La prescription de médicament hors AMM est légitime quand elle s’appuie sur les connaissances médicales acquises ou validées au moment de la proposition de soins, lors du colloque singulier patient-médecin. L’AMM d’un médicament ne représente qu’un sous-ensemble de connaissances médicales, sans cesse changeantes, qui ne peut être regardée comme le référentiel idoine de la prescription d’un médicament, à la fois sur un plan médical et sur un plan juridique. La démocratie sanitaire est particulièrement inachevée dans la gestion européenne ou nationale de l’AMM d’un médicament. / The off-label drug prescribing is legitimate when it is based on accepted or validated medical knowledge at the time of the proposal care during the patient-physician singular interview. The marketing authorization of a drug represents only a fraction of medical knowledge, constantly changing, which can not be considered as a suitable reference document of drug prescribing, both from a medical and legal aspect. Health democracy is particularly incomplete in the European or national management of the drug marketing authorization.

O tabagismo mata um a cada 10 fumantes no mundo e é a principal causa evitável de morbimortalidade. O Brasil possui cerca de 25 milhões de tabagistas. Os profissionais de Saúde têm um importante papel no controle da pandemia do tabagismo, seja como educadores, formadores de opinião ou como promotores de prevenção e tratamento. A epidemia de tabagismo nas últimas décadas caracteriza-se pela redução do número de usuários de cigarro e crescente uso de formas alternativas de tabaco. Este estudo teve como objetivo caracterizar o perfil de consumo, crenças, percepção de risco, atitudes e conhecimentos a respeito de tabagismo em estudantes de Medicina do 1º e 6º anos. Trata-se de um estudo observacional transversal, com componente descritivo e com componente analítico. Foram entrevistados alunos do curso de Medicina de uma faculdade pública (FMRP-USP) e de três faculdades privadas (UniSEB, UNAERP e Centro Universitário Barão de Mauá) da cidade de Ribeirão Preto-SP. O questionário incluiu dados sócio demográficos, de exposição ao tabaco e outras substâncias psicoativas, motivação para cessação, avaliação de conhecimento médico sobre tabagismo, atitudes perante o tabaco e percepção de risco. A coleta de dados aconteceu nos anos de 2016 e 2017. A análise de dados foi realizada com o auxílio do programa estatístico Statistical Package for the Social Sciences (SPSS). Adotou-se como nível de significância para todas as análises p <= 0,05. 859 alunos foram convidados a participar da pesquisa e 420 responderam o questionário, 63,3% era do sexo feminino. Os achados do presente estudo vão ao encontro com o que vem sendo descrito na literatura. A prevalência de tabagismo encontrada foi semelhante à prevalência de tabagismo no Brasil, porém uma prevalência menor em alunos do 1º ano. A idade média de experimentação foi de 17,5 anos. A maioria dos estudantes não se via como dependente de tabaco, fazia uso ocasional e utilizava principalmente o Narguilé (15,2%), produto considerado mais prejudicial quando comparado ao cigarro comum (p>0,001). O consumo de álcool foi elevado e descrito como um facilitador para o uso de tabaco. A nicotina foi considerada viciante (p>0,001). O fumo ocasional foi considerado prejudicial (88,3%), assim como o uso dos diferentes produtos de tabaco na gestação. No que diz respeito ao papel dos profissionais de saúde, 93,1% acredita que deveria aconselhar seus pacientes a parar de fumar; 63,7% que profissionais fumantes seriam menos propensos a aconselhar seus pacientes; 81,3% acredita que deveria aconselhar seus pacientes a evitar outras formas de tabaco e 78,2% considera esses profissionais modelo para pacientes e público em geral. Verificou-se a falta de conhecimento e percepção de risco distorcida (crenças) quanto ao potencial de dependência dos produtos alternativos de tabaco e riscos do tabagismo. Sextanistas relataram ter recebido treinamento formal para abordagem do fumante e cessação do tabagismo e sentir-se seguros para orientar seus pacientes. Formação e treinamento adequados são essenciais e demandam maior responsabilidade social e acadêmica pelos estudantes de Medicina. Investir em ações que trabalhem especialmente as crenças, percepções de risco e atitudes a respeito dos diferentes tipos de tabaco, são necessárias para uma maior conscientização quanto ao uso e prejuízos à saúde causados pelo tabagismo. / Smoking kills one out of every 10 smokers in the world and is the leading preventable cause of morbidity and mortality. Brazil has about 25 million smokers. Health professionals play an important role in the control of the tobacco pandemic, whether as educators, opinion makers, or as promoters of prevention and treatment. The smoking epidemic in recent decades is characterized by reduction in the number of cigarette users and increasing use of alternative forms of tobacco. This study aimed to characterize the profile of consumption, beliefs, perception of risk, attitudes, and knowledge about smoking in medical students of 1st and 6th years. This is an observational cross-sectional study, with descriptive and analytical component. Medical students of a public college (FMRP-USP) and of three private colleges (UniSEB, UNAERP and Centro Universitário Barão de Mauá) of the city of Ribeirão Preto-SP were interviewed. The questionnaire included socio-demographic data, exposure to tobacco and other psychoactive substances, motivation for cessation, assessment of medical knowledge about tobacco use, attitudes, and perception of risk. Data collection occurred in 2016 and 2017. Data analysis was performed with the aid of the statistical program Statistical Package for the Social Sciences (SPSS). The significance level adopted for all analyses was p <= 0.05. Among 859 students invited, 420 answered the questionnaire, 63.3% female. The findings of this study respond to what has been described in the literature. The smoking prevalence found was similar to Brazil\'s average, but lowest in first-year students. The average age of experimentation was 17.5 years. Most students did not identify themselves as tobacco addicts, were occasional users and used mainly hookahs (83%), product considered more harmful when compared to cigarettes (p > 0.001). Alcohol consumption was high, described as a facilitator for the use of tobacco; nicotine is regarded as addictive (p > 0.001); casual smoke as harmful (88.3%), as well as the use of different tobacco products in pregnancy. With regard to the role of health professionals, 93.1% believe they should advise their patients to quit smoking; 63.7% believe that professionals who are smokers would be less likely to advise their patients; 81.3% believe they should advise their patients to avoid other forms of tobacco, and 78.2% consider these professionals an example for patients and the general public. A lack of knowledge and distorted perception of risk (beliefs) was noted about the addictiveness of alternative products of tobacco and risks of smoking. Sixth-year students reported having received formal training to approach the smoker and cessation of smoking and feel safe to guide their patients. Appropriate education and training are essential and require greater academic and social responsibility by medical students. Investing in actions that work especially on beliefs, perception of risk and attitudes regarding the different types of tobacco are necessary for a greater awareness regarding the use and damage to health caused by smoking.

<p>This study describes and analyses understanding ‘illness’ among clients and</p><p>leaders of the spiritual tradition Candomblé in Rio de Janeiro. The study</p><p>focuses on the individuals’ narratives of illness and of healing rituals within</p><p>the cult. Particular attention is given to the consultation ritual called jogo de</p><p>búzios, which is one of the main practices of finding the reason for the illness</p><p>as well as its cure. The emphasis in this study is on the necessity to look at</p><p>medical pluralism, the socio-individual context of illness and narrativity as an</p><p>intersubjective practice. The conclusion is reached that illness within</p><p>Candomblé ideology can be understood as disequilibrium in a person’s</p><p>lifeworld.</p><p>The individual is approached from within the plurimedical context of</p><p>both biomedical and Candomblé healing tradition in Rio. Here it is argued that</p><p>the person creates meaning of the illness in relation to different aspects of his</p><p>lifeworld. The individual’s lifeworld includes the urban context of Rio de</p><p>Janeiro; therefore a brief discussion is developed about how this context</p><p>influences the individual meaning production of the illness. The Candomblé</p><p>house is described with its social structure and other elements that are</p><p>important for understanding how the cult might work for the clients as an</p><p>alternative and/or complementary medical treatment.</p><p>The study progressively introduces and analyses the lifestories of the</p><p>individuals that approach the Candomblé cult in order to seek treatment. It</p><p>also is concerned with stories of the Candomblé leaders and their view on the</p><p>phenomenology of the Body, the Self and the social milieu of the person.</p><p>Finally, the study emphasises the importance of studies that focus on the</p><p>individual’s interpretation of the relations between the Self and the Body, and</p><p>the individual’s understanding of medical knowledge and practice.</p>

This study describes and analyses understanding ‘illness’ among clients and leaders of the spiritual tradition Candomblé in Rio de Janeiro. The study focuses on the individuals’ narratives of illness and of healing rituals within the cult. Particular attention is given to the consultation ritual called jogo de búzios, which is one of the main practices of finding the reason for the illness as well as its cure. The emphasis in this study is on the necessity to look at medical pluralism, the socio-individual context of illness and narrativity as an intersubjective practice. The conclusion is reached that illness within Candomblé ideology can be understood as disequilibrium in a person’s lifeworld. The individual is approached from within the plurimedical context of both biomedical and Candomblé healing tradition in Rio. Here it is argued that the person creates meaning of the illness in relation to different aspects of his lifeworld. The individual’s lifeworld includes the urban context of Rio de Janeiro; therefore a brief discussion is developed about how this context influences the individual meaning production of the illness. The Candomblé house is described with its social structure and other elements that are important for understanding how the cult might work for the clients as an alternative and/or complementary medical treatment. The study progressively introduces and analyses the lifestories of the individuals that approach the Candomblé cult in order to seek treatment. It also is concerned with stories of the Candomblé leaders and their view on the phenomenology of the Body, the Self and the social milieu of the person. Finally, the study emphasises the importance of studies that focus on the individual’s interpretation of the relations between the Self and the Body, and the individual’s understanding of medical knowledge and practice.

196 f. / Submitted by Suelen Reis (suziy.ellen@gmail.com) on 2013-05-06T16:09:44Z No. of bitstreams: 1 Tese Rita Souza.pdf: 1248030 bytes, checksum: 88dee4918617d159897c11eb77478aac (MD5) / Approved for entry into archive by Maria Auxiliadora Lopes(silopes@ufba.br) on 2013-06-10T20:12:42Z (GMT) No. of bitstreams: 1 Tese Rita Souza.pdf: 1248030 bytes, checksum: 88dee4918617d159897c11eb77478aac (MD5) / Made available in DSpace on 2013-06-10T20:12:42Z (GMT). No. of bitstreams: 1 Tese Rita Souza.pdf: 1248030 bytes, checksum: 88dee4918617d159897c11eb77478aac (MD5) Previous issue date: 2009 / A presente investigação procurou analisar a constituição do campo da Educação Especial em Sergipe imersa na conjuntura nacional e internacional do século XIX e início do século XX, através das produções dos intelectuais sergipanos das áreas médica e jurídica desse período, artigos de jornais, relatórios de governo. Tem como principais aportes teóricos as categorias de apropriação e representação de Roger Chartier, campo de Pierre Bourdieu, normal e anormal de Foucault e Canguilhem; além do estudo das produções do século XIX e sobre o século XIX e início do século XX local e nacional. O estudo inspira-se nos pressupostos da nova história cultural, da História da Educação e da Educação Especial e contribui para a compreensão da constituição desse campo de conhecimento através das relações entre o saber e poder médico e jurídico e sua influência nas apropriações e representações materializadas socialmente, num período em que se tornou imperativo cuidar e educar para civilizar o anormal. / Salvador

This master thesis aims to show how a qualitative approach to early modern medical practitioners’ perspectives can provide a basis for a better understanding of the disease of dysentery. The focus is on: 1) How the disease of dysentery was described and how the challenge of dysentery was perceived. 2) What individual measure and commitments were taken for the patients and why. 3) How the cause of the disease was understood and explained. 4) How perspectives differed between physicians and surgeons.Of particular interest when it comes to the disease of dysentery is how the disease and its cause were perceived.Eleven texts written by mainly British medical practitioners from primary sources such as reports, logbooks and letters on dysentery written during the years 1740 - 1800 have been used for close readings and a qualitative analysis was performed on the collected data.The analysis showed (i) that medical practitioners expressed considerable interest in dysentery and in trying to understand it as a great suffering for individuals, for society and for humanity as a whole. (ii) Medical practitioners took treatment measures based on how they understood the cause of the disease outbreak. Either the dysentery was referred to internal causes, as sickness in organs, especially the organs that produced bodily fluids, or it was referred to external causes, as a sickness caused by heat, cold, weather, winds, air, climate, seasons, lunar position, etc. (iii) The cause of the disease was understood and explained both as an infection and as a pre-disposition for imbalances in body fluids. (iv) Both physicians and surgeons understood that the disease of dysentery was a global phenomenon and that the disease often was connected to the climate and weather. This standpoint was based on the fact that dysentery distinguished itself as an autumnal disease. Its eruption usually began with a few scattered cases in July, then increased in August and culminated in September. Theories about the disease, its causes and treatment did not differ significantly between physicians and surgeons. However, the views of different physicians did differ.The thematic map of understanding related to disease of dysentery, shows that medical practitioners’ knowledge, theories and ideas behind the medical practice of dysentery, have an ambiguity in the view of both the dysentery and the treatment of it. This was probably due to interpretation based both on observable causes of diseases, and on a more theoretical abstract meaning, where diseases to a greater extent was understood on the basis of symptoms and signs.It is suggested that regardless of the knowledge base of the individual medical practitioner, no one represented an independent knowledge base for their treatment of dysentery; rather they participated actively with each other in a mutually constitutive way in order to shape their understanding of the dysentery. This theses’ qualitative approach, allows dysentery patients and their medical practitioners via the texts of the medical practitioners, to offer very personal accounts of a highly contagious disease.

Enligt tidigare forskning upplever homosexuella, bisexuella och transpersoner (HBT) att de blir diskriminerade och osynliggjorda i vården till skillnad från heterosexuell befolkning. HBT-personer undviker delvis att uppsöka vården, samt att vara öppna med sin sexuella läggning av rädsla för negativt bemötande vilket får konsekvenser för deras hälsa. Därför efterfrågas mer HBT-kunskap i vården av dessa patienter. HBT-patienter efterfrågar en öppenhet för att kunna tala om livet i alla dess aspekter i vården. Studiens syfte var att undersöka vad sjuksköterskor innefattar i HBT-kunskap och hur det påverkar vården, bemötande för denna patientgrupp i praktiken. Studien genomfördes som en empirisk kvalitativ intervjustudie. Intervjuer gjordes med åtta legitimerade sjuksköterskor som har erfarenhet av HBT-patienter och/eller har genomgått kurs i HBT-kunskap. Materialet analyserades med kvalitativ innehållsanalytisk ansats. Analysen resulterade i ett tema – förhållningssätt, två huvudkategorier – vård på lika villkor, kompetens och fyra underkategorier – att förhålla sig öppen, medvetenhet om heteronormativitet, att känna till HBT-personers hälsa/levnadsvillkor, att ha utbildning/erfarenhet om sexuell mångfald. Av studiens resultat framgår att viljan att ta till sig och behovet av HBT-kunskap är stort hos sjuksköterskor. Men det finns också en brist i hur vården uppfyller de ramlagar som finns, som säger att vård skall ges på lika villkor till hela befolkningen. / According to previous studies, lesbian, gay, bisexual and transgender persons (LGBT) feel discriminated and made invisible in the healthcare sector apart from the heterosexual population. They partly avoid seeking healthcare and being open with their sexuality for fear of negative reception, which has consequences for their health. Therefore more LGBT-knowledge is demanded in healthcare by this patients. LGBT-patients is asking for an openness from healthcare personnel so they can be able to talk about life in every aspect. The aim of the study is to examine what LGBT-knowledge means for nurse practitioners, how it affects healthcare for this group of patients. The study was carried out as an empirical interview study. Interviews were done with eight registered nurse practitioners who have experience of LGBT-patients or/and had taken a course in LGBT-knowledge. The analysis has an approach to qualitative content analysis. The analysis resulted in a theme – attitudes with two main categories – healthcare on equal conditions and competence – and four secondary categories – to be open minded, to be conscious of heteronormativity, to be aware of LGBT-persons health and living conditions and to have knowledge about sexual multitude. The result shows that there is a strong will to learn and a need for LGBT-knowledge among nurse practitioners. But there is also a lack of willingness to accept the general rules to provide equal healthcare to the entire population.

In the past three years, evidence based medicine emerged as a powerful force in an effort to improve quality and health outcomes, and to reduce cost of care. Computerized physician order entry (CPOE) applications brought safety and efficiency features to clinical settings, including ease of ordering medications via pre-defined sets. Order sets offer promise of standardized care beyond convenience features through evidence-based practices built upon a growing and powerful knowledge of clinical professionals to achieve potentially more consistent health outcomes with patients and to reduce frequency of medical errors, adverse drug effects, and unintended side effects during treatment. While order sets existed in paper form prior to the introduction of CPOE, their true potential was only unleashed with support of clinical informatics, at those healthcare facilities that installed CPOE systems and reap rewards of standardized care. Despite ongoing utilization of order sets at facilities that implemented CPOE, there is a lack of quantitative evidence behind their benefits. Comprehensive research into their impact requires a history of electronic medical records necessary to produce large population samples to achieve statistically significant results. The study, conducted at a large Midwest healthcare system consisting of several community and academic hospitals, was aimed at quantitatively analyzing benefits of the order sets applied to prevent venous thromboembolism (VTE) and treat pneumonia, congestive heart failure (CHF), and acute myocardial infarction (AMI) - testing hospital mortality, readmission, complications, and length of stay (LOS) as health outcomes. Results indicated reduction of acute VTE rates among non-surgical patients in the experimental group, while LOS and complications benefits were inconclusive. Pneumonia patients in the experimental group had lower mortality, readmissions, LOS, and complications rates. CHF patients benefited from order sets in terms of mortality and LOS, while there was no sufficient data to display results for readmissions and complications. Utilization of AMI order sets was insufficient to produce statistically significant results. Results will (1) empower health providers with evidence to justify implementation of order sets due to their effectiveness in driving improvements in health outcomes and efficiency of care and (2) provide researchers with new ideas to conduct health outcomes research.

Criada em 1864, a Academia Nacional de Medicina passou diversas transformações ao longo da segunda metade do século XIX em decorrência das mudanças no cenário sociopolítico mexicano e da própria dinâmica das ciências médicas no mundo Ocidental. Nesta dissertação, busca-se compreender como ocorreu o processo de institucionalização da medicina acadêmica no México a partir da trajetória da Academia Nacional de Medicina e como foram produzidos determinados saberes entre as décadas de 1860-1880. Assim, foram estudados o processo de consolidação de uma deontologia médica, além da produção, regulação e normatização de saberes médicos relacionados à concepção de vida e aos procedimentos de partos. À luz de uma perspectiva microssociológica e contextualista, demonstram-se como os embates e as controvérsias científicas serviram à organização da academia, às normas de produção e à formulação de saberes sobre vida e parto. Esta pesquisa também apontou como tais saberes serviram à estruturação do Estado mexicano durante a segunda metade do século XIX. Foram analisados os relatórios clínicos e as atas publicados na Gaceta Médica de México (periódico da Academia), os códigos civil e penal sancionados na virada das décadas de 1860-70 e os manuais de medicina legal e medicina obstétrica elaborados pelos médicos Luis Hidalgo y Carpio e Juan María Rodríguez. / Created in 1864, the Academia Nacional de Medicina went through several transformations during the second half of the 19th century as a result of changes at the mexican sociopolitical scenario and the dynamics of medical science in the Western World. Within this dissertation, it is searched to understand how did the process of institutionalization of academic medicine happen in Mexico starting from the trajectory of the Academia Nacional de Medicina and how certain knowledge were produced during the decades of 1860-1880. Therefore, were studied process of consolidation of a physician deontology, in addition to the production, regulation and normatization of medical knowledge related to the conception of life and childbirth procedures. At the light of a microsociological and contextualist perspective, it is shown how the dispute and the scientific controversy served to the organization of the academy, to its norms of production and to the formulation of knowledge about life and childbirth. This research also pointed how such knowledge served to the structuring of the mexican State during the second half of the 19th century. Were analysed clinical reports and minutes published in the Gaceta Médica de México (Academias journal), the civil and criminal Codes sanctioned at the turn of the 1860-70 decade and the manuals of legal medicine and obstetrical medicine made by the physicians Luis Hidalgo y Carpio and Juan María Rodríguez.

Medicine has been called a science, as well as an art or a craft, among other terms that express aspects of its practical nature. Medicine is not the abstract pursuit of knowledge. Medical researchers and clinical practitioners aim primarily to help people. As a first approximation then, given its practical focus on the person, the most important question in medicine is: what works? To answer that question, however, we need to understand how we know what works. What are the standards, methods and limits of medical knowledge? That is the central focus and subject of this inquiry: how we know what works in medicine. To explore medical knowledge and its limits, this thesis examines the common notion that laughter is the best medicine. Focusing on laughter provides a robust case study of how we know what works in medicine; it also, in part, reveals the thin, perhaps even non-existent, distinction in medicine between empirically-grounded knowledge and intuition. As there is no single academic discipline devoted to laughter in medicine, the first chapter situates and charts the course of this unusual project and explains why inquiry into laughter in medicine matters. In the following chapters, we encounter claims from distinguished sources that laughter and humor are the best medicine. These claims are examined from a variety of perspectives including not only the orthodox view of evidence-based medicine, but also from narrative, evolutionary and complexity views of medicine. The rarely explored serious negative side of laughter is also examined. No view provides a firm foundation for belief in laughter medicine. A general conclusion from this inquiry is that none of the approaches effectively tame the complexity of medical phenomena; indeed each starkly reveals a greater complexity than found at first glance. A narrower conclusion is that providing a basis for claims about laughter in medicine poses its own specific challenges. A third conclusion is that, as things stand, none of the existing approaches seems up to the task of determining whether something such as laughter is the best medicine.