abstract: Overview: Transition from the pediatric to adult care setting for 'emerging adults' (ages 18- 26) continues to develop as a growing concern in health care. The Adolescent Transition Program teaches chronically ill 'emerging adults' disease self-management skills while promoting a healthy lifestyle. Transferring this knowledge is vital for successful health care outcomes. Unfortunately, patients who have been transferred to the adult care setting, report that they felt lost in the system due to lack of communication between care teams, inadequate support systems, and insufficient disease management knowledge. To address these gaps, the design of the physical environment must adapt to these challenges while also meeting the needs of various chronic illnesses. Methodology: Design thinking or human-centered design was utilized as the vehicle to discover unmet 'emerging adult' and adolescent health clinician needs. Ethnographic research methods involved observations at adolescent health clinics and in learning environments outside of the healthcare setting as well as interviews with 5 outpatient adolescent clinicians. A survey was also conducted with 16 'emerging adults' to understand how they learn. Lastly, a literature review explored the history of the adolescent, adolescent development, adolescence and chronic illness, and The Adolescent Transition Program. Results: Findings revealed that physical environment must be conducive to meet a variety of clinical and education activities such as chronic disease management, support adolescent development, and should be more human-centered. The space should transform to the patient education or clinical activity rather than the activity transforming to the space. Five design recommendations were suggested to ensure that the outpatient clinic supported both clinician and 'emerging adults' needs. / Dissertation/Thesis / M.S.D. Design 2014

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2017-08-07T14:15:11Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Tese doutorado Keyla Mendonça.pdf: 1892604 bytes, checksum: 11d46f4a20b26b6f0556122ab34f0316 (MD5) / Made available in DSpace on 2017-08-07T14:15:12Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Tese doutorado Keyla Mendonça.pdf: 1892604 bytes, checksum: 11d46f4a20b26b6f0556122ab34f0316 (MD5) Previous issue date: 2016-08-05 / CNPQ / A radioiodoterapia (RIT) para hipertireoidismo é feita ambulatorialmente há cerca de 70 anos, com poucas restrições quanto à segurança radiológica dos familiares de convívio domiciliar. Diante disso, o objetivo do estudo foi avaliar o impacto radiológico da RIT para hipertireoidismo por meio de levantamento das exposições no ambiente domiciliar destes pacientes nos primeiros seis dias pós-tratamento, para servir como um parâmetro real na tomada de decisões relacionadas com a conduta terapêutica e estabelecimento de novas recomendações práticas e seguras desta terapia. Dosímetros termoluminescentes TLD-100 foram colocados nos acompanhantes e nos ambientes domiciliares de 25 pacientes hipertireóideos tratados com atividades de 555 MBq (n=9), 740 MBq (n=7) e 1110 MBq (n=9). Além disso, foram verificadas as contaminações superficiais de objetos e materiais desses pacientes. As doses efetivas obtidas por meio dos TLDs-100 foram de 0,9 mSv, 0,6 mSv e 0,2 mSv, para atividades administradas de 555 MBq, 740 MBq e 1110 MBq, respectivamente. Os valores médios de equivalente de dose ambiental dos locais mais frequentados dos pacientes, como quarto, cozinha, banheiro e sala foram de: 2,11; 0,15; 0,20 e 0,44 mSv, respectivamente. A monitoração de objetos e materiais de âmbito domiciliar para cada grupo de atividade 555, 740 e 1110 MBq variaram de valores indetectáveis até próximos a 150 Bq.cm-2. No Brasil, a norma 3.05 da Comissão Nacional de Energia Nuclear estabelece que pacientes tratados com 131I possam realizar terapia com atividades até 1850 MBq, em regime ambulatorial, sem nenhuma restrição de isolamento. Além disso, a norma 3.01da Comissão nacional de energia Nuclear estabelece os limites de dose efetiva para indivíduos do público e acompanhantes/voluntários, como sendo de 1 mSv e 5 mSv por ano, respectivamente. Comparando a população estudada com a norma vigente, apenas duas acompanhantes de pacientes ultrapassaram o limite estabelecido. Pressupõe-se que o contato físico próximo e constante delas aos pacientes, em consequência da exiguidade do espaço domiciliar, resultou nessas doses efetivas. Conclui-se que o tratamento do hipertireoidismo em regime ambulatorial com atividades de até 1.110 MBq, foi realizado de forma segura e forneceu informações úteis sobre a proteção e exposição dos familiares e acompanhantes de pacientes. / The radioiodine therapy (RIT) for hyperthyroidism is done on an outpatient basis for about 70 years, with few restrictions on radiological safety of household living family. Thus, the objective of the study was to evaluate the radiological impact of RIT for hyperthyroidism through survey of exposures in the home environment of these patients in the first six days after treatment, to serve as an actual parameter in making decisions related to the therapeutic approach and establishment of new practices and safe recommendations of this therapy. TLD-100 thermoluminescent dosimeters were placed in the accompanying domestic environments and 25 hyperthyroid patients treated with 555 MBq Activity (n = 9), 740 MBq (n = 7) and 1110 MBq (n = 9). Furthermore, the surface contamination of objects and materials of these patients were checked. The effective doses obtained through the TLDs-100 were 0.9 mSv 0.6 mSv and 0.2 mSv for administered activity of 555 MBq 740 MBq and 1110 MBq, respectively. The average values of ambient dose equivalent of the busiest places of the patients, such as bedroom, kitchen, bathroom and living room were: 2,11; 0.15; 0.20 and 0.44 mSv, respectively. Monitoring objects and home environment of materials for each activity group 555, 740 and 1110 MBq ranged from undetectable to near 150 Bq.cm-2. In Brazil, the standard 3:05 of the National Nuclear Energy Commission established that patients treated with 131I can perform therapy activities up to 1850 MBq, in an outpatient setting, without any isolation restriction. In addition, the standard 3.01da National Nuclear Energy Commission shall establish the effective dose limits for individuals from the public and chaperones / volunteers, as of 1 mSv to 5 mSv per year, respectively. Comparing the study population with the current regulations, only two companions of patients exceeded the limit. It is assumed that the close physical contact and constant them to patients as a result of the paucity of home space, resulted in these effective doses. We conclude that treatment of hyperthyroidism on an outpatient basis with up to 1,110 MBq activities was carried out safely and provided useful information on the protection and exposure of family members and patients companions.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / Trata-se de um estudo transversal sobre adesÃo ao tratamento da hi-pertensÃo e seus determinantes, realizado de novembro de 1997 a fevereiro de 1998, com 177 pacientes selecionados aleatoriamente e entrevistados apÃs a con-sulta mÃdica no ambulatÃrio do Hospital de Messejana, Fortaleza-CE. Tais pacien-tes foram visitados em domicÃlio para continuidade da entrevista e contagem de comprimidos, a primeira vez entre 13 e 25 dias apÃs a consulta e a segunda vez entre 13 e 25 dias apÃs a primeira visita. A maior parte (65,8%) dos medicamentos prescritos nÃo foi dispensada no hospital e destes 22,3% nÃo foram adquiridos em outro lugar, portanto 14,7% dos medicamentos prescritos nÃo foram adquiridos pe-los pacientes. A taxa de adesÃo determinada no presente estudo, pelo mÃtodo de entrevista, foi de 62,1%, e pelo mÃtodo contagem de comprimidos, foi de 38,4%. De acordo com o teste de Kappa, o grau de concordÃncia entre os dois mÃtodos foi muito baixo (33,68%). O desempenho da entrevista como uma medida de adesÃo teve as seguintes caracterÃsticas: baixa sensibilidade (52,3%) para detectar pacien-tes nÃo aderentes, alta especificidade (85,3%) para detectar pacientes aderentes, alto valor preditivo (85,1%) para a nÃo adesÃo e baixo valor preditivo (52,7%) para a adesÃo. Devido o baixo desempenho da entrevista para determinar adesÃo, os re-sultados apresentados referem-se ao mÃtodo contagem de comprimidos. As variÃ-veis que se mostraram significantes atravÃs do teste de Fisher (p < 0,15) na anÃlise univariada em relaÃÃo a uma maior adesÃo ao tratamento, foram analisadas para identificar efeitos independentes atravÃs de um modelo de regressÃo logÃstica. Na anÃlise multivariada, maior renda familiar e a ajuda que o paciente recebe da famÃlia para tomar os medicamentos favoreceram uma maior adesÃo ao tratamento (OR = 3,19 - IC [1,01 - 10,04] e OR = 3,00 - IC [1,16 - 7,74], respectivamente). Os resulta-dos tambÃm sugerem como fatores que dificultam a adesÃo dos pacientes ao tra-tamento: nÃmero reduzido de consultas/ano por paciente, grande intervalo entre as consultas, deficiÃncias na orientaÃÃo mÃdica durante a consulta, desabastecimento de medicamentos no hospital e pouco envolvimento dos pacientes no programa de apoio ao paciente hipertenso.

Master of Public Health - MPH / Background: The Western Cape's Comprehensive Service Plan (CSP) is committed to "treating the right patient at the right level right, with the right skills and at the right cost" (Page 1, Tygerberg Hospital Annual Report, 2007). Occupational therapy (OT) Managers in the Metro District, Western Cape Province are in the process of aligning the OT services to the new CSP document. A major problem is the high default rate (non attendance) and irregular attendance (patient attends but skips sessions) amongst paediatric out-patients. In order to properly improve the OT paediatric services, it is vital for the OT managers to know the reasons for the poor utilisation of the OT services at the paediatric out-patient units. Purpose of study: The irregular attendance and high default rates (where patients stop attending the OT sessions completely) among children are a major problem at three OT out-patient units in Cape Town, Western Cape Province. The occupational therapists who work at these units are adamant that this impacts negatively on the child's progress. This study sought to explore the factors influencing the utilisation of the OT service in these three OT paediatric out-patient units in the hope of providing relevant information to the OT managers of these units in order to rethink the current service and make appropriate changes to improve adherence and treatment progress. Study design: This was an exploratory study using qualitative research methods. In-depth interviews were conducted with ten parents of children who have to attend the OT out-patient services. One group discussion was conducted with the occupational therapists that provide the services at the out-patient units. Sampling: Purposive sampling methods were employed to select four occupational therapists (at least one from each unit) and ten parents (at least three from each unit, with at least two who attended poorly and one that attended regularly). Analysis: Thematic analysis was used to interpret the data. The data was coded and categorised according to themes that emerged during data analysis. Results: The results of this study revealed that the factors that impact the utilisation of the OT service at the three OT units is complex. Factors that influenced the utilisation of the OT services in this study were related to the OT service such as staff attitude, relationship between the occupational therapist and the mothers as well as their child, communication between the mother and the occupational therapist, treatment progress, parent involvement in the OT programme and access to the OT service. Other factors such as the mothers' perception of the severity of the child's health condition, family support, work factors and family support were important factors related to the mother. The findings also revealed that environmental factors namely stigma, discrimination and travelling to the OT units impacted utilisation of the OT service. The participants made recommendations on how to improve the service. Conclusion: This study describes the complexity of what impacted the utilisation of the OT services and how closely interlinked these different factors are. It is evident from the findings of this study that a comprehensive, client centred approach is required to properly deal with the factors that negatively impact the utilisation of this service. Recommendations: A multi-faceted approach is required. Important issues to address are the shortage of occupational therapists across the levels of health care in the Western Cape Province; improving on the client centred approach in OT intervention programmes; advancing advocacy against stigma and discrimination against children with disabilities; and making public transport more accessible to children and their mothers.

After 1994 with the inception of the South African Democratic Government, the health care delivery system was one of the areas that had to be reviewed. The vehicle for a comprehensive health care system was based on primary health care which encouraged people and patients to take responsibility for their health by being involved in all aspects of their care. For this purpose the Batho Pele principles were introduced, a concept which is informed by 8 principles, namely: consultation, service standards, access, courtesy, information, openness and transparency, redress and value for money. These principles are meant to restore the dignity and the rights of patients which are paramount in the Constitution of South Africa. (Constitution of South Africa 108 of 1996 Chapter 2) The nurses claim that since the introduction of the Batho Pele Principles, patients and their families have been “impossible” towards nurses, making unnecessary and sometimes impossible demands. The nurses also experience patients and their families as being informed of their “rights” but not of their responsibilities as patients. They were also unaware of the rights of the nurses. The objectives of the study were:- To explore and describe the experiences of professional nurses working in the outpatient departments of the introduction of the Batho Pele principles in state hospitals, and to Recommend guidelines that will enhance better understanding and implementation of the Batho Pele principles by the professional nurses. The study is founded on a qualitative research paradigm based on explorative, descriptive and contextual framework. The data was collected from focus groups from each hospital of the Port Elizabeth Hospital Complex. Each group consisted of four to six willing participants all of them were professional nurses who have worked at least five or more years in the outpatient department of the Port Elizabeth Hospital Complex. Data was collected via semi-structured audio-taped interviews together with the researcher’s field notes. Data analysis was done using Tesch’s data analysis spiral. The assistance of independent coder reinforced the truth value of the findings. Themes and subthemes emerged from the data that was collected and revealed that the professional nurses experienced that the Batho Pele Principles as a good policy, but that it was difficulty to uphold due to inadequate planning of health services prior to implementation of the Batho Pele Principles. They experience not getting from their management and they also experience that there was lack of discipline in their institutions. Based on these findings, guidelines that will recommend better implementation of the Batho Pele Principles by nurses were compiled by the researcher and future research in this regard was recommended.

Bakgrund: Barnmorskans bemötande är av stor betydelse för kvinnans upplevelse av att känna sig trygg och hantera smärtan under latensfasen och förlossningen. Målet är att kvinnan ska vara hemma under latensfasen då sjukhusmiljön kan ha en negativ inverkan på det fysiologiska förlossningsförloppet. Mödrahälsovården har en viktig roll genom att stötta och förbereda den gravida kvinnan inför förlossningen. Syfte: Att undersöka kvinnors upplevelse av att under latensfasen sökt vård på förlossningsavdelningen och sedan fått åka hem. Metod: En kvalitativ intervjustudie har gjorts och baseras på fem enskilda intervjuer med förstföderskor. Datamaterialet analyserades enligt innehållsanalys. Resultat: Kvinnorna kände sig oförberedda och uttryckte en okunskap om latensfasen. Bemötandet från barnmorskan på förlossningen var av betydelse för hur kvinnorna upplevde och kunde hantera latensfasen och förlossningen. Smärtsamma förvärkar och sömnbrist var de huvudfaktorer som gjorde att de besökte förlossningen. Slutsats: Studien visade att  informationen från barnmorskan på mödrahälsovården gällande latensfasen var bristfällig och behöver förbättras. Kvinnorna hade svårt att avgöra när de var i aktiv fas och skulle åka in till förlossningen. Barnmorskan på förlossningen behöver se den enskilda kvinnan och anpassa omhändertagandet individuellt. Även partner/närstående kan vara i behov av råd och stöd från barnmorskan för att lättare kunna hjälpa kvinnan under latensfasen. / Background: The midwife's attitudes are important for a woman’s experience of feeling secure and manage pain during latent phase and delivery. The goal is that the woman should be at home during latent phase, because of that the hospital environment can have a negative impact on the physiological delivery process during this phase. Maternal health care has an important role by supporting and preparing the pregnant woman for birth. Objective: To explore women's experiences of latent phase, sought care at the maternity ward, and then had to go home. Method: A qualitative study has been done and is based on five individual interviews with first-time mothers. The data were analyzed according to content analysis. Results: The women felt unprepared and expressed ignorance about latent phase. The treatment from the midwife at the maternity ward was important for the women and how they could handle their experience of latent phase and delivery. Painful contractions and sleep deprivation were the main factors that made the women visit the maternity ward. Conclusion: The study showed that the information about latent phase from the midwife at the maternal health care center was inadequate and need improvement. The women found it  difficult to determine when they were in active phase and would go into the maternity ward. The midwife at the maternity ward need to see the individual woman and adapt care individually. Partners / relatives may be in need of advice and support from the midwife to make it easier to help the woman in latent phase.

Brain injury (i.e., traumatic brain injury, stroke) is a considerable public health issue due to complicated outcomes of the injury, increasing incidence, and high costs linked with medical treatment. Rehabilitation centers are challenged to help individuals manage the resultant associated conditions and prevent secondary and chronic conditions. Research has shown that health promotion programs (HPP) that incorporate education about physical activity (PA) are one mode of rehabilitation that can improve the health of individuals with disabilities. However, PA is not included in the rehabilitation program for individuals with a brain injury, indicating a gap in the services provided. Consequently, the purpose of this study was to create and implement a physical activity centered education (PACE) program within an outpatient rehabilitation program. PACE consisted of an 8-week (16 session) program which aimed to (1) increase PA self-efficacy, (2) increase intention to change PA behaviors, (3) increase amount of PA completed regularly, and (4) promote positive rehabilitation outcomes. Based on previous research it was hypothesized that participation in PACE would result in (1) increased PA self-efficacy, (2) forward progression in intention to change PA behaviors, (3) increased amount of PA completed, and (4) improved rehabilitation outcomes (i.e., abilities, adjustment, participation). The PACE program resulted in an average increase of 16.1% in participants’ PA self-efficacy (effect size [ES] = 0.41), an increase from three of nine participants at pre-test to six of nine participants at post-test reporting to be in a stage of change in which they are most likely to be successful in regular PA participation (i.e., action or maintenance), and a comparable improvement in MPAI-4 scores (rehabilitation outcomes) after discharge to a rehabilitation program without a PA education component. In conclusion, the PACE program can improve PA self-efficacy, intention to change PA behaviors, and short-term rehabilitation outcomes.

The aim of this study was to examine how social workers in outpatient programs fordrug and alcohol abuse explain the process of working with parenthood and theparental ability amongst clients with children. The study was conducted throughqualitative interviews with five different social workers, who worked within anoutpatient programs. The analysis was done through two different perspectives; onewith focus on the clients engagement in different social systems and one regarding theclients relationships and interaction with others. The main findings of this study arethat the outpatient programs work with parenthood is initiated through the client'sown wishes to work on certain aspects of the parent-child relationship, and indialogue with social workers and other members of the outpatient program. It wasalso discovered that children were involved in the therapeutic work to some extent,but that working with parenthood also revolved around the client being able toexpress feelings of shame and guilt, and how to overcome these feelings with the helpof the social workers and fellow outpatients.

El presente plan de negocio tuvo como objetivo demostrar la viabilidad técnica y económica de la implementación del servicio de diagnóstico y tratamiento de enfermedades vasculares para el rescate del pie diabético mediante procedimientos angiográficos ambulatorios en el Centro de Especialidades Médicas Intervencionistas – CEMI ubicado en la ciudad de Lima. Al respecto, existe una demanda no satisfecha y una oportunidad de negocio, que será atendida por medio de una estrategia de liderazgo en costos. La propuesta de valor es un servicio oportuno, de calidad, alta tecnología y médicos reconocidos. El mercado potencial, con 48 IAFAS, es de un total de 4 196 asegurados con pie diabético. El modelo de negocios se basará en convenios y contratos con dichas IAFAS. También se espera, como parte de los objetivos estratégicos no financieros, fidelizar al 95% de los clientes, usar la capacidad instalada a más del 75% y mantener nexos con los diferentes profesionales de la salud asociados a la subespecialidad en diabetes y la comunidad. Según el análisis económico y financiero, se requiere una inversión inicial de S/ 4 831 045,70, 40% financiada a 5 años y 60% asumida por los socios. A los 10 años este proyecto creará un Valor Presente Neto Económico (VPNE) de 28 015 047,31 y una Tasa Interna de Retorno (TIR) de 60%. Financieramente, generará un Valor Presente Neto Incremental (VPNI) de 17 687 598,28 y una Tasa Interna de Retorno Incremental (TIRI) de 78%. Todo lo anterior indica que se trata de una buena inversión, con un modelo estable y riesgos controlables. / The aim of this business plan was to demonstrate the technical and economic feasibility in the implementation of the diagnosis and treatment service of vascular diseases for rescue of the diabetic foot through outpatient angiographic procedures at the Centro de Especialidades Médicas Intervencionistas - CEMI located in the city of Lima. In this regard, there is an unmet demand and a business opportunity, which will be met through a cost leadership strategy. The value proposition is a timely service, quality, high technology and recognized doctors. The potential market, with 48 IAFAS, is a total of 4 196 insured with diabetic foot. The business model will be based on agreements and contracts with these Health care financing sources. It is also expected, as part of the non-financial strategic objectives, to retain 95% of the clients, use the installed capacity over than 75% and maintain connection between different Health professional asocciated with diabetes specialization and, community. According to economic and financial analysis, an initial investment of S/ 4 831 045.70, 40% financed at 5 years and 60% assumed by the partners, is required. In ten years, this project will create an Economic Net Present Value (NPV) of 28,015,047.31 and an Internal Rate of Return (IRR) of 60%. Financially, it will generate an Increasing Net Present Value (NPV) of 17 687 598.28 and an Incremental Internal Return Rate (IRR) of 78%. All of the above indicates that it is a good investment, with a stable model and controllable risks. / Trabajo de investigación

Ewing-like sarcomas (ELS) are a heterogenous group of neoplasms that typically occur in the bone and soft tissue of pediatric and young adult patients. ELS share various degrees of morphological, immunohistochemical, molecular, and clinical similarity with Ewing sarcomas. However, these tumors lack the pathognomonic molecular hallmark of Ewing sarcoma, which is defined as translocation between a gene of the RNA-binding TET family (EWSR1 or FUS) with a gene of the ETS-transcription family (FLI1, ERG, ETV1, ETV4, or FEV). Accurate classification and distinction from classical Ewing sarcomas is important for patient management. A subset of ELS harboring the BCOR-CCNB3 fusion has been described recently – the majority of which that have been reported to date are bone-based tumors, though there have been cases of discrete soft tissue-based tumors. We herein present a case of ELS harboring the BCOR-CCNB3 translocation occurring in a pediatric patient presenting with a large abdominal mass discovered on chest CT after failed outpatient treatment for pneumonia with effusion. This patient was a 14-year-old Caucasian boy with a past medical history significant for obesity and three episodes of pneumonia since 6-years-old. Imaging showed a large heterogeneous mass at the posterior left upper quadrant of the abdomen protruding through the posterior aspect of the left hemidiaphragm causing atelectasis. The mass abuts the inferior leftward aspect of the descending thoracic aorta and also protrudes between the 11th and 12th posterior lateral left rib. Pathology revealed this mass to be an Ewing-like sarcoma with a BCOR-CCNB3 fusion. Patient was treated with chemotherapy and radiation. This case demonstrates the importance of determining an accurate diagnosis to provide specific management.