Thesis (M.Tech.: Chiropractic)--Durban University of Technology, 2009 / Objective: The efficacy of manipulation as compared to placebo in the treatment of two groups of weight trainers with Acromioclavicular (AC) Joint Dysfunction. Methods: Twenty patients (n=20), using randomised sampling were allocated to two intervention groups. Patients in each group received four treatments each over a two-week period and assessed at initial, one week, two weeks and one month follow ups. Objective measures included Algometer and Inclinometer readings. Numerical Pain Rating Scales (NRS), Shoulder Rating Questionnaire (SRQ) and the Shoulder Pain and Disability Index (SPADI) measured subjective outcomes. Results: Manipulation demonstrated significant improvement in objective findings. Subjective outcomes did not show significant difference between the manipulation and placebo groups. Conclusion: Manipulation, when compared to placebo, can be considered as an effective treatment intervention for the treatment of AC joint dysfunction with particular reference to objective outcomes. Although, caution needs to be utilised in accepting this outcome due to limitations in sample size, subjective measure sensitivity and specificity as well as the stringency of the inclusion and exclusion criteria.

Thesis (M.Tech.: Chiropractic)--Durban University of Technology, 2009 / Objective: The efficacy of manipulation as compared to placebo in the treatment of two groups of weight trainers with Acromioclavicular (AC) Joint Dysfunction. Methods: Twenty patients (n=20), using randomised sampling were allocated to two intervention groups. Patients in each group received four treatments each over a two-week period and assessed at initial, one week, two weeks and one month follow ups. Objective measures included Algometer and Inclinometer readings. Numerical Pain Rating Scales (NRS), Shoulder Rating Questionnaire (SRQ) and the Shoulder Pain and Disability Index (SPADI) measured subjective outcomes. Results: Manipulation demonstrated significant improvement in objective findings. Subjective outcomes did not show significant difference between the manipulation and placebo groups. Conclusion: Manipulation, when compared to placebo, can be considered as an effective treatment intervention for the treatment of AC joint dysfunction with particular reference to objective outcomes. Although, caution needs to be utilised in accepting this outcome due to limitations in sample size, subjective measure sensitivity and specificity as well as the stringency of the inclusion and exclusion criteria.

The analgesic effect of 600 mg and 1500 mg of a pain killing drug to metastatic bone pain, and associated side effects, were assessed. The experimental design was a double-blind cross over clinical trial involving 44 patients known to suffer from metastatic bone pain. Each patient received the active drug in one of two dosages and the placebo in a random order, each lasting about 14 consecutive days. The data consisted of daily measurements of several pain and side effect variables. A few covariates were available. It was found that the patient and the investigator achieved a high degree of agreement on the blinded preference of the active drug to the placebo. A multivariate analysis of variance (MANOVA) on three different summary scores (mean, median, trmean) calculated on the daily measurements for which the patient received the active drug and on those for which the patient received the placebo was conducted. It was found that for the group of pain variables the order of application and the treatment do not have a significant effect marginally, but that they interact significantly. Variation between subjects was also significant. For the group of side effect variables, however, only significant variation between subjects was found. This suggests that the drug does not have noticeable overall side effects. To account for correlations among the response measurements within each patient, the methodology of generalized estimating equations was used to assess the significance of the effects of the predictors. Although the results are less reliable as they depend on the asymptotic behaviour of statistics, it was found that regardless of the level of correlation within patient response measurements, only the interaction of order of application with treatment has a significant effect on each of the pain variables. All the statistical analyses were carried out using Minitab, SAS, Matlab and Splus. / Thesis / Master of Science (MS)

A hipotermia perioperatória está associada a diferentes complicações, tais como: aumento da incidência de infecção de sítio cirúrgico, arritmias cardíacas, aumento do sangramento no período intraoperatório e desconforto térmico do paciente na sala de recuperação pós-anestésica, entre outras. Na literatura há evidências de que o pré- aquecimento da superfície corporal do paciente antes da indução anestésica é efetivo para a redução da hipotermia, pela diminuição do gradiente de temperatura entre os compartimentos central e periférico do organismo humano. Assim o objetivo do estudo foi avaliar o efeito do pré-aquecimento na manutenção da temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas. Trata-se de ensaio clínico controlado randomizado, com a participação de 86 pacientes submetidas a cirurgia ginecológica eletiva, aleatorizadas em dois grupos. Na sala de admissão do Centro Cirúrgico, as participantes do grupo experimental (n=43) foram aquecidas durante 20 minutos com o sistema de ar forçado aquecido (manta térmica para o corpo todo), o equipamento foi ligado na temperatura de 38o C, e as participantes do grupo controle (n=43) foram cobertas com lençol de algodão e cobertor, durante o mesmo tempo. No período intraoperatório, todas as pacientes foram aquecidas com o sistema de ar forçado aquecido (manta térmica para a parte superior do corpo). A temperatura timpânica foi mensurada com termômetro timpânico infravermelho nos períodos pré e intraoperatório. A partir da entrada da paciente na sala de operação, a temperatura e umidade do ar da sala cirúrgica foram mensuradas. As médias da temperatura e umidade do ar da sala cirúrgica, entre os grupos experimental e controle, foram analisadas por meio do teste t- Student. As médias da temperatura corporal, entre os grupos experimental e controle, foram analisadas por meio de modelo linear de regressão de efeitos mistos. Na análise descritiva dos dados relativos às características sociodemográficas e clínicas das pacientes e do procedimento anestésico-cirúrgico, evidenciou-se similaridade entre os grupos experimental e controle. Após o pré-aquecimento, a média da temperatura corporal foi de 38o C no grupo experimental e de 37,8o C no grupo controle, com diferença estatisticamente não significante (p=0,27). No T150 (150 minutos após o início da cirurgia), houve diferença estatisticamente significante entre os grupos (p=0,01). No final da cirurgia, a temperatura média dos grupos estudados foi igual, ou seja, 36,8o C, com diferença estatisticamente não significante (p=0,66). Os resultados da média da temperatura da sala de operação, nos diferentes períodos mensurados, não apresentaram diferença estatisticamente significante entre os grupos estudados. Em relação à umidade do ar da sala de operação, somente no período T120 (120 minutos após o início da cirurgia), os resultados evidenciaram diferença estatisticamente significante entre os grupos (p=0,03). O pré-aquecimento com o sistema de ar forçado aquecido não teve efeito na temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas / Perioperative hypothermia is associated with various complications, such as an increased incidence of surgical site infection, cardiac arrhythmias, increased bleeding in the intraoperative period, and thermal discomfort of the patient in the post- anesthetic recovery room, among others. In the literature there is evidence that prewarming the body surface of the patient prior to induction of anesthesia is effective in reducing hypothermia, by lowering the temperature gradient between the central and peripheral compartments of the human organism. Thus, the objective of the present study was to evaluate the effects of prewarming on maintaining the body temperature of patients undergoing elective gynecological surgery. This is a randomized controlled clinical trial involving 86 patients undergoing elective gynecological surgery, randomized into two groups. In the admission room of the Surgical Center, participants in the experimental group (n=43) were warmed for 20 minutes using the forced air heating system (thermal blanket over the whole body), the equipment was turned on at a temperature of 38o C, and the control group (n = 43) were covered with a cotton sheet and blanket for the same period. During the intraoperative period, all patients were warmed using the forced air heating system (thermal blanket for the upper body). The tympanic temperature was measured using an infrared tympanic thermometer in the pre- and intraoperative periods. From the moment of each patient\'s entry into the operating room, the temperature and humidity of the air in the room were measured. The mean temperatures and humidity levels of the operating room, between the experimental and control groups, were analyzed using the Student t-test. The mean body temperatures between the experimental and control groups were analyzed using a linear mixed effects regression model. The descriptive analysis of data on the sociodemographic and clinical characteristics of the patients and the surgical anesthetic procedure demonstrated similarity between the experimental and control groups. After prewarming, the mean body temperature was 38o C in the experimental group and 37.8ºC in the control group, with no statistically significant difference (p = 0.27). At T150 (150 minutes after the start of surgery) there was no statistically significant difference between the groups (p = 0.01). At the end of surgery, the mean temperature of the studied groups was the same, i.e., 36.8o C, with no statistically significant difference between the groups (p = 0.66). The results of the mean operating room temperatures, in the different periods measured, presented no statistically significant differences between groups. In relation to the humidity of the operating room, the results demonstrated a statistically significant difference between groups (p = 0.03) only in the period T120 (120 minutes after the start of surgery). Prewarming with the forced air heating system had no effect on body temperature of patients undergoing elective gynecological surgery

Apesar da importância da alimentação saudável, já nos primeiros anos de vida, tem-se observado durante a infância baixo consumo de dieta saudável diversificada, e consumo elevado de alimentos processados, ricos em gordura, sal e açúcar. Entre os determinantes que influenciam os hábitos alimentares das crianças incluem-se a idade materna e a coabitação com as avós maternas. Por isso, o presente estudo teve como objetivo principal avaliar o efeito de intervenção para a promoção do aleitamento materno e da alimentação complementar saudável, junto a mães adolescentes e avós maternas, realizada nos primeiros 4 meses de vida da criança, sobre o cumprimento dos Dez Passos para uma Alimentação Saudável para Crianças Menores de 2 Anos, recomendados pelo Ministério da Saúde, no primeiro ano de vida; e como objetivo secundário avaliar a influência da duração do aleitamento materno exclusivo sobre a qualidade da alimentação da criança aos 12 meses de vida. Para isso, foi realizado ensaio clínico randomizado com 320 mães adolescentes e seus filhos, mais 169 avós maternas quando em coabitação, recrutados na maternidade do Hospital de Clínicas de Porto Alegre e randomicamente alocados para o grupo intervenção ou controle. A intervenção consistiu de seis sessões de aconselhamento em aleitamento materno e alimentação complementar saudável, a primeira na maternidade e as demais no domicílio, aos 7, 15, 30, 60 e 120 dias de vida da criança, por uma equipe composta por um pediatra, duas enfermeiras e uma nutricionista. Em todas as sessões abordou-se a importância da amamentação exclusiva nos primeiros 6 meses de vida e, na última, aos 120 dias, a ênfase foi na alimentação complementar saudável a ser introduzida na idade de 6 meses, com distribuição de livreto com conteúdo baseado nos Dez Passos para a Alimentação Saudável para Crianças Menores de 2 anos. As informações relativas à alimentação da criança foram obtidas mensalmente nos primeiros 6 meses de idade e, depois, a cada 2 meses até a criança completar 12 meses, mediante registro de frequência alimentar semanal, por entrevistadores cegos aos grupos aos quais as mães pertenciam. Para avaliar o cumprimento dos Dez Passos elaborou-se um sistema de escore que pontuou o cumprimento de cada passo: os passos cumpridos integralmente receberam dois pontos, os parcialmente cumpridos um ponto, e os não cumpridos não pontuaram (zero pontos). Considerou-se dieta saudável diversificada o consumo de frutas/hortaliças, carnes, feijões e cereais/tubérculos pelo menos 4 vezes na semana, além de baixo consumo (no máximo 1 vez por semana) de alimentos ricos em gordura, sal e açucares. O teste t de Student foi utilizado para comparar as médias dos escores dos grupos controle e intervenção, e o modelo de regressão multivariada de Poisson com estimação robusta foi utilizado para estimar o efeito da intervenção sobre o cumprimento dos passos. Para medir a associação entre duração do aleitamento materno exclusivo e a qualidade da alimentação da criança aos 12 meses, utilizou-se o modelo de regressão multivariada de Poisson com estimação robusta, adotando-se como ponto de corte a mediana do escore de toda a população estudada. A média dos escores obtidos no grupo intervenção foi maior que no grupo controle (12,4 ± 2,5 versus 10,5 ± 2,3, respectivamente; p = 0,00), sendo que a intervenção dobrou a chance de o escore ser maior ou igual à mediana (RR = 1,93; IC95% 1,44-2,58), e não houve influência da coabitação com a avó materna. Além disso, a intervenção aumentou em mais de 10 pontos percentuais o cumprimento de 6 dos 10 passos (passos 2 a 7), relativos à época de introdução, frequência, consistência e variedade dos alimentos complementares, além da flexibilidade de quem alimenta a criança quanto a horários e atitude frente à recusa dos alimentos. No entanto, a intervenção não afetou um dos passos mais importantes, a saber, o passo 8, que recomenda evitar açúcar, café, enlatados, frituras, refrigerantes, balas, salgadinhos e outras guloseimas. Houve associação entre duração da amamentação exclusiva e dieta diversificada saudável. A probabilidade de a criança consumir dieta mais saudável aos 12 meses de idade aumentou em 28% para cada mês de aleitamento materno exclusivo (RR 1,28; IC 95% 1,19 -1,38). / Despite the importance of healthy eating already in the early years of life, a pattern of low intake of healthy diverse diet and high consumption of processed foods and foods rich in fat, salt, and sugar has been observed during childhood. Maternal age and cohabitation with maternal grandmother are known to be among the factors that influence the dietary habits of children. Therefore, the objective of the present study was to assess the effect of an intervention designed to promote breastfeeding and healthy complementary feeding, directed at adolescent mothers and maternal grandmothers, and performed during the first 4 months of life, on compliance, during the first year of life, with the Ten Steps to Healthy Feeding for Children under Two Years, recommended by the Brazilian Ministry of Health. A secondary objective was to assess the influence of exclusive breastfeeding duration on the quality of the infant's diet at 12 months. In order to do that, a randomized clinical trial was conducted involving 320 adolescent mothers and their infants, plus 169 maternal grandmothers when cohabiting. Participants were recruited at the maternity ward of Hospital de Clínicas de Porto Alegre and randomly assigned to either the intervention or the control group. The intervention consisted of six counseling sessions on breastfeeding and healthy complementary feeding, the first one held at the maternity ward and the others at the mothers’ homes at 7, 15, 30, 60, and 120 days of life, by a team comprising a pediatrician, two nurses, and a nutritionist. All sessions addressed the importance of exclusive breastfeeding in the first 6 months of life; the last session, at 120 days, emphasized healthy complementary feeding, to be introduced as of 6 months of life. A booklet based on the Ten Steps was given to each mother at this session. Infant feeding information was collected monthly over the first 6 months of life and then every 2 months until 12 months, by recording weekly frequency of consumption of different foods. Interviewers were blind to group allocation. Compliance with the Ten Steps was assessed using a scoring system as follows: full compliance with a step received 2 points per step; partial compliance received 1 point; and noncompliance received 0 points (no score). Healthy diverse diet was defined as the intake of fruit/vegetables, meat, beans, and cereals/tubers at least 4 times weekly, and a low intake (maximum once weekly) of foods rich in fat, salt, and sugar. Student's t test was used to compare mean scores obtained in the intervention and control groups, and Poisson's multivariate regression model with robust estimation was used to estimate the effect of the intervention on compliance with the Ten Steps. The association between exclusive breastfeeding duration and quality of the infant's diet at 12 months was also assessed using Poisson's multivariate regression model with robust estimation, using the median score obtained in the whole sample as cut-off point. Mean scores obtained in the intervention group were higher than those obtained in the control group (12.4 ± 2.5 versus 10.5 ± 2.3, respectively; p = 0.00), and the intervention doubled the chance of the score being greater than or equal to the median (RR = 1.93; 95%CI 1.44-2.58). No influence of cohabitation with maternal grandmother was detected. The intervention increased compliance, by over 10 percentage points, with six of the Ten Steps (Steps 2 to 7), related to the time of introduction, frequency, consistency and variety of complementary foods, in addition to caretaker flexibility with regard to feeding times and attitude towards food refusal. Nevertheless, the intervention did not affect one of the most important steps, namely, Step 8, which recommends avoiding the intake of sugar, coffee, canned foods, fried foods, candies, processed snacks and other unhealthy foods. There was an association between exclusive breastfeeding duration and healthy diverse diet. The likelihood of the infant being on a healthy diet at 12 months of age increased by 28% for each additional month of exclusive breastfeeding (RR = 1.28; 95%CI 1.19-1.38).

A hipotermia perioperatória está associada a diferentes complicações, tais como: aumento da incidência de infecção de sítio cirúrgico, arritmias cardíacas, aumento do sangramento no período intraoperatório e desconforto térmico do paciente na sala de recuperação pós-anestésica, entre outras. Na literatura há evidências de que o pré- aquecimento da superfície corporal do paciente antes da indução anestésica é efetivo para a redução da hipotermia, pela diminuição do gradiente de temperatura entre os compartimentos central e periférico do organismo humano. Assim o objetivo do estudo foi avaliar o efeito do pré-aquecimento na manutenção da temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas. Trata-se de ensaio clínico controlado randomizado, com a participação de 86 pacientes submetidas a cirurgia ginecológica eletiva, aleatorizadas em dois grupos. Na sala de admissão do Centro Cirúrgico, as participantes do grupo experimental (n=43) foram aquecidas durante 20 minutos com o sistema de ar forçado aquecido (manta térmica para o corpo todo), o equipamento foi ligado na temperatura de 38o C, e as participantes do grupo controle (n=43) foram cobertas com lençol de algodão e cobertor, durante o mesmo tempo. No período intraoperatório, todas as pacientes foram aquecidas com o sistema de ar forçado aquecido (manta térmica para a parte superior do corpo). A temperatura timpânica foi mensurada com termômetro timpânico infravermelho nos períodos pré e intraoperatório. A partir da entrada da paciente na sala de operação, a temperatura e umidade do ar da sala cirúrgica foram mensuradas. As médias da temperatura e umidade do ar da sala cirúrgica, entre os grupos experimental e controle, foram analisadas por meio do teste t- Student. As médias da temperatura corporal, entre os grupos experimental e controle, foram analisadas por meio de modelo linear de regressão de efeitos mistos. Na análise descritiva dos dados relativos às características sociodemográficas e clínicas das pacientes e do procedimento anestésico-cirúrgico, evidenciou-se similaridade entre os grupos experimental e controle. Após o pré-aquecimento, a média da temperatura corporal foi de 38o C no grupo experimental e de 37,8o C no grupo controle, com diferença estatisticamente não significante (p=0,27). No T150 (150 minutos após o início da cirurgia), houve diferença estatisticamente significante entre os grupos (p=0,01). No final da cirurgia, a temperatura média dos grupos estudados foi igual, ou seja, 36,8o C, com diferença estatisticamente não significante (p=0,66). Os resultados da média da temperatura da sala de operação, nos diferentes períodos mensurados, não apresentaram diferença estatisticamente significante entre os grupos estudados. Em relação à umidade do ar da sala de operação, somente no período T120 (120 minutos após o início da cirurgia), os resultados evidenciaram diferença estatisticamente significante entre os grupos (p=0,03). O pré-aquecimento com o sistema de ar forçado aquecido não teve efeito na temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas / Perioperative hypothermia is associated with various complications, such as an increased incidence of surgical site infection, cardiac arrhythmias, increased bleeding in the intraoperative period, and thermal discomfort of the patient in the post- anesthetic recovery room, among others. In the literature there is evidence that prewarming the body surface of the patient prior to induction of anesthesia is effective in reducing hypothermia, by lowering the temperature gradient between the central and peripheral compartments of the human organism. Thus, the objective of the present study was to evaluate the effects of prewarming on maintaining the body temperature of patients undergoing elective gynecological surgery. This is a randomized controlled clinical trial involving 86 patients undergoing elective gynecological surgery, randomized into two groups. In the admission room of the Surgical Center, participants in the experimental group (n=43) were warmed for 20 minutes using the forced air heating system (thermal blanket over the whole body), the equipment was turned on at a temperature of 38o C, and the control group (n = 43) were covered with a cotton sheet and blanket for the same period. During the intraoperative period, all patients were warmed using the forced air heating system (thermal blanket for the upper body). The tympanic temperature was measured using an infrared tympanic thermometer in the pre- and intraoperative periods. From the moment of each patient\'s entry into the operating room, the temperature and humidity of the air in the room were measured. The mean temperatures and humidity levels of the operating room, between the experimental and control groups, were analyzed using the Student t-test. The mean body temperatures between the experimental and control groups were analyzed using a linear mixed effects regression model. The descriptive analysis of data on the sociodemographic and clinical characteristics of the patients and the surgical anesthetic procedure demonstrated similarity between the experimental and control groups. After prewarming, the mean body temperature was 38o C in the experimental group and 37.8ºC in the control group, with no statistically significant difference (p = 0.27). At T150 (150 minutes after the start of surgery) there was no statistically significant difference between the groups (p = 0.01). At the end of surgery, the mean temperature of the studied groups was the same, i.e., 36.8o C, with no statistically significant difference between the groups (p = 0.66). The results of the mean operating room temperatures, in the different periods measured, presented no statistically significant differences between groups. In relation to the humidity of the operating room, the results demonstrated a statistically significant difference between groups (p = 0.03) only in the period T120 (120 minutes after the start of surgery). Prewarming with the forced air heating system had no effect on body temperature of patients undergoing elective gynecological surgery

Apesar da importância da alimentação saudável, já nos primeiros anos de vida, tem-se observado durante a infância baixo consumo de dieta saudável diversificada, e consumo elevado de alimentos processados, ricos em gordura, sal e açúcar. Entre os determinantes que influenciam os hábitos alimentares das crianças incluem-se a idade materna e a coabitação com as avós maternas. Por isso, o presente estudo teve como objetivo principal avaliar o efeito de intervenção para a promoção do aleitamento materno e da alimentação complementar saudável, junto a mães adolescentes e avós maternas, realizada nos primeiros 4 meses de vida da criança, sobre o cumprimento dos Dez Passos para uma Alimentação Saudável para Crianças Menores de 2 Anos, recomendados pelo Ministério da Saúde, no primeiro ano de vida; e como objetivo secundário avaliar a influência da duração do aleitamento materno exclusivo sobre a qualidade da alimentação da criança aos 12 meses de vida. Para isso, foi realizado ensaio clínico randomizado com 320 mães adolescentes e seus filhos, mais 169 avós maternas quando em coabitação, recrutados na maternidade do Hospital de Clínicas de Porto Alegre e randomicamente alocados para o grupo intervenção ou controle. A intervenção consistiu de seis sessões de aconselhamento em aleitamento materno e alimentação complementar saudável, a primeira na maternidade e as demais no domicílio, aos 7, 15, 30, 60 e 120 dias de vida da criança, por uma equipe composta por um pediatra, duas enfermeiras e uma nutricionista. Em todas as sessões abordou-se a importância da amamentação exclusiva nos primeiros 6 meses de vida e, na última, aos 120 dias, a ênfase foi na alimentação complementar saudável a ser introduzida na idade de 6 meses, com distribuição de livreto com conteúdo baseado nos Dez Passos para a Alimentação Saudável para Crianças Menores de 2 anos. As informações relativas à alimentação da criança foram obtidas mensalmente nos primeiros 6 meses de idade e, depois, a cada 2 meses até a criança completar 12 meses, mediante registro de frequência alimentar semanal, por entrevistadores cegos aos grupos aos quais as mães pertenciam. Para avaliar o cumprimento dos Dez Passos elaborou-se um sistema de escore que pontuou o cumprimento de cada passo: os passos cumpridos integralmente receberam dois pontos, os parcialmente cumpridos um ponto, e os não cumpridos não pontuaram (zero pontos). Considerou-se dieta saudável diversificada o consumo de frutas/hortaliças, carnes, feijões e cereais/tubérculos pelo menos 4 vezes na semana, além de baixo consumo (no máximo 1 vez por semana) de alimentos ricos em gordura, sal e açucares. O teste t de Student foi utilizado para comparar as médias dos escores dos grupos controle e intervenção, e o modelo de regressão multivariada de Poisson com estimação robusta foi utilizado para estimar o efeito da intervenção sobre o cumprimento dos passos. Para medir a associação entre duração do aleitamento materno exclusivo e a qualidade da alimentação da criança aos 12 meses, utilizou-se o modelo de regressão multivariada de Poisson com estimação robusta, adotando-se como ponto de corte a mediana do escore de toda a população estudada. A média dos escores obtidos no grupo intervenção foi maior que no grupo controle (12,4 ± 2,5 versus 10,5 ± 2,3, respectivamente; p = 0,00), sendo que a intervenção dobrou a chance de o escore ser maior ou igual à mediana (RR = 1,93; IC95% 1,44-2,58), e não houve influência da coabitação com a avó materna. Além disso, a intervenção aumentou em mais de 10 pontos percentuais o cumprimento de 6 dos 10 passos (passos 2 a 7), relativos à época de introdução, frequência, consistência e variedade dos alimentos complementares, além da flexibilidade de quem alimenta a criança quanto a horários e atitude frente à recusa dos alimentos. No entanto, a intervenção não afetou um dos passos mais importantes, a saber, o passo 8, que recomenda evitar açúcar, café, enlatados, frituras, refrigerantes, balas, salgadinhos e outras guloseimas. Houve associação entre duração da amamentação exclusiva e dieta diversificada saudável. A probabilidade de a criança consumir dieta mais saudável aos 12 meses de idade aumentou em 28% para cada mês de aleitamento materno exclusivo (RR 1,28; IC 95% 1,19 -1,38). / Despite the importance of healthy eating already in the early years of life, a pattern of low intake of healthy diverse diet and high consumption of processed foods and foods rich in fat, salt, and sugar has been observed during childhood. Maternal age and cohabitation with maternal grandmother are known to be among the factors that influence the dietary habits of children. Therefore, the objective of the present study was to assess the effect of an intervention designed to promote breastfeeding and healthy complementary feeding, directed at adolescent mothers and maternal grandmothers, and performed during the first 4 months of life, on compliance, during the first year of life, with the Ten Steps to Healthy Feeding for Children under Two Years, recommended by the Brazilian Ministry of Health. A secondary objective was to assess the influence of exclusive breastfeeding duration on the quality of the infant's diet at 12 months. In order to do that, a randomized clinical trial was conducted involving 320 adolescent mothers and their infants, plus 169 maternal grandmothers when cohabiting. Participants were recruited at the maternity ward of Hospital de Clínicas de Porto Alegre and randomly assigned to either the intervention or the control group. The intervention consisted of six counseling sessions on breastfeeding and healthy complementary feeding, the first one held at the maternity ward and the others at the mothers’ homes at 7, 15, 30, 60, and 120 days of life, by a team comprising a pediatrician, two nurses, and a nutritionist. All sessions addressed the importance of exclusive breastfeeding in the first 6 months of life; the last session, at 120 days, emphasized healthy complementary feeding, to be introduced as of 6 months of life. A booklet based on the Ten Steps was given to each mother at this session. Infant feeding information was collected monthly over the first 6 months of life and then every 2 months until 12 months, by recording weekly frequency of consumption of different foods. Interviewers were blind to group allocation. Compliance with the Ten Steps was assessed using a scoring system as follows: full compliance with a step received 2 points per step; partial compliance received 1 point; and noncompliance received 0 points (no score). Healthy diverse diet was defined as the intake of fruit/vegetables, meat, beans, and cereals/tubers at least 4 times weekly, and a low intake (maximum once weekly) of foods rich in fat, salt, and sugar. Student's t test was used to compare mean scores obtained in the intervention and control groups, and Poisson's multivariate regression model with robust estimation was used to estimate the effect of the intervention on compliance with the Ten Steps. The association between exclusive breastfeeding duration and quality of the infant's diet at 12 months was also assessed using Poisson's multivariate regression model with robust estimation, using the median score obtained in the whole sample as cut-off point. Mean scores obtained in the intervention group were higher than those obtained in the control group (12.4 ± 2.5 versus 10.5 ± 2.3, respectively; p = 0.00), and the intervention doubled the chance of the score being greater than or equal to the median (RR = 1.93; 95%CI 1.44-2.58). No influence of cohabitation with maternal grandmother was detected. The intervention increased compliance, by over 10 percentage points, with six of the Ten Steps (Steps 2 to 7), related to the time of introduction, frequency, consistency and variety of complementary foods, in addition to caretaker flexibility with regard to feeding times and attitude towards food refusal. Nevertheless, the intervention did not affect one of the most important steps, namely, Step 8, which recommends avoiding the intake of sugar, coffee, canned foods, fried foods, candies, processed snacks and other unhealthy foods. There was an association between exclusive breastfeeding duration and healthy diverse diet. The likelihood of the infant being on a healthy diet at 12 months of age increased by 28% for each additional month of exclusive breastfeeding (RR = 1.28; 95%CI 1.19-1.38).

Apesar da importância da alimentação saudável, já nos primeiros anos de vida, tem-se observado durante a infância baixo consumo de dieta saudável diversificada, e consumo elevado de alimentos processados, ricos em gordura, sal e açúcar. Entre os determinantes que influenciam os hábitos alimentares das crianças incluem-se a idade materna e a coabitação com as avós maternas. Por isso, o presente estudo teve como objetivo principal avaliar o efeito de intervenção para a promoção do aleitamento materno e da alimentação complementar saudável, junto a mães adolescentes e avós maternas, realizada nos primeiros 4 meses de vida da criança, sobre o cumprimento dos Dez Passos para uma Alimentação Saudável para Crianças Menores de 2 Anos, recomendados pelo Ministério da Saúde, no primeiro ano de vida; e como objetivo secundário avaliar a influência da duração do aleitamento materno exclusivo sobre a qualidade da alimentação da criança aos 12 meses de vida. Para isso, foi realizado ensaio clínico randomizado com 320 mães adolescentes e seus filhos, mais 169 avós maternas quando em coabitação, recrutados na maternidade do Hospital de Clínicas de Porto Alegre e randomicamente alocados para o grupo intervenção ou controle. A intervenção consistiu de seis sessões de aconselhamento em aleitamento materno e alimentação complementar saudável, a primeira na maternidade e as demais no domicílio, aos 7, 15, 30, 60 e 120 dias de vida da criança, por uma equipe composta por um pediatra, duas enfermeiras e uma nutricionista. Em todas as sessões abordou-se a importância da amamentação exclusiva nos primeiros 6 meses de vida e, na última, aos 120 dias, a ênfase foi na alimentação complementar saudável a ser introduzida na idade de 6 meses, com distribuição de livreto com conteúdo baseado nos Dez Passos para a Alimentação Saudável para Crianças Menores de 2 anos. As informações relativas à alimentação da criança foram obtidas mensalmente nos primeiros 6 meses de idade e, depois, a cada 2 meses até a criança completar 12 meses, mediante registro de frequência alimentar semanal, por entrevistadores cegos aos grupos aos quais as mães pertenciam. Para avaliar o cumprimento dos Dez Passos elaborou-se um sistema de escore que pontuou o cumprimento de cada passo: os passos cumpridos integralmente receberam dois pontos, os parcialmente cumpridos um ponto, e os não cumpridos não pontuaram (zero pontos). Considerou-se dieta saudável diversificada o consumo de frutas/hortaliças, carnes, feijões e cereais/tubérculos pelo menos 4 vezes na semana, além de baixo consumo (no máximo 1 vez por semana) de alimentos ricos em gordura, sal e açucares. O teste t de Student foi utilizado para comparar as médias dos escores dos grupos controle e intervenção, e o modelo de regressão multivariada de Poisson com estimação robusta foi utilizado para estimar o efeito da intervenção sobre o cumprimento dos passos. Para medir a associação entre duração do aleitamento materno exclusivo e a qualidade da alimentação da criança aos 12 meses, utilizou-se o modelo de regressão multivariada de Poisson com estimação robusta, adotando-se como ponto de corte a mediana do escore de toda a população estudada. A média dos escores obtidos no grupo intervenção foi maior que no grupo controle (12,4 ± 2,5 versus 10,5 ± 2,3, respectivamente; p = 0,00), sendo que a intervenção dobrou a chance de o escore ser maior ou igual à mediana (RR = 1,93; IC95% 1,44-2,58), e não houve influência da coabitação com a avó materna. Além disso, a intervenção aumentou em mais de 10 pontos percentuais o cumprimento de 6 dos 10 passos (passos 2 a 7), relativos à época de introdução, frequência, consistência e variedade dos alimentos complementares, além da flexibilidade de quem alimenta a criança quanto a horários e atitude frente à recusa dos alimentos. No entanto, a intervenção não afetou um dos passos mais importantes, a saber, o passo 8, que recomenda evitar açúcar, café, enlatados, frituras, refrigerantes, balas, salgadinhos e outras guloseimas. Houve associação entre duração da amamentação exclusiva e dieta diversificada saudável. A probabilidade de a criança consumir dieta mais saudável aos 12 meses de idade aumentou em 28% para cada mês de aleitamento materno exclusivo (RR 1,28; IC 95% 1,19 -1,38). / Despite the importance of healthy eating already in the early years of life, a pattern of low intake of healthy diverse diet and high consumption of processed foods and foods rich in fat, salt, and sugar has been observed during childhood. Maternal age and cohabitation with maternal grandmother are known to be among the factors that influence the dietary habits of children. Therefore, the objective of the present study was to assess the effect of an intervention designed to promote breastfeeding and healthy complementary feeding, directed at adolescent mothers and maternal grandmothers, and performed during the first 4 months of life, on compliance, during the first year of life, with the Ten Steps to Healthy Feeding for Children under Two Years, recommended by the Brazilian Ministry of Health. A secondary objective was to assess the influence of exclusive breastfeeding duration on the quality of the infant's diet at 12 months. In order to do that, a randomized clinical trial was conducted involving 320 adolescent mothers and their infants, plus 169 maternal grandmothers when cohabiting. Participants were recruited at the maternity ward of Hospital de Clínicas de Porto Alegre and randomly assigned to either the intervention or the control group. The intervention consisted of six counseling sessions on breastfeeding and healthy complementary feeding, the first one held at the maternity ward and the others at the mothers’ homes at 7, 15, 30, 60, and 120 days of life, by a team comprising a pediatrician, two nurses, and a nutritionist. All sessions addressed the importance of exclusive breastfeeding in the first 6 months of life; the last session, at 120 days, emphasized healthy complementary feeding, to be introduced as of 6 months of life. A booklet based on the Ten Steps was given to each mother at this session. Infant feeding information was collected monthly over the first 6 months of life and then every 2 months until 12 months, by recording weekly frequency of consumption of different foods. Interviewers were blind to group allocation. Compliance with the Ten Steps was assessed using a scoring system as follows: full compliance with a step received 2 points per step; partial compliance received 1 point; and noncompliance received 0 points (no score). Healthy diverse diet was defined as the intake of fruit/vegetables, meat, beans, and cereals/tubers at least 4 times weekly, and a low intake (maximum once weekly) of foods rich in fat, salt, and sugar. Student's t test was used to compare mean scores obtained in the intervention and control groups, and Poisson's multivariate regression model with robust estimation was used to estimate the effect of the intervention on compliance with the Ten Steps. The association between exclusive breastfeeding duration and quality of the infant's diet at 12 months was also assessed using Poisson's multivariate regression model with robust estimation, using the median score obtained in the whole sample as cut-off point. Mean scores obtained in the intervention group were higher than those obtained in the control group (12.4 ± 2.5 versus 10.5 ± 2.3, respectively; p = 0.00), and the intervention doubled the chance of the score being greater than or equal to the median (RR = 1.93; 95%CI 1.44-2.58). No influence of cohabitation with maternal grandmother was detected. The intervention increased compliance, by over 10 percentage points, with six of the Ten Steps (Steps 2 to 7), related to the time of introduction, frequency, consistency and variety of complementary foods, in addition to caretaker flexibility with regard to feeding times and attitude towards food refusal. Nevertheless, the intervention did not affect one of the most important steps, namely, Step 8, which recommends avoiding the intake of sugar, coffee, canned foods, fried foods, candies, processed snacks and other unhealthy foods. There was an association between exclusive breastfeeding duration and healthy diverse diet. The likelihood of the infant being on a healthy diet at 12 months of age increased by 28% for each additional month of exclusive breastfeeding (RR = 1.28; 95%CI 1.19-1.38).

Fear of cancer recurrence (FCR) is defined as “fear, worry, or concern relating to the possibility that cancer will come back or progress (Lebel et al., 2016, p. 3266). FCR is the most frequently reported concern identified among cancer survivors (Baker, Denniston, Smith, & West, 2005; Lebel, Rosberger, Edgar, & Devins, 2007). Although approximately 50% of cancer survivors experience moderate-to-high levels of FCR (Simard et al., 2013), few psychosocial interventions exist that directly target this construct. The overarching study objectives were: (a) to adapt a manualized, 6-week, cognitive-existential group therapy intervention for FCR to an individual format; (b) to pilot-test the feasibility, acceptability, and satisfaction of this individual intervention on n=3 participants; and (c) to further pilot-test the efficacy of the individual intervention on n=25 participants, via a randomized controlled trial (RCT). In study 1, n=3 cancer survivors (1 male, 2 females) completed the one-on-one therapy intervention for the psychological treatment of FCR. Sessions were 60-90 minutes long, and included cognitive restructuring exercises, behavioural experiments, relaxation techniques, existential processing of the here-and-now, and finding meaning in life post-diagnosis. Participants completed questionnaire packages throughout the intervention and an exit interview to determine their overall feedback on the intervention. Quantitative analyses revealed downwards trends in fear of cancer recurrence and cancer-specific distress across participants. Qualitative analyses of the exit interviews revealed that all participants found the intervention useful, and that the sessions had favourable pacing and length. In study 2, the FCR intervention was further pilot-tested via an RCT. Twenty-five female cancer survivors were randomized to an experimental group or a wait-list control group. Sessions included cognitive restructuring techniques, behavioural experiments, confronting existential distress, and relaxation exercises. Nineteen women (n=9 intervention, n=10 control) completed the 6-week therapy intervention, and completed questionnaire packages at pre-, post- and 3-month follow-up. Between-within ANOVAs revealed significant interactions in the primary outcome measure of FCR, and secondary outcome measures of cancer-specific distress and uncertainty in illness for participants in the experimental group. Repeated measures ANOVAs revealed reductions in FCR, cancer-specific distress, uncertainty in illness, reassurance-seeking, cognitive avoidance, and intolerance of uncertainty, and revealed improvements in positive reinterpretation and growth, use of emotional support and mental health (improved quality of life) for participants in the experimental group, as compared to the wait-list control group. The variables that changed either maintained or improved at follow-up. Results from this study demonstrate promising results in addressing FCR in cancer survivors via a cognitive-existential intervention. Future research should continue investigating the specific therapeutic ingredients that are most effective for the psychological treatment of FCR.

Background: Given that 43-97% of preterm infants face postnatal growth restriction by hospital discharge, monitoring of growth is challenging but critical for clinical management of preterm infants. Currently, serial anthropometric measurements of weight and height are used to monitor growth but lack sensitivity. Thus, by the time significant deviations in growth trajectory are identified, an infant has already reached sub-optimal growth. A biomarker that is predictive of sub-optimal growth can serve as a preventative tool in clinical decision making. Blood urea nitrogen (BUN) may be one such potential metabolic biomarker, as it has been used as a measure of protein adequacy and thus, may additionally indicate quality of growth. While protein intake has a well-established correlation with growth, it is currently unknown if BUN is correlated with postnatal growth and if it can be used as a biomarker for growth. Objectives: 1) to examine the relationship between BUN and macronutrient intake factors such as protein intake, protein-to-energy (P:E) ratios, and carbohydrate to non-protein energy (CHO:NPE %) to better understand BUN response; 2) to examine the potential of using BUN as a predictive metabolic biomarker of growth status in a multiple linear regression. We hypothesize that BUN will positively correlate with protein intake, P:E and negatively with CHO:NPE ratio. It will also be positively correlated with growth parameters: growth velocity, length gain, head circumference gain and fat free mass. Methods: Very low birth weight preterm infants (n=101) born ≤30 weeks of gestation at McMaster Children’s Hospital’s level III NICU were included. BUN was assessed at three time points: baseline (SDay1), study day 14 (SDay14) and study day 21 (SDay21). Intake of protein and energy were collected for the 24-hour period prior to the BUN measure, their averages computed over SDay14 and SDay21 and included as confounding predictor variables. Other confounding variables such as maternal characteristics and baseline study group characteristics were also considered. Growth velocity, length gain and head circumference gain at SDay14 and SDay21, and body composition (FFM%, FFMI) between 36-40 weeks were examined as dependent growth variables. After an initial univariate analysis of baseline and maternal confounders, multiple linear regression models were then developed in a block design as follows: for the analysis of BUN vs macronutrient factors- block 1: 24-hour macronutrient intake factors + relevant baseline and/or maternal confounders; block 2: average macronutrient factors; for the analysis of BUN vs growth- block 3: BUN. Results: In the analysis of BUN and macronutrient intake, BUN was found to have a significant positive correlation with P:E ratio at all time points. Protein intake was positively correlated with BUN only at SDay1 and SDay21. CHO:NPE ratio did not correlated with BUN at any time point. The R2 for the multiple regression of BUN and macronutrient factor analysis at SDay1, SDay14 and SDay21 was 0.19, 0.42 and 0.44 respectively. In the analysis of BUN vs growth, SDay1 BUN had a significant negative correlation with SDay21 growth velocity (p=0.02). The addition of SDay1 BUN to the model of SDay21 growth velocity was significant (p<0.01 of F change statistic, R2= 0.17). SDay21 BUN also had a significant negative correlation with SDay21 growth velocity (p<0.01) and its addition was significant to the model (p<0.01 of F change statistic, R2 =0.22). BUN was not related to SDay 14 growth velocity, or to length gain, head circumference gain or any body composition estimates at any time point. Additionally, P:E was found to be significantly negatively correlated with growth. Conclusion: BUN is a statistically and clinically significant marker of nutritional adequacy, both of protein intake and energy in relation to protein intake. Addition of BUN adds to the explanation of variation in growth, and this is statistically significant, however, the additional variation explained may be too small to be clinically significant. Additionally, we observed that P:E ratio was significantly negatively correlated with growth. Thus, it may be more clinically pertinent to use high BUN values as a marker of inadequate energy to protein intake to prevent future sub-optimal growth. / Thesis / Master of Science (MSc)