Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2012-08-29T21:19:29Z No. of bitstreams: 1 Simone de Souza Oliveira Avaliação de estratégia otimizada para triagem....pdf: 656689 bytes, checksum: 2248d68384fab994772907132553ea61 (MD5) / Made available in DSpace on 2012-08-29T21:19:29Z (GMT). No. of bitstreams: 1 Simone de Souza Oliveira Avaliação de estratégia otimizada para triagem....pdf: 656689 bytes, checksum: 2248d68384fab994772907132553ea61 (MD5) Previous issue date: 2011 / Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, Bahia, Brasil / A Leishmaniose Visceral Humana (LVH) é uma das seis endemias mundiais de prioridade da OMS. São registrados anualmente cerca de 500 mil casos novos, destes 90% ocorrem em cinco países: Bangladesh, Índia, Nepal. Sudão e Brasil. O cão doméstico é considerado o principal reservatório no ambiente urbano e o responsável pela persistência da doença. OBJETIVO: Avaliar a eficácia de estratégia otimizada para triagem e eliminação de cães soropositivos no controle e prevenção da LVH. MÉTODOS: Foi realizado um estudo de ensaio comunitário, com crianças entre 6 meses a 12 anos de idade, residentes numa região endêmica para LVH, dividida aleatoriamente em duas áreas: área de intervenção (triagem e eliminação de cães a cada sete meses) e área controle. A população do estudo foi acompanhada por um período de 30 meses. O desfecho principal foi infecção por Leishmania, definida como soroconversão por teste imunoenzimático, que era realizado em inquéritos soroepidemiológicos a intervalos de 15 meses, aproximadamente. RESULTADOS: Foram incluídas inicialmente 1206 crianças. No final do primeiro período (15 meses), após dois ciclos da intervenção, a incidência de soroconversão na área da intervenção não diferiu significativamente da incidência na área controle (RR=1,59; IC 95% 0,85-2,97). No entanto, no final do segundo período (30 meses), depois de quatro ciclos da intervenção, a incidência de soroconversão foi menor na área da intervenção (RR=0,23; IC 95% 0,08 - 0,65). CONCLUSÃO: A intervenção não foi eficaz no primeiro período do estudo, mas, no final do segundo período ela reduziu a taxa de soroconversão. Assim, a eficácia da intervenção foi dependente do número de ciclos de triagens realizadas. É possível que as limitações e deficiências dessa estratégia sejam minimizadas com a repetição dos ciclos e que a persistência da intervenção por mais tempo permita que os benefícios se acumulem e sejam alcançados os resultados dessa medida de controle da LVH. / Human visceral leishmaniasis is within the six worldwide OMS’s priority endemic diseases. About 500 thousand new cases are recorded annually around the world, 90% of them in five countries: Bangladesh, India, Nepal, Sudan and Brazil. Domestic dogs are the most important reservoir host at urban area and the cause of HVL persistence. OBJECTIVE: Measure the efficiency of optimal strategy for screening and elimination of seropositive dogs in HVL control and prevention. METHODS: a screening study in a HVL endemic area, 1206 children between 6 months and 12 years old were included in this study. They were living in two different areas: area of intervention (dog screening and elimination every seven months) and a control area. The studied population was accompanied for a period of 30 months. The parameter to verify the efficacy of the chosen strategy was the seroconversions detected by ELISA, defined as immunoenzymatic test in seroepidemiologic surveys conducted about every 15 months. RESULTS: By the end of the first period (15 months), after two intervention cycles the seroconversions incidence at the intervention area wasn’t statistically different of the control area. However at the end of second period (30 months), after four intervention cycles, its incidence was lower at the intervention area. CONCLUSIONS: the intervention wasn’t effective on the study first period, but, by the end of the second period it reduced the seroconversion rate.Therefore the intervention efficacious was dependent of the number of screening cycles performed. Possibly, the limitations and deficiencies of this strategy would be minimized by cycle repetition and longer period of intervention, allowing benefits to accumulate and the results for this procedure to be reached.

Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2015-05-14T12:50:58Z No. of bitstreams: 1 Aline Silva Tavares Prevalencia... 2014.pdf: 1360759 bytes, checksum: b29a492abee32a44d3e293381bda88af (MD5) / Approved for entry into archive by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2015-05-14T12:51:11Z (GMT) No. of bitstreams: 1 Aline Silva Tavares Prevalencia... 2014.pdf: 1360759 bytes, checksum: b29a492abee32a44d3e293381bda88af (MD5) / Made available in DSpace on 2015-05-14T12:51:11Z (GMT). No. of bitstreams: 1 Aline Silva Tavares Prevalencia... 2014.pdf: 1360759 bytes, checksum: b29a492abee32a44d3e293381bda88af (MD5) Previous issue date: 2014 / Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, BA, Brasil / A dengue é uma doença febril aguda transmitida pela picada do mosquito Aedes aegypti. Em torno de 40% da população mundial vive em áreas tropicais e subtropicais sob risco de infecção e desenvolvimento da doença. No Brasil, a dengue é uma doença de grande impacto para a saúde pública. Entretanto, poucos estudos de coorte prospectiva foram realizados para estimar a incidência de infecções e para identificar grupos populacionais de maior risco para infecção. Identificar grupos de risco pode ajudar a orientar os programas de prevenção e controle da dengue, de modo a reduzir a carga da doença. Este estudo teve como objetivos determinar a soroprevalência e a densidade de incidência e fatores demográficos e socioeconômicos associados à infecção pelo vírus da dengue em uma comunidade urbana. Um estudo de coorte foi realizado nas comunidades de São Marcos e Pau da Lima, bairros periféricos de Salvador-BA que apresentam infra-estrutura sanitária deficiente. Foram incluídos 2.323 participantes com idade ≥5 anos, residentes em domicílios selecionados aleatoriamente na comunidade. A coorte foi recrutada entre janeiro e junho de 2010 e o seguimento se deu após um ano, entre janeiro e maio de 2011. Em 2010, durante visitas domiciliares, os moradores dos domicílios selecionados que aceitaram participar do estudo assinaram o Termo de Consentimento Livre e Esclarecido e foram entrevistados para obtenção de dados demográficos e socioeconômicos. Amostras de sangue foram coletadas, transportadas no mesmo dia para a FIOCRUZ e, após centrifugação, alíquotas de soro foram congeladas a -20°C. Este procedimento foi repetido durante o seguimento da coorte em 2011. O teste utilizado para detectar anticorpos específicos contra dengue nas amostras de soro foi o ELISA IgG indireto. Medidas de tendência central, de dispersão e frequências foram utilizadas para descrever as características demográficas e socioeconômicas da população. A soroprevalência e a soroincidência foram calculadas de acordo com essas características. IC de 95% foram calculados para os indicadores de prevalência e de incidência. Dos 2.323 participantes testados no estudo de base em 2010, 2.036 (87,6%; IC 95%: 86,2 - 88,9) foram soropositivos para a presença de anticorpos IgG contra a dengue. A soroprevalência de dengue foi semelhante entre homens e mulheres. A análise da soroprevalência estratificada por faixa etária mostrou que quanto maior a idade dos indivíduos maior a soroprevalência de dengue (10 a 15 anos RP=1,75 [IC 95% 1,50 - 2,04] e maiores de 15 anos 2,19 [IC 95% 1,90 - 2,52]). Indivíduos de cor parda e branca apresentaram menor soroprevalência do que a cor preta. Aqueles com maior renda per capita e maior escolaridade apresentaram maior soroprevalência. Dos 240 membros da coorte que tiveram as amostras negativas para a presença de anticorpos IgG contra a dengue, 116 apresentaram uma infecção primária inaparente durante o seguimento, o que corresponde a uma incidência de 53,9 (IC 95%: 44,7-64,4) infecções primárias 8 inaparentes por 100 pessoas-ano. Os resultados apresentados mostram que a dengue apresenta uma intensa transmissão em comunidades urbanas pobres do Brasil. A urgente necessidade de estratégias alternativas para controle da dengue no Brasil faz-se necessário, a exemplo de vacinas. / Dengue fever is an acute febrile disease transmitted by the mosquito Aedes aegypti. Around 40% of the world population lives in tropical and subtropical areas at risk of infection and disease development. In Brazil, dengue is a disease of great impact on public health. However, few prospective cohort studies have been conducted to estimate the incidence of infections and to identify population groups at higher risk for infection. The identification of risk groups can help guide prevention programs and dengue control in order to reduce the burden of disease. This study aimed to determine the prevalence and incidence density and socioeconomic and demographic factors associated with dengue virus infection in an urban community. A cohort study was conducted in the communities of San Marcos and Pau da Lima, outskirts of Salvador-BA who have poor health infrastructure. About 2,323 participants aged ≥ 5 years, residents in households randomly selected in the community were included. The cohort was recruited between January and June 2010 and follow-up occurred after one year, between January and May 2011. In 2010, during home visits, residents of selected households agreed to participate and signed a consent form Informed and were interviewed to collect demographic and socioeconomic data. Blood samples were collected, transported the same day to FIOCRUZ and, after centrifugation, serum aliquots were frozen at -20°C. This procedure was repeated during follow-up of the cohort in 2011. Test used to detect specific antibodies in serum samples from dengue was IgG ELISA indirect. Absolute and relative frequencies were used to describe the demographic and socioeconomic characteristics of the population. The seroprevalence and seroincidence were calculated according to these characteristics by means of chi-square or Fisher's exact test. 95% CI were calculated for indicators of prevalence and incidence density. Of the 2,323 participants tested at baseline in 2010, 2,036 (87.6%, 95% CI: 86.2 to 88.9) were positive for the presence of IgG antibodies against dengue. The seroprevalence of dengue was similar between men and women. The analysis of seroprevalence by age group showed that the older individuals of higher seroprevalence of dengue (10 to 15 years PR = 1.75 [95% CI 1.50 to 2.04] and over 15 years 2, 19 [95% CI 1.90 to 2.52]). The brown and white individuals had a lower prevalence than black subjects. Higher income per capita and higher education showed a higher seroprevalence. Of the 240 members of the cohort who had negative samples for the presence of IgG antibodies against dengue fever, 116 had a silent primary infection during follow-up, corresponding to an incidence of 53.9 (95% CI: 44.7 to 64 4) inapparent primary infections per 100 person-years. The results show that dengue has an intense transmission in urban poor communities in Brazil. The urgent need for alternative strategies for dengue control in Brazil it is necessary, like vaccines.

Introdução: A estratégia de tratamento baseado em metas tem sido extensamente estudada em pacientes com AR inicial. No entanto, estudos sobre os benefícios de longo prazo do controle de atividade de doença em pacientes com AR estabelecida ainda são escassos. Objetivo: Avaliar a efetividade de longo prazo da estratégia de tratamento baseado em metas em pacientes com artrite reumatoide estabelecida na prática diária. Métodos: Pacientes com AR, previamente tratados de forma convencional, iniciaram estratégia de tratamento baseado em metas, sendo incluídos de março de 2005 a fevereiro de 2007 e acompanhados até dezembro de 2014. Os pacientes eram avaliados a cada 3 meses até remissão ou baixa atividade de doença serem alcançadas, e após a cada 6 meses. O tratamento seguiu um escalonamento de acordo com as recomendações vigentes. A atividade de doença foi mensurada através do DAS28 e do CDAI e a capacidade funcional, através do HAQ-DI. As informações foram extraídas pela revisão de formulários e de tabelas padronizadas. Variações na atividade de doença e na capacidade funcional foram comparadas pelo teste de Wilcoxon e Equações de Estimativas Generalizadas (GEE) A mortalidade foi avaliada através da curva de Kaplan-Meier. Resultados: Duzentos e vinte e nove pacientes foram incluídos, com duração média de doença 10,6±7,4 anos. Dentre os pacientes em moderada e alta atividade de doença no início da coorte, houve significativa redução do DAS28 (4,6±0,1 vs. 3,1±0,1; p<0,001) e do CDAI (21,2±1,0 vs. 7,9±0,7; p<0,001). Também houve redução do HAQ-DI (1,3±0,05 vs 1,0±0,1; p<0,001). A proporção de pacientes em remissão ou em baixa atividade de doença aumentou de 20% para 62% pelo DAS28. Com a estratégia de tratamento baseado em metas, houve um aumento na proporção de pacientes em uso de biológico para 30%. A taxa de mortalidade foi de 24,2 por 1000 pacientes-ano, discretamente superior à descrita na literatura. Conclusão: A estratégia de tratamento baseado em metas com objetivo de remissão e de baixa atividade de doença é efetivo em pacientes com AR estabelecida. / Introduction: Treating RA to a target has become a landmark strategy to be pursued in every patient. Nonetheless, few studies have addressed the true long-term impact of a T2T strategy in a real-world setting with established RA patients. Objective. To examine the long-term effectiveness of a treat-to-target (T2T) strategy in patients with established rheumatoid arthritis (RA) in daily practice. Methods. Patients with RA who were previously given the standard of care were started on a T2T strategy between March 2005 and February 2007 and followed through December 2014. Participants were seen every 3 months until remission/low disease activity was achieved and every 6 months thereafter. Treatment escalation followed a step-up strategy, according to national recommendations. Disease activity was measured by the DAS28 score and Clinical Disease Activity Index (CDAI), and physical function by the Health Assessment Questionnaire (HAQ). Data were extracted with standardized forms and a chart review. Changes in disease activity and physical function were compared using Wilcoxon’s test and generalized estimating equations. Mortality was analyzed using a Kaplan–Meier survival curve. Results. Two hundred and twenty-nine patients were included, with a mean (S.D.) disease duration of 10.6 (7.4) years. Significant reductions were observed in DAS28 (4.6±0.1 vs. 3.1±0.1; p<0.001), CDAI (21.2±1.0 vs. 7.9±0.7; p<0.001), and HAQ (1.3±0.05 vs 1.0±0.1; p<0.001) scores. The proportion of participants in remission/with low disease activity according to DAS28 increased from 20% to 62%. During implementation of the T2T strategy, a gradual increase in the proportion of participants using biologics was observed, to nearly 30%. The mortality rate was 24.2 per 1000 patient-years, slightly higher than that reported in other cohorts. Conclusion. A treat-to-target strategy aiming for remission or low disease activity is effective in patients with established RA.

Introdução: O prognóstico dos carcinomas epidermóides de laringe é limitado e a taxa de sobrevida em cinco anos é menor que 70%. A relação de características clínicas e epidemiológicas tem sido investigada na sobrevida de pacientes com tumores de laringe, mas pouco se conhece sobre o efeito dos polimorfismos genéticos no prognóstico da doença. Objetivo: Estudar o papel dos polimorfismos genéticos de genes relacionados aos processos de invasão e metástase (MMP1 e MMP3), de inflamação (Interleucina 2, Interleucina 6, LTA) e reparo de DNA(XRCC1) no prognóstico do carcinoma epidermóide de laringe. Material e métodos: Coorte com 170 pacientes com carcinoma epidermóide de laringe,confirmados por exame anátomo-patológico. Os casos tiveram origem em estudo caso-controle conduzido em cinco hospitais de São Paulo, um hospital em Porto Alegre e outro em Goiânia. As informações sobre o status vital dos pacientes foram levantadas dos prontuários médicos e dos bancos de óbitos municipais e estaduais. A extração do DNA das amostras de sangue dos pacientes foi realizada pelo Instituto de Medicina Tropical da USP e a genotipagem dos polimorfismos genéticos pela Fundação Hemocentro de Ribeirão Preto da Faculdade de Medicina da USP. Resultados: Os polimorfismos genéticos estudados (MMP1 1607, MMP1 -519,MMP3 -1171, IL2 -384, IL2 114, IL6 -174, LTA 252 e XRCC1) não apresentaram efeitos com significância estatística na sobrevida global ou específica pela doença quando analisados isoladamente. Para a sobrevida global, o consumo excessivo de álcool, em g/L/dia, reduziu a sobrevida dos pacientes (80-119 g/L/dia: hazard ratio(HR)=4,0 intervalos com 95% de confiança (IC95%)=1,10-14,53; _120 g/L/dia: HR=5,6 IC95%=1,71-18,24). No modelo de Cox múltiplo, quando ajustados pelo polimorfismo genético MMP3 -1171, a sobrevida piorou para esses pacientes (80-119 g/L/dia: HR=4,9 IC95%=1,07-22,91; _120 g/L/dia: HR=6,3 IC95%=1,49-26,84). Para a sobrevida específica pela doença, o estadiamento clínico IV reduziu a sobrevida dos pacientes (HR=3,5 IC95%=1,67-7,28). No modelo de Cox múltiplo,com ajuste pelos polimorfismos genéticos IL6 -174 e MMP1 1607, a sobrevidaespecífica pela doença piorou para esses pacientes (HR=4,7 IC95%=1,38-16,25).Conclusões: Na coorte examinada, somente três dos oito polimorfismos genéticos estudados relacionaram-se com a sobrevida global e específica pela doença, porém apenas alterando o efeito dos valores dos HR brutos dos fatores consumo de álcool e estadiamento clínico, respectivamente na sobrevida global e sobrevida específica pela doença. Isoladamente, nenhum polimorfismo genético estudado interferiu na sobrevida dos pacientes com câncer de laringe. / Introduction: The prognosis of laryngeal squamous cell carcinoma is limited and survival rate is lower than 70%. The relationships between clinical and epidemiological characteristics have been fully investigated on the survival of patients with laryngeal tumors, but the effect of genetics polymorphisms on squamous cell carcinoma of larynx is not well-known. Objective: To study the role of genetic polymorphisms of genes related to the processes of invasion and metastasis (MMP1 and MMP3), inflammation (Interleukin 2, Interleukin 6, and LTA) and repair of DNA (XRCC1) in the prognosis of laryngeal squamous cell carcinoma. Material and methods: Cohort with 170 laryngeal squamous cell carcinoma patients with histological confirmation. The cases have their origin in a case-control study carried out in hospitals of Sao Paulo, Porto Alegre and Goiania. The information about vital status of patients had been raised from medical records. The extraction of DNA was carried out by Institute of Tropical Medicine of USP and genotyping was carried out by the Center of Cellular Therapy of the Hemocentro of Ribeirao Preto of Medical School of USP. Results: The studied genetic polymorphisms (MMP1 1607, MMP1 -519, MMP3 -1171, IL2 -384, IL2 114, IL6 -174, LTA 252 and XRCC1), separately analyzed, did not have any statistical significant effect on the overall and cause-specific survival. High levels of alcohol consumption (g/L/day) reduced the overall survival (80-119 g/L/day: hazard ratio(HR)=4.0 intervals with 95% of confidence (95%CI)=1.10-14.53; _120 g/L/day:HR=5.6 95%CI=1.71-18.24). Multiple Cox model revealed, when adjusted for MMP3 -1171 genetic polymorphism, lower survival for those patients (80-119g/L/day: HR=4.9 95%CI=1.07-22.91; _120 g/L/day: HR=6.3 95%CI=1.49-26.84). The clinical staging (CS) IV was a factor for low cause-specific survival (CS IV:HR=3.5 95%CI 1.67-7.28). In the multiple Cox model, adjusted for genetic polymorphism IL6 -174 and MMP1 1607, the survival of those patients droppe(HR=4.7 95%CI=1.38-16.25). Conclusions: In this cohort, only three of eight genetic polymorphisms studied were showed to be related with overall and causespecific survival, however only modifying the effect of unadjusted HR of alcohol consumption and tumor clinical staging in the overall and cause-specific survival respectively. None of the studied genetic polymorphisms, when analyzed separately,affected the survival of laryngeal cancer patients.

Submitted by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T13:29:36Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Kelli_Pereira_Gerbes.pdf: 6550088 bytes, checksum: 681e1b38680962a1ca05088c48890c61 (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T13:57:27Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Kelli_Pereira_Gerbes.pdf: 6550088 bytes, checksum: 681e1b38680962a1ca05088c48890c61 (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T13:57:33Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Kelli_Pereira_Gerbes.pdf: 6550088 bytes, checksum: 681e1b38680962a1ca05088c48890c61 (MD5) / Made available in DSpace on 2018-05-24T13:57:33Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Kelli_Pereira_Gerbes.pdf: 6550088 bytes, checksum: 681e1b38680962a1ca05088c48890c61 (MD5) Previous issue date: 2017-08-11 / Sem bolsa / A imagem corporal é a figuração do corpo formada na mente, definida como a percepção e o sentimento do indivíduo em relação ao próprio corpo, influenciada por fatores físicos, psicológicos, ambientais e comportamentais. A insatisfação corporal ocorre quando a percepção corporal e a imagem corporal ideal não são congruentes. Estudos têm evidenciado que a prevalência de insatisfação corporal tem se mostrado elevada em adultos de diferentes populações em indivíduos com excesso ou baixo peso, mas também presente em indivíduos com peso normal, sendo mais frequente em mulheres. E associada a diversos fatores, como: prática de dieta, desejo ou uso de suplementos para emagrecer, comportamentos alimentares anormais, transtornos ou distúrbios alimentares, consumo excessivo de álcool, aumento de depressão e baixa autoestima, percepção de saúde mais precária, comportamento de saúde mais positivo, alterações na aparência e busca por cirurgia plástica. Os membros da Coorte de Nascimentos de Pelotas de 1982, aos 23 anos, apresentaram uma prevalência de insatisfação corporal de 64%. Em busca de uma melhor compreensão sobre a insatisfação corporal em adultos, a presente dissertação teve como objetivo descrever a prevalência de insatisfação corporal em participantes da Coorte de Nascimentos de Pelotas de 1982 aos 30 anos comparando com as prevalências observadas aos 23 anos, bem como, identificar possíveis fatores associados ao desfecho. O estudo da Coorte de Nascimentos de Pelotas de 1982 foi iniciado com um inquérito de saúde perinatal e vários estudos de acompanhamento desses indivíduos foram realizados ao longo do tempo. Foi possível avaliar a insatisfação corporal utilizando a Escala Corporal de Stunkard e a associação entre insatisfação corporal e variáveis demográficas, socioeconômicas, comportamentais e de saúde foi investigada. / Body image is the figuration of the body formed in the mind, defined as the perception and feeling of the individual in relation to the body itself, influenced by physical, psychological, environmental and behavioral factors. Body dissatisfaction when body perception and ideal body image are not congruent. Studies have shown that the prevalence of body dissatisfaction has been high in adults from different populations and in individuals with excess or low weight, but also present in individuals with normal weight, being more frequent in women. It is associated with several factors, such as: diet, desire to lose weight or use of dietary supplements, abnormal eating behaviors, eating disorders or disorders, excessive alcohol consumption, increased depression and low self-esteem, poorer health, more positive health, changes in appearance and search for plastic surgery. The prevalence of body dissatisfaction was 64% in the 1982 Pelotas Birth Cohort members, at age 23 years. To better understand adult body dissatisfaction, this dissertation aimed to describe the prevalence of body dissatisfaction in participants from the 1982 Pelotas Birth Cohort at age 30 years, comparing with the prevalence observed at age 23, and to identify some possible factors associated with the outcome. The Pelotas Birth Cohort study of 1982 started with a perinatal health survey and several follow-up studies of these individuals were conducted over time. It was possible to evaluate the body dissatisfaction using the Stunkard Body Scale, and the association between body dissatisfaction and demographic, socioeconomic, behavioral and health variables was also investigated.

I assessed the accuracy of two clinical prediction rules, the d-dimer blood test and point of care ultrasound for diagnosing lower limb deep vein thrombosis. Emergency physicians were trained in ultrasound and prospectively scanned emergency department patients with suspected deep vein thrombosis. Accuracy of the Wells and AMUSE rules and the ultrasound result was compared to radiology-performed ultrasound and a 90-day clinical outcome. Univariate and multivariate analyses were performed assessing which factors were associated with the outcome. The sensitivity and specificity of the Wells score for the clinical outcome was 85.7% and 68.5%; the AMUSE score 85.7% and 54.4%. Ultrasound had a sensitivity of 91.7% and specificity of 91.7% for radiology-diagnosed thrombus and 78.6% and 95.0% for clinical outcome. The odds ratio of a positive outcome with a positive ultrasound was 65.1. After receiving the ultrasound training program, emergency physicians were unable to demonstrate sufficient accuracy to replace current diagnostic strategies.

Background: Current cesarean delivery (CD) rates in many industrialized countries are well above the recommended rates. Objective: The overall goal of this thesis was to identify sources for unnecessary CD. Specific objectives were to: 1) analyze the leading indications for CD and their associations with neonatal outcomes; 2) compare adverse birth outcomes between elective primary cesarean delivery (EPCD) and trial of labor after vaginal birth (TOLAV), and between elective repeat cesarean delivery (ERCD) and trial of labor after cesarean birth (TOLAC); and 3) assess the cost-effectiveness of ERCD and TOLAC. Methods: A retrospective cohort study was conducted. Leading indications for CD were analyzed and risks of neonatal outcomes between “soft” indications and “hard” indications were compared first, using 2006 to 2013 Better Outcomes and Registry Network Ontario data. A pair of analyses: comparing risks of adverse birth outcomes between EPCD and TOLAV and between ERCD and TOLAC, were then conducted using United States 2005 to 2010 birth registration data. Analysis were performed using logistic regression and propensity score matching models. Finally, a cost-effectiveness analysis between ERCD and TOLAC was performed. Results: The single largest contributor for overall CD was ERCD (34.3%) and for primary CD was dystocia (31.9%) in Ontario. Compared with infants of mothers with CD for “hard” indications, the risks of Apgar score <7 at 5 minutes for infants of mothers with CD for non-reassuring-fetal-status was increased, while the risks of Apgar score <7 at 5 minutes and neonatal death for infants of mothers with ERCD and dystocia were decreased. Compared with infants of mothers who underwent TOLAV, infants of mothers who underwent EPCD were more likely to require antibiotics and ventilation support, but less likely to have birth injury. On the other hand, compared with infants of mothers who underwent TOLAC, infants of mothers who underwent ERCD were less likely to require antibiotics and ventilation support. ERCD was similar to the TOLAC birth option in terms of cost effectiveness. Conclusions: Tight up criteria for “soft” indications such as labor dystocia could result in substantial reduction in CD without harming the infants.

L'exposition médicale diagnostique aux rayonnements ionisants représente environ 40% de l'exposition totale aux radiations en France. L'utilisation du scanner, beaucoup plus irradiant que l'imagerie conventionnelle, ne cesse de progresser, y compris chez les enfants, dont la radiosensibilité est supérieure à celle des adultes. Plusieurs études récentes sont en faveur d'une augmentation du risque de leucémie et de tumeur cérébrale après exposition au scanner dans l'enfance. Une cohorte nationale multicentrique a été mise en place à l'IRSN depuis 2009 incluant plus de 108 137 enfants soumis à un ou plusieurs scanners avant l'âge de 10 ans sur la période 2000-2010 dans 23 services de radiologie pédiatriques de CHU, répartis sur l'ensemble du territoire. L'estimation des doses reçues au niveau des principaux organes a été faite en fonction des protocoles utilisés. La grande variabilité des doses selon les services témoigne de la nécessité d'optimisation des protocoles. Près de 3% des enfants de la cohorte présentaient un facteur de prédisposition aux cancers étudiés. Le croisement de la cohorte avec le registre national des cancers pédiatriques a identifié 106 cas incidents de cancer, dont 22 tumeurs cérébrales et 17 leucémies. Chez les enfants sans facteur de prédisposition, un excès de risque positif mais non significatif était observé pour la leucémie et les tumeurs cérébrales en fonction de la dose, similaire à celui observé pour la population d'étude dans son ensemble. Chez les enfants avec un facteur de prédisposition au cancer, le risque diminuait, possiblement en lien avec une mortalité précoce augmentée entrainant un déficit de risque de cancer radio-induit à plus long terme. Le projet européen EPI-CT inclut 9 cohortes nationales, dont la cohorte française et regroupera plus d’un million d’enfants exposés au scanner. L’analyse conjointe de ces données permettra d’apporter prochainement des résultats complémentaires sur ce sujet. / Medical diagnostic exposure to ionizing radiation represents about 40% of the total annual radiation exposure in France. The CT scans, which represent only 5% of the total number of X-rays examinations, account for half of the total collective dose associated with medical diagnostic exposure. However, its use continues to grow, including in children, for whom the radio sensitivity is known to be greater than in adults. Several recent studies support an increased risk of leukemia and brain tumors after exposure to CT scan in childhood. A national multicenter cohort was set up at the IRSN since 2009 including 108 137 children subjected to at least one CT scans before the age of 10 during the 2000 to 2013 period in 23 French University hospital’s pediatric radiology departments. Children's exposure was assessed based on radiological protocols. It was observed high variability of doses according to the participant departments, reflecting the need for protocol optimization. Moreover, children with predisposing factor for studied cancers represented 3% of the study population, a percentage well above that observed in the general population. The linkage of the cohort with the National Register of pediatric cancers identified 106 incident cases of cancer in the cohort, 22 brain tumors and 17 leukemias. For children without predisposing factor, it was observed a non-significant excess risk of cancer according to the received dose, similar to that observed for the whole study population. For children with predisposing factor to cancer, the risk decreased without reaching significance, possibly linked to earlier non-cancer mortality in this group and then to a lower risk to develop later radiation induced cancer. The European project EPI-CT, which includes 9 national cohorts (including the French cohort), will include more than one million children and then will bring further results on this topic.

L’endocardite infectieuse (EI) est une maladie rare, de diagnostic difficile et de pronostic réservé. Staphylococcus aureus (SA) et les streptocoques oraux en sont les principaux microorganismes responsables. L’évaluation du risque de survenue de l’EI et l’amélioration des connaissances justifiant la stratégie de prévention nécessitent la mise en place de grandes cohortes cliniques et l’utilisation de bases médico-administratives. Chez les 2 008 patients (pts) présentant une bactériémie à SA de la cohorte multicentrique nationale VIRSTA, nous avons développé et validé un score prédictif d’EI comportant les caractéristiques initiales des pts et celles initiales et évolutives de la bactériémie. Les pts dont le score était ≤ 2 avaient un très faible risque d’EI (1% ; valeur prédictive négative [IC95%] = 99% [98;99]) comparés à ceux dont le score était ≥ 3, à risque d’EI élevé (17%) pour lesquels une échocardiographie devrait être effectuée. Utilisant la base médico-administrative du SNIIRAM, nous avons évalué la relation entre la pratique de gestes buccodentaires invasifs (GBDI) et la survenue d’EI à streptocoques oraux à partir d’une cohorte de 138 876 porteurs de prothèses valvulaires cardiaques ainsi que d’un plan expérimental de type case-crossover incluant 648 EI à streptocoques oraux. L’incidence d’EI à streptocoques oraux [IC95%] était de 93,7 pour 100 000 PA [82,4;104,9] sans augmentation significative du risque dans les 3 mois suivant un GBDI (RR= 1,25 [0,82;1,82]). Dans l’analyse case-crossover, la fréquence d’exposition à un GBDI dans les 3 mois précédent l’EI était faible mais plus élevée que lors de périodes contrôles antérieures (5,1% vs 3,2% ; OR : 1,66 [1,05;2,63]). Les GBDI pourraient contribuer au développement des EI à streptocoques oraux dans la population de pts porteurs de prothèses valvulaires cardiaques.La qualité des données de VIRSTA associée à la puissance du SNIIRAM ont permis l’identification des pts à risque d’EI à SA et la clarification de la contribution des GBDI dans les EI à streptocoques oraux. / Infective endocarditis (IE) is a rare disease, difficult to diagnose, with high morbidity and mortality rates. Main involved microorganisms are Staphylococcus aureus and oral streptococci. Clinical research to improve IE risk assessment and IE prevention strategy requires the establishment of large clinical cohort studies and the use of medico-administrative databases. Using data from the multicenter French prospective VIRSTA cohort study on 2 008 adult patients (pts) with Staphylococcus aureus bloodstream infection (SAB), we have developed and validated an IE prediction score taking into account pts’ background and initial SAB characteristics. Pts with a score ≤ 2 had a very low risk of IE (1%, negative predictive value [95% CI] = 99% [98;99]) compared to those with a score ≥ 3, at higher risk of IE (17%) for whom an echocardiography is needed. Using the medico-administrative SNIIRAM database, we assessed the relation between invasive dental procedures (IDP) and oral streptococcal IE in a population-based cohort study of 138 876 pts with prosthetic heart valves and a case-crossover study including 648 pts with oral streptococcal IE. Incidence rate of oral streptococcal IE [95% CI] was 93.7 per 100 000 PA [82.4;104.9] without significant increase within the 3 months following IDP (RR = 1.25 [0.82;1.82]). In the case-crossover analysis, exposure to IDP was more frequent in the 3 months preceding IE than during previous control periods (5.1% vs. 3.2%, OR: 1.66 [1.05;2.63]). IDP may contribute to the development of oral streptococcal IE in pts with prosthetic heart valves.The quality of data from VIRSTA study combined with the power of SNIIRAM database made possible the identification of IE at-risk SAB pts and the evaluation of the IDP contribution in oral streptococcal IE.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23067号 / 医博第4694号 / 新制||医||1049(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 武藤 学, 教授 妹尾 浩 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM