Introdução: Conquistar a integralidade, a mais complexa diretriz do SUS, se constitui um permanente desafio, visto que, ao contrário da universalidade do acesso e da descentralização, parece, ainda, distante de ser alcançada. Objetivo: Caracterizar óbitos perinatais ocorridos em residentes em Fortaleza, 2006, para compreender o potencial da integralidade da atenção no sistema local de saúde. Métodos: Foram utilizados métodos complementares de pesquisa - quantitativa e qualitativa. Na abordagem qualitativa realizaram-se entrevistas individuais às mães de crianças que sobreviveram ao período neonatal e mães que perderam seus conceptos no período perinatal. Estudo transversal que incluiu o universo dos óbitos perinatais, a partir de dados dos sistemas oficiais de informação sobre mortalidade e sobre nascidos vivos e do relacionamento de dados entre os mesmos, consubstanciou a pesquisa quantitativa. Resultados e Discussão: A taxa de mortalidade perinatal foi 17,0/1000 nascidos totais - 8,2 para óbitos fetais e 8,8 para neonatais precoces. As principais causas encontradas foram: asfixia (24por cento ) - 4 vezes maior entre natimortos; baixo peso ao nascer cuja mortalidade foi 30 vezes maior entre os 25por cento com menos de 2500g; prematuridade (32,4por cento ); malformações congênitas (9,5por cento ) e infecções (7,0por cento ) inclusive 03 casos de sífilis congênita. Fatores de risco potenciais, como idade da mãe de 10 -14 anos, mais freqüente entre óbitos neonatais precoces, e de 35 e mais anos entre os fetais. A mortalidade foi mais alta (98,0/1000 nascidos totais) entre filhos de mães com nenhuma escolaridade - risco potencial importante - cuja elevada freqüência foi também percebida nas entrevistas que, por sua vez, evidenciaram uma categoria acrescentada ao estudo: a relação médico-paciente, considerada falha e desatenciosa, na percepção das mães, quanto aos esclarecimentos sobre alto risco na gestação e no parto. Destacou-se, ainda, o sentimento das mães sobre a falta da visita domiciliar na gravidez e de acompanhante no parto. Conclusões e algumas considerações: A baixa escolaridade pareceu um critério de 9 evitabilidade mais apropriado para uso em países em desenvolvimento, como o Brasil, do que aqueles da classificação de Wigglesworth, inclusive de acesso mais complexo nestes países. Para gestantes com baixa ou nenhuma escolaridade, o sistema de saúde poderia ofertar atenção especial, fortalecendo atividades educativas, adotando a interconsulta especializada e acompanhante no parto / Introduction - To achieve the integrality (comprehensive health care), the more complex SUS guideline, is an ongoing challenge, because, unlike the universality of access and decentralization, it still seems very far. Objective - To characterize perinatal deaths occurred among residents in Fortaleza, 2006, in order to understand the potential of the integrality of the care in the health system. Methods - It was adopted both, quantitative and qualitative methodologies that are complementary one to another. In the qualitative approach, individual interviews were carried out to mothers of children who survived the neonatal period and mothers who lost their babies in the perinatal period. A cross-sectional study that included the universe of perinatal deaths, based on data from official systems of information on births and deaths and also using the relationship of data between them, embodied quantitative research. Results and discussion - The perinatal mortality rate was 17.0 / 1,000 births - 8.2 to 8.8 for stillbirths and early neonatal deaths, respectively. The main causes were: asphyxia (24per cent ) - four times higher among stillbirths; low birth weight whose mortality was 30 times higher among the 25per cent weighting less than 2500g; prematurity (32.4per cent ); congenital malformations (9.5per cent ) and infections (7.0per cent ) including three cases of congenital syphilis. Potential risk factors such as maternal age of 10 -14 years old, more frequent among early neonatal deaths, while the fetal deaths occurred more among mothers are 35 and more. Mortality was highest (98.0/1,000 births) among children of mothers with no education - important potential risk factor which high frequency was also seen among the interviewee that, in turn, added a new category to the study as doctor-patient relationship considered failure and disrespectful on the perception of mothers regarding the details of high risk in pregnancy and childbirth. Was highlighted, too, the feeling of mothers about the lack of home visit by community health work during pregnancy and, also, of companion at childbirth. Conclusion and considerations - The low 11 educational level seemed a criterion more suitable for use in developing countries like Brazil, to avoid perinatal deaths, than those of Wigglesworth\'s classification, which is more difficult to obtain in these countries. For pregnant women with low/no education, the health system could strength health educational activities, adopt specialized attention and companion at hospital

In this thesis, a phenomenological approach is taken as the purpose is to discuss how the healthcare experiences of Swedish patients with chronic illness are affected by political state reforms and governing technologies. The thesis compares the discourse of Swedish healthcare policy with the discourse of healthcare in practice. Swedish healthcare has gone through major changes during the past decades, which have affected the state-to-patient relationship. This shift involved a transfer of responsibility from the state to its citizens, enabled through patient empowerment. In this change, a new ideal patient-role emerged, which is the patient as an informed and active consumer. What this thesis shows is the existence of a discrepancy between the ideal patient-role in governmental writing and the same ideal patient-role in the reality of the healthcare system. The ethnography consists of a literature study of healthcare policy documents and interviews with ten informants about their experiences of healthcare, in connection with the chronic diseases that affected their lives. The aim has been to examine the governing qualities of healthcare policy and practice, implementing Foucault’s theory of governmentality and technologies of the self.

No description available.

L'objet de la thèse, préparée dans le cadre de la convention de co-tutelle entre l’Université de Trento en Italie et l’Université Paris Ouest Nanterre la Défense en France, consiste dans une analyse comparée du rôle de la déontologie médicale dans les sources du droit en Italie, France et Allemagne. Le spectre d’analyse adopté est double. On cherche d’abord à rendre compte des aspects architecturaux des rapports entre droit et déontologie médicale ; ce faisant, on concentre l’analyse sur les modalités de la codification de l’éthique professionnelle en France, en Allemagne et en Italie, sur le pouvoir normatif des ordres professionnels, et sur la valeur juridique des codes de déontologie médicale et leur intégration dans le système des sources du droit. En second lieu, on cherche, dans une perspective plus substantielle, à comprendre les relations entre droit et déontologie, et notamment le rôle de la déontologie médicale dans le domaine du biodroit. Ce spectre d’analyse est en outre élargi à la procédure disciplinaire et à la perspective européenne. La première partie de la thèse est dédiée à certaines remarques préliminaires et notamment à un effort de définition de la déontologie médicale, à certaines « questions ouvertes » de son rapport avec le droit et à la relation, en perspective comparée, entre langue et droit dans la signification du mot « déontologie ». La seconde partie est dédiée à la codification de l’éthique professionnelle, alors que le rôle de la déontologie médicale dans le biodroit est l’objet de la troisième partie. La quatrième partie concerne la procédure disciplinaire et, finalement, la cinquième partie est dédiée à la reconstruction et l’analyse critique des résultats de la comparaison, à la perspective européenne et à la proposition d’un nouveau modèle italien des rapports entre le droit et la déontologie médicale. / The thesis aims at analysing, from a comparative perspective, the role of medical ethics in Italy, France and Germany. The survey focuses on both the formal and substantive aspects of the relationships between law and medical ethics. As to the first issue, the thesis analyses the codification of medical ethics, the normative function of the medical councils, the binding value of the codes of medical ethics and their position in the hierarchy of norms. With regard to the second aspect, the role of medical ethics is studied from a more substantial perspective, analysing the concrete interrelations between law and medical ethics in the field of biolaw. The survey is then extended to the disciplinary procedure and to the European level. In the first part, the relationships between law and medical ethics are analysed from a linguistic perspective, aiming at underlining some specific features of the concepts referred to as “déontologie”, “deontologia” or “Standesrecht” and “Berufsordnung” in France, Italy and Germany. This part also deals with some “open questions” characterising the relationships between medical ethics and the law. The second part concerns the codification of medical ethics, while its role in the field of biolaw is analysed in the third part. The fourth part deals with deontological liability and disciplinary procedures. Lastly, the fifth part aims at elaborating a theoretical reconstruction of the results of the comparative analysis, at highlighting the main roles of medical ethics at the European level and at suggesting a different model for the relationships between law and medical ethics in the Italian system. / L’obiettivo della tesi è un’analisi comparata del ruolo della deontologia medica nel sistema delle fonti del diritto in Italia, Francia e Germania. Per tenere conto della complessità del rapporto tra diritto e deontologia, sono stati analizzati sia gli aspetti formali di tale rapporto, sia i profili sostanziali del ruolo della deontologia medica nel biodiritto. Nella prima parte alcune considerazioni preliminari e l’analisi linguistica hanno permesso di definire l’ambito di indagine e i profili di maggiore complessità del rapporto tra dimensione deontologica e dimensione giuridica sui quali nelle parti successive si è concentrata l’indagine. La seconda parte, dedicata alla codificazione dell’etica medica, ha messo in luce la varietà di soluzioni e di modalità di ingresso della norma deontologica nell’ordinamento giuridico. Nella terza parte sono stati analizzati il ruolo della deontologia medica nell’ambito del biodiritto e l’influenza di alcuni fattori particolarmente rilevanti sull’evoluzione dei contenuti concreti dei codici deontologici e sulla loro portata pratica. La quarta parte è dedicata alla violazione della deontologia e ai procedimenti disciplinari. Infine la parte conclusiva contiene una ricostruzione teorica dei risultati emersi dall’analisi comparata, lo studio di alcuni profili legati alla dimensione europea della deontologia e la proposta di alcune ipotesi di riforma per un modello italiano più coerente, flessibile ed efficace dei rapporti tra diritto e deontologia.

Introdução: Conquistar a integralidade, a mais complexa diretriz do SUS, se constitui um permanente desafio, visto que, ao contrário da universalidade do acesso e da descentralização, parece, ainda, distante de ser alcançada. Objetivo: Caracterizar óbitos perinatais ocorridos em residentes em Fortaleza, 2006, para compreender o potencial da integralidade da atenção no sistema local de saúde. Métodos: Foram utilizados métodos complementares de pesquisa - quantitativa e qualitativa. Na abordagem qualitativa realizaram-se entrevistas individuais às mães de crianças que sobreviveram ao período neonatal e mães que perderam seus conceptos no período perinatal. Estudo transversal que incluiu o universo dos óbitos perinatais, a partir de dados dos sistemas oficiais de informação sobre mortalidade e sobre nascidos vivos e do relacionamento de dados entre os mesmos, consubstanciou a pesquisa quantitativa. Resultados e Discussão: A taxa de mortalidade perinatal foi 17,0/1000 nascidos totais - 8,2 para óbitos fetais e 8,8 para neonatais precoces. As principais causas encontradas foram: asfixia (24por cento ) - 4 vezes maior entre natimortos; baixo peso ao nascer cuja mortalidade foi 30 vezes maior entre os 25por cento com menos de 2500g; prematuridade (32,4por cento ); malformações congênitas (9,5por cento ) e infecções (7,0por cento ) inclusive 03 casos de sífilis congênita. Fatores de risco potenciais, como idade da mãe de 10 -14 anos, mais freqüente entre óbitos neonatais precoces, e de 35 e mais anos entre os fetais. A mortalidade foi mais alta (98,0/1000 nascidos totais) entre filhos de mães com nenhuma escolaridade - risco potencial importante - cuja elevada freqüência foi também percebida nas entrevistas que, por sua vez, evidenciaram uma categoria acrescentada ao estudo: a relação médico-paciente, considerada falha e desatenciosa, na percepção das mães, quanto aos esclarecimentos sobre alto risco na gestação e no parto. Destacou-se, ainda, o sentimento das mães sobre a falta da visita domiciliar na gravidez e de acompanhante no parto. Conclusões e algumas considerações: A baixa escolaridade pareceu um critério de 9 evitabilidade mais apropriado para uso em países em desenvolvimento, como o Brasil, do que aqueles da classificação de Wigglesworth, inclusive de acesso mais complexo nestes países. Para gestantes com baixa ou nenhuma escolaridade, o sistema de saúde poderia ofertar atenção especial, fortalecendo atividades educativas, adotando a interconsulta especializada e acompanhante no parto / Introduction - To achieve the integrality (comprehensive health care), the more complex SUS guideline, is an ongoing challenge, because, unlike the universality of access and decentralization, it still seems very far. Objective - To characterize perinatal deaths occurred among residents in Fortaleza, 2006, in order to understand the potential of the integrality of the care in the health system. Methods - It was adopted both, quantitative and qualitative methodologies that are complementary one to another. In the qualitative approach, individual interviews were carried out to mothers of children who survived the neonatal period and mothers who lost their babies in the perinatal period. A cross-sectional study that included the universe of perinatal deaths, based on data from official systems of information on births and deaths and also using the relationship of data between them, embodied quantitative research. Results and discussion - The perinatal mortality rate was 17.0 / 1,000 births - 8.2 to 8.8 for stillbirths and early neonatal deaths, respectively. The main causes were: asphyxia (24per cent ) - four times higher among stillbirths; low birth weight whose mortality was 30 times higher among the 25per cent weighting less than 2500g; prematurity (32.4per cent ); congenital malformations (9.5per cent ) and infections (7.0per cent ) including three cases of congenital syphilis. Potential risk factors such as maternal age of 10 -14 years old, more frequent among early neonatal deaths, while the fetal deaths occurred more among mothers are 35 and more. Mortality was highest (98.0/1,000 births) among children of mothers with no education - important potential risk factor which high frequency was also seen among the interviewee that, in turn, added a new category to the study as doctor-patient relationship considered failure and disrespectful on the perception of mothers regarding the details of high risk in pregnancy and childbirth. Was highlighted, too, the feeling of mothers about the lack of home visit by community health work during pregnancy and, also, of companion at childbirth. Conclusion and considerations - The low 11 educational level seemed a criterion more suitable for use in developing countries like Brazil, to avoid perinatal deaths, than those of Wigglesworth\'s classification, which is more difficult to obtain in these countries. For pregnant women with low/no education, the health system could strength health educational activities, adopt specialized attention and companion at hospital

During recent decades, lumbar spinal stenosis (LSS) has become the most common indication for spine surgery, a change that coincides with a higher worldwide prevalence of overweight and obesity. Thus, surgical treatment of LSS in the overweight and obese population is common and increasing in scope. The overall aim of this thesis was to investigate whether body mass index (BMI) is related to the development of LSS, and whether BMI is linked to outcome after surgery for LSS. We further evaluated whether there are specific experiences of LSS from a patient perspective. Data were obtained for all patients registered in the Swedish Spine Register who had undergone surgery for LSS between January 1, 2006 and June 30, 2008. After adjusting for differences in baseline characteristics, patients with obesity showed both poorer results after surgery and a higher rate of dissatisfaction than patients with normal weight (odds ratio 1.73; 95% confidence interval, CI, 1.36-2.19). Furthermore, patients with obesity in the cohort reported modest weight loss at follow-up (2.0 kg; 95% CI, 1.5-2.4), and only 8% reported a clinical important weight loss 2 years after surgery. Our analysis of 389,132 construction workers, showed that overweight (incidence rate ratio, IRR 1.68; 95% CI, 1.54-1.83) and obesity (IRR 2.18; 95% CI, 1.87-2.53) were associated with an increased future risk in developing LSS when compared with patients with normal weight. To gain insight into the patients' perspective of LSS, we performed interviews with 18 patients who were on a waiting list for LSS surgery. The transcripts, analyzed with content analysis, revealed that living with LSS is a physical, mental and social challenge in which resources to cope with the condition are of major importance. In summary, obesity is associated with poorer results after surgery, and patients with obesity report modest weight loss during follow-up. In addition, obesity is associated with an increased risk to develop LSS. Our findings revealed that being a patient with LSS, naturally involves considerable suffering and pain, but it also implies being a person with his or her own resources who is able to cope with these adverse conditions.

Il 40 per cento degli intervistati afferma che non ha trovato informazioni esaustive sui rischi e benefici dei farmaci trovati, mentre il 52 per cento afferma che le informazioni trovate hanno aiutato a seguire le indicazioni e i consigli del medico. Tra i rispondenti che si sono sottoposti a visita medica e che hanno discusso le informazioni trovate online con il proprio medico di fiducia, l'84 per cento ha ricevuto la prescrizione di farmaci. Di questi, solo il 17 per cento riporta che il farmaco prescritto era lo stesso trovato online, il 74 per cento è stato inviato da uno specialista e l'80 per cento ha ricevuto una prescrizione per test diagnostici. Più della metà dei rispondenti ha anche riportato azioni intraprese dal medico diverse dalla prescrizione del farmaco trovato online. Il 20 per cento degli intervistati afferma che le informazioni trovate sul farmaco da prescrizione in Internet hanno ridotto il suo / la sua fiducia nel medico, mentre il 41 per cento afferma che lo ha aiutato ad avere una comunicazione migliore con il proprio medico di fiducia. Nonostante le preoccupazioni sulle conseguenze negative della comunicazione di salute online, non abbiamo riscontrato differenze in termini di effetti sulla salute tra i pazienti che hanno assunto i farmaci “menzionati” online e coloro che hanno preso altri farmaci da prescrizione. / We conducted a national online survey about health care experiences associated with digital communication of prescription drugs. 46 percent of the sample (265 adults) found information about prescription drugs during their online search in the last 12 months. 40 percent of respondents agreed they didn’t find exhaustive information about risks and benefits while 52 percent agreed it helped in following their physician’s indications and advise. Among the respondents who had a physician visit during which health information found online was discussed, 84 percent received a drug prescription with only 17 percent being the same drug found on internet, 74 percent was sent to a specialist and 80 percent received a diagnostic test prescription. More than half also reported actions taken by their physician other than prescribing the drug brand found online. 20 percent respondents states that info found on the prescription drug in Internet reduced his/her trust in the physician while 41 percent states it helped in his/her communication with physician. Despite concerns about online health communication’s negative consequences, we found no differences in health effects between patients who took “advocated”/”mentioned” drugs and those who took other prescription drugs.