Medicine unavailability, also known as stock-outs is a global problem. South Africa is not exempt from this problem which impacts negatively on the way in which healthcare services are rendered, more especially in the public sector. Communities are complaining about the unavailability of medicines at public health facilities particularly in primary health care clinics. In an effort to address this problem, the Minister of Health has declared medicine availability as one of the six priorities of the Department of Health. The aim of this study was to explore and describe the experiences and perceptions of healthcare professionals practicing at primary healthcare clinics in a peri-urban area of the Eastern Cape regarding the unavailability of medicines. Understanding the experiences and perceptions was expected to assist in addressing the problem at hand and help management in developing ways to address the problem and support the employees. Semi-structured interviews were conducted with healthcare professionals working at primary health care clinics in and around Mdantsane Township in the Eastern Cape. The main findings of the study can be divided into the following topics: perceived causes of medicine stock-outs, the implications of stock shortages, actions taken in the case of stock-outs and the role to play by in mitigating the impact of stock shortages. The limitations of the study include the research sample which was not truly representative of all healthcare professionals working at Mdantsane sub-district primary healthcare clinics. The study recommends various strategies that management should follow to assist in addressing medicine shortages. The researcher recommends further research to describe the experiences of healthcare professional regarding medicine unavailability.

A hybrid methodology of game theory and Monte Carlo Tree Search was developed and the hybrid methodology was tested with various case studies through the nurse scheduling problem to show that it was able to form Pareto front dominance solutions, finding feasible solutions that were optimal and finding feasible partial solutions in over-constrained problems. The performance comparison was carried out with the Genetic Algorithm on the Resident Physician Scheduling problem and showed that the hybrid methodology was able to produce better quality solutions compared to the state of the art approach.

Rufus of Ephesus's 'Quaestiones Medicinales' is an under-studied work by one of the most respected doctors of Greco-Roman antiquity. This thesis presents a new translation - the first in English of the complete work - and a reassessment of the treatise. I propose that, far from being a simple handbook teaching doctors how to take a patient history, as has hitherto been assumed, QM is an ardent plea for doctors to recognise the limits of their own knowledge and the indispensability of questioning the patient. I argue that QM articulates the idea that the aim of medicine cannot be achieved through medical knowledge alone, and that, in constructing the patient as an essential partner in diagnosis and decisions about treatment, Rufus implies a sharing of authority between doctor and patient that is noticeably different from the emphasis that other authors, particularly the determinedly hierarchical Galen, place on securing patients' obedience, a subject on which Rufus is noticeably silent. I argue that Rufus is unusual in the clarity and candour with which he perceives and acknowledges the limits of medical knowledge, in his conceptualisation of questioning as a discursive rather than a formulaic activity, in his explicit insistence that it must be addressed directly to the patient, in his psychological concept of habits, and in his recommendation of questioning as a strategy for resolving the tension between universal theory and individual experience. I look at modern cross-cultural research into the factors that drive patient compliance, and note that chief among them is patients feeling they are partners in the treatment process. This raises the question whether and to what extent the features that drive compliance are diachronically as well as cross-culturally consistent, and whether Rufus's shared authority model is more likely to have produced successful treatment outcomes than the autocratic paradigm promoted by Galen, and subsequently absorbed into Western medical tradition, that seems to have met with so much resistance.

Objetivo: Verificar graus de concordância diagnóstica pela Angio-TC entre médicos da emergência, residentes de radiologia e radiologistas torácicos em casos suspeitos de tromboembolismo pulmonar (TEP). Material e Métodos: Foram retrospectivamente estudados 123 pacientes consecutivos com suspeita de TEP, de maço/2012 a fevereiro/2013, os quais realizaram Angio-TC pulmonar, obtida com colimação por multidetector 64x0,5. As imagens foram inicialmente interpretadas isoladamente por dois médicos da Emergência e por dois médicos residentes da Radiologia, e subsequentemente por dois Radiologistas Torácicos em consenso, verificando-se o grau de concordância interobservador entre eles quanto à presença de TEP. Resultados: O grau de concordância entre os Residentes da radiologia e os Radiologistas torácicos foi muito bom (Índice Kappa de 0,82 e 0,81); entre os Médicos da Emergência e os Radiologistas torácicos foi baixo ou moderado (Kappa de 0,37 e 0,42.), com um índice de 40,0% de relatos falso-positivos, aproximadamente. Aproximadamente 40,0% das interpretações falso-positivas correlacionaram-se principalmente com casos de TEP lobar e segmentar, enquanto que as falso-negativas ocorreram mais vezes com casos de TEP segmentar e subsegmentar. O grau de concordância geral entre todos os observadores mostrou-sei também moderado (Kappa de 0,50). Conclusão: Usando a Angio-TC no diagnóstico do TEP, o grau de concordância entre os radiologistas torácicos e os residentes da radiologia foi muito bom; entretanto, a concordância entre os médicos da emergência com os radiologistas torácicos foi baixa, com tendência a superestimar o diagnóstico da condição. / Purpose: To assess interobserver agreement rates between the Radiology resident, the thoracic radiologist and the Emergency physician for diagnosing pulmonary embolism (PE) in Computed Tomography Pulmonary Angiography (CTPA) examinations. Methods: Two Emergency physicians and two Radiology residents retrospectively evaluated 123 CTPA scans at our institution, and reported the presence of PE or not, individually. Two thoracic radiologists then reviewed the images, and a consensus was reached. Statistical analysis was performed, in order to provide the interobserver agreement. Results were expressed in kappa values for subsequent comparison. Results: Very good agreement in CTPA reading was observed between Radiology residents and thoracic radiologists (kappa index of 0.82 and 0.81). Fair and moderate agreement (kappa index of 0.39 and 0.42) was demonstrated between Emergency physicians and thoracic radiologists, with a rate of 40% false-positive reports, approximately, mainly in cases of both lobar and segmental involvement, whereas false-negative occurred more times in cases of segmental and subsegmental PE. The overall agreement was also moderate (kappa index of 0.50). Conclusion: The inter-observer agreement in CTPA examinations between radiology residents and thoracic radiologists in PE diagnoses was good, but it was low between the emergency physicians and the radiologists, with a tendency of overestimating that diagnoses.

Este trabalho volta-se ao estudo das diretivas antecipadas sobre o fim da vida na relação médica no Brasil. Pretende-se verificar a legitimidade bioética e a legitimidade e possibilidade jurídicas da prática das diretivas antecipadas sobre o fim da vida como objetivo central. Busca-se aferir a adequação, bioética e jurídica, das diretivas antecipadas como veículo próprio de autodeterminação da pessoa diante de suas possibilidades existenciais e da formulação de seu projeto de vida e de morte digna. Ademais, especificamente, procura-se determinar a possibilidade jurídica das diretivas antecipadas no Ordenamento brasileiro: a coerência com as garantias constitucionais e a existência de institutos aptos a tal prática. Propõe-se sustentar a legitimação jurídica das diretivas antecipadas no Brasil, indicando possíveis caminhos às soluções interpretativas no plano jurídico, e os efeitos na relação médica a partir, também, das considerações bioéticas. Com essa finalidade, pretende-se averiguar a compatibilidade entre as normas deontológicas de origem bioética e as normas jurídicas de status constitucional de proteção à pessoa humana. A tese também propõe a análise do contexto em que as diretivas antecipadas são utilizadas para (i) problematizar as ideias de capacidade e competência para a prática desse ato de autonomia pessoal, (ii) problematizar sobre como a perspectiva familiar, a perspectiva técnica dos profissionais da saúde e a perspectiva do Poder Judiciário contingenciam a liberdade desse ato e (iii) aferir a eficácia desses atos no espaço clínico e familiar. Para tanto, será empreendido estudo teórico mediante pesquisa bibliográfica e de referências, que levantará as publicações, nacionais e internacionais, sobre os temas da tese. O levantamento bibliográfico compreenderá, preferencialmente, obras sobre filosofia, ética, bioética e direito, que permitam a análise das questões teóricas envolvidas no estudo. O desenvolvimento do trabalho estrutura-se em três capítulos. O primeiro pretende estabelecer as bases conceituais e os fundamentos legais das diretivas antecipadas. O segundo capítulo apresentará a sistematização entre os valores bioéticos e jurídicos que se relacionam a tal prática. O capítulo três apresentará as questões fundamentais pertinentes à validade e eficácia da prática das diretivas antecipadas no Brasil. A partir das premissas construídas ao longo do desenvolvimento, o desfecho da pesquisa pretende reforçar seu argumento central demonstrando, então, a legitimação bioética e a legitimidade e a possibilidade jurídicas das diretivas antecipadas sobre o fim da vida no atual contexto brasileiro.

Summary Relations between a nurse and a physician underwent many changes in the past. Nowadays, the relations have trended towards equal position of nurses and physicians in the health care system. It is just the equal position of the both professions in care for the client which is a prerequisite of good team cooperation and a guarantee of good-quality nursing as well as therapeutical care. The aim of our work was to find the prevailing forms of relations between nurses and physicians in the examined set of nurses and to determine whether or not nurses think they are equal partners of the physicians within the team cooperation. The quantitative method of research survey was used for the thesis elaboration. We used a questionnaire survey for the data collection. The research sample consisted of nurses working in the Institute of Clinical and Experimental Medicine in Prague. The data were collected from April till June 2008. One hundred and fifty-two questionnaires were used for the results evaluation. We made 7 hypotheses for the research purposes. Hypothesis no. 1: Nurses with a longer than 10-year professional experience evaluate the relations with physicians more positively than nurses with a shorter professional experience. This hypothesis was disconfirmed on the basis of statistical analysis.Questioned nurses evaluated the relations with physicians most often as good {--} 56.5 %. Hypothesis no. 2: Nurses with higher education feel to be perceived as the physician{\crq}s partner in the care for patients more often than nurses with secondary education. This hypothesis was also disconfirmed on the basis of statistical analysis. Out of the questioned nurses, 60.5 % do not feel to be perceived by the physicians as their equal partners. Hypothesis no. 3: Nurses at the intensive care units are charged by the physicians with works that do not fall within their competence more often than nurses at standard departments. This hypothesis was confirmed. On the basis of our research, we have found that the questioned nurses at the intensive care units are charged with some highly specialized works that fall within the physicians{\crq} competence. Hypothesis no. 4: Conflict situations in the relation nurse {--} physician are alleged more often by nurses with professional experience un till 10 years as compared to nurses with longer professional experience. The statistical analysis did not confirm this hypothesis. Existence of conflict situations at the work site was stated by 54.7 % of al questioned nurses. Hypothesis no. 5: Nurses solve the conflict situations with physicians through their superiors. This hypothesis was confirmed. In case of a conflict with a physician, the questioned nurses most often contact the head nurse. Hypothesis no. 6: Nurses{\crq} relations with physicians influence their job satisfaction. This hypothesis was confirmed. Relations with physicians are important for job satisfaction of 96.7 % of the questioned nurses. Hypothesis no. 7: In their relation to nurses, physicians observe the rules of etiquette. This hypothesis was confirmed as well. Our proposal to improve the team cooperation between nurses and physicians is as follows. Time should be devoted to interpersonal relations already during the studies of both physicians and nurses; techniques developing cooperation of nurses and physicians should be integrated in their continuing education; measures to improve cooperation should be implemented on the management level of health care facilities; and other researches relating this topic should be executed.

Objetivo: Verificar graus de concordância diagnóstica pela Angio-TC entre médicos da emergência, residentes de radiologia e radiologistas torácicos em casos suspeitos de tromboembolismo pulmonar (TEP). Material e Métodos: Foram retrospectivamente estudados 123 pacientes consecutivos com suspeita de TEP, de maço/2012 a fevereiro/2013, os quais realizaram Angio-TC pulmonar, obtida com colimação por multidetector 64x0,5. As imagens foram inicialmente interpretadas isoladamente por dois médicos da Emergência e por dois médicos residentes da Radiologia, e subsequentemente por dois Radiologistas Torácicos em consenso, verificando-se o grau de concordância interobservador entre eles quanto à presença de TEP. Resultados: O grau de concordância entre os Residentes da radiologia e os Radiologistas torácicos foi muito bom (Índice Kappa de 0,82 e 0,81); entre os Médicos da Emergência e os Radiologistas torácicos foi baixo ou moderado (Kappa de 0,37 e 0,42.), com um índice de 40,0% de relatos falso-positivos, aproximadamente. Aproximadamente 40,0% das interpretações falso-positivas correlacionaram-se principalmente com casos de TEP lobar e segmentar, enquanto que as falso-negativas ocorreram mais vezes com casos de TEP segmentar e subsegmentar. O grau de concordância geral entre todos os observadores mostrou-sei também moderado (Kappa de 0,50). Conclusão: Usando a Angio-TC no diagnóstico do TEP, o grau de concordância entre os radiologistas torácicos e os residentes da radiologia foi muito bom; entretanto, a concordância entre os médicos da emergência com os radiologistas torácicos foi baixa, com tendência a superestimar o diagnóstico da condição. / Purpose: To assess interobserver agreement rates between the Radiology resident, the thoracic radiologist and the Emergency physician for diagnosing pulmonary embolism (PE) in Computed Tomography Pulmonary Angiography (CTPA) examinations. Methods: Two Emergency physicians and two Radiology residents retrospectively evaluated 123 CTPA scans at our institution, and reported the presence of PE or not, individually. Two thoracic radiologists then reviewed the images, and a consensus was reached. Statistical analysis was performed, in order to provide the interobserver agreement. Results were expressed in kappa values for subsequent comparison. Results: Very good agreement in CTPA reading was observed between Radiology residents and thoracic radiologists (kappa index of 0.82 and 0.81). Fair and moderate agreement (kappa index of 0.39 and 0.42) was demonstrated between Emergency physicians and thoracic radiologists, with a rate of 40% false-positive reports, approximately, mainly in cases of both lobar and segmental involvement, whereas false-negative occurred more times in cases of segmental and subsegmental PE. The overall agreement was also moderate (kappa index of 0.50). Conclusion: The inter-observer agreement in CTPA examinations between radiology residents and thoracic radiologists in PE diagnoses was good, but it was low between the emergency physicians and the radiologists, with a tendency of overestimating that diagnoses.

Objetivo: Verificar graus de concordância diagnóstica pela Angio-TC entre médicos da emergência, residentes de radiologia e radiologistas torácicos em casos suspeitos de tromboembolismo pulmonar (TEP). Material e Métodos: Foram retrospectivamente estudados 123 pacientes consecutivos com suspeita de TEP, de maço/2012 a fevereiro/2013, os quais realizaram Angio-TC pulmonar, obtida com colimação por multidetector 64x0,5. As imagens foram inicialmente interpretadas isoladamente por dois médicos da Emergência e por dois médicos residentes da Radiologia, e subsequentemente por dois Radiologistas Torácicos em consenso, verificando-se o grau de concordância interobservador entre eles quanto à presença de TEP. Resultados: O grau de concordância entre os Residentes da radiologia e os Radiologistas torácicos foi muito bom (Índice Kappa de 0,82 e 0,81); entre os Médicos da Emergência e os Radiologistas torácicos foi baixo ou moderado (Kappa de 0,37 e 0,42.), com um índice de 40,0% de relatos falso-positivos, aproximadamente. Aproximadamente 40,0% das interpretações falso-positivas correlacionaram-se principalmente com casos de TEP lobar e segmentar, enquanto que as falso-negativas ocorreram mais vezes com casos de TEP segmentar e subsegmentar. O grau de concordância geral entre todos os observadores mostrou-sei também moderado (Kappa de 0,50). Conclusão: Usando a Angio-TC no diagnóstico do TEP, o grau de concordância entre os radiologistas torácicos e os residentes da radiologia foi muito bom; entretanto, a concordância entre os médicos da emergência com os radiologistas torácicos foi baixa, com tendência a superestimar o diagnóstico da condição. / Purpose: To assess interobserver agreement rates between the Radiology resident, the thoracic radiologist and the Emergency physician for diagnosing pulmonary embolism (PE) in Computed Tomography Pulmonary Angiography (CTPA) examinations. Methods: Two Emergency physicians and two Radiology residents retrospectively evaluated 123 CTPA scans at our institution, and reported the presence of PE or not, individually. Two thoracic radiologists then reviewed the images, and a consensus was reached. Statistical analysis was performed, in order to provide the interobserver agreement. Results were expressed in kappa values for subsequent comparison. Results: Very good agreement in CTPA reading was observed between Radiology residents and thoracic radiologists (kappa index of 0.82 and 0.81). Fair and moderate agreement (kappa index of 0.39 and 0.42) was demonstrated between Emergency physicians and thoracic radiologists, with a rate of 40% false-positive reports, approximately, mainly in cases of both lobar and segmental involvement, whereas false-negative occurred more times in cases of segmental and subsegmental PE. The overall agreement was also moderate (kappa index of 0.50). Conclusion: The inter-observer agreement in CTPA examinations between radiology residents and thoracic radiologists in PE diagnoses was good, but it was low between the emergency physicians and the radiologists, with a tendency of overestimating that diagnoses.

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No. of bitstreams: 2 Dissertação - Fabiano Calixto Fortes de Arruda - 2016.pdf: 1310988 bytes, checksum: 47a7fc51ab994e5a56cd5aec2e6f7310 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-12-09 / Quality of life (QoL) is the result of the individual's perception of their position in life, in the context of the culture and in the value system in which they live and their relationship with their goals, expectations, standards and concerns. It is a well-studied subject in the health area, and in 2015 alone we obtained about 25,000 publications on the subject according to PUBMED data. In its current concept it relates factors such as: health, social relations, psychological and environmental aspects of the individual with their environment and with other individuals. Plastic surgery is a medical surgical specialty that developed mainly during the great world wars, thanks to the development of anesthesia and antibiotic therapy. The surgeons in this area develop activity in the aesthetic and reconstructive area. The purpose of this dissertatio n is to describe the quality of life of the plastic surgeon in the State of Goiás. This study is about a dissertation constructed in the form of a scientific article. The first article is an integrative review of published studies on the quality of life of the physician in Brazil. Medical related studies are still scarce and do not present the same instrument in the evaluation of professionals, but indicate that the worst domains of the WHOQOL instruments are related to the environment, social and psychological relations. The second article describes the sociodemographic and professional profile of the plastic surgeon in the state of Goiás. It presents a young population, predominantly male, with a time of activity in the area of less than 10 years, with about 2 children, working more than 40 hours a week and performing Aesthetic and reconstructive surgeries. When compared in relation to the time of action, it is observed that they increase the monthly income, the number of surgeries and decrease the weekly workload. The third article reports the results found on the quality of life of the plastic surgeon in the state of Goiás relating to variables present in the sociodemographic and professional profile. The study showed that surgeons who have children, are married, have a monthly income of more than R $ 30,000.00 (about 34 minimum wages), do not perform shifts or are performed in the specialty, work up to 40 hours a week and have more That 4 surgeries per week, present domains with better quality of life. It is concluded that the quality of life of the Goias’ plastic surgeon is influenced by factors such as marital status,professional working time, condition of association with the SBCP, no work shifts in another specialty, weekly workload and number of surgeries performed per week. Older surgeons have better quality of life. Therefore, it is necessary to create mechanisms that can cooperate with the new specialist so that he can adapt to the market and enjoy a better quality of life. / Qualidade de vida (QV) é o resultado da percepção do indivíduo de sua posição na vida, no contexto da cultura e no sistema de valores nos quais vive e a relação destes com seus objetivos, expectativas, padrões e preocupações. É um tema bastante estudado nas áreas da saúde, daí só no ano de 2015 termos obtido cerca de 25.000 publicações sobre o tema segundo dados do PUBMED. Em seu conceito atual ela relaciona fatores como: a saúde, as relações sociais, aspectos psicológicos e ambientais do indivíduo com seu meio ambiente e com os outros indivíduos. A cirurgia plástica é uma especialidade médica cirúrgica que se desenvolveu principalmente durante as grandes guerras mundiais, graças ao desenvolvimento da anestesia e da antibioticoterapia. Os cirurgiões nesta área desenvolvem atividade na área estética e reconstrutiva. O objetivo desta dissertação é descrever a qualidade de vida do cirurgião plástico no Estado de Goiás. Este estudo trata se de uma dissertação construída na modalidade de artigo científico. O primeiro artigo é uma revisão integrativa sobre os estudos publicados sobre qualidade de vida do médico no Brasil. Os estudos relacionando médico ainda são escassos e não apresentam o mesmo instrumento na avaliação dos profissionais, porém indicam que os piores domínios dos instrumentos WHOQOL estão relacionados ao meio ambiente, relações sociais e psicológico. O segundo artigo descreve o perfil sóciodemográfico e profissional do cirurgião plástico no estado de Goiás. Apresenta uma população jovem, predominantemente masculina, com tempo de atividade na área inferior a 10 anos, com cerca de 2 filhos, trabalhando mais de 40 horas semanais e realizando cirurgias estéticas e reconstrutivas. Quando comparados em relação ao tempo de atuação é observado que estes aumentam o rendimento mensal, o número de cirurgias e diminuem a carga horária semanal. O terceiro artigo relata os resultados encontrados sobre a qualidade de vida do cirurgião plástico no estado de Goiás relacionando com variáveis presentes no perfil sóciodemográfico e profissional. O estudo mostrou que os cirurgiões que têm filhos, são casados, apresentam renda mensal superior a R$ 30.000,00 (cerca de 34 salários mínimos), não realizam plantões ou se realizam são na própria especialidade, trabalham até 40 horas semanais e têm mais que 4 cirurgias por semana, apresentam domínios com melhor qualidade de vida. Conclui-se que a qualidade de vida do cirurgião plástico do Estado de Goiás é influenciada por fatores como estado civil, tempo de atuação como profissional, condição de associação com a SBCP, não realizar plantões em outra especialidade, carga horária semanal e número de cirurgias realizadas por semana. Os cirurgiões mais antigos apresentam melhores condições de qualidade de vida. Portanto, é necessário a criação de mecanismos que possam cooperar com o especialista novo para que este possa se adaptar ao mercado e desfrutar de uma melhor qualidade de vida.

Este estudo teve como proposições: compreender o processo da interação entre profissionais de saúde e usuários estrangeiros nas Unidades Básicas de Saúde (UBS) e Programa Saúde da Família (PSF); conhecer o significado da experiência dos profissionais de saúde ao interagir com os usuários estrangeiros; evidenciar questões bioéticas na experiência de interação entre profissionais e usuários estrangeiros. Utilizou-se como referencial teórico o Interacionismo Simbólico e como referencial metodológico a Teoria Fundamentada nos Dados, até a codificação axial. A análise dos dados, apresentada como ordenamento conceitual, levou à definição de quatro grandes temas: (1) procurando comunicar-se; (2) percebendo limites; (3) percebendo interação como processo; (4) percebendo perspectivas diferentes. O percurso de interação profissional usuário estrangeiro foi desencadeado a partir de uma escolha: atender a todos indiscriminadamente, tornando possível a aproximação. Perceber ou não no usuário estrangeiro sua dignidade de pessoa humana parece ser determinante na abertura do profissional à interação, na sua disposição a buscar estratégias. / This study had the following objectives: to understand the interaction processes among health professionals and foreign users in the Unidades Básicas de Saúde (UBS) and the Program for Family Health (PSF); to get to know the significance of the health professionals experience as they interact with foreign users; to put in evidence bioetiques issues in the experience of professionals and foreign users interaction.It was used as a theorical referential the Symbolic Interacionism and as methodological reference a Grounded Theory up to an axial coding. Data analysis presented as conceptual ordering, lead to the definition of four great issues: (1) trying to communicate; (2) detecting limits; (3) recognizing interaction as a process; (4) recognizing different perspectives. The route of professional foreign users interaction was developed from one choice: attend everyone (indiscriminately) making approximation possible. To recognize or fail to recognize in the foreign user the dignity of human person seems to be the determining factor for the openness of the professional to the interaction, in his disposition to seek strategies.