Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research.

BACKGROUND: The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. AIM: To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. DESIGN & SETTING: Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. METHOD: Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. RESULTS: The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). CONCLUSION: Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics.

Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains-the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system-and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions-for example, between demand management and patient choice-leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing on guiding principles applied with contextual judgement. We complement the PERCS framework with a set of principles for informing its application in practice, including education of professionals and patients.

Experience of mobile nursing workforce from Portugal to the NHS in UK: influence of institutions and actors at the system, organization and individual levels.

In UK, since 2010 shortages of nurses and policy changes led many health service providers to become more active in recruiting nurses from the European Union Member States. This article analyses the experience of Portuguese nurses working in the English NHS considering the individual and organizational factors that affect the quality and duration of nurses' migration experience, future career plans and expectations. Twenty-seven semi-structured interviews were conducted at the individual, organizational and policy levels in UK with Portuguese nurses and NHS healthcare staff in 2015-16. The results demonstrate that organizational settings, conditions, actors' attitudes and level of support influence nurses' level of commitment to their employer and their overall mobility experience. Professional achievements, professional and personal sources of support made these nurses evaluate their overall mobility experience as positive, even overcoming personal challenges such as homesickness. The results reveal that migration is accomplished through constant interaction between institutions and individual actors at different levels. Understanding the influencing factors as well as the complex and dynamic nature of a professional's decision-making can design more effective retention responses.

A call for action to establish a research agenda for building a future health workforce in Europe.

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

Biofilm, adherence, and hydrophobicity as virulence factors in Malassezia furfur.

Malassezia species are natural inhabitants of the healthy skin. However, under certain conditions, they may cause or exacerbate several skin diseases. The ability of this fungus to colonize or infect is determined by complex interactions between the fungal cell and its virulence factors. This study aims to evaluate "in vitro" the hydrophobicity levels, the adherence on a plastic surface and the biofilm formation of 16 clinical isolates of Malassezia furfur. Cellular surface hydrophobicity (CSH) levels were determined by two-phase system. The biofilm formation was determined by tetrazolium salt (XTT) reduction assay and by Scanning Electron Microscopy (SEM). Results showed many isolates were hydrophobic, adherent, and producers of biofilm on abiotic surfaces with different capacity. SEM observations confirmed an abundant extracellular matrix after 48 h of biofilm formation. About 63% of strains with high production of biofilm showed medium to high percentage of hydrophobicity and/or adherence. In addition, it has been demonstrated a correlation between hydrophobicity, adherence, and biofilm formation in about 60% of strains examined. These important virulence factors could be responsible of this yeast changing from a commensal to a pathogenic status.

O desejo na direção da análise com crianças / Desire and conducting the analytical process

Este trabalho objetiva discutir sobre a questão da análise com crianças e o desejo do analista. O que é o desejo para a psicanálise? Há uma diferença entre o desejo do analista de crianças? E uma última questão: o que pode almejar uma análise com crianças? Creio que são questões pertinentes e que tentarei elaborar, sem a pretensão de criar um caminho, apenas traçá-lo, uma vez que o caminho da formação de um analista é feito sob uma noção lógica, que contraria o discurso de mestria. Um caminho singular que só é possível através da aventura de uma análise, um caminho este que estou traçando dia a dia(AU)

This paper aims at discussing the subject of psychoanalysis with children and the analyst’s wish. What does wish mean for psychoanalysis? Is there a difference in the wish of a child’s therapist? And one last question: what may children analysis pursue? I believe these are relevant questions, which I will try to elaborate, without trying to create a way, just to trace it, once the way that forms an analyst is built on a logic notion, which goes against the mastery discourse. A unique way which is only possible through the adventureof psychoanalysis, a way I trace every day(AU)

Cell wall composition and biofilm formation of azoles-susceptible and -resistant Candida glabrata strains.

In the present study, three strains of Candida glabrata have been investigated to shed light on the mechanisms involved in azole resistance during adherence and biofilm formation. In particular, a clinical isolate, susceptible to azole-based drugs, DSY562 and two different resistant mutagenic strains deriving from DSY562, SFY114 and SFY115, have been analysed with different approaches for their cell wall composition and properties. A proteomic analysis revealed that the expression of six cell wall-related proteins and biofilm formation varied between the strains. The SFY114 and SFY115 strains resulted to be less hydrophobic than the susceptible parental counterpart DSY562, on the other hand they showed a higher amount in total cell wall polysaccharides fraction in the total cell wall. Accordingly to the results obtained from the hydrophobicity and adherence assays, in the resistant strain SFY115 the biofilm formation decreased compared to the parental strain DSY562. Finally, the total glucose amount in resistant SFY115 was about halved in comparison to other strains. Taken together all these data suggest that azole drugs may affect the cell wall composition of C. glabrata, in relation to the different pathogenic behaviours.

Chemical Composition and Bio-efficacy of Essential Oils from Italian Aromatic Plants: Mentha suaveolens, Coridothymus capitatus, Origanum hirtum and Rosmarinus officinalis.

The chemical composition, antifungal, antioxidant and cytotoxic activities of the essential oils (EOs) of mint (Mentha suaveolens), thyme (Coridothymus capitatus), oregano (Origanum hirtum) and rosemary (Rosmarinus officinalis) were investigated. The antifingal properties of the EOs were investigated againstfour species of Candida by a microdilution method. Cytotoxicity was tested on human keratinocyte (HaCaT) and lung cancer (A549) cell lines using the MTT test. DPPH· and ABTS·+ spectrophotometric assays and DPPH-- ABTS-+(HP)TLC-bioautographic assays were used to evaluate the antioxidant activity. The main compounds of thyme and oregano EOs were carvacrol and thymol, respectively; piperitenone oxide and y-terpinene were the most abundant compounds ofmint and rosemary EOs, respectively. All EOs showed activity against all Candida species in a range between 760 ± 290 to 3120 ± 0.0 µg/mL. Among the EOs, that of M suaveolens showed a stronger cytotoxic activity on HaCaT cells. Thyme, oregano and rosemary EQs exhibited important antioxidant activities by ABTS` assay compared with trolox.

Properties and limits of some essential oils: chemical characterisation, antimicrobial activity, interaction with antibiotics and cytotoxicity.

Because of the emergence of multi-drug resistance bacteria and fungi, alternatives to conventional antimicrobial therapy are needed. This study aims to evaluate in vitro the antimicrobial activity of: Mirtus communis, Coriandrum sativum, Pelargonium capitatum, Cuminum cyminum, Ocimum basilicum, Citrus aurantium amara, Cymbopogon. winterianus, Cymbopogon martini, Salvia sclarea, Melaleuca alternifolia and Mentha suaveolens essential oils on bacteria and fungi, in relation to their chemical composition. The potential interaction of M. alternifolia (TTO), C. sativum (CDO) and M. suaveolens (EOMS) essential oils when used in combination with gentamicin and fluconazole has been evaluated. The results obtained showed a synergic effect on some bacteria and fungi, with FICI values ≤5. The cytotoxicity of TTO, CDO and EOMS was investigated towards HeLa cells. Only EOMS did not result cytotoxic at the active concentrations on micro-organisms. Further studies are necessary to obtain optimal ratios and dosing regimens for higher therapeutic efficacy and to decrease toxicological profiles.

Work environment issues and intention-to-leave in Portuguese nurses: A cross-sectional study.

This study extends the Registered Nurses Forecasting (RN4CAST) study evidence base with newly collected data from Portuguese nurses working in acute care hospitals, in which the measurement of the quality of work environment, workload and its association with intention-to-leave emerge as of key importance. Data included surveys of 2235 nurses in 144 nursing units in 31 hospitals via stratified random sampling. Multilevel multivariate regression analysis shows that intention-to-leave is higher among nurses with a specialty degree, nurses aged 35-39, and in nursing units where nurses are less satisfied with opportunities for career advancement, staffing levels and participation in hospital affairs. Analysis with moderation effects showed the observed effect of age and of having a specialty degree on intention-to-leave during the regression analysis is reduced in nursing units where nurses are more satisfied with opportunities for career advancement. The most important finding from the study suggests that promoting retention strategies that increase satisfaction with opportunities for career advancement among Portuguese nurses has the potential to override individual characteristics associated with increased turnover intentions.

[Primary health care reform and implications for the organizational culture of Health Center Groups in Portugal]. / Reforma na atenção primária à saúde e implicações na cultura organizacional dos Agrupamentos dos Centros de Saúde em Portugal.

The health sector's increasing complexity poses major challenges for administrators. There is considerable consensus on workforce quality as a key determinant of success for any health reform. This study aimed to explore the changes introduced by an action-training intervention in the organizational culture of the 73 executive directors of Health Center Groups (ACES) in Portugal during the primary health care reform. The study covers two periods, before and after the one-year ACES training, during which the data were collected and analyzed. The Competing Values Framework allowed observing that after the ACES action-training intervention, the perceptions of the executive directors regarding their organizational culture were more aligned with the practices and values defended by the primary health care reform. The study highlights the need to continue monitoring results over different time periods to elaborate further conclusions.

Integrated disease management: a critical review of foreign and Portuguese experience.

INTRODUCTION: The present article reviews findings from empirical evaluations of integrated disease management programmes. The objective is to provide insights on integration levels, priority interventions and their effect on patient outcomes. MATERIAL AND METHODS: The literature review identified 1 251 articles, published from 2006 to 2011. Upon a detailed screening 61 articles were selected for bibliometric analysis and critical discussion. RESULTS: Among several findings, it can be noted that United States of America is the country with the highest amount of published evidence on the subject under study. The most frequently referred disease is diabetes mellitus and the main reported issue of integrated disease management is self-management support. The majority of the studies were developed and exclusively managed by managed care organizations, organized family doctors or hospitals. From a total of 360 interventions reported in studies, patient interventions are the most frequently used across all disease groups, followed by professional interventions. To monitor the effectiveness of the disease programmes, the most frequently used outcomes are patient physiological measures, service use and patient health status. DISCUSSION: Every country has its own way to implement the integrated disease management strategy. The focus of practice lies on patient empowerment, particularly through self-management. Physiological measures and service use are the outcomes with the highest rate of assessment, which are also the indicators that show higher impact among all integrated disease management programmes. CONCLUSION: The Portuguese health care system still faces challenges in the coordination and integration of care for patients with chronic disease thus improvements at integrated disease management programmes should be incorporate.

Introdução: O artigo faz uma revisão de literatura sobre os programas de gestão integrada da doença, apresentando resultados sobre o nível de integração dos cuidados, as intervenções prioritárias utilizadas nos programas e o seu efeito, nomeadamente, nos doentes.Material e Métodos: A revisão de literatura identificou 1 251 artigos, publicados entre 2006 e 2011. Depois de uma criteriosa seleção identificaram-se para a análise bibliométrica e discussão crítica, 61 artigos.Resultados: Realçamos o facto de serem os Estados Unidos da América o país que mais publica sobre esta matéria; A doença mais reportada é a diabetes mellitus e o domínio de intervenção da gestão integrada da doença, predominante, é o 'apoio ao auto-cuidado'. A maioria dos estudos foram implementados por managed care organizations, médicos de medicina geral e familiar organizados para o efeito ou hospitais. Das 360 intervenções reportadas, as mais utilizadas são as dirigidas aos doentes e aos profissionais. Os resultados mais observados nos doentes, aquando da monitorização dos programas, são: resposta clínica, utilização de serviços e estado de saúde.Discussão: Cada país tem a sua própria forma de implementar a estratégia de gestão integrada da doença. O foco de atenção da prática clínica é o empoderamento dos doentes, particularmente através da promoção da auto-gestão. Os resultados clínicos e os de utilização dos serviços para além de serem os mais utilizados, são também, aqueles com maior impacto nos programas de gestão integrada da doença.Conclusão: O sistema de saúde Português ainda enfrenta sérios desafios no tocante à coordenação e integração de cuidados dirigidos à pessoa com doença crónica pelo que se sugere a atualização do programa.

Reforma na atencao primaria a saude e implicacoes na cultura organizacional dos Agrupamentos dos Centros de Saude em Portugal / Primary health care reform and implications for the organizational culture of Health Center Groups in Portugal / La reforma de la atencion primaria de la salud y las implicaciones en la cultura organizacional de los Agrupamientos de los Centros de Salud en Portugal

A crescente complexidade dos desafios do setor da saúde implica um aumento das responsabilidades para aqueles que nela assumem funções de gestão. Há consenso que a qualidade da força de trabalho em saúde é um fator crítico para o sucesso de qualquer reforma no setor. O objetivo desta investigação é estudar e analisar a alteração induzida por uma intervenção de formação-ação intensiva na cultura organizacional de 73 diretores executivos dos Agrupamentos dos Centros de Saúde (ACES) em Portugal durante a reforma na atenção primária à saúde. Os dados foram coletados e analisados em dois períodos temporais, antes e depois da intervenção do Programa Avançado em Gestão, Governação Clínica e Liderança para os ACES, o qual teve um ano de duração. O modelo Competing Values Framework permitiu observar que, depois da intervenção de formação-ação, as percepções dos diretores executivos sobre a sua cultura organizacional se encontram mais alinhadas com a reforma da atenção primária à saúde, valorizando o tipo de práticas e valores que esta defende. É necessário continuar a monitorizar os resultados em vários períodos temporais para elaborar conclusões a esse respeito.

The health sector’s increasing complexity poses major challenges for administrators. There is considerable consensus on workforce quality as a key determinant of success for any health reform. This study aimed to explore the changes introduced by an action-training intervention in the organizational culture of the 73 executive directors of Health Center Groups (ACES) in Portugal during the primary health care reform. The study covers two periods, before and after the one-year ACES training, during which the data were collected and analyzed. The Competing Values Framework allowed observing that after the ACES action-training intervention, the perceptions of the executive directors regarding their organizational culture were more aligned with the practices and values defended by the primary health care reform. The study highlights the need to continue monitoring results over different time periods to elaborate further conclusions.

La creciente complejidad de los desafíos del sector de la salud implica un aumento de las responsabilidades para quienes asumen funciones de gestión. Existe consenso en que la calidad de la fuerza de trabajo en la salud es un factor crítico para el éxito de cualquier reforma en la salud. El objetivo de esta investigación es estudiar y analizar las alteraciones introducidas por una intervención de formación-acción intensiva en la cultura organizacional de 74 directores ejecutivos de los Agrupamientos de Centros de Salud (ACES) en Portugal, durante la reforma de la atención primaria de la salud. Fueron recogidos y analizados datos en dos periodos temporales, antes y después de la intervención de Programa Avanzado en Gestión, Gobernanza Clínica y Liderazgo para los ACES, que tuvo la duración de un año. El modelo Competing Values Framework permitió observar que, después de la intervención de formación-acción, las percepciones de los directores ejecutivos sobre su cultura organizacional se encuentran más alineadas con la reforma de la atención primaria de la salud, valorizando el tipo de prácticas y valores que esta defiende. Es necesario continuar supervisando los resultados en varios períodos.

Health professionals moving to... and from Portugal.

The mobility of health professionals in the European Union is a phenomenon which policy-makers must take into account to provide the conditions to adjust for demand and supply of health services. This paper presents the case of Portugal, a country which at the same time imports and exports health workers. Since the early 1990s Portugal became a destination country receiving foreign health care professionals. This situation is now changing with the current economic situation as fewer immigrants come and more Portuguese emigrate. Foreigners coming to Portugal do so in part for similar reasons that bring Portuguese to want to emigrate, mainly the search for better work conditions and professional development opportunities. The emigration of Portuguese health professionals is also stimulated by the difficulty for recently graduated nurses, dentists and diagnostic and therapeutic technicians to find employment, low salaries in the public and private sectors, heavy workloads, remuneration not related to performance and poor career prospects. The paradoxes described in this study illustrate the consequences of the absence of a policy for the health professions. Strategies based on evidence, and on an integrated information system that captures the dynamic evolution of the workforce in health are not only necessary but also a good investment.

Transferência com a criança autista: há um lugar possível ao analista? / Transfer with an autistic child

A transferência é um dos conceitos fundamentais criados pela psicanálise e este artigo se propõe a discutir como acontece a transferência na clínica com crianças autistas. Como articular este conceito na prática clínica quando a criança autista recusa o contato com o outro e não faz uma demanda ao analista? A recusa ao contato com o outro indica que há uma escolha e o analista faz uma aposta otimista da existência de um sujeito, portanto, há a possibilidade de estabelecer um trabalho transferencial, não como na criança neurótica, mas pelo real do corpo que se apresenta, ou seja, pelo avesso(AU)

Transfer is one of the fundamental concepts created by psychoanalysis and this article aims to discuss how transference happens in the clinic with autistic children. How to formulate this concept in practice when the autistic children. How to formulate this concept in practice when the autistic child refuses to interact with others and does not make a demand to the analyst? Refusing interaction with others shows there is a choice and the analyst makes an optimistic prediction that there is a subject. Therefore, there is the possibility to establish transferential work, not as with neurotic children, but through their body signs, that is, inside-out(AU)

Trends of cross-border mobility of physicians and nurses between Portugal and Spain.

CONTEXT: Health workforce cross-border mobility has an impact not only on individual health workers, but also on how health services are organized, planned, and delivered. This paper presents the results of a study of current mobility trends of health professionals along the borders between Portugal and Spain. The objective was to describe the profile of mobile physicians and nurses; to elicit the opinions of employers on mobility factors; to describe incentive policies to retain or attract health professionals; and to collect and analyse employers' opinions on the impact of this mobility on their health services. METHODS: Phone interviews of key informants were used to collect relevant data. The interviews were conducted during December 2010 and January 2011 in health organizations along the border of the two countries. In Portugal and Spain, four and 13 organizations were selected, respectively. Interviews were obtained in all the Portuguese organizations and in four of the Spanish organizations. RESULTS: Findings suggest that cross-border mobility between the two countries has decreased. From Spain to Portugal, mobility trends are mainly of physicians who seek professional development in the form of specialization, the availability of positions, better salaries, and the perceived good living conditions. The mobility of nurses lasted until 2008, when reforms improved working conditions in Spain and contributed to reversing the flow. Since then, there has been an increase of Portuguese nurses going to Spain seeking better working conditions or simply a job. Portuguese nurses as well as Spanish physicians are well considered in terms of professionalism and qualifications by their Spanish and Portuguese hosts, respectively. CONCLUSIONS: There is a deficit of valid data on the health workforce in general. The present study allowed further exploration of the reality of the mobility trends between Portugal and Spain. At present, the mobility trends are mainly of Spanish physicians to Portugal and Portuguese nurses to Spain. There is a consensus on both sides of the border that the benefits of migratory flows are much greater than the limited problems (for example, language and salary differences) that they may bring.

Controvérsias no tratamento psicanalítico com crianças: Qual o lugar dos pais? / Children psychoanalytical treatment controverses: Wich place for the parents?

A clínica psicanalítica com crianças é uma prática intrigante, pois a cada novo caso algumas questões emergem constantemente em torno da participação dos pais no trabalho clínico desde a primeira entrevista: qual a demanda dirigida ao clínico pelos pais; que relação o sintoma da criança apresenta com seus outros primordiais quando e quantas vezes os pais devem ser chamados. Enfim, qual o lugar dos pais na análise com uma criança? Operar na intersecção destas duas posições discursivas - a da criança e de seus pais e/ou responsáveis - exige uma estratégia de intervenção clínica que precisa se sustentar em operadores conceituais rigorosos, indicando aí uma especificidade nesta particular forma de fazer psicanálise. Desta forma, este artigo discute qual o lugar dos pais na clínica psicanalítica com crianças, a partir das perspectivas teórico-clínicas de Anna Freud, Melanie Klein e autores lacanianos contemporâneos. Propõe entender que o cálculo clínico que se efetua na intervenção junto aos pais depende da particular concepção de criança com a qual se trabalha, indicando assim, a perspectiva teórica da qual se parte para exercer o ofício de psicanalista de crianças, o que também nos leva ao imperativo ético de uma escolha, já que não há como analisar a criança baseando-se em várias linhas de pensamento, já que cada uma delas indica uma especial direção de cura.

Controvérsias no tratamento psicanalítico com crianças: Qual o lugar dos pais? / Children psychoanalytical treatment controverses: Wich place for the parents?

Resumo : A clínica psicanalítica com crianças é uma prática intrigante, pois a cada novo caso algumas questões emergem constantemente em torno da participação dos pais no trabalho clínico desde a primeira entrevista: qual a demanda dirigida ao clínico pelos pais; que relação o sintoma da criança apresenta com seus outros primordiais quando e quantas vezes os pais devem ser chamados. Enfim, qual o lugar dos pais na análise com uma criança? Operar na intersecção destas duas posições discursivas - a da criança e de seus pais e/ou responsáveis - exige uma estratégia de intervenção clínica que precisa se sustentar em operadores conceituais rigorosos, indicando aí uma especificidade nesta particular forma de fazer psicanálise. Desta forma, este artigo discute qual o lugar dos pais na clínica psicanalítica com crianças, a partir das perspectivas teórico-clínicas de Anna Freud, Melanie Klein e autores lacanianos contemporâneos. Propõe entender que o cálculo clínico que se efetua na intervenção junto aos pais depende da particular concepção de criança com a qual se trabalha, indicando assim, a perspectiva teórica da qual se parte para exercer o ofício de psicanalista de crianças, o que também nos leva ao imperativo ético de uma escolha, já que não há como analisar a criança baseando-se em várias linhas de pensamento, já que cada uma delas indica uma especial direção de cura(AU)

Avaliaçäo de um serviço básico de saúde: uma abordagem comunitária / Evaluation of a primary attention health school service: a communitary approach

O Centro de Saúde tem por finalidade assistir a toda a populaçäo de sua área de abrangência, funcionando como porta de entrada do sistema de Saúde. Nesse sentido, um serviço-escola de atençäo primária à saúde foi avaliado: 150 famílias frequentadoras do serviço (grupo estudo) e 150 näo frequentadoras (grupo controle) foram estudadas, por meio de entrevista, em visitas domiciliares. A maioria das famílias é composta por quatro a cinco pessoas, sendo baixo o universo de gestantes, nutrizes e lactentes. A populaçäo estudada, em geral, procura o Centro de Saúde por motivo de doença, além de outros serviços de saúde. A orientaçäo alimentar näo acontece na maioria dos casos, sendo que quando ocorre é atribuida ao profissional médico. O aleitamento materno é considerado importante, tanto no grupo estudo como no controle, entretanto parte das mäes do grupo controle introduz mais precocemente alimentos na dieta do lactente. Discute-se a necessidade de ampliar e melhorar a qualidade do atendimento nesse serviço