O diagnóstico de câncer é uma experiência traumática que pode precipitar sintomas do Transtorno de Estresse Pós Traumático TEPT. São poucos os estudos que avaliaram a prevalência e o impacto do TEPT na qualidade de vida de mulheres com câncer de mama, antes do início dos tratamentos. Este trabalho teve como objetivos estimar a prevalência e o impacto dos sintomas do TEPT Agudo na qualidade de vida de mulheres recém diagnosticadas com câncer de mama, investigando as variáveis sócio-demográficas e clínicas associadas ao TEPT. Foi realizado um estudo do tipo corte transversal no Centro de Referência da Saúde da Mulher Hospital Pérola Byington. Os sintomas de TEPT foram avaliados com a Post-Traumatic Stress Disorder Checklist- Civilian Version, os sintomas de Ansiedade e Depressão com a Escala Hospitalar de Ansiedade e Depressão, e a Qualidade de Vida com o SF-36. Comparamos as variáveis sócio-demográficas e clínicas nas mulheres com TEPT, TEPT Subsindrômico e sem TEPT. Foi feita uma análise de co-variância, com comparação pos-hoc pelo método de Tukey, para avaliar o impacto do TEPT sobre a qualidade de vida. Identificamos que 81% das mulheres apresentaram ao menos um sintoma de estresse pós-traumático clinicamente significativo, 17,9% tinham sintomas de TEPT e 24,5% de TEPT subsindrômico. As características sóciodemográficas e estadiamento do câncer não estavam associadas ao TEPT. História de tratamentos psiquiátricos mostrou uma tendência de associação (p<0,056), enquanto os escores das escalas de ansiedade e depressão estavam significativamente associados ao TEPT (p<0,001). Pacientes com TEPT tinham prevalência de Ansiedade seis vezes maior (Razão de Prevalência - RP = 6,56), e de Depressão quatorze vezes maior (RP = 14,41), do que as pacientes sem TEPT. As mulheres com TEPT e TEPT subsindrômico apresentaram os piores escores em todos os domínios da qualidade de vida, comparadas àquelas sem TEPT, mesmo controlando para a influência das variáveis sócio-demográficas e clínicas. Os domínios Capacidade Funcional e Aspecto Social estavam significativamente reduzidos nas mulheres com TEPT e com TEPT subsindrômico comparados ao grupo sem TEPT (p < 0,05) quando adicionamos no modelo os sintomas de ansiedade e depressão. Os sintomas de TEPT foram prevalentes e repercutiram negativamente na qualidade de vidas das mulheres recém diagnosticadas com câncer de mama, sugerindo que a avaliação destes sintomas nessa fase da doença é importante, pelas possibilidades de intervenção precoce. / Receiving a diagnosis of cancer is a traumatic experience which may trigger Post Traumatic Stress Disorder PTSD. To date, few studies have assessed the prevalence and impact of PTSD on the quality of life in women with breast cancer prior to commencement of treatment. The present study aimed to estimate the prevalence and impact of Acute PTSD symptoms on the quality of life in women recently diagnosed with breast cancer, while investigating the socio-demographic and clinical variables associated to PTSD. A transversal, cross-sectional type study was conducted at a Reference Center for Womens Health Byington Pérola Hospital. The PTSD symptoms were assessed using the Post-Traumatic Stress Disorder Checklist - Civilian Version, the Anxiety and Depression symptoms were evaluated with the Hospital Anxiety and Depression Scale, while Quality of Life was evaluated by the SF-36 questionnaire. The socio-demographic and clinical variables of the women with PTSD, Subsyndromal PTSD, and without PTSD were compared. Co-variance analysis was performed to assess the impact of the symptoms of PTSD on quality of life, independently from the potential effects of socio-demographic and clinical variables or psychiatric comorbidities, followed by Tukeys post-hoc comparison. We found a high prevalence of clinically significant post-traumatic stress symptoms. A total of 81% of women presented at least one symptom, 17.9% were diagnosed with PTSD, and 24.5% with subsyndromal PTSD. The sociodemographic characteristics and clinical staging of cancer were not associated with PTSD. Prior history of treatment and consultations for psychiatric problems presented a tendency toward association (p<0.056), while scores on the anxiety and depression scales were significantly associated with PTSD (p<0.001). We identified high comorbidity among PTSD, Anxiety and Depression. Patients with PTSD had a six-fold higher prevalence of Anxiety (Prevalence Ratio PR = 6.56), and a fourteen-fold higher rate of Depression (PR = 14.41) compared to patients without PTSD. Scores on domains of the quality of life scale were significantly lower in women with PTSD and subsyndromal PTSD. After controlling for influence of socio-demographic variables, cancer staging and psychiatric history, scores across all domains of the quality of life scale remained significantly lower in PTSD and subsyndromal PTSD groups. In the final step of the co-variance analysis, when anxiety and depression symptoms were included, the scores on the Functional Capacity and Social Aspect domains remained significantly lower in PTSD and subsyndromal PTSD groups than in the group without PTSD (p < 0.05). PTSD symptoms were prevalent and had a negative impact on the quality of life of women recently diagnosed with breast cancer, suggesting that the assessment of these symptoms during this stage of the disease is important to enable early intervention.

Submitted by Silvana Teresinha Dornelles Studzinski (sstudzinski) on 2015-06-22T17:51:32Z No. of bitstreams: 1 Maximiliano das Chagas Marques.pdf: 3744641 bytes, checksum: 1cfecd198604a95595d2331b8c97913e (MD5) / Made available in DSpace on 2015-06-22T17:51:32Z (GMT). No. of bitstreams: 1 Maximiliano das Chagas Marques.pdf: 3744641 bytes, checksum: 1cfecd198604a95595d2331b8c97913e (MD5) Previous issue date: 2010 / Nenhuma / O objetivo deste estudo seccional aninhado ao estudo de Coorte de Pacientes Portadores de Doenças Cardiovasculares e Cerebrovasculares foi determinar a prevalência de hipertensão arterial sistêmica (HAS) e verificar a associação com diferentes fatores entre os 370 adultos entrevistados de 2009 a 2010, ingressados no Instituto de Medicina Vascular do Hospital Mãe de Deus. A realização deste estudo esteve vinculada à execução das coletas de campo do baseline da Coorte. Inicialmente havia a expectativa de ingresso de aproximados 480 pacientes em um ano. Com o menor ingresso, algumas medidas de associação não foram possíveis neste momento. Foram realizadas análises descritivas de freqüência, com a caracterização da população ingressada no estudo, aplicando-se os testes do qui-quadrado e da associação linear de Pearson. Analisaram-se as razões de prevalência empregando a Regressão de Poisson robusta. As variáveis foram analisadas em três níveis hierarquizados, sendo as comorbidades ingressadas individualmente para controle do efeito de colinearidade. Entre os sujeitos deste estudo, a prevalência de HAS foi de 45,1%, (IC95%: 43,5-46,7). Observou-se maior prevalência de HAS nas mulheres (RP=1,26, IC95%: 1,00-1,59), nos com registro em prontuário de acidente vascular cerebral (AVC) (RP=1,36, IC95%: 1,08-1,71), de diabetes mellitus (RP=1,26, IC95%: 1,00-1,60) e entre os portadores de algumas outras comorbidades (RP=4,13, IC95%: 2,54-6,72 para uma e RP=5,47, IC95%: 3,41-8,77 para duas ou mais). Nos com infarto agudo do miocárdio (IAM), a prevalência de HAS foi menor (RP=0,69, IC95%: 0,53-0,91). Após ajuste, mantiveram associação com HAS sexo, AVC, IAM, diabetes mellitus e ocorrência de uma ou mais comorbidades. Neste estudo a presença de comorbidade se apresentou como um fator que pode contribuir para a maior prevalência de HAS, sendo importante a determinação de fatores de risco e a sugestão de ações de cuidado para a melhor aderência ao tratamento e controle dos níveis pressóicos. / The aim of this seccional study nested with the Cohort of Patient Carrier of Cardiovascular and cerebrovascular disease was to determine the prevalence of systemic hypertension (HAS) and to check the association with different factors between the 370 adults interviewed of 2009 and 2010, entered in the Vascular Medicine Institute of Mãe de Deus Hospital. The achievement of this study was bound the execution of the baseline field collect of Cohot. Initially had a expectation of entrance of approximately 480 patient in one year. With a lower entrance, some association measures were not possible in this moment. Were descreptive analyzis of frequency, with caracterization of the study population, applying the tests of chi-square e linear association of Pearson. Were analyzed the prevalence ratio employing the robust Poisson regression. The variables were analyzed in three hierarchical levels, being the comorbidity entered individually for control of collinearity effect. Between the study sujects, the prevalence of HAS was 45,1%, (CI95%: 43,5-46,7). Observed greater prevalence of HAS in woman (RP=1,26, IC95%: 1,00-1,59), in sujects with chart register of stroke (AVC) (RP=1,36, IC95%: 1,08-1,71), of diabetes mellitus (RP=1,26, IC95%: 1,00-1,60) and between the carrier others comorbidities (RP=4,13, IC95%: 2,54-6,72 for one and RP=5,47, IC95%: 3,41-8,77 for two or more). In the sujects with char register of acute myocardial infarction (IAM), the prevalence of HAS was lower (RP=0,69, IC95%: 0,53-0,91). After akept association with HAS the variable of sex, AVC, IAM, diabetes mellitus and to have one or more comobidities. In this study the prevalence of 8 comorbidity presented like a factor that may contribute for the greater prevalence of HAS, is important the determine the risk factors and the suggestion of actions of care for the most effective compliance of treatment and blood pressure levels control.

The etiology of obesity is heterogeneous as are the cardio-metabolic complications, associated with it. The cardio-metabolic profile of obese individuals places them at risk of a range of chronic metabolic diseases including diabetes. Paradoxically, a subset of the population classified as obese based on established methods present with few metabolic abnormalities, whereas a subset classified as non-obese present with a wide range of abnormalities. The observed heterogeneity suggests not only that excess adiposity is likely one of many determinant of metabolic complications, but also that our methods of measuring obesity might not be fully capturing the underlying biological mechanisms at play. The heterogeneity by which obesity presents itself in the general population is becoming more pertinent to the field of infectious diseases as findings increasingly implicate obesity in impaired host defenses and increased susceptibility to a range of different infectious organisms, one of which is Staphylococcus aureus. S. aureus is an opportunistic pathogen with significant infectious burdens in clinical, community as well as incarcerated settings. The organism also asymptomatically colonizes human mucosal surfaces, particularly the anterior nares. The anterior nares of approximately 25-30% of US adults are colonized at any given time, and prior colonization serves as a strong predictor of subsequent infection. Obese females have been consistently shown to be at elevated risk of S. aureus colonization, however, findings amongst obese males have been inconsistent. The mechanism by which obesity increases risk of colonization remain unclear, however, many cite the underlying metabolic dysfunction that frequently accompanies obesity. Given the global burden of obesity and increasing evidence that it impairs host defenses, understanding how obesity increases host colonization with S. aureus is imperative. The overall objective of this dissertation was therefore to evaluate the influence of obesity and metabolic abnormalities on S. aureus colonization among New York State Maximum-Security prison inmates. The objective of the dissertation was met using three aims. First a systematic review was conducted to assess the different definitions used to define persistent S. aureus colonization in community dwelling adults, as well as the reported prevalence estimates associated with those definitions. The study demonstrated that a considerable amount of variation existed in the way persistent colonization was defined in the extant literature. Despite the variation however, the prevalence of persistent S. aureus carriage remained relatively consistent after categorizing the different definitions into four general groups. The review also demonstrated that two groups of persistent carriers might exist. Therefore, differentiating strain persistence carriers from species persistence carriers may reconcile some of the inconsistencies with regard to length of strain carriage reported in the literature. Second, the influence of metabolic heath (a measure incorporating both body mass index (BMI) and metabolic abnormalities) was assessed. A significantly higher probability of S. aureus colonization of the anterior nares and/or oropharynx was observed among metabolically abnormal normal weight (BMI < 25 kg/m²) as well metabolically abnormal obese (BMI ≥ 30 kg/m²) females when compared to metabolically healthy females. No significant association was observed between the categories of metabolic health and the prevalence of S. aureus colonization among males. We did, however observe a significant decline in exclusive oropharyngeal colonization among obese male inmates with metabolic abnormalities. Lastly, factors associated with persistent S. aureus carriage were evaluated in the third aim. Approximately 27% of the population was persistent carriers at the species level and 17% were persistent carriers at the strain level. Obesity was independently associated with species persistent carriage but not strain persistent carriage. Correspondence analysis evaluating strain compositional differences between exclusive persistent anterior nares carriers, exclusive persistent oropharynx carriers, exclusive persistent carriers at both the anterior nares and oropharynx and intermittent carriers suggested compositional differences existed between the different groups. More specifically, the relative abundance of certain S. aureus strains appeared more prominent among exclusive nasal carriers as compared to all other carriage/mucosal site types (exclusive oropharynx, both nasal and oropharynx.

O ciúme romântico é um complexo de pensamentos, emoções e ações que visam proteger o relacionamento diante de uma ameaça percebida real ou imaginária e tem como objetivo eliminar os riscos da perda do objeto de amor. O ciúme excessivo (patológico) é uma preocupação infundada, irracional e irreal, composto de diversas emoções e pensamentos que provocam prejuízos significativos no funcionamento pessoal e relacional. O objetivo deste trabalho foi explorar a presença de transtornos psiquiátricos, características sócio-demográficas, aspectos emocionais (tais como impulsividade, personalidade, depressão, ansiedade e agressividade), comportamentos excessivos, adequação social, intensidade do ciúme e características do relacionamento amoroso (tais como qualidade, tipo de apego e estilo de amor) em três amostras distintas: 32 sujeitos com ciúme excessivo, 33 sujeitos com amor patológico e 31 sujeitos saudáveis. Os resultados mostraram que os indivíduos com ciúme excessivo comparativamente aos indivíduos saudáveis, apresentam elevada sintomatologia depressiva e elevada impulsividade e maior agressividade, elevada busca de novidades e esquiva ao dano e menor autodirecionamento e cooperatividade. São mais submissos no relacionamento e trabalham excessivamente. Apresentam pior adequação social e mais história de abuso infantil. Além disso, são mais insatisfeitos com o relacionamento, apresentam mais frequentemente o tipo apego ansioso-ambivalente e o estilo de amor Mania. Diferentemente dos sujeitos com amor patológico, a maior parte dos indivíduos com ciúme excessivo mora com o parceiro. Já o estilo de amor Ágape é mais presente nos sujeitos com amor patológico, que apresentam maior autodirecionamento, estão mais insatisfeitos no relacionamento e são menos agressivos comparativamente aos sujeitos com ciúme excessivo. Conclui-se que pessoas com ciúme excessivo apresentam uma série de características emocionais e psicossociais que necessitam ser levadas em consideração no desenvolvimento de estratégias terapêuticas / Romantic jealousy is a complex of thoughts, emotions and actions aimed to protect the relationship in face of a perceived threat - real or imaginary - and to eliminating the risks of loss of the love object. Excessive (pathological) jealousy is an unfounded, unreasonable and unrealistic concern, composed of various emotions and thoughts that cause significant losses in personal and relational functioning. The aim of this study was to explore psychiatric disorders, socio-demographic characteristics, emotional aspects (such as impulsivity, personality, depression, anxiety and aggression), excessive behaviors, social adjustment, jealousy intensity and romantic relationship characteristics (such as quality, type of attachment and love style) in three different samples: 32 subjects with excessive jealousy, 33 subjects with pathological love and 31 healthy subjects. The results showed that individuals with excessive jealousy display intense depressivce symptomatology and compared to healthy individuals, show high impulsivity and increased aggressiveness, higher novelty seeking and harm avoidance and lower self-directedness and cooperativity. They are workaholic and more submissive in the relationship. They have worse social adjustment and more history of childhood abuse. Moreover, they are more jealous and dissatisfied with the love relationship, often show the ambivalent-anxious attachment type and Mania love style. Unlike subjects with pathological love, most individuals with excessive jealousy live with their partner. Agape love style is more present in subjects with pathological love. Pathological love subjects have higher self-directedness, are more dissatisfied in their relationship and are less aggressive compared to subjects with excessive jealousy. We conclude that people with excessive jealousy present a series of emotional and psychosocial characteristics that need to be taken into account in the development of therapeutic strategies

Orientador: Antonio Carlos Cicogna / Banca: Camila Renata Corrêa Camacho / Banca: Alessandra Medeiros / Resumo: As modificações da função cardíaca decorrentes da obesidade podem estar associadas a diversos fatores, como o sistema β-adrenérgico, que executa importante papel na regulação do desempenho do coração e encontra-se hiperativo na presença de excesso de tecido adiposo corporal. Considerando a carência de informações a respeito da via β-adrenérgica cardíaca nessa patologia e a frequente associação entre ácidos graxos saturados e complicações cardiovasculares, a proposta desse estudo foi investigar se a obesidade acarreta alteração no comportamento dos componentes do sistema β-adrenérgico miocárdico de ratos obesos por dieta hiperlipídica saturada. Ratos Wistar foram distribuídos em dois grupos: controle (C; n=18; dieta normolipídica saturada) e obeso (Ob; n=19; dieta hiperlipídica saturada) por 30 semanas. A obesidade foi determinada pelo índice de adiposidade e foram avaliadas as comorbidades. O perfil morfológico cardíaco foi estimado por análise macroscópica post mortem. As expressões proteicas de receptores β1 e β2, adenilato ciclase (AC), proteína Gαs e proteína quinase A (PKA) foram realizadas pelo método de Western Blotting, e os níveis de adenosina monosfato cíclico (AMPc) e atividade da PKA, pela técnica de ELISA. Os ratos obesos apresentaram aumento no índice de adiposidade (p<0,001) e várias comorbidades como, hipertensão arterial sistêmica (p=0,009), intolerância à glicose (p<0,001), resistência insulínica (p=0,02) e dislipidemia, caracterizada pela hipertrigliceridemia (p=0,001) e hipercolesterolemia (Colesterol total, p=0,037; LDL, p=0,033). Não foi encontrada remodelação cardíaca no estudo macroscópico (p>0,05). A expressão proteica da AC miocárdica foi significativamente elevada no grupo Ob em relação ao C (p=0,025); adicionalmente, não houve alteração nos demais componentes avaliados (p>0,05). Em conclusão, a obesidade por dieta hiperlipídica saturada... / Abstract: The changes in cardiac function resulting from obesity may be associated with several factors such as the β-adrenergic system, which performs an important role in regulating heart performance and is hyperactive in the presence of excess body fat. Considering the lack of information on cardiac β-adrenergic pathway in this disease and the frequent association between saturated fatty acids and cardiovascular complications, the purpose of this study was to investigate wheter the obesity leads to change in behavior of the components of myocardial β-adrenergic system in obese rats by saturated high-fat diet. Male Wistar rats were divided into two groups: control (C, n=18; saturated normolipidic diet) and obese (Ob; n=19; saturated high-fat diet) for 30 weeks. Obesity was determined by adiposity index and comorbidities were evaluated. Cardiac morphological profile was estimated by post-death macroscopic analysis. The protein expressions of β1 and β2 receptors, adenylate cyclase (AC), Gαs protein e protein kinase A (PKA) were performed by the method of Western Blotting, and cyclic adenosine monosfato (cAMP) levels and activity of PKA, by ELISA. Obese rats showed increased adiposity index (p<0.001) and several comorbidities such as hypertension (p=0.009), glucose intolerance (p<0.001), insulin resistance (p=0.02) and dyslipidemia, characterized by hypertriglyceridemia (p=0.001) and hypercholesterolemia (total cholesterol, p=0.037; LDL, p=0.033). There was no cardiac remodeling in the macroscopic study (p>0.05). Protein expression of myocardial AC was significantly elevated in the Ob group compared to C (p=0.025); additionally, there was no change in the other components evaluated. In conclusion, obesity by saturated high-fat diet resulted in increased protein levels of AC in myocardial β-adrenergic system, without affecting the other componentes / Mestre

Métodos: Foi utilizado o SCID-IP para o diagnóstico de esquizofrenia e do TOC. Sessenta pacientes responderam às escalas DY-BOCS, Y-BOCS, PANSS e CGI. Os testes Qui-quadrado com correção de Yates, Mann-Whitney U e Kruskal-Wallis foram usados na análise estatística. Resultados: Dentre os sessenta pacientes avaliados, dez (16,7%) apresentavam critérios diagnósticos pelo DSM-IV para esquizofrenia e TOC; treze (21,7%) tinham SOC, mas não TOC e trinta e sete (61,6%) não tinham TOC ou SOC. A prevalência de TOC ou SOC foi semelhante em pacientes tomando clozapina ou haloperidol (40% VS 35%, respectivamente). Contudo, pacientes tomando clozapina apresentaram maior gravidade dos SOC quando comparados aos pacientes tomando haloperidol. (P= 0.027). Pacientes com esquizofrenia e TOC apresentaram maior gravidade dos sintomas da esquizofrenia quando comparados aos pacientes com esquizofrenia sem SOC (P= 0.002). Conclusões: Apesar da presença de SOC ou TOC ter sido semelhante entre os grupos tomando clozapina ou haloperidol, pacientes em uso de clozapina apresentaram escores mais elevados na YBOCS. Estes resultados podem sugerir uma associação entre a exacerbação do fenômeno obsessivo-compulsivo e o uso de clozapina. Pacientes com esquizofrenia e TOC apresentaram uma maior gravidade dos sintomas da esquizofrenia comparativamente aos demais grupos / Objective: We conducted a cross-sectional study to compare the prevalence and severity of obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorder (OCD) in patients with schizophrenia treated with clozapine or haloperidol. Methods: SCID-I/P was used for the diagnoses of schizophrenia and OCD. Sixty subjects completed Y-BOCS, PANSS and CGI scales. Chi-square with Yates correction, Mann-Whitney U and Kruskal-Wallis tests were used for the statistical analyses. Results: Among the sixty schizophrenia patients evaluated, ten (16,7 %) met DSM-IV criteria for both schizophrenia and OCD; thirteen (21,7 %) had OCS but not OCD and thirty-seven (61,6 %) had neither OCD nor OCS. The prevalence of OCD or OCS was similar in patients taking clozapine or haloperidol (40% vs 35%, respectively). However, patients using clozapine showed higher severity of OCS than patients using haloperidol (P= 0,027). Patients with schizophrenia and OCD also showed higher severity of schizophrenic symptoms when compared to patients with schizophrenia without OCS (P= 0,002). Conclusions: Although the presence of OCS or OCD was similar between the groups taking clozapine or haloperidol, patients using clozapine showed higher scores in the YBOCS. These results may support an association between the exacerbation of obsessive-compulsive phenomena and the use of clozapine. Patients with schizophrenia and OCD showed a higher severity on psychotic symptoms than the other groups

Introduction: Research suggests that patients with head and neck cancer from poorer backgrounds are more likely to have recurrences or die earlier than similar patients from affluent backgrounds. Survival is influenced by tumour characteristics on presentation and a range of individual factors such as socioeconomic status and comorbidity. Deprived patients of more advanced age have a higher likelihood of having comorbidity; this may be due to high-risk lifestyle behaviours such as smoking and drinking. Therefore, it seems reasonable to assume that survival will be lower in these deprived patients which can be attributed to comorbidity compared to index diseases such as the head and neck cancer itself. Survival rates for head and neck cancer patients are approximately 50% in the first five years in Scotland. This is dependent on a range of individual and tumour-related factors such as head and neck cancer sub-type and stage at diagnosis. The risk of head and neck cancer developing in deprived patients has been likened to that of developing head and neck cancer in heavy smokers. While the relationship between deprivation and comorbidity in head and neck cancer has been established, how both factors affect survival is yet to be explored. Reviewing these two factors individually has demonstrated the need to assess how both interact with each other in determining clinical presentation and survival. Aim: The aims of this thesis are:- 1. To investigate the roles and interrelationship between comorbidity and deprivation on the survival of HNC patients. 2. To investigate whether there are differences in HNC presentation based on comorbidity and deprivation. 3. To ascertain whether patients from deprived backgrounds with comorbidity present with more advanced cancers. Methods: In order to answer the research questions, this project began by describing the index disease, HNC and how comorbidity and deprivation are placed within the epidemiology of this disease using systematic review methods. The rationale for embarking upon this study was highlighted. Data linkage of administrative datasets We used anonymised patient data that was accessed through an encrypted repository held by the Health Informatics Centre. The data that was used in the retrospective cohort analysis was obtained from a prospective dataset collected by the Fife Head and Neck cancer Specialist Nurse (Fife data) and a retrospective case note review from the Tayside oncology records held by the Ear Nose and Throat Department and the Oral and Maxillofacial Surgery team. Thereafter we matched the patient data with that from routine medical datasets such the Scottish Morbidity Records, SMR01- inpatient discharges and SMR06 – Cancer Registry data. We conducted survival analysis methods with the intent of assessing the impact of both comorbidity and deprivation in determining survival. Results: The systematic review found that worsening levels of comorbidity were linked to reduced survival whereas patients with low incomes and poor educational attainment also had poor survival outcomes. Being young and having severe comorbidity appeared to also be associated with poorer survival. In the retrospective cohort analysis, the level of association between risk of death with comorbidity and deprivation could not be clearly ascertained in the patients from Fife. The Tayside data to a larger extent supported the systematic review findings particularly for the comorbidity measures with clearly defined measures of association for the Scottish Index of Multiple Deprivation income and education domains. Conclusions: This thesis was able to use evidence triangulation by way of a systematic review of the literature followed by a retrospective cohort analysis to investigate what influence on prognosis both comorbidity and deprivation posed in patients with head and neck cancer. There was substantiation of both factors interacting with head and neck cancer to cause a significantly reduced impact on survival. The inherent difficulties of measuring socioeconomic status and comorbidity encountered in this thesis may go some way towards illustrating the complexity and multifaceted nature of both comorbidity and socioeconomic status; particularly the quite complex interplay between socioeconomic status, comorbidity, stage at diagnosis, and access to care in head and neck cancer, and these factors’ ultimate impact on survival. We found that socioeconomic status i.e. deprivation, comorbidity, stage at diagnosis, access to care, and survival are all potentially causally related. Future work directed at using administrative data linked to medical records would not be sufficient; there is need for epidemiological and clinical studies to unravel the survival disadvantage. To this end clinical cohorts could be nested within larger registry based studies which would allow for uniform interventions based on clinical practice guidelines, uniform SES measurement and ascertainment of comorbidity using a head and neck cancer comorbidity index, i.e. the Washington University Head and Neck Cancer Index.

Une comorbidité entre les troubles neurodéveloppementaux est repérée de façon très fréquente chez les enfants d’âge scolaire. Plusieurs modèles se fondent sur l’existence de déficits sous-jacents communs pour tenter d’expliquer l’apparition concomitante de ces troubles. Afin de contribuer à une meilleure compréhension de la comorbidité entre la dyslexie et le trouble de l’acquisition de la coordination (TAC), trois recherches ont été réalisées au cours de cette thèse. Elles sont toutes basées sur l’analyse de la graphomotricité, en termes de processus et de produit. L’objectif principal de ce travail était de repérer les processus à l’œuvre dans les tâches graphomotrices qui pourraient être affectés dans ces deux troubles, tout en tenant compte des particularités de chacun. Nous avons fait l’hypothèse, en référence au modèle du déficit d’apprentissage procédural (Nicolson et Fawett, 2007), que les enfants avec des difficultés en lecture et en motricité se différencieraient de ceux sans difficulté lors d’un apprentissage graphomoteur. Les résultats montrent que la sévérité et la nature des atteintes influencent les performances des enfants pour un ensemble varié de tâches graphomotrices et pour l’apprentissage graphomoteur. L’ensemble des résultats traduit un certain nombre de particularités communes chez les enfants avec une dyslexie et/ou un TAC, au niveau de l’intégration visuo-motrice, ainsi que de l’apprentissage et de l’automatisation de gestes graphomoteurs. En outre, les travaux de cette thèse mettent en relief la pertinence de l’approche dimensionnelle pour étudier la complexité des profils d’enfants avec des troubles comorbides . / Comorbidity between neurodevelopmental disorders is frequently found in children of school age. Several models are based on the existence of common underlying disorders to try and explain the concomitant appearance of these disorders. Three studies, all based on graphomotoricity analyses in terms of the processes and products, were conducted during this thesis so as to contribute to a better understanding of comorbidity between dyslexia and developmental coordination disorder (DCD). The main objective was to identify the processes involved during graphomotoricity tasks that could be affected in these two disorders, taking into account the peculiarities of each. We hypothesised, referring to the procedural learning disorder model (Nicolson & Fawcett, 2007) that children with reading and motor difficulties would differentiate themselves from those without difficulty for graphomotor learning. enabling us to assess their reading and motor levels. Results showed that the severity and nature of the disorders influenced the children’s performance for a diverse set of graphomotricity tasks and graphomotor learning. The overall results reflected a number of common features in children with dyslexia and / or DCD, concerning visuo-motor integration, as well as graphomotor gestures in learning and automation. In addition, the studies carried out during this thesis emphasised the relevance of the dimensional approach so as to study the complexity of the profiles of children with comorbid disorders.

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Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent and impairing childhood disorders (5%; American Psychiatric Association, 2013), yet it is often studied in isolation. Such an approach is at odds with the clinical reality, where ADHD has a high comorbidity with oppositional defiant disorder, anxiety, and depression (Jensen, Martin, & Cantwell, 1997). Based on the possible presentations of ADHD with both externalizing and internalizing symptoms, there may be differences in associated characteristics, areas of impairment, and resulting assessment interventions. Therefore, the present study investigated how ADHD comorbidities manifested in a population of 233 elementary age children and how these profiles varied in already established characteristics (i.e., traits, social behaviors) and areas of deficit for children with ADHD (i.e., social functioning, academics, narrative comprehension). Characteristics and outcomes were examined using rating scales, behavior observations, laboratory tasks, and grades. Based on latent profile analyses, different patterns of comorbidity were identified using both parent and teacher ratings of ADHD. Based on parent and teacher report, those with high ADHD/ODD symptoms had more negative characteristics and outcomes. Network analyses corroborated these results, showing that internalizing symptoms were less relevant for associated characteristics and outcomes compared to ADHD and ODD symptoms. Overall, these results suggest that ADHD comorbidities may be primarily driven by ADHD and ODD symptoms, with this profile displaying more severe negative characteristics and outcomes.