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Als Bundesland mit dem höchsten Altersdurchschnitt in Deutschland und besonderen Strukturmerkmalen ländlich geprägter Gebiete sind die Folgen des demographischen Wandels bereits heute in Sachsen spürbar. Um die medizinische Versorgung von Parkinson-Patienten zu verbessern, bedarf es einer Status-quo-Analyse der aktuellen Versorgungspraxis. Ziel der Arbeit (Fragestellung) Inwieweit unterscheidet sich die Inanspruchnahme der medizinischen Leistungserbringung von Parkinson-Patienten im Vergleich von städtisch und ländlich geprägten Gebieten sowie im Vergleich von Parkinson-Patienten mit und ohne Neurologenkontakt im Beobachtungszeitraum von 2011 bis 2019? Material und Methoden Die Kohortenstudie basiert auf umfangreichen Routinedaten der Krankenkasse AOK PLUS der Jahre 2010 bis 2019 für Sachsen. Untersucht wurde eine Kohorte von insgesamt 15.744 Parkinson-Patienten (n = 67.448 Patientenjahre) und eine gematchte Vergleichskohorte (n = 674.480 Patientenjahre; Kriterien: Geburtsjahr, Geschlecht, Versicherungsjahr, Wohnsitz Stadt/Land) ohne ICD-10-Kodierung einer Bewegungsstörung. Ergebnisse Insgesamt war eine kontinuierliche Zunahme der Anzahl der Erkrankten in der dynamischen Kohorte von 2011 (n = 6829) bis 2019 (n = 8254) zu beobachten. Stadt-Land-Unterschiede zeigten sich insbesondere in der geringeren (Mit‑)Behandlung durch niedergelassene Neurologen in ländlich geprägten Gebieten. Parkinson-Patienten hatten ein 3,5- bzw. 4‑fach erhöhtes Risiko zu versterben im Vergleich zu Versicherten der Vergleichskohorte. Veränderungen der medikamentösen Parkinson-Therapie (Zunahme COMT- und MAO-Inhibitoren) sowie der Heilmittelerbringung (Zunahme Ergotherapie und Logopädie) über die Beobachtungszeit zeigten sich primär bei Parkinson-Patienten mit Neurologenkontakt. Diskussion In der Studie konnten eine erhöhte Morbidität und Mortalität bei Parkinson-Patienten identifiziert werden, die sich als Ziel für innovative Versorgungskonzepte eignen. Die zunehmende Zahl an Patienten und die beschriebenen Unterschiede dokumentieren hierfür den Bedarf. Gleichzeitig zeigen die Veränderungen in der Verordnungspraxis, dass innovative Therapien von niedergelassenen Neurologen eingesetzt werden. / Background The consequences of demographic change are already noticeable in Saxony, the federal state with the highest average age in Germany and predominantly rural areas. In order to improve medical care for patients with Parkinson’s disease (PwP), a status quo analysis of current care practice is required. Objective To what extent does the utilization of medical services by PwP differ a) between urban and rural areas in Saxony and b) between PwP with and without neurologist contact in the observation period from 2011 to 2019? Material and methods The cohort study was based on extensive routine data for Saxony from the health insurance company AOK PLUS from 2010 to 2019. A cohort of 15,744 PwP (n = 67,448 patient-years) was compared to a matched cohort (n = 674,480 patient-years; criteria: year of birth, gender, year of insurance, place of residence: urban/rural) without an ICD-10 coding of a movement disorder. Results Overall, there was a steady increase in the number of PwP in the dynamic cohort from 2011 (n = 6829) to 2019 (n = 8254). Urban-rural differences included a smaller proportion of patients being seen by a neurologist in rural areas. The PwP had a 3.5 to 4‑fold higher risk of dying compared to those in the comparison cohort. Changes in drug therapy for Parkinson’s disease (i.e., increases in COMT and MAO inhibitors) and in remedy delivery (i.e., increases in occupational therapy and speech therapy) over the observation period were primarily seen in PwP who were seen by a neurologist. Discussion The study identified increased morbidity and mortality in PwP who are suitable targets for innovative care concepts. The increasing number of patients and the described differences document the need for this. At the same time, changes in prescription practice show that innovative forms of treatment are being used by neurologists in outpatient care.

INTRODUÇÃO: Neutropenia febril (NF) é frequente complicação quimioterapia para tumores sólidos e é de suma importância a identificação dos pacientes de alto risco para o seu desenvolvimento. OBJETIVOS: Caracterização clínica, laboratorial e dos fatores de risco para NF em pacientes admitidos para antibioticoterapia. MATERIAL E MÉTODOS: Estudo retrospectivo de todos os pacientes consecutivamente internados com NF no ICESP (Instituto do Câncer do Estado de São Paulo) entre maio de 2008 e maio de 2012. Critérios de inclusão: idade >= 16 anos, diagnóstico de NF (temperatura axilar >= 37,8ºC e neutrófilos < 500/mm3 ou entre 500-1000/mm³ com tendência à queda) em pacientes portadores de tumor sólido. Dados clínico-laboratoriais e de evolução foram coletados; realizada análise univariada e multivariada a fim de investigar a relação entre os fatores de risco e o desenvolvimento de complicações. RESULTADOS: 333 episódios de NF em 295 pacientes com tumores sólidos foram avaliados. Idade mediana de 57 anos (16-88), 150 do sexo feminino (51%). Os sítios primários das neoplasias mais frequentes foram mama (15%), pulmão (14%), sarcomas (13%), colorretal (10%), estômago (9%), cabeça e pescoço (8%) e testículo (5%). 31 pacientes (10%) apresentaram mais de um episódio de NF. À admissão, a mediana de contagem de neutrófilos foi 690/mm3, e a mediana de MASCC atribuído 19 (7-26). Sítios de infecção mais comumente identificados foram pulmão (19%), trato urinário (15%), corrente sanguínea (13%), abdominal (10%) e partes moles (8%); quanto à etiologia, bacilos Gram-negativos isolados em 36 (11%) episódios e cocos Gram-positivos em 15 (9%). Mediana de internação de 10 dias (0-106 dias). Alguma complicação grave foi identificada em 248 (74%) episódios, sendo que hipotensão (47%), admissão em UTI (35%), insuficiência renal (30%), insuficiência respiratória (19%) e alteração do estado mental (17%) as mais comuns (> 10%). A mortalidade foi 14% (46 pacientes). A análise univariada revelou como fatores de risco para complicações idade >= 60 anos (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controle sistêmico da neoplasia (OR 0.51, 95%CI 0.31-0.85, p 0.01), DPOC (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presença de sintomas ao diagnóstico (OR 2.16, CI95% 1.26-3.69, p 0.0063), desidratação (OR 4.63, CI95% 2.57-8.31, p<0.0001) e regular ou mau estado geral (OR 3.31, CI95% 1.93-5.68, p<0.0001). Na análise multivariada, permaneceram como fatores de risco a desidratação (OR 3.7, CI95% 2.09-6.78, p 0.000009), DPOC (OR 3.7, CI 95% 1.27-11.04, p 0.0166) e idade >= 60 anos (OR 2.5, CI95% 1.37-4.58, p 0.0029). O modelo multivariado corretamente classificou os episódios como de alto risco em 75% dos eventos. Elaboramos um novo escore de risco baseado nos valores de OR, onde pacientes desidratados receberam quatro pontos, aqueles com DPOC três pontos e aqueles com idade >= 60 anos, dois pontos. O escore final corresponde à soma das parcelas acima. Consideramos os pacientes como de alto risco com escore > 5 pontos (sensibilidade 72%, especificidade 64%). CONCLUSÕES: Complicações clínicas graves são comuns durante os episódios de NF, em pacientes com tumores sólidos. DPOC, idade >= 60 anos e desidratação representam fatores de risco para o desenvolvimento de complicações. Um novo escore de fácil execução foi proposto, o qual deverá ser validado prospectivamente / BACKGROUND: Febrile neutropenia (FN) is a frequent complication during chemotherapy in solid tumors, and to identify those patients (pts) with higher risk of developing complications during FN episodes is important. Here we aimed to characterize those risk factors for severe complications during FN episodes in pts with solid tumors, admitted for intravenous antibiotics. MATERIAL AND METHODS: It is a retrospective study of all consecutive pts admitted with FN at ICESP (Instituto do Câncer do Estado de São Paulo) between May/2008 and May/2012. Eligibility criteria included: age >= 16y, the diagnosis of FN (documented axillary temperature greater than 37.8°C, and neutrophil count < 500/mm3 or expected to fall below 500/mm3) as an adverse event of chemotherapy for a solid tumor. Potentially life-threatening complications during FN episodes were collected and univariate and multivariate logistic regression analyses were performed to assess the relationship between risk factors and these complications. RESULTS: 333 FN episodes in 295 pts with solid tumors were studied. Median age was 57 y (16-88), 150 female (51%). Most frequent primary sites included: breast (15%), lung (14%), bone/soft tissues (13%), colorectal (10%), stomach (9%), head & neck (8%) and testis (5%). 31 pts (10%) presented more than 1 FN episode. At admission, median neutrophil count was 690/mm3, and the median MASCC score was 19 (7-26). Infection sites were identified as pulmonary (19%), urinary tract (15%), bloodstream (13%), abdominal (10%) and soft tissues (8%), and regarding etiology, Gram-negative bacilli could be isolated in 36 (11%) and Gram-positive cocci in 15 FN episodes (9%). All pts were admitted with a median duration of hospital stay of 10 d (0-106 d). Overall, a severe complication as a consequence of FN was detected in 248 episodes (74%), being hypotension (47%), ICU admission (35%), renal failure (30%), respiratory failure (19%) and altered mental state (17%) the most common (> 10%), and 46 pts died (14%). A univariate analysis revealed age >= 60y (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controlled cancer (OR 0.51, 95%CI 0.31-0.85, p 0.01), previous COPD (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presence of symptoms (OR 2.16, CI95% 1.26-3.69, p 0.0063) or dehydration (OR 4.63, CI95% 2.57-8.31, p < 0.0001) and regular or bad general condition (OR 3.31, CI95% 1.93-5.68, p < 0.0001) as risk factors for complications. On multivariate analysis, only dehydration (OR 3.7, CI95% 2.09-6.78, p 0.000009), previous COPD (OR 3.7, CI 95% 1.27-11.04, p 0.0166) and age >= 60y (OR 2.5, CI95% 1.37-4.58, p 0.0029) were associated with severe complications. The multivariate model correctly classified 75% of all FN episodes as complicated. We elaborated a new risk score based on the OR, where dehydrated pts scored 4 points, those with COPD 3 points and those with age >= 60y 2 points. The final score was calculated by the sum of all above. We have considered as high risk pts those who scored > 5 points (sensitivity 72%, specificity 64%). CONCLUSIONS: Severe complications were common during febrile neutropenic episodes in pts with solid tumors. COPD, age >= 60 y and dehydration represent clinically significant risk factors for severe complications in FN pts. A new score was proposed, though it should be prospectively validated

Ng, Po Yan. / Thesis submitted in: November 2006. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2007. / Includes bibliographical references (leaves 109-120). / Abstracts in English and Chinese. / Acknowledgement --- p.i / Abstract --- p.ii / 摘要 --- p.iii / Table of Contents --- p.iv / List of Figures --- p.viii / List of Tables --- p.xi / List of Abbreviation --- p.xii / Chapter Chapter 1 --- Introduction / Chapter 1.1 --- A General Introduction to the Development and Clinical Activities of Platinum Drugs --- p.1 / Chapter 1.1.1 --- Platinum Drugs used in a Clinical Setting --- p.4 / Chapter 1.1.2 --- Platinum Drugs under Clinical Trials --- p.5 / Chapter 1.1.3 --- Platinum Compounds with Dual Mechanisms --- p.7 / Chapter 1.2 --- Platinum Drug Antitumor Mechanism --- p.9 / Chapter 1.3 --- Limitations of Platinum Drugs --- p.12 / Chapter 1.3.1 --- Toxicity --- p.12 / Chapter 1.3.2 --- Drug Resistance or Cross Resistance --- p.15 / Chapter 1.3.2.1 --- Reduced Drug Accumulation or Increased Drug Efflux --- p.16 / Chapter 1.3.2.2 --- Drug Inactivation --- p.18 / Chapter 1.3.2.3 --- Enhanced DNA Repair --- p.19 / Chapter 1.4 --- Why Combinational Therapy? --- p.21 / Chapter 1.4.1 --- Antimetabolites --- p.20 / Chapter 1.4.2 --- Topoisomerase Inhibitors --- p.22 / Chapter 1.4.3 --- Tubulin-Active Antimitotic Agents --- p.24 / Chapter 1.4.4 --- Demethylcantharidin as a potential candidate for drug combination --- p.28 / Chapter 1.5 --- Study Objectives --- p.31 / Chapter Chapter 2 --- Materials and Methods / Chapter 2.1 --- Cell Lines --- p.33 / Chapter 2.2 --- Cancer Cell Preparation / Chapter 2.2.1 --- Chemicals and Reagents --- p.33 / Chapter 2.2.2 --- Cell Culture Practice --- p.34 / Chapter 2.2.2.1 --- Subcultures --- p.35 / Chapter 2.2.2.2 --- Cryopreservation --- p.37 / Chapter 2.2.2.3 --- Thawing Cryopreservated Cells --- p.38 / Chapter 2.2.3 --- Development of Drug-Resistant Cell Lines --- p.39 / Chapter 2.3 --- Growth Inhibition Assay / Chapter 2.3.1 --- Evaluation of Cytotoxicity in vitro --- p.40 / Chapter 2.3.2 --- Drug Pretreatment --- p.43 / Chapter 2.3.3 --- Drug Pre-sensitization with Concurrent Treatment --- p.44 / Chapter 2.4 --- Calculations for Drug Combinations --- p.46 / Chapter 2.5 --- Statistical Analysis --- p.49 / Chapter Chapter 3 --- Results and Discussions / Chapter 3.1 --- In vitro Cytotoxicity and Evaluation of Drug Resistance --- p.50 / Chapter 3.2 --- Role of Leaving Ligand in a Platinum Complex --- p.58 / Chapter 3.3 --- Priority in Selecting the Most Effective Drug Combination --- p.66 / Chapter 3.4 --- Drug Combination Studies / Chapter 3.4.1 --- Drug Combination Prescreening --- p.68 / Chapter 3.4.1.1 --- Comparison of the effectiveness of the three Drug Combinations --- p.72 / Chapter 3.4.1.2 --- Rationale for Drug Combination Studies presented in Section 3.4.2 & 3.4.3 --- p.73 / Chapter 3.4.2 --- Drug Pre-sensitization Studies in Colorectal Cancer Cell Lines --- p.74 / Chapter 3.4.2.1 --- Comparison of Drug Pre-sensitization Treatment in Sensitive Colorectal Cancer Cell Lines --- p.84 / Chapter 3.4.2.2 --- Comparison of Drug Pre-sensitization Treatment in Sensitive and Oxaliplatin Resistant HCT116 Colorectal Cancer Cell Lines --- p.87 / Chapter 3.4.3 --- Drug Pre-sensitization Studies in Liver Cancer Cell Lines --- p.89 / Chapter 3.4.3.1 --- Comparison of Drug Pre-sensitization Treatment in Sensitive Liver Cancer Cell Lines --- p.99 / Chapter 3.4.3.2 --- Comparison of Drug Pre-sensitization Treatment in Sensitive and Cisplatin Resistant SK-Hepl Liver Cancer Cell Line --- p.101 / Chapter 3.5 --- Possible Explanation to the Observed Drug Combination Effect --- p.103 / Chapter 3.6 --- General Protocols for Drug Combinations --- p.105 / Chapter Chapter 4 --- Conclusions / Reference --- p.109 / Appendices --- p.121 / Chapter I a. --- "Raw Data of Pre-screening for HCT116 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.122 / Chapter I b. --- "Raw Data of Pre-screening for HCT116 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.123 / Chapter II a. --- "Raw Data of Pre-screening for SK-Hepl (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.124 / Chapter II b. --- "Raw Data of Pre-screening for SK-Hepl ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.125 / Chapter III a. i) --- "Isobolograms for HCT116 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.126 / Chapter III a. ii) --- "Raw Data for HCT116 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.127 / Chapter III b. i) --- "Isobolograms for HCT116 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.128 / Chapter III b. ii) --- "Raw Data for HCT116 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.129 / Chapter IV a. i) --- "Isobolograms for HCT1160xaR (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.130 / Chapter IV a. ii) --- "Raw Data for HCT1160xaR (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.131 / Chapter IV b. i) --- "Isobolograms for HCT1160xaR ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.132 / Chapter IV b. ii) --- "Raw Data for HCT1160xaR ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.133 / Chapter V a. i) --- "Isobolograms for HT29 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.134 / Chapter V a. ii) --- "Raw Data for HT29 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.135 / Chapter V b. i) --- "Isobolograms for HT29 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.136 / Chapter V b. ii) --- "Raw Data for HT29 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.137 / Chapter VI a. i) --- Isobolograms for Hep G2 (Cisplatin and [Pt(DMC)(NH3)2]) --- p.138 / Chapter VI a. ii) --- Raw Data for Hep G2 (Cisplatin and [Pt(DMC)(NH3)2]) --- p.139 / Chapter VI b. i) --- "Isobolograms for Hep G2 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.140 / Chapter VI b. ii) --- "Raw Data for Hep G2 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.141 / Chapter VII a. i) --- "isobolograms for SK Hep 1 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.142 / Chapter VII a. ii) --- "Raw Data for SK Hep 1 (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.143 / Chapter VII b.i) --- "Isobolograms for SK Hep 1 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.144 / Chapter VII b. ii) --- "Raw Data for SK Hep 1 ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.145 / Chapter VIII a. i) --- "Isobolograms for SK Hep ICisR (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.146 / Chapter VIII a. ii) --- "Raw Data for SK Hep ICisR (Cisplatin, [Pt(DMC)(NH3)2] and Pt(DMC)(NH2CH3)2])" --- p.147 / Chapter VIII b. i) --- "Isobolograms for SK Hep ICisR ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.148 / Chapter VIII b. ii) --- "Raw Data for SK Hep ICisR ([Pt(DMC)(R,R-DACH)] and Oxaliplatin)" --- p.149

Made available in DSpace on 2016-01-26T12:51:39Z (GMT). No. of bitstreams: 1 celiaalvesdesouza_dissert.pdf: 2396843 bytes, checksum: 970ffd922abef05b55903b9955668ba5 (MD5) Previous issue date: 2012-05-11 / The increasing of attendances in the Chemotherapy Center has demanded from the nurses a better standard of time management and productivity. Considering this, the measurement of the work load becomes fundamental. This investigation, which is based on observation, has used the sample work technique and it presents the following aims: 1- identifying and validating the activities developed by nurses in a Chemotherapy Center and; 2- to measure the work load and productivity. The stage is a Chemotherapy Central placed in the South-East of Brazil. Nine assistant nurses have taken part (moments 1 and 2) and other seven of them (moments 3 and 4) during the period from May, 2010 to March, 2011. The study has been conducted in four moments: 1- identification of the interventions/activities, 2- validation of content, 3. pilot test and, 4- measuring of work load. In order to identify the activities performed by the nurses, a device was built using triangulation of data, combining three sources of information: semi-structured interview, documents analysis and questionnaire. The activities mapped have been categorized according to the language patterned by the Nurse Intervention Classification (NIC). Afterwards, the device has been submitted to content validation through meetings with the members. The final instrument was formed by 35 interventions and 48 activities organized in five areas (basic physiologic and complex physiologic, behaviorist, security and health system) and 11 classes. The pilot test using the instrument, conducted by two nurses during four consecutive days, has totaled 1000 samples and has resulted in 38 interventions and 88 activities. The sample size has been statistically established. The observations have been conducted during five days totalizing 1.487 samples of interventions/activities. It has been observed that 43,2% of the nurses time have been spent in indirect care, 33,2% indirect care, 11,6% in associated activities and 12% in personal activities. The average productivity has corresponded to 88%. This study has allowed the mapping and the validation of interventions/activities conducted during the attendance process. There has been concluded that nurses from the investigated unit have spent most of their time performing activities of indirect care. It has highlighted, furthermore, productivity indexes above the recommended ones present in the literature. / O aumento do volume de atendimento em central de quimioterapia tem exigido dos enfermeiros melhor gestão do tempo de trabalho e produtividade para atender a demanda. Dessa forma, a mensuração da carga de trabalho torna-se de fundamental importância. Essa investigação, de natureza observacional, utilizou técnica de amostragem de trabalho e teve como propósitos: 1- identificar e validar as atividades desenvolvidas por enfermeiros em Central de Quimioterapia e; 2- mensurar a carga de trabalho e produtividade. O cenário constitui-se em uma central de quimioterapia localizada na região sudeste do Brasil. Participaram do estudo nove enfermeiros assistenciais (momentos 1 e 2) e sete(momentos 3 e 4) durante o período de maio de 2010 a de março de 2011.O estudo foi realizado em quatro momentos: 1- identificação das intervenções/atividades, 2- validação de conteúdo, 3- teste piloto e, 4- mensuração de carga de trabalho. Para identificar as atividades realizadas pelos enfermeiros foi construído um instrumento utilizando triangulação de dados, combinando três fontes de informações: entrevista semiestruturada, análise de documento e questionário. As atividades mapeadas foram categorizadas segundo a linguagem padronizada pela Classificação de Intervenção de Enfermagem (NIC). Posteriormente, o instrumento foi submetido à validação de conteúdo através de reuniões com os participantes. O instrumento final foi composto por 35 intervenções e 48 atividades organizadas em cinco domínios (fisiológico básico e fisiológico complexo, comportamental, segurança e sistema de saúde) e 11 classes. O teste piloto com o instrumento, conduzido por duas enfermeiras durante quatro dias consecutivos, totalizou 1000 amostras e resultou em 38 intervenções e 88 atividades. O tamanho amostral foi estabelecido estatisticamente. As observações foram conduzidas durante cinco dias totalizando 1.487 amostras de intervenções/atividades. Observou-se que 43,2% do tempo dos enfermeiros foram consumidos em cuidados indiretos, 33,2% em cuidados diretos, 11,6% em atividades associadas e 12% em atividades pessoais. A produtividade média correspondeu a 88%. Este estudo permitiu mapear e validar as intervenções/atividades realizadas durante o processo assistencial. Concluiu que enfermeiros da unidade investigada consumiram a maior parte de seu tempo em atividades de cuidados indiretos. Revelou, ainda, índice de produtividade acima dos recomendados na literatura.

Ho Toi Sze Joyce. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (leaves 65-74). / Abstracts in English and Chinese. / Acknowledgement --- p.ii / Contents --- p.iii / Abstract --- p.viii / List of Abbreviations --- p.xvii / List of Tables --- p.xix / List of Figures --- p.xx / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- The role of Non-steroidal anti-inflammatory drugs (NSAIDs) --- p.1 / Chapter 1.2 --- NSAID-induced gastrointestinal (GI) toxicity --- p.1 / Chapter 1.2.1 --- Pathogenesis of NSAID-induced GI toxicity --- p.2 / Chapter 1.2.2 --- GI symptoms --- p.4 / Chapter 1.2.3 --- GI ulcers --- p.4 / Chapter 1.2.4 --- GI complications --- p.5 / Chapter 1.2.5 --- Risk factor for GI complications --- p.6 / Chapter 1.2.6 --- Ulcerogenicity of different NSAIDs in upper GI events --- p.6 / Chapter 1.3 --- Prevention of NSAID-induced GI toxicity --- p.7 / Chapter 1.3.1 --- H2-receptor antagonists --- p.8 / Chapter 1.3.2 --- Misoprostol --- p.8 / Chapter 1.3.3 --- Proton Pump Inhibitor (PPI) --- p.9 / Chapter 1.3.4 --- Selective COX-2 Inhibitors --- p.10 / Chapter 1.3.4.1 --- GI safety of selective COX-2 inhibitors --- p.11 / Chapter 1.3.4.1.1 --- Gastrointestinal outcomes research of rofecoxib --- p.13 / Chapter 1.3.4.1.2 --- Celecoxib Long term Arthritis Safety Study --- p.14 / Chapter 1.3.4.2 --- Cardiovascular toxicity of NSAIDs --- p.15 / Chapter 1.3.4.2.1 --- Cardiovascular toxicity of non-selective NSAIDs --- p.15 / Chapter 1.3.4.2.2 --- Cardiovascular toxicity of selective COX-2 inhibitors --- p.16 / Chapter 1.4 --- Guidelines on the management of osteoarthritis (OA) and rheumatoid arthritis (RA) --- p.21 / Chapter 1.4.1 --- American College of Rheumatology (ACR) Subcommittee --- p.22 / Chapter 1.4.2 --- National Institute for Clinical Excellence (NICE) --- p.23 / Chapter 1.4.3 --- Hong Kong Hospital Authority (HA) --- p.23 / Chapter 1.5 --- Cost of illness of upper GI events in the setting of an emergency room of a regional hospital in Hong Kong and cost analysis of selective COX-2 inhibitor with non-selective NSAID plus gastroprotective agent --- p.24 / Chapter 1.6 --- Objectives --- p.25 / Chapter Chapter 2 --- Cost of illness of upper GI events in the setting of an emergency room of a regional hospital in Hong Kong --- p.26 / Chapter 2.1 --- Methods --- p.28 / Chapter 2.1.1 --- Study site --- p.28 / Chapter 2.1.2 --- Cohort participants --- p.28 / Chapter 2.1.3 --- Resource data collection --- p.29 / Chapter 2.1.4 --- Cost data --- p.30 / Chapter 2.1.5 --- Statistical Methods --- p.31 / Chapter 2.1.6 --- Study perspective --- p.31 / Chapter 2.2 --- Results --- p.31 / Chapter 2.2.1 --- Demographic data --- p.31 / Chapter 2.2.2 --- Total direct medical cost of upper GI complaints in UCH --- p.33 / Chapter 2.3 --- Discussion --- p.35 / Chapter 2.3.1 --- Total direct medical cost of upper GI events --- p.35 / Chapter 2.3.2 --- Cost of upper GI events associated with NSAID usage --- p.38 / Chapter 2.3.3 --- Low dose aspirin on NSAID-induced GI toxicity --- p.38 / Chapter 2.3.4 --- Limitation --- p.39 / Chapter 2.3.5 --- Future study --- p.41 / Chapter 2.4 --- Conclusion --- p.41 / Chapter Chapter 3 --- Cost analysis of selective COX-2 inhibitor versus non-selective NSAID with gastroprotective agent --- p.43 / Chapter 3.1 --- Methods --- p.46 / Chapter 3.1.1 --- Local randomized clinical trial --- p.46 / Chapter 3.1.1.1 --- Study population --- p.46 / Chapter 3.1.1.2 --- Cost data --- p.47 / Chapter 3.1.1.3 --- Statistical Methods --- p.48 / Chapter 3.1.1.4 --- Sensitivity analysis --- p.49 / Chapter 3.1.2 --- Large randomized clinical trial --- p.49 / Chapter 3.1.2.1 --- Study population --- p.49 / Chapter 3.1.2.2 --- Cost data --- p.50 / Chapter 3.2 --- Results --- p.50 / Chapter 3.2.1 --- Local randomized clinical trial --- p.51 / Chapter 3.2.1.1 --- Demographic data --- p.51 / Chapter 3.2.1.2 --- Cost analysis --- p.52 / Chapter 3.2.1.3 --- Sensitivity analysis --- p.53 / Chapter 3.2.2 --- Large randomized clinical trial --- p.54 / Chapter 3.2.2.1 --- Demographic data --- p.54 / Chapter 3.2.2.2 --- Cost analysis --- p.55 / Chapter 3.3 --- Discussion --- p.55 / Chapter 3.3.1 --- Cost analysis --- p.55 / Chapter 3.3.2 --- Sensitivity analysis --- p.59 / Chapter 3.3.3 --- Low dose aspirin on NSAID-induced GI toxicity --- p.59 / Chapter 3.3.4 --- Limitation --- p.60 / Chapter 3.4 --- Future study --- p.62 / Chapter 3.5 --- Conclusion --- p.62 / Chapter Chapter 4 --- Conclusion --- p.63 / Chapter Chapter 5 --- Reference --- p.65 / Appendix Data collection form --- p.75

Conclusions. Regardless the method the information on benefit was provided, the maximum amount of money which people are willing to pay for antihypertensive varied substantially. Using relative risk to present the benefit would distort the viewpoint of the public regarding the importance of drug treatment. Residents were much more conservative in antihypertensive drugs than physicians. Most hypertensive patients in China would probably not accept drugs treatment for primary prevention if they are adequately informed. Rural residents were on average, less willing to take antihypertensive drugs than urban residents. Residents had a poor perception of their cardiovascular risk due to hypertension and the benefit of drug treatment. Most physicians in our study did not have good knowledge on overall risk approach and Chinese national guidelines. They had also very poor knowledge and skills related to evidence based medicine. (Abstract shortened by UMI.) / Objective. To assess the maximum amount of money residents are willing to pay for antihypertensive drugs given the actual benefit of treatment. To decide the minimum benefit (expressed in NNT) above which people are willing to pay for antihypertensive drugs at the current cost. To determine the minimum risk of cardiovascular disease (CVD) above which people would be willing to pay for antihypertensive at the current cost. To assess whether reporting of study results by using relative risk reduction and NNT affects people's willingness to pay for and physicians' willingness to prescribe antihypertensive drugs. To evaluate patients' and physicians' perception of perceived CVD risk due to hypertension and benefit of treatment. To assess knowledge, attitude and perception of the public and physicians regarding antihypertensive drugs and physicians' knowledge and skills on evidence based medicine. / Results. The response rate for residents was 91%. 95% of respondents reported that they would be willing to take antihypertensive drugs if they found to have high blood pressure. The majority of residents did not know the ultimate goal of blood pressure lowering was to reduce the risk of CVD. 91% said that they had not enough knowledge and information to make drug-taking decisions. The perceived 5-year baseline risk in the absence of treatment, absolute risk reduction and relative risk reduction was 70%, 40% and 60% respectively. Rural residents tended to over-rate their risk and benefit more than urban residents. Overall, 2%, 3% and 47% of residents were not willing to pay anything for antihypertensive drugs when information on benefit of treatment was described in general, with RRR and with NNT respectively. The median cost the residents were willing to pay was $500, $700 and $100 respectively for responding three ways of describing the benefit. / The response rate for physicians was 95%. The perceived 5-year baseline risk, absolute risk reduction and relative risk reduction was 40%, 20% and 39% respectively. Internists tended to give a slightly higher estimate of the 5-year risk (40% vs 30%, p&lt;0.05) and of the RRR (39 vs 29, p&lt;0.05). Overall, physicians were more likely to prescribe antihypertensive drugs when the benefit information was expressed in RRR than when it was expressed in NNT (p&lt;0.001). The median minimum NNT and the 5-year CVD risk above which physicians are willing to prescribe was 200 and 1.5% respectively. / Wang Weizhong. / "November 2006." / Adviser: Jinling Tang. / Source: Dissertation Abstracts International, Volume: 68-08, Section: B, page: 5119. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 105-114) / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest dissertations and theses, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

INTRODUÇÃO: Neutropenia febril (NF) é frequente complicação quimioterapia para tumores sólidos e é de suma importância a identificação dos pacientes de alto risco para o seu desenvolvimento. OBJETIVOS: Caracterização clínica, laboratorial e dos fatores de risco para NF em pacientes admitidos para antibioticoterapia. MATERIAL E MÉTODOS: Estudo retrospectivo de todos os pacientes consecutivamente internados com NF no ICESP (Instituto do Câncer do Estado de São Paulo) entre maio de 2008 e maio de 2012. Critérios de inclusão: idade >= 16 anos, diagnóstico de NF (temperatura axilar >= 37,8ºC e neutrófilos < 500/mm3 ou entre 500-1000/mm³ com tendência à queda) em pacientes portadores de tumor sólido. Dados clínico-laboratoriais e de evolução foram coletados; realizada análise univariada e multivariada a fim de investigar a relação entre os fatores de risco e o desenvolvimento de complicações. RESULTADOS: 333 episódios de NF em 295 pacientes com tumores sólidos foram avaliados. Idade mediana de 57 anos (16-88), 150 do sexo feminino (51%). Os sítios primários das neoplasias mais frequentes foram mama (15%), pulmão (14%), sarcomas (13%), colorretal (10%), estômago (9%), cabeça e pescoço (8%) e testículo (5%). 31 pacientes (10%) apresentaram mais de um episódio de NF. À admissão, a mediana de contagem de neutrófilos foi 690/mm3, e a mediana de MASCC atribuído 19 (7-26). Sítios de infecção mais comumente identificados foram pulmão (19%), trato urinário (15%), corrente sanguínea (13%), abdominal (10%) e partes moles (8%); quanto à etiologia, bacilos Gram-negativos isolados em 36 (11%) episódios e cocos Gram-positivos em 15 (9%). Mediana de internação de 10 dias (0-106 dias). Alguma complicação grave foi identificada em 248 (74%) episódios, sendo que hipotensão (47%), admissão em UTI (35%), insuficiência renal (30%), insuficiência respiratória (19%) e alteração do estado mental (17%) as mais comuns (> 10%). A mortalidade foi 14% (46 pacientes). A análise univariada revelou como fatores de risco para complicações idade >= 60 anos (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controle sistêmico da neoplasia (OR 0.51, 95%CI 0.31-0.85, p 0.01), DPOC (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presença de sintomas ao diagnóstico (OR 2.16, CI95% 1.26-3.69, p 0.0063), desidratação (OR 4.63, CI95% 2.57-8.31, p<0.0001) e regular ou mau estado geral (OR 3.31, CI95% 1.93-5.68, p<0.0001). Na análise multivariada, permaneceram como fatores de risco a desidratação (OR 3.7, CI95% 2.09-6.78, p 0.000009), DPOC (OR 3.7, CI 95% 1.27-11.04, p 0.0166) e idade >= 60 anos (OR 2.5, CI95% 1.37-4.58, p 0.0029). O modelo multivariado corretamente classificou os episódios como de alto risco em 75% dos eventos. Elaboramos um novo escore de risco baseado nos valores de OR, onde pacientes desidratados receberam quatro pontos, aqueles com DPOC três pontos e aqueles com idade >= 60 anos, dois pontos. O escore final corresponde à soma das parcelas acima. Consideramos os pacientes como de alto risco com escore > 5 pontos (sensibilidade 72%, especificidade 64%). CONCLUSÕES: Complicações clínicas graves são comuns durante os episódios de NF, em pacientes com tumores sólidos. DPOC, idade >= 60 anos e desidratação representam fatores de risco para o desenvolvimento de complicações. Um novo escore de fácil execução foi proposto, o qual deverá ser validado prospectivamente / BACKGROUND: Febrile neutropenia (FN) is a frequent complication during chemotherapy in solid tumors, and to identify those patients (pts) with higher risk of developing complications during FN episodes is important. Here we aimed to characterize those risk factors for severe complications during FN episodes in pts with solid tumors, admitted for intravenous antibiotics. MATERIAL AND METHODS: It is a retrospective study of all consecutive pts admitted with FN at ICESP (Instituto do Câncer do Estado de São Paulo) between May/2008 and May/2012. Eligibility criteria included: age >= 16y, the diagnosis of FN (documented axillary temperature greater than 37.8°C, and neutrophil count < 500/mm3 or expected to fall below 500/mm3) as an adverse event of chemotherapy for a solid tumor. Potentially life-threatening complications during FN episodes were collected and univariate and multivariate logistic regression analyses were performed to assess the relationship between risk factors and these complications. RESULTS: 333 FN episodes in 295 pts with solid tumors were studied. Median age was 57 y (16-88), 150 female (51%). Most frequent primary sites included: breast (15%), lung (14%), bone/soft tissues (13%), colorectal (10%), stomach (9%), head & neck (8%) and testis (5%). 31 pts (10%) presented more than 1 FN episode. At admission, median neutrophil count was 690/mm3, and the median MASCC score was 19 (7-26). Infection sites were identified as pulmonary (19%), urinary tract (15%), bloodstream (13%), abdominal (10%) and soft tissues (8%), and regarding etiology, Gram-negative bacilli could be isolated in 36 (11%) and Gram-positive cocci in 15 FN episodes (9%). All pts were admitted with a median duration of hospital stay of 10 d (0-106 d). Overall, a severe complication as a consequence of FN was detected in 248 episodes (74%), being hypotension (47%), ICU admission (35%), renal failure (30%), respiratory failure (19%) and altered mental state (17%) the most common (> 10%), and 46 pts died (14%). A univariate analysis revealed age >= 60y (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controlled cancer (OR 0.51, 95%CI 0.31-0.85, p 0.01), previous COPD (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presence of symptoms (OR 2.16, CI95% 1.26-3.69, p 0.0063) or dehydration (OR 4.63, CI95% 2.57-8.31, p < 0.0001) and regular or bad general condition (OR 3.31, CI95% 1.93-5.68, p < 0.0001) as risk factors for complications. On multivariate analysis, only dehydration (OR 3.7, CI95% 2.09-6.78, p 0.000009), previous COPD (OR 3.7, CI 95% 1.27-11.04, p 0.0166) and age >= 60y (OR 2.5, CI95% 1.37-4.58, p 0.0029) were associated with severe complications. The multivariate model correctly classified 75% of all FN episodes as complicated. We elaborated a new risk score based on the OR, where dehydrated pts scored 4 points, those with COPD 3 points and those with age >= 60y 2 points. The final score was calculated by the sum of all above. We have considered as high risk pts those who scored > 5 points (sensitivity 72%, specificity 64%). CONCLUSIONS: Severe complications were common during febrile neutropenic episodes in pts with solid tumors. COPD, age >= 60 y and dehydration represent clinically significant risk factors for severe complications in FN pts. A new score was proposed, though it should be prospectively validated

In the last decade, prescription of anticonvulsants for treatment of low back pain (LBP) increased 4-fold. Among them, topiramate has frequent side effects and a mechanism of action that is not fully understood. The authors describe a 65-year-old woman with dependence on topiramate prescribed for chronic LBP and discuss how she was successfully weaned off topiramate using duloxetine. A significant agonistic effect by topiramate on α-2 adrenergic receptors in the brain likely accounts for the symptoms of withdrawal that were seen. We attribute the resolution of her topiramate withdrawal symptoms to reduced norepinephrine (NE) release, a known effect of duloxetine administration.