-verbal communication, and to adequate its use to the kind of patient being attended.

Le terme de réadaptation, n'apparaît qu'au début du XXème siècle, au même moment que celui de handicap dans son sens actuel : conséquence sociale néfaste d'une pathologie. Ces apparitions simultanées ne sont pas un hasard. Depuis la fin du XVIIIème siècle se sont noués de nouveaux rapports au travail et à la santé, à partir desquels les aptitudes et inaptitudes des individus à certaines activités ont pu être jugées autrement que comme le résultat de traits naturels, sur lesquels la société n'aurait pas ou peu de prise.Par l'aménagement des conditions de travail et des interventions sur le marché de l'emploi, l'appartenance égale de chacun à la société a pu être sinon conçue du moins repensée, tandis que la médecine connaissait d'importants progrès et portait une attention de plus en plus grande aux milieux d'existence, à la prévention et à l'hygiène. Sur ces bases, le médical et le social ont pu se nouer et la réadaptation des individus être envisagée, c'est-à-dire l'instauration de capacités nouvelles ou meilleures pour ces individus, en fonction des environnements envisageables, des possibles sociaux et de la connaissance des natures individuelles.Par une analyse des idées directrices des médecines de la réadaptation (rééducation, ergothérapie, thérapies comportementales...), et de la manière dont nos sociétés ont élaboré une connaissance d'elles-mêmes en tant que population et ensemble organisé d'activités, il s'agit de comprendre la genèse et les conditions de possibilité de nos projets normatifs de réadaptation, par là leur nature etlimites, en particulier au travers du handicap, tel que nous le définissons au croisement de critères vitaux et professionnels. / It is not a universal and obvious project that initially guides rehabilitation, the idea to rehabilitate somebody or to rehabilitate oneself. This work aims to trace their history - which is recent - and their way of arranging individuals and societies - which is both precise and in search of general effects. Since the First World War, with rehabilitations we have been jointing medicine and labor to ensure the lives of the disabled and to avoid social assistance. Rehabilitations have thus gradually drawn the field of handicaps which is, like them, the product of a history, whatever may be the timelessness in which we come to grasp the ideas of infirmity or disability.We tried to perceive in this research the displacements of structures, the events, the sets of actors which, correlated, made formulate the procedures of rehabilitation and the conceptualization of the disability during the XXth century. Thus, it may be possible to approach not only one form of the relationship between medical standards (epistemologically, ethically, socially based) and social norms (of health, work and activity), but also how people bind themselves to normative complexes, voluntarily, necessarily.

Orientador : Oswaldo Vital Brazil / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-07-16T09:05:46Z (GMT). No. of bitstreams: 1 Eugenio_AlvaroGuilhermeBezerril_D.pdf: 1205743 bytes, checksum: 5c0bd806832267209f26c635a81efc17 (MD5) Previous issue date: 1974 / Resumo: Cinqüenta parturientes, consideradas clinicamente como casos ideais, de acordo com os critérios propostos por CRAWFORD, foram divididas ao acaso em dois grupos de vinte e cinco. Em um deles utilizou-se bloqueioperidural lombar contínuo com bupivacaína como método de analgesia obstétrica. No outro, que serviu de controle, o trabalho de parto e a parturição desenvolveram-se sem que qualquer tipo de analgesia fosse empregado. Objetivou-se avaliar as repercussões nas condições de vitalidade dos recém-natos da analgesia do parto pela técnica do bloqueio peridural contínuo, utilizando-se a bupivacaína como agente anestésico. Para tal, estudou-se o estado acidobásico desses recém-natos no momento do nascimento e na vigésima quarta hora de vida. Os resultados obtidos permitem concluir: l) O bloqueio peridural lombar contínuo com bupivacaína, como método de analgesia obstétrica em parturientes ideais, não altera o estado acidobásico dos recém-natos no momento do nascimento. 2) O bloqueio peridural lombar contínuo com bupivacaína, como método de analgesia obstétrica em parturientes ideais, não altera o estado acidobásico dos recém-natos na vigésima quarta hora de vida / Abstract: Not informed / Doutorado / Doutor em Ciências Médicas

L’endocardite infectieuse (EI) est une maladie rare, de diagnostic difficile et de pronostic réservé. Staphylococcus aureus (SA) et les streptocoques oraux en sont les principaux microorganismes responsables. L’évaluation du risque de survenue de l’EI et l’amélioration des connaissances justifiant la stratégie de prévention nécessitent la mise en place de grandes cohortes cliniques et l’utilisation de bases médico-administratives. Chez les 2 008 patients (pts) présentant une bactériémie à SA de la cohorte multicentrique nationale VIRSTA, nous avons développé et validé un score prédictif d’EI comportant les caractéristiques initiales des pts et celles initiales et évolutives de la bactériémie. Les pts dont le score était ≤ 2 avaient un très faible risque d’EI (1% ; valeur prédictive négative [IC95%] = 99% [98;99]) comparés à ceux dont le score était ≥ 3, à risque d’EI élevé (17%) pour lesquels une échocardiographie devrait être effectuée. Utilisant la base médico-administrative du SNIIRAM, nous avons évalué la relation entre la pratique de gestes buccodentaires invasifs (GBDI) et la survenue d’EI à streptocoques oraux à partir d’une cohorte de 138 876 porteurs de prothèses valvulaires cardiaques ainsi que d’un plan expérimental de type case-crossover incluant 648 EI à streptocoques oraux. L’incidence d’EI à streptocoques oraux [IC95%] était de 93,7 pour 100 000 PA [82,4;104,9] sans augmentation significative du risque dans les 3 mois suivant un GBDI (RR= 1,25 [0,82;1,82]). Dans l’analyse case-crossover, la fréquence d’exposition à un GBDI dans les 3 mois précédent l’EI était faible mais plus élevée que lors de périodes contrôles antérieures (5,1% vs 3,2% ; OR : 1,66 [1,05;2,63]). Les GBDI pourraient contribuer au développement des EI à streptocoques oraux dans la population de pts porteurs de prothèses valvulaires cardiaques.La qualité des données de VIRSTA associée à la puissance du SNIIRAM ont permis l’identification des pts à risque d’EI à SA et la clarification de la contribution des GBDI dans les EI à streptocoques oraux. / Infective endocarditis (IE) is a rare disease, difficult to diagnose, with high morbidity and mortality rates. Main involved microorganisms are Staphylococcus aureus and oral streptococci. Clinical research to improve IE risk assessment and IE prevention strategy requires the establishment of large clinical cohort studies and the use of medico-administrative databases. Using data from the multicenter French prospective VIRSTA cohort study on 2 008 adult patients (pts) with Staphylococcus aureus bloodstream infection (SAB), we have developed and validated an IE prediction score taking into account pts’ background and initial SAB characteristics. Pts with a score ≤ 2 had a very low risk of IE (1%, negative predictive value [95% CI] = 99% [98;99]) compared to those with a score ≥ 3, at higher risk of IE (17%) for whom an echocardiography is needed. Using the medico-administrative SNIIRAM database, we assessed the relation between invasive dental procedures (IDP) and oral streptococcal IE in a population-based cohort study of 138 876 pts with prosthetic heart valves and a case-crossover study including 648 pts with oral streptococcal IE. Incidence rate of oral streptococcal IE [95% CI] was 93.7 per 100 000 PA [82.4;104.9] without significant increase within the 3 months following IDP (RR = 1.25 [0.82;1.82]). In the case-crossover analysis, exposure to IDP was more frequent in the 3 months preceding IE than during previous control periods (5.1% vs. 3.2%, OR: 1.66 [1.05;2.63]). IDP may contribute to the development of oral streptococcal IE in pts with prosthetic heart valves.The quality of data from VIRSTA study combined with the power of SNIIRAM database made possible the identification of IE at-risk SAB pts and the evaluation of the IDP contribution in oral streptococcal IE.

Unidentified bodies in the forensic setting constitute a global problem. Though this should be of great concern to many governments, very little data on the extent of this phenomenon is available in international literature and few countries require that statistics on the number of unidentified deceased be kept. To determine the extent of this phenomenon in South Africa, a study into the number of unidentified deceased at the Pretoria Medico-Legal Laboratory and their demographic profile was undertaken. The study has indicated that between 7% and 10% of bodies remain unidentified at the Medico-Legal Laboratory in Pretoria. Publications further indicate that a total of 846 bodies remained unidentified at Medico-Legal Laboratories in Gauteng for the period January 2010 to August 2010. This number is very high when compared to international literature. Of great concern is the fact that these statistics do not include the cases in which persons die in hospital facilities from natural causes without an identity, which are not referred to the Forensic Pathology Service for investigation. The true extent of the problem may thus be far greater than imagined. Determining the true extent of this phenomenon in South Africa is therefore important, as these unidentified bodies have many social and economic consequences. Not only are families unaware that their loved ones have passed away, but they are also unable to bury and mourn them. Unidentified bodies at Medico-Legal Laboratory facilities also impacts on the service delivery capability of the government departments involved in the investigation of such cases. The drafting of additional legislation for the management of unidentified bodies is therefore required. A need to establish and enforce specific protocols to be followed in the event of unidentified bodies has also been identified. The creation of a National Unidentified Decedent website and DNA database is recommended as they will greatly assist in reducing the number of unidentified bodies throughout South Africa. It is however only through coordinated efforts and interdepartmental cooperation that these proposals will be successful. AFRIKAANS : Ongeïdentifiseerde liggame in die forensiese omgewing is ‘n wêreldwye probleem. Alhoewel dit ‘n bron van kommer vir meeste regerings behoort te wees, is baie min data oor die omvang van hierdie verskynsel beskikbaar in die internationale literatuur, met min lande wat vereis dat amptelike statistieke oor onbekende oorledenes versamel word. Om die omvang van hierdie verskynsel in Suid Afrika te bepaal, is ‘n studie na die aantal onbekende liggame by die Regsgeneeskundige Laboratorium in Pretoria en hul demografies profiel onderneem . Die studie het getoon dat tussen 7% en 10% van alle liggame wat deur die Regsgeneeskundige Laboratorium in Pretoria opgeneem word, onuitgeken bly. Publikasies dui ook aan dat 846 liggame ongeïdentifiseerd was by Regsgeneeskundige Laboratoriums vir die tydperk Januarie 2010 to Augustus 2010. Hierdie getal is aansienlik hoër as díe wat in die internasionale literatuur gesien word. ‘n Groot bron van kommer is die feit dat hierdie statistieke nie gevalle insluit waar die oorledene in ‘n hospitaal gesterf het as gevolg van natuurlike oorsake, sonder dat hul identiteit bekend is. Die ware omvang van die problem kan dus veel groter as geskat wees. Die bepaling van die omvang van hierdie verskynsel in Suid Afrika is belangrik, omdat ongeïdentifiseerde liggame beide sosiale en ekonomiese gevolge het. Nie net is families onbewus daarvan dat hul geliefdes gesterf het nie, maar kry hul ook nie die geleentheid om hul geliefdes te begrawe en oor hul afsterwe te rou nie. Ongeïdentifiseerde liggame by Regsgeneeskundige Laboratoriums het ook ‘n invloed op die diensleweringskapasiteit van die verskeie staatsdepartemente wat betrokke is by die ondersoek van sulke gevalle. Die opstel van addisionele wetgewing wat die bestuur van ongeïdentifiseerde liggame reguleer is dus nodig. Die behoefte aan spesifieke protokolle vir die hantering van sulke gevalle is ook geïdentifiseer. Daar word verder aangeraai dat ‘n Nasionale Onuitgekende Liggaam webwerf en DNS databasis geskep word in ‘n poging om die aantal ongeïdentifiseerde liggame in Suid Afrika te verminder. Dit is egter slegs deur middel van gekoördineerde pogings en interdepartmentele samewerking wat hierdie voorstelle sukses sal behaal. Copyright / Dissertation (MSc)--University of Pretoria, 2011. / Forensic Medicine / unrestricted

[pt] A dissertação tem como objeto a análise do consentimento informado do paciente no âmbito da telemedicina, especialmente na relação médico-paciente realizada em estabelecimento hospitalares. Nesse sentido, são destacadas as modalidades da telemedicina com o escopo de identificar e atribuir a responsabilidade civil pela violação do consentimento informado do paciente em cada categoria, com base nas normas deontológicas e na legislação pertinente. Com efeito, a dissertação buscará responder os seguintes questionamentos: (a) como respeitar o consentimento informado do paciente na seara da telemedicina? (b) como deve ser efetivado o termo de consentimento informado em cada modalidade da telemedicina? (c) como imputar a responsabilidade civil na relação médico-paciente oriunda da violação do consentimento informado no campo da telemedicina? (d) como provar o consentimento do paciente no âmbito da telemedicina? Para tanto, analisa-se a evolução do consentimento informado do paciente, chegando-se a conclusão de que a autodeterminação é parte integrante da dignidade humana e deve ser respeitada na relação médico-paciente, sob pena de ser imputada a respectiva responsabilidade civil. Nessa toada, discorre-se sobre o desenvolvimento do atendimento médico realizado à distância, bem como são analisadas decisões judiciais a respeito do tema a fim de demonstrar as dificuldades concernentes à consumação do consentimento informado do paciente no âmbito da telemedicina. Por conseguinte, são apresentadas proposições para inclusão no termo de consentimento livre e esclarecido com o escopo de facilitar a compreensão do paciente no atendimento telepresencial e possibilitar a concretização do consentimento informado. Enfim, considerando a dificuldade na produção probatória relacionada ao consentimento informado do paciente, é apresentada uma recomendação que visa contribuir com o aperfeiçoamento da relação médico-paciente no campo da telemedicina. / [en] The dissertation has as its object the analysis of the patient s informed consent in the context of Telemedicine, especially in the doctor-patient relationship carried out in hospitals. In this sense, it is intended to discuss the modalities of telemedicine, identifying and attributing civil liability for the violation of the patient s informed consent in each category, based on deontological norms and on the institutes of the Consumer Defense Code. Consequently, the dissertation will seek to answer the following questions: (a) how to respect the informed consent of the patient in the field of telemedicine? (b) how should the informed consent form be implemented in each modality of telemedicine? (c) how to impute civil liability in the doctor-patient relationship arising from the violation of consent in the field of telemedicine? (d) how to prove the patient s consent in the context of telemedicine? To this end, the evolution of the patient s informed consent is analyzed, reaching the conclusion that self-determination is an integral part of human dignity and must be respected in the doctor-patient relationship, under penalty of being imputed the respective civil liability. In this sense, the development of remote medical care is discussed, as well as judicial decisions on the subject are analyzed in order to demonstrate the difficulties concerning the consummation of the patient s informed consent in the context of telemedicine. Indeed, propositions are presented for inclusion in the free and informed consent form with the aim of facilitating the patient s understanding in telepresence care and enabling the implementation of informed consent. At the end, considering the difficulty in producing evidence related to the patient s informed consent, a recommendation is presented that aims to contribute to the improvement of the doctor-patient relationship in the field of telemedicine.

[pt] Adesão é o estabelecimento de uma atividade conjunta, na qual o paciente não apenas obedece a orientação médica, mas entende, concorda e segue a prescrição recomendada pelo seu médico. Significa que deve existir uma aliança terapêutica entre médico e paciente, na qual são reconhecidas não somente a responsabilidade específica de cada um no processo, mas também de todos os que estão envolvidos direta ou indiretamente no tratamento. A adesão varia devido a inúmeros fatores que estão relacionados com a doença, o tratamento, o doente e o método de medição. Não há consenso absoluto na definição de adesão, contudo, estudiosos concordam que a adesão não é universal e que algum tipo de não adesão é sempre esperado, mesmo no caso de doenças graves. Existem diversos fatores psicossociais que influenciam a adesão ao tratamento, dentre eles a relação médico-paciente e a resiliência. As doenças cardiovasculares são hoje uma das maiores causadoras de internações e mortes no Brasil. A Insuficiência Cardíaca é uma síndrome, com múltiplas possíveis causas, em que a boa adesão ao tratamento faz a diferença entre a vida e a morte, assim como na qualidade de vida do paciente. O objetivo deste estudo foi investigar a influência da resiliência na adesão ao tratamento e quais são os outros fatores que mais ajudam e dificultam os pacientes a aderir. Métodos: Foram investigados 50 pacientes de um ambulatório de Insuficiência Cardíaca de Hospital Universitário no Rio de Janeiro. Instrumentos: Questionário Sociodemográfico, Inventário Beck de Ansiedade, Inventário Beck de Depressão, Escala de Avaliação de Agenciamento de Autocuidado (ASAS-R), Escala de Resiliência (RS-14), Questionário de Qualidade de Vida (SF-36) e entrevista semiestruturada. Os dados foram analisados com o programa SPSS e as respostas das entrevistas foram analisadas utilizando a metodologia qualiquanti. Resultados: O tipo de adesão mais forte é a medicamentosa (t49=4,30; p<0,05). A resiliência não se associou significativamente com a adesão medicamentosa (ρ=0,17; p>0,05) e a adesão às atividades físicas (ρ=0,30; p>0,05), mas apresentou significância estatística na adesão nutricional (ρ=0,39; p<0,05). Além disso, a relação médico-paciente apresentou-se como grande facilitadora da adesão ao tratamento. Em contrapartida, percebeu-se que a depressão atrapalha na adesão nutricional (ρ= -0,33; p<0,05) e às atividades físicas (ρ= -0,48; p<0,05), assim como no autocuidado (ρ= -0,42; p<0,05). Conclusão: Devido à amostra pequena, novos estudos com maior número de sujeitos devem ser realizados para uma melhor compreensão das atitudes dos sujeitos em relação ao tratamento. Contudo, tanto a resiliência como uma boa relação médico-paciente auxiliam o paciente a conquistar um maior grau de adesão ao tratamento. / [en] Adherence is the establishment of a joint activity, in which the patient not only obeys the medical orientation, but understands, agrees and follows the prescription recommended by the doctor. It means that there must be a therapeutic alliance between doctor and patient in which not only the specific responsibilities of each party in the processis recognized, but also of all those involved directly or indirectly in treatment. The adherence varies due to several factors which are related to the disease, the treatment, the patient and the measuring method. There is no absolute consensus on the definition of adherence, but scholars agree that aderence is not universal and that some type of non-adherence is always expected, even in the case of serious diseases. There are several psychosocial factors that influence treatment adherence, including the doctor-patient relationship and resilience. Cardiovascular disease is now a major cause of hospitalization and death in Brazil. Heart failure is a syndrome with multiple possible causes, where the good treatment adherence makes the difference between life and death, as well as the quality of life of the patient. The objective of this study was to investigate the influence of resilience in adherence to treatment and what other factors that help and hinder patients adherence. Methods: Fifty patients from a heart failure clinic of University Hospital in Rio de Janeiro were investigated. Instruments: Socio-demographic questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, Appraisal of Self Care Agency - Revised (ASAS-R), Resilience Scale (RS-14) Quality of Life Questionnaire (SF-36) and semi-estructured interview. Th data was analyzed using SPSS and the responses of the interviews were analyzed using the quali quantitative analysis. Results: The strongest type of adherence is to the medication (t49=4,30; p<0,05). Resilience was not significantly associated with medication adherence (ρ=0,17; p>0,05), and adherence to physical activities (ρ=0,30; p>0,05), but it was statistically significant in nutritional adherence (ρ=0,39; p<0,05). In addition, the doctor-patient relationship has been shown as a great facilitator of adherence. On the other hand, it was noted that depression impairs the nutritional adherence (ρ= -0,33; p<0,05) and adherence to physical activities (ρ= -0,48; p<0,05), as well as self-care (ρ= -0,42; p<0,05). Conclusion: Due to small sample, further studies with larger numbers of subjects should be conducted to better understand the attitudes of the subjects regarding the treatment. However, both resilience as a good doctor-patient relationship help the patient to achieve a greater degree of adherence to treatment.

The fastest growing field of law is undoubtedly that of Medical Law with the civil and disciplinary cases flowing from it. Globalization, international communication, development and evolution of Law as well as Medicine, cause this worldwide rising medical litigation. Humanitarian rights, post-modern scepticism and even iconoclastic attitudes contribute to this phenomenon. Medico-legal litigation and disciplinary complaints rise (in South Africa) up to 10 per cent per year. To assist the courts and legal profession, in medico-legal issues, helping the parties where the plaintiff has the burden of proof and the defendant for rebuttal, a medical expert witness must be used. The dilemmas and pitfalls arise, in that although knowledgeable medical experts could be used to guide the courts to the correct decision, the lack of a legal mind setting, court procedure and legal knowledge could affect the relevance, credibility and reliability, making the medical evidence of poor quality. The legal profession, deliberately, could “abuse” medical expert witnesses with demanding and coercion of results, which have unrealistic and unreasonable expectations. “Case building” occurs, especially in the adversarial systems of law, making the medical expert vulnerable under cross-examination, when it is shown that the witness has turned into a “hired gun” or is unfair. Thus, lacunae develop, making reasonable cases difficult and a quagmire of facts have to be evaluated for unreasonableness, credibility and appropriateness, compounded by the fact that seldom, cases are comparable. The danger is that the presiding officer could be misled and with limited medical knowledge and misplaced values, could reach the wrong findings. Several cases arguably show that this has led to wrongful outcomes and even unacceptable jurisprudence. The desire to “win” a case, can make a medical witness lose credibility and reasonableness with loss of objectivity, realism and relevance. With personality traits and subjectivity, the case becomes argumentative, obstinate and could even lead to lies. The miasmatic, hostile witness emerges, leading to embarrassing, unnecessary prolongation of court procedures. The medical expert witness should be well guided by the legal profession and well informed of the issues. Medical witnesses should have legal training and insight into the legal and court procedures. At the time of discovery of documents, via arbitration or mediation, medical experts should strive to reach consensus and then present their unified finding, helping the parties fairly and expediting the legal procedure and processes. / Private Law / LLM

The fastest growing field of law is undoubtedly that of Medical Law with the civil and disciplinary cases flowing from it. Globalization, international communication, development and evolution of Law as well as Medicine, cause this worldwide rising medical litigation. Humanitarian rights, post-modern scepticism and even iconoclastic attitudes contribute to this phenomenon. Medico-legal litigation and disciplinary complaints rise (in South Africa) up to 10 per cent per year. To assist the courts and legal profession, in medico-legal issues, helping the parties where the plaintiff has the burden of proof and the defendant for rebuttal, a medical expert witness must be used. The dilemmas and pitfalls arise, in that although knowledgeable medical experts could be used to guide the courts to the correct decision, the lack of a legal mind setting, court procedure and legal knowledge could affect the relevance, credibility and reliability, making the medical evidence of poor quality. The legal profession, deliberately, could “abuse” medical expert witnesses with demanding and coercion of results, which have unrealistic and unreasonable expectations. “Case building” occurs, especially in the adversarial systems of law, making the medical expert vulnerable under cross-examination, when it is shown that the witness has turned into a “hired gun” or is unfair. Thus, lacunae develop, making reasonable cases difficult and a quagmire of facts have to be evaluated for unreasonableness, credibility and appropriateness, compounded by the fact that seldom, cases are comparable. The danger is that the presiding officer could be misled and with limited medical knowledge and misplaced values, could reach the wrong findings. Several cases arguably show that this has led to wrongful outcomes and even unacceptable jurisprudence. The desire to “win” a case, can make a medical witness lose credibility and reasonableness with loss of objectivity, realism and relevance. With personality traits and subjectivity, the case becomes argumentative, obstinate and could even lead to lies. The miasmatic, hostile witness emerges, leading to embarrassing, unnecessary prolongation of court procedures. The medical expert witness should be well guided by the legal profession and well informed of the issues. Medical witnesses should have legal training and insight into the legal and court procedures. At the time of discovery of documents, via arbitration or mediation, medical experts should strive to reach consensus and then present their unified finding, helping the parties fairly and expediting the legal procedure and processes. / Private Law / LLM