No description available.

La problématique du consentement éclairé en santé mentale demeure au coeur des préoccupations des cliniciens, médecins spécialistes et médecins experts. Le travail auprès des cérébrolésés ou des patients souffrant de troubles mentaux graves, tout comme les questions qui me sont adressées depuis près de 20 ans par les médecins spécialistes, juristes ou résidents en psychiatrie, m’ont amenée à y réfléchir davantage. J’ajouterais que le constat personnel d’une compréhension des comportements, attitudes, motivations et jugements des patients vulnérables qui s’est modifiée au fil des ans, et le constat de l’importance de la notion du consentement vs le flou de sa définition et la fragilité des paramètres établis pour l’évaluer et la définir ont ravivé cette réflexion. La présente étude n’a aucunement pour but d’élaborer quelque règle de conduite que ce soit, ni de définir ce que devrait être le consentement éclairé en psychiatrie, mais plutôt d’explorer les dilemmes éthiques et les questionnements cliniques auxquels sont confrontés les médecins psychiatres afin de raviver une réflexion éthique qui semble s’estomper au profit de procédures juridiques et administratives. / In the mental health field, the topic of informed consent has always been among the most important problems to address for clinicians and psychiatrists. My clinical work with head injured patients and patients with severe mental health disorder, as well as all the questions addressed by physicians, residents or lawyers for the last decade lead me to think about it more deeply. Moreover, the personal observation of cognitively impaired patients and the fact that the concept of informed consent is so present compared to the lack of parameters to assess it has lead me to think about it otherwise. This study does not pretend to lead the actions or clinical behaviour, nor as it pretend to find a better definition of the concept of informed consent. It is only a way to explore some aspects of the complexity and clinical difficulties over the legal and administrative frame in which the medical field is evolving.

Thesis (M.A. (Health Social Science))--Mahidol University.

Orientador: Adriano Dias / Resumo: Análise da incidência, identificação dos casos e distribuição dos critérios para a morbidade materna grave, no Distrito Federal. Utilizou-se para a identificação dos casos os critérios da OMS (2010). Inicialmente, delineou-se um estudo transversal, desenvolvido em nove hospitais públicos do Distrito Federal que são referência para a assistência a gestação e ao parto de risco habitual e alto risco, no período entre 01 de julho de 2013 e 29 de dezembro de 2015, a fim de verificar a incidência e identificar os casos de condições potencialmente ameaçadoras da vida (CPAV) e near miss (NM) por meio de busca ativa dos casos e entrevista direta com a paciente. Identificou-se 174 casos de morbidade materna grave em 62.706 nascidos-vivos, gerando uma incidência de 2,77 casos por mil nascidos-vivos. Dos 174 casos entrevistados, 26 foram classificados como CPAV e 148 como NM correspondendo a incidências de 0,4/1.000 e 2,36/1.000, respectivamente. As condições hemorrágicas foram as condicionantes primárias mais significantes (p<0,001) nos casos de maior gravidade (NM). Concomitantemente, desenvolveu-se um estudo caso-controle para estimar a associação entre os fatores de risco para a ocorrência de morbidade materna grave (MMG) utilizando-se o modelo de regressão logística múltipla hierarquizada. Verificou-se a associação entre cada variável preditora e a variável desfecho por meio do teste do Quiquadrado, em sequência, a análise multivariada foi realizada seguindo a entrada hierarquizada ... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Diante do enigma representado pelos alunos incluídos, sobretudo, aqueles com graves problemas psíquicos, ou com transtornos globais do desenvolvimento, o conhecimento do professor parece ser insuficiente. Na falta de beira do pedagógico, o discurso clínico é chamado a margear os processos de ensino e aprendizagem, sendo recorrente a desligitimação da escola como espaço potente e a indicação de práticas reeducativas. Que razões levam a escola a não reconhecer seu papel constitutivo? A educação, ao se ocupar dos que estão fora do ideal de normalidade, perdeu a referência de sujeito como uma trama enigmática? Trata-se de um estudo teórico, no qual essas questões são problematizadas a partir da experiência profissional da pesquisadora, das fontes primárias da educação especial (Relatórios de Jean Itard – 1901 – e Tratado médico filosófico sobre alienação mental ou mania – 1800 – de Phillip Pinel), do campo da psicopatologia médico-biológica e fundamental e do conto A terceira margem do rio, de Guimarães Rosa. Defendemos a partida de Itard como gesto capaz de partir áreas e instaurar um novo espaço-tempo, uma terceira margem, no que antes era dual. Educação – especial. O traço que une e separa, surge da aposta, do diagnóstico como margem, de Itard na transformação de Victor pela educação. Traço instaurador de uma área e de um sujeito, não guarda um sentido a priori. A fim de sublinhar a função constitutiva da escola e do professor, o traçado precisa deslizar do ideal de normalidade à pergunta pelas condições de possibilidade de uma educação, duvidando, suspendendo, verdades cristalizadas e empobrecedoras do humano. / Given the enigma represented by the students included, especially those with severe psychological problems, or with Global Development Disorders, the knowledge of the teachers seems to be insufficient. In the absence of pedagogical border, clinical discourse is called to do margin in the processes of teaching and learning, often not legitimating the school as potent and powerful space, and indication of re-educational practices. What reasons lead school not to recognize his role constitutive? The education, dealing with the "out of the ideal of normality", lost the individual as an enigmatic plot? It is a theoretical study, in which these issues are raised from the professional experience of the researcher, the primary sources of special education (Reports of Jean Itard- 1901- and A treatise on insanity and others disorders affecting the mind -1800- Philippe Pinel), the field of biological medical and fundamental psychopathology and from the tale called “A terceira margem do rio” (The third margin of the river) written by Guimarães Rosa. We advocate the departure of Itard as capable of break off areas and establish a new space-time, a third margin, in what used to be dual. Special – education. The lineament that unites and separates, arises from the investment, the diagnosis as margin, from Itard believing in Victor transformation through education. Lineament originator of an area and an individual, don't keep a sense a priori. In order to emphasis the constitutive function of the school and the teacher, the stroke need to slide off the ideal of normalcy to question the conditions of possibility of an education, doubting, suspending, petrified and depleting the human truths.

A prevalência de Doença Mental Grave (do inglês Severe Mental Illness, SMI) atinge 5,4% em um ano segundo os estudos Baltimore Epidemiologic Catchment Area e National Comorbidity Survey. O conceito de SMI surgiu na década de 1970 para o planejamento dos serviços de saúde e apresentou importância crescente a partir do movimento de desinstitucionalização psiquiátrica. Uma das definições para SMI deriva do NIMH (National Institute of Mental Health) em 1987, e utiliza como critérios a presença de prejuízo funcional, decorrente de déficits em aspectos básicos do dia-a-dia, bem como a duração da doença. Casos agudos de SMI podem necessitar tratamento em Unidade de Internação Psiquiátrica em Hospital Geral (UIPHG). No entanto, há poucos estudos disponíveis no Brasil avaliando esta modalidade de tratamento e os desfechos destes pacientes. Evidências também apontam que os pacientes com transtornos psiquiátricos apresentam níveis reduzidos de Fator Neurotrófico Derivado do Cérebro (Brain-Derived Neurotrophic Factor, BDNF). O BDNF age no sistema nervoso central (SNC) promovendo crescimento e diferenciação de neurônios. Dentro deste contexto, a presente tese apresenta como objetivo principal a avaliação naturalística de desfechos clínicos e funcionais, associados à avaliação dos níveis séricos de BDNF, em pacientes com SMI. Os pacientes que foram encaminhados para tratamento na Unidade de Internação Psiquiátrica do Hospital de Clínicas de Porto Alegre foram incluídos se apresentassem os critérios de SMI: Avaliação Global de Funcionamento (Global Assessment of Functioning, GAF) menor ou igual a 50 e tempo de tratamento maior ou igual a dois anos. As avaliações ocorreram em dois momentos (admissão e alta). Compreenderam avaliação sociodemográfica, clínica e coleta de sangue (com dosagem de BDNF sérico). Foram realizadas avaliação diagnóstica pelo Mini-International Neuropsychiatric Interview (MINI) e aplicação das escalas Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression scale (CGI-S), GAF e World Health Organization Quality of Life Instrument—Short Version (WHOQOL-Bref). Ainda, foram aplicadas escalas específicas nos diagnósticos principais (i.e., depressão maior, depressão bipolar, episódio maníaco, esquizofrenia): Hamilton Depression Rating Scale (HAM-D); Young Mania Rating Scale (YMRS). O primeiro artigo desta tese descreve os desfechos clínicos, funcionais e também de qualidade de vida durante a internação psiquiátrica. Observou-se melhora significativa nos parâmetros avaliados nos pacientes com SMI como um todo. Os pacientes com episódio maníaco apresentaram maior chance (em relação aos com episódio depressivo) de atingir remissão pela CGI (OR: 4.03; 95% CI: 1.14-14.30; p=0.03). A duração média da hospitalização (LOS) foi 28,95 (± 19,86) dias. No segundo artigo, observou-se redução dos níveis séricos de BDNF nos pacientes com SMI em relação aos controles saudáveis, independentemente do diagnóstico. Houve aumento significativo no BDNF entre a admissão e a alta. Os resultados apresentados replicam dados previamente publicados a partir de amostra única de pacientes com SMI, sua característica diferencial. Estes resultados reforçam que a internação em UIPHG, uma intervenção relativamente breve, demonstra desfechos positivos e é alternativa bem estabelecida no tratamento da SMI. Além disso, a redução inespecífica do BDNF sérico seguida de um pequeno aumento associado ao tratamento reforçam a possibilidade do BDNF como marcador transdiagnóstico de transtorno mental. / The estimated prevalence of Severe Mental Illness (SMI) according to Baltimore Epidemiologic Catchment Area and National Comorbidity Survey studies is 5.4% in one year. One suggested definition of Severe Mental Illness (SMI) derives from the 1987 National Institute of Mental Health (NIMH) definition and is based on two criteria: 1. duration, characterized as involving “prolonged illness”, and 2. disability, which includes dangerous or disturbing social behavior, and mild impairment in achieving basic needs. These acute psychiatric conditions may require psychiatric inpatient treatment located in acute wards in General Hospitals. However, little data is currently available evaluating the characteristics and the outcomes during an acute inpatient stay in Brazil. Evidence also suggests that Brain-derived neurotrophic factor (BDNF) levels are significantly decreased in neuropsychiatric disorders. BDNF is found throughout the brain and is involved in neurogenesis and neuroplasticity. So, the main objectives of this work are to evaluate SMI patients’ outcomes during treatment in a psychiatric unit in a general hospital by symptomatology, functionality, quality of life and by the evaluation of BDNF serum levels. After the admission to a psychiatric unit in a general hospital in Brazil, patients were included and if they had two of the SMI criteria: Global Assessment of Functioning (GAF) ≤ 50 and duration of services contact ≥ 2 years. Patients were assessed in admission and upon discharge with Mini-International Neuropsychiatric Interview (MINI), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression Scale (CGI), GAF, World Health Organization’s QOL Instrument—Short Version (WHOQOL-Bref) and diagnostic specific scales (Hamilton Depression Rating Scale, HAM-D; Young Mania Rating Scale, YMRS; and Hamilton Anxiety Rating Scale, HAM-A). Blood samples were also obtained. The first manuscript showed that SMI patients had marked and significant improvements in symptomatic and functional measures during psychiatric hospitalization. Patients with manic episode had higher chance of CGI remission (OR: 4.03; 95% CI: 1.14-14.30; p=0.03) when compared with patients with depressive episode. Mean LOS was 28.95 (± 19.86) days. The second manuscript showed that BDNF serum levels were equally reduced among different SMI diagnoses. Also, the observed improvements in SMI patients were associated with a significant, but small increase in mean serum BDNF levels. Therefore, the results replicate evidence from previous findings in single samples, suggesting that SMI patients can have marked acute improvements during a a relatively short intervention (approximately 1 month) represented by the psychiatric hospitalization in a general tertiary hospital. Also, the similar reduction observed in BDNF levels among SMI patients with different diagnoses and the significant increase but non-restoration indicate that BDNF serum levels could be considered a marker for the presence of an unspecific psychiatric disorder and possibly a transdiagnostic and unspecific marker of disease activity.

Play is an important contributor to children’s development: it reflects, reinforces, and results in development (Johnson, Christie, Wardle, 2005). However, the tools available to support planning and measurement of play are not sufficiently detailed or focused on children with autism and severe learning difficulties (SLD). Play for children with autism is consistently identified as restrictive and repetitive. Although extensive research examines symbolic play, the content and structure of functional play, which is considered a valuable precursor of symbolic play, is rarely the subject of focused research (Williams, 2003; Lifter, Foster-Sanda, Arzamarski, Briesch, & McClure, 2011). Given the developmental potential that play presents, the aim of this study was to examine the functional play presented by children with autism and SLD, with a view to designing a play framework that enables teachers to support functional play development in the classroom. A pragmatic mixed methods approach was adopted across a three-stage study in three schools. Study 1 provides the background for creating a functional play framework, while Study 2 focuses on the creation of the framework through objective observations of the play activity of a total of 27 children with autism and SLD, as well as interviews with nine classroom teachers. Study 3 was a process of trialling the framework in two schools and collaborating with eight teachers to finalise the functional play framework, in particular by considering its usability. Data collected across the three studies provided a description of functional play that suggests it is more complex than traditionally defined. Four key areas of functional play were identified: interacting with one object; interacting with two (or more) objects; interacting with self; and interacting with the environment. Additionally, 12 subcategories were established as components related to functional play. Teachers reported that they could use the framework to baseline play, set targets and measure play progression for children with autism and SLD. The framework was also identified as a tool that supports classroom management and continuing professional development. The proposed framework facilitates the identification of small increments of progress and extends on other available play frameworks. By developing detailed descriptions of the play that children with autism and SLD present, the framework provides a greater ability to identify precise deficits and, more specifically, to target support in the area of play. Additionally, the collaborative approach with classroom teachers provides diverse viewpoints but also begins to merge the gap between researchers and practitioners in order to ensure a useful resource. Recommendations for further descriptive accounts, greater involvement of classroom professionals in the development of resources and additional trials of the framework are acknowledged.

Em março de 2009, foram identificados os primeiros casos de vírus influenza A, não subtipado anteriormente e que levou a comunidade internacional a enfrentar a primeira pandemia do século XXI, na vigência do novo Regulamento Sanitário Internacional de 2005. No intervalo das semanas epidemiológicas 16 e 33, foram notificados 34.506 casos de síndrome respiratória aguda grave no Brasil. No Brasil, a maior incidência ocorreu nas faixas etárias de crianças ≤ 5 anos (3.8/100.000) e com idades entre 20-29 anos (4.6/100.000). Neste período os casos ficaram concentrados nas regiões sul e sudeste, com 94% dos casos notificados. A taxa de mortalidade na população durante este período foi 0.39/100.000 habitantes. Pessoas que apresentaram comorbidades relacionadas apresentaram o dobro de risco de evolução para o óbito, quando comparado às pessoas sem comorbidade. (RR = 1,89 IC 95% 1,64-2,18). Apesar do clima tropical, o Brasil foi um dos países mais afetados pela pandemia. No entanto, este evento está possibilitando o fortalecimento das ações de vigilância e assistência que serão úteis em todas as situações de emergências de saúde pública de importância nacional e internacional. / In March 2009, identified the first cases of a new influenza A virus, not subtyped previously. Without immunity, the international community suffered the first pandemic of the century, the term of the International Health Regulations 2005. Between epidemiological weeks 16 and 33, were reported 34,506 cases of severe acute respiratory syndrome in Brazil. In Brazil, the highest incidence occurred in younger children ≤ 5 year (3.8/100,000) and one at ages 20-29 years (4.6/100,000). Ninety-four percent of cases concentrated in two of Brazil’s five geographic regions – the south and southeast. . The mortality rate in the population during this period was 0.39/100,000 inhabitants. Cases with a reported comorbidity had approximately twice the risk of those without (RR=1.89; 95%CI 1.64 – 2.18). Despite the tropical climate, Brazil was one of the countries most affected by the pandemic. However, this event is allowing the strengthening of surveillance and assistance that will be useful in all situations of public health emergencies of national and international concern.

Children with intellectual disabilities (ID) in inclusive classrooms differ in ways of processing information and learning speed compared to their peers without disabilities. Therefore teaching methods must be adapted to their individual needs. Peer support is seen as an additional form of improving students’ academic engagement. This systematic review focuses on peer supported interventions which facilitate academic engagement of children and youth with mild to profound ID. It contains six studies, which met pre-determined inclusion criteria focusing specifically on academic engagement. The studies were analysed to examine (a) different types of peer support, (b) peer support characteristics, (c) definition of academic engagement of students with ID and (d) if a change in academic engagement as an outcome can be evaluated after a peer support intervention. In this review, the data of 18 students with mild to profound ID and their peers in the age of 8 to 17 years, were included. Four different types of peer support intervention were identified, which included different characteristics mostly focussing on supporting students’ communication, access to information and active participation in class. The different definitions of academic engagement which were found hindered comparison of results. Nevertheless, all studies had a positive effect on the academic engagement of students with ID. Future research is needed to investigate the long-term impact of different types of peer support on academic engagement of students with ID and their need in relation to specific forms of ID.

Diante do enigma representado pelos alunos incluídos, sobretudo, aqueles com graves problemas psíquicos, ou com transtornos globais do desenvolvimento, o conhecimento do professor parece ser insuficiente. Na falta de beira do pedagógico, o discurso clínico é chamado a margear os processos de ensino e aprendizagem, sendo recorrente a desligitimação da escola como espaço potente e a indicação de práticas reeducativas. Que razões levam a escola a não reconhecer seu papel constitutivo? A educação, ao se ocupar dos que estão fora do ideal de normalidade, perdeu a referência de sujeito como uma trama enigmática? Trata-se de um estudo teórico, no qual essas questões são problematizadas a partir da experiência profissional da pesquisadora, das fontes primárias da educação especial (Relatórios de Jean Itard – 1901 – e Tratado médico filosófico sobre alienação mental ou mania – 1800 – de Phillip Pinel), do campo da psicopatologia médico-biológica e fundamental e do conto A terceira margem do rio, de Guimarães Rosa. Defendemos a partida de Itard como gesto capaz de partir áreas e instaurar um novo espaço-tempo, uma terceira margem, no que antes era dual. Educação – especial. O traço que une e separa, surge da aposta, do diagnóstico como margem, de Itard na transformação de Victor pela educação. Traço instaurador de uma área e de um sujeito, não guarda um sentido a priori. A fim de sublinhar a função constitutiva da escola e do professor, o traçado precisa deslizar do ideal de normalidade à pergunta pelas condições de possibilidade de uma educação, duvidando, suspendendo, verdades cristalizadas e empobrecedoras do humano. / Given the enigma represented by the students included, especially those with severe psychological problems, or with Global Development Disorders, the knowledge of the teachers seems to be insufficient. In the absence of pedagogical border, clinical discourse is called to do margin in the processes of teaching and learning, often not legitimating the school as potent and powerful space, and indication of re-educational practices. What reasons lead school not to recognize his role constitutive? The education, dealing with the "out of the ideal of normality", lost the individual as an enigmatic plot? It is a theoretical study, in which these issues are raised from the professional experience of the researcher, the primary sources of special education (Reports of Jean Itard- 1901- and A treatise on insanity and others disorders affecting the mind -1800- Philippe Pinel), the field of biological medical and fundamental psychopathology and from the tale called “A terceira margem do rio” (The third margin of the river) written by Guimarães Rosa. We advocate the departure of Itard as capable of break off areas and establish a new space-time, a third margin, in what used to be dual. Special – education. The lineament that unites and separates, arises from the investment, the diagnosis as margin, from Itard believing in Victor transformation through education. Lineament originator of an area and an individual, don't keep a sense a priori. In order to emphasis the constitutive function of the school and the teacher, the stroke need to slide off the ideal of normalcy to question the conditions of possibility of an education, doubting, suspending, petrified and depleting the human truths.