Orientador: Francisco Leydson Formiga Feitosa / Resumo: A transferência nuclear de células somáticas de animais de produção é realizada há mais de 20 anos. No que concerne aos bovinos, uma série de anormalidades tem sido observada, tanto do ponto de vista metabólico como fisiológico. O objetivo deste trabalho foi avaliar os índices de morbimortalidade de bezerros da raça Nelore clonados durante o primeiro mês de vida. Desta forma, foram avaliadas as características clínico-laboratoriais, bem como as principais alterações anatomopatológicas em bezerros da raça Nelore oriundos de transferência nuclear de células somáticas (TNCS)-clonagem, comparando-os com animais desta mesma raça, frutos de fertilização in vitro (FIV). Para tanto, os animais foram alocados em dois grupos, a saber: Grupo I (GI) - 10 animais frutos de TNCS; e, Grupo II (GII) - 10 animais oriundos de FIV. Nos respectivos bezerros, todos obtidos por cesariana, foram realizadas as avaliações físicas, bem como coleta de amostras de sangue nos momentos 0 (ao nascimento), 2, 4, 6 e 12 horas de vida a fim de avaliar os resultados de hemograma, análises bioquímicas e proteinograma sérico, comparando-os entre os grupos e momentos avaliados. Nos animais que vieram a óbito foi realizada a necropsia para investigar a “possível” causa mortis. A mortalidade atingiu 90% dos animais do GI e 20% do GII, durante as primeiras 48 horas de vida. Ao exame físico observou-se que 50% dos bezerros do GI e 10% do GII apresentavam peso excessivo ao nascimento. Ademais, 30% dos animais do GI er... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Over past 20 years, the production animal species have been successfully cloned from somatic cell lines including cattle. In this specie metabolic and physiological complications have been seen. The aim of this study was to evaluate morbity-mortality of Nelore cloned calves during the first 30 days of life. For this clinical, laboratorial and pathological disturbances of Nelore cloned calves derived from somatic cell nuclear transfer (SCNT) was took over and compare them with animals from the same breed from in vitro fertilization (IVF). For this, two groups were formed. Group I (GI): Ten calves derived from SCNT and group II (GII): Ten calves derived from IVF. In both groups delivered by cesarean section, the physical and blood collection for laboratorial assessments was carried out at birth, 2, 4, 6 and 12 hours after delivered to evaluate clinical, hematological, biochemistry and serum proteinogram compared then between the groups and the moments. Necropsy was performed in every animal that died to identify the possible causa mortis. The mortality rate was 90% in GI and 20% in GII during the first 48 hours. Based on physical examination 50% of the GI animals and 10% of the GII animals had overweight at birth. Limb flexural deformity was noted in 30% of calves in GI. At birth 80% and 60% of the calves in GI and GII, respectively had low and moderate APGAR score index. It was noted that the low score was negative correlated with plasma lactate concentration with no relation ... (Complete abstract click electronic access below) / Doutor

Background Measuring pain in infants is important but challenging for researchers and health care professionals. The measurement of skin conductance (SC) is considered as a measure of stress and a surrogate indicator of pain. Purpose This dissertation provides insight on the validity of SC for pain measurement in infants and consists of two studies: 1) a scoping review synthesizing the methods and findings of previous studies on validating or using SC for measuring pain in infants; 2) a primary study evaluating the validity of SC for measuring pain in mechanically ventilated infants. Methods Arksey and O’Malley’s framework informed the methods of the scoping review. Nine electronic databases were searched. Data were analyzed and presented descriptively. The primary study used a prospective cross-sectional observational design. Eligible infants were those up to 12 months of age, hospitalized in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures. Results Scoping review: Twenty-eight studies with 1061 infants were included, including 23 cross-sectional observation studies and five interventional studies. The validity evidence of SC was tested in relation to referent pain measures (13 variables), stimuli (13 variables), age (2 variables) and other contextual variables (11 variables). Fifteen studies evaluated the validity evidence in relation to phase of painful procedure, and SC increased significantly during painful procedures in most studies (n=14/15). However, inconsistent findings on other validity evidence and wide variation in methods existed across studies. Primary study: SC showed good validity in relation to the category of procedure, the phase of procedure and the referent pain measures in critically ill mechanically ventilated infants. The findings from diagnostic test accuracy showed that SC had good capacity of detecting moderate to severe pain. However, the values of SC need to be used with caution, due to the imperfect correlations with the referent pain measures and imperfect positive predictive value. Conclusions SC is a promising approach to measuring pain in critically ill infants. Further research testing the validity of SC in relation to pain treatments and advancing the technology of measuring and analyzing SC is needed before it can be recommended for clinical use.

The topic of this master’s thesis is design of infant incubator. The thesis concerns own design of infant incubator that meet the basic technical, ergonomical and social requirements and also brings a new look and shape as solution to the main topic. The infant incubator is designed in regard to modern materials and technologies.

The issue of child mortality is currently under international spotlight, as the rates of neonatal and under five mortality are sobering. „About 29,000 children under the age of five [approximately] 21 each minute die every day, mainly from preventable causes‟. Although there has been a decline in global child mortality rates since 1990, sub-Saharan Africa still has the highest rates, where one child in eight dies before age five. As contained in the Millennium Development Goals (MDGs) 2010 report, in 2008, sub-Saharan Africa bore half of the 8.8 million deaths in children under five. / Thesis (LLM (Human Rights and Democratisation in Africa))--University of Pretoria, 2012. / http://www.chr.up.ac.za/ / nf2012 / Centre for Human Rights / LLM

Hearing loss in early childhood and infancy often goes undetected because it exhibits no obvious indication and symptoms. The primary aim of newborn hearing screening is to detect permanent hearing loss. Since otoacoustic emissions (OAE) and automated auditory brainstem response (AABR) are sensitive to hearing loss, they are often used as screening tools. On the other hand, these screening tests can be affected by transient outer ear and middle ear conditions that are often present at birth. This is an especially characteristic state of affairs for NICU neonates. These false positive results may render screening programmes inefficient and can lead to increased parental anxiety. Wideband acoustic immittance (WAI) has shown potential for accurate assessment of middle ear function in neonates, and is therefore recommended as an adjunct tool for newborn hearing screening programmes. The main aim of the study was to determine the feasibility of using WAI in NICU neonates in terms of tone and click stimuli. Testing was conducted in the NICU units of three private hospitals in Pretoria. As part of the selection criteria all the neonates had to pass both DPOAE and AABR screenings before they were included in the study. In total, 56 NICU infants (106 ears) with a gestation age of between 32 and 37 weeks and a mean gestational age of 35.6 weeks who passed both DPOAE and AABR hearing screens in one or both ears were selected. For WAI measurements there were two measurements, one for each channel in the probe (chirp and tone stimuli). Normative regions were defined across the wideband reflective spectrum for both tone and chirp stimuli and for integrated frequency ranges. The chirps and tone stimuli compared relatively well with each other at the 90th percentile with the same amount of reflectance across all frequencies. The median reflectance reached a minimum of 0.67 at 1-2 kHz but increased to 0.7 below 1 kHz and 0.72 above 2 kHz for the tone stimuli. For chirp stimuli the median reflectance reached a minimum of 0.51 at 1-2 kHz but increased to 0.68 below 1 kHz and decreased to 0.5 above 2 kHz. Results of this study identified WAI patterns that had not previously been reported in the literature. High reflective values were obtained across all frequency ranges, especially in the frequency ranges below 3 kHz and above 4 kHz. The age of the neonates when tested (mean gestational age 35.6 weeks, with a standard deviation of 1.6) might have influenced the results. The neonates in this study were of a very young age compared to the ages of the infants in previous studies on WAI. Environmental noise in NICU might have influenced the results. Additional research is required to investigate WAI testing in ears with and without dysfunction. / Dissertation (M Communication Pathology)--University of Pretoria, 2016. / Speech-Language Pathology and Audiology / M Communication Pathology / Unrestricted

Orientador: Maria Regina Bentlin / Resumo: Introdução: A sepse tardia (ST) é um grande desafio para neonatologistas por ser frequente e grave. Objetivos: Em prematuros de muito baixo peso (PT MBP): investigar a incidência da ST, clínica e confirmada, e a distribuição dos agentes etiológicos; analisar os fatores de risco; avaliar o prognóstico da sepse em curto prazo. Métodos: Coorte retrospectiva, com coleta prospectiva de dados, aprovado pelo Comitê de Ética, realizado entre 2013-2017 na UTI Neonatal do HC FMB - UNESP. Foram selecionados todos os PT com peso de nascimento (PN) ≤ 1.500 g internados na UTI e incluídos aqueles com idade gestacional (IG) entre 23 e 33 semanas, que sobreviveram por mais de 72h e acompanhados até alta, óbito ou 120 dias de internação. Não incluídos os PT com malformações múltiplas, infecções congênitas sintomáticas. ST foi definida como sinais clínicos e laboratoriais de infecção, confirmada ou não por hemocultura (HMC). Variáveis estudadas: gestacionais, neonatais, procedimentos e agentes etiológicos. Desfechos: óbito, displasia broncopulmonar (DBP), hemorragia peri e intraventricular (HPIV) grave, leucomalácia cística e retinopatia da prematuridade (ROP) ≥ estágio 2. Comparação entre grupos: Sem ST vs ST confirmada (HMC+) vs ST clínica (HMC-). Estatística: ANOVA com comparação múltipla de Tukey ou de Wald (distribuição gama); regressão logística múltipla (stepwise e ajuste para IG). Significância: 5%. Resultados: Foram incluídos 346 PT MBP. A incidência de ST foi de 32% (21% ST confirmad... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Late onset sepsis (LOS) remains a challenge for neonatologists because it is a frequent and severe disease. Aim: In very low birth weight (VLBW) preterm infants (PT): to investigate the incidence of LOS, proven and clinical, and the distribution of etiologic agents; to analyze the risk factors evolved; to evaluate the prognosis in the short term. Methods: Retrospective analysis of cohort, with prospective data collect, approved by the Ethics Committee, performed between 2013-2017 at the Neonatal Intensive Care Unit (NICU) of the Botucatu Medical School - UNESP. All PT with birth weight (BW) ≤ 1.500 g admitted in the NICU were selected. PT with gestational age (GA) between 23 and 33 weeks, admitted for more than 72 hours and followed up until discharge, death or 120 days of NICU stay were included. Not included multiple malformations and symptomatic congenital infections. LOS was defined as clinical and laboratory signs of infection, confirmed or not by blood culture (BC). Variables: gestational, neonatal, procedures and etiological agents. Outcomes: death, bronchopulmonary dysplasia (BPD), severe peri and intraventricular hemorrhage (PIVH), cystic leukomalacia and retinopathy of prematurity (ROP) ≥ stage 2. Comparison among groups: No LOS vs Proven LOS (BC+) vs Clinical LOS (BC-). Statistical analysis: ANOVA with multiple Tukey or Wald comparison (gamma distribution); multiple regression (stepwise), with adjustment for GA. Significance: 5%. Results: 346 PT were ... (Complete abstract click electronic access below) / Mestre

This dissertation consists of three essays in health economics, paying special attention to neonatal care provision and newborn health outcomes in the United States. The first chapter evaluates physician productivity, focusing on the matching between physician skills and patient conditions. High U.S. spending on health care is commonly attributed to its intensity of specialized, high-tech medical care. A growing body of research focuses on physicians whose medical decisions shape treatment intensity, costs, and patient outcomes. Often overlooked in this research is the assignment of physician skills to patient conditions, which may strongly affect health outcomes and productivity. This matching may be especially important in the case of hospital admissions as high-frequency fluctuations in patient flow make it challenging to maintain effective matches between the best-suited physicians and their patients. This paper focuses on hospitals’ responses to demand shocks induced by unscheduled high-risk admissions. I show that these demand shocks result in physician–patient mismatches when hospitals are congested. Specifically, highly specialized physicians who are brought in to treat unscheduled high-risk admissions also treat previously admitted lower-risk patients. This leads to increased treatment intensity for lower-risk patients, which I attribute to persistence in physician practice style. Despite the greater treatment intensity, I find no detectable improvement in health outcomes, which prima facie could be viewed as waste. However, the mismatches observed only at high congestion levels more likely reflect hospitals’ careful assessment of costs and benefits when assigning physicians to patients – maintaining preferred physician–patient matching can be particularly costly when congestion is high. My findings highlight the need to consider both heterogeneity within patient and physician type, and furthermore show how the common phenomenon of demand uncertainty can promote mismatch between these types. The second chapter assesses hospital self-reported facility data quality using annual Institutional Cost Report (ICR). In the United States, hospital facilities are under public and government supervision. The central motivation behind this is that overbuilding and redundancy in health care facilities will lead to overutilization and higher health care costs. However, little is known about the effectiveness of these facility regulation policies. Taking certified capacities recorded by the Department of Health as reliable benchmarks, this paper presents evidence that hospitals upcode their neonatal intensive care unit (NICU) bed levels when reporting capacities in ICR. Reported NICU utilization in ICR is mostly under the top level NICU bed, which matches the bed capacity upcoding pattern. This indicates either significant overutilization which leads to NICU overcrowding, or upcoding in medical billing that results in inflated medical charges. Findings in this paper point to a potentially effective way for regulators and insurers to limit overutilization – improving hospitals’ compliance with their certified capacities. This paper also provides important guidelines for a large body of research that uses ICR data by developing an assessment of ICR data quality. The third chapter, which is joint work with Douglas Almond, measures gender inequality in perinatal health among Chinese-American newborns. The literature on “missing girls" suggests a net preference for sons both in China and among Chinese immigrants to the West. Perhaps surprisingly, we find that newborn Chinese-American girls are treated more intensively in US hospitals: they are kept longer following delivery, have more medical procedures performed, and have more hospital charges than predicted (by the non-Chinese gender difference). What might explain more aggressive medical treatment? We posit that hospitals are responding to worse health at birth of Chinese-American girls. We document higher rates of low birth weight, congenital anomalies, maternal hypertension, and lower APGAR scores among Chinese American girls – outcomes recorded prior to intensive neonatal medical care and relative to the non-Chinese gender gap. To the best of our knowledge, we are the first to find that son preference may also compromise “survivor" health at birth. On net, compromised newborn health seems to outweigh the benefit of more aggressive neonatal hospital care for girls. Relative to non-Chinese gender differences, death on the first day of life and in the post-neonatal period is more common among Chinese-American girls, i.e. later than sex selection is typically believed to occur.

Universal Newborn Hearing Screenings have largely been successful since the National Institute if Health Consensus Development recommended, in 1996, that all infants should receive a newborn hearing screening prior to hospital discharge. Currently, the implementation of newborn hearing screening programs is varied across states and hospitals in the U.S. Due to this high variability, it is the responsibility of each individual hospital to formulate and consistently maintain a protocol for their newborn hearing screening program. This can create a great burden among hospitals as they must obtain the appropriate equipment, as well as employ and train screeners. However, national medical groups may be utilized to alleviate this burden. These medical groups supply the equipment, and more importantly, employ and train the screeners. This not only alleviates the burden on hospitals, but also provides a degree of standardization across newborn hearing screening programs which may reduce lost-to-follow-up statistics. Hospitals who do not utilize a national medical group may not have the expertise to formulate a comprehensive newborn hearing screening protocol. Our study is interested in examining if birthing hospitals that utilize a national medical group have more standardized medical protocols and have better (lower) lost-to-follow-up statistics. A survey was administered to current universal newborn hearing screeners employed at five hospitals across the eastern region of Tennessee. The survey examined various aspects of a typical newborn hearing screening program including training protocols and requirements, screening equipment, data recording and tracking, and methods of delivery of test results. In our presentation, we will be sharing the results of this study and interpret the data in light of determining best practices for newborn hearing screenings.

This dissertation consists of three essays on Health Economics. Chapter 1 analyzes the effects of abortion costs for minors on abortions, sexual behavior, and births. We exploit a 2015 change in parental involvement (PI) laws in Spain as a natural experiment in costs, together with rich population-level data on abortions and births. Using the exact date of teenager birth, we first document a decrease in abortions by 17-years-olds using a difference-in-difference comparison with 18-years-olds, consistent with the law that targeted Spanish minors. Using bunching methods from the Public Finance literature, we show evidence of temporal displacement. Some 17-years-old delayed their abortion and waited until they turned 18 and thereby avoided involving their parents. Second, we consider how the law change may have influenced health-related behaviors, finding implicitly that sexual behaviors changed so as to reduce the likelihood of becoming pregnant before turning 18 (and thereby internalized the cost of parental involvement). This is seen in the permanent shift in the number of abortions at age 18 that exists after removing the temporal displacement abortions around the age 18 threshold and an increase in the number of births to mothers who were pregnant at age 17. This paper finds that an important dimension of risky youth behavior responds to incentives contained in parental notification laws. Chapter 2 analyzes the effects of abortion costs on sex-selection by exploiting a 2010 abortion liberalization in Spain and the difference in son-preferences by nationality and child order documented in the literature. We show using a difference-in-difference comparison a significant increase in the fraction of boys for Chinese parents giving birth to their third child or above relative to children born of Spanish parents. Consistent with the literature, we do not find any effect on the fraction of boys for the first or the second child. Using the provincial number of abortion centers per person as a measure of access to abortion, we show, at the correlation level, that the effects come from those provinces with higher access to abortions. Finally, we find suggestive evidence that birth outcomes of Chinese girls who are the third children, and thus are now more likely to be ``wanted'' after the reform, improve. Gestational weeks increase, and the chance of being born prematurely decrease although our evidence suffers from lack of power. Finally, chapter 3 analyzes the effects of a universal, unconditional cash transfer announcement on birth outcomes by exploiting the 2007 cheque bebé policy in Spain that provided 2,500 euros per child to all mothers giving birth immediately after its announcement (Jul 2007). We use a difference-in-difference analysis comparing those born before and after the announcement. By exploiting the timing of the policy announcement we can avoid the composition effects caused by the incentives to have children generated by the policy. We show that the birth weight of those children born after the policy announcement (Sept-Dec) significantly improved relative to those born before (Apr-Jun) using previous years to control for the seasonal effects. Moreover, we provide suggestive evidence that those who are more vulnerable, as measured by the average municipality income level, parents' marital status, or parents' age, experience the most substantial improvements on birth weight.

Orientador: Regina Helena Garcia Martins / Resumo: Introdução: A sífilis congênita é citada como indicador de risco para deficiência auditiva e apesar de ter sido erradicada após a era da penicilina, nos últimos anos houve um progressivo aumento de sua incidência no Brasil, no entanto poucos casos acarretam com o desfecho de deficiência auditiva, em decorrência da identificação precoce da sífilis materna, ainda no pré-natal, o que possibilita o tratamento precoce, evitando-se ao máximo a contaminação do feto pelo Treponema pallidum. Ainda assim, a literatura recomenda o acompanhamento do desenvolvimento auditivo dessas crianças, inclusive as que foram apenas expostas a sífilis materna na gestação. Objetivo: Analisar as respostas auditivas de recém-nascidos expostos à sífilis materna, por meio de exames eletroacústicos e eletrofisiológicos. Método: Participaram do estudo 90 recém-nascidos a termo, divididos em dois grupos: Grupo exposto à sífilis materna, composto por 41 recém-nascidos e Grupo controle, composto por 49 recém-nascidos sem indicadores de risco para deficiência auditiva. Os recém-nascidos foram atendidos no programa de triagem auditiva neonatal universal, do Hospital das Clínicas da Faculdade de Medicina de Botucatu, por meio do exame de emissões otoacústicas por estímulo transiente (EOE-t), com resultado “passa”, em ambas as orelhas, e potencial evocado auditivo de tronco encefálico (PEATE) com diferentes taxas de repetição do estímulo clique sendo: 21.1 c/s, 51.1 c/s e 91.1c/s. Resultados: Mesmo apresentando re... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Congenital syphilis is reported as a risk indicator for hearing loss and although it has been eradicated after the penicillin era, in recent years there has been a progressive increase in its incidence in Brazil; however, few cases lead to hearing loss due to early identification of maternal syphilis during prenatal care, which enables early treatment, and avoids, as much as possible, the contamination of the fetus by Treponema pallidum. Nevertheless, the literature recommends monitoring the auditory development of these children, including those who were only exposed to maternal syphilis during pregnancy. Objective: To analyze the auditory responses of newborns exposed to maternal syphilis through electroacoustic and electrophysiological assessments. Method: Ninety full term newborns participated in the study, divided into two groups: Group exposed to maternal syphilis, composed of 41 infants and Control group, composed of 49 newborns without risk indicators for hearing loss. The newborns were treated in the universal neonatal hearing screening program of Botucatu Medical School General Hospital through transient-evoked otoacoustic emission (TEOAE), with “pass” results, in both ears, and brainstem auditory evoked potential (BAEP) with different click stimuli repetition rates: 21.1 c/s, 51.1 c/s and 91.1c/s. Results: Even with the “pass” result, TEOAE amplitudes of the group exposed to syphilis presented lower values when compared to control group, especially at... (Complete abstract click electronic access below) / Doutor