The purpose of this study was to develop a medico-judicial framework for the rehabilitation of forensic psychiatric patients in Zimbabwe. The study used the grounded theory approach utilising a mixed sequential dominant status design. Purposive sampling of key stakeholders was the primary method and theoretical sampling became necessary as the study evolved in the qualitative phase. A confirmatory retrospective document review of 119 files of patients was done in the quantitative phase. Pierre Bourdieu’s conceptual canon of field, habitus and capital was utilised as the theoretical point of departure for the study. Findings and results showed dislocation and dissonance between and within the habitus of social fields the judiciary, health (medical) and the prison systems with an ensuing hysteretic effect that negatively affected the outcome of forensic psychiatric rehabilitation in special institutions in Zimbabwe. Forensic psychiatric patients were caught up in a double bind situation of aligning to both of the contradictory functions of the medical and the prison systems. The result of this hysteretic scenario seemed to breed some kind of rehabilitative schizophrenia. The developed medico-judicial framework is projected to transform the libido dominandi of the present into a widened scope of therapeutic jurisprudence. The medico-judicial framework is forwarding the forensic psychiatric practitioner to a new address since it has changed its residence from the special institution to the forensic psychiatric hospital. It is inviting the person involved with forensic psychiatric rehabilitation to begin again, inciting him or her to be open to the possibilities of mapping a path through the tangled growth of current realities into an increased width and depth of comprehensive forensic psychiatric practice that follows an empowering legislative prescript / Health Studies / D. Litt. et Phil. (Health Studies)

Made available in DSpace on 2016-04-28T20:39:20Z (GMT). No. of bitstreams: 1 EDUARDO GOLDENSTEIN.pdf: 870373 bytes, checksum: 3d2e971540a9c347550f42beab244033 (MD5) Previous issue date: 2006-08-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / From the end of the Second World War on, medicine started to develop clinically and surgically in a way hitherto unknown. Due to more accurate diagnoses, new therapeutic resources and the development of new drugs and technological procedures that allowed physicians to risk major surgeries, sicknesses simply became extinct or controlled and life could start earlier and end later. But all this technological development ended up causing two new problems and two new challenges: the increase of sicknesses without well-established physiopathological bases, such as psychosomatic anxieties and illnesses, and a kind of deconstruction of the humanistic face of medicine -- a deconstruction that came to be known as the dehumanization of medicine. Perhaps this dehumanization of medicine should be understood as a need to reformulate the humanistic bases of the same, adapting to current technological advances, which certainly have changed the training and the performance of the physician as he exercises his profession. The focus of our attention during this research was to go back to the previous matter: the double concept of dehumanization-humanization of medicine, especially in hospitals. Theoretical support for understanding these concepts will be presented in the introductory chapters. The objective of this research has been to analyze the experience of the clinical practice of ICU pediatricians in a humanized hospital. We, therefore, adopted a specific qualitative research methodology based on the phenomenological-existential approach of Heidegger, Boss and Buber. Interviews were made and analyzed with five ICU pediatricians that work in a humanized children s hospital The doctors accounts reveal different views on: how to deal with death, with anxiety and with guilt; the presence of mothers in the ICU and the effect on hospital routine and medical clinical practice; the recognition (or non-recognition) of the physician s work by the parents and ICU professionals; (positive or negative) aspects of the physical environment of the ICU and of working conditions. Starting from the data collected, a profile can be made of the clinical experiences of those interviewed, emphasizing the strategies used by them to deal with the difficulties and adversities generally present in ICUs. The analysis of these experiences has revealed the importance of listening to the physicians and including the voice of the doctor in the humanization process of medicine and hospitals. New research fronts, in which are heard the voice of other doctors, other professionals, the mothers and the children too, have shown themselves to be important / A partir do final da Segunda Guerra Mundial, a medicina tomou um impulso de desenvolvimento clínico e cirúrgico até então desconhecidos. Por conta de diagnósticos mais precisos, de novos recursos terapêuticos, do desenvolvimento de novas drogas e de procedimentos tecnológicos que propiciaram aos médicos se arriscarem em cirurgias de grande porte, doenças foram simplesmente extintas ou controladas, a vida pôde se iniciar mais cedo e terminar mais tarde. Entretanto, toda esse desenvolvimento tecnológico acabou por gerar dois novos problemas e dois novos desafios: a expansão de doenças sem bases fisiopatológicas bem estabelecidas, tais como ansiedades e doenças psicossomáticas, e uma certa descaracterização da face humanística da medicina, descaracterização essa que passou a ser conhecida como desumanização da medicina. Possivelmente essa desumanização da medicina deva ser entendida como uma necessidade de uma reformulação das bases humanísticas da mesma, numa acomodação com os avanços tecnológicos vigentes, os quais certamente mudaram a formação e a atuação do médico no exercício de sua profissão. O foco de atenção nessa pesquisa se volta para essa última questão: o binômio desumanização humanização da medicina, especificamente dos hospitais. Subsídios teóricos para a compreensão destes conceitos estão apresentados nos capítulos introdutórios. O objetivo desta pesquisa foi analisar a vivência da prática clínica de médicos pediatras intensivistas de um hospital humanizado. Adotou-se, para tanto, uma metodologia específica de pesquisa qualitativa referenciada pela abordagem fenomenológica-existencial de Heidegger, Boss e Buber. Foram realizadas e analisadas entrevistas com cinco médicos pediatras e intensivistas que trabalham em um hospital infantil humanizado. As falas dos médicos revelaram diferentes visões sobre: o lidar com a morte, com a angústia e a culpa; a presença das mães na UTI e suas decorrências na rotina hospitalar e na prática clínica médica; o reconhecimento (ou não-reconhecimento) do trabalho médico pelos pais e profissionais da UTI; aspectos (positivos ou negativos) do ambiente físico da UTI e das condições de trabalho. A partir dos dados colhidos, pôde-se traçar um perfil geral das vivências clínicas dos entrevistados, com ênfase nas estratégias por eles usadas para lidar com dificuldades e adversidades em geral presentes em UTIs. A análise dessas vivências revelou a importância de se ouvir os médicos e englobar a voz dos médicos no processo de humanização da medicina e dos hospitais. Novas frentes de pesquisa, nas quais se dê voz a outros médicos, a outros profissionais, às mães e às próprias crianças revelaram-se importantes

Le diabète de type 2 (DT2) est une maladie chronique associée à de graves et coûteuses complications. Dans un contexte de restriction budgétaire, il est nécessaire de pouvoir estimer les ressources à affecter à la prise en charge des maladies chroniques et donc de suivre l’évolution épidémiologique et économique d’une telle maladie. Une base de données a été construite à partir des données médico-administratives de l’assurance maladie luxembourgeoise. Elle comprenait les consommations de soins, associées au diabète et ses complications, des patients diabétiques de type 2 traités entre 2000 et 2006. L’objectif était d’étudier les champs d’utilisation de ces données et leurs applications possibles pour les décisions en santé publique. Cette thèse en donne quelques exemples. En 2006, la prévalence du DT2 au Luxembourg était de 3,79% (N= 17 070). Un algorithme a permis d’identifier trois stades de la néphropathie diabétique (3,77% des cas de DT2 en 2006). L’analyse de l’adhérence aux recommandations européennes de bonnes pratiques médicales a mis en évidence une situation critique associée à certains facteurs (médecin traitant, type de traitement, région de résidence…). Les dépenses moyennes d’un patient en hémodialyse a été estimé à 116 647€/patient en 2006. Enfin, une analyse médico-économique a montré la dominance coût-efficace d’une stratégie d’implémentation de la dialyse péritonéale sur la situation actuelle. Malgré les difficultés à évaluer leur qualité, les données médico-administratives offrent une source d’informations précieuses pour les décideurs publics et les professionnels de la santé, dans le but d’améliorer la prise en charge des patients. / Type 2 diabetes (T2D) is a chronic disease associated with many severe and costly complications. In a context of budgetary constraint, it is necessary to obtain an estimate the amount of resources to allocate to the management of chronic diseases. This includes monitoring the epidemiologic and economic evolutions. A database was built from medico-administrative databases of the national health insurance of Luxembourg. It included the healthcare consumptions associated with diabetes and its complications, of all type 2 diabetic patients treated in Luxembourg between 2000 and 2006. The objectives were to study the fields of use of this database and the possible applications for public health decision-making. This thesis gives some examples. In 2006, T2D prevalence in Luxembourg was 3.79% (N= 17070). An algorithm was built and permitted to identify three stages of diabetic nephropathy (3.77% of T2D cases in 2006). The analysis of the adherence to European follow-up guidelines showed a critical situation associated to several factors (treating physician, type of treatment, living region…). The mean costs associated with patients in dialysis were estimated at 116 647€/patient in 2006. Finally, a health-economic evaluation showed the dominance of a strategy promoting peritoneal dialysis in Luxembourg over the present situation.

Made available in DSpace on 2016-04-29T14:17:50Z (GMT). No. of bitstreams: 1 Monica Nardy Marzagao Silva.pdf: 961278 bytes, checksum: d1f16122b9ee80ad3f19d7e8ab7e947c (MD5) Previous issue date: 2009-05-05 / This work discusses the institutionalization of children and education of ISE - Institute of Social and Educational and Sama - Food Medical Service, both in Bragança Paulista, São Paulo State, from its foundation until the present day. The establishments had and are intended to house abandoned children (read poor), symbolizing a political action intended to mix life and rules of conduct for them, based health-medical discourse, in its way prophylactic in nature extremely ideological. The theoretical assumption that the discussion Embase were the work of Goldmann and Foucault, with its discursive articulation based on documentary sources and of those involved in the historical process of incorporation of each institution examined. The intention motivating the research was to recognize what was behind the two institutions, namely the political relationship between the practice of sheltering and ideals of the Brazilian state, in its authoritarian aspects. Waste derived from the logic of capitalist rationalization updated, corrective and educational practices in both institutions, had to be exclusionary and disciplinary functions, in response to the demands of the dominant elites in that historical moment of the Brazilian reality / Este trabalho discute a institucionalização e a educação das crianças do ISE Instituto Social e Educacional e do SAMA Serviço Médico Alimentar, ambos em Bragança Paulista, Estado de São Paulo, a partir de suas fundações até os dias atuais. Os estabelecimentos tinham e têm por objetivo abrigar crianças abandonadas (leia-se pobres), simbolizando uma ação política que tencionava homogeneizar regras de vida e conduta para as mesmas, tendo por fundamento o discurso médico-sanitário, em sua via profilática, de cunho extremamente ideológico. O pressuposto teórico que embasou a discussão foram as obras de Goldmann e Foucault, tendo sua articulação discursiva assentada em fontes documentais dos agentes envolvidos no processo histórico constitutivo de cada instituição analisada. A intenção motivadora da pesquisa foi a de reconhecer o que estava subjacente nas duas instituições, a saber: a relação política entre a prática do abrigamento e o ideário do Estado brasileiro, em sua vertente autoritária. Resíduo da racionalização derivada da lógica capitalista atualizada, as práticas educativas e corretivas, em ambas instituições, apresentaram-se como funções disciplinadoras e excludentes, em atendimento às demandas das elites dominantes, naquele momento histórico da realidade brasileira

The purpose of this study was to develop a medico-judicial framework for the rehabilitation of forensic psychiatric patients in Zimbabwe. The study used the grounded theory approach utilising a mixed sequential dominant status design. Purposive sampling of key stakeholders was the primary method and theoretical sampling became necessary as the study evolved in the qualitative phase. A confirmatory retrospective document review of 119 files of patients was done in the quantitative phase. Pierre Bourdieu’s conceptual canon of field, habitus and capital was utilised as the theoretical point of departure for the study. Findings and results showed dislocation and dissonance between and within the habitus of social fields the judiciary, health (medical) and the prison systems with an ensuing hysteretic effect that negatively affected the outcome of forensic psychiatric rehabilitation in special institutions in Zimbabwe. Forensic psychiatric patients were caught up in a double bind situation of aligning to both of the contradictory functions of the medical and the prison systems. The result of this hysteretic scenario seemed to breed some kind of rehabilitative schizophrenia. The developed medico-judicial framework is projected to transform the libido dominandi of the present into a widened scope of therapeutic jurisprudence. The medico-judicial framework is forwarding the forensic psychiatric practitioner to a new address since it has changed its residence from the special institution to the forensic psychiatric hospital. It is inviting the person involved with forensic psychiatric rehabilitation to begin again, inciting him or her to be open to the possibilities of mapping a path through the tangled growth of current realities into an increased width and depth of comprehensive forensic psychiatric practice that follows an empowering legislative prescript / Health Studies / D. Litt. et Phil. (Health Studies)

La littératie en santé (LS) désigne les connaissances, la motivation et les compétences permettant d’accéder, comprendre, évaluer et appliquer l’information dans le domaine de la santé. C’est un déterminant majeur de santé qui est fréquemment considéré comme un mécanisme des inégalités sociales de santé. Ce travail de thèse a comme objectif fondamental d’évaluer l’association entre la LS, les inégalités d’information et l’état de santé des personnes atteintes de cancers. Toutefois, devant le manque d’instruments de mesure de la LS, nos premiers travaux ont consisté en la validation d’outils de mesure en France. Nos travaux empiriques se sont appuyés sur les analyses de trois enquêtes.Ces analyses ont permis d’obtenir des éléments de validation de plusieurs échelles subjectives en version française évaluant la LS, la numératie et la décision partagée.Un niveau limité de LS a été montré associé à une moindre participation au processus de décision partagée, des comportements de recherche d’information et un état de santé mentale et physique altéré. De plus, les patients avec un niveau limité de LS sollicitent davantage le médecin généraliste et les services sociaux.La prise en compte du niveau de LS des patients pendant tout le parcours de soins nous parait indispensable. Cela pourrait permettre d’adapter l’information au niveau de LS afin de réduire les inégalités d’information et augmenter la participation des patients à la prise de décision. En outre, cela pourrait également permettre aux professionnels de santé de proposer un accompagnement particulier pour les personnes à faible niveau de LS afin d’améliorer leur état de santé et leur qualité de vie. / Health Literacy (HL) refers to the knowledge, motivation, and skills to access, understand, evaluate, and apply information in the health field. It is a major determinant of health that is frequently considered as a mechanism of the social inequities of health. The main objective of this thesis is to evaluate the association between HL, information inequities and the health status of people with cancer. However, given the lack of HL measuring instruments in France, we started with the psychometric validation of measurement tools.Our empirical work is based on analyzes of three surveys.These analyses allowed having valid French version of subjective scales measuring HL, numeracy and shared decision-making process. Our analyzes have shown that a limited level of HL is associated with less involvement in the shared decision process, more information seeking and impaired mental and physical health status. In addition, patients with limited level of HL consulted more often the general practitioner and the social worker. Considering the patients’ HL level during all the course of their care seems mandatory. This would allow information to be tailored to patients’ HL level, to reduce information inequities and increase patient participation in decision-making. In addition, this would also allow health professionals to propose special care for people with low levels of HL to improve their health and quality of life.

Adverse drug reactions (ADRs) constitute a significant health problem with consequences for the patient as well as for society. Suspected ADRs have been reported to occur in about 2-14% of hospitalised patients. In about 5% of deceased hospitalised patients suspected ADRs may have caused or contributed to the fatal outcome. When a pharmaceutical drug is approved for marketing, the drug has been tested only on a limited number of patients (often <6000) for a limited time period in a controlled environment. Hence mostly common ADRs are detected in these trials. Moreover, certain patient groups, for example patients with co-morbidities, elderly patients, children and pregnant women are often not included in these studies. Thus, it is important to closely monitor the use of drugs after marketing to observe new effects and detect new ADRs. The aim of this thesis is to describe the pattern of pharmaceutical substance use related to morbidity and mortality and to investigate two serious ADRs. We have studied the incidence of fatal ADRs, fatal intoxications, cerebral haemorrhage related to warfarin treatment and venous thromboembolism (VTE) related to treatment with antipsychotic drugs. Observational studies form the basis for this thesis. Data from the Swedish Cause of Death Register, medical case records, the Swedish database on ADRs, the forensic pathology and forensic toxicology databases, and Swedish and Danish hospital discharge registers, Danish prescription registers, and civil registry systems were used. In Paper I we found that 3% of all fatalities in a Swedish population were related to a suspected ADR. Of the deceased hospitalised patients, 6% were related to a suspected ADR. Haemorrhage was the most commonly observed fatal suspected ADR, accounting for almost two-thirds of the events and anticoagulantia was the most common drug group associated with fatal suspected ADRs (almost 50%). A suspected intoxication could have contributed to the fatal outcome in 0.6% of the deceased. Among the fatal intoxications in Swedish medico-legal autopsies studied in Paper II, on average four substances were detected per case. The five most commonly detected substances in individuals with a fatal intoxication were ethanol, propoxyphene, paracetamol, diazepam and flunitrazepam. Among patients diagnosed with cerebral haemorrhage, 10% (59 cases) were treated with warfarin at onset of symptoms (Paper III). Of these, 7 cases (12%) were considered to have been possibly avoidable since the patients were treated with concomitant drugs that have the potential to enhance warfarin effects. The results from Paper IV and Paper V in combination with the published literature suggest that patients treated with antipsychotic drugs have an increased risk for VTE. Compared with non-users, an adjusted odds ratio for VTE of 2.0 was found for users of any antipsychotic drugs in a Danish population. In a medico-legal autopsy series, an adjusted odds ratio for fatal pulmonary embolism of 2.4 and 6.9 was found for users of first-generation low-potency antipsychotics and second-generation antipsychotics, respectively. In summary, drug-related morbidity and mortality is a significant problem and suspected ADRs contribute to a substantial number of deaths. Fatal intoxications are relatively common and it is important to observe changes in patterns of substances associated with fatal intoxications to be able to discover new trends and monitor effects of preventive work. A significant proportion of warfarin-related cerebral haemorrhage was caused by drug-drug interactions and was considered possible to avoid. Users of antipsychotic drugs may increase the risk of VTE. / Idag finns det säkra och effektiva behandlingar mot många sjukdomar. Läkemedel är den vanligaste behandlingsformen i sjukvården och under 2006 hämtade sex miljoner svenskar (68%) ut ett eller fler recept på ett apotek i Sverige. Även om läkemedelsbehandling har många positiva effekter kan även oönskade och skadliga effekter vid läkemedelsbehandling uppkomma, dvs. läkemedelsbiverkningar. Innan ett läkemedel kommer ut för försäljning har man studerat effekter och biverkningar på ett begränsat antal individer (ofta <6000) under en begränsad tidsperiod där patienterna övervakas noga. Dessutom är det i regel enbart patienter med få andra sjukdomar och läkemedel som ingår i dessa studier. Därför är oftast enbart de vanligaste biverkningarna kända när ett läkemedel börjar säljas till allmänheten. När ett läkemedel blir tillgängligt för ett stort antal patienter är det därför viktigt att man med olika metoder fortsätter att följa läkemedlets effekter och biverkningar. Tidigare har man visat att ungefär 2-14% av inläggningar på sjukhus beror på läkemedelsbiverkningar. Dessutom kan biverkningar ha bidragit eller orsakat dödsfallet i ungefär 5% av de som avlider på sjukhus. Biverkningar orsakar mycket lidande för patienten och kostar samhället både tid och pengar. Om det skulle vara möjligt att förhindra några av dessa sjukhusinläggningar eller dödsfall skulle man vinna mycket. Det är svårt att uppskatta hur många biverkningar som kan förhindras. Genom att studera faktorer som kan öka risken för en oönskad effekt kan man bättre anpassa behandlingen till den enskilde patienten och därmed förhindra biverkningar. Syftet med den här avhandlingen är att beskriva mönster av läkemedelsrelaterade sjukdomar och dödsfall, och att undersöka risken för två allvarliga läkemedelsbiverkningar. Förekomsten av misstänkta läkemedelsbiverkningar, vilka faktorer som kan öka risken för att få en läkemedelsbiverkan, samt vilka läkemedel och biverkningar som förekommer har studerats. Detta gjordes utifrån uppgifter hämtade från dödsorsaksregistret, svenska biverkningsregistret, journaler, rättsmedicinska register, slutenvårdsregister och receptregister. Genom att utnyttja sådan information har vi i närmare detalj studerat förekomsten av dödsfall där ett eller flera läkemedel kan ha haft betydelse för dödsfallet, förgiftningsdödsfall, blödningar i samband med blodförtunnande medicinering och blodproppar i samband med antipsykotisk medicinering. I de arbeten som ingår i avhandlingen har vi funnit att en läkemedelsbiverkan misstänks ha bidragit eller orsakat dödsfallet i ungefär 3% av de som avlidit i en svensk population (Arbete I). Blödningar står för nästan två tredjedelar av dessa biverkningar och blodförtunnande medel misstänks vara inblandade i nästan hälften av de misstänkta läkemedelsbiverkningarna. I den här svenska populationen avled 0,6% till följd av misstänkt läkemedelsförgiftning. Bland rättsmedicinskt undersökta förgiftningsdödsfall påvisades i genomsnitt fyra substanser per fall (Arbete II). De fem vanligaste påvisade substanserna i studien var alkohol, dextropropoxifen, paracetamol, diazepam och flunitrazepam. Bland patienter som får hjärnblödning behandlades 10% vid blödningstillfället med ett blodförtunnande medel, warfarin (Arbete III). I 7 fall (12%) skulle hjärnblödningen möjligen kunna ha förhindrats då patienterna samtidigt behandlades med andra läkemedel som kan ha ökat blödningsrisken. Den sammantagna bilden av den litteratur som finns publicerad och resultatet av Arbete IV och Arbete V, tyder på att patienter som behandlas med antipsykotiska preparat har en ökad risk för att få blodpropp. Flera faktorer har föreslagits som kan förklara den ökade risken för blodpropp bland patienter som behandlas med antipsykotika som har med sjukdomen att göra och/eller behandlingen med antipsykotiska läkemedel. Sammanfattningsvis visar detta avhandlingsprojekt att läkemedelsbiverkningar är ett väsentligt sjukvårdsproblem som bidrar till ett betydande antal dödsfall. Förgiftningsdödsfall med läkemedel är också relativt vanliga och det är viktigt att bevaka effekter av preventiva åtgärder och se om de substanser som används ändras över tid. En del läkemedelsrelaterade biverkningar skulle kunna förhindras då t.ex. en betydande andel av warfarinrelaterade hjärnblödningar beror på läkemedelsinteraktioner. Förekomsten av venösa blodproppar verkar vara förhöjd bland patienter som behandlas med antipsykotiska läkemedel, men fler studier behövs för att avgöra detta och vad det i så fall beror på.

A radiografia panorâmica e a tomografia computadorizada por feixe cônico (TCFC) são métodos de imagem amplamente utilizados na Odontologia, pois fornecem uma visão geral do complexo dentomaxilofacial, sendo importantes no diagnóstico e tratamento de lesões que acometem esta região. A radiografia panorâmica é considerada um procedimento de baixa dose e a TCFC apresenta doses inferiores quando comparada à tomografia computadorizada (TC). Apesar de baixas, as doses provenientes destes exames expõem órgãos radiossensíveis, como tireoide e glândulas salivares, aos riscos da radiação ionizante. Conhecer os níveis de radiação à que estes órgãos estão expostos é importante para a escolha adequada do método de imagem e parâmetros de exposição a serem utilizados, reduzindo os riscos associados à radiação ionizante, conforme o princípio de radioproteção ALARA (As Low As a Reasonably Achievable - tão baixo quanto razoavelmente exequível). O objetivo deste estudo foi avaliar as doses absorvidas por estes órgãos radiossensíveis durante a realização de radiografias panorâmicas e exames de TCFC, utilizando diferentes parâmetros de exposição. Dosímetros termoluminescentes (TLDs - Thermoluminescent Dosimeters) foram inseridos em um phantom antropomórfico Alderson Radiation Therapy (ART) para identificar as doses absorvidas pela tireoide e glândulas salivares, em um equipamento de radiografia panorâmica e dois equipamentos de TCFC, com diferentes protocolos. As doses absorvidas variaram de 0,01 a 0,22 mGy na tireoide e de 0,26 a 2,96 mGy nas glândulas salivares. Na TCFC as doses variaram de acordo com o protocolo selecionado, porém foram superiores às doses de uma radiografia panorâmica. Os protocolos de TCFC que utilizaram longos tempos de exposição, considerados como protocolos de alta resolução, resultaram em doses superiores quando comparados aos protocolos que utilizaram baixos tempos de exposição. Protocolos que utilizaram campos de visão (FOVs - Fields Of View) maiores, expuseram a tireoide a níveis mais altos de radiação. Diante dos resultados obtidos, pode-se concluir que a TCFC somente deve ser solicitada caso a informação diagnóstica não possa ser obtida através da radiografia panorâmica, sendo a escolha adequada dos fatores técnicos imprescindível para reduzir a dose de radiação durante a realização de exames de TCFC. / Panoramic radiograph and cone beam computed tomography (CBCT) are imaging methods widely used in dentistry because they provide an overview of dentomaxillofacial complex, being important in the diagnosis and treatment of lesions that affect this region. Panoramic radiograph is considered a low-dose procedure and CBCT presents lower doses when compared with computed tomography (CT). Although low, the doses from these imaging methods expose radiosensitive organs, such as thyroid and salivary glands, to the risks of ionizing radiation. Knowing the levels of radiation these organs are exposed is important to select the appropiate imaging method and exposure parameters to be used, reducing the risks associated with ionizing radiation, according to the principle of radioprotection ALARA (As Low As a Reasonably Achievable). The aim of this study was to evaluate the absorbed doses by these radiosensitive organs during the course of panoramic radiographs and CBCT examinations, using different exposure parameters. Thermoluminescent dosimeters (TLDs) were inserted into an anthropomorphic phantom Alderson Radiation Therapy (ART) to identify the absorbed doses by the thyroid and salivary glands, in a panoramic x-ray unit and two CBCT units with different protocols. Absorbed doses ranged from 0.01 to 0.22 mGy in the thyroid and 0.26 to 2.96 mGy in the salivary glands. Doses in CBCT varied according to the selected protocol, but were higher than the dose of a panoramic radiograph. The CBCT protocols that used long exposure times, considered as high-resolution protocols, resulted in higher doses compared to protocols that used low exposure times. Protocols that used fields of view (FOVs) higher, exposed the thyroid at higher levels of radiation. Based on the results obtained, it can be concluded that CBCT should only be requested if the diagnostic information can’t be obtained through the panoramic radiograph and the appropriate choice of technical factors essential to reduce the radiation dose during examinations CBCT.

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.

[pt] A presente dissertação de mestrado em metrologia relaciona- se à qualidade laboratorial do setor da saúde, notadamente da saúde pública, contribuindo para o desenvolvimento da confiabilidade metrológica do setor médico-hospitalar em pelo menos 4 aspectos básicos: (i) identificação da legislação metrológica disponível no Brasil, via de regra organizada de forma esparsa e não facilmente acessível ao profissional usuário final,cuja pesquisa bibliográfica explicita grande carência de literatura especializada; (ii) análise do acervo de normas e recomendações metrológicas para o setor; (iii)diagnóstico da qualidade laboratorial em um Laboratório Central de Saúde Pública (LACEN), como implementação de uma estratégia alternativa para implantação de sistema da qualidade em laboratório da saúde pública com base em uma nova abordagem que focaliza a qualidade laboratorial da Rede nacional de laboratórios Oficiais de Controle da Qualidade e Saúde, criando um mecanismo que permite ao laboratório demonstrar sua competência técnica; (iv) diagnóstico da conformidade metrológica de instrumentos médico-hospitalares fundamentado nos estudos de caso de balanças para controle da massa de neonatos e de instrumentos biomédicos para medição da pressão arterial, como exemplo de ação do controle metrológico de instrumentos de amplo uso no ambiente médico-hospitalar.A despeito da complexidade e abrangência do setor da saúde no Brasil, a pesquisa desenvolvida revelou não apenas carência e inadequação da literatura técnica disponível bem como forte vulnerabilidade no controle metrológico de laboratório e de equipamentos médico-hospitalares. O diagnóstico realizado em um laboratório típico da saúde pública evidenciou também grandes desafios para a implantação do sistema da qualidade laboratorial.A despeito dos complexos problemas de natureza política e econômica que afetam o sistema da saúde no Brasil, as limitações de caráter metrológicos relacionam-se (i) à falta de uma adequada cultura metrológica no setor, fator intrínseco que entrava a implementação do sistema da qualidade laboratorial, imprescindível à comprovação da competência técnica do laboratório (credenciamento) e (ii) uma surpreendente diversidade de modelos, tipos e quantidade de instrumentos/equipamentos em uso no setor, via de regra dependentes de calibração sofisticada que demandam complexa infra-estrutura laboratorial e métodos e práticas de calibração não disponíveis nos laboratórios credenciados que integram as redes laboratoriais implementadas no País. Sem a pretensão de exaurir tema de tal abrangência e complexidade, porém com o propósito de exemplificar duas importantes áreas que apresentam nítida vulnerabilidade em setores tradicionais cujo envolvimento metrológico não se constitui em barreira ao profissional- usuário do equipamento, a pesquisa analisou (a) o desempenho de dezesseis balanças disponíveis em seis hospitais maternidades, utilizadas para controle da massa de recém- nascidos, como estratégia de orientação do diagnóstico médico e (b)resultados do desempenho de esfigmomanômetros para controle da pressão arterial no ambiente hospitalar. O presente trabalho constitui parte de um esforço mais amplo, desenvolvido em articulação com a Agência Nacional de Vigilância Sanitária (ANVISA), para fortalecer a qualidade laboratorial no setor da saúde pública brasileira. / [en] The present dissertation for a Master`s degree in metrology is related to laboratory quality in the health care sector in general and to public health services in particular, and its purpose is to contribute to the development of reliable measurement practices in the hospital care section within the scope of at least 4 basic aspects: (i) identification of the available metrology legislation in Brazil which, as a rule, is sparsely organized and is not easily accessible to the end-user/practitioner, whose bibliographical research reveals an explicit lack of specialized literature; (ii) analysis of the compiled measurement standards and recommendations for the sector; (iii) diagnosis of laboratory quality in a Central Public Health Care Laboratory (Laboratório Central de Saúde Pública - LACEN)as a means by which to implement an alternative strategy for introducing a quality system in a public health care laboratory based on a new approach that focuses on the quality of the laboratories that comprise the National Network of Official Quality and Health Care Control Laboratories, and the subsequent creation of a type of mechanism that will allow a laboratory to demonstrate its technical competence; (iv) diagnosis of instruments that are employed in hospital services in terms of their conformity to measurement standards based on case studies of scales for controlling the mass of neonates, and of biomedical instruments for measuring blood pressure, as an example of how measurement is controlled in the case of instruments that are widely used in the hospital care environment.Despite the complexity and reach of the Brazilian health care sector, the research that was carried out not only revealed that the technical literature available is insufficient and unsuitable, but also that the measurement provided by laboratories and hospital care equipment are controlled in a high vulnerable manner. The diagnosis that was performed in a typical health care laboratory also brought to light a number of major challenges for the introduction of a laboratory quality system. Apart from the complex political and economic problems that affect the Brazilian health care system as a whole, the limitations associated with measurements are related to (i)the lack of a suitable metrology culture within the sector because this intrinsic factor hampers the implementation of a laboratory quality system and the latter is an essential requirement for proving that a laboratory is technically competent (accreditation), and (ii) the astonishing variety and number of models and types of instruments/equipment that are in use in this sector, which, as a rule, depend on sophisticated calibration procedures and require complex laboratory infrastructures and calibration methods and practices that are not available in the accredited laboratories within the laboratorynetworks that have been implemented in the country. This paper does not propose to exhaust such a broad and complex topic. Rather, its purpose is to consider the examples of two important areas that are clearly vulnerable in traditional sectors whose involvement with metrology does not represent an obstacle to the practitioner/user of the equipment. To this end, the research has focused on (a) the performance of sixteen scales that are available in six maternity hospitals and are used for controlling the mass of newborn infants as a strategy for the orientation of medical diagnoses and (b) the performance results of sphygmomanometers that are used for controlling blood pressure in hospital environments. This paper is part of a more encompassing initiative towards the improvement of laboratory quality in the Brazilian public health care sector and has been developed as a joint effort with the National Agency of Sanitary Vigilance (Agência Nacional de Vigilância Sanitária - ANVISA).