Atualmente a maioria das instituições vem buscando a qualidade da assistência, a segurança dos pacientes e o gerenciamento de riscos nos serviços de saúde, a fim de proporcionarem uma assistência livre de riscos e danos, o que pressupõe que incidentes sejam analisados para prevenir sua ocorrência. Trata-se de um estudo do tipo exploratório, cujo objetivo foi analisar dois tipos de incidentes relacionados à segurança do paciente, na assistência de enfermagem, que foram notificados em um hospital geral e privado, do interior do Estado de São Paulo, no período de janeiro a março de 2012, por meio da metodologia da Análise de Causa Raiz. Dessa forma, o universo em estudo foi constituído por 62 incidentes relacionados à segurança do paciente, sendo 11 quedas e 51 erros de medicação notificados. A pesquisa foi realizada em duas fases, sendo que, na primeira fase, os dados dos formulários de notificação e dos prontuários dos pacientes foram transcritos para o instrumento de coleta de dados. Na segunda fase, incidentes relacionados à segurança dos pacientes e que causaram danos, em relação às quedas, ou que tinham potenciais, no caso dos erros de medicação, foram submetidos a essa análise. Assim, 82,3% dos incidentes notificados foram erros de medicação, e 17,7% foram quedas. A maioria dos incidentes ocorreu nas alas de internação, e a equipe de enfermagem se envolveu em 78,5% dos incidentes. Os erros de omissão (31,5%), de horário (22,2%), de técnica de administração (14,8%) e de dose (14,8%) foram os principais tipos de erros de medicação ocorridos. O custo das quedas foi R$ 91,88 e dos erros de medicação foi R$ 1.188,43. Os eletrólitos, antimicrobianos e analgésicos foram os principais medicamentos envolvidos nos erros de medicação. Com relação aos fatores causais das quedas analisadas, 25,7% foram relacionadas à categoria paciente, 22,9%, à equipe, 17,1%, ao ambiente, 14,3%, à tarefa, 11,4%, ao indivíduo e 8,6%, à gestão. Um total de 83 causas contribuiu com a ocorrência dos erros de medicação, sendo que a categoria gestão contribuiu com 32,6% dos erros, indivíduo com 21,7%, equipe com 19,3%, ambiente com 12,0%, tarefa com 9,6% e paciente com 4,8%. Posteriormente, recomendações para evitar a ocorrência desses incidentes na instituição, focando as melhores práticas, foram propostas. / Presently, most institutions have sought care-provision quality, patient safety and risk management in health care services so as to provide risk- and damage-free caregiving, which presupposes that incidents should be analyzed in order to prevent their occurrence. This is an exploratory study the objective of which was to analyze two types of patient-safety-related incidents occurring during nursing care at a general private hospital in São Paulo state from January to March 2012 by means of the Root Cause Analysis Methodology. Hence, the universe under study consisted of 62 patient-safety-related incidents, of which 11 were falls and 51 were reported medication errors. The study was conducted in two phases, and in the first phase, the data on report forms and on patients\' medical records were transcribed to the data collection instrument. In the second phase, the patient-safety-related incidents that caused harm in relation to falls or those that were potentially harmful in the case of medication errors were analyzed. Hence, 82.3% of the reported incidents were medication errors, and 17.7% were falls. Most of the incidents occurred in the hospitalization wards, and the nursing staff was involved in 78.5% of the incidents. Omission (31.5%), time (22.2%) administration-technique (14.8%) and dose (14.8%) errors were the major medication-error types that occurred. The cost of falls was R$ 91,88 (USD 44.15), and that of medication errors was R$ 1.188,43 (USD 571.06). Antimicrobial electrolytes and analgesics were the main medicines involved in medication errors. As regards the causal factors of the analyzed falls, 25.7% were related to the patient category, 22.9% to the team, 17.1% to the environment, 14.3% to the task, 11.4% to the individual and 8.6% to management. A total of 83 causes contributed to medication-error occurrence, and the management category contributed with 32.6% of the errors. The individual category contributed with 21.7%, the team with 19.3%, the environment with 12.0%, task with 9.6% and patient with 4.8%. Later, recommendations to prevent the occurrence of these incidents in the institution were proposed with a focus on best practices.

Introdução: A presença de doença crônica e de várias comorbidades, somados à mobilidade reduzida e fraqueza muscular são fatores frequentemente associados ao risco de quedas em idosos, sendo o dano do equilíbrio um dos mais importantes preditores de quedas. Atualmente, há uma crescente evidência de que pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC) são bastante suscetíveis a quedas visto que têm apresentado importantes déficits de equilíbrio. Há alguns estudos que avaliam o papel de fatores isolados deste déficit, contudo, a avaliação de múltiplos fatores na mesma população de pacientes ainda não foi muito investigada, assim como o impacto desta alteração de equilíbrio na predição de quedas nesta população ainda é pouco conhecido. Objetivos: Determinar que fatores estão associados à alteração de equilíbrio postural em pacientes com DPOC e avaliar o impacto desta alteração do equilíbrio na predição de quedas nesta população. Métodos: Este estudo prospectivo de coorte incluiu 70 pacientes ambulatoriais com diagnóstico prévio de DPOC. Para a avaliação do equilíbrio os pacientes foram submetidos ao Mini-BESTest (Balance Evaluation Systems Test). As variáveis sexo, idade, frequência de exacerbações / hospitalizações decorrentes da doença respiratória no último ano foram coletados a partir de entrevista pessoal e de registros clínicos. A presença de comorbidades foi avaliada por meio da aplicação de uma escala denominada Functional Comorbidity Index (FCI). O nível de atividade física foi mensurado por meio de um sensor de movimento (acelerômetro), a força isométrica muscular máxima de membros inferiores foi avaliada por um dinamômetro, a qualidade do sono mensurada por meio do questionário Pittsburgh Sleep Quality Index, a dispneia pela modified Medical Research Council (mMRC) dyspnoea scale, o medo de quedas pela escala Falls Efficacy Scale-International (FES-I) e a função pulmonar por meio da prova de função pulmonar completa. Além disso, a incidência de quedas nos pacientes foi seguida por um ano sendo avaliada mensalmente por um diário de autorrelato de quedas, entregue ao paciente após a avaliação inicial, e confirmada por ligações telefônicas. Para a análise estatística foram utilizados modelos de análise de regressão e análise de poder discriminativo através da Receiver operator characteristic curve (ROC curve). O nível de significância foi ajustado para todas as análises e foi de 5% (p < 0,05). Resultados: Verificou-se que o equilíbrio postural (Mini-BESTest - pontuação total) esteve independentemente associado à força muscular de quadríceps, ao medo de queda (FES-I) e à idade, ajustados pela inatividade física (p < 0,001, r2 ajustado=0,49). Ao analisar cada domínio correspondente a um sistema do controle postural separadamente pudemos verificar também que o equilíbrio postural esteve independentemente associado a: idade e inatividade física, ajustados pelo índice de massa corpórea (IMC) no domínio \"Ajustes Posturais Antecipatórios\" (p=0,001, r2 ajustado=0,22); idade, força muscular de quadríceps e pressão inspiratória máxima (PImáx), ajustados pelo aprisionamento aéreo no domínio \"Respostas Posturais Reativas\" (p < 0,001, r2 ajustado=0,47); medo de queda e força muscular de dorsiflexores de tornozelo no domínio \"Orientação Sensorial\" (p=0,001, r2 ajustado=0,16); e qualidade do sono, inatividade física, idade e força muscular de plantiflexores de tornozelo no domínio \"Estabilidade na marcha\" (p < 0,001, r2 ajustado=0,24). Além disso, 37,3% dos pacientes apresentaram pelo menos um evento de queda em um período de 12 meses de seguimento. Verificou-se também que um melhor desempenho no controle postural, avaliado pelo Mini-BESTest esteve associado a um menor risco de queda [Odds ratio (OR)=0,50] e que o Mini-BESTest mostrou ser um bom instrumento para predizer quedas futuras em pacientes com DPOC [Area under the curve (AUC)=0,87, sensibilidade=84% e especificidade=73,8%]. Conclusões: A alteração do equilíbrio postural nesta população de pacientes com DPOC está associada à idade, fraqueza muscular de membros inferiores, medo de queda, qualidade do sono, inatividade física e à função pulmonar. Além disso, a alteração no equilíbrio postural é um bom preditor de quedas futuras nesta população, sendo o Mini-BESTest um bom instrumento para identificar os pacientes com maior risco de quedas. A implementação de programas de reabilitação que incluam treinamento de equilíbrio específico e prevenção de queda pode ser necessária para estes pacientes / Introduction: The presence of chronic disease and several comorbidities, added to reduced mobility and muscle weakness are often associated with the risk of falls in the elderly, with balance impairment being one of the most important predictors of falls. Currently, there is growing evidence that patients with chronic obstructive pulmonary disease (COPD) are quite susceptible to falls since they have presented significant balance deficits. There are some studies that evaluate the role of isolated factors in this deficit, however, the evaluation of multiple factors in the same sample of patients has not yet been much investigated, as well as the impact of this balance impairment in the prediction of falls in this population is not clear in the literature. Objectives: To determine the factors that are associated with postural balance impairment in patients with COPD and to evaluate the impact of this impairment on the prediction of falls in this population. Methods: This prospective cohort study included 70 outpatients with a previous diagnosis of COPD. Postural balance was evaluated by the Mini-BESTest (Balance evaluation systems test). Gender, age, frequency of exacerbations / hospitalizations resulting from respiratory disease in the last year were collected from an initial interview and patients\' medical records. The presence of comorbidities was evaluated using the scale of Functional Comorbidity Index (FCI). The level of physical activity was measured using a motion sensor (accelerometer type), the maximal isometric muscle strength of the lower limbs was assessed using a dynamometer, the sleep quality measured by the Pittsburgh Sleep Quality Index, the dyspnea by the modified Medical Research Council (mMRC) dyspnoea scale, the fear of falling by the Falls Efficacy Scale-International scale (FES-I) and the lung function obtained by the Complete Pulmonary Function Test. In addition, the incidence of falls was followed for one year, assessed monthly by a calendar of self-reports of falls, given to the patient after the initial assessment, and confirmed by telephone calls. For the statistical analysis, regression analyses models and discriminative power analysis by receiver operator characteristic curve (ROC) were used. The level of significance was adjusted for all analyses and was 5% (p < 0.05). Results: Postural balance (Mini-BESTest) was independently associated with quadriceps muscle strength, fear of falling (FES-I) and age, adjusted for physical inactivity (p < 0.001, adjusted r2=0.49). When analyzing each domain corresponding to a postural control system separately, we could also verify that the postural balance was independently associated with: age and physical inactivity, adjusted by the body mass index (BMI) in the domain \"Postural Anticipatory Adjustments\" (p=0.001, adjusted r2=0.22); age, quadriceps muscle strength and maximal inspiratory pressure (MIP), adjusted by air trapping in the \"Postural Reactive Responses\" domain (p < 0.001, adjusted r2=0.47); fear of falling and ankle dorsiflexors muscle strength in the domain \"Sensory Orientation\" (p=0.001, adjusted r2=0.16); and sleep quality, physical inactivity, age and ankle plantiflexors muscle strength in the domain \"Balance during gait\" (p < 0.001, adjusted r2=0.24). In addition, 37.3% of patients had at least one fall event over a 12-month follow-up period. It was also verified that a better performance in postural control evaluated by Mini-BESTest was associated with a lower risk of fall [Odds ratio (OR) = 0.50] and that Mini-BESTest was showed to be a good tool to predict future falls in patients with COPD [Area under the curve (AUC)= 0.87, sensitivity = 84% and specificity = 73.8%]. Conclusions: Postural balance impairment in patients with COPD is associated with age, lower limb muscle weakness, fear of falling, sleep quality, physical inactivity and lung function. In addition, the postural balance impairment is a good predictor of future falls in this population, and Mini-BESTest is a good tool to identify patients at greater risk of falls. The implementation of rehabilitation programs that include specific balance training and fall prevention may be required for these patients

INTRODUÇÃO: Os efeitos da levodopa (LD) e da estimulação cerebral profunda (ECP) de núcleo subtalâmico (STN) sobre o equilíbrio e sintomas axiais são até o momento controversos. OBJETIVOS: Avaliar quantitativamente os efeitos da ECP de STN e da LD sobre o equilíbrio estático em pacientes com DP operados, em comparação com a LD em pacientes não operados. MÉTODOS: Trinta e um pacientes submetidos a ECP de STN entre 3 meses e 1 ano e meio antes da avaliação e 26 controles portadores de DP não operados, estágios Hoehn e Yahr 2 a 4 foram avaliados usando UPDRS para avaliação clínica e plataforma de força para avaliar oscilações posturais. O primeiro grupo foi avaliado com ECP e sem medicação, com ECP e com medicação e sem ECP e sem medicação. O segundo grupo foi avaliado com e sem medicação. Cada paciente foi avaliado com os olhos abertos e fechados. O deslocamento do centro de pressão anteroposterior, laterolateral, a área, velocidade e deslocamento total linear foram medidos pela plataforma de força. Os dados paramétricos foram comparados usando o teste t de Student e os dados não-paramétricos foram comparados pelo teste de Kruskal-Wallis. A avaliação clínica consistiu na parte 3 da escala UPDRS e na escala Hoehn e Yahr. Nível de significância estatística considerada foi p=0,05. RESULTADOS: Os pacientes não operados oscilaram mais quando sob efeito da levodopa do que sem medicação. No grupo operado, a maior oscilação é no grupo com ECP desligada e sem medicação. Tende a reduzir sob efeito da ECP apresenta redução significativa sob efeito simultâneo de ECP e levodopa. CONCLUSÃO: A associação da ECP de NST com medicação tem impacto positivo sobre o controle postural. O efeito da ECP de NST reverte o efeito negativo da levodopa sobre as oscilações observadas em pacientes não operados / INTRODUCTION: The effects of bilateral subthalamic (STN) DBS and medication on balance and on axial symptoms in PD have been so far inconsistent. OBJECTIVE: To assess quantitatively the effects of DBS on static balance in PD. METHODS: Thirty-one patients submitted to STN DBS over 3 months before and 26 non-operated controls with PD on Hoehn & Yahr stage \"on\" 2 to 4 were evaluated using UPDRS and a force plate to measure sway. The first group was evaluated on-DBS/off-medication, on-DBS/on-medication and off-DBS/off-medication. The second group was evaluated on and off medication. Each group was assessed with eyes open and then closed. Antero-posterior, laterolateral postural displacements of the center of pressure (COP), as well as 95% sway area, path length and speed of oscillation were analyzed and compared using t-Student test for parametrical data and Kruskal-Wallis test for non-parametrical data. Level of significance was set to p < 0.05. Clinical assessment consisted of UPDRS part 3 and Hoehn & Yahr scores for each of the conditions. RESULTS: Control patients tended to oscillate more in the on medication condition than off medication. DBS patients tended to oscillate more in the off-DBS/off medication condition, with a tendency to decrease the sway when on DBS/off medication with additional decrease when on DBS/on medication. CONCLUSION: Association of bilateral STN DBS and medication positively influences postural control in PD and surgery reverses the tendency of medication to increase body sway in non-operated patients

O Acidente Vascular Encefálico (AVE) freqüentemente ocasiona alterações de equilíbrio, decorrentes de lesões no sistema nervoso central que afetam os aspectos motores, sensoriais e de integração do controle do movimento. Os objetivos deste estudo foram descrever as alterações de equilíbrio em indivíduos hemiparéticos que haviam sofrido AVEs isquêmicos nos 12 meses anteriores (grupo de estudo - GE), em comparação a um grupo de indivíduos saudáveis (grupo controle, GC), e correlacionar medidas observacionais (Escala de Equilíbrio de Berg: EEB; e Sub-Escala de Equilíbrio do teste de Fugl-Meyer: SEE-FM) e laboratoriais (resultados da Posturografia Dinâmica computadorizada - PDC) no GE. Na PDC, foram realizados o teste de organização sensorial e o teste de controle motor. Foram avaliados 21 pacientes que apresentavam alto nível de desempenho funcional (avaliado pelo Índice de Barthel e pela Categoria de Deambulação Funcional, CDF), e comprometimento neurológico leve (avaliado pela escala de AVE do National Institutes of Health, NIHSS) e sensório-motor dos membros inferiores (avaliado pela sub-escala motora de membros inferiores de Fugl-Meyer). O desempenho do GE foi inferior ao do GC em todas as avaliações de equilíbrio. Os resultados da PDC indicaram pior integração das informações visual e vestibular no GE, comparado ao GC. Adicionalmente, os indivíduos do GE apresentaram maior assimetria na distribuição de peso e na força empregada pelos membros inferiores para se recuperarem de desequilíbrios impostos pelo teste. A PDC foi o único instrumento cujos resultados foram associados a comprometimento da dorsiflexão ativa e da propriocepção na articulação do tornozelo. Houve correlação estatisticamente significativa entre o Índice de Barthel e as escalas de equilíbrio, mas não com a PDC. As pontuações na CDF e na sub-escala motora de membros inferiores de Fugl-Meyer se correlacionaram significativamente com todas as medidas de avaliação de equilíbrio. As pontuações na NIHSS não se correlacionaram significativamente com as medidas observacionais nem com os resultados da PDC. Os três instrumentos de avaliação do equilíbrio apresentaram correlação entre si, e com o antecedente de quedas. As informações obtidas através da PDC contribuíram para melhor caracterização das anormalidades de equilíbrio em doentes hemiparéticos após o AVE. / Abnormal balance after stroke can be a consequence of changes in motor, sensory and integrative aspects of motor control. The aims of this study were to describe balance impairments in hemiparetic patients with ischemic strokes in the last 12 months compared to healthy subjects, and to correlate observational scores (Berg Balance Scale and balance subscale of the Fugl-Meyer assessment scale) and laboratory measurements (results of the Computerized Dynamic Posturography CDP) in the stroke group. The Sensory Organization Test and the Motor Control Test were performed in PDC. Twenty-one patients were evaluated. They had high functional levels (evaluated with the Barthel Index and with the Functional Ambulatory Category, FAC), mild neurological deficits (evaluated with the National Institutes of Health Stroke Scale, NIHSS) and mild sensory and motor impairment in the lower limbs (evaluated with the motor subscale of the Fugl-Meyer assessment scale). Patients had lower scores than healthy volunteers in all balance evaluations. CDP results showed worse visual and vestibular integration in the stroke group compared to healthy subjects. Weight and strength asymmetries in the lower limbs were greater in the stroke group. Only CDP results were significantly correlated with ankle dorsiflexion and proprioception. The Barthel Index correlated significantly with balance scales but not with PDC results. FAC and the motor subscale of the Fugl-Meyer assessment scale correlated significantly with all types of balance assessment. NIHSS scores did not correlate with observational scores or CDP results. The three instruments of balance evaluation were significantly correlated with each other and with history of falls after stroke. Information provided by CDP contributed to better characterize balance abnormalities in hemiparetic stroke patients.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-04-11T11:37:13Z No. of bitstreams: 1 danielletelesdacruz.pdf: 3213427 bytes, checksum: ab0cd9e1ccc636cecb3de0a9ca0f99cf (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-04-11T11:47:54Z (GMT) No. of bitstreams: 1 danielletelesdacruz.pdf: 3213427 bytes, checksum: ab0cd9e1ccc636cecb3de0a9ca0f99cf (MD5) / Made available in DSpace on 2017-04-11T11:47:54Z (GMT). No. of bitstreams: 1 danielletelesdacruz.pdf: 3213427 bytes, checksum: ab0cd9e1ccc636cecb3de0a9ca0f99cf (MD5) Previous issue date: 2017-02-14 / CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico / Fragilidade, quedas e medo de cair são síndromes geriátricas que se configuram como importantes problemas de saúde pública. São condições frequentes, passíveis de prevenção, responsáveis pela redução da capacidade funcional e da qualidade de vida e preditoras de institucionalização, morbidade e mortalidade. O objetivo foi verificar a prevalência de fragilidade e analisar os fatores associados. São ainda objeto de análise o estudo e compreensão do evento queda, queda recorrente e medo de cair. Inquérito domiciliar realizado entre outubro de 2014 e março de 2015, com 400 idosos (60 anos ou mais), ambos os sexos, não institucionalizados, na Zona Norte de Juiz de Fora. Foram analisadas características demográficas e socioeconômicas, perfil de saúde, uso de serviços de saúde, fragilidade (Escala de Fragilidade de Edmonton), quedas, medo de cair (Falls Efficacy Scale – Internacional – Brasil) e capacidade funcional (Escala de Lawton e Brody). Os dados foram processados em banco de dados no software Statistical Package for Social Sciences, módulo de análise complexa, versão 15.0. O uso do software Stata 9.2 permitiu o incremento das análises. Foram empregados diferentes métodos de análise estatística para o alcance dos objetivos. Nível de significância foi de 5%. Para a análise dos fatores associados à fragilidade, foi construído um modelo teórico de determinação com três blocos hierarquizados, ajustados por regressão de Poisson. A prevalência de fragilidade foi 34,5% e associou-se com dificuldade para andar, necessidade de dispositivo auxiliar para locomoção, presença de cuidador e dependência funcional para realização das atividades instrumentais. A prevalência de quedas foi 35,3%. A maior parte ocorreu no domicílio e no período da manhã. Foi realizada abordagem teórica hierárquica em 3 níveis para estimativas e ajustes de variáveis. Após todos ajustes, idade e relato de dificuldade para andar permaneceram associados à queda. Para a investigação de quedas recorrentes foi realizado um estudo observacional de seguimento por meio de duas ondas de corte transversal. Para isso utilizou-se também dados do primeiro Inquérito em Saúde realizado em 2010. A regressão logística multinomial foi empregada para estimar a associação das variáveis independentes com os desfechos queda no seguimento e queda recorrente. 44,5% dos idosos não relataram quedas, 39% sofreram queda em pelo menos um dos inquéritos, e 16,5% manifestaram ter sofrido queda nos dois inquéritos. Não foram encontradas associações para o desfecho queda recorrente. Queda no seguimento associou-se à sexo feminino e ao segmento etário de 71 a 80 anos. A prevalência do medo de cair foi 95,2%. A correlação de Spearman indicou correlação do medo de cair com idade, autopercepção de saúde, dificuldade para andar, uso de dispositivo auxiliar para marcha, quedas e capacidade funcional. Os resultados revelam alta prevalência de fragilidade, quedas e medo de cair e evidenciam a multifatoriedade e complexidade das interações de diversos fatores na condição de saúde dos idosos. É eminente a necessidade de desenvolvimento de políticas públicas e ações de saúde voltadas para essa população, com ênfase em ações educativas, preventivas, e de promoção à saúde, de cunho interdisciplinar, a partir da identificação dos grupos de riscos e fatores associados. / Frailty, falls and fear of falling are geriatric syndromes that characterize significant issues of public health. Those conditions are frequent, preventable, responsible for the reduction of functional capacity and life quality, and predictors of institutionalization, morbidity and mortality. The purpose was to verify the frailty prevalence and analyze the associated aspects. Moreover, the comprehension of the events fall, recurrent fall and fear of falling are also issues to be analyzed in this study. Household survey realized between October 2014 and March 2015, with 400 elderly (60 years old and over), both sex, not institutionalized, north zone of Juiz de Fora City. It was considered demographic and socioeconomic characteristics, health profile, use of health services, frailty (Edmonton Frail Scale), falls, fear of falling (Falls Efficacy Scale – International – Brazil) and functional capability (Lawton and Brody Scale). The data was processed in a database on the software Statistical Package for Social Sciences, complex analyze module, 15.0 version. The software Strata 9.2 was used to increment the results. Several methods of statistical analysis were adopted to achieve the goals. The significance level was 5%. For frail associated aspects, a theoretical model of determination with three hierarchical blocks, adjusted by Poisson regression, was built. The fragility prevalence was 34.5% and was associated to walking difficulties, need of auxiliary device for mobility, a caregiver assistance and functional dependency for instrumental activities accomplishment. The falling prevalence was 35.3%. The majority of the events happened at home, during the mornings. For estimation and variable adjustments, a hierarchic theoretical approach, ranked in 3 levels, was adopted. After all the adjustments, age and reports of walking difficulties kept associated to falling. For the investigation of recurrent falls, an observational follow-up study was carried out using two cross-sectional waves. For this, data from the first Health Survey conducted in 2010 was also applied. Multinomial logistic regression was used to estimate the association of independent variables with the outcomes follow-up fall and recurrent fall. 44.5% of the elderly do not report falls, 39% suffered falling events in, at least, one of the surveys, and 16.5% reported falling events in both surveys. None association was found for the outcome recurrent fall. Follow-up fall was related to female and age segment from 71 to 80 years old. The prevalence of fear of falling was 95.2%. The Spearman correlation revealed correspondence of fear of falling with age, self-perception of health, walking difficulties, use of auxiliary device for mobility, falls and functional capacity. The results reveal high prevalence of frailty, falls and fear of falling, and evidenced the multifactorial and complexity of the interactions of several factors in the health condition of the elderly. The need for development of public policies and health actions aimed to this population, emphasizing educational, preventive and health promotion actions of an interdisciplinary nature, is eminent, based on the identification of groups in risk and associated factors.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-10-31T11:53:54Z No. of bitstreams: 1 jessicadecastrosantos.pdf: 3277357 bytes, checksum: 8eae545231d51036daec573a9e18524b (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-11-09T13:56:45Z (GMT) No. of bitstreams: 1 jessicadecastrosantos.pdf: 3277357 bytes, checksum: 8eae545231d51036daec573a9e18524b (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-11-09T14:04:28Z (GMT) No. of bitstreams: 1 jessicadecastrosantos.pdf: 3277357 bytes, checksum: 8eae545231d51036daec573a9e18524b (MD5) / Made available in DSpace on 2017-11-09T14:04:28Z (GMT). No. of bitstreams: 1 jessicadecastrosantos.pdf: 3277357 bytes, checksum: 8eae545231d51036daec573a9e18524b (MD5) Previous issue date: 2017-08-18 / Pesquisa de método misto realizada nos domicílios de pessoas com idade ≥65 anos. Objetivou-se analisar as situações e/ou circunstâncias individuais, grupais e ambientais de vulnerabilidade/risco que predispõe as pessoas com idade ≥65 anos à queda no (peri)domicílio; compreender suas representações sociais sobre quedas e gerar tecnologia leve-dura para subsidiar a avaliação do ambiente (peri)domiciliar na modalidade de consulta de enfermagem. Amostra de seleção completa. Foram critérios de inclusão: pessoas com idade ≥65 anos, lúcida, com fala coerente e ser moradora de uma área adstrita a uma Unidade de Atenção Primária à Saúde (UAPS). Dados coletados por entrevistas individuais com apoio de Open Data Kit e analisados com apoio dos Programas SPSS® (estatística descritiva e correlacional), EVOC 2000® (para subsidiar a elaboração de análise prototípica) e NVIVO pro11® (Correlação de Pearson ≥0,70 segundo análise de conteúdos de Bardin). Atendidos todos os requisitos éticos e legais de pesquisa envolvendo seres humanos. Participaram 220 idosos assim caracterizados: 78,5% mulheres; 29,6% com idade ≥80 anos (65-96 anos) e 68,6% com companheiros. Escala de Snellen aferiu dificuldade visual em 54,1% (olho esquerdo: OE) e 50,6% (olho direito: OD) com capacidade de leitura ≤5 ou diopitria 20/40; Escala de Jaeger mensurou que 55,2% e 53,2% participantes não enxergavam nada ou enxergavam mal OD e OE, respectivamente; 41,6% enxergavam mal com OD e OE. Escala de Eficácia de Quedas 53,5% evidenciou medo para atividades de vida diária, sendo preditor de quedas. Foram componentes simbólicos emergentes na abordagem estrutural e corroborados por trechos de discurso na abordagem processual: poder cair (comportamentais: “tonteira-vertigem-labirintite” e objetivais: “chinelo-calçado”), cair dentro de casa (comportamentais: “cair”, “cuidado-atenção” e “medo”) e cair fora de casa (objetival: “buraco” e comportamentais: “cair” e “tropeçar”). Emergiram três categorias: origem dos conteúdos simbólicos individuais, grupais e ambientais. Foram fatores ambientais intervenientes para queda: no domicílio (piso escorregadio, escada e corrimão com p-valor ≤ 0,04) e no peridomicílio (muitos objetos no ambiente e degraus com p-valor≤ 0,04). A presente investigação traçou um diagnóstico de uma região coberta pela Atenção Primária à Saúde sobre as vulnerabilidades para quedas em pessoas com idade ≥65 anos, apresentou um protocolo (tecnologia leve-dura) para subsidiar consulta de enfermagem domiciliar e decisões gerenciais de cuidados para o (peri)domicílio com uma abordagem de prevenção para a ocorrência de quedas. / Mixed method search performed in the households of people aged ≥65 years. The objective was to analyze the individual and group situations and/or circumstances of vulnerability/risk that predisposes people aged ≥65 years to the (peri) domicile. Understand their social representations about falls and generate light-hard technology to subsidize the evaluation of the environment (peri) domicile in the modality of nursing consultation. Sample full selection. Inclusion criteria were: people aged ≥65 years, lucid, with coherent speech and being residents of an area attached to a Primary Health Care Unit (UAPS). Data collected by individual interviews with support from the Open Data Kit and analyzed with the support of the SPSS® programs (descriptive and correlational statistics), EVOC 2000® (to support the elaboration of prototypical analysis) and NVIVO pro11® (Pearson Correlation ≥0.70 According to Bardin's content analysis). Meeting all ethical and legal research requirements involving human beings. 220 elderly people participated in this study: 78.5% were women; 29.6% aged ≥80 years (65-96 years) and 68.6% with partners. Snellen's scale showed visual impairment in 54.1% (left eye: OE) and 50.6% (right eye: OD) with reading ability ≤5 or 20/40 diopter; Jaeger's scale measured that 55.2% and 53.2% participants did not see anything or perceived poorly OD and OE; 41.6% perceived poorly with OD and OE. Falls Efficacy Scale 53.5% evidenced fear for activities of daily living, being a predictor of falls. They were symbolic components emerging in the structural approach and corroborated by passages in the procedural approach: falling (behavioral: "dizziness-vertigo-labyrinthitis" and objective: "slippery footwear"), falling into the house (behavioral: "Care-attention" and "fear") and falling out of the house (objective: "hole" and behavioral: "falling" and "stumbling"). Three categories emerged: origin of individual, group and environmental symbolic contents. The following factors were involved in the fall: at home (slippery floor, ladder and handrail with p-value ≤ 0.04) and in the peridomicile (many objects in the environment and steps with p-value ≤ 0.04). The present investigation outlined a region covered by Primary Health Care on vulnerabilities for falls in people aged ≥65 years, presented a protocol (light-hard technology) to subsidize home nursing consultation and management decisions for nursing care. (Peri) domicile with a prevention approach to the occurrence of falls.

Submitted by Aline Batista (alinehb.ufpel@gmail.com) on 2018-04-25T22:28:13Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Tese_Fernanda_dos_Santos.pdf: 3378422 bytes, checksum: c0252515dbd893c986f93186c3b6452f (MD5) / Made available in DSpace on 2018-04-27T20:15:18Z (GMT). No. of bitstreams: 2 Tese_Fernanda_dos_Santos.pdf: 3378422 bytes, checksum: c0252515dbd893c986f93186c3b6452f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2017-11-10 / Sem bolsa / Objetivo: identificar a prevalência de quedas e seus fatores associados entre idosos residentes na zona rural. Metodologia: estudo transversal com idosos residentes na zona rural do município de Pelotas. Este estudo faz parte de um projeto intitulado “Prevalência e fatores associados à Síndrome da Fragilidade na população idosa”. A amostra foi composta de 820 idosos cadastrados nas Unidades Básicas de Saúde com a modalidade de Estratégia Saúde da Família, no período de julho a outubro de 2014. Para avaliar as quedas utilizou-se um questionário com questões fechadas e semiestruturadas e os programas Epi Info 6.05d e STATA® 11.1 para as análises. A existência de associação entre o relato de quedas em 12 meses e seus fatores associados foi verificada por análise bivariada (Teste de Qui-Quadrado e Exato de Fischer, conforme a indicação), e multivariada, empregando-se a Regressão Logística. O projeto foi aprovado pelo Comitê de Ética em Pesquisa (466/12) sob o número 649.802. Resultados: a maioria dos idosos que sofreram queda não foi atendida por profissionais de saúde (69,8%), não relatou trauma físico (52,1%) e não teve fratura (86,4%). A metade da amostra referiu medo de voltar a cair (50,0%). Teve predominância do sexo feminino (56,1%), cor da pele branca (90,2%) e faixa etária 60-69 anos (54,9%). As variáveis independentes sexo feminino (RP: 1,401; p valor 0,016), ter HAS (RP: 1,184; valor p 0,023) e ter DM (RP: 1,576; p valor 0,011) mantiveram associação com o desfecho na Regressão Logística. A prevalência de quedas foi de 27,9%. Conclusão: acerca dos resultados cabe aos profissionais da saúde um olhar mais atento sobre os idosos que apresentam essas doenças crônicas, especialmente no âmbito de ESF, que tem um acesso mais pleno às condições de vida de cada paciente de sua área e trabalha de forma longitudinal com eles. / Objective: to identify the prevalence of falls and their associated factors among elderly people living in rural areas. Methodology: cross-sectional study with elderly residents in the rural area of the city of Pelotas. This study is part of a project titled "Prevalence and factors associated with Fragility Syndrome in the elderly population". The sample consisted of 820 elderly people enrolled in the Basic Health Units with the Family Health Strategy modality, from July to October 2014. To evaluate the falls, a questionnaire was used with closed and semi-structured questions and the Epi Info programs 6.05 from STATA® 11.1 for analysis. The existence of an association between the reporting of falls in 12 months and their associated factors was verified by bivariate analysis (Chi-Square and Exact Fischer Test, as indicated), and multivariate analysis using Logistic Regression. The project was approved by the Research Ethics Committee (466/12) under number 649.802. Results: the majority of the elderly who suffered falls were not attended by health professionals (69.8%), did not report physical trauma (52.1%) and did not have a fracture (86.4%). Half of the sample reported fear of falling again (50.0%). The predominance was female (56.1%), white skin color (90.2%) and age group 60-69 years (54.9%). The independent variables female gender (RP: 1.401, p value 0.016), had SA (RP: 1.184, p value 0.023) and had DM (RP: 1.576; p value 0.011) maintained association with the outcome in Logistic Regression. The prevalence of falls was 27.9%. Conclusion: about the results, it is incumbent upon health professionals to take a closer look at the elderly who present these chronic diseases, especially in the scope of FHT, which has a fuller access to the living conditions of each patient in their area and works longitudinally with them.

La modélisation inverse de la dispersion atmosphérique consiste à reconstruire les caractéristiques d’une source (quantité de polluants rejetée, position) à partir de mesures de concentration dans l’air, en utilisant un modèle direct de dispersion et un algorithme d’inversion. Nous avons utilisé dans cette étude deux modèles directs de dispersion atmosphérique SIRANE (Soulhac, 2000; Soulhac et al., 2011) et SIRANERISK (Cierco et Soulhac, 2009a; Lamaison et al., 2011a, 2011b). Il s’agit de deux modèles opérationnels de « réseau des rues », basés sur le calcul du bilan de masse à différents niveaux du réseau. Leur concept permet de décrire correctement les différents phénomènes physiques de dispersion et de transport de la pollution atmosphérique dans des réseaux urbains complexes. L’étude de validation de ces deux modèles directs de dispersion a été effectuée après avoir évalué la fiabilité des paramétrages adoptés pour simuler les échanges verticaux entre la canopée et l'atmosphère, les transferts aux intersections de rues et la canalisation de l’écoulement à l’intérieur du réseau de rues. Pour cela, nous avons utilisé des mesures en soufflerie effectuées dans plusieurs configurations académiques. Nous avons développé au cours de cette thèse un système de modélisation inverse de dispersion atmosphérique (nommé ReWind) qui consiste à déterminer les caractéristiques d’une source de polluant (débit, position) à partir des concentrations mesurées, en résolvant numériquement le système matriciel linéaire qui relie le vecteur des débits au vecteur des concentrations. La fiabilité des résultats et l’optimisation des temps de calcul d’inversion sont assurées par le couplage de plusieurs méthodes mathématiques de résolution et d’optimisation, bien adaptées pour traiter le cas des problèmes mal posés. L’étude de sensibilité de cet algorithme d’inversion à certains paramètres d’entrée (comme les conditions météorologiques, les positions des récepteurs,…) a été effectuée en utilisant des observations synthétiques (fictives) fournies par le modèle direct de dispersion atmosphérique. La spécificité des travaux entrepris dans le cadre de ce travail a consisté à appliquer ReWind dans des configurations complexes de quartier urbain, et à utiliser toute la variabilité turbulente des mesures expérimentales obtenues en soufflerie pour qualifier ses performances à reconstruire les paramètres sources dans des conditions représentatives de situations de crise en milieu urbain ou industriel. L’application de l’approche inverse en utilisant des signaux instantanés de concentration mesurés en soufflerie plutôt que des valeurs moyennes, a montré que le modèle ReWind fournit des résultats d’inversion qui sont globalement satisfaisants et particulièrement encourageants en termes de reproduction de la quantité de masse totale de polluant rejetée dans l’atmosphère. Cependant, l’algorithme présente quelques difficultés pour estimer à la fois le débit et la position de la source dans certains cas. En effet, les résultats de l’inversion sont assez influencés par le critère de recherche (d’optimisation), le nombre de récepteurs impactés par le panache, la qualité des observations et la fiabilité du modèle direct de dispersion atmosphérique. / The aim of this study is to develop an inverse atmospheric dispersion model for crisis management in urban areas and industrial sites. The inverse modes allows for the reconstruction of the characteristics of a pollutant source (emission rate, position) from concentration measurements, by combining a direct dispersion model and an inversion algorithm, and assuming as known both site topography and meteorological conditions. The direct models used in these study, named SIRANE and SIRANERISK, are both operational "street network" models. These are based on the decomposition of the urban atmosphere into two sub-domains: the urban boundary layer and the urban canopy, represented as a series of interconnected boxes. Parametric laws govern the mass exchanges between the boxes under the assumption that the pollutant dispersion within the canopy can be fully simulated by modelling three main bulk transfer phenomena: channelling along street axes, transfers at street intersections and vertical exchange between a street canyon and the overlying atmosphere. The first part of this study is devoted to a detailed validation of these direct models in order to test the parameterisations implemented in them. This is achieved by comparing their outputs with wind tunnel experiments of the dispersion of steady and unsteady pollutant releases in idealised urban geometries. In the second part we use these models and experiments to test the performances of an inversion algorithm, named REWind. The specificity of this work is twofold. The first concerns the application of the inversion algorithm - using as input data instantaneous concentration signals registered at fixed receptors and not only time-averaged or ensemble averaged concentrations. - in urban like geometries, using an operational urban dispersion model as direct model. The application of the inverse approach by using instantaneous concentration signals rather than the averaged concentrations showed that the ReWind model generally provides reliable estimates of the total pollutant mass discharged at the source. However, the algorithm has some difficulties in estimating both emission rate and position of the source. We also show that the performances of the inversion algorithm are significantly influenced by the cost function used to the optimization, the number of receptors and the parameterizations adopted in the direct atmospheric dispersion model.

Abstract High age is a distinguished risk factor of falling, but there remains gaps in epidemiological data among very old people. Also, effects of exercise-oriented intervention implemented by geriatric teams is not known. The aims were to describe the incidence and risk factors of falls, the risk of fall-related injuries associated with physical activity, and to investigate the effect of pragmatic exercise intervention on fall risk among a home-dwelling population aged 85 years and older. The target population consisted of home-dwelling citizens of Oulu aged 85 years or more (N = 827). Altogether 555 people (mean age 88 SD ± 3), representing 67% of the population sample, were evaluated by interviews and clinical assessments. Falls and physical activity were monitored via telephone nine times during a 27-month follow-up constituting 1114 person years. Risk factors of falls were determined during an 11-month period before intervention, as were the effects of the intervention during a 16-month period thereafter. Negative binomial regression, pooled logistic regression and Cox regression analyses were used to analyze data. The incidence rates of falls, major soft tissue injuries and fractures were 1039 (95% CI 974–1093), 74 (58–92) and 89 (72–108), respectively. The probability of getting injured was higher in the morning and evening than in the daytime. The contribution of the ongoing activity and the type of falling to the risk of injury was less than that previously reported among younger home-dwellers. The risk factors of falls were a history of recurrent falling, trouble with vision when moving, use of an antipsychotic drug, and feelings of anxiety, nervousness or fear. Exercise other than walking was associated with a reduced risk of injury-causing falls. Pragmatic intervention wasn’t effective in preventing falls, but it was effective in preserving balance performance. Among those with better functional abilities, intervention was effective in reducing the risk of the first four falls. Adherence to recommended interventions was relatively low. In conclusion, the frequency of falls and fall-related fractures increases up to the highest ages. Anxiety-related disorders may be more important risk factors of falls than are drugs commonly used in treatment. Exercise related to everyday activities is safe among the most elderly. The effects of practical exercise intervention are promising, but attention needs to be paid to adherence to exercise in order to improve these effects.

Dans le cadre de l’Approche Ecosystémique des Pêches (AEP), il est nécessaire d’évaluer l’impact de la pêche thonière tropicale à la senne sur les espèces ciblées et sur les espèces accessoires. Parmi ces dernières, les espèces de la mégafaune, telles que des requins, raies, cétacés, tortues, oiseaux marins, sont souvent emblématiques et vulnérables. Les thoniers senneurs tropicaux recherchent activement à la surface de l’eau tout indice de la présence de bancs de thon (e.g. oiseaux, objets flottants, baleines, dauphins ou requins baleines). Dans l’est de l’océan Atlantique et l’ouest de l’océan Indien, les deux modes de pêches principaux sont les captures de thons en bancs libres et celles sur bancs associés à un objet flottant, naturel ou artificiel, rassemblés ici sur sous le terme de dispositif de concentration de poisson (DCP). Les calées associées aux requins baleines et aux cétacés sont toutefois peu étudiées. L’objectif de cette thèse est donc d’analyser les co-occurrences et/ou interactions spatio-temporelles entre requins baleines, cétacés et pêche thonière à la senne, dans une perspective de conservation de l’écosystème. Ce travail, basé sur des données de livres de bord et d’observateurs scientifiques embarqués, a montré que la co-occurrence pêche thonière/ mégafaune se localise dans des strates spatio-temporelles relativement précises: i) du Gabon à l’Angola (avril–septembre), ii) dans le Canal du Mozambique (juin–septembre) et iii) à l’est des Seychelles (avril–septembre). Les baleines et requins baleines étant planctivores, la co-occurrence avec la pêche à la senne est principalement liée à une forte productivité primaire (appréhendée à travers des proxys tels que la concentration en chlorophylle-a). De plus, les calées sur ces deux groupes étaient assez élevées avant 2000 (jusqu’à 20% des calées), et qu’elles sont moins fréquentes aujourd’hui (AC3 et 1,5% des calées associées à des baleines et des requins baleines, respectivement). L’impact de la pêche à la senne sur ces espèces semble relativement faible au regard du taux de mortalité apparente de 1,4% pour les requins baleines et 5,6% pour les cétacés. Des marquages satellites réalisés sur les requins baleines, confirment ces observations sur le plus long terme, mais la taille de l’échantillon limite la formulation de conclusions définitives. Concernant les dauphins, bien que présents sur les zones de pêche, ils interagissent très peu avec celle-ci, soulignant ainsi une différence majeure avec l’océan Pacifique est où ce mode de pêche est majoritaire. La diversité spécifique des espèces cible et accessoire associées aux calées sur mégafaune a également été étudiée. Les requins baleines sont associés aux listaos et à l’albacore (dans une large gamme de tailles), alors que les baleines le sont principalement à de gros albacores. De plus, la capture accessoire associée à ces deux groupes de mégafaune est relativement faible et dominée par le requin soyeux et la diversité spécifique est proche de celle trouvée sous les bancs libres de thons. Enfin les effets de mesures de conservation vis-à-vis de la mégafaune encerclée ou de mesures de gestion de l’effort de pêche, notamment les moratoires sur DCP réelles ou simulées (e.g. moratoires élargis), ont été analysés. Les premières ont eu un effet limité en terme de captures cibles et accessoires, alors que les moratoires impactent peu le nombre de calées associés à la mégafaune, ceci en raison du décalage spatio-temporel des co-occurrences. Cependant des moratoires élargis pourraient être bénéfiques pour les thons juvéniles et certaines espèces associées. Par l’analyse quantitative des interactions entre la pêche thonière à la senne et la mégafaune, cette thèse apporte des connaissances essentielles sur les espèces étudiées dans le cadre de la mise en place d’une AEP, applicable à la pêche thonière tropicale. / In the frame of the Ecosystem Approach to Fishery (EAF) management, impact of the tropical tuna purse-seine fishery on targeted and incidentally captured species should be investigated. They may include megafauna species, such as sharks, rays, cetaceans, turtles or sea birds, which often are emblematic and vulnerable species. Tropical tuna purse-seiners actively search, at the surface of the sea, for clues indicating the presence of tuna schools (e.g. birds, floating objects, whales, dolphins or whale sharks). In the eastern Atlantic and western Indian Oceans, the main two fishing modes are sets on free swimming tuna schools and schools associated to natural or artificial floating objects, thereafter called Fish Aggregating Device (FAD). However dedicated studies on fishing sets associated to whale sharks and cetaceans are still lacking. The aim of this thesis is therefore, using logbook and scientific onboard observer data, to investigate the spatio-temporal co-occurrences and/or interactions between whale sharks, cetaceans and the tuna purse-seine fishery within an ecosystem conservation perspective. This work underlines that the megafauna/ fishery co-occurrence occurs in specific spatio-temporal strata: i) Gabon to Angola (April–September), ii) the Mozambique Channel (June–September), and iii) East of Seychelles (April–September). As baleen whales and whale sharks are filter feeders, the co-occurrence with the purse-seine fishery was mostly linked to highly productive environments (i.e. using proxys including chlorophyll-a concentration). In addition fishing sets involving megafauna were relatively high before 2000 (up to 20% of the sets), but are nowadays less frequent (AC3 and 1.5% of the sets associated to baleen whales and whale sharks). The purse-seine fishery appears to have a relatively low impact on megafauna species with mortality rates of 1.4% for whale sharks and 5.6% for cetaceans. Whale shark satellite tagging also confirms these results on the longer term, but the low sample size precludes any final conclusion. While dolphins are present in fishing areas, very few interactions with the fishery was detected, which highlights the striking difference with the eastern Pacific Ocean where half the sets are associated to dolphin herds. In addition, the diversity of targeted and bycatch species captured under whale shark and baleen whale sets was also investigated. Whale sharks are principally associated to skipjack and yellowfin (of various sizes) tunas and baleen whales mostly to large yellowfin tuna. In addition, bycatch species associated to these two megafauna groups was relatively low and dominated by the silky shark, and bycatch diversity was close to the one found for free swimming tuna schools. Finally, real and/or simulated encircled megafauna conservation measures or fishing effort management measures (especially FAD moratoria including larger ones) were investigated. The first ones were found to have limited consequences on tuna catch and bycatch. Conversely FAD moratoria had limited impacts on the number of megafauna associated fishing sets, due to the fact that the main spatio-temporal strata of megafauna and FAD sets differ. However larger and longer moratoria could be beneficial for juvenile tuna and some bycatch species. Overall, this thesis has lead to increase the knowledge on megafauna/ fishery interactions, essential in the general framework of setting up an EAF in the tropical tune purse-seine fishery.