Magister Legum - LLM

Magister Curationis - MCur / The purpose of the study will be to explore the discharge referral pathway for patients that have been discharged from hospital to home in the Western Cape Province. A mix of quantitative and qualitative research, using a descriptive design will be undertaken. Quantitatively, following the patient paper trail from Tertiary Hospital to grassroots level. Qualitatively, to identify whether the referral pathway was user friendly. Records of discharged patients from the Tertiary Hospital will be used as the study population. Patient information will be accessed from patient files at the hospital. Interviews will be conducted with the relevant discharge liaison officers at the Tertiary Hospital, and Primary Health Care level. Relevant staff members within the non–governmental –organisations (NGOs), will also be interviewed in order to determine their perception of the discharge referral pathway. The findings of the study will be used to inform policy guidelines. Challenges encountered by staff members in referring patients for continuum of care, and the perception of consumers will also be described and documented.

Introdução: Os Centros de Referência (CR) são serviços especializados, parte de um projeto inovador de parceria entre a academia e os gestores do Sistema Único de Saúde (SUS). O principal objetivo de um CR é promover a assistência através de acompanhamento multidisciplinar, facilitando o acesso ao medicamento fornecido pelas Secretarias Estaduais de Saúde (SES). Objetivos: avaliar a efetividade da assistência de pacientes com Mieloma Múltiplo (MM) em um CR no âmbito do SUS (Centro de Referência para Mieloma Múltiplo do Hospital de Clínicas de Porto Alegre [CRMM-HCPA]); comparar a qualidade de vida entre portadores de MM atendidos no CRMM-HCPA e em outros serviços de saúde que não são CR. Metodologia: Foi realizado um estudo prospectivo de 6 meses, com participantes que recebiam a Talidomida pela SES-RS, e eram tratados pelo CRMM-HCPA, em comparação com os que recebiam tratamento em outras instituições, fora de um CR. Foram incluídos 32 participantes da pesquisa, sendo 19 do CRMM-HCPA e 13 participantes de outras instituições. Para análise da efetividade do CRMM-HCPA foi considerado como desfecho principal o tempo, a partir do diagnóstico, em que os participantes da pesquisa levaram para realização do Transplante Autólogo de Células Tronco Hematopoiéticas (TACTH), por ser considerado este a terapia “padrão ouro” para o MM. Para análise deste tempo, foram aplicados questionários específicos do estudo e para análise da qualidade de vida foi aplicado o questionário SF-36. Resultados: Na análise de qualidade de vida encontramos diferença significativa em relação ao item aspecto social (do SF-36), relacionado à realização de atividades sociais (P = 0,02). O tempo (em meses) a partir do diagnóstico até o transplante de medula óssea, em cada grupo, foi medido apenas em participantes da pesquisa com idade \65 anos (n=25), dos quais, nesta análise, 15 eram do HCPA e 10 das outras instituições. Encontramos diferença significativa (P=0,036) em relação ao tempo em que os participantes da pesquisa foram encaminhados para realizarem o transplante autólogo, demonstrando que os do CRMM (HCPA) são encaminhados para o transplante em tempo significativamente inferior (mediana: 9 meses; IIQ: 8,5 a 14,5) do que são atendidos nas demais instituições (mediana: 24 meses; IIQ: 16 a 24). Conclusões: Os participantes do CRMM demonstraram mais facilidade em executar atividades sociais, com menos interferências relacionadas a problemas físicos ou emocionais. O CRMM demonstrou ser uma estratégia de tratamento mais efetiva do que outros serviços de saúde do SUS, que não são CR, uma vez que permitiu uma redução do tempo para a realização do transplante. / Introduction:Within the Brazilian Unified Health System (SUS), Referral Centers (RCs) are care facilities that provide specialized services as part of an innovative partnership project between universities and SUS managers. The main goal of RCs is to promote care through a multidisciplinary approach, facilitating access to medicines supplied by state health departments (SHDs).Objectives:To evaluate the effectiveness of care provided to patients with multiple myeloma (MM) in a RC within SUS (Hospital de Clínicas de Porto Alegre Referral Center for Multiple Myeloma, CRMM-HCPA) and to compare quality of life between patients with MM treated at CRMM-HCPA and other non-RC health care facilities. Methods: A 6-month prospective cohort study was conducted in patients receiving thalidomide from the Rio Grande do Sul SHD (SHD-RS) and treated at CRMM-HCPA, as compared to patients receiving treatment at other non-RC health care facilities. Thirty-two patients were included in the study, 19 from CRMM-HCPA and 13 from other institutions. To analyze the effectiveness of CRMM-HCPA, the main outcome measure was the time from diagnosis to referral for autologous hematopoietic stem cell transplantation (HSCT), as this is considered the gold-standard treatment for MM. Time from diagnosis to referral for autologous HSCT was assessed using questionnaires specifically designed for this study, and quality of life was assessed using the SF-36 questionnaire. Results: On quality of life analysis, there was a significant difference in the “social functioning” domain of the SF-36 questionnaire, which relates to performance of social activities (P=0.02). The time (in months) from diagnosis to referral for autologous HSCT, in each group, was measured only in patients aged \65 years (n=25); of these, 15 were from CRMM-HCPA and 10 from other institutions. In this analysis, there was a significant difference (P=0.036) in time between diagnosis and referral for autologous HSCT, which was significantly shorter for patients treated at CRMM-HCPA (median, 9 months; IQR, 8.5–14.5) than for those treated elsewhere (median, 24 months; IQR, 16–24).Conclusions:Patients treated at CRMM-HCPA demonstrated greater ease in performing social activities, with less interference from physical or emotional problems. CRMM-HCPA offers a more effective treatment strategy as compared with other non-RC health care facilities, as it enabled a reduction in time to transplantation.

A interconsulta cardiológica corresponde a uma parcela considerável das atividades assistenciais e de ensino do cardiologista, refletindo gasto extra de tempo e recursos. Apesar disso, essa atividade não tem recebido a devida atenção da literatura, com poucos estudos sobre o tema. O objetivo do presente estudo foi, primariamente, comparar a evolução clínica dos pacientes envolvidos na interconsulta cardiológica que tiveram as recomendações seguidas pela equipe médica solicitante (grupo ACEITADOR) com aqueles em que as recomendações não foram seguidas (grupo NÃO ACEITADOR). De forma secundária, procuramos identificar as variáveis determinantes da aceitação das sugestões da equipe cardiológica. Para isso, foi realizado um estudo observacional envolvendo pacientes internados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, para os quais foram solicitadas interconsultas cardiológicas, no período de março a setembro de 2008. Os dados referentes às interconsultas foram coletados pelo investigador de maneira prospectiva a partir do prontuário dos pacientes. Dentre as 589 interconsultas selecionadas para o estudo, 271 consistiam em avaliações clínicas e 318 avaliações pré-operatórias. Em relação à taxa de aceitação das recomendações cardiológicas, 77% dos pacientes foram classificados no grupo ACEITADOR e 23% classificados no grupo NÃO ACEITADOR. A análise da evolução clínica demonstrou que, dentre os pacientes do grupo NÃO ACEITADOR, 38,8% evoluíram de forma desfavorável (piora clínica ou óbito) contra 5,4% dos pacientes do grupo ACEITADOR (P<0,0001). Após análise de regressão logística, pertencer ao grupo NÃO ACEITADOR (P<0,001; OR 10,25; IC 95% 4,45 - 23,62) e a idade dos pacientes (P=0,017; OR 1,04; IC 95% 1,01 1,07) estiveram associados de forma independente a uma evolução clínica desfavorável. Foram identificados quatro preditores independentes de aceitação das recomendações: a realização de visitas de seguimento (P<0,001; OR 2,43; IC 95% 1,48 4,01), reforço verbal das recomendações (P=0,001; OR 1,86; IC 95% 1,23 2,81), número de recomendações sugeridas (P=0,001; OR 0,87; IC 95% 0,80 0,94) e idade dos pacientes (P=0,002; OR 0,98; IC 95% 0,96 0,99). Portanto, na presente análise, a não aceitação das recomendações da equipe cardiológica por parte da equipe médica solicitante esteve associada a uma evolução clínica desfavorável dos pacientes envolvidos. A realização de visitas de seguimento, reforço verbal, número limitado de recomendações e a menor idade dos pacientes estiveram associados a uma maior aceitação das recomendações da equipe cardiológica / Cardiology referral represents an important part of cardiologist activities, accounting for substantial workload and demanding extra time and resources. Despite the importance of these facts, it has received little attention in the medical literature in the last years. The purpose of this study was to compare the clinical outcome of patients involved in cardiology referral who had the cardiologic recommendations followed by the requesting service (ACCEPTING group) with those whose recommendations were not followed (NON-ACCEPTING group). Secondly, we aimed to determine which of the variables involved in cardiology referral were related to acceptance to consultants recommendations. An observational study was performed at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, involving cardiology consultations during the months of March 2008 through September 2008. Data regarding consultations were prospectively extracted from the medical records by a physician-researcher. Among the 589 cardiology consultations selected for the study, 271 were clinical evaluations and 318 were preoperative evaluations. Regarding compliance of the referring service in following the recommendations offered by cardiology team, 77% of patients were classified in the ACCEPTING group and 23% in the NON-ACCEPTING group. A clinical outcome analysis was performed and showed that 38,8% of patients allocated to NON-ACCEPTING group had evolved unfavorably (clinical deterioration or death) against 5,4% of patients allocated to accepting group (P<0.0001). After logistic regression analysis, belong to NON-ACCEPTING group (P<0.001; OR 10.25; CI 95% 4.45 23.62) and patients age (P=0.017; OR 1.04; CI 95% 1.01 1.07) were variables independently associated to an unfavorable clinical outcome. The multivariate analysis indentified 4 independent predictors of acceptance to consultants recommendations: follow-up notes in the chart (P<0.001; OR 2.43; CI 95% 1.48 4.01), personal communication (P=0.001; OR 1.86; CI 95% 1.23 2.81), number of recommendations (P=0.001; OR 0.87; CI 95% 0.80 0.94) and patients age (P=0.002; OR 0.98; CI 95% 0.96 0.99). Therefore, in this analysis of cardiology referral, a poorer acceptance of cardiologic recommendations was associated to an unfavorable clinical outcome. Follow-up notes in the chart, personal communication, limited number of recommendations and lower patients age were associated to greater acceptance of cardiologic recommendations

La collaboration entre la CCJA et les juridictions nationales de cassation, s’effectue dans le contentieux des Actes uniformes. Il met en oeuvre la supranationalité judiciaire de la CCJA qui se manifeste par sa substitution aux juridictions nationales de cassation soulevant des questions liées aux Actes uniformes. Il faut reconnaître que la complémentarité de la collaboration entre la CCJA et les juridictions nationales de cassation dans le recours en cassation devant la CCJA fait ressortir différents des problèmes : une inconstitutionnalité du Traité ou des Actes uniformes dans le processus d’intégration, des inquiétudes dans la procédure de recours en cassation (pas d’auto-saisine de la CCJA, absence de cas d’ouverture à cassation devant la CCJA, formule exécutoire sur les arrêts de la CCJA), l’évocation, la substitution des juridictions nationales de cassation créent devant la CCJA, une controverse dans l’identification du juge compétent dans les procédures de l’AUPSRVE, un risque de conflit de compétence et de lois avec des organisations régionales surtout (UEMOA). Cette collaboration se poursuit entre le juge étatique et la CCJA dans l’arbitrage, c’est le mode de règlement des litiges dans le système OHADA, à cause de l’éthique de l’arbitrage. Ce mode de règlement des litiges dans le mode des affaires ne répond plus au critère du monde des affaires. Même si l’arbitrage OHADA est dual (ad hoc et CCJA), il faut trouver des moyens dans divers droits plus adéquats pour pallier aux divers problèmes évoqués dans le monde des affaires. / The collaboration between the CCJA and the national courts of cassation, in substance, takes place in the dispute of the Uniform Acts. It implements a judicial supranationality of the CCJA that manifests itself by its substitution to the national courts of cassation of substance raising issues related to the Uniform Act. It must be recognized that the complementarity between the collaboration between the CCJA and the national courts in the cassation appeal before the CCJA brings out different problems : an unconstitutionality of the Treaty even see uniform Acts in the process of integration, Concerns in the procedure upon appeal in cassation (no self-referral of the CCJA, no case of opening to cassation before the CCJA, the executory formula on the judgments of the CCJA), the evocation, the substitution of national courts of cassation, grounds before the CCJA, controversy in identifying the judge competent in the procedures of the AUPSRVE, the risks of conflict of competence and laws with regional organizations ( UEMOA). This collaboration continues between the state judge and the CCJA in arbitration, this is the mode of dispute resolution in the OHADA system, in the face of the ethics of arbitration. This mode of dispute resolution in the business mode no longer meets the criteria of the business world. Even though the OHADA arbitration is dual (ad hoc and CCJA), it is necessary to find ways in various law more adequate to address the various problems evoking for the business world.

abstract: Special education identification processes related to English language learners (ELs) in the United States have puzzled the field for decades. The phenomenon of referrals, the first step toward identification, is complex since it requires deciphering the root cause of students’ learning struggles—e.g., second language (L2) factors, the possibility of a learning disability (LD), or the combination of multiple other influences. To investigate the various influences contributing to learning difficulties, I centered this study on three potential sources, individual, institutional, and interpersonal. I aimed to answer, how did sociocultural influences mediate a teacher’s understanding of ELs’ competence? How did sociocultural influences mediate whether a teacher referred ELs to special education services? Using a cultural-historical theoretical approach, I sought deeper theoretical and empirical understandings into how institutional factors (e.g., tiered intervention contexts, policies), combined with other influences, mediated ELs’ referral decisions. I used a multiple parallel case study design following two fifth-grade ELs who faced the possibility of a referral. Interested in the interpersonal domain (e.g., interactions and communication among people), I zoomed in to a local process, student-teacher conferences to examine how classroom processes shaped teachers’ thoughts of students’ competence, and ultimately, referral decisions. I video-recorded teacher-student conference sessions over 14 weeks, and audio-recorded viewing sessions of the recorded conferences to understand teacher and student interpretations of learning competence. To understand how other dimensions (individual and institutional) contributed to teachers’ overall views about the student competence, I interviewed parents and school personnel, wrote observational field notes, and examined archival documents related to student learning over the entire fifth-grade year. I used inductive and iterative qualitative analytical approaches to craft the findings. My findings reaffirmed the complexity involved in finalizing ELs’ referral decisions. I found cultural factors intertwined with structural forces, driving students’ special education candidacies in divergent directions: one evaluated (LD); the other, retained. I also found the referral decisions were based on narrow understandings of learning and behaviors, lack of attention to students’ L2 needs, and faulty and overpowering structural forces which undermined teacher’s professional opinions about the referrals. These findings have implications for research, practice, and policy. / Dissertation/Thesis / Doctoral Dissertation Special Education 2020

This study aims to identify referral criteria for music therapy which can be used at an institution for children affected by HIV / AIDS in South Africa. The purpose of this research is a) to identify the needs of institutionalised children and how music therapy can be applied to treat these needs; b) to establish the current referral process in this institution; and c) to develop referral criteria which can be used to refer these children to music therapy. Interviews conducted with different staff members at the institution, as well as a music therapist who worked at the institution, showed that some of the needs, challenges and resulting behaviours of the children are not currently referred to music therapy. This study shows that music therapy can be used to address a wide range of these difficulties. / Dissertation (MMus)--University of Pretoria, 2007. / Music / MMus / Unrestricted

Bakgrund: Kolorektalcancer är en av världens vanligaste cancersjukdomarna i världen. Sjuksköterskans roll när en patient får ett diagnosbesked är att stötta, informera och lyssna. Sjuksköterskor upplever dock svårigheter med att bemöta patienter i samband med diagnsobeskedet. Svårigheter sjuksköterskan uppelver är att ge tillräckligt med stöd och information samtidigt som distansen bibehålls till patienten. I omvårdnadsforskningen idag finns stora brister i kunskapen gällande hur diagnosbeskedet påverkar individen. Syfte: Syftet var att belysa patienter upplevelser i samband att diagnostiseras med kolorektalcancer. Metod: Studien genomfördes som en allmän litteraturstudie med induktiv ansats. Resultat: Resultatet bestod av tio vetenskapliga artiklar och presenterades i tre katergorier: Blandade upplevelser av diagnosen, Behovet av stöd och Behovet av tydlig kommnikation. Vid diagnos upplevde patienter chock, ilska och förnekelse, för att sedan komma till acceptans av sjukdomen. Patienterna konfronterades också med sin egen dödlighet. Resultaet visade även att patienterna upplevde kommunikationen från hälso-och sjukvården väldigt varierande. Stödet från både anhöriga och hälso-och sjukvårdspersonalen var viktig för att orka. Slutsats: Litteraturstudien belyser sårbarheten hos de patienter som får diagnosen kolorektalcancer, vilka tankar och känslor ett allvarligt diagnosbesked väcker. Resultatet kan öka sjuksköterskors kunskap om patienters upplevelser av att diagnostiseras av kolorektalcancer, vilket kan hjälpa dem att ge patienterna ett bättre bemötande. / Background: Colorectal cancer is one of the most common cancer diseases in the world. The nurse´s role when the patient receives the diagnosis is to support, inform and listen. Hoewver, nurses experince difficulties to meet the patients in connection with diagnosis. Difficulties the nurses are experiencing  is to give sufficient support and information and still maintain a distance to the patient. In nursing research today there are major shortcomings in the knowledge regarding how the diagnosis decision affects the indivdual. Aim: THe aim was to highlight patients experiences associated with being diagnosed with colorectal cancer. Method: The study was conducted as a general literature study with an inductive approach. Results: The results consisted of ten scientific articles and were presented in three categories: Mixed experiences of the diagnosis, The need for support and The need for clear communication. At diagnosis, patients experienced schock, anger, and denial, and then to come to acceptance of the disease. Patients were also confronted with there own mortaality. The results also showed that patients experienced communication from the health care system very varied. The support was important of both relatives and the healht care professionals was important for coping. Conclusion: The literature study highlights the vulnerability of patients diagnosed with colorectal cancer, which  thoughts, and feelings a serious diagnosis raises. The result may increase knowledge of patients experiences of being diagnosed with colorectal cancer, and what thoughts and feelings a serious diagnosis raises. Ther result can increase nurses knowledge of patients experiences of being diagnosed with colorectal cancer, whitch can help them provide patients with a better treatment.

BACKGROUND: Women seeking abortion services in the U.S. often encounter challenges of stigma, cost, transportation, and other logistics. In 2011, 1.7% of women aged 15–44 had abortions, and 89% of counties had no abortion clinic. Many states regulate abortion through prohibition of insurance coverage and other restrictions. Accurate, non-judgmental referrals from health care professionals may lessen obstacles and counteract stigma. STUDY QUESTION: What are women’s experiences accessing abortion care, and what is the role of professional referrals? METHODS: I conducted semi-structured qualitative interviews with 45 women seeking abortions to learn what steps they took to obtain abortion care, whether they sought or received professional referrals, and what obstacles or supports they encountered. All interviews were conducted at three clinics in South Carolina. Using Zurek et al’s (2015) conceptual framework, process mapping and thematic analysis were conducted to understand the sequence and variations of steps taken. RESULTS: Nearly half of participants had contact with a health professional for pregnancy confirmation, but only seven received referrals. Professional referrals ranged in their perceived helpfulness. Positive referrals included direct, supportive communication without judgment. Negative experiences were characterized by stigmatizing action or language. Some women indicated they did not seek a referral due to social pressure or stigma. Without a referral, women located abortion clinics through online searches, previous experience, and information from friends or family. Women encountered structural and social obstacles when arranging abortion care, such as out of pocket costs, transportation challenges, and stigma at multiple levels. Social support and help with logistics and finances counteracted these obstacles. CONCLUSIONS: Resourcefulness is evident in women’s stories of accessing abortion, particularly in the absence of referrals, but positive professional referrals carry some benefit. Abortion access may be improved through expanding health provider capacity to make accurate, supportive referrals. IMPLICATIONS: To improve abortion access, obstacles and stigma must be reduced through increased support and reduction of systematic obstacles. Health system policies should ensure that providers know how to appropriately refer for abortion, and how to support women navigating predictable challenges. / 2017-11-05T00:00:00Z

Indiana University-Purdue University Indianapolis (IUPUI) / More than 20 million people in the United States have a substance use disorder, resulting in negative individual and societal outcomes. An evidence-based intervention, Screening, Brief Intervention, and Referral to Treatment (SBIRT), involves screening patients to assess for substance use and then providing a brief intervention and referral to treatment when indicated. This evidence-based intervention is underutilized in healthcare settings. The purpose of this dissertation was to contribute to the body of evidence regarding the implementation of SBIRT in healthcare settings. Specifically, the aims of this dissertation were to 1) provide an overview of the evidence regarding the use of implementation strategies to facilitate the implementation of SBIRT, 2) describe implementation of SBIRT by nurses in acute care hospitals, and 3) examine individual and organizational characteristics associated with the intra-organizational adoption of SBIRT. To review the literature, a scoping review was completed on 18 articles that met the inclusion criteria. The review found that leaders often train and educate stakeholders to facilitate the implementation of SBIRT, but less attention has been given to adapting the intervention or engaging patients. Additionally, implementation efforts led to increases in screening, but the evidence regarding the effect on brief intervention is inconclusive, and evidence regarding referral to treatment is scarce. Eighteen nurses participated in a qualitative descriptive study of the implementation of SBIRT, and data were analyzed using content analysis. Participants identified barriers and facilitators associated with the nurses’ attitudes and beliefs about SBIRT, organizational factors, and patients’ response to the SBIRT process. Participants indicated that SBIRT was a useful intervention that was best implemented by providing a clear process and incorporating SBIRT into an established workflow. To examine factors related to intra-organizational adoption of a tool to screen patients for substance use, two hundred twenty-two nurses participated in a crosssectional study. Results of this study indicate that training and the perception of peer usage of the intervention were significantly related to individual nurses’ use of the intervention in practice. The findings of this dissertation can inform research and practice regarding the implementation of SBIRT in healthcare settings.